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HUGHES' 
 
 COMPEND OF PRACTICE 
 
 PHYSICIANS' EDITION. 
 
TO PHYSICIANS. 
 
 The several essential qualities which a good Visiting 
 List should possess are, compactness, convenience 
 of arrangement, and strength to resist the unusual 
 hard wear it receives. These qualities are all com- 
 bined in Lindsay &: Blakiston's Physicians' Visiting 
 List, which has now been published for forty-one 
 years, and no better evidence of the practical worth 
 of this book can be offered than the uniform increase 
 in popularity it has enjoyed with each successive issue. 
 One of its chief features is its size ; it measures 
 6J^ X 3j^ inches, and the smallest size weighs but t,}4 
 ounces and is only ^ of an inch thick. The large 
 sizes are a little thicker and heavier; it is, however, 
 the smallest and lightest Visiting List published. 
 Our many years' experience has enabled us to put it 
 together in the best manner, and to add many im- 
 provements during the past few years. It is arranged 
 for 25, 50, 75 and 100 patients per day or week, inter- 
 leaved and plain, dated, undated and monthly. Prices 
 range from 75 cents to $3. Complete circular will 
 be sent you upon application. P. Blakiston, Son 
 & Co., Medical Publishers and Booksellers, 1012 
 Walnut Street, Philadelphia. 
 
COMPEND 
 
 OF THE 
 
 PRACTICE OF MEDICINE. 
 
 BY 
 
 DAN'L E. HUGHES, M.D., 
 
 CHIEF RESIDENT PHYSICIAN PHILADELPHIA HOSPITAL ; 
 
 LATE DEMONSTRATOR OF CLINICAL MEDICINE IN THE JEFFERSON MEDICAL COLLEGE 
 
 OF PHILADELPHIA; FELLOW OF THE COLLEGE OF PHYSICIANS 
 
 OF PHILADELPHIA, ETC. 
 
 PHYSICIANS' EDITION. 
 
 THOROUGHLY REVISED AND ENLARGED. 
 BASED ON THE FOURTH REVISION OF THE QUIZ-COMPEND EDITION 
 
 AND 
 
 INCLUDING A VERY COMPLETE SECTION ON SKIN DISEASES. 
 
 PHILADELPHIA: 
 
 P. BLAKISTON, SON & CO., 
 
 No. IOI2 Walnut Street. 
 1892. 
 

 )rti 
 
 Copyright, 1889, by P. Blakiston, Son & Co. 
 
 Pbesb of Wm. F. Fell & Co., 
 1220-24 Sanbom Sr., 
 
 PHILADELPHIA 
 
TO 
 
 HIS ESTEEMED FRIEND AND TEACHER, 
 
 J. M. DA COSTA, M.D., 
 
 Professor of the Practice of Medicine 
 
 IN the 
 
 Jefferson Medical College, 
 
 THIS WORK 
 
 IS RESPECTFULLY DEDICATED BY 
 
 THE AUTHOR. 
 
PREFACE 
 
 TO 
 
 THE PHYSICIANS' EDITION. 
 
 The favor with which the " Compends of the Practice of Medicine," 
 as pubhshed in the Quiz-Compend series, have been received, together 
 with the knowledge that many practitioners have made use of them, 
 suggested the advisabihty of preparing an edition especially for Physi- 
 cians. To that end the Compends have been thoroughly revised and 
 enlarged, by the incorporation of the more recent improvements in 
 practice and the addition of a very complete section upon Diseases of 
 the Skin, which, with the addition of a complete index, and its publi- 
 cation in one volume, renders it much more convenient for reference. 
 
 The exceptional character of the advantages afforded the Author 
 for clinical work, as Demonstrator of CKnical Medicine in the Jeffer- 
 son Medical College, and also as Assistant-in-charge of the Medical 
 Dispensary of the College Hospital for a number of years, together 
 with his system of notes employed in the Quiz-room during the past 
 five years, have formed the basis of this Compend, which may there- 
 fore be regarded as a full set of notes upon the Practice of Medicine. 
 
 Free reference has been made to the latest writings and teachings 
 of Professors Da Costa, Bartholow, Pepper, Fhnt, Loomis, Reynolds, 
 Duhring, Fred. T. Roberts and others, to whom acknowledgment is 
 here made. 
 
 DANIEL E. HUGHES. 
 
 PREFACE TO FOURTH EDITION. 
 
 The rapid sale of the previous editions of this book has encouraged 
 the author to make a very complete revision for the fourth edition. 
 This has necessitated the rewriting of many sections and a slight 
 enlargement of the work, so as to include all new methods and dis- 
 coveries in Diagnosis, Pathology and Treatment. Every effort has 
 been made to keep it as compact as is compatible with clearness, and 
 to make it a thorough guide to the practice of medicine. 
 
 D. E. H. 
 
CONTENTS. 
 
 PAGE 
 
 INTRODUCTION, 9 
 
 FEVERS, 14 
 
 Continued, 16 
 
 Periodical, 30 
 
 Eruptive, 3g 
 
 DISEASES OF THE MOUTH, 52 
 
 DISEASES OF THE STOMACH, 58 
 
 DISEASES OF THE INTESTINAL CANAL, 72 
 
 INTESTINAL PARASITES, 98 
 
 DISEASES OF THE PERITONEUM, 102 
 
 DISEASES OF THE BILIARY PASSAGES, 107 
 
 DISEASES OF THE LIVER, no 
 
 DISEASES OF THE KIDNEYS, 118 
 
 ACUTE GENERAL DISEASES, 143 
 
 DISEASES OF THE RESPIRATORY SYSTEM, 174 
 
 DISEASES OF THE NASAL PASSAGES, 193 
 
 DISEASES OF THE PHARYNX 198 
 
 DISEASES OF THE LARYNX, 203 
 
 DISEASES OF THE BRONCHIAL TUBES, 216 
 
 DISEASES OF THE LUNGS, 238 
 
 DISEASES OF THE PLEURA, 261 
 
 DISEASES OF THE CIRCULATORY SYSTEM, 268 
 
 DISEASES OF THE NERVOUS SYSTEM, 297 
 
 DISEASES OF THE SPINAL CORD, 33^ 
 
 CEREBRO-SPINAL NEUROSES, 346 
 
 DISEASES OF THE NERVES, 357 
 
 DISEASES OF THE BLOOD, 362 
 
 DISEASES OF THE SKIN 37^ 
 
 INDEX, 449 
 
 viii 
 
COMPEND 
 
 OF THE 
 
 PRACTICE OF MEDICINE. 
 
 INTRODUCTION. 
 
 The Principles of Medicine constitute what may be termed 
 Medical Scze?tce. 
 
 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 a deviation or alteration in the func- 
 tions, properties or structure of some tissue or organ, whereby its 
 office is no longer performed in accordance with the natural standard : 
 Organic disease, when^ associated with an organic change in the af- 
 fected part ; Functional disease, when the phenomena are indepen- 
 dent of any apparent structural lesion. 
 
 The study of disease, whether organic or functional in character, 
 is termed Pathology. 
 
 Pathology explains the origin, causes, clinical history and nature 
 of the various morbid conditions to which the economy is liable. 
 
 The study of individual diseases constitutes Special Pathology; 
 while the study of the morbid conditions common to a greater or less 
 number of diseases, constitutes General Pathology. 
 
 Nomenclature, or the naming of diseases, is a subdivision of gen- 
 eral pathology. The value of nomenclature as applied to disease is 
 I 9 
 
10 ' PRACTICE OF MEDICINE. 
 
 that the name chosen shall express the morbid condition involved, as 
 well as 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 n2im.tdi peritonitis. 
 
 If the morbid condition is catarrhal, Buch as a transudation or flux, 
 the liquid escaping upon a mucous surface, the suffix rhcea is used ; 
 thus, a catarrhal inflammation of the intestinal tract is termed diar- 
 rhcea 2in& enteror/icea. 
 
 If the morbid condition be a flow of blood or hemorrhage from a 
 mucous surface, the suffix rhagia is used ; thus, a hemorrhage from 
 the small intestines is termed enterorhagia. 
 
 If the morbid condition be pain without inflammation, the suffix 
 a/gia is used. The various forms of neuralgias being an example ; 
 thus, neuralgia of the stomach is \.evm.td gastralgia. 
 
 If the morbid condition be in the blood, the suffix cB7nia is used. 
 Thus, AncEmia is impoverishment of the blood; Urcsmia, the morbid 
 accumulation of urea in the blood ; SepticiEmia, putrid infection of 
 the blood ; Pyamia, purulent infection of the blood. 
 
 If the morbid condition is in the urine, the ending uria is used to 
 indicate it. Albinni7iuria, when albumin in the urine ; Hcematiina, 
 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. Thus, a dropsical accumulation in the 
 peritoneum is termed hydro-peritoneinn. 
 
 If the morbid condition be that of air in an unnatural part, the 
 ^r^^x p7teumo to the name of the part is used, as in pjteumo-pericar- 
 dium. 
 
 If the morbid condition be an inflammation of the membrane 
 investing the part inflamed, the prefix peri is made use of. Thus, 
 for an inflammation of the investing membrane of the kidney the 
 term is perinephritis. 
 
 Inflammation of the connective tissue surrounding an organ is 
 designated by the ^^xg-^x para. Thus, /ara;«<?/r?//^ for inflammation 
 of the connective tissue about the womb. 
 
 A termination in oma signifies a tumor, as in sarco?na or carcinoma. 
 
 The s\\^\ pathy is used to designate a morbid condition of a part, 
 without indicating its particular character, an example being the use 
 of the term encephalopathy. 
 
INTRODUCTION. H 
 
 Morbid Anatomy is the study of the changes in the tissues and 
 fluids of the body appreciable to the naked eye or with the aid of the 
 microscope. 
 
 Histolog'y is the study of the minute anatomy ot the tissues and 
 fluids of the body with the microscope. 
 
 Pathogenesis is the study of the origin and development of 
 pathological processes, 
 
 Lesions 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 morbid 
 action is of value in the prevention, management and removal of 
 disease. 
 
 The Causes of disease may be divided into internal, external, 
 ordijiary, specific, prijnary, secondary, predisposing and exciting. 
 
 Examples of ifiternal or intrinsic causes are those having their 
 origin in the m.ind, 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 or lactic acid. 
 
 External ox 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 ; to 
 wit, atmospherical changes. 
 
 Specifix or special causes are those producing a distinct and specific 
 disease, such as the special cause of typhoid fever, yellow fever, 
 smallpox and cholera. 
 
 A contagious disease is one due to a special cause, whose causative 
 agent is a specific poison that, introduced into the body 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 multiplication. An infectious disease may or may not be 
 contagious. 
 
 An example of z. primary cause is any external traumatic cause. 
 
 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. 
 
12 PRACTICE OF MEDICINE. 
 
 Inherited or constitutional predisposition to certain diseases is also 
 termed Diathesis ; an example is in the offspring of phthisical parents, 
 who are said to be of a phthisical diathesis. 
 
 Acquired predisposition is such as arises from — 
 
 I. Habits, to wit: Strain upon the nervous system resulting in 
 
 nervous diseases. 
 
 II. Age, to wit : 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, to wit : Miners, weavers and cutlers, lung dis- 
 
 eases. 
 
 IV. Sex, to wit: Women, emotional nervous diseases. 
 Men, as more exposed, rheumatism and pneumonia. 
 
 V. Race, to wit : Negro, phthisis and scrofula : exempt from 
 
 malaria. 
 
 Exciting causes are those giving rise to morbid conditions in those 
 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 troubles. 
 
 The Clinical History of disease includes all the symptoms and 
 signs which may occur from the period of ittcubation until its final 
 terjnination. 
 
 Symptoms and Signs are such alterations in the healthy func- 
 tions as give evidence of the existence of a diseased condition or per- 
 verted function, and may be either objective or subjective. Objective 
 when evident to the senses of the observer, such as redness or swell- 
 ing. Subjective, when felt by the patient, such as pain or numbness. 
 
 The Period of Incubation is that interval between the entrance 
 of the poison into the system and its manifestation, and seldom pre- 
 sents recognizable symptoms. 
 
 The Prodromes are the earliest recognizable symptoms ; as the 
 rigors or chills during the invasion of fever, and the various aura pre- 
 ceding an epileptic fit. 
 
 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 
 
INTRODUCTION. 13 
 
 are less intense the disease is said to be sub- acute ; when gradual 
 or slow in development, duration and intensity the disease is said 
 to be cJironic. 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, to wit : 
 the rusty sputum of pneumonia. 
 
 Physical Signs are, strictly speaking, objective symptoms. 
 The Termination of a diseased action may occur in one of three 
 ways, to wit : Cure, Secondary Process, or in Death. 
 Cure may occur by — 
 
 I. Lysis, or slow return to health. 
 
 II. Crisis, abrupt termination, usually with a critical discharge. 
 III. Metastasis, or changing from one location to another. 
 Secondary processes is when the diseased action is substituted by 
 a new morbid process, to wit : Rheumatism followed by endocarditis ; 
 apoplexy by cerebral softening. 
 
 By DeatJi is meant a complete cessation of tissue change occurring by 
 I. Asthenia, or an ever increasing debility, to wit : phthisis, 
 cancer, Bright's disease. 
 II. AncBinia, or insufficient quantity or quality of blood. 
 
 III. Apnoea or non-aeration of blood, to wit : acute lung dis- 
 
 eases, or croup, 
 
 IV. Coma, death beginning at the brain, to wit : ursemia, 
 
 narcotic poisoning, cerebral hemorrhage. 
 
 Diagnosis of disease,, or the discrimination of diseases, implies a 
 complete, exact and comprehensive knowledge of the case under 
 consideration, as regards the origin, seat, extent and nature of all its 
 morbid conditions. 
 
 A direct diagnosis is made when the morbid condition is revealed 
 by a combination of clinical phenomena, or some one or more 
 pathognomonic 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 pres- 
 ence of which is not actually indicated by any positive symptoms. 
 
 Prognosis of disease is the ability or knowledge to foretell the 
 
14 - PRACTICE OF MEDICINE. 
 
 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 of the 
 study of medicine, from a practical point of view, is to learn how to 
 cure, relieve, or prevent disease, and it must be borne in mind that 
 this does not consist solely in the administration of drugs, but requires 
 strict faithful attention to diet and hygie?te. 
 
 When the object is to prevent disease, such as smallpox by vaccina- 
 ation, 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. 
 
 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 /l?//m//2/^ treatment. 
 
 When marked weakness and prostration are to be overcome, it is 
 called Restorative treatment. 
 
 FEVERS. 
 
 Fever is a condition in which there are present the phenomena 
 of rise of teinperature, quickened circulation, marked tissue change 
 and disordered secretion. 
 
 The primary cause of the fever phenomena is a disorder of the 
 sympathetic nervous system giving rise to disturbances of the vaso- 
 motor filaments. 
 
 Rise of temperatnre is the preeminent feature of all fevers, and 
 can only be positively determined by the use of the clinical ther- 
 mometer. The Xcrxn feverishftess is used when the temperature ranges 
 from ()(f to ioo° Fahr. ; slight fever if ioo° or ioi° ; moderate, 102° or 
 103°; high if 104° or 105'^ ; and ititense if it exceed the latter. 
 
 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 Fahr. is usually attended with an increase of eight to 
 ten beats of the pulse per minute. 
 
FEVERS. 15 
 
 The following table gives a fair comparison between temperature 
 and pulse : — 
 
 A temperature of 98° F. corresponds to a pulse of 60 
 
 (( a pgO Y, " " " 70 
 
 " " ioo° F. " " " 80 
 
 " " 101° F. " " " 90 
 
 << u J020 F. " " *' 100 
 
 " " 103° F. " " " 1 10 
 
 « " 104° F. " " " 120 
 
 « i( iQ^o jr^ «< « « j^o 
 
 " " 106° F. " " " 140 
 
 TA^ tissue waste \s 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. 
 
 An Idiopathic or Essential fever is one in which no local affec- 
 tion causes the fever phenomena, although lesions may arise during 
 its progress. 
 
 A Symptomatic or Secondary fever is one dependent upon 
 an acute inflammation. 
 
 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 severe cases. Cool 
 sponging is of decided advantage. Quinina, in gr. xx doses repeated, 
 is usually reliable. Aiitipyrine , gr. xx repeated and antifebrin gr. x-xv 
 repeated, are also recommended. 
 
 2. Lessen the circulation. If the pulse be full, strong and rapid, 
 use aconitwn. If the circulation be weak, stiinulajits with digitalis 
 or caffeina, 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 scantv and thick with tissue waste. Watch the 
 
16 , PRACTICE OF MEDICINE. 
 
 Stools, that you may judge whether the food, be it soHd or hquid, is 
 being 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, and other light nutritious food, in small quantities, but at 
 frequent intervals. 
 
 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 : 
 cleanhness, cheerfulness, regularity, ventilation and light. 
 
 CONTINUED FEVERS. 
 
 All continued fevers are characterized by a steady progress of the 
 febrile movernent, 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, not the result of a specific poison, rarely fatal, but when death 
 does occur, presenting no characteristic lesion. 
 
 Causes. Fatigue, mental and physical ; exposure to the sun, 
 great heat or cold ; excesses in eating and drinking ; excitement and 
 violent emotion. Most common in childhood. It is not a miasmatic 
 fever, neither is it contagious. 
 
 Symptoms. Onset sudden with an abrupt feeling of lassitude, 
 followed by a decided chill or chilliness, a sudden and rapid rise of 
 tefnperature, quick tense pulse, headache, dry skin, great thirst, coated 
 tongue, costive bowels, and scafity high-colored uri7ie. Cases due to 
 errors in diet are accompanied by nausea and voiniting. Attacks 
 occurring during childhood, due to excitement, fright or the emotions, 
 may be associated with convulsions. The temperature may within an 
 hour or two reach 103° F,, or more, when slight deliriicm 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 oi crisis ; or it may 
 continue for several days gradually falling to the r\oxvi\{lysis^. Herpes 
 
FEVERS. 17 
 
 about the lips and nostrils are often observed at the close of an attack. 
 Convalescence is rapid. 
 
 Diagnosis. Unless the fever can be attributed to some one of the 
 causes that give rise to it, 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 in this affection. A child, apparently 
 in the best of health, is at play, or. may be at school, suddenly complains of 
 nausea and may vomit, the skin becoming hot, dry and flushed or soon covered 
 with an erythematous rash, the pulse is quick and tense, there is headache, 
 pains in the limbs, and great fretfulness or nervousness. The axillary tempera- 
 ture may reach I02°-I04° F. The whole aspect is most alarming, when a 
 laxative is administered, the surface sponged with a tepid lodon, sleep follows 
 during which there may be free perspiration, and the following day the child is 
 and continues perfectly well. 
 
 Prognosis. Recovery, without sequelae, the rule. 
 
 Treatment. Very little medicine. Rest in bed. A full dose of 
 hydrargyri chloridiun mite, or an e7iema, sp07iging the surface with 
 .cold or tepid water, and the administration of salme diaphoretics and 
 diuretics. If there is great arterial excitement aconitum may be 
 added. Light liquid diet is most agreeable. Cases in which the 
 nervous symptoms are prominent do well on Fothergill's " fever mix- 
 ture of the future," to wit: — 
 
 U. Acid, hydrobrom., f.^ss-j 
 
 Syr. simplicis, . . {"2^ ss-j 
 
 Aquae, f^ij-iij. M. 
 
 SiG. — Every four hours. 
 QuinificB sulphas in tonic doses during convalescence. 
 
 CATARRHAL FEVER. 
 
 Synonyms. Influenza; epidemic catarrhal fever; contagious 
 catarrh. 
 
 Definition. A continued fever, occurring generally as an epi- 
 demic ; due to a specific cause; characterized by a catarrhal inflam- 
 mation of the respiratory organs, and sometimes of the digestive, 
 always accompanied by nervous phenomena and a debility out of 
 proportion to the intensity of the fever and the catarrhal processes. 
 During the prevalence of an epidemic animals suffer more than man. 
 
 Causes. A specific vegetable gerui, uninfluenced by soil, climate 
 
18 • PRACTICE OF MEDICINE. 
 
 or atmospheric changes. It is not contagious. One attack does not 
 give immunity from another attack, but rather predisposes to it. 
 
 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 sudden, with a ^//z7/ followed hy fever, the temperature 
 reaching ioi° to 103°, a quick, compressible pulse, and severe sJiooting 
 pai?is in the eyes, frontal sinuses, joints and muscles. The chill and 
 fever are rapidly followed by chilliness along the spijie, pain in the 
 throat, hoarseness, deafness, coryza, sneezing, injected, watery eye, 
 and a dry, irritative, laryngeal cough, sometimes becoming ^r^«r/!za/. 
 The tongue is furred, there is anorexia, epigastric distress, nausea, 
 vomiting, and oftentimes diarrhcea. In some epidemics the digestive 
 symptoms are the most prominent, when dysentery may occur. 
 
 The above symptoms are always associated with decided weakness 
 and debility altogether out of proportion to the intensity of the fever 
 and the catarrhal phenomena. Delirium is rare, but marked hebetude 
 and cutaneous hypercssthesia are common. 
 
 Duration. Four to seven days, with protracted convalescence. 
 Relapses frequently occur. 
 
 Complications. Lobar or catarrhal pneumonia frequently occur, 
 which adds to the gravity of the attack. The cough may outlast the 
 disease several weeks. 
 
 Diag"nosis. Isolated cases maybe mistaken for a "bad cold." 
 But when epidemic, the sudden onset, 7narked general catarrh and 
 decided prostration, should prevent error. 
 
 Prognosis. Recovery is the rule when it occurs in the healthy 
 and vigorous. Grave when the very young, very old, or those suffer- 
 ing from organic disease, such as Bright's disease, fatty heart, or 
 emphysema, are attacked. 
 
 Treatment. No specific. Support the system and treat indica- 
 tions. All measures, of whatever kind, that tend to depress the gen- 
 eral nervous system, or the functional activity of the respiration, and 
 especially the heart-power, are to be avoided. The catarrh, pains 
 and cough are at least ameliorated by the following : — 
 
 \\. Pulvis ipecacuanhae et opii, g''- v 
 
 I'otassii nitrat., gr- v. 
 
 Every three hours. 
 
FEVERS. 19 
 
 Or— 
 
 R . Quininaesulph,, . . ' grs. ij-iv 
 
 Morphinae sulph., g'"- tV 
 
 Aqu£e lauro-cerasi, 3J. M. 
 
 SiG. — Every four hours. 
 
 The frequent inhalation of tincturcz benzoiji comp., 3ss-j, in aquce 
 buL, Oj, reheves the naso-pharyngeal and bronchial catarrh. 
 If the bro7ichial symptoms become troublesome, use — 
 
 R. Ammonii muriat., grs. x 
 
 Spts. frumenti, f o ss 
 
 Mist, glycyrrh. comp., ^iss. M. 
 
 p. r. n. 
 
 Should Pneumonia occur, treat as an ordinary case, but never de- 
 press. 
 
 During convalescence administer strychnines sulph., gr. -^ four 
 times daily. 
 
 TYPHOID FEVER. 
 
 Synonyms. Enteric fever; gastric fever; nervous fever; entero- 
 mesenteric fever ; abdominal typhus ; autumnal fever. 
 
 Definition. An acute, self-limited, febrile affection, due to a 
 special poison ; characterized by insidious prodromes ; epistaxis ; dull 
 headache followed by stupor and delirium ; red tongue, becoming 
 dry, brown and cracked ; abdominal tenderness, early diarrhoea and 
 tympany; a peculiar eruption upon the abdomen; rapid prostration 
 and slow convalescence ; a conslant lesion of Peyer's patches, the 
 mesenteric glands and of the spleen. 
 
 Causes. Predisposing and exciting. 
 
 The chief predisposing causes are Age, to wit, young adults, 
 between eighteen and twenty-five years ; rare after forty years. I 
 have seen well-marked cases with typical symptoms at eighteen 
 months and at five years of age ; and Season, to wit, a dry and hot 
 autumn. 
 
 The exciting cause is a special typhoid germ, the bacillus typhosus. 
 
 The poison usually results from the decomposition of the typhoid 
 stools and the sputum, although it has been claimed that the disorder 
 may be generated under certain undetermined circumstances, de ?iovo, 
 from ordinary filth and decomposition. 
 
 The atmosphere is never impregnated with the fever germ. The 
 poison gains its entrance into the system by means of infected water, 
 
20 - PRACTICE OF MEDICINE. 
 
 milk, ice, meat or other food. The germ is easily destroyed by thor- 
 ough disinfection of the stools and sputum with heat, mercuric bichlo- 
 ride or acidum carbolicum, but it is to be borne in mind that 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 consists in changes in the Peye?'ia7i patches dind solitary 
 glands, which may be divided into well-defined stages, as follows : — 
 
 First Stage. Swelling, from infiltration and excessive proliferation 
 of their cellular elements ; the surrounding mucous membrane is 
 also infiltrated with cells. The Peyer's patches are thickened, hard- 
 ened 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. Softeni?ig, slotighitig and tdceration of the solitary 
 and agminate glands constitute this stage. Either of the processes 
 going on in different glands at the same time. Not all the patches 
 necessarily slough ; in a certain number of them the morbid changes 
 are arrested before softening. This stage constitutes the anatomical 
 changes of the second and third week. 
 
 Fourth Stage. Cicatrization, or in rare cases, perforation. The 
 ulcer gradually diminishes in size, the surface becoming covered with 
 a delicate layer of granulations, which is soon transformed into con- 
 nective tissue and covered with epithelium, the resulting scar being 
 slightly depressed. The gland structure is never regenerated. 
 
 The Mesenteric gla?tds become infiltrated, enlarged and softened, 
 but seldom ulcerate. 
 
 The Spleen also enlarges and softens. There is besides, parenchy- 
 matous degeneration or granular changes in all the tissues of the body. 
 
 Syraptoms. Stage of Prodromes. — The onset is insidious, with 
 a feeling o{ general malaise, vertigo, headache, disordered digestion, 
 disturbed sleep, epistaxis, depression, and muscular weakness, fol- 
 lowed by a chill ox chilliness, the patient being unable to designate 
 the day when the symptoms began. In rare instances the disease 
 begins abruptly with a chill, followed by high fever; this is particu- 
 larly the case in malarial districts. 
 
FEVERS. 21 
 
 First Week, dates from onset of the fever, when are present increas- 
 ing temperature, freque7it pulse, coated tongue, 7iausea, diarrhoea, 
 headache, and upon the seventh day a few reddish spots reseniblijig 
 fiea bites appear upon the abdomen, chest or back. 
 
 Secottd Weeky the foregoing symptoms are exaggerated ; fever con- 
 tinuous, frequent and coinpressible pulse, tympanitic, tender abdome7i, 
 gurgling in the right iliac fosses, 7iocturnal delirium, severe and con- 
 stant headache, often stupor, a short cough, with distinct bronchial rales 
 on auscultation, irregular muscular contractions {subsultus te7idinu77i), 
 sordes upon the teeth and lips, the diarrhoea continuing. During 
 this stage deafness develops, often increasing until complete, continu- 
 ing into convalescence. Disturbances of visio7i are frequent in pro- 
 nounced cases. 
 
 Third Week. Fever changes from continuous to remittent ; the 
 evening excerbations continue as high as the preceding week, and all 
 the symptoms remain about the same until near the end of the week, 
 when a marked amelioration begins. 
 
 Fourth Week. The fever decidedly remits ; almost normal in 
 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 ema- 
 ciated, which condition may continue for several weeks. 
 
 Analysis of Symptoms. The te77iperature record of typhoid 
 fever is a characteristic 07ie. The fever on the morning of the first 
 day may be stated at 98.5° F., evening 100.5° J second morning 99.5°, 
 evening 101,5°; third morning 106.5°, evening 102.5° I fourth morning 
 101.5°, evening 1035°; 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. 
 
 Diarrhoea is the principal intestinal symptom ; if absent, the lesion 
 is slight. The stools are at first dark, but early in the second week 
 they become fluid, offensive, ochre-yellow in color, resembling " pea 
 soup," and may be .streaked with blood. They number from tJiree to 
 Hfteen in the twenty-four hours. 
 
 Constipation occurs more frequently than is supposed. I have seen 
 fifty cases with constipation within the past five years. 
 
 Eruption is almost constant. Consists oi ixovsx five to twenty small, 
 rose-colored spots on the abdo?7ten, chest or back, sometimes on the 
 
22 PRACTICE OF MEDICINE. 
 
 limbs, appearing in crops, lasting about five days, disappeanyig on 
 pressure and at death. Returning with relapses. Eruption day 
 from the seventh to the ninth. 
 
 Rarely spots of a delicate blue tint — the " taches bleuatres " of 
 French authors — are observed. 
 
 Xen'oiis syniptoins are, pronounced headache, early and severe, 
 dullness of intellect soon following, passing into drowsi?iess and stupor, 
 with great prostration. Deafness pronounced. Sight impaired, in 
 grave cases double vision. Delirium low and muttering, generally 
 pleasant in character ; always present in marked cases. Cotna vigil 
 is a grave symptom, the patient lying perfectly quiet with eyes open, 
 taking no heed to his surroundings. 
 
 Muscular symptoms are developed late in the second or early in 
 the third week, and consist of irregular contractions or subsultus tefi- 
 dinum, and are the result of great debility. The reverse of muscular 
 contractions, to wit, perfectly motionless in bed, attempting no mus- 
 cular effort of any kind, is a grave sign. 
 
 Convalescence shows great debility, great anaemia and great nerv- 
 ousness, often very protracted. It is during convalescence that great 
 irritability of the heart, profuse night sweats and insomnia occur, and 
 in woman loss of the hair. 
 
 Complications. Intestinal hemorrhage is the most frequent 
 and at times the most critical of any of the complications of typhoid 
 fever. The hemorrhage may occur any time between the fourteenth 
 and twentieth day ; a sudden decline of the temperature to the norm 
 or below frequently precedes the passage of blood by stool. The 
 hemorrhage is due to the erosion of a vessel during the ulcerative 
 action. 
 
 Perforation makes the case almost hopeless. Peritonitis without 
 perforation adds to the gravity, but not necessarily fatal. Lobar pneu- 
 monia, hypostatic congestion and bronchitis are frequent occurrences. 
 Albuminuria may occur, as may phlegmasia dolens. 
 
 Relapses are common. The symptoms all return abruptly ; the 
 duration is half the time of the original attack ; occur at the end of 
 the fourth or beginning of the fifth week. Not so fatal as generally 
 supposed. 
 
 Abortive typhoid fever are cases of mild character, having many 
 ot the typical symptoms, running its course in about two weeks. 
 The so-called walking cases are often ot this character. 
 
FEVERS. 23 
 
 Diagnosis. An error that is constantly being made is that of 
 confounding typhoid fever with the typhoid (depressing) symptoms or 
 condition developing during the course of many acute diseases. The 
 absence of the characteristic diarrhcea, the peculiar eruption, and the 
 typical teinperahire record, should prevent the error. 
 
 Enteritis has intestinal disorders alone. 
 
 Peritonitis, abdominal symptoms only, with constipation. 
 
 Acute miliary tuberculosis often mistaken for typhoid fever, an 
 error difficult to prevent at times. 
 
 Meningitis lacks the intestinal symptoms and fever record. 
 
 The so-called typho-malarial or malaria-typhoid fever has many 
 symptoms in common, but lacks the diarrhcea, eruption, and tempera- 
 ture record. 
 
 Prognosis. A positive prognosis cannot be made. Favorable 
 indications are constipation, slight diarrhoea, low temperature, and 
 moderate delirium. Unfavorable symptoms are obstinate and severe 
 diarrhoea, early high temperature, marked nervous symptoms with 
 coma vigil or stupor, albuminuria, and repeated intestinal hemor- 
 rhages. 
 
 The prognosis is always more favorable in winter than in summer. 
 
 The mortality in typhoid fever in private practice is about one 
 death in twenty ; in hospital practice it varies from one death in five 
 to ten cases. 
 
 Treatment. No specific. Chiefly symptomatic and expectant, 
 with intelligent nursing, pure air, quiet sick chamber, and disinfecting 
 the uritie and the stools, with a nutritious liquid diet at intervals of 
 every two or three hours. A word of caution, however, as to the 
 quantity of food administered. The amount should be small, as 
 the digestive capacity of the patient is greatly lessened by the febrile 
 phenomena. Much harm results in typhoid fever from stuffing the 
 patient. 
 
 The following remedies have advocates, claiming that they modify 
 the course of the disease ; to wit : Hydrargyrum, iodum, aciduni car- 
 bolicum, mineral acids, argentmn nitras, and ergota. 
 
 A mild case of the disease will do well with acidiim hydrochloricum 
 dilutum, TTLx-xx, well diluted, every four hours, alternated with 
 quinincE sulphas, gr. ij. 
 
 Cases with high temperature and costive bowels are sometimes 
 wonderfully benefited by the following : — 
 
24" PRACTICE OF MEDICINE. 
 
 R . Hydrarg}Ti chlor. mite, ST' /4 
 
 Pulv. ipecacuanha, §T' /^ 
 
 Pulv. opii, §r. )^. 
 
 Repeated every three or four hours, and qicinincB sulphas, gr. ij, every four 
 hours. 
 
 The present so-called "specific treatment" of this disease consists 
 in the administration every second evening, until four doses are 
 taken, of hydrargyri chlor. mite, gr. vij-x, which seemingly lessens 
 the frequency of the stools in the later stages of the attack, although 
 slightly increasing them at the time. Also administering from the 
 beginning of the attack — 
 
 R. Tine, iodi., ^ij 
 
 Acid, carbol. liq., 3J. M. 
 
 SiG. — One, two, or three drops in ice water, every two or three hours, after food. 
 
 To reduce the temperature, use either the cold bath, cold pack, and 
 cold sponging, with qui7tincE sulph., gr. xv-xx, repeated within an 
 hour, or antipyrine , gr. xx, repeated j^r^ re nata. 
 
 Diarrhoea should not be checked unless it exceeds three stools in 
 twenty-four hours, when may be used — 
 
 R. Bismuth subnit., gr. xx 
 
 Acid, carbol., gtt. j 
 
 Tinct. opii deodorat., gtt. x-xv 
 
 Mucil. acacise, 55 j 
 
 Aquae, ^iij. M. 
 
 SiG. — Every three or four hours. 
 Or— 
 
 R . Cupri sulph., gr. ^ 
 
 Extracti opii, g^"- X' ^* 
 
 SiG. — In pill, every four hours. 
 
 For Tympajiites ; cold compresses or turpentine stupes to the abdo- 
 men, or R. ol. terebi7ithi7icE , gtt. x, morphines sulph., gr. -^j^, in emul- 
 sion, every third hour, or tinct. tiucis vomicis, gtt. y.,p. r. ?i. 
 
 Tympany with constipation is relieved by the use of olei terebinthince , 
 gtt. X, olei ricini, gtt. xv, in emulsion every three or four hours. 
 
 For Thirst ; cooling drinks, in moderation, or pellets of ice slowly 
 dissolved in the mouth. 
 
 Headache ; cold to the head, mustard to the neck, and foot-baths ; 
 if these fail to relieve, morphina or atropina hypodermically. 
 
 Delirium ; if from debility, increase the stimulants ; other causes, 
 use morphina. 
 
FEVERS. 25 
 
 Restlessness and coma vigil ; chloral alone or with pofassii bro- 
 fnidujn, or morphina. 
 
 Debility ; food every two or three hours; do not permit sleep to 
 interfere with nourishment. Stiimilants are indicated early ; the best 
 guide being the heart's action ; an average amount would be ^vj spts. 
 villi gallici, per diem, or chloroformi Ttiij-v every hour or two, well 
 diluted, or moschus, gr. x, repeated p. r. n. 
 
 The bladder should be examined at each visit. 
 
 Ifitestinal hemorrhage ; at once morphina, gr. ^, hypodermically, 
 and ext. ergotcB fl., f^j, repeated p. r. n., or MonseV s sohition, gtt. 
 ij-iv, every two hours, or acidum tannicum, gr. ij-v, with. pidv. opii ei 
 ipecaciiatihcz, gr. iij every hour. 
 
 Perforation and peritotiitis ; at once morphijia sulphas, gr. yi, 
 hypodermically followed with extractiim opii, gr. j every hour, hot 
 application to the abdomen and bold stimulation. 
 
 TYPHUS FEVER. 
 
 Synonyms. Contagious fever ; ship fever ; jail fever. 
 
 Definition. An acute febrile, epidemic disease ; highly contagious, 
 and characterized by sudden invasion, profound depression of the vital 
 powers, sickening odor, and a peculiar petechial eruption ; favorable 
 cases terminating by crisis about the fourteenth day. No lesion. 
 
 Cause, A special infecting germ, the character of which is un- 
 known, but which is influenced by filth and overcrowding. Rarely 
 seen in the United States. 
 
 Pathology. No constant lesion. Blood dark and thin, with les- 
 sened fibrin ; tissues dark, soft and flabby. 
 
 Symptoms. Begins abruptly ; chill followed by violent feve7 ; 
 temperature within a few days reaching 104° to 105° F. ; a frequent, 
 bounding pulse, soon becoming compressible ; severe headache, fol- 
 lowed by violent delirium ; from \.h.e fifth to the seventh day, a coarse, 
 red, measly eruption, with a mottling of the skin all over the body, 
 except the face, not disappearing on pressure ; constipation the rule. 
 End of the second week, the temperature suddenly declines and the 
 case passes into a rapid convalescence. 
 
 Complications. Pneumonia and swollen parotid glands are 
 common. 
 
 Diagnosis. From typhoid jever,\\\^ age, season, onset of the 
 disease, character of the eruption, and the intestinal symptoms. 
 
26. PRACTICE OF MEDICINE. 
 
 Measles begin milder, with coryza and cough, and seldom have 
 such pronounced nervous phenomena, but there occurs an early- 
 eruption appearing on the face. 
 
 Prog"nosis. Unfavorable indications ; high temperature, frequent 
 pulse, early stupor, presentiment of death. Favorable ; youth, mod- 
 erate temperature and pulse, and mild nervous phenomena. 
 
 Treatment. Symptomatic. As typhus fever is distinctly conta- 
 gious, isolation is imperative, with immediate x^T^Q\2X2,wdi disinfection 
 of the patient's excreta. 
 
 All cases are benefited by small doses of the mineral acids alter- 
 nating with quinines sulphas. 
 
 For high temperature, cold pack, cold bath, cold sponging, full 
 doses of guifiina or a7itipyri7ie . 
 
 For the headache and delirium, cold to the head, in the young and 
 strong, a few leeches to the temple, and chloral^ with or without the 
 bromides. 
 
 For constipation, mild laxatives. 
 
 Debility; alcohol early and in full doses, spi7-itus chloroformi in 
 drachm doses, whenever danger of collapse. 
 
 CEREBRO-SPINAL FEVER. 
 
 Synonyms. Epidemic cerebro-spinal meningitis; epidemic cere- 
 bro-spinal fever; spotted fever ; cerebro-spinal typhus. 
 
 Definition. A malignant epidonic fever, characterized by head- 
 ache, vomiting, painful contractions of the muscles of the back of 
 the neck, retraction of the head, hypersesthesia, disorders of the 
 special senses, delirium, stupor, coma, and frequently an eruption 
 of petechia or purpuric spots — a subcutaneous extravasation of blood. 
 Lesions of cerebral and spinal membranes are found at the post- 
 morietn. 
 
 Cause. A special microorganism, of oval shape, occurring mostly 
 in pairs and faintly tremulous, resembling those found in pneumonia 
 and erysipelas, though hardly identical. Bad hygiene seems to favor 
 the development of this affection, but can hardly be considered its 
 cause. 
 
 The disease seems to have a predilection for the young. Occurs 
 most frequently in the winter months. Not contagious. 
 
 Pathological Anatomy. The extent of lesion present in a 
 
FEVERS. 27 
 
 given case depends upon the duration of the illness. In cases rapidly 
 fatal, it is probable that the subject is overwhelmed by the poison ere 
 the characteristic anatomical changes have time to develop. 
 
 The changes in this disease are twofold, to wit : those due to the 
 direct action of the infecting poison upon the blood, producing the 
 group of symptoms constituting the fever ; and those giving rise to 
 the local inflammation, viz. : HypercBmia of the membranes of the 
 brain and spinal cord followed by an exiidatioti of lymph and an 
 effusion of serum, resulting in pressure on the brain and cord. The 
 inflammatory changes are more marked in the membranes at the 
 base of the brain than elsewhere. 
 
 Symptoms. Divided, according to the severity of the lesion, 
 into three groups, to wit : the common form, the fuhnmant, and the 
 abortive. 
 
 The Co?nmon Form begins abruptly with a chill, excruciating head- 
 ache, persistent nausea, vo7niti?ig, vertigo, and an overwhelming sense 
 of weakness. Within a few hours the muscles of the back of the neck 
 become rigid and retracted, with decided paiji upon moving the 
 head; this rigidity and retraction soon extends to the back, when 
 opisthotonos occurs. There is great restlessness, and the surface of 
 the body becomes highly sensitive {hypercssthesia). Cramps in the 
 muscles of the legs and elsewhere, and spasmodic twitchings of the 
 lips and eyelids come and go, and finally convulsiojis or delirium 
 occur. Intolerance of light, and in some cases amaurosis, more or 
 less deafness, loss of sense of smell and taste soon following. The 
 temperature and pulse records are irregular. From \}!\^ first day to 
 \.h.Q fifth an eruption of petechias or purpura occurs in the majority of 
 cases. The disease reaches its height in from three to eight days, 
 and passes into stupor d^nd co)na, or ameliorates imd passes into a 
 protracted convalescence. 
 
 The Fulminant Form. Severe chill, depression, and in a few hours 
 collapse. The patient is overcome by the poison and never reacts. 
 
 The Abortive Form'zox\.svsXs of one or more pronounced character- 
 istic symptoms during the course of an epidemic. 
 
 Sequelae. Result from thickening of either the cerebral or spinal 
 membranes ; persistent headache, blindness or deafiess, partial or 
 complete ; epilepsy, or different forms of sfinal palsies. 
 
 Complications. Pneumonia; typhoid fever; pleuritis ; intesti- 
 nal catarrh, in infants. 
 
28 , PRACTICE OF MEDICINE. 
 
 Diagnosis. TypJwid fever begins slowly, has a characteristic 
 temperature record, ivitJioict so mtense headache, muscular rigidity, 
 vomiting, early delirium, ending in coma. 
 
 Typhus fever has higher fever, is of longer duration, and has a 
 peculiar measly eruption, is not attended with muscular rigidity and 
 retraction, hyperaesthesia, nor disorders of the special senses. 
 
 Titbercular vieni7igitis is not epidemic, has no characteristic erup- 
 tion ; is preceded by long prodromes, and runs a tedious course. 
 
 A congestive r///// resembles i\\&fuhni7ia7it c2iSQ:s, in suddenness of 
 depression, but the latter has not the history of the former. 
 
 Inflammation of tJie nieninges of the cord is due to exposure to 
 cold, or syphilis, and is not attended with cerebral symptoms or an 
 eruption. 
 
 Prognosis. Varies according to epidemic ; from twenty to fifty, 
 and even seventy-five per cent. die. 
 
 Treatnient. There is no abortive plan of treatment for cerebro- 
 spinal fever, nor can the antiphlogistic treatment of the inflammatory 
 symptoms be advised. Like the infectious diseases in general, sus- 
 taining measures are indicated in all but the most sthenic cases. 
 
 Nutritious and easily assimilated food, such as milk, eggs, meat- 
 juice and broths, should be given at regular intervals night and day. 
 If food cannot be taken by the mouth, nutritious enemata should be 
 substituted. 
 
 The drug that holds the highest place in the treatment of this dis- 
 ease is opium. 
 
 The hypodermic use of morphijia, gr. ^ to ^ every two or three 
 hours ; or extractum opii, gr. j every hour until stage of effusion in 
 adults, when quinina in tonic doses and poiassii iodidum are indicated. 
 Prof. DaCosta zSx^xvidXts potassii bromidutn with opium, especially in 
 children. 
 
 Locally, warmth to the surface, with hot sponging along the spinal 
 column and to the nape of the neck. The cautious use of cold com- 
 presses to the head for headache may be useful in some cases. 
 
 For sequela;, potassii iodidum, a course of hydrargyrum, oleum 
 morrhucE, and flying blisters along the spinal column. 
 
FEVERS. 29 
 
 RELAPSING FEVER. 
 
 Synonyms. Famine fever ; bilious typhoid fever. 
 
 Definition. An epidemic, contagious, febrile disease, self limited ; 
 characterized by a febrile paroxysm, succeeded by an entire inter- 
 mission, which is in turn followed by a r^/«/^^ similar to the first 
 seizure. No specific lesion. 
 
 Cause. A specific poison ; contagious ; acquiring the greater 
 activity the more filthy, crowded and unhealthy the population amid 
 which it prevails. 
 
 Pathological Anatomy. During the febrile paroxysm only, 
 blood contains minute cork-screw-shaped organisms or spiral fila- 
 ments — spirilli, constantly twisting and rotating. 
 
 Liver and spleen greatly swollen. 
 
 Symptoms, '^o prodromes. Onset abrupt, with fever, io2°-ic4°; 
 frequent, rather weak pulse, headache, nausea, voniitijig, and lanci- 
 nating /^zVz^ in limbs and muscles, marked in the calf of leg ; secojid 
 day, feeling oi fullness 2Sv^ pre s stir e in right and left hypochondrium, 
 due to swollen liver and spleen ; /azm^//*:.? is frequent; seventh day 
 fever ends by crisis ; fourteenth day symptoms return in milder form, 
 continuing about four days, when enters slow convalescence, much 
 emaciated. No eruption. Several relapses may occur. 
 
 Diagnosis. Yellow fever has 'many points of resemblance, but 
 has a shorter febrile stage, remissions not so complete, vomiting late 
 and characteristic, normal spleen, and the late appearance of yellow 
 color. 
 
 Re?nittent fever begins with a decided chill, followed by fever and 
 sweats, and not the progressive rise of temperature till the fifth or 
 seventh day. 
 
 Prognosis. Recovery the rule, but protracted, and decided 
 emaciatioti results. 
 
 Treatment. Expectant. Act on secretions; nourish patient and 
 meet urgent symptoms. For fever, antipyretic doses of quinina which, 
 however, has no power to prevent the relapses; for pain, hypoder- 
 mic injections of vioiphiiia ; for nausea and vomiting, acidum carbo/i- 
 cum or cerii oxalas ; during re mission, /t'rr/^;;/ and guitwta in tonic 
 doses. 
 
30 PRACTICE OF MEDICINE. 
 
 PERIODICAL FEVERS. 
 
 These affections are characterized by the distinct periodicity of the 
 phenomena, having intervals during which the patient is wholly or 
 TiQ2Lx\y free from fever. 
 
 INTERMITTENT FEVER. 
 
 Synoriyms. Ague ; chills and fever ; malarial fever ; swamp 
 fever. 
 
 Definition. A paroxysmal fever, the phenomena observing a 
 regular succession ; characterized by a cold, a hot and a sweating 
 stage, followed by an interval of complete intermission or apyrexia, 
 varying in length, according to the variety of the attack. 
 Cause. Malaria. Bacillus Malaria ? 
 
 The period of incubation varies from a few days to weeks, months 
 or even years, an auxiliary condition such as exposure to cold, over- 
 exertion, excesses in eating and drinking, or great excitement often 
 being necessary to give efficiency to the special cause. 
 
 Either sex and all ages are susceptible to the poison. 
 
 Pathological Anatomy. Blood dark, from the formation of 
 pigment {Melancsmia). Spleen swollen {Ague cake). Liver engorged 
 and swollen. 
 
 Varieties. Quotidian when a daily paroxysm ; tertian when every 
 other day ; quartan when it occurs first and fourth days ; octa7i when 
 weekly; duplicated quotidian when two paroxysms daily; duplicated 
 tertiaii, two every second day ; double tertiaft, daily paroxysm, but 
 more severe every second day. Dumb ague, or masked ague, pre- 
 sents irregularity of the characteristic phenomena. 
 
 Symptoms. Each paroxysm has three stages, the cold, hot and 
 sweating. 
 
 Cold stage begins with prodromes, to wit : lassitude, yawning, head- 
 ache and nausea, followed by a chill ; the teeth chatter, skin pale, 
 nails and lips blue, the surface rough and pale, the so-called goose- 
 skin or cutis anseri7ia, nausea and great thirst, while the thermometer 
 in the axilla or mouth shows a decided rise of temperature, 102° F.- 
 104° ; these phenomena continuing from one-half to an hour. 
 
 Hot stage begins gradually, by the shivering ceasing, the surface 
 becoming hot and flushed, the temperature rising to 106° F., or more, 
 pulse full, headache, nausea, intense thirst, dry, flushed, swollen skin, 
 
FEVERS. 31 
 
 scanty urine and other phenomena of Pyrexia, continuing from one 
 to eight or ten hours. 
 
 Sweating stage begins gradually, first appearing on the forehead, 
 then spreading over the entire surface ; \}^^fei>er lessejis, the tempera- 
 ture rapidly falling to 99° or 98°, pulse less full, headache lessens, and 
 a general feeling of comfort exists, sleep often following ; duration of 
 the sweating from one to four hours, when the intermission occurs, the 
 patient apparently well, except for a feeling of general debility. 
 
 The occurrence of the next paroxysm depends upon the variety of 
 the attack. 
 
 The paroxysm may be ushered in by a decided pain in one or more 
 nerves, instead of the cold stage, to wit : " brow ague.'' 
 
 Diagnosis. No difficulty when the characteristic chill, fever, and 
 sweats occur. 
 
 Hectic fever. Distinguished by its irregularity, and occurring sec- 
 ondary to an organic disease. 
 
 PycBinia produced by other causes than malaria. 
 
 Nervous chills show an absence of the temperature rise. 
 
 Prognosis. Recovery the rule. Without treatment many cases 
 end favorably after several paroxysms ; others passing into the chronic 
 form or malarial cachexice. 
 
 Treatment. Cold stage can be averted and the other stages 
 greatly modified by a hypodermic injection of either morphines sulph., 
 gr. y%-%, ox pilocarpincE hydrochloras, gr. yi, or chloroformi spts., f^j, 
 by the stomach. Hot stage, cool drinks and cold sponging. Sweat- 
 ing stage, when excessive, sponging with alujnen and hot water. 
 
 Intermission ; 2l\. once a brisk purgative, followed by cinchofia in 
 some form, the most efficient being guini?icB sidph., gr. xx-xxiv, in 
 solution or freshly-made pills, in one or two doses, three \o five hours 
 before the expected paroxysm. Many substitutes are lauded to replace 
 the salts of cinchona bark, but without avail. 
 
 After the paroxysms are broken up, use liq. potassii arsenit., gtt. 
 v-x, /. d., for a long time, or tinct. ferri chloridi, gtt. xx, every four 
 hours, or a combination like the following : — 
 
 R. Ferri reducti, 
 
 Quininse sulph., aa gr. xlviij 
 
 Acidi arseniosi, gr. j 
 
 01. pip. nigr., gtt. xv. M. 
 
 Ft. pil. No. xxiv. 
 
 SiG. — One pill after meals, continued for one month, at least. 
 
32 PRACTICE OF MEDICINE. 
 
 Relapses being common, quifihia should be given on the second or 
 third 6.2LY, fourth to the sixth, twelfth to the fourtce7ith, and tiine- 
 ieenih to the tivefity-frst days. 
 
 REMITTENT FEVER. 
 
 Synon37TQS. Bilious fever; bilious remittent fever; marsh fever; 
 typho-malarial fever ? 
 
 Definition. A paroxysmal fever, with exacerbations and reinis- 
 siois ; characterized by a moderate cold stage (which does not recur 
 with each paroxysm) ; an intense hot stage, with violent headache 
 and gastric irritability ; and an almost imperceptible sweating stage, 
 which is frequently wanting. 
 
 Cause. Malaria, aided by high temperature. 
 
 Pathological Anatomy. Blood dark {^Melancemid) ; spleen 
 enlarged, soft, filled with blood, and of an olive color ; liver con- 
 gested and swollen, and of a bronze hue; the brain hypersemic and 
 olive-colored ; gastro-intestinal canal markedly hyperaemic. 
 
 Symptoms. Cold stage ; moderate chill, the temperature rising 
 1° to 2^, coated, dry tongue, oppressio7i at the epigastrium, slight 
 headache, and pains throughout the body. 
 
 Hot stage ; persistent vomiting, furred ionguQ, full pulse, rising to 
 loo or I20, flushed face, i7ijected eye, violent Jieadache, pains in limbs 
 and loins, hurried respiratio7t, the te77iperature rising to 104° F., or 
 106°. The bowels costive, stools tarry and offensive, and the surface 
 becoming yellow. Deliriu77i occurs when the temperature is very 
 high. 
 
 Sweating stage ; after six to twenty-four hours, the above symptoms 
 abate, and slight sweati7tg occnrs ; Xho. pulse, headache and vo77iiting 
 subside, and the te7nperature falls to 100° F., or 99°. 
 
 This is the re77iission. 
 
 After some two to eight or twelve hours, the symptoms of the hot 
 stage return, generally 7ninus the chill, and this is termed the exacer- 
 bation, which is in turn again followed by the re7)iissio7i. 
 
 Duration. From seven to fourteen days, the average. Fre- 
 quently the fever ceases to re77tit, and instead, becomes continuous, 
 the symptoms resembling, if they are not identical with, the typhoid 
 state, whence the term typho-77ialarial fever, or 77ialario-typhoid 
 feifer. 
 
FEVERS. 33 
 
 Sequelae. The malarial cachexia results when the poison has 
 not been eliminated from the system. 
 
 Persistent headache and vertigo are the results of the intense 
 meningeal hyperaemia that sometimes occurs. 
 
 Diagnosis. In intermittent fever each paroxysm begins with 
 a chill, while the chill seldom recurs in remittent fever ; a distinct 
 intermission follows each paroxysm of the intermittent form, while a 
 remission occurs in remittent, the thermometer showing that the fever 
 does not wholly disappear; during the intermission the patient is 
 apparently well ; such is not the case in the remission of remittent 
 fever. 
 
 Typhoid fever is mistaken for remittent fever, but the absence of 
 the characteristic temperature record, diarrhcea, eruption, tympanites, 
 deafness, and severe prostration, should prevent such an error. 
 
 ProgTiosis. Uncomplicated cases are favorable. 
 
 Treatment. QuinincB sulph., gr. xvj-xx per diem, is the remedy. 
 Better administered during the remission, if possible. If an irritable 
 stomach prevents its administration by the mouth, use it by the hypo- 
 der7nic ii^ethod or in a suppository. During the hot stage, cool spong- 
 ing, cold to the head, and if a tendency to cerebral congestion, dry or 
 wet cups to the nape of the neck and — 
 
 Ijt. Tinct. acoait. tad., gtt- Hj 
 
 Liq. potas. citrat., ^ij 
 
 Liq. ammon. acetat., ^ij. M. 
 
 Every two hours. 
 
 Purgatio7i during the remission, with — 
 
 R . Hydrarg. clilor. miti? gr- v 
 
 Sodii bicarb,, gr. x 
 
 Pulv. aromat., gr. v, M, 
 
 In pulv. p. r. n. 
 
 The same precautions are essential after the paroxysms are broken 
 up, to prevent their return on the septenary periods, that were recom- 
 mended for intermittent fever. 
 
 PERNICIOUS FEVER. 
 Synonyms. Congestive fever ; mahgnant intermittent fever ; 
 
 malignant remittent fever. 
 
 Definition. A malignant, destructive malarial fever, which may 
 
34 PRACTICE OF MEDICINE. 
 
 be of the intermittent or remittent form ; characterized by intense 
 congestion of one or more internal organs, together with dangerous 
 perversion of the functions of innervation. 
 
 Cause. A high degree of malarial poison. 
 
 Varieties. G astro-enteric ; thoracic; cerebral; hemorrhagic; 
 algid. 
 
 Symptoms. Any of these varieties may begin either as in inter- 
 ?nittent or remittent fever; again, \}i\& first paroxysm is rarely per- 
 nicious, but appears as the ordinary malarial attack. 
 
 T\iQ gastro-ejiteric variety has as distinctive features, intense nausea 
 and vomiti7ig, purging of thin discharges mixed with blood, tenesmus, 
 burning heat in stomach, intense thirst, frequent, weak pulse, face, 
 hands and feet cold, with shrunken features, and intense depression 
 of all the vital forces. This condition continues from half an hour to 
 several hours, when either an inter- or remission occurs. 
 
 Thoracic variety often combined with the one just described. Its 
 characteristic features are due to overwhelming congestion of the 
 lungs, such as violent dyspjioea, gaspi?tg for air, fifty to sixty respira- 
 tions per minute, oppressed cough with slight amount of blood- streaked 
 s-^vA.2i,freque7it, weak pulse, cold surface, and terror-stricken features. 
 Duration same as the above. 
 
 Cerebral variety, due to intense congestion of the brain ; sometimes 
 effusion of serum into the ventricles, or even rupture of small blood- 
 vessels. Characterized by viole?tt delirium, followed by stupor and 
 coma, slow, full pulse, the surface ^\\\v&x flushed ox livid. Cases may 
 either resemble apoplexy — comatose variety, or acute mejiingitis — 
 delirious variety. Duration same as the other forms. 
 
 Hemorrhagic variety, or the yellow disease, as it has been termed, 
 begins as an ordinary inter- or remittent fever, soon followed by signs 
 o{ internal congestion, to wit : 7iaicsea, vomiting, dyspnoea, severe pains 
 over liver and kidjiey, continuing for a few hours, when the surface 
 suddenly X.wxn's, yellow and bloody tcri7ie is voided, after which an inter- 
 or remission and marked abatement occur, to be sooner or later fol- 
 lowed by a second paroxysm, which is more severe, with additional 
 signs o{ cerebral congestion. Blood may also escape from other parts 
 than the kidneys. 
 
 Algid \z.x\e\.y '\s characterized by intense cold7iess of the surface, 
 while the rectal temperature ranges from 104° to 107° F. The attack 
 begins with a chill, which is soon followed hy fever oi variable dura- 
 
FEVERS. 35 
 
 tion, when the body becomes cold, the axillary temperature falling to 
 90°, 88° or even 85° F., a cold sweat covers the surface, the tongue is 
 white, moist and cold, the breath is icy, the voice feeble and indistinct, 
 \.\i& pulse slow, feeble and often absent at the wrist, and with all these 
 symptoms, the patient complains of a sensa.tion of burning and intense 
 thirst. The mind is clear, but the countenance is death-like. 
 
 Duration. Pernicious fever, in any of its forms, may continue 
 from a few hours until one, two or three days. Recovery is rare after 
 a second, almost never after a third, paroxysm. 
 
 Diagnosis. Yellow fever is most apt to be confounded with the 
 hemorrhagic variety, and as they both occur in the same localities, 
 the diagnosis is difficult ; the early yellowness of the surface, with 
 hcematuria, and the absence of the black vomit, an epidemic preva- 
 lence, are the chief points of distinction. 
 
 The cerebral variety may be mistaken for cerebral apoplexy, men- 
 ingitis ?\i.x\di urcemic convulsions. Nor is it always an easy matter to 
 differentiate between these conditions. 
 
 The gastro-e?tteric variety may be mistaken for the early stage and 
 the algid variety for the latter stage of cholera, but the epidemic 
 prevalence of the latter should be of material aid in determining the 
 diagnosis. 
 
 Prog'nosis. In all varieties the result is unfavorable, unless it 
 can be controlled prior to the second paroxysm. Cases in which an 
 ititermission occurs are better controlled than where a remission 
 follows. The mortality is otie in eight from all plans of treatment. 
 
 Treatment. The first indication in all varieties is to bring about 
 reactio7i. If the cold stage, heat to the surface, with stimulating lo- 
 tions ; if the hot stage, cold to the surface and the hypodermic injection 
 oi 7norphina, gr. ]^ , at once. After reaction, guinincE sulph., not less 
 than gr. xl, repeated p. ri n, ; administer by stomach, rectum, or better 
 still, by hypodermic injection. Dr. Bartholow pronounces the follow- 
 ing one of the best formulas for the hypodermic use of quinina : — 
 
 R- Quininge disulph., , , gr. 1 
 
 Acid, sulph. dil., m^c 
 
 Aquae font., ^j 
 
 Acid, carbol. liq., TT\^v. M. 
 
 The following formula, known as " Warburg's Tincture," has dur- 
 ing the last few years gained considerable reputation in the various 
 forms of malarial fevers : — 
 
36 " PRACTICE OF MEDICINE. 
 
 R . Rad. rhei, P. aloe soc. and Rad. angelica 
 
 officinalis, aa ^iv 
 
 Rad. helenii, Crocus Hispan., Sem. foeni- 
 
 culi, and Cretce preparat., . . . aa . . . ^ij 
 Rad. gentian, Rad. zedoar, P. cubeb, G. 
 myrrh, G. camphor, and Boletus Lari- 
 
 cis, aa .^j 
 
 Confect. damocratis,* ,^ iv 
 
 Quinince sulph., ^Ixxxij 
 
 Spt. vini rect., Oxx 
 
 Aquae purae, Oxij 
 
 Macerate in a water bath twelve hours, express and filter. 
 
 Each half ounce contains quininae sulph., gr. vijss. If the stomach 
 is too irritable to retain the tincture, the tincture may be evaporated 
 to dryness and admini.stered in capsules, each containing the equiva- 
 lent of either one or two drachms. 
 
 For the gastro-ejiteric variety. Prof. Da Costa suggests — 
 
 R . Morph. sulph., gr. | 
 
 Pulv. camph., gr. j 
 
 Mass. hydrarg., g^- ij 
 
 Pulv. capsici., gr. ss. M. 
 
 In pills every half-hour until the character of the stools change. 
 
 For the thoracic variety, dry or wet cups and ammo7iii carbonas. 
 For the cerebral variety, venesection, or cups or leeches to the 
 
 neck, cold to the head, prompt purgation, and acting on the kidneys 
 
 and skin. 
 
 * Formula of Confectio damocratis : — 
 
 Cinnamon xiv Gm. 
 
 Myrrh xj Gm. 
 
 White agaric, Spikenard, Ginger, Spanish saffron 
 
 Treacle, Mustard seed, Frankincense, and 
 
 Chian turpentine aa x Gm. 
 
 Camel's hay, Costus arabacus, Zeodary, Indian 
 
 leaf, Mace, French lavender, Long pepper, 
 
 Seeds of harwort, Juice of rape cistus, Strained 
 
 storax, Opponex, Strained galbanum, Balsam of 
 
 Gilead, Oil of nutmeg, Russian castor. . aa . . viij Gm. 
 Water germunder, Balsam tree fruit, Cubeb, 
 
 White pepper. Seeds of carrot of Crete, Foley 
 
 mont, Strained bdellium aS, . . . . vij Gm. 
 
 Gentian root, Celtic hard, Leaves of Dittany of 
 
 Crete, Red rose, Seeds of Macedonium, Parsley, 
 
 Sweet fennel seed, Seeds of lesser cardamon, 
 
 Gum arable. Opium a.S. v Gm. 
 
 Sweet flag, Wild valerian, Anise seed, Sagaper- 
 
 num aa . , iij Gm. 
 
 Spigrul.St. John's wort. Juice of acacia. Catechu, 
 
 Dried bellies of skunk . . . . aa ijss Gm. 
 
 Clarified honey cmxv Gm. 
 
 The roots to be finely powdered and the whole mixed thoroughly. 
 
FEVERS. 37 
 
 For the algid variety warjnth to the surface, hypodermic use of 
 morphina and the free use of ammonii carbonas and alcoholic stimu- 
 lants. 
 
 For the hemorrhagic variety, purgatives, morphina hypodermic- 
 ally, and either acid sulph. dil., acid, gallic, MonseF s solution, or 
 terebijithina, for the hemorrhages. 
 
 The following is highly spoken of for hemorrhages : — 
 
 R • Ext. ergotse fld., ,^ ss 
 
 Acid, sulph. dil., .... f,:^iss 
 
 Acid, gallic, ^j 
 
 Syr. zingib., f .^ iij 
 
 Aqu^, q. s., ad . . . . f^iij. M. 
 
 SiG. — Dessertspoonful every 4 hours, well diluted. 
 
 After the paroxysms are controlled, a long course oi ferrtmi, with 
 quinina on the septenary days. 
 
 YELLOW FEVER. 
 
 Synonyms. Bilious malignant fever ; typhus icterode ; Medi- 
 terranean fever ; sailors' fever. 
 
 Definition. An acute, infectious, paroxysmal disease of three 
 stages, to wit : the febrile, the rejnission, and the collapse ; character- 
 ized by violent fever, yellowness of the surface, and " black or coffee- 
 ground vomit." Tendency fatal ; one attack confers immunity from 
 a second. 
 
 Cause. A specific poison, existing only with a high temperature 
 and destroyed by frost. Not due to the malarial poiso7i. 
 
 Patholog"ical Anatomy. Skin lemon or greenish-yellow color, 
 due to dissolution of the red blood corpuscles ; heart softened by 
 granular degeneration ; stomach, veins deeply engorged, the mucous 
 membrane softened, and containing more or less " coffee-ground" 
 matter, which consists of blood corpuscles deprived of their haemo- 
 globin, white corpuscles, epithelial cells and debris, hitestiiies much 
 the same as the stomach ; liver, yellow color and a fatty degeneration 
 of the hepatic cells ; kidneys, granular degeneration of the epithelium 
 of the tubules. 
 
 Symptoms. First stage, the febrile, beginning either with the 
 prodromata of malaise, headache and anorexia, or suddenly with a 
 chill, high fever, in a few hours reaching 104° to 106° F., high pulse 
 
38 ■ PRACTICE OF MEDICINE, 
 
 90-100 beats, /^rzy/zVz;// <?/<?, flushed countenance, coated tongue, irn- 
 tabi/iiy o^ lh.Q stomach, and severe neuralgic pains in the head, Hmbs, 
 epigastrium, back and large joints. The patients are restless, anx- 
 ious, with a feeling of general prostration. In severe attacks ^<?/m«??? 
 is frequent. Albumin in the urine, and a peculiar and characteristic 
 odor is emitted from the patient. Duration of the first stage from 
 thirty-six hours to three or four days. 
 
 Second stage, the remission, when the temperature declines to 100° 
 or 101° F,, and all the distressing symptoms abate or subside and, 
 with some critical evacuation, convalescence occurs, or, more com- 
 monly, after from a few hours to one to four days, the 
 
 Third stage, the stage of collapse, or the period of secondary fever, 
 is ushered in by a return of all the symptoms of the first stage in an 
 exaggerated form, followed by yellowness of the skin, passing to a 
 deep mahogany color, black vomit and hemorrhages from other parts, 
 feeble pulse, cold surface, irregular respiration, and death from ex- 
 haustion, the mind remaining clear until the end. 
 
 The above symptoms represent a sthenic case ; other varieties are 
 the algid, hemorrhagic and typhus. 
 
 Duration. Depends upon the variety ; from a few hours to a few 
 days. Rarely continues longer than one week. 
 
 Diagnosis. Pernicious fever, hemorrhagic variety, is apt to be 
 mistaken for yellow fever. Yellow fever is a disease of one paroxysm, 
 and one remission, epidemic, with albuminuria and black vomit. Per- 
 nicious fever has more than one paroxysm, not epidemic, rarely black 
 vomit or albumin in urine. 
 
 Prognosis. One in four perish. Short cases unfavorable, as are 
 the hemorrhagic and algid varieties. 
 
 Treatment. No specific ; a " self-limited " disease. The indica- 
 tions are to treat the symptoms and nourish the patient. Good nursing, 
 ventilation, early emesis and purgation, with diaphoretics and diu- 
 retics, are apparently beneficial. Large doses of quinina, early in 
 the attack, for high temperature ; for the irritable stomach, ice slowly 
 dissolved in the mouth and acidum carbolicum, gr. % in aqua me7ithcE 
 pip., every two hours, alternated with liquor calcis and milk, each an 
 ounce, or — 
 
 R . Hydrargyri chlor. mite, g*"* A 
 
 Morphina: sulph., g*"- 21- 
 
 Every two hours until nausea controlled. 
 
FEVERS. 39 
 
 For the black vomit and hemorrhages, either liquor ferri subsul- 
 phatis or phimbi acetas. The pains, restlessness or delirium are best 
 controlled by the hypodermic use of morphina or atropina. Free 
 stimulation from the onset is essential. 
 
 ERUPTIVE FEVERS. 
 
 As a group, the eruptive or exanthematous fevers have many fea- 
 tures in common. All have a period of incubation, are characterized 
 by a fever of more or less intensity preceding the eruption, by an erup-, 
 tion which is peculiar to each, occurring most commonly in childhood, 
 rarely attacking the same person twice, very prone to occasion serious 
 sequelae, and are contagious. Their origin is as yet undetermined. 
 
 SCARLET FEVER. 
 
 Synonym, Scarlatina. 
 
 Definition, An acute, self-limited, infectious disease ; character- 
 ized by high temperature, rapid pulse, a diffused scarlet eruption, 
 terminating with desquamation, inflammation of the throat, and 
 frequently more or less grave nervous phenomena. Serious sequelae 
 frequently follow an attack. One attack confers immunity from the 
 disease. 
 
 Pathological Anatomy. An acute inflammation of the skin, 
 with exudation — a true Dermatitis. A granular change in all the 
 glandular structures, most marked in the Peyerian glands, although 
 also occurring in the stomach and kidneys. 
 
 Cause. A specific poison, maintaining its vitality for along time. 
 Highly contagious, the contagion residing chiefly in the desqua- 
 mated epidermis. Klebs' micrococci, the " monas scarlatinosum," 
 may prove to be the poison. Incubation short, one to seven days. 
 
 Varieties. Scarlatina simplex, scarlatina anginosa and scarlati?ta 
 maligna. 
 
 Symptoms. A mild case is a very trivial affection, but in its 
 severest form there are few diseases more malignant. 
 
 Onset sudden with a decided chill and vomiting (in infants, con- 
 vulsions), pain in throat followed by high fever, soon reaching 105° ; 
 a rapid pulse, no to 140 being common. At the end of twenty-four 
 hours a bright scarlet rash appears on the neck and chest, spreading 
 
40> PRACTICE OF MEDICINE. 
 
 over the entire body within a few hours ; the eruption is not raised, 
 there is no intervening heahhy skin, and scattered irregularly are 
 points of a darker hue. With the appearance of the eruption occurs 
 burning heat of surface, burning in the throat and difficulty in deglu- 
 iitio7i, the throat on inspection presenting the appearance of a catar- 
 rhal \n^2imm.2i\.\on. Tongue at first furred, later, red, with prominent 
 papillae — the " strawberry tongue." There also occnrs headache, great 
 restlessfiess, and in severe cases delirium. Diarrhoea quite common. 
 
 On the fourth or fifth day the fever declines by lysis, the eruption 
 fading, and on the fifth or eighth day desquamation begins, continu- 
 ing for a week or more, the convalescence being slow, the patient 
 etnaciated and pale. 
 
 Scarlatifia ajtgifiosa are cases with the addition of great inflamma- 
 tion and swelling of the pharynx, nose, palate, to7isils and neighbor- 
 ing glands, the swollen glands pressing upon the surrounding parts, 
 causing difficulty of breathing and of deglutition. 
 
 Scarlatina maligna are cases with decided nervous phenomena, to 
 wit : coftvulsions, deliriu?n and muscular twitching, the temperature 
 reaching 107° to 110°, the pulse rapid, feeble and irregular, the erup- 
 tion delayed, of a purplish color, and in patches. 
 
 Sequelse. Chronic sore throat; conjunctivitis; otorrhcea ; chronic 
 diarrhoea ; subacute rheumatism ; chorea ; endocarditis ; pleuritis ; 
 acute Bright's disease and cutaneous dropsy. 
 
 Diagnosis. A typical case should cause no difficulty ; the high 
 fever, rapid pulse, sore throat, and early scarlet erupti6n, followed by 
 desquamation, should leave no doubt. 
 
 Measles ; the above symptoms are absent, and catarrhal symptoms 
 present. 
 
 Stnallpox ; eruption on the third day in spots, changing to pustules 
 with secondary fever. 
 
 Dengue or break-bone fever ; absence of the above typical symp- 
 toms, and presence of severe pains in the back. 
 
 Diphtheria ; gradual invasion, great prostration, and no eruption, 
 but the frequent complication of scarlatina and diphtheria must be 
 remembered. 
 
 Meningitis may be suspected from the symptoms of scarlatina 
 maligna; the epidemic influence, eruption, and rapid pulse, are 
 points of difference. 
 
 Prognosis. Depends upon the character of the attack. Never 
 
FEVERS. 41 
 
 can be positive of the result. Mortality ranges from ten to twenty- 
 five per cent. 
 
 Treatment. As with other eruptive fevers so with scarlatina ; 
 there are no specific remedies by means of which it can be arrested 
 or controlled. Symptomatic treatment judiciously applied, however, 
 may afford relief and diminish the fatality. 
 
 The indications are for good ventilation, isolation, disinfection, 
 cooling drinks, action upon the skin and light nourishment. 
 
 For cases with \i\^ fever and rapidity of pulse, aco7iitum, digitalis, 
 quinina or antipyritie , with cool sponging, cold bath, douche or pack. 
 
 If the surface be pale, the circulation feeble, and the eruption tardy 
 in appearing, benefit will follow the administration of tinctura bella- 
 do7incE, gtt. j-x, according to age. 
 
 For scarlatina anginosa, internal use of tinctura ferri chloridi and 
 potassii chloratis, and stiimtlants. Externally, ice or cold compresses, 
 unless they cause chilliness ; if so, heat. Astringent gargles and 
 small pellets of ice dissolved in the mouth are of use. The throat 
 and nasal cavities are kept clean and the breathing relieved by the 
 use of Dobell's solution used in a hand atomizer every hour. 
 
 Dr. J. L. Smith warmly lauds the following mixture for cases with 
 decided throat symptoms : — 
 
 R . Acid boracic, ^ ss 
 
 Potass, chlor., , ^ij 
 
 Tinct. ferri chlor., f 5 ij 
 
 Glycerinae, 
 
 Syrupi, aa f^j 
 
 Aquae, f^ij- M. 
 
 SiG. — One tablespoonful every two hours, to a child of five years. 
 
 For scarlatifia maligna, in addition lo ferrtnn and qiiinina, the chief 
 reliance must be on alcoholic stimulants, guiding the amount by their 
 effects. In children wine-whey, milk-punch, and egg-nog are eligible 
 for the administration of stimulants and nourishment. 
 
 For the pruritus, the local use of oils or fats in some form affords 
 great relief, the following formula being most efficient, as well as a 
 disinfectant : — 
 
 li . Acidi carbolici, gr. x-xxx 
 
 Vaseline, ^iij. M. 
 
 SiG. — To be applied over the entire surface after sponging or bath. 
 Convulsiotis result from the high grade of fever, or are the result of 
 
42 PRACTICE OF MEDICINE. 
 
 uraemia. If due to the former cause, the cold bath and cold affusion 
 are the indications ; if the latter cause, the inhalation of chloroformum 
 is indicated. 
 
 For the headache, disturbance of vision and cotna, the result of 
 uraemia, free purgation and diaphoresis with pilocarpus are to be 
 employed. 
 
 Prof. DaCosta advocates the administration of ammonii carbonas, 
 in small doses at frequent intervals, to prevent the liability of heart- 
 clot, and for its salutary influence over the disease. 
 
 It is claimed that a characteristic micrococci is found in the blood, 
 and that, consequently, the disease can be favorably influenced by 
 acidum carbolicum, thymol or acidum boricum ; an eligible way of 
 administering acidum carbolicum is the syr. ammonicE pheftatis 
 (Declat), foss-foj, four to six times daily. 
 
 For the various sequelcE, the treatment is the same as if they 
 occurred primarily, jZ^/z^i- tonics. 
 
 The disease being infectious, 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. 
 
 Ssmonyms. Morbilli ; rubeola. 
 
 Definition. An acute epidemic and contagious disease ; charac- 
 terized by catarrhal symptoms, referable to the naso-broncho -pul- 
 monary mucous membrane, fever, and a crimson eruption which 
 terminates by desquamation. 
 
 Cause. A specific poison, with a special susceptibility for child- 
 hood. Contagious by contact, and has been communicated by in- 
 oculation. One attack, as a rule, protects from a second. Incubation , 
 ten days. 
 
 Pathological Anatomy. There are no special anatomical 
 characters exclusive of the eruption, which is considered among the 
 symptoms of the disease. 
 
 Symptoms. Onset gradual, irregular chills, fever, the tempera- 
 ture rising to ioi° or 102°, muscular soreness, headache, and intense 
 7iasal, pharyngeal and laryngeal catarrh ; on the evening of the 
 second day a decided remission takes place in \.h.Q fever, the catarrh 
 
FEVERS. 43 
 
 continuing; on "dx^ fourth day occurs an eruption of a crimson color, 
 on the face, soon spreading over the body, in the form of dots, shghtly 
 elevated, which coalesce into irregular circles or crescents, and with 
 the appearance of the eruption \k\.Q. fever returns, the catarrh is aggra- 
 vated, but the character of the discharge, instead of remaining clear 
 and watery, becomes turbid, thick, and yellowish, and extends to the 
 bronchial mucous membrane. About the ninth day (the fourth of 
 the eruption), the eruption fades, the symptoms abate, and slight 
 desquamation occurs. Some cough and catarrh may remain for a 
 long period. 
 
 Black measles, sometimes called heinorrhagic rubeola, or camp 
 measles, is a variety occurring in camps and jails, in which occur 
 dangerous chest symptoms, and black spots or petechise from deteri- 
 orated blood, and severe prostration. 
 
 Rather common complications are tonsillitis, lobar, and catarrhal 
 pneumonia. 
 
 Sequelae. In those oi strumoics diathesis, scrofula or phthisis may 
 develop. 
 
 Diagnosis. A typical case begins gradually, with chilliness, nasal 
 catarrh, watery eye, and fever, which decline before the eruption, 
 rising afterward, the eruption crescentic in shape, and of a crimson 
 color. 
 
 Scarlet fever ; absence of catarrh, and earlier appearance and dif- 
 ferent character of the eruption with high fever and rapid pulse. 
 
 ProgTlosis, As a rule, a perfect recovery. If phthisis develop, 
 the prognosis is bad. Black measles, the majority perish. 
 
 Treatment. No specific. Mild cases require no medicine, simply 
 regulating the diet and bowels, and cool sponging ; the indications 
 are to render the patient as comfortable as possible, the disease pur- 
 suing a favorable course without therapeutical interference. 
 
 If the febrile reaction is high the following soon controls it : — 
 
 R . Tinct. aconiti rad., Tt\^ ss-j 
 
 Spts, aetheris nitrosi, Tr\^ x-xv 
 
 Liquor, potassii citrat., ad . . . . f^j. M. 
 
 Every two hours. 
 
 For the. pruritus of the eruption, the local use of oils andyJz/j, For 
 catarrhal symptoms, inunction of the nose, neck, and chest with catn- 
 phorated oil and small doses of pulv. ipecac et opii, at bedtime ; if the 
 catarrh extends to the bronchial mucous membrane, expectorants. 
 
44 PRACTICE OF MEDICINE. 
 
 During convalescence, for the strumous, protect from exposure, and 
 administer oleum viorj-hucB with syr. ferri iodidi. For black measles, 
 bold stimulation, Wiih. fefnan and qui7iina. 
 
 ROTHELN. 
 
 SynonyTQS. Epidemic roseola ; German measles ; French 
 measles ; false measles. 
 
 Definition. An acute, self-limited disease ; characterized by mild 
 fever, suffused eyes, cough, and sore throat, enlargement of the lym- 
 phatic glands of the neck, and a rose-colored eruption, in patches of 
 irregular size and shape, appearing on the first day. 
 
 Cause. Propagated by infection. That a peculiar germ exists is 
 probable, but thus far it has not been isolated, l7ictibaiio7i from one 
 to three weeks. 
 
 Symptoms. Onset sudden, with mild fever, suffused eyes, with 
 little or no coryza, sore throat, and enlargeme?it of the cenncal glands, 
 not limited to those about the angle of the jaw, as in scarlatina. 
 Any time from the Jirst to the fourth day appear rose-colored spots, 
 size of a pin head, slightly elevated, which coalescing, form irregular 
 shaped and sized patches, with intervening healthy skin, fading on 
 the upper part of the body while just appearing on the lower. Symp- 
 toms all terminate within a week by lysis, the patient showing no ill 
 effects from the attack. 
 
 Diag'nosis. From scarlet fever, by absence of high fever, the 
 rapid pulse, the color and character of the eruption and the sequelae. 
 
 From measles, by absence of intense catarrhal symptoms, the late 
 appearance of eruption and not of a crescentic shape. 
 
 Prognosis. Most favorable. 
 
 Treatment. Mild laxatives and restricted diet. U fever high, 
 saline mixture. For itching of skin, sponging with vinegar and 
 water. 
 
 SMALLPOX. 
 
 Synonym. Variola. 
 
 Definition. An acute epidemic and contagious disease ; charac- 
 terized by severe lumbar pains, vomiting, and an initial fever, lasting 
 from three to four days, followed by an eruption, at ^x^X. papular, then 
 vesicular and afterwards pustular ; the development of the pustule 
 
FEVERS. 45 
 
 being accompanied by a secondary fez^er, during the presence of which 
 grave comphcations are prone to occur. 
 
 Causes. A specific poison whose nature is unknown, maintaining 
 its contagious vitality for a long period. There is no period, from the 
 initial fever to the final desquamation, when the disease is not con- 
 tagious, although the stage of suppuration is the most virulent. One 
 attack, as a rule, protects from a second. Vaccijiation has a positive 
 protective influence from the disease, an extensive observation having 
 fully proven that in proportion to the efficiency of vaccination is 
 the rarity and mildness of variola. Incubation, fourteen to sixteen 
 days. 
 
 Pathological Anatomy. A granular and fatty degeneration 
 occurs in the liver, spleen, kidneys and heart. The pustules are 
 found in the larynx, trachea, bronchial tubes, and on the pleura. 
 
 Varieties. Discrete ; confluent ; malignant ; varioloid or modified 
 smallpox. 
 
 Symptoms. Discrete form. Onset sudden, with a "i/z^/^^/r-^z"//, 
 vomiting, and Sigomzing pains in the back, shooting down the limbs ; 
 fever, in short time rising to 103° or 104° F. ; full, stro7ig and rapid 
 pulse, ranging from 100 to 130; the face red, eyes injected, intense 
 headache and sleeplessness • delirium and convulsions occur at times. 
 During the third day the characteristic eruption makes its appear- 
 ance, first on the forehead and lips, consisting of coarse red spots ; 
 with the appearance of the eruption all the marked symptoms of the 
 fever abate, the patient feeling quite comfortable. On the ffth day 
 of the disease the spots become papules; on \h& sixth day, trans- 
 formed into vesicles, which are soon timbilicated ; on the eighth day the 
 vesicles change to pustules ; on the fiinthday the pustules are entirely 
 purulent, and each surrounded with a broad red band — the halo or 
 areola, the face becoming swollen, and the features distorted ; on the 
 eleveiith day, pus oozes from the pustules, and drying, forms the scab 
 or crust, which, on the seventeenth to twenty -first day drops off, leav- 
 ing a red, ghstening depression or pit, soon changing into a white 
 cicatrix. With the formation of the pustules {eighth day) severe 
 rigors and fever set in, and a characteristic odor is emitted, all the 
 original symptoms returning ; this seco7idary fever is the most critical 
 period of the disease, and is generally attended with violent delirium. 
 In favorable cases the secondary fever subsides after three or four 
 days, and convalescence is established. 
 
46 PRACTICE OF MEDICINE. 
 
 Confiitent smallpox differs from the discrete in the greater severity 
 of all the symptoms and the marked prostration of the patient, the 
 eruption appearing during the second day, the ^//^//^/t'j coalescing into 
 large patches, causing great distortion of the features. 
 
 Malignant smallpox is characterized by the greater intensity and 
 the irregularity of the symptoms, death resulting before the character- 
 istic eruption appears, by convulsions or coma. In these cases hem- 
 orrhages are frequent and petechias are observed. 
 
 Varioloid, or modified smallpox, is the form modified by previous 
 vaccination or by a former attack of smallpox. Its course is shorter 
 and milder than the other forms, the eruption appearing a day later, 
 and is not attended with secofidary fever. 
 
 Complications. During the course of the secondary fever there 
 is a great tendency to grave inflammations, such as pleitritis, pneu- 
 mo7iitis and dysentery. During convalescence, boils and abscesses on 
 the skin are frequent. 
 
 Diag"nosis. Cannot be confounded with any other disease if it 
 have typical symptoms, such as chill, vomiting, pains in back and 
 legs, high fever and pulse, all declining on third day, when the erup- 
 tion appears, first spots, then papules, then vesicles, finally pustules, 
 drying and forming crusts, and with the marked secondary fever. 
 
 Prognosis. Depends upon the variety of the attack, the age of 
 the patient, and whether vaccinated or not. Discrete, mortality four 
 per cent. ; confluent, fifty per cent. ; malignant, all perish ; underyfz/^ 
 years and ov ox forty years, fifty per cent. die. 
 
 Treatment. No specific ; the disease will run its course under 
 any plan of medication, although cases seem to do better if acidum 
 carbolicum, thy??iol or the sulphites are used. 
 
 For the initial fever and iho, full pulse, relief follows the use of — 
 
 R . Tinct. aconit. rad , gtt. j-ij 
 
 Spts. aether, nitrosi, '^^ss 
 
 Liq.ammonii acetat., f 3 ij 
 
 Aqu£e, £3 iss. M. 
 
 Every hour or two. 
 
 Antipyrine should be serviceable in this stage, not only for the fever, 
 but to relieve the pains. 
 
 If headache and backache are intense, hypodermic injections of 
 morphina, or an ice bag to the head and along the spine. 
 
FEVERS. 47 
 
 For sleeplessness and restlessness or early deliriujn full doses of 
 potassii bromidufn, or chloral. 
 
 For secondary fever the best remedy is quinina, gr. v, every three 
 hours, 2inAior cerebral excitement oi this period, either full doses of 
 potassii bromidum, by stomach, or the following by rectum : — 
 
 R. Chloral, gr. xv-xx 
 
 Mucil. acacia, fgij 
 
 Aquce, ^SU' M* 
 
 p. r. n. 
 
 The secondary fever being pysemic in character, the depression 
 should be anticipated by large doses of tinct. ferri chloridi and judi- 
 cious stiimilation, brandy in tablespoonful doses being most efficient. 
 
 From the onset, milk, eggs, animal broth, oysters and beef juice 
 should be administered every three hours. Ice is always grateful and 
 should be given freely, and if pustules appear in the mouth, ice should 
 be held in the mouth as long as possible, and washes oi potassii 
 chloras or acidum carbolicuni employed. 
 
 The disease being contagious, isolation, ve7itilation, cleanliness and 
 disinfection are imperative. 
 
 To prevent pitting keep patient in a dark room, well ventilated. 
 Masks of some unctuous material, thoroughly applied, to exclude the 
 air, have a beneficial effect, a good formula being R. Ung. hydrarg., 
 pulv. mara7itce, eqtial parts, ox glycerit. amyli, painted over eruption, 
 changing to tinct. iodi as vesicles are about to develop. Success is 
 claimed by a number of observers from the use of colloditim applied 
 once or twice daily. Cold water dressings constantly to face and 
 hands are beneficial, besides allaying heat, pain and swelling. Hot 
 water can be used if more grateful. 
 
 VACCINATION. 
 
 Definition. Inoculation with the matter of vaccijtia or cow-pox 
 — bovine virus. The person properly vaccinated is, as a rule, pro- 
 tected from an attack of smallpox, and especially from a severe or 
 fatal attack. 
 
 Vaccination should be performed at least twice in every individual, 
 to wit : during infancy and txX puberty ; and it is safer to have it again 
 performed if special exposure be liable to occur. 
 
48 PRACTICE OF MEDICINE. 
 
 In practicing vaccination the skin should be rapidly scraped until 
 the true skin is reached and is ready to bleed, the lymph being then 
 brushed over the abraded surface ; or, instead, making three or four 
 horizontal and transverse cuts, about four lines long, and rub the 
 virus over them ; a little blood, but not much bleeding, should be 
 caused. 
 
 S3niiptonis. If the vaccination " takes," on the third day a 
 papule appears ; on the sixth day a. vesicle has formed, with a central 
 depression ; on the eighth day a. pustule, fully formed and distended 
 with lymph, with a reddish areola, which becomes very wide. The 
 areola begins to fade on the te7iih day, the pustule begins to dry, and 
 by iht fourteenth day a brown mahogany scab or crust has formed, 
 which is detached about the twenty- third day. The cicatrix is circu- 
 lar, depressed, radiated and foveated, becoming, after a time, paler 
 than the surroundingr intesrument. 
 
 During the course of a vaccination, more or less constitutio nal dis- 
 turbance occurs, especially in children. 
 
 Ecsematous and papular eruptions often develop in strumous chil- 
 dren, for which the virus is unjustly held responsible. 
 
 VARICELLA. 
 
 S37TLonyin. Chicken-pox. 
 
 Definition. A mild, slightly contagious, febrile affection ; char- 
 acterized by a moderate fever, and the appearance of a vesicular 
 eruption, drying up and falling off in from three to five days. 
 
 Cause. A peculiar poison ; attacking only children ; occurring 
 sporadically and as an epidemic. 
 
 Symptoms. Moderate /^2/<?r, thirst, anorexia and constipation, 
 followed by the eruption of vesicles, which rapidly dry, and within 
 the week drop off, leaving a slight pit. Pustules almost never 
 occur. Symptoms are so slight, that, were it not for the vesicles, 
 the affection would be often overlooked. The eruption appears on 
 the trunk and extremities, very rarely on the forehead and in the 
 mouth. 
 
 Prognosis. Most favorable. 
 
 Treatment. Entirely symptomatic. If vesicles on the face, 
 efforts may be used to prevent pitting. 
 
FEVERS. 49 
 
 ERYSIPELAS. 
 
 Synonyms. Erysipelatous dermatitis ; the rose ; St. Anthony's 
 lire. 
 
 Definition. An acute, specific, infectious disease ; characterized 
 by a fever of low type, and a peculiar inflammation of the skin, gen- 
 erally of the neck and face. This inflammation exhibits a marked 
 tendency to spread, to induce serous infiltration and suppuration of 
 the areolar tissue, and to affect the lymphatic vessels and glands. 
 
 Cause. A poison, the nature of which is unknown. Feebly con- 
 tagions. One attack predisposes to another. The etiology of idio- 
 pathic (medical) and traumatic (surgical) erysipelas are identical. 
 
 Symptoms. Onset sudden ; a chill, followed by fever, which 
 soon reaches 104° or 10"^°, frequent pulse, 100 to 130, coated tongue, 
 nausea and vojniting, severe pains in the limbs, with epistaxis in 
 adults and convulsions in children, and often diarrhoea. 
 
 Delirium is frequent, and in those of alcoholic habits it resembles 
 delirium tremens. 
 
 The eruption soon follows the chill, beginning in red spots, which 
 rapidly coalesce and spread ; a sense of heat, tension and tingling is 
 caused by ^ho. great cedema, which presents a tense, shi7iy appearance, 
 the swelling being so great at times as to close the eyes and distort 
 the features. In many cases small vesicles develop, which may 
 coalesce, forming blebs, of considerable size, containing a clear yellow 
 serum. After five or six days the eruption begins to subside, the 
 symptoms abate, the part affected becomes tender, and there is mod- 
 erate desquamation. 
 
 During the height of the attack albumin appears in the urine, so 
 that the possibility of tircemic symptoms must be remembered. 
 
 When extensive infiltration into the areolar tissue occur, the swelling 
 and tension become greater, and it is termed phlegmonous erysipelas. 
 
 When the eruption spreads to different parts of the body, it is 
 termed erysipelas ajnbulans. 
 
 Complications. Thrombosis of cerebral capillaries or sinuses, 
 or as it is sometimes called, "erysipelas of the brain," is explained 
 by the intimate anatomical connection of the facial vein with the 
 pterygoid plexus and cavernous sinus. 
 
 (Edematous laryngitis, from extension to the larynx. 
 
 Pneumonia, pleurisy and meningitis are frequent complications. 
 4 
 
50 PRACTICE OF MEDICINE. 
 
 Diag'nosis. Not difficult. The fever, early spreading eruption, 
 with burning, swelling, tension and tingling, and albuminous urine, 
 separate it from the other eruptive fevers and erythema. 
 
 Prog'nosis. Usually favorable. Unfavorable if it attack drunk- 
 ards ; if it becomes gangrenous ; if thrombosis of sinuses occur, or if 
 it extends to the larynx. 
 
 The convalescence, even from the mildest attack, is slow, the 
 patient continuing weak and anaemic for a long time. 
 
 Treatment. Mildest cases only require a laxative, nourishing 
 diet, and locally vaseline or bismuth oleat., to modify the heat and 
 burning. 
 
 Prof. Da Costa strongly urges the use oi free purgatiori before the 
 use of the remedies usually administered. 
 
 According to Reynolds, aco?iitum will cut short an attack. He 
 administers Ti:\, %-], every fifteen minutes for the first two hours ; then 
 in hourly doses, until the surface is moist and the temperature lowered. 
 The author corroborates this plan, from a personal experience. 
 
 In severe cases, tinct. ferri chlor., gtt. xx-xxx, every third hour, 
 well diluted. Also qici7iina in gr, ij, every third hour. Ext. bella- 
 donnce, gr. % , added, with benefit. The diet from the onset should 
 be of the most nourishing character, and administered at regular 
 intervals. Dr. Waugh strongly lauds extractum pilocarpi fiuidwn in 
 erysipelas. 
 
 Prof. Da Costa reports excellent results in cases with rapid spread- 
 ing \.^Vi^Q.x\.Q.^ , from the use oi pilocarpijicE hydrochloras, gr. yi, hypo- 
 dermically or ext. pilocarpi fluidum, gtt. xx-xl, every two hours. Or 
 good results are obtained in a fair number of cases from potassii 
 iodidum. 
 
 Cerebral symptoms, stimulants, opium and chloral. 
 
 Extension to throat, argenti nitras, brushed over parts. If symp- 
 toms of oedema of the glottis develop, tracheotomy is indicated. 
 
 Locally, soothing applications are indicated, to wit : Vaseline, ung. 
 zinci oxidi, ol. oHvce cum glycerince, bismuth oleat. or U7igt. hydrar- 
 gyrum. 
 
 In phlegmonous variety, argenti nitras, ^j, spts. cetheris 7iitrosi, 
 3ij, brushed over and beyond the affected part, with the internal use 
 of large doses of quinina, ferrum and stimulajits. 
 
FEVERS. 51 
 
 DENGUE. 
 
 Synonyms. Break-bone fever ; neuralgic fever ; dandy fever. 
 
 The word dengue is pronounced dangay. 
 
 Definition. An acute, epidemic, febrile disease, consisting of 
 two paroxysms of fever with an intermission. The first paroxysm 
 is characterized by high fever, distressing pains in the joints and 
 muscles, and a peculiar eruption ; the second paroxysm is charac- 
 terized by a milder fever, an eruption of different character, attended 
 with intense itching, by some recurrence of the joint pains, and by 
 debility. 
 
 Cause. Unknown; but it is evident that a peculiar condition of 
 the atmosphere has some influence in its development. 
 
 Symptoms. Onset sudden— ^^z/*?;-, 103° to 105°, intense headache, 
 burning pains in the temples, backache, severe aching and swelling of 
 the joi7its and stiffness of 7miscles, nausea, vomiting, constipation 
 and the appearance of a rash, resembling scarlatina, from which the 
 disease has been mistaken for scarlatinal rheumatism. After some 
 hours to two or three days, a distinct intermission obtains, of one or 
 two days' duration. 
 
 The onset of the second paroxysm is also sudden, but the symp- 
 toms are much less severe, although the patient is greatly debilitated ; 
 it is at this time that the characteristic eruption appears, being either 
 erythematous or rubeolous, and attended with intense itching, remaining 
 for about two days, when desquamation occurs and convalescence is 
 established, but is prolonged by the great debility of the patient. 
 Average duration of the disease eight days. Relapses are common. 
 
 Diagnosis. Most apt to be mistaken for acute articular rheiuna- 
 tism, especially during the first paroxysm, but the course of the dis- 
 ease and the epidemic influence should prevent such an error. 
 
 The eruption might mislead for scarlet fever or measles, were it 
 not for the severe joint and muscular pains. 
 
 Prognosis. Favorable. 
 
 Treatment. No specific. Entirely symptomatic. 
 
 At the onset, free purgatioji and diaphoresis. 
 
 For \he fever, quitiina, gr. v every five hours, or ajitipyrine , gr. x-xx, 
 repeated p. r. n. 
 
 For the paijis, opium or acidum salicylicum. 
 
 For the itchi?tg, lotion of acidum carbolicum. 
 
52 PRACTICE OF MEDICINE. 
 
 DISEASES OF THE MOUTH. 
 
 CATARRHAL STOMATITIS. 
 
 Synon37TQS. Simple stomatitis ; erythematous stomatitis ; catarrh 
 of the mouth. 
 
 Definition. An acute catarrhal inflammation of the whole or a 
 portion of the mucous membrane of the mouth and tongue, charac- 
 terized by pain, redness, swelling and disordered secretion. Most 
 common in infants and children. Chronic stomatitis occurs mostly 
 in adults, the result of alcoholic or tobacco excesses. 
 
 Causes. Introduction of hot and irritating substances into the 
 mouth ; difficult dentition; secondary to disorders of the stomach, to 
 measles, scarlet fever and variola. 
 
 Pathological Anatomy. The buccal mucous membrane and 
 tongue have a dark red appearance, are much swollen, the tongue 
 often appearing as if too broad to lie between the teeth, the sides 
 showing the impressions of the teeth ; the secretions are at first les- 
 sened, afterward increased, a turbid mucus covering the cheeks, gums 
 and tongue, thus giving a coated tongue. 
 
 Symptoms. Oral catarrh begins with a burning, smartifig pain, 
 and tejision in the mouth, in those old enough to describe their suffer- 
 ing. Very young children refuse to nurse or allow their mouth to be 
 touched, have slight fever, disordered stomach, ?irQ fretful 2iT\d sleep- 
 less, craving cooling drinks. 
 
 The sense of taste is blunted, and there is usually an unpleasant 
 bitter taste in the mouth. 
 
 If the catarrh becomes chronic, the breath has a fetid odor and the 
 tongue is coated in the morning, the taste is disordered, and there is 
 generally more or less depression of spirits. 
 
 Diagnosis. If the buccal cavity be examined, the condition is 
 readily discerned. 
 
 Prognosis. Recovery is the rule for the acute variety. 
 
 The chronic cases are usually due to the use of tobacco or alcohol, 
 and are only modified by the absolute withdrawal of the exciting 
 cause. 
 
 Treatment. The most important point in the treatment is the 
 removal of the exciting cause, attention to the secretions and diet, and 
 
DISEASES OF THE MOUTH. 53 
 
 Locally — 
 
 R . Sodii boratis, 5 iss 
 
 Aquas destillat.. f,^j 
 
 Mel. rosse, f^j. 
 
 FOLLICULAR STOMATITIS. 
 
 Synonyms. Aphthae ; vesicular stomatitis ; croupous stomatitis. 
 
 Definition. An acute inflammation of the follicles and mucous 
 membrane of the mouth and tongue, characterized by a fibrinotis or 
 croupous exudatio7i ; the exudation first appearing in isolated spots 
 {aphthcE discrete), afterward coalesciiig, and forming large and irregu- 
 lar-sized patches {aphthca co7ifluens^, which rupture, leaving an ulcer, 
 which slowly heals. 
 
 Causes. A disease principally of childhood. Difficult dentition ; 
 disorders of digestion ; uncleanliness, such as neglect to rinse the 
 child's mouth after nursing ; with measles and diseases of the buccal 
 cavity. 
 
 Pathological Anatomy. Begins as a small, whitish papulo- 
 vesicular elevation, semi-transparent, hard and tender, with a distinct 
 red zone about their base ; there may be as few as six or as many as 
 twenty ; they may remain isolated {aphthcB discrete) or coalesce 
 {aphthcB confiuens) ; they are regarded as either a peculiar deposit or 
 a local croupous exudation. After a day or two they rupture, leaving 
 an irregular white or grayish ulcer, which slowly heals. The seat of 
 the affection is the internal surface of the lips and cheeks, the gums, 
 tongue and roof of the mouth. 
 
 Symptoms. In infants the pain is so severe that the child 
 refuses to nurse. In older children, _^rtm from talking, mastication, 
 and deglutition. Salivation is marked, the saliva dribbling from the 
 mouth. There is sWght feveriskftess , fretfulness and sleepless7iess. 
 Digestion is impaired, and quite commonly diarrhcea occurs. A dis- 
 agreeable, penetrati?ig odor escapes from the buccal cavity. 
 
 Diagnosis. Impossible to confound with any other affection if 
 the buccal cavity is examined. 
 
 Prognosis. Always favorable. 
 
 Treatment. Removal of the exciting cause. Attention to the 
 dietary and the secretions is paramount. 
 
 Internally, excellent results follow the use of potassii chloras, 
 
54 PRACTICE OF MEDICINE. 
 
 gr. j-iij, every three or four hours, according to the age. Protracted 
 cases require tonic doses of quhiincE sulphas. 
 
 Locally, good results are obtained from strong solutions of poiassii 
 chloras, infusum coptis or bismuth, applied directly to the ulcers. 
 
 ULCERATIVE STOMATITIS. 
 
 Synonyms. Diphtheritic stomatitis ; gingivitis ulcerosa. 
 
 Definition. An acute diphtheritic inflammation of the mucous 
 membrane of the mouth, continuing until extensive and unhealthy 
 tilceratio7i occur. It usually begins on the margin of the lower gums, 
 and often extends to the lips, cheeks or tongue. 
 
 Causes. Usually seen in children only. Most frequently in the 
 families of the poor, the result of unfavorable hygienic surroundings, 
 personal uncleanliness and poor food. Often seen in those reduced 
 by severe acute disease. Perhaps contagious, as epidemics are not 
 rare. 
 
 Pathological Anatomy. The gutns first appear congested, 
 swollen, bleeding readily and separated from the teeth ; soon a firmly 
 adherent deposit in the form of patches appears, at first whitish, 
 speedily becoming gray or even black, from disintegration, becoming 
 soft and pulpy, the separated slough leaving irregular-shaped ulcers, 
 with raised margins from oedema of the surrounding tissue. They 
 are not deep, and their surface is covered with a pulpy, yellowish 
 substance. The morbid process usually extends to the inner side of 
 the lips, cheeks, and to the tongue. 
 
 Symptoms. Pain constantly, aggravated by mastication or 
 deglutition : food and drink must be of the blandest character. The 
 mouth is hot, the saliva dribbles away, mixed with blood and shreds 
 of puipy ?natter, the breath is fetid, the appetite, digestion, and bowels 
 disordered. The patient is feverish, fretful and sleepless. 
 
 There is always enlargement and tenderness of the submaxillary 
 glands. 
 
 The affection is often associated with entero-colitis. 
 
 Diagnosis. Apt to be confounded with gangrenous stomatitis, 
 than which, however, there is less constitutional symptoms and a 
 slower course of the malady. 
 
 Prognosis. Favorable. If promptly and properly treated, the 
 
DISEASES OF THE MOUTH. 55 
 
 ulcerated surface rapidly heals, although quite commonly some teeth 
 are lost. 
 
 Treatment. The etiology of the affection must be borne in mind 
 and remedied. Strict attention to the diet, to the secretions, and 
 absolute cleanliness. 
 
 Interiially, the prompt use of potassii chloras, gr. j-v, frequently 
 repeated, often acts like a specific. The general health often calls 
 for quinina, ferrum and stimulants. 
 
 Locally, a strong solution oi potassii chloras, or keeping the ulcer 
 covered with bismuth, or frequent applications oi alwnen exsiccatiim 
 are valuable. Cases which resist these remedies should have applied 
 the following combination, proposed by the late Dr. Dewees : — 
 
 U . Cupri sulphat., gr. x 
 
 Pulv. cinchonse opt., . ^ij 
 
 Pulv. g. arab., 5J 
 
 Mel. commun., f 3 ij 
 
 Aquae font., f.^ iij- M. 
 
 Ft. sol. 
 SiG. — The ulceration to be touched twice daily, with the point of a 
 camel's- hair pencil. 
 
 If a spreading tendency occur, the application of argenti nitras 
 dihctus, or a diluted solution of acidtim nitricum is indicated. 
 
 THRUSH. 
 
 Sjrnonyms. Muguet; sprue; white mouth. 
 
 Definition. An inflammation of the mucous membrane of the 
 mouth, associated with or caused by the growth of a parasitic piatit, 
 the o'idium albicans ; characterized by pain, disorders of digestion and 
 of the bowels. 
 
 Causes. The development of the thrush-fungus, oidium albicans, 
 is promoted by all those conditions designated as unhygienic, by de- 
 bilitated conditions of the general system, and by neglect to thor- 
 oughly rinse the mouth after nursing or bottle feeding. 
 
 The age is considered a predisposing cause, seldom being seen 
 after two years of age. In adults, only toward the last stages of can- 
 cer or consumption. 
 
 Pathological Anatomy. The mucous membrane of the mouth 
 assumes a dark red appearance in isolated patches, on which whitish 
 Poifits appear, which rapidly coalesce into large areas. They closely 
 
56 PRACTICE OF MEDICINE. 
 
 resemble curdled milk, from their soft consistency. These whitish 
 points consist of epithelium and fat, in which are embedded the 
 sporules and filaments of the fungus. 
 
 The deposit first appears about the angles of the mouth, soon 
 extending to all parts of the cavity, often to the pharynx and 
 oesophagus. 
 
 The mouth is usually swollen and tender, the breath often fetid. 
 
 Symptoms. Pain, aggravated by nursing or mastication. The 
 lips are swollen, the saliva is i?icreased, the breath hot and somewhat 
 fetid. There is usually increased temperature, Diarrhcea is frequent, 
 the stools green and sour, causing an erythema of the buttocks. 
 
 Diagnosis. The curd-like appearance of the deposit, showing the 
 presence of parasites upon microscopical examination, will prevent 
 error. 
 
 Prognosis. Favorable, unless occurs toward the termination of 
 exhausting diseases. 
 
 Treatment. Absolute cleanliness of the mouth is all important. 
 
 Internally, remedies should be directed to the removal of the dis- 
 orders of the gastro-intestinal tract. 
 
 Prompt relief has followed the use of sodii hyposuiphitis saturat. 
 sohit., gtt. iij-x, every two or three hours, and the local application 
 of the same solution. 
 
 Locally, solutions of sodii boras often answer every indication, the 
 best vehicle being glycerinu7n, and not 7?tel or saccharum, a good 
 formula being — 
 
 R . Sodii boratis, 3 j 
 
 Glycerini, f^ij 
 
 Aquae, ,^ vj. M. 
 
 SiG. — Thoroughly applied four or five times daily, and continued for a 
 week after the disappearance of the affection. 
 
 GLOSSITIS. 
 
 Definition. An inflammation of the parenchyma of the tongue ; 
 characterized by great swelHng of the organ, with difficult mastication, 
 deglutition and vocaHzation. 
 
 The affection may be either acute or chronic. 
 
 Causes. The acute variety is usually the result of some direct 
 irritation to the tongue, such as direct injury, contact of boiling 
 
DISEASES OF THE MOUTH. 57 
 
 liquids, the action of acrid or corrosive substances, or the sting of the 
 tongue by an insect, such as the bee or wasp. 
 
 The chrojiic variety is generally circumscribed ; it may follow the 
 acute ; be due to the sharp edges of the teeth, or the use of a tobacco 
 pipe. 
 
 Patholog'ical Anatoray. Acute glossitis begins with intense 
 hyperasmia, redness and swelling of the organ ; the size often be- 
 comes so great that the tongue is too large for the mouth, and thus 
 protrudes between the teeth ; its surface is covered with a thick secre- 
 tion, and it becomes a pale or grayish color. The swelling may 
 rapidly decline, or abscesses may form, which leave a more or less 
 decided depressed cicatrix. 
 
 Chronic glossitis occurs usually along the edges of the organ, the 
 cicatricial changes being in circumscribed hard spots. If the entire 
 tongue is affected with chronic inflammation, the action is superficial, 
 and has been termed "psoriasis of the mouth." 
 
 Symptoms. Acute glossitis begins rather abruptly with fever, 
 increased pulse, restlessness, anxiety, enlargement of the tongue, a sen- 
 sation of heat in the mouth, with pain, and increased flow of saliva. 
 Mastication and deglutition become difficult, if not impossible, the 
 voice muffled and dyspncea decided. The glands at the angles of the 
 jaw are enlarged, which, in turn, compress the vessels of the neck. 
 
 When suppuration supervenes, the constitutional symptoms become 
 severe and the oral symptoms are intensified. Death has occurred 
 from suffocation in severe cases. 
 
 Chronic glossitis presents pain as the chief symptom, aggravated 
 by movements of the organ. 
 
 Diag'nosis. The rapid course oi acute glossitis should prevent its 
 being mistaken for any other affection. 
 
 Chro7iic glossitis, if severe, might be mistaken for cancer of the 
 tongue, although the slow and mild progress of the former contrasts 
 strongly with the rapid, severe and painful course of the latter, with 
 its marked constitutional symptoms. 
 
 Prognosis. Acute glossitis usually terminates in recovery within 
 a week, although the danger of suffocation must always be remem- 
 bered. 
 
 Chronic glossitis is an incurable malady in the majority of in- 
 stances. 
 
 Treatm.ent. For acute glossitis prompt measures are demanded. 
 5 
 
58 PRACTICE OF MEDICINE. 
 
 For the fever and rapid pulse, fmctiira aconiti, gtt. j to iij every 
 half hour or hour until its physiological effects are produced. 
 
 For the ejilargenient of the organ, either ice constantly applied in- 
 ternally and externally, at the angles of the jaw, or the persistent use 
 of Jiot luater held in the mouth and externally ; if prompt relief does 
 not follow these measures, or if the case is an aggravated one, the 
 prompt deep scarification of the tongue must be resorted to. 
 
 If abscesses form, promptly open them and administer quinina. 
 
 If suffocation appear imminent, tracheotomy must be performed. 
 
 For chronic glossitis, the removal of the exciting cause and the local 
 use of argenti nitras to the ulcerated edges. 
 
 " For psoriasis of the tongue," the local use oi argentum or acidiwi 
 carbolicum. 
 
 The general health must always receive due attention. 
 
 DISEASES OF THE STOMACH. 
 
 ACUTE GASTRIC CATARRH. 
 
 Synonyms. Acute mild gastritis ; gastric fever ; bilious fever ; 
 acute indigestion ; subacute gastritis. 
 
 Definition. An acute catarrhal inflammation of the mucous mem- 
 brane of the stomach ; characterized by feverishness, loss of appetite, 
 nausea, with occasional vomiting, painful digestion, irregularity of the 
 bowels, and in severe attacks, vertigo {stomachic vertigo^. 
 
 Causes. Deficient quantity of or quality in the gastric juice. 
 Errors in diet, insufficient mastication of food, swallowing liquids 
 which are either too hot or too cold, and particularly the abuse of 
 alcoholic liquors. 
 
 Often secondary to infectious diseases, such as scarlet fever, measles, 
 smallpox, diphtheria, and typhoid fever. Occasionally the result of 
 sudden changes of temperature. 
 
 Pathological Anatomy. The mucous membrane is irregularly 
 congested and engorged, and covered with a grayish, semi-transparent 
 and te7iacious ?m(cus, having an alkaline reaction. The true gastric 
 juice is secreted in lessened amount or is entirely suspended. 
 
DISEASES OF THE STOMACH. 59 
 
 Symptoms. At first, loss of appetite, at times disgust for food^ 
 heavily coated tongue, bad taste and breath, persistent nausea, and 
 at times voyniting, first of undigested food, then viscid mucus, acid 
 and bitter, and finally, bilious matter ; moderate irritative fever is 
 present, with headache, considerable thirst and flashes of heat with 
 sensations of burning in the palms of the hands and soles of the feet ; 
 acid drinks eagerly sought after ; digestion imperfect, giving rise to 
 pain, tenderness , feeling of weight and eructations ; bowels often 
 loose, sometimes, however, constipated. Vertigo with pain in the 
 nucha, is a prominent symptom in many cases, causing great anxiety 
 and depression of spirits. The urine is scanty, containing lithates 
 and pigment. 
 
 The symptoms are aggravated by errors in diet, and if saccharine 
 or fatty articles are taken, heartburn occurs. 
 
 Towards the termination of an attack, herpetic eruptions appear 
 about the mouth. 
 
 Diag'nosis. Acute gastric catarrh with fever may be confounded 
 with remittent and typhoid fever of the first week, but all doubts will 
 disappear as these maladies develop. 
 
 The vertigo may be mistaken for cerebral disease, but the disappear- 
 ance of this symptom when stomachic treatment is inaugurated 
 removes all apprehension. 
 
 Prognosis. Favorable. Duration about a week ; recovery slow, 
 even under treatment, as far as perfect digestion is concerned. 
 
 Treatm.ent. Give the stomach as complete rest as possible. If 
 the stomach is overloaded, an ipecac einetic is indicated, or if vomit- 
 ing has begun, it may be encouraged by swallowing large draughts of 
 hot water, which will act as a sedative if the stomach be empty. 
 Irritability of the stomach is readily controlled by — 
 
 R . Hydrarg. chlor. mitis, gr. ^^-^^ 
 
 Sodii bicarb., gr. ij 
 
 Pulv. aromat., gr. v. M. 
 
 Every two hours, 
 
 which has the additional advantage of relieving the bowels, or — 
 
 R. Bismuthi subnit., gr. xv 
 
 Acid, hydrocyanici, dil., TT\^ij 
 
 Mucil. acacise, f^ss 
 
 Aq. menth. pip., f^iss. M. 
 
 SiG. — Every two or three hours. 
 
60 PRACTICE OF MEDICINE. 
 
 Many cases are rapidly benefited by one or two drop doses of tinc- 
 tura micis vomicis every hour. 
 Weak alkaline vimeral waters or liqiwr calcis sh.o\\\d. be freely used. 
 After the acute symptoms have subsided — 
 
 R. Strychninae sulph., g''-^V 
 
 Acid, hydrochlor. dil., gtt. x 
 
 Tinct. gent, co., f^j. M. 
 
 Before meals, will improve the appetite and digestion. 
 
 ACUTE GASTRITIS. 
 
 Synonym. Toxic gastritis. 
 
 Definition. An acute and violent inflammation of the mucous, 
 submucous and muscular coats of the stomach, with loss of tissue ; 
 characterized by great pain, constant vomiting of blood-streaked or 
 bloody mucus and symptoms of collapse. 
 
 Causes. Ingestion of irritant and corrosive poisons, such as the 
 mineral acids, arsenic, corrosive sublimate, copper and carbolic acid. 
 
 Pathological Anatomy. The mucous membrane is vividly 
 red and injected, more marked at some portions than at others ; it is 
 soft and friable ; erosions are irregularly scattered, and the sub- 
 mucous, muscular, and at times serous coats show decided destructive 
 changes. The gastric tubules are destroyed in large numbers. In 
 many cases the oral mucous membrane presents signs of severe 
 inflammation. 
 
 Symptoms. Immediately or soon after swallowing the irritant 
 there ensues a deadly nausea, with rapid and persistent vomiting ; 
 first, of the contents of the stomach acted upon by the poison, after- 
 ward, shreds of mucous membrane and blood clots ; there are also 
 present great anxiety and depression, a weak, rapid pulse, slow and 
 shallow respiration, cold skin, covered with a cold sweat, intense 
 burning heat at the epigastrium, /^zV^/with burning in \ki% fauces and 
 gullet, and exhaustive purging ; the features are inore or less retracted 
 or sunken ; these symptoms terminating in collapse and death, or slow 
 convalescence and recovery with a crippled stomach. 
 
 A diagnosis of the character of the poison swallowed is often 
 afforded by the stain of the lips, face and mucous membrane, to wit: 
 sulphuric acid, blackish eschar ; nitric acid, yellowish eschar ; caustic 
 
DISEASES OF THE STOMACH. 61 
 
 potash, spreading widely and softening the tissues ; corrosive sublimate, 
 whitish or glazed ; carbolic acid, white and corrugated. 
 
 Prognosis. Very grave. Many perish from shock, and the de- 
 struction of the mucous membrane, which prevents nourishing. Early 
 treatment when no perforation of the walls of the stomach has occurred 
 and recovery is possible, the organ being ever after much weakened. 
 
 Treatment. At once, hypodermic injection of morphina, re- 
 peated at regular intervals. 
 
 Vomiting should be encouraged by the free use of demulcetits. 
 
 If the case be seen within a short period of the swallowing of the 
 poison, the proper antidote should be used ; but if some hours have 
 elapsed, it is useless. Ice, internally and externally, gives great relief. 
 The stomach should be washed out with the stomach pump, thereby 
 removing any remaining poison, while at the same time it acts as a 
 sedative to the inflamed membrane ; also bismuthi subnit., grs. xx-xxx 
 every hour or two, is beneficial. 
 
 Milk and lime water is the only food that should be given by the 
 stomach, enemata being used to support the system. 
 
 CHRONIC GASTRIC CATARRH. 
 
 Synonyms. Chronic gastritis ; chronic dyspepsia ; drunkards' 
 dyspepsia. 
 
 Definition. A chronic catarrhal inflammation of the stomach, 
 with thickening of the coats and atrophy of the gastric glands ; char- 
 acterized by tenderness over the epigastrium, impaired appetite, pain- 
 ful and imperfect digestion, thirst, and great depression of spirits or 
 melancholia. 
 
 Causes. Repeated attacks of acute gastric catarrh ; habitual use 
 of spirituous liquors ; malaria ; disease of the heart, lungs, pleura or 
 liver, producing chronic congestion of the stomachic vessels ; cancer- 
 ous or other degenerative diseases of the stomach. 
 
 Pathological Anatomy. The mucous membrane is of a brown- 
 ish or slate color, elevated into ridges from hypertrophy, the result 
 of constant congestion ; the peptic glands first increase in size, 
 then undergo granular change, atrophy of their cells resulting. 
 The mucous membrane is covered with a thick, alkaline, tenacious 
 mucus. These changes may affect the entire organ or be limited 
 in extent. 
 
62 PRACTICE OF MEDICINE. 
 
 Symptoms. Loss of appetite, disagreeable feeling of gnawing 
 and at times fullness in the stomach, tenderness at the epigastrium, 
 but slightly influenced by eating, prominence of the epigastrium, from 
 distention by decomposing gases, occasional nausea and voifiitijig, the 
 latter more common in drunkards, occurring on arising, termed 
 7norning vomiting and consisting of glairy mucus raised after great 
 retching ; constant thirst, water and at times stimulus being craved ; 
 often great bunting at the pit of the stomach, the result of acidity ; 
 bowels constipated, urine high colored. A feeling of mental depressiojt 
 and sieepiessness, with occasional attacks of vertigo, add to the misery 
 of the patient. Follicular pharyngitis of an aggravated type adds to 
 the general distress of the patient. The imperfect digestion causes 
 more or less loss of flesh, the fat disappearing, the muscles relaxed 
 and the skin dry. 
 
 Prognosis. Favorable as to life, but not as to complete recovery, 
 the atrophied glands more or less hindering digestion and assimilation. 
 
 Treatraent. Regulated diet. Avoid fatty, saccharine and starchy 
 food. A milk diet is beneficial, to which may be added beef in small 
 amounts, eggs, oysters and a few fresh green vegetables. Avoid all 
 tonics, bitters, or acids, unless specially indicated. 
 
 Locally, a few leeches, dry cups, a blister, or emplastrum belladotince 
 over the epigastrium. 
 
 Purgatives are doubly indicated ; first, relieving the constipation ; 
 and second, clearing the stomach of the tenacious mucus, which neu- 
 tralizes what gastric juice is secreted. Appropriate purgatives are the 
 natural mineral waters, such as Saratoga or Friedrichshall, or — 
 
 li . Magnesii sulph., .^i-ij 
 
 Sodii et potass, tart., S^M 
 
 Acid, tartaric, gr. xx, M. 
 
 Dissolved in a glass of water and drank, effervescing, an hour before 
 breakfast. 
 
 Digestion may be temporarily aided by pepsitium or lactopeptin 
 with the meals. 
 
 Great relief follows the systematic drinking of one-half to one pint 
 of hot water an hour before meals. 
 
 For the morbid condition itself may be used, liq. potassii arsenitis, 
 g\X.\-\], before yneals, or bismuth subnit., gr. x-xx, before meals, to 
 which may be added sodii bicarb., gr. v ; or argenti nitrat., gr. %-% , 
 
DISEASES OF THE STOMACH. 63 
 
 OX argenti oxidum, ^x. j^-j, in pill, before meals, or acidum hydro- 
 chlorictcm diliitiim, in water, before meals. 
 
 Paiti is so severe in some cases that resort must be had at times to 
 opium or belladonna in small doses, after meals. 
 
 Rest of the body is almost as imperative as rest of the stomach. 
 
 GASTRIC ULCER. 
 
 Synonyms. Chronic gastric ulcer ; perforating ulcer. 
 
 Definition. A solution of continuity, involving the mucous mem- 
 brane and one or more layers of which the walls of the stomach are 
 composed ; characterized by pain, disorders of digestion and vomiting 
 of blood. 
 
 Causes. Anaemia or its sequelae the chief factor. Most common 
 in young anaemic women. Virchow claims that emboli or thrombi 
 form in the nutrient gastric arteries which have lost their tonicity, an 
 ulcer forming at the point of obstruction. 
 
 Pathological Anatomy. In the majority of cases the ulcer is 
 solitary. The posterior wall near the pylorus is the most common site. 
 
 In a typical case there is a circular hole, with sharp borders in the 
 serous coat of the stomach ; the loss of substance is greater in the 
 mucous membrane than in the muscular coat, and greater in this than 
 in the serous coat, so that the ulcer looks like a shallow funnel, the 
 apex at the outer wall, the base at the inner wall of the stomach ; it 
 is first round, growing, becomes elliptical, bulging at portions, becom- 
 ing irregular ; size, from X^K inch in diameter. When the ulcer 
 heals before all the coats are perforated, a distinct cicatrix marks the 
 location. During its progress nutrient vessels are eroded, causing 
 profuse hemorrhage. Chronic gastric catarrh complicates the majority 
 of cases. 
 
 Symptoms. More or less prominent symptoms of indigestion. 
 Pain constant at the " pit of the stomach," increased by taking food, 
 especially of an irritant kind, the pain often felt in the back, of a 
 burning, gnawing character. Tenderness at one or more points, ex- 
 tending from the front to the back. Vomititig is almost as constant as 
 pain, coming on soon after eating if the ulcer is at the cardiac orifice, 
 an hour or so after if it is at or near the pylorus. Rejected matter 
 may be undigested or partly digested food, or simply acrid mucus. 
 
64 PRACTICE OF MEDICINE. 
 
 Vofniiing of blood in large quantities and arterial in color is almost 
 diagnostic of gastric ulcer ; the blood may be dark in color if it has 
 remained in the stomach some time before being rejected. 
 
 Severe and frequent attacks of gastralgia may add to the suffering 
 of the patient. The general condition of the patient is not significant, 
 some being greatly debilitated, while in others the nutrition is but 
 little deranged. 
 
 Duration. The ulcer is slow in forming, and runs a very chronic 
 course, an average duration being, perhaps, a year. Cases are re- 
 corded in which the disease has suddenly developed and terminated by 
 perforation, perit07iiiis and death within two weeks, but such are rare. 
 
 DiagTiosis. Duodenal ulcer presents symptoms so akin to those 
 of gastric ulcer that a differential diagnosis is impossible. 
 
 Chronic gastritis \s often confounded with gastric ulcer; the dis- 
 tinctive points are, absence of vomiting of blood, no localized con- 
 stant pain aggravated by food, and no tenderness in the back ; while 
 the symptoms of indigestion are marked and persistent, with, as a 
 rule, a history of spirit drinking, and the age of the patient — middle 
 life ; ulcer in the young. 
 
 The points of distinction between ^<^^/rzV cancer 2,Xi6L gastralgia vi\}i\. 
 be pointed out when considering those affections. 
 
 Prognosis. Not very unfavorable. Recoveries are frequent. 
 The dangers 2iXQ perforation, peritonitis ox fatal hemorrhage . 
 
 Treatment. Give the stomach as complete a rest as possible ; 
 this is accomplished by rectal alimentation, or where it cannot be 
 carried out, exclusive milk diet, adding lime water, to enable the 
 stomach to better retain the milk ; the amount of milk should be one 
 or two ounces every two hours. Rest in bed is paramount, and 
 should be insisted upon. 
 
 Y or pain, small doses of morphina should be used as needed. 
 
 For hemorrhage, hypodermic injections o{ ergot a are most reliable. 
 Plumbi acetas, gr. j-iij, arrests the bleeding and exercises a favorable 
 influence over the ulcer. 
 
 For the ulcer, lig. potassii arsenit.^ gtt. j-ij every five hours, has 
 given excellent results in several cases treated by the author ; bismuthi 
 sub?iitrat., gr. xx-xxx, combined with sodii bicarb., gr. iij-v, three times 
 a day, often does well; arge?tti nitras, gr. ^-j/^, every four hours, 
 or argenti oxidum, gr. ss, every four hours, are at times beneficial. 
 
 \i perforation and peritonitis result, full doses of opium are indicated. 
 
DISEASES OF THE STOMACH. 65 
 
 GASTRIC CANCER. 
 
 Synonyms. Cancer of the stomach ; gastric carcinoma. 
 
 Definition. A peculiar malignant growth, occurring for the most 
 part at the pyloric extremity of the stomach, making constant pro- 
 gress, destroying the gastric tissues and infecting the lymphatic glands ; 
 characterized by disorders of digestion, pain, vomiting, marked anae- 
 mia, and terminating in all cases by the death of the patient. 
 
 Cause. Hereditary. Develops after forty years, for the most part. 
 
 Pathological Anatomy. Cancer of the stomach is the most 
 common form of cancer. It is, as a rule, a primary cancer. The 
 variety is most commonly the scirrhus, next in frequency, inechillary, 
 the least frequent, colloid. As regards the location, eighty per cent. 
 occur at the pylorus. 
 
 It originates usually in the tubules, rapidly infiltrating the remain- 
 ing tissues, thickening everywhere as it progresses, and either remains 
 a hard nodulated mass or undergoes ulceration. The hard nodulated 
 growth at the pylorus constricts the orifice, resulting in dilatation of 
 the stomach. The lymphatic glands adjacent to the stomach are 
 infiltrated, secondary cancers resulting. Ulceration into an artery 
 causes hemorrhage into the peritoneum, resulting in local peritonitis. 
 
 Complications. Fatty heart ; thrombosis ; tuberculosis. 
 
 Symptoms. The development of gastric cancer is insidious 
 with indigestio7i, progressive in character, associated with marked 
 acidity, Jlatulency and a fetid breath. 
 
 The majority of cases have vo7niting immediately after eating, if at 
 the cardiac orifice, and some hours after it at the pylorus ; if much 
 dilatation of the stomach develop the vomiting occurs some days after 
 eating. The rejected matter is food in various stages of digestion, 
 associated frequently with black grunious masses of altered blood. 
 Paitt, marked and constant, dull, heavy, increased by pressure, 
 seldom lancinating. Marked ancemia, emaciation, are present, the 
 surface having an earthy or fawn color. QEdema of the ankles is an 
 early diagnostic symptom in carcinoma of the stomach, often occur- 
 ring as early as the third month. A tumor is found in three-fourths 
 of the cases, occupying the epigastric region, 7tot moviiig with in- 
 spiration. 
 
 The duration of the disease is about one year, the patient dying 
 from exhaustion, perito7iitis, or hemorrhage. 
 
 Diagnosis. The continuous presence of free hydrochloric acid 
 
66 PRACTICE OF MEDICINE. 
 
 in the stomach is a diagnostic sign of great value in excluding the 
 probable existence of gastric cancer. Chronic gastric catarrh differs 
 from gastric cancer, in the absence of a tumor, bloody vomit, charac- 
 teristic pain, peculiar color of the surface, dropsy and the rapid 
 emaciation. 
 
 Gastric iilcer differs in the character of the pain, age of the patient, 
 large amount of bloody vomit, absence of a tumor and progressive 
 emaciation. Still the diagnosis is often difficult. 
 
 Abdominal ticmors may raise the question of a gastric cancerous 
 tumor ; the points of distinction are the characteristic symptoms of 
 gastric cancer, and that abdominal tumors, especially of the liver and 
 spleen, the ones most apt to cause error in diagnosis, are influenced 
 by inspiration, while tumors of the stoinach are 7iot so influenced. 
 
 When a scirrhus of the pylorus lies upon the aorta, a pulsation may 
 be communicated to it, raising the question of aneurism of the abdomi- 
 nal aorta, but the expansile pulsation of aneurism (Corrigan's sign) 
 is wanting, as are the other symptoms of the affection, and if the 
 patient is made to rest upon his hands and feet, the stomachic tumor 
 falls away from the aorta and pulsation ceases. 
 
 Mikuliez claims that, by the use of his gastroscope, regular rhyth- 
 mical motions can be seen when the pylorus is not the seat of cancer, 
 and that such movements are absent when it is the seat of cancer. 
 
 Prognosis. Unfavorable. Internal medication offers no hope, 
 the patient usually succumbing from starvation. 
 
 Gastric carcinoma occurring under thirty years of age is rapidly 
 fatal, not conforming to the usual symptoms as seen later in life ; the 
 characteristic cachexia is commonly absent and hasmatemesis is rare. 
 
 Treatment. We possess no means of arresting the disease. 
 " Six operations have been practiced for the relief of stenosis of the 
 pylorus: ist. Pylorectomy ; 2d. Gastro-enterostomy ; 3d. Gastrectomy; 
 4th. Gastrostomy ; 5th. Duodenostomy ; 6th. Digital divulsion of the 
 pylorus." Professor Billroth has excised the pylorus, thereby pro- 
 longing life ten months. 
 
 For acidity 2cs\(S. fetor of the breath, acidum carbolicum, gr. }i-]/2,, or 
 carbo animalis purificatus, gr. x-xxx, affords some relief. 
 
 For vomitings bismuth and opium, or the washing out of the stomach 
 with the stomach-pump. 
 
 For pain, jnorphina. 
 
 Avoid stimulants. 
 
DISEASES OF THE STOMACH. 67 
 
 GASTRIC DILATATION. 
 
 Synonyms. Pyloric obstruction ; pyloric stenosis. 
 
 Definition. An abnormal increase of the cavity of the stomach, 
 with the walls either hypertrophied, or decreased in thickness ; char- 
 acterized by pronounced indigestion, vomiting of partly digested and 
 partly decomposed food at intervals of a day or two, and noisy mov- 
 ing of flatus in the abdomen (borborygmus). 
 
 Causes. Most common cause a stricture of the pylorus, the 
 result of cancer ; pressure of tumor against the pylorus, preventing 
 exit of stomachic contents. Loss of muscular tone, occurring in 
 anaemia. Prof. Bartholow cites cases resulting in excessive beer- 
 drinkers, who drank thirty to forty glasses of beer habitually, every 
 day. 
 
 Pathological Anatomy. When obstruction exists at the pylorus, 
 the whole organ is dilated, with hypertrophy of the muscular layer of the 
 stomach. In dilatation without pyloric obstruction, the muscular layer 
 is thinner than normal, paler in color, and presents signs of fatty de- 
 generation ; the mucous membrane is also pale, thin, and without rugse. 
 
 Symptoms. Those of the disease producing the obstruction ^/2<;.? 
 those of obstinate chronic gastric catarrh, with characteristic voniit- 
 ijig : the cavity having a greatly increased capacity, large accumula- 
 tions take place, which are rejected every day or two, partly digested 
 and partly decomposed. Regurgitation of partly digested aliment, 
 acrid, acid and offensive, is very common. Bowels constipated, the 
 stools hard and dry. 
 
 Physical signs of gastric dilatation are : on ijispection, abnormal 
 prominence of the whole epigastric region, with a tumor in \)!xq. pyloric 
 region which seems to be connected with the stomach ; percussiofi, if 
 empty, tympanitic note extending to or below the umbilicus, having 
 a metallic quality ; if the stomach be filled, high-pitched flat note ; 
 auscultation, splashing and rumbling sound, the succussion sound 
 being distinct if the body be shaken. 
 
 Diagnosis. Copious vomiting of food partly digested, once in 
 twenty-four hours or less often, epigastric distress and pain resulting 
 from foul smelling and acid eructations and from obstinate constipa- 
 tion. 
 
 Penzoldt's modification of Piorry's method of determining gastric 
 dilatation is to withdraw the contents of the stomach by means of the 
 oesophageal tube and then refilling the stomach with fluid. By noting 
 
B8 PRACTICE OF MEDICINE. 
 
 the lower limit of percussion dullness thus produced, the lower border 
 of the stomach can be accurately determined. 
 
 Treatment. Regulated diet. Restrict the use of fluids, using a 
 " dr)- diet" exclusively. 
 
 If the result of pyloric stenosis, one of the operations mentioned 
 for pyloric cancer may be indicated. 
 
 Regardless of the cause, washing out the stomach with the stomach 
 pump, every day or two, gives relief, and, if no stricture be present, 
 administer strycJmina or 7iux vomica, and very favorable results may 
 follow. 
 
 GASTRIC HEMORRHAGE. 
 
 Synonyms. Haematemesis; gastrorrhagia. 
 
 Definition. Gastric hemorrhage is not, strictly speaking, a dis- 
 ease, but a symptom ; still, vomiting of blood occurs under such a 
 variety of conditions, that a separate consideration is desirable. 
 
 Causes. Ulcer of the stomach ; cancer of the stomach ; scurvy ; 
 purpura ; hemorrhagic malarial fever ; congestion of the liver or 
 spleen ; vicarious at menstrual period ; yellow fever. 
 
 Symptoms. Added to the symptoms of the cause of the hemor- 
 rhage, are difeelmg offaintfiess and smkmg at the pit of the stomach, 
 followed by the ejection of blood of a black, grumous, or coffee-ground 
 appearance. Rarely, and then generally in gastric ulcer, the ejected 
 blood may have a bright red appearance, the gastric juice not having 
 had time to act upon it. If the amount of blood escaping into the 
 stomach is large, blood will be voided by stool. 
 
 Diagnosis. Hemorrhage from the liiftgsva^y be confounded with 
 gastric hemorrhage. In the former, the blood is red, is coughed up, 
 not vomited, and is associated with a history of pulmonary disease. 
 The chief point of distinction between pulmonary hemorrhage and 
 the vomiting of red blood is, that in the former you can discern rales 
 on auscultating the chest, and they are absent in the latter. 
 
 Prognosis. Depends entirely upon the cause, the most unfavor- 
 able being the resulCof either gastric ulcer or cancer. 
 
 Treatment. Perfect rest in bed. Ice, internally and applied in 
 bladders over the epigastrium and along the spine. 
 
 Hypodermic injections of morphiiia quiet the patient's fear, and at 
 the same time have a constringing effect upon the vessels: Extrac- 
 
DISEASES OF THE STOMACH. 69 
 
 turn ergotcB fluidutn or ergotin hypodermically, after the patient is 
 quieted, or liquor ferri siibsiclphatis, gtt. j-v, well diluted, by stomach. 
 
 Cases resulting from congestion of the liver or spleen are benefited 
 by saline purgatives. 
 
 Allow no food by the stomach for several days, nourishing the 
 patient by rectal alimentation. 
 
 The hemorrhage controlled, the future treatment is guided by the 
 exciting cause. 
 
 GASTRALGIA. 
 
 Synonyras. Cardialgia ; gastrodynia ; stomachic colic ; spasm 
 of the stomach ; neuralgia of the stomach. 
 
 Definition. A painful condition of the sensory nerves of the 
 stomach, induced by various sources of irritation ; characterized by 
 violent paroxysms of gastric pain and spasm, associated with feeble 
 cardiac action, and symptoms of collapse. 
 
 Causes. The affection belongs to the group of neuralgiae. The 
 most important factor in its causation is a general nervous depression ; 
 other causes are malaria, rheumatic or gouty diathesis, anaemia, and 
 certain articles of diet. 
 
 Symptoms. Like most neuroses, gastralgia is distinguished by 
 its paroxysmal character. Romberg thus describes an attack : — 
 
 " Suddenly, or after a feeling of pressure at the prsecordium, there 
 is severe griping pai?t in the stomach, usually extending to the back, 
 with a feeling of faintness, a shrunken countenance, cold hands and 
 feet, and an itttermittent pulse. The pahi becomes so excessive that 
 the patient cries out. The epigastrium is either puffed out, like a ball, 
 or retracted, with tension of the abdominal walls. There is oiten pul- 
 sation of the epigastrium. External pressure is well borne, and not 
 unfrequently the patient presses the pit of the stomach against some 
 firm substance, or compresses it with his hands. Sympathetic pains 
 often occur in the thorax, under the sternum, and in the oesophageal 
 branches of the pneumogastric, while they are rare in the exterior of 
 the body. 
 
 " The attack lasts from a few minutes to half an hour or longer ; then 
 the pain gradually subsides, leaving the patient much exhausted ; or 
 else it ceases suddenly, with eructation of gas or watery fluid, or with 
 vomiting and with a gentle, soft perspiration, or with the passage of 
 reddish urine." 
 
"70 PRACTICE OF MEDICINE. 
 
 Besides such severe attacks, we often see painful sensations in the 
 epigasirijnn, of various degrees of intensity, with passing faintness or 
 sinking at the "pit of the stomach." 
 
 Diagnosis. From myalgia of the abdominal muscles, by the pain 
 of gastralgia being more acute and lancinating, accompanied by 
 nausea and vomiting and the absence of tenderness on pressure. 
 
 From intercostal netcralgia, by the fact that in this affection the 
 pain is in the left hypochondrium, with painful spots along the course 
 of the nerve trunk and at the spine, and absence of nausea and 
 vomiting. 
 
 From gastric cancer, by the age, character of the vomited matter, 
 constancy of the pain, the cachexia, emaciation and the tumor. 
 
 From gastric ulcer, by the localized pain and its constancy, with 
 tenderness and vomiting of blood, and constant dyspeptic symptoms, 
 which is not the case in gastralgia. 
 
 Prognosis. As to perfect recovery, unfavorable, but not danger- 
 ous to life. A chronic affection, in that attacks are prone to 
 return from time to time. The cause has much to influence a radical 
 cure. 
 
 Treatment. For the paroxysi7i, hypodermic injections of mor- 
 phina, gr. X2~i> *^^ ^^ stomachic administration of the " compound of 
 anodynes," the so-called chlorodyne, in doses of ttlx-xxx p. r, n. 
 The relief afforded by opium in some form is so decided that it is 
 prone to lead to the opium habit when the attacks are frecjuent. 
 
 In the interval, regulated diet and one or more of the following 
 remedies : quinina, arsenicui7i, bismuth, ferrum, liq. iodi. comp., or 
 small doses oi potassiiiodidum. 
 
 ATONIC DYSPEPSIA. 
 
 Synonyms. Dyspepsia ; indigestion ; heartburn ; pyrosis. 
 
 Definition. A functional derangment of the stomach, with either 
 deficient secretion in the quantity or quality of the gastric juice ; char- 
 acterized by disorders of the functions of digestion and assimilation 
 and the presence of sympathetic nervous symptoms. 
 
 Causes. Imperfect mastication; bolting of food; eating large 
 quantities of food ; same diet long continued ; depressed nervous 
 system, from worry and fatigue ; sedentary habits or occupations. It 
 is often inherited. 
 
DISEASES OF THE STOMACH. 71 
 
 Symptoms. Perverted appetite, capricious or lost ; difficult di- 
 gestion, a feeling of weight or fullness in the epigastrium ; acidity 
 from the decomposition of albuminoids; heartburn, flatidejicy, regur- 
 gitation, or vo7niting of portions of partly digested food or acrid 
 fluid — water-brash or pyrosis. Pain or soreness at the " pit of sto- 
 mach " during digestion. Tongue either clean or broad, flabby and 
 pale, showing marks of the teeth. Bowels constipated ; iirine gener- 
 ally scanty and high-colored, with excess of urates or oxalates, or, in 
 persons of nervous type, it is pale, of low specific gravity, and contains 
 phosphates. Drowsiness after meals, with wakefulness at night, 
 defective 7nejnory, headache and absent mental vigor, vfiXh flashes of 
 heat, followed by more or less perspiration. Palpitation of the heart 
 with irregularity in rhythm. 
 
 Varieties of Dyspepsia. — I. Nervous dyspepsia, atonic form, seen in 
 active business or busy professional men, especially those of thin, 
 spare build, of nervous temperament, who eat meals rapidly and 
 hurry off to their business. These cases present all the marked ner- 
 vous phenomena. II. Flatulent dyspepsia, seen in hysterical indi- 
 viduals, and showing immense development of gas throughout 
 abdomen, and nervous symptoms. III. Acid dyspepsia, water- 
 brash. Seen when the diet is coarse. Acidity of the gastro-intestinal 
 canal and of the urine. IV. Irritative dyspepsia. Vomiting a 
 prominent symptom. In these cases the tongue is small, red and 
 pointed. 
 
 Prognosis. With careful living, dyspepsia, functional in charac- 
 ter, is curable. It has been aptly termed " remorse of the stomach." 
 
 Treatm.ent The most important indication is to regulate the 
 diet. Forbid saccharine, starchy, or fatty articles of food. Eat small 
 amounts at a time. Perfect insalivation and mastication. Rest after 
 eating, from a half to an hour. Allow but small quantities of liquids 
 with the meals. In the vast majority of C2iS&s forbid the use of stimu- 
 lants with the meals. 
 
 Aid digestio?i with pepsinum, with or without acidtun hydrochlori- 
 cum dilutum. 
 
 Stimulate stomachic peristalsis with mix voinica, gentian or cinchona. 
 
 For acidity, alkalies, at time of acidity. 
 
 For flatulency , carbo atiimalis purificatiis, gr. x-xx, or one or more 
 of the carminatives, with tinctura 7iucis vomica before meals. 
 
 Y ox pyrosis, bismuth zjidpulvis aroinaticus, in large doses. 
 
PRACTICE OF MEDICINE. 
 
 For vomiting, sodii bromidimi in small doses, or acidutn carbolicum, 
 gr. \-\, three or four times daily. 
 
 For consfipatiojt, resifia podophylhan, at bedtime. 
 For ancBmia, massa ferri carbonatis or ferri lactas. 
 
 DISEASES OF THE INTESTINAL CANAL. 
 
 INTESTINAL INDIGESTION. 
 
 Synonym. Intestinal dyspepsia. 
 
 Definition. A derangement in the functions of intestinal diges- 
 tion, resulting in the more or less complete decomposition of the 
 chyme, from defects in the pancreatic, biliary or intestinal secretions, 
 or from deficient peristalsis, one or more, singly or combined ; char- 
 acterized by abdominal pain, distention, tympanites some hours after 
 meals and nervous perturbation, anaemia and emaciation. 
 
 Causes. Imperfect diet; over eating; anaemia; deficient exercise ; 
 worry ; immoderate use of tobacco ; diseases of the intestinal tract, 
 liver or pancreas ; malaria. Frequently inherited. 
 
 Symptoms. Intestinal indigestion may be either actcte or chronic, 
 the latter the more common. 
 
 Acute variety, the result of an irritant in the duodenum ; rapidly 
 developed paiii, flatulency, borborygmi, slight feverishness, coated 
 tongue, loss of appetite, headache, pains ifi the limbs, usually termi- 
 nating in a mild attack of diarrhcea. 
 
 If the attack develops rapidly, the sudden formation of gases 
 results in a paroxysm of colic. 
 
 Severe attacks are associated with disordered hepatic function, to 
 wit: light-colored stools, slight jaundice and high-colored urine. 
 
 Chronic variety, resulting from a greater or less decomposition of 
 the partly altered food from the stomach. Pain, varying in char- 
 acter, occurring from two to four or six hours after meals, with slight 
 tenderness and some fiilhiess in the right hypochondrium, epigas- 
 trium or the umbilical region. Tyinpanites and borborygmi are 
 marked, the result of gaseous accumulations which have resulted 
 
DISEASES OF THE INTESTINAL CANAL. 73 
 
 from the decomposition of the intestinal contents. Dyspncea, the re- 
 sult of pressure against the diaphragm, is of frequent occurrence. 
 Marked nervous phenomena develop, the result of the ansemia from 
 deficient assimilation and from the depressing influence on the ner- 
 vous system of the absorption of the "gases of decomposition ;" de- 
 pression of spirits, hypochondriasis , sleeplessness, disturbi)ig dreams, 
 headache, vertigo, buzzing in the ears, musca volitantes, deficient 
 mental application, cardiac irritability, numbness and tingling in the 
 extremities, anomalous pains throughout the body, and in marked 
 cases, attacks oi fainting, epileptifori7i and cataleptic attacks. 
 
 The skin is harsh and dry, the bowels are sluggish or constipated, 
 the urine is high colored, of increased density, decidedly acid, and 
 on coohng deposits lithates, uric acid and oxalate of lime crystals. 
 
 Functional derangement of the liver follows after a time, adding to 
 the general distress. 
 
 AncB7nia and e?naciation result if the attack be protracted. 
 
 Diagnosis. With our present knowledge it is usually impossible 
 to designate forms of intestinal indigestion due to defects in the 
 quantity or quality of either the pancreatic, biliary or intestinal 
 secretions. 
 
 Acute intestinal indigestioji differs from gastric indigestion in the 
 time of development of the various phenomena, in the latter the 
 symptoms appearing almost immediately after meals, while in the 
 former not appearing until two, four or six hours after. 
 
 Chronic intestinal indigestion may mislead the physician if the 
 various nervous phenomena are of a marked character, and a careful 
 history of the case is not developed. 
 
 Prognosis. Favorable if proper and early treatment is inaugu- 
 rated, unless the result of an organic lesion. 
 
 Treatment. Acute variety, the result of indigested food, is best 
 treated by opium in some form, to relieve the acute suffering, warmth 
 to the abdomen, and a prompt cathartic to cause its rapid expulsion. 
 
 Chronic variety. Of the first importance is the diet, which should 
 be restricted in amount and confined almost entirely to such articles 
 as are readily digested in the stomach, such as beef, eggs and milk. 
 
 The hepatic, pancreatic and intestinal secretions should be stimu- 
 lated by a course of alkalies, one of the most efficient being sodiiphos- 
 phas, 5j-ij, three times a day. 
 
 Aid intestinal digestion by the administration of the liquor pa7icre- 
 6 
 
74 PRACTICE OF MEDICINE. 
 
 aticus, fo J~^'^'' of ^'^^ extractum pancreatis, gr. ij-vj, with sodii bicar- 
 bonatis, gr. v-x, two or three hours after meals. 
 
 For constipation, bitter waters, such as Friedrichshall, Pullna, or 
 Hunyadi Janos, or resma podop]iylluin, at bedtime. 
 
 INTESTINAL COLIC. 
 
 Synonyms. Enteralgia ; tormina ; gripes. 
 
 Definition. A spasmodic contraction of the muscular layer of 
 the intestinal tube ; characterized by acute paroxysmal pain near the 
 umbilicus, relieved by pressure, and associated with feeble cardiac 
 action. 
 
 Causes. Constipation ; presence of indigestible food ; collections 
 of flatus; an abnormal amount of bile discharged into the intestines; 
 lead poisoning ; syphilis ; chronic malaria ; rheumatism ; hysteria. 
 
 Symptoms. Ro)nberg \}[\Vi's describes a paroxysm: "There are 
 attacks of pain, spreading from the navel over the abdomen, alter- 
 nating with intervals of ease. The pain is fearing, C7ctting, pressi?tg, 
 most frequently twitching, pine hi7ig, accompanied by peculiar bear- 
 ing-down pains. The patient is restless, and seeks relief \n changing 
 his position and in compressing the abdomen ; his surface may be cold 
 and his features pinched. The pulse is small and hard. The abdo- 
 men is tense, whether puffed up or drawn inward. There are often 
 nausea and vomiting, and desire for stool. There is usually constipa- 
 tion, but sometimes the bowels are regular or even too loose. Dura- 
 tion 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 blue line, heavy breath, 
 with sweetish metallic taste, obstinate constipation, impaired appetite, 
 slow pulse and contracted abdominal walls. 
 
 Diagnosis. Gastralgia differs from colic, in the pain being in the 
 epigastric region and associated with disorders of digestion. 
 
 In hepatic colic, or the passage of gall stones, 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, 
 
DISEASES OF THE INTESTINAL CANAL. 75 
 
 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 on pressure over the ovaries, 
 with hysterical phenomena. 
 
 Inflammatory disorders of the abdonieji 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 
 accomplished by a hypodermic injection of viorphifia, gr. ye-yi, 
 which has the additional advantage of relaxing the spasm, thereby 
 favoring the action oi purgatives, which should soon follow. One of 
 the best in colic, no matter from what cause, is masses hydrargy- 
 rum, gr. v-x, or hydrargy?'i chloridiim mite, gr. Yz every half hour 
 until four or five grains are taken, followed by a mild saline 
 cathartic. 
 
 After the relief of the pain and free action of the bowels, the cause 
 of the attack should be ascertained and corrected, to prevent future 
 suffering. 
 
 For lead colic, morphina, for the pain ; oleum rici7ii or magnesii 
 sulphas, ^j, every hour for the constipation, and potassii iodidum 
 gr, v-x, after meals, to eliminate the metal from the system. 
 
 CONSTIPATION. 
 
 Synon37ms. 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 ; 
 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 straitiing 
 and distress, the face often fli^shed, the cerebral vessels full. 
 
n 
 
 PRACTICE OF MEDICINE. 
 
 Or in other cases the bowels may be relieved once a day, but the 
 stoolis small a7id hard, causing great pain. 
 
 Another group of cases \i-^\Q. frequent stools during the day, small 
 and non-for?ned, 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, palpi- 
 tation on exertion, and in many cases with great distention of the 
 abdomen. 
 
 Prognosis. Death never results from functional constipation. 
 
 Treatment. The successful treatment depends upon the removal 
 of the cause and the hearty co-operatio7i of the patient. 
 
 First, the patient must have a regular hour each day for goifig to 
 stool, and must remaifi a sufficie?tt tijne to permit a thorough evacua- 
 tion of the bowels. 
 
 Second, the diet must be carefully regulated. 
 
 Third, purgative mineral waters or cathartic medicines are to be 
 used with caution, their reckless administration often doing more 
 harm than good. 
 
 Fourth, either of the following formulae, aided by the enforcement 
 of the above rules, will give good results : — 
 
 B . Ext. nucis vomicse, gr* X 
 
 Ext. belladonnae alco., gf- X 
 
 Extract aloes aqua, gr. ss 
 
 Pulv. rhei, gr. j 
 
 Olei cajuputi, gtt. j. M. 
 
 In pill, at bedtime, and after a week, every second or third night. 
 
 R . Resinoe podophyl., 
 
 Ext. physostig., 
 
 Ext. belladonnae alco., 
 
 Aloine, aa gr. X- 
 
 In pill, every night, or second or third night. 
 
 R;. Ext. cascarse sagradoe fld., n\^xxx 
 
 Glycerini, . . . rT\,x 
 
 Syr. sarsaparilkc, n\^xx. 
 
 Hour after meals, or once a day, as indicated. 
 
 Success often follows an enema oi glycerini 3j-iv, or a suppository 
 oi glycerinum. 
 
 Electricity to the abdomen is worthy a trial ; one pole over ab- 
 domen the other at anus ; using either galvanism or faradism. 
 
DISEASES OF THE INTESTINAL CANAL. 77 
 
 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 indigestiofi, 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 predis- 
 pose to an attack of diarrhoea. 
 
 Forms. Acute and chronic. 
 
 Symptoms, Acute diarrhoea presents itself in several varieties, 
 the result of its particular cause, to wit : — 
 
 Fectilent diarrhcea. A few hours after meals the patient feels colicky 
 pains atid flatulency , with a desire for stool. There is often nausea, 
 coated tongue, but seldom vomiting. The pain is generally relieved 
 by the purging which ensues. The stools have a feculejit character, 
 are of brown fluid, containing fseces, often offensive, the color 
 becoming lighter after four or five evacuations. Constitutional symp- 
 toms are wanting. 
 
 This form is the result of over eating, eating too rapidly, or indi- 
 gestion of different forms, or worms in the intestinal canal, and 
 patients generally recover in a day or two. 
 
 Lienteric diarrhcea. In this form there is, with the frequency of 
 evacuations, a wa^it of assimilation oi food, which passes through the 
 intestines more or less unaltered. The stools are frequent, mucous 
 or serous, more or less covered with bile, mixed with U7idigested 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 diarrhoea. The stools are frequent, green or yellow, with 
 scaldi7ig sensations at the anus and gripifig pains in the abdomen. 
 Excessive biliary secretion is the irritating cause. 
 
7-8 
 
 PRACTICE OF MEDICINE. 
 
 Any of the above forms may pass into chronic diarrhoea by excit- 
 ing permanent diseases of the intestines. Diarrhoea due to constitu- 
 tional 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 symptoms, as far as the stools 
 are concerned, are much the same as the acute disease, except they 
 are paler, whence it has been termed white flux ; in addition, dyspep- 
 tic symptoms, aphthous condition of the mouth and \.ov\g\iQ,/laticlency , 
 colic, emaciation and ance7nia. The appetite is at times capricious, 
 again impaired. 
 
 Prognosis. Favorable \n 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 caused by indigestion the indi- 
 cation is for a laxative ; for adults, tinct. rhei. or ol. ricini, or both ; 
 for children between one and two years of age — 
 
 1 
 
 K . Pulv. ipecac, gr. 
 
 Pulv. rhei, gr. X~/^ 
 
 Sodii bicarb., gr. ss-ij. 
 
 Every four hours until the character of the stools change. 
 
 M. 
 
 After the irritant is removed, for an adult, opium in some form, 
 combined with kino or tannin ; or the following modification of 
 " Squibb's diarrhoea mixture : " — 
 
 R . Tinct. opii deodorat., 
 Tinct. camphorge, . 
 Tinct. capsici, . . . 
 Chloroformi purse, . 
 Spts. villi gallici, 
 
 Alcoholis, ad 
 
 SiG. — One teaspoonful, \^. r. n. 
 
 f 2 viss 
 
 f 3; iiss 
 f 31V. 
 
 M. 
 
 For children — 
 
 R . Bismuth, gr. iij-v. 
 
 Cretce prsep., gr. v. 
 
 Every two hours. 
 
 M. 
 
 In adults, an opium suppository often checks a flux that is unin- 
 fluenced by opium internally. 
 
DISEASES OF THE INTESTINAL CANAL. 79 
 
 For the bilious form — 
 
 R . Hydrargyri chlor. mitis, gi"- /^ 
 
 Sodii bicarb., gi"- ij 
 
 Pulv. opii, gi". >(• M. 
 
 In powder, every two or three hours, until eight powders are used, fol- 
 lowed by large doses of bismuth and pepsinum. 
 
 In all acute forms restricted and regulated diet are imperative, pure 
 milk with liquor calcis being the most suitable. 
 
 Chronic diarrhcea. Bismuth, gr. xxx-xl, in milk, every four hours ; 
 Hope'' s cajnphor mixture, every four hours ; cupri sulphas, gr. -J^-, 
 ext. opii, gr. y^, every four hours ; argenti nitras, gr. Yz, ext. opii, gr. 
 \, every five hours ; may all be used with more or less success ; when 
 dry tongue 2indi great flatulency, use — 
 
 ^. 01. terebinthini, , f^j 
 
 01. amygdal, express,, f^ss 
 
 Tinct. opii, f.^ij 
 
 Mucil. acacise f,::^v 
 
 Aq. lauro-cerasi, f^ss. M. 
 
 SiG. — f 5J every three or four hours. 
 
 The diet should be nutritious in character, and moderate stimulants 
 are indicated. Activity of the skin and kidneys should be encouraged. 
 
 CATARRHAL ENTERITIS. 
 
 Synonyms. Ileo-colitis ; acute diarrhcea ; 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 dzwdenitis. 
 
 Pathological Anatomy. There first ensues hypercemia of the 
 mucous membrane and intestinal glands, manifested by redness, 
 swelling and cedema ; this is followed by increased secretio7i and an 
 overgrowth and desquamation of the epithelium, together with a copi- 
 ous ^^«(?nz//^« of young cells. As a result of the hyperaemia, rupture 
 of the capillaries and extravasation of blood often occur. 
 
 The swollen glands show a strong tendency to ulcerate. This 
 catarrhal process may involve the whole tube or be limited to portions 
 of it 
 
80 PRACTICE OF MEDICINE. 
 
 Causes. Improper and indigestible food ; summer temperature 
 and exposure to cold and wet while perspiring. 
 
 Symptoms. Begins with languor, followed by chillijiess and 
 fever, the temperature ranging at io2°-io3°, this is followed hy pain, 
 colicky and paroxysmal in character, situated above the umbilicus, 
 localized te7iderness and loose evacuatio7ts. Nausea and vomitinsr 
 often occur. The stools contain but little fecal matter, are yellow or 
 greenish-yellow in color, mixed with undigested food ; if the stools are 
 numerous, they become whitish and watery, the so-called '^rice- 
 water"' discharges. The appetite is impaired, and this, with the want 
 of assimilation and great waste, soon produce extreme weakness and 
 emaciation, which is always more marked in children. 
 
 Duration. In mild cases, four or five days ; severe cases continue 
 more or less marked for a w-eek 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 
 temperature record and eruption. 
 
 For points of distinction from dysentery or peritonitis , see those 
 affections. 
 
 Prognosis. Favorable, if early and proper treatment is ob- 
 served. 
 
 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 cases do well with — 
 
 R. Ext.opii, gr. %-y2 
 
 Camphoroe, gr. iij. M. 
 
 In pill, every three hours. 
 
 Or— 
 
 R . Tinct. opii deodorat., gtt. x 
 
 Liq. potassii cilrat.. ^ij. M, 
 
 Every four hours. 
 
 The strength and the frequency of administration of either of these 
 formulae must be governed by the severity of the attack. 
 
DISEASES OF THE INTESTINAL CANAL. 81 
 
 For children — 
 
 5t . Tinct. opii deodorat., gtt. j 
 
 Bismuth subnit., gr. v 
 
 Mist, cretse, f^j. M. 
 
 Every four hours, for a child of one year. 
 
 If the case shows the least tendency to linger, the acid treatment 
 should be substituted for the above, the best of which is " Hope's 
 Camphor Mixture," the formula being — 
 
 R . Acidi nitrosi, f 5 j 
 
 Tinct. opii, gtt. xl 
 
 Aquae camphorae, f^^viij. M. 
 
 The dose ranging from i'^\ to f ^ ij, according to the age. 
 
 Acidum sulphuricimi dilutuni may be substituted for the acidum 
 nitrosum in the above formula. 
 
 Locally, poultices, warm fomentations, or tuig. belladonn(E or 
 oleum camphoratce, give great relief. 
 
 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 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. 
 
 Pathological Anatomy. A subacute inflammation of the small 
 intestines, 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 its under surface into the intestinal follicles. 
 
 Symptoms. Begins by feverishness, feeling of soreness and dis- 
 tention of the abdomen ; these are followed by pains of a colicky 
 character, severe and depressing, felt around the tnnbilictis, continuing 
 for half an hour, an hour or longer, and after a longer or shorter inter- 
 val occurring again ; these phenomena continue for a day or two, when 
 7 
 
82 PRACTICE OF MEDICINE. 
 
 looseness of the bowels, with distressing /^z;z and tenesmus occur, the 
 stools containing ynucus, with or without blood, and shreds of ineinbrane 
 or cylindrical casts of the bowel. Great relief is then experienced, 
 although 2. feeling of rawness or soreness persists for a day or two 
 
 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 
 appear. 
 
 Prognosis. Favorable as to life, but one of the most difficult of 
 diseases to eradicate. 
 
 Treatment. The diet must be such as contains but a minimum 
 of fecal-forming matter. 
 
 For the pain and stifferi7ig, opium in some form is indicated, the 
 most effective being a hypodermic injection of morphina. 
 
 For constipation during a paroxysm, an emulsion of oleum ricini 
 and terebinthina is of benefit. To prevent a return of the paroxysms 
 either lig. potassii arsenitis, gtt. j-ij, before meals, or hydrargyri 
 chloriduni corrosivum, gr. -^j^, three times a day, with a course of 
 oleum moT^huae, seems to answer in the majority of cases. Prof. Da 
 Costa speaks highly of pix liquida in some form, as an alterative to 
 the mucous membrane. 
 
 Under no circumstances must the bowels become constipated. 
 
 CHOLERA MORBUS. 
 
 Synonyms. Sporadic cholera ; English cholera ; bilious cholera. 
 
 Definition. An acute catarrhal inflammation of the mucous 
 membrane of the stomach and intestines, oi sudden onset; character- 
 ized by violent abdominal pains, incessant vomiting and purging, 
 cold surface, rapid, feeble pulse, spasmodic contractions of the mus- 
 cles ot the abdomen and extremities, and prostration. 
 
 Causes. A disease of summer and early autumn, climatic influ- 
 ence being an important factor. Irritants of all kinds, unripe fruits 
 and vegetables, and fermentation of food. 
 
DISEASES OF THE INTESTINAL CANAL. 83 
 
 Patholo^cal Anatomy. Cases in which death has occurred 
 within a few hours present no pathological changes. 
 
 Generally, however, the gastro-intestinal mucous membrane is con- 
 gested 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 cases 
 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 
 contents of the stomach, and the stools of ordinary faeces, but soon 
 the discharges by vomit and stool are liquid^ whitish or of a green or 
 yellowish tint ; if the attack is severe or protracted the discharges 
 partake of the "rice-water''' character. The patient is rapidly ^w«- 
 ciated and reduced in strength, the body shrinks, the surface cold and 
 covered with a clammy sweat, and the pulse 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 
 treatment, 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 an irritable stomach and bowels for a 
 week or two. 
 
 Grave cases, the true cholera type, recover from the prostration 
 very gradually ; reaction coming on slowly and usually passes 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 history. 
 
 Prognosis. In the majority of cases favorable. The mortality 
 is about five per cent. 
 
84 PRACTICE OF MEDICINE. 
 
 Treatment. At once, regardless of the cause, a hypodermic 
 injection of morphines sulph., gr. }i-}i> and atropincE suiph., gr. y^, 
 to be repeated in half an hour if no improvement; for patients who 
 object to the hypodermic mode, opium in some form by the mouth or 
 rectum, giving the preference to the liquid preparations. 
 
 Ca^nphora and opium combined often act well, or the diarrhoea 
 mixture mentioned on page 78, and if much depression, small doses 
 of brandy or dry champagne. 
 
 The intense thirst must not be gratified by the use of liquids, but 
 small pellets of ice by the stomach are grateful. 
 
 If the vomiting and purging continue, make use of — 
 
 Ji. Bismuth, subnit., gr- xx 
 
 Acid, carbol., gr. i^ 
 
 Glycerini, gtt. xx 
 
 Aquae, ad f^iv. M. 
 
 Every hour or two. 
 
 Dr. Hartshorne strongly recommends — 
 
 5t . Spts. amnion, aroraat. f^j 
 
 Magnes. optim., f_:^j 
 
 Aq. menth. pip., f^iv. M. 
 
 SiG. — ^j every twenty minutes. 
 
 If the case is seen early, and if the diarrhoea is copious, he adds 
 tinct. opa camph., f^iv, to the mixture. 
 
 The closer the case approaches the true cholera type, the more 
 severe are the muscular crajnps, and their treatment is indicated. 
 Prof. Da Costa suggests — 
 
 R. Chloral, _:^iv 
 
 Cosmoline, ^j. M. 
 
 To be rubbed over the affected muscles. 
 
 Dr. Bartholow suggests — 
 
 R. Chloral, ^iij 
 
 Morphine sulph., gr. iv 
 
 Aquoe, f^j. M. 
 
 SiG. — Twenty minitns, hypodermically. 
 
 Locally, sinapis, in the form of poultices or the dry powder, should 
 be applied from the onset. 
 
 The after treatment depends upon the symptoms ; generally an 
 acid mixture and a regulated diet, with tonic doses of quinina, are 
 indicated. 
 
DISEASES OF THE INTESTINAL CANAL. 85 
 
 ENTERO-COLITIS. 
 
 Synonym. Inflammatory diarrhoea. 
 
 DeJBnition. A catarrhal inflammation of the lower portion of the 
 small — ihum — 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. 
 
 Causes. Improper and indigestible food ; summer temperature ; 
 impure air ; uncleanliness ; exposure to cold and damp air. 
 
 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 close examination 
 such is found not to be the case. 
 
 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 inches in diameter, oval or circular in shape, and either have 
 sharp-cut edges, as though the piece of mucous membrane had been 
 cut out with a punch, or the mucous membrane bounding them is 
 undermined." The small ulcers often coalesce, so that large, irregu- 
 lar ulcerated patches are formed, having for their base the submucous 
 or muscular coats, and have a grayish-white color. 
 
 The mesenteric glands are enlarged, but seldom, if ever, undergo 
 ulceration. 
 
 Symptoms. Acute form ; may develop slowly, with restlessness 
 and fretfulness, or suddenly -with, feverishness, toss of appetite, thirst, 
 nazisea, moderate vomiting, abdominal /(^z>z / or rt^/^rr/^^^ may be the 
 first indication of illness on the part of the child. Regardless of the 
 character of the onset, \}[\q. stools soon present the characteristic appear- 
 ance ; they are semi-fluid, heterogeneous, greenish, acid, mixed with 
 
8^ PRACTICE OF MEDICINE. 
 
 yellowish fragynents of ordinary faeces, and tindigested casein, termed 
 the " chopped spinach " stools. The abdomen is enlarged 2in6. tender. 
 
 Emaciation is marked in proportion to the severity of the symptoms ; 
 in marked cases the child is reduced to a condition of the greatest 
 debility within a very few days. 
 
 Chrofiic form ; usually follows the acute form, the character of the 
 symptoms being less severe, but decidedly persistent, the strength 
 fails, the temper is very irritable, the complexion grows dark, sallow 
 and unhealthy, the skin dry and harsh, and in consequence of the 
 marked emaciation, either hangs in folds around the shrunken limbs, 
 or is drawn tightly over the joints ; the abdomen is enlarged and 
 tender, the stools numbering from six to a dozen during the day and 
 night, consisting of the products of an imperfect digestion mixed with 
 mucus, serum, pus, and oftentimes blood, having a semi-fluid con- 
 sistency, and an extremely offensive odor. 
 
 Duration. Acute, from ten days to about two weeks, subsiding 
 gradually ; chronic, from one to two or three months, or even longer. 
 
 Diagnosis. The acute form can hardly be mistaken for any 
 other condition, if the characteristic stools and other abdominal 
 symptoms are present. The chronic form has been frequently mis- 
 taken for diarrhoea of tuberculosis, an error that can hardly occur if 
 a physical examination of the chest has been made. 
 
 Prognosis. Always a very serious malady, and proves fatal if it 
 attacks the weak during midsummer, or when surrounded by unfavor- 
 able hygienic conditions ; in vigorous children, who have passed 
 through their first dentition, the prognosis is quite favorable. 
 
 Treatment. For the acute form, restricting the amount of food 
 for the first few days is of importance. Fresh, pure air, cleanliness 
 and rest are also of great importance. 
 
 Any one of the following formulae may be used with advantage : — 
 
 R. Calcii carbon, precip., 3J 
 
 Tinct, opii camph., '^.^ ss 
 
 Tinct. lavanduke comp., f^ij 
 
 Syr. gallae aromat., '.S'ss 
 
 Syr. acaciae, f^j. M. 
 
 SiG. — Teaspoonful, repeated every hour or two. 
 Or— 
 
 H. Tinct. opii camph., f.^'U 
 
 Tinct. catechu comp., ^.^iv 
 
 Mistune cretae., • fSiix* 
 
 SiG. — One or two teaspoonfuls, every hour or two. 
 
DISEASES OF THE INTESTINAL CANAL. 87 
 
 Or— 
 
 R- Bismuth subnit., ^iv 
 
 Pulv. acacise, 
 
 Sacc. alb aa q. s. 
 
 Syr. gallae aromat., f^j 
 
 Spts. vini gallici, f^ij 
 
 Aquas, ad fo"J- ^* 
 
 SiG. — One or two teaspoonfuls, every two hours. 
 Or— 
 
 R. Pulv. ipecac, g'"- X 
 
 Bismuth subnit., . . .ur. v 
 
 Cretae pr^p., g^- i'j- M. 
 
 SiG. — After each stool. 
 
 Many cases do well with pulvis kino comp., others with minute 
 doses, frequently repeated, of acidiun lacticum. 
 
 Locally, warmth to the abdomen, with mustard, turpentine stupes 
 or the spice poultice, made as follows ; cloves, allspice, cinnamon and 
 anise seeds, each half an ounce, pounded (not powdered) in a mortar, 
 and placed between two pieces of coarse flannel about six inches 
 square and quilted in ; soak this for a few minutes in hot brandy or 
 hot whisky and water, equal parts, and apply to the abdomen, heat- 
 ing a^ain as it becomes cool. 
 
 Y or chronic form; carefully regulated diet, rest and fresh air, and 
 one of the following formulae : — 
 
 R . Acidi carbolici, gr. yV~S" 
 
 Tincturse iodi, gtt. j-ij 
 
 Aquae menthae, 3J. M. 
 
 SiG. — Every three or four hours. 
 Or— 
 
 JJ. Tinct. calumbae, f^iij 
 
 Liq. ferri nitratis, TT^xxvij 
 
 Syrupi zingib., f^iij- M. 
 
 SiG. — One or two teaspoonfuls, according to age, every three or four 
 hours. 
 
 CHOLERA INFANTUM. 
 
 Synonyms. Choleriform diarrhoea ; summer complaint. 
 
 Definition. An acute catarrhal inflammation of the mucous 
 membrane of the stomach and intestines, together with an irritation 
 of the sympathetic nervous system, occurring in children during their 
 first dentition ; characterized by severe colicky pains, vomiting, purg- 
 ing, febrile reaction and prostration. 
 
88 PRACTICE OF MEDICINE. 
 
 Cause. Age ; bad hygiene, or as it is now entitled, " civic mala- 
 ria ; " continuous high temperature ; improper food; dentition; con- 
 stitutional, as in the feeble, delicate, nervous or irritable. 
 
 Pathological Anatomy. Resembles closely, if not identical 
 with, the phenomena of catarrhal gastritis and enteritis, together with 
 a powerful irritation of the fibres of the sympathetic system. 
 
 Syraptonis. The onset is sudden in a child previously well, or 
 in a child suffering from a bowel affection. 
 
 Begins with voiniiing, picrgiitg, aLbdommal/famf/ezfer, rapid pulse 
 and intense thirst. 
 
 The vojnited matter is partly digested food, sero-mucus, and finally 
 bilious, and is accompanied with distressing retching. The thirst is a 
 marked phenomena of the disease, and ice and water will be taken 
 incessantly, although rejected only a few moments after. 
 
 The stools are first partly fecal, but soon watery or serous, soaking 
 the clothing, leaving a faint greenish or yellowish stain ; their odor 
 is musty, at times fetid ; their number is from ten to twenty in the 
 day. 
 
 Pains precede the vomiting and purging, colicky in character. 
 
 The fever begins at once, the temperature varying from ioi° to 
 105°, with morning remissions. 1h.t pulse is rapid and feeble, rang- 
 ing from 130 to 160. 
 
 These symptoms continue but a few hours, before rapid wasting 
 ensues, the body shrinks, the eyes are sunken and partly closed, the 
 mouth partly open, the lips dry, cracked and bleeding. The child, 
 at first irritable and restless, passes into a semi-comatose condition, 
 the pulse becoming more and more feeble, the surface has a clammy 
 coldness, the contracted pupils not responding to light, and the stupor 
 deepens, death soon following, or the symptoms slowly ameliorate, 
 convalescence being slow and tedious. 
 
 Diagnosis. The entero-colitis or inflammatory diarrhoea of child- 
 hood is constantly being mistaken for cholera infantum. The symp- 
 toms of the former are : gradual onset ; W\\.\\fretfulness, loss of appetite, 
 feverishness, nausea, and moderate vomiting, soon followed by diar- 
 rhoea, the stools being semi-fluid, greenish, mixed with yellowish par- 
 ticles of faeces and undigested casein, with a sour odor, the "chopped 
 spinach " stools, the abdomen distended and tender, moderate fever 
 and thirst, and having a duration of about two weeks. 
 
 Prognosis. Difficult to predict the result, and so care must be 
 
DISEASES OF THE INTESTINAL CANAL. 89 
 
 used in giving a prognosis. The duration of the choleraic symptoms 
 is short, under five days, but relapses are common, and the sequelae 
 are protracted. 
 
 Treatment. The first indication is to arrest the vomiting and 
 purging, for which use — 
 
 R. Bismuth subnit., gr, v-x 
 
 Mucil. acacise, J^ss 
 
 Acidi carbolici, gr. j-i^-^ 
 
 Tinct. opii deodorat., gtt. j 
 
 Mist, cretse, ^iss. M. 
 
 Every two hours for a child between one and two years. 
 
 Or— 
 
 R • Hydrargyri chlor. mit., S^- -^o 
 
 Bismuth subnit., gr. ij-v. M. 
 
 SiG. — A powder every half hour. 
 
 If these fail, or the stomach will not retain them, /z>zr/. o^iz may be 
 given by the rectum, with sifici siilph. and amylum. 
 
 Cases that have resisted other remedies have rapidly improved 
 under the following : — 
 
 B- Tinct. verat. alb., f^^^ij 
 
 Morphinae acetat., .... gr. ij. 
 
 Spts. vini gallici, fjij- M. 
 
 Et adde ^j to 
 
 Aquae calcis, 
 
 Aquse menthae, aa f^j. M. 
 
 SiG. — One teaspoonful, repeated every hour, if needed. 
 
 The diet must be restricted in amount : for the first day or two 
 gtt. v-xxx brandy in barley water at frequent intervals will be all 
 that is required. 
 
 Yor fever, quinijia or aco7iituni are indicated. 
 
 For depression, regulated nursing or feeding, every two hours, 
 and water or ice to quench the intense thirst, and cognac brafidy, 
 gtt. x-xxx, every hour or two, in water. 
 
 Locally ; over epigastrium, mustard or a spice poultice, or turpen- 
 tine stupes. 
 
 If the ftervous symptoms become aggravated, small dose oi potassii 
 bro?7zidum, or valerian, which " reduces the reflex excitability, motility 
 and sensibility," is indicated. 
 
90 PRACTICE OF MEDICINE. 
 
 ACUTE DYSENTERY. 
 
 Svnonyms. Colitis ; colonitis ; ulcerative colitis ; bloody flux. 
 
 Definition. An acute inflammation of the mucous membrane of 
 the large intestines, either catarrhal or croupous in character ; charac- 
 terized by fever, tormina, tenesmus and frequent, small, mucous and 
 bloody stools. 
 
 It occurs either in the sporadic, endemic or epidemic form. 
 
 Causes. Sporadic and endemic dysentery is caused most com- 
 monly by atmospheric changes, such as hot days with cool nights ; 
 also from malarial attacks, and rarely from errors in diet. 
 
 Epidemic dysentery prevails in armies, jails and tenement houses, 
 propagated by decomposition of dysenteric stools^ and the unfavorable 
 hygienic surroundings. 
 
 // is not contagious. 
 
 Pathological Anatomy. Sporadic dysentery is catarrhal in 
 character ; congestion, swelling and oedema of the mucous membrane 
 and sub-mucous tissue, with an over production of mucus ; the folli- 
 cles are enlarged, from retention of their contents, the result of the 
 swelling ; the congested vessels often rupture ; the mucous membrane 
 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. 
 
 Epidemic dysetitery is croupous in character ; begins with intense 
 congestion, swelling, and oedema of the mucous and sub-mucous tis- 
 sue, with extravasations of blood and the whole mucous membrane 
 covered with a firm, fibrinous exudation ; the mucous membrane 
 softens and sloughs, leaving large ulcers and gangrenous spots. If 
 recovery occur, large cicatrices form, which narrow the calibre of the 
 intestinal tube. 
 
 The mesenteric glands enlarge, soften, and abscesses form in them ; 
 the liver becomes the seat of small abscesses, from embolic obstruc- 
 tion of the radicles of the portal vein ; the heart muscles are flabby 
 and more or less fatty. 
 
 Symptoms. Catarrhal form begins gradually, with diarrhoBa, 
 loss of appetite, nausea, and very slight fever, which continues for two 
 or three days, when the true dysenteric syxr\\)\.oms develop, to ^\\.,pain 
 on pressure along the transverse and descending colon, tormina or 
 colicky pains about the umbilicus, bur nitig pain in the rectum, with 
 the sensation of the presence of a foreign body and a constant desire 
 
DISEASES OF THE INTESTINAL CANAL. 91 
 
 to expel it, or tenesmus, which is almost constant ; the stools for the 
 first day or two contain more or less fecal matter, but they soon 
 change to a grayish, tough, transparefit inucus, containing more or 
 less blood and pus ; during the tormina, nausea and vomiting may 
 occur ; the urine is scanty and high colored ; the number of stools 
 range from five to twenty or more in the twenty-four hours. 
 
 The duration is about one week, the patient being much emaciated 
 and enfeebled. 
 
 The croupous or epidejnic form sets in suddenly, the stools being 
 more frequent, containing more blood and pus, with patches of mem- 
 brane, even casts of the bowel, together with more or less gangrenous 
 mucotcs membrane ; nausea, vojniting, and great prostration, cold 
 skin, feeble ptdse, and e7naciation with anxious expression, the odor 
 surrounding the patient being fetid. 
 
 The duration of the grave symptoms is three or four days, when 
 collapse and death occur, or slow convalescence begins, continuing 
 for weeks. 
 
 Coniplications. Peritonitis; hepatic abscesses ; phlebitis of the 
 intestinal veins ; intestinal perforation. 
 
 Diagnosis. Enteritis lacks the tenesmus and characteristic 
 stools. 
 
 Peritonitis, when idiopathic, shows higher temperature, greater ten- 
 derness and constipation. 
 
 Prognosis. Catarrhal form favorable. Croupous form, the prog- 
 nosis always grave, for if recovery does occur the bowel may be 
 crippled, from loss of structure, or from narrowing of its calibre, the 
 result of cicatrices. 
 
 Treatment. Emaciation being rapid, the diet must be of the 
 most nourishing yet bland character, to which stimulus should be 
 added if much prostration occur. 
 
 The most common treatment is opium, combined with one or more 
 astringents, to wit : — 
 
 R . Ext. opii, gr. ss 
 
 Plumbi acetat., gr- ij- M. 
 
 Every two hours ; or — 
 
 R . Pulv. opii, gr. ss 
 
 PlumV^i acetat., gr- ij 
 
 Pulv. ipecac, g""- j- M. 
 
 Every two hours ; 
 
9^ PRACTICE OF MEDICINE. 
 
 Or — R . Pulv. ipecac et opii, gr. x 
 
 Bismuth subnit., gr. xx. M. 
 
 Ever}' two hours. 
 
 If the case is seen early the very best prescription possible is — 
 
 R. Magnesii sulph., 3J 
 
 Acid, sulph. dil., V\v 
 
 Tinct. opii deodorat., n^x 
 
 Aquae menth., ,^ij. M. 
 
 Every two or three hours, until faeces appear in the stools, when 
 small doses of opium and quini7ia may be used. 
 
 Ipecacua7iha in gr. xx-xl, is largely used in the first stages of dys- 
 entery, until the characteristic ipecac stools appear ; the first doses 
 being often rapidly rejected by the stomach, the treatment is difficult 
 to pursue outside of hospital practice ; but of its efficacy in many 
 cases there can be no doubt. 
 
 Dr. Loomis speaks strongly of ipecaua?tha, gr. %. every half-hour, 
 with sufficient opium to secure quietness. 
 
 Ringer recommends hydrargyri chloridum corrosivum, gr. ^^, 
 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 efficacious : — 
 
 R . Pulv. ipecacuanha, SV- /^ 
 
 Bismuth subnit., gr. v 
 
 Cretse prep., gr- "j* M- 
 
 SiG. — Every two hours. 
 
 The patient should be confined to bed in even the mildest attacks, 
 and the stools removed at once and disinfected. 
 
 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. 
 
 Lingering or chronic cases are benefited by one or any of the fol- 
 lowing remedies : Terebinthina, acidum carbolicum, argentum 7tiiras, 
 cupri siclphas, or zinci oxidum. 
 
DISEASES OF THE INTESTINAL CANAL. 93 
 
 TYPHLITIS. 
 
 Synonyms. Inflammation of the caecum; catarrh of the caecum. 
 
 Definition. A catarrhal inflammation of the mucous membrane 
 of the caecum and ascending colon ; characterized by pain, tender- 
 ness, constipation, and in certain cases a characteristic vomiting. 
 
 Causes. In a majority of cases mechanical, from the lodgment 
 of seeds or hardened faeces. 
 
 Pathological Anatomy. Similar to the catarrhal inflammation 
 of dysentery. 
 
 Symptoms, Pain and tenderness in the right iliac fossa and 
 along the ascending colon, with some prominence of this region; the 
 bowels are usually constipated, or small liquid stools may occur from 
 time to time, due to the accumulation of hardened faeces in the saccu- 
 lated periphery of the caecum, leaving a central canal through which 
 the liquid contents of the upper bowel can pass. 
 
 In severe cases, "the \0c2l pain, tenderness 2ind. swelling zxq greater, 
 there are impaction oi fceces and no movements. There are decided 
 fever, restlessness, and also nausea and vomiting. The vomited mat- 
 ters, at first the contents of the stomach, then the duodenum, with 
 bilious matter, and ultimately, if the impaction persists, of material 
 having the odor of faeces. With these symptoms occux great depres- 
 sion of the vital powers. Peritonitis is finally developed by contiguity 
 of tissue or by rupture of the bowel." 
 
 Duration. The mild form lasts about one week. The severe 
 form may terminate in subacute peritonitis, continuing about two 
 weeks. 
 
 Diagnosis. The mild form 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 for?n idiVorzhlQ. Severe for tn gxdiYe., 2L\ih.owgh. 
 not necessarily fatal. 
 
 Treatment. The patient should be kept in bed, and placed on a 
 strictly milk diet. 
 
 In mild cases, act upon the bowels, with either oleum ricini or mag- 
 nesii sulphas in small doses, followed by an opium influence, to be 
 maintained until convalescence is pronounced. 
 
94 PRACTICE OF MEDICINE. 
 
 In severe cases, begin an opium influence at once, by hypodermic 
 injections of morphina guarded with atropiiia, continued until all 
 symptoms of inflammation have subsided, when attempts to remove 
 the accumulated faeces may be made by irrigation of the bowel with 
 warm soapsuds, and the cautious administration of viagnesii sulphas 
 in drachm doses, every two hours. 
 
 If suppuration develop, laparotomy with strict ^«//J(?//zV precautions 
 is the indication. 
 
 Locally. Leeches over the caecum followed by hot fomentations or 
 ice bags, or cold compresses. 
 
 PERITYPHLITIS. 
 
 Synonyms. Perityphlitic abscess ; suppurative appendicitis ; 
 pericaecal abscess. 
 
 Definition. An acute inflammation of the connective tissue 
 around the caecum, tending to the formation of an abscess ; charac- 
 terized by pain, swelling, and febrile reaction. 
 
 Causes. Injuries to the abdomen over the caecum ; and also 
 extension of the inflammation from the caecum by perforation. Often 
 occurs with typhlitis. 
 
 Symptoms. Begins with 2^ feeling of weight, soreness 3.nd parox- 
 ysms of acute pain extending into the hip, thigh and abdomen, with 
 the development of a hard swelling in the right iliac region. Its 
 special tendency is toward suppuration, which is announced by irreg^ 
 ular chills, feverishness, and sweats, and a feeling of tensiott and 
 throbbing. Its development is slow, and if associated with typhlitis 
 the symptoms of that affection are added. 
 
 Diagnosis. Differs from typhlitis by the absence of the colicky 
 pains, dyspeptic symptoms, costive bowels, and tympanites preceding 
 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 fecal odor. Rental 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 
 painting with tinctura iodi ; if suppuration is evident, hasten hy poul- 
 
DISEASES OF THE INTESTINAL CANAL. 95 
 
 tices, and follow by evacuation of the pus with the aspirator or 2. free 
 opening, conjoined with the use of opium and quinina. 
 
 If the disease is not rapidly controlled, a laparotomy with strict 
 antiseptic precautions is indicated. 
 
 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 frequent 
 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 of purgatives ; diseases of 
 the liver. 
 
 Patholog'ical Anatomy. Similar to those occurring in catar- 
 rhal dysentery. 
 
 Symptoms. Uneasy sensations and burning in the rectum, with 
 a constant desire for stool, or tenesjnus, often so severe as to cause a 
 prolapse of the mucous membrane. The stools may be either hard- 
 ened fceces or scybala from the distended colon, which cause inte?ise 
 pain when they reach the rectum ; or the stools may be of mucus, 
 muco-pus 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 con- 
 nective tissue around the rectum occurs, causing periproctitis, which 
 usually terminates in various kinds of fistulae. 
 
 Complications. Periproctitis ; peritonitis ; hepatic abscesses. 
 
 Diagnosis, In ?nales, the disease cannot be confounded with 
 any other affection, save, perhaps, hemorrhoids. In females, dis- 
 placements of the uterus may somewhat simulate the symptoms of 
 proctitis. 
 
 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, for which the magjiesia mixture mentioned for 
 dysentery is the most suitable remedy ; after which emollient ene- 
 mata, with opiujn, are indicated. Irrigation of the bowel with warm 
 
% PRACTICE OF MEDICINE. 
 
 water once or twice daily assists in the liquefaction of the hardened 
 faeces. Either enemata or suppositories oi glyceri?iwn should answer 
 in certain cases. 
 
 Cases other than those due to constipation, emollient enemata and 
 opium, one of the best being — 
 
 R . 01. olivx, ^ ij 
 
 Tinct. opii deodorat., TT\,xv. M. 
 
 If symptoms oi periproctitis occur, use ice to the parts, and if sup- 
 puration ensue, evacuation by a free opening and quinina. 
 
 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 
 collapse. 
 
 Causes. The numerous causes are arranged as follows : — 
 
 1. Accumulations withift 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. 
 
 4. Stra7igulations , due to the numerous forms of hernia. 
 
 5. Invagination or intussusception, the most common. 
 
 6. Twisting, volvulus or rotation of the bowels. 
 Pathological Anatomy, hivagijtation is the only form calling 
 
 for special description. 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 
 ox gradual, and are as follows : — 
 
DISEASES OF THE INTESTINAL CANAL. 97 
 
 Constipation, with more or less severe colicky pains, not relieved by 
 either purgatives or injections ; feeling of weight and soreness with 
 distention of the abdomen and naiisea and vomiting ; the symptoms 
 all grow more pronounced, the pain becoming violent, tetiderness in 
 limited areas, the vomiting becoming stercoraceoiis, the abdomen hard 
 and tense, the eyes siitiken, the pulse quick and feeble, the skin cold 
 and covered with a clammy sweat. The above continue 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, fecal, 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 site of the occlusion can rarely be determined 
 positively. 
 
 Intestinal obstruction may be mistaken for i7itestinal colic, hernia, 
 enteritis, peritonitis, hepatic or renal colic. 
 
 Prognosis. Always grave, but guided by the cause. Impacted 
 fceces favorable. Invagination less favorable, but recoveries occur ; 
 the longer the symptoms continue, the more favorable the outlook. 
 Strangulations unfavorable, but many recoveries recorded. Strict- 
 ures, due to cancer, cicatrized ulcers and the like, are the most 
 unfavorable. 
 
 Treatment. Stop all forms of purgatives as soon as the diagnosis 
 of obstruction is determined. 
 
 Opium is indicated in all forms with pain, and is best administered 
 in the form of morphina, combined with small doses of atropina, 
 hypodermically. 
 
 The author has seen the most brilliant results follow the plan of 
 wasJmig out the stomach as suggested by Kiissmaul, and with full 
 doses of atropina hypodermically, for its action on intestinal peristal- 
 sis, and with electricity, one pole over abdomen, the other in rectum. 
 
 Cases resulting from impacted faeces are rapidly cured by the above 
 plan combined with irrigation of the lower bowels with tepid soap- 
 suds. 
 
 If invagination, raising the buttocks and lowering the chest, and 
 repeated ittjections of warmed oil, are recommended. 
 
 Distention of the bowel by pwnping air through long rectal tubes, 
 or disengaging carbonic acid gas in the bowel, by first injecting a 
 8 
 
98 ' PRACTICE OF MEDICINE. 
 
 solution of sodii bicarbonas, and follow this with a solution of acidinn 
 tartaricitm, about one drachm of each, pressure being made against 
 the anus, to prevent escape ; but the danger of rupture of the bowel 
 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 nutritioti of the patient is best attained by injections of either 
 peptonized foods or defibrinated blood, or both. 
 
 INTESTINAL PARASITES. 
 
 TAPEWORMS. 
 
 Varieties. Tcenia solium ; Tcsnia sagiftata ; Bothriocephalus 
 latus. 
 
 Causes. The Tcznia solium, the " armed tapeworm," is the most 
 common in this country. It is derived from the embryos contained 
 in pork, known as the cysticercus cellulosus. 
 
 The Tcenia saginata, the "unarmed tapeworm," a not uncommon 
 variety, is derived from the embryos contained in beef, known as 
 cysticercus bovis. 
 
 The Bothriocephalus latus, also "an unarmed tapeworm," the 
 largest parasite infesting man, is supposed to be derived from an 
 embryo found vafish. 
 
 The embryo or ova is introduced into the intestinal canal with the 
 food and drink. The parasite reaches its final growth after its en- 
 trance 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 tcetiia solium is from six to thirty feet in length, 
 has a globular head, or scolex, a slender neck connecting its numer- 
 ous flat segments or joints. The head, or scolex, measures about -^^ 
 of an inch, has a double circle of booklets, — whence the term " armed 
 tapeworm," — and is provided with from two to four suckers. The seg- 
 ments or joints {strobila) are flat, and vary from one-eighth to one- 
 
INTESTINAL PARASITES. 99 
 
 half an inch in length, and each contain both male and female sexual 
 organs, the uterus being a long, numerously branched tube, in which 
 the ova develop ; the ova measure about yJ^o of an inch in diameter. 
 An .ordinary tapeworm contains some five million ova. 
 
 The parasite is firmly imbedded 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 f^ces. 
 
 The tcBnia 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 no booklets, — whence the term 
 " unarmed tapeworm ; " the neck is short and thick and the segments 
 are larger, stronger and thicker than those of the T. 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. 
 
 Symptoms. Not unfrequently a tcenia produces no symptoms 
 whatever. 
 
 Usually, however, there are colicky pains throughout the abdomen, 
 inordinate appetite, disorders of digestion, emaciation, constipation, 
 attacks of cardiac palpitation, faintness, disorders of the special senses 
 and pruritus of the anus and nose. Any or all of these symptoms 
 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 segments 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, to 
 wit: extractum granati rad. cort. fiuidum, f^ss-ij, or a decoctum 
 granati rad. cort. (5ij bark of root, aquas Oj), wineglassful every 
 hour until all is taken, as suggested by Prof. Bartholow ; or oleoresifia 
 aspidii, 5ss doses repeated, or oleum pepo express., 3j-iv. followed 
 by oleum ricini. Creosota has been successful in a number of cases. 
 Several cures are reported {xoxvl glycerinum, f3ij-5J, repeated p. r. n, 
 
 A much pleasanter remedy is pelletierine, the active constituent of 
 
lOQ PRACTICE OF MEDICINE. 
 
 granatin}!, used in the form of the tafmate, gr. x-xx, or Tanrefs solu- 
 tion of pelletierine. 
 
 Cases which resist these nieans are often cured by the following : — 
 
 B; . Chloroformi, 
 
 Ext. aspidii fid., aa f^j 
 
 Emul. olei ricini, . . . . (B. Ph.) . . . . 5iij. M. 
 
 SiG. — To be taken in the early morning ; no food until after thorough 
 action of the bowels. 
 
 An important precaution in the management is close attention to 
 the "preparatory treatment" rendered essential to remove the mucus 
 in which the head (scolex) is imbedded. It consists in the adminis- 
 tration of a good purgative for one or two days, and a light diet, such 
 as milk and broths, preceding the use of the tceniafuge. 
 
 ROUND WORMS. 
 
 Varieties. Ascaris lumbricoides ; Oxyuris ver?nicularis. 
 
 Causes. The ascaris hunbricoides 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 oxyicris 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 lumbricoides, or the round worm, is of 
 a brown 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 worjn 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 
 
INTESTINAL PARASITES. 101 
 
 terminating as a sharp point. The ova are oval, produced in large 
 numbers, each female containing about ten thousand, are surrounded 
 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. 
 
 Sjrmptoms. The ascaris lumbricoides, or round worm, may be 
 present in great numbers and yet produce no characteristic symptoms 
 other than gastric and intestinal irritation, such as 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, 
 the only positive proof being the passage of the parasite. 
 
 The oxytiris ver?nicularis, or seat worm, produces intense itching 
 about the anus, with a desire for stool, the passage 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 result, which, unless speedily corrected, leads in children to 
 masturbation. 
 
 Treatment. The ascaris lumbricoides are readily removed by 
 the following " worm powder " : — 
 
 R. Santonini, gr. X-j-ij 
 
 Hydrargyri chlor. mite, gr. ^-ij. M. 
 
 Ft. chart. 
 
 SiG. — At bedtime, followed by a dose of oleum ricini before breakfast. 
 
 For the oxyuris vermicularis the above santonimim powder, with 
 the use of enetnata of quassia, alumen, sodii chloridtan, or R., acidi 
 carbolici, gr. v-x, aqu83, Oj, according to the age, the injection not to 
 be retained. Washing the anus and external genitals with a solution 
 of acidum carbolicum should also be employed. 
 
102 PRACTICE OF MEDICINE. 
 
 DISEASES OF THE PERITONEUM. 
 
 PERITONITIS. 
 
 Synonym. Inflammation of the peritoneum. 
 
 Definition. A fibrinous inflammation of the peritoneum, either 
 acute or chronic in character, characterized by fever, intense pain, 
 tenderness, tympanites, vomiting and prostration. It may be limited 
 to a part — local, or it may involve the whole membrane — general, 
 peritonitis. 
 
 Causes. Acute variety : Intense cold ; protracted irritation by 
 blisters ; blows upon the abdomen ; inflammation or perforation of 
 the stomach, intestines, gall or urinary bladder ; vermiform appendix 
 or inflammation of this part or the surrounding parts ; inflammation 
 of the pelvic viscera ; septicaemia or pyaemia ; erysipelas ; hernia. 
 
 Many surgeons doubt that peritonitis is ever an idiopathic disease, 
 but that rarely it does so occur is certain. 
 
 Chronic variety : Tuberculosis ; albuminuria ; scrofula ; cancer ; 
 sclerosis of the liver. 
 
 Pathological Anatomy. Acute form : hypersemia 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. 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. 
 
DISEASES OF THE PERITONEUM. 103 
 
 Symptoms. Acute form ; when idiopathic, the onset is sudden, 
 with a chill, fever, \02-'^ , pulse 100-140, wiry and tense, severe pain, 
 cutting or boring in character, and tenderness, becoming so great that 
 the shghtest touch aggravates it, the decttbitus being on the back, with 
 flexed thighs ; the abdomen is distended and rigid, from constipation, 
 effusion 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 impaired 
 appetite, and nausea and vomiting are almost constant, as is hiccough. 
 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. 
 li from perforatioji, it is announced by severe pain and all the symp- 
 toms of shock. If pus forms, symptoms of hectic develop. 
 
 These symptoms continue from six to eight days, when they begin 
 to ameliorate and a tedious convalescence ensues, or pain and tender- 
 ness grow more marked, strength fails, surface cold, pulse rapid, and 
 collapse, with hippocratic face, to wit : anxious expression, pinched 
 features, sunken eyes and drawn upper lip. 
 
 Chronic form : irregular chills, fever znd sweats; distended abdo- 
 men, constipation, alternating with diarrhoea ; diffused tefiderness, 
 \f'\\.h. points of i?itenseness and hardness ; colicky pai?ts during diges- 
 tion, 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 this disease is of great 
 importance, as it so frequently, if not always, is associated with the 
 diseases and accidents of the abdomen. Acute gastritis differs from 
 peritonitis in having a history of corrosive 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 with marked 
 diarrhoea ; constipation being the rule in peritonitis. 
 
 Rheumatism of the abdominal muscles occurs with a rheumatic his- 
 tory, is subacute, lacks the great abdominal distention of peritonitis, 
 and while tenderness exists, it is not aggravated by deeper pressure. 
 
104 PRACTICE OF MEDICINE. 
 
 Biliary colic, or the passage of a gall-stone, has, as a prominent 
 symptom, excruciating pain, locahzed over the common bile duct, 
 which is of a paroxysmal character and followed by jaundice. In 
 renal colic the acute pain follows the course of the ureters, with re- 
 tracted testicle and altered urinary secretion. 
 
 Prognosis. Idiopathic cases favorable, and especially if they 
 continue longer than a week, as fatal cases usually end during the 
 first week. Cases from perforation unfavorable. 
 
 Chronic peritonitis being generally of tuberculous origin, the prog- 
 nosis is unfavorable, although partial or complete recovery results in 
 the cases following the acute form of the disease. 
 
 Treatment. Actcte form : Idiopathic and robust cases, locally, 
 leeches or wet cups, followed by cold or hot applications, as most 
 agreeable to the patient, or covering the abdomen with a blister ; 
 adynamic cases, dry cups, followed by warm applications medicated 
 with tinctura opii. 
 
 The profession are divided between two plans of treatment of peri- 
 tonitis, one side favoring opium and the other party as strongly urging 
 saline purgatives and laparotomy. 
 
 Prof. Da Costa says opium and guittifta are the remedies indicated 
 at the onset of the disease, to wit : at once hypodermic of jnorphina, 
 gr. X~/^» maintaining the effect by hourly doses of either ?norphina 
 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 grs., the second day 472 grs., 
 the third day 236 grs., fourth day 120 grs., fifth day 54 grs., sixth day 
 22 grs., and on the seventh day 8 grains. Prof. Clark found that, 
 as a rule, however, jnorphina, gr. ye-%, every two hours, would 
 maintain the effects of the drug. The opium should be guarded 
 with sufficient doses of atropina. Quinina, gr. v, every four hours 
 until exudation, after which gr. ij, four times a day, is of marked 
 benefit. 
 
 While the opium treatment places the patient as well as the bowels 
 "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, thereby 
 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- 
 
DISEASES OF THE PERITONEUM. 105 
 
 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 with strict antisepsis is indicated. 
 
 The decline of vital powers must be averted by regulated nutri- 
 tion, diVidfree stimulation. 
 
 Locally, an ointment of belladonna and hydrargyrum, are of advan- 
 tage. 
 
 During convalescence, perfect quiet, nourishing diet, moderate stim- 
 ulation, scattered flying blisters, and the following — 
 
 5c . Potassii iodidi, gr. v-x 
 
 Ferri pyrophos., gr. ij 
 
 Tinctura lavandulae comp., TT\^xv 
 
 Aquae destillat£e, ad .... ^ij. M. 
 
 Every six hours. 
 
 should constitute the treatment, with tonic doses of guinina. 
 
 Peritonitis from perforation, absolute quiet, hypodermic injections 
 of morphina, ice locally, and stimulants per mouth, rectum, or hypo- 
 dermicaliy, and laparotomy. 
 
 Chronic peritonitis ; locally tinctura iodi, and internally opium, for 
 pain ; potassii iodidum as an absorbent, with nourishing diet, oleum 
 7norrhua> and stimulants, and rest in bed. 
 
 ASCITES. 
 
 Synonyms. Dropsy of the abdomen ; peritoneal dropsy. 
 
 Definition. A collection of serous fluid in the abdomen, or more 
 correctly in the peritoneal cavity ; characterized by swollen abdomen, 
 fluctuation, dullness on percussion, displacement of viscera, embar- 
 rassed respiration,//?^^ the symptom.s 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 ?nechani- 
 cal obstruction of the portal system, from cirrhosis of the liver, tumors, 
 diseases of the heart or lungs. 
 
 Pathological Anatomy. The quantity of fluid in the perito- 
 neal sac ranges 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 
 
 9 
 
106 PRACTICE OF MEDICINE. 
 
 points to cancer as a cause. The peritoneum betomes cloudy, sodden, 
 and thickened, from long contact with the fluid. 
 
 Symptoms. The onset is insidious, and considerable swelling 
 of the abdo/nen occurs before the disease attracts attention. Constipa- 
 tion, from pressure of the fluid on the sigmoid flexure. Scanty t^ritte, 
 from pressure on the renal vessels. Embarrassed respirati07i and car- 
 diac action, from pressure on the diaphragm upward. The iwtbilicus 
 is forced outward. 
 
 Physical signs ; on palpatioti, 2i peculiar wave-like impulse is im- 
 parted to the hand laying 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 tyynpanitic note 
 above ; if the patient turns on his side the fluid changes, and dullness 
 over the fluid, tympanitic over the distended intestines. 
 
 Diagnosis. Ovarian tumors differ from ascites in the history, 
 in that the enlargement is limited to the iliac fossa, instead of a uni- 
 form 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 mammse, change in the 
 neck of the uterus, absence of fluctuation, and the presence of the 
 sounds of the foetal heart. 
 
 Diste7ition of the bladder has 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. 
 
 Chronic peritonitis is differentiated by the history, pain, tenderness, 
 more or less vomiting, thickened abdominal walls, and its generally 
 being associated with tubercle or cancer. 
 
 Chronic tympanites presents the enlarged abdomeri, 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. 
 \^ peritoneal, generally favorable. If from organic disease, most 
 unfavorable, for while the [dropsy may be removed, it as rapidly 
 returns. 
 
DISEASES OF THE BILIARY PASSAGES. 107 
 
 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, to wit '.first, 
 by hydragogue cathartics, second , d\\irQt\cs, and third, tapping. The 
 first and second modes may be combined, as follows : — 
 
 R. Pulv. jalapse comp., 5J-ij- 
 
 In water, an hour before breakfast ; 
 
 And — R . Potassii acetat., gr. x-xx-xl 
 
 Tinct. scillae, 5 ss 
 
 Infus. digitalis, f^iss. M. 
 
 Every six hours. 
 
 Or instead use the following : — 
 
 1^ . Hydrargyri chlor. mite, gr. iij 
 
 Ext, opii, gr. -^-^. M. 
 
 Et ft. pil. 
 
 SiG. — 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 better still, the aspirator. 
 
 DISEASES OF THE BILIARY PASSAGES. 
 
 CATARRHAL JAUNDICE. 
 
 Synonyms. Catarrh of the bile ducts ; icterus. 
 
 Definition. An acute catarrhal inflammation of the mucous mem- 
 brane of the bile ducts and of the duodenum ; characterized by 
 gastro-intestinal derangement, yellowness, itching of the skin, fever- 
 ishness 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 hyperaemic, 
 swollen and thickened, from an efl"usion of serum into the submucous 
 
lOS PRACTICE OF MEDICINE. 
 
 tissue ; the result of this condition is the closure of the biliary- 
 passages, 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, impaired 
 appetite, nausea, with, perhaps, vomiting and loose?iess of the bowels 
 and slight feverishness, the phenomena of a gastro-intestinal catarrh. 
 In from three to five days the eyes become yellow, and jaundice 
 gradually appears over the whole body ; the feverishness disappears, 
 the skin becomes harsh, dry and itchy, the bowels constipated, the 
 stools whitish or clay-colored, accompanied with much Jiatus and 
 colicky paifis; the uriyie 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 blue, violet, red, and yellow, or 
 brown. 
 
 When the jaundice is complete, the surface is cold, the heart's 
 action slow, the mind torpid and greatly depressed, and pain or ten- 
 derness on pressure over the hepatic region. 
 
 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. After the appearance of the jaundice, mistakes are 
 impossible. 
 
 The numerous diseases of which jaundice is a symptom will be 
 differentiated when treating of them. 
 
 Prognosis. Always favorable ; if the attacks are of frequent 
 occurrence, however, they are apt to lead to organic hepatic changes. 
 
 Treatment. At the onset, quinina, gr, x, morning and night, 
 may modify the disease, but as soon as the diagnosis is established 
 the indications are for diaphoretics, diuretics 2ir\d purgatives. 
 
 For diaphoresis, the warm bath, to which potassii carbonas, 5J, 
 may be added, morning and night. 
 
 For diuresis, potassii bitartras lemo7iade, every four hours. 
 
 Y ox purgatives, c\\hQr sodii Pyrop ho s., 3j-iji every four hours, well 
 diluted, ammonii murias, gr. xv-xx, every five hours, well diluted, 
 
DISEASES OF THE BILIARY PASSAGES. 109 
 
 magnesii sulphas, gr. xx, every couple of hours, or hydrargyri 
 chloridi mite , gr. ^, every hour until free purgation. 
 
 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 dislodge the mucous lining ob- 
 structing the gall ducts. When the bile flows into the intestine, diges- 
 tion is resumed and the catarrhal inflammation subsides." Other 
 remedies maybe conjoined with the irrigation method. 
 
 Restricted diet, avoiding all starchy, fatty or saccharine articles, 
 milk being the most suitable article of diet. 
 
 For convalescence — 
 
 Ut . Acid, riitro-hydrochlorici dil., gr. v-x 
 
 Elix. taraxaci comp , 3J-ij- M. 
 
 Before meals. 
 
 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 attempts 
 to pass along the ducts, when an attack of 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. Hepatic colic begins suddenly, at the moment a 
 gall stone passes from the gall bladder into the cyst 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 
 
ILO PRACTICE OE MEDICINE. 
 
 shoulder ; the abdominal muscles are crainped and tender ; there is 
 7iaiisea and vomitmg, a small, feeble 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. 
 
 faundice 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 
 consQ(\\itn\. peritonitis follow, the calculi discharging by the intestine, 
 stomach, or through the abdominal walls. 
 
 Diagnosis. The malady should not be mistaken if severe pai7i, 
 diverging from the hepatic region, and nausea and vomitiJig are 
 present, suddenly terminating, and followed by slight Jau?idice. 
 
 Prognosis. Usual termination is in health. The prognosis be- 
 coming more unfavorable if ulcerative perforation result. 
 
 Treatment. For the colic, hypodermic injections of morphina, 
 gr. Ye-yi-yi, combined with atropina, gr. y^^, and warm fomenta- 
 tions over the hepatic region, are indicated. 
 
 Prof. Bartholow strongly urges the following prophylactic treat- 
 ment : Carefully regulated diet, abstinence from all fatty and sac- 
 charine substances, daily exercise, stoppage of all excesses, and the 
 long use oi sodii pkosphas, Z], before meals, well diluted, to which 
 may be added, if gastro -intestinal catarrh be present, sodii arsenias, 
 gr. ^^^, or aurii et sodii chloridum, gr. -^^, together with either Vichy or 
 Saratoga Vichy water. 
 
 DISEASES OF THE LIVER. 
 
 CONGESTION OF THE LIVER. 
 
 Synonyms. Torpid liver ; biliousness. 
 
 Definition. An abnormal fullness of the vessels of the liver, 
 with consequent enlargement of that organ ; it is termed active 
 when arterial ; passive when venous. The condition is charac- 
 
DISEASES OF THE LIVER. Ill 
 
 terized by torpidity of the digestive and mental functions, and slight 
 jaundice. 
 
 Causes. Active congestion ; heat, atmospherical or artificial ; 
 habitual constipation ; malaria ; excess in eating and drinking ; alco- 
 holic or malt liquor. In females, an arrested menstrual epoch may 
 give rise to an attack. 
 
 Passive congestion ; cardiac and pulmonary diseases. 
 
 Pathological Anatomy. The liver is enlarged in all directions, 
 and is abnormally full of blood. Cases due to obstructive diseases 
 of the heart or lungs present the so-called " nutmeg liver," to wit: 
 " At the centre of each lobule the dilated radicle of the hepatic vein, 
 enlarged and congested, may be discerned, while the neighboring 
 parts of the lobule are pale," the radicles of the portal vein containing 
 less blood. 
 
 Long-continued congestion establishes atrophic degeneration of the 
 organ ; the decrease in size is confounded with the condition of cir- 
 rhosis, but the " atrophic liver " is smooth, while the " cirrhotic liver " 
 is nodulated. 
 
 Symptoms. Active congestion ; following cause, rapidly pro- 
 duced malaise, aching of limbs, evening feveriskness, headache, 
 depression of spirits, yellowish tongue, disgust for food, nausea, and, 
 may be, vomiting, constipation, scanty, high-colored uri7ie, with a 
 feeling oi fullness, weight and soreness in the hepatic region, with 
 dull pain extending to the right shoulder, and '^\<^t jaundice, the eye 
 yellow, and the complexion muddy. Duration about a week. 
 
 Passive congestion ; onset gradual, with a feeling of weight and 
 fullness in the hepatic region, slight jaundice, and symptoms of gas- 
 tro-intestinal catarrh. 
 
 On percussion the hepatic dullness is increased in all directions. 
 
 Diagnosis. Acute congestion is continually confounded with 
 catarrhal jaundice ; the latter begins with marked gastro-intestinal 
 symptoms and distinct jaundice ; in the former these are less marked. 
 
 Obstructive congestion is diagnosticated by the clinical history. 
 
 Atrophic or nutmeg liver will be differentiated from cirrhotic liver 
 when speaking of the latter. 
 
 Prognosis. Active congestioji favorable, unless repeated attacks 
 occur, rapidly succeeding each other, when " atrophic degeneration " 
 results. 
 
 Passive congestion controlled entirely by the cause. 
 
112 PRACTICE OF MEDICINE. 
 
 Treatment. Attacks due to excess in eating and drijiking — 
 
 R. Sodii bicarb., gr. v 
 
 Pulv. ipecac ; ' * gr. ss 
 
 Hydrargyri chlor. mit., gr. iij-v, 
 
 repeated, or sodii phospJiaiis, Z], every four hours until free catharsis, 
 or small doses of hydrargyri chloridi mite, with sodii bicarbotias 
 repeated several times, followed with saline, followed by — 
 
 R . Acidi nitro hydrochlorici dil., Tt\^viiss 
 
 Elix. taraxaci comp., ^ij. 
 
 Before meals, and a milk diet. 
 
 Attacks due to jnalaria ; the above purgative followed by qtcinincE 
 suiph., gr. iv, every four hours. 
 
 Attacks occurring with cardiac or pulmonary diseases must be 
 managed by treating the cause. 
 
 The tendency to constipation must be overcome by the saline lax- 
 ative waters, to wit : Congress or Hathorn, Pullna or Friedrichshall, or 
 sodii pJiosphas, 3j-'ji three or four times daily, well diluted. 
 
 Locally, in acute attacks, hot cloths or sinapisms are of benefit. 
 
 In chronic cases benefit follows elix. quinines, ferri et strychnince, 
 5j, three times a day, and great comfort and support is given by the 
 use of the '''hydropathic belt,'' which is made of stout muslin, shaped 
 to the abdomen, with cross pieces of tape on the inner side, which 
 keeps next to the skin a fold of cloth wrung out of cold water, and a 
 piece of waterproof cloth or oiled silk, to prevent evaporation. 
 
 In persons who seem to have a predisposition to attacks of con- 
 gestion of the liver upon the slightest exposure to any of the various 
 exciting causes, the habits and diet must be regulated, to which must 
 be added a course of alkaline waters and reg^ulated exercise. 
 
 ABSCESS OF THE LIVER. 
 
 Synonyms. Parenchymatous hepatitis ; acute hepatitis ; sup- 
 purative hepatitis. 
 
 Definition. A diffused or circumscribed inflammation of the 
 hepatic cells, resulting in suppuration, the abscesses being sometimes 
 single, at times double; characterized by irregular febrile attacks, 
 hepatic tenderness and symptoms of deranged gastro-intestinal and 
 hepatic functions. 
 
DISEASES OF THE LIVER. 113 
 
 Causes. The result of the absorption of putrid material by the 
 portal radicles in dysentery ; ulcers of the stomach ; malaria ; blows 
 and injuries; heat; pyaemia. 
 
 Pathological Anatomy. Hypersemia, swelling, effusion of 
 lymph, degeneration and softening of the hepatic cells ; suppuration, 
 beginning in points in the lobules and coalescing. The abscess walls 
 consist of the liver structure, more or less changed. 
 
 The abscess may advance toward the surface of the liver, bursting 
 into the peritoneum, intestines, stomach, gall bladder, hepatic duct 
 or vein, or into the pleura or lungs, or externally through the 
 abdominal walls; after the discharge of pus, cicatrization occurs, 
 or the pus may be absorbed, the tissues around forming a dense 
 cicatrix. 
 
 Symptonis, Very obscure. Fever simulating markedly inter- 
 mittent or remittent fevers ; disorders of the gastro-intestinal canal, 
 with obstinate vomiting, debility, and great irritability of the nervotis 
 system, melancholia, slight jaundice, constipation, the stools light col- 
 ored, and if of long duration, typhoid symptoms. 
 
 Locally, if the abscess is near the surface, ^r^;;/z«^;z^^ of the hepatic 
 region, throbbing, limited tenderness, and if it tends to the surface, 
 redness, oedema and fluctuation. The abscess may burst into the 
 intestines, stomach, lungs, or pleura, the symptoms of which will be 
 pronounced. 
 
 Diagnosis. Hepatic abscess may be confounded with hydatids 
 of the liver, hepatic or gastric cancer, abscess of the abdominal walls, 
 and purulent effusion in the right pleural cavity. 
 
 The differentiation is most difficult, but great aid is obtained from 
 the use of the aspirator. 
 
 Prognosis. Unfavorable. Recoveries, however, do occur. If 
 the abscess bursts into the lungs, bowels, or externally through the 
 abdominal wall, the case is more favorable. 
 
 Treatment. Symptomatic, and when pus is present, the use of 
 the aspirator to remove it, and sustaining treatment, to wit : quitiina, 
 ferricm, alcohol, and oleum morrhuce. 
 
114 PRACTICE OF MEDICINE. 
 
 ACUTE YELLOW ATROPHY. 
 
 S3nionyms. General parenchymatous hepatitis ; malignant jaun- 
 dice ; hemorrhagic icterus. 
 
 Definition. An acute, diffused or general inflammation of the 
 hepatic cells, resulting in their complete disintegration ; characterized 
 by diminution in the size of the liver, deep jaundice, and profound 
 disturbance of the nervous system ; terminating in death, usually, 
 within one week. 
 
 Causes. Unsettled. It occurs frequently in young pregnant 
 women, from the third to the sixth month of pregnancy. Other causes 
 are venereal excesses ; syphilis ; action of phosphorus, arsenic or 
 antimony. 
 
 Pathological Anatomy. Begins with hyperaemia of the he- 
 patic cells, with a grayish exudation between the lobules, followed by 
 softening, dull yellow color, and disappearance of the cells, fat glob- 
 ules taking their place. The liver is reduced in size and in weight. 
 The peritoneum covering the liver is thrown into folds. The spleen 
 is enlarged. The kidneys undergo degeneration. The blood con- 
 tains a large amount of urea and considerable leucin. The urine is 
 loaded with bile pigment, and contains albumin. 
 
 Symptoms. Prodromic period ; begins as a gasiro-intestinal 
 catarrh, coated tongue, nausea, vomiting, tenderness over the epigas- 
 trium, headache, quickened pulse, slight fever and s\\^\. jaundice. 
 
 Icteric period ; jaundice deepens, pulse slow, headache increases, 
 and great and obstinate sleeplessness. 
 
 To xcemic period ; fever, rapid pulse, more cora^lQiejatmdice, pain, 
 nausea, vomiting of blackish, grujnous blood, or " coffee grounds," 
 tarry stools, ecchymotic patches, convulsio7ts or epileptiform attacks, 
 coma, insensibility, death. 
 
 Percussion shows markedly decreased hepatic dullness. 
 
 Duration. Short. After appearance of jaundice, about six days. 
 
 Prognosis. Unfavorable. 
 
 Treatment. Entirely symptomatic. Prof. Bartholow " advises 
 the trial of very small doses of phosphorus, as early as possible, as 
 this remedy affects the organ specifically, and an action of antagon- 
 ism may be discovered between them." 
 
DISEASES OF THE LIVER. 115 
 
 SCLEROSIS OF THE LIVER. 
 
 Synonyms. Intestinal hepatitis; cirrhosis of the liver ; hob- 
 nailed liver ; gin-drinkers' liver. 
 
 Definition. An inflammation of the intervening connective 
 tissue of the liver, chronic in its progress, resulting in an induration 
 or hardening of the organ and an atrophy of the secreting cells ; 
 characterized by gastro-intestinal catarrh, emaciation, slight jaundice 
 and ascites. 
 
 Causes. The prolonged use of alcohohc stimulants, gin, whisky, 
 beer, or porter ; syphilis. 
 
 Pathological Anatomy. First stage ; hyperaemia of the con- 
 nective tissue (Glisson's capsule) of the liver, and the development 
 of brownish-red connective-tissue elements, whereby the organ is 
 increased in size and density ; this increase of the connective-tissue 
 presses upon the hepatic cells, causing them to undergo fatty degene- 
 ration. 
 
 Second stage ; the newly formed, imperfectly developed connective 
 tissue contracts, causing decrease in the size and induration of the 
 organ, its surface being nodulated. The hepatic and portal circula- 
 tion is obstructed, from obliteration of their radicles. 
 
 The hepatic peritoneum is thickened and opaque, and adhesions 
 are formed to the diaphragm, gall-bladder and stomach. 
 
 Cases occur in which the sclerosis takes place while the organ con- 
 tinues enlarged ; these cases are known as hypertrophic sclerosis. 
 
 Symptoms. No characteristic symptoms of the early stage of 
 the affection. Persistent gastro-intestinal catarrh, with attacks of 
 jaundice, in a drinking man, are suspicious. Symptoms of the second 
 stage are, abdominal dropsy, ejtlargement of the superficial abdominal 
 veins, dyspepsia, localized peritoneal pain, hemorrhages from the 
 stojnach or intestines, muddy or slightly jaundiced skin and decided 
 emaciation; the enormously distended abdomen with thin legs are 
 characteristic of sclerosis of the liver. 
 
 Diagnosis. Atrophy of the liver, or the nutmeg liver, is almost 
 always confounded with sclerosis; the former occurs most commonly 
 with obstructive diseases of the heart and lungs, and the surface of the 
 organ is not nodulated, nor is there a history of alcoholism. 
 
 Cancer a7td tubercle of the peritoneum have many symptoms akin 
 to sclerosis. The points of differentiation are, great tenderness over 
 abdomen, rapidly developed ascites, rapid dechne in strength and 
 
116 PRACTICE OF MEDICINE. 
 
 flesh, absence of jaundice, absence of long-continued dyspepsia, ab- 
 sence of hepatic changes on percussion, and the presence of tubercle 
 or cancer deposits in other organs. 
 
 Prognosis. Terminates in death. Average duration after ap- 
 pearance of the dropsy, one year. 
 
 Treatment. For the changes in the hepatic structure, little, if 
 anything can be done; the following are some of the remedies recom- 
 mended, to wit, hydrargyri chloridiim corrosivinn, gr. ^V"T(J> three 
 times a day ; hydrargyri chloridtiin mite, gr. y^^, three times a day ; 
 a2irii et sodii chloridtini, gr. -^q, after meals; sodii phosphas, 3ss-j, 
 after meals ; potassii iodidum, after meals. 
 
 The diet must be regulated, milk being the most suitable, and 
 avoiding fatty and saccharine foods. 
 
 The abdominal dropsy may be temporarily benefited by purgatives 
 and diuretics, but sooner or later tapping becomes imperative. 
 
 AMYLOID LIVER. 
 
 Sjnaonyms. 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 anaemic 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 anilin 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. 
 
DISEASES OF THE LIVER. 117 
 
 The amyloid change involves the spleen, kidney, intestines, and 
 their organs. 
 
 Symptoms. Nothing characteristic. Hepatic dullness increased, 
 with prominence over the liver. Absence of pain. Splenic dullness 
 increased. Emaciation and anaemia. 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. 
 
 Prognosis. Unfavorable. The progress is rapid or slow, depend- 
 ing upon the cause. 
 
 Treatment. No specific. Prof. Da Costa recommends ammonii 
 murias, gr. x-xx, three times daily, for several weeks, then change 
 for same length of time to syriipiis ferri iodidum, beginning with rr^x 
 gradually increased to f^j after meals, then to the former again, and 
 so on, for months. Symptomatic, with prolonged use oi ferrimi, syr. 
 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 ; from 
 extension from other organs, when it is termed secondary cancer. It 
 is a disease of advanced life, from forty to sixty years. 
 
 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 cir- 
 culation. 
 
 The cancer may develop in nodules or masses, or may be 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 
 
118 PRACTICE OF MEDICINE. 
 
 a history of dyspepsia, flatulency and constipation. The uneasiness, 
 'Weight and/az>z, increased by pressure, are noticed \ jaundice, ascites, 
 occasional intestinal hemorrhages, emaciatiofi, feebleness, ancemia, 
 cold, dry, harsh ski?t, pinched featitres, with dejected, worn expressiojt. 
 Fever never occurs. The hepatic dullness is increased, with pains on 
 palpation, and the liver is indurated, irregular and nodulated. 
 
 The duration is less than a year from the time the disease is 
 recognized. 
 
 Diagnosis. The points of differentiation are the age, cachexia, 
 pain and tenderness, enlarged liver with hard nodules, and rapid 
 progress. 
 
 Prognosis. Always terminates in death. 
 
 Treatment. Early, symptomatic. Sooner or later (?^Z2^;« must be 
 used, to relieve the terrible and persistent pain. 
 
 DISEASES OF THE KIDNEYS. 
 
 THE URINE. 
 
 The normal quantity of urine varies from twenty to fifty ounces 
 in the twenty-four hours ; it is decreased by free perspiration and 
 increased by chilling of the skin. 
 
 The normal color is light amber, due to urobilin ; the color deepens 
 if the quantity voided be decreased, and vice versa. 
 
 The 7iormal 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 1.008 to 1.020; it is low 
 when an increased quantity is passed and high when the quantity is 
 diminished. 
 
 The most important organic and inorganic solid constituents held 
 in solution are, urea (the index of nitrogenous excretion), from 308 
 to 617 grains daily ; uric acid, from 6 to 12 grains ; urates of sodium, 
 am.monium, potassium, calcium and magnesium, from 9 to 14 grains; 
 phosphates of sodium, etc., from 12 to 45 grains, and chlorides of 
 sodium^ etc., from 154 to 247 grains daily. 
 
DISEASES OF THE KIDNEYS. 
 
 119 
 
 I. Quantitative test 
 for urea, by hypobro- 
 mite of sodium(Davy's 
 Method). 
 
 II. Tests for urates 
 and uric acid by nitric "! 
 acid. 
 
 III. Quantitative test 
 for uric acid by nitric 
 acid. 
 
 Fill a graduated glass tube one-third full 
 of mercury, and add one-half drachm of the 
 24 hours' urine ; then fill the tube evenly 
 full with a saturated solution of hypobromiie 
 of sodium, and close it immediately with the 
 thumb ; invert the tube and place its open 
 end beneath a sat. sol. oi chloride of sodium ; 
 the mercury flows out and is replaced by the 
 solution of salt; nitrogen gas is disengaged 
 from the urea in the upper part of the tube. 
 
 Each citbic inch of gas represents .645 gr. 
 of urea in the half drachm, from which the 
 amount passed in 24hours may be calculated. 
 
 Urine containing an excess of urates and 
 uric acid, on cooling, precipitates them (viz.: 
 " brickdust deposits " in " pot de chambre"). 
 Neat 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 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 tiric acid and altered coloring 
 matter will form at their union ; and a dense, 
 milky zone of acid urates above this, which, 
 however, dissolves upon agitation. (See 
 albumin test.) 
 
 To three ounces of the 24 hours' urine 
 (after being slightly acidulated, boiled and 
 filtered while hot) add 07ie-tenth as much 
 7iitric 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 repre- 
 sents the uric acid in part excreted, approxi- 
 mately. 
 
120 
 
 PRACTICE OF MEDICINE. 
 
 IV. Test for the 
 earthy and alkahne 
 phosphates by the 
 magnesian fluid. 
 
 by acetic acid and li- 
 quor iodi comp. 
 
 V. Test for the chlo- 
 rides by nitrate of sil- 
 ver. 
 
 VI. Test for 7nucus \ 
 
 VII. Test for albu- 
 
 Heat or /igtior potassa\ncre.2ise.% 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, to wit : R- 
 Magnesii sulph., ammonii chloridum purae, 
 liquor ammonicC, each one part ; aquae destil., 
 eight parts; if the precipitate has a milky, 
 cloudy appearance, the quantity of phos- 
 phates is normal ; if creamy, the phosphates 
 are in excess. 
 
 To a convenient quantity of urine add a 
 small amount of nitric acid, to prevent the 
 formation of the phosphates and other salts 
 of silver; filter this, if cloudy; add to this 
 one drop of a solution of nitrate of silver (i 
 part to 8) and the precipitate of white cheesy 
 lumps of chloride of silver denotes that the 
 amount of chlorides is normal ; if, however, 
 only a faint milki7iess occurs, the chlorides 
 are diminished. 
 
 Mucus alone is not visible, but causes 
 cloudiness, from having entangled mucus 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 o{ mucin are made 
 visible. The addition of nitric acid dis- 
 solves them. 
 
 Slightly acidulate the urine, if necessary, 
 by addition of nitric or acetic acid, and boil ; 
 this causes a white deposit of coagulated 
 albinnin, 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 
 
DISEASES OF THE KIDNEYS. 
 
 121 
 
 mi7i by heat and nitric 
 acid. 
 
 VIII. Quantitative 
 test for albumin. Ap- 
 proximately. 
 
 IX. Test for blood 
 by heat and nitric acid. 
 
 X. Test for blood by 
 heat and caustic pot- 
 ash (Heller's). 
 
 XI. Test {qx pus by 
 liquor potassa. 
 
 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 ritig of coagulated albumin appears. Pre- 
 caution, see tests Nos. 3, 4, 9 and 11. 
 
 Add a few drops of 7iitric 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 
 indication, viz., X~X> etc. 
 
 Heat or nitric acid causes deposit of albu- 
 min, with the coloring matter changed to a 
 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 dirty, 
 yellowish-red color to the sediment, viewed 
 by reflected light, and when seen by trans- 
 mitted light, gives a s^\^v\.^\^ 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- 
 agulation of the albumin in pus. 
 
 Add to the urine, or preferably to its de- 
 posit from standing, an equal volume of 
 liquor potassa ; when well mixed, a viscid 
 gelatinous fluid or mass is formed, which 
 pours like the white of an t^z, or jelly. 
 
 10 
 
122 
 
 PRACTICE OF MEDICINE. 
 
 XII. Test for 3//^ by 
 " fuming "or red nitric 
 acid. 
 
 XIII. Test for bile 
 pigment by pure hy- 
 drochloric and pure 
 nitric acids (Heller's). 
 
 XIV. Test for sugar 
 by liquor potassa and 
 heat (Moore's). 
 
 XV. Test for sugar 
 by subnitrate of bis- 
 muth, liquor potassa 
 and heat. 
 
 Allow a specimen of urine and a few drops 
 of red "fuming" nitric acid to gradually 
 intermingle on a porcelain dish, and a " play 
 of colors," ^<f^«, bhte, violet, red and yellow 
 or broiun, occurs, if biliary coloring matter be 
 present. 
 
 Pour into a test-tube about 1.6 f^ of pure 
 hydrochloric acid, and add to it, drop by 
 drop, just sufficient urine to 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^^;z, it is biliverdin. 
 
 Add to the urine half its volume of liquor po- 
 tassa. ( Cautio7i. This ;;mj/give a white, flaky 
 precipitate of the earthy phosphates, which 
 should be removed by filtering.) Now boil ; 
 this causes, at first, z. yellow-brownish color, 
 becoming darker if much sugar is present, 
 due to glucic, and finally to melassic acid. 
 
 Add to the urine half its volume of liqtcor 
 potassa, and then a little bismuth subnitrate, 
 shake and thoroughly boil ; the presence of 
 sugar reduces the salt and black metallic 
 bismuth is deposited, or if but little sugar, a 
 gray deposit occurs. 
 
 Caution. Albumin must be absent. 
 
DISEASES OF THE KIDNEYS. 
 
 123 
 
 XVI. Test for sugar 
 by a solution of cupric 
 sulphate, liquor po- ^ 
 tassa and heat (Trom- 
 mer's). 
 
 XVII. Quantitative 
 test for sugarhy Pavy s 
 solution, to wit : — 
 
 R. 
 
 Cupric sulphate, gr. 320 
 Neutral potassic 
 
 tartrate, . . gr. 640 
 Caustic potash, . gr. 1280 
 Distilled water, f ^ 20 
 
 Keep corked. 
 
 XVIII. Quantitative 
 test for sugar by fer- 
 mentation and the 
 specific gravity. 
 
 Add to the urine a few drops of a solution 
 of cupric sulphate, and then its own volume 
 q{ liquor potassa. {Cauiio?i. 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, gives a transparent blue liquid.) 
 Now boil, and a yellowish precipitate of 
 hydrated cupric suboxide, occurring at once, 
 denotes xYio. presejice of sugar. 
 
 Caution. Albumin must be absent. 
 f 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 2. yellow- 
 ish precipitate of hydrated cupric suboxide, 
 if sugar be present. 
 
 Note carefully the gradual disappearance 
 of the bhie 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 cofttaining one grain of 
 sugar being just sufficient to reduce the 200 
 minims of the copper solution. 
 
 Take two measured specimens from the 
 24 hours' urine, and to one add a XiVX^q yeast. 
 Place each specimen in a temperature of 75° 
 to 80° Fah. ; in 24 hours, fermentation 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. 
 
12.4 PRACTICE OF MEDICINE. 
 
 CONGESTION OF THE KIDNEYS. 
 
 Synonyms. Renal hyperaemia ; catarrhal nephritis. 
 
 Definition. An increase in the amount of blood in the vessels 
 of the kidneys ; when arterial, it is termed active congestion ; when 
 \^x\.o\is, passive congestion ; characterized by pain, frequent desire for 
 urination, the amount of urine scanty, high-colored, occasionally con- 
 taining albumin or blood. 
 
 Causes. Active; from cold; irritating substances eliminated by 
 the kidneys, to wit : turpentine, copaiba, cantharides ; during the 
 eruptive or continued fevers ; injuries over the kidneys. 
 
 Passive ; obstructive diseases of the heart or lungs, and pressure of 
 the pregnant uterus. 
 
 Pathological Anatomy. The kidneys enlarge and increase 
 in weight ; increased redness (the color being bluish if 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 continue for some time, increase 
 of the connective tissue, with consequent induration and contraction, 
 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 tiritie 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, inflamination of the kidney results. 
 
 Passive ; the kidney changes are marked by the lung or heart 
 trouble, until dropsy, scanty, high-colored, albiuninoics urine is observed. 
 
 Prognosis. Active ; if recognized and properly treated, favorable. 
 
 Passive, controlled by the cause, and if prolonged, terminating in 
 interstitial nephritis. 
 
 Treatment. Rest of the body ; dry or wet cups over the loins ; 
 dilute the urine by increasing the quantity of bland fluids consumed ; 
 saline purgatives; warm bath or other mild diaphoretics; itifusiim 
 digitalis is pre-eminently the remedy for congestion of the kidneys ; 
 if great irritability of the bladder, camphora, gr. ij-iv, every four hours, 
 
DISEASES OF THE KIDNEYS. 125 
 
 combined with 7norphmce sidph., gr. ^^ \ , or the hypodermic injec- 
 tion of morpJiina, gr. ^. 
 
 The treatment of the passive form resolves itself into the treatment 
 of the cause. 
 
 ACUTE BRIGHT' S DISEASE. 
 
 Synonyms. Acute desquamative nephritis ; acute parenchyma- 
 tous nephritis ; acute tubal 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 uraemia. 
 
 Causes. The young more liable than the aged; cold and ex- 
 posure ; scarlatina ; persistent use of irritants, to wit : turpentine 
 and cantharides. Blows and injuries of the back have caused this 
 affection. 
 
 Pathological Anatomy. The kidneys are generally swollen, 
 engorged, more vascular, and of a 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. 
 
 If a favorable termination, the swelling lessens, the vascularity 
 diminishes, the tubules returning to a normal condition. 
 
 Symptoms. Usually begins suddenly. Fever, with nausea and 
 violent ^.nd. persistent vomiting, dull pain over the kidneys, following 
 the ureters ; frequent desire to urinate ; diarrhoea ; s^in harsh and 
 dry ; pulse quick, tense and full. Soon dropsy appears, the eyelids 
 and face become puffy and swollen, followed by general oedema of 
 the extremities, scrotum and abdominal walls. If the attack follow 
 scarlatina there are from the onset much greater pallor and general 
 debility. 
 
 The urijie is of high specific gravity, scanty, smoky (like beef wash- 
 ings) in color, due to the presence of blood. Albuniiii is present in 
 large quantities, and the microscope reveals casts of the uriniferous 
 tubules, blood corpuscles, uric acid, urates and oxalate crystals and 
 epithelium. 
 
 Duration from one to four weeks. 
 
 Complications. Pericarditis, pleuritis, pneumonitis, peritonitis, 
 
126 PRACTICE OF MEDICINE. 
 
 or acute tircsmia, 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. 
 
 Albumuuiria 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, to wit : diphtheria, 
 cholera, yellow fever or erysipelas. 
 
 ProgTlosis. Favorable. Majority of cases recover under prompt 
 treatment. Rarely passes into chronic Bright's disease. Urcemic 
 symptoms add to the gravity of the prognosis. 
 
 Treatment. Absolute rest in bed. Milk diet, or if much depres- 
 sion, also weak animal broths and oysters. Drink freely of water, but 
 neither tea, coffee nor stimulants. Counter-irritatioft over the kid- 
 neys by dry or wet cups and poultices of digitalis. 
 
 For the dropsy, purgation hy pulv. jalapCB conip., 3j. in water, 
 before breakfast, or elateriiim, gr. ^. 
 
 Diaphoresis, by warm baths, or extractujn pilocarpi fluidum, tt^x- 
 XXX, every three or four hoars, or vinum ipecacuanhce, gtt. j-ij, every 
 half hour. 
 
 Diuresis, by — 
 
 R. Potass, acetas, gr. x-xx 
 
 Infus. digital., f,^ij 
 
 Infus. juniperi, f 3 ij- M. 
 
 Every two or four hours. 
 
 As soon as the blood disappears from the urine, a course o{ferrum, 
 in the shape of Bashaitis 7nixture, until albumin disappears and 
 health is restored. The following is the formula of Basham's mix- 
 ture : — 
 
 % . Liq. ammon. acetat., ^,f ^j 
 
 Acid, acetic, ^iij 
 
 Tinct. ferri chlcr., f ,^ v 
 
 Alcoholis, 5ij 
 
 Syrup, • f.V^ 
 
 Aquae fjiv- M. 
 
 SiG.— Dose, f^j-f Jj. 
 
DISEASES OF THE KIDNEYS. 127 
 
 CHRONIC PARENCHYMATOUS NEPHRITIS. 
 
 Synonyms. Chronic Bright's disease ; 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 anemia, with attacks of acute urceiiiia. 
 
 Causes. Occasionally follows the acute form ; syphilis ; chronic 
 malaria ; chronic alcoholism ; chronic mercurialism ; lead poisoning ; 
 protracted suppuration ; some undetermined nervous condition. 
 
 It is a disease of the young, rarely occurring after forty. 
 
 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 dyspnosa from ascites or hydrothorax, although in many 
 cases the dropsy is a late symptom, the patient becoming /-a:/^, debili- 
 tated s^nd suffering from cardiac palpitatioji, increasing dyspficea, and 
 vo7niting, all gradually developing without apparent cause ; also 
 headache, vertigo and defective visio?t. The tirine is scanty, high- 
 colored, albuminous , and under the microscope showing hyaline and 
 granular tube casts, granular epithelium, and if fatty degeneration 
 occur, 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. Irritable bladder is a very constant 
 symptom. 
 
128 PRACTICE OF MEDICINE. 
 
 AncEJuia is pronounced, from the large waste of albumin. Gastro- 
 intestinal disorders and vague neuralgic pains are common occur- 
 rences. Cardiac hypertrophy is of common occurrence. Bronchial 
 catarrh, with slight cedevia of the larynx, causing husky voice, are 
 frequent complications. Amaurosis, the result of neuro-retifiitis, 
 occurs in a greater or less degree in all pronounced cases. Urcemic 
 symptoms occur, and especially urcemic asthma (renal asthma). 
 
 Complications. Pneumonia, pleuritis, pericarditis, peritonitis, 
 menmgitis, and cardiac hypertrophy. 
 
 Prognosis. Not unfavorable, unless urine persistently contains 
 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. 
 
 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 into the hope of an early and complete 
 recovery, when, as suddenly, an attack of acute uraemia terminates 
 life. 
 
 Rest and diet are important elements in the treatment. 
 
 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 should be entirely, or as nearly so as possible, a milk diet, 
 the daily amount used being from two to four quarts. The moderate 
 use of a light wine is at times of advantage if taken with the food, 
 although a fair number of cases do better without stimulants. 
 
 The use of diaphoretics and hydragogue cathartics are only indi- 
 cated when the dropsy is marked, the skin harsh and dry, the urinary 
 secretion scanty and uraemic symptoms are threatening, for which 
 administer the following : — 
 
 R . Ilydrargyri chlor. mite, 
 
 Pulv. scillse, 
 
 Pulv. digital., aa gr. j. M. 
 
 Et ft. pil. 
 SiG. — Three times daily for a few days. 
 
 Diuresis should be promoted, if the secretion is small, by digitalis, 
 
DISEASES OF THE KIDNEYS. 129 
 
 casein or arbiitin internally, and dry cups and poultices over the 
 loins. 
 
 Iron is preeminently the drug for this variety of Bright's disease, 
 the tinctura ferri chloridum the best form for administration. 
 
 The ajicemia is to be treated by oleum 7norrkii6s, arseniciim and 
 ferrum, an excellent formula for the latter being — 
 
 R . Strychninos sulph., S^' /^ 
 
 Tinct. ferri chloridi, . . . f^ss 
 
 Acidi acetici purae, fziss 
 
 Curacose alba f ^j 
 
 Liq. ammonii acetat., ad . . . . f^^vj. M. 
 
 SiG. — Tablespoonful every five hours, followed by a glass of cold 
 water. 
 
 Another good formula is — 
 
 R . Hydrargyri chlor. corrosiv., gr. j 
 
 Aurii et sodii chloridi, • • gr. j 
 
 Ferri per hydrogen, gr. xxiv. M. 
 
 Ft. pil. xxiv. 
 
 SiG. — A pill after meals. 
 
 To check the waste of albumin, a difficult matter, the following 
 remedies have been used with more or less success: ergota, quinina, 
 acidum gallicum, acidum bejtzoicitm, tinctura cantharidis, potassii, 
 iodidum, and, lastly, the Russian remedy, blatta orientalis (cock- 
 roach). 
 
 For dropsy, purgatives, such as pulvis jalapa co7npositus, hydra- 
 gogue cathartics and alkaline mineral waters; act on skin with vapor 
 baths, or pilocarpus inuriat., gr. yi, repeated if not much cardiac 
 depression, or combining pulvis ipecacua7thcE et opii, gr, iij, with 
 potassii nitras, gr. iij-v, every tw^o or three hours. If there be great 
 distention of the serous cavities, interfering with the respiration, the 
 aspirator ^o\A^ be used. Puncture of the skin may be necessary at 
 times, and 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 corrosivwn chloridum and potassii 
 iodidum with oleicm morrhucE. 
 II 
 
130 PRACTICE OF MEDICINE. 
 
 INTERSTITIAL NEPHRITIS. 
 
 Synonyms. Chronic Bright's disease ; sclerosis of the kidneys ; 
 contracted kidneys ; 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 frequent 
 passing of large amounts of pale, albuminous urine, of low specific 
 gravity, disorders of the gastro-intestinal and nervous systems, and 
 a strong tendency to cardiac hypertrophy and changes in the 
 vessels. 
 
 Causes. A disease of middle life, from forty to sixty years. 
 Gout a very common cause ; lead cachexia ; syphilis ; alcoholism ; 
 long-continued worry, anxiety or grief ; alterations in the renal gan- 
 glionic centres (DaCosta and Longstreth). 
 
 Pathological Anatomy. The kidneys are reduced in size. 
 The capsule is thickened, opaque and adherent. The surface of 
 the kidney is granular, with cysts of various sizes, of transparent 
 color, irregularly over the surface. On section the tissue of the 
 kidney is tough and resistant. The cortical portion is thin, from 
 atrophy, being only a line or two in thickness. The C07i7iective tissue 
 is greatly thickened, compressing the tubules into mere threads, the 
 glomeruli being 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 degene- 
 ration. 
 
 In many cases there occur fatty degeneration of the retinal tissues, 
 or sclerosis of the nerve-fibre layer, changes which are termed 
 retinitis albuminuria. 
 
 The '' ganglionic centres'' undergo fatty degeneration and atrophy 
 (DaCosta and Longstreth). 
 
 Apoplexy is a frequent termination of interstitial nephritis, the 
 rupture of a cerebral vessel suggesting it to be a disease of degene- 
 ration. 
 
 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 
 
DISEASES OF THE KIDNEYS. 131 
 
 majority of cases, the disease being apparently latent, until some spe- 
 cial outbreak cause a more thorough examination of patient, when he 
 is found to have an interstitial nephritis. 
 
 Any of the following symptoms may first attract attention, to wit : 
 frequent micturition, increased amount of urine of a pale color, 
 containing a small amount of albumin, which may be absent for 
 days, occasional epithelial cells and hyaline casts. No dropsy, but a 
 little puffiness and (sdejna of the coiijunctiva — the Bright' s eye. Dis- 
 orders of vision. Forcible cardiac action with high arterial tension. 
 And any of the following symptoms, the result of urcE?nia : Persistent 
 dyspepsia, occasional vomiting, regardless of food ; headache, vertigo 
 and stupor ox drowsiness ; violent itchi?tg oi the skin ; trejnors, con- 
 vulsiojts, 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. 
 
 The termination is usually by convulsions, coma and death. 
 
 Complications. Bronchitis; pneumonia; pleuritis; pericarditis; 
 cardiac hypertrophy. 
 
 Diagnosis. Differs ixova parenchymatous nephritis in the follow- 
 ing : large quantity of urine, clear, of low specific gravity, small 
 amount of albumin, with few hyaline casts ; the hypertrophied heart 
 and tense arteries and marked disorders of vision. 
 
 Prognosis. Pursues a very chronic course ; cases recorded under 
 observation eleven years ; but the termination is always fatal. 
 
 Treatment. Regulated diet. Diaphoretics. Diuretics. Avoid 
 alcoholic stimulants. As nearly absolute rest as patient's general 
 health will permit. 
 
 To prevent the growth of the connective tissue, the following reme- 
 dies are recommended, to wit: potassii iodidum, hydrargyri corrosi- 
 vum chloridum, gr. 2V. cLurii et sodii chloridum, gr. ^^i f^f^i iodidum 
 and arsenicum. 
 
 For urczmia, if patient is conscious, purgatives, diaphoretics and 
 diuretics. If unconscious, morphina hypodermically or chloroforfn 
 inhalations. 
 
 AMYLOID KIDNEY. 
 
 Synonyms. Chronic Bright's disease ; waxy kidney ; lardaceous 
 kidney. 
 
 DeJSnition, A peculiar infiltration into, or a degeneration of, 
 
132 PRACTICE OF MEDICINE. 
 
 the Structure of the kidney, from the deposit of an albuminoid mate- 
 rial, having a superficial resemblance to starch granules. Similar 
 changes occur in the liver, spleen, intestines, and other organs. 
 
 Causes. The chief cause is prolonged suppuration, especially of 
 the bones ; coxalgia ; syphilis ; cancer. 
 
 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 affords a certain test 
 of the atnyloid deposit. 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 
 amyloid change may be associated either parenchymatous or inter- 
 stitial nephritis. 
 
 Symptoms. Associated with wasting are cedevia of the lower 
 extremities and ascites, with an increased flow of urine, pale, watery, 
 and of low specific gravity, containing albiunin 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 diarrhosa adds to 
 the suffering, caused by amyloid changes in the intestinal canal. 
 
 Diagnosis. Differs from 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, 
 absence of uraemia, 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 
 
DISEASES OF THE KIDNEYS. 133 
 
 is associated ; the termination, when the amyloid change is fully- 
 developed, 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 of ferri iodidum, alternating with 
 ammonii niurias and oleum morrhucE. 
 
 If caused by syphilis, a thorough course oi potassii iodidum, ferri 
 iodidum and hydrargyri corrosiviim chloridujn, with oleum morrkuce. 
 
 PYELITIS. 
 
 Synonyms. Suppurative nephritis ; pyelo-nephritis. 
 
 Definition. An acute catarrhal inflammation of the pelvis of the 
 kidney ; the term 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 ; if 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 ; abuse of certain drugs ; 
 rheumatism ; sequels 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 process of suppuration, they are 
 enlarged, deeply congested, except where suppuration is proceeding, 
 when they are of a yellowish-white color — pyelo-nephritis. Pus 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 as pyelo-Jiephritis. 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. 
 
134 PRACTICE OF MEDICINE. 
 
 Begins by chilliness, feverishness, liunbar pains following the 
 course of the ureters, frequent micturition, the urine milky in appear- 
 ance when voided, acid or neiitral 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 ih^pus. 
 
 Cases of pyelitis due to renal calculi frequently show hemorrhages ; 
 the bloody urine after some extra exertion. 
 
 If pyelo-nephritis follow, symptoms of pyaemia supervene, to wit : 
 fever, typhoid in character, low, muttering delirium, subsultus tendi- 
 man, stupor, decline in strength and loss of flesh, with perhaps a 
 ticmor in the lumbar region. 
 
 If both kidneys are affected urcEmic symptoms are frequent. 
 
 Diagnosis. From cystitis, by history, lumbar pains and acidity 
 of purulent urine, the urine in cystitis being always alkaline. A 
 microscopical examination of the urine will aid the diagnosis very 
 much. 
 
 Peri-nephritis, a disease of loose tissue, around about the kidneys, 
 terminating in abscess, causing lumbar pain, increased by motion or 
 pressure, hectic fever, sense of fluctuation over kidneys, the urine 
 remainittg 7iormal. 
 
 Prog'nosis. Simple cases, where there is no obstruction to flow of 
 pus, recover in a week or ten days. If obstruction of the ureter, the 
 prognosis is grave. Suppurative cases unfavorable. 
 
 Treatment. Rest in bed. Milk diet. Free use of water to 
 dilute the urine, and free diaphoresis. Quinifia to keep down tem- 
 perature, prevent formation of pus, and maintain the powers of life. 
 
 To change the character of the secretion. Prof. DaCosta strongly 
 recommends pix liquida ; other remedies are oleu?n santali, copaiba, 
 eucalyptol, terebinthina, 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, alume^t, gr. xx, repeated p. r. n., is suc- 
 cessful. 
 
 If abscess results, aspiration, quinina and stimulants. Extirpation 
 of the diseased kidney has been followed with fair health. 
 
DISEASES OF THE KIDNEYS. 135 
 
 ACUTE UREMIA. 
 
 S3monynis. Ursemic poisoning ; urasmic intoxication ; uraemic 
 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 ; cystic, tubercular or cancerous kidney ; the puerperal state ; 
 operations 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 ; although it must be 
 borne in mind that in rare instances, during, or immediately prior to, 
 the appearance of the uraemic phenomena, the normal urinary flow 
 has been largely exceeded. 
 
 The onset is usually with headache, dimness of vision, dilated, slug- 
 gish pupils, drowsiness, vertigo, deafness, dusky countenance, nausea, 
 vomiting, and either a chill followed by fever, or a cool skin from 
 the onset ; the mind is dull, deepening into stupor, to be followed by 
 coma, or convulsions precede the coma, which terminates in death, 
 unless the poison causing the attack is rapidly eliminated. If the 
 amount of accumulated urea is small the phenomena may not 
 approach the pronounced coma described, the patient being able to 
 be aroused. When convulsions occur they rapidly succeed one 
 another, consciousness seldom being complete between the fits. 
 
 Diagnosis. Cerebral apoplexy may be mistaken for uraemic 
 coma, or the reverse. The chief points of distinction are, 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 urcnmic 
 stertor IS a sharp, hissing sound, while that of apoplexy is "snoring." 
 Apoplexy is followed by paralysis, uraemic coma is not. 
 
 An epileptic seizure is preceded by the sharp cry and extreme 
 
13^ PRACTICE OF MEDICINE. 
 
 pallor of the face, the countenance being dusky in urasmic con- 
 vulsions. 
 
 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. The indications in acute uraemia are : first, to 
 arrest the nervous phenomena; secondly, to promote elimination. 
 Prof. Loomis has succeeded in meeting both of these indications by 
 hypodermic injections oimorphina, gr. Ye-yi-yi, repeated, if required, 
 every two hours. He says, "the most uniform effect of morphine so 
 administered is, first, to arrest muscular spasms; second, to establish 
 profuse diaphoresis ; third, to facilitate the action of cathartics and 
 diuretics, especially the diuretic action of digitalis." 
 
 Following the injection of morphina, diaphoresis should be pro- 
 moted by means of the vapor-bath, or the hot wet-pack, or the hypo- 
 dermic use oi pHocarpijicE hydrochloras, gr. yV~/^~X» provided no 
 counter-mdication to its use exists, or frequent doses of caffeina. 
 
 The co7ivuhive phenomena are rapidly controlled by inhalations of 
 chlorofonnwn, or the internal or rectal administration of chloral. 
 
 Diuresis should be promoted by infusmn digitalis, and dry or wet 
 cupping, and poultices over the loins. 
 
 Catharsis is best produced by elaterium, gr. xV"3^- 
 
 For warding off attacks of uraemia, good results follow the use 
 of acidum be7izoicmn, acidiim nitricum dilutum, or acidum hydro- 
 chloricwn dilutum, in small, frequently repeated doses. 
 
 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 
 substance acting as a nucleus. 
 
 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, pyelitis is produced ; or more rarely, they are voided by the 
 urine without exciting any symptoms. 
 
 V>^ gravel \s meant very small concretions, which are often passed 
 in the urine in larg-e numbers. 
 
DISEASES OF THE KIDNEYS. 137 
 
 Causes. Occur at all ages ; frequent before the fifth year, and 
 from five to fifteen. 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. Uric acid, as calculi and gravel, and especially 
 associated with the gouty diathesis. 
 
 2. Urates, chiefly urate of ammonia ; nearly always in childhood. 
 
 3. Oxalate of Ihne or 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 calciili, consisting of alternate layers of two or more 
 primary deposits. 
 
 Anatomical Characters. In structure, a urinary calculus 
 u sually consists of a central nucleus, surrounded by the body, and 
 o utside 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. The clinical signs of renal calculi are those con- 
 sequent on the results of their presence, to wit : renal hetnorrhage, 
 re7ial congestion, i7iflammation, terminating in abscess, pyelitis, or 
 pyelo-nephritis, cystitis, or renal colic. 
 
 The symptoms of renal colic begin abruptly, by severe, agonizing 
 pain in the lumbar region, following the ureters into the corres- 
 ponding groin and thigh. Paiji and retraction of corresponding 
 testicle, also of glans penis. Face pale and features pinched, the 
 surface cold and damp. Irritability of the bladder, the urine passed 
 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, tircemic symptoms 
 will arise. 
 
 The paroxysm usually terminates suddenly after some minutes or 
 hours, the stone escaping into the bladder. 
 
 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 
 
138 PRACTICE OF MEDICINE. 
 
 apt to recur. Renal sand {gravel) and small concretions may, after 
 more or less delay, be voided with the urine. 
 
 Treatment. An attack of re?ial colic is best relieved by a 
 hypodermic injection of niorphina and atropina, and a warm bath or 
 a suppository oi ext. opii, gr. j ; ext. belladofincB alco., gr. ss, repeated 
 if needed. 
 
 For attacks of gravel, liquor potassii citratis, f^ss, every three 
 hours, and, if much vesical irritability, adding tinct. opii cainph. 
 f3ss-j. 
 
 Y ax renal hemorrhage, Prof. Bartholow reports success with 
 
 R . Extracti ergotae fluidi, 
 
 Tincturae krameriae, aa ^ ij. M. 
 
 SiG. — 3J every two or more hours. 
 
 I have always successfully controlled renal hemorrhages with 
 twenty-grain doses of ahiine?t, repeated p. r. n. 
 
 For uric acid calculi, as a solvent, Buffalo Lithia Springs water or 
 the Rockbridge Alum Springs watec of Virginia, or potassii tartra- 
 borates, " obtained by heating together four quarts 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." 
 
 For phosphatic calculi, as a solvent, ammonii benzoas, well diluted 
 and long continued. 
 
 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. 
 
 Causes. Acute variety ; long retention of urine; foreign bodies 
 in the bladder; pyelitis; urethritis; blows over the pubes ; myelitis, 
 and secondary to fevers or diphtheria. Chronic variety: following 
 the acute variety ; retention the result of enlarged prostate or an 
 urethral stricture ; calculi; gout; chronic Bright's disease. 
 
 Pathological Anatomy. In acute catarrhal cystitis, there first 
 ensues hyperccmia of the mucous membrane of the entire or a por- 
 tion of the bladder, manifested by redness, swelling and oedema; 
 
DISEASES OF THE KIDNEYS. 139 
 
 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 hypersemia be decided, rupture of the capillaries and 
 extravasation of blood occur. 
 
 If the inflammation be intense suppuration of the sub-mucous con- 
 nective tissue may result, and ulceration of the mucous membrane 
 permit the sub-mucous 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. 
 
 In chro7iic 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 fever, loss of appetite, sleeplessness, a feeling of depression ; 
 frequent micturition, but the urine is only voided drop by drop, 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 ; burning along the 
 urethra adds to the distress of the patient. 
 
 The uritie is cloudy, of an alkaline reaction, and at times is fetid, 
 the microscope showing epithelium, and red blood corpuscles. 
 
 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 but scanty micturi- 
 tion, the tirine is alkaline, 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 cor- 
 puscles, extremely regular both in contents and in shape, may be 
 detected. 
 
 Although the quantity of urine voided by the patient is small, yet 
 
140 PRACTICE OF MEDICINE. 
 
 if immediately after micturition the catheter is used, several ounces 
 oi fetid, cloudy, alkaline tirine may be removed. 
 
 Patients with chronic cystitis usually present decided constitutional 
 debility. 
 
 Severe local pain, emaciation and occasional bloody urine, indi- 
 cate 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 actite variety is, as a rule, good, being controlled 
 by the cause. 
 
 The chronic variety continues for years, and after hypertrophy of 
 the bladder is incurable. 
 
 Treatment. Rest is paramount. The diet must be restricted, 
 all highly-seasoned articles being particularly interdicted ; milk is the 
 most suitable diet. 
 
 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 draughts of pure water 
 and particularly the alkaline mineral waters, to wit : Farmville Lithia, 
 Buffalo Lithia or the Rockbridge Alum, or Vichy waters. The follow- 
 ing formulae are of decided benefit : — 
 
 R. Acidi benzoici, 
 
 Sodii borat., aa ^ i j 
 
 Infusi buchu, vel., 
 
 Infusi uvse ursse . . f ^ vj. M. 
 
 SiG. — Tablespoonfu] every 2 hours, well diluted. 
 Or— 
 
 R . Liquor, potassje, f .^ iij 
 
 Mucil. acacias, ad {"^ viij. M. 
 
 SiG. — Tablespoonfu] every 4 hours, well diluted. 
 
 For the pain and tenesmics relief is afforded by a suppository of 
 extractufn opii and extractuvi belladonncs, repeated as needed. 
 
 The vesical tenesmus is often benefited by extractufn cannabis 
 indie CB fiuiduin, f.'^ss, every three or four hours. 
 
 Chro7iic cystitis. The bladder should be completely emptied with 
 the catheter several times in the twenty-four hours. 
 
 The use of eucalyptol, gtt, x-xv, every four hours, well diluted, or 
 a good preparation of tar, or extractuin griiidelia fiuidtwi, n\^xx-f 5j, 
 
DISEASES OF THE KIDNEYS. 141 
 
 three or four times daily, and washing out the bladder with the fol- 
 lowing mixture, has been of decided benefit in the hands of- the 
 author : — 
 
 R. Sodii borat., , .^j 
 
 Glycerin], f,^ij 
 
 Aquae, f|ij. M. 
 
 SiG. — f^ ss-iss added to warm water and injected into the bladder once 
 or twice daily. 
 
 The diet should be nutritious, but without spices of any kind. The 
 free use of the alkaline mineral waters is of advantage. 
 
 MOVABLE KIDNEY. 
 
 Synonyms. Floating kidney ; wandering kidney ; ectopia renis. 
 
 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 hernias. 
 
 The condition may be congenital or acquired, more frequently the 
 latter. It is far more frequent in women than in men. 
 
 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 exam- 
 ination 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 melan- 
 cholia aggravated by the mental anxiety the presence of a twnor 
 in the abdomen causes the patient, in spite of the assurances of the 
 physician that it is not a cancer. 
 
142 PRACTICE OF MEDICINE. 
 
 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. This condition has 
 been ascribed to a twisting of the ureter and consequent retention of 
 the urine in the pelvis of the kidney, or to a 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 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 coun- 
 ter-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 inconve- 
 nience 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 
 in bed, hot applications over the abdomen, 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. 
 
ACUTE GENERAL DISEASES. 143 
 
 ACUTE GENERAL DISEASES. 
 
 PAROTIDITIS. 
 
 Synonym. Mumps. 
 
 Definition. An acute specific infectious inflammation of one or 
 both parotid and other salivary glands and the surrounding connect- 
 ive tissue, with a very strong tendency to migrate into the mammae or 
 testes ; characterized by pain, swelling and disordered function of the 
 glands. 
 
 Causes. A specific poison. Contagious. Occurs in epidemics, 
 although isolated cases are seen. Males more liable than females. 
 The most common ages between five years and puberty. As a rule, 
 it occurs but once in the same individual. 
 
 TYvQ. period of incubation is from one to three weeks. 
 
 Pathological Anatomy. There is inflammation of one or both 
 parotid glands, and in severe epidemics the cellular tissue pervading 
 the gland is involved. 
 
 The catarrhal inflammation begins in the gland ducts and rapidly 
 extends to the gland proper. There is congestion, swelling and an 
 infiltration of serous fluid, with more or less infiltration of the adja- 
 cent tissues. The swelling may suddenly reach an enormous size 
 and as suddenly decline, the gland returning to its normal condition, 
 or, rarely, an abscess results, with partial or complete destruction of 
 the gland. Occasionally the submaxillary gland is involved, also the 
 mammae and testes. 
 
 Metastatic parotiditis occurs secondary to severe blood poisoning, 
 as in pyaemia, typhoid or typhus fevers or diphtheria. The usual 
 termination of secondary parotiditis is by suppuration and destruction 
 of gland structure. 
 
 Symptoms. The onset is rather sudden, by malaise, chill, fever, 
 ioi°-i03° F., quick pulse, headache, dry skin, scanty tirine, followed 
 within a day or two by stiffness at the angles of the jaw, swelling of 
 the parotid and other salivary glands, pai^t, increased by moving the 
 jaws, v/'\\h. general oedema of the affected side of the face, at times the 
 skin being reddened. Salivation is frequent, and occasionally deaf- 
 ness occurs. 
 
 The swelling and other glandular symptoms subside about the 
 
144 PRACTICE OF MEDICINE. 
 
 sixth or seventh day, to be followed by restoration to health, or what 
 is more common, the involvement of the opposite gland. 
 
 At any time during the disease metastasis to the maiiwicE, ovaries, 
 or testes is apt to occur, when the symptoms peculiar to such affection 
 will be added. It has been noted that a continuance of the tempera- 
 ture after the decline of the parotid symptoms has begun, usually is 
 significant of metastasis. It is claimed that the involvement of other 
 organs during the course of mumps is not an example of metastasis, 
 but a true transfer of the disease. 
 
 Diag'nosis. An error seems impossible. 
 
 Prognosis. Simple mumps, favorable ; the chief danger being 
 from the altered function of the mammae, ovary or testes after 
 metastasis. 
 
 Treatment. The disease being self4imited, the indications are 
 entirely symptomatic, with attention to the secretions, although ex- 
 tractiim pilocarpi fiiiidum, rr^x-xxx, repeated, has been used with 
 varying success as a specific. 
 
 Locally, either cold or warmth to the affected gland, whichever is most 
 agreeable, or equal parts of iingiientum belladonjice et hydrargyrtim. 
 
 If the swelling shows a tendency to linger, use small blisters over 
 the part and administer potassii iodidum ; if suppuration occur, 
 evacuate pus, apply poultices and administer quinina. 
 
 If orchitis occur, the use of the belladonna and mercurial ointment 
 and the internal use of potassii iodidum. 
 
 DIPHTHERIA. 
 
 Synonyms. Putrid sore throat ; malignant ulcerous sore throat ; 
 malignant quinsy; membranous angina. 
 
 Definition. An acute, specific, constitutional disease, both epi- 
 demic and contagious, beginning by an affection of the throat, char- 
 acterized by a local exudation and glandular enlargements ; attended 
 with great prostration of the vital powers and albuminuria, and having 
 for its sequelae various paralyses. 
 
 Causes. A specific poiso?i, the character of which is unknown. 
 It is preeminently 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. 
 
ACUTE GENERAL DISEASES. 145 
 
 The poison exists in the exudation and secretions of the fauces and 
 in the breath, and floats in the atmosphere at a considerable distance 
 from the original source. 
 
 The theory of " No bacteria, no diphtheria," is not proven. 
 
 The period of z7tcubation 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 membrane. 
 
 At first there is redness, which may begin in any part of the throat, 
 associated with swelling and an increased secretion of viscid mucus. 
 The redness spreads over the entire mucous surface, when the exuda- 
 tion makes its appearance. 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 exten- 
 sive 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 of membrane, examined by the microscope, is 
 composed of fibrin, pus corpuscles, epithelial granular cells and 
 bacteria. 
 
 If the larynx, trachea, or nasal mucous membranes participate in 
 the disease, the croupous and not the diphtheritic form of inflamma- 
 tion occurs. 
 
 T\iQ, lymphatic 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 alteration, being black and fluid. 
 
 12 
 
146 PRACTICE OF MEDICINE. 
 
 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 itivasioji may be mild, with rigors succeeded by moderate 
 fever, headache, languor, loss of appetite, stiffness of the neck, tender- 
 ness about the angles of the jaw, or slight soreness of the throat. 
 
 In other cases the invasion is more abrupt and severe, with chilli- 
 ness followed by %xq.2X febrile reaction, 103° to 105° Y ., pain in the 
 ear, achi?tg of the limbs, loss of strejigth, paiiiful deglutitioft and 
 swelliftg of the ?teck, 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 being either regular 
 or slightly relaxed. Th.Q pulse, at first full and strong, soon becomes 
 either frequent or slow, but compressible. The uritie is scanty, high 
 colored and contains albumin. 
 
 The /(?rrt/ symptoms in the majority of cases are associated with the 
 throat. The patient 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 the diphtheritic exu- 
 dation ; sometimes the tonsils and tivula are greatly swollen and 
 spotted with exudation. In bad cases, more or less ulceration or 
 sloughing may be observed. Not unfrequently fragments of exuda- 
 tion, \kv^ false membrane, are expectorated, with particles of the ulcer- 
 ated tissues, having an offe7isive odor, which is transmitted to the 
 breath. The lymphatic glands of the neck are 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 dis- 
 charge from the nose, with attacks of epistaxis. 
 
 Extension to the larynx is indicated by hoarseness or complete loss 
 of voice, croupy cough and obstructive dyspnoea, which often become 
 urgent, the breathing being 7ioisy 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 
 
ACUTE GENERAL' DISEASES. 147 
 
 for weeks with a pale and cachectic appearance, due to the profound 
 blood alteration. 
 
 Paralysis is a common sequelae, following the mild as often as the 
 severe attacks. Usually not occurring until the patient seems fully 
 convalescent. 
 
 Pharyngeal paralysis is the most common, causing difficulty or in- 
 ability of deglutition, fluids regurgitating through the nose. 
 
 Cardiac paralysis is not unfrequent, the pulsations descending to 
 60, 50, 40, and in a case seen by the author, to 20 per minute. 
 
 Diphtheritic paralysis may affect the motor muscles of the eye, 
 causing strabismus ; the muscles of one side, hemiplegia ; of the legs, 
 paraplegia ; and of the bladder, leading to retetition of tirine or 
 difficulty in passing it. 
 
 Sensation is also diminished in the paralyzed parts. 
 
 Diagnosis. From follicular ulcer atio7i of the tonsils, which is 
 frequently termed diphtheria, by the shght or absent systemic 
 symptoms, the ulcerated condition being limited to the tonsils, 
 but often one, and the absence of glandular enlargement and fol- 
 lowing palsies. 
 
 Yrom 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. 
 
 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 me- 
 chanical obstruction of the respiration by the membranous exudation. 
 The pathology of croup is simple and easy of investigation ; diph- 
 theria is obscure in its etiology and progress. The temperature record 
 of croup is a high one until carbonic acid poisoning is imminent from 
 the mechanical obstruction of respiration, while in diphtheria, the 
 tendency to a decline in the temperature after the second day is 
 nearly characteristic, regardless of the amount of laryngeal obstruc- 
 tion. 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 
 
14S PRACTICE OF MEDICINE. 
 
 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 occurring 
 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, great depression, spreading exudation, 
 great swelling of the cervical glands, large amount of albumin, exten- 
 sion to larynx and nasal mucous membranes, hemorrhages from the 
 fauces and nose, and an epidemic character. 
 
 Treatment. No specific plan of medication has been found uni- 
 formly successful. It is a disease of debihty. The blood being more 
 or less altered, it follows that sustaitiing measures should be resorted 
 to in all cases. 
 
 The diet should be of the most nutritious character from the onset, 
 with such articles as milk, eggs, broths and oysters, at intervals of 
 every two or three hotirs. If deglutition be too painful, resort must be 
 had to nutritious enemata, the following being a suitable formula : — 
 
 R. Milk, f^j 
 
 Spts. frumenti, f^iv 
 
 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 to sixty 
 miiiims o{ spiritus vini gallici or spiritus frinne7iti, every two or three 
 hours ; an adult from two iofour drachms every three hours. 
 
 Ferrian and potassii chloras, m full doses, frequently repeated, have 
 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 : — 
 
 IJ. Tinct. ferri chlor., gtt. v-x-xx 
 
 Potassii chlor., gr. iij-v 
 
 Glycerini, f^ss 
 
 Syr. zingib., ad f.^j-ij- M. 
 
 SiG. — In water every three hours, for a child of two or three years. 
 
ACUTE GENERAL DISEASES. 149 
 
 The efficacy of the above is greatly enhanced, in the author's expe- 
 rience, by the addition to each dose oi tinctura belladonncE, gtt.j-v. 
 
 Quinina, gr. xvj-xxiv per day for a young adult, and gr. v-x for 
 a child, should be used throughout the disease ; if irritability of the 
 stomach prevent its administration by the mouth, it can be used as a 
 suppository or locally in the form of the oleate. 
 
 Calomel in small doses, combined with sodii bicarbonas every hour 
 until the breath becomes fetid, is beneficial, and especially in cases 
 showing a tendency to spread towards the larynx. Indeed, a tolerance 
 to calomel seems to exist in dipht?i,eria of the larynx. 
 
 Hydrarg. chlor. corros., gr. -^g— ^, repeated every second or third 
 hour, also acts well in many cases, combined as follows : — 
 
 ^. Hydrargyrichlorid. corros iv., g^- ?V 
 
 Tinct, ferri chlorid., Tl^v-x 
 
 Glycerini, . , TT\^x 
 
 Aquae, ad 3j. M. 
 
 SiG. — One teaspoonful every hour or two, well diluted. 
 
 Locally. Cleanliness of the fauces is of the utmost importance, and 
 if a non-irritating disinfectant be added, its value is enhanced. Prof. 
 Bartholow " has seen excellent results from the frequent application 
 of a solution of acidum lacticum, strong enough to taste sour, by means 
 of a mop." The following, used as 3. gargle, or applied by a mop, is 
 useful : — 
 
 R . Acid, salicyl., gr. xx 
 
 Glycerini, f5j 
 
 Aquae destil,, f^iij- M. 
 
 Or— 
 
 Be . Potass, chloras, ^ iv. 
 
 Acid, carbol., gr. ij-iv. 
 
 Tinct. myrrh., ?j 
 
 Inf. cinchonse, gij. M. 
 
 Or— 
 
 B:. Ext. pancreatis, ^j 
 
 Sodii bicarb., giij. M. 
 
 SiG. — Add 3J to aquae gvj, and apply with camel's-hair pencil. 
 
 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. 
 
 For laryngeal diphtheria the same general treatment, especially the 
 
150 PRACTICE OF MEDICINE. 
 
 mercurial, 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 glycerin, in an atomizer, every half hour or hour, or liq. trypsin, 
 as a spray. If these means fail, resort must be had to tracheotomy, 
 or intubation of the larynx, which have succeeded in many desperate 
 cases. 
 
 For nasal diphtheria, the same general treatment, and syringing the 
 nose every two or three hours with a weak solution potassii chloras, 
 or acidum carbolicu?n, or the following : — 
 
 R. Sodii sulphit., ^iij 
 
 Glycerini, f^ij 
 
 Aquse, f^iv- M- 
 
 For the paralysis, strychttina and ferrum internally, or strychnina 
 hypodermically, with the galvanic or faradic current locally. 
 
 ACUTE ARTICULAR RHEUMATISM. 
 
 Synon3niis. Rheumatic fever ; inflammatory rheumatism. 
 
 Definition. A constitutional disease, characterized by fever, in- 
 flammation in and around the joints, occurring in suc<:ession, and a 
 great tendency to inflammation of either the endocardium or peri- 
 cardium. 
 
 Causes. T\i^ predisposing causes are inherited tendency, scarla- 
 tina, and the puerperal state. 
 
 The exciting causes, exposure to cold and chilling of the body. 
 Rheumatism rarely occurs before seven or after fifty years. The 
 liability to the disease is increased by having had an attack. 
 
 Pathological Anatomy. The blood contains an excess of 
 lactic acid. The joijits bear the brunt of the attack ; the synovial 
 membrane is reddened, the vascularity of the synovial fringes is 
 increased, so with the synovial fluid, which is thinner, of a reddish 
 color, containing some gelatinous coagula of fibrin, and under the 
 microscope nucleated cells, ordinary pus cells being rarely seen. 
 
 The swelling visible about the affected part depends mostly on 
 inflammatory oedema of the connective tissue around the joint. 
 
 The /am is probably due, in all cases, to stretching of and pressure 
 on the elements of the tissues by the dilated capillaries and the inflam- 
 
ACUTE GENERAL DISEASES. 151 
 
 matory oedema. For the changes which ensue when the endo- and 
 pericardium are attacked, the reader is referred to the sections on 
 those diseases. 
 
 Syraptoms. Begins suddenly, generally at night, with a chill or 
 chilliness, pam and stiffness in the joints, loss of appetite, at times, 
 nausea and vomiting, followed hy fever, the temperature soon reach- 
 ing 102°, F., to 104°. in rare cases 108° to 110° {the hyperpyrexia), the 
 pulse seldom exceeding c)^, 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. Sleep is prevented by the pain and the "proinso. perspirations. 
 The strength is moderately well preserved. 
 
 The skin is often covered with an eruption of miliaria rubra, red 
 papulce and miliaria alba, the result of irritation at the orifices of the 
 perspiratory glands, from the excessive sweating. 
 
 The local phenomena are pain, tenderness, increased heat, swelling 
 and redness of one or m.ore joints; if but one joint, it is termed 
 monoarthritis, if more than one, polyarthritis. Pain is aggravated 
 by motion and pressure. Swelling is most apparent in those joints 
 not covered with muscle, to wit : 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 im- 
 portant pathological law, to wit : 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 
 sides 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. 
 
 Diagnosis. A typical case cannot be mistaken for any other 
 
152 PRACTICE OF MEDICINE. 
 
 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 shght if any fever, no sweats or cardiac lesions. 
 
 Gonorrhccal rheinnatisjn is associated with a gleety discharge, 
 attacks either the ankle or wrist only, is slowly influenced by treat- 
 ment, and lacks the febrile phenomena. 
 
 Pycsmia 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 of the disease. Garrod claims that "colored water" is 
 about as potent as anything else, for it is, he says, a " self-limited 
 disease," sometimes running a long and sometimes a short course. 
 Rest in bed, whether the pain forces it or not, is imperative. 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 salicylicum or 
 the salicylates in large and frequently repeated doses, to wit : — 
 
 R . Acidi salicylici, gr- xx 
 
 Liq. ammonii acetat., f^iss 
 
 Spts. setheris nitrosi 'n\^xx 
 
 Syr. simplicis, TT\,xv. 
 
 Every three hours, well diluted. 
 
 Or— 
 
 U. Sodii salicyl., 5^j 
 
 Sodii bicarb., ^iv 
 
 Aq. menth. pip., ftij 
 
 Aq. destillat., f^ij. M. 
 
 SiG. — One teaspoonful every three or four hours. Omit the soda as 
 soon as urine becomes alkaline. 
 
 If benefit follows, the evidence is quickly afforded in the relief of pain 
 
ACUTE GENERAL DISEASES. 153 
 
 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 a/ka/ine tresitvaent, which consists 
 in the administration of an ounce and a half of the alkaline carbon- 
 ates, either alone or v/ith a vegetable acid, each twenty-four hours, 
 until the uritie becomes tieiitral or alkaline, when the quantity is 
 reduced to an amount sufficient to maintain alkaline urine, to wit : — 
 
 R . Potassii bicarbonatis, ^ ij 
 
 Acid, tartaric, gr. xxx. 
 
 Dissolved in a glass of water and drank effervescing, every three hours. 
 Or— 
 
 U . Potass, bicarb. , 'T^'x] 
 
 Succi limonis, f .^ iv 
 
 Aquae cinnamomi, aa f J ss. M. 
 
 SiG. — In water, every three hours. 
 
 After the more acute symptoms are passed, change either of the above 
 for tinct. ferri chlor., gtt. xx, every four hours, well diluted, or full doses 
 of Basham's mixture. 
 
 Pale, feeble and anaemic patients, or attacks following scarlatina, 
 are most favorable influenced with — 
 
 R . Tinct. ferri chlor., git. xx-xxx 
 
 Syr. limonis, gtt. xx 
 
 Aquae, aa f^j. M. 
 
 SiG. — Every four hours, in a glass of water. 
 Or— 
 
 R. Acid, salicylic!, 9^'j 
 
 Ferri pyrophos., ^ iv 
 
 Sodii phosphat., ^^iij 
 
 Aquce font., f^ij- M- 
 
 SiG. — Dessertspoonful every three or four hours. 
 
 Prof. DaCosta reports a lessened proportion of cardiac complica- 
 tions with amjnonii bromidwn, gr. xv-xx, every four hours. 
 
 Subacute attacks and lingering cases are favorably influenced by 
 
 R . Lithii salicylatis, gr. xv-xx 
 
 Syr. zingiberis, f^j 
 
 Aq. lauro cerasi, f^j. M, 
 
 Every four hours. 
 
 13 
 
1d4 practice of medicine. 
 
 Good results follow, in a fair number of cases, sa/ol, gr. v-x, every 
 four hours, also from aiitipyrine , gr. xv, every three or four hours. 
 
 Whichever plan, acidum salicylicum, salicylates, alkaline or ferrum, 
 is adopted, quiniiia, gr. xij-xx, per day, should also be used. 
 
 Pain and restlessness should be controlled by opium in some form, 
 in full doses, or atropitia, gr. g^^, hypodermically. 
 
 For the hyperpyrexia, guifii7ta, gr. xxx-lx, 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 tiftctiira opii, one part, and liq. 
 phitnb. subacetat. dil, two parts, or — 
 
 R. Sodii bicarbonatis, 5ij 
 
 Tinct. opii, ^5^5 
 
 Aquce bul., Oij. 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 applica- 
 tions. It is by no means so painful and disagreeable as it appears at 
 first sight. The blisters remarkably relieve the pain, bring about a 
 more alkaline condition of the blood, and render the urine less acid, 
 or bring it to neutral, or even to alkaline." 
 
 The complications are to be treated according to their character. 
 
 MUSCULAR RHEUMATISM. 
 
 Synonyms. According to location, to wit: cephalodynia ; lum- 
 bago ; torticollis ; pleurodynia. 
 
 Definition. An affection of the voluntary muscles, inflammatory 
 in character, either acute 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 another. 
 Almost always due to cold and damp, or direct draughts of cold air. 
 Gout increases the tendency to attacks. 
 
 Pathological Anatomy. The true nature of muscular rheuma- 
 tism is not yet determined. Virchow suggests a " hypersemia of, and 
 scanty serous exudation between, the muscular striae, and in chronic 
 cases inflammatory proliferation of the connective tissue." 
 
ACUTE GENERAL DISEASES. 155 
 
 Symptoms. The first attack is generally acute. Onset rather 
 sudden, W\\\i pain in the affected muscles, with slight tefiderness, and 
 considerable stiffness, and difiiczilty of movement, by which also the 
 pain is increased. 
 
 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. 
 
 Duratio7i, acute form, about one week. C//r^«zV returns frequently, 
 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. Distin- 
 guished from neuralgia of the trifacial, or occipital nerve, by pain on 
 both sides of the head, excited or aggravated by 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 at- 
 tacked, 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 attempt- 
 ing to turn to the opposite side. Rheumatism of the muscles of the 
 back of the neck, cervicodynia, may be mistaken for occipital neu- 
 ralgia. 
 
 3. Pleurodynia. Situated in the thoracic muscles, and may be 
 mistaken for pleuritis, or intercostal neuralgia, from which it is differ- 
 entiated by the absence of the diagnostic features of each. Pain is 
 excited by forced breathing, coughing and sneezing. 
 
 4. Lumbodynia or lumbago. Situated in the mass of muscles and 
 fasciae which occupy the lumbar region. Most common variety. 
 Usually affects both sides. It may set in rapidly and become very 
 severe. Motion of any kind aggravates the pain, often becoming 
 very sharp or stabbing in character. It is sometimes complicated 
 with acute sciatica, when the suffering is agonizing. 
 
 Diagnosis. The different varieties may be mistaken for any of 
 the following ailments, to wit : trifacial, occipital or intercostal 
 
156 PRACTICE OF MEDICINE. 
 
 neuralgia, pains of progressive muscular atrophy, syphilis, metallic 
 poisons, or painful affections of the loins, arising from calculi or 
 gravel in the kidney. 
 
 A careful examination of the history is usually sufficient to arrive 
 at a correct diagnosis. 
 
 Prognosis. Difficult to eradicate, and in chronic cases to amelio- 
 rate ; but it is not dangerous to life. Death never results. 
 
 Treatment. Rest is the first indication. This is accomplished 
 in pieurody}iia by firmly strapping the affected side with broad strips 
 of plaster, extending from mid-spine to mid-sternum. 
 
 The local application to the affected muscles of hot poultices, made 
 of two-thirds pilocarpicslQdiWQS, and one.-th\r<l flaxseed meal, changing 
 them every two hours, is, in the opinion of the author, the most 
 rapidly successful treatment in acute cases. 
 
 Internally, sodii salicylat., gr. xv-xx, every two or three hours, is a 
 most valuable remedy. Prof. Bartholow declares that lithii brojnidujti 
 is almost a specific in muscular rheumatism. 
 
 For the/«m, and consequent sleeplessness, use — 
 
 li . Pulv. ipecac et opii, gf- x 
 
 Potass, nitras, gr. v-x. M. 
 
 SiG. — In powder, morning and night. 
 
 Or, hypodermically, at the seat of pain, morphina, gr. >^-X. ^i^^ 
 atropina, gr. ■^, p. r. n. 
 
 The following liniment is valuable in many cases : — 
 
 K. Quininae salph., gr- xl 
 
 Ol. gaultherire, f 5j 
 
 Lin. saponis CO., • f^iij- M. 
 
 SiG. — Thoroughly applied several times a day. 
 
 In attacks where the disease is limited to a few muscles, the follow- 
 ing liniment is valuable : — 
 
 R . Chloral hydrat., 
 
 Camphorse, aa gss. 
 
 M. et adde 
 
 Lanoline, '5]. M. 
 
 SlG. — Apply locally. 
 
 Chronic cases : Rest, flannel worn next to the skin, stimulating and 
 anodyne liniment, mild galvanism, dry heat, as ironing over the 
 
ACUTE GENERAL DISEASES. 157 
 
 affected part with a common flat-iron, a piece of paper or towel 
 being placed next to the skin. 
 
 Internally, potassii iodidum, ammonii murias, sulphur, guaiacuin, 
 or arsetiiciini, variously combined. 
 
 RHEUMATOID ARTHRITIS. 
 
 Synonyms. Arthritis deformans ; rheumatic gout. 
 
 Definition. An inflammation of the joints, accompanied with 
 but slight fever, without suppuration, progressive in character, causing 
 nearly symmetrical enlargement and deformity of various articula- 
 tions. 
 
 Causes. More common in females than in males, and in the 
 weak and anaemic. Among the causes are bad hygiene, exposure, 
 prolonged lactation, frequent pregnancies, .menopause, grief, tuber- 
 cular diathesis, and following attacks of articular rheumatism. 
 
 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 soditcm 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 dislocations to occur. The inter-articular 
 fibro-cartilages ulcerate and disappear, as do the cartilages covering 
 the ends of the bones, the ends of the bones becoming smooth and 
 eburnated, and often greatly enlarged. 
 
 Symptoms. Either acute or chronic, the latter most common. 
 
 Acute form involves several joints atthe 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 articulation becomes rigid or slightly 
 movable after prolonged attempts. Redness and tenderness are 
 wanting. Crepitatio7i is distinct after ulceration has destroyed the 
 cartilage. 
 
158 PRACTICE OF MEDICINE. 
 
 The hands are first involved, the disease spreading symmetrically 
 from articulation to articulation, until in severe cases every joint is 
 deformed. 
 
 Diagnosis. Chro7iic articular rheumatism is often confounded 
 with rheumatoid arthritis ; but the former lacks the marked structural 
 changes and the progressive involvement of joint after joint. 
 
 Gout differs from rheumatoid arthritis by the presence of deposits 
 of urate of sodium in the joints, the ears, tips of fingers and the 
 bursae over the olecranon process of the elbow, the presence of uric 
 acid in the blood, and the decided history of acute paroxysms. 
 
 Gonorrhceal rheumatism, so-called, has symptoms akin to rheu- 
 matoid arthritis, but the history of urethral suppuration clears up the 
 diagnosis. 
 
 Paralysis agiians, when pronounced, might be confounded with 
 rheumatoid arthritis, if the examination were limited to the joints, 
 but the whole history, such as the tremor, the gait, etc., should pre- 
 vent error. 
 
 Prognosis. If early treatment be instituted, the disease may be 
 held in abeyance for several years. After pronounced structural 
 changes have begun, the malady is incurable, although it may 
 remain stationary for a long time. 
 
 Treatment. If treatment be instituted before serious structural 
 lesions have occurred, the author has seen benefit in many cases by 
 the following treatment : Oleum morrhuoe carefully and thoroughly 
 rubbed into the affected joints, three times a day, with the internal 
 use of lithii citras effervescetites, 3j, three times a day, and the follow- 
 ing tonic mixture : — 
 
 5c. Massse ferri carbonat., gr. v 
 
 Liquor, potass, arsenit., TT^ v 
 
 Vini xerici, .^j 
 
 Aquoe, 3J. M. 
 
 After meals, well diluted. 
 
 Sodii salicylicum is recommended early in the disease. 
 
 Complete recoveries are reported from the long-continued admin- 
 istration in small doses of liqicoris potassii arseiiilis. 
 
 Attention to diet and hygiene are also necessary. When structural 
 changes have destroyed portions of the joint, palliative treatment is 
 the only indication. 
 
ACUTE GENERAL DISEASES. 159 
 
 GOUT. 
 
 Synonyms. Podagra, gout in the foot; chiragra, the hand; 
 gonagra, the knee. 
 
 Definition. A constitutional disease, usually inherited; charac- 
 terized by the sudden occurrence of a paroxysm of severe pain and 
 swelling in one of the smaller joints — the great toe usually — with the 
 presence of uric acid in the blood, and the deposit of the urate of 
 sodium in the structure of the joint. 
 
 Causes. Predisposing ; inherited ; male more than female — 
 women after menopause. 
 
 Exciting. Malt liquor and wine drinking, whether male or female ; 
 large consumption of animal food ; lead poisoning ; winter season. 
 
 When inherited tendency, may begin early in life ; when acquired 
 tendency, after thirty-five years. 
 
 The pathological cause consists in the presence of an excess of uric 
 acid in the blood, in the form of urate of sodium. 
 
 Pathological Anatomy. Gout is characterized by the deposit 
 of urate of sodium from the blood into the structure of joints and 
 tissues that are not very vascular. The deposit is associated with 
 signs of inflammation, to wit: hyperemia, 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 deposit 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. 
 
 Hypertrophy of the left ventricle and of the arteries, ending in 
 atheromatous changes, are results of gout. 
 
 Symptoms. Acute gout is rare in the United States. It occurs 
 in paroxysms ; one year's interval between the first and second 
 attack ; six months usually between the second and third, after which 
 it may occur at any time. 
 
 Prodromes usually precede the paroxysm for several days, to wit : 
 acid dyspepsia, constipation, headache and lassitude. 
 
160 PRACTICE OF MEDICINE. 
 
 The paroxysm begins suddenly, between midnight and 2 a.m., 
 with acute paiti in the ball of the great toe, which becomes red, 
 hot, sivollen, and so sefisitive 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, chiH, fever, quickened pulse, thirst, coated 
 tongue, constipation, and scanty, acid, high-colored urine, which de- 
 posits, on cooling, a heavy brick-dust sediment. 
 
 Toward 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 
 bursae, 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, viiium colchici 
 radicis, gtt. xv-xx- xxx, every two hours, well diluted, either alone or 
 in combination with a potassa salt, or sodii salicylas, gr. xx, every 
 three or four hours, well diluted, or Prof. Bartholow's pill — 
 
 U . Colchicinse g*"- 7V 
 
 Ext. colocynth. comp., gr. ss. 
 
 Quininio sulph., gr. iij. 
 
 Every two or three hours. 
 
ACUTE GENERAL DISEASES. 161 
 
 Or the following, recommended by Loomis : — 
 
 K • Pulv. ipecac, gr. j 
 
 Ext. colchici acet., gr. j 
 
 Hydrargyri chlor. mite, gr. j 
 
 Ext. aloes aq., gr. j 
 
 Ext. nucis vomicae, S^- X- ■^■ 
 
 Ft. pil. No. I. 
 
 SiG. — Every three hours. 
 
 For the J>a in, hypodermic injection of inorphina, and wrapping the 
 inflamed joint in cotton wool saturated with liq. plumb, sub-acetat. dil. 
 and tmctura opii. 
 
 The diet must be restricted to liquid food. 
 
 For chronic gout, regulated diet, free action on the secretions, and 
 lithii citras effervescentes, 5j, three or four times a day, well diluted 
 with water ; and perhaps a course of guinma, ferrtivi and arseiii- 
 cuni. 
 
 To prevent paroxysm, keep secretions acting, by the free use of 
 pure water or a good alkaline water, especially the Saratoga Vichy. 
 
 The diet is of the greatest importance, and should consist chiefly 
 of vegetables and fruit, excepting tomatoes and strawberries ; fresh 
 meat may be used once a day, as may oysters, fish and soups. Alco- 
 holic and malt liquors are contraindicated, as are tea and coffee ; 
 skimmed milk 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 bath are of 
 benefit. 
 
 Changing from a cold to a warm climate in winter, and the use of 
 flannel under-clothing, are strongly recommended. 
 
 LITH^MIA. 
 
 S37Tionyras. Lithiasis ; uric acid diathesis ; half gout. 
 
 Definition. A condition in which the fluids of the body are satu- 
 rated with nitrogenized waste, in the form of lithic or ui'ic acid ; char- 
 acterized by marked dyspepsia, various nervous phenomena, muscular 
 and articular pains, bronchial catarrh, all or any of these associated 
 with scanty, high-colored, acid urine. 
 
162 PRACTICE OF MEDICINE. 
 
 Causes. High living, with little exercise ; imperfect digestion of 
 nitrogenized food ; impaired elimination of uric acid. 
 
 Symptoms. Those of dyspepsia associated with irregular bowels, 
 scanty, high-colored, acid urine, sp. gr. 1.024-1.028, containing neither 
 sugar nor albumin, but showing an increased proportion of urates. 
 Also, depressed spirits, impaired inemory, loss of interest in occupa- 
 tion, sleepless Jiigkts, attacks of vertigo, neuralgic ^^z/«? in the head, 
 and a constant dread of apoplexy or cerebral disease. Also, pains in 
 the joints, neuralgic in character. 
 
 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. 
 
 DiagTiosis. From gout, by the absence of acute paroxysms and 
 resulting changes in the joints. 
 
 Prognosis. If properly recognized and treated, complete recovery 
 will result, although it is a disorder of long duration. 
 
 If not properly treated, develops some one of the organic diseases 
 mentioned. 
 
 Treatment. Regulate diet, using fresh meat once daily, poultry, 
 game (plainly cooked), fresh fish, oysters, occasionally eggs, lettuce, 
 spinach, celery, cold slaw and tomatoes ; avoid all stimulants, tea and 
 coffee, using milk, skimmed milk or milk and cream. Act freely on 
 all the secretions. Systematic exercise. Avoid tonics, bromides, 
 chloral and opium. Long course of alkaline waters. Good results 
 follow lithii citras, gr. xx, t. d., sodii phosph., gr. xxx, ter die, or 
 acidum be7izoicuni, gr. x, t. d., all well diluted with water. The author 
 strongly urges the use of acidu7n nitricum dilutum, gtt. x, in half a 
 glass of water, four times a day, with the occasional use oi pilules rhei 
 compositce at bedtime. 
 
 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. Occurs at all ages, but most 
 frequently between twenty-five and fifty years. It is often hereditary. 
 
ACUTE GENERAL DISEASES. 163 
 
 Disorders of the nervous, hepatic and renal systems. Excessive use 
 of farinaceous food and malt liquors. Sexual excesses. 
 
 The ex2LCt pathology of diabetes mellitus differs in different cases, 
 and in the present state of our 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. 
 
 Pathological Anatomy. None peculiar to diabetes are yet 
 recognized. 
 
 Hyperaemia and hypertrophy of the liver and kidneys are gener- 
 ally present, the result of increased functional activity. 
 
 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 
 an acute course. The symptoms of a typical case may be arranged 
 under the following heads : — 
 
 Urinary Organs and Urine. Micturition more frequent and the 
 urine increased in quantity. Paiji 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 ^^ 
 1.050. It ferments rapidly if kept in a warm place. It yields grape 
 sugar to the usual tests, the amount present varying from an ounce to 
 two pounds in 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. 
 
164 PRACTICE OF MEDICINE. 
 
 ■The patient complains of feeling very weak, languid, and of sore- 
 ness and pain in the litnbs, there is more or less eniaciatioti, 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 diminished. Defects of vision are 
 present. 
 
 The blood and various secretions contain sugar. 
 
 Complications. Pulmonary phthisis ; Bright's disease; defects 
 of vision from atrophy of the retina or the formation of a soft cataract ; 
 boils and carbuncles, and chronic skin affections, such as psoriasis 
 and eczema. 
 
 Course. The clinical history varies in different cases. In the 
 majority of instances the course is chronic, lasting for years, the 
 symptoms beginning insidiously, and becoming progressively worse, 
 with, at times, decided remissions. Occasionally the disease runs an 
 acute course, death occurring within four or five weeks. 
 
 Termination. The majority of cases ultimately prove fatal, the 
 symptoms markedly changing, the urine and sugar dimiftishing in 
 quantity, the occurrence of a/bumi7tu?'ia, disgust for food and drink, 
 and the development of hectic fever or colliquative diarrhoea. 
 
 The fatal result usually arises from gradual exhaustio?i, from blood 
 poisoning, leading to stupor, ending i?i complete coma, or occasionally 
 to delirium or co7ivulsions, or from complications. 
 
 Rarely death occurs suddenly, from urcemic cotivulsions or urceinic 
 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." 
 
 When grape sugar is present in the urine, with more or less in- 
 crease in the urinary flow, it can be mistaken for no other affection. 
 
 From Bright' s diseases, by the absence of dropsy, and of tube-casts 
 in the urine ; the amount of albumin in the urine is never so great or 
 constant in diabetes mellitus as in Bright's diseases. 
 
 From Diabetes insipidus, by the absence of sugar in the blood and 
 urine, and the larger quantity of urine voided in polyuria. 
 
 Si?nple glycosuria differs from diabetic glycosuria in that the amount 
 of sugar in the urine is not constant — at one time being present, at 
 another absent — the amount of urine voided is never in excess of 
 
ACUTE GENERAL DISEASES. 165 
 
 health ; simple glycosuria is a disease of the aged ; diabetic glycosuria 
 usually appears under fifty years. Simple glycosuria often results 
 from the inhalation of chloroform, the use of chloral, in the insane, 
 from excitement, or the result of injuries to the head. 
 
 Prognosis. Most unfavorable as regards a cure, it being fairly 
 questionable if complete recovery has ever occurred in a typical case. 
 Still, decided amelioration may take place in the symptoms, and the 
 progress of the malady be greatly retarded. The younger the patient, 
 the more rapid the fatal termination. 
 
 Treatment. Impress upon patients the importance of a strictly 
 regulated diet. Prohibit or restrict the consumption of such articles 
 as contain sugar or starch, especially ordinary bread or flour, sugar, 
 honey, potatoes, peas beans, rice, arrowroot, cracked wheat, oat meal, 
 turnips, beets, corn and carrots ; prunes, grapes, figs, bananas, pears, 
 apples, and liquors of all kinds whether distilled or fermented. 
 
 The main diet should be of animal food, including meat, poultry, 
 game and fish. 
 
 A moderate amount of fluids should be allowed, and in a majority 
 of cases jnilk will prove beneficial, although, theoretically, contra- 
 indicated. Tea, coffee and cocoa, without sugar, may be allowed in 
 moderation, 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 Treatinent. It is difificult to estimate justly the action 
 of any drug in this disease, for, as is so 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 maintained in all cases. Pavy strongly urges the use of 
 codeia in doses of gr. ^ to iij, three times a day. The use oi morphina 
 hydrochloras, gr. j daily, ox pulvis opii, gr, iij-v daily, or codcina, gr. 
 v-x-xv daily, I have seen of some value. Prof. DaCosta 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 aDimonii carbonas. The author has met 
 with decided partial success with uranii nitras, gr. j-iij, three times a 
 day, the cases not yet being under observation a sufficient length of 
 time to pronounce them cured, although in two the urine has been 
 
166 PRACTICE OF MEDICINE. 
 
 diminished from three quarts per day to normal, the quantity of sugar 
 from nine ounces to less than half an ounce, in the twenty-four hours. 
 Liquor bromuium arsenitis, n^ iij-v, three times a day, often gives good 
 results. Dickinson remarks that '' strychniiia is, of all remedies, the 
 most constantly useful." 
 
 Potassii bromidinn, 5j during the twenty-four hours, is strongly 
 urged. The following remedies are recommended by different ob- 
 servers, to wit : pepsijium, liquor potassii arse?iitis, iodum, potassii 
 iodidum, sodium salicylas, acidum lacticum, glyceri7ium, quinina and 
 tinctura cannabis indica. The evidence in favor of the majority of 
 these drugs is far from satisfactory. 
 
 Symptomatic treatment is mostly called for. For emaciation and 
 anaemia, y^'rr//;;/ and oleum inorrhucE ; for sleeplessness and restless- 
 ness, viorphina, potassii bro7?iidu7?i, chloral^ or hyoscyamia. For boils 
 and carbuncles, calcii sulphide. Duchenne suggests the following 
 solution for the excessive thirst of diabetic patients : — 
 
 R . Potassii phosphat., two parts. 
 
 Aquae, seventy-five parts. 
 
 SiG. — One teaspoonful twice or thrice daily, in wine or hot tea. 
 
 The dyspepsia and lung symptoms must be managed on general 
 principles. 
 
 The coTis\.2^\\. galvanic current )\2iS been productive of good results. 
 
 A change of scene and air is beneficial. 
 
 Surgical operation should on no account be undertaken on diabetic 
 patients. 
 
 DIABETES INSIPIDUS. 
 
 Synonyms. Polyuria ; polydipsia. 
 
 Definition. An affection characterized by the habitual discharge 
 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 nerv- 
 ous system ; exposure to cold ; drinking freely of cold water ; fatigue; 
 prolonged debility ; malaria ; syphilis. 
 
 The probable immediate cause of the excessive flow of urine con- 
 sists in dilatation of the renal vessels, the result of paralysis of their 
 
ACUTE GENERAL DISEASES. 167 
 
 muscular coat, caused by derangement of innervation, as the condi- 
 tion can be induced experimentally by irritating a spot in the fourth 
 ventricle, or by section of portions of the sympathetic nerve. 
 
 Sjnnptoms. The affection is characterized \iy great thirst, 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 1.001-1.007. 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. 
 
 The large flow of urine is usually preceded by various nervous 
 phenomena, as nervousness, irritability, iiiability to concentrate the 
 mi7id, viind imagination, failu7'e 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, etc. 
 
 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 iodidum and hydrargyrum 
 are of real benefit. Prof. DaCosta 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 ^«/7/«;z/5w in cases 
 not cured by potassii iodidum, placing "one electrode to the neck 
 below the occiput, the other to the hypochondriac regions in turn." 
 Valerian and potassii bromidum have been used. The author has 
 effected a cure in three cases, where other remedies had failed, by the 
 use, internally, of — 
 
 R . Strychnince sulph., g""- To 
 
 Acii. hyciroclilc)r. dil., rT^x 
 
 Aquae lauro-cerasi, , ^ij. M. 
 
 Well diluted. 
 
 The obstinate constipation is best overcome by pilulce catharticcs 
 composites, one at bedtime. 
 
168 PRACTICE OF MEDICINE. 
 
 CHOLERA. 
 
 Synon3rms. 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 
 vomiting of a similar material, severe muscular cramps, and a condi- 
 tion 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, probably the "comma bacillus" of 
 Koch. Cholera is but feebly contagious, in the usual acceptation of 
 that word, but it is unquestionably infectious. 
 
 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 stools of the 
 water used for drinking purposes. Milk may also be the vehicle by 
 which it spreads. Little, if any, danger exists from being in the pres- 
 ence 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 a 
 slight infective property, the " bacteria of decomposition " probably 
 destroying the cholera germs. One attack does not afford protection 
 against another. 
 
 The period of incubation is short, under a week, usually. 
 
 Pathological Anatomy. This is, as yet, far from satisfactory. 
 The morbid appearances in the majority of cases of death from 
 cholera 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 power- 
 ful 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 membrane are congested, and 
 present evidence of extravasations and ecchymoses, or are bleached 
 
ACUTE GENERAL DISEASES. 169 
 
 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 peculiar bacillus. It is thought by 
 many that the stripping-off of the epithelium is a post-mortem phe- 
 nomena. 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 liver is more or less advanced in fatty degeneration, 
 presenting a somewhat mottled, yellowish discoloration. The kidneys 
 are congested, the epithelium 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 dila- 
 tation of the vessels 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, vomiting and depression. Such cases are 
 termed Cholerine, the stools of which are infectious. 
 
 In a typical case there are three stages : first, diarrhoea ; second, 
 prostration ; third, collapse, or, in favorable cases, reaction. 
 
 First Stage, Begins with chilliness, excessive thirst, coated tongue, 
 unpleasant taste in the mouth, slight abdominal pain, and three or 
 four copious, zvatery, yet fecal stools during the day, and a decided 
 feeling of weakness, the stools rapidly becoming whey-like, easily 
 voided, but with force, and only shght 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 be- 
 comes most intense, increasing or diminishing with the variations in 
 14 
 
170 PRACTICE OF MEDICINE. 
 
 the number of the vomiting and stools ; severe muscular 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 ap- 
 pearance 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 have the sodden appearance of the "washerwoman who has 
 washed all day," and if picked up in folds, the fold but slowly dis- 
 appears. 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 
 urijie markedly diminished and albuminous. The mind is not cloudy, 
 but most patients are apathetic and indifferent to their danger. This, 
 the algid stage 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 Reaction. The temperature of the body rises, the pulse 
 gradually becomes fuller and stronger, the countenance becomes 
 brighter, the stools less frequent and more fecal, the vomiting de- 
 creases, the thirst lessens, the urine increases in amount, but con- 
 tinues albuminous, the padent 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 the develop- 
 ment of severe bed sores, boils, bronchitis, pneumonia or parotitis. 
 
 Sequelae. Suppuration of the parotid gland ; painful tetanic con- 
 traction of the flexor muscles of the limbs ; abscesses or ulcers of 
 the limbs; profuse sweats; roseola, erythema, urticaria, and rarely 
 vesicular eruptions. 
 
 Diagnosis. The epidemic character, and rapid spreading, and 
 great mortality of the affection prevent 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. 
 
ACUTE GENERAL DISEASES. l7l 
 
 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 stage ; 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 that in the stage of collapse its cure by any means whatever 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. 
 
 First Stage. The remedy of all others is opiwn in some form, to 
 which may be added, with h^ne^t, pi umbi ac etas, in doses of gr. iij-v, 
 repeated p. r. n., or aciduin sulp/mricum dilutuin combined with 
 tifictiira opii deodoraia, and at the same time applying mustard over 
 the abdomen. Water and food should be used with great caution, 
 but ice is indicated in limited amounts, and at times iced dry 
 champagne. The patient must be kept quiet, in bed. 
 
 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, followed with small doses — gr. ^ — every two 
 hours." 
 
 Second Stage. The opium treatment should be continued, together 
 with the free use of stimulants . For the distressing vomiting, ice, 
 iced champagne, acidum carbolic um or acidum hydrocyanicum may 
 sometimes give relief. 
 
 Locally either continue the mustard application to the abdomen or 
 the constant use of rubber bags filled with boiling water, or cold cloths. 
 
 For the crainps, hot water in bottles, hot irons or bricks applied 
 over painful parts, or an ointment of chloroform or chloral, chloroform 
 or ether inhalations, or the use of the following hypodermic solution, 
 strongly recommended by Prof. Bartholow :— 
 
172 PKACTICE OF MEDICINE. 
 
 . R . Chloral, .^5 iij 
 
 Morphin^e sulph., gr. iv 
 
 Aq. lauro-cerasi, f^j. M. 
 
 SiG. — Fifteen to thirty minims each injection. 
 
 For the collapse, heat to the surface and the free use oi stimiila7its, 
 or spiritus friimenti, or spiritus vi?ii gallici, hypodermically, also 
 the hot, and in some cases, the cold bath has been of advantage; 
 the intravenous injection of saline fluids was unusually successful 
 during the 1884 epidemic in France, and as the modus operandi 
 becomes more perfect, its success will be the more marked. 
 
 If reaction occur, treat indications as they arise, and use tonics, 
 such 2l's, ferrum , qitinina and arse7iiciwi. 
 
 All the discharges from the patient should be thoroughly disinfected 
 as soon as voided, and the stools and vomited material buried. 
 
 TRICHINOSIS. 
 
 Synonyms. Trichinae; 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 Trichina spiralis are introduced into the human 
 body by eating infected hog's flesh, either raw or but imperfectly 
 cooked. 
 
 Description. The parasite is found in two forms, to wit : intes- 
 tinal trichina, which is sexually mature, and imiscle trichina, which is 
 sexually immature. 
 
 The intestinal trichifta is a small, hair-like worm, the male meas- 
 uring yV of an inch, and the female yi 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. 
 
ACUTE GENERAL DISEASES. 173 
 
 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 parasite 
 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 occurs, and in about two weeks the migrating progeny 
 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 trichinse. There 
 are three stages described, to wit : the intestinal, the migration, and 
 the encapsulation. 
 
 Intestinal Stage. A gastro-intestinal inflammation, with 7iausea, 
 vomiting, and a 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. 
 
 Encapsulatio7i Stage. If the number of parasites ingested have 
 been few, recovery may occur in this stage, but if the number have 
 been large, the gastro-enteritis, fever and muscular 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-colitis or 
 typhoid fever. 
 
 Prognosis. Depends upon the number of trichina in the pork 
 eaten. Mortality between twenty and fifty per cent. 
 
 Treatment. The preventive treatment consists in eating no pork 
 
17-4 PRACTICE OF MEDICINE. 
 
 that has not been so prepared as to kill any trichinae that might exist. 
 If the parasites have been recently taken, within the first four or five 
 davs, emetics and purgatives 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 g/ycerini, one part, agucB, two parts ; or a trial can be 
 made of acidum carboliciim and tifict. iodi, as suggested by Prof. 
 Bartholovv. Quinina gave the best results in the cases seen by Dr. 
 Sutton. 
 
 After migratio7i has begun, the powers of life should be sustained 
 by nourishing food, stimulants and tonics. 
 
 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 condidon of the structures within, and 
 are known 2lS physical signs. 
 
 " Physical signs are, then, the exponents of physical conditions, and 
 of nothing more.'' 
 
 The methods employed in the physical exploration of the chest, 
 are:— I, Inspection; II, Palpation; III, Mensuration; IV, 
 Percussion; V, Auscultation; VI, Succussion. 
 
 Percussion and auscultation, dealing with sounds, are of the greatest 
 value clinically. 
 
 For the purposes of physical exploration, the chest is mapped off 
 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. 175 
 
 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: — Itifra-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 : — Supra- scapular. 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 betaken 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 \}i\^form, size, color, and movements oi the chest, 
 as well as the condition of the superficial parts. 
 
 In health the sides of the chest are for the most part symmeiricalxvi 
 form, size, color and movements, both sides rising equally during the 
 act of inspiration, and falling equally during the act of expiration. 
 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. 
 
 Inspiratio7i is almost entirely the result of muscular action ; expira- 
 tion, on the other hand, is chiefly 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 movement'x's, visible over the whole thorax, although 
 in males and in children it is most distinct at the lower portion 
 {inferior costal breathing) , while in the female it is most distinct at 
 the upper portion of the chest {superior costal breathing). 
 
176 PRACTICE OF MEDICINE. 
 
 PALPATION. 
 
 By palpation is meant the application of the palmar surfaces of 
 the hands and fingers to the chest, by which means we appreciate 
 impressions which are capable of being conveyed by the sense of 
 touch. 
 
 The objects of palpation are : — 
 
 First : — To give more accurate information regarding 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 fremitus (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 : — Broiichial fremitus, produced by the passage of air 
 through mucus, blood or pus, in the bronchial tubes, during the act of 
 respiration. 
 
 Fourth : — Friction fremitus, produced by the rubbing together of 
 the roughened surfaces of the pleurae. 
 
 When the normal chest vibrates lightly, it is termed the normal 
 vocal fremitus. 
 
 The vocal fremitus 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 transmission 
 of the vibrations, the vocal fremitus is diminished or absent. 
 
 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 circwnferential, in different 
 
DISEASES OF THE RESPIRATORY SYSTEM. 177 
 
 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 mid-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 ot 
 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 composi- 
 tion of structures, affords signs and information of 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 cjuality 
 of percussion sounds. 
 
 Mediate, or indirect percussion, may be practiced in three different 
 ways, to wit : — 
 
 First : — With the finger of one hand interposed between the body 
 percussed and the percussing finger. 
 
 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 
 
 15 
 
178 PRACTICE OF MEDICINE. 
 
 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 modus ope- 
 rcDidi, 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 is used, the other fingers 
 being raised from the chest, so as not to mttrfere with the sound 
 vibrations ; they should be applied firmly and evet^Iy 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 
 efids 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 of resistance or elasticity of the organs percussed. 
 
 The main sounds elicited by percussion are the dull, clear and 
 tympanitic. Familiarity with the iiitensity, 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 
 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. 
 
DISEASES OF THE RESPIRATORY SYSTEM. 179 
 
 The character is termed pti/monary 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 tyjnpanitic 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 towards 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 mammary 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 
 direction, from the sternum to the left nipple. This dull sound 
 in the left mammary region is lessened in extent during full inspi- 
 ration, and in emphysema, when the lung more completely covers 
 the heart. 
 
 In the infra-mamjnary 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- 
 mary 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- 
 cussed, the arms should hang loosely by the sides ; the hands may 
 be clasped across the top of the head during the percussion of the 
 axillary region ; during the examination of the back the head must 
 be bent forward and the arms tightly crossed in front. 
 
180 PRACTICE OF MEDICINE. 
 
 On the posterior surface of the chest the sound also varies according 
 to the part percussed. 
 
 Over the scapulcE 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 be 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 dicller, 
 owing to the presence of the liver ; at the corresponding situation on 
 the left side, the sound is clear or tympanitic, 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, providmg the tension of the chest walls 
 be not altered, occurring in emphysema of the lungs, atrophy of the 
 lungs, or consolidation of the opposite lung. 
 
 Second : — Dullness or an absence of resonance due to the relative 
 increase of soHd tissues in proportion to the amount of air, as seen in 
 the different stages of phthisis, in pneumonia, or pleurisy. 
 
 The pitch is increased or heightejied in proportion to the diminution 
 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 
 he flat ; if there is a slight decrease in the resonance of the part the 
 note is said to be impaired. 
 
 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 : — Tyfnpanitic, or the drum-like percussion note, is a non- 
 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 arc yielding, but neither tense nor very thick. 
 
 When elicited over the chest it may be due to the transmitted 
 
DISEASES OF THE RESPIRATORY SYSTEM. 181 
 
 sound of the distended stomach or colon. It is obtained over the 
 chest in pneumothorax, in moderate pleural effusions above the level 
 of the hquid, over the seat of cavities in the pulmonary tissues, and 
 in oedema 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, 
 elastic walls. 
 
 The cracked-pot or cracked-metal sound is another variety of the 
 tympanitic sound. The condition most commonly occasioning 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- 
 ments. 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. DaCosta has designated this method, respira- 
 tory percussion. 
 
 AUSCULTATORY PERCUSSION. 
 
 This method consists in listening, with a stethoscope appHed to the 
 thorax, to the sounds ehcited 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 stetho- 
 scope." 
 
 AUSCULTATION. 
 
 Auscultation, or listening to the sounds produced within the 
 chest during the act of respiration, coughing, or speaking, furnishes 
 the most rehable means of studying the condition of the lungs, and 
 is, therefore, the most valuable method of discriminating between the 
 various conditions which may affect the organs of respiration. 
 
 Auscultation is either immediate or mediate. 
 
182 PRACTICE OF MEDICINE. 
 
 It is immediate when the ear is applied directly to the chest, which 
 may be either denuded or thinly covered. 
 
 It is mediate 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 un- 
 cleanliness of the person examined, the stethoscope is to be preferred. 
 Moreover, there are certain parts of the chest which can only be ex- 
 plored satisfactorily by the aid of a stethoscope, and moreover, this 
 instrument has the additional advantage of i7itensifying the sound. 
 
 In auscultation, the following rules, formulated by Prof. DaCosta, 
 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 a 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." 
 
 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 respiration. 
 Its intensity is variable, its pitch hit^h, 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 nontial laryngeal respiration, and is 
 identical in character, duration and pitch with an important morbid 
 sound, termed bronchial respiration. 
 
DISEASES OF THE RESPIRATORY SYSTEM. ] 83 
 
 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 normal vesiculat 
 mumtur. 
 
 The inspiratory portion of the sound is of variable intensity, its 
 pitch is low, its quality soft and breezy, designated vesicular ; its 
 duration 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 expiration. 
 
 It is to be remembered, however, that the vesicular murmur will be 
 found 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 tubular 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. 
 
 Scapular Region. — 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. 
 
 Inter-scapular Region. — 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-mammary Regions. — The murmur in these 
 regions differs from that heard in the infra-clavicular region, in being 
 of less intensity. 
 
 Axillary and Infra-axillary Regiojis. — The respiratory sound in 
 
184 PRACTICE OF MEDICINE. 
 
 the " axillan,' 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 IN 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 in- 
 tensity, 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 resotiance. 
 
 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 manner, 
 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 pro- 
 duced by the air in the bronchial tubes during the act of expiration. 
 
 SOUNDS IN DISEASE. 
 
 The vesicular murmur may undergo, in disease, changes in its in- 
 tensity, its rhythm, and in its character. 
 
 The intensity of the respiratory murmur may be : — 
 
 1. Exaggerated ox increased. 
 
 2. Dimi7iished ox feeble. 
 
 3. Absent 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 one 
 
DISEASES OF THE RESPIRATORY SYSTEM. 185 
 
 lung, one-sided deposits, obstruction of the bronchial tubes by secre- 
 tion, or inflammation of the lung structure, necessitate a siipple- 
 jnentary 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 termed 
 puerile respiration. 
 
 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, diseases of the larynx and 
 bronchial tubes, pleuritic pain, rheumatism cr paralysis of the chest 
 walls, or in thickening of the pleural membrane, we observe superfi- 
 cial or diminished respiration. When one side of the chest is 
 partially 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 pressure 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 — 
 
 1 . Bitemcpted or jerky. 
 
 2. The interval between inspiration and expiratioii prolonged, 
 
 3. Expiration prolonged. 
 
 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 
 
186 PRACTICE OF MEDICINE. 
 
 be prolonged, instead of these two sounds closely succeeding one 
 another. 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 consohdation of 
 the lungs; iftheexpiratory sound is delayed, it is the result of lessened 
 elasticity of the lung structure, and is most commonly associated 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 in 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-bronchial respiration . 
 
 2. Broftchial. 
 
 3. Cavernous. 
 
 4. Amphoric. 
 
 Harsh respiration, or, as it is termed by Prof, DaCosta, vesiculo- 
 bronchial 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 obscure the sound produced by the passage of 
 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 respiratio7i 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 hii^^-h pitch and tubular in 
 
DISEASES OF THE RESPIRATORY SYSTEM. 187 
 
 character; expiration still higher iti pitch, of greater intensity, /r^- 
 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 act 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 is 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 
 musical or metallic quality. It is a variety of bronchial respiration 
 produced in a large cavity whh firm walls, permitting the reflection 
 of the sound. An imitation of this sound, although only an imperfect 
 one, is produced by blowing over the mouth of an empty bottle. 
 The amphoric character is present with both the act of inspiration 
 and expiration. 
 
 Amphoric or metallic respiration is indicative of a large cavity, not 
 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. 
 
188 PRACTICE OF MEDICINE. 
 
 '3. Vesicular rales. 
 
 4. Cavernous rales. 
 
 5. Pleural rales. 
 
 Rfiles may be divided into two groups, according to their character, 
 to wit : dry and vioist, 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 is low-pitched, 
 more musical in character, or so?iorous. 
 
 Dry rales are particularly prone to be dislodged by coughing, and 
 when they are uninfluenced by the acts of breathing or 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 rfiles 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 exists in the large bronchial tubes, the rales are said to be 
 large bubbling or mucous. 
 
 Moist rales are not persistent, but vary in intensity, and shift their 
 positions as the air drives the liquid which occasions them before 
 it, or during violent attacks of coughing, or after copious expectora- 
 tion. 
 
 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 acts of 
 expectoration, as in croup or inflammation of these parts in the very 
 feeble. 
 
 The dry rales produced within the larynx or trachea are generally 
 
DISEASES OF THE RESPIRATORY SYSTEM. 189 
 
 caused by spasm of the glottis, to wit: laryngismus stridulus, 
 whooping 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 larger-sized branchial tubes, the rales are said to be large 
 bubbling, or large mucous rales, and are heard 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 set 
 in 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 notes. 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 sonorous or 
 low-pitched rales. They principally occur in the dry stage of bron- 
 chitis, 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 fiiie soitnd, or rather series of very fi7ie 
 uniform sounds, occurring in puffs and liinited to inspiration.'' It 
 resembles the noise occasioned by throwing salt on the fire, or alter- 
 nately pressing and separating the thumb 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 stages of pneumonia, and when limited 
 to the apices, are significant of the incipient stage of phthisis. 
 
 Cavernous rales, or, as they are commonly termed, gurgling 
 
190 PRACTICE OF MEDICINE. 
 
 rates, 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 produced 
 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 rules may be either dry or moist. 
 
 Dry pleural rales, or, as they are more commonly termed, friction 
 sounds, are occasioned when the surfaces of the pleurae 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. This sound is diagnostic of the 
 first stage of pleurisy. 
 
 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 a 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 tinklin<^ sounds, of high pilch, silvery or 
 metaUic in tone, and is very well imitated by dropping a small marble 
 
DISEASES OF THE RESPIRATORY SYSTEM. 191 
 
 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, 
 
 THE VOICE IN DISEASE. 
 
 The normal vocal resonance, as heard over the third rib of 
 the chest anteriorly on either side, may have its intensity — 
 
 1 . Diminished or absent, 
 
 2. Increased or exaggerated. 
 
 Or its resonance may be of the character of — 
 
 3. Bronchophony . 
 
 4. Pectoriloquy. 
 
 5. JEgophony. 
 
 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. 
 
 Exag'gerated vocal resonance differs from the normal vocal 
 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 pulmon- 
 ary 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. 
 
 u^gophony 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 effusion, or of pleuro-pneumonia. 
 
 Amphoric voice, or "the echo," as it is sometimes called, is a 
 musical sound, of a somewhat hollow, metallic character, like that 
 
192 
 
 PRACTICE OF MEDICINE. 
 
 produced by blowing into an empty bottle. It is sometimes pro- 
 duced in large cavities within the lung, but is especially incident to 
 pneumothorax. 
 
 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 SUCCUSSion or splashing sound is pathognomonic of one 
 affection, namely, pneumo-hydrothorax. 
 
 It is obtained by jerking the body of the 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 pro- 
 tect against this error. 
 
 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 Auscultation Vocal 
 
 Percussion. 
 
 OF 
 
 Respiration. 
 
 OF Voice. 
 
 Fremitus. 
 
 Physical Conditions. 
 
 Clear Vesicular mur- Normal vocal Unimpaired. Lung tissue healthy or 
 
 mur or its resonance. nearly so ; at any rate, 
 
 modification, no increased density 
 
 from deposits, etc. 
 
 Dull, 
 
 Bronchial, or Bronchophony. Increased, 
 harsh respi- 
 ration. 
 
 Absent respira- Absent voice. 
 tion. 
 
 Diminished 
 or absent. 
 
 Solidification of pulmon- 
 ary structure. 
 
 Effusion into pleural sac. 
 
 Tympanitic... Cavernous or Uncertain; cav- Uncertain; Increased quantity of air 
 
 feeble, ac- 
 cording to 
 cause. 
 
 ernous or di- 
 minished. 
 
 mostl 
 niin 
 
 tly 
 isli 
 
 di- 
 ed. 
 
 Amphoric or 
 metallic. 
 
 Cracked metal 
 sound. 
 
 Amphoric or Amphoric or Mostly di- 
 
 metallic. metallic. minished. 
 
 Cavernous res- Cavernous res- Uncertain, 
 
 piration. piration. 
 
 vk^ithin the ghest, due to 
 a cavity or to ovcrdistcn- 
 tion of the air cells. 
 
 Large cavity with elastic 
 walls. 
 
 Generally a cavity commu- 
 nicating with a bronchial 
 tube. 
 
DISEASES OF THE NASAL PASSAGES. 193 
 
 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, mucus, or muco-purulent in character. 
 
 Pathological Anatomy. Hypercemia of the mucous mem- 
 brane, attended with redness, swelling and deficient secretion. This 
 tumefaction is partly increased by an cedematous infiltration, causing a 
 quantity of colorless, salty and very thin liquid to flow from the nose. 
 This 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 
 hypersemia and the swelling of the membrane diminishing. 
 
 The respiratory portions of the nasal fossse 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. 
 
 Irritating gases and vapors, dust, certain powders, as ipecac and 
 tobacco, excite an irritation of the nasal mucous membrane. 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. 
 
 Epidemic influence occasionally prevails on an extensive scale. 
 The poison of syphilis or the use of the iodide of potassium not un- 
 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 
 i6 
 
194 PRACTICE OF MEDICINE. 
 
 of lassitude or weariness and more or less frontal headache ; 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 sneeze. This is soon followed by an 
 abundant watery 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 
 fuUess of the head and difficult obstructed nasal respiration rapidly 
 returning. The anterior nares are red and i7ifla})ied, 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, the secretion lessens, health 
 being restored in about ten days from the beginning of the attack. 
 
 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 irritating 
 discharge. 
 
 Extension of the catarrh to the ethmoid or sphenoid cavities or 
 frontal simcs, causing increased and severe frontal headache ; or to 
 the antru7n of Highmore, causing tenderness over one or both 
 cheeks. 
 
 Extension to the Eustachian tube and middle ear, causing impaired 
 hearing; or to the pharynx 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 inabihty to take the breast. 
 
 Treatment. Attacks the result of atmospherical causes may be 
 aborted by the early administration of quinina sulphas, gr. x-xv, with 
 morphincc sulphas, gr. % , or the early use oi pulvis ipecacuanhcE et 
 opa, gr. V, repeated every two hours. 
 
 The following errhi7ie used at the very onset has proved successful 
 in aborting many cases : — 
 
DISEASES OF THE NASAL PASSAGES. 195 
 
 R . Aluminis, 
 
 Bismuthi carb., 
 
 Pulv. talc, aa ^' ^."^ 
 
 Morphinse hydrochlor., gr- ij- M. 
 
 SiG. — Insufflate one powder in each nostril after clearing the nose. 
 (Sajous.) 
 
 If the attack has already developed, relief is soon afforded by 
 iinctura belladonncB, gtt. ij, every hour until six doses are taken, after 
 which one drop every two or three hours until the physiological 
 actions of the drug are produced; if much fever be present, iinctura 
 aconiti, gtt. i-ij, may be added; or the following combination of Dr. 
 Sajous :— 
 
 R . Ammonii chlor., . . ^ij 
 
 Tinct. opii, ■n:\^xxiv 
 
 Sacch. alb., ^j 
 
 Aq. camphorse, ad ... . f^^j. M. 
 
 SiG. — One teaspoonful in water every hour or two. 
 
 An efficient plan of treating acute coryza is by producing free 
 diaphoresis with •' Dover's powder," gr. x, repeated if need be, 
 followed by — 
 
 R . Potassii citratis, '^ ij-iv 
 
 Syrupi ipecac, 
 
 Tinct. opii camph., aa ^ij-i^ 
 
 Syr. limonis, 'T^'w 
 
 Aquae, ad ^iij. M. 
 
 SiG. — One or two teaspoonfuls every hour or two. 
 
 Attacks of acute rhinitis unaccompanied by febrile reaction are 
 generally promptly aborted by a four per cent, solution of cocaine 
 dropped in the nostrils, repeated every half hour. 
 
 With either of the above plans may be added one of the following 
 errhines : — 
 
 K. Bismuth, subnit., ... ^vj 
 
 Pulv. acaciae, ^ij 
 
 Morphinse hydrochlor., gr. ij- M. 
 
 SiG. — Every hour or two. (Ferrier.) 
 Or— 
 
 R. Pulv. cubebae, 5J 
 
 Bismuth, subnit., 5 ij 
 
 Morphinse muriat., g^- ij. M. 
 
 SiG. — Used by insufflation every two or three hours. 
 
196 PRACTICE OF MEDICINE. 
 
 Or— 
 
 B. . Pulv. fol. belladonnae, ^ j 
 
 Pulv. morpbinre sulph., K*"* ij 
 
 Pulv. g. acaciie, . ad .^ ss. M. 
 
 SiG. — Use, with powder blower, to anterior and posterior nares. 
 (Robinson.) 
 
 Acute coryza occurring in infants at the breast is controlled by 
 either one of the following errhines : Throw into the nose, with a 
 powder blower, finely powdered saccJiariim alba, or equal parts of 
 finely powdered saccharum album and camphora, or Robinson's 
 errhine of saccharum alba and camphora, each half ounce finely 
 powdered, and acidum taimictim, gr. xl. 
 
 Attacks of nasal catarrh due to the poison of syphilis should at 
 once be placed upon the proper constitutional treatment. 
 
 Attacks of nasal catarrh associated with the eruptive or mild fevers 
 require no special treatment. 
 
 It is well to remember that attacks of nasal catarrh occurring in 
 very young children are generally the result of hereditary syphilis, 
 and should be treated accordingly. 
 
 CHRONIC NASAL CATARRH. 
 
 Synonyms. Chronic rhinitis ; chronic coryza. 
 
 Definition. A chronic inflammation of the mucous membrane 
 lining the nasal passages, with more or less alteration of structure; 
 characterized by a sensation of fullness in the nares, increased 
 secretion and a perversion of the special sense of smell and of 
 hearing. 
 
 Causes. The result of repeated attacks of the acute variety ; 
 inhalation of irritating vapors and dust; syphilis and scrofula. 
 
 Pathological Anatomy. The mucous membrane of the nares 
 is thickejied, of a dark-red, sometimes grayish^ color, the superficial 
 veins dilated and varicose, often forming polypoid enlargements. In 
 many cases there is ulceration of the structure, with more or less loss 
 of substance; the secretion is thick, tough, of a greenish character, 
 and often very fetid ; large collections of dried mucus are often 
 formed upon the turbinated bones and septum. 
 
 Symptoms. A feeling oi fullness in the 7iares, increase of the 
 secretion, the character being thick and greenish, which, dropping 
 
DISEASES OF THE NASAL PASSAGES. 197 
 
 posteriorly into the pharynx, causes paroxysms of " hawking," which 
 are more marked in the morning immediately after rising. 
 
 The special se7ise of smeli is more or less impaired, and in many 
 cases entirely abolished ; the special sense of hearing is more or less 
 diminished, from an extension of the inflammation to the Eustachian 
 tubes ; the voice has a peculiar 7iasal intonation. 
 
 An almost constant &<}X\. frontal headache, associated with a feeling 
 of weio-ht, showing the extension of the disease to the infundibulum 
 and frontal sinus. 
 
 Sudden changes of temperature cause acute exacerbation of these 
 symptoms, when there is superadded difficult nasal respiration. 
 
 If tdceration of the nares occur, the discharge has a fetid odor. 
 This condition is termed ozcena. 
 
 From extension of the inflammation to the nasal duct or its ob- 
 struction, the tears flow over the malar eminence {epiphora^, leading 
 to more or less congestion of the eyes. 
 
 Diagnosis. Hypertrophy of the turbinated bones and naso- 
 pharyngeal catarrh are constantly misnamed chronic nasal catarrh. 
 The rhinoscope readily determines the diagnosis. 
 
 Prognosis. Permanent cure is seldom obtained, the disease 
 being so decidedly chronic and obstinate, the treatment is of neces- 
 sity protracted, and the majority of patients tire of it before a com- 
 plete cure is effected. 
 
 Treatment. If it depends upon diathetic conditions, the cause 
 must be ascertained and treatment directed accordingly. 
 
 When no diathetic cause can be determined, attention should be 
 paid to the general health, the secretion constantly attended to, and 
 the diet be nutritious and digestible. 
 
 Cleanliness of the nasal passages is of the utmost importance, 
 and is best effected by the post-nasal syringe, with either simple 
 or medicated tepid waters, or a cleansing solution, such as Do- 
 bell's, to wit : — 
 
 Jj. Acidi carbolici, gr. j 
 
 Sodii bicarbonat,, 
 
 Sodii borat , , . . aa gr. v 
 
 Glycerin], "Z] 
 
 Aquae, , Jj. M, 
 
 SlG. — As a spray or with a proper syringe. 
 
198 PRACTICE OF MEDICINE. 
 
 Or "the following combination of Dr. Sajous : — 
 
 R . Sodii bicarb., 
 
 Sodii bibor., ^9. gr. viij 
 
 Ext. pinus canad. fld., V(\xv 
 
 Glycerinoe, f Zij 
 
 Aquam, ad ..... f^iv. M. 
 
 SiG. — Apply with atomizer three or four times daily. 
 
 After which decided benefit follows the use of one of the following : — 
 
 R . Hydrargyri chlor. mite, 
 
 Pulv. aluminis, ...... aa ^ ss 
 
 Morphinae hydrochlor., gr. ij. M. 
 
 R. Sodii borat., 3J 
 
 Bismuth, subnit., ^ij 
 
 Morphinae muriat., gr. j. M. 
 
 Or— 
 
 R. lodoformi, 3J 
 
 Acid, tannici, gr. v 
 
 Pulv. camphorae, ^j 
 
 Bismuth, subnit., 5J. M. 
 
 SiG. — To be used by insulation or as a snuff, every three or four 
 hours. 
 
 Or— 
 
 R . Ammonii muriat., • • • 3J 
 
 Glycerini, Zij 
 
 Ext. pinus canad. fld., i%\ 
 
 Aquam, ad f.^ij- M. 
 
 SiG. — Five to ten drops, dropped into each nostril two or three times a 
 day. 
 
 DISEASES OF THE PHARYNX. 
 
 ACUTE CATARRHAL PHARYNGITIS. 
 
 S37Tionyin8. Catarrhal tonsillitis ; angina catarrhalis ; acute 
 " sore throat." 
 
 Definition. An acute catarrhal inflammation of the mucous 
 membrane of the tonsils, uvula, soft palate and pharynx ; character- 
 ized by rigors, fever, painful deglutition, coughing, or constant desire 
 to clear the throat, with a more or less decided nasal intonation of the 
 voice. 
 
DISEASES OF THE PHARYNX. 199 
 
 Causes. Exposure to cold and damp ; swallowing hot fluids or 
 food ; during the prevalence of scarlatina, measles or variola. 
 
 Pathological Anatomy. The mucous membrane and sub- 
 mucous tissues of the uvula, soft palate, fauces, tonsils and pharynx 
 are congested, red and swollen, the secretion is at first lessened or 
 entirely arrested ; later it is increased, but of a thick, tenacious, opaque 
 character. The swelling is most evident at the uvula, due to the 
 amount of relaxed sub-mucous tissue, which is especially thick and 
 long, often resting on the root of the tongue (" the palate is down "). 
 
 Frequently one or both tonsils are swollen to such an extent that 
 the fauces are completely occluded, and the condition is mistaken for 
 the graver phlegmonous tonsillitis. 
 
 In severe attacks of catarrhal angina, white or grayish-white mem- 
 branous masses form in small, irregular, roundish spots on the red- 
 dened mucous membrane of the tonsils, soft palate and pharynx, 
 causing the affection to be frequently mistaken for diphtheria. 
 
 Symptoms. The onset is usually sudden, with rigors, fever, 
 thirst, headache, loss of appetite, coated tongue, bad taste, foul 
 breath, dryness in the throat, painful deglutition, and constant desire 
 to clear the throat, due to the increased length of the uvula ; as the 
 inflammation proceeds the secretions are increased, the fluid often 
 filling the mouth and also causing a constant desire to swallow, each 
 act being associated with acute pains. Not infrequently earache adds 
 to the patient's distress, from, extension of the " catarrh" to the Eus- 
 tachian tubes and tympanum. 
 
 In severe attacks of catarrhal pharyngitis, cases which, from the 
 intense hyperaemia, have been termed erysipelatous or erythematotis 
 pharyngitis, the muscles of the palate are infiltrated with serum, 
 which greatly interferes with their function. Under normal conditions 
 the contraction of the muscles of the anterior half arches of the palate 
 prevents the return of the food and drink into the mouth ; while the 
 contraction of the muscles of the posterior half arches, together 
 with the uvula, closes the passage to the nose; if the function of 
 these muscles be impaired, fluids would be driven through the nose 
 or back into the mouth by the contraction of the pharynx in the act 
 of deglutition. 
 
 In all affections of the pharynx a nasal tone is pathognomonic, 
 especially if the muscles of the half arches are interfered with. 
 
 Varieties. Exanthematous Pharyngitis is the form of the affec- 
 
200 PRACTICE OF MEDICINE. 
 
 tion complicating the acute infectious diseases, such as scarlatina, 
 measles aad smallpox. 
 
 Erysipelatous Pharytigitis is the form complicating facial erysipelas ; 
 rarely, however, the affection begins in the pharynx, spreading to the 
 face and other parts. 
 
 Gangrenous Pharyngitis may occur with diphtheria, scarlatina, 
 erysipelas, smallpox and typhoid fever. The symptoms assume a 
 typhoid (depressed) character, the termination being usually fatal. 
 
 P/i/egmonous Pharyngitis is the variety in which is present an accu- 
 mulation of pus in the submucous and deeper tissues of the pharynx, 
 constituting a retro-pharyngeal abscess. This variety of pharyngitis 
 may follow the penetration of a sharp piece of bone or be secondary 
 to caries of the cervical vertebrae. 
 
 Fibrinous Pharyngitis, or, as it is sometimes termed, pseudo-mem- 
 branous, is considered with croup and diphtheria, of which it consti- 
 tutes a part. 
 
 Diagnosis. On account of the great swelling of the tonsils, it may 
 be mistaken iox acute tonsillitis; but the mild inflammatory symp- 
 toms should prevent the error. 
 
 Cases with membranous deposits on the tonsils, soft palate and 
 pharynx, are no doubt often misnamed diphtheria ; the marked dif- 
 ference in the constitutional symptoms should prevent the error. 
 
 Prognosis. Favorable, the affection terminating in three or four 
 days by the raising of a quantity of thick, opaque mucus. 
 
 Treatment. Perhaps the most successful treatment of this affec- 
 tion is by insufflation, every hour or two, with sodii bicarbonas. 
 
 Tinctura opii, n^v-x for a dose or two at the very onset of an attack, 
 will often abort the catarrh. 
 
 If the inflammatory symptoms are severe, ti?ictura aconiti, gtt. j-ij, 
 at short intervals, is of decided advantage. At times tinctura bella- 
 donjicB may be added. 
 
 Locally, cocaine painted over the inflamed parts, of the strength of 
 a four per centum solution, or used in the form of lozenges, is a valu- 
 able remedy. Holding small pellets of ice in the mouth is useful, as 
 is the application of cither heat or cold to the angles of the jaws. 
 Gargles or sprays of aluminis (gr. viij-aquae f^j), afnmonii murias 
 (g. xx-aquae f3j). or potassii chloras (gr. xij-aquae f^j), used at fre- 
 quent intervals, often allay the congestion and consequent swelling. 
 
DISEASES OF THE PHARYNX. 201 
 
 ACUTE TONSILLITIS. 
 
 Synonyms. Amygdalitis ; quinsy ; phlegmonous pharyngitis. 
 
 Definition. An acute parenchymatous inflammation of one or 
 both tonsils, with a strong tendency toward suppuration ; character- 
 ized by moderate fever, pain in the throat, a constant desire to relieve 
 the throat, painful and difficult deglutition, impeded respiration, and 
 more or less muffling of the voice. 
 
 Causes. Generally attributed to exposure to cold, but, in the 
 majority of cases, the exposure is so slight that there must be a pre- 
 disposition to the affection ; for persons once affected are particularly 
 prone to repeated attacks, upon the slightest exposure. 
 
 Pathological Anatomy. One or both tonsils will be seen, on 
 inspection, to project from its bed, as a rounded, deep red body, which 
 may even extend beyond the median line, when they may entirely 
 occlude the isthmus of the fauces ; the half arches and posterior border 
 of the soft palate are reddened and somewhat swollen. The surface 
 of the tonsils is often covered with small, yellowish points, which 
 closely resemble patches of false membrane, but careful inspection 
 will show that they are beneath the mucous membrane, being only 
 the distended follicles of the gland. The mucous membrane of the 
 fauces and pharynx is more or less red and swollen. 
 
 Symptoms. Onset more or less sudden, with rigors, rise in tem- 
 perature, 102° to 104° Y., full, frequent pulse, 100 to 120, headache, 
 thirst, pain and swelling at the angle of the jaw, with a constant desire 
 to clear the throat, difficult and painful deglutition, from the enlarged 
 tonsils almost closing the fauces, when the respiration is more or less 
 inipeded ; the voice is more or less muffled, and attempts at phonation 
 increase the pain. 
 
 Darting pains along the Eustachian tubes are of frequent occur- 
 rence, the patient complaining of earache and more or less deafness. 
 
 If suppuration be imminent, the throat becomes more painful, the 
 character of the pain throbbing, the febrile phenomena increase, with 
 more or less depression, the symptoms seeming to be of great danger, 
 when suddenly, after an effort at vomiting, or spontaneously, the ton- 
 sillar abscess bursts, a quantity of pus escapes from the mouth, and 
 prompt relief follows. 
 
 Duration. The disease lasts from three to seven days, terminating 
 either by suppuration or the gradual resolution of the enlarged glands. 
 17 
 
202 PRACTICE OF MEDICINE, 
 
 Diagnosis. Tonsillitis can hardly be mistaken for any other 
 affection, if the fauces are inspected. 
 
 Prognosis. In the majority of cases the result is favorable, it 
 very rarely proving fatal, except in children, and only then by ob- 
 structing the respiration, and, at the same time, so seriously interfer- 
 ing with nutrition that the child's strength fails. 
 
 Treatment. '' Instar specifici in hoc inorbo operatur'' well said 
 Holmes when referring to giiaiacuin in the first hours of a true 
 tonsillitis, for experience has amply proven its power to cut short an 
 attack if administered early. I usually order tinctura giiaiaci aviino- 
 niata, foj, in water or milk every hour or two, until its good effects are 
 produced. The drug is all the more successful if at the same time it 
 be used locally in the form of trochisctis giiaiact (aa gr. ij) frequently 
 repeated, or the following gargle at intervals of every half an hour to 
 an hour: — 
 
 R . Tinctune guaiaci ammoniat., 
 
 Tincturae cinchonae comp., . . . . aa . . . .f^ij 
 
 Mel. despumati, 3^j- 
 
 M. and shake together until the sides of the containing vessel are well 
 greased, then 
 Adde— 
 
 Potassii chlorat., 9^^ 
 
 Aquae destil., f^iv 
 
 M. and add gradually, continuing shaking. 
 
 Should the febrile reaction be high, tinctura aco?titim small doses 
 frequently repeated, either alone or alternating with guaiacum, rapidly 
 reduces the temperature and the frequency of the pulse, and by its 
 local action lessens the pain and swelling. If from any cause the 
 internal use of aco7titum be contraindicated, the tinctura aconiti may 
 be diluted w'lih. glycerimctn and painted over the affected parts. The 
 author has seen excellent results follow the use of sodii salicylat., gr. 
 x-xv in solution, every three hours. Prof. Da Costa has seen attacks 
 of acute tonsillitis aborted by prompt emesis with pulvis ipecactiankcr, 
 gr. XX, also by the early administration of qtiinina sulphas, gr. xx for 
 an adult, or gr. viij for children. 
 
 Cases not seen until two or three days after the onset are benefited 
 by the following : — 
 
 li . TinclurLc ferri chlor., f .:^ ij 
 
 Giycerini, ad . . . . f 5 ij M. 
 
 Sio. — Teaspoonful every two hours. 
 
DISEASES OF THE LARYNX. 203 
 
 This palatable mixture, suggested by Dr. Bosworth, acts as a local 
 astringent in passing over the inflamed tonsils, and should not be 
 followed by water or food for an hour at least, 
 
 Scarificatio7i, a long, sharp bistoury being used to make five or six 
 cuts, affords great relief when the tonsils are much inflamed ; the ex- 
 ternal ws^ oi ice over the site of the glands, and small pellets allowed 
 to dissolve in the mouth, afford great relief. If the application of 
 cold be objectionable, heat m.ay be substituted in the form of warm 
 compresses or poultices. 
 
 In all cases we must also have recourse to such general therapeutic 
 measures as are calculated to guide the morbid action to a favorable 
 issue ; the bowels should be kept open and the skin and kidneys active ; 
 the diet should be in the shape of gruels, as it is impossible for 
 the patient to swallow any solid substance, and in cases where even 
 gruels cause painful deglutition, thin oatmeal gruel can be used with 
 advantage. 
 
 When suppuration cannot be averted, hot applications should be 
 apphed to the angles of the jaws, hot gargles and the steam atomizer 
 resorted to, medicated with opium, belladonna, benzoin or cocaine, 
 and as soon as fluctuation can be detected the abscess should be 
 opened. Also during this stage administer qtiinince sulphas, gr, iij-v, 
 every three or four hours. After the acute symptoms have subsided, 
 assist the return of the glands to their normal condition by the topi- 
 cal application of cupri sulphas (gr. xx-aquse fjj) or liquor fer^'i sub- 
 sulphaiis (f^j-aquse f^j). 
 
 DISEASES OF THE LARYNX. 
 
 ACUTE CATARRHAL LARYNGITIS. 
 
 Synonyms. Catarrhal laryngitis ; " sore throat." 
 
 Definition. An acute catarrhal inflammation of the mucous 
 
 membrane of the larynx ; characterized by feverishness, diminished 
 
 or suppressed voice, painful deglutition, and more or less difficulty 
 
 of respiration. 
 
 Causes. Atmospherical changes ; cold draughts of air whether 
 
 directly inspired or exposure of parts or all of the body to the same. 
 
204 PRACTICE OF MEDICINE. 
 
 Cold, wet feet ; inhUation of irritating vapors, such as gas, smoke or 
 ammonia ; inhalation of dust. Prolonged efforts at public speaking 
 or sinking or the same efforts under difficuldes. In children, from 
 violent fits of crying. 
 
 Pathological Anatomy. In mild cases there is a transient 
 cono-fstion (hypera^mia) of the mucous membrane over the entire, but 
 more commonly circumscribed, portions of the larynx, with more or 
 less swelhng and diminished secretion ; the mucous membrane soon 
 returns to its normal condition, the secretion being slightly increased. 
 
 Symptoms. The attack begins rather suddenly with a feehng 
 of dryness, rawness, and ticklhig, referring to the larynx, with the 
 sensation of the presence of a foreign body in the throat, and with 
 hoarsetu ss and a disposition to cough. Deglutition causes pain by the 
 upward movement of the larynx and by the pressure of the food on 
 the larynx as it passes along the gullet. Attempts at speaking are 
 attended with more or less distress and the larynx is tender on 
 pressure. 
 
 Coughing, from the onset, of a noisy, har<:h, hoarse, or toneless 
 character and the act of coughing attended with a sensation of 
 scratching in the larynx. The first day or two there is scanty expec- 
 toration, but in a short time the secretion is increased, giving the 
 cough a loose character. In the early stages the sputa may be 
 slighdy streaked with blood. Rarely a hemorrhage occurs from the 
 mucous membrane of the larynx. The voic is at first decidedly 
 hoarse, soon followed by complete aphonia. The respiration is but 
 slighdy, if at all, affected in adfilts. There may be more or less 
 febrile reacdon. In children the onset is with fiver, white coated 
 t07igue, frequent, tense pulse, hot skin, ^r\d flushed face, embarrassed 
 respiration ; the voice hoarse and whispering with harsh, ringing, 
 croupy cough and great resdessness. During the night the child is 
 subject to suffocative attacks (laryngismus stridulus). 
 
 Laryngoscopic appearances. These vary with the severity of the 
 attack and the stage of the inspection. In mild cases, at an early 
 period the mucous membrane presents a bright red appearance. 
 Severe cases present, in addition to the bright redness, the mucous 
 membrane swollen, to such an extent at Umes as to conceal the 
 vocal cords, they appearing only as slender threads of a reddish tint. 
 At umes the mucous membrane presents the appearance of erosions 
 or ulcerations, due to a desquamation of the epithelium. 
 
DISEASES OF THE LARYNX. 205 
 
 Duration. Usually about one week ; if very severe, two or three 
 weeks may elapse before the larynx returns to its normal condition. 
 
 Prognosis. Simple catarrhal laryngitis never terminates fatally. 
 
 Treatment. Confinement to an apartment of uniform tempera- 
 ture, the air kept moist by the vapor of water being disengaged in it, 
 and particularly in the case of children. 
 
 Locally, a hot pack should be kept constantly wrapped about the 
 throat, and if its application is preceded by the temporary use of a 
 weak mustard plaster, the relief afforded is more rapidly obtained. 
 At the very beginning of an attack the feet should be placed in a hot 
 mustard foot bath, and a saline cathartic administered. 
 
 Prompt action on the skin at the very onset will frequently shorten 
 the duration of a catarrh of the larynx. Use for this purpose in adults, 
 pulvis ipecacuanhcE et opii (gr. iij) combined with potassii nitras 
 (gr. iij) every three or four hours. If there be much febrile reaction 
 benefit follows the use of tinctura aconiti, iU.j-ij. every half hour until 
 five or six doses are taken, after which every hour or two, combined 
 with tinctura opii, ^]-v ; or diaphoresis may be produced by antimonii 
 et potassii tartras, gr. -io—^^, every hour, or by a hypodermic injection 
 oi pilocarpus murias, gr. i^. 
 
 For children, several doses of the following powder a couple of 
 hours apart, until the bowels are freely moved : — 
 
 R . Hydrargyri chloridi mite, S^- H 
 
 Pulvis ipecacuanhse, . . . gr. /^ 
 
 Sacc. lac, gr. ij. 
 
 to be followed by the following : — 
 
 li. Potassii citrat., ^iv 
 
 Tinct. aconiti, V(\iv 
 
 Tinct. opii camphorat., ^ ij-iv 
 
 Syr. scillae, _:^ ij 
 
 Syr. tolu, ad ^iij. M. 
 
 SiG. — One teaspoonful every two hours. 
 
 If a tendency to spasm of the glottis obtains, full doses of the dro- 
 mides should be administered at once. 
 
 Inhalations from the onset are not only soothing but curative in 
 their actions. Either of the following are recommended : — 
 
 U . Infusi humulus, Oj 
 
 Vinegar, f^ss-j. M. 
 
 SiG. — Inhale hot every hour. 
 
206 PRACTICE OF MEDICINE. 
 
 R. Tinct. benzoin comp., f3J~U 
 
 Aquae bull., Oj. M. 
 
 SiG. — Inhale hourly. 
 
 The local application of cocaine is of great benefit. 
 
 Attacks of acute laryngitis occurring from efforts in public speaking 
 or singing are wonderfully benefited by the use of acidiim 7iitricum 
 dilutum, Tt\,ij-v, every hour or two. 
 
 The patient should abstain altogether from the use of the voice and 
 from taking food or drink of an irritating character. 
 
 GEDEMATOUS LARYNGITIS. 
 
 Synonym. CEdema of the glottis. 
 
 Definition. An acute inflammation of the mucous membrane of 
 the larynx and that about the glottis, with an infiltration of the areolar 
 tissue by a serous, sero-purulent or purulent fluid ; characterized by 
 obstructed or stridulous breathing and dysphonia or aphonia. 
 
 Causes. The result of acute laryngitis ; abscess in or about the 
 throat or tonsils ; erysipelas of the face ; scarlatina ; smallpox ; 
 Bright's disease. Rare in children. 
 
 Patholog'ical Anatomy. Infiltration into the loose connective 
 tissue of the ary-epiglottic folds, the glosso-epiglottic ligament, the 
 base of the epiglottis, and the inter-arytenoid space. If the true 
 vocal cords are inflamed, their color changes, and instead of appear- 
 ing white, glistening and brilliant, they are dull, grayish-red or violet- 
 red in patches. If the swelling be the result of purulent infiltration, 
 the parts affected present a deeply congested color, with here and 
 there spots of a yellowish hue. 
 
 Serous infiltration, sufficient to cause fatal oedema, disappears 
 with death, leaving but slight traces to account for the formidable 
 symptoms. 
 
 Symptoms. The onset is much the same as a simple catarrhal 
 laryngitis with a gradually increasing' impedi?neni to the respiration. 
 The patient experiences the sensation of a foreign body in the throat, 
 and after a short time a dijfficulty of breathing, which ultimately 
 threatens suffocation. The deglutitio7i is rendered difficult, owing to 
 the swelling of the epiglottis ; the voice, at first muffled, gradually 
 becomes weaker and weaker, until finally it is almost extinct ; the 
 cough at first is dry and harsh, but as the infiltration increases it 
 
DISEASES OF THE LARYNX. 207 
 
 becomes stridulous and suppressed ; there is no expectoration except 
 that, after great effort to clear the throat, a httle frothy mucus is raised. 
 The difficiilty of respiration, as the disease progresses, becomes greater 
 and greater, and the paroxysms of impending suffocation more fre- 
 quent. The inspiration is accompanied by awhisthng sound, char- 
 acteristic of the narrow condition of the glottis, the patient sits up in 
 bed, his mouth open, gasping for breath, his eyes protruding, the 
 whole body trembling with intense convulsive movements, and after a 
 time a general cyanosis commences, the face assuming a bluish hue, 
 all these symptoms continuing for a few moments, when slight relief 
 occurs, to be again followed by another paroxysm, in one of which, 
 if nature or art does not afford prompt relief, death occurs from 
 asphyxia. 
 
 A physical examination of the parts may be made by gently pass- 
 ing the finger into the throat, when the epiglottis may be felt very 
 much thickened, and the ary-epiglottic folds may have attained such 
 tumefaction as to convey to the finger an impression similar to that 
 which is given by touching the tonsils. 
 
 Laryngoscopic appearance. The mucous membrane has a bright 
 red appearance. The epiglottis has the appearance of a semi-trans- 
 parent roll-like body, or it is often merely erect and tense. It is this 
 condition of the epiglottis which explains the pain and difficulty in 
 deglutition. Rarely the vocal cords are infiltrated. 
 
 Diagnosis. Any disease which gives rise to dyspnoea may sim- 
 ulate cedematous laryngitis, but the history of the case and the laryn- 
 goscopic examination will generally furnish conclusive evidence as to 
 the real nature of the malady. 
 
 Prognosis. As a rule unfavorable. If early and vigorous treat- 
 ment be instituted, recovery is possible, but without it death is the 
 inevitable result, the patient dying asphyxiated. Even when local 
 measures have removed the obstruction to free respiration, the patient 
 is very likely to perish subsequently from exhaustion or blood poison- 
 ing, or from pneumonia or other lung complication. The duration of 
 infiltration of the larynx varies from a few hours to several days. 
 
 Treatment. Prompt local treatment must be adopted in order to 
 remove the laryngeal obstruction. Leeches placed over the sides of 
 the larynx in mild cases may effect so much reduction in the oedema 
 as to render the subsequent progress of the case free from danger. 
 
 If the infiltration has already occurred and is slight in amount, 
 
208 . PRACTICE OF MEDICINE. 
 
 scarification , guiding the instrument by the index finger of the oppo- 
 site hand, may afford rehef, or the hypodermic injection of ///<?t7?r- 
 pincE anurias, gr. y^, repeated, may lessen the swelHng. 
 
 Niemeyer recommends \.\i& persistent wst of small pellets of ice swal- 
 lowed or held far back in the mouth till dissolved, early in the attack. 
 Trousseau recommends the ijiJialation or spray of a strong solution of 
 aciduvi tannicum. Prof. DaCosta suggests the application as near the 
 seat of the disease as possible of liquor ferri subsulphatis (Monsel's 
 solution), full or half strength. Mackenzie says the patient should be 
 kept constantly under the influence of potassii bromiduni. 
 
 If these means fail, iracheotoiny is indicated ; ift those cases of sud- 
 den and rapid infiltration of the glottis or larynx occurring in Bright's 
 disease, erysipelas or scarlatina, and especially the former, trache- 
 otomy should be perforined at once. 
 
 In all cases of infiltration of the larynx stimulants should be boldly 
 administered per rectum, if stomachic administration be impossible. 
 
 If the infiltration be composed of pus, quinitiCE sulphas., gr. v, 
 every four hours, and stimulants are indicated. 
 
 SPASMODIC LARYNGITIS. 
 
 Synonyms. Spasmodic croup ; false croup ; catarrhal croup ; 
 child-crowing. 
 
 Definition. A catarrhal inflammation of the mucous membrane 
 of the lar>'nx, associated with spas?nodic contraction of the glottis ; 
 characterized by paroxysmal coughing, difficulty of breathing and 
 attacks of threatening suffocation. 
 
 Mackenzie describes it as " a form of convulsion occurring in ill- 
 nourished infants, characterized by spasmodic action of the abductors 
 of the vocal cords, and in severe cases by spasm of the diaphragm 
 and intercostal muscles." 
 
 Causes. Delayed or difficult dentition ; excesses in eating and 
 drinking ; excitement ; violent emotion and atmospherical changes, 
 are all given as causes for simple croup. It is often hereditary. 
 
 Pathological Anatomy. Coiigestio7i of the mucous mem- 
 brane of the larynx, with slight swelling and deficient secretion, are 
 the only changes that have thus far been noted. 
 
 Symptoms. The attack occurs chiefly during the Jiight, the child 
 on retiring having either its usual health, or, perhaps, being a little 
 
DISEASES OF THE LARYNX. ^ 209 
 
 feverish. After several hours of sleep the child is suddenly awakened 
 by 2. paroxysm of suffocation, and a dry, harsh, ringing cough. After 
 half an hour or an hour or two the breathing becomes easier, the cough 
 less " croupy," the skin is covered with more or less perspiration, and 
 the child falls asleep. The next day there is present cough of a loose 
 character, the respiration being about normal. If no treatment be 
 instituted, the same phenomena occur on the second night, the child 
 being apparently well during the second day, the cough being less in 
 amount ; phenomena of a similar character, but of much less sever- 
 ity, are present the third night, after which the disease usually dis- 
 appears. 
 
 If the symptoms of the first paroxysm continue pronounced for 
 two or three days, there is a strong probability that the inflamma- 
 tion may become fibrinous in character, or that true croup may 
 develop. 
 
 Diagnosis. The symptoms are so characteristic that it seems 
 impossible for the affection to be mistaken for any other disease. 
 
 Prognosis. Spasmodic or simple croup always terminates favor- 
 ably. 
 
 Treatment. During the paroxysm, the child should at once be 
 placed in a hot bath and hot or cold compresses wrapped about the 
 throat. These means should be preceded or followed by a mild 
 emetic. The late Chas. D. Meigs always used aluminis, with or with- 
 out syr. ipecacuanhcB ; Prof. Barker recommends hydrargyri sulphas 
 fiava (turpeth mineral), gr. j-iij ; Prof. DaCosta suggests the cautious 
 use of apojnorphia, gr. ^, hypodermically. A favorite remedy for 
 emesis, in Germany, when the jaws are not closed, and one that is 
 highly successful, is tickling the fauces with the finger or a feather 
 until vomiting is produced. Inhalations of chloroformum often at 
 once relieve the spasms, but must never be employed by non-profes- 
 sional persons. Having by any of the above means broken up the 
 attack, nausea and diaphoresis should be maintained by the following 
 combination : — 
 
 Ut . Extract, ipecacuanhae fluid., . , TTLxij-xxiv 
 
 Tinct. opii camphoratae, f^ij-iv 
 
 Liq.potassii citratis, ad f^iij- M. 
 
 SiG. — One teaspoonful every two hours. 
 
 To ward off further spasms, no one remedy equals potassii bromi- 
 dum, gr. v-xv, every three or four hours, or chloral, gr, v, at bedtime. 
 
210 PRACTICE OF MEDICINE. 
 
 Mackenzie advises the use of 7nusk 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 : — 
 
 B . Moscbi, gr. iss 
 
 Sacch. alb., gr. ij 
 
 Pulv. acaciae, gr. ij 
 
 Syr. aurantii flor., 
 
 Aquam, aa . . . . ad . . ,:^j. M. 
 
 SiG. — A dose. 
 
 The air of the room should be moistened by the vapor of steam 
 constantly disengaged in it. 
 
 After the attack has passed off, the general condition of the child 
 must be attended to ; for this purpose it is well to administer a dose 
 of hydrargyri chloridiim mite, to be followed by a dose of oleum 
 ricini or jnagnesii carbonas. The diet must be regulated, all farina- 
 ceous articles being absolutely forbidden. 
 
 CROUPOUS LARYNGITIS. 
 
 Synonyms. Membranous croup ; true croup. 
 
 Definition. An acute inflammation of the mucous membrane of 
 the larynx, attended with the exudation of a tough secretion — the 
 false membrane — and the occurrence of spasm of the glottis ; charac- 
 terized by febrile reaction, frequent ringing cough, dyspnoea, with loud 
 inspiratory sound, and altered or extinct voice, showing a strong ten- 
 dency toward death by asphyxia. 
 
 Causes. A disease of childhood, most common in strong, vigor- 
 ous, well-nourished males. Certain families present a strong, heredi- 
 tary tendency. Most common during a humid winter. 
 
 We cannot assent to the dictum of some authorities, that laryngeal 
 diphtheria and croupous laryngitis are identical. 
 
 Pathological Anatomy. Intense hyperemia of the mucous 
 membrane of the larynx, associated with swelling, oedema and marked 
 redness. There soon appears on the surface of the mucous mem- 
 brane a grayish pellicle, rapidly coalescing and becoming thicker — 
 the opaqiie, false membrane — which differs in extent, thickness and 
 adhesiveness in different portions of the larynx. In all cases the 
 false membrane is found on the vocal cords and inner surface of the 
 epiglottis. The first exudation (membrane) softens by the scrum 
 
DISEASES OF THE LARYNX. 211 
 
 which is exuded, and is then mechanically dislodged by acts of 
 coughing or vomiting, but is followed by successive deposits upon the 
 mucous membrane. 
 
 When the false membrane is detached the mucous membrane of 
 the larynx is found unaffected, so far as the loss of structure is con- 
 cerned. Several successive crops of membrane may occur after the 
 detachment, or it may entirely cease to form after the removal of the 
 first exudation. 
 
 On microscopical exami?iation the false membrane is found to be 
 composed of a fine network of fibrillae, holding in their interstices 
 leucocytes of an albuminous or fibrinous nature. 
 
 The false membrane may^ extend into the pharynx, but especially 
 is it liable to extend into the trachea and bronchial tubes, and, as the 
 inflammation extends downwaid, the character of the exudation 
 changes from fibrinous to muco-purulent. 
 
 Symptoms. The onset of "true croup" is either suddenly, by 
 an attack of spasmodic croup, or gradually, as an acute catarrh of 
 the larynx, rapidly increasing in severity, with a feeling of heat in the 
 throat, huskiness of the voice, harsh cotigh, fever dSidi. thirst, the hoarse- 
 ness soon becoming marked, and the cough }\2i\\ng2i inetailic , '' croupy'" 
 character, rapidly changing to a stridulotis , husky sound ; every few 
 minutes the child takes a sudden, deep stridulous inspiration, the 
 voice becoming more and more husky. Difficulty of breathing now 
 follows, the child is unable to lie down, or if, exhausted by the efforts 
 at inspiration, it is quiet for a moment, it soon starts up in fright, 
 breathing more heavily, with a shrill, whistling inspiration. Soon, 
 from the narrowing of the glottis, from the presence of the membrane, 
 the expiration becomes difficult and noisy, and suffocatioji seems im- 
 minent, from the paroxysmal attacks of spasm of the glottis, when 
 the child tosses wildly about, tears at its throat, as if to remove some 
 obstacle, the face becoming cyanosed, the alae of the nose working 
 rapidly, the mouth wide open, the inspiratory efforts gasping, the body 
 covered with a profuse sweat, and death seems imminent, when the 
 spasm is relaxed, air enters the chest, the breathing becomes some- 
 what easier, and the child, exhausted and partially stupefied, drops 
 into a fitful sleep of a few moments' duration. 
 
 The suffocative attacks return at short intervals, or there occur 
 decided remissions between them, considerable portions of the false 
 membrane being expelled, when the child falls into a refreshing sleep. 
 
212 PRACTICE OF MEDICINE. 
 
 In those cases which tend to a favorable termination, the appear- 
 ance of improvement noted between the suffocative attacks is main- 
 tained, the paroxysms of suffocation becoming less frequent, the 
 expectoration of membrane more marked, the difficulty of breathing 
 lessens, the cough looser, the voice gradually returning, the fever, 
 which has been more or less high during the attack, disappearing. 
 
 If, instead of improvement, the case tends toward a fatal termina- 
 tion, the suffocative attacks become more frequent, expectoration is 
 absent, the voice and cough inaudible, although the efforts at speak- 
 ing and coughing are visible, the difficulty of breathing continues, the 
 respirations becoming more frequent and shallow, but without whist- 
 ling and stridor, cyanosis deepens, the countenance has an indiffer- 
 ent, drowsy and stupid look, the eyes dull and nearly closed, with 
 symptoms of depression, the pulse rapid and weak, the surface 
 covered with a cold, clammy sweat, the extremities cold, stupor and 
 insensibility more marked, the child dying of carbonic acid poisoning 
 or asphyxia. 
 
 Duration. The duration of true croup is about one week, rarely 
 continuing ten days. 
 
 Diagnosis. (Edema of the glottis may be mistaken for croup 
 until the period of the formation of the characteristic membrane. 
 The chief points of distinction from the onset are, however, absence 
 of fever, paroxysmal attacks of difficult respiration, followed by a 
 complete return to the normal condition. 
 
 Laryngeal diphtheria differs from true croup in its history, its 
 epidemic character, the marked depression, even before obstruction 
 of the larynx produces imperfectly aerated blood, the presence of 
 albumin in the urine, and the sequelae. 
 
 Prognosis. A very fatal disease. The danger is great in pro- 
 portion to the age and feebleness of the child. 
 
 The unfavorable symptoms are : Loud, stridulous, inspiratory and 
 expiratory sounds, laborious and prolonged expiration, depression of 
 the base of the thorax during inspiration, whispering voice or com- 
 plete aphonia, congestion of the face and neck, stupor, weak, rapid 
 and irregular pulse, cold extremities, and a cold, clammy perspiration. 
 
 The favorable symptojns are : Expectoration of false membrane, 
 decrease of the stridulous respiration, voice changing from whisper- 
 ing to hoarseness, looseness of the cough, moderation of the fever, 
 and an improvement in the general condition. 
 
DISEASES OF THE LARYNX. 213 
 
 Treatment. The indications for treatment are to detach and 
 remove the false inejjibrane , to prevent its formation, to prevent the 
 attacks of spasm of the glottis, and to maintain the strength. 
 
 To detach and remove the membrane emetics are of the highest 
 utility, the favorite of this class being the one first used in this 
 disease by Dr. Fordyce Barker, consisting oihydrargyri sulphas flava 
 (turpeth mineral), gr. ij, for a child of two years of age, repeating the 
 dose as often as rendered necessary by the obstructed breathing ; 
 but the unnecessary administration of emetics should be avoided, as 
 the strength of the patient must be maintained. 
 
 To prevent the formation of the membranous exudation a number 
 of remedies have been recommended and highly lauded by their 
 respective proposers. If seen early, as the fever and husky voice are 
 developing, tinctura aconiti, ^}i-], every fifteen minutes, and qui- 
 nince sulphas, gr. ij-v, every hour until cinchonism is produced, are 
 of unquestionable utility ; another plan strongly urged is with aminonii 
 brojnidum in full doses alternated with quinijtcE sulphas, gr. iij-v, every 
 three hours ; still another and popular remedy is hydrargyrum, which 
 is certainly one of the most reliable agents we possess ; it may be 
 used as hydrargyri chloridum corrosivum, gr. 43 " 2V ' every two or three 
 hours, or in the following formula : — 
 
 R. Hydrargyri chloridi mite, ........ gr. yi-}^-}^, 
 
 Sodii bicarbonat., gJ"- ij 
 
 Pulvis ipecac, . . gr. ^-^\. M. 
 
 SiG. — One powder every two hours. 
 
 Prof. DaCosta suggests either of the following combinations : — 
 
 R . Antimonii sulphurati, • • gr. ^ 
 
 Pulv. opii et ipecacuanhae, gr- /^ M. 
 
 SiG. — In powder every two hours. 
 Or— 
 
 R . Hydrargyri chloridum mite, S^- }4 
 
 Pulv. opii et ipecacuanhae, gr. /^ M. 
 
 SiG. — In powder every two hours. 
 
 Antimonii et potassii tartras, a remedy that some years ago was 
 popular in large doses, is again brought forward in doses of gr. -g\)-jV. 
 QuinincE sulphas, gr. v, every three hours until six doses have been 
 taken, if given before the exudation has formed, it is claimed will 
 prevent its formation. 
 
214 PRACTICE OF MEDICINE. 
 
 To prevent the paroxysms of spasm, small doses of opium in the 
 form of pulvis ipecac et opii (Dover's powder), or full doses of the 
 bromides, preference being given to ammonii bromidum, as suggested 
 by Prof. Bartholow, on account of its being " eliminated by the bron- 
 chial and faucial mucous membrane, thus acting locally." 
 
 To maintain the strength of the patient, alcoholic stitnulanis in full 
 doses, nutritious but easily digested aii??ient, gui?ii7ia in tonic doses, 
 and avimonii carbonas, are particularly indicated. 
 
 Locally, the use of all caustic or irritating applications to the fauces 
 or lar>'nx is emphatically contraindicated. 
 
 The inhalation of the vapor of slaked, freshly burned lime is one 
 of the most ready and efficient means for assisting in the detachment 
 of the false membrane. The application of cold or hot co7npresses, 
 according to the feelings of the patient, around the throat, have a 
 strong tendency to prevent the recurrence of the spasms. After the 
 formation of the membrane, great relief follows the use of the vapor 
 inhalations and oxygen gas, which with stimulants and liquid nour- 
 ishment may safely carry the patient through the disease. Cases 
 in which the membrane presents a tendency to slowly loosen itself, if 
 the patient's strength does not contraindicate it, are greatly benefited 
 by the application of siyiapis, or even small flying-blisters, to the 
 larynx. 
 
 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. 
 
 Relief from the obstructed respiration is obtained and the affection 
 beneficially influenced by the use of " O'Dwyer's tubes." 
 
 If the exudation still continues, regardless of the means employed, 
 the propriety of tracheotomy must be decided. 
 
 LARYNGISMUS STRIDULUS. 
 
 Synonyms. Spasm of the glottis ; pseudo-croup ; " Kopp's 
 asthma." 
 
 Definition. A temporary spasm of the muscles of the larynx 
 innervated by the inferior or recurrent laryngeal nerves ; character- 
 
DISEASES OF THE LARYNX. 215 
 
 ized by a sudden development of dyspnoea and the appearance of 
 deficient oxygenation of the blood. 
 
 Causes. Most common in children, the result of teething, laryn- 
 gitus, indigestion, scrofula or other cachexia. Attacks in adults are 
 not uncommon. 
 
 Patholog'ical Anatomy. Death the result of spasm of the 
 glottis is such a very rare occurrence that the changes in the larynx 
 are illy understood. 
 
 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, which is reflected through the 
 inferior laryngeal nerve — the efferent nerve — the motor influence 
 resulting in the spasm of the laryngeal muscles. 
 
 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 croupy cough — and with great dyspncea, with loud, crowing, stridu- 
 lus inspirations, the result of narrowing of the larynx from spasm, 
 with wheezy, stridtdous 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 fasces 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, has 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. 
 
 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 the paroxysm, the inhalation of a few drops of 
 
216 PRACTICE OF MEDICINE. 
 
 chl-oroforfnum is the most prompt method, due care being exercised ; 
 complete anaesthesia is unnecessary. Success is reported from the 
 prompt inhalation oi amyl nitris, also from tiitro-glycerinum , in small, 
 but frequently repeated doses ; the following combination is a prompt 
 antispasmodic : — 
 
 R . Potassii bromidi, ^5 ij 
 
 Chloral, ffr. xxxij 
 
 Syr. aurantii corticis, fjj 
 
 Aqure menth., f3J. M. 
 
 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 obviated by the steady 
 and continued use o{ potassii bromidum, in moderate doses. Emetics 
 are often useful in suspending an attack, especially if it be due to 
 indigestion. 
 
 Locally, the hot, alternating with the cold, pack, should be con- 
 stantly applied to the throat. 
 
 DISEASES OF THE BRONCHIAL TUBES. 
 
 ACUTE BRONCHITIS. 
 
 Synonyms. Bronchial catarrh ; acute bronchial catarrh ; "cold 
 on the chest." 
 
 Definition. An acute catarrhal inflammation of the bronchial 
 tubes of the larger, middle and third size ; characterized by fever, 
 sub-sternal 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 membrane 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 
 
DISEASES OF THE BRONCHIAL TUBES. 217 
 
 combined with a low temperature, and especially where there are 
 sudden and marked variations. 
 
 Patholog'ical Anatomy. Hyperczmia of the mucous mem- 
 brane of the bronchial tubes, manifested by a diffused redness, swell- 
 ing, asdema, and diminished secreiio7i ; this is 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. As a result of the hypersemia, 
 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, they 
 becoming hyper^mic, swollen and filled with secretion, and not 
 unfrequently the glandular elements undergo a hyperplasia, and 
 finally the " cheesy " degeneration. 
 
 Symptoms. The invasioji is usually characterized by the occur- 
 rence of either nasal or laryngeal catarrh, or both, the patient feeling 
 chilly, followed hy flushes of heat, the liinbs, joints, and even the body, 
 are affected with paiii 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, burning or tearhig character, aggravated by a deep 
 inspiration or by coughing ; the pain also radiates toward the sides, 
 following the course of the primary bronchial tubes.^ Te7iderness 
 over the sternum is often experienced. 
 
 Cough from the onset, at first in paroxysms of a hard, dry charac- 
 ter, changing as the disease progresses, and becoming looser, fol- 
 lowed by free expectoration. The expectoratioji 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 
 consistency. 
 iS 
 
218 PRACTICE OF MEDICINE. 
 
 There are present slight fever, hot, dry skin, frequent //^Av, loss of 
 appetite, moderate thirst and constipatioti. 
 
 A feehng of languor and weariness, and often considerable depres- 
 sion, quite out of proportion to the febrile state, are not infrequent. 
 
 Percussion. Xormal, 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 mucous membrane 
 being swollen and dry , the respiratory murmur is harsh or vesiciilo-bron- 
 chial in character, associated with diffused sonorous and sibilant rales. 
 
 Second Stai^e : The secretion from the bronchial mucous membrane 
 being increased, the respiratory murmur is /ess harsh in character, 
 but is associated with /aro^e and small moist or biibblinsc rales. 
 
 Diagnosis. The points of resemblance and difference between 
 acute bronchitis and other diseases of the chest will be pointed out 
 when those affections are described. 
 
 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. 
 
 Treatment. During the invasion, quini?ice stilphas, gr. x, com- 
 bined with jEorphincB sjilph., gr. ye, will usually prevent or abort an 
 attack of acute bronchitis. 
 
 In \h.Q first stage, in adults, when the mucous membrane is swollen 
 and dry, either of the following prescriptions will give prompt relief : — 
 
 R . Antimonii et potassii tart., gr. ij 
 
 Liquor, ammonii acetatis, f,^ iv 
 
 Spts. aetheris nitrosi, f ^j 
 
 (Tinct. aconiti, if indicated), f.^ss 
 
 Syr. simplicis, ad ^S^j- M. 
 
 SiG. — One teaspoonful every two or three hours. 
 
 Or- 
 
 U . Vini ipecacuanha, f _:^ ij 
 
 Liq. jxjtassii citrat., f 5v 
 
 Syr. acaciie, f^j. M. 
 
 SiG. — Tablespoonful every two or three hours. 
 
 If the cough of the dry stage be severe, or if looseness of the bowels 
 follow the use of either of the above combinations, tinctura ofiii cam- 
 phorata may be added with advantage. 
 
DISEASES OF THE BRONCHIAL TUBES. 219 
 
 For young children, the above in proportionately reduced doses, or 
 the following : — 
 
 R . Pulv. ipecac et opii, gr. x 
 
 Pulv. scillae, gr- xij 
 
 Hydrargyri chlor. mite, gr. iv 
 
 Sacch. lact , gr. x. 
 
 Ft. chart. No. xij. 
 
 SiG. — One every two hours. 
 
 Locally : Hot mustard foot bath, and sinapis or terebinihina stupes 
 over the chest, 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, marked benefit follows the use of the following com- 
 bination by Prof. H. C. Wood : — 
 
 R . Ammonii chloridi, 
 
 Ext. glycyrrhizse, aa .^iss 
 
 Glycerini, f^ss 
 
 Mucil. acacise, f^ij 
 
 Syrupi simplicis, 
 
 Aquae, aa .... ad ^J"j- ^• 
 
 SiG.— Dessertspoonful every two hours. 
 
 Attacks showing a tendency to linger are greatly benefited by the 
 following : — 
 
 R . Terpine hydrate, gr. xlviij 
 
 Glycerinse, q. s. sol. 
 
 Syr. laclucarii, ad f J ij- M. 
 
 SiG. — Teaspoonful every hour or two. 
 
 During the attack, attention must be given to the secretions and the 
 diet of the patient. 
 
 CAPILLARY BRONCHITIS. 
 
 Synonyms. Broncho-pneumonia ; " suffocative catarrh." 
 Definition. An acute catarr hal infla mmation of the termifial 
 bronchiajhtjjbes, or bronchioles ; characterized by fever, impeded and 
 increased_ respiration, impe ded circ ulation, sligh^ough and scanty 
 expectoration. "" 
 
 Causes. Most common in childhood, following exposure to cold 
 
220 PRACTICE OF MEDICINE, 
 
 or. sudden changes of temperature; associated with measles and 
 whooping cough. 
 
 Pathological Anatomy. H}^^er^jnia, redness and swellirig of 
 the Hning membrane of the bronchioles, with the exudation of a_tou^h, 
 tenacious secretion. 
 
 The air vesicles may remain unaffected, but in the rrmjorit^_ofcases 
 they are involved, producing the complication known as " catarrhal 
 pneunioniay 
 
 In those cases in which the air cells are not involved in the inflam- 
 matory changes, 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 futicHonal emphysema. If the 
 secretion produces complete closure of any of the smaller tubes, the 
 air previously drawn into the vesicles will be absorbed, causing 
 collapse (atelectasis). 
 
 If the inflammation extends to the alveoli of the lungs, it produces 
 the condition known as bro7icho-p7ieumonia, a frequent complication in 
 children and feeble elderly people ; it is most commonly lobular in 
 character, whence the term " lobular pneu7nonia'' 
 
 Symptoms. Usually preceded by more or less ordinary bron- 
 chitis, followed by rise of temperature, 102-103° F., difficult 7\.nd 
 increased respiratio7i, with paroxys77is in which the dyspnoea is 
 markedly aggravated, when cyanosis rapidly develops. 
 
 The circulation through the lungs is impeded by the dyspnoea, the 
 pulse becomes feeble and flickering, and there results general con- 
 gestion of the venous system, the countenatice livid, the lips a7td nails 
 blue, the surface cold, and often covered by a clam77iy perspiration, 
 the mind dull, and in children stupor and convulsions rapidly super- 
 vene, the result of the no7i-aeratio7i of the blood. The cough is slight, 
 but of a suppressed character, the expectoration scanty. When cyan- 
 osis occurs the cough may almost entirely cease ; expectoration also 
 ceases, death soon following from ap7ia'a and depression. 
 
 Percussion. Normal, except over those portions of the lungs 
 which are in a condition of collapse, when dullness rapidly develops 
 and may as rapidly disappear, changing to other portions of the 
 lung. 
 
 Auscultation. First stage, harsh or vesiculo-bronchial, soon 
 
DISEASES OF THE BRONCHIAL TUBES. 221 
 
 followed by dhmnished respiratory muri7iur, associated with sub- 
 crepita7it rales. 
 
 Diagnosis. — Capillary bronchitis is often mistaken for true 
 catarrhal pneumonia, the points of distinction between which will be 
 pointed out when discussing that affection. 
 
 Prognosis. In children, on account of their inability to expecto- 
 rate, 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 varying between 75° and 80°, the air moistened with steam. 
 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 the jacket poultice, if the child be not too 
 young to permit so heavy an application without adding to the distress 
 in the breathing. 
 
 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 its different stages, hence milk, eggs, chicken, mutton 
 and beef broths, with the free use of stimulants, commenced early 
 and in amounts large enough to overcome the signs of depression 
 which are present early in the attack. 
 
 If the fever be high, over 102° F., quinincB sulphas is indicated in 
 full doses, for a child ; either in suppository or the following : — 
 
 R . Quininas sulphatis, '^'■^ 
 
 Acid, sulphurici dilut., q. s. 
 
 Spts, setheris nitrosi, , f^^iv 
 
 Syr. tolu., f.^^iv 
 
 Aquae menth. p., f^j. M. 
 
 SiG. — One teaspoonful every two or three hours. 
 Or— 
 
 R . Antipyrine, gr. xxxij 
 
 Sacch. alb., f^^j 
 
 Aq, menth. p., ^J 
 
 Elix. simplicis, ^^ij. M. 
 
 SiG. — One teaspoonful every hour or two till four or five doses. 
 
222 PRACTICE OF MEDICINE. 
 
 For the catarrhal process either of the following, regulating the 
 dose in accordance with the age of the patient : — 
 
 R. S>T. ipecac, n\^v-xx 
 
 Spts. jetheris nitrosi, TT\^v-xv 
 
 Tinct. opii camp TT\^v-xx 
 
 Tinct. scillae, TT\^v-xx 
 
 Liq. potassii citrat., n\^xl-5ij. M. 
 
 SiG. — Every two hours. 
 
 Or— 
 
 R. Potassii iodidi, gr. ij-v 
 
 Ammonii carbonat., gr. iij-v 
 
 Syr. glycyrrh., f.^ss 
 
 Syr. tolu, f^ss M. 
 
 SiG. — Every two or three hours. 
 
 If suffocation is imminent the use of e?netics is indicated ; the most 
 suitable are ipecacuanha or hydrargyri sulphas flava, care being 
 taken not to repeat emesis so often as to produce exhaustion. Prof. 
 H. C. Wood, in desperate cases of suffocative catarrh, advises the 
 alternate use of the hot and cold douche conjointly with stimulating 
 remedies. 
 
 CROUPOUS BRONCHITIS. 
 
 Synonyms. Membranous bronchitis ; plastic bronchitis ; diph- 
 theritic bronchitis. 
 
 Definition. An acute inflammation of the mucous membrane 
 of the larger and middle-sized bronchial tubes, attended with an 
 exudation, forming a membraniform layer, which is closely adherent 
 to the mucous surface; characterized by febrile reaction, cough, diffi- 
 cult breathing, scanty expectoration, followed by the expulsion of the 
 false membrane in the form of patches or casts. 
 
 Causes. Associated with membranous laryngitis from extension 
 downward ; asthma; emphysema ; phthisis ; but most commonly the 
 result of exposure to cold and damp, in those of strong and vigorous 
 constitutions. 
 
 Pathological Anatomy. Hypercemia of the mucous mem- 
 brane of the bronchial tubes, associated with swelling and cedema, 
 during which the surface is covered with a white or grayish-white, 
 firmly adherent, membranous deposit, cemented together by a coagu- 
 lable exudation, and prolonged by rootlets from its under surface 
 
DISEASES OF THE BRONCHIAL TUBES. 223 
 
 into the bronchial follicles, which sooner or later is loosened and de- 
 tached by suppurative process and is expectorated after a violent fit 
 of coughing or vomiting. When expectorated, the false jnembratie , 
 as it has been termed, has either the form of patches or is thrown off 
 entire 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 microscopical exajjiination, the detached membrane presents 
 fibrillae which characterizes fibrine 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 nietnbrane. 
 
 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, sub-acute 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 or emphysema. In 
 young children it may cause obstruction to the respiration, and not 
 unfrequently 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 cases of ordinary acute 
 bronchitis. 
 
 As soon, however, as the character of the inflammation can be de- 
 termined, acute emesis is the most effective means of removing the 
 obstruction caused by the false membrane, the best agents of this 
 class being either hydrargyri sulphas fiava, ipecacuanha, or zinci 
 sulphas, to be repeated as indicated. 
 
 Inhalations of the vapor of water, and especially of lime water, are 
 highly serviceable. 
 
 To prevent the formation of membrane, Prof. Bartholow strongly 
 urges the use of ammonii iodiduiii and carbonas combined, in small 
 
224 PRACTICE OF MEDICINE. 
 
 dpses every hour or two. In a case treated by the author after this 
 method, excellent results followed. 
 
 In cases showing a tendency to become chronic, good results 
 will follow the application of flying blisters to the chest and the 
 internal administration of arsenicion and some preparation of 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 oi emphysema of the lungs, which complicates the majority 
 of cases. 
 
 Chronic bronchitis may be either primary or secondary. 
 
 Causes. Primary, the exposure to wet or cold, or the repeated 
 inhalation of dust, vapors, or other irritants. Secondary, due to gout, 
 rheumatism, syphilis, cardiac, renal or pulmonary diseases, or alco- 
 holism. 
 
 Varieties. I. Mucous catarrh, associated with moderate expecto- 
 ration. II. Bronchorrhcea, profuse expectoration. III. Dry catarrh, 
 scanty expectoration. IV. Fetid bronchitis. 
 
 Patholog'ical 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 membrane are dilated. The mucous membrane is thick- 
 ened, resulting in the 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, " bro?ichial di/atation.'' The dilata- 
 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. 
 
DISEASES OF THE BRONCHIAL TUBES. 225 
 
 In the mucous variety the secretion consists of young cells and 
 mucous corpuscles, having a yellowish color ; in the dry variety, the 
 "catarrh sec " of Laennec, or " dry bronchial irritation," the secre- 
 tion is scanty, tough, semi transparent, and occurs in defined globular 
 masses; in bronchorrhcea, which is usually associated with bronchial 
 dilatation, the secretion is abundant, greenish yellow in color, and 
 often fetid. 
 
 Symptoms. The most characteristic symptoms of chronic bron- 
 chitis are the cough and expectoration. 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 yel- 
 lowish mucus. 
 
 Dry catarrh is characterized by a harsh cough, a feeling of sore- 
 ness or rawness under the sternum, and the expectoration of small 
 globular masses ; this variety occurs with emphysema, gout, rheuma- 
 tism and asthma. 
 
 Bronchorrhcea, 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. 
 
 Percussion. Unless complicated with other affections, Jtormal ; 
 bronchial dilatation occur, there are diffused spots of the tyynpanitic 
 or amphoric percussion sound, the physical condition being a 
 circumscribed cavity containing air and connecting with a bron- 
 chial tube. 
 
 Auscultation. Harsh or vesiculo-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 
 
 19 
 
226 PRACTICE OF MEDICINE. 
 
 somewhat modified, and will be pointed out when discussing that 
 affection. 
 
 ProgTiosis. If unassociated with disease of the lungs or heart, 
 chronic bronchitis is never dangerous to life, although the symptoms 
 are present more or less continually, and aggravated upon the least 
 exposure. 
 
 If associated with phthisis, emphysema, disease of the heart, or of 
 the kidney, the prognosis is governed by those affections. 
 
 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 under-clothing, taking care that the opposite 
 extreme of too much clothing be not practiced. 
 
 The medical treatmefit is guided by the cause, character zjidi severity 
 of the disease. 
 
 If secondary to other affections, in the majority of cases remedies 
 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 
 oi potassii iodidwn, or lithii citras, or a residence at one of the alkaline 
 springs. 
 
 For mucous catarrh, with acute exacerbations : — 
 
 R . Ammonii chloridi, .^ ij 
 
 Glycerini, ^%^^ 
 
 Codeinse sulph., ?,^- /4 
 
 Vini picis, ^^"j 
 
 Syr. prun. virg., f^iss. M. 
 
 SiG. — Tablespoonful every three or four hours. 
 
 Dry catarrh is greatly benefited by — 
 
 R . Potassii iodidi, gr. v-x 
 
 Elix. cinchonoe, Ii^xx 
 
 Villi picis, liq., ad ... . ^j. M. 
 
 Three times a day. 
 Or— 
 
 R. Ext. eucalypt. fld., f,5J 
 
 Ammonii cliloridi, ,^ i j 
 
 Ext. glycyrrhi/se, ^ij 
 
 Syr. tolu, fo'jj- M. 
 
 SiG. — One teaspoon ful every three or four hours. 
 
DISEASES OF THE BRONCHIAL TUBES. 227 
 
 For bronchorrhoea, copaiba, gtt. v-x every three hours, or spts. 
 terebinthincB, gtt. v, every four hours or acidiim carbolicuni, gr. ss, 
 four times a day, and at the same time using ol. morrhticz and 
 arsenicum, or, if these means fail, inhalations of alwjien, aciduin 
 galliciiin or acidiim iatinicuin. 
 
 If the expectoration be fetid, "fetid bronchitis," Prof. DaCosta 
 recommends the internal use of acidum carboticum, gtt, j every third 
 hour, with inhalatiotis of acidwn carbolicum (gr. v, aqua, ^j) two or 
 three times a day. 
 
 Locally, irritation with tinctura iodi, or flying blisters, repeated once 
 or twice weekly, is of advantage. 
 
 ASTHMA. 
 
 Synonyms. Nervous asthma ; bronchial asthma. 
 
 DeJB.nition. A paroxysmal spasmodic contraction of the muscular 
 layer surrounding the bronchial tubes, and perhaps associated with a 
 tonic spasm of the diaphragm, and more or less bronchial catarrh ; 
 characterized by spasmodic attacks of great dyspnoea, continuing 
 usually for several hours. 
 
 Causes. A true neurosis of the respiratory apparatus. 
 
 The result of peripheral or local disturbances in the nervous system, 
 often hereditary ; pressure on the pneumogastric nerve ; cardiac dis- 
 ease ; gastric catarrh and constipation, resulting in irritation of the 
 end organs of the pneumogastric ; uterine, hepatic, or nephritic dis- 
 ease ; inhalation of various substances, as ipecac, turpentine, or irri- 
 tating dusts ; climate ; mental and moral influences. 
 
 Asthma is more common in men than in women ; in childhood and 
 young adults than those of middle life and old age ; in the well-to-do 
 and wealthy than in the poor. 
 
 Symptoms. The onset of z. first attack of asthma is abrupt and 
 sudden, the succeeding attacks being preceded hy prodromes, which 
 the individual rapidly learns to appreciate, to wit : coryza, bronchial 
 irritation, thoracic constriction, marked dyspepsia, or a large passage 
 of pale, limpid urine, the "hysterical urine." 
 
 The paroxysm begins, in the majority of cases, in the early morn- 
 ing hours or during the afternoon, with a feeling of anguish and con- 
 striction in the chest and an i^ttense desire for air. The breathing is 
 accompanied with loud wheezing, the face is flushed, at times even 
 
228 PRACTICE OF MEDICINE. 
 
 cyanosed, and bathed in perspiration, the eyes stare, the eyeballs pro- 
 trude, 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. 
 
 After some minutes or hours the respiration becomes easier, 
 more air enters the lungs, the cyanosis disappears, and gradually 
 the paroxysm ceases, the patient feeling exhausted and the chest 
 fatigued. 
 
 During the paroxysms there is a short, dry cough, becoming looser 
 as the attack subsides, the expectoration either consisting of white 
 pellets of mucus, at times streaked with blood, or profuse watery 
 mucus. 
 
 The duration of an attack varies from three to ten hours. Instead 
 of single paroxysms, slight remissions may occur at intervals of one, 
 two or three hours, to be followed by exacerbations lasting from four 
 to six hours, continuing for a week or two, preventing the patient 
 lying down or taking food. 
 
 Percussion. During the paroxysm, hyper-resonance over both 
 lungs, termed vesiculo-tyuipanitic , the " bandbox tone " of Bamberger. 
 
 Auscultation. First stage feeble or absoit vesicular murmur, 
 with prolonged expiration associated with loud wheezing, 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 and valvular diseases of the heart. 
 
 Treatment. There are two indications, to wit : the relief of the 
 paroxy^^m, and to prevent its recurrence. 
 
 To reliei)e the paroxysm, no medication is so effective as the hypo- 
 dermic injection of morphince sulph., gr. y^ to }( , combined with 
 atropine? sulph., gr. y^^. Chloral, gr. x, repeated, where no heart 
 complication exists, is often effective ; drinking strong, hot black 
 coffee is often serviceable ; chloroformum, cether or amyl nitris 
 inhalations have been recommended ; also nauseant expectorants, to 
 wit: lobelia, ipecac, scilla, or ext. grindelia fid., gtt. xx, repeated 
 every two or three hours. 
 
DISEASES OF THE BRONCHIAL TUBES. 229 
 
 Dr. Pepper speaks highly of the following for the paroxysm : — 
 
 R . Ammonii bromidi, 5 'J 9 ij 
 
 Ammonii muriat., 3'^^^ 
 
 Tinct. lobelice, ^,^iij 
 
 Spts. Ktheris comp., f5j 
 
 Syr. acacije q. s., , . f^iv. M. 
 
 .SiG. — Dessertspoonful in water every hour or iwo. 
 
 A combination that often affords decided relief is — 
 
 Be. Chloral, ^viij 
 
 Ammonii chloridi, ^iij 
 
 Morphinge muriat., gi"- i'j 
 
 Antimonii et potassii tartras, gr. iiss 
 
 Ext. grindelise robust, fluid,, f^j 
 
 Ex. glycyrrh., 3 ij 
 
 Syr. aurantiicort., .... ad ^iv. M. 
 
 SiG. — One teaspoonful in sweetened water every three or four hours. 
 (Davis.) 
 
 Another remedy that at times is successful is syrupus hydriodic. 
 acidum, n^xv-xxx every three or four hours. 
 
 Inhalations of the fumes of belladonna, stramonium, nitre-paper, 
 chloroform, ethyl bromidum, or the use of various pastilles or cigar- 
 ettes, are of immense benefit in many cases. A twenty per cent, 
 solution of menthol as an inhalation has been successful in some 
 cases. 
 
 Paroxysms of asthma are said to be relieved by rectal injections of 
 sulphuretted hydrogen after the manner suggested by Bergeon of Paris. 
 
 If an attack is impenditig it may often be aborted by drinking 
 freely of strong black coffee, or by full doses of the bromides. 
 
 To prevent recurrence of the paroxysms, the general health must 
 be strictly watched, any of the complications or causes of the attack 
 attended to, systematic exercise, bathing, regulated diet, and change 
 of climate when possible. 
 
 Internally, good results are sometimes attained by a long course of 
 belladonna, arsenictim ox potassii iodidum. 
 
 HAY ASTHMA. 
 
 Synonyms. Hay fever ; autumnal catarrh ; rose fever. 
 Definition, An acute catarrhal inflammation of the upper air 
 passages, extending to the bronchial tubes, associated with spasmodic 
 
230 PRACTICE OF MEDICINE. 
 
 contraction of their muscular layer; characterized by coryza, croupy 
 or wheezy cough and difficult respiration. 
 
 Causes. An affection of the nervous system ; often hereditary. 
 
 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 hypersesthesia 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 severe coryza, with sneezing, a clear, 
 watery, nasal discharge, congested eyes and Eustachian tubes, rapidly 
 extending to the larynx and bronchial tubes, when occur a hoarse , 
 crouPy and wheezing cough, and difficulty of breathing. The dyspnoea 
 occurs in paroxysms, which are often as severe as those occurring 
 during a regular asthmatic attack. 
 
 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 sequelce may result, to wit : Asthma, chronic 
 bronchitis, or loss of the special sense of hearing or smelling. 
 
 Treatment. No specific, unless the hypertrophy of the turbin- 
 ated bones be a constant phenomena, when their removal by the 
 galvano-cautery would at once produce a cure. 
 
 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 Mountains, 
 or a sea voyage. 
 
 Attacks are sometimes aborted and always relieved by the 
 
DISEASES OF THE BRONCHIAL TUBES. 231 
 
 application to the nares of tablets of cocaine hydrochlorate, gr. ^ 
 every hour. 
 
 Success has followed the use of quinina, gr. v, three times a day, 
 beginning one month before the expected paroxysm. After the attack 
 has fairly begun, potassii iodidum, gr. xv, three times a day, seems 
 to modify somewhat the severity of the paroxysms ; or the following 
 powder, by insufflation : — 
 
 R. Bismuth, subnit., ^ij 
 
 Acid, tannic , ^j 
 
 lodoformi, gr. xv. M. 
 
 SiG. — Every three or four hours. 
 
 Prof. Bartholow "has seen several cases benefited greatly " by a 
 solution of quinina applied to the nares, as suggested by Helmholtz ; 
 " but to achieve success the application must be thorough and timely." 
 
 The following applied thoroughly to the nostrils has a high repute : — 
 
 R. Menthol., 5J 
 
 Cerat. simpl., 5ij 
 
 01. amygd. dulcis, .1 ^ss 
 
 Zinci oxidi purse, , ^j 
 
 Acid, carbolici, .5ss. M. 
 
 SiG. — Apply every few hours. 
 
 Cases accompanied by a profuse watery discharge have this symp- 
 tom at least modified by minute doses of atrophincs sulphas, with 
 morphincz sulphas, every three or four hours. 
 
 A long course of arsenicum in minute doses sometimes removes 
 the susceptibility to the disease. 
 
 WHOOPING COUGH. 
 
 Synonyms. 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, one attack generally 
 removing the susceptibility ; contagious ; the result of an unknown 
 poison, perhaps atmospheric, affecting the nervous system. 
 
 Pathology. The changes, if any, occurring in the nervous 
 
232 PRACTICE OF MEDICINE. 
 
 system 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." 
 
 Hypercemia of the mucous membrane of the nares, pharynx, 
 lar)'nx and bronchial tubes, with diminished secretion^ followed by 
 an increased secretion of a transparent mucus, afterward becoming 
 purulent, the mucous membrane pale and anaemic. 
 
 Symptoms. Divided into three stages, to wit : catarrhal, spas- 
 modic and terminal. 
 
 Catarrhal stage originates as an ordinary naso-laryngo-bronchial 
 catarrh with a loose cough. Duration one or two weeks. 
 
 Spastnodic stage. The cough becomes paroxysmal, consisting of 
 a succession of short, rapid, expiratory efforts, the face becoming 
 red, the eyes swoUen and protruding, the body bending forward, 
 and when these expiratory efforts have exhausted the breath, they 
 are followed by a deep, loud, crowing inspiration — the whoop ; each 
 paroxysm being composed of three such spells, the last one followed 
 by the expectoration of a small amount of totigh, viscid 7nucus. 
 
 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. VxoiMSO. epistaxis is not infrequent. Duration 
 about four weeks. 
 
 Terminal stage. The paroxysms recur at longer intervals, are of 
 short 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." 
 
 Complications. Congestion of the lungs, capillary broncliitis, 
 pneumonia and emphysema, or, rarely, convulsions, hydrocephalus, 
 or apoplexy. 
 
 Diagnosis. During the catarrhal stage, whooping cough cannot 
 be distinguished from a common cold, but on the advent of the 
 characteristic whoop the diagnosis is evident. 
 
 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 
 
DISEASES OF THE BRONCHIAL TUBES. 233 
 
 will not cure the disease, but often modify the severity of the 
 symptoms. 
 
 Prof. Da Costa prefers quinincB sulphas, in full doses, or chloral in 
 good-sized doses, often advantageously combined with the bromides, 
 and the use of a spray of sodii bromidum (gr. xx, and aquse, f^j) to 
 which may be added extractum belladottncE Jltddum, n\^ij. A remedy 
 of great utility is ajnmonii bromidum. I have seen excellent results 
 from antipyriiie in doses of gr. j-ij every three hours ; if added to 
 some expectorant mixture it seemed to act better. The paroxysms are 
 lessened in severity by the following : — 
 
 R . Codeinge sulph., gr. j 
 
 Acid, carbolic, lU-'^^J 
 
 Syr. simplicis, f.^ss 
 
 Glycerini, f 5j 
 
 Syr. limonis, fsss. M. 
 
 SiG. — One teaspoonful every two or three hours. 
 
 Belladonna may be added to any of the remedies named with 
 advantage. 
 
 The use of cocaine lozenges modifies the paroxysms in some cases. 
 
 Dr. Keating reports " remarkable improvement in four cases of 
 whooping cough by the use, four or six times daily, of a spray com- 
 posed of" — 
 
 R. Ammonii bromid., 
 
 Potassii bromid., aa ^j 
 
 Tinct. belladcnnae, f,:^j 
 
 Glycerini, f ^^ j 
 
 Aquse rosse, q. s. ad ^S^^'* 
 
 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 of the chest, 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 
 
234 PRACTICE OF MEDICINE. 
 
 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 — 
 the theory of expiration. 
 
 What is known as vicarious emphysema is a distention of the air 
 cell of the healthy portions 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. 
 
 Pathological Anatomy. The situation of vesicular emphysema 
 is, in the majority of cases, the stiperior 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 lighter, 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 cysts (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, whereby the emphysematous tissue is 
 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. This distention of the veins results 
 in a general venous stasis, to wit : nutmeg liver, congested kidneys, 
 and gastro-intestinal catarrh. 
 
 Symptoms. The chief symptoms of vesicular emphysema are 
 difficulty of breathing, greatly aggravated on exertion, more or less 
 cough, the result of an attending bronchitis, and the various symp- 
 toms resulting from dilatation of the heart. The distress of the patient 
 is often increased 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 
 
DISEASES OF THE BRONCHIAL TUBES. 235 
 
 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 
 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 weakened, and in pro- 
 nounced cases almost absent. If bronchitis be present, the inspiratory 
 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 
 bubblitig rales. 
 
 Th.Q first sound of the. h.Q3xt 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 dis- 
 ease. In itself it rarely proves fatal, but if aggravated, from any 
 cause, or if associated with severe or prolonged asthmatic paroxysms 
 the cardiac changes are hastened, general dropsy supervenes, death 
 occurring from exhaustion, or, more commonly, as the result of inter- 
 current 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, morphince sulphas 
 
236 PRACTICE OF MEDICINE. 
 
 combined with atrophicE sulphas may be used hypodermically, or ext. 
 quebracho fld., oss-j, every hour until relief, or large doses oi potassii 
 bromidiim , frequently repeated. 
 
 For attacks of bronchial catarrh use — 
 
 R . Ammonii chloridi, ,:^ ij 
 
 Spts. frument., ^Tt}^ 
 
 Glycerini, f t j 
 
 Syr. prun. virg., ad f^iv. M. 
 
 SiG. — Half-tablespoonful every few hours. 
 
 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: — 
 
 B . Potassii iodidi, gr. v 
 
 Strychninae sulph., S^- iV 
 
 Liq. potassii arsenit., TT^v 
 
 Aq. lauro cerasi ^7i\- M* 
 
 SiG. — Four times a day. 
 
 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. 
 
 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, or, if this fails, scilla combined with hydragogue 
 cathartics. 
 
 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 /«(5<?rr«/(«r disposi- 
 tion in the walls of the minute bronchial arteries ; excessive cardiac 
 action ; bronchial congestion ; excessive bodily exertion, straining, 
 lifting or running ; a symptom of hcemophilia ("bleeders' disease"). 
 
 Pathological Anatomy. Haemoptysis 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. 
 
DISEASES OF THE BRONCHIAL TUBES. 237 
 
 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. 
 Unless the clots are rapidly removed by expectoration or absorption, 
 a secondary inflammation originates around about them. 
 
 Symptoras. " Spitting of blood " occurs suddenly ; rarely, it is pre- 
 ceded by epistaxis, cardiac palpitation and some difficulty of breathing. 
 
 It begins with a sensation of warmth under the sternum, tickling 
 in the throat, a sweetish taste in the mouth, which, upon attempting to 
 remove by the act of coughing, a wan?i, saltish, bright red, frothy 
 liquid gushes 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 /a/^, trejuulous, oil&n fainting. 
 
 The attack may subside within half an hour to several hours, 
 returning 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, bubblijtg rales are discerned in circum- 
 scribed 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. 
 
 HcBmatemesis, 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 afterwards raised by vomiting, or when the hem- 
 orrhage 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. Haemoptysis in itself rarely terminates fatally, al- 
 though causing much depression ; the patient rapidly recovers, unless 
 secondary pneumonia results. In nine cases out of ten it is the prog- 
 nostic sign of phthisis. 
 
238 PRACTICE OF MEDICINE. 
 
 Treatment. Perfect rest in bed, the head and shoulders elevated, 
 and perfect quiet, the diet to be bland, the drinks cool, the patient 
 slowly swallowing small particles of ice. C-'jnmon salt, slowly dis- 
 solved 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 ergotin, gr. x-xxx, or the internal 
 administration of extractum ergotcz Jluidum, 5ss-j, are valuable, or : — 
 
 R. Acid, gallic, gr- xv 
 
 Acid, sulph. dil., TT^x 
 
 Aqua cinnamon, 3 '^' ^' 
 
 Repeated every fifteen or twenty minutes. 
 
 Or tinctura matico, 5j, or extractum hajnamelis fld., n\,xx-3j, ahcme7i, 
 gr. XX, or acidum galliciim, gr. v-x, frequently repeated. 
 
 If the hemorrhage causes great nervous excitement, or depression, 
 opium, either hypodermically or internally, to quiet the patient, is 
 indicated. 
 
 Inhalations, by msans of the steam atomizer, of either MonseVs 
 solution or tinctura ferri chloridum, are recommended when the 
 above means fail. 
 
 Prof. DaCosta recommends, for frequent small hemorrhages, con- 
 tinuing day after day, cupri sulphas (gr. y\), ext. opii (gr. j^). P« ^^- ^i. 
 
 DISEASES OF THE LUNGS. 
 
 CONGESTION OF THE LUNGS. 
 
 Synonym. Hyperaemia of the lungs. 
 
 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 ; 
 valvular diseases; low fevers (hypostatic congestion); Bright's 
 diseases. 
 
DISEASES OF THE LUNGS. 239 
 
 Patholog'y. The hypersemic 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 
 {sple7iiJicatio7i) . 
 
 Symptoms. Active. Rapidly developing thoracic distress and 
 difficulty of breathing, flushed face, stroftg, full pulse, throbbing caro- 
 tids, cardiac palpitatio7i 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 with 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 sudden that death rapidly supervenes. 
 
 Passive. Developed slowly and subject to great variations, depend- 
 ing upon the cause. 
 
 Diagnosis. Active congestion of the lungs cannot be distinguished 
 from the stage of engorgement of a true pneumonia, in the majority 
 of cases. 
 
 Prognosis. An acute congestion of the lungs may prove fatal 
 within a few hours, but under prompt treatment it generally termi- 
 nates 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 general venesection. 
 Internally, tinctura acoftiti, gtt. j-ij every half hour or hour, as indi- 
 cated, -with free catharsis with saline purgatives. 
 
 Passive. Dry or wet cups over the chest, hydragogue cathartics, 
 and the internal administration of digitalis ; if much depression of 
 the vital powers, stimulants such as spiritus vini gallici and ammonii 
 carbonas are indicated. 
 
240 PRACTICE OF MEDICINE. 
 
 OEDEMA OF THE LUNGS. 
 
 Definition. An effusion of serum upon the free surface of the 
 lung, to wit : in the puhnonary vesicles ; characterized by dyspnoea, 
 cough, and frothy, blood-streaked expectoration. 
 
 Causes. Result of cardiac diseases ; Bright's disease ; over- 
 exertion ; alcoholic excesses ; mental excitement ; inhalation of cold 
 or hot air. 
 
 Pathological 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 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 
 liquid, 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, providing the air 
 cells have not been entirely filled with serum, thereby excluding the air. 
 
 Symptoms. Following a more or less rapidly developing hyper- 
 aemia of the lungs are great oppression of and extreme rapidity i?i 
 breathing, with a strong sense of oppressioti, great anxiety, rapid and 
 tumultuous cardiac action, throbbing carotids and temporals, fullness 
 of the head and headache, flushed face and congested eyes, with a 
 constant short cough, and the expectoration of a tough, frothy mucus, 
 streaked with blood. 
 
 If the effusion into the air cells be sufficient to prevent the entrance 
 of air, symptoms of cyanosis rapidly supervene, the pulse becoming 
 feeble, the surface cold, the breathing shallow and hurried, the cough 
 suppressed, stupor replacing the restlessness, soon deepening into coma. 
 
 Percussion. Slightly impaired or vesiculo-tympanitic. 
 
 Auscultation. The vesicular murmur is supplanted by sub- 
 crepitant and bubbling rales. 
 
 Diagnosis. Pneumonia in the earlier stages is the only condition 
 likely to be confounded with oedema of the lungs, and the subsequent 
 course of the two maladies soon determines the diagnosis. 
 
 Prognosis. (Edema of the lungs is always a serious malady, and 
 frequently, unless promptly relieved, terminates fatally. 
 
 Treatment. If the oedema be of an active kind, prompt ^/.9^^- 
 letting, either by venesection or wet cups to the chest, is indicated. 
 
DISEASES OF THE LUNGS. 241 
 
 The internal administration of tinctura aconiti, gtt, j-ij, repeated 
 every fifteen minutes, until the cardiac action is markedly reduced, 
 after which every hour or two, with the use of the preparations of 
 ammonimn, either the carbonas or iodidum, to liquefy the effusion, 
 produce marked relief. 
 
 The above means may be aided by counter-irritation to the chest, 
 hot mustard foot baths, active saline purgatives, and diuretics. 
 
 CROUPOUS PNEUMONIA. 
 
 Synonyms. Lobar pneumonia ; pneumonitis ; fibrinous pneu- 
 monia ; pleuro-pneumonia ; lung fever ; winter fever. 
 
 Definition. An acute croupous inflammation involving the vesi- 
 cular structure of the lungs, rendering the alveoli impervious to air ; 
 characterized by a severe chill, fever, pain, dyspnoea, cough, rusty 
 sputum and great prostration. 
 
 Causes. The question of pneumonia being a constitutional dis- 
 ease is still sub judice, although the belief is growing, as it presents 
 such a marked difference from other inflammations, in that it is self- 
 limited, and terminates by crisis. It is most common in winter, at 
 times occurring epidemically , the result of atmospheric conditions ; 
 exposure to draughts and cold ; injuries to the chest walls ; alcoholic 
 excesses ; gout or rheumatism. 
 
 Pathological Anatomy. The inflammatory changes most 
 commonly affect the lower right lobe, rarely the upper lobe, very 
 rarely corresponding lobes in both lungs. 
 
 The changes are, I. Hypercsmia (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 hypercEmia or engorgement consists in the vessels of 
 the alveoli being distended to their utmost, encroaching upon the 
 cavity of the air vesicle ; the lung has a reddish-brown color, is heavier, 
 sinking somewhat lower in water than a normal lung, and having a 
 slight exudation upon the vesicular surface. The same changes are 
 perceived in the adjacent bronchioles. 
 
 II. Stage of exudation consists in the exudation of a viscid, fibrin- 
 ous fluid, admixed with white and red corpuscles and blood, which 
 rapidly coagulates, firmly enclosing the corpuscles and completely 
 
 20 
 
242 PRACTICE OF MEDICINE. 
 
 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 Lccnnec termed it red hcpatisation. 
 
 III. Resolution, or gray hepatization, follows the above condition in 
 the majority of cases, the coagulated albuminous exudation under- 
 going liquefaction and absorption, the cellular element undergoing a 
 fatty degeneration, the greater part being absorbed, the remainder 
 expelled during acts of expectoration, 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 purulent tmnsforjnation, 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 lung structure proper 
 remaining intact. The purulent contents may be ejected in part, the 
 remainder undergoing fatty degeneration 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 empyema and exhaus- 
 tion, or open into the bronchi and are expectorated, or an interstitial 
 pnetwiotiia is developed and the abscess encapsulated in a firm cica- 
 tricial tissue. 
 
 Gangrene of the lungs may result from blocking up of the bronchial 
 or pulmonary arteries by coagula, during any stage of the disease. 
 
 The uninflamed portions of the lungs are hyperaemic and their 
 functional activity is increased. 
 
 Death sometimes results from a general oedema 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-pneujnonia, 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. 
 
DISEASES OF THE LUNGS. 243 
 
 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. 
 
 Seat : The most frequent seat of croupous pneumonia is the lower 
 right lobe ; the next most frequent seat is the lower left 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. 
 
 Syraptoms. Begins with a severe and usually protracted chill 
 (in children often convulsions, adults, vomiting), followed by a rapid 
 rise of te7nperature^ 103°-I04° F., a strong, full, but rapid pulse, soon 
 showing evidences of embarrassed cardiac action from obstructed 
 respiratory circulation, either a dull or sharp pain near the nipple, 
 aggravated by pressure, breathing or coughing, shortness of breath, 
 the number of respirations increasing to 40, 50 or more per minute, 
 causing interrupted speech ; cough, first short, ringing and harsh, 
 soon followed by a scanty, frothy mucus, soon becoming semi-trans- 
 parent, 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, save in drunkards, 
 epistaxis, flushed countenance, and especially over the malar bones is 
 a well-defined mahogany blush ; gastric disturbances and scanty, 
 high-colored urine, with diminished chlorides, often albuminuria. 
 
 From the very onset of the disease the prostration is of the most 
 marked character. 
 
 The above symptoms continue more or less marked until either the 
 fifth, seventh, nitith or eleventh day, when a 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 
 
244 PRACTICE OF MEDICINE. 
 
 accompanied by signs of extreme prostration, delirium, tremor, very 
 high temperature and profuse and prolonged exudation. They may 
 also terminate by a crisis. 
 
 Bilious pneumo7iia occurs in cases accompanied by congestion of 
 the liver, the result of venous stasis from pulmonary obstruction or 
 from an accompanying acute catarrhal Jautidice. In malarial dis- 
 tricts pneumonia and malaria are often associated, when jaundice, 
 more or less pronounced, occurs. Such cases are termed inalarial or 
 in term it tent pneumon ia . 
 
 If purulent infiltration follow the stage of red hepatization, instead 
 of a crisis, symptoms of exhaustion occur, with profuse purulent ex- 
 pectoration, high temperature, severe sweats ; the tongue brown and 
 dry, sordes collecting on the teeth, recovery slow and convalescence 
 tedious. 
 
 Pneumonia occurring in persons of intemperate habits usually 
 begins with symptoms closely resembling an attack of delirium 
 tremens, cough and expectoration, the pain very slight, or even absent. 
 
 Inspection. First stage, deficient movement of the affected side, 
 due to the 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 repiration). 
 
 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 noted 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 
 murinur, 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. 
 
DISEASES OF THE LUNGS. 245 
 
 Bronchophony, or distinctly transmitted voice, at \\m.es pectoriloquy, 
 or distinct transmission of articulated sounds. 
 
 Third stage, breathing changing from bronchial to vesiculo-bron- 
 chial, the crepitant (crepitatio 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 manner." — (Da Costa.) 
 
 I Stage of engorgement Crepitant rale ; slight percus- Cough: beginning dyspnoea 
 and beginning exuda- sion dullness. and rapidly developed fever 
 
 tion. heat. 
 
 II. Stage of solidification of Percussion dullness; bron- Rusty-colored sputum ; dysp- 
 lung-tissue (red hepat- chial respiration; broncho- noea ; cough; high fever, 
 ization). phony. with marked evening ex- 
 
 acerbations and morning 
 remissions. 
 
 III. Stage of softening (gray The same physical signs as Chills; prostration, etc.; puru- 
 
 hepatization). in the second stage, unless lent or brownish sputum ; 
 
 large abscesses have formed. generally high 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 a collateral cedema of the uninflamed lung, or cardiac failure 
 and impaired nerve force. 
 
 If abscesses occur, there are exhaustion 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, fetid sputum, 
 and the physical signs of a pulmonary cavity. 
 
 Diagnosis. (Edema of the lungs may be confounded with the 
 first stage of pneumonia, but the subsequent history, its presence on 
 both sides, and the watery expectoration and absence of chill and 
 pain and the physical signs of pneumonia soon determine the 
 diagnosis. 
 
 Complications. Acute pleuritis is a frequent complication of 
 croupous -pneumoniaj occurring as often as from ten to twenty-five 
 
246 PRACTICE OF MEDICINE. 
 
 per- cent, of cases. The more acute localized pain, the greater em- 
 barrassment of respiration, and the usual physical signs of effusion 
 are the evidences of a pleiiro-pneumonia. 
 
 Capillary bronchitis is a rare but dangerous complication. 
 
 Pericarditis, rheumatism and gout are rare complications. 
 
 Pleurisy is oftener confounded with pneumonia than any other dis- 
 ease, the points of distinction between which will be pointed out when 
 discussing that affection. 
 
 Prognosis. Depends upon the extent of the inflammation, the 
 dangerous features of croupous pneumonia being cardiac failure, the 
 result of the embarrassed respiratory circulation, and the rapid tissue 
 waste associated with extreme fever, 105°, resulting in impaired nerve 
 force; double pneumonia is a very grave prognosis, but is not nearly 
 so frequent as was at one time supposed. The co-existence of pleuritis 
 adds to the gravity of the prognosis, although not as fatal as it formerly 
 was. Pneumonia of drunkards almost invariably terminates fatally. 
 Typhoid pneumonia, the so-called bihous pneumonia, purulent infiltra- 
 tion, 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 treatment than does the intestinal ulcer of typhoid fever, but the 
 general condition of the patient is to govern in the management of 
 the case and not the local changes going on 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 0/ pneufnonia." Called to a case in the first stage of the disease, 
 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 
 bleeding is indicated, and the same may be said when symptoms of 
 collateral oedema threaten ; this is bleeding for symptoms and not for 
 the disease per se. 
 
 Called to the majority of cases, during the first stage, after a rapidly 
 acting purgative, administer quinines sulphas, gr. v, with or without 
 
DISEASES OF THE LUNGS. 247 
 
 antipyrine, gr. iij-v, every three hours until their effects are produced, 
 using at the same time small doses of such arterial sedatives as 
 aconitum, veratruin viride or digitalis until a decided impression is 
 made on the circulation. It is also in this stage that either wet or dry- 
 cups over the chest, followed by the application of poultices, seems 
 to act beneficially. In the feeble or aged poultices are to be used 
 from the onset. 
 
 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 reduce the temperature, we have at least two safe and reliable 
 drugs, if administered in sufficient amounts. I refer to quinince sulphas 
 and antipyrine. The dose of quininae sulphas as an antipyretic in 
 pneumonia is gr. x-xv, repeated as needed. The doses of thirty and 
 forty grains recommended I have never seen required ; in fact, it 
 would seem to me to be contraindicated on account of the cardiac 
 depression such amounts would produce. Antipyrine is also a very 
 reliable antipyretic either alone or combined with the quinine. The use 
 of the cold pack or of cold baths for reducing the temperature in acute 
 pneumonia has not met with the approval of practical clinicians. 
 
 To sustain the heo^rt is one of the most important indications in the 
 treatment of acute pneumonia, for experience shows that cardiac 
 failure is responsible for a large number of deaths in this affection. 
 Without question, alcoholic stimulants judiciously employed are the 
 most efficient means for preventing or overcoming the cardiac failure. 
 The amount can only be determined by a careful study of each case, 
 as a few ounces in the twenty hours may answer in one case, 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 indicator of the heart's condition is the pulse. In the aged, the 
 feeble, or in those accustomed to the use of alcohol, stimulation is 
 indicated from the onset. Other indications would be a frequent, 
 feeble, irregular or intermitting pulse; a dicrotic pulse; delirium, 
 muscular tremor and subsultus ; immediately following crisis, and the 
 period of collapse. 
 
 Other cardiac stimulants that may be used are ammonii carbonas, 
 digitalis and moschus. 
 
 It is also during this period that the diet must be of the most nutri- 
 tious but easily digestible character, and given at periods of every 
 three hours. 
 
248 PRACTICE OF MEDICINE. 
 
 Third stage. The treatment is a continuation of the second stage, 
 gradually reducing the antipyretics as the fever declines, and adding 
 one of the preparations oi ferrum. 
 
 Convalescejice. Nutritious diet, quininae sulphas in tonic doses, 
 ferrum, 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, quinina, ferrum, 
 nutritious diet and bold stimulation, and the free use of aminonii 
 carbonas are the indications. 
 
 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-r 
 sema ; diseases of the heart ; most frequently seen in childhood and 
 old age. 
 
 Pathological Anatomy. Hypercemia of the mucous membrane 
 of the bronchi, and also of the bronchioles and air cells, with swelling 
 and succulence of these tissues, accompanied by an abnormal secretion 
 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 
 
DISEASES OF THE LUNGS. 249 
 
 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 become 
 thickened, from a hyperplasia of the connective tissue {peri-bronchi- 
 tis), and their calibre is often dilated. 
 
 Symptoms. Catarrhal pneumonia begins as a catarrhal bron- 
 chitis. It may be either actite, sub-acute or chronic in its course. 
 
 Acute variety : Its onset is announced by a gradual rise of tempera- 
 ture to io2°-i03° F., the febrile phenomena assuming atypical remit- 
 tent character, with rapid, laborious and shallow breathing, as shown 
 by the widely dilated nares and violent action of all the accessory 
 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 ; ih.^ pulse isfrequefit, 100-120 or 
 more, and somewhat compressible ; the cough, which, during the 
 bronchitis, was loose, now becomes short, hacking, dry and painful, 
 soon followed by more or less copious muco-purulent expectoration ; 
 the appetite is impaired, bowels somewhat loose, urine scanty, high- 
 colored, and the surface frequently covered with a more or \qs'S> prof use 
 perspiration. 
 
 The sub-acute and chronic varieties have the same general symp- 
 toms, but the duration is longer and the exhaustion greater. 
 
 The progress of catarrhal pneumonia is sometimes, although not 
 often, a very acute one. The disease may prove fatal in a few days, 
 especially if it attack feeble children; in such the countenance 
 becomes pale and livid, the lips bluish, the eyes dull, and a rest- 
 lessness 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 tynt- 
 panitic note. 
 
 Auscultaiion. Vesiciilo-bronchialhxe.2lh\ng, changing to moist 
 bronchial breathing, associated with small bubbling (sub crepitant) 
 rales. As the disease progresses toward resolution, the rales become 
 21 
 
250 PRACTICE OF MEDICINE. 
 
 larger (large bubbling) and more copious. 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 
 results. 
 
 Diagnosis. Ordinary broiichial catarrh differs from catarrhal 
 pneumonia by the absence of dyspnoea, fever, and dullness on per- 
 cussion, and the presence of the large bubbling rales, and also by the 
 subsequent history of the two affections. 
 
 Croupous pneumonia is a unilateral disease ; catarrhal pneumonia 
 is bilateral and diffused over both lungs ; the former a self-limited 
 disease, the latter having no fixed duration. 
 
 Acute tuberculosis at its onset is characterized by the presence of a 
 capillary bronchitis, a differentiation being possible only by a study 
 of the clinical history and course of the two maladies. 
 
 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- 
 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 suit- 
 able. The steady use of brandy or whisky throughout the attack is 
 of importance, regulating the amount by the age of the patient and 
 the severity of the attack. 
 
 For the fever, quinines sulphas, gr. xv-xx each day, is the most re- 
 liable of all antipyretics, or antipyrine in full doses may be substituted. 
 
 For the catarrhal process, the air of the apartment should be main- 
 
DISEASES OF THE LUNGS. 251 
 
 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., gr. v 
 
 Ammonii iodidi. gr. v-x 
 
 Mucil. acacise, q. s. 
 
 Syr. glycyrrh., 3J-ij 
 
 Syr. prun. virg., q. s. ad gij-iv. M. 
 
 SiG. — Every three hours. - 
 
 A much pleasanter way of administering the ammonia salts is in 
 capsules, each containing about two and one-half grains of each salt 
 with an aromatic oil. Terpene hydrate acts remarkably well in many 
 cases. 
 
 For convalescence, nutritious food, ferri iodidtim, quinmcE sulphas, 
 and oleum morrhucB. 
 
 Locally : repeated application of mustard poultices or turpentine 
 stupes followed by demulcent poultices. If the inflammatory process 
 tends to become chronic, scattering blisters should be used. 
 
 PULMONARY CONSUMPTION. 
 
 Synonyms. Phthisis pulmonalis ; phthisis ; consumption. 
 
 Definition. Four varieties of pulmonary consumption are now 
 admitted to exist : Pneumonic phthisis ; tubercular phthisis ; fibroid 
 phthisis ; acute miliary tuberculosis. 
 
 As these forms present differences at all points, they will be de- 
 scribed separately. 
 
 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 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. 
 
252 PRACTICE OF MEDICINE. 
 
 • 
 
 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 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 certain occu- 
 pations, to wit : weaving, grinding, mining, hatters, millers, cigar 
 makers, and the like. 
 
 Pathological Anatomy. When a pneumonia terminates in 
 resolution the inflammatory products are absorbed by first undergoing 
 2i fatty meiatnorp/iosis. 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 and the fatty degeneration 
 of the cellular elements and the granular disintegration of the fibrin- 
 ous material, so that ultimately a soft, solid mass is produced, yellow- 
 ish in color, having the appearance of cheese. 
 
 The destructive changes are thus described by Niemeyer : " Cells, 
 the products of inflammation, accumulate 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 
 changes is usually at the apex, but it may occur at any portion of the 
 lungs, or a whole lung becomes infiltrated, and undergoes the cheesy 
 degeneration (phthisis florida). 
 
 In many cases tubercle is deposited in the inflamed lung, hastening 
 its destruction and the formation of cavities. 
 
 Symptoms. Pneumonic phthisis occurs in three forms, the 
 chronic, the sub-acute and the acute. 
 
 Chronic form. The origin is rather insidious, the individual being 
 susceptible to " colds," or " catarrhs," on the slightest exposure ; grad- 
 ually a persistent cough, with the expectoration of muco-pus, is estab- 
 lished, each severe cold being accompanied with cJiill, fever, 
 pain in the chest, and either slight hemorrhage or blood-streaked 
 sputa. Finally the catarrhal symptoms become persistent, with 
 morning chills, evening fevers and rather profuse flight sweats, dis- 
 tressing cough, profuse muco-purulent sputa, great weakness and 
 exhaustion, loss of appetite and feeble digestion, the symptoms 
 
DISEASES OF THE LUNGS. 253 
 
 growing persistently worse, death occurring from exhaustion after one 
 or two years' duration. 
 
 Sub-acute variety. History of an acute attack of pneumonia of one 
 or two weeks' duration, followed by a decided improvement, but not 
 complete recovery. After a lapse of some weeks or months, symp- 
 toms of pulmonary softening begin, destroying the lung structure and 
 forming cavities, accompanied by chills, fever, 7iight sweats, emaci- 
 ation, cough, muco-purtilent and blood-streaked expectoration, the 
 patient dying from exhaustion within a year. 
 
 Acute variety, the so-called phthisis florida, runs a rapid course, 
 beginning as a 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 cong'n., profuse, purulent and 
 blood-streaked sputa, loss of appetite, feeble digestion, rapid emaciation, 
 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. 
 
 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 oi the normal note to dullness, and when cavities are formed, 
 associated with scattered points of the tympa7iitic or hollow note. If 
 the cavities communicate with a bronchial tube the cracked-pot or 
 cracked-?netal 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 is feeble or indistinct if many bronchioles 
 are obstructed ; and is harsh or blowing if the bronchioles are nar- 
 rowed. The inspiratory sound will be jerking, and the expiratory 
 sound prolonged and blowifig when the lung has lost its elasticity. 
 
 Associated with the impaired vesicular murmur is 2, fine, dry, crack- 
 ling sound (crepitation), appearing at the end of inspiration. If bron- 
 chitis be associated, large and small moist or bubbling rales are heard 
 during the respiration. 
 
254 PRACTICE OF MEDICINE. 
 
 When cavities form, either bronchial or broncho-cavernotis respira- 
 tion is heard, associated with more or less distinct gurg/ing rales. 
 If the cavity be free from pus and have rather firm walls, the breath- 
 ing is more amphoric in character. 
 
 Diagnosis. Catarrhal bronchitis has many points of resemblance 
 to pneumonic phthisis. The subsequent course of the latter, with the 
 high temperature, prostration, emaciation, and physical signs, should 
 prevent error. 
 
 Tubercular phthisis is often confounded with pneumonic phthisis, 
 an error difficult to prevent in many cases. 
 
 Prognosis. Acute variety, the phthisis florida, usually terminates 
 fatally within a few months. 
 
 The sub-acute and chronic varieties may, under judicious treatment 
 and favorable hygienic conditions, be arrested, the caseous matter 
 partly expectorated and partly absorbed, leaving more or less loss of 
 structure, cicatricial tissue supplying its place, which after a time con- 
 tracts, causing more or less contraction of the chest walls. 
 
 Cases not properly treated, either from carelessness or poverty, suc- 
 cumb after a year or two. 
 
 Treatment. An attempt should always be made to remove the 
 caseous matter by absorption and expectoration. The following pre- 
 scriptions will sometimes prove successful : — 
 
 R . Ammon. carb., gr. v 
 
 Ammon. iodidi, gr. v-x 
 
 Syr. tolu, 5 ij 
 
 Syr. prun. virg., ^ij. M. 
 
 Every five hours, alternating with 
 
 R. Liq. p';tassii arsenitis, TT^v 
 
 Mass. ferri carb., gr- v 
 
 Vini xerici, '7^\ 
 
 Aquae dest., q. s. ad f^ss. M. 
 
 The diet should be of the most nutritious character, the clothing 
 warm, and, if practicable, change of residence should be made to a 
 dry and elevated climate. If the digestion will permit, oleum mor- 
 rhucE^ 3j-Jj. three times a day. 
 
 For the fever, quinines sulphas, gr. xv-xx, is more successful than 
 the combination of quinina and digitalis in small doses ; experience 
 has demonstrated that the antipyretic properties of quinina are 
 markedly increased if rest in bed for the time being be enjoined. 
 
DISEASES OF THE LUNGS. 255 
 
 Loomis has found that the antipyretic properties of quinina in phthisis 
 are increased by the addition of morphina to each dose. 
 
 Night sweats are best controlled by atropitice sulphas, gr. -g-^-, at 
 bedtime, or 
 
 R. Extract, belladonnje, gr. ss 
 
 Zinci oxidi, gr. iij- M. 
 
 At bedtime. 
 
 For the cough and sleeplessness, codeines sulphas, gr. ss-j, p. r. n. 
 
 TUBERCULAR PHTHISIS. 
 
 Synonyms. Tuberculosis ; consumption ; incipient phthisis. 
 
 Definition. The deposition of tubercle in the lung structure, 
 which undergoes softening, followed by more or less loss of the pul- 
 monary tissue proper ; characterized by fever, cough, dyspnoea, ema- 
 ciation and exhaustion. 
 
 Causes. Chiefly hereditary ; closely associated with scrofula and 
 struma ; probably contagious under certain conditions; secondary to 
 catarrhal (caseous) pneumonia; the theory of the "bacillus ticbercu- 
 losis'' of Koch is still subjudice. 
 
 Patholog'ical Anatomy. Tubercle is a grayish-white, trans- 
 lucent and semi-solid granulation, about the size of a millet seed, 
 most commonly deposited in the walls of the bronchioles, exciting a 
 low form of inflammation, the result of its own death. The masses 
 of tubercle soon undergo softening (cheesy transformation) ; the lung 
 structure is secondarily affected, undergoes softening, which results 
 in more or less destruction of the tissue, whence cavities are formed. 
 
 The inflammation may extend to the small arteries, causing hem- 
 orrhage. 
 
 The deposit of tubercle is generally at one of the apices, soon 
 spreading toother parts; depositions may also occur in the brain, 
 intestines and liver. 
 
 The pleura is usually the seat of a chronic inflammation (dry pleu- 
 risy), resulting in the obliteration of the pleural cavity. 
 
 Symptoms. The symptoms correspond closely to the stages of 
 deposition, of softening, and of the formation of cavities. 
 
 The development is insidious, with increasing dyspepsia, irritable 
 heart, a light, dry, hacking cough, referred to the throat or stomach. 
 
256 PRACTICE OF MEDICINE. 
 
 scanty, glmry ex/>ecfora/ion,gr3.dua.\ loss of weight, impaired muscular 
 strength, pallid appearance, xv^ox^ or less copious hcemoptysis Q){x.^rv 
 following. Pain, sharp in character, below the clavicles, is often 
 present. 
 
 The beginning of softening is announced by increased cough, freer 
 expectoration, dyspnoea increased on exertion, w\oxnmgchil/s, evening 
 fez'er, night sweats — the so-called hectic fever, diarrhoea, increased 
 emaciation and weakfiess, the patient, however, continuing very 
 hopeful. 
 
 With i\\& formation of the cavities, the cough is more aggravated, 
 with profuse and purulent expectoration, at times containing yellow 
 striae, the amount depending upon the number and size of the cavi- 
 ties ; haemoptysis not common at this stage ; the pulse rapid and 
 weak, increased hectic, burning of the soles and palms, copious 7tight 
 sweats, greater debility and emaciation, with osdema of the feet and 
 ankles, denoting failure of the circulation, death soon following from 
 asthenia, the mind clear and hopeful to the end. 
 
 Inspection. First stage, often shows slight depressio?ts in the 
 supra-clavicular, and at times in the infra-clavicular regions. 
 
 Palpation. Second stage, the vocal fremitus is slightly increased. 
 
 Percussion. First stage, slight impairment of the normal per- 
 cussion resonance can sometimes be elicited. Seco?id stage, the 
 resonance is impaired, and may be even dull. Third stage, dullness 
 with circumscribed spots of the amphoric, or tympajiitic or cracked- 
 pot sound. 
 
 Auscultation. First stage, inspiration jerky, expiration pro- 
 longed, the pitch higher than normal, the inspiration associated with 
 crackling rales. 
 
 Second stage, vesiculo-branchialhrQ2i\h\ng, associated with sub-crepi- 
 tant and large and moist or bubbling tales. 
 
 Third stage, bronchial, bro7icho-cavernous and cavernous respira- 
 tion, associated with large and small moist or bubbling, and localized 
 gurgling rales. 
 
 Bronchophony in its various degrees is associated with the second 
 and third stages of tuberculosis. 
 
 Complications. Tubercular diseases of the brain, larynx, pleura, 
 intestines and peritoneum ; perineal abscess leading to fistula. 
 
 Diagnosis. The early diagnosis of tubercular phthisis rests 
 mainly on the history, together with the symptoms and physical signs. 
 
DISEASES OF THE LUNGS. 257 
 
 In the first stage it is often mistaken for dyspepsia, anaemia, malarial 
 fever, or disease of the heart. 
 
 Prognosis. In the main unfavorable, although under proper 
 treatment, change of climate and like favorable conditions life may- 
 be prolonged for years. The question of perfect recovery is, to say 
 the least, doubtful. 
 
 Treatment. While I have never seen a case of incipient phthisis 
 cured, in the broad acceptation of that term, I have repeatedly seen 
 life prolonged for a number of years, and the deposition of tubercle 
 long delayed by a change of climate early in the history of the case, 
 warm clothing, life and exercise in the open air short of fatigue, and 
 systematic bathing and a nutritious plan of dieting. If the diet is 
 arranged in accordance with the appetite, the latter will gradually 
 increase, but should it not, it may be stimulated by such bitters as 
 nucis voinicis, ignatia a7?iara, Colombo ox gentian. 
 
 The sym.ptoms are to be met as they arise, and drugs are not to be 
 used simply because the patient has the physical signs of beginning 
 tubercle. For the general debility and malaise that accompanies the 
 early stages of this malady, any one or a combination of the follow- 
 ing drugs, exercising care that they in no way interfere with the 
 appetite : 01. morrhucE, ferri iodidum, arsenicum, hypophosphites, or 
 the elixir quitiina ferri et strychnin a. 
 
 Great temporary improvement in the symptoms of phthisis some- 
 times follows the rectal injection of stilphuretied hydrogen after the 
 manner suggested by M. Bergeon, of Paris, but that recovery will 
 occur is hardly probable. 
 
 Dr. H. C. Wood suggests the administration of the remedy by the 
 stomach, claiming as great success by that means as when admin- 
 istered per rectum. To cover the disagreeable taste of the remedy 
 he uses a saturated solution of the sulphuretted hydrogen, using : "At 
 first half an ounce, afterwards an ounce, of the saturated solution of 
 the sulphuretted hydrogen should be placed in a tumbler, and two 
 or three ounces of carbonic acid water be run into it from a highly- 
 charged siphon, the whole being drunk while effervescing. This may 
 be given three to five times a day, so that the patient will receive daily 
 between half a pint and a pint of the sulphuretted hydrogen gas." 
 
 Special symptoms require treatment only when indicated, care 
 being exercised to avoid everything which tends to impair the appe- 
 tite, disorder digestion, or lower the vital powers. 
 
258 PRACTICE OF MEDICINE. 
 
 For the y^T^^r the " Niemeyer pill" is usually recommended; its 
 formula being — 
 
 R. Quinincesulph., gr. j 
 
 Pulv. digitalis, gr. ss 
 
 Pulv. opii, £•"• X 
 
 Pulv. ipecac, S^- ^- ^^• 
 
 From a very considerable experience with this "famous" pill, I 
 can recall few cases in which it has proven of the least benefit. The 
 following is much more effectual : — 
 
 li . Quininre sulph., gf- x 
 
 Quininae muriat., gr. x 
 
 Pulv. opii et ipecac, g''- i'j- M. 
 
 Ft. capsul No. ij. 
 
 SiG. — One capsule five hours, and the other three hours before the de- 
 cided rise of temperature. 
 
 For «/>/// sweats, not the result of the diurnal fever, atropince 
 sulphas, gr. ^^o~iV' at bedtime, is an effective agent. It is claimed that 
 sulphonal, gr. vij-x, at bedtime, controls the night sweats and also 
 produces a quiet, refreshing sleep. 
 
 For cough, if not modified by the arrest of temperature and night 
 sweats, the following is of use : — 
 
 Ijt. Codeince sulphat., gr. ^-^ 
 
 Acid, hydrocyanici dil., TT\^ij 
 
 Syr. lolu, 5J. M. 
 
 SiG. — Several times a day. 
 
 The ^i/J^/Z/r symptoms are wonderfully relieved by the following : — 
 
 R . Pepsini cryst., gr. ij 
 
 Acid, muriat. dil., rr\^x 
 
 Glycerini, TT^xx 
 
 Succi liminos, Ti:\^xv 
 
 Aqua,' aurantii flor. ad, ^ij. M. 
 
 SiG — Whh meals. 
 
 FIBROID PHTHISIS. 
 
 Synonyms. Chronic interstitial pneumonia; cirrhosis of the 
 lungs ; Corrigan's disease. 
 
 Definition. A hyperplasia (thickening) of the pulmonary con- 
 nective tissue, resulting in atrophy and degeneration of the vesicular 
 
DISEASES OF THE LUNGS. 259 
 
 Structure, associated with bronchial inflammation ; characterized by- 
 cough, profuse expectoration, fever, emaciation, and ultimately death 
 by asthenia. 
 
 Causes. Hereditary ; inhalation of irritants ; chronic bronchitis ; 
 alcoholism. 
 
 Patholog'ical Anatomy. Thickening of the bronchial mucous 
 membrane and dilatation of the air tubes ; hyperplasia of the pulmon- 
 ary connective tissue, resulting in the compression and consequent 
 destruction of the vesicular structure, which is assisted by the contrac- 
 tion of the newly formed tissues. Sooner or later catarrhal pneu- 
 monia results, the product undergoing the cheesy degeneration, cavi- 
 ties being formed, and as a result of the long-continued suppuration 
 tubercular depositions occur, hastening the destruction of the lung 
 tissue. 
 
 Prof. Da Costa has reported a number of cases of "grinders' 
 phthisis," in whose sputum was found the "bacillus tuberculosis," in 
 whose family history there were no traces of consumption. 
 
 Symptoms. The course is chronic, beginning as a bronchial 
 catarrh, worse in winter, better in summer, when, after several years, 
 the cough becomes more continuous, the expectoration freer and 
 muco-purulent, often raised in paroxysms, in large amounts, hectic 
 fever develops, 7iight sweats , dyspnoea and rapid emaciation, soon fol- 
 lowed by cedema of the feet and ankles, the result of failing circula- 
 tion, death occurring by asthenia. 
 
 Inspection. Depression of the chest walls. 
 
 Percussion. Impaired resonance, followed by dullness, with 
 irregular spots of amphoric or tyrnpatiitic percussion note over the 
 points of depression. 
 
 Auscultation. First stage, vesiculo-bronchial, or harsh respira- 
 tion associated with large and small, moist or bubbling rales, followed 
 by bronchial, broiicho-cavernous and cavernous respiration, with cir- 
 cumscribed gurgling rales. 
 
 Diag'nosis. Beginning as a bronchial catarrh, slowly progressing, 
 with the remission of the symptoms during the summer months, 
 finally becoming progressively worse, with the formation of cavities, 
 and symptoms of asthenia, are the chief points in the diagnosis. 
 
 Prog'nosis. The duration of fibroid phthisis is most protracted, 
 six or twelve years being the average duration ; death, however, is 
 the inevitable termination. 
 
260 PRACTICE OF MEDICINE. 
 
 Prof. Da Costa has records of one hundred deaths from "grinders' 
 consumption " whose average Hfe was twelve years. 
 
 Treatment. To prevent the hyperplasia of the connective tissue, 
 hydrargvri coyrosivin)i ch/oriduni, potassii iodidmn or aurii et sodii 
 chloridum, are recommended. Oleum inorrhiicc is of benefit. 
 
 The bronchial catarrh, hectic fever and 7iight sweats should be 
 treated onlv when their severitv becomes marked. 
 
 ACUTE PHTHISIS. 
 
 Sjmonyms. Acute miliary tuberculosis ; galloping consumption. 
 
 Definition. An acute febrile affection, due to the rapid deposition 
 throughout the body, but especially in the lungs, of the gray tubercle- 
 granule; characterized by high fever, rapid pulse, hurried respiration, 
 pain in the chest, cough, profuse expectoration and rapid prostration. 
 
 Causes. Most common 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." 
 
 The result of caseous or suppurative changes in the lungs. 
 
 Pathological Anatomy. " The gray granulation or miliary 
 tubercle consists of a fine reticulation of fibres, with a mass of epi- 
 thelioid 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 hyperaemia, 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, pleura, intestines, peritoneum 
 and kidneys. 
 
 Symptoms. The onset is usually sudden, with a chill or chilli- 
 ness;, followed by fever, J02'^-i04° F., rapid, d'xcroUc />ulse, 120-140, 
 cough, with scanty, glairy sputum, increased respiration, 30-50 per 
 minute,/^/;/ in the chest, hot skin, dry tongue, deranged digestion 
 and great prostration, the severity of the symptoms rapidly increasing, 
 the sputum becoming more abundant and often rusty in color, with 
 more or less frequent attacks of hcEinoptysis, soon followed by head- 
 ache, vertigo, sleeplessness, often delirium, coma and death. 
 
DISEASES OF THE PLEURA. 261 
 
 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 the amphoric 
 percussion note is present. 
 
 Auscultation. Vesiculo-bronchial breathing, associated with 
 large and small, moist or bubbling rales, soon followed by bronchial 
 and broncho-cavernous breathing, with large and small, moist and 
 circumscribed gurgling rales. 
 
 Duration. Acute phthisis terminates fatally in from four to 
 twelve weeks. 
 
 Diagfnosis. Commonly mistaken for typhoid fever with lung 
 complications, an error that is readily made unless a close study of 
 the history, symptoms and physical signs be made. 
 
 Treatment. There are no means of retarding the progress of 
 this malady. Loomis says: " Morphia in small doses — one-twentieth 
 of a grain hypodermically every six or eight hours — has, in my hands, 
 been more satisfactory in staying the progress of the disease, pro- 
 longing life, and keeping the patient comfortable, than any other 
 plan." 
 
 Dr. McCall Anderson claims that subcutaneous injections of atro- 
 pina check the exhausting sweats ; and that quinina, digitalis and 
 opium reduce the temperature, and if they fail, ice cloths to the abdo- 
 men will accomplish the desired result. 
 
 The various symptoms should be met as they occur, the patient at 
 the same time being supplied with large quantities of sti7nula7its. 
 
 DISEASES OF THE PLEURA. 
 
 PLEURISY. 
 
 Synonyms. Pleuritis; "stitch in the side." 
 
 Definition. A fibrinous inflammation of the pleura, either acute, 
 subacute or chronic in character, occurring either idiopathically or 
 secondarily; characterized by a sharp pain in the side, a dry cough. 
 
262 PRACTICE OF MEDICINE. 
 
 dyspnoea and fever. It may be limited to a part, or may involve the 
 whole of one or both membranes. 
 
 Causes. Idiopathic pleuritis is said to be due to cold and expo- 
 sure, to injuries of the chest walls, or the result of muscular exertion. 
 
 Secondary pleuritis occurs during an attack of pneumonia, peri- 
 carditis, rheumatism, smallpox, Bright's disease, or puerperal fever. 
 
 Chronic pleurisy follows an acute attack, or is the result of tuber- 
 culosis, Bright's disease, or alcoholism. 
 
 Pathological Anatomy. The course pursued by an inflam- 
 mation of a serous membrane is JiypercE)nia followed by exudation of 
 lymph, the effusio)i of fluid, its absorption and the adhesion of the 
 membranes. 
 
 The first or dry stage of pleurisy is hyperaemia or diffused, irreg- 
 ular redness of the membrane, with little specks of exudation. The 
 second stage is characterized by the copious exudation of lymph, more 
 or less completely covering the membrane, giving it a dull, cloudy, 
 or shaggy appearance. If the inflammation ceases at this point, it is 
 termed dry pleurisy. The third, or stage of effusion, is characterized 
 by the pouring out of a semi-fibrinous liquid ; more or less completely 
 filling and distending the pleural cavity, and floating in the fluid are 
 fibrinous flocculi, blood and epithelial cells. 
 
 Absorption of the fluid and more or less of the exudative lymph 
 soon occurs, the unabsorbed portion becoming organized, forming 
 adhesions which obliterate the pleural cavity. 
 
 The effusion, if on the right side, pushes the heart further to the 
 left ; if on the left side, the heart is displaced to the right, the impulse 
 often being seen to the right of the sternum. The lungs are also 
 compressed and displaced upward and against the spinal column, 
 and, on removal of the fluid, expand again, except in cases of chronic 
 pleurisy, when the functional activity of the pulmonary structure is 
 more or less permanently impaired. 
 
 Chronic pleurisy results when the fluid is not absorbed or when it is 
 effused into the cavity in a slow and insidious manner. The mem- 
 brane is irregularly thickened, with firm adhesions, fluid being found 
 in the meshes, and depressions of the thoracic walls also occurring. 
 The fluid may be serum, pus {empyema), or pus and blood. Openings 
 may form, through which there is a permanent discharge, either ex- 
 ternally (fistulous empyema) or into the bronchi, or rarely, into the 
 bowels. 
 
DISEASES OF THE PLEURA, 263 
 
 Symptoms. Acute attack : Begins with a chill, followed by a 
 sharp lancinating ^«z>? (stitch) near the nipple or in the axilla, aggra- 
 vated by coughing and breathing, associated with slight tenderjicss on 
 pressure. The respirations are rapid and shallow, 30-35 per minute, 
 a short, dry, hacking cough, moderate fever, compressible pulse, 90- 
 120. With the effusion of liquid the dyspnosa becomes aggravated, 
 the cough more distressing, the cardiac action embarrassed, the coun- 
 tenaiice wearing an anxious expression, the patient usually lying on 
 the affected side. With the absorption of the fluid the symptoms 
 gradually ameliorate, convalescence being more or less rapid. 
 
 Subacute attack : Begins insidiously after cold, exposure and 
 fatigue in those enfeebled. Patients usually complain of a sense of 
 weariness, shortness of breath, aggravated on exertion, evening y^z/^r, 
 followed by night sweats, short, harassing cough, none or very scanty 
 sputum ; the pulse is small, feeble but frequent, 100-120 beats per 
 minute. The characteristic pain in the side is usually wanting. 
 
 Chronic variety, irregular chills, fever, night sweats, dyspnoea, 
 palpitation, embarrassed circulation, with more or less prostration. 
 
 Inspection. First stage, deficient movement of the affected side, 
 on account of the pain induced by full breathing. 
 
 Second stage, bulging or fullness of the affected side, with oblitera- 
 tion of the intercostal spaces and displacement of the cardiac impulse. 
 
 Palpation. Second stage, vocal frejnitus feeble or absent over 
 the site of the effusion, exaggerated above the site of the fluid. 
 'R.2iYQ[y , fluctuation may be obtained. 
 
 Percussion. First stages, may be slightly impaired. 
 
 Second stage, dullness or even flatness over the site of the effusion ; 
 tympanitic percussion note above the fluid. 
 
 Auscultation. First stage, feeble vesicular murmur over the 
 affected side, the patient breathing superficially, to prevent the pain ; 
 ?L friction sound, slight and grating or creaking, becoming louder as 
 the exudation of lymph increases, limited usually to the angle of the 
 scapula of the aft'ected side, rarely heard over the entire side, accom- 
 panies the respiratory movements. 
 
 Second stage, feeble or absent vesicular murmur on the affected 
 side, depending upon partial or complete compression of the lungs by 
 the fluid. Above the fluid puerile breathing, and iust at the upper 
 margin of the fluid a friction sound may be heard. 
 
 The vocal resonance is diminished or absent over the site of the 
 
264 PRACTICE OF MEDICINE. 
 
 fluid and markedly increased above, CEgophony being present at the 
 upper margin of the fluid. 
 
 With the absorption of the fluid the vesicuhir murmur gradually 
 returns, associated with a moist friction sound. 
 
 Diag'nosis. Acute pneumonia is often mistaken for the effusion 
 stage of pleurisy. The points of distinction are, in pneumonia there 
 is the pronounced chill, high fever, and characteristic sputa, bronchial 
 breathing, exaggerated vocal fremitus and resonance, and no dis- 
 placement of the heart, the reverse occurring in pleurisy. 
 
 Enlargement of the liver may be mistaken for pleurisy with effusion, 
 the chief point of distinction being that, in enlargement of the liver, 
 the superior line of dullness is depressed upon full inspiration, while 
 in pleurisy with effusion inspiration does not modify the location of 
 the dullness, 
 
 Prog'nosis. Idiopathic pleurisy usually terminates in recovery 
 within three weeks. Pleurisy the result of constitutional causes has 
 its prognosis modified by the condition with which it is associated. 
 Etnpyema, unless the result of a diathesis, terminates favorably. 
 Double pleurisy is imfavorable. 
 
 Treatment. At the onset, in plethoric patients, wet cups over the 
 affected side ; if great dyspnoea, severe pain and high arterial tension, 
 even venesection, and in anaenic or weak persons, dry cups, follow- 
 ing the use of either wet or dry cups with poultices or turpentine 
 stupes. The severe pain is promptly relieved by the hypodermic in- 
 jection of morpJmice sulphas over its site, repeated as indicated, or 
 the frequent use of small doses o^ pulvis opii et ipecacuanh(Z. 
 
 Tinct. verat. virid., or tinctura aconiti, in small doses, frequently 
 repeated, in the plethoric, and digitalis in the weak, control the circu- 
 lation, and lessen the amount of blood distributed to the affected 
 membrane. 
 
 After effusion has begun, extractum pilocarpi fiuidum, gtt. xx, 
 every two or three hours, or in drachm doses every other day for a 
 week or two, after which twice weekly, or — 
 
 U • Potassii acetat., gr. xxx 
 
 Ir)fus. digitalis, ^ij. M. 
 
 Every ihree or four hours. 
 
 If the effusion be uninfluenced by the above, usq potassii iodidum, 
 gr. XV, every four hours, with flying blisters over the affected side ; -or 
 
DISEASES OF THE PLEURA. 265 
 
 the fluid may be evacuated by aspiration, using at the same time 
 full doses of mistura ferri et amvionii acetatis {Basham's mixture). 
 Locally in the arm-pits, groins, or over the site of the effusion, tm- 
 guentum hydrargyri. 
 
 The effusion of pleuritis is rapidly removed by the method of treat- 
 ment suggested by Prof. Matthew Hay, of Scotland, consisting in the 
 use of a concentrated solution of saline cathartics : " order the patient 
 to take nothing after the evening meal, and then, an hour or so before 
 breakfast, the salt is given dissolved in as little water as possible. 
 Usual dose from 5iv-vj to ^j-ij magnesii sulphatis to an ounce or 
 two of water, no fluids to be used after the dose ; this usually produces 
 from four to eight watery stools without pain or discomfort and also 
 acts as a diuretic." 
 
 The essence of the " Hay method " consists in getting the concen- 
 trated solution into the intestines at a time when the fluid contents 
 are scanty. 
 
 If double pleuritic effusion, evacuate the fluid at once with the aspi- 
 rator, and use the potassium and digitalis mixture mentioned above. 
 
 Chronic pleurisy : if the effusion be still serous, it is often absorbed 
 by the internal use oi potassii iodidum, alternating with " B as ham's 
 mixture,'" and blisters, the secretions being regularly attended to. If, 
 however, the liquid is pus {empyema), the aspirator should be used at 
 once, the patient placed upon " Basham's mixture,'' stimulants and 
 quinina. 
 
 Usually, however, within a very few days after aspiration, another 
 accumulation of pus will have taken place. Should this occur, the 
 purulent pleurisy should then be treated as an abscess, an incision 
 being made between the fifth and sixth ribs, the pus evacuated, a 
 drainage tube introduced and an antiseptic dressing applied. If the 
 tendency to pus secretion still remains the pleural cavity must be 
 washed out with an antiseptic solution, the constitutional treatment 
 being continued. 
 
 HYDROTHORAX. 
 
 Synonym. Dropsy of the pleura. 
 
 Definition. The effusion of fluid into the pleural cavities (bilat- 
 eral), the result of a general dropsy from renal or cardiac disease. 
 
 Pathological Anatomy. More or less clear serous fluid in 
 both pleural sacs, compressing the lungs. No signs of inflammation 
 are present. 
 
 22 
 
266 PRACTICE OF MEDICINE. 
 
 Symptoms. Following dropsy of the abdomen occurs dyspnoea, 
 with signs of deficient blood aeration, both lungs being compressed. 
 
 Palpation. Absent vocal fremitus over the site of the fluid. 
 
 Percussion. Dullness over the site of the fluid. 
 
 Auscultation. Absent vesicular murmur over the site of the 
 fluid. 
 
 Diagnosis. Easily determined by association of the symptoms 
 with a general dropsy. 
 
 Prognosis. Controlled by the cause producing the general 
 dropsy. 
 
 Treatment. Depending upon the condition causing the dropsy. 
 Dry cups over the chest afford relief. If the symptoms of non-aera- 
 tion of the blood are severe, the fluid should be at once evacuated 
 with the aspirator. 
 
 PNEUMOTHORAX. 
 
 Synonyms. Air in the pleural cavity ; hydropneumothorax. 
 
 Definition. The accumulation of air in the pleural cavities, with 
 the consequent development of inflammation of the membranes; 
 characterized by sharp pain, followed by rapidly developing dyspnoea 
 and cough. 
 
 Causes. Generally the result of tubercular phthisis, causing per- 
 foration of the pleura. Perforation may take place from the pleura 
 into the lung, in connection with empyema or abscess of the chest 
 walls. Direct perforation from without, by laceration of fractured 
 rib or severe contusion. 
 
 Pathological Anatomy. The gas in the pleural cavity consists 
 of oxygen, carbon anhydride, and nitrogen in variable proportions. 
 It may fill the pleural sac completely, compressing the lung, or is 
 sometimes limited by adhesions. The gas tends to excite inflamma- 
 tion, the resulting effusion being either serous or purulent. 
 
 Symptoms. Symptoms of pneumothorax, the result of perfora- 
 tion, are sudden or sharp pain in the side, intense dyspnoea, attended 
 with symptoms of collapse, coldness of the surface and cold sweats. 
 
 The above symptoms, in many instances, follow a severe or violent 
 "p^xox^svcy o{ coughing. In severe cases there is never a moment's 
 cessation of the acute pain and distressing dyspnoea, causing orthop- 
 ncea from the onset until death. 
 
DISEASES OF THE PLEURA. 267 
 
 Inspection. Enlargement of the affected side, the intercostal 
 spaces being widened and effaced, or even bulged out so that the 
 surface of the chest is smooth. Respiratory movements of the affected 
 side are diminished or absent. 
 
 Percussion. Immediately after the rupture the percussion note 
 is hyper-resonant, or even tympanitic or amphoric in quality. If the 
 amount of air in the pleural cavity becomes extreme there is dullness 
 on percussion, associated with a feeling of great resistance or density. 
 When effusion of blood occurs dullness is observed over the lower 
 part of the chest, hyper-resonant or tympanitic percussion note over 
 the upper portions of the chest, these sounds changing as the patient 
 changes his position. 
 
 Auscultation. The normal vesicular murmur may be diminished 
 or absent. The typical amphoric respiratory sound is heard when 
 the fistula is open, usually associated with a metallic echo. 
 
 Metallic tinkling, or the bell sound, is sometimes distinctly pro- 
 duced by breathing, coughing or speaking, after the development of 
 inflammation of the pleura. 
 
 The vocal resonance may be diminished or absent, or, rarely, it 
 may be exaggerated, with a distinct metallic echo. 
 
 After the development of inflammation in the pleura, suddenly 
 shaking the patient gives rise to a splashing seiisation, the succussion 
 sound, if both air and fluid are present in the pleural cavity. 
 
 Prognosis. When occurring as the result of tuberculosis, the 
 prognosis is extremely unfavorable; rarely, the fistulous opening 
 being closed by inflammatory action ; the case then becomes one of 
 chronic pleurisy. 
 
 Treatment. At once a hypodermic injection- of morphincE 
 sulphas, which relieves the severe pain and somewhat modifies the 
 distressing dyspnoea, followed by the evacuation of the fluid and air 
 with the aspirator. 
 
 If the fistulous opening be closed by inflammatory action, the case 
 resolves itself into one of chronic pleurisy, the treatment indicated for 
 that affection plus the treatment of tuberculosis, being tl^e indication. 
 
268 PRACTICE OF MEDICINE. 
 
 DISEASES OF THE CIRCULATORY 
 SYSTEM. 
 
 The methods employed in making a physical examination of the 
 heart are : I. Inspection. II. Palpation. III. Percussion. IV. Aus- 
 cultation. 
 
 Inspection indicates the exact point of the cardiac iinfiulse, 
 and whether there be any abnormal pulsations or any c/iafige in the 
 form of prcECordium. 
 
 Normally the impulse is visible only in \hejifth interspace, midway 
 between the left nipple and the left border of the sternum, its area 
 covering about one square inch, most distinct in the thin, wdiile often 
 barely seen in the very fleshy ; often displaced downward by full in- 
 spiration and elevated by complete expiration. 
 
 Disease may alter the position and area of the impulse. 
 
 The position of the impulse is moved to the right by left pleuritic 
 
 effusions ; downward by hypertrophy or emphysema ; upward by 
 
 pericardial effusion. 
 
 The area of the impulse is changed and enlarged by pericardial 
 
 adhesions, cardiac dilatation, or hypertrophy. 
 
 Palpation confirms the observations of inspection, and also deter- 
 mines the force, frequency and regularity of the cardiac ijnpulse. 
 
 The impulse is dijninished by cardiac dilatation, fatty degenera- 
 tion of the heart, emphysema, pericardial effusion, and adynamic 
 disease. 
 
 The impulse is increased by cardiac hypertrophy, during the first 
 stage of endocarditis and pericarditis, functional cardiac disturbances 
 and sthenic inflammations. 
 
 Percussion will indicate the boundaries of the superficial and 
 deep cardiac space, the so-called prcEcordium. It is essential that the 
 upper, lower, and two lateral boundaries of the pericardial region be 
 memorized, to wit : superior boundary, the upper edge of the third 
 rib ; the lower boundary is a horizontal line passing through the fifth 
 intercostal space; the left lateral boundary is about or a little within 
 a vertical line passing through the nipple, the li7iea ma^nmalis ; and 
 the right lateral boundary is an imaginary vertical line situated one- 
 half an inch to the right of the sternum. These boundaries vary 
 
DISEASES OF THE CIRCULATORY SYSTEM. 269 
 
 somewhat in health, but are sufficiently accurate for all practical 
 purposes. 
 
 The superficial cardiac space represents that portion of the heart 
 uncovered with lung ; it is triangular in form, its apex being the junc- 
 tion of the lower border of the left third rib with the sternum, its 
 area not exceeding two inches in any direction. 
 
 The superficial space is increased by cardiac hypertrophy, dilatation 
 or pericardial effusion. 
 
 Diminished at the end of full inspiration or by emphysema. 
 
 The deep cardiac space represents that portion of the heart covered 
 by lung, and extends from the upper border of the third rib to the 
 lower edge of the fifth interspace, and from half an inch to the right 
 of the sternum to near the left nipple. 
 
 It is increased by hypertrophy or dilatation of the heart, left pleuritic 
 effusion, and apparently increased by consolidation of the anterior 
 border of the investing lung. 
 
 Auscultation indicates the character of the normal cardiac 
 sounds and the point of greatest intensity at which they are heard, 
 and should be thoroughly familiarized if abnormal sounds are to be 
 fully appreciated. 
 
 The ear or stethoscope applied to the prsecordium distinguishes two 
 sounds, separated by a momentary silence — the short pause, and the 
 second sound followed by an interval of silence — the long patise. 
 
 The first sound, corresponding to the contraction of the heart — the 
 systole — is louder, longer and of lower pitch and a more booming 
 quality than the second sound, and has its point of greatest intensity 
 at the cardiac apex or a little to the left. It corresponds closely to the 
 pulsations as felt in the carotid or radial arteries. 
 
 The second sound is shorter, weaker and higher in pitch than the 
 first sound, and has a clicking or valvular quality, having its point of 
 greatest intensity at the second right costal cartilage and a little 
 above, and corresponds to the closure of the aortic and pulmonary 
 valves. The sound made by the closure of the tricuspid valves is 
 best isolated at the ensiform cartilage. The sound made by the 
 closure of the pulmonary valves at the third left costal cartilage. 
 
 The extent of surface over which the cardiac sounds are heard 
 varies according to the size of the heart and the condition of the 
 adjacent organs for transmitting sounds. 
 
 The cardiac sounds may be altered in intensity, quality, pitch, seat 
 
27U PRACTICE OF MEDICINE. 
 
 and rhythm, or they may be accompanied, preceded or followed by 
 adventitious or new sounds, the so-called endocardial miirmurs. 
 
 The intensity is increased by cardiac hypertrophy, irritability of the 
 heart or consolidation of adjacent lung structure. 
 
 The intensity is diminished by cardiac dilatation or degeneration, 
 during the course of adynamic fevers, emphysematous lung overlap- 
 ping the heart, or pericardial effusion. 
 
 The quality and pitch of the first sound may be sharp or short 
 and of higher pitch when the ventricular walls are thin, the valves 
 being normal ; its pitch and quality are also raised during the course 
 of low fevers. The second sound becomes duller and lower in pitch 
 when the elasticity of the aorta is diminished or the aortic valves 
 thickened. Either or both sounds have a more or less metallic qual- 
 ity in irritable heart and during gaseous distention of the stomach. 
 
 The seat of greatest intensity o{ the cardiac sound is changed by 
 displacement of the heart, pleuritic effusion, pericardial effusion, and 
 abdominal tympanites. 
 
 The rhythm is often interrupted by a sudden pause or silence, the 
 heart missing a beat, or the sounds are irregular, confused and tumul- 
 tuous, the result of organic changes in the cardiac muscles, valves, 
 or orifices ; or a reduplication of one or both sounds of the heart may 
 occur. 
 
 The adventitious cardiac sounds or jnurmurs are of two kinds, those 
 made external to the heart, as pericardial, exocardial or frictional 
 murmurs, and those made within the cardiac cavity, endocardial 
 7nurmurs. 
 
 Pericardial murmurs, or friction sounds, are made by the rubbing 
 upon one another of the roughened surfaces of the pericardial mem- 
 brane during the early stages of inflammation. The sounds have a 
 rubbing, creaking, or grating character, and are differentiated from a 
 pleural friction sound by their being limited to the praecordium, syn- 
 chronous with every sound of the heart, and not influenced by respi- 
 ration. 
 
 They are distinguished from an endocardial murmur by their super- 
 ficial rubbing, creaking or grating character, and by not being trans- 
 mitted beyond the limits of the heart, either along the course of the 
 vessels, or to the left axilla, or back. 
 
 Endocardial murtnurs are of two kinds, to wit : organic and func- 
 tional. 
 
DISEASES OF THE CIRCULATORY SYSTEM. 271 
 
 Functional endocardial OX blood murmurs are the result of changes 
 in the natural constituents of the blood. 
 
 Their character is soft, they are heard most distinctly at the base to 
 the left of the sternum, during the systole, and not transmitted beyond 
 the limits of the heart, either to the left axilla or the back, and are 
 associated with general anaemia. 
 
 Organic endocardial murmurs are produced by blood currents 
 pursuing either a normal or an abnormal direction. 
 
 In health there are two direct blood currents upon each side of the 
 heart, to wit : the current from the left auricle to the left ventricle, the 
 mitral direct currefit ; the current from the left ventricle to the aorta, 
 the aortic direct current ; the current from the right auricle to the right 
 ventricle, the tricuspid direct current, and the current from the right 
 ventricle to the pulmonary artery, the pulmonic direct current. 
 
 When, from disease, the valves are not properly closed, the blood 
 is allowed to flow back against the direct current, producing abnormal 
 blood currents, to v/it: when the mitral valve is incompetent, the 
 blood flows from the left ventricle back to the left auricle during the 
 cardiac systole, producing the mitral regurgitant or indirect current ; 
 when the aortic valves are incompetent, the blood is permitted to 
 flow from the aorta into the left ventricle during the cardiac systole, 
 producing the aortic regurgitant or indirect current ; when the 
 tricuspid valves are incompetent, the blood flows from the right 
 ventricle back into the right auricle during the systole, producing 
 the tricuspid regurgitant or indirect current; when the pulmonary 
 valves are incompetent, the blood flows from the pulmonary artery 
 into the right ventricle, producing the pulmonic regurgitant or indirect 
 current. 
 
 The mitral direct current occurs during the contraction of the left 
 auricle, or just before the first sound of the heart and immediately 
 after its second sound. The aortic direct current is produced by the 
 contraction of the left ventricle, and occurs with the first sound of the 
 heart. The tricuspid direct curroit occurs during the contraction of 
 the right auricle, or just before the first or immediately after the second 
 sound. The pulmonic direct current is produced by the contraction 
 of the heart, occurring during its first sound. 
 
 The mitral direct, or presystolic murmur, occurs before the first 
 sound of the heart and immediately after the second sound. It is 
 caused by a narrowing of the mitral orifice, has a blubbering quality, 
 
272 PRACTICE OF MEDICINE. 
 
 well imitated by throwing the lips into vibration by the breath, of a 
 low pitch, and it has its seat of greatest intensity at the cardiac apex, 
 and is not transmitted to the left axilla or to the base of the heart. 
 
 The mitral regurgitant, or systolic murfnur, occurs with the first 
 sound of the heart, resulting from the failure of the mitral valves to 
 close the mitral orifice during the systole, in consequence of which 
 the blood flows back, or regurgitates into the left auricle. It is usually 
 of a blowing or churning character, and has its seat of greatest in- 
 tensity at the cardiac apex, being well transmitted to the left axilla 
 and inferior angle of the left scapula. 
 
 The aortic direct murmur occurs with the second sound of the heart. 
 It is caused by a narrowing of the aortic orifice, has a rough or creak- 
 ing character, is of high pitch, having its seat of greatest intensity in 
 the second intercostal space, to the right of the sternum, and is well 
 transmitted over the carotid artery. 
 
 The aortic res^iirsritant murmur occurs with the second sound of the 
 heart, and is caused by the failure of the aortic valves to close the 
 aortic orifice during the diastole, whereby the blood flows back or 
 regurgitates into the left ventricle. It is usually of a blowing or 
 churning character and of low pitch, having its seat of greatest in- 
 tensity over the base of the heart, and is well transmitted downward 
 toward or below the cardiac apex. It is the only organic murmur 
 produced in the left side of the heart which occurs with the second 
 sound of the heart. 
 
 The tricuspid direct murmur occurs before the first sound of the 
 heart and immediately after the second sound. It is caused by a nar- 
 rowing of the tricuspid orifice, has a blubbering quality, and is low 
 in pitch, having its seat of greatest intensity near the ensiform car- 
 tilage. This murmur is exceedingly rare. 
 
 The tricuspid regurgitant murmur occurs with the first sound of 
 the heart, the result of the failure of the tricuspid valves to close the 
 tricuspid orifice during the systole, thus allowing the blood to flow 
 back or regurgitate into the right auricle. It is usually of a blowing, 
 or soft, churning character, having its seat of greatest intensity at the 
 ensiform cartilage. This murmur is also very infrequent, and occurs 
 mostly when the right ventricle is considerably dilated, without the 
 existence of any valvular disease. 
 
 The pulmonic direct 7mtrmur occurs with the first sound of the 
 heart. It is generally connected with congenital lesions. It occurs 
 
DISEASES OF THE CIRCULATORY SYSTEM. 273 
 
 at the same instant that the aortic direct murmur occurs, and is dis- 
 tinguished from the latter by its not being transmitted into the carotid 
 artery, whereas the aortic direct murmur is always thus transmitted. 
 
 The pidmonic regurgitant muriniir occurs, like the aortic regurgi- 
 tant murmur, with the second sound of the heart. This murmur is 
 exceedingly rare, and its presence is only positively differentiated 
 from the aortic regurgitant murmur by the absence of aortic lesions 
 and symptoms. 
 
 ACUTE PERICARDITIS. 
 
 Definition. An acute hbrinous inflammation of the pericardium ; 
 characterized by slight fever, pain, prsecordial distress and disturbed 
 cardiac action and circulation. 
 
 If the inflammation be limited to the parietal or visceral layer, or 
 to a part of either, it is termed partial or circuinscribed pericarditis ; 
 if it involve the whole of both surfaces it is termed general or diffused 
 pericarditis. 
 
 Causes. May follow injuries of the chest walls, or be the result 
 of taking cold, but generally secondary to either acute articular rheu- 
 matism, pneumonia, pleurisy, erysipelas, Bright's disease or pyaemia. 
 
 Path.olog"ical Anatomy. The same as serous membranes in 
 other situations, 
 
 Hyper(E7tiia 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 on 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 •vovcnimg, prcEcordial distress, acute shooting paints, increased by 
 breathing and coughing, tenderness, dry, suppressed cough, increased 
 cardiac actio7i, 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. Duration of 
 this early stage, from a few hours to a day. 
 
 Effusioti stage : The symptoms of this stage depend upon the amount 
 23 
 
274 PRACTICE OF MEDICINE. 
 
 and rapidity of the effusion ; precordial oppression, tendency to 
 syncope, dyspncea, sometimes amounting to orthopnoea, dysphagia, 
 ?iiccough, nausea and vomiting, feeble, irregular pulse, 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. 
 
 Palpation. Early stage, excited or tumultuous impulse ; peri- 
 cardial frictio7i 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 tria7igular shape, with the base of the 
 triangle on a line with the sixth rib, extending from the right of the 
 sternum to the left of the left nipple, narrowing as it proceeds 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 posi- 
 tion of the patient. 
 
 Auscultation. Early stage, excited cardiac action, and usually 
 a friction soujid (exocardial murmur) synchronous with cardiac 
 sounds and uninfluenced by respiration, but often increased by pres- 
 sure with the stethoscope. 
 
 Effusion stage, cardiac sounds feeble and deep-seated at the cardiac 
 apex, becoming louder and distinct toward the cardiac base. The 
 friction sound is sometimes heard at the cardiac base. 
 
 If absorption occur the above signs gradually give place to the 
 norma), the friction sound returning, ot 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. 
 
 Cardiac hypertrophy or dilatation is sometimes confounded with 
 
DISEASES OF THE CIRCULATORY SYSTEM. 275 
 
 pericardial effusion ; the difference between them will be pointed out 
 when discussing those affections. 
 
 Hydropericardhim may be mistaken for pericardial effusion ; see 
 that affection. 
 
 ProgTlGsis. Controlled by the severity of the inflammation and 
 coexisting affections. If slight effusion, favorable. Death has rapidly 
 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 ; for vigorous patients, the appli- 
 cation of leeches or wet cups to the prsecordium, followed by the 
 application of either ice or poultices ; in the feeble dry cups to the 
 praecordium, followed by poultices. 
 
 Early stage ; in the strong, control the excited cardiac action by 
 small doses of aconitum or veratrum viride, in the feeble using digi- 
 talis ; in all cases quinina is indicated. 
 
 Effusio'ii stage ; as the effusion progresses the free administration 
 of alkalies, to wit: ammonii-carb., gr. v, every two hours, with liquor 
 ainmonii acetatis, or potassii acetatis, or potassii carbonatis, with 
 quinina, nutritious liquid diet and stimulants, being cautious with 
 the use of cardiac sedatives or tonics. 
 
 If the effusion has a tendency to linger, blisters to the prsecordium, 
 or paracentesis, is indicated. Dr. Roberts, in his monograph, gives 
 an account of sixty cases of paracentesis with twenty-four recoveries. 
 He advises that the tapping be done in the fossa between the ensi- 
 form and costal cartilages on the left side, or in the fifth left interspace 
 near the junction of the sixth rib with its cartilage. 
 
 CHRONIC 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. 
 
 Pathological Anatomy. If the effusion be absorbed, the peri- 
 cardial surfaces are agglutinated by several layers of lymph, which in- 
 crease the thickness of the membranes half an inch or more, and the 
 outer surface of the pericardium becomes adherent to the chest walls. 
 
276 PRACTICE OF MEDICINE. 
 
 If the fluid be 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 alow grade of 
 inflammation supervenes, the fluid becoming purulent, 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, irregular, fgeble car- 
 diac action, dysfiH<za aggravated by movement and disturbed cir- 
 cidation. 
 
 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 praecordial surfaces as well as 
 with the chest walls, inspection reveals depression of the prcBcordiiim, 
 narrowing of the spaces, increased extent but displaced impulse, un- 
 influenced by deep inspiration, and recessio?i 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 
 adhesion, 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 pmecordium, with potassii 
 iodidiini to hasten absorption, the patient supported by nutritious diet, 
 quinina, ferrwn and stimulants, and perfect c^uiet. If these means 
 fail to remove the fluid, or if the fluid be y^\xx\A(tx\\., paracentesis should 
 be performed at once. 
 
 If adhesions of the pericardiuin have resulted, the application of 
 blisters to the praecordium with the administration of potassii iodi- 
 dum, alternating with ferritin and quinina, are indicated, with nutri- 
 tious diet, stimulants and perfect quiet. 
 
DISEASES OF THE CIRCULATORY SYSTEM. 277 
 
 HYDRO-PERICARDIUM. 
 
 Synonym. Pericardial dropsy. 
 
 Definition. The accumulation of water in the pericardial sac, 
 minus inflammation ; characterized by praecordial distress, disturbed 
 cardiac action, dyspnoea and dysphagia. 
 
 Causes. Ubually 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 that the symptoms are but an aggravation of those 
 attending upon that condition, to wit: disturbed cardiac action, dysp- 
 ncea, dysphagia, dry cough, and feeble circulation. 
 
 The physical signs are exactly those of the stage of effusion of 
 pericarditis, minus a friction sound. 
 
 Diag'nosis. Pericarditis with effusion and hydro-pericardium 
 present nearly the same signs and symptoms, a differentiation being 
 possible only by a history of the case and the symptoms of the attack. 
 
 Prognosis. Controlled entirely by the cause. 
 
 Treatment. Depends upon the cause of the attack. If the 
 amount of fluid in the pericardial sac be great, paracetitesis will give 
 relief. 
 
 ACUTE ENDOCARDITIS. 
 
 Sjmonym, Valvulitis. 
 
 Definition. An acute fibrinous inflammation of the serous mem- 
 brane lining the cavity of the heart and forming its valves ; charac- 
 terized by cough, dyspnoea, nausea and vomiting, disturbed cardiac 
 action, resulting in changes in the valves or orifices of the heart. 
 
 Acute endocarditis occurs in two distinct forms : plastic or simple 
 exudative endocarditis ; ulcerous or diphtheritic endocarditis. 
 
 Causes. Usually secondary to acute articular rheumatism, pleu- 
 ritis, pneum.onia, pericarditis or Bright's disease. In the ulcerative or 
 diphtheritic variety, a depressed condition of the vital forces, probably 
 the result of the diphtheritic poison, seems to be the determining cause. 
 
278 PRACTICE OF MEDICINE. 
 
 Pathological Anatomy. Inflammation of the endocardium is 
 usually limited to the left side of the heart after birth, durins^ 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 menibrane in 
 these situations, and to the strain which falls upon the valves during 
 the performance of their functions. 
 
 Hyperemia from congestion of the vessels beneath the membrane, 
 with considerable swelling of the valves, the result of an exiidatioK 
 of lymph and scrum beneath and on the free surface of the membrane 
 covering the valves and chorda fendinecB, resulting in the roughening 
 of the surfaces and the agglutination of the mitral valves to each 
 other, and of the aorta 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 in- 
 creased by the deposit of fibrin from the blood within the cavities 
 of the heart. 
 
 These vegetations maybe detached by friction, giving rise to emboli 
 which may be washed by the blood current on the left side of the 
 brain, into the kidneys and spleen. 
 
 In the ulcerative variety a process of softening takes place in the 
 fibrinous deposits, leading to ulcerations and perforations. 
 
 Syraptoms. This afl"ection is usually masked by the course of 
 another disease until disturbances of the circulation attract attention 
 to the heart. 
 
 The onset is often by i7icrease of temperature, prcecordial distress, 
 short cough, slight dyspnoea, more or less persistent vomiting, in- 
 creased 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 rapidity, with more or less con- 
 gestion of the lungs and venous stasis. 
 
 Auscultation. Shows a change in the character of the sounds 
 or the development of murmurs at the various orifices, the character 
 and points of distinction between which will be pointed out when 
 discussing valvular diseases of the heart. 
 
 Duration. Between one and three weeks. 
 
 Diagnosis. Pericarditis h distinguished from endocarditis by the 
 character of the physical signs. In pericarditis the murmur or friction 
 sound is heard with either sound, is near to the ear and influenced by 
 
DISEASES OF THE CIRCULATORY SYSTEM. 279 
 
 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, with the 
 absence of change or increased dullness on percussion. 
 
 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. Perfect rest in bed. At the onset leeches or wet cups 
 to the prsecordium, followed by ice, or, what is preferable, j?^^^^///^^^. 
 
 The excited circulation should be controlled by aconitum, veratrum 
 viride, or digitalis. 
 
 The free administration of alkalies, to wit : aminonii carbonas, 
 potassii acetas or carbonas, until the urine is decidedly alkaline, may 
 prevent permanent changes in the valves or orifices. 
 
 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 oedematous, with congestion of the lungs, 
 the free use of a7ninonii carbonas, digitalis and stimulants is indi- 
 cated. The free use of ammonii carbonas will often prevent or break 
 up heart clots. After the acute symptoms have subsided, more or 
 less absorption of the exuded lymph has followed the free use of 
 potassii iodidum. During the entire course of the affection the diet 
 should be of the most nutritious character. 
 
 ACUTE MYOCARDITIS. 
 
 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 ; pysemia ; 
 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 
 
280 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 muscle are very obscure. If, during the course of one of the 
 maladies mentioned, there are developed pain, irregular and feeble 
 cardiac action, pyrexia of a low type, with symptoms of blood poison- 
 ing, 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 and 
 femnn. 
 
 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 
 accelerated circulation. 
 
 Causes. Obstruction of the outflow of blood, to wit : aortic sten- 
 osis ; emphysema ; Bright's disease ; functional over-action ; excessive 
 use of tobacco, tea, coffee, or excessive muscular action. 
 
 Varieties. I. Simple hypertrophy , or a simple increase in the 
 thickness of the cardiac walls; II. Eccentric hypertrophy, increase 
 in the cardiac walls and dilatation of the cavities, to wit : Dilated 
 hypertrophy : III. Concentric hypertrophy, increase in the cardiac 
 walls and decrease of the cavities, a very rare form. 
 
 Pathological Anatomy. Hypertrophy of the heart is usually 
 limited to the left side, the ventricliss more commonly than the 
 auricles, the latter dilating. 
 
 The shape of the heart is altered by hypertrophy ; if the right 
 ventricle, .the heart is widened transversely and the apex blunted ; if 
 
DISEASES OF THE CIRCULATORY SYSTEM. 281 
 
 the left ventricle, the heart is elongated and, as a rule, the cavity is 
 dilated ; if both ventricles arehypertrophied, 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. 
 
 Symptoms. Depend upon the amount of hypertrophy. The 
 most common are increased arid forcible cardiac atr//^;?, the arteries 
 becoming fuller, the veins less full and the circulation accelerated, 
 pulsating carotids and aorta, headache, often vertigo, frequent epis- 
 taxis, congestion of the face and eyes, tinnitus auriuin, dysp7icea on 
 exertion, /fry r^z/T^^, restless nights, with more or less jerking of the 
 limbs, occasional 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 
 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. 
 
 Diag'nosis. 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 hypertrophy 
 is said to be compensatory. If the result of Bright's disease, emphy- 
 
282 PRACTICE OF MEDICINE. 
 
 sema of the lung, or if occurring late in life, or associated with athero- 
 matous 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 to lesse7i 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 aconi- 
 ium in small doses, gtt. j-ij, three times a day, or veratriim vin'de, 
 gtt. j-ij, three times a day, at the same time keeping the bowels, 
 kidneys and skin acting freely. 
 
 The habits of the patient are to be corrected, all laborious or active 
 exercise to be restricted, the patient to be in the recurribent 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 
 relieved by digitalis, the cardiac distress being secondary to the kid- 
 ney disease for which the digitalis is used. 
 
 Cases of cardiac hypertrophy associated with anaemia should, in 
 addition to the above, be placed upon a course oiferrum. 
 
 DILATATION OF THE HEART. 
 
 Definition. An increase in the size of one or more of the cavities 
 of the heart, without any increase or thickening of the cardiac walls ; 
 in fact, the walls are frequently thinner ; characterized by feebleness of 
 the circulation, terminating in venous stasis, oedema and exhaustion. 
 
 Causes. Over-exertion in those of feeble resisting powers, as 
 youths or soldiers, as first pointed out by Prof. Da Costa ; insuffi- 
 ciency of the valves ; emphysema ; chronic bronchitis ; gout ; Bright's 
 disease. 
 
 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 
 
DISEASES OF THE CIRCULATORY SYSTEM. 283 
 
 is altered, according to 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-v^entricular, resulting in 
 the valves becoming incompetent to close the orifices, and this latter 
 effect is added to by the removal of the basis of the papillary muscles 
 to a great 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, dyspncea ; 
 \\v ox, jaundice ; stomach, dyspepsia; intestines, cons/ipation ; kid- 
 neys, scanty, often albuminous, tirine ; brain, dullness of the mind and 
 vertigo, often relieved by a copious epistaxis ; and, finally, dropsy, 
 beginning in the lower extremities, 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 insuf^ciency, 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. 
 
284 PRACTICE OF MEDICINE. 
 
 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 proscordia. 
 
 Prognosis. Unfcivorable, death resulting from gradual exhaus- 
 tion, or suddenly by cardiac paralysis if there be undue excitement. 
 
 Treatment. Dilatation of the heart is incurable. Palliative 
 measures are of but temporary benefit. In all cases there are two 
 important indications to be met, the first to maintain the general 
 nutrition of the patient to the uttermost, and the second to control or 
 prevent all irregular or violent cardiac action. The first indication is 
 accomplished by a generous diet, moderate exercise, with bitters to 
 increase the appetite and ferrwn 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 or 
 infusion, tinctura strophanthiis Y(\j.]-x, t. d., exi. cotivallarice fld., gtt. 
 V, t. d., guinina, caffeina and morphincz siclph., in small doses, the 
 latter, when the dropsy becomes great and 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, — 
 
 R . Ferri redact., gr. j-ij 
 
 Quininse sulph., gr. j-ij 
 
 Pulv. digitalis, gr. j 
 
 Morphina; sulph., gr. ^'j. M. 
 
 SiG. — Three times a day. 
 
 The secretions should be stimulated by purgatives , diuretics and 
 diaphoretics. 
 
 If pulmonary congestion, dry cups, digitalis and stimulants. 
 
 For cardiac asthma, dry cups, viorphiufp. sulph. hypodermically, or 
 spts. (ztheris compositus (Hoffman's Anodyne). 
 
 For hepatic congestion, bhte mass ox podophyllin. 
 
 For dropsy, dry cups over the kidney, digitalis or potassii acetas, 
 with scoparius 2Si(S.juniperiis, ^x\A pulv. jalapa; coinp., 3j-'ji in water, 
 before breakfast. 
 
DISEASES OF THE CIRCULATORY SYSTEM. 285 
 
 If the dropsy is uninfluenced by the above means, success will follow 
 the use of hydrargyri chloridi mite, gr. iij, guarded with piUv. opii, 
 gr. j^2> three or four times a daj', as I have frequently witnessed. 
 
 FATTY DEGENERATION OF THE HEART. 
 
 Definition. A change in the muscular fibres of the heart, in 
 which the transverse strice 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 ; disease of the coronary arteries. 
 
 Pathological Anatomy. The distinction must be made be- 
 tween a deposit of fatty tissue upon or around the heart, and the 
 degeneration of its muscular tissue. 
 
 The fatty metamorphosis may affect the whole organ, or the entire 
 ventricles, or be limited to portions of them. If the degeneration 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, gradually 
 becoming more and more obscured, and finally disappearing alto- 
 gether, 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 actiofi, couipressible 
 pulse, prcscordial distress, often aggravated by attacks of angina pec- 
 toris ; dyspncea, aggravated on exertion, with anaemia of the various 
 organs from the feeble propulsive power ; if of brain, vertigo, swoon- 
 ing, 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 constipatioii ; if of kidneys, 
 scanty urine, at times albuminous ; and finally, dropsy, beginning 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 
 
286 PRACTICE OF MEDICINE. 
 
 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 change in the vessels, 
 and the arc us sefii/is. 
 
 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. If aged persons, or those exposed to the causes, have 
 feeble heart, associated with atheroma of the vessels and the arcus 
 senilis, the diagnosis of fatty heart is almost positive. If dropsy occur, 
 however, it is difficult to distinguish from dilatation of the heart. 
 
 Prognosis. Incurable, the affection 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 morrhucE, and the "triple elixirs," — elixir 
 ferri, quitiijicE et strycJinincE. 
 
 All the excreting organs must be kept active, so as to relieve the 
 crippled heart as much as possible. 
 
 To sustain the cardiac action, caffeina or inorphina in small doses, 
 or hypodermically for the so called cardiac asthma. Digitalis is 
 contra-indicated in advanced cases. 
 
 Quain says: " Galva7iism applied from the back of the neck to the 
 praicordium, by the interrupted current, has been found useful." 
 
 VALVUL.\R DISEASES OF THE HEART. 
 
 Definition. Alterations in the cardiac valves or orifices, render- 
 ing the former incapable of properly closing the latter, or causing the 
 latter to interrupt the blood current in its normal movement. 
 
 The lesions are of two kinds, to wit : obstructive and regurgitant. 
 
DISEASES OF THE CIRCULATORY Si'STEM. 287 
 
 A regurgitajit lesion, termed also insufficiency , is such change in the 
 valves as to permit a portion of the blood to flow backward instead 
 of onward, the true direction of the blood current. 
 
 An obstructive lesion, termed also stejtosis, is a narrowing of the 
 orifice, thereby obstructing the passage of the blood. 
 
 Varieties. I. Mitral regurgitation, II. Aortic regurgitation. III. 
 Tricuspid regurgitation. IV. Pulmonic regurgitation. V. Mitral 
 obstruction. VI. Aortic obstruction. VII. Tricuspid obstruction. 
 VIII. Pulmonic obstruction. 
 
 Causes. In the young, usually the result of endocarditis, and 
 generally affecting the mitral orifice or valves ; in the elderly, chronic 
 endocarditis or atheromatous degeneration, most commonly affecting 
 the aortic orifice or valves. 
 
 Prof. Da Costa has clearly established the production of aortic dis- 
 ease in early life by overwork and strain of the heart ; syphilis ; 
 dilatation of the heart ; atrophy or contraction of the valves, and 
 congenital malformations. 
 
 MITRAL REGURGITATION. 
 
 Patholog'ical 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 ; 
 rupture of the chordcB tendincB, and also contraction and hardening 
 of the musculi papillares. 
 
 As a result of the regurgitation of the blood into the left auricle, 
 there is dilated hypertrophy. 
 
 Symptoins. 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. When the "compensation 
 ruptures " there occurs prcecordial distress, cough, dyspnoea, feeble, 
 soft, rapid, irregular pulse ; finally pulmonary congestion, cedematous 
 limbs, the abdominal cavity filled, liver congested, urine scanty and 
 albuminous, the patient dying " drowned in his own fluid." 
 
 Inspection. Cardiac impulse lower than normal, the heart being 
 enlarged. 
 
 Palpation. Early, forcible and diffused impulse ; later, feeble 
 diffused impulse. 
 
288 PRACTICE OF MEDICINE. 
 
 Percussion. Transverse and vertical cardiac dullness increased. 
 
 Auscultation. Systolic blowing or churning murmur, audible 
 in the mitral area, propagated to the apex, left axilla and under the 
 angle of the scapula, either occurring with or taking the place of the 
 first sound of the heart ; the second sound markedly accentuated. 
 
 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. 
 
 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, per- 
 mitting the regurgitation of the blood. These deficiencies in the valves 
 are usually associated with more or less narrowing of the orifices. 
 
 The cardiac muscle rapidly hypertrophies, its cavity enlarging — 
 dilated hypertrophy. 
 
 Symptoms. Those of marked hypertrophy, to wit : forcible car- 
 diac 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 recedmg pulse, which is 
 particularly characteristic — forcible impulse but rapidly declining, 
 called " water-hammer " pulse ; also, the " Corrigan pulse." 
 
 When " compensation ruptures," dyspnoea, cough, hepatic enlarge- 
 ment, congestion of the kidneys, with scanty, albuminous urine, ascites 
 and dropsy. If mitral insufficiency is now superadded, general 
 venous stasis and death rapidly occur. 
 
 Inspection. Forcible cardiac muscle. 
 
 Palpation. Strong, full cardiac impulse. 
 
 Percussion. Cardiac dullness increased transversely and verti- 
 cally. 
 
 Auscultation. First sound, forcible; second sound, replaced or 
 associated with a chur?iing, 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 
 
DISEASES OF THE CIRCULATORY SYSTEM. 289 
 
 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 jicgular, 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, praecordial distress, sudden suffocative 
 attacks and dropsy. 
 
 Percussion. The cardiac dullness extending to the right of the 
 sternum. 
 24 
 
290 PRACTICE OF MEDICINE. 
 
 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. 
 
 Prog"nosis. Death results, sooner or later, from dropsy and 
 exhaustion. 
 
 MITRAL OBSTRUCTION. 
 
 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 " button-hole " mitral valve. 
 Vegetations on the valves lead to more or less obstruction of the 
 blood current. 
 
 Symptoms. Hypertrophy of the left auricle results from ob- 
 struction of the mitral orifice, the symptoms of stenosis being unob- 
 servable until the "compensation ruptures," when occur irregular, 
 small and feeble pulse, dyspnoea, cough, 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 irregu- 
 lar in rhythm. The second sound normal. A blowing, sometimes 
 rasping, sound is heard, immediately after the second sound of the 
 heart ceases, and vc(\\\\^i^\2X^\y before the first sound begins — a pre- 
 systolic murmur, heard most distinctly in the mitral area, lessening in 
 intensity toward the cardiac base. The cardiac sounds are all more 
 or less enfeebled if cardiac dilatation occur. 
 
 Prognosis. The prognosis is controlled by the hypertrophy. 
 Under favorable circumstances mitral stenosis is compatible with a 
 long and rather active life. 
 
 AORTIC OBSTRUCTION. 
 
 Pathological Anatomy. Stenosis of the aortic orifice depends 
 upon the projection of the valves inward, and their becoming rigid 
 and thickened, or atheromatous or calcareous, so that they cannot be 
 pressed back by the blood, but remain constantly in the current of 
 
DISEASES OF THE CIRCULATORY SYSTEM. 291 
 
 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 only permit the passage of the smallest article. 
 
 Symptoins. Hypertrophy of the left ventricle rapidly super- 
 venes upon aortic stenosis. The pulse is small, slow and hard. The 
 supply of blood to the brain is insufficient in many cases, and hence 
 attacks of vertigo, syncope or slight epileptiform seizures occur ; 
 finally, dilatation of the left ventricle and incompetence of the mitral 
 valve result, with subsequent 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 slightly affected. 
 
 Auscultation. The first sound replaced or associated 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 murmur occurs, having its greatest intensity 
 at the base of the heart, the so-called see-saw murmur. 
 
 Prognosis. So long as compensation is maintained the symp- 
 toms of aortic stenosis are nil. When the compensation is ruptured, the 
 usual symptoms of dilatation, venous stasis and dropsy, soon follow. 
 
 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- 
 
292 PRACTICE OF MEDICINE. 
 
 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 diseases of the heart, strict attention must be paid to the 
 points of greatest intensity at which the several murmurs are heard. 
 
 A inurfjiur occurring with or taking the place of the first sou7id 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 murtmtr. 
 
 A rnnjnnur occurring with or taking the place of \)i\^ first sound oi the 
 heart, with its point of greatest intensity at the xiphoid appendix, signi- 
 fies regurgitation at the tricuspid orifice — tricuspid systolic 7mirinur. 
 
 A miirjmir heard with the first soii7id 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 — a7i aortic systolic i7iu7'mur. 
 
 A 7)iuri7iur heard with the first sound of the heart, soft in character, 
 with its point of intensity most distinct at the junction of the third 
 left costal cartilage with the sternum, signifies obstruction at the pul- 
 monic orifice — a puhiioiiic systolic 7nur77iur. 
 
 A mur77iur 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 77iitral 
 77iur77iur. 
 
 A murmur heard with or taking the place of the seco7id sound of the 
 
DISEASES OF THE CIRCULATORY SYSTEM. 293 
 
 heart, most distinct at the second costal cartilage, to the right of the 
 sternum, and well transmitted toward the apex or below, signifies in- 
 sufficiency or regurgitation at the aortic orifice — aji aortic regurgitant 
 or diastolic 7nurmur. 
 
 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 murmitr be heard with ^h^ first sound of the heart, it is almost 
 certainly aortic obstructive or initral regurgitant ; and if heardWx'Ca. 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 ancFinic murmurs may be confounded with the various 
 forms of valvular disease of the heart. The chief points of distinction 
 between them are, that an anaemic murmur, which is always heard at 
 the base of the heart, is always systolic in time, not transmitted 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. 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 
 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." 
 
 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 
 complete, attention to the condition of the bowels, kidneys and diges- 
 tion, with some general directions as to exercise, is all that is required. 
 
 If the hypertrophy become marked and excessive, it is best con- 
 trolled by either aconitum, veratrum viride, or nitro-glycerin. 
 
 If dilatation have occurred, the heart weak and feeble, the circula- 
 tion impeded, and venous stasis has followed, digitalis, strophanthus, 
 or sparteine sulphate, with more or less active purgation, is indicated. 
 
294 PRACTICE OF MEDICINE. 
 
 If fatty degeneration of the heart result, the indications are for car- 
 diac rest, stimulants, stropJuxnthus and attention to the excretions. 
 
 If the cardiac rhythm is disturbed, add belladonjia to whatever 
 other plan of treatment is being used. 
 
 If the capillary circulation is weak, strophanthus and nitro-glycerin 
 (glonoinum) act better than digitalis, which has the power of contract- 
 ing the arterioles. 
 
 Any of the secondary results of the valvular affection are to be 
 treated according to the particular indications. 
 
 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; dys- 
 pepsia ; 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, prcEcordial oppression or 
 Paifi, rapid, tumultuous beating, the impulse being visible through 
 the patient's clothing, dyspnoea, anxiety, and a sense of chokijig or 
 fullness in the throat, the recumbent position impossible, vertigo, 
 faintness, flashes of light, the pulse full and strong or feeble, \\\^face 
 flushed or pale, the patient having a feeling of anxiety with a sense 
 of impendijig 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 vari- 
 ous 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 by a combination of digitalis and 
 
DISEASES OF THE CIRCULATORY SYSTEM. 295 
 
 belladonjta. Permanent relief is often afforded by a combination of 
 potassii bromidum cin^veratruni viride. Chloral \^ also useful. If 
 the patient be anaemic, the author has had excellent results follow the 
 prolonged use of the elixir ferri^ quinincB et strychiiince. Locally, 
 emplastrum belladonncs to the prascordium affords relief. 
 
 ANGINA PECTORIS. 
 
 SynonjTTQ. Neuralgia of the heart. 
 
 Definition. Paroxysms in which there occur sharp cardiac pains, 
 extending usually into the left shoulder and down the left arm, accom- 
 panied by a feeling of constriction of the thorax and a strong sense 
 of impending death. 
 
 Causes. Depending upon the variety, whether nervous origin or 
 organic. Often hereditary ; associated with chronic cardiac changes, 
 as diseases of the coronary arteries or calcification of the valves ; the 
 excessive use of tobacco ; according to Trousseau, it is a form of 
 masked epilepsy, and may alternate with true epileptic attacks ; often 
 associated with hysteria. 
 
 Pathological Anatomy. Nervous form, "the pathological 
 changes which stand in a causative relation to the attacks are those 
 of the cardiac plexus of the phrenic and of the pneumogastric nerves. 
 Pressure of enlarged lymphatics, inflammation of parts of the cardiac 
 plexus, with changes in the coronary artery, seem to be most con- 
 stant." 
 
 Organic form, a disease of the arteries, ossification and occasion- 
 ally obliteration of the cardiac arteries, producing cardiac ischemia. 
 
 Symptoms. A paroxysmal affection, the attacks occurring irreg- 
 ularly ; in the interval entire absence of symptoms. 
 
 "The patient suddenly sits up in his bed; with a cry of horror 
 indicates the sense of pain at the praecordium. This pain is of great 
 intensity, but is of a cold and sickening character ; the chest is fixed, 
 the breathing quickened, and the hand placed over the epigastrium 
 finds that the heart's action is slight and enfeebled. The face wears 
 a look of horror, pale and slightly leadened ; a cold sweat breaks out 
 upon the forehead ; worse than the pain is the feeling of fearful sick- 
 ness and depression. The poor patient gasps, ' I shall die ! I shall 
 die ! ' and sometimes his short but concentrated sufferings in a few 
 moments end in death." 
 
296 PRACTICE OF MEDICINE. 
 
 The unpleasant sensations of these patients during an attack, and 
 the nervous disorder associated with it, slowly bring about a mental 
 change. They are depressed and gloomy, sometimes suicidal, often 
 developing epilepsy. 
 
 Diagnosis. The points to be remembered are that the attacks 
 are always paroxysmal, the patient having a sense of coldness, and 
 frequently a cold sweat, the heart's action not increased, the chest 
 fixed and the breathing slow. 
 
 Prognosis. Unfavorable, the patient, sooner or later, either suc- 
 cumbing during a paroxysm or from exhaustion, the result of the 
 cardiac changes. 
 
 Treatment. During the intervals between the attacks, an attempt 
 should be made to remove the exciting cause or diminish its predis- 
 posing power. 
 
 For the organic form, no one remedy is comparable with a long 
 course of potassii iodidi, gr. x-xx, three times daily, as the frequency 
 and intensity of the attacks are diminished and a fair number of cases 
 are cured, proving the axiom, "the iodides are the digitalis of the 
 arteries." 
 
 For the nervous form, all violent emotions and active physical 
 exercise is to be avoided, the diet regulated and the excretions 
 watched. Among the drugs that are useful are ferrum, arsetiiciim, 
 strychnina, phosphorus and zincwn. If the cardiac action be weak, 
 use strophatithiis. Trousseau urges the administration of belladonna 
 in continuous small doses, on the ground of the analogy of the affec- 
 tion to epilepsy. Quain states that a continuous current, the positive 
 pole on the sternum and the negative pole on the lower vertebrae, 
 lessens the severity and frequency of the anginal paroxysms. 
 
 For the attack, prompt relief follows the use of atnyl nitris, n\^iij, 
 inhaled at the instant, or 7norphince stilphas, gr. Ye-ji , to which may 
 be added with advantage atropmce sulphas, gr. y^g^, hypodermically, 
 or nitro glycerin, gr. TUTrVir"^^- every three or four or five hours. In 
 many cases the use of gr. ^jj^ of this powerful drug, three or four 
 times a day for a long time, lessens not only the frequency but the 
 severity of the paroxysms. 
 
DISEASES OF THE NERVOUS SYSTEM. 297 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 CONGESTION OF THE BRAIN. 
 
 Synonyms. Cerebral hyperemia ; cerebral congestion. 
 
 Definition. An abnormal fullness of the vessels (capillaries) of 
 the brain ; active, when arterial fullness ; passive, when venous full- 
 ness ; characterized by headache, vertigo, disorders of the special 
 senses, and if the hyper^emia be decided, convulsions. 
 
 Causes. Active. Increased cardiac action, the result of hyper- 
 trophy of the left ventricle ; general plethora ; excesses in eating and 
 drinking ; alcoholism ; sunstroke ; prolonged mental labor ; dimin- 
 ished amount of arterial blood in other parts, the result of the com- 
 pression of the abdominal aorta ; ligation of a large artery, and th e 
 suppression of an habitual bleeding hemorrhoid are examples. 
 
 Passive. Dilatation of the right heart ; pressure upon the veins 
 returning the cerebral blood. 
 
 Pathological Anatomy. The post-7nortein appearances are, 
 overloading of the venous sinuses and of the meningeal vessels, 
 including the finer branches ; the pia mater appears vascular and 
 opaque ; the gray 7natter of the convolutions unduly red ; the convo- 
 lutio7is may be compressed and the ventricles contracted, with the 
 displacement of a corresponding amount of cerebro-spinal fluid. 
 
 Long-continued or repeated congestions lead to enlargement and 
 tortuosity of all the vessels, a moist and slimy condition (oedema) 
 of the cerebral substance, and an increase in the sub-arachnoid 
 fluid. 
 
 Symptoms. "Rush of blood to the head" maybe gradual or 
 sudden in its onset, the symptoms aggravated by the recumbent 
 position. Headache, with paroxysmal neuralgic darts, disorders of 
 vision and hearing, buzzing in the ears and sparks before the eyes, 
 contracted pupils, vertigo, blunted intellect, inability to concentrate 
 the mind, irritable temper and curious hallucinations. The face is 
 red, the eyes congested, and the carotids pulsating. The sleep is dis- 
 turbed by dreams and jerkings of the limbs. If the attack be sudden 
 (apoplectiform), sudden unconsciousness with muscular relaxation 
 occur. 
 
 Cerebral hyperaemia in children often presents alarming symptoms, 
 
 25 
 
298 PRACTICE OF MEDICINE. 
 
 such as great restlessness^ insomnia, night terrors, gnashing of the 
 teeth during sleep, vomiting, contraction of pupils followed hy general 
 convulsions. Any or all of these symptoms may continue more or 
 less marked from an hour or two to a day, the child enjoying its usual 
 health after a sound sleep, save some fatigue. 
 
 Prog"nosis. Mild cases terminate favorably in a few hours to a 
 day or two, but show a strong tendency to recur. Severe cases (apo- 
 plectiform) may termmate in health, but usually foretell cerebral 
 hemorrhage. 
 
 T\i& passive form is controlled by the lesions giving rise to it. 
 
 Treatment. Active form. Remove the cause if possible. Elevate 
 the head and apply cold, either cold cloths or the ice cap, at the same 
 time warmth to the feet. Leeches to the mastoid, or cups to the neck, 
 or in the apoplectiform variety venesection, to diminish the intercranial 
 blood pressure ; compression of the carotids, or ligatures about the 
 thighs, have been recommended. 
 
 An active purgative or an enemata of water and vinegar is also 
 indicated, to lessen the vascular tension. 
 
 In mild cases the application of cold 2ind potassii bromidiim, gr. 
 xxx-xl, repeated, controls the congestion; extraction ergota fluidwn 
 is often beneficial ; in more severe cases any or all of the above-men- 
 tioned means, together with full doses of tinctura veratri viridis or 
 tinctitra aconiti, may be needed. 
 
 Passive form. Becomes a part of the treatment producing the 
 
 hyperaemia. 
 
 «» 
 
 CEREBRAL ANEMIA. 
 
 Definition. An abnormal decrease in the quantity of blood in the 
 cerebral vessels ; general, when the diminished supply includes all the 
 vessels ; partial, when the diminished supply is limited in area ; char- 
 acterized by pallor, headache, vertigo, some loss of power, and, rarely, 
 convulsions. 
 
 Causes. Partial cerebral anaemia results from obstruction of a 
 vessel, from embolism or thrombosis. General cerebral anuimia 
 results from hemorrhages, wasting diseases, during convalescence 
 from severe attacks of fevers, sudden shock, feeble cardiac action and 
 general anaemia. 
 
 Pathological Anatomy. The cerebral vessels contain less 
 blood than normal ; the brain is pale and milky in color, and on 
 
DISEASES OF THE NERVOUS SYSTEM. 299 
 
 transverse section there are no bloody points ; the ventricles and 
 perivascular lymph spaces are well filled with fluid. 
 
 In partial anaemia the local conditions differ somewhat from the 
 above. 
 
 Symptoms. General anainia ; headache, relieved by the re- 
 cumbent position ; vertigo, aggravated by exertion ; general pallor 
 and anaemia, with attacks oi fainting ; when the general cerebral 
 anaemia is sudden and decided, convulsions occur. 
 
 Partial an OB mia ; sudden loss of power, of a limited muscular area, 
 gradually returning to the normal condition. 
 
 Prognosis. Favorable in all cases save those the result of severe 
 and repeated hemorrhages. 
 
 Treatm.ent. Regulated nourishment, with stimulants. A certain 
 number of hours daily in the recumbent position is of advantage. 
 When a tendency to attacks or swooning exists, stimulants or even the 
 cautious inhalation of amyl nitris are indicated. To improve the 
 quantity or quality of the blood — 
 
 ^ . Tinct. ferri chlor., rr^xv 
 
 Acid, phosph. dil., IT^v 
 
 Liq. Arsenic! chloridi, ITj^iij 
 
 Syr. limonis, 'tTLxx 
 
 Syr. zingiberis, q. s. ad . . ^ij. M. 
 
 SiG. — Every six hours, well diluted. 
 Or— 
 
 R- Extracti erythroxyli cocoae fld., f^ss 
 
 Vini albifort., f 3 ss. M, 
 
 SiG. — One hour after meals. 
 
 CEREBRAL THROMBOSIS AND EMBOLISM. 
 
 Synonym.s. Partial cerebral anaemia ; occlusion of cerebral ves- 
 sels ; cerebral apoplexy (?). 
 
 Definition. The occlusion of a cerebral vessel, from the forma- 
 tion of a //^r^;;2/5z/.y, or the presence of an embolus, thus Z2i.ViS\x\g ajicFviia 
 of some portion of the brain ; characterized by — the gradual, when the 
 result of thrombosis, and the sudden, when due to embolism — devel- 
 opment of headache, vertigo, disorders of intelligence, with more or 
 less complete insensibility and paralysis. 
 
 Causes. Thrombosis, or the formation of a clot in the vessel — 
 an ante mortem coagulation — is almost always the result of chronic 
 
300 PRACTICE OF MEDICINE. 
 
 endarteritis, as seen in the aged, together with a slowing and weaken- 
 ing of the blood current. Chronic alcoholism and syphilis are the 
 usual causes of cases occurring in young adults. 
 
 Emboli, in the great majority of cases, results from an endocarditis 
 — cardiac emboli ; small particles of the exudation are carried into the 
 circulation and are deposited in the brain. Emboli may also be 
 derived from aortic aneurism, or syphiloma of the great vessels. 
 
 Patholog'ical Anatomy. The cerebral arteries may be 
 obstructed by emboli or thrombi ; the cerebral veins and sinuses by 
 thrombi only. The changes in the cerebral tissue are those of anae- 
 mia of the part or parts supplied by the occluded vessels. The sub- 
 sequent changes depend upon the anatomy of the vessels. If the 
 obstructed artery has anastomoses, the collateral circulation is soon 
 established and the brain tissue assumes its normal condition. If, on 
 the other hand, the occluded vessel be one of " Cohnheim's terminal 
 arteries " — arteries without anastomoses — the blood in the whole extent 
 of the occluded vessel coagulates, thus preventing the backward flow 
 of blood from the surrounding capillaries and so obstructing collateral 
 circulation, whence the anaemic tissue dies or undergoes necrobiosis, 
 followed by yellowish-white softening ; or, if the vessel beyond the 
 seat of the occlusion remains pervious, blood flows back through the 
 capillaries from the nestrest artery or vein ; the parts that a short time 
 before were bloodless now become deeply engorged, the succeeding 
 changes in the vessels permitting diapedesis of the red blood globules ; 
 the tissues which are undergoing disintegration are colored by the 
 red globules, causing the appearances entitled "red softening," which 
 after some weeks becomes " yellow softening," finally changing to 
 " white softening," when there is a milky, or rather creamy, fluid 
 mixed with masses or particles of broken-down nerve elements. 
 
 The vessel most commonly occluded is the left middle cerebral 
 artery, which sends branches to the second and third frontal convolu- 
 tions, the anterior and superior portions of the three temporal convo- 
 lutions, the island of Reil, the parietal convolutions, part of the 
 external and all of the internal capsule, the lenticular nucleus, and 
 most of the corpus striatum, — the motor cejitres. 
 
 Symptoms. Two distinct modes of onset; gradual, when the 
 result of thrombosis ; sudden or apoplectic, when due to embolism. 
 
 Cerebral thrombosis. Most common in the aged. Persistent /ztv?^- 
 ache and vertigo, at one time severe and at another mild. Next, 
 
DISEASES OF THE NERVOUS SYSTEM. 301 
 
 alterations of the patient's character, irritable, morose and despondent, 
 with periods oi absent-mindedness, disorders of vision and impair7ne7it 
 of memory , speech becoming hesitating and mumbling. Unpaired loco- 
 motiojt, the result of the vertigo, and of muscular weakness and 
 trembling, followed sooner or later by hemiplegia, which may be pre- 
 ceded by sudden insensibility or occur gradually, the symptoms slowly 
 proceeding to senile dementia and death from exhaustion ; or rarely, 
 the symptoms are not so grave, and partial or complete recovery 
 occurs after the hemiplegia from establishment of the " collateral 
 circulation." 
 
 Cerebral embolism. The symptoms are sudden, but either mild or 
 grave in character. 
 
 Mild variety : sudden and severe vertigo, confusion of mind, mus- 
 cular twitchings, usually one-sided, and vomiting, followed by hemi- 
 plegia, most frequently of the right side, the intellect clear but hesi- 
 tating. After some weeks or months the paralysis usually disappears 
 and recovery is complete. 
 
 Grave or apoplectic variety. Sudden headache, vertigo, flushing 
 ox pallor of \kvQface, or the patient may utter a sharp cry, fall to the 
 ground with sudden unconsciousness and complete muscular resolution, 
 followed by death, or a gradual return of consciousness with hemi- 
 plegia, which is generally right-sided, remaining for several weeks or 
 months, or is persistent, the 7nind remaining normal or enfeebled and 
 the em,otional nature highly excitable and the reason and judgment 
 clouded, continuing thus for years, or gradually developing into 
 dementia, exhaustion and death. 
 
 Duration. Thrombosis, essentially an affection of the elderly, has 
 a chronic course. Months or years may be occupied with the various 
 symptoms until the phenomena of senile dementia develop. 
 
 Embolism is of sudden onset, and may be followed by a rapid 
 recovery. 
 
 Diagnosis. Thrombosis is associated with changes in the vessels, 
 the arcus senilis and other evidences of senile degeneration. 
 
 Embolism may be mistaken for cerebral apoplexy, and while a 
 positive differentiation cannot always be made,' the chief points will 
 be considered when discussing that affection. 
 
 Prog'nosis. Thrombosis is a perm.anent and progressive condition 
 in the majority of instances. Recovery is a rare termination. 
 
 Embolism may be followed by a perfect recovery. Usually, how- 
 
302 PRACTICE OF MEDICINE. 
 
 ever, some evidences of the plugging remain permanently. Death 
 may be the result within a day or two, from the plugging of a large 
 vessel, the patient never emerging from the coma. In other cases the 
 patient arouses from the coma, the hemiplegia with aphasia persisting, 
 and the case pursues the usual course of localized cerebral softening. 
 
 Treatment. The indications in the early stage of embolism and 
 thrombosis is the reestablishment of the circulation within the district 
 deprived of blood-supply, in order to prevent the changes incident to 
 defective nutrition ; this is accomplished by means to strengthen the 
 heart's action, tonics, perfect rest for some time after the attack, a 
 plain but nutritious diet, and attention to the various excreta. 
 
 Prof. Bartholow "has had remarkable results from the following 
 plan of treatment in thrombosis:" Aminonii carbonas, gr. x, with 
 ammonii iodidi, gr. v, three times a day, continued for several months, 
 " the object being dual — to increase the action of the heart and arte- 
 ries and to effect a solution of thrombi forming by maintaining the 
 alkalinity of the blood." 
 
 In the aged, presenting indications of degeneration, much benefit 
 results from the use of — 
 
 IJk . Liquor potassii arsenitis, ■n^iij-v 
 
 Syr. calcii lacto-phosphat., ,^j~y- ^• 
 
 SiG. — After meals. 
 It may be combined with oleiun morrhucE with decided advantage. 
 For embolism, the immediate and persistent use of the following 
 may dissolve the plug: — 
 
 li . Ammonii carbonat., gt"* v 
 
 Liquor ammonii acetatis fgj- M* 
 
 SiG. — Tliree or four times daily. 
 " In a month or two a very light galvanic current (from two cups) 
 may be passed through the brain in both directions." (Bartholow.) 
 
 CEREBRAL HEMORRHAGE. 
 
 Synonym. Apoplexy. 
 
 Diagnosis. The sudden rupture of a cerebral vessel and escape 
 of blood into the cerebral tissue, causing pressure and more or less 
 destruction of the brain substance ; characterized by sudden uncon- 
 sciousness, irregular, noisy respiration and complete muscular relaxa- 
 tion. 
 
DISEASES OF THE NERVOUS SYSTEM. 303 
 
 Causes. Rare under forty years of age. The principal cause is 
 'disease of the vessels — a periarteritis, resulting in miliary aneurisms, 
 and especially if associated with cardiac hypertrophy ; hereditary 
 tendency ; Bright's disease ; syphilis ; gout. More frequent in the 
 spring and autumn. 
 
 Pathological Anatomy. The most common locations of cere- 
 bral hemorrhage are the corpus striatum and thalamus opticus ; less 
 common the anterior and middle lobes and the cerebellum ; next in 
 frequency the p07is and medulla oblongata ; and rarely on the con- 
 vexity of the brain, termed meningeal \i^xn.oxx\\2.g&. 
 
 When the hemorrhage is large, the blood may break into the ven- 
 tricles and pass by the iter from the third to the fourth ventricle. 
 
 A recent clot is dark in color, and in consistency a soft, grumous 
 mass, composed of coagulated blood and brain substance in varying 
 proportions, at whose centre is the opening into the ruptured vessel. 
 The <r/(9/ excites inflammation around it, resulting in its being encysted, 
 by the development of new connective tissue from the neuroglia, and 
 then gradually absorbed, leaving a cicatrix, or the brain tissue around 
 the clot softens and degenerates — localized softening. 
 
 Sjnnptoras. Two modes of onset, to wit: with and without /r^- 
 dromes or "warnings." 
 
 Prodromes. Headache, vertigo, transient deafness or blindness, 
 sensations of numbness of the extremities, with local palsies, together 
 with the constant dread of an attack. 
 
 The attack begins with vomiting, followed by either partial or com- 
 plete insensibility ; respiration slow, irregular and noisy ; during the 
 inspiration the paralyzed cheek is drawn in, and puffed out in expira- 
 tion ; pulse slow and full ; pupils uninfluenced by light, the face 
 flushed, the eyes congested and the carotids throbbing ; the tempera- 
 ture declines below the normal a degree or two. 
 
 The muscular system is profoundly relaxed, and the reflex move- 
 ments are abolished. The head and eyes deviate, in many cases, 
 toward ih.^ affected side in the brain or from the paralyzed side. 
 
 If the unconsciousness continues longer than twenty-four hours, 
 death is the usual termination, preceded by pale face, irregular and 
 rapid pulse and respiration, and rise of temperature. 
 
 Reaction obtains in from a half to three hours, consciousness re- 
 turning, reflex excitability reviving, associated with headache, con- 
 
304 PRACTICE OF MEDICINE. 
 
 fusion of mind, and more or less paralysis of motion and sensibility 
 of one side of the body, termed — hemiplegia. 
 
 The electro-excitability of the paralyzed parts is preserved. 
 
 Restoration may be delayed by inflammatory symptoms, the tem- 
 perature rising to ioi°-io4° F., with tonic contractions {early rigidity) 
 of the paralyzed muscles and severe neuralgic pains. 
 
 Sequelae. Paralysis of the muscles of the face, tongue, body and 
 extremities of one side, opposite to the location of the hemorrhage, 
 termed unilateral paralysis or right or left hemiplegia. 
 
 Paralysis of both sides of the body, due to simultaneous hemorrhage 
 on both sides, termed bilateral hemiplegia. 
 
 Paralysis oi one side of the face and the extremities of the opposite 
 side, due to hemorrhage into the pons varolii, termed alternating ox 
 crossed paralysis. 
 
 Occasionally tonic contractions occur in muscles long paralyzed, 
 termed late rigidity, and is evidence of a secondary degeneration of 
 the nerve fibres. 
 
 Choreic movements in paralyzed muscles are termed post-hemi- 
 piegic chorea, due, according to Charcot, to changes in the motor 
 centres. 
 
 The mental powers are always more or less permanently impaired, 
 the patient irritable and emotional, and the same holds good concern- 
 ing the niemory. 
 
 Diagnosis, hisensibility from drink differs from apoplexy in the 
 following points, to wit : insensibility is not so complete, no drawing 
 in and puffing out of one cheek with respiration, the pulse frequent 
 instead of slow, the pupils influenced by light ; upon raising both legs 
 no difference is apparent on allowing them to drop ; the eyes and head 
 are not turned to one side, and lastly, the condition is ameliorated on 
 the inhalation of ammonia. I have satisfactorily used Dr. von Wede- 
 kind's test for temulence, to wit : " By simply pressing on the supra- 
 orbital notches with a steadily increasing force you may, with certainty 
 of success, bring an unconscious alcoholic to his senses, and thus dif- 
 ferentiate between alcoholic and other comas." 
 
 Opium poiso7iing differs from apoplexy by the gradual approach of 
 the coma, and that the patient can be momentarily aroused, and also 
 by the absence of the heavy stertor of apoplexy. 
 
 Urcemia causes a coma that closely resembles apoplexy. A history 
 
DISEASES OF THE NERVOlJS SYSTEM. 305 
 
 of Bright's disease at once clears up the case ; again, uraemic coma is 
 always preceded by convulsions, and has a continued depressed tem- 
 perature. 
 
 Cerebral embolism cannot always be differentiated from apoplexy. 
 We may suspect cerebral plugging, if the patient be young ; if he be 
 laboring under acute, subacute or chronic valvular trouble ; if, within 
 brief periods, several incomplete attacks have occurred before a com- 
 plete comatose condition obtains; or, if hemiplegia results with pass- 
 ing or slight consciousness ; or, if the phenomena are sooner or 
 later followed by cerebral softening, as embolism and thrombosis are 
 the most common causes of softening. 
 
 Syncope or a fainting-fit is of sudden onset, but being due to a 
 failure of the circulation, the pulse is feeble, the face pale, the respi- 
 ration quiet, and the duration of unconsciousness short, all the very 
 opposite of an apoplectic attack. 
 
 Prognosis. If the patient survive the immediate effects of a 
 cerebral hemorrhage, he is always in danger of a new attack, since 
 the causes of the original attack still remain. Another attack or two 
 is the usual course, a fatal termination ultimately occurring. 
 
 The hemiplegia is uncertain ; a partial recovery may occur within 
 a few months, or it may continue for years.- 
 
 Treatment. If there are prodromal indications, the most prompt 
 means of reducing the intra-cranial blood pressure is by ve7iesectio7i, 
 followed by a brisk purgative ; if the patient be weak, however, leeches 
 to the mastoid, and potassii bromidum, gr. xl-lx, or extractu7n ergota 
 fiuidiim, f^ss-j, may be substituted. 
 
 For the attack, loosen clothing, elevate the head, remove constric- 
 tions, place in a cool room, have perfect quiet, placing the patient 
 sufficiently on his side, with the face somewhat downward, for the 
 tongue and palate and secretions to fall forward instead of backward 
 into the pharynx, and at once venesection, cold to head, a mustard 
 footbath, and oleum tiglii, gtt. j-iij, with glycerinum, gtt. xv, placed 
 on back of tongue ; if the pulse be full and strong, when conscious- 
 ness is regained, either tinctura veratri viride or tinctura aconiti 
 is indicated. 
 
 If during the attacks ih.&face be pallid and the pulse irregular, the 
 patient is prostrated by the shock and stiimilants and digitalis are 
 indicated, with, perhaps, leeches to the mastoid and an enema of 
 terebinihina. 
 
306 PRACTICE OF MEDICINE. 
 
 For the secondary fever, either iinctura aconiti or tinctura veratri 
 viyide ; for the headache and dehrium, camphorcE bromidian. 
 
 For promoting the absorption of the clot, keep the secretions active, 
 a good diet and a course oi potassii iodidiim or hydrargyri chloridum 
 corrosivum, alternated with — 
 
 R. Liq. potassii arsenit., gr. v 
 
 Syr. calcii lacto-phosph., fSU- 
 
 Three times a day. 
 
 After two or three months a weak galvanic current appHed directly 
 to the brain, by placing an electrode on each mastoid process, pro- 
 motes absorption. 
 
 For the paralyzed muscles, the faradic current applied by placing 
 one electrode over or near the nerve innervating the muscle and the 
 other over its belly, acts as a tonic, preventing wasting ; it is assisted 
 by hypodermic injections of strychnifice sulph., gr. -^^ three times a 
 week. 
 
 ACUTE MENINGITIS. 
 
 Synonyms. Cerebral fever ; arachnitis. 
 
 Definition. An acute inflammation of the cerebral pia mater and 
 arachnoid me7nbranes ; characterized by headache, chill, fever, deli- 
 rium, and followed by symptoms of general collapse. 
 
 Causes. Cerebral overwork ; prolonged wakefulness ; acute alco- 
 holism ; exposure to the sun ; disease of the internal ear ; erysipelas ; 
 secondary,to disease of serous membranes, and the continued and 
 eruptive fevers. Most frequent in early adult life and in young chil- 
 dren, and in males rather than females. 
 
 Pathological Anatomy. The inflammatory changes may be 
 limited either to the convexity or to the base of the brain. 
 
 Intense hypercEmia of both membranes, followed by a purulent and 
 fibrinous exudation. The ventricles may be filled with fluid, com- 
 pressing and flattening the convolutions. 
 
 Symptoms. Vary according to the stages: — 
 
 Prodromes ; headache, vertigo, cerebral vomiting, more or less 
 feverishness, continuing from a few hours to one or two days, when 
 occurs the 
 
 Stage of Invasion ; onset sudden, with chill, \\\g\\ fever, io3°-io4°, 
 pulse 100-I20, face flushed, with congested eyes^ headache, ringing in 
 
DISEASES OF THE NERVOUS SYSTEM, 307 
 
 the ears, photophobia, vertigo, the nausea aggravated, and projectile 
 vomiting. 
 
 Stage of Excitement ; general sensibility of the body increased, 
 sensitiveness to light, and acuteness of hearing, delirium furious, 
 often resembling insanity, continual jerking of the limbs, oscillations 
 of the eyeballs, twitching of the muscles of the face, followed by 
 powerful contractions of the flexor muscles, even to the extent of 
 opisthotonus, and in children convulsions. Duration, from one day 
 to a week or two. 
 
 Stage of Depression or Collapse ; the patient gradually becomes 
 more quiet ; the delirium subsides, as well as the muscular agitation ; 
 sofnnolence occurs, passing into coma, at times temporary conscious- 
 ness, coma soon following again ; pulse irregular and s\o\f, fever less ; 
 various palsies, to wit : strabismus, ptosis, pupils uninfluenced by lighti 
 mouth drawn to one side, urine and faeces involuntarily discharged. 
 Death following, either by convulsions or by deepening coma. 
 
 Diag'nosis. Cerebrospinal fever closely resembles acute menin- 
 gitis, the points of distinction between which are the first named 
 occurring epidemically, associated with marked spinal symptoms and 
 an eruption. 
 
 The cerebral symptojns of rheumatism are differentiated from idio- 
 pathic meningitis by the association of the joint trouble. 
 
 Cerebral sympto7ns of typhoid and typhus fever have a close resem- 
 blance to idiopathic meningitis, and are only determined by a study 
 of the clinical history. 
 
 In acute urcemia the face is turgid, with puffiness of the eyelids ; in 
 meningitis the face is pale and no cedema ; uraemia has decided albu- 
 minuria ; it is slight or absent in meningitis ; meningitis has chills 
 followed by fever ; ursemia has not. 
 
 In delirium tremens the delirium is a busy one, the patient imagin- 
 ing persons and animals around him, and is wild in his gestures and 
 utterances ; the temperature is normal or subnormal, the skin wet 
 and clammy. In meningitis the delirium is mild but incoherent, the 
 surface is hot and dry, and there is severe vomiting and headache. 
 
 Prog'nosis. Not very favorable. If recognized early and treated, 
 a fair number of recoveries occur, but it usually leaves the patient 
 subject to attacks of epilepsy or with a persistent headache. 
 
 Treatment. Must be prompt and energetic from the onset. 
 
 At once, active purgation by oleum tiglii, gtt. \], glycerinum, X(\y, 
 
308 PRACTICE OF MEDICINE. 
 
 dropped on the tongue ; and if the urinary secretion be scanty, dry 
 cups or digitalis poiiltices ov^er the kidneys. 
 
 In vigorous subjects a copious vejiesection or leeches applied behind 
 the ears, to the temples, or the nuchal region, followed by the appli- 
 cation of cold to the head, and that it may be thoroughly applied, the 
 head should be shaven. 
 
 Control the active circulation by aconitum in full doses, frequently 
 repeated, combined -^AxSx potassii bromidum, gr. xx-xl, or use extrac- 
 tiim ergotce flitiduvi, foss-j every few hours. The cerebral circulation 
 may be markedly influenced by compression of the carotids. 
 
 The apartment should be cool, the air pure, the patient's head 
 elevated. The diet should be nutritious but easy of assimilation. 
 
 The secretions must be carefully watched, the catheter being fre- 
 quently used in the stage of collapse. 
 
 If the case show a disposition to linger, small doses of hydrargyri 
 chloridutn ynite or potasii iodidzim are of benefit. 
 
 Third stage: Free stinndation, nutritious ioo^,ferri iodidwn and 
 flying blisters. 
 
 PACHYMENINGITIS. 
 
 SjTTlonyrQS. Meningitis ; haematoma of the dura mater. 
 
 Definition. Inflammation of the dtira mater ; when the external 
 layer is primarily involved it is termed pachymenifigitis externa; 
 when the internal layer is primarily involved it is termed pachymen- 
 ingitis interna. 
 
 Causes. Pachytnetiingitis exterria is a surgical malady, excited 
 by fractures, penetrating wounds, and other injuries of the skull. 
 
 Pachymeningitis iftterna is due to blows upon the head without 
 injury to the skull. A predisposition may be created by chronic 
 alcoholism, scurvy, Bright's disease and syphilis. Chronic internal 
 otitis and suppurative inflammation of the orbit may cause it, also 
 inflammation in the venous sinuses the result of a thrombus under- 
 going suppurative changes. 
 
 Pathological Anatomy. Pachymeni?igitis interna. Hyper- 
 aemia of the membrane, followed by an exudation which develops 
 into a membranous new formation, containing a great number of 
 vessels of considerable size but having very thin walls. Hemor- 
 rhages from these new vessels are of frequent occurrence, which 
 increase the size and thickness of the neo-membrane. 
 
DISEASES OF THE NERVOUS SYSTEM. 309 
 
 The usual position of the neo-membrane or new formation is on 
 the upper surface of the hemispheres, extending downward toward 
 the occipital lobe. The changes in the adjacent portion of the brain 
 are dependent on the size and thickness of the neo-membrane. 
 Bartholow observed a case in which the "cyst" was half an inch in 
 thickness at its thickest part, and it depressed the hemisphere corre- 
 spondingly, the convolutions being flattened, the sulci almost obliter- 
 ated, and the ventricle lessened one-half in size. 
 
 In Pachymeningitis syphilitica, the pathological lesion is in the form 
 of gummatous tumors or masses which may degenerate and become 
 either cheesy masses or be converted into a purulent-looking fluid. 
 
 In old age the dura mater becomes thick, cartilaginous and of a 
 dull white color. The sheaths of the arteries are also thickened. 
 
 Symptoms. Very obscure ; principally those of cerebral pres- 
 sure. Cases of persistent headache, vertigo, photophobia, anorexia, 
 insomnia, gradual impairment of i7itellect and locomotion, followed 
 by delirium, and convulsions and coma, or by apoplectic attacks and 
 paralysis ; in the aged, or those in whom some one of the causes of 
 the affection are present, an inflammation of the dura mater may be 
 suspected. 
 
 Circumscribed painful oedema behind the ear and less fullness of 
 the jugular of the corresponding side, the phlegmasia alba dolens en 
 miniature of Griesinger, are indicative of thrombosis in the transverse 
 sinus, as was first shown by Virchow. 
 
 Diagnosis. Always problematical, as the symptoms are masked 
 and so obscure that a positive diagnosis is impossible. 
 
 Prognosis. Most unfavorable for either forms, although the course 
 of the malady is usually slow. Surgical treatment in traumatic cases 
 offers some hope. 
 
 Treatment. Pachymeningitis externa is to be treated surgically. 
 Trephining is indicated in some cases. It is claimed that benefit 
 has followed a thorough course of potassii iodidum. In the great 
 majority of cases, however, all that can be done is to treat symp- 
 toms. 
 
310 PRACTICE OF MEDICINE. 
 
 TUBERCULAR MENINGITIS. 
 
 Synon3mis. Basilar meningitis; acute hydrocephalus. 
 
 Definition. An inflammation of the membrane of the brain, 
 more particularly the basal pia mater, attended with or due to the 
 deposit of gray miliary tubercle ; characterized by gradual decline of 
 the bodily and mental powers. 
 
 Causes. Most frequently occurs in children between two and six 
 years of age, although numerous cases are reported occurring between 
 the ages of twenty and thirty years ; scrofulous diathesis ; inherited 
 diathesis. The "gelatinous children of albuminous parents," as the 
 phrase goes, possess a special susceptibility to tubercular meningitis. 
 
 Pathological Anatomy. The deposition of tubercle usually 
 occurs at the base of the brain. 
 
 Depositions of grayish-white granules, of a translucent, somewhat 
 gelatinous appearance — miliary tubercle, are distributed along the 
 vessels of the pia mater, resulting in inflammation and the exudation 
 of lymph, with the consequent thickening and opacity of the mem- 
 branes. 
 
 The cerebral tissue is not usually involved, although on section the 
 lines indicative of blood-vessels are very much increased in number. 
 The ventricles are distended by a clear, or milky, or even bloody 
 serum. 
 
 Tubercular deposits occur in the lungs, intestines, and, at times, in 
 other organs. 
 
 The presence of the tubercles alone may give rise to no symptoms 
 until the exudative products of the resultant inflammation develop. 
 
 Symptoms. The advent is either gradual and insidious, or with 
 convulsions, in which cases the after progress is rapid. 
 
 Prodromes : the child grows irritable, with loss of appetite, loss of 
 flesh, swollen abdomen, constipation alternating with diarrhoea, irreg- 
 ular attacks of feverishness, with attacks of grinding its teeth during 
 sleep or sleeplessness. Headache occurs, as shown by the child, even 
 when at play, suddenly stopping and resting its head on its hand or 
 on the floor. Duration of this stage is from one week to a month or two. 
 
 Stage of excitation : the onset is rather sudden, with obstinate 
 vomiting, severe headache, convulsions, fever, io2°-i03° in the even- 
 ing, falling to 99° in the morning, pulse soft and compressible, with 
 irregular rhythm. On drawing the finger nail lightly over the surface 
 
DISEASES OF THE NERVOUS SYSTEM. 311 
 
 a red line results, " the cerebral stain " of Trousseau. The symptoms 
 grow progressively worse with exaltation of the special and general 
 senses ; the least pinch or even touch causing exquisite pain ; spas- 
 modic movements of the muscles, with contraction and rigidity, at 
 times opisthotonus. Duration of this stage is about two weeks. 
 
 Stage of depression ; the result of the pressure of the exudation ; the 
 pulse slow and compressible with irregular rhythm ; temperature de- 
 pressed ; tendency to somnolence alternating with quiet delirium, 
 mental stupor, continual movement of the fingers, as in picking up 
 objects ; convulsions from time to time, strabismus, oscillation of the 
 eyeballs, followed by intervals of wakefulness, when the headache is 
 excruciating, causing the peculiar, unearthly shrill cry or shriek, " the 
 hydrocephalic cry," associated with contraction of the muscles of the 
 face, as if suffering were experienced; finally collapse, occurring with 
 the " Cheyne-Stokes " respiration, the co7na deepening, followed by 
 death, convulsions often ending the scene. Duration, from a day or 
 two to two weeks. 
 
 Diagnosis. Acute meningitis and tubercular meningitis have 
 closely analogous symptoms during the stage of excitation, but the his- 
 tory and clinical course of the two maladies determine the diagnosis. 
 
 Prognosis. Unfavorable. Usual duration, three or four weeks 
 after fully developed prodromes. If ushered in by convulsion the 
 duration is shorter. 
 
 Treatment. Most unsatisfactory. No means of retarding the 
 disease. Treat symptoms as they develop. Blisters, leeches, active 
 purgation, pustulating ointments, potassii iodidum and hydrargyrum, 
 are all useless. 
 
 If the hereditary tendency be marked, nutritious food, oleum 
 morrhucs, ferri iodidum and gui?tina may somewhat delay the 
 development of the affection. 
 
 ACUTE HYDROCEPHALUS. 
 
 Synonyms. Acquired hydrocephalus ; serous apoplexy. 
 
 Definition. Strictly speaking, hydrocephalus signifies water in the 
 brain ; but it is here restricted to the presence of a serous fluid in the 
 arachnoid spaces, in the pia mater, in the ventricles, and in the brain 
 substance (oedema) ; characterized by the more or less sudden develop- 
 ment of cerebral excitation, followed by depression and usually death. 
 
312 PRACTICE OF MEDICINE. 
 
 Causes. Most common between the ages of one and five, 
 although it may occur at any age. " The predominance of the ner- 
 vous system in the bodily conformation " is a strong predisposing 
 cause. Among the exciting causes are unfavorable hygienic condi- 
 tions, dentition, eruptive fevers, blows on the head, mechanical causes 
 preventing the return of the blood from the vena Galeni and the 
 right sinus, compression of the jugular vein, diseases of the right 
 heart, and Bright's disease. 
 
 Patholog'ical Anatomy. The effusion may be limited to the 
 ventricles, although there is usually considerable distention of the 
 subarachnoid spaces and oedema of the pia mater and neighboring 
 portions of the brain, whence results more or less softening, especially 
 around the ventricles. The choroid plexus is hyperaemic and may 
 be the seat of minute extravasations. 
 
 Symptoms. There are three varieties of acute hydrocephalus 
 with characteristic symptoms, to wit : comatose, co7ivulsive and the 
 ordi7iary. 
 
 Comatose variety, known also as "serous apoplexy," begins 
 abruptly with the phenomena of apoplexy, the result of the sudden 
 effusion. The pressure is usually so great on the medulla oblongata 
 that it ceases to functionate, death resulting in a few hours, rarely 
 lasting several days. 
 
 Convulsive variety, the result of Bright's disease or a general 
 dropsy, is ushered in with headache, nausea and vomiting, followed 
 in a day or two with convulsions, passing into coma, which usually 
 terminates fatally, although rarely a remission may precede death for 
 a day or two. 
 
 Ordinary variety, the most common in children, begins with fever- 
 ishness, headache, vertigo, photophobia, restlessness, nocturnal deli- 
 rium, insomnia, twitching and spasmodic contractions of the muscles 
 and great hyperaesthesia of the skin. Such symptoms continue for 
 several days, when convulsions occur, followed by death, or a con- 
 tinuance of the symptoms, followed by rigidity, stupor and death. 
 
 Prognosis. Unfavorable. 
 
 Treatment. An attempt may be made to remove the fluid by 
 diuretics and full doses of potassii iodidum. 
 
DISEASES OF THE NERVOUS SYSTEM. 313 
 
 CONGENITAL HYDROCEPHALUS. 
 
 Synonym. Chronic hydrocephalus (?). 
 
 Definition. An excessive accumulation of the cerebro-spinal 
 fluid — a cerebral dropsy — in the ventricles — internal hydrocephalus, 
 or in the meshes of the pia mater — external hydrocephalus, or in both 
 — mixed hydrocephalus ; characterized by enlargement of the head 
 and more or less pronounced nervous phenomena. 
 
 A disease of infants or very young children. 
 
 Causes. Imperfect or arrested development of the brain or its 
 membranes. Occurs in the offspring of tubercular, scrofulous or 
 syphilitic parents. Inflammatory changes in the ventricles and 
 ependyma. 
 
 Pathological Anatomy. Enlargement of the head is the chief 
 external pathological condition, although there is no constant ratio 
 between the size of the head and the amount of fluid, the quantity 
 varying from an ounce to a pint or more. The liquid is transparent, 
 of a straw color, containing a small amount of albumin and chloride 
 of sodium. 
 
 If the quantity of fluid be small the ventricles are simply distended, 
 if the amount be large the optic thalami and corpus striatum are 
 depressed and flattened, the roof of the ventricles thinned and the 
 foramen of Monro is greatly enlarged. The enlargement of the head 
 may occur before birth and impede or prevent natural delivery, or 
 the head may be normal at birth and increase after. As enlargement 
 progresses the bones are so thinned as to be translucent, the fonta- 
 nelles and sutures are widened, the lateral portions of the cranium pro- 
 ject, the forehead bulges out over the eyes, and the orbital plates are 
 depressed, forcing the eyes outward and downward, producing a 
 variety of exophthalmus ; the head has an irregular, triangular shape, 
 the base of the triangle being the top of the head. The scalp, being 
 stretched by the pressure within, becomes tense and thin and but 
 scantily covered with hair, the veins which ramify in it are unusually 
 prominent and large, and the entire head is elastic on pressure, from 
 the amount of liquid beneath. 
 
 Hilton, in Rest and Pain, says, " In almost every case of internal 
 
 hydrocephalus which I have examined after death I found that this 
 
 cerebro-spinal opening (between the fourth ventricle and the spinal 
 
 canal) was so completely closed that no cerebro-spinal fluid could 
 
 26 
 
314 PRACTICE OF MEDICINE. 
 
 escape from the interior of the brain ; and, as the fluid was being 
 constantly secreted, it necessarily accumulated there, and the occlu- 
 sion formed, to my mind, the essential pathological element of internal 
 hydrocephalus." 
 
 Symptoms. The increased size of the head, with the emaciated 
 condition of the child, who seemingly eats well, is what first attracts 
 the attention. The head appears too heavy, the eyes have a promi- 
 nent but downward direction, the face is devoid of expression, old 
 and wrinkled, the voice feeble ; the mental development is not in 
 comparison with the age. When the period for standing or walking 
 arrives the power is found wanting. The further history is but a 
 continuation and exaggeration of this, until co7ividsions occur, which 
 sooner or later terminate fatally. 
 
 The duration of congenital hydrocephalus is usually slow but pro- 
 gressively worse. The majority terminate within the first year ; cases 
 are recorded of ten and fifteen years' duration. 
 
 Diagnosis. In rachitis the volume of the head is increased, due 
 in part, at least, to a deposit of calcareous matter on the exterior of 
 the cranial bones. Rachitis may be mistaken for hydrocephalus in 
 cases in which the amount of liquid is small. The differential diag- 
 nosis is based on the shape of the head, round in rachitis, square or 
 triangular or with prominences in hydrocephalus ; with the persistent 
 downward direction of the eyes and the elasticity of the head on 
 pressure. 
 
 Prognosis. Unfavorable. Arrest of progress and even cures are 
 reported. Spontaneous cures are reported following the accidental 
 discharge of the fluid. But such reports are exceptional. 
 
 Treatm.ent. The use of the finest aspirator needle to evacuate 
 the fluid is fully justifiable. The proper situation for the puncture is 
 the coronal suture, about an inch or an inch and a half from the 
 anterior fontanelle. Firm but gentle compression of the cranium with 
 adhesive strips should be made during the escape of the fluid and 
 afterward. A few ounces of fluid only should be withdrawn at a time. 
 The internal use of potassii iodiduni is recommended. 
 
 All measures that tend to promote the constructive metamorphosis 
 are to be used. 
 
DISEASES OF THE NERVOUS SYSTEM. 315 
 
 CEREBRAL ABSCESS. 
 
 Synonym. Acute encephalitis ; suppurative encephalitis. 
 
 Definition. An acute suppurative inflammation of the brain 
 structure, either localized or diffused, primary or secondary ; charac- 
 terized by impairment of intellect, sensation and emotion. 
 
 Causes, Primary cerebral abscess is exceedingly rare. Pyaemia ; 
 g-landers : embolus from ulcerated endocarditis. 
 
 Secondary cerebral abscesses result from injuries to the cerebral 
 tissues, to wit: apoplexy, embolism, thrombosis, and injuries to the 
 cranial bones. 
 
 Pathological Anatomy. Abscess of the brain affects the left 
 side more frequently than the right. They are usually encysted or 
 inclosed in a limiting membrane. Abscess of the brain may be single 
 or multiple, varying in size from an almond to an ^Z'g. 
 
 It occupies a limited and well-defined region of the cerebral tissue, 
 to wit : either corpora striata, optic thalami, gray matter of the cortex, 
 the cerebellum, or the white matter of the hemispheres. 
 
 " The initial stage at the site of the abcess is hyperasmia. Minute 
 extravasations take place (capillary hemorrhages), giving to the in- 
 flamed area a dark, reddish color, whence the term red softening. 
 Migration of white corpuscles, diapedesis of some red corpuscles and 
 exudation of serum holding albumin and fibre in solution, occur 
 simultaneously. The brain tissue, being soft and easily broken up, is 
 rapidly disassociated and its elements disintegrated, and in a short 
 time a soft, pultaceous, red mass results, which more and more as- 
 sumes a purulent character, becoming first reddish-yellow, then yel- 
 low or greenish-yellow, ultimately almost white. The injury caused 
 by an abscess is not limited to the portion of the brain inflamed, but 
 the neighboring territory is in the condition of collateral hypersemia 
 and cedema" (Bartholow). 
 
 Symptoms. A concise description of the symptoms of abscess 
 of the brain is very difficult, on account of the wide variations de- 
 pendent on its location, and also the difficulty of isolating it from the 
 affections to which it is secondary. 
 
 The onset varies according to the cause, although all cases are asso- 
 ciated with headache, irritative fever, persistent and spreading paraly- 
 sis, and convulsions. 
 
 If following apoplexy, thrombosis, or emboli, there occurs fever and 
 
316 PRACTICE OF MEDICINE. 
 
 delirium, the paralysis remaining and spreading with spasmodic con- 
 tractions of the affected muscles. 
 
 Occasionally cases run a chronic course, the onset rather insidious ; 
 dull, persistent headache, changed disposition, peevish, irritable, un- 
 reliable, with decline of moral sensibility ; easily fatigued by mental 
 work; inabilityto stand exertion; memory impaired; vertigo; dys- 
 pepsia, soon followed by slight palsies, which progressively increase, 
 becoming general, with involuntary discharges, death following from 
 exhaustion. 
 
 Diagnosis. A positive diagnosis is only possible by a close study 
 of the clinical histor}^ as the symptoms at times indicate meningitis, 
 cerebral congestion, epilepsy or cerebral tumor. 
 
 Prognosis. The usual termination is in death. The course de- 
 pends upon the character and extent of the injury, varying from a few 
 days to several months. 
 
 Treatment. Surgical treatment has been attended with marked 
 success in some cases of abscess of the brain, the withdrawal of the 
 pus being followed by recovery. For traumatic abscess the operation 
 of trephining is indicated. Symptomatic treatment for relief of the 
 various symptoms as they arise. 
 
 INTRA-CRANIAL TUMORS. 
 
 Synonym. Cerebral tumors. 
 
 DeJBLnition. Tumor of the brain is either a growth in the cere- 
 bral tissue, on the meninges, or in the vessels ; characterized by symp- 
 toms of pressure upon the brain structure. 
 
 Causes. Injuries to the head; syphilis; changes in the vessels ; 
 tubercle and cancer ; hereditary. 
 
 Pathological Anatomy. The size of tumors vary, and may 
 become as large as an orange before they will give rise to symptoms. 
 
 Tumors of the brain are of various kinds, to wit : vascular tumors 
 — aneurisms ; parasitic tumors — cysticercus ; diathetic tumors — tu- 
 bercle or syphilis ; accidental tumors — fibroplastic. 
 
 Whatever the character of growth, it produces irritation to the sur- 
 rounding parts, and by pressure, destruction of the tissues, or it in- 
 terferes with the arterial or venous flow. 
 
 Symptoms. Those common to tumors in general are, headache, 
 persistent and increasing in intensity, defects of vision, even blind- 
 
DISEASES OF THE NERVOUS SYSTEM. 317 
 
 ness, defects of hearing, taste and of speech, the result of paresis of 
 the vocal cords, vertigo, associated with nausea and vomiting ; con- 
 vulsions, epileptiform in character, usually limited to one side of the 
 body, occurring at regular intervals, or confined to the eyeballs or 
 one limb, with no loss of consciousness ; palsies, beginning first as 
 strabismus, ptosis and dilatation of the pupil^ of the facial muscles, 
 paraplegia and general hemiplegia ; defects of sensibility, to wit : 
 sensations of numbness, and coldness in the limbs and body. Oc- 
 casionally disturbances of equilibrium manifested by a tendency to 
 go backward or turn to the right or left ; intellectual faculties well pre- 
 served until late in the affection, when the memory becomes impaired 
 or lost for certain articles, and finally a gradually advancing imbecility. 
 
 Diagnosis. Rarely can a positive diagnosis be made. The fol- 
 lowing points will aid : long-continued, persistent headache, without 
 appreciable cause, epileptiform convulsions, unilateral, without loss 
 of consciousness, difficulty of vision, hearing and speech, associated 
 with nausea and vomiting, and local and general palsies. 
 
 The location of the tumor may be determined by the more or less 
 pronounced character of certain symptoms. 
 
 The diagnosis of the character of the growth can only be deter- 
 mined by a close study of the history. 
 
 Prognosis. Unless of syphilitic origin, unfavorable ; but it is to 
 be borne in mind that all syphilitic tumors of the brain do not have 
 a favorable termination. 
 
 Treatment. Unsatisfactory. Mostly symptomatic. As benefit 
 occasionally follows the use of potassii iodidum, gr. xx three times a 
 day, or ext. ergotcBfid., 3ss-j three times a day, continued until their 
 physiological effects are produced, these remedies should be used in 
 all cases, discontinuing them if no benefit follow. 
 
 The surgical treatm.ent of tumors of the brain was given a great im- 
 petus from the report of the case operated upon in the practice of 
 Hughes-Bennett. The surgical treatment is promising for the future. 
 
 APHASIA. 
 
 Definition. The inability to use spoken language or give vocal 
 utterance to ideas. 
 
 Ajnnesic aphasia, or loss of the memory of words by which ideas 
 are expressed. 
 
318 PRACTICE OF MEDICINE. 
 
 Ataxic aphasia, the inability to combine the different parts of the 
 vocal apparatus for vocal expression, although the memory of words 
 still remains, so that the afflicted person can write his ideas intelli- 
 gently. 
 
 Agraphia, the inability to recognize and make the signs by which 
 ideas are communicated in written language. 
 
 Amnesic agraphia, the inability to combine the muscular apparatus 
 — "writers' cramp." 
 
 Paraphasia, the mental state in which the wrong words are used to 
 express the idea. 
 
 Paragraphia, the state in which wrong or meaningless written signs 
 are used to express the idea. 
 
 Pathological Anatomy. The distinction between aphasia and 
 aphonia must be clearly determined. 
 
 Aphasia is not the result of any one specific lesion, but occurs dur- 
 ing the course of several, to wit : occlusion of certain cerebral vessels ; 
 cerebral hemorrhage ; cerebral abscess or softening ; meningitis ; 
 tumors ; mental or moral causes ; hysteria. 
 
 It is now almost definitely determined that lesions of the left middle 
 cerebral artery, island of Reil, third frontal convolution, and parts of 
 the corpus striatum, are associated in the production of aphasia. The 
 lesions are usually upon the left side of the brain, the aphasia being 
 associated with right hemiplegia. 
 
 Symptoms. The degree to which articulate language is im- 
 paired varies, from the loss of a few words to complete inability to 
 communicate ideas. The intellect does not suffer in proportion to the 
 loss of words ; for, showing the individual an article, while he may 
 miscall it, if you call it by name he will recognize it. This inability 
 to convey thoughts is a source of great mental suffering, in some 
 leading to a suicidal tendency. 
 
 A strange clinical fact is the strong tendency to profanity shown 
 by aphasic patients. 
 
 Diagfnosis. Aphonia, or loss of voice, should not be confounded 
 with aphasia, or the inability to remember words. 
 
 Paralysis of the tongue, or inability to move this organ, thereby 
 interfering with articulate language, should not be confounded with 
 aphasia, which, as a rule, is not associated with paralysis of the 
 tongue. 
 
 Prognosis. Controlled entirely by the cause. If the result of 
 
DISEASES OF THE NERVOUS SYSTEM. 319 
 
 congestion of the brain or a syphilitic tumor, the prognosis is favor- 
 able. If associated with hemiplegia the clot may undergo absorption, 
 and recovery follow. If associated with softening of the brain, how- 
 ever, the disease grows progressively worse. 
 
 Treatment. Depends upon the cause, which must be energeti- 
 cally treated, as the aphasia pursues a course parallel to the asso- 
 ciated malady. Cases not associated with cerebral softening have 
 regained the memory of words by a course of carefully conducted 
 speech lessons. 
 
 Cases of aphasia of sudden occurrence are strongly diagnostic of 
 injury due to a spicula of bone if a history of a head wound, or from 
 the pressure of a clot, and the operation of trephining will be of 
 benefit. 
 
 VERTIGO. 
 
 Synonym. Dizziness. 
 
 Definition. Vertigo or dizziness is a subjective state, in which 
 the individual affected, or the objects about him, seem to be in rapid 
 motion, either of a rotary, circular, or a to-and-fro kind. 
 
 Causes. The etiology of an attack of vertigo depends upon the 
 particular variety. 
 
 Ocular vertigo results from the paresis of one or more of the ocular 
 muscles, eye-strain or astigmatism. 
 
 Aural or Auditory vertigo, or Mtniere s diseases, results from disease 
 of the semicircular canals and cochlea. Meniere's disease properly 
 so called, is a sudden severe vertigo, the result of either a hemorrhage 
 or a serous or purulent exudation into the semicircular canals. 
 
 Gastric vertigo is the most common variety, and results from either 
 stomachic or intestinal dyspepsia, disordered hepatic function or consti- 
 pation. " The mechanism of the vertigo is complex. There are two 
 factors ; one consists in the toxic effect of the imperfectly oxidized 
 materials which accumulate in the blood ; the other is reflex. An 
 impression made on the end organs of the pneumogastric in the 
 stomach is reflected over the sympathetic ganglia." (Bartholow.) 
 
 Nervous vertigo is associated with migraine, sick or nervous head- 
 ache, and is also caused by physical or nervous excesses, also by the 
 immoderate use of tea, coffee, alcohol and tobacco. It is also a result 
 of many of the organic diseases of the brain. 
 
 Senile vertigo is the result of the disordered cerebral circulation 
 resulting from changes in the heart and vessels. 
 
320 PRACTICE OF MEDICINE. 
 
 Symptoms. In all varieties of vertigo the symptom of a sensa- 
 tion of objects moving around the patie7it or the patient moving 
 around objects which remain stationary is present in some degree. 
 The attack o{ giddiness comes on suddenly, with an indistinctness of 
 vision and slight confusion of the thoughts. The patient may fall 
 unless he grasps something to steady himself. Nausea and vomiti?ig 
 and cardiac palpitation with tinnitus aurium are often associated with 
 the vertiginous sensations. There is 7io loss of consciousness. 
 
 In the ocular vertigo the attack is usually the result of reading, 
 writing, sewing, or other close application of the eyes, the ordinary 
 symptoms of vertigo being preceded by headache, nausea, specks 
 before the eyes, and pain in the eyeballs. 
 
 In Meniere'' s disease the vertigo is associated with serious tinnitus 
 aurium and the vertiginous sensations being of various forms, such as 
 a see-saw movement, a gyratory motion, right or left; a vertical whirl, 
 or a sensation of rising and falling like unto the swell of the ocean. 
 The symptoms are of long duration, becoming marked in paroxysms. 
 The attack of aggravated vertigo is so sudden and overwhelming at 
 times that the person is suddenly thrown to the ground as if receiv- 
 ing a blow, associated with nausea and vomiting. As the condition 
 continues the character of the individual changes, becoming morose, 
 irritable and suspicious. 
 
 Not all cases of Meniere's disease become permanent, but it may 
 occur in isolated attacks, the interval being free from all sensations. 
 
 Gastric vertigo is by far the most frequent variety. Persons subject 
 to vertigo of this kind live in constant dread of cerebral disease, 
 which frequently results in true melancholia. 
 
 The vertiginous sensations usually occur during the course of well- 
 marked and long-standing stomach and intestinal disorders, such as 
 pain or oppression after meals, nausea, pyrosis, heartburn, frequent 
 eructations and constipated or rarely diarrhoea. The abdomen is often 
 distended with flatus. Great pain in the nucha is a very frequent 
 occurrence. The attack may be associated with either hypera^mia or 
 anaemia of the brain. The symptoms are not constant, but recur at 
 intervals, sometimes remote, at others very close on each other. 
 
 In nervous vertigo the vertiginous symptoms are usually associated 
 with more or less irritability of temper, restlessness and insomnia. 
 The onset is sudden, after some one of the etiological factors. In 
 megrim there is headache, nausea and vomiting. This form of vertigo 
 
DISEASES OF THE NERVOUS SYSTEM. 321 
 
 often precedes or replaces the epileptic convulsion, it also often pre- 
 cedes the softening of the brain. 
 
 In senile vertigo the vertiginous symptoms are the result of anasmia 
 of the brain. The attacks are developed by any exertion, often by 
 merely assuming the erect posture. There is a swimming sensation 
 in the head, darkness falls on the eyes with a sensation of chilliness 
 and prostration. 
 
 Diag'nosis. The diagnosis of the various forms of vertigo can 
 only be determined after a close study of the history and course of 
 the attack. The existence of organic cerebral disease must always 
 be kept in mind in solving any case. 
 
 Prognosis. This will be influenced by the variety of the vertigo. 
 The prognosis is favorable in ocular and gastric vertigo. Unless the 
 result of organic disease the prognosis is good in nervous vertigo. 
 In auricular vertigo the prognosis is fair, bui in genuine Meniere's 
 disease the prognosis is unfavorable, as it also is in senile vertigo. 
 
 Treatment. For ocular vertigo rest for the eyes and properly 
 adjusted glasses. 
 
 For cases of Meniere's disease rest in the recumbent position and 
 the use of full doses of quinina (grs. x to xv) daily for a long period, 
 as suggested by Charcot. 
 
 For gastric vertigo a careful regulation of the diet. At the begin- 
 ning of the treatment it is often of great advantage to place the 
 patient on an exclusively milk diet, gradually widening the variety as 
 improvement occurs. In these cases a course of arsenicum is often 
 serviceable. If the digestion is torpid, the use of iinctiira nucis 
 vornicis is indicated. If the bowels are constipated, benefit is obtained 
 from extractiim cascarcB sagradce Jiuidutn. 
 
 For nervous vertigo the removal of the exciting cause and the use 
 of such remedies 2.'=, ferriim , qnmiiia and strychnina, either alone or 
 variously combined. 
 
 For senile vertigo, a highly nutritious but easily digested diet, the 
 use of a good spiritus frunienti and a course of hydrargyri chloridum 
 corrosivum or arsenicum with tmctiira ferri chloridum. 
 
 MIGRAINE. 
 Synonyms. Megrim ; hemicrania ; sick-headache. 
 Definition. A unilateral paroxysmal pain in the head, periodical, 
 accompanied with nausea, often vomiting, intolerance of light and 
 27 
 
322 PRACTICE OF MEDICINE. 
 
 soiind and incapability of mental exertion, the brain for the time 
 being temporarily prostrated and disturbed. 
 
 Causes. In the majority of patients the nervous predisposition to 
 migraine is inherited, but whether inherited or acquired, it commonly 
 develops before the age of thirty. 
 
 Among the many exciting causes are disturbances of digestion, irri- 
 tation of the ovaries or womb, worry, exacting mental labor, sexual 
 excesses and insufficient sleep. The causes of many attacks, how- 
 ever, are wrapped in mystery. 
 
 Symptoms. Attacks of migraine occur in irregular paroxysms, 
 the intervals being free from pain or nervous disturbance. 
 
 For a day or two preceding the paroxysm, it will be ascertained, 
 on close questioning, that there was a feeling of fatigue without 
 apparent cause, heaviness over the eyes, with some flatulency and 
 indigestion. 
 
 The attack proper is ushered in by chilliness, nausea, often vomit- 
 ing, yawning and general muscular sore?iess, with intolera?ice of light, 
 and noises in the ears and incapability for menial exertion and pain 
 of a sharp, shooting character oi great ijitensity and persistency local- 
 ized most frequently in either the frontal, temporal or occipital regions 
 of the left side ; at the same time there is a tenderness over the whole 
 side of the head. Rarely the pain is felt on the right side and still 
 more rarely on both sides at the same time. The nausea and other 
 digestive symptoms may follow the onset of the pain instead of pre- 
 ceding it. 
 
 There is more or less disturbance of the circulation, temperature 
 and secretions of the affected parts. At times there is marked con- 
 traction of the vessels, when the face is pale, the eyes shrunken and 
 the pupils dilated ; again, the vessels may be dilated, when the face 
 is flushed, the conjunctivae injected and the pupils contracted. 
 
 Motion, sound and light aggravate the acute suffering. 
 
 The attack may continue with more or less intensity for a few hours 
 to two or three days, the average duration being twenly-four hours. 
 
 Diagnosis. The symptoms are so characteristic that an error 
 seems impossible. It may, however, be confounded with anaemic 
 headache, hyperiemic headache, dyspeptic or bilious headache and 
 neuralgic or rheumatic headache. 
 
 Prognosis. While few cases of true migraine arc permanently 
 cured, the affection is free from danger to life. In a fair number of 
 
DISEASES OF THE NERVOUS SYSTEM. 323 
 
 cases the susceptibility to attacks declines as the person advances in 
 years, it being rarely seen after fifty years. 
 
 Treatment. To abort an attack of migraine or dispel a paroxysm 
 after its onset, two remedies are almost infallible — one is a hypodermic 
 injection of niorphi7icz sulphas (gr. ^) with atropince sulphas (gr. y^^), 
 or antipyrine (gr. xx) repeated in an hour or two ; a large experience 
 with the latter convinces me that the sufferings of those subject to this 
 distressing malady is a thing of the past. A combination for attacks 
 associated with contracton of the vessels is — 
 
 R.. Potassii bromid., gr. xxx 
 
 Morphinse sulph., M^- X 
 
 vel 
 
 Codeinse sulph., gr. j 
 
 vel 
 
 Tr. opii deodorat., Tl^xxx 
 
 Aquae menth. p., ad f^ss. M. 
 
 SiG. — Repeated p. r. n. 
 
 In the intervals between the paroxysms measures to improve the 
 general system should be used, and to overcome as far as possible 
 any of the etiological factors in its production. 
 
 " If the disposition to the malady is inherited, the prophylaxis is 
 very important, and should include diet, exercise, clothing, and the 
 avoidance of all those conditions which tend to develop an abnormal 
 excitability of the nervous system. The best results have been ob- 
 tained from galvanization of the superior gangha of the sympathetic ; 
 the positive pole over the ganglion and the negative on the epigas- 
 trium in the tetanic (contracdon of vessels) form ; and the poles 
 reversed in the paralytic (dilatation of vessels) form." (Bartholow.) 
 
 ALCOHOLISM. 
 
 Varieties. Acute alcoholism ; chronic alcohohsm, 
 
 Synonynis. Acute variety, X.^x^ivXo.n'Cx^.', mania-a-potu. 
 
 Chro7iic variety, dehrium tremens ; dipsomania or oinomania. 
 
 It would hardly be correct to consider these terms interchangeable ; 
 they are rather names applied to various conditions due to acute or 
 chronic alcoholic poisoning. 
 
 Definition. Alcoholism is the term used to designate the physi- 
 cal and mental phenomena induced by the abuse of alcohol. 
 
 Temulentiay meaning drunkenness; mania-a-poiu is an acute 
 
324 PRACTICE OF MEDICINE. 
 
 mental derangement, occurring in those of strong neurotic tendencies ; 
 d€liriu))i tremens is an attack of delirium associated with tremors in 
 persons with the numerous changes resulting from chronic alcoholism ; 
 dipsomania or oinomania, an alcohol insanity in which an individual 
 at longer or shorter intervals has paroxysms of alcoholic desires, 
 between which he neither wishes nor craves alcohol. 
 
 Causes. Predisposing causes are influences arising from unfavor- 
 able moral, social and personal conditions. Heredity. 
 
 Exciting causes are the immoderate use of alcoholic beverages, of 
 which there are three groups : i, spirits, or distilled liquors ; 2, wines, 
 or fermented liquors, and 3, malt liquors. 
 
 Pathological Anatomy. Acute Alcoholism. The brain is the 
 seat of an active hyperiemia ; the mucous membrane of the stomach 
 and duodenum is markedly injected and covered with a ropy 
 mucus slightly tinged with blood, and the gastric juice is altered in 
 quality and quantity. The kidneys are also the seat of an active 
 hyperaemia. 
 
 Chronic Alcoholism. In this condition of the economy there are 
 no organs or tissues which do not present morbid changes. The 
 gastro-intestinal mucous membrane presents the changes of chronic 
 catarrhal inflammation ; the liver, the first organ to receive the poison 
 after the stomach, presents the changes of congestion, cirrhosis or 
 fatty degeneration ; the kidneys show chronic congestion and often 
 the changes incident to chronic interstitial nephritis ; the muscular 
 structure of the heart may undergo fatty degeneration and the vessels 
 the senile changes of the aged. The brain structure presents the 
 changes of sclerosis in various stages, and there may be chronic 
 meningitis and pachymeningitis with ha^matoma. The nerves are 
 altered, atrophied and hardened, and the neuroglia, vessels and 
 ganglion cells of the spinal cord show similar changes. 
 
 Symptoms. Acute alcoholism, resulting from the use of a large 
 quantity of alcoholic fluid, occurs with symptoms of mild intoxication, 
 to drunkenness passing to acute delirium and acute coma. The 
 condition begins with a period of exhilaration, passing to semi- 
 delirium, and ending in an acute coma, when the brcathini( is ster- 
 torous, the face bloated and congested, the lips swollen and purplish, 
 the pupils contracted, the pulse feeble and slow, the skin cold and 
 clammy, the temperature depressed and frequently co7itrol of sphincters 
 lost. An individual so affected is said to be " dead drunk.'' 
 
DISEASES OF THE NERVOUS SYSTEM. 325 
 
 The cases of ordinary drunkenness do not often pass beyond the 
 stage of exhilaration ending in a mild coma or sleep. 
 
 Mania-a-potu, or acute alcoholic delirium, is the direct result of 
 alcoholic excess in those engaged in a sudden debauch, or who have 
 drunk alcoholic beverages very " hard " for a comparatively short 
 period. The individuals grow more and more excitable, lose all 
 desire for food, are unable to sleep, become the prey of horrible 
 hallucinations — "the horrors" — finally terminating in mania which 
 resembles delirium tremens in all save the tremor, which is absent. 
 
 Chronic Alcoholism. The condition to which this term has been 
 given is truly a disease. It is the result of the continued use of alco- 
 holic beverages until one or more of the morbid organic changes 
 have occurred. These persons are markedly dyspeptic, with coated 
 tongue, fetid breath and early morning vomiting, straining or retch- 
 ing, attended with much distress. There is a gradually developing 
 muscular tremor, progressing to the ataxic gait, and insomnia. The 
 face may either become pallid, flabby and bloated with an imbecile 
 expression, or swollen, rough and dusky, with great bladders under 
 the eyes, with yellow injected conjunctivas. There is headache, 
 vertigo, and attacks of hallucinations ; the memory grows weaker, 
 the judgment less accurate, the moral sense blunted and the will 
 power weak and erratic. These and many other symptoms add to 
 the distress of the individual, which he attempts to overcome by the 
 use of more and more of the poison. 
 
 Delirium Tremens. In the majority of instances delirium results 
 from a prolonged debauch, in an old drinker. It begins by an in- 
 creased tremor, insomnia, irritable, excitable manner, followed by the 
 characteristic hallucinations and illusions, during which snakes and 
 all forms of repulsive reptiles are seen, causing the most intense hor- 
 ror and abject fear. There also occur illusions of smell and hearing. 
 This marked excitement is followed by great depression, the skin is 
 cold and clammy, the pulse feeble, the muscular system weak, the 
 mind in a condition of coma-vigil, and a febrile condition, typhoid in 
 character, develops. 
 
 The ordinary duration of an attack of delirium tremens is about 
 two weeks, although death may occur at any time from cardiac failure, 
 cerebral hemorrhage, or alcoholic pneumonia. Convalescence dates 
 from the beginning of refreshing sleep, the patient awakening with a 
 clear mind and desire for food. Should the delirium subside, but the 
 
326 PRACTICE OF MEDICINE. 
 
 patient continue to mutter and pick at the bed-clothing, the tongue 
 become dry and cracked and the regurgitation of dark brownish and 
 bilious matter occur, the condition is critical and an eariy fatal termi- 
 nation may be expected. 
 
 Dipsomania or oinomania is the inherited mental condition which 
 craves the drinking of intoxicating liquors. This is a true mental 
 disease. It manifests itself in periodical attacks of excessive indul- 
 ence in alcoholic drinking, or this symptom of this sad disease 
 may be replaced by other irresistible desires of an impulsive kind, 
 such as lead to the commission and repetition of various crimes, 
 the gratification of other depraved appetites, robbery, or even homi- 
 cide. 
 
 The paroxysms at first occur at long intervals, but gradually the 
 intervals become shorter and shorter until the individual entirely sur- 
 renders himself to alcoholic and other excesses. 
 
 Diagnosis. Profound drunkenness or alcoholic coma may and 
 often is confounded with apoplectic and uraemic coma. Von Wede- 
 kind suggests the following method for diagnosing drunkenness : 
 " By simply pressing on the supraorbital notches with a steadily 
 increasing force you may, with certainty of success, bring an un- 
 conscious alcoholic to his senses, and thus differentiate between 
 alcoholic and other comas." 
 
 The symptoms of chronic alcoholism often bear a close resem- 
 blance to the following maladies : general paralysis, paralysis agitans, 
 locomotor ataxia, cerebral and spinal softening, epilepsy, dementia 
 and nervous dyspepsia. 
 
 In individuals whose habits are secret the question of diagnosis is 
 attended with considerable difficulty. Anstie lays much stress upon 
 the importance of the following four points, diagnostic of chronic 
 alcoholism : insomnia, morning vomiting, m,uscular tretnor and 
 causeless inc7ital restlessness. 
 
 Prognosis. In acute alcoholism the prognosis is good if the 
 patient is manageable. 
 
 In chronic alcoholism the organic changes the direct result of the 
 alcoholic habit tend to shorten life by the production of fatty heart, 
 Bright's disease, insanity, impotence, epilepsy, melancholia and 
 organic brain diseases. The danger in delirium tremens is heart 
 failure of a deepening coma. Acute lobular pneumonia is a very fatal 
 complication of all forms of alcoholism. 
 
DISEASES OF THE NERVOUS SYSTEM. 327 
 
 Treatment. The treatment of a case of drunkenness requires 
 no consideration, as the rapid elimination of the alcohol soon occurs 
 if its ingestion be stopped. Liquor ammonii acetatis in large, frequently 
 repeated doses, assists the elimination of the poison. 
 
 For maiiia-a-potii the immediate and complete withholding of alco- 
 holic beverages is essential for its successful treatment. If the stom- 
 ach will tolerate food, and usually it will, milk, diluted with liquor 
 calcis, or seltzer water, or hot beef tea strongly seasoned with capsi- 
 cumi, should be frequently administered, together with such cerebral 
 sedatives diSipofassu bromiduni and chloral. If the attack be associated 
 with symptoms of cardiac depression, brisk frictions, artificial warmth, 
 stimulating enemata and hypodermic injections of niorphincB sulphas 
 (gr. ^ with atropiiicE stdphas (gr. j^q) or digitalis, are indicated. " If 
 chloral be inadmissible by reason of weakness of the circulation, 
 paraldehyde may be substituted, in doses of from half a drachm to 
 one drachm, repeated at intervals of from one to two hours until 
 quietude is produced." (J. C. Wilson.) 
 
 For the collapse following a lethal dose of alcohol, the stomach 
 should be immediately emptied by emetics or the stomach tube or 
 pump and the organ washed out with warm water or coffee, the patient 
 placed in the recumbent position and surrounded with artificial warmth, 
 hot frictions to the lower extremities, the use of artificial respiration 
 or the use of faradism to the thorax, inhalations of ammonia, hypo- 
 dermic injections of digitalis, strophanthus or atropia. "The flagging 
 heart may be stimulated by occasionally tapping the prsecordia with 
 a hot spoon — Corrigan's hammer." (J, C. Wilson.) 
 
 Chronic Alcoholis7n.—Th.Q combine of symptoms termed chronic 
 alcoholism are the direct result of the continuous action of a 
 single toxic principle, and no success of even a temporary kind can 
 be expected unless the poison be withdrawn. The rapidity with which 
 this can be accomplished is a question for the skill, judgment and 
 experience of the physician to determine ; the chief obstacle to its 
 success will be found moral rather than physical. Next to the disuse 
 of alcohol is the question of diet. Much progress will be made as 
 the appetite and digestion improve, and so great attention should be 
 given to it. The general health will also be benefited by fresh air, 
 exercise, mental occupation and cold or tepid sponging and an occa- 
 sional hot bath at bedtime. For the combination of symptoms of 
 spirit craving, morning vomiting, muscular tremor, mental restless- 
 
328 PRACTICE OF MEDICINE. 
 
 ness and insomnia, no drug is comparable with strycJinincE sulphas, 
 either hypodermically twice weekly or, what is preferable, per the 
 stomach to secure its local action on the mucous membrane. If the 
 insomnia be persistent, in spite of the foregoing treatment, the tempo- 
 rary use may be made of such remedies as chloral, inorphiiia, paralde- 
 hyde, or extractinn lupuli7i ethereal (gr. j-iij). In many cases it is 
 desirable, for its mental effect, if no other, to administer what the 
 patient terms a substitute for his alcoholic beverages. The following 
 is a good combination for that purpose : — 
 
 R. Tinctune nucis vom., _^ss 
 
 Tincturae capsici, 5j 
 
 Ex. lupulin rid., ^iij 
 
 Inf. gent, co., ^iss, M. 
 
 SiG. — Dessertspoonful three or four times daily. 
 
 For anaemia, loss of strength, and mental debility, benefit may 
 follow the use of syrupus hypophosphitis. 
 
 Delirium Tre?nens. — The patient should be isolated, have a skillful, 
 sensible nurse, the quantity of alcohol entirely withdrawn or greatly 
 reduced, supplied with easily digested nutritious diet, and remedies 
 used to combat the excited nervous system. For this latter purpose 
 no one combination is comparable with hypodermic injections of 
 morphincB sulphas (gr. X). with atropine? sulphas (gr. xTff)> repeated 
 p. r. n. ; chloral in the following combination also acts well, if the 
 stomach be not too irritable : — / 
 
 R. Chloral, "% 
 
 Tr. capsici, f.^ss 
 
 Aquse menth. p., f^^vss. M. 
 
 SiG. — Talilespoonful every two hours until sleep, alternated with a 
 cup of hot beef tea to which has been added a bolus of capsicum, 
 gr. XX. 
 
 Care is necessary that a condition of coma be not produced by the 
 remedies mentioned. 
 
 For depression and cardiac weakness the internal use of any one 
 of the following drugs is serviceable: Spiritus chloroformi, a7nmonii 
 carbonas, tinctura strophanthus, or digitalis. 
 
 Dipsomania. — The management of these cases is much the same 
 as has already been mentioned for chronic alcoholism, although the 
 strychnina treatment should be given the preference. 
 
DISEASES OF THE NERVOUS SYSTEM. 329 
 
 HEAT STROKE. 
 
 Synonyms. Insolation ; sun-stroke ; thermic fever ; coup-de- 
 soleil ; heat exhaustion. 
 
 Definition. A depression of the vital powers, the result of 
 exposure to excessive heat. The condition manifests itself as acute 
 meningitis (rare), heat exhaustion (common), and as true sun- 
 stroke. 
 
 Causes. Exposure to the influence of excessive heat, either to 
 the direct rays of the sun or artificial heat in confined quarters, or 
 diffused atmospheric heat without proper ventilation. 
 
 Among the predisposing causes, which act by lessening the power 
 of the system to resist the heat, are great bodily fatigue, overcrowding 
 and intemperance. 
 
 Pathological Anatomy. The action of the heat upon the 
 organism is so sudden, and the malady so rapid in its course, that 
 structural changes have not developed. The left ventricle is firmly 
 contracted (Wood). The right heart and vessels are gorged with 
 dark fluid blood. All the tissues and organs of the body are 
 in a stage of great venous congestion. The blood is dark, thin, 
 and either but feebly alkaline or decidedly acid, and its power of 
 coagulability is destroyed. The post-7nortem rigidity is early and 
 marked. 
 
 Symptoms. Depending upon the variety. 
 
 Acute Meningitis the result of exposure to heat is similar to that 
 due to other causes. 
 
 Heat-exhaustio7i develops with a rapid feeling of weakness and 
 prostration, the surface cool, the face pale, the voice weak, the pulse 
 rapid and feeble, the respirations increased, the vision growing dim 
 and indistinct, noises develop in the ears, the individual, overcome, 
 becomes partially or completely unconscious. In some cases the 
 attack of prostration is sudden, the person falling unconscious, with 
 perhaps convulsions or tremors, and shrunken features. 
 
 Sun-stroke. The symptoms, developing suddenly, with or without 
 prodromata, are, insensibility , with or without deliriufn, or convulsio?ts, 
 or paralysis, the surface flushed and hot, the conjunctiva ijijected, the 
 breathing either rapid and shallow or labored and stertorous, lYvepulse 
 quick and either bounding or weak, and the temperature in the axilla 
 ranging from 105°, to 108°, to 110°, with suppression of all glandular 
 
330 PRACTICE OF MEDICINE. 
 
 action. Death occurring, the result of asphyxia, or from a slow failure 
 of respiration and cardiac action. 
 
 Diagnosis. It is of great importance, therapeutically, to distin- 
 guish at once between attacks of sun-stroke and heat-exhaustion. 
 Cases of sun-stroke are to be differentiated from cerebral hemor- 
 rhage and alcoholic insensibility, for which purpose the clinical ther- 
 mometer is indispensable. 
 
 Prognosis. Attacks of heat-exhaustion, if properly and promptly 
 treated, favorable. The prognosis of sun-stroke or heat-fever is 
 unfavorable in the majority of cases, death resulting in from half an 
 hour to several hours. Unfavorable indications are, increased tem- 
 perature, cardiac failure, convulsions, absent reflexes, followed by 
 complete muscular resolution. 
 
 Favorable indications are, decline in surface heat and axillary or 
 rectal temperature, stronger pulse, increased depth of respirations, 
 restored reflexes, and return of consciousness. 
 
 Treatment. Cases of heat-exhaustion are successfully treated by 
 placing the patient in the recumbent position, with the head low, and 
 the use of stimulants. If able to swallow administer at once spiritus 
 vmi gallici, ^ss-j, with tinctura opii deodorata, n\^xx-xxx, to be 
 repeated p. r. n. ; if he be unable to swallow, the remedies may be 
 thrown into the rectum, ox spiritus frumenti and tinctura digitalis can 
 be used hypodermically. As convalescence occurs tonic doses of 
 quinines sulphas and strycJuiiiice sulphas should be prescribed. 
 
 For sun-stroke, the indications for treatment are the very opposite. 
 The patient is in imminent danger from the extraordinary tempera- 
 ture, and measures to reduce it must at once be instituted. Of these 
 none give such excellent results as rubbing with ice, or the cold bath 
 or cold pack, and cold effusions, cold enemata, and the hypodermic 
 use of quinince sulphas or antipyrine. The tendency to subsequent 
 rise of temperature is met by wrapping the patient in a wet sheet, or 
 the repetition of the hypodermics mentioned if consciousness has not 
 been regained, when they can be given by the mouth. If convulsions 
 and restlessness occur, the hypodermic use of morphince sulphas, gr. 
 y^-yi, cautiously repeated, is successful. If symptoms of depression 
 occur, the stomachic, rectal or hypodermic administration of stimu- 
 lants is indicated. 
 
 For convalescence, use quinince sulphas, strychnittCB sulphas or 
 ferrum. 
 
DISEASES OF THE SPINAL CORD. 331 
 
 DISEASES OF THE SPINAL CORD. 
 
 SPINAL HYPEREMIA. 
 
 Synonyms. Special congestion ; plethora spinalis. 
 
 Definition. An abnormal fullness of the vessels of the meninges 
 and cord ; active when arterial hyperasmia ; passive when venous 
 hyperemia ; characterized by pain in the back, with more or less pro- 
 nounced disorders of sensation and locomotion. 
 
 Causes. Cold and exposure ; arrested menses ; arrest of habitual 
 hemorrhoidal discharge ; malaria; protracted erect posture ; injuries 
 to the back ; certain spinal poisons, as strychnina, picrotoxinum, and 
 alcoholic excesses. 
 
 Pathological Anatomy. Active. The post-mortem appear- 
 ances are congestion of the meninges and cord, the same vessels 
 supplying both, with numerous points of extravasation, due to the rup- 
 ture of capillary vessels. The spinal fluid is increased in amount. 
 
 Passive. A general bluish discoloration, owing to the abnormal 
 fullness of the large anastomosing vessels ; the spinal fluid somewhat 
 increased. 
 
 Symptoms. Active. Dull pain in the dorsal or lumbar region, 
 shooting into the hips and thighs, persistent and increased by pres- 
 sure ; tenderness on motion ; tingli7tg sensations in the limbs and feet, 
 and sometimes in the hands and arms; a feeling of constriction 
 about the abdomen is often present, with rigidity of the abdominal 
 muscles. Increased reflexes, with disorders of motility, and when the 
 patient is in the recumbent '^osi\\on,jerki7ig of the limbs. On attempt- 
 ing to walk it is accomplished with difficulty, from an ijicomplete loss 
 of power. 
 
 If the upper part of the cord be affected, dyspnoea 2iTid. 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 
 increased or exalted. 
 
332 PRACTICE OF MEDICINE. 
 
 Duration. From a few hours to several days ; if longer, myelitis 
 may result. 
 
 Diagnosis. Ancrj?na causes more or less spinal irritability and 
 tenderness ; but the history, pallor and general weakness, unassociated 
 with defects of motility or sensibility, will prevent error. 
 
 spinal menijigeal hemorrhage is more sudden in its onset, its vio- 
 lence and its range of symptoms. 
 
 Myelitis a7id spinal meningitis\v2,v^ symptoms in common with spinal 
 congestion, which will be pointed out when discussing those affections. 
 
 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 perspiration, pilocarpus. If fol- 
 lowing suddenly arrested menses, aconitinn. If associated with an 
 active circulation, ^^/^^.y/z bromidum ox fiuidwn gelsemii extractum, 
 TT\^v, every four hours, or extractwn ergotce fluidM77i, f^ss-j, repeated 
 p. r. n. ; in all cases active purgation. 
 
 For the passive form, treating the cause, ergota, digitalis, tonics and 
 purgatives. 
 
 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. Exposure to cold and dampness; injuries to the verte- 
 brae or membranes ; rheumatism; puerperal fever ; syphilis. 
 
 Pathological Anatomy. Acute. Hyperaemia 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. 
 
 Chrofiic. Adhesions of the membranes, with more less accumu- 
 lation of fluid, resulting in atrophic degeneration of the cord from 
 pressure. 
 
DISEASES OF THE SPINAL CORD. 333 
 
 Symptoms. 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 
 contractions 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 are the seat, there occur retention of 
 urine and constipation ; if upper part, dysphagia, dyspncea and feeble 
 heart. The muscular contractions are excited or increased by motion, 
 but uninfluenced by pressure. Reflex inovejnents are not abolished. 
 The rigidity and spasmodic contraction of the muscles are followed 
 by 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, vomiting and delirium. 
 
 Electro-contractility \Qsstne.d. or absent, both as to motility and sen- 
 sibility, in the affected parts. 
 
 Chronic form succeeds to the acute or originates spontaneously, 
 and presents the same form and order of symptoms — excitation and 
 depression. 
 
 Diagnosis. The points of importance are, deep, boring pain in 
 the back, aggravated by motion but not by pressure, with spasmodic 
 contraction of the m^uscles followed by paralysis. 
 
 Myelitis will be differentiated from spinal meningitis when discuss- 
 ing that affection. 
 
 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 
 movements of the limbs does do so ; progressively increasing and not 
 associated with fever. 
 
 Prognosis. Grave. Death is either sudden, from paralysis of the 
 respiration and of the heart, or gradual, the result of exhaustion. 
 
 Critical discharges, such as profuse perspiration, urinary flow or 
 epistaxis occur and are followed by rapid recovery. Cases recovering 
 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 mus- 
 tard. Active purgation. 
 
334 PRACTICE OF MEDICINE. 
 
 ■ To reduce the amount of blood in the vessels of the cord, aco7iitu7n 
 and ergota combined with an opium impression. When paralysis 
 (depression) occurs, quinmce sulphas, gx. iij, combined with ext. bella- 
 donncE alcoholic, gr. X. three times a day, ox potassii iodidiim, gr. 
 xx-xxx, three times a day, with flying blisters along the spine. If the 
 paralysis still persist, a hydrargyrum impression often benefits. 
 
 For paralysis, \.\\t galvanic ciirrefit to the spine and nerve trunks, 
 and the faradic current to the affected muscles, with the deep injec- 
 tion of strychnina and the use of massage. 
 
 PACHYMENINGITIS SPINALIS. 
 
 Synonyms. Pachymeningitis spinalis interna ; hypertrophic 
 pachymeningitis ; pseudo-membranous pachymeningitis. 
 
 Definition. An inflammation of the spinal dura mater ; charac- 
 terized by violent pains in the head, neck, shoulders and arms, fol- 
 lowed by paralysis of the upper extremities. 
 
 Causes. Exposure to cold and damp; alcoholism; syphilis; 
 gout ; injuries. 
 
 Pathological Anatomy. Hypertrophic pachymefiingitis is 
 characterized by an exudation upon the inner surface of the dura 
 mater, which gradually solidifies into a layer of compact connective 
 tissue, which presses upon the spinal cord and nerves, producing a 
 myelitis and an 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-fnetnbranous form a membranous exudation also 
 occurs, in which large numbers of blood-vessels develop and rupture, 
 the hemorrhagic extravasations forming a cyst — ha^matoma — which 
 causes pressure on the cord and nerves. 
 
 Symptoms. The onset is slow and gradual, with irregular chills 
 2iX\d feverishness, violent pains in the head, neck, shoulders and arms, 
 continuous but subject to exacerbations, and associated with 2i pain- 
 ful cojistrictiofi of the upper thorax. These symptoms may continue 
 off and on for several months, when the muscles of the painful parts 
 begin to atrophy, followed by spasmodic contraction and paralysis. 
 
 The general health deteriorates with the progress of the muscular 
 symptoms. 
 
 The electro-contractility is lost. 
 
DISEASES OF THE SPINAL CORD. 335 
 
 Prognosis. If early recognized and promptly treated, the hyper- 
 trophic form may be cured. 
 
 Treatment. Rest; nutritious diet; olewn morrhiKE and the 
 hypophosphites ; large doses oi potassii iodidujn, and repeated but 
 systematic counter- irritation. 
 
 ACUTE MYELITIS. 
 
 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 lh.Qgray 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, de- 
 scending or transverse in its extension. The disease is characterized 
 by more or less sudden and complete loss of motion and sensation. 
 
 Causes. Following spinal meningitis ; exposure to cold and damp; 
 injuries to the vertebras ; prolonged functional activity of the cord ; 
 typhus fever ; rheumatism ; syphilis ; puerperal fever, or during the 
 course of the exanthemata ; arsenical 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 softening of 
 the structure of the cord, the color changing to yellow and white, the 
 nerve elements undergoing fatty degeneration, presenting the appear- 
 ance and consistency of cream. The membranes also undergo more 
 or less change. 
 
 Symptoms. The severity of the symptoms depends upon the 
 extent and location of the inflammation. 
 
 The onset is usually sudden, with a chill, fever, lo-^ , freque7it piclse, 
 with alterations in sensibility attd motility, to wit : paiti in the back, 
 aggravated by touch and by heat and cold, with sensations of formi- 
 cation ("pins and needles"), the limb feeling as if asleep, or else 
 complete ancEthesia, associated with severe ?teuralgic pains. 
 
 The distinction between ancEstkesia, insensibility to touch, and 
 analgesia, insensibility to pain, must be clearly determined. 
 
 A sensation oi constriction around the body and limbs, as if encircled 
 by a tight cord, "the girdle pains ; " rapidly developing paraplegia, 
 complete in a few hours, with involuntary discharges. The reflex 
 functions are usually abolished, as seen by attempting to cause move- 
 
336 PRACTICE OF MEDICINE. 
 
 ment of the limbs by tickling the feet or by striking the patella ten- 
 don ; rarely are they diminished, very rarely exaggerated. The tem- 
 perature of the affected limbs is lowered three or four degrees. 
 
 Sloughs and bedsores and muscular atrophy result if the anterior 
 cornucC — the trophic centres — are affected. 
 
 The above symptoms oi loss of motion and sensibility are associated 
 with more or less pronounced vomiting, hepatic disorders, irregularity 
 of the heart, dyspnoea, dysphagia, apncea and painful priapisms. The 
 urine is markedly alkaline in reaction. 
 
 Among the late manifestations are shooting pains and spasmodic 
 twitchings or co7itraciions of one or all of the muscles of the paralyzed 
 parts. 
 
 The electro-contractility is abolished in the paralyzed parts. 
 
 Diagnosis. Acute 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 hyperaesthesia, which is absent in 
 myelitis. 
 
 Congestion of the spinal cord vs> characterized by the mild character 
 and short duration of all the symptoms. 
 
 Hemorrhage in the spinal cafial 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, lowered 
 temperature in the affected parts, early and persistent sloughing 
 (bedsores) and alkaline urine. 
 
 Prognosis. Varies according to the location of the lesion. 
 
 If the paralysis is of the ascending variety, death occurs within a 
 few days, from paralysis of the muscles of respiration. 
 
 If the trophic centre is affected, there occur bedsores, intense pylo- 
 nephritis and cystitis and changes in the joints ; death from exhaus- 
 tion, in several weeks. 
 
 Central myelitis, or inflammation of ihc 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. 
 
DISEASES OF THE SPINAL CORD. 337 
 
 Locally, considerable relief follows the use of hot-water bags or 
 sponges dipped in Jcot water and applied along the spine every few 
 hours. 
 
 The remedies most strongly recommended are : digitalis, ergota, 
 belladonna, bromides, cimicifiiga, and qiiini7ia^ although I have never 
 observed a cure with any plan of medication, after it was fairly estab- 
 lished, save those due to syphilis, by large doses of potassii iodidmn. 
 
 INFANTILE SPINAL PARALYSIS. 
 
 Synonyms. Poliomyelitis anterior acuta ; essential paralysis of 
 children. 
 
 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. 
 
 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. 
 
 Patholog'ical Anatomy. The early changes are : medullary 
 hyperasmia, 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 degeneration 
 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 cejitre and the nerve 
 degeneration of the muscular flbres supplied, there ensue changes in 
 the bones and joints, leading to great deformities. 
 
 Symptoms. The onset of the affection varies ; it is usually sud- 
 den, 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 para- 
 lyzed. 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 
 28 
 
338 PRACTICE OF MEDICINE. 
 
 hemiplegia. The bladder and rectum are not affected, nor can an- 
 iEsthesia or numbness be detected. The temperature of the paralyzed 
 limb is low and the appearance cyanosed. After a few days there is 
 a slight improvement in the paralyzed parts, although the muscles 
 show a rapid wasting, which is progressive until all muscular tissue is 
 gone. 
 
 The reflex jnovevtents are vnpaired or abolished. 
 
 The electro-contractility by the faradic current is abolished in the 
 paralyzed parts. 
 
 With \.\\Q 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 reaction is necessary. 
 
 The normal formulae 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. 
 
 Second. The second most effective are produced by the a7tode {post' 
 live) pole on closing the circuit. 
 
 Third. The next most effective is by the anode pole on opening the 
 circuit. 
 
 Fourth. Cathode pole contractions on opening circuit are rarely 
 seen in the physiological state. 
 
 The "reactions of degeneration " are shown by any reversal of the 
 regular formulae, to wit: if the anodal closure shows stronger contrac- 
 tions than cathodal closure ; still greater degeneration is shown if 
 anodal openi?tg contractions are stronger than either of the above ; 
 and almost complete degeneration is shown by the complete reversal 
 of the normal formulae as shown by distmct cathodal opening con- 
 tractions. 
 
 Diagnosis. Hemiplegia from acute cerebral affections in children 
 can be distinguished from infantile paralysis by the disorders of in- 
 telligence 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 bedsores. 
 
 Pseudo-muscular hypertrophy, with paralysis, begins gradually, 
 becoming progressively worse with increase in the size of the limbs. 
 
 Progrnosis. Depends upon the treatment. If prompt and proper, 
 
DISEASES OF THE SPINAL CORD. 339 
 
 recovery may be said to be the rule. Mild cases recover within a few 
 days, others as many weeks, more severe cases a month or two. If 
 proper treatment be not pursued for several months or years, the 
 question of final recovery can be determmed by testing for the 
 "reactions of regeneration" with the galvanic current. There is no 
 danger to hfe. 
 
 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, quinina, belladonna and ergota. 
 
 With the improvement that follows the above measure, use inter- 
 nally, tinctura nucis vomicce, Hij-iij t. d., or hypodermic injections of 
 strychnincE sulphas, gr. ^ to y^ twice a week, ^.ndi faradism to the 
 paralyzed muscles. 
 
 CHRONIC PROGRESSIVE BULBAR PARALYSIS. 
 
 Synonyms. Glosso-labio-laryngeal paralysis; bulbar paralysis. 
 
 Definition. A progressive muscular paralysis of the laryngeal 
 muscles, tongue, soft palate and lips. 
 
 Causes. Obscure. Rare before the fortieth year. Among many 
 others are 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 
 ganghon cells is 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, which increases until that organ is com- 
 pletely paralyzed. The paralysis gradually invades the soft palate 
 and pharyngeal muscles, causing difficulty in deglutition, the orbicu- 
 laris oris, preventing closure of the lips, the laryngeal muscles inter- 
 fering with articulation. When the disease is fully developed the 
 condition of the patient is most pitiable, indeed; articulation is im- 
 
340 PRACTICE OF MEDICINE. 
 
 paired or impossible, deglutition interfered with, the lips remaining 
 apart allowing the saliva to dribble from the mouth, and liquids to 
 return through the nose if attempts are made to swallow them. As 
 the malady advances soon the pneumogastric nucleus becomes 
 involved, causing loss of voice, difficulty of respiration and cardiac 
 irregularity. The general health gradually suffers from insufficient 
 nutrition and imperfect respiration, although the mind is clear until 
 the end. The " reactions of degeneration " are present. 
 
 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.) 
 
 SPINAL SCLEROSIS. 
 
 S3monyni. 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. Cerebro-spitial sclerosis ; III. 
 Posterior sclerosis or locomotor ataxia. 
 
 Causes. Generally a hereditary neuropathic diathesis ; syphilis ; 
 mineral poisons ; shocks or injuries to the cord ; exposure to cold and 
 wet ; mostly occurring between the ages of thirty-five and fifty-five ; 
 males more hable 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 concussion. 
 
 Pathological Anatomy. The changes in the cord are gradual 
 in their development and follow a longitudinal instead of a transverse 
 direction. 
 
 The form, consistency and color of the cord are altered, it being 
 atrophied, indurated and of a grayish color. 
 
 The changes are hyperplasia of the connective tissue, with granular 
 degeneration, atrophy and disappearance of the proper nerve ele- 
 ments. The nerve roots undergo the same fibroid change. The joints 
 undergo remarkable atrophic degeneration. 
 
DISEASES OF THE SPINAL CORD. 341 
 
 LATERAL SCLEROSIS. 
 
 Synonyms. Antero-lateral sclerosis ; spasmodic tabes dorsalis 
 (Charcot) ; spastic spinal paralysis (Erb). 
 
 Pathogeny. The site of the lesion is the lateral white columns, 
 in some cases extending to the anterior horn, extending the whole 
 length of the cord. The changes consist in an interstitial hyperplasia 
 of the connective tissue and an atrophy of the nerve elements. 
 
 Symptoms. The chief symptom is paraplegia, or entire loss of 
 motion in the lower extremities. Preceding the paralysis there occur 
 jerking and twitching, with cramps atid stiffness of the muscles of 
 the affected parts. As the disease is progressing the gait is of a pecu- 
 liar character, termed by Hammond "the waddle," the patient step- 
 ping on the toes and showing a tendency to fall forward. There is a 
 gradual and increasing feeling of heaviness and weakness in the 
 affected limbs. Sensation is unaffected. Reflex phenomena are 
 preserved, at times greatly exalted. As the morbid process extends 
 upward, the superior extremities suffer in the same manner as those 
 of the lower. 
 
 Electro- contractility early impaired, and gradually declining until 
 abolished. 
 
 CEREBRO-SPINAL SCLEROSIS. 
 
 Synonyms. Multiple sclerosis of the brain and cord ; cerebral 
 sclerosis ; spinal sclerosis ; disseminated sclerosis (Charcot). 
 
 Pathog'eny. The disease consists of the development of patches 
 of grayish, translucent, tough nodules, varying in size from a minute 
 microscopical object up to the size of a walnut, varying in number 
 and widely distributed in the white matter of the hemispheres, ven- 
 tricles, optic thalamus, corpus striatum, peduncles, pons and cere- 
 bellum, while in the cord they are found in both the white and gray 
 matter and in the columns. The deposits are also found in the nerve 
 roots and nerve trunks. The nodules are composed of the neuroglia 
 much altered and a newly-formed connective tissue. The result of 
 the nodules is pressure upon the nerve structure, ending in its degen- 
 eration. 
 
 Symptoms. Charcot divides this variety of sclerosis into three 
 varieties, depending upon the site of the marked changes, as the 
 brain, the cord or a combination of the two. The latter variety is 
 the more common. 
 
342 PRACTICE OF MEDICINE. 
 
 Rarely the malady is ushered in with apoplectiform symptoms, but 
 generally the onset is insidious, with pains more or less severe in the 
 limbs and back, which are attributed by the patient to rheumatism. 
 Also a feeling of formication, itching and burning in the limbs. Loss 
 of coordination of the hands in writing, or the feet in walking, fol- 
 lowed after a time by paresis, more or less general, with contracture 
 of the muscles. Voluntary movements of the paretic limbs develop 
 a tremor — the shaking tremor — which subsides when the limbs are at 
 rest. It is these motor symptoms that have given rise to the "wad- 
 dle," or "hop" gait when walking. There are also present ^<?«^- 
 ache, vertigo, niejital disturbances, nausea, dyspeptic distresses, dis- 
 orders of vision and hearing, sexual disturbances, vesical disorders, 
 and often the development of bedsores. 
 
 The disease is progressive, the symptoms developing as the various 
 nerve tracts are invaded. 
 
 Duration. Ranges from a year to twenty years, an average being 
 five or ten years. 
 
 PROGRESSIVE LOCOMOTOR ATAXIA. 
 
 Synonyms. Posterior spinal sclerosis ; tabes dorsalis. 
 
 Pathog'eny. The sclerosis begins and may be confined to the 
 posterior columns in the upper lumbar and dorsal regions. Fre- 
 quently it extends the entire length of the cord and invades the 
 lateral columns. The sclerotic changes also invade the sciatic, crural 
 and brachial nerves. 
 
 Symptonis. Locomotor ataxia may be divided into three pe- 
 riods: I, disturbances of sensation ; 2, loss of coordinating power ; 3, 
 paralysis. 
 
 The onset of the disease is gradual by sharp, darting, electric-like 
 pains in the lower limbs, with disorders of the gastro-intestinal and 
 genito-urinary tracts. Associated with the pains is a loss of sensation 
 in the feet, the patient being unable to distinguish between hard and 
 soft substances in walking, and, if the upper portion of the spinal cord 
 be affected, is unable to coordinate the muscles of the fingers suffi- 
 ciently to button his clothing. A sensation of formication over the 
 surface, especially over the lower limbs, and about the waist, the 
 knee and the ankle. 
 
 Loss of coordination, the subject being unable to walk upon a 
 straight line with his eyes closed, and with difficulty if his eyes are 
 
DISEASES OF THE SPINAL CORD. 343 
 
 opened. Inability to preserve the erect position with the feet close 
 together, and as the malady progresses he throws his feet and legs in 
 the most grotesque manner. Although the patient is unable to coor- 
 dinate the muscles, their power is not lost, for, on being supported, he 
 can kick or strike with his usual force. 
 
 The sight is early impaired ; either double vision or inability to dis- 
 tinguish between different colors. As the disease progresses the sen- 
 sation becomes more and more blunted and pain is slowly felt, in 
 cases it being several minutes until the sticking of a pin is felt. A 
 characteristic sign of the disease is the abolition of the patellar tendon- 
 7-eflex as well as other reflexes in the lower limbs. Loss of the sensa- 
 tion of temperature also occurs. T he electro-contractility is decreased 
 in the affected limb. General emaciation is marked. 
 
 Paralysis finally ends the suffering of the patient. There is gener- 
 ally an entire absence of cerebral phenomena. 
 
 Diagnosis. The symptoms of these three varieties of sclerosis 
 are so characteristic that with care an error in the diagnosis seems 
 impossible. 
 
 Chronic myelitis is characterized by paralysis, and the course of the 
 affections are otherwise so different that an error should not occur. 
 
 Disease of the cerebellum presents symptoms of disordered coordi- 
 nation, but they are the result of vertigo, and associated with head- 
 ache, nausea and vomiting. 
 
 Paraplegia is a true paralysis, while sclerosis is not. Neuralgic 
 pain is not a symptom of paraplegia. 
 
 Paralysis agitans may be mistaken for disseminated sclerosis. Chief 
 points in the diagnosis are the presence in paralysis agitans of the fine 
 tremor continually without shaking of the head, while in cerebro- 
 spinal sclerosis the tremor is produced only on movement of the 
 muscle, and is associated with shaking of the head. Paralysis agitans, 
 a disease of middle life, sclerosis under forty years. Changes in the 
 voice, speech and vision are present in cerebro-spinal sclerosis, but 
 absent in paralysis agitans. 
 
 Prognosis. Unfavorable. Few if any recoveries are recorded of 
 antero-lateral or disseminated sclerosis, although rarely their progress 
 has been retarded for a long time. There are some claims of recov- 
 eries of locomotor ataxia in the early stage, but that a cure of a gen- 
 uine case, extending to the second stage, is ever effected, seems very 
 questionable. 
 
344 PRACTICE OF MEDICINE. 
 
 Treatment. In the management of the various scleroses, rest, as 
 near absolute as possible, is of the first importance, — it will be all the 
 more effective if it be in bed, for a period of several months. 
 
 Following the suggestion of Erb, use may be made of cold along 
 the spine, in the shape of cold sponging, cold spinal pack or short 
 application of the cold douche to the spine. T\\q galvanic continuous 
 current along the spinal column is warmly advocated, \v\\k\. faradisin 
 to the wasting muscles. 
 
 Potassii iodidum, or hydrargyri chloridum corrosivum, in full doses, 
 or atirii et sodii chloridum, gr. ^, three times a day, often remarkably 
 retard the progress of the affection. The best results are obtained, 
 however, from argenti 7iitras , gr. X~/^> or oxidu?n,gr. yi, three times 
 a day, withholding it at intervals of a few weeks, to prevent discolor- 
 ation of the skin (argyria). 
 
 Temporary success, at least, seems to have followed, in some cases 
 of locomotor ataxia, from the '' suspefision treatment as recom- 
 mended by Charcot. The treatment consists of the suspension of the 
 patient during a period varying from one to four minutes, by means 
 of the Sayre apparatus for applying the plaster jacket in spinal 
 deformities. 
 
 The severe and sharp pains require treatment, at first giving prefer- 
 ence to any of the substitutes of opium, but finally opiu7n itself will 
 have to be resorted to. 
 
 The diet should be of a nutritious, easily-assimilated character. 
 Nutrition can also be promoted by the use of oleum mon'hu<z and 
 syrupus calcii lacto-phosphatis. 
 
 PROGRESSIVE MUSCULAR ATROPHY. 
 
 Synonym. Wasting palsy. 
 
 Definition. A gradual, progressive wasting and atrophy of the 
 voluntary muscular system, resulting from trophic changes due to a 
 central nerve lesion. 
 
 Causes. In many instances the disease is hereditary. A predis- 
 posing cause seems to exist in those who habitually use one set of 
 muscles. Exposure to cold and damp ; lead, syphilis ; injuries to the 
 spinal column. 
 
 Patholo^cal Anatomy. Two theories as to the origin of the 
 pathological changes are held : one that the initial lesion is in the 
 
DISEASES OF THE SPINAL CORD. 345 
 
 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 muldpolar gan- 
 glion-cells of the anterior horns, and hyperplasia of the neuroglia, 
 and 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 band 
 with numerous fat-cells, the development of this latter material taking 
 place outside of the muscular elements and in the newly-formed con- 
 nective tissue." (Bartholow.) 
 
 Symptoms, The invasion is gradual, the disease having been 
 in progress some weeks or months before the patient discovers its 
 existence. 
 
 Wasting begins usually in the hand, the first dorsal inter-osseus 
 being the first to be attacked, then the muscles of the thenar and 
 hypothenar ejninence, then the deltoid, and so on from muscular group 
 to group. Often, however, the extension is very erratic in its course, 
 jumping from one group to another at some distance. 
 
 In the immense majority of cases the disease is permanently limited 
 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 attacked are 
 those of mastication and those that move the eye-ball (Roberts). 
 
 Fibrillary contractions is an early symptom, continuing more or 
 less marked so long as any muscular fibres remain. It consists of 
 wave-like movements of the muscles, excited automatically, by 
 draughts of air or percussion. Coincident with the wasting is loss 
 of power, disorders of sensation^ coolness of the surface, 2in6. 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. The 
 hand is frequently the seat of a very singular deformity — the " claw- 
 shaped" hand. 
 
 The electro- contractility is preserved so long as muscular fibres 
 remain. 
 
 Diagnosis. >When wasting palsy is fully developed its diagnosis 
 29 
 
346 PRACTICE OF MEDICINE. 
 
 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. 
 
 ProgTiosis. Very unfavorable, although the danger of 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 />o/assn zodi'dum 
 should be used, and if syphilis be suspected a course of potassii iodi- 
 du)n and hydrargyruvi should be administered. 
 
 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, ^rt/- 
 vatiism. Numerous observations attest its value when applied locally 
 to the affected muscles " (Roberts). 
 
 I have seen improvement from the faradic 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 rubbiitg 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 
 glycerine solution into the wasting muscles." 
 
 CEREBRO-SPINAL NEUROSES. 
 
 CHOREA. 
 
 Synonyms. St. Vitus's dance ; insanity of the muscles. 
 
 Definitions. A functional (?) disorder of the nervous system : 
 characterized by irregular spasmodic movements of groups of muscles, 
 with muscular weakness, more or less approaching paralysis 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. 
 
CEREBRO-SPINAL NEUROSES. 347 
 
 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 
 by decided, irregular jactations 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- 
 ties, interfering with motility; in severe cases, inability of self-feeding 
 or of holding anything in the hands. The speech is often unintelligible, 
 the tongue constantly moving in an irregular manner. 
 
 The heart's action is tumultuous and irregular, associated with a 
 soft, blowing, systolic murmur, most distinct at the base. The mus- 
 cles 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 hetni-chorea. 
 
 Diagnosis. Chorea was confounded with epilepsy until the points 
 of distinction were pointed out by Sydenham. 
 
 Paralysis agitans has general muscular tremor, beginning in one 
 limb, gradually progressing, uninfluenced by treatment ; a disease of 
 the elderly. 
 
 Post-hemiplegic 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- 
 phina or chloral are indicated. Regulate the secretions. 
 
 Arsenicwn 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, gtt. v, increased to gtt. x, or even gtt. xv, 
 three times a day. Extractwn ciinicifugcB fiuidu7n, Ti^xx-3j, t. d., 
 is serviceable, especially in cases following a rheumatic attack. 
 Cases resisting the arsenicum treatment may succumb to hyos- 
 cyamine, gr. ^^—j-^. three times daily. A patient of mine, aged 
 1 6 years, that resisted all the remedies mentioned, was promptly 
 
348 PRACTICE OF MEDICINE, 
 
 cured by antipyrine, gr. x, four times daily. The same case in a former 
 attack was arrested by ))io7-phincE sulphas, gr. %, four times daily, 
 but this latter remedy failed in the attack controlled by the anti- 
 pyrine. If anaemia be present, combine or alternate arsenicum with 
 f err urn. 
 
 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. Heredity ; rarely, worry, anxiety, depression or fright. 
 Pressure from a tumor at the periphery, or thickening of the mem- 
 branes of the brain, causing pressure ; dyspepsia (?) ; syphilis ; uterine 
 diseases. 
 
 Pathological Anatomy. There are no constant anatomical 
 lesions, as yet, associated with epilepsy. 
 
 Varieties. I. Epilepsia gravior, le grand mal ; II. Epilepsia 
 mitior, le petit mal. 
 
 Symptoms. Le grand mal is preceded by a more or less pro- 
 nounced and curious sensation, the so-called atcra epHeptica. 
 
 The attack proper is siiddeti, the subject suddenly fallijig, 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 a 
 coma of several hours' duration. The subject awakens with a con- 
 fused or sheepish expression, with no knowledge of what has 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 mal is manifested either by attacks of vertigo, the conscious- 
 ness being preserved, or by 2i passing absent-mindedness, either form 
 being associated with slight convulsive phenomena, followed by coma 
 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. 
 
 Diagnosis. Urcemic convulsions closely resemble an epileptic 
 
CEREBRO-SPINAL NEUROSES. 349 
 
 attack ; but the dropsy or general oedema and albuminous urine of 
 the former should guard against error. 
 
 Feigned epilepsy often misleads the most practical expert. 
 
 Prog'nosis. 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 reilex causes usually recover when the 
 cause is removed. 
 
 Treatment. To avert an impending attack, inhalations of amyl 
 nitris, gtt. iij-v, a few whiffs of chloroforinum, or the hypodermic 
 injection of morphma. 
 
 To prevent the return of attacks, remove the cause if possible ; 
 attention to the secretions, and the internal administration of potassii 
 bro?mdum in doses sufficient to abolish the faucial reflex and produce 
 the symptoms of bromism, has 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 the bromides are not serviceable are sometimes benefited by 
 argenti nitras, belladonna, or cannabis indica. Weak and anaemic 
 subjects usually do better with strychnina in full doses than with 
 potassii bromidum. If a history of syphilis can be obtained, the 
 combination of potassii iodiduni and potassii bro7nidum will effect a 
 cure. 
 
 Whichever of the above remedies are beneficial in any particular 
 case, the permanency of the relief can only be maintained by the 
 continuation 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 bromid., gr. xx 
 
 Tinct. digital., Tli^x. M. 
 
 SiG. — Three times a day. 
 
 Another good combination is the following : — 
 
 Ij^. Potassii bromid., . gr. xv 
 
 Sodii bromid., ... . sr. xv 
 
 JLiq, potassn arsenit., rt\^ij 
 
 Ext. conii fid., n\^iij 
 
 Aq. cinnamomi, ^j 
 
 Inf. gentian comp., ad .... ^bs. 
 
 SiG. — Two hours after meals. 
 
350 PRACTICE OF MEDICINE. 
 
 Brown-Sequard's mixture for epilepsy is as follows : — 
 
 R. Potassii iodidi, 8 parts. 
 
 Potassii bromidi, 8 " 
 
 Ammonii bromidi, 4 " 
 
 Potassii bicarb., 5 " 
 
 Inf. columbo, 360 " 
 
 SiG. — One teaspoonful before meals and three dessertspoonfuls on 
 going to bed. 
 
 Prof. Da Costa has used with success a bromide of nickel m cases 
 that have withstood the other combinations of the bromides. 
 
 HYSTERIA. 
 
 Definition. A functional 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 almost exclusively to 
 women. Young girls, old maids, widows and childless married 
 women are the most frequent subjects of this disorder. The parox- 
 ysms frequently develop during the menstrual epoch. The meno- 
 pause 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 manifesta- 
 tions 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, as seen in males, is a condition 
 much like the hysteria of the female. 
 
 Pathogeny. Structural alterations have thus far not been 
 detected in cases of hysteria ; it is thus 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 paroxysms and the hysterical state. 
 
 The Hysterical Paroxysm or Fit occurs nearly always in the pres- 
 ence of others, and develops gradually with sighing, meaningless 
 
CEREBRO-SPINAL NEUROSES. 351 
 
 laughter, causeless moaning, nonsensical talking and gesticulations, 
 or a condition of fidgets, followed with a sensation of choking, 
 dyspncea and a ball in the throat, the 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, throw- 
 ing 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, 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, sen- 
 sory-motor functions respectively. It may be a permanent condition 
 or occur at intervals with greater or less severity. 
 
 Mental disturbances. The patients are emotional, erratic, excit- 
 able, impatient and self-important, showing marked defects of will 
 and mental power. 
 
 Sensory disturbances. This is either a condition of exaggerated 
 sensibility or hypersesthesia, as shown by the marked effects from the 
 slightest irritation and the cutaneous tenderness along the spine, or a 
 condition of ansesthesia as shown by the apparent absence or recog- 
 nition of pain after severe irritation, or a perverted sensibility as 
 shown by the feeling of tingling, numbness and formication. Sensi- 
 bility 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 hemianaesthesia, paresis, or contracture 
 
352 PRACTICE OF MEDICINE. 
 
 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 hysterica, but 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 are impaired. Hysterical paralysis is 
 liable to frequent and sudden changes, the loss of power often disap- 
 pearing suddenly. Aphonia, from paralysis of the laryngeal muscles, 
 is a frequent form of paresis. Some hysterical patients refuse to even 
 make an attempt at speech. 
 
 "A curious enlargement of the abdomen is observed sometimes, 
 constituting the so-called phaiitom tumor. 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 
 painful. Vaginal examination gives negative results, and under 
 chloroform the prominence immediately subsides, returning again as 
 the patient regains consciousness." 
 
 Among the numerous other symptoms that may develop in a 
 hysterical patient are disturbances of digestion, the circulation, the 
 respiration, disorders of micturition and menstrical disorders. 
 
 Among other phenomena that belong to the Hysterical state are 
 to be mentioned Hystero-epHepsy, 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 alrnost ceased ; Ecstacy, a condition in which 
 the individual pretends to see visions and acts in the most ridiculous 
 manner. 
 
 Diagnosis. The hysterical state is so general in its manifestations 
 that it is to be borne in mind in diagnosing all ailments occurring in 
 
CEREBRO-SPINAL NEUROSES. 353 
 
 woman. 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 
 valerianate, Hoffmaii s anodyne or spiritiis ammonicB aromaticus 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. 
 
 Moral and hygienic measures are of the first importance in the 
 management of an hysterical patient. 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 is successful in a fair 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 and chloral. 
 
 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. 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 
 
354 PRACTICE OF MEDICINE. 
 
 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 is 
 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 
 
 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. 
 
 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. 
 
 ProgTiosis. Unless there be a tendency to mental disorders the 
 prognosis is good. 
 
 Treatment. Attention to the secretions, diet and surroundings. 
 Rest and diversion of mind is essential to success. Travel, short of 
 fatigue, pleasant companionship, and relief from responsibility. 
 Bathing, massage and galvanism are important aids to the manage- 
 ment of cases. 
 
 Among the internal remedies that are of benefit may be mentioned, 
 arsenicutn, strych?tina, ferrum, zinci valerianate, phosphorus, ex- 
 tractum cocce Jluidum, vinum coccb and syrupus hypophosphitis comp. 
 
 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. 
 
CEREBRO-SPINAL NEUROSES. 355 
 
 Causes. An undemonstrative 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 common in women than in men. 
 
 Pathological Anatoray. " 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 dila.ted, the result of a vasomoter 
 paralysis. The enlargement of the gland is the result of the dilated 
 vessels, a serous infiltration of its tissues, followed, if long continued, 
 by hypertrophy. A considerable mcrease of fat behind the eyeballs 
 has been observed. In the majority of cases more or less anaemia 
 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, the pulse rate varying from 90 to 120, 150 and 
 rarely as high as 200 beats per minute ; soon pulsations of the vessels 
 of the neck and thyroid gland may be felt and seen. The enlarge- 
 ment 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 Mrz7/ similar to an aneurism. The degree of enlargement 
 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 exophthalmus — 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 
 cover the balls. Associated with the protrusion of the eyeballs is 
 incoordination in the movements of the eyelids and the eyeball, the 
 diagnostic rule of Graefe, so that when the eyes are quickly cast down 
 the eyelids do not follow them, the sclerotic being visible below the 
 upper lid. Vision is unimpaired. Conjunctivitis may arise, the result 
 of the imperfect protection of the protruding ball by the eyelids. 
 
 Associated with the pathognomonic symptoms are nervousness. 
 
356 PRACTICE OF MEDICINE. 
 
 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 dia-^-nosis, but during its incipiency, before the characteristic symp- 
 toms have appeared, the disease may be confounded with such con- 
 ditions as cardiac disease, neurasthenia, lithaemia, malaria, or incipient 
 phthisis. 
 
 Prognosis. Recovery occurs in a fair numbers of cases, 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, poiassii bromidum or siilphonal ; it is better, how- 
 ever, not to use this class of drugs in a routine manner, but for the 
 special indications. 
 
 The chief indication, next to rest, is the condition of the circulation. 
 To control this two remedies are of inestimable value, they are digi- 
 talis and sirophanthus. The results I have seen from tinctura stro- 
 pha7ithus, ■n\^v from three to six times daily, have been most satisfac- 
 tory. Dr. Bartholow " has had good effects from quinina, belladonna 
 and ergotin, in combination." 
 
 The associated anaemia is to be treated by ferrum, arsenicum and 
 an easily digestible and nutritious diet. Galvanism to the cervical 
 sympathetic and pneumogastric is an important adjuvant to the 
 medicinal treatment. 
 
DISEASES OF THE NERVES. 357 
 
 DISEASES OF THE NERVES. 
 
 NEURITIS. 
 
 Definition. An inflammation of the nerve trunks ; character- 
 ized by pain and paresis of the parts supplied by the affected nerve 
 trunk. 
 
 Causes. Wounds and injuries ; cold and damp. 
 
 Pathological Anatomy. Hyperaemia, followed by exudation 
 into the nerve, " which becomes softened and ultimately breaks down 
 into a diffluent mass." Migration of white corpuscles takes place into 
 the neurilemma. Recovery may occur before destruction of the 
 nerve elements is produced, absorption of the exudation occurring. 
 " It is important to note that when inflammation occurs in a nerve it 
 may extend from the point first diseased upward {neuritis ascendens), 
 or downward {neuritis descendens).'' 
 
 Symptoms. The onset may be accompanied with febrile reac- 
 tion. The most decided symptom is pain along the course of the 
 nerve trunk and its peripheral distribution, of a burning, tingling, 
 tearing, intense character, increased by pressure or motion. If the 
 affected nerve be a mixed one — sensory and motor— spasmodic con- 
 tractions and muscular cramps occur, followed by impaired motion, 
 terminating in paresis of the muscles innervated by the affected 
 trunk. 
 
 If the inflammation proceed to destruction of the nerve trunk, wast- 
 ing and degeneration of the muscular tissue ensues. Various trophic 
 changes also occur, such as cutaneous eruptions and clubbing of the 
 nails. The electro-contractility is impaired or lost. 
 
 Diagnosis. Myalgia or muscular pain is not associated with 
 paralysis, nor does the pain follow the course of a nerve trunk. 
 
 Prognosis. Generally favorable, with proper treatment. 
 
 Treatment. Repeated blistering along the course of the nerve, 
 with full doses of potassii iodidum are usually successful. As the 
 more acute symptoms subside the use of galvanism or a feeble, slowly 
 interrupted /"ar^^^zr current restores the interrupted function. 
 
 For the pain and muscular contractions, hypodermic injections of 
 morphina. 
 
35S PRACTICE OF MEDICINE. 
 
 NEUR.\LGIA. 
 
 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. I. Neuralgia of the fifth nerve ; II. Cervico-occipital 
 neuralgia; III. Cervico-brachial neuralgia ; IV. Dorso intercostal 
 neuralcria : \. lADiibo-abdonitial Jieitral^a ; VI. Sciatica. 
 
 Causes. Heredity; anaemia; malaria; syphilis; metallic poi- 
 sons ; anxiety ; mental exertion ; exposure to cold and damp ; injuries 
 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 determined. A fair number of cases present the changes of 
 neuritis. 
 
 NEURALGIA OF THE FIFTH NERVE. 
 
 Synonyms. Tic-douloureux ; Fothergill's disease. 
 
 Symptoms. Paroxysmal pain, 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 lachrymation. When of any duration nutritive changes are 
 observed in the nervous distribution, to wit: osdema along the course 
 of the nerve, gray eyebrows and C07ivulsive twitches of the muscles, 
 termed " tic-douloureux,'' tenderness at the infra- and supra-orbital 
 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 hyperesthesia of the skin, and with cramps in 
 the cervical muscles, and with attacks of Jicrpcs. A sensation of 
 cracking at the nape of the neck is an annoying symptom in many 
 cases. 
 
 CERVICO-BKACHIAL NEURALGIA. 
 
 Symptoms. Paroxysmal pain, of a severe, boring, burning or 
 tensive character, with sensations of numbness and weakness of the 
 
DISEASES OF THE NERVES. 359 
 
 arm, hand, shoulder, scapula and mamma, with tenderness along the 
 cervical plexus. (Edema 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 hmb at times becoming pale, 
 the skin glossy, dry and harsh. 
 
 DORSO-INTERCOSTAL NEURALGIA. 
 
 Symptoms. Paroxysjnal 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." 
 
 Tendertiess 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. 
 
 SymptomiS. Paroxysmal pain of a sharp and lancinating, at 
 times heavy and dull character, following the course of the ileo-hypo- 
 gastric nerve, ileo-inguinal and external spermatic nerve, supplying 
 the integument of the hip, the inner side of the thigh, the scrotum 
 and labium. 
 
 SCIATICA. 
 
 Definition. 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. 
 
 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, in- 
 creased upon motion, shooting along the course of the nerve into the 
 hip, inner side of the thigh, half 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. 
 
 Diagnosis. Rheu7naiism, so-called, is the only condition likely 
 to be confounded with neuralgia. 
 
 The history of the attack, the character of the pain, with its local- 
 ized spot of tenderness, should prevent such an error. 
 
 Prognosis. If promptly and properly treated, unless the result 
 of pressure of an exostosis, aneurism or other tumor, favorable. 
 
360 PRACTICE OF MEDICINE. 
 
 • Treatment of Neuralgia. Rest ; easily assimilated but nutri- 
 tious diet; removal of the cause, if possible. If anaemic, y^rrww and 
 arsenicum. If rheumatic, alkalies. If syphilitic or the result of 
 metallic poisons, potassii iodidum. If malarial, quinina. 
 
 For an attack, morphina and atropina, hypodermically, afford the 
 most prompt and ready relief. 
 
 Success usually follows the use of the well-known " Gross (Prof. S. 
 D.) neuralgic pill:" — 
 
 R, Quinina sulphas, gT- ij 
 
 Morphince sulphas. g"^* ^V 
 
 Strychninse, g""- -jV 
 
 Acidi arseniosi, g'"- 5lr 
 
 Extracti aconiti, %^- \' M. 
 
 Ft. pil. No. I. 
 
 SiG. — One every one, two or three hours. 
 
 Few attacks of trigeminal neuralgia will resist the following powerful 
 prescription : — 
 
 R. Aconitinae (Duquesnel), g^- tV 
 
 Glycerini, 
 
 Alcoholis, aa . . . . '7^\ 
 
 Aquae menth. pip., ad ^ ij. M. 
 
 SiG. — Teaspoonful repeated from four to eight times daily, carefully 
 watching. 
 
 Facial neuralgia is often wonderfully benefited by the internal 
 administration oi ext. gelsemiifld., gtt. iij-v, every three or four hours, 
 until its physiological effects are produced. Excellent results often 
 follow the administration of Mb us sellers pills (s-comtine andquininum). 
 
 For sciatica, antipyrine, gr. xx, repeated two or three times daily, 
 has given relief. The deep injection of chloroformum is recommended 
 by Bartholow. A spray oi chloride of methyl 2i\ong the course of the 
 nerve for a few moments, watching the skin, will relieve the distress- 
 ing pain. Rarely full doses potassii iodidum with a blister, along the 
 course of the nerve gives relief. 
 
 All forms of neuralgia are more or less benefited by — 
 
 R. Quininae sulph., g^"- iij 
 
 P'erri reflact, gr. j 
 
 Acid, arsenious, g"*- 2V 
 
 Aconitiae, gr. j^g. M. 
 
 In pill every four or five hours. 
 
DISEASES OF THE NERVES. 361 
 
 The following formulae of Bardet is highly recommended for all 
 varieties of neuralgia : — 
 
 R. Exalgine, . . . . , ^j 
 
 Spts. rect., ^x 
 
 Aq. destil, ad ^v. M. 
 
 SiG. — One to three tablespoonfuls during the twenty-four hours. 
 
 FACIAL PARALYSIS. 
 
 Synonym. Bell's palsy. 
 
 Definition. An acute paralysis of the seventh cranial or 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 stapedms, 
 and one palate muscle, the levator palati ; by means of the chorda 
 tympani branch it controls the secretion of the parotid and submaxil- 
 lary glands, and, possibly, the sense of taste. It also furnishes motor 
 power to the azygos uvulse, the tensor tympani and the tensor palati 
 muscles. 
 
 The onset is usually sudden, with tmgling of the lips and tongue, 
 and upon looking into the mirror the patient is surprised by the per- 
 fectly blank, motionless side of the face, the corner of the mouth is 
 depressed, the eyelids open, the face drawn toward the well side, and 
 with inability to expectorate, whistle or swallow. 
 
 Any of the muscles innervated by the nerve may participate in the 
 paresis. 
 
 The electro-co7tiractility is feeble or lost. The reflexes are abolished. 
 
 Diagnosis. Paralysis of the muscles of the face occurs in hemi- 
 plegia ; the points of differentiation 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 aquaeductus 
 Fallopii. 
 
 It is the result of cold if the taste be normal and the uvula straight. 
 30. 
 
3(12 PRACTICE OF MEDICINE. 
 
 , 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 potassii acetas, vel iodidian, and blisters 
 in front of ear, and the use oi galvanism to the affected muscles. 
 
 DISEASES OF THE BLOOD. 
 
 ANEMIA. 
 
 Synonyms. Spanaemia ; hydraemia. 
 
 Definition. A deficiency of red corpuscles and albuminoid com- 
 pounds — a poverty of the blood ; characterized by pallor and general 
 weakness. 
 
 OligcEjnia is a lessening in the amount of blood ; Ischcsmia is a 
 localized anaemia. 
 
 Causes. Predisposing and exciting. 
 
 Predisposijtg. Sex ; the female, pregnancy and menopause ; 
 heredity. 
 
 Exciting. Deficient food, air or sunshine ; excessive work ; mental 
 worry ; prolonged and frequent nocturnal emissions ; excessive nurs- 
 ing ; chronic intestinal catarrh ; Bright's disease ; malaria. 
 
 Pathological Anatomy. Post-inortem, 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. 
 
 Symptoms. Pallor, gums, tongue, ear and conjunctiva pale. 
 Muscular weakness, 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 oi swooning, hysteria, and rarely epilepsy. 
 Irritable heart, with soft systolic basic muntiurs and attacks of hysteria. 
 Nocturnal emissions in male and deficient menses in female. Maras- 
 
DISEASES OF THE BLOOD. 363 
 
 mi^s in children. More or less general cedema of the eyelids and 
 ankles. Long continued, symptoms of fatty changes in various 
 organs or gastric 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 rind exercise short of fatigue. Purga- 
 tives with stomachic tonics, to promote digestion. 
 
 For the anaemia proper, ferrujn in some form is the most valuable 
 remedy, always remembering that it is not assimilated if the intestines 
 and liver be torpid. 
 
 The following alterative tonic, known as Smith's (Dr. A. H.) '* four 
 chlorides," is frequently of value: — 
 
 R. Hydrargyri chloridi corrosivum, ...... gr. j-ij 
 
 Liq. arsenici chloridi, f^j 
 
 Tinct. ferri chloridi, 
 
 Acidi hydrochlorici dil., . . . . aa . . . . f^iv 
 
 Syrupi, „ f^iij 
 
 Aquae, ad f^YJ- M. 
 
 SiG. — One dessertspoonful in a wineglassful of water after each meal. 
 
 Cases of anemia with weak stomach can take the following " iron 
 lemonade" with ease: — 
 
 li . Tinct. ferri chloridi, f ^ j 
 
 Acid, phosphor, dil., . f^ij 
 
 Syr. limonis, f,f jss 
 
 Aquae, , f J ij- M. 
 
 SiG. — One teaspoonful well diluted. 
 
 CHLOROSIS. 
 
 S3nionyni. Green sickness. 
 
 Definition. A pronounced anaemia, occurring in girls about the 
 age of puberty. 
 
 Causes. Obscure; inherited; menstrual irregularities. Ham- 
 mond maintains "that it is an affection of the nervous system, the 
 blood changes being secondary." 
 
364 PRACTICE OF MEDICINE. 
 
 Pathological Anatomy. The blood is deficient in red cor- 
 puscles, the vokime of the fluid normal or nearly so. Rarely the 
 mass, of blood is increased. The body is well nourished and the sub- 
 cutaneous fat well distributed. The organs are abnormally pale. 
 The spleen, the lymphatics and the marrow of the bones are not 
 affected in any manner. 
 
 Symptoms. The condition is associated with disorders of men- 
 struation. The young girl experiences a chajige of disposition, becom- 
 ing morose and despondent, or rarely hysterical. 
 
 "As respects the actual condition of the sexual organs, there are 
 two forms of derangement which happen in chlorosis ; there are the 
 amejiorrhcEic form and the inenorr]iagic form." After an attack of 
 menorrhagia or after the failure of the flow to appear, the changes 
 occur. The complexion changes, blondes becoming pallid, waxy and 
 puffy without oedema ; 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. 
 The appetite is vitiated, the digestion imperfect; attacks of gastralgia 
 are frequent. 
 
 A not infrequent complication is gastric ulcer. Phthisis develops in 
 those having the slightest predisposition. 
 
 Prognosis. As a rule, unfavorable, on account of the liability 
 to grave complications. Those recovering are always liable to 
 relapses. 
 
 Treatment. A generous, nutritious diet ; fresh air ; moderate 
 exercise ; change of scene ; cheerful surroundings. Ferruin and 
 arsenicum are of the greatest utility. A good combination is — 
 
 H . Ferri arseniatis, gr. ^^-\ 
 
 Ext. nucis vomicse, . , gr. \-\. M. 
 
 Ft. pil. No. I. 
 SiG. — After meals. 
 
 The following is Bland's formula, so highly lauded by Niemeyer: — 
 
 R. Pulv. ferri sulph., 
 
 I'oiassii carbonat. puroe, . . . aa ^^ss 
 
 Tragacanthce, q. s. M. 
 
 Ft. pi. No. xcvj. 
 
 SiG. — One to three or four pills three times daily. 
 
DISEASES OF THE BLOOD. 365 
 
 PROGRESSIVE PERNICIOUS ANEMIA. 
 
 Synonyms. Anaematosis ; essential anaemia; anaemia of fatty 
 heart. 
 
 Definition. A pernicious, progressive form of anaemia, of unknown 
 cause, resisting all treatment, and toward its termination associated 
 with fever. 
 
 Pathological Anatomy. The blood is scanty and pale, with 
 diminished red corpuscles, albuminates and fibrin, 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 anaemic, 
 causing fatty changes in those organs. The skin may contain pete- 
 chiae 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. 
 
 Symptoms. It begins insidiously, with increasing languor and 
 
 pallor, the muscular weakness compelling the patient to take his bed. 
 
 Cardiac palpitation, dyspncea, attacks oi syncope, oede7na and swelling 
 
 about the ankles, with petechial spots scattered irregularly over the 
 
 surface. 
 
 The appetite is waning, and nausea and vomiting occur, associated 
 with marked dyspepsia and persistent diarrhoea. As the disease pro- 
 gresses a remittent form oi fever develops, the temperature frequently 
 showing 102-104° F. 
 
 Disorders of vision are the result of the retinal hemorrhage. The 
 cardiac sounds are feeble and associated with soft basic or anaemic 
 murmurs. 
 
 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 increase in the white corpuscles. 
 
 Prognosis. Unfavorable. 
 
 Treatment. Symptomatic. 
 
366 PRACTICE OF MEDICINE. 
 
 LEUCOCYTHEMIA. 
 
 S37Tlonyins. 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. It may assume either a 
 splenic, a lymphatic, or a myelogenic form, and is characterized by 
 symptoms of pronounced anaemia. 
 
 Causes. The real cause and nature of the affection is un- 
 known. 
 
 Pathologrical Anatomy. The spleen is increased in size, 
 density and firmness ; the lymphatic glands all over the body also 
 enlarge, but are soft to the touch, often fluctuating ; the ^narrow 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 1.055 to 1.040 or lower, and the 
 white corpuscles increased in number and in size, the red corpuscles 
 being lessened in number and size. 
 
 Symptoms. The onset and early progress of the disease is iden- 
 tical with that of simple anaemia, accompanied by swelling oi the 
 abdomen and a feeling o{ fullness and pain in the splenic region, due 
 to enlargement of that organ. 
 
 In the lymphatic variety, enlargement of the glands in the groin, 
 neck and axillary region are associated with \.h.Q great pallor. 
 
 In the myelogenic variety, the bones, more particularly the ribs and 
 sternum, are tender on pressure, the patient developing a waxy ap- 
 pearance. 
 
 In each variety the appetite is poor, the digestion feeble, the bowels 
 loose, the patient easily fatigued, with cardiac palpitation, and dysp- 
 noea, with oedema of the eyelids and ankles. The urine is scanty and 
 of high specific gravity — i. 020-1. 030. 
 
 Diagnosis. This should cause but little trouble if enlarged spleen, 
 lymphatic glands and tender bones are associated with great pallor, 
 and the characteristic appearance of the blood as demonstrated by a 
 " puncture of the finger of the patient and receiving the blood on a 
 piece of white linen or a lawn handkerchief, and placing by the side 
 of it a similar stain of blood from a healthy subject. The full color 
 of the latter contrasts strikingly with the stain of the former, which 
 is hardly of a blood color and translucent." 
 
DISEASES OF THE BLOOD. 367 
 
 Prognosis. No case of recovery has yet been recorded. The 
 average duration is between two and three years. 
 
 Treatment. Symptomatic. A combination of the following rem- 
 edies with generous diet, fresh air, sunshine, pleasant surroundings, 
 oleum morrhncB and the hypophosphites have at times seemed of 
 temporary utility, to wit : quinina, arsenicum, ferru7n and ergota. 
 
 ADDISON'S DISEASE. 
 
 Synonym. Melasma supra-renalis. 
 
 Definition. "The bronzed-skin disease." Thus defined byAver- 
 beck : "A well-marked constitutional disease, exhibiting itself locally 
 as a chronic inflammation of the supra-renal capsules, but in its 
 essence consisting in a peculiar anaemic condition, always tending 
 toward death, which is characterized by intense development of pig- 
 ment in the cells of the rete malpighii and in the epithelium of the 
 mucous membrane of the mouth." 
 
 Causes. Uncertain. Tubercle, scrofula and syphilis have each 
 been given as the cause. 
 
 Pathological Anatomy. A low form of inflammation, termi- 
 nating in degeneration of the supra-renal capsule. The blood is 
 deficient in fibrin and red corpuscles, with a slight increase of the 
 white corpuscles. Fatty degeneration of the heart and vessels has 
 been observed in some cases. 
 
 "The most striking change during life — the abnormal pigmenta- 
 tion — is due to the deposition of granular pigment in the cells of the 
 rete malpighii, in the papillary portion of the cutis, and even in the 
 connective tissue corpuscles. No change occurs in the proper struc- 
 ture of the skin. Similar pigment deposits occur in the mucous mem- 
 brane of the mouth, especially along the edges of the teeth." 
 
 "The disease of the supra-renal capsules excites an irritation of 
 the vaso-motor system — the trophic system — which leads to the pig- 
 mentation." 
 
 Symptoms. The onset of the disease is insidious, with a feeling 
 of extreme languor, muscular fatigue , asthenia, indigestion, anorexia, 
 dyspnoea, cardiac palpitation, vertigo, melancholia and excessive 
 drowsiness. 
 
 The surface is first pale, then changes to a hue like that of melan- 
 CEtnia, changing to icteroid, finally resembling the color of a mulatto, 
 
368 PRACTICE OF MEDICINE. 
 
 and then to a lustreless bronze. These changes also occur on the 
 mucous membrane of the lips, tongue, gums and mouth. 
 
 Prognosis. An incurable disease. Duration, a year or two. 
 
 Treatment. Symptomatic. 
 
 HAEMOPHILIA. 
 
 Synonyms. Hemorrhagic diathesis ; " bleeders' disease." 
 
 Definition. A congenital condition characterized by the habitual 
 occurrence of hemorrhages. 
 
 Cause. Hereditary. 
 
 Symptoms. The bleeding appears about the period of first 
 dentition, and consists of spontaneous hemorrhages from the mucous 
 membrane of the nose, mouth, lungs, stomach, intestines, or genito- 
 urinary passages, or in perfect cases, hemorrhages occur directly from 
 the fingers, toes, lobes of the ears, back of the hands or arms, without 
 any apparent change in the skin, and continue, in spite of the most 
 powerful means, for days or weeks. Traumatic hemorrhages occur if 
 an injury of any kind is sustained about the period of the develop- 
 ment of the bleeding. 
 
 Epistaxis is the most common form of all those named. 
 
 As a result of the great loss of blood, the subject suffers from all 
 the symptoms of profound anaemia. 
 
 Diagnosis. It is impossible to confound the " bleeders' disease " 
 with any other affection. 
 
 Prognosis. Death is the usual termination within a few weeks 
 from the time of its development, which may not be until adult Hfe. 
 
 Treatment. Entirely symptomatic. It is claimed that " potassii 
 chloras — an ounce of a saturated solution three times a day — com- 
 bined with tinctura ferri chloridi,'' WiW eradicate the constitutional 
 tendency. 
 
 SCORBUTUS. 
 
 Synonym. Scurvy. 
 
 Definition. A peculiar condition of malnutrition or anaemia, 
 gradually developing upon a dietary deficient in fresh vegetable 
 material; characterized by decided anaemia, debility, mental lethargy, 
 petechiae and a swollen and spongy state of the gums, with a ten- 
 dency to bleed upon the slightest irritation. 
 
DISEASES OF THE BLOOD. 369 
 
 Causes. The disease only occurs when fresh vegetable nutriment 
 or some appropriate substitute has been for a time partially or com- 
 pletely withheld. 
 
 Patholog'ical Anatomy. An undetermined derangement in 
 the composition of the blood, with diminished proportion of the 
 potash salts. Spleen enlarged. The tissues are wasted and present 
 extravasations, due to either one of, or the combined presence of, the 
 following conditions, to wit : liquid condition of the blood, allowing 
 it to escape from the vessels, alterations in the walls of the vessels, or 
 a vaso-motor paralysis. 
 
 Symptoms. General weakness, lassitude, indisposition to either 
 mental or physical exertion. The skin is dry, rough and of a muddy 
 pallor, the face pale and bloated. Swelling and sponginess of the 
 gums, with great tendency to bleed and an exceedingly offensive 
 breath. Looseness of the teeth, hemorrhages from mucous surfaces, 
 and extravasations of blood within and beneath the skin. The lips 
 are pale, which is in striking contrast to the redness of the gums ; the 
 ey^s are sunken and surrounded by a dark blue circle. 
 
 Hemorrhages occur from the stomach, mouth, bronchial tubes, 
 intestinal canal and vagina. The skin is dry and rough, resem- 
 bling that of a plucked fowl. QEdema of the face and ankles not 
 infrequent. 
 
 Depression of the spirits is characteristic. Palpitation and dyspnoea 
 on exertion. Urine high colored, speedily becoming fetid. 
 
 The patient usually longs iox fresh vegetables dund. fruits. 
 
 Com.plications. Dysentery. Scorbutic dysentery is a frequent 
 complication. It may co-exist with typhoid and typhus fever. 
 
 Prog'nosis. Favorable, if early and properly treated. 
 
 Treatm.ent. The chief indication is the assimilation of the ali- 
 mentary principles needed for the healthy constitution of the blood 
 and the invigoration of the system. 
 
 The juice of lemons, oranges and other fruits. Antiscorbutic vege- 
 tables, to wit: raw cabbage, cresses and raw potatoes, in conjunction 
 with meats, milk and farinaceous food. 
 
 Improve the appetite and digestion by the use of strychnina, 
 quinina, mineral acids and bitter infusions. Potassii chloras, locally, 
 will relieve the oral symptoms. 
 31 
 
370 PRACTICE OF MEDICINE. 
 
 PURPURA. 
 
 Synonym. Hemorrhoea petechialis. 
 
 Definition. An acute disease, characterized by purplish discol- 
 orations of the skin, the result of hemorrhages into the upper layers 
 of the cutis and beneath the epidermis. 
 
 Varieties. Purpura simplex ; purpura hemorrhagica ; purpura 
 urticans. 
 
 Causes. Not properly understood. It may occur at any age, 
 but is especially frequent in children and elderly people. Its occur- 
 rence after the ingestion of certain articles of diet has been observed. 
 
 Symptoms. Purpura simplex is the mildest form of the afifection, 
 and is characterized by the sudde?t appearance of s?)iaii, bright red 
 spots — a cutaneous hemorrhage — most commonly on the legs, asso- 
 ciated with slight lassitude, mild febrile reaction, and aching pains in 
 the limbs. The hue of the spots rapidly fades to a purplish color and 
 slowly disappears. Relapses are common. 
 
 Purpura hemorrhagica has, in addition to the eruption of purpura 
 simplex — the cutaneous hemorrhage — a flow of blood from the free 
 surface of mucous membranes. The most common hemorrhage is 
 epistaxis, slight or profuse. Other hemorrhages are hcsmateviesis, 
 malcena, hcsmaturia, hcB?noptysis, 7nenorrhagia, and also into the sub- 
 stance of the mucous membranes of the palate, cheeks and gums. 
 This variety is associated with great debility and depression, moderate 
 fever and disorders of digestion. Marked ancemia results from the 
 hemorrhages. 
 
 Purpura urticans is a combination of urticaria and purpura sim- 
 plex. It is characterized by " rounded and reddish elevations of the 
 cuticle, resembling wheals, but which are not accompanied, like the 
 wheals of urticaria, by any sensation of itching or tingling." They 
 are usually seated on the legs, thighs, breast and arms, and are inter- 
 spersed with petechiiE. They gradually form and subside within 
 twenty-four or thirty-six hours. Relapses are frequent. 
 
 This variety is also associated with malaise, moderate fever, and 
 pains in the limbs. 
 
 Prognosis. Purpura simplex and purpura urticans are favorable, 
 but relapses are very frequent. Purpura hemorrhagica is always a 
 grave disease, often proving fatal from exhaustion, or more rarely 
 
DISEASES OF THE SKIN. 371 
 
 cerebral or pulmonary hemorrhage. Recovery occurs frequently, 
 under judicious treatment. 
 
 Treatment. Rest and a concentrated nutritious diet, and the 
 moderate use of stimulants, to combat the resulting anaemia. 
 
 The internal use of oleum terebitithince is one of the most reliable 
 remedies for all forms of the disease. The following is an eligible 
 formula : — 
 
 R. 01. terebinthinae, f^^^ij 
 
 01. amygdalae express., . . f^j 
 
 Tinct, opii deodorat., ■. . . . fgss 
 
 Mucil. acacite, ^5J 
 
 Aq. lauro-cerasi, - f ^ iij, M. 
 
 SiG. — One teaspoonful every three or four hours. 
 
 Among the other numerous remedies suggested, the most reliable 
 have been acidtwi sulphur icimi dilutum 2ir\d tinctura ferri chhridi. 
 Good results have followed acidum carbolicwn, gtt. ij-iij every three 
 hours, in cases seen by the author, and a particularly persistent case 
 was cured by full doses of potassii iodidum. 
 
 " If hemorrhages that are threatened come on with a strong pulse, 
 flushed face, headache and excitement, digitalis, quinitia and ergota 
 are the approximate medicaments." (Bartholow.) 
 
 Locally, to arrest bleeding, astringents and either hot or cold water 
 or ice. 
 
 DISEASES OF THE SKIN. 
 
 DISORDERS OF SECRETION. 
 
 SEBORRHCEA. 
 
 Synon3niis. Acne sebacea ; pityriasis ; tinea furfuracea ; dan- 
 druff. 
 
 Definition. A functional disorder of the sebaceous glands of the 
 skin ; characterized by an excessive and abnormal secretion of seba- 
 ceous matter, forming upon the skin either as an oily coating, or in 
 crusts and scales. 
 
 Varieties. Seborrhasa oleosa ; seborrhcea sicaa. 
 
372 PRACTICE OF MEDICINE. 
 
 Causes. In newly-born infants an increased secretion of seba- 
 ceous matter — the vernix caseosa — is a physiological process. 
 
 The origin of the disease is for the most part illy understood, 
 anaemia being a factor in many cases. 
 
 Pathology. Seborrhoea is a functional derangement of the 
 glands ; if it be allowed to become very chronic, there occurs atrophy 
 of the glands and follicles. 
 
 Symptoras. The affection may occur upon any portion of the 
 body, its most frequent seat being, however, the scalp {seborrhoea 
 capitis ox pityriasis capitis), and next in frequency the _/h;^^ {seborrhoea 
 faciei). 
 
 Seborrhoea oleosa ; appears as an oily, greasy coating upon the 
 skin, without hyperaemia, and not attended with itching. The secre- 
 tion is of an oily character, the quantity at times being so great as to 
 collect in minute drops of a clear, yellowish fluid upon the surface. 
 
 The most common seat for this variety is the face — seborrhosa faciei 
 — and nose — seborrhoea ?iasi. 
 
 Seborrhoea sicca, consists in the formation of dry, more or less 
 greasy inasses of scales or crusts of 2i grayish, yellowish, or brownish- 
 yellow color, having a strong tendency to adhere to the skin, and 
 attended with decided itching. Occurring upon the scalp — seborrhoea 
 capitis — it is a frequent source of pretnature baldness. 
 
 Diagnosis. Seborrhoea capitis may be mistaken for dry eczema, 
 but the former is always a dry disease, while in eczema moisture has 
 occurred at some period of the affection. The scales in seborrhoea 
 are very abundant and pale ; in eczema the scales are scanty and 
 reddish, the parts irritated, infiltrated and thickened. 
 
 Seborrhoea sicca and psoriasis have many points of resemblance, 
 whether occurring on the scalp or on the body. In seborrhoea the 
 scales are minute or caked, grayish or yellowish in color, of an unctuous 
 feel and usually uniformly diffused. In psoriasis the scales are very 
 dry, abundant, thick, white, irregularly dispersed, with intervening 
 healthy skin, and the surface beneath the scales is always reddish a?id 
 inflamed. The clinical histories of the diseases are entirely different. 
 
 Prognosis. If properly treated, favorable, although the affection 
 is obstinate to eradicate. ' 
 
 Treatment. The secretions require attention. If anaemia be 
 present, /t'/'r/^w and arsenicum are indicated. The following formula 
 of Sir Erasmus Wilson, and lauded by Hebra, is valuable : — 
 
DISEASES OF THE SKIN. 373 
 
 R . Vini ferri, ^ d ^^^ 
 
 Syr. simplex, 
 
 Liquor potassii arsenit., . . . aa ^ij 
 
 Aqu£e destil., f^ij- M. 
 
 SiG. — Teaspoonful three times a day, with meals. 
 
 Duhring recommends calcii sidphid., gr, xq-\, several times daily. 
 
 Local measures are the most important in seborrhoea. For sebor- 
 rhcea capitis the following plan will usually be successful : — 
 
 The scales are to be thoroughly moistened with either oleum oHvcb, 
 oleum morrhuce, or adeps, to facilitate their removal ; it is best applied 
 at night and the head covered with a flannel or other cap. As soon 
 as the crusts are well soaked they should be removed by washing 
 with soap and warm water, or equal parts of soap, glycerine and 
 water, or the following will be found valuable : — 
 
 R. Saponis viridis (Hebra), f^i'^ 
 
 Spts. vini rect., f^ij- 
 
 Solve et filtra. 
 SiG. — Dilute and use as a soap- wash or shampoo. 
 
 The scalp is to be thoroughly cleansed of either of the above by 
 again washing with warm water and then dried by means of soft 
 towels. Then should be applied some oily or fatty substance depend- 
 ing upon the condition of the scalp. 
 
 If much irritation, either vaseline or oleum amygdalce expressum. 
 If no irritation be present, a stimulating preparation will be found of 
 great benefit. Either of the following may be used : — 
 
 R . Tinct. cantharidis, f 3 "J 
 
 Tinct. capsici, f^iij 
 
 Ol. ricini, f.^^ij 
 
 Alcoholis, f,^ij 
 
 Spts. rosmarini, . . . . f Jj. M. 
 
 — Duhring. 
 Or— 
 
 R . Bismuthi subnitratis, f ^ j 
 
 Ung, hydrargyri ammon., 3ij~^^ 
 
 Ung. aquae rosae, ad %\. M. 
 
 The above should be repeated every day or two, as the symptoms 
 may require, until a cure is effected. 
 
374 PRACTICE OF MEDICINE. 
 
 The following combination is useful for dandruff: — 
 
 R . Ammonii muriat., gr- x 
 
 Glycerin^e, f,5J 
 
 Aq. rosje, ^y. M. 
 
 SiG. — Apply to head. 
 
 The seborrhoea of other portions of the body are to be treated upon 
 the same general principles. 
 
 COMEDO. 
 
 SjTTionjTTQS. Acne punctata nigra ; black heads or worms. 
 
 Definition. A disorder of the sebaceous glands; characterized 
 by retention in the excretory ducts of an inspissated secretion which 
 is visible upon the surface as yellowish or whitish pin-point and pin- 
 head-sized elevations, containing in their centre blackish points. 
 
 Causes. The true etiology is unknown. Among the causes 
 assigned are, anaemia, menstrual disorders, urethral irritations, dys- 
 pepsia and constipation. 
 
 Patholog'y. Comedo is an affection of the sebaceous glands and 
 ducts, consisting of an accumulation of sebum and epithelial cells in 
 the glands and follicles, dilating the ducts to such an extent as to pro- 
 duce the point or elevation upon the surface. The obstructed gland 
 may relieve itself, or it may continue distending until a papule is 
 formed. The duct sometimes contains small hairs, and also the micro- 
 scopic mite — demodex folUciiloyu})i — having a length of from yi^ to 
 TjJ- of an inch, and breadth of about ^^jy of an inch, which was at one 
 time erroneously supposed to be the cause of the affection. 
 
 Symptoms. Essentially a chronic affection, observed for the 
 most part on the face, neck, chest and back. Each single elevation 
 or black-head or point is designated a comedo, or if a number, in the 
 plural, as comedones. 
 
 Each comedo is small, varying from a pin-point to a pin-head in 
 size, having a brownish or blackish appearance, from the dust or 
 dirt that has adhered to their unctuous surface. \{ they form in great 
 numbers upon the face they are disfiguring, giving the individual the 
 appearance of having had minute grains of powder implanted in the 
 skin. There are no evidences of inflammation unless acne is asso- 
 ciated, but, on the contrary, the skin has a dirty, greasy, unwashed, 
 appearance. 
 
DISEASES OF THE SKIN. 375 
 
 Diagnosis. There is no condition resembling comedo, so that 
 its recognition is easy, unless complicated with acne ; but even then 
 the inflammatory appearance of acne should prevent an error. 
 
 Prognosis. Favorable, although often remarkably obstinate. 
 
 Treatment. Derangements of any of the functions of the body 
 should be corrected, and strict attention be given to the rules for pro- 
 moting the general health. 
 
 Local measures are usually sufficient to promote a cure of the 
 affection. 
 
 The parts affected should be thoroughly softened by bathing with 
 soap and warm water, when the comedones are removed by friction 
 with a Turkish towel, pressure between the thumb nails, the appli- 
 cation of a watch key, or the instrument known as the " comedo 
 extractor," and their return prevented by an unguentutn medicated, 
 to meet the indications, with either sulphur, alkalies, or hydrargy- 
 rum. 
 
 Piffard's acne application I have found valuable : — 
 
 Jje . Sulphur sublim., 
 
 ^Icoholis, 
 
 Tinct. lavend. comp., 
 
 Glycerini, 
 
 Aquae camphorse, aa f^j- M- 
 
 SiG. — Apply freely, after removal of the comedones. 
 
 MILIUM. 
 
 Synonyms. Grutum ; tubercula miliaria or sebacea ; acne punc- 
 tata albida. 
 
 Definition. An accumulation of sebum in the sebaceous glands 
 which are minus their excretory ducts ; characterized by the forma- 
 tion of small, roundish, whitish, sebaceous, non-inflammatory eleva- 
 tions, situated immediately beneath the epidermis. 
 
 Cause. The origin of the affection is not understood. 
 
 Pathology. The sebaceous gland is distended with the sebum, 
 which is unable to escape owing to the obliteration of the duct, nor 
 can the contents be squeezed out, as no sign of aperture is to be 
 found, the formation being completely enclosed. 
 
 Rarely the retained secretion undergoes a metamorphosis into hard, 
 calcareous, stone like masses — sebaceous concretions or cutaneous 
 calculi. 
 
376 PRACTICE OF MEDICINE. 
 
 Symptoms. Milia may occur upon any portion of the body ; 
 their usual seat, however, is upon the face, forehead, and about the 
 eyes. They form gradually, are about the size of a millet seed, of a 
 whitish, pearl or yellowish color, hard, and of a rounded shape, giv- 
 ing the sensation to the touch of hard bodies embedded in the skin. 
 They are not associated with injflammatory symptoms. 
 
 Diagnosis. Milium and comedo are somewhat similar in ap- 
 pearance ; the differences are that in milium the sebaceous gland is 
 distended without an opening, while in comedo the duct of the gland 
 is always patulous upon the surface. Milium usually exists singly, 
 the skin looking normal ; while comedo is more general, the surface 
 having a soiled and greasy appearance. 
 
 Prognosis. Favorable. 
 
 Treatment. As a riile no treatment is needed, the number being 
 few and their presence of no consequence. 
 
 If their removal be desirable, two modes suggest themselves: one, 
 to open the cyst with a fine-bladed bistoury, and turning the contents 
 out, destroying the remaining sack by the application of either tinctura 
 iodi or acidum chromici ; or, the cyst may be destroyed by electrolysis. 
 If a tendency to recur is shown, the plan may be repeated. 
 
 SEBACEOUS CYST. 
 
 Synonyms. Wen ; sebaceous tumor ; encysted tumor. 
 
 Definition. A distention of the sebaceous gland and duct, with 
 hypertrophy of the walls, which forms a thick, tough sack or cyst ; 
 characterized by the appearance of a firm or soft, more or less rounded 
 tumor, having its seat in the skin or subcutaneous connective tissue. 
 
 Cause. Unknown. 
 
 Pathology. Hypertrophy of the gland and duct walls, the result 
 of pressure from the accumulated contents, which consist of the altered 
 products of the sebaceous secretion. 
 
 Symptoms. The development of wens is slow and insidious. 
 The localities where they are more commonly developed are the scalp, 
 face, back and scrotum. 
 
 The tumors occur singly or in numbers, in size from a pea to a 
 walnut, or larger, in shape either rounded, flattened or semi-globular; 
 in consistency they are either hard or soft, and doughy ; they are 
 freely movable and painless. 
 
DISEASES OF THE SKIN. 377 
 
 Diagnosis. Sebaceous cysts may be confounded with fatty 
 tumors. 
 
 Treatment. Excision and careful and thorough dissection of the 
 cyst. 
 
 HYPERIDROSIS. 
 
 Synonyms. Hydrosis ; ephidrosis ; excessive sweating. 
 
 Definition. A functional disorder of the sweat glands ; charac- 
 terized by an increased secretion of sweat. The sweating may be 
 either general or partial. 
 
 Causes. Often undetermined ; occasionally inherited ; nervous 
 derangements ; malaria ; diseases of the heart and lungs. 
 
 Pathology. A functional derangement of the sudoriparous 
 glands, over which the vasomotor system has control. The char- 
 acter of the secretion, chemically, may not differ from the normal. 
 
 Symptoms. Universal general sweating, such as occurs during 
 the course of pneumonia, rheumatism, tuberculosis, typhoid and other 
 febrile maladies, can hardly be considered a distinct affection. 
 
 Hyperidrosis may be acute or chronic, the amount slight or large, 
 being constant or paroxysmal, the extent general or local, and it may 
 or may not be symmetrical. 
 
 Bromidrosis is the designation when the secretion has an offensive 
 odor. 
 
 Chromidrosis is the designation when the fluid poured forth is vari- 
 ously colored. 
 
 Uridrosis is the designation when the excretion from the sweat 
 glands contains the elements of the urine and particularly urea. 
 
 Phosphoridrosis is the designation when the perspiration appears 
 luminous in the dark. 
 
 Local hyperidrosis occurs most commonly upon the palms, soles, 
 axillae and genitalia. 
 
 Hyperidrosis of the palms may be so profuse that the fluid accumu- 
 lates and keeps the parts constantly macerated, the wearing of gloves 
 being impossible, for as soon as the parts are wiped dry they are again 
 bathed in the secretion. 
 
 Hyperidrosis of the soles is a disagreeable and often distressing 
 condition, as the socks and shoes become saturated, and thus keep 
 the soles constantly bathed, allowing the macerated epidermis to peel 
 off", leaving the more tender skin exposed, causing pain and distress 
 
378 PRACTICE OF MEDICINE. 
 
 when walking. The maceration of the epidermis, the secretion about 
 the toes, together with the moisture of the 'socks and the soles of the 
 shoes, promote the rapid development oi X}ci.^ bacteria fcetidum ; all 
 these together produce a most disagreeable, disgusting and persistent 
 odor, which is termed broinidro sis pedum. 
 
 Hyperidrosis of the genitalia attacks males more particularly, giving 
 rise to a disagreeable, penetrating odor. 
 
 The sweating may be limited to one side — U7iilateral hyperidrosis. 
 
 Prognosis. The majority of cases are extremely intractable; 
 complete recovery is rare in a fair proportion, while some cases are 
 easily relieved. 
 
 Treatment. The general condition of the patient must receive 
 proper attention. 
 
 Local treatfnent is the most valuable, however, in this alfTection. 
 
 The parts should be cleansed and immediately dried, and then 
 dusted with some one of the numerous dusting powders. The follow- 
 ing is a valuable powder : — 
 
 R. Acidi salicylat., gr. xx 
 
 Zinci oleat., ^j. M. 
 
 Perhaps the very best local application is tinctura belladonncE, either 
 diluted or full strength. 
 
 In hyperidrosis of the palms and soles, the following are valuable, 
 first washing the parts with a weak solution of acidum carbolicum : — 
 
 R . Acidi salicylici, .^ss 
 
 Cretae ])raep., 5j 
 
 Aluminis exsic, ^j. 
 
 M. et powder finely. 
 
 SiG. — Apply to parts with puff ball. 
 
 Or— 
 
 Or— 
 
 R. Acid, salicylici, 3 parts 
 
 Pulv. amyli 10 parts 
 
 Pulv. soapstone 87 parts. M. 
 
 Sic;. — Sift into shoes and stockings. 
 
 R. Ungt. picis lirjuidoe, 
 
 Ungt. suiphuris, aa J^'y 
 
 SiG. — Spread on cloth and applied with bandage. (Wilson.) 
 
DISEASES OF THE SKIN. 379 
 
 Or— 
 
 R . Potassii permanganat., gr. ij 
 
 Aquae, destil., f^j. M. 
 
 A saturated solution of acidiim boracicum applied frequently to the 
 hands and feet often proves curative. 
 
 For obstinate cases, involving the palms or soles, the following plan 
 of treatment, as suggested by Hebra, will be found of the greatest 
 service. It is imperative that the various steps be closely followed : 
 " The parts are to be cleansed with water and soap, and the follow- 
 ing ointment appHed on pieces of cloth cut to the size of the region. 
 Lint smeared with the ointment is also to be placed between the toes 
 or fingers, so that every portion of the skin may be covered with a 
 layer of the ointment. 
 
 R . Emplast. diacbyli, , f^Vf 
 
 Olei olivffi, f J iv. 
 
 The plaster to be melted, and the oil added and stirred until a homo- 
 geneous mass results. 
 SiG. — To be used on cloths. 
 
 " The cloths are to be changed every twelve hours, when the parts 
 are not to be washed, but rubbed with dry lint and starch dusting 
 powder, after which new dressings are again to be applied in the 
 same manner. This proceeding is to be continued from one to two 
 weeks. When the disease is upon the soles, the patient may walk 
 about in loose shoes." After a week or ten days the ointment can 
 be discontinued, but the dusting powder is to be continued for a con- 
 siderable period. If relapses occur, the original treatment should 
 again be instituted. 
 
 SUDAMINA. 
 
 Synonyms. Sudamen ; miliaria crystaUina (Hebra). 
 
 Definition. A non-inflammatory affection of the sweat glands ; 
 characterized by the rapid development of millet-seed-sized, translu- 
 cent, whitish vesicles, in great numbers, upon any portion of the body. 
 
 Causes. A high temperature, causing unusual activity of the 
 sudoriparous glands. 
 
 Patholog'y. The glands being excited beyond their capacity for 
 normal excretion, the excessive fluid, instead of escaping upon the 
 
380 PRACTICE OF MEDICINE. 
 
 surface, from some cause collects between the layers of the epidermis, 
 in the form of minute, translucent, pin-point-sized vesicles. 
 
 Symptoms. Each minute vesicle is distinct, but they exist in 
 great numbers, very closely resembling drops of free sweat. They 
 develop rapidly, never coalesce, become puriform or rupture. Fresh 
 crops form from time to time. Their duration is transitory ; the fluid 
 is absorbed, the covering of each dries, forming a thin, delicate mem- 
 brane, which disappears as a slight desquamation. 
 
 Treatment. The treatment is that of the disease with which 
 they occur. 
 
 ANIDROSIS. 
 
 Definition. A functional disorder of the sweat glands ; charac- 
 terized by a diminished or insufficient secretion of sweat. 
 
 Cause. The result of a congenital deficiency of the sweat 
 glandular apparatus. Local anidrosis may result from injury to a 
 nerve, during the course of chronic diseases of the skin, as ichthyosis, 
 eczema, psoriasis, lepra and elephantiasis arabum. In rare cases an 
 individual ceases to sweat entirely at times ; in such cases the general 
 health is impaired, and during the hot season much suffering may 
 ensue. 
 
 Treatment. Means to promote the activity of the skin and 
 glands is the indication, such as the ingestion of large quantities of 
 water, hot baths and steam baths, friction and the use of sudorifics, 
 the most valuable of which \s pilocarpus. 
 
 HYPERiEMIAS OF THE SKIN. 
 
 ERYTHEMA SIMPLEX. 
 
 Definition. An acute affection of the skin, in which occurs an 
 abnormal quantity of blood in the dermal vessels; characterized by 
 discoloration, which disappears upon pressure and with more or less 
 local increase of temperature. 
 
 Varieties. Idiopathic erythema ; symptomatic erythema. 
 
 Causes. Idiopathic erythema; heat, cold, pressure, friction, or 
 the contact of irritants, such as mustard, arnica and dyestuffs. 
 
 Symptomatic erythema occurs most frequently in childhood, from 
 diseases of the stomach and intestines; during the course of the 
 various exanthemata. 
 
DISEASES OF THE SKIN. 381 
 
 Symptoms. A more or less rapidly developed redness of the 
 skin, varying in color from pink or light red to dark red, which 
 disappears upon pressure, to rapidly return again. The extent and 
 form of the congestion varies according to the cause, at times being 
 as small as a coin and isolated, and again diffused over a large 
 area. The temperature of the congested part is slightly above the 
 normal. 
 
 Slight itching and burning are, usually, associated with the discol- 
 oration. 
 
 Diagnosis. Erythema resembles acute dermatitis in color, but 
 the subjective symptoms of the latter are so decided that an error 
 should not occur. 
 
 Treatment. Controlled by the cause, which should be removed, 
 and the local application of some one of the various dusting powders. 
 
 ERYTHEMA INTERTRIGO. 
 
 Definition, An acute congestion of the skin ; characterized by 
 redness, heat, increased perspiration, and an abraded surface, with 
 maceration of the epidermis. 
 
 Causes. In the fleshy, from contact or friction of opposing sur- 
 faces exposed to warmth — chafing. In children and infants contact 
 of moist clothing; also disorders of digestion. 
 
 Symptoms. Parts where the natural folds of the skin come in 
 contact with one another, as the nates, perineum, groins, axilla and 
 beneath the mammse, in the fleshy and in infants, become red, hot, 
 painful, and have an increased flow of perspiration, which in turn 
 softens the epidermis, giving rise to an acrid mucoid fluid. If not 
 checked by the removal of the cause and the application of the dust- 
 ing powders, inflammation — dermatitis — results. 
 
 Treatment. The congested parts should be thoroughly washed 
 with water and castile soap, or with bran-water, and carefully dried 
 with a soft towel. The opposing folds of the skin are to be kept sepa- 
 rated with lint or soft linen, the parts first covered with cretcE pra- 
 parata, zinci oxiduni, bismuthi subnitras, amylutn, lycopodiujn or 
 buckwheat flour. 
 
382 PRACTICE OF MEDICINE. 
 
 INFLAMMATIONS OF THE SKIN. 
 ECZEMA. 
 
 Synonyms. Tetter ; salt rheum ; scall. 
 
 Definition. A non-contagious inflammation of the skin, charac- 
 terized by any or all of the results of inflammation at once or in suc- 
 cession, such as erythema, papules, vesicles or pustules, accompanied 
 by more or less infiltration and itching, terminating in a serous dis- 
 charge, with the formation of crusts, or in desquamation. 
 
 Forms. Aaite ; chronic. 
 
 Varieties. Eczema erythematosnin ; eczema vesiciilosum ; eczema 
 pustu/os2if?i ; ec ze?n a papillosum ; eczema rubrttm ; eczema squa77iosMm ; 
 eczema fissum; eczema verrucosum ; eczema sclerosum. 
 
 Cause. Eczema attacks persons in all spheres, the rich, the poor, 
 the infant or the aged, and males or females. Many families, espe- 
 cially those having the " catarrhal predisposition or peculiarity of con- 
 stitution," seem more liable; indeed, it appears probable that a pre- 
 disposition to eczema may be transmitted from parent to child. 
 Among the causes suggested are : dentition, improper food, gastro- 
 intestinal disorders, intestinal parasites, deficient urinary secretion, the 
 rheumatic and gouty diathesis, vaccination, prolonged contact of hot 
 fomentations, heat and cold, and contact with the poison vine (rhus 
 toxicondendron) and poison tree (rhus venenata). 
 
 Pathology. Eczema is a catarrhal inflammation of the skin — 
 a dermatitis with superficial serous exudation. There is first hyper- 
 CEmia or congestion of the vessels of the skin — eczema erythematosum 
 when uniformly distributed, eczema papulosum when the congestion 
 is limited to distinct points. The hypersemia is soon followed by a 
 serous exudation. If the superficial exudation be profuse enough to 
 form small drops, and if the epidermis possess sufficient resisting 
 power not to give away immediately before it, vesicles form, producing 
 the variety known as eczema vesiculosum ; if the vesicles contain a 
 large admixture of young cells, so that the serum be turbid, yellow and 
 purulent, the vesicles become pustules, termed eczema pustulosum ; 
 if the serous exudation be not sufficient to either elevate or break 
 through the epidermis, instead of either vesicles or pustules forming 
 there occur dry scales, rising from the reddened skin — eczema squa- 
 mosum. When the exudation is sufficient to detach the epidermis, 
 thus exposing the red and moist corium, it is termed eczema rubrum. 
 
DISEASES OF THE SKIN. 383 
 
 In chronic eczema the skin is sub-acutely inflamed ; is very much 
 thickened, hardened and infiltrated with cells which extend through- 
 out the entire corium, even into the subcutaneous connective tissue. 
 The papillae are enlarged and at times may be distinguished with the 
 naked eye. Pigmentation may take place in the deep layers of the 
 rete, and in the corium, especially about the vessels. 
 
 Symptoms. Eczema is the most common of all cutaneous affec- 
 tions, with symptoms varying in accordance with the particular va- 
 riety of the affection and its location, although the general character- 
 istics of a catarrhal inflammation are present in all ; these are redness ^ 
 either limited or diffused, heat of the part affected, swelling, the result 
 of the serous exudation, giving rise either to a discharge (weeping), 
 with subsequent crusting, or to the deposition of plastic material. 
 The most constant, annoying and troublesome symptom is the itching, 
 or at times burning, which varies from that which is simply annoying 
 to that which is almost unendurable. 
 
 Eczema runs its course either as an acute affection, lasting a few 
 weeks, not to return, or to return acutely at wide intervals, or, as is 
 much more frequently the case, it assumes a chronic state, continuing 
 with more or less variations for months, years or even a lifetime. It 
 may appear upon any portion of the body, or involve the whole 
 integument {eczema universale). The varieties are named in the 
 order which the lesions assume at its commencement. 
 
 Eczema Erythematosum. An erythema or redness of the 
 surface, with a yellow tinge. The size of the macule may be very 
 small or quite extensive, with irregular outlines. There may be slight 
 swelling of the patch, but no discharge occurs unless it be where two 
 surfaces come into contact {eczema intertrigo), as about the genitalia. 
 Cases without discharge are covered after a few days with a thin film 
 of dry, exfoliating epidermis or scale {eczema squamosu7n). When a 
 discharge (weeping) or moisture occurs, it is followed with more or 
 less crusting. 
 
 Intense itching is a constant symptom. 
 
 Eczem.a Vesiculosum. Begins with burning, paiti, redness and 
 swelling, followed by an immense number of minute vesicles, either 
 discrete or confluent, rapidly distending with a clear or yellowish 
 fluid and attended with intense itching. Soon the vesicles rupture, 
 the fluid rapidly diffusing over the surface and drying into yellowish, 
 honey-like crusts. New crops of vesicles soon follow, or if subsequent 
 
384 PRACTICE OF MEDICINE. 
 
 vesication do not occur, the fluid rapidly diffuses over the excoriated 
 surface, which also, in turn, dries into large, yellowish crusts. After 
 a variable time the various symptoms gradually subside. 
 
 Itching \s the most prominent subjective symptom, is iatense, and 
 eives rise to an irresistible desire to scratch. 
 
 All portions of the body are liable to this variety of eczema, the 
 most frequent location, however, being the face, and when occurring 
 in children is commonly known as crusta lactea. 
 
 Eczema Pustulosura, or Eczema Impetiginosum. This 
 variety usually begins as vesicular eczema, the fluid rapidly changing 
 to pus. After a short period, during which the pustules have in- 
 creased in size, they burst and the escaped fluid forms thick, greenish- 
 yellow crusts, which, in turn, rapidly dry and fall off, or crumble 
 away. 
 
 The location of this variety is most usually upon the scalp and face. 
 It is stubborn to treatment. Itching \% a prominent symptom. 
 
 Eczema Papulosum, or Lichen Simplex. This variety of 
 eczema appears in the form of small, rounded papules, the size of a 
 pin-head, of bright red, or at times dark red color ; they may be either 
 discrete or confluent. In some cases all, while in others a greater or 
 less number of the papules pass into vesicles and run much the same 
 course as vesicular eczema. The itching is of the most intense char- 
 acter, leading to severe scratching, by which the summits of the 
 papules are torn, causing them to bleed, the blood forming dark red 
 crusts. 
 
 Eczema Rubrum, or Eczema Madidans. This is a variety 
 only from a clinical standpoint. It may result from any of the fore- 
 going varieties. The surface of the skin is inflamed and infiltrated, 
 red, moist and weeping, the profuse serum rapidly drying into thick, 
 yellowish, greenish or brownish crusts, the color depending upon the 
 character of the fluid, which may be serum, pus or blood from the 
 exposed and lacerated corium. The crusts adhere closely and firmly 
 to the part, and, unless removed by mechanical means, may remain 
 indefinitely, the disease pursuing its course beneath. 
 
 Eczetna rubrum, or niadidajis, "then, presents two appearances — 
 as it occurs with its crust, and as it exists without this covering. In 
 the one case the skin itself is altogether obscured l)y a dirty, yellowish 
 or brownish crust ; in the other the skin presents a bright or violaceous 
 red. punctate, wounded surface, deprived in great part of its epider- 
 
DISEASES OF THE SKIN. 385 
 
 mis, and exuding a scanty or profuse, clear or opaque, syrupy, yel- 
 lowisli fluid. Sometimes tliis is streaked with blood." The itching 
 and burning are severe. It may develop upon any portion of the 
 body, but is most commonly seen upon the legs, particularly in elderly 
 people. Its course is chronic and increasing in severity. 
 
 Eczeraa Squamosura. This is also a clinical variety. It results 
 from the erythematous, vesicular, pustular or papular varieties of the 
 affection, but more particularly the first named. A typical case pre- 
 sents itself in the form of variously sized and shaped reddish patches, 
 which are dry, or more or less scaly, the skin being more or less infil- 
 trated or thickened. Its course is usually chronic. 
 
 Eczema Pissum, or Riraosum. Another clinical variety. 
 During the progress of the erythematous, vesicular or pustular varieties 
 of eczema, cracks ox fissures result when the lesion occurs upon regions 
 subject to constant motion, such as between the fingers, toes and the 
 various joints. At times the fissures are extensive and deep, and of 
 a bright red color, showing the true skin, and intensely painful upon 
 motion. Chapped hands are typical instances of fissured eczema. 
 
 Eczema Sclerosum.. This variety of eczema, occurring most 
 commonly on the palms, soles and finger-tips, is characterized by hy- 
 pertrophy of the papillae, showing itself as hard, thickened, infiltrated, 
 localized patches, which are most apt to crack (eczema fissum). 
 
 Eczema Verrucosum, or Papillomatosum, differs from the 
 foregoing in that the thickened, infiltrated patch has a warty verru- 
 cous appearance. Its course is chronic. 
 
 Eczema Acutumi et chronicura. The line which divides 
 these two conditions is drawn by means of the clinical and patho- 
 logical features. The course of eczema, in the majority of instances, 
 is chronic. It may be said that so long as the general inflammatory 
 symptoms are high and the secondary changes slight, the affecdon is 
 acute, and that when the process has settled itself into a definite line 
 of action, continually repeating itself and accompanied by secondary 
 changes, it is chronic. 
 
 Diag'nosis. The many varieties in which eczema manifests itself 
 renders the diagnosis a matter of importance. The following charac- 
 teristic features of eczema are of value in arriving at a diagnosis : 
 infiamination, sxvelling and cedeina, thickening from cell infiltration, 
 redness, the discharge or moisture, followed by crustifig, on removal 
 of which a moist surface is presented, and itching and burning. 
 32 
 
386 PRACTICE OF MEDICINE. 
 
 Erysipelas may be confounded with erythematous or vesicular 
 eczema. The points of difference are the fever and other general 
 disturbances, the deep-seated inflammation of the skin, rapidly- 
 spreading, with heat, swelling and oedema without moisture, giving 
 the surface a deep red, shining and tense appearance, are character- 
 istic of erysipelas and very different from eczema. 
 
 Herpes and vesicular eczema bear some resemblance to each other; 
 herpes zoster is distinguished by the neuralgic pains which are asso- 
 ciated with it and are never associated with eczema. The other varie- 
 ties of herpes occurring about the face and genitalia run their course 
 in a few days, while eczema is of much longer duration and has a 
 discharge followed by crusting. 
 
 Seborrhcea of the scalp and squamous eczema of the same region 
 closely resemble each other. In eczema, however, the skin is more 
 or less red, inflamed and thickened, and the scales larger, less abun- 
 dant and less greasy and drier than seborrhcea. In eczema the scales 
 are usually seated upon a circumscribed patch, while in seborrhcea, as 
 a rule, they cover the scalp uniformly. Itching occurs with both dis- 
 orders. The history of the two affections should be of material aid 
 to render the diagnosis clear ; still, however, in many cases the diffi- 
 culty is marked. Both are frequent affections. 
 
 Psoriasis should never be confounded with a typical case of eczema, 
 but chronic eczema, with infiltrated, inflammatory, scaly patches, fre- 
 quently looks very much like psoriasis. 
 
 Treatment. There is no specific. The indications are for the 
 removal of the cause, where it can be ascertained, if it be possible, 
 and attention to the general health. The diet should be of the most 
 nutritious, but easily digestible character ; fresh air and moderate 
 exercise are also essential elements in the treatment, together with 
 attention to the secretions. If the bowels be sluggish, much benefit 
 follows the use of such laxative mineral spring waters as the Hathorn, 
 or Hunyadi Arpad, or a morning dose of iJiagnesii sulphas. For chil- 
 dren, syrupus rhei, to which may be added magnesia ; or what is per- 
 haps more efficient, a small dose of hydrargyri chloridimi mite. If 
 the urinary secretion be small and the urine heavy, use should be 
 made of full doses of poiassii acetas and large draughts of water. If 
 either a rheumatic or gouty disposition exist, lithium salts, to which 
 may be added vinuin colchici seminis. If a scrofulous tendency 
 exist, use oleum morrhuce and syrupus ferri iodidi. If anaemia, 
 
DISEASES OF THE SKIN. 387 
 
 ferriim, quinina, strychnina and the mineral acids, or syrupus hypo- 
 phosphitis comp., are indicated. 
 
 Locally : the most important means of treatment for all the varie- 
 ties of eczema are with local remedies, suiting the appropriate ones 
 for each particular case, as no one combination is applicable for all 
 varieties. It maybe stated, as a principle, that nothing irritant is ever 
 to be applied to the surface in acute eczema, and that in the chronic 
 form nothing can hardly be too stimulating. The too frequent wash- 
 ing or general baths are to be avoided, as they have a tendency to 
 macerate the already softened epidermis. For cleansing purposes, in 
 the majority of instances, ordinary Castile soap is sufficient. 
 
 Crusts and scales are nearly always present in eczema, and are to 
 be removed before medicaments can be successfully applied. Their 
 removal is to be secured by saturation with oily preparations, a starch 
 or other mild poultice, or a saturated solution of acidum. boracicum. 
 After their removal the parts are to be cleansed with Castile soap and 
 water. 
 
 For acute erythematous or vesicular eczema, use but little, or what 
 is better, no soap or water ; instead, cover the parts with a dusting 
 powder, such as — 
 
 R. Pulv. camphorae, ^j 
 
 Zinci oleat., ^\] 
 
 Pulv. amyii., J j. M. 
 
 SiG. — Dusting powder. 
 
 For acute vesicular eczona, Dr. J. C. White recommends bathing 
 the affected part with lotio nigra (hydrargyri chlor. mite gr. viij, 
 liquor calcis f^j), full strength, or diluted with equal parts of lime 
 water, apphed by means of a sponge or a piece of cloth, for ten or 
 fifteen minutes at a time, and at intervals of a few hours or longer, 
 the sediment being allowed to remain on the skin ; after which tmg. 
 zinci oxid. is to be gendy rubbed over the part. As a rule, the itching 
 and burning are relieved at once, and the affection often arrested. 
 Good results follow the use of a saturated solution of acidum bora- 
 cicu7n. 
 
 There are cases which do better from the application of ointments, 
 of which the following is valuable : — 
 
 R • Zinci oleat., 
 
 Olei olivae, aa ..... ;^iv. ]VI. 
 
388 PRACTICE OF MEDICINE. 
 
 Or, bismuth oleaie, made according to the following formula of Dr. 
 McCall Anderson : — 
 
 R. Bismuthi oxidi, .^j 
 
 Acidi oleici, ^j 
 
 Cerre albse, ,^iij 
 
 Vaselini, 3;ix 
 
 01. rosae, TT\^ij. M. 
 
 If the discharge be excessive, the following formula of Prof. Bar- 
 tholow I have seen useful : — 
 
 R. Plumbi acetat, ^ss 
 
 Pulv. camphorse, J^r- xv 
 
 01. amygdal., f^ij 
 
 Cerat. flav., ^j. M. 
 
 The late Dr. Frank Maury was partial to the following formula in 
 vesicular eczema : — 
 
 R. Hydrargyri chlor, mite, gr. xx 
 
 Ung. zinci oxid. benz., ^j. M. 
 
 For eczema papulosum the following lotions are particularly 
 valuable : — 
 
 R. Acid, carbolici, 3J-ij 
 
 Glycerini, f^iv 
 
 Alcoholis, f^iv-vj 
 
 Aquse destil, ad Oj. M. 
 
 — DUHRING. 
 
 Or— 
 
 R. Thymol, gr. x-xx 
 
 Alcoholis, f 5j 
 
 Aquae destil i%\. M. 
 
 After the disappearance of the more acute symptoms, more stimu- 
 lating applications are indicated, among which are acidum carboli- 
 cum, thymol, pix liquida or oleum cadimim. It is to be remembered, 
 however, that the more chronic the affection and the less the inflam- 
 matory symptoms, the more successful is tar in the treatment of 
 eczema. 
 
 Dr. Duhring considers the following one of the most elegant of the 
 tarry ointments : — 
 
DISEASES OF THE SKIN. 389 
 
 R. Olei cadini, f.^iss 
 
 Cerati simplicis, Jj 
 
 01. amygdal amar., gtt. x. M. 
 
 Ft. ungt. 
 
 Or— 
 
 R. Picis liquidae, fgj 
 
 Glycerini, f^] 
 
 Alcoholis, f^vj 
 
 01. amygdal. amar., gtt, xv, M. 
 
 SiG. — To be rubbed firmly into the skin. 
 
 The following is Dr. Bulkley's valuable "liquor picis alkalinus : "— 
 
 R. Picis liquidse, f^ij 
 
 Potassae causticse, 5J 
 
 Aquae destillatae, f 3 v- M. 
 
 The potassa to be dissolved in water and gradually added to the tar 
 with rubbing in a mortar. 
 
 SiG. — To be used diluted. 
 
 A very elegant preparation of tar is the French mixture known as 
 " Goudron de Guyot." 
 
 For eczema rubrmn, one of the most intractable varieties of the 
 disease, especially the chronic eczema of the legs, the following 
 mode of treatment, first suggested by Hebra, is the treatment par 
 excellence. 
 
 The accompanying instructions are to be adhered to. A lump of 
 the sapo viridis (made originally of herring fat and potassa, and con- 
 taining three per cent, of caustic potassa), the size of a small nut, is 
 smeared upon a piece of wet flannel and applied to the affected part, 
 and firmly rubbed until the soap has disappeared, when the flannel is 
 to be dipped into warm water and again applied to the part and 
 rubbed until an abundant lather forms, more water being added 
 from time to time until the suds are most abundant, when the surface 
 is thoroughly washed and freed from all the soap and carefully dried, 
 after which the following (Hebra's diachylon) ointment, having been 
 spread before the application of the soap, is to be applied. It is pre- 
 pared as follows : — 
 
 " Fifteen ounces of the best olive oil are added to two pounds of 
 water, and heated to boiling in the water bath. Three ounces and 
 six drachms of an equally good article of litharge (plumbi oxidum) 
 are dusted over the fluid in ebullition, which is constantly stirred 
 
390 PRACTICE OF MEDICINE. 
 
 throughout, in order to prevent the formation of fatty acids. During 
 the cooking, water is occasionally added as required. The stirring is 
 to be continued until the ointment is quite cold." 
 
 The ointment is spread upon strips of soft muslin and the affected 
 part enveloped, care being exercised that neither folds nor wrinkles 
 occur, the whole being covered by a firm roller and the patient being 
 able to go about as usual. The entire operation is to be repeated 
 twice daily. 
 
 A modification of the above ointment, technically known as 
 " unguentum diachyli albi of Hebra,'' has been successful in my 
 hands in a number of cases. The formula is : — 
 
 H . Eraplast. plumbi, 
 
 Vaseline, aa ^j 
 
 01. lavandulse, q. s. M. 
 
 Dissolve with heat and stir till cold. 
 
 SiG. — Apply on strips, etc. 
 
 Prof. Da Costa has used with success in eczema rubra, liquor 
 arsenici et hydrargyri iodidi, TT\,ij-v, t. d., and — 
 
 R. Ung. plumbi subacet., ^iv 
 
 Acid, carbolici cryst., gr- "j 
 
 Ungt. petrolei, ^iv. M. 
 
 SiG. — Apply freely on muslin strips. 
 
 An excellent formula in eczema vulva is : — 
 
 R. lodoformi, ^ss 
 
 Bal. peru., '7^\ 
 
 Vaseline, f,^j. M. 
 
 SiG. — Apply on soft cloths. 
 
 Eczema capitis is either erythematous, vesicular or pustular in 
 character. If the first named, it at once tends to become chronic, 
 settling into the variety known as eczema squamosum, often involving 
 the entire scalp and accompanied with intense itching. The pustular 
 variety is the more common form, occurring upon the scalp of chil- 
 dren and young adults, existing as a few patches, or, what is more 
 frequent, involving the entire scalp. The pustules soon rupture, the 
 liquid drying into greenish-yellow crusts, which, if the affection be 
 extensive, cover the whole scalp with a cap of crust. The hair be- 
 comes matted and caked, the sebaceous secretion collects, and if the 
 part be not cleansed the head becomes offensive. In severe cases of 
 
DISEASES OF THE SKIN. 391 
 
 pustular eczema of the scalp, enlargement of the lymphatic glands of 
 the back of the neck and of those behind the ear occur ; they never 
 suppurate. Pediculi are frequently associated with eczema capitis of 
 children, either as a primary cause or a result of the matted condition 
 of the hair constituting a favorable habitat for them. When present 
 they call for active treatment. 
 
 Eczema capitis may be confounded with psoriasis, seborrhoea, 
 syphihs, tinea favosa, and tinea tonsurans. 
 
 Treatment. If the pustular variety, removal of the crusts is the 
 first indication. This is accomplished by saturating the scalp either 
 with oleum oHvce or oleum amygdalcs dulcis, and then washing with 
 warm water and soap, or the use of a starch poultice ; after their 
 removal the application of the following ointment, used by Prof. 
 Da Costa : — 
 
 R. Hydrargyri chlor. mite., gr. xx 
 
 Acid, carbol. cryst., gT- "j 
 
 Ung. petrolei, ^j. M. 
 
 SiG. — Thoroughly applied. 
 
 The late Prof. Ellerslie Wallace was fond of the following : — 
 
 R. Sodii carb., gr, xxx 
 
 Ung. petrolei, ^j, M. 
 
 SiG. — Apply thoroughly after removal of the crusts. 
 
 I have usually been successful with cleanliness, proper dietary, the 
 internal use of liquor arsenici et hydrargyri iodidi, TTLss-j, well 
 diluted, after meals, and the local use of unguentum picis liquidce 
 diluted with vaseline. 
 
 In cases associated With, pediculi, I have succeeded with the follow- 
 ing, after removal of the crusts : — 
 
 R . Hydrargyri ammoniat., gr. x-xx 
 
 Adeps benzoat., 5j. M. 
 
 SiG. — Thoroughly applied. 
 
 For the squamous variety of the scalp, the following formula, 
 recommended by Dr. Duhring, is excellent : — 
 
 B . Picis liquidae, f ^ j 
 
 Glycerini, f^j 
 
 AlcohoHs, f^vj 
 
 01. amygdalae amar., gtt. xv. M. 
 
 SiG. — Diluted or full strength, rubbed thoroughly into scalp. 
 
392 PRACTICE OF MEDICINE. 
 
 - Eczema faciei. In this location the affection may be either acute 
 or chronic. In adults the erythematous variety is frequently encoun- 
 tered in patches about the forehead and cheeks. Eczema of the face 
 is more common in children, however, the varieties being the vesicu- 
 lar and pustular. It is seen on the forehead, nose and upper lip, and 
 is associated with severe itching. 
 
 Treatment. The same as eczema capitis, or the following : — 
 
 R . Zinc oleat., ^\ 
 
 Ung. petrolei, ^j. M. 
 
 Eczema labiormn. Eczema attacks the lips, either alone or in con- 
 nection with other parts of the face. One or both lips may be affected. 
 The symptoms are : swelling, redness, heat, infiltration, slight scali- 
 ness and fissures. The affection may be in the skin around the border 
 of the mouth, or the vermilion and mucous membrane of the lips. 
 The mouth may be contracted and the lips partly glued together by 
 the exudation and crusts. 
 
 Eczema labiorum may be confounded with herpes labialis and 
 syphilis. 
 
 Treatment. Very difficult and discomforting to the patient. Among 
 the remedies at times successful are : ar genii nitras, potassa nitras, 
 acidujn carbolicum, pix liquida, oleicm, ergota and collodium,fiexile. 
 
 Eczema palpebrariwi. A frequent occurrence in scrofulous chil- 
 dren, showing itself along the edges of the eyelids. Pustules involve 
 the hair foUicles, followed by the usual crusting. The symptoms are 
 swelling, redness and itching, and unless the parts are frequently 
 cleansed, the lids tend to glue together. Conjunctivitis frequently 
 complicates the affection. 
 
 Treatment. In mild cases success follows the use of zinci oleat. or 
 glyceritum acidi tannici. In severe cases the plan recommended by 
 McCall Anderson should be pursued. It consists in the extraction of 
 the eyelashes and touching the edges of the lids with a solution of 
 potassa in water, ten grains to the ounce. The edges should be care- 
 fully dried and the lid everted, a very small quantity on a delicate 
 brush being applied, immediately neutralizing the alkali with acidum 
 aceticum or vinegar. 
 
 Eczema barbce. Eczema of the beard is characterized by the forma- 
 tion of extensive pustules, with preference for about the hairs, drying 
 as yellowish or greenish crusts, matting the hairs together and adher- 
 
DISEASES OF THE SKIN. 393 
 
 ing to the parts. The affection may be confined to the hairy portions 
 ot the face, or extend to other regions of the face, be locahzed or gen- 
 eral, acute or chronic. 
 
 Eczema barbae in general features somewhat resembles both tinea 
 sycosis and sycosis non-parasitica, but sycosis is an inflammation of 
 the hair follicles only and is rarely associated with crusting, while 
 crusting is abundant in eczema. 
 
 Treatment. Must be energetic and decided. The crusts are to be 
 removed by poultice or warm water and soap. Then the part is to be 
 cautiously shaved ; although quite painful the first time, it is hardly so 
 afterward, as it is to be repeated every two or three days. After shav- 
 ing, if the attack be acute, the same plan of medication as recom- 
 mended by Hebra for eczema rubrum is to be practiced, the application 
 to be continuous both day and night, or only at night. If the attack 
 be chronic, the following ointment should be applied after cleansing 
 and shaving the beard : — 
 
 R. Hydrargyri ammoniat., . . , gr. xv-xxx 
 
 Sulphur, 3^^~j 
 
 Ung. petrolei, ............. 3J. M. 
 
 SiG. — To be thoroughly applied. 
 
 In this variety of eczema I have seen marked benefit from the use 
 of liquor arsenici et hydrargyri ijdidi, ni,ij-v, three or four times 
 daily. 
 
 Eczema auriutn. Eczema of the ears may be either erythematous, 
 vesicular or pustular. If the former, thickening results, with desqua- 
 mation of flakes or large scales ; if either of the latter, crusts form, 
 which may envelop the whole ear, the symptoms being swelling, red- 
 ness and severe burning and itching, and if the process extend into 
 the meatus, occlusion may result, causing temporary deafness. The 
 most characteristic symptoms of erythematous eczema of the external 
 auditory canal, besides the appearance of small flakes, is intense and 
 persistent itching. 
 
 Treatment. For acute vesicular or pustular eczema, removal of the 
 crusts and the use of hydrargyri chloridi mite as an ointment of the 
 strength of thirty grains to the ounce. If chronic, the use of pix 
 liquida, as already suggested. For chronic erythematous eczema of 
 the external auditory canal, the following formula has generally con- 
 trolled this stubborn condition : — 
 33 
 
394 PRACTICE OF MEDICINE. 
 
 R . Hy('rargyri flav. oxid , gr. j-iij 
 
 Morphinne sulph., . gr. j 
 
 Vaseline, ^ij. M. 
 
 SiG. — Apply to the canal. 
 
 Eczema genitalium. This is a most distressing condition. In the 
 male the-scrotum and penis are involved alone or together, the former 
 alone being the more common, and is complicated with eczema of 
 the inner side of the thigh or thighs. The symptoms of eczema of 
 the scrotum are, swelling, often oedema as well, moisture, crusts, and 
 painful fissures, followed by extensive thickening and accompanied 
 by intense itching. In the female the affection attacks the labiae, and, 
 rarely, the vagina and mons veneris, and may extend to the surround- 
 ing parts, especially to the perineum. The symptoms of eczema of 
 the labia are, great swelling, oedema, redness, with great heat and a 
 free discharge, forming crusts, which are apt to glue the opposing 
 surfaces together. If the variety be the erythematous, in place of a 
 discharge with crusts, the symptoms named are followed by slight 
 scales. The twitching is most violent and distressing. 
 
 Treat7ne7it. The parts attacked should be kept constantly envel- 
 oped in cloths wet with a saturated solution of acidiim boracicum until 
 the more pronounced inflammatory symptoms subside, when should 
 be applied ointments of zinci oleat. or hydrargyri chloridum mite. 
 Persistent cases will often succumb to the plan of treatment suggested 
 by Hebra for eczema rubrum. 
 
 Eczejna ani. The anus may be attacked alone or associated with 
 eczema of the perineum and genitalia. The symptoms are : redness, 
 swelling, infiltration and thickening, with or without fluid exudation. 
 Fissures of the anus are usually present, and add to the distress of 
 the patient the pain attending each stool. Persistent itching and 
 burning, worse after retiring, adds to the misery of the patient. 
 
 Pruritus ani may be mistaken for eczema ani. In the former the 
 itching is only associated with such symptoms of inflammation as 
 result from the irritation of scratching, while in the latter inflammatory 
 symptoms precede the itching. 
 
 Treatment. The more acute symptoms are relieved by bathing 
 the parts with a solution of acidum boracicu?n, after which a weak 
 application of acidum. carbolictim^ either as a lotion or ointment. 
 The late Prof, S. D. Gross recommended the application of the 
 following : — 
 
DISEASES OF THE SKIN. 395 
 
 R. Zinci oxidi, 3 vj 
 
 Hydrargyri chlor. corrosiv., gr. j 
 
 Glycerini, 3 ij. M. 
 
 SiG. — Apply thoroughly to affected parts. 
 
 Eczema intertrigo. Parts of the body that naturally come into con- 
 tact with each other, as about the joints, the inner surfaces of the 
 nates, in the groins and beneath the mammae, are frequently attacked 
 with erythematous eczema, which is frequently, but erroneously, 
 termed erythema intertrigo or chafing. The symptoms are : redness, 
 heat, and a moist, macerated surface, aggravated by movement of 
 the affected parts. 
 
 Treatment. The application of a solution of acidum boracicum, 
 or the use of dusting powders, such as zinci oleat., aiJiylum ox hydrar- 
 gyri chloridtim mite. It is essential for successful treatment that the 
 opposing surfaces be separated by means of lint or cloths. 
 
 Eczema manimariim. The nipples, and more particularly those of 
 primiparse, are at times the seat of a vesicular eczema, with the form- 
 ation of crusts and fissures, and unless speedily reheved develops 
 eczema rubrum. The pain on nursing becomes so severe that the 
 mother is compelled to refuse the child. It must be borne in mind 
 that eczema mammarum occurs in women who are not nursing and 
 in single women. 
 
 Treatnient. Dr. Tilbury Fox advises the following plan : — 
 
 " I. Great cleanliness and care in washing away any remnants of 
 milk after each time that the child is put to the breast ; and, if the 
 nipple be tender and excoriated, use — 
 
 " 2. A little liquor plumbi and calamine powder, as follows : — 
 
 ]^ . Liq. plumbi, f^iss 
 
 Pulv, calaminse praep., ^iss 
 
 Glycerini, ^j 
 
 Adipis, ad 5J. M. 
 
 "3. I cover over the nipple with a lead nipple shield. This ex- 
 cludes the air, keeps the part from being chafed, and I think the 
 lead does good after the part has become less red and sore. I often 
 use a little glyceral tannin, painted on night and morning. 
 
 " The above application can always be removed with a little cold 
 cream and a little warm water sponging before the child goes to the 
 breast." 
 
396 PRACTICE OF MEDICINE. 
 
 Eczema palmanim et plantarum. The features of the affection in 
 both these regions are identical. The diagnosis is often obscured by 
 the thickened state of the epidermis. The symptoms are : infiltration, 
 thickening, callosity, moisture followed by dryness, and Assuring, the 
 last named frequently becoming so deep and painful that the patient 
 is unable to use his hands, or, if on the soles, to walk. 
 
 The affection is almost chronic, affecting either of the parts alone, 
 or all at one and the same time. Itching is a constant and annoying 
 symptom. 
 
 The diagnosis is to be made between eczema of these parts and 
 psoriasis or syphilis. 
 
 Treatment. The plan of Hebra for eczema rubrum will usually be 
 successful for this variety. The following formula is also valuable : — 
 
 H. Hydrargyri oleat. 5-15 per cent., ^iv 
 
 Olei cadini, ^ss 
 
 Cerat. simp., ^iv. M. 
 
 SiG. — Rub well into part morning and night, first macerating with hot 
 water. 
 
 Eczema tmguium. The nails are seldom attacked alone, but in 
 connection with eczema manuum. The symptoms are roughness, 
 want of polish, unevenness and a punctate or honeycomb appear- 
 ance similar to that seen in psoriasis of the nails. The nail becomes 
 depressed, particularly at its root, thus interfering with its nutrition, 
 resulting in loss of this appendage. 
 
 Treatment. Internally arsenicum is of the greatest value. Locally, 
 the following : — 
 
 R. Ung. picis liq., ^iv 
 
 Hydrargyri chlor. mite, ^ss 
 
 Vaselini, :5 iv. M. 
 
 SiG. — Apply thoroughly. 
 
 It is a remarkable clinical fact, that very many cases of eczema, 
 whether acute, subacute or chronic, are rapidly cured by the use of 
 potassii iodidicm in variable doses. 
 
 URTICARIA. 
 
 Synonyms. Hives ; nettle-rash. 
 
 Definition. An inflammation of the skin characterized by the 
 development of wheals of a whitish, pinkish or reddish color, accom- 
 panied by stinging, pricking and tingling sensations. 
 
DISEASES OF THE SKIN. 397 
 
 Causes. Very frequently the result of sudden surface hyperaemia, 
 or rather too rapid circulation through the superficial capillaries, the 
 result of exposure to heat. Irritants and poison produce an attack 
 when brought in contact with the skin. Gastric, intestinal, hepatic, 
 nephritic, ovarian, uterine and cystic derangements are very frequent 
 causes. Certain medicaments; malaria; nervous disorders; asso- 
 ciated with purpura and rheumatism ; pregnancy ; lactation ; meno- 
 pause. 
 
 Patholog'y. An acute inflammation of the papillary layer of the 
 skin ; characterized by the rapid development of a "wheal " — a more 
 or less firm elevation — consisting of a circumscribed collection of a 
 semi-fluid material, the result of a rapid exudation into the upper 
 layers of the skin. The production of the wheal is the immediate 
 result of a disturbance of the vaso-motor system, which is shown by 
 the interference of the circulation in the wheal, the blood being 
 driven from its centre to its periphery, causing the whitish apex and 
 red areola, so characteristic of the developed wheal. 
 
 Symptoms. An attack of "hives" is characterized by the sud- 
 den development of w-^^^xA upon the cutaneous surface, which usually 
 as suddenly disappear, their site being temporarily marked by a spot 
 of redness or hyperaemia. 
 
 With the appearance of the wheal occur distressing itching, burn- 
 ing, tiftgiing, crawling, pricking and stinging sensations, to relieve 
 which the patient still further irritates, tears or otherwise wounds the 
 surface by scratching, whence are often developed deep-colored, flat, 
 lenticular papules. 
 
 Very frequently an attack of " hives " is associated with fever, head- 
 ache and gastric disorder. The "wheals" may appear upon any 
 portion of the body ; their size varies from that of a pea to that of a 
 walnut or an ^^g — the " giant wheals;" the number varying from a 
 very few to being so numerous as to cover the whole surface of the 
 body. The shape, size, color and number of the wheals that may occur 
 in any given case have given rise to a number of names to designate 
 the lesions. Thus, urticaria ajimilaris occurs in rings ; urticaria 
 figurata occurs in spirals ; urticaria vesiculosa has a vesicular devel- 
 opment on the summit of the wheal ; urticaria bullosa, a bullous 
 development at the summit ; urticaria papulosa or lichen urticatus, 
 the wheal and a small papule are combined ; tirticaria tuberosa, or 
 
398 PRACTICE OF MEDICINE. 
 
 g^ant wheals ; urticaria hemorrhagica or ptirpiirata urticaria, a com- 
 bination of urticaria and purpura ; urticaria evanida, a rapid appear- 
 ance and disappearance of the lesion ; urticaria perstans, slow dis- 
 appearance ; urticaria cofiferta, when the wheals are confluent ; 
 urticaria pigmentosa, where the wheals are succeeded by pigmenta- 
 tions of the site, the tints varying from dark brown, greenish yellow, 
 to a chocolate color ; urticaria febritis, when the wheals are associated 
 with fever; urticaria ab ingestis, when associated with indigestion. 
 
 Treatment. To prevent the recurrence of the disorder a thorough 
 investigation of the cause must be made, and when found (not always 
 possible) be removed. 
 
 Attention should be directed to the state of the general health, the 
 diet and the secretions. 
 
 Thie following remedies, alone or variously combined, are often of 
 benefit : quinina, sodii saiicylas, pilocarpus, airopina, tinctura bella- 
 donnce, ajiiinonii chloridutn, arsenicuni and potassii bromiduin. The 
 following pill is valuable in many cases : — 
 
 R . Pulv. pilocarpus, 
 
 Ext. guaiaci, aa gr. iss 
 
 Lithii benzoat., gr. iij. M. 
 
 SiG — Two to four each twenty-four hours. 
 
 If there be atonic dyspepsia and constipation, the following com- 
 bination is useful : — 
 
 li . Magnesii sul])hat., 3J 
 
 Ferri sulphat., gr. xvj 
 
 So'iii chloridi, '^s% 
 
 Acidi sulphuric! dil., f ^^5 ij 
 
 Inf. cascarillne, f Jiv. M. 
 
 SiG. — Tablespoonful before breakfast, diluted. 
 
 Z^r<2/ measures are of the greatest value, either as baths, lotions or 
 dusting powders. The following are among the most serviceable ; 
 sponging with alcohol, brandy, whisky, vinegar and water, salt water, 
 alkaline baths and ^^/c/ baths. Duhring recommends the following: — 
 
 Ijt . Acidi cnrliolici, 3 iss 
 
 Glyc<-'rini, f,^ij 
 
 Alcoholis, f.^viij 
 
 Aq. amygdal amar., fjviij. M. 
 
 SiG. — Use as lotion, two or three limes daily. 
 
DISEASES OF THE SKIN. 399 
 
 Bulkley suggests the following : — 
 
 R . Chloralis, 
 
 Camphorae, aa . . . . f^j 
 
 Misce, and rub and incorporate with 
 
 Pulveris amyli, ,lj~ij- 
 
 Misce, and keep tightly corked in a wide-mouthed bottle. 
 
 SiG. — Rub in with hand. 
 
 A serviceable formula is the following : — 
 
 R. Chloroformi, f^'] 
 
 Ung. zinci oxid., ^\]. M. 
 
 SiG. — Apply with hand. 
 
 HERPES. 
 
 Definition. An acute inflammation of the skin ; characterized by 
 the development of one or more groups oi vesicles, filled with a clear 
 serum, occurring for the most part about the face {herpes facialis) 
 and genitalia {herpes progenitalis). 
 
 Causes. Herpes facialis : during the course of febrile and nervous 
 disorders ; in connection 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 dries 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 
 frequently about the lips — herpes labialis: The alee of the nose, 
 auricles and the mucous membranes of the mouth and tono-ue are 
 
400 PRACTICE OF MEDICINE. 
 
 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 prcFputialis). In the female they are comparatively rare ; but 
 when occurring it is upon the labia majora and minora and the skin 
 about the vulva. 
 
 This variety is preceded by burning, itching or neuralgic pains, 
 accompanied with redness, congestion and more or less cedema. 
 
 The lesion in these parts 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, 
 attended 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 of herpes labialis protection with liquor gutta-percha 
 or collodium flexile promote desiccation. 
 
 Herpes progenitalis ; cleanliness is of the first importance. Coat- 
 ing the eruption with the medicaments mentioned above or washing 
 with a saturated solution of aciduin boraciciim, and afterward dusting 
 with hydrargyri chloridum mite, are useful. 
 
 The parts may be rendered less sensitive in frequently recurring 
 cases by astringent lotions, as aciduui ta?inicum or zinci sulphas. 
 Circumcision, where required, may be practiced. 
 
 HERPES ZOSTER. 
 
 Synonyms. Zona ; 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 
 immcdij.lc result of an inflammation of the ganglia or of the nerve 
 trunks and branches — a neuritis — probably of the trophic fibres 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, and the medicinal use of arsenicum. 
 
DISEASES OF THE SKIN. 401 
 
 Pathology. An inflammation of either the gangha, 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 corium. 
 
 Symptoms. Begins with neuralgic pains, either of a burning or 
 lightning-like character, with slight febrile phenomena, followed by 
 the appearance oi papulovesicles alotig 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 also disappear after a 
 time or, rarely, is 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 (bi- 
 lateral) 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 auricularis, zoster 
 nuc hcB, zoster brachialis, zoster pectoralis, zoster abdominalis, zoster 
 femoralis. 
 
 In the very young the eruption may develop and pursue its course 
 without the neuralgic pains. 
 
 Diagnosis. The characteristics of herpes zoster or shingles are 
 usually so well marked that an error in diagnosis should not occur. 
 The neuralgic pain preceding the eruption and its development in 
 distinct groups upon inflamed bases following a nerve tract are so dif- 
 ferent from simple herpes of the face, or genitalia, or from the lesion 
 of eczema. 
 
 Prognosis. Favorable. Tlie affection is self-limited, the dura- 
 tion being about two weeks. It is said that " zoster of the orbital 
 region may seriously involve the eye and prove fatal." 
 
 Treatment. The affection being self-limited, it follows that reme- 
 dies to cut it short are useless. The following combination diminishes 
 the pain and modifies the duration : — 
 
402 PRACTICE OF MEDICINE. 
 
 R . Zinci phosphidi, 
 
 Ex. nucis vom., aS. gr. x. 
 
 M. et ft. pil. No. XXX. 
 SiG. — One every two to four hours. (Bulkley.) 
 
 Prof. Bartholow "has seen excellent results in cases of shingles 
 from galvanization of the affected intercostal nerves — the positive 
 pole being placed over the point of emergence of the nerves, and the 
 negative brushed over the terminal filaments in the skin." 
 
 The general symptoms are to be treated as indicated. Anaemia or 
 depression are benefited by full doses/erri et quinines citras. 
 
 For the pain no remedy seems comparable with the hypodermic use 
 of morphincE siilph., gr. Y^-Yi with atropiiia sn/ph., gr. yi^, near the 
 lesion. Antipyrine , gr. xv, repeated every three or four hours, relieves 
 the pain in many cases. 
 
 Locally, relief follows coating the " shingles" with either collodium 
 flexile or liquor gutta-perchcE, to which inorphincE sulphas may be 
 added. 
 
 MILIARIA. 
 
 Synonyms. Lichen tropicus ; miliaria rubra ; miliaria alba ; 
 prickly heat. 
 
 Definition. An acute inflammation of the sweat glands ; char- 
 acterized by the development of discrete, whitish or reddish, pin-point 
 and millet-seed-sized papules, vesicles or vesiculo-papules, productive 
 of pricking, tingling and burning sensations of a most aggravated 
 character. 
 
 Causes. Excessive heat, the result of excessive or tightly-fitting 
 clothing, or a high external temperature. Most common in fleshy 
 adults who perspire freely, and in children. Nervous prostration ; 
 severe dyspepsia and general debility seem to predispose to " prickly 
 heat." 
 
 Varieties. Miliaria papulosa ; tniliaria vesiculosa. 
 
 Pathology. The pathology of the two varieties is the same, both 
 being inflammatory affections of the sweat glands ; in the one papules, 
 and in the other vesicles develop about the orifices of the excretory 
 ducts. 
 
 In either variety there occurs hyperaemia of the vascular plexus of 
 the sweet gland, followed by slight exudation about the ducts, giving 
 rise to the minute papule or vesicle, which remain until the cause has 
 been modified or removed, when they are rapidly absorbed. 
 
DISEASES OF THE SKIN. 403 
 
 Symptoms. Miliaria papulosa; known as lichen tropicus and 
 "prickly heat," is of sudden onset, with the occurrence of numerous 
 minute, acuminated bright red papules, about the size of a pin head 
 or millet-seed, and but slightly raised above the level of the skin. 
 The papules are preceded by and accompanied with sweating (hyperi- 
 drosis), and distressing tijigling, pricking and burning sensations. 
 If the attack be severe, vesico-papules and vesicles are freely inter- 
 spersed among the numerous papules. 
 
 Miliaria vesiculosa ; in this variety, instead of papules, immense 
 numbers of vesicles develop, of the size of pin points and pin heads, 
 of a whitish {miliaria alba) or yellowish-white color. The surface 
 from which they arise is of a bright-red color, owing to each vesicle 
 being surrounded by an areola {miliaria rubra). The vesicles are 
 preceded and accompanied with sweating (byperidrosis) and most 
 distressing, tingling, pricking and burning sensations. 
 
 Either variety may attack all parts of the body, but the abdomen, 
 chest, back, neck and arms are the regions usually invaded. 
 
 Duration. This varies with the cause. It may appear, fully 
 develop and disappear in a few hours. In those predisposed, it may 
 continue more or less marked throughout the entire summer. 
 
 Diagnosis. If the cause, nature and seat of the affection are 
 taken into consideration, no error should occur. 
 
 Eczema papulosum has a resemblance to " prickly heat," but the 
 course of eczema is slov/, and the papules are larger, more elevated, 
 and firmer than those of miliaria papulosa. 
 
 Eczema vesiculosum and miliaria vesiculosa are to be differentiated 
 by the marked differences in the progress of each, the former slow, 
 the latter rapid, the vesicles of the former rupturing spontaneously, 
 those of the latter only when severely irritated. 
 
 Sudamen is not an inflammatory affection, while miliaria is. 
 
 Prognosis, The affection is often most rebellious in fleshy per- 
 sons and children, and if neglected it passes into eczema or an 
 erythematous intertrigo. 
 
 Treatment. The patient should be kept as cool as possible, and 
 avoid undue perspiration. The fears entertained by the laity, of 
 danger from retrocession of the eruption, are groundless ; the sooner 
 it disappears the better for the comfort of the patient, 
 
 The food should be light and unstimulating; wine, spirits and beer 
 are to be avoided. 
 
404 PRACTICE OF MEDICINE. 
 
 The ingestion of water, lemonade, Apollinaris water, Vichy water, 
 together with refrigerant diuretics, as potassii citrus vel acetas, a cool 
 apartment, and absolute rest will ordinarily insure speedy relief. 
 
 Locally; sponging vf'iXh alkaline XoXions, liquor plumbi subacetatis 
 dilutiis, extracttim grittdelicE fiuiduiti well diluted, or cupri sulphas, 
 in solution (gr. x, agues, f5J), or acidi carbolici, gr. y^y., glyceriti ainyli, 
 ^iij, or a dusting powder, consisting oi lycopodiiwi, zinci oxidum and 
 amylum, singly or combined. 
 
 PEMPHIGUS. 
 
 Synonym. Water blisters. 
 
 Definition. An inflammatory disease of the skin, either acute 
 or chronic, characterized by the development of a succession of 
 rounded, irregular-shaped blebs or bullae, varying in size from a pea 
 to an tgg. 
 
 Varieties. Pemp higus vulgaris ; pemphigus foliaceus. 
 
 Cause. Obscure. It is usually associated with a depressed state 
 of the general system ; disorders of menstruation ; during pregnancy. 
 
 Pathology. Hebra thus describes the appearance of the blebs: 
 "Sometimes a circumscribed, hght-red spot appears, perhaps of the 
 size of a bean or a large coin ; this is paler in the centre, and may even 
 present a tinge of white, indicating the point at which the bleb is to 
 form, and from which it will spread outward over the surrounding 
 skin, and, in fact, is at first a wheal, passing afterward into a bleb* 
 In other cases the bleb is not preceded either by a red spot or by a 
 wheal, but b egins originally as a small collection of clear fluid beneath 
 the cuticle. Thus, hyperaemia of the skin may exist before exudation 
 is poured out, or the latter may be formed before any congestion of 
 the papillary layer is discoverable." 
 
 The contents of the blebs or bullae are yellowish or colorless serum, 
 of a neutral or alkaline reaction, the older the fluid the more alkaline 
 it becomes. In the late stages of a bleb the fluid becomes puriform. 
 In rare instances blood is contained in the bleb (pemphigus hemor- 
 rhagicus). 
 
 Symptoms. Pemphigus vulgaris ; the onset is slow {^pemphigus 
 chronicus), without constitutional symptoms, or acute {pemphigus 
 acutus) preceded by febrile reaction. The lesions are the successive 
 development of blebs, usually from half a dozen to a dozen, varying 
 in size from a pea to an tgg, of a round or oval shape, their walls 
 
DISEASES OF THE SKIN. 405 
 
 distended with a colorless fluid, the color becoming yellowish or puri- 
 form as they grow older. They develop abruptly from the sound 
 skin, with a definite hne of demarcation, unattended with symptoms 
 of inflammation. A characteristic phenomena of the lesion is their 
 successive appearance ; a crop no sooner disappears than another 
 forms, throughout the course of the affection, each crop running its 
 course in from three to six or ten days. With the appearance of the 
 blebs occur itching and burning, usually of a mild character, although 
 occasionally in a distressing degree (^pemphigus pruriginosus). 
 
 Pemphigus maligmis is characterized by the great size and number 
 of the blebs, which coalesce, rupture and are succeeded by excoriated 
 surfaces which occasionally take on ulcerative action, the patient's 
 health being seriously impaired. 
 
 Pe^nphigus foliaceus differs from pemphigus vulgaris in that the 
 blebs, instead of being distended or tense, are flaccid and only par- 
 tially filled with fluid, as they rupture before arriving at their state of 
 full development. This variety also appears and disappears in crops. 
 After rupture the fluid immediately dries into thin whitish flakes, 
 which are detached in quantity, leaving a red, excoriated surface — 
 the rete and corium. If the affection has continued for some time, 
 the skin presents the appearance of a superficial scald. The course 
 of this variety is essentially chronic. 
 
 All portions of the body are liable to the lesion, as also the mucous 
 membrane of the mouth and vagina. It is most common, however, 
 upon the limbs. 
 
 Diagnosis. In a typical case no difficulty should be experienced 
 in making a diagnosis. The mere presence of blebs, however, does 
 not necessarily constitute pemphigus, for it must be remembered that 
 they are at times developed in other diseases as well as by artificial 
 means ; the appearance of blebs in crops is a strong diagnostic point. 
 
 Prognosis. The course of the affection is most uncertain, and 
 relapses are frequent. In arriving at an opinion, the occurrence of 
 fatal cases must not be forgotten. 
 
 Treatment. Attention to the general health of the patient is of 
 the greatest moment. A careful study of the cause should be made, 
 and if determined, means for its removal are of the first importance. 
 
 Two remedies, arsenicuni and guinina, are of great value, the secret 
 of success being the persistent use of the former ; or if the latter be 
 used, the dose should be large. 
 
406 PRACTICE OF MEDICINE. 
 
 Local measures are also of importance. The blebs should be 
 punctured and evacuated as soon as formed. The use of dusting 
 powders of zinci oxiditm, ainylum, or violet-powder, or lotions of 
 liquor plumbi subacetatis dilutuvi, are valuable. 
 
 Hebra recommends the continuous bath. 
 
 IMPETIGO. 
 
 Definition. An acute inflammatory disease, characterized by the 
 development of one or more discrete, rounded and elevated firm 
 pustules, about the size of a pea, unattended with itching. 
 
 Causes. Occurs for the most part between the ages of three and 
 ten years, in the well nourished and healthy. It is not associated 
 with eczema. It is not contagious. 
 
 Pathology. The lesion is a well-formed, typical pustule, develop- 
 ing abruptly from the surface, containing a whitish-yellow fluid, pus 
 corpuscles, blood corpuscles, epithelial cells and cellular detritis. 
 The abscess or pustule is about the size of a pea, circumscribed and 
 superficial. 
 
 Synonyms. The affection manifests itself by the development 
 of from one or two to a dozen or more ^\si\xiz\. pustules, about the size 
 of a split pea, of a rounded shape, raised above the surface, with thick 
 walls, of a yellowish or whitish color, surrounded by a distinct areola, 
 which soon fades, are without a central depression or umbilication, 
 and unattended with either itching or burning. 
 
 The affection runs an acute course, usually lasting a couple of 
 weeks. The pustules, after attaining their full size, remain stationary 
 for a few days, when they disappear by absorption and desiccation, 
 the crusts dropping off, displaying a reddish base, which soon dis- 
 appears with pigmentation or scar. 
 
 The pustules occur on all portions of the body, the most frequent 
 locations being the face, hands, fingers, feet, toes and lower extremities. 
 
 Diagnosis. Impetigo is unassociated with general symptoms, 
 and its particular lesion — the pustule — is discrete, points of import- 
 ance in the diagnosis. 
 
 Eczema pustulosum is also a pustular affection, but the large num- 
 ber, their disposition to coalesce, their location upon an inflammatory 
 base, their rupture and subsequent crusting and itching, are diag- 
 nostic points. 
 
DISEASES OF THE SKIN. 407 
 
 The diagnostic points from ecthyma will be pointed out when 
 describing that affection. 
 
 Prognosis. Favorable. 
 
 Treatment. The pustules should be opened as soon as they 
 mature, the contents removed by washing with tepid water and 
 soap, and the floor covered with hydrargyri chloridum mite or zinci 
 oleat. 
 
 Coating the pustules with coUodiuin fiexile or liquor gutta-perchce, 
 if they are located where irritation be liable, is a valuable mode of 
 treatment. 
 
 ECTHYMA. 
 
 Definition. An affection of the skin, characterized by the forma- 
 tion of one or more large, isolated, flat pustules, situated upon an 
 inflammatory base. 
 
 Cause. It is most common among those who live in squalor and 
 poverty, and in delicate and poorly-nourished children. Improper 
 and insufficient diet, want of ventilation, excessive work, and un- 
 cleanliness are all prominent causes. 
 
 Pathology. The lesion is a typical postular process, severe but 
 superficial, and not extending beyond the papillary layer of the 
 corium. The pustule is situated upon a firm and highly-inflamed 
 base ; the number varies from one to a dozen or more. 
 
 Symptoms. The disease is characterized by the development of 
 one or more round or oval, yet flat, pustules about the size of a pea- 
 bean, attended with a moderate heat, hurtling and pain, and if the 
 number be large, slight febrile reaction. The pustules are first 
 yellowish in color, surrounded by a firm and sensitive bright-red 
 areola, the pustule afterward becoming reddish from the admixture of 
 blood, soon drying into flat crusts of a brownish color. The dura- 
 tion of each pustule is between two and three weeks, new ones form- 
 ing, until the cause is removed. 
 
 The most prominent sites are the thighs, legs, shoulders, and back. 
 
 Diagnosis. Ecthyma and eczema pustulosum have points of 
 resemblance, but a study of the clinical history of the latter should 
 prevent error. 
 
 Impetigo differs from ecthyma in the size of the pustule and crust. 
 
 Ecthyma differs from a boil in not having a central core. 
 
408 PRACTICE OF MEDICINE. 
 
 Prognosis. With care and the removal of the cause, recovery is 
 always prompt. 
 
 Treatment. The general treatment of the patient is of the first 
 importance. Nutritious and wholesome food, cleanliness, bathing, 
 fresh air and regulated exercise should be advised, together with such 
 tonics 3.sfernnn, arseniciim, quinma, strychnina and mineral acids. 
 
 Locally : remove the crusts by first soaking with oil or fat, or water 
 dressings, and apply — 
 
 R. Ungt. zinci oxid. benz., 5ss 
 
 Vaselini, ^ss 
 
 Hydrargyri ammoniati, 3 J- M. 
 
 Ft. ungt. — DUHRING. 
 
 Pustules showing a sluggish disposition to heal should be stimulated 
 by touching with either argenti nitras or acidum carbolicum. 
 
 FURUNCULUS. 
 
 Synonyms. Furunculosis ; furuncle ; boil. 
 
 Definition. An acute affection of the skin, characterized by the 
 occurrence of one or more circumscribed cutaneous or subcutaneous 
 abscesses (boils), which usually terminate by necrosis of the central 
 tissue, its subsequent expulsion in the form of pus or a core, and a 
 resulting cicatrix. 
 
 Cause. The result of a depraved condition of the system, induced 
 by general debility, excessive fatigue, nervous depression, improper 
 food and exercise, anaemia, diabetes, uraemia, or the result of local 
 friction, pressure or contusions. 
 
 Pathology. The process resulting in a "boil" has its origin in 
 either a sebaceous gland, a sweat gland, or a piliary follicle, and never 
 begins in the meshes of the corium. " It begins as a small, roundish 
 spot, which increases in size until certain dimensions are attained, 
 when it undergoes suppurative change, resulting in the formation of a 
 central point or core, composed of the tissue of the gland in which 
 the furuncle originated, which, together with the pus, is cast off. It shows 
 no disposition to become diffuse, being always a circumscribed in- 
 flammation. After the discharge of the core, a cavity of more or less 
 depth remains, showing the tissues around it to be hard and infiltrated. 
 After a few days or a week it fills up by granulation, leaving a cicatrix, 
 
DISEASES OF THE SKIN. 409 
 
 which is often permanent. The central point or core, when thrown 
 off, is composed of a whitish, tough, pultaceous mass of dead tissue, 
 varying in size with the extent and depth of the inflammation." 
 (Duhring.) 
 
 Hydro-adenitis, as seen in the axillae, around the nipples and about 
 the anus or perineum, differs from the ordinary "boil " merely in 
 being deeper seated. 
 
 Syraptoms. "Boils" may occur singly, or more commonly in 
 crops of two, three or more, another crop following their disappear- 
 ance {furunculosis). 
 
 The abscess begins as a small, rounded, imperfectly defined, isolated, 
 reddish spot, of a highly inflamed character, painful on presstire, its 
 size gradually increasing, its central point presenting evidences of 
 suppuration. It reaches its full development in about a week, when 
 it consists of a slightly raised, rounded and pointed inflammatory 
 swelling with a yellowish point in the centre — the " core." Abscesses 
 with no central suppuration or core are called "blind boils." The 
 size of a developed boil varies from a split pea to a walnut, the color 
 deep red, with a yellow centre, and is surrounded by a slight areola. 
 The pain of a boil is dull and throbbing, painful on pressure, and is 
 usually worse at night. The constitutional symptoms are mild or 
 severe, according to the number and size of the lesions. 
 
 Any portion of the body may be attacked ; its preference, however, 
 is for the face, neck, back, axillae, nipples, buttocks, anus, perineum 
 and labias. 
 
 Diagnosis. The characteristics of furuncle are so marked that 
 an error seems im.possible. It may be, however, mistaken for car- 
 buncle, the differences between which will be pointed out when dis- 
 cussing that affection. 
 
 Prognosis. No danger results from occasional boils, but when 
 occurring in crops they impair the general health and are rebellious 
 to treatment. 
 
 Treatment. The treatment of a single boil is well expressed in 
 the word " time ; " warm applications are said to hasten the stage of 
 suppuration, and when reached an incision permits the expulsion of 
 the " core," after which the cure soon follows. If the lesion is located 
 where friction or pressure is likely, protection by either covering with 
 adhesive or soap-plaster, smoothly spread, is ample. 
 
 When, however, successive crops of boils occur {^furunculosis^, the 
 34 
 
410 PRACTICE OF MEDICINE. 
 
 treatment should be both constitutional and local. The economy being 
 below par. such tonics as arsenicum, quinina ^rxd/erruni are of value. 
 Calcii siilphid., gr. ^^-\, every two or three hours, is valuable in these 
 cases. 
 
 Locally, attempts to abort the process may well claim attention, 
 among which are : crucial incisions, to relieve the tension of the cen- 
 tral point, will often abate the inflammation and prevent the gangrene ; 
 this little operation is rendered painless by the use of«the ether spray. 
 Acidiim carbolicum, used in five per cent, solution, of which two to 
 five drops injected into the apex of the boil, is valuable. Painting 
 the forming boil with argenti tiitras or tinctura iodi are also recom- 
 mended ; a paste made by adding together equal parts o( glycerinum 
 and extractum belladonncE will often abort a boil ; the same is also 
 claimed for imgiieiitwn hydrargyri tiitratis. 
 
 ANTHRAX. 
 
 Synonyms. Carbunculus ; carbuncle. 
 
 Definition. An indurated, more or less circumscribed, dark red, 
 painful, deap-seated inflammation of the skin and subcutaneous con- 
 nective tissue, terminating in a slough and the subsequent production 
 of a permanent cicatrix 
 
 Causes. Not positively determined. A deep-seated bruise is a 
 supposed cause. Perhaps, as in furuncle, impairment of the general 
 health is the important factor. It is generally noted to occur in 
 middle life and old age, and in men more frequently than in women. 
 A " specific" cause for anthrax is not an improbable discovery. 
 
 Pathology. Although Billroth regards furuncle and carbuncle 
 as differing only in degree, the explanation of Warren, of Boston, 
 seems the more probable, he being the first to call the attention of 
 histologists " to the existence of small columns of adipose tissue lead- 
 ing from the panniculus adiposus up to the roots of the lanugo hairs, 
 taking an oblique direction in a line with the erectores pilorum. The 
 inflammation resulting in suppuration of the subcutaneous adipose 
 tissue must either form an abscess or become diffuse. In phlegmo- 
 nous erysipelas the latter condition is observed. But when the inflam- 
 mation is in the dermoid texture, the exudates infiltrate the skin and 
 naturally follow the canals occupied by the ' columniE adiposai.' The 
 pressure thus exerted upon the whole dermoid tissue cannot fail to 
 
DISEASES OF THE SKIN. 411 
 
 Strangulate the circulation, and thus produce gangrene of the tissue, 
 even if the exudate be not poisonous enough to destroy the cell by its 
 presence. It can, by this explanation, be easily understood why this 
 disease is apt to affect the skin on the nape of the neck and the back 
 more than on other parts of the body. At this point the skin is dense, 
 its fibrous element extending deep into the adipose layer, which is 
 surrounded with strong bands ; hence, the pus confined in such a 
 place, seeking the easiest outlet, will travel along these miniature 
 adipose canals, producing the peculiar appearance pathognomonic of 
 carbuncle." 
 
 Symptoms. Carbuncle is recognized by its peculiar form ; com- 
 mencing in the lower layers of the cutaneous tissue, it first resembles 
 somewhat a phlegmon minus its bright redness. At first it is some- 
 what rounded, with a strong tendency to the production of vesicles 
 on its surface, soon, however, becoming firm, circular and flat, and 
 raised above the surrounding parts, spreading through the subcuta- 
 neous tissue and skin, becoming at times enormously large, and having 
 a dark red or violaceous color. As the disease progresses, the pressure 
 results in the softening of the tissues, the skin becoming gangrenous, 
 breaking down at numerous points, forming perforations, through 
 which centres of suppuration appear in different stages of advance- 
 ment, either as whitish, fibrous plugs, or as cavities, from which a 
 yellowish, sanious fluid oozes, the surface of the anthrax having a 
 cribriform appearance, perforated like a sieve. The entire mass ter- 
 minates in a slough, which, on being detached, leaves a large, open, 
 deep ulcer, with firm, everted edges, granulating slowly, a permanent 
 cicatrix marking the site of the lesion. The development of the car- 
 buncle is attended with severe paiti of a deep throbbing 2ind burning 
 character. 
 
 The constitutional symptoms vary with the size, number and severity 
 of the disease ; loss of appetite, coated tongue, general malaise, and 
 moderate febrile reaction accompanies all cases, to which are added 
 those of septicaemia in severe cases. 
 
 The duration is from two to six weeks. Its favorite site is the back 
 of the neck, shoulders, back and buttocks. It is usually single. 
 
 Diagnosis. The disease is distinguished from furuncle by its 
 great size, its flat ioxxxs., its course, the multiple points of suppuration, 
 and the character of the slough. Also by the pain ; in furuncle, sen- 
 sitive and painful to the touch, carbuncle not being particularly 
 
412 PRACTICE OF MEDICINE. 
 
 sensitive. Furuncles generally occur in numbers or in crops ; car- 
 buncle is almost always single. 
 
 Prognosis. A guarded opinion should always be given, as death 
 is not infrequent from anthrax, especially in elderly people with 
 impaired health. The mortality, however, is not so great as the laity 
 suppose. 
 
 A great danger is septicaemia, from the action of the poison on the 
 blood, or the result of secondary abscesses. 
 
 Treatment. Constitutional and local measures are both of the 
 greatest value. Nutritious diet, stimulants and full doses of such 
 remedies as tinctura fcrri chloridi, qidnitiCB sulphas, arsenicum and 
 aynmonii carbonas are beneficial. Good results are reported from 
 calcii stiiphid., gr. y% every two hours. 
 
 Locally ; the crucial incision, so generally practiced informer years, 
 is seldom performed now, the frequent occurrence of hemorrhages 
 being too debilitating. The following are valuable plans: — 
 
 Caustic potash, applied to the carbuncle before an opening occurs, 
 until an eschar is fully formed ; or, making several small punctures with 
 a scalpel and inserting a small piece of caustic potash well into the 
 diseased tissue ; or, if openings have already occurred, insertion of the 
 caustic stick into them, allowing it to remain until melted. By either 
 of these methods I have seen the slough cast ofif more readily than in 
 cases where the crucial incision was made or in those left to nature. 
 Another method is, "a saturated solution of pure aciduju carbolicuin 
 is injected through the several apertures in every direction into the 
 sloughing tissues, by the aid of an hypodermic syringe. The pain is 
 severe but short-lived." 
 
 Prof. Agnew recommends painting collodiu?n cum cantharide 2iro\xnd 
 the anthrax, in the form of a broad zone, the effect of the blister being 
 to relieve the tension. Tinctura iodi is also used for a similar purpose. 
 Hebra advocates cloths wrung out in ice water, or ice bags, in the 
 early stage, changing to warm fomentations as soon as suppuration 
 has begun. Dr. Ashhurst has practiced with success the use of pres- 
 sure by means of adhesive plaster applied in much the same manner as 
 used for swelled testicle. Success often follows the application o{ un- 
 guentum hydrargyrinitratis, spread at least one-eighth of an inch thick 
 and covered with adhesive plaster, changing every twenty-four hours. 
 
 The resulting ulcer, after expulsion of the slough, is to be treated 
 on general principles. 
 
DISEASES OF THE SKIN. 413 
 
 ACNE. 
 
 Synonyms. Acne vulgaris; acne disseminata; varus; stone- 
 pock. 
 
 Definition. An inflammation, usually chronic, of the sebaceous 
 glands ; characterized by the development of papules, tubercles or 
 pustules, or by a combination of such lesions, usually in various stages 
 of formation, occurring for the most part upon the face. 
 
 Varieties. Acne papulosa ; acne pustulosa ; ac7ie artificialis. 
 
 Cause. Not always understood, as the affection is frequently 
 associated with apparently the most robust health. A frequent cause 
 is puberty. Among the other causes observed are gastro-intestinal 
 disorders, anaemia, chlorosis, uterine disorders, urethral irritation, 
 scrofula, and the use of large doses of the bromides and iodides. 
 Acne may exist alone or be associated with comedo or seborrhcea. 
 
 Pathology. An inflammation of the sebaceous gland structure 
 and surrounding tissues. There first occurs retention of the sebaceous 
 secretion, which is soon followed by hyperasmia and exudation about 
 the glands and in the gland wall {acne papulosa), infiltration of the 
 connective tissue {acne tubercula), followed by suppuration {acne pus- 
 tulosa). If the inflammatory action be severe, destruction of the gland 
 with a resulting cicatrix occurs. 
 
 Symptoms, Acne papulosa or acne punctata. This variety of 
 the affection is the earliest stage of the inflammatory action, and is 
 usually of short duration, being soon followed by the development of 
 pus. It is characterized by the occurrence oi pin-head to pea size, 
 flat, more or less pointed papules, situated about the sebaceous follicles, 
 lightish in color, with a minute central black point, the opening of the 
 sebaceous duct. Pustules are not infrequently observed scattered 
 among the papules. The lesion is unaccompanied with either local 
 or constitutional symptoms. While the forehead is the most frequent 
 seat for this variety, they sometimes are seen elsewhere. 
 
 Acne pustulosa. This is the fully developed affection. It is seen 
 upon the face, neck, shoulders and back, as pi?i-head to pea-sized, 
 rounded or acuminated pustules, seated upon an infiltrated, reddish 
 base of superficial or deep inflammatory product {acne induraia). 
 Scattered among the pustules may be seen numerous papules. There 
 are no constitutional symptoms, nor is pain complained of unless the 
 pustule be handled. 
 
414 PRACTICE OF MEDICINE. 
 
 Acne artificialis is rather a clinical variety, the result, usually, of 
 large doses of the bromides or iodides, the lesion being identical with 
 acne pustulosa. 
 
 Diag'nosis. The lesion is so characteristic, the course so chronic, 
 and the location so frequently upon the face, that an error seems 
 impossible if care be exercised. 
 
 The resemblance of the papular and pustular syphiloderms must 
 not be mistaken for acne. 
 
 Prognosis. Essentially a chronic affection, lasting for a number 
 of years ; but if persistent treatment be employed recovery will occur. 
 
 Treatment. To successfully combat an attack of acne, both con- 
 stitutional and local measures must be employed. 
 
 Constitutional treatment. The successful treatment of a case of 
 acne depends upon a knowledge of its cause and familiarity with the 
 constitutional habits of the patient. Disorders of digestion and consti- 
 pation should be corrected. If anaemia be present, /^rrz^w and arseni- 
 cum are indicated. Scrofula is an indication for oleum morrhucs and 
 ferri iodidum. Uterine disorders, if present, should receive proper 
 attention. In young adult males I have seen wonderful improve- 
 ment follow the passage of a fair-sized bougie once or twice weekly. 
 
 Calcii suiphid., gr. xV~^> every two or three hours, is valuable in 
 many cases, as is hydrargyri chloridum corrosivum, gr. x^ff-i-.V, three 
 times daily. A remedy highly spoken of by Dr. Bulkley is glycer- 
 inum in tablespoonful doses, two or three times daily. Dr. Duhring 
 recommends that it be given in combination with ferri et quinincB 
 citras. Prof. Bartholow " has seen excellent results from the use of 
 syrupus hypophosphitum comp. in acne indurata." 
 
 Local treat7nent. In acne of not very long duration I have seen 
 excellent results from the following plan : Just before retiring, the parts 
 affected are to be thoroughly washed with water as hot as can possibly 
 be borne, and after the water has partly dried the parts are to be 
 thoroughly covered with sulphur sub lijnatum, applied by means of a 
 powder-puff ball, no rubbing or friction to be employed, and on 
 arising in the morning the sulphur is to be washed off with hot water 
 and the face lightly mopped dry, or what is better, sulphur again 
 applied, if the patient is willing to permit it, during the day. 
 
 Dr. Hyde recommends that the contents of the papules and pustules 
 be evacuated by means of a needle, rather encouraging slight bleeding, 
 after which the parts are to be bathed with water as hot as can be 
 
DISEASES OF THE SKIN. 415 
 
 tolerated ; and while the part is still wet, it is thoroughly scrubbed 
 with lotio saponis vzridis, then cleansed with water, carefully dried 
 and anointed with a sulphur ointment. 
 
 Prof. Bartholow suggested, in a case of acne indurata seen with 
 the author, the following successful plan. To dissolve the sebaceous 
 matter — 
 
 R. Liquor potassse, f.^j 
 
 Aquae destil., f ^j. M. 
 
 SiG. — Applied to the acne spots only. 
 
 After which they were anointed with — 
 
 R. Plumbi nitrat., gr. xv 
 
 Ung. petrolei, ^j. M. 
 
 SiG. — Apply twice daily. 
 
 Dr. Duhring recommends the use of the following, after washing 
 the parts with hot water : — 
 
 R. Sulphuris praecip., 3J 
 
 Glycerini, ^S^s 
 
 Adipis benz , § j 
 
 01. rosae, gtt. iij. M. 
 
 Ft. ung. 
 
 SiG. — To be thoroughly rubbed into the skin at night. 
 
 ACNE ROSACEA. 
 
 Synonyms. Gutta rosea ; gutta rosacea. 
 
 Definition. A chronic hyperaemia or inflammatory affection of 
 the nose and cheeks ; characterized by redness, hypertrophy of the 
 skin and dilatation and enlargement of the blood vessels supplying 
 the part, and the development of more or less acne. The nose and 
 cheeks are the most frequent location. 
 
 Causes. Not always determined. It occurs in young women 
 about puberty who are anaemic, or suffer from a general debility, 
 nervous irritability or prostration, dyspepsia or menstrual irregulari- 
 ties. It often appears during the menopause. In young males the 
 affection can often be traced to nervous or general debility, or dys- 
 pepsia. The use of spirituous liquors or of large amounts of condi- 
 ments are frequent causes, as is constant exposure to the weather. 
 It is frequently associated with seborrhoea. 
 
416 PRACTICE OF MEDICINE. 
 
 Pathology. There first occurs blood stasis in the vessels of the 
 part, producing the undue redness first noticed. As a result of the 
 stasis, sooner or later the capillaries are dilated and hypertrophied, and 
 as a result of the interrupted circulation inflammation of the sebaceous 
 gland (acne) results, with the development of papules and pustules. 
 This constitutes the typical acne rosacea. The affection may proceed 
 no further, remaining at this point for years, or, rarely, the pathology 
 of this stage is exaggerated, the involved tissues all hypertrophying, 
 and the connective tissue undergoing a true hyperplasia, causing 
 increased size and abnormal shape of the nose. 
 
 Symptoms. The onset of the affection is slow and insidious, 
 characterized at first by more or less diffused redjiess of the part, the 
 color aggravated by water or cold air. If the nose be the part 
 attacked, it is usually greasy (seborrhoeic), and is apt to be cool or even 
 cold. This condition may remain for years, but sooner or later the 
 evidence of dilatation and hypertrophy of the capillaries is apparent 
 by the more decided and permanent redness, and upon close exami- 
 nation the enlarged minute cutaneous blood vessels are seen as deli.- 
 cate or coarse red lines, running superficially over the skin in an 
 irregular and tortuous course. Soon are developed upon the hypersemic 
 and hypertrophied skin papules (acne papulosa) and pustules (acne 
 pustulosa), their number never, however, being very great. This 
 constitutes true acne rosacea. The disease may remain in this state, 
 or, rarely, the cutaneous tissues are greatly hypertrophied, the blood 
 vessels enormously dilated, the glands enlarged and the connective 
 tissue undergoes hyperplasia, resulting in permanent, dark red, bulky 
 formations, the shape of the nose being contorted into various irregular 
 forms. Duhring reports a case in which the nose was the size of the 
 patient's fist (rhinophyma). 
 
 The nose and cheeks are the usual location of the disease, although 
 rarely it involves the forehead. 
 
 Diagnosis. The characteristics of the disease are so marked, 
 consistmg of rosacea — the dilated and hypertrophic blood vessels — 
 with papular and pustular acne superadded, that an error can hardly 
 occur, if due care be exercised. 
 
 Lupus vulgaris bears some resemblance to acne rosacea, as it is 
 apt to develop about the face, and especially the nose ; but the papules, 
 tubercles and pustules of lupus vulgaris soon ulcerate, followed by 
 crusts and cicatrices, which never occur in acne rosacea. 
 
DISEASES OF THE SKIN. 4l7 
 
 Lupus erythematosus may be confounded with acne rosacea if it 
 occurs upon the end of the nose ; but in the former the skin is harsh 
 and covered with adherent whitish and yellowish scales connected 
 with the openings of the sebaceous follicles, which is never the case 
 in acne rosacea. 
 
 Frostbite resembles the first stage of acne rosacea, but the history 
 of the two conditions soon determines the diagnosis. 
 
 Prognosis. Favorable, if treatment be instituted during the first 
 stage. After hypertrophy has occurred but little can be accomplished. 
 
 Treatment. The cause is to be sought after and removed, and 
 the general health to be promoted. The use of all alcoholic drinks 
 is to be interdicted and but small amounts of tea and coffee are to 
 be allowed. In the first stage good results may be obtained from the 
 following formula, known as " Kummerfeld's lotion : " — 
 
 R. Sulphur praecipitat., ^^iv 
 
 Pulv, camphorae, gr. x 
 
 Pulv. tragacanthae, ^^j 
 
 Aquae calcis, f 5ij 
 
 Aquae rosse, f^ij- M. 
 
 SiG. — Shake the bottle before using and apply every few hours. 
 Or— 
 
 R . Hydrargyri chlor. corrosiv., gr. ij 
 
 Ung. petrolei, ^j. M. 
 
 SiG. — Apply thoroughly. 
 
 Or, the following, suggested by G. H. Fox — 
 
 ^. Chrysarobini, / ?ss 
 
 Collodii, gj. M. 
 
 SiG. — Put a brush through the cork and paint lesion every evening. 
 
 For the second stage stronger applications are usually required. 
 The dilated capillaries should be incised with a sharp knife, in the 
 hope that adhesive inflammation may close the calibre of the vessels, 
 cold water compresses being used to control the bleeding, a few of 
 the dilated vessels being thus treated every day or two, until all have 
 been incised. Another plan is to paint the affected parts, once or 
 twice a week, with a ten to twenty grain solution of pofassa, following 
 its application with an emollient poultice. Electrolysis has also been 
 recommended. 
 
 In the third stage the knife is the only effectual remedy. 
 35 
 
418 PRACTICE OF MEDICINE. 
 
 PSORIASIS. 
 
 Synonyms. Lepra ; alphos ; psora ; English leprosy. 
 
 Definition. A chronic affection of the skin, characterized by 
 reddish, more or less thickened and elevated, dry, inflammatory and 
 somewhat wrinkled patches, variable as to size, shape and number, 
 and covered with abundant whitish or grayish-colored, imbricated 
 scales. It is not contagious. 
 
 Cause. Not known. The source of the affection is, no doubt, 
 limited to the skin itself, as no external or internal factors can produce 
 it. It occurs in the robust and in the feeble, and in males and females. 
 It usually first appears in early life, and recurs at intervals for years. 
 
 Pathology. According to Dr. A. R. Robinson, of New York, 
 " the disease is essentially a hyperplasia of the normal constituents 
 of the Malpighian layer (mucous layer). The increase takes place 
 chiefly in the interpapillary portion of the layer, the growth of which 
 downward causes an apparent increase in the size of the papillae of 
 the corium, which, however, on closer examination, are found not to 
 be enlarged. In the later stages of the disease the more superficial 
 blood vessels of the corium become dilated, a more or less consider- 
 able emigration of the white blood corpuscles takes place, and the 
 immediate neighborhood of the vessels, together with the connective 
 tissue of the corium, becomes the seat of a round-cell infiltration, 
 which, with the effusion of serum, separates the connective-tissue 
 bundles and fibres into an open mesh work. During the period of 
 disappearance of the disease there is a gradual return to the normal 
 condition, until the hyperplasia, dilatation of the blood vessels, and 
 cell infiltration have completely disappeared. The hair in psoriasis is 
 affected from the beginning of the disease, hyperplasia of the external 
 root sheath, the structure corresponding to the Malphigian layer of the 
 epidermis, taking place, with extension of the hyperplastic structure 
 into the surrounding cutis. The sebaceous and sweat glands are not 
 at any time affected." 
 
 Symptoms. Psoriasis begins as small, reddish spots, of the size 
 of a pin's head, which immediately become covered with scanty or 
 abundant whitish ox grayish, imbricated scales. The spots gradually 
 increase in diameter, forming patches of various sizes and shapes. 
 
 If one of the scales be detached by means of the finger nail, it will 
 be found to adhere quite firmly to the skin, and to be about the thick- 
 
DISEASES OF THE SKIN. 419 
 
 ness of a card-board. If the reddish patch thus made bare be pinched 
 up between the finger and thumb, and compared with a similar pinch 
 of the healthy skin, its inflammatory thickening will be discerned. 
 There is no watery discharge at atiy time. 
 
 The skin between the patches is perfectly healthy. 
 
 While the anatomical lesions are always identical, the eruption 
 assumes such features, as to the size and shape of the patches, as to 
 give rise to special names. 
 
 Psoriasis punctata. The eruption occurs as small, rounded patches, 
 about the size of a pin's head. This is a rare variety, as the lesion 
 rapidly increases in size. 
 
 Psoriasis guttata. The eruption occurs in the form and size of 
 drops, and when covered with scales gives the skin the appearance 
 of having been splashed with mortar, A quite frequent variety. 
 
 Psoriasis mummularis. The eruption resembles variously- sized 
 coins. This is frequently as large as the patches grow. 
 
 Psoriasis circinata. The eruption about the size of the former 
 variety, the centre clearing away, leaving the skin normal, although 
 it may continue to enlarge at the periphery, after the manner of tinea 
 circinata. 
 
 Psoriasis gyrata. The eruption in wavy lines, of the width of about 
 half an inch, resembling circles and semicircles. This variety is a 
 continuation of the former, from the joining of the patches of psoriasis 
 circinata. 
 
 Psoriasis diffusa. The patches of eruption are large and of irregu- 
 lar shape, covering a considerable amount of surface. This variety 
 occurs more frequently on the front of the leg and the outer aspect of 
 the forearm. 
 
 Psoriasis palmaris et plantar is. In these regions the eruption is 
 characterized by larger, thicker and less lustreless scales, and by the 
 occurrence of deep and painful fissures, from which exudes either a 
 serous or sanguineous fluid. 
 
 Psoriasis U7igiduin. In psoriasis of the nails they become thick- 
 ened, opaque, grayish in color, deeply grooved transversely and 
 often pitted, and in 'rare cases the nails are replaced by a scaly 
 incrustation. 
 
 Any portion of the body is liable to be attacked with psoriasis. The 
 only discomfort the patient suffers is the itching, which at times is 
 very severe and distressing. 
 
420 PRACTICE OF MEDICINE. 
 
 Diagnosis. A typical case of psoriasis presents no difficulty in 
 diagnosis. There are a few affections, however, which may be con- 
 founding in irregular cases. 
 
 Eczema squamosum occurring upon the legs closely resembles 
 psoriasis, and if the former has been attended with a very small 
 amount of moisture and the latter has been considerably irritated by 
 scratching, the diagnosis will be very difficult. 
 
 The papulo-squamous syphiloderm and psoriasis are frequently 
 mistaken for each other, the diagnosis at times being extremely 
 difficult. 
 
 Tinea circinata and psoriasis circinata resemble each other, but 
 the patches of the latter are less inflammatory, red and infiltrated, 
 and the scales more abundant and larger than in the former. Tinea 
 circinata is usually the result of contagion, and the scales contain a 
 fungus. 
 
 Seborrhoea of the scalp and psoriasis of the same region frequently 
 are difficult of diagnosis. In the former the scalp is paler, the scales 
 are finer, smaller, more generally diffused, of a grayish or yellowish 
 color, and greasy, sebaceous character. Psoriasis of the scalp is 
 in patches, which are reddish and infiltrated, and there are almost 
 always patches of the disease on other parts of the body. 
 
 Prog"nosis. An attack can easily be removed, but it is always 
 apt to return, so that a permanent cure can never be promised. 
 
 Treatment. Constitutional and local measures are both needed 
 in the majority of attacks of psoriasis. 
 
 Constitutional treatment. Attention to the general health, removing 
 all deleterious influences, such as dyspepsia, constipation, liathiasis, 
 malaria, anaemia or catarrhs. 
 
 Among the most valuable remedies used in the treatment of psoriasis 
 is arsenicum, given in full doses for a long period. It is to be borne 
 in mind, however, that the drug is contraindicated in all acute and 
 inflammatory cases. Chrysarobin, gr. yi, t. d., gradually increased, 
 has been suggested, but of its utility I have had no experience. 
 Phosphorus, acidum carbolicum and pix liquida have all been used 
 with variable success. 
 
 Local treatment. The character of the local measures should be 
 controlled by the duration of the disease, its extent, location and 
 obstinacy. 
 
 The first step is the thorough removal of the scales. This may be 
 
DISEASES OF THE SKIN. 421 
 
 accomplished by repeated washings with soft soap and water, by either 
 plain or alkaline baths, medicated washes or caustic ointments. 
 
 In the early stage, with highly inflammatory symptoms, soothing 
 applications, such as water dressings or inunctions with oils, of which 
 oleum olivcB rubbed over the patch several times each day is very 
 serviceable. 
 
 For chronic cases nothing seems comparable with the following 
 formula, suggested by Dr. G. H. Fox: — 
 
 R. Chrysarobin, gr. x-xx-^j 
 
 ^theris et alcoholis, , . . .ad q. s. 
 
 Collodii, %]. M. 
 
 SiG. — Rub the chrysarobin with a little alcohol and ether and add to 
 the collodion. 
 
 If a camel's-hair pencil be placed through the cork, this may be 
 painted over the affected patch after the removal of the scales, and 
 after drying it will not stain the clothing. Care must be exercised 
 that the strength be not too great, or a dermatitis may result. 
 
 Other local remedies are : pix liquida, saponis viridis, creasotwn, 
 stdphur, calcium sulphuretum and acidum carbolicum. 
 
 HYPERTROPHIES OF THE SKIN. 
 
 LENTIGO. 
 
 Synonym. Freckles. 
 
 Definition. A pigmentary deposit of the skin, characterized by 
 irregularly- shaped, pin-head or pea-sized, yellowish, brownish or 
 blackish spots, occurring for the most part about the face and back 
 of the hands. 
 
 Cause. In the majority of instances exposure to the sun is the 
 exciting cause. 
 
 Pathology. In anatomical structure freckles consist of a circum- 
 scribed, increased amount of normal pigment, differing from chloasma 
 only in the peculiar form and size of the deposit. 
 
 Symptoms. The number of " freckles " varies from a very few 
 to immense numbers. They occur as brownish or yellowish-brown, 
 small, roundish, irregular spots, most commonly upon the face and 
 hands. Rarely the number is very great, and they give to the skin 
 an uncleanly appearance. They are apt to occur at all ages, but 
 rarely before the third year. 
 
422 PRACTICE OF MEDICINE. 
 
 They are unattended with itching or other subjective symptoms. 
 
 Prognosis. Usually favorable. Their course, when left to them- 
 selves, is chronic, lasting for years or a lifetime. They ordinarily 
 appear in the summer, fading away as cold weather approaches, to 
 return the following summer. 
 
 Treatment. The following application has been usually success- 
 ful in my hands : — 
 
 li . Hydrargyri chlor. corrosiv., ....... gr. iij 
 
 Acid, hydrochlorici dil., f zj 
 
 Alcoholis, f 5j 
 
 Glyccrini, ^%^^ 
 
 Aquae rosse, ad f ^ iv. M. 
 
 SiG. — Apply at bedtime, and remove with soap and water in the 
 morning. 
 
 CHLOASMA. 
 
 Synonyms. Liver spots ; moth. 
 
 Definition. A pigmentary discoloration of the skin, characterized 
 by variously-sized and shaped, more or less defined, smooth patches, 
 or of a discoloration, yellowish, brownish or blackish in color. 
 
 Cause. The etiology of chloasma depends upon whether the 
 pigmentation is idiopathic or symptomatic in its occurrence. 
 
 Idiopathic chloasma results from the irritation of long-continued 
 scratching, such as is practiced in severe eczema or pediculosis, the 
 application of blisters and sinapisms, heat, the direct rays of the sun, 
 and various medicinal and chemical substances, such as follows the 
 prolonged use of argentum (argyria). 
 
 Symptomatic chloasma occurs in connection with cancer, malaria, 
 tuberculosis, disease of the supra renal capsule (Addison's disease), 
 disease of the womb, pregnancy (chloasma uterinum), neurotic dis- 
 turbances, ansemia and chlorosis. 
 
 Pathology. The affection is an increased deposit of the normal 
 pigment, having its seat in the mucous layer of the epidermis. The 
 deposition of the pigment is the result of a nervous derangement, 
 possibly of the trophic system. 
 
 Symptoms. Chloasma is simply a discoloration of the skin, un- 
 attended with alteration of the surface. 
 
 The patches vary in size and shape ; they may be as minute as a 
 coin or as large as the hand, or much larger, even to a universal 
 
DISEASES OF THE SKIN. 423 
 
 discoloration of the entire surface, and they may be roundish or 
 irregular in outline. 
 
 The usual color is yellowish, brownish or muddy, or even blackish 
 {melas7na, tnelano derma) . 
 
 In Addison s Disease, of a typical character, " the coloration is 
 brownish, with an olive-greenish or bronze tint, and is general, 
 although as a rule, especially pronounced upon regions having a 
 disposition to normal increase of pigment, as the face, backs of the 
 hands, axillas, areolae of the nipples, and the genital organs ; the hair, 
 also, may become darkened. It may. also, occur with or follow other 
 pigmentary changes, as of the hair. Gaskoin reports a case, occurring 
 in a woman aged forty-five, where the patch, situated on the cheek, 
 near the nose, was intensely dark. It had existed nine years. The 
 color of the hair had, fifteen years previously, changed from carroty- 
 red to black." For additional symptoms, see page 367. 
 
 In Argyria, or discoloration of the skin resulting from the internal 
 use of nitrate of silver, the color is a bluish, bluish-gray, slate, bronze 
 or blackish, varying as to the shade. It occurs over the surface 
 generally, but is more pronounced upon parts exposed, as the face 
 and hands. 
 
 Chloasma uteritium occurs most frequently between the ages of 
 twenty-five and fifty, seldom after the menopause, caused, in the 
 greater number of instances, by changes, physiological and patho- 
 logical, which take place in connection with the uterus. It is seen 
 in the married and single, although much commoner in the former. 
 Pregnancy is the most frequent cause, although also associated with 
 either dysmenorrhcea, chlorosis, anaemia or hysteria. 
 
 It is seen in the mildest degree about the eyelids, especially during 
 the menstrual epoch, as a duskiness or swarthiness of the complexion, 
 either lasting a few days or being permanent. As usually encoun- 
 tered, however, chloasma of this variety consists in the presence of 
 one or several patches, appearing generally about the forehead or 
 other parts of the face, upon the trunk, about the nipples and upon 
 the abdomen. Rarely the entire face is' covered with a discoloration, 
 resembling a mask. Cases are recorded in which the pigmentary 
 deposit was general, resembling Addison's disease. 
 
 Diagnosis. Tinea versicolor and chloasma resemble each other 
 in the color of the patches, but otherwise they have nothing in com- 
 
424 PRACTICE OF MEDICINE. 
 
 mon. Tinea versicolor occurs on the trunk, while chloasma occurs 
 upon the face and about the nipples, and in cases the result of preg- 
 nancy about the umbilicus, except in those comparatively rare 
 instances in which the discoloration is diffused. The patches of 
 chloasma are smooth, those of tinea versicolor furfuraceous, as can 
 readily be demonstrated by gently scraping the discoloration with the 
 finger nail. 
 
 Prognosis. Unless the result of Addison's disease, the prolonged 
 use of argentum, tuberculosis or cancer, favorable. 
 
 Treatment. Chloasma, not the result of organic disease, or the 
 use of argentum, is usually removed by either of the following 
 formulae : — 
 
 R . Hydrargyri chloridi corrosiv., gr. viiss 
 
 Zinci sulphat., ^ss 
 
 Plumbi acetatis, ;5 ss 
 
 Aquoe, f.^ iv- M* 
 
 SiG. — Lotion. Apply morning and evening. 
 
 — Hardy. 
 
 Or— 
 
 R . Hydrargyri chloridi corrosiv., gr- vj 
 
 Acidi acetici dil., f^ij 
 
 Boracis, h^ij 
 
 Aquae rosae, f ^ iv. M. 
 
 SiG. — Lotion. Apply twice daily. 
 
 — BULKLEY. 
 
 Or- 
 
 R. Hydrarg. ammoniat., ^} 
 
 Bismuthi subnit., Z] 
 
 Ung. petrolei., 5J. M. 
 
 SiG. — Apply frequently. 
 
 For argyria, the first step is the withdrawal of the argentum, and, 
 according to Prof. Bartholow, " a persistent and long-continued use 
 o{ potassii iodidum and sodii hypophosphis has, in a few fortunate 
 instances, caused the absorption and excretion of the silver deposits. 
 The action of these systemic remedies for the discoloration may be 
 aided by baths of the hyposulphites, and by the cautious use of lotions 
 containing potassii cyanidum, which possesses a decided solvent 
 power over the silver deposits." 
 
DISEASES OF THE SKIN. 425 
 
 CALLOSITAS. 
 
 SynonyrQS. Tyloma ; callus ; callosity. 
 
 Definition. Callositas or tyloma consists in the development of 
 a hard or horny, thickened patch of skin, variable in extent, and of 
 a grayish, yellowish or brownish color, and unattended with pain. 
 The most frequent location is upon the hands and feet. 
 
 Causes. The result of pressure or friction, as in the case of 
 the hands of the mechanic, the effect of his tools ; or, if upon the 
 foot, the result of ill-fitting shoes or from unusual walking. Cal- 
 losities are also seen upon the fingers of violin, banjo and harp 
 players. 
 
 Pathology. A hypertrophy of the horny layer of the skin, the 
 corium remaining normal. The cells of the epidermis become so 
 closely packed together as often to simulate horn substance. 
 
 Symptoms. Callositas consists in an increase in the thickness 
 of the skin of the affected part, presenting a firm, dense, more or 
 less circumscribed structure, the extent of hardness varying consid- 
 erably, sometimes being horny. The patch of hardness is generally 
 about the size of a coin, roundish in shape and somewhat elevated 
 above the surrounding skin. The color of the patch may be either 
 grayish, yellowish or brownish. 
 
 Callosities are usually upon the palms, fingers, soles and toes, 
 although other parts, if exposed to the cause, may also be the seat. 
 At times great pain and discomfort are experienced from the 
 growth. 
 
 Occasionally callosities are complicated by hyperasmia, fissure, acute 
 inflammation, abscess, erysipelas, and serve readily as foci for such 
 cutaneous diseases as eczema and psoriasis. 
 
 Course. Their formation and development is always slow and 
 gradual. If the cause be removed, the prognosis is favorable. 
 
 Treatment. If the removal of the callous growth be desirable, 
 the part should be repeatedly soaked in warm water, or a poultice 
 applied, or warmed oil kept in contact by compresses of flannel, 
 which will soften the induration and permit its removal by paring 
 or scaping, layer by layer, with a sharp knife. Success has been 
 reported from the use of a plaster of india-rubber containing acidum 
 salicylicum. 
 
426 PRACTICE OF MEDICINE. 
 
 CLAVUS. 
 
 Synonym. Corn. 
 
 Definition. A corn is a small, circumscribed, usually flat, deep- 
 seated hypertrophy of the epidermis, having a horny feel, projecting 
 slightly from the skin, painful upon pressure, situated, for the most 
 part, about the toes. 
 
 Cause. Continued pressure or friction, usually from ill-fitting or 
 tight boots or shoes. 
 
 Pathology. A clavus consists of a circumscribed, excessive 
 hypertrophy of the epidermis, of the same character as occurs in 
 callosity, and of a central portion — the core. The core extends deeply 
 into the tissues, in the shape of an inverted cone, the base of the cone 
 being directed outward and appearing upon the surface as a roundish 
 elevation, its apex resting upon the papillary layer of the corium. 
 The core of a clavus consists of a whitish, opaque, firm, tenacious 
 body, composed of epidermic cells, arranged in concentric laminae. 
 
 The pain attending the presence of corns results from pressure 
 upon the true skin by the hard core, causing irritation of the nerve 
 filaments of the papillae. 
 
 Corns existing between two toes are constantly bathed with the 
 moisture of the part, which macerates and softens the formation, 
 which thus receives the name of soft corn, in contradistinction to the 
 hard corn. 
 
 Symptoms. Until the growth attains a considerable size no dis- 
 comfort, as a rule, is felt. After, however, its depth has reached the 
 true '^\i\xi,pain 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 
 desired, the use of a properly fitting foot-covering must be practiced, 
 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. 
 
DISEASES OF THE SKIN. 427 
 
 For soft corns, the application of argenti nitras, in solid stick form , 
 is highly spoken of, to be used after the growth has been sufficiently- 
 softened. 
 
 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 filiformis ; verruca 
 digitata; verruca acuminata. 
 
 Cause. Obscure. The various assigned causes are probably 
 incapable of producing the affection. 
 
 Pathology. While the anatomy of warts differs somewhat accord - 
 ing to their variety, in all forms there exist 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 . 
 
 Symptoms. 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 sur- 
 rounding 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. 
 
 Verruca plaiia 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. 
 
428 PRACTICE OF MEDICINE. 
 
 Their most frequent site is upon the scalp. 
 
 Verruca acuminata, 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 ; 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 t.g%, 
 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 
 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 the 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 
 cent, solution of aciduni chrc7nicu7n has been recommended. The 
 topical application of caustics, such as acidimi aceticum, acidum 
 nitricutn, argenti nitras or ferri perchloriduin are 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 generally sold by pharmacists : — 
 
 R . Acidi salicylic!, ,:5 ss 
 
 Ext. cannab. indica*, ^r. v-x 
 
 CoUodii, 5 ss-j. M. 
 
 SiG. — Apply once or twice daily. 
 
DISEASES OF THE SKIN. 429 
 
 An excellent formula is : — 
 
 U . Acidi salicylici, 
 
 Acidi boracici, aa gr. xv 
 
 Hydrargyri chlor. mite, gr- x. M. 
 
 SiG. — Sprinkle over twice dail y. 
 
 ICHTHYOSIS. 
 
 S3nionyins. Ichthyosis vera ; fish-skin disease. 
 
 Definition. Ichthyosis is a congenital, chronic deformity or hyper- 
 trophic 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 
 regarded 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 
 blood vessels. In well-marked cases of ichthyosis hystrix, the 
 elongated papillae are surmounted 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 a wide variation in its symptoms. 
 In one mdividual it amounts to but a 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- 
 
430 PRACTICE OF MEDICINE. 
 
 diiction 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 developments 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. They 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. 
 
 Course. Ichthyosis siinplex 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. 
 
DISEASES OF THE SKIN. 431 
 
 Duhring says : " It may be stated, then, that, as a rule, the more fre- 
 quemly 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"; 
 afterward inunction with a simple ointment is to be applied, in order 
 to prevent Assuring of the new skin. 
 The following is a useful formula : — 
 
 R. Adipis benz., ^j 
 
 Glycerini, ... TT^xl 
 
 Ung. petrolei, ^ss. M. 
 
 SiG. — Apply daily, after washing or bathing. 
 
 — Duhring. 
 Or— 
 
 U . Potassii iodidi, gr. xx 
 
 Olei bubuli, 
 
 Adipis, aa, ^ss 
 
 Glycerini, ^j. M. 
 
 SiG. — Apply after bathing. 
 
 — Milton. 
 
 PARASITIC DISEASES OF THE SKIN. 
 TINEA FAVOSA. 
 
 S3nionyins. Favus ; porrigo favosa ; honeycombed 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. It is rare in the United States. 
 
 Pathology. Tinea favosa may have its seat either in the hair 
 
432 PRACTICE OF MEDICINE. 
 
 follicle and hair, or upon the surface of the skin or the nails ; the 
 former, however, are the structures most commonly attacked. 
 
 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 tinea favosa pilaris, when the epidermis, ti7iea favosa epi- 
 dermis, and when the nails, ti7iea favosa unguium. 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 pin- 
 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 \ki^ 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- 
 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 a very few to immense numbers. The usual size is abo ut 
 that of a split-pea. In tinea favosa pilaris et capitis the affection is 
 often accompanied with 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 folUcles 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 the 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 
 fragment of a crust be placed upon a glass slide with a drop of 
 
DISEASES OF THE SKIN. 433 
 
 liquor potasses, covered with a thin glass and placed under a micro- 
 scope with a power of from two hundred and fifty to five hundred 
 diameters, the features of the Achorion Schonlemii will determine the 
 affection to be tinea favosa. 
 
 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. Cleanliness is essential to successful management. 
 
 For tinea favosa pilaris et capitis, two remedies are essential — 
 parasiticides and depilation. The hair should be cut 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 
 
 Ammonii chlorid. pur., "T^^s 
 
 Misturae amygdalse amar., ^ iv. M. 
 
 SiG. — Apply thoroughly. 
 
 — BULKLEY. 
 
 Or— 
 
 R. Sulphur, 5J 
 
 Hydrarg. ammoniat., gr. xx 
 
 Ung. petrolei, f ^ j. M. 
 
 SiG. — Rub in well. 
 
 Tinea favosa of non-hairy parts requires the removal of the crusts 
 and the application of either of the above formulae. 
 
 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. 
 
 Cause. Ringworm of the body is caused by the presence of a 
 36 
 
434 PRACTICE OF MEDICINE. 
 
 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 poorly nourished. In adults it is usually 
 associated with a decline in the general health. 
 
 Pathology. The fungus is seated between the strata of the 
 epidermis, 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 {tinea 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 
 
DISEASES OF THE SKIN. 435 
 
 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. 
 
 Diag'nosis. Tinea circinata may be mistaken for squamous or 
 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 
 microscope. The examination can readily be made in the following 
 manner: "A few of the scales maybe scraped, with a blunt knife 
 blade, from the suspected patch and placed upon a glass slide con- 
 taining a drop of liquor potassas, 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 two hundred and fifty to five hundred 
 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 apphcation of one of the following ointments : — 
 
 R . Cupri acetat. , gr. x 
 
 Ung. aquse rosse, ^j. M. 
 
 SiG. — Keep in contact with the patch. 
 
 Or— 
 
 R . Hydrargyri ammoniat., gr. xx-xxx 
 
 Ung. petrolei, Jj. M. 
 
 SiG. — Keep in contact with the patch. 
 
436 PRACTICE OF MEDICINE. 
 
 " In obstinate tinea circinata cruris the following, recommended by 
 Tilbury Fox, may be employed : — 
 
 R. Creasoti, TT\^ xx 
 
 Olei cadini, f.^iij 
 
 Sulphuris sublimati, ^iij 
 
 Potassii bicarb., ^] 
 
 Adipis, ^j. M. 
 
 SiG. — Keep in contact with the affection. 
 
 TINEA TONSURANS. 
 
 Synonyms. Tinea trichophytina capitis ; herpes tonsurans ; 
 ringworm of the scalp. 
 
 Definition. A contagious, parasitic affection of the scalp, due to 
 the trichophyton fungus ; characterized by the development of cir- 
 cumscribed, vesicular or squamous, more or less bald patches, show- 
 ing the hair to be diseased and usually broken off close to the scalp. 
 
 Cause. The result of 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 
 disintegration and destruction. The hair follicle, also, becomes dis- 
 tended 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 pre- 
 sent the changes of minute vesicles and desquamation, or, in severe 
 cases, oedema and inflammatory symptoms, with fluid exudation {tinea 
 kerion). ■ 
 
 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 
 
DISEASES OF THE SKIN. 437 
 
 prominent, giving the characteristic appearance of the disease — the 
 goose-skin or plucked-fowl 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. 
 
 Ringworm of the face or body {tinea circiftata) 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. 
 
 Tinea 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 purplish in color, 
 and are more or less raised, cedematous and boggy. They are uneven 
 and honeycomb-like (whence the name ken'on), and studded with 
 yellowish, suppurative points, or, later, v/ith 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, 
 devoid of scales, eruption, or hair. Ringworm has the vesicular or 
 scaly patch, with broken-off 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 potasses 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 satisfactory in the majority of 
 instances of tinea tonsurans. 
 
438 PRACTICE OF MEDICINE. 
 
 Mild cases should be treated by cuttting the hair as close as possible 
 and thoroughly scrubbing the patches with j'tz/^ viridis and water, and 
 the application twice daily of a six per cent, solution of oleatum hy- 
 drargyri, or either of the following : — 
 
 R. Sodii borat., 5J 
 
 Aceti destil., f^xy M. 
 
 SiG. — Apply thoroughly several times daily. 
 
 Or— 
 
 R. Acidi boracici, gr. xv 
 
 Sulphur, flor., gr. xv 
 
 Vaselini, f5iss. M. 
 
 SiG. — Apply morning and night. 
 
 Or, use may be made of Morris' thymol solution, to wit : — 
 
 R. Thymol, ^ss 
 
 Chlorofurmi, 3 ij 
 
 01. olivse, ^vj. 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 maybe reapplied. A few applications often suffice. Its formula is — 
 
 R. lodi, 3ij 
 
 Olei picis f3J. M. 
 
 The iodine and oil of tar should be gradually and slowly mixed. 
 
 An excellent application in rebellious cases is — 
 
 R. Potassse (caustic), gr. ix 
 
 Acid carbolici, gr. xxiv 
 
 Lanoline, . .^ 5ss 
 
 01. theobromse, •••.... 5ss. M. 
 
 SiG. — A small amount rubbed into head night and morning. If the 
 scalp is not shaved the application is retained better. 
 
 Cases which resist these means are to be treated by removing the 
 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 is to be applied. 
 
DISEASES OF THE SKIN. 439 
 
 TINEA SYCOSIS. 
 
 Synonyms. Tinea trichophytina barbae; sycosis parasitica ; bar- 
 bers* itch ; ringworm of the beard. 
 
 Definition. A contagious, parasitic affection of the hair, hair 
 folhcles 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. 
 
 Cause. 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, unknown 
 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, incline to break, and many 
 of them are already loose. The process rapidly increases, the skin be- 
 comes distinctly nodular and lumpy, and points of pustulation develop 
 about the openings of the hair follicles. The subcutaneous connective 
 tissue is also involved, giving rise to thick, firm masses of induration. 
 
 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. 
 
440 PRACTICE OF MEDICINE. 
 
 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. 
 
 Itching, burning pain and swelling 2ihN2iys accompany the affection, 
 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-parasitic a 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-contagious 
 affection of the hair follicles, characterized by the development of pap- 
 ules and pustules, which are perforated with hairs, the hairs themselves 
 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 are 
 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 
 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, after which the parts are 
 sponged freely for several minutes with a solution of sodii hyposul- 
 phitis, ,5j, aqucE, f,^j, after which the parts are again thoroughly 
 washed with hot water, carefully dried and smeared with an un- 
 guentum sulphur., containing Sj-ij to the ounce. This procedure is 
 
DISEASES OF THE SKIN. 441 
 
 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 to the above, 
 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 so painful as one would suppose. Shav- 
 ing and depilation upon alternate days should be faithfully practiced 
 until the new hairs show themselves to be healthy. 
 
 In addition to the parasiticides mentioned, any of those recom- 
 mended for the other vegetable parasitic diseases may be used. 
 
 TINEA VERSICOLOR. 
 
 Syiaonynis. Pityriasis versicolor ; liver-spots. 
 
 Definition. A contagious, parasitic affection of the skin, due to 
 the Tnicrosporon 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 niicrosporon 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 epi- 
 dermis, never the hair or nail, and gives rise to the irregular-shaped 
 and sized maculee, of a yellowish or brownish color. As a rule, it 
 gives rise to neither hypersemia nor inflammatory symptoms. 
 
 Symptoms. Tinea versicolor occurs in the form of irregular, 
 roundish, circumscribed or reticulated maculae. The spots vary in 
 size from that of a small silver coin to that of the hand. By coal- 
 escing 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, 
 37 
 
442 PRACTICE OF MEDICINE. 
 
 deep brown, and, rarely, even blackish hue. At times mild itching 
 accompanies the eruption. 
 
 Diagnosis. The characteristics of the eruption are so distinct 
 that errors in diagnosis can hardly occur. If any doubt exist, a few 
 of the scales placed upon a glass slide, with a drop of liquor potass(B, 
 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. The parts should be cleansed with soap and water, 
 and either of the following lotions applied : — 
 
 R . Sodii sulphitis, ^iij 
 
 Glycerini, f^ij 
 
 Aquae, ad f ^ iv. M, 
 
 SiG. — Apply frequently. 
 Or— 
 
 R. Hydrargyri chlorid. corrosiv., gr- iv 
 
 Alcoholis, f^yj 
 
 Ammonii muriat., 2ss 
 
 Aquae rosae, ad f 3 vj- M. 
 
 SiG. — Apply frequently. 
 
 — Tilbury Fox. 
 
 SCABIES. 
 
 S3naonyin. The itch. 
 
 Definition. A contagious, animal parasitic disease of the skin, 
 due to the acarus or sarcoptes scabiei ; characterized by the forma- 
 tion of cuniculi (burrows), papules, vesicles and pustules ; followed 
 by excoriations, crusts and general cutaneous inflammation, and 
 accompanied with itching. 
 
 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 in 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 being said to 
 
DISEASES OF THE SKIN. 443 
 
 take no part in causing the affection, and so are rarely seen. They 
 are said to die in about a week after copulation with the female. The 
 female finds her way by boring through the horny layer into the 
 mucous layer of the epidermis, and, being impregnated, begins 
 at once laying her eggs and at the same time making her burrow. 
 A variable number of eggs are deposited, usually about a dozen, after 
 which she perishes in the skin. The ova hatch out in eight or ten 
 days. 
 
 Symptoms. Scabies being an artificial dermatitis or eczema, 
 according to the amount of irritation produced by the presence of the 
 parasite and the traumatism the result of 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 burrov/ 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 they at once begin to care 
 for themselves and to burrow, resulting in the formation of as many 
 additional cunictdi as there are active female mites. It is the presence 
 of these burrowing parasites that constitutes the irritation resulting in 
 the inflammation of the skin, characterized by the formation of minute 
 papules, vesicles and pustules, with more or less inflammatory indura- 
 tion. Add to these the excoriations, scratch marks, 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 cuniculus, as it is termed, is formed by the mite 
 entering and making its way beneath the horny layer of the epidermis, 
 which is raised, very much as a mole undermines the ground. It 
 occurs as a slight linear elevation of the epidermis, varying from a 
 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. 
 
 "Wi^ papules are the first inflammatory lesion, are numerous, and of 
 small size, and may be the extent of the disease. 
 
 The vesicles are the next stage, varying in size and number, having 
 an inflamed base, sometimes presenting cunicula upon their summits. 
 
 The pustules represent the completion of the inflammatory action, 
 their size and number varying with the severity of the irritation. 
 
444 PRACTICE OF MEDICINE. 
 
 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 manmias, 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 where the individual 
 has re-contracted 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 one of the following ointments is to be thoroughly 
 rubbed into every portion of the body, special attention being devoted 
 to the hands, fingers and other parts usually the seat of the disease. 
 
 R . Styracis liquidis, ^^ ij 
 
 Ung. sulphuris, z ij-iv 
 
 Ung. petrolei, ad 5J. M. 
 
 SiG. — Apply after washing. 
 
 — BULKLEY. 
 
 Or- 
 
 1^. Sulphuris sublimat., .^j 
 
 Balsam. Peruviani, Zss 
 
 Adipis, 5J. M. 
 
 SXG. — For children. 
 
 — DUHRING. 
 
DISEASES OF THE SKIN. 445 
 
 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 
 pediculosis capitis or head louse. The ova, or nits, are readily recog- 
 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, 
 resulting in the wounding of the scalp, with oozing of a serous or 
 purulent fluid mixed with blood, which soon mats the hair and forms 
 into crusts. In those predisposed to eczema, the presence of the para- 
 site will give rise to that condition. 
 
 The general health is usually unaffected by the presence of the 
 pediculi. 
 
 Pediculosis corporis. This variety of 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 
 
446 PRACTICE OF MEDICINE. 
 
 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 irregularly-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 pre- 
 sence of the pediculis 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. 
 
 They may be found crawHng 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 itchijig 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. 
 
DISEASES OF THE SKIN. 447 
 
 Pediculosis capitis. The most effective application of this variety 
 is to thoroughly soak the head two or three times a day with ordinary 
 petroleum or kerosene oil, and keep it wrapped in a cloth for twenty- 
 four hours. At the end of this time the head should be thoroughly 
 washed with soft soap and hot water, dried and saturated with the 
 official unguentum hydrargyri arnmoniati. 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 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 be 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 
 chloridum corrosivurn or unguentum hydrargyri ammoniati will be 
 effectual. 
 
INDEX. 
 
 Abdominal dropsy, 105. 
 
 typhus, 19. 
 Abscess, cerebral, 315. 
 
 of the liver, 112. 
 
 perityphlitic, 94. 
 Acne, 413. 
 
 artificialis, 414, 
 
 disseminata, 413. 
 
 indurata, 413. 
 
 papulosa, 413. 
 
 Piffard's solution for, 375. 
 
 punctata, 374. 
 
 pustulosa, 413. 
 
 rosacea, 415. 
 
 sebacea, 371. 
 
 tuber cula, 413. 
 
 vulgaris, 413. 
 Aconite in erysipelas, 50- 
 Aconitinse in neuralgia, 360. 
 Acute articular rheumatism, 1 50. 
 
 Bright's disease, 125. 
 
 gastric catarrh, 58. 
 
 gastritis, 60. 
 
 general diseases, 143. 
 
 hepatitis, 112. 
 
 meningitis, 306. 
 
 yellow atrophy, 114. 
 Addison's disease, 367, 423. 
 Ague, 30. 
 
 brow, 31. 
 
 cake, 30. 
 
 dumb, 30. 
 Agraphia, 318. 
 
 amnesic, 318. 
 Albumin, tests for, 120, 121. 
 Albuminuria, 126. 
 
 chronic, 127. 
 Alcoholism, 323. 
 
 acute, 323. 
 
 chronic, 323. 
 Anaemia, 362. 
 
 Blaud's pill for, 364. 
 
 Anaemia, cerebral, 298. 
 
 essential, 365. 
 
 of fatty heart, 365. 
 
 progressive pernicious, 365. 
 
 splenica, 366. 
 Ansematosis, 365, 
 Anatomy, morbid, II. 
 Angina pectoris, 295. 
 Anidrosis, 380. 
 Antipyrine in migraine, 323. 
 Anodynes, compound of, 70. 
 Anthrax, 410. 
 Aphasia, 317. 
 
 amnesic, 317- 
 
 ataxic, 318. 
 Aphonia, 318. 
 Aphthffi, 53. 
 
 discrete, 53. 
 
 confluens, 53. 
 Apnoea, 13. 
 Apoplexy, 302. 
 
 serous, 311. 
 Arachnitis, 306. 
 Argyria, 423. 
 
 Arteries, Cohnheim's terminal, 300. 
 Arthritis deformans, 157. 
 
 mono-, 151. 
 
 poly-, 151. ^ 
 Ascaris lumbricoides, lOO. 
 Ascites, 105. 
 Asthenia, 13. 
 Asthma, 227. 
 
 bronchial, 227. 
 
 hay, 229. 
 
 Kopp's 214. 
 
 nervous, 227. 
 Ataxia, locomotor, 342. 
 Atonic dyspepsia, 70. 
 Atrophy, acute yellow, 114. 
 
 of the liver, 115. 
 Aura epileptica, 348. 
 Auscultation, 181. 
 
 449 
 
450 
 
 INDEX. 
 
 Auscultation, Da Costa's rules for,i82. 
 Autumnal fever, 19. 
 
 Bacillus, comma, 16S. 
 
 malaria, 30. 
 
 tuberculosis, 255. 
 
 typhosus, 19. 
 Bacteria of decomposition, 168. 
 Barber's itch, 439. 
 Basedow's disease, 354. 
 Basham's iron mixture, 126. 
 Bell's palsy, 361. 
 Belt, hydropathic, 112. 
 Biliary calculi, 109. 
 Bile, test for, 122. 
 
 pigment, test for, 122. 
 Bilious fever, 32. 
 
 malignant fever, 37. 
 
 remittent fever, 32. 
 
 typhoid fever, 29. 
 Biliousness, no. 
 Black-heads, 374. 
 Bladder, catarrh of, 138. 
 Blaud's pill, 364. 
 Bleeders' disease, 368. 
 Blepharospasm, 347. 
 Blisters in rheumatism, 154. 
 
 vk'Eter, 404. 
 Blood currents, direct, 271. 
 
 indirect, 271. 
 
 test for, 121. 
 
 white cell, 366. 
 Bloody flux, 90. 
 Boil, 408. 
 Borborygmus, 67. 
 Bothriocephalus latus, 98. 
 Bowels, inflammation of, 79. 
 Brain, congestion of, 297. 
 Break-bone fever, 51. 
 Bright's disease, acute, 125. 
 
 chronic, 127, 130. 
 Bromidrosis, 377. 
 
 pedum, 378. 
 Bronchial dilatation, 224. 
 
 hemorrhage, 236. 
 Bronchitis, acute, 216. 
 
 capillary, 219, 248. 
 
 catarrhal, 216. 
 
 chronic, 224, 
 
 croupous, 222. 
 
 diphtheritic, 222. 
 
 Bronchitis, fetid, 225. 
 
 membranous, 222. 
 
 peri-, 249. 
 
 plastic, 222. 
 
 secondary, 224. 
 Broncho-pneumonia, 219, 248. 
 Bronchorrhagia, 236. 
 Bronchorrhoea, 225. 
 Bronzed-skin disease, 367. 
 
 Caecum, catarrh of, 93. 
 Calculi, alternating, 137. 
 
 biliary, 109. 
 
 cutaneous, 375. 
 
 hepatic, 109. 
 
 oxalate of lime, 137. 
 
 phosphatic, 137. 
 
 renal, 136. 
 
 uric acid, 137. 
 Callositas, 425. 
 Callus, 425. 
 Cancer, gastric, 65. 
 
 hepatic, 1 17. 
 Carbuncle, 410. 
 Carbunculus, 410. 
 Carcinoma, gastric, 65. 
 Cardiac dilatation, 282. 
 
 fatty degeneration, 285. 
 
 hypertrophy, 280. 
 
 murmurs, 270. 
 
 paralysis, 147, 
 
 see-saw murmurs, 291. 
 
 valvular diseases, 286. 
 Cardialgia, 69. 
 Catalepsy, 352. 
 Catarrh, acute bronchial, 216. 
 
 acute gastric, 58. 
 
 acute nasal, 193. 
 
 autumnal, 229. 
 
 chronic bronchial, 224. 
 
 chronic gastric, 61. 
 
 chronic nasal, 196. 
 
 contagious, 17. 
 
 dry, 225. 
 
 mucous, 225. 
 
 of the bile ducts, 107. 
 
 of the bladder, 138. 
 
 of the caecum, 93. 
 
 of the mouth, 52. 
 
 of the rectum, 95. 
 
 sec. of Laennec, 225, 
 
INDEX. 
 
 451 
 
 Catarrh, suffocative, 219. 
 Catarrhal enteritis, 79. 
 
 jaundice, 107. 
 
 nephritis, 124. 
 
 stomatitis, 52. 
 
 tonsillitis, 198. 
 Cephalodynia, 155. 
 Cerebral abscess, 315. 
 
 anaemia, 298. 
 
 congestion, 297. 
 
 embolism, 299. 
 
 fever, 306. 
 
 hemorrhage, 302. 
 
 hypersemia, 297. 
 
 softening, 303. 
 
 thrombosis, 299. 
 
 tumors, 316. 
 Cerebro-spinal fever, 26. 
 
 neuroses, 346. 
 Cervico-brachial neuralgia, 358. 
 Cervico-occipital neuralgia, 358. 
 Chicken-pox, 48. 
 Child- crowing, 208. 
 Chills and fever, 30. 
 Chloasma, 422. 
 
 uterinum, 423. 
 Chlorides, test for, 120. 
 Chlorosis, 363. 
 Cholera, 168. 
 
 Asiatic, 168. 
 
 asphyxia, 170. 
 
 bilious, 81. 
 
 English, 82, 
 
 epidemic, 168. 
 
 infantum, 87, 
 
 malignant, 168. 
 
 morbus, 82. 
 
 saline fluids in, 172. 
 
 solution, Bartholow's, 172. 
 
 spasmodic, 168. 
 
 sporadic, 82, 
 
 typhoid, 169. 
 Cholerine, 186. 
 Chorea, 346. 
 
 post-hemiplegic, 304, 347. 
 Chromidrosis, 377. 
 Chronic dyspepsia, 61. 
 
 gastric catarrh, 61. 
 
 gastritis, 61. 
 Clark's treatment of peritonitis, 104. 
 Clavus, 426. 
 
 Clinical history, 12. 
 
 Cohnheim's terminal arteries, 300. 
 
 Cold on the chest, 216. 
 
 in the head, 193. 
 Colic, hepatic, 109. 
 
 intestinal, 74. 
 
 lead, 74. 
 
 ovarian, 75. 
 
 renal, 136. 
 
 stomachic, 69. 
 
 uterine, 75. 
 Colitis, 90. 
 
 ulcerative, 90. 
 Coma, 13. 
 
 ursemic, 135. 
 Comedo, 374. 
 Comedones, 374. 
 Comma bacillus, 168. 
 Congestion, cerebral, 297. 
 
 of the kidneys, 1 24. 
 
 of the lungs, 238. 
 Congestive fever, 33. 
 Constipation, 75. 
 
 glycerinum for, 76. 
 Consumption, pulmonary, 251. 
 
 galloping, 260. 
 Contagious fever, 25. 
 
 catarrh, 17. 
 Convulsions, uraemic, 135. 
 Corns, 426. 
 
 soft, 427. 
 Corrigan's disease, 258. 
 
 hammer, 327. 
 
 sign, 66. 
 Coryza, acute, 193. 
 
 chronic, 196. 
 Coster's paste, 438. 
 Costiveness, 75. 
 Cough, winter, 224. 
 Crackling, 244. 
 Crepitatio redux, 245. 
 Crisis, 13. 
 Croup, catarrhal, 208. 
 
 false, 208. 
 
 membranous, 210. 
 
 pseudo, 214. 
 
 spasmodic, 208. 
 
 true, 210. 
 Croupous enteritis, 81. 
 
 laryngitis, 210. 
 
 stomatitis, 53. 
 
452 
 
 INDEX. 
 
 Cry, hydrocephalic, 311. 
 Cyst, renal, 133. 
 
 sebaceous, 376. 
 Cysticercus cellulosus, 98. 
 
 bovis, 98. 
 Cystitis, 138. 
 
 acute, 138. 
 
 chronic, 138. 
 
 Dandruff, 371. 
 Dandy fever, 51. 
 Death, 13. 
 Declat syrup, 42. 
 Degeneration, caseous, 252. 
 
 reaction of, 338. 
 Delirium tremens, 325, 
 Dengue, 51. 
 
 Dewees' mouth caustic, 55* 
 Diabetes insipidus, 1 66. 
 
 mellitus, 162, 
 Diagnosis, 13. 
 
 by exclusion, 13. 
 
 differential, 13. 
 
 direct, 13. 
 
 physical, 174. 
 Diarrhoea, 77. 
 
 acute, 77, 79. 
 
 biUous, 77. 
 
 choleriform, 87. 
 
 chronic, 78. 
 
 feculent, 77. 
 
 inflammatory, 85. 
 
 lienteric, 77. 
 
 mixture, Squibb's, 78. 
 Diathesis, 12. 
 Dilatation, bronchial, 224. 
 
 cardiac, 282. 
 
 gastric, 67. 
 Diphtheria, 144. 
 
 bronchial, 222. 
 
 laryngeal, 1 46, 2lo. 
 
 nasal, 146. 
 Diphtheritic, paralysis, 147. 
 
 stomatitis, 54. 
 Dipsomania, 326. 
 Discharges, chopped spinach, 86. 
 
 rice water, 80, 83, 169. 
 Disease, 9. 
 
 acute, 12. 
 
 Addison's, 367, 423. 
 
 Basedow's, 354. 
 
 Disease, bleeders', 368. 
 
 Bright's, 135, 127, 130. 
 
 causes of, 1 1 . 
 
 chronic, 13. 
 
 Corrigan's, 258. 
 
 defined, 9. 
 
 Duchenne's, 340. 
 
 fish-skin, 429. 
 
 flesh-worm, 172. 
 
 Fothergill's, 358. 
 
 functional, 9. 
 
 Graves', 354. 
 
 Meniere's, 319. 
 
 organic, 9. 
 
 predisposition to, ii. 
 
 subacute, 13. 
 
 termination of, 13, 
 Diseases, acute, general, 143. 
 
 of the biliary passages, 107. 
 
 of the blood, 362. 
 
 of the bronchial tubes, 216. 
 
 of the circulatory system, 268. 
 
 of the intestinal canal, 72. 
 
 of the kidneys, 1 18. 
 
 of the larynx, 203. 
 
 of the liver, no. 
 
 of the lungs, 238. 
 
 of the mouth, 52. 
 
 of the nasal passages, 193. 
 
 of the nerves, 357. 
 
 of the nervous system, 297. 
 
 of the peritoneum, 102. 
 
 of the pharynx, 198. 
 
 of the pleura, 261. 
 
 of the respiratory system, 174. 
 
 of the skin, 371. 
 
 of the spinal cord, 331. 
 
 of the stomach, 58. 
 Disorders of secretion, 371. 
 Dizziness, 319. 
 Dropsy, cutaneous, 40. 
 
 of the abdomen, 105. 
 
 pericardial, 277. 
 
 peritoneal, 105. 
 
 pleural, 265. 
 Duchenne's disease, 340. 
 Duodenitis, 79. 
 Dysentery, acute, 90. 
 
 epidemic, 90. 
 
 sporadic, 90. 
 
 washing rectum in, 92. 
 
INDEX. 
 
 453 
 
 Dyspepsia, 70. 
 acid, 71. 
 atonic, 70. 
 chronic, 61. 
 drunkard's, 61. 
 flatulent, 71. 
 hot water in, 62. 
 intestinal, 72. 
 irritative, 71. 
 nervous, 71. 
 
 Ecstasy, 352. 
 Ecthyma, 407. 
 Eczema, 382. 
 
 acute, 385. 
 
 ani, 394. 
 
 aurium, 393. 
 
 barbae, 392, 
 
 capitis, 390. 
 
 chronic, 385. 
 
 erythematosum, 383. 
 
 faciei, 392. 
 
 fissum, 385. 
 
 genitalium, 394. 
 
 impetiginosum, 384. 
 
 intertrigo, 383, 395. 
 
 labiorum, 392. 
 
 madidans, 384. 
 
 mammarum, 395. 
 
 marginatum, 434. 
 
 palmarum, 396. 
 
 palpebrarum, 392. 
 
 papillomatosum, 385. 
 
 papulosum, 384. 
 
 plantarum, 396, 
 
 pustulosum, 384. 
 
 rimosum, 385, 
 
 rubrum, 384. 
 
 sclerosum, 385. 
 
 squamosum, 385. 
 
 unguium, 396. 
 
 universale, 383. 
 
 verrucosum, 385. 
 
 vesiculosum, 383. 
 Electrical storm, 348. 
 Elixir, triple, 286. 
 Embolism, cerebral, 299. 
 Emetic, Dr. Fordyce Barker's, 213. 
 Emphysema, 233. 
 Empyema, 262. 
 Encephalitis, acute, 315. 
 
 Encephalitis, suppurative, 315. 
 Endocarditis, acute, 277. 
 Enteralgia, 74. 
 Enteric fever, 19. 
 Enteritis, catarrhal, 79. 
 
 croupous, 81. 
 
 membranous, 81. 
 Entero-colitis, 85. 
 
 mesenteric fever, 19. 
 Enterorrhoea, 77. 
 Ephemeral fever, 16. 
 Epidemic catarrhal fever, 17. 
 
 cerebro-spinal fever, 26. 
 
 roseola, 44. 
 Epilepsy, 348. 
 Errhine, Ferrier's, 195. 
 
 Robinson's, 196. 
 Erysipelas, 49. 
 
 ambulans, 49. 
 
 of the brain, 49. 
 
 phlegmonous, 49. 
 Erysipelatous dermatitis, 49. 
 Erythema simplex, 380. 
 
 intertrigo, 381. 
 Erythematous stomatitis, 52. 
 Essential anaemia, 365. 
 Etiology, II. 
 
 Eucalyptol in cystitis, 140. 
 Exophthalmic goitre, 354. 
 
 Facial paralysis, 361. 
 Famine fever, 29. 
 Favus, 431. 
 Febricula, 16. 
 Ferrier's errhine, 195. 
 Fever, 14. 
 
 abdominal typhus, 19. 
 
 autumnal, 19. 
 
 bilious, 32. 
 
 bilious remittent, 32. 
 
 bilious typhoid, 29. 
 
 breakbone, 51. 
 
 catarrhal, 17. 
 
 cause of, 14. 
 
 cerebral, 306. 
 
 cerebro-spinal, 26. 
 
 congestive, 33. 
 
 contagious, 25. 
 
 continued, 16. 
 
 dandy, 51. 
 
 enteric, 19. 
 
454 
 
 INDEX. 
 
 Fever, entero-mesenteric, 19. 
 
 ephemeral, 16, 
 
 epidemic cerebro-spinal, 26. 
 
 essential, 15. 
 
 famine, 29, 
 
 gastric, 19,58. 
 
 hay. 229. 
 
 intermittent, 30. 
 
 irritative, 16. 
 
 jail, 25. 
 
 lung, 241. 
 
 malarial, 30. 
 
 malignant intermittent, 23- 
 
 malignant remiitent, 23- 
 
 marsh, 32. 
 
 Mediterranean, 37. 
 
 nervous, 19. 
 
 neuralgic, 51. 
 
 pernicious, 33. 
 
 relapsing, 29. 
 
 remittent, 32. 
 
 rheumatic, 150. 
 
 rose, 229. 
 
 sailors', 37. 
 
 scarlet, 39, 
 
 secondary, 15. 
 
 ship, 25. 
 
 simple, continued, 16. 
 
 spotted, 26. 
 
 swamp, 30. 
 
 typhoid, 19. 
 
 typho-malarial, 32. 
 
 thermic, 329. 
 
 typhus, 25. 
 
 winter, 241. 
 
 yellow, 37. 
 Fevers, 14. 
 
 continued, 16. 
 
 eruptive, 39. 
 
 essential, 15. 
 
 general treatment of, 15. 
 
 periodical, 30. 
 
 primary cause of, 14. 
 
 secondary, 15. 
 Fish-skin disease, 429. 
 Flesh -worm disease, 172. 
 Floating kidney, 141. 
 Fluxes, vicarious, 77. 
 Follicular stomatitis, 53. 
 Fothergill's disease, 358. 
 
 fever mixture, 17. 
 
 Freckles, 421. 
 Fremitus, bronchial, 176. 
 
 friction, 176. 
 
 tussive, 176. 
 
 vocal, 176. 
 Furuncle, 408. 
 Furunculus, 408. 
 Furmiculosis, 408. 
 
 Gall stones, 109. 
 Gastralgia, 69. 
 Gastric cancer, 65. 
 
 carcinoma, 65. 
 
 dilatation, 67. 
 
 fever, 19. 
 
 hemorrhage, 68. 
 
 neuralgia, 69. 
 
 ulcer, 63. 
 Gastritis, acute, 60, 
 
 chronic, 61. 
 
 subacute, 61. 
 
 toxic, 60. 
 Gastrodynia, 69. 
 Gastrorrhagia, 68. 
 Gastroscope, uses of, 66. 
 German measles, 44. 
 Girdle, a, 400. 
 Glossitis, 56. 
 Glottis, oedema of, 206. 
 
 spasm of, 214. 
 Glycosuria, 162. 
 
 simple, 164. 
 Goudron de Guyot, 389. 
 Gout, 150. 
 
 half, 161. 
 
 rheumatic, 157. 
 Gravel, 136. 
 Graves' disease, 354. 
 Green sickness, 363. 
 Gripes, 74. 
 
 Gross', Prof S. D., neuralgic pill, 360. 
 Grutum, 375. 
 Gutta rosea, 415. 
 
 rosacea, 415. 
 
 Hjematemesis, 68. 
 
 Haematoma of the dura mater, 308. 
 
 Ha-mophilia, 368. 
 
 Haemoptysis, 236. 
 
 Heat stroke, 329. 
 
 Heart, anaemia of fatty, 365. 
 
INDEX. 
 
 455 
 
 Heart, dilatation of, 282. 
 
 fatty degeneration of, 285. 
 hypertrophy of, 280. 
 
 irritable, 294. 
 
 neuralgia of, 295. 
 
 palpitation of, 294. 
 
 physical examination of, 268. 
 
 valvular diseases of, 286. 
 Heartburn, 70. 
 Hemicrania, 321. 
 Hemiplegia, 304. 
 Hemorrhage, bronchial, 236. 
 
 cerebral, 302. 
 
 gastric, 68. 
 
 renal, 137. 
 Hemorrhagic diathesis, 368. 
 Hemorrhcea petechialis, 370. 
 Hepatic cancer, 117. 
 
 colic, 109. 
 
 calculi, 109. 
 Hepatitis, acute, 112. 
 
 general parenchymatous, 1 14. 
 
 interstitial, 115. 
 
 parenchymatous, 1 12. 
 
 suppurative, 112. 
 Herpes, 299. 
 
 circinatus, 433. 
 
 facialis, 399. 
 
 gestationis, 4CX>, 
 
 labialis, 399. 
 
 praeputialis, 400. 
 
 progenitalis, 400. 
 
 tonsurans, 436. 
 
 zoster, 400. 
 Histology, II. 
 Hives, 396. 
 Hooping cough, 231, 
 Hydrsemia, 362. 
 Hydro-adenitis, 409. 
 Hydrocephalus, acquired, 3 II, 
 
 acute, 310, 311. 
 
 chronic, 313. 
 
 congenital, 313. 
 Hydropathic belt, 112. 
 Hydropericardium, 277. 
 Hydropneumothorax, 266. 
 Hydrosis, 377. 
 Hydrothorax, 265. 
 Hypersemia, cerebral, 297. 
 
 renal, 124. 
 
 spinal, 331. 
 
 Hypersemias of the skin, 380. 
 Hyperidrosis, 377. 
 
 local, 377. 
 
 unilateral, 378. 
 Hypertrophies of the skin, 421. 
 Hypertrophy, cardiac, 280. 
 Hysteria, 350. 
 Hystero-epilepsy, 352. 
 
 Ichthyosis, 429. 
 Icterus, 107. 
 
 hemorrhagic 1 14. 
 Ileo-colitis, 79. 
 Impetigo, 406. 
 Incubation, period of, 12. 
 Indigestion, 70. 
 
 acute, 58. 
 
 intestinal, 72. 
 Inflammation of the skin, 382 
 Influenza, 17. 
 Insolation, 329. 
 Inspection, 175. 
 Intercostal neuralgia, 400. 
 Intermittent fever, 30. 
 Intestinal colic, 74. 
 
 dyspepsia, 72. 
 
 obstruction, 96. 
 
 parasites, 98. 
 
 strictvire, 96. 
 
 torpor, 75. 
 Intestines, diseases of, 72. 
 
 irrigation of, 97. 
 Introduction, 9. 
 Invagination, 96. 
 Ipecacuanha in dysentery, 92 
 Iron lemonade, 363. 
 Irritative fever, 16. 
 Ischaemia, 362. 
 Itch, 442. 
 
 barbers', 439. 
 
 Jail fever, 25. 
 Jaundice, catarrhal, 107. 
 malignant, 114. 
 
 Kidneys, amyloid, 131. 
 congestion of, 124. 
 contracted, 120. 
 diseases of, 118. 
 floating, 141. 
 gouty, 130. 
 
456 
 
 INDEX. 
 
 Kidneys, lardaceous, 131. 
 
 movable, 141. 
 
 sclerosis of, 130. 
 
 small red, 130. 
 
 wandering, 141. 
 
 waxy, 131. 
 
 white, large, 127. 
 Klebs' micrococci, 39. 
 Kummertield's lotion, 417. 
 
 Laryngismus stridulus, 214. 
 Laryngitis, acute catarrhal, 203. 
 
 croupous, 210. 
 
 oedematous, 206. 
 
 spasmodic, 208. 
 Law of parallelism, 151. 
 Lentigo, 421. 
 Lepra, 418. 
 Leprosy, English, 418. 
 Leptomeningitis, spinalis, 332. 
 Leucaemia, 366. 
 Leucocythemia, 366. 
 Lichen simplex, 384. 
 
 tropicus, 402. 
 Liquor picis alkalinus, 389, 
 Lithaemia, 161, 
 Lithiasis, 1 61. 
 Liver, abscess of, 112. 
 
 albuminoid, 1 16. 
 
 amyloid, 116. 
 
 atrophy of, 115. 
 
 carcinoma of, 117. 
 
 cirrhosis of, 115. 
 
 congestion, 1 10. 
 
 diseases of, no. 
 
 gin drinkers', 1 15. 
 
 hob-nailed, 115. 
 
 hypertrophic sclerosis of, 115. 
 
 lardaceous, 1 1 6. 
 
 nutmeg, ill. 
 
 sclerosis of, 115. 
 
 scrofulous, 116. 
 
 spots, 422, 441. 
 
 torpid, no. 
 
 w4xy, 116. 
 
 yellow atrophy of, 1 14. 
 Locomotor ataxia, 342. 
 Lotio nigra, 387. 
 Lousiness, 445. 
 Lumbago, 155. 
 Lumbo-abdominal neuralgia, 359. 
 
 Lumbodynia, 155. 
 Lungs, cirrhosis of, 258. 
 
 congestion of, 238. 
 
 consumption of, 251. 
 
 gangrene of, 242. 
 
 hyperemia of, 238. 
 
 oedema of, 240. 
 Lysis, 13. 
 
 Malignant intermittent fever, 33. 
 
 remittent fever, 33. 
 Mai le grand, 348. 
 Mai le petit, 348. 
 Malarial fever, 30. 
 Mania-a-potu, 325 
 Marsh fever, 32. 
 Measles, 32. 
 
 black, 43. 
 
 false, 44, 
 
 French, 44. 
 
 German, 44. 
 Mediterranean fever, 37. 
 Megrim, 321. 
 Melangemia, 30. 
 Melasma, supra-renalis, 367. 
 Melituria, 162. 
 Meniere's disease, 3I9. 
 Membranous enteritis, 81. 
 Meningitis, acute, 306. 
 
 basilar, 310. 
 
 cerebro -spinal, epidemic, 26, 
 
 spinal, 332. 
 
 tubercular, 310. 
 Mensuration, 176. 
 Metastasis, 13. 
 Migraine, 321. 
 Miliaria, 402. 
 
 alba, 400. 
 
 papulosa, 403. 
 
 rubra, 402. 
 
 vesiculosa, 403. 
 Milium, 375. 
 Mixture, Bartholow's cholera, 84. 
 
 Basham's iron, 128. 
 
 Brovvn-Sequard's, for epilepsy, 
 
 350. 
 Da Costa's muscular cramps, 84. 
 Davis's asthma, 229, 
 Fothergill's fever, 17. 
 Hartshorne's cholera, 84. 
 Hope's camphor, 87. 
 
INDEX. 
 
 457 
 
 Mixture, Keating's pertussis spray, 
 
 233- 
 
 Pepper's asthma, 229. 
 
 Smith's tonic, 363. 
 
 Squibb' s diarrhoea, 78. 
 Morbid anatomy, ii. 
 Morbilli, 42. 
 Morphina in acute uraemia, 136. 
 
 in cardiac dilatation, 284. 
 Morris's thymol solution, 438. 
 Moth, 422. 
 Moussette's pill, 360, 
 Mouth, catarrh of, 52. 
 
 diseases of, 52. 
 
 psoriasis of, 57. 
 
 white, 55. 
 Movable kidney, 141. 
 Mucus, test for, 120. 
 Muguet, 55. 
 Mumps, 143. 
 Murmurs, aortic, 272. 
 
 endocardial, 270. 
 
 exocardial, 270. 
 
 mitral, 271. 
 
 pericardial, 270. 
 
 pulmonic, 272. 
 
 see-saw, 291. 
 
 tricuspid, 272, 
 Muscles, insanity of, 346. 
 Myelitis, acute, 335. 
 Myocarditis, 279. 
 
 Nasal, acute catarrh, 193. 
 
 chronic catarrh, 196. 
 Nephritis, acute desquamative, 125. 
 
 catarrhal, 124. 
 
 chronic parenchymatous, 127. 
 
 interstitial, 130. 
 
 parenchymatous, 125. 
 
 peri-, 134. 
 
 pyelo-, 133. 
 
 suppurative, 133. 
 
 tubal, 125, 127, 
 Nephro-lithiasis, 136. 
 Nephrosis-pyelo, 136. 
 Nervous dyspepsia, 71. 
 
 exhaustion, 353. 
 
 fever, 19. 
 
 prostration, 353, 
 Nettle-rash, 396. 
 Neuralgia, 358. 
 38 
 
 Neuralgia, cervico-brachial, 358. 
 
 cervico-occipital, 358. 
 
 dorso-intercostal, 359, 
 
 intercostal, 400. 
 
 lumbo-abdominal, 359. 
 
 of the fifth nerve, 358. 
 
 of the heart, 295. 
 
 sciatic, 359. 
 Neuralgic fever, 51. 
 Neurasthenia, 353. 
 Neuritis, 357. 
 
 Neuroses, cerebro spinal, 346. 
 Nickel in epilepsy, 350. 
 Nomenclature, 9, 10. 
 Nystagm.us, 347. 
 
 Obstruction, aortic, 290. 
 
 intestinal, 96. 
 
 mitral, 290. 
 
 pulmonic, 291. 
 
 pyloric, 67. 
 
 tricuspid, 291, 
 Occlusion of cerebral vessels, 299, 
 Oidium albicans, 55. 
 Oinomania, 326. 
 
 Ointment, diachylon, Hebra's, 390. 
 Oligaemia, 362. 
 Oxyuris vermicularis, 100. 
 Ozsena, 197. 
 
 Pachymeningitis, 308. 
 
 spinalis, 334. 
 Pains, the girdle, 335. 
 Palpation, 176. 
 Palsy, Bell's, 361. 
 
 wasting, 344. 
 Paragraphia, 318. 
 Paralysis, 304, 
 
 bilateral, 304. 
 
 bulbar, 339. 
 
 cardiac, 147. 
 
 chronic progressive bulbar, 339. 
 
 crossed, 304. 
 
 diphtheritic, 147. 
 
 essential, of infants, 337. 
 
 facial, 361. 
 
 glosso-labio-laryngeal, 339. 
 
 infantile spinal, 337. 
 
 of the tongue, 318, 
 
 pharyngeal, 147. 
 
 unilateral, 304. 
 
45S 
 
 INDEX. 
 
 Paraphasia, 31S. 
 Parasites, intestinal, 98. 
 Parasitic diseases of the skin, 431. 
 Parotiditis, 143. 
 
 metastatic, 143. 
 Paste, Costers, 438. 
 Pathogenesis, 1 1. 
 Pathognomonic, 13. 
 Pathology, 9. 
 Pediculosis, 445. 
 
 capitis. 445. 
 
 corpDris, 445. 
 
 pubis, 446. 
 Pemphigus, 404. 
 
 foliaceus, 405. 
 
 malignus, 405. 
 
 pruriginosus, 405. 
 
 vulgaris, 404. 
 Percussion, 177 
 
 auscultatory, 181. 
 
 immediate, 177. 
 
 mediate, 177. 
 
 objects of, 178. 
 
 respiratory, l8l. 
 Pericarditis, acute, 273. 
 
 chronic, 275. 
 
 dry, 273. 
 Pericardium, adherent, 276. 
 
 effusion of, 273. 
 
 hydro-, 277. 
 Peri nephritis, 134. 
 Periodical fevers, 30. 
 Peri-proctitis, 95. 
 Peritoneal dropsy, 105. 
 Peritonitis, 102. 
 
 saline purgatives in, 104. 
 Peri-typhlitis, 95. 
 Pernicious fever, 33. 
 Pertussis, 231. 
 Pharyngeal paralysis, 147. 
 Pharyngitis, acute catarrhal, 198. 
 
 erysipelatous, 200. 
 
 exanthematous, 199. 
 
 fibrinous, 200. 
 
 gangrenous, 200. 
 
 phlegmonous, 200, 201. 
 Phosphates, tests for, 1 20. 
 Phosphoridrosis, 377. 
 Phthiriasis, 445. 
 Phthisis, 251. 
 
 acute, 260. 
 
 Phthisis, caseous, 251. 
 
 catarrhal, 251. 
 
 chronic, 258. 
 
 fibroid, 258, 
 
 Florida, 253. 
 
 incipient, 255. 
 
 pneumonic, 251. 
 
 pulmonalis, 251. 
 
 subacute, 251. 
 
 tubercular, 255. 
 Physical diagnosis, 174. 
 
 signs, 13- . . 
 
 signs, association of, 192. 
 PifFard's acne solution, 375. 
 Pill, Bartholow's gout, 1 60. 
 
 Blaud's, 364. 
 
 DaCosta's, for hemorrhage, 238. 
 
 Gross's neuralgic, 360. 
 
 Loomis's gout, 1 61. 
 
 Moussette's, 360. 
 
 Niemeyer's, 258. 
 Pilocarpus for spreading erysipelas, 
 
 so- 
 Pitting, to prevent, 47. 
 Pityriasis, 37 1. 
 
 versicolor, 441. 
 Pleurisy, 261. 
 Pleuritis, 261. 
 
 chronic, 262. 
 
 dry, 262. 
 Pleurodynia, 155. 
 Pleuro-pneumonia, 241. 
 Pneumonia, bilious, 244. 
 
 caseous, 251. 
 
 catarrhal, 248. 
 
 chronic catarrhal, 251. 
 
 chronic interstitial, 258. 
 
 croupous, 241. 
 
 lobar, 241. 
 
 lobular, 248. 
 
 typhoid, 243. 
 Pneumonitis, 241. 
 Pneumothorax, 266. 
 Podagra, 159. 
 
 Poliomyelitis anterior acuta, 337, 
 Polyuria, 166. 
 
 Posterior spinal sclerosis, 342. 
 Poultice, pilocarpus, 156. 
 
 spice, 87. 
 Predisposition, 11. 
 
 acquired, 12. 
 
INDEX. 
 
 459 
 
 Predisposition, inherited, 12. 
 
 Prickly heat, 402. 
 
 Proctitis, 95. 
 
 Proctitis, peri-, 95, 
 
 Prodromes, 12. 
 
 Prognosis, 13. 
 
 Progressive muscular atrophy, 344. 
 
 pernicious anaemia, 365. 
 Psoriasis, 418. 
 
 circinata, 419. 
 
 diffusa, 419. 
 
 guttata, 419. 
 
 gyrata, 419. 
 
 mummularis, 419. 
 
 of the mouth, 57. 
 
 of the tongue, 57. 
 
 palmaris, 419. 
 
 plantaris, 419. 
 
 punctata, 419. 
 
 unguium, 419. 
 Pulse, Corrigan, 288. 
 
 receding, 288. 
 Purging, 77. 
 Purpura, 370. 
 
 hemorrhagica, 370. 
 
 simplex, 370. 
 
 urticans, 370. 
 Pus, test for, 121. 
 Pyelitis, 133. 
 Pyelo-nephritis, 133. 
 
 nephrosis, 133. 
 Pyloric obstruction, 67. 
 
 stenosis, 67. 
 Pyrosis, 70. 
 
 Quinina in trichinosis, 1 74, 
 Quinsy, 201. 
 
 guaiacum in, 202. 
 
 malignant, 144. 
 
 Rales, 187. 
 
 bronchial, 189. 
 
 cavernous, 189. 
 
 dry, 188. 
 
 laryngeal, 188. 
 
 moist, 188. 
 
 pleural, 190. 
 
 tracheal, i88. 
 
 vesicular, 189. 
 Reactions of degenerations, 338. 
 Rectitis, 95. 
 
 Rectum, catarrh of, 95. 
 
 washing out the, 92. 
 Regurgitation, aortic, 288. 
 
 mitral, 287. 
 
 pulmonic, 289. 
 
 tricuspid, 289. 
 Relapsing fever, 29. 
 Remittent fever, 32. 
 Renal cyst, 133. 
 Respiration, Cheyne-Stokes', 285. 
 
 oscillating, 286. 
 Rheumatic fever, 150. 
 
 gout, 157. 
 Rheumatism, acute articular, 150. 
 
 gonorrhoeal, 152. 
 
 hyperpyrexia of, 151. 
 
 inflammatory, 150. 
 
 muscular, 154. 
 Rheumatoid arthritis, 157 
 Rhinitis, acute, 193. 
 i chronic, 196. 
 
 ' Rhinophyma, 416 
 Ringworm, honeycombed, 431. 
 
 of the body, 433. 
 
 of the scalp, 436. 
 
 of the beard, 439. 
 Robinson's errhine, 196. 
 Rosacea gutta, 415. 
 Rosea gutta, 415. 
 Rose, the, 49. 
 Rotheln, 44. 
 Round worms, 100. 
 Rubeola, 42. 
 
 Sailors' fever, 37. 
 
 Saline fluids in cholera, 1 72. 
 
 Salt rheum, 382. 
 
 Sand, renal, 138. 
 
 Sapo viridis, 389. 
 
 Scabies, 442. 
 
 Scall, 382. 
 
 Scarlatina, 39. 
 
 mixture. Smith's, 363. 
 Scarlet fever, 39. 
 Sciatica, 359. 
 Sclerosis, lateral, 341. 
 
 cerebro- spinal, 34I. 
 
 disseminated, 341. 
 
 hepatic hypertrophic, 115. 
 
 of the liver, 115. 
 
460 
 
 INDEX. 
 
 Sclerosis, posterior, 342. 
 
 spinal, 340. 
 Scorbutus, 368. 
 Scurvy, 36S. 
 Sebaceous cyst, 376. 
 Seborrhoea, 371. 
 
 capitis, 372. 
 
 faciei, 372, 
 
 oleosa, 372. 
 
 sicca, 372. 
 Secondary processes, 13. 
 Shingles, 400. 
 Ship fever, 25. 
 Sick-headache, 321. 
 
 antipyrine in, 323. 
 Sickness, green, 363. 
 Sign, Corrigan's, 66 
 Signs, 12. 
 
 physical, association of, 192. 
 Silver nitrate in phlegmonous erysipe- 
 las, 50. 
 Skin, hypersemias of, 380. 
 
 inflammation of, 382. 
 Smallpox, 44. 
 
 Smith's, Dr. A. H., tonic, 363. 
 Solution, Dobell's, 197. 
 
 Tanret's, of pelletierine, 100. 
 Sore throat, acute, 198. 
 
 putrid, 144. 
 Sounds, in disease, chest, 184. 
 
 in health, chest, 183. 
 
 normal cardiac, 269. 
 Spansemia, 362. 
 Spasm, histrionic, 347. 
 Spinal sclerosis, 340. 
 
 hyperemia, 331. 
 
 irritation, 353. 
 
 meningitis, 332. 
 Spinalis pachymeningitis, 334. 
 Splenification, 239. 
 Spotted fever, 26. 
 Sprue, 55. 
 
 St. Anthony's fire, 49. 
 Stomach, cancer of, 65. 
 
 diseases of, 58. 
 
 neuralgia of, 69, 
 
 remorse of, 71. 
 
 sjjasm of, 69. 
 
 washing out the, 97. 
 Stomatitis, catarrhal, 52. 
 
 croupous, 53. 
 
 Stomatitis, diphtheritic, 54- 
 
 erythematous, 52. 
 
 follicular, 53. 
 
 simple, 52. 
 
 ulcerative, 54. 
 
 vesicular, 53. 
 Stonepock, 413. 
 Stones, chalk, 160. 
 Stools, chopped spinach, 88. 
 Storm, electrical, 348. 
 Stricture, intestinal, 96. 
 St. Vitus's dance, 346. 
 Succussion, 192. 
 Sudamen, 379. 
 Sudamina, 379. 
 Sugar, test for, 122, 123. 
 Summer complaint, 87. 
 Sun stroke, 329. 
 Swamp fever, 30. 
 Sweating, excessive, 378. 
 Sycosis parasitica, 439. 
 Synocha, 16. 
 Symptoms, 12. 
 Syncope, 305. 
 Syrup, Declat, 42. 
 
 Tabes dorsalis, 342. 
 Taenia saginata, 98. 
 
 solium, 98. 
 Tapeworm, armed, 98. 
 
 unarmed, 98. 
 Temulentia, 323. 
 Test for albumin, 1 21. 
 
 bile, 122. 
 
 bile pigment, 122. 
 
 blood, 121. 
 
 chlorides, I20. 
 
 mucus, 120. 
 
 phosphates, 120. 
 
 pus, 121. 
 
 sugar, 122, 123. 
 
 urates, 119. 
 
 urea, 1 19. 
 Tetter, 382. 
 Throat, acute sore, 198. 
 
 putrid sore, 144. 
 Thrombosis, cerebral, 299. 
 Thrush, 55. 
 
 Thymol solution, Morris's, 438. 
 Tic-douloureux, 358. 
 
INDEX. 
 
 46] 
 
 Tincture, Warburg's, 35, 
 Tinea circinata, 433. 
 
 favosa, 431. 
 
 furfuracea, 371. 
 
 kerion, 336. 
 
 sycosis, 439, 
 
 tonsurans, 436. 
 
 versicolor, 441. 
 Tinkling, metallic, 190. 
 Tone, bandbox, of Bamberger, 228. 
 Tongue, strawberry, 40. 
 Tonic, Dr. A. H. Smith's, 363. 
 
 Sir Erasmus Wilson's, 373. 
 Tonsillitis, acute, 201. 
 
 catarrhal, 198. 
 Tormina, 74. 
 Torticollis, 155. 
 Toxic gastritis, 60. 
 Trance, 352. 
 Treatment, 14. 
 
 abortive, 14. 
 
 expectant, 14. 
 
 preventive, 14. 
 
 restorative, 14. 
 Tremens, delirium, 325. 
 Trichinse, 172. 
 
 spiralis, 172. 
 Trichinosis, 172. 
 Tubercular meningitis, 310. 
 Tuberculosis, 255. 
 
 acute miliary, 260. 
 Tumor, phantom, 352. 
 
 sebaceous, 376. 
 Tumors, abdominal, 66. 
 
 intracranial, 316, 
 Turpentine in purpura, 371. 
 Turpeth mineral in croup, 209. 
 Tyloma, 425. 
 Tympanites, chronic, 106. 
 Typhlitis, 93. 
 Typho-malarial fever, 32. 
 Typhoid fever, 19. 
 Typhus fever, 25. 
 
 icterode, 37. 
 
 Ulcer, duodenal, 64. 
 
 gastric, 63. 
 
 perforating, 63. 
 Ulcerative colitis, 90. 
 
 stomatitis, 54. 
 
 Ulcerosa gingivitis, 54. 
 Uraemia, acute, 135, 
 
 morphina in, 136. 
 Ursemic coma, 135. 
 
 convulsions, 135. 
 Urates, test for, 119. 
 Urea, test for, 119. 
 Uric acid diathesis, 161. 
 
 test for, 119. 
 Uridrosis, 377. 
 Urine, 118. 
 
 hysterical, 227. 
 
 normal color, 1 1 8. 
 
 normal constituents, 118. 
 
 normal quantity, 1 1 8. 
 
 reaction, 118. 
 Urticaria, 396, 
 
 Vaccination, 47. 
 
 Vaccinia, 47. 
 
 Valvular diseases of the heart, 286. 
 
 diagnosis of, 292. 
 Valvulitis, 277. 
 Varicella, 48. 
 Variola, 44. 
 Varus, 413. 
 Verruca, 427. 
 Vertigo, 319. 
 
 aural, 319. 
 
 auditory, 319. 
 
 nervous, 319. 
 
 senile, 319. 
 
 stomachic, 58, 319. 
 Vesicular stomatitis, 53. 
 Voice in disease, 191. 
 Vomit, black, 37. 
 
 coffee ground, 37. 
 
 Waddle, the, 341. 
 Warburg's tincture, 34. 
 Wart, 427. 
 
 venereal, 428. 
 Water blisters, 404. 
 
 colored as a treatment, 152. 
 Wens, 376. 
 Wheals, 397 
 White blood, 366. 
 
 cell blood, 366. 
 
 mouth, 55. 
 
462 
 
 Whooping-cough, 231. 
 Wilson's, Erasmus, tonic, 373. 
 Worms, tape, 98. 
 
 round, 100. 
 
 seat, 100. 
 
 INDEX. 
 
 Xeroderma, 429. 
 Yellow fever, 37. 
 Zona, 400. 
 
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 graved Illustrations, many of which are printed in colors. Edi- 
 ted by Henry Morris, f.r c.s., and contributed to by many well- 
 known writers. Octavo. Nearly Ready. Price about 6.00 
 *:„* Send for Descriptive Circular and Sample Pages. 
 
 Macalister's Human Anatomy. 816 Illustrations. A new 
 Text-book for Students and Practitioners, Systematic and Topo- 
 graphical, including the Embrj-olog^'-, Histology, and Morphology 
 of Man. With special reference to the requirements of 
 Practical Surgery and Medicine. With 816 Illustrations, 
 40c of which are original. Octavo. Cloth, 7.50; Leather, 8.50 
 
 Ballou's Veterinary Anatomy and Physiology. Illustrated. 
 By Wm. R. Ballou, m.u., Professor of Equine Anatomy at New 
 York College of Veterinary' Surgeons. 29 graphic Illustrations, 
 lamo. Cloth, 1. 00; Interleaved for notes, 1.25 
 
 Holden's Anatomy. A manual of Dissection of the Human 
 Body. Fifth Edition. Enlarged, with Marginal References and 
 over 200 Illustrations. Octavo. 
 
 Bound in Oilcloth, for the Dissecting Room, $4.50. 
 
 Holden's Human Osteology. Comprising a Description of the 
 Bones, with Colored Delineations of the Attachments of the 
 Muscles. The General and Microscopical Structure of Bone and 
 its Development. With Lithographic Plates and Numerous Illus- 
 trations. Seventh Edition. 8vo. Cloth, 6.00 
 Holden's Landmarks, Medical and Surgical. 4th ed. Clo., 1.25 
 Potter's Compend of Anatomy. Fifth Edition. Enlarged. 
 16 Lithographic Plates. 117 Illustrations. See Page 14. 
 
 Cloth, 1. 00; Interleaved for Notes, 1.25 
 
 CHEMISTRY. 
 
 Hartley's Medical Chemistry. Second Edition. A text-book 
 prepared specially for Medical, Pharmaceutical, and Dental Stu- 
 dents. With 50 Illustrations, Plate of Absorption Spectra and 
 Glossary of Chemical Terms. Revised and Enlarged. Cloth, 2.50 
 
 Trimble. Practical and Analytical Chemistry. A Course in 
 Chemical Analysis, by Henry Trimble, Prof, of Analytical Chem- 
 istry in the Phila. College of Pharmacy. Illustrated. Fourth 
 Edition, Enlarged. 8vo. Cloth, 1.50 
 
 Bloxam's Chemistry, Inorganic and Organic, with Experiments. 
 Seventh Edition. 281 Illustrations. Cloth, 4.50; Leather, 5.50 
 tf^ See pagex 2 to 3 /or list 0/ Students' Manuals . 
 
STUDENTS' TEXT-BOOKS AND MANUALS, 7 
 
 Chemistry : — Continued, 
 
 Richter's Inorganic Chemistry. Third American, from Fifth 
 German Edition. Translated by Prof. Edgar F. Smith, ph.d. 
 89 Wood Engravings and Colored Plate of Spectra. Cloth, 2.00 
 
 Richter's Organic Chemistry, or Chemistry of the Carbon 
 Compounds. Illustrated. Second Edition. Cloth, 4.50 
 
 Symonds. Manual of Chemistry, for the special use of Medi- 
 cal Students. By Bkandreth Symonds, a.m., m.d., Asst. 
 Physician Roosevelt Hospital, Out- Patient Department; Attend- 
 ing Physician Northwestern Dispensary, New York. Cloth, 2.00 
 
 Leffmann's Compend of Chemistry, Inorganic and Organic. 
 Including Urinary Analysis. Third Edition. Revised. 
 Seepage i_^. Cloth, i. 00; Interleaved for Notes, 1.25 
 
 Leffmann and Beam. Progressive Exercises in Practical 
 Chemistry. i2mo. Illustrated. Cloth, i.oo 
 
 Muter. Practical and Analytical Chemistry. Fourth Edi- 
 tion. Revised, to meet the requirements of American Medical 
 Colleges, by Prof. C. C. Hamilton. Illustrated. Cloth, 2.00 
 
 Holland. The Urine, Common Poisons, and Milk Analysis, 
 Chemical and Microscopical, For Laboratory Use. Fourth 
 Edition, Enlarged. Illustrated. Cloth, i.oo 
 
 Van Niiys. Urine Analysis. Illus. Cloth, 2.00 
 
 CHILDREN. 
 
 Goodhart and Starr. The Diseases of Children. Second 
 Edition. By J. F. Goodhart, m.d.. Physician to the Evelina 
 Hospital for Children ; Assistant Physician to Guy's Hospital, 
 London. Revised and Edited by Louis Starr, m.d.. Clinical 
 Professor of Diseases of Children in the Hospital of the Univer- 
 sity of Pennsylvania; Physician to the Children's Hospital, 
 Philadelphia. Containing many Prescriptions and Formulse, 
 conforming to the U. S. Pharmacopoeia, Directions for making 
 Artificial Human Milk, for the Artificial Digestion of Milk, etc. 
 Illustrated. Cloth, 3.00; Leather, 3.50 
 
 Hatfield. Diseases of Children. By M. P. Hatfield, m.d.. 
 Professor of Diseases of Children, Chicago Medical College. 
 Colored Plate. i2mo. Cloth, i.oo; Interleaved, 1.25 
 
 Starr. Diseases of the Digestive Organs in Infancy and 
 Childhood. With chapters on the Investigation of Disease, 
 and on the General Management of Children. By Louis Starr, 
 M.D., Clinical Professor of Diseases of Children in the Univer- 
 sity of Pennsylvania. Illus. Second Edition.. Cloth, 2.25 
 ^^ See pages 14 and 15 for list of? Quiz- Comp ends? 
 
8 STUDENTS' TEXT-BOOKS AND MANUALS. 
 
 DENTISTRY. 
 
 Fillebrown. Operative Dentistry. 330 lUus. Cloth, 2.50 
 
 Flagg's Plastics and Plastic Filling. 4th Ed. Cloth, 4.00 
 Gorgas. Dental Medicine. Fourth Edition. Cloth, 3.50 
 
 Harris. Principles and Practice of Dentistry. Including 
 Anatomy, Physiology', Pathology, Therapeutics, Dental Surgery 
 and Mechanism. Twelfth Edition. Revised and enlarged by 
 Professor Gorgas. 1028 Illustrations. Cloth, 7.00 ; Leather, 8.00 
 Richardson's Mechanical Dentistry. Fifth Edition. 569 
 Illustrations. 8vo. Cloth, 4.50; Leather, 5.50 
 
 Sewill. Dental Surgery. 200 Illustrations. 3d Ed. CIo., 3.00 
 Taft's Operative Dentistry. Dental Students and Practitioners. 
 Fourth Edition. 100 Illustrations. Cloth, 4.25 ; Leather, 5.00 
 Talbot. Irregularities of the Teeth, and their Treatment. 
 Illustrated. Svo. Second Edition. Cloth, 3.00 
 
 Tomes' Dental Anatomy. Third Ed. 191 lUus. Cloth, 4.00 
 Tomes' Dental Surgery. 3d Edition. 292 lUus. Cloth, 5.00 
 Warren. Compend of Dental Pathology and Dental Medi- 
 cine, Illustrated. Cloth, i.oo; Interleaved, 1.25 
 
 DICTIONARIES. 
 
 Gould's New Medical Dictionary. Containing the Definition 
 and Pronunciation of all words in Medicine, with many useful 
 Tables etc. J^ Dark Leather, 3.25 ; J^ Mor., Thumb Index, 4.25 
 
 Gould's Pocket Dictionary, 12,000 Medical Words Pro- 
 nounced and Defined. Containing many Tables and an 
 Elaborate Dose List. Thin 64mo. Jtist Ready. Leather, 1.25 
 
 Harris' Dictionary of Dentistry. Fifth Edition. Completely 
 revised by Prof. Gorgas. Cloth, 5.0c; Leather, 6.00 
 
 Cleaveland's Pronouncing Pocket Medical Lexicon. Small 
 pocket size. Cloth, red edges .75 ; pocket-book style, i.oo 
 
 Longley's Pocket Dictionary. The Student's Medical Lexicon, 
 giving Definition and Pronunciation, with an Appendix giving 
 Abbreviations used in Prescriptions, Metric Scale of Doses, etc. 
 24™o- Cloth, I.oo; pocket-book style, 1,25 
 
 EYE. 
 
 Hartridge on Refraction. 5th Edition. Illus. Cloth, 2.00 
 
 Swanzy. Diseases of the Eye and their Treatment, 176 
 
 Illustrations. Fourth Edition. Cloth, 3 00; Leather, 3.50 
 
 Fox and Gould. Compend of Diseases of the Eye and 
 Refraction. 2d Ed. Enlarged. 71 Illus. 39 Formulae. 
 
 Cloth, 1.00 ; Interleaved for Notes, 1.25 
 
 HfS" See pages 2 to S /'>''' '"'' ^ Students' Manuals. 
 
STUDENTS' TEXT-BOOKS AND MANUALS. 9 
 
 ELECTRICITY. 
 
 Bigelow. Plain Talks on Medical Electricity. Cloth, i.oo 
 
 Mason's Compend of Medical Electricity. Cloth, i.oo 
 
 Steavenson and Jones. Medical Electricity. A Practical 
 
 Handbook. Just Ready, Illustrated. i2mo. Cloth, 2.50 
 
 HYGIENE. 
 
 Coplin and Bevan. Practical Hygiene. By W. M. L. Cop- 
 lin. Adjunct Professor of Hj'giene, Jefferson Medical College, 
 Philadelphia, and Dr. D. Bevan. Illustrated. In Press, 
 
 Parkas' (Ed. A.) Practical Hygiene. Seventh Edition, en- 
 larged. Illustrated. 8vo. Cloth, 4.50 
 
 Parkes' (L, C.) Manual of Hygiene and Public Health. 
 Second Edition. i2mo. Cloth, 2.50 
 
 Wilson's Handbook of Hygiene and Sanitary Science. 
 
 Seventh Edition. Revised and Illustrated. Cloth, 3.25 
 
 MATERIA MEDICA AND THERAPEUTICS. 
 
 Potter's Compend of Materia Medica, Therapeutics, and 
 Prescription Writing. Fifth Edition, revised and improved. 
 See pag^e ij. Cloth, i.oo; Interleaved for Notes, 1.25 
 
 Davis. Essentials of Materia Medica and Prescription 
 Writing. By J. Aubrey Davis, m.d.. Demonstrator of Obstet- 
 rics and Quiz-Master on Materia Medica, University of Penn- 
 sylvania. i2mo. Interleaved. Net, 1.50 
 
 Biddle's Materia Medica. Eleventh Edition. By the late 
 John B. Biddle, m.d. Revised by Clement Biddle, m.d., 8vo, 
 illustrated. Cloth, 4.25; Leather, 5.00 
 
 Potter. Handbook of Materia Medica, Pharmacy, and 
 Therapeutics. Including Action of Medicines, Special Thera- 
 peutics, Pharmacology, etc. By Saml. O. L. Potter, m.d., 
 M.R.c.p. (Lond.), Professor of the Practice of Medicine in 
 Cooper Medical College, San Francisco. Third Revised and 
 Enlarged Edition. 8vo. Cloth, 4.00; Leather, 5.00 
 
 White and Wilcox. Materia Medica, Pharmacy, Phar- 
 macology, and Therapeutics. A Handbook for Students. 
 By Wm. Hale White, m.d., f.r.c.p., etc., Physician to and 
 Lecturer on Materia Medica, Guy's Hospital. Revised by 
 Reynold W. Wilcox, m.d.. Professor of Clinical Medicine at the 
 New York Post Graduate Medical School, Assistant Physician 
 Bellevue Hospital, etc. American Edition. Clo,, 3.00 ; Lea., 3.50 
 
 ■ See pages 14 and /j for list of ? Quiz- Cotnpends ? 
 
10 STUDENTS' TEXT-BOOKS AND MANUALS. 
 
 MEDICAL JURISPRUDENCE. 
 
 Reese. A Text-book of Medical Jurisprudence and Toxi- 
 cology. By John J. Reese, M.D., Professor of Medical Juris- 
 prudence and Toxicology in the Medical Department of the 
 University of Pennsylvania ; Physician to St. Joseph's Hospital. 
 Third Edition. Cloth, 3.00; Leather, 3.50 
 
 NERVOUS DISEASES. 
 
 Gowers. Manual of Diseases of the Nervous System. 
 A Complete Text-book. By William R. Gowers, m.d.. Prof. 
 Clinical Medicine, University College, London. Physician to 
 National Hospital for the Paralyzed and Epileptic. Second 
 Edition. Revised, Enlarged, and in many parts Rewritten. 
 With many new Illustrations. Octavo. 
 Vol. L Diseases of the Nerves and Spinal Cord. 616 
 
 pages. Cloth, 3.50 
 
 Vol. II. Diseases of the Brain and Cranial Nerves. 
 
 General and Functional Diseases. Nearly Ready. 
 
 Ormerod. Diseases of Nervous System, Student's Guide to. 
 By J. A. Ormerod, m.d., O.xon., f.k.c.p. (London), Member Path- 
 ological. Clinical, Ophthalmological, and Neurological Societies, 
 Physician to National Hospital for Paralyzed and Epileptic and 
 to City of London Hospital for Diseases of the Chest, Demon- 
 strator of Morbid Anatomy, St. Bartholomew's Hospital, etc. 
 With 75 Wood Engravings. Cloth, 2.00 
 
 OBSTETRICS AND GYNiECOLOGY. 
 
 Davis. A Manual of Obstetrics. By Edw. P. Davis, Dem- 
 onstrator of Obstetrics, Jefferson Medical College, Philadelphia. 
 Colored Plates, and 130 other Illustrations. lamo. Cloth, 2.00 
 
 Byford. Diseases of Women. The Practice of Medicine and 
 Surgery, as applied to the Diseases and Accidents Incident to 
 Women. By W. H. Byford, a.m., m.d.. Professor of Gynaecology 
 in Rush Medical College and of Obstetrics in the Woman's Med- 
 ical College, etc., and Henry T. Byford, m.d., Surgeon to the 
 Woman's Hospital of Chicago. Fourth Edition. Revised and 
 Enlarged. 306 Illustrations, over loc of which are original. 
 Octavo. 832 pages. Cloth, 5.00; Leather, 6.00 
 
 Lewers' Diseases of Women. A Practical Text-book. 139 
 Illustrations. Second Edition. Cloth, 2.50 
 
 Parvin's WincUel's Diseases of W^omen. Second Edition. 
 Including a Section on Diseases of the Bladder and Urethra. 
 150 lUus. Revised. Seepages. Cloth, 3.00; Leather, 3.50 
 
 Morris. Compend of Gynaecology. Illustrated. Cloth, i. 00 
 
 ■Winckel's Obstetrics. A Text-book on Midwifery, includ- 
 ing the Diseases of Childbed. By Dr. F. Winckel, Professor 
 of Gynaecology, and Director of the Royal University Clinic for 
 Women, in Munich. Authorized Translation, by J. Clifton 
 Edgar, m.d.. Lecturer on Obstetrics, University Medical Col- 
 lege, New York, with nearly 20^^ handsome Illustrations, the 
 majority of which are original. 8vo. Cloth, 6.00; Leather, 7.00 
 
 4^ See pagei 2 to s/or iist 0/ New Manuals. 
 
STUDENTS' TEXT-BOOKS AND MANUALS. 11 
 
 Obstetrics and Gynaecology : — Continued. 
 Landis' Compend of Obstetrics. Illustrated. 4th Edition, 
 Enlarged. Cloth, i.oo; Interleaved for Notes, 1.25 
 
 Galabin's Midwifery. By A. Lewis Galabin, m.d., f.r.c.p. 
 
 227 Illustrations. See page 3. Cloth, 3.00; Leather, 3.50 
 
 PATHOLOGY, HISTOLOGY, ETC. 
 
 AVethered. Medical Microscopy. By Frank J. Wethered, 
 
 M.D., M.R.c.p. 98 Illustrations. Cloth, 2,50 
 
 Bowlby. Surgical Pathology and Morbid Anatomy, for 
 
 Students. 135 Illustrations. i2mo. Cloth, 2.00 
 
 Gilliam's Essentials of Pathology. A Handbook for Students. 
 47 Illustrations. i2mo. Cloth, 2.00 
 
 Virchow's Post-Mortem Examinations. 3d Ed. Cloth, 1.00 
 
 PHYSICAL DIAGNOSIS. 
 
 Fenwick. Student's Guide to Physical Diagnosis. 7th 
 Edition. 117 Illustrations. lamo. Cloth, 2.25 
 
 Tyson's Student's Handbook of Physical Diagnosis. Illus- 
 trated. i2mo. Cloth, 1.25 
 
 PHYSIOLOGY. 
 
 Yeo's Physiology. Fifth Edition. The most Popular Stu- 
 dents' Book. By Gerald P'. Yeo, m.d., f.r.c.s.. Professor of 
 Physiology in King's College, London. Small Octavo. 758 
 pages. 321 carefully printed Illustrations. With a Full 
 Glossary and Index. See page 3, Cloth, 3.00; Leather, 3.50 
 
 Brubaker's Compend of Physiology. Illustrated. Sixth 
 Edition. Cloth, 1.00; Interleaved for Notes, 1.25 
 
 Kirke's Physiology. New 13th Ed. Thoroughly Revised and 
 Enlarged. 502 IlliLstrations, some of which are printed in colors. 
 
 Cloth, 4.00; Leather, 5.C0 
 
 Landois' Human Physiology. Including Histology and Micro- 
 scopical Anatomy, and with special reference to Practical Medi- 
 cine. Fourth Edition. Translated and Edited by Prof. Stirling. 
 845 Illustrations. Cloth, 7.00; Leather, 8.00 
 
 " With this Text-book at his command, no student could fail in 
 
 his examination." — Lancet. 
 
 Sanderson's Physiological Laboratory. Being Practical Ex- 
 ercises for the Student. 350 Illustrations. 8vo. Cloth, 5.00 
 
 PRACTICE. 
 
 Taylor. Practice of Medicine. A Manual. By Frederick 
 Taylor, m.d., Physician to, and Lecturer on Medicine at, Guy's 
 Hospital, London ; Physician to Evelina Hospital for Sick Chil- 
 dren, and Examiner in Materia Medica and Pharmaceutical 
 Chemistry, University of London. Cloth, 2.00; Leather, 2.50 
 
 VS' See pages 14 and jj /or list 0/ ? Quiz- Comp ends f 
 
12 STUDENTS' TEXT-BOOKS AND MANUALS. 
 
 Practice : — Continued. 
 
 Roberts' Practice. New Revised Edition. A Handbook 
 of the Theor}' and Practice of Medicine. By Frederick T. 
 Roberts, m.d., m.r.c.p., Professor of Clinical Medicine and 
 Therapeutics in University College Hospital, London. Seventh 
 Edition. Octavo. Cloth, 5.50 ; Sheep, 6.50 
 
 Hughes. Compend of the Practice of Medicine. 4th Edi- 
 tion. Two parts, each. Cloth, i.oo; Interleaved for Notes, 1.25 
 
 P.\RT I. — Continued, Eruptive and Periodical Fevers, Diseases 
 of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, 
 Kidneys, etc., and General Diseases, etc. 
 
 Part ii. — Diseases of the Respiratory System, Circulatory 
 System, and Ner%'ous System; Diseases of the Blood, etc. 
 
 Physicians' Edition. Fourth Edition. Including a Section 
 on Skin Diseases. With Index, i vol. Full Morocco, Gilt, 2.50 
 
 From John A. Robinson, M.D., Assistant to Chair 0/ Clinical 
 Medicine , now Lecturer on Materia Medica, Rush Medical Col- 
 lege, Chicago. 
 " Meets with my hearty approbation as a substitute for the 
 
 ordinar}'^ note books almost universally used by medical students. 
 
 It is concise, accurate, well arranged, and lucid, . . . just the 
 
 thing for students to use while studying physical diagnosis and the 
 
 more practical departments of medicine." 
 
 PRESCRIPTION BOOKS. 
 
 Wythe's Dose and Symptom Book. Containing the Doses 
 and Uses of all the principal Articles of the Materia Medica, etc. 
 Seventeenth Edition. Completely Revised and Rewritten. Jt^t 
 Ready. 32mo. Cloth, i. 00; Pocket-book style, 1.25 
 
 Pereira's Physician's Prescription Book. Containing Lists 
 of Terms, Phrases, Contractions, and Abbreviations used in 
 Prescriptions, Explanatory' Notes, Grammatical Construction of 
 Prescriptions, etc., etc. By Professor Jonathan Pereira, m.d. 
 Sixteenth Edition. 32mo. Cloth, i. 00; Pocket-book style, 1.25 
 
 PHARMACY. 
 Stewart's Compend of Pharmacy. Based upon Remington's 
 Text-book of Pharmacy. Third Edition, Revised. With new 
 Tables, Index, Etc. Cloth, i.oo ; Interleaved for Notes, 1.25 
 
 Robinson. Latin Grammar of Pharmacy and Medicine. 
 By H. D. Robinson, ph.d.. Professor of Latin Language and 
 Literature, University of Kansas, Lawrence. With an Intro- 
 duction by L. E. Sayre, ph.g., Professor of Pharmacy in, and 
 Dean of, the Dept. of Pharmacy, University of Kansas. i2mo. 
 
 Cloth, 2.00 
 
 SKIN DISEASES. 
 Anderson, (McCall) Skin Diseases. A complete Text-book, 
 with Colored Plates and numerous Wood Engravings. 8vo. 
 
 Cloth, 4.50; Leather, 5.50 
 
 Van Harlingen on Skin Diseases. A Handbook of the Dis- 
 eases of the Skin, their Diagnosis and Treatment (arranged alpha- 
 betically). By Arthur Van Harlingen, m.u., Clinical Lecturer 
 on Dermatology, Jefferson Medical College; Prof, of Diseases of 
 the Skin in the Philadelphia Polyclinic. 2d Edition. Enlarged. 
 V/ith colored and other plates and illustrations. 72mo. Cloth, 2.50 
 9f^ See pages 2 to S for list 0/ New Manuals. 
 
STUDENTS' TEXT-BOOKS AND MANUALS. 13 
 SURGERY AND BANDAGING. 
 
 Moullin's Surgery. 500 Illustrations (some colored), 200 of 
 which are original. 2d Ed. Cloth, net 7.00; Leather, net 8.00 
 
 Jacobson. Operations in Surgery. A Systematic Handbook 
 for Physicians, Students, and Hospital Surgeons. By W. H. A. 
 Jacobson, b.a. Oxon., f.r.c.s. Eng. ; Ass't Surgeon Guy's Hos- 
 pital ; Surgeon at Royal Hospital for Children and Women, etc. 
 199 Illustrations. 1006 pages. 8vo. Cloth. 5.00; Leather, 6.00 
 
 Heath's Minor Surgery, and Bandaging. Ninth Edition. 142 
 Illustrations. 60 Formulae and Diet Lists. Cloth, 2.00 
 
 Horwitz's Compend of Surgery, Minor Surgery and 
 Bandaging, Amputations, Fractures, Dislocations, Surgical 
 Diseases, and the Latest Antiseptic Rules, etc., with Differential 
 Diagnosis and Treatment. By Orville Horwitz, b.s., m.d.. 
 Demonstrator of Surgery, Jefferson Medical College. 4th edition. 
 Enlarged and Rearranged. 136 Illustrations and 84 Formulae. 
 i2mo. Cloth, i.oo; Interleaved for the addition of Notes, 1.25 
 _***The new Section on Bandaging and Surgical Dressings con- 
 sists of 32 Pages and 41 Illustrations. Every Bandage of any 
 importance is figured. This, with the Section on Ligation of 
 Arteries, form.s an ample Text-book for the Surgical Laboratory. 
 
 Walsham. Manual of Practical Surgery. Third Edition. 
 By Wm. J. Walsham, m.d., f.r.c.s., Asst. Surg, to, and Dem- 
 of Practical Surg, in, St. Bartholomew's Hospital ; Surgeon to 
 Metropolitan Free Hospital, London. With 318 Engravings. 
 See page 2. Cloth, 3.00 ; Leather, 3.50 
 
 URINE, URINARY ORGANS, ETC. 
 
 Holland. The Urine, and Common Poisons and The 
 Milk. Chemical and Microscopical, for Laboratory Use. Illus- 
 trated. Fourth Edition. i2mo. Interleaved. Cloth, i.oo 
 
 Ralfe, Kidney Diseases and Urinary Derangements. 42 Illus- 
 trations. i2mo. 572 pages. Cloth, 2.75 
 
 Marshall and Smith. On the Urine. The Chemical Analysis of 
 the Urine. By John Marshall, m.d.. Chemical Laboratory, Univ. 
 of Penna; and Prof. E. F. Smith, ph. d. Col. Plates. Cloth, i.oo 
 
 Memminger. Diagnosis by the Urine. Illustrated. 
 
 Cloth, I.oo 
 
 Tyson. On the Urine. A Practical Guide to the Examination 
 of Urine. With Colored Plates and Wood Engravings. 7th Ed. 
 Enlarged. i2mo. Cloth, 1.50 
 
 Van Niiys, Urine Analysis. lUus. Cloth, 2.00 
 
 VENEREAL DISEASES. 
 
 Hill and Cooper. Student's Manual of Venereal Diseases, 
 with Formulae. Fourth Edition. i2mo. Cloth, i.oo 
 
 See pages 14 and ij for list of ? Quiz- Contp ends f 
 
POUIZ-COMPENDS? 
 
 The Best Compends for Students' Use 
 in the Quiz Class, and when Pre- 
 paring for Examinations. 
 
 Compiled in accordance with the latest teachings of promi- 
 nent Lecturers and the most popular Text-books. 
 
 They form a most complete, practical, and exhaustive 
 set of manuals, containing information nowhere else col- 
 lected in such a condensed, practical shape. Thoroughly 
 up to the times in every respect, containing many new 
 prescriptions and formulae, and over two hundred and 
 rifty illustrations, many of which have been drawn and 
 engraved specially for this series. The authors have had 
 large experience as quiz-masters and attaches of colleges, 
 with exceptional opportunities for noting the most recent 
 advances and methods. 
 
 Cloth, each $i.cx3. Interleaved for Notes, $1.25. 
 
 No. I. HUMAN ANATOMY, "Based upon Gray." Fifth 
 Enlarged Edition, including Visceral Anatomy, formerly 
 published separately. 16 Lithograph Plates, New 
 Tables, and 117 other Illustrations. By Samuel O. L. 
 Potter, m.a., m.d., m.r.c.p. (Lend.), late A. A. Surgeon U. S. 
 Army, Professor of Practice, Cooper Aledical College, San Fran- 
 cisco. 
 
 Nos. 2 and 3. PRACTICE OF MEDICINE. Fourth Edi- 
 tion. Hy Daniel E. Hughes, m.u., Demonstrator of Clinical 
 Medicine in Jefferson Medical College, Philadelphia. In two parts. 
 
 Part I. — Continued, Eruptive, and Periodical Fevers, Diseases 
 of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, 
 Kidneys, etc. (including Tests for Urine), General Diseases, etc. 
 
 Part II. — Diseases of the Respiratory System (including Phy- 
 sical Diagnosis), Circulatory System, and Nervous System; Dis- 
 eases of the Blood, etc. 
 
 %* These little books can be regarded as a full set of notes upon 
 the Practice of Medicine, containing the Synonyms, Definitions, 
 Causes, Symptoms, Prognosis, Diagnosis, Treatment, etc., of each 
 disease, and including a number of prescriptions hitherto unpub- 
 lished. 
 No. 4. PHYSIOLOGY, including Embryology. Sixth 
 
 Edition. By Albert P. Brubakek, m.u., Prof, of Physiology, 
 
 Penn'a College of Dental Surgery ; Demonstrator of Physiology 
 
 in Jefferson Medical College, Philadelphia. Revised, Enlarged, 
 
 with new Illustrations. 
 
 No. 5. OBSTETRICS. Illustrated. Fourth Edition. By 
 Henry C Lanuis, m.d., Prof, of Obstetrics and Diseases of 
 Women in Starling Medical College, Columbus, O. Revised 
 Edition. New Illustrations. 
 
BLAKISTON'S ? QUIZ-COMPENDS ? 
 
 No, 6. MATERIA MEDICA, THERAPEUTICS, AND 
 PRESCRIPTION WRITING, Fifth Revised Edition. 
 
 With especial Reference to the Physiological Action of Drugs, 
 and a complete article on Prescription Writing. Based on the 
 Last Revision of the U. S. Pharmacopoeia, and including many 
 unofficiual remedies. By Samuel O. L. Potter, m.a., m.d., 
 M.R.c.P. (Lond.), late A. A. Surg. U. S. Army ; Prof, of Practice, 
 Cooper Medical College, San Francisco. Improved and Enlarged, 
 with Index. 
 No. 7. GYN.ffiCOLOGY. A Compend of Diseases of Women. 
 By Henry Morki?, m.d., Demonstrator of Obstetrics, Jefferson 
 Medical College, Philadelphia. 45 Illustrations. 
 
 No. 8. DISEASES OF THE EYE AND REFRACTION, 
 
 including Treatment and Surgery. By L. Webster Fox, m.d.. 
 Chief Clinical Assistant Ophthalmological Dept., Jefferson Med- 
 ical College, etc., and Geo. M. Gould, m.d. 71 Illustrations, 39 
 Formulas. Second Enlarged and improved Edition. Index. 
 
 No. 9, SURGERY, Minor Surgery and Bandaging. Illus- 
 trated. Fourth Edition. Including Fractures, Wounds, 
 Dislocations, Sprains, Amputations, and other operations; Inflam- 
 mation, Suppuration, Ulcers, Syphilis, Tumors, Shock, etc. 
 Diseases of the Spine, Ear, Bladder, Testicles, Anus, and 
 other Surgical Diseases. By Orville Horwitz, a.m., m.d.. 
 Demonstrator of Surgery, Jefferson Medical College. Revised 
 and Enlarged. 84 Formulse and 136 Illustrations. 
 
 No. 10. CHEMISTRY. Inorganic and Organic. For Medical 
 and Dental Students. Including Urinary Analysis and Medical 
 Chemistry. By Henry Leffmann, m.d., Prof, of Chemistry in 
 Penn'a College of Dental Surgery, Phila. Third Edition, Revised 
 and Rewritten, with Index. 
 
 No. II. PHARMACY. Based upon " Remington's Text-book 
 of Pharmacy." By F. E. Stewart, m.d., ph.g., Quiz-Master 
 at Philadelphia College of Pharmacy. Third Edition, Revised. 
 
 No. 12. VETERINARY ANATOMY AND PHYSIOL- 
 OGY. 29 Illustrations. By Wm. R. Ballou, m.d., Prof, of 
 Equine Anatomy at N. Y. College of Veterinary Surgeons. 
 
 No. 13. DENTAL PATHOLOGY AND DENTAL MEDI- 
 CINE. Containing all the most noteworthy points of interest 
 to the Dental student. By Geo. W. Warren, d.d.s.. Clinical 
 Chief, Penn'a College of Dental Surgery, Philadelphia. Illus. 
 
 No, 14. DISEASES OF CHILDREN. By Dr. Marcus P. 
 Hatfield, Prof, of Diseases of Children, Chicago Medical 
 College. Colored Plate. 
 
 Bound in Cloth, $1. Interleaved, for the Addition of Kotes, $1.25. 
 
 These books are constantly revised to keep up with 
 the latest teachings and discoveries^ so that they contain 
 all the new methods and principles. No series of books 
 are so complete in detail, concise in language^ or so well 
 printed and bound. Each one for7ns a coviplete set of 
 notes upon the subject under consideration. 
 
 Illustrated Descriptive Circular Free. 
 
JUST PUBLISHED. 
 
 GOULD'S NEW 
 
 Medical Dictionary 
 
 COMPACT. 
 COxN'CISE. 
 PRACTICAL. 
 ACCURATE. 
 
 QS I COMPREHENSIVE 
 n^ UP TO DATE. 
 
 It contains Tables of the Arteries, Bacilli, Gan- 
 glia, Leucomaines, Micrococci, Muscles, 
 Nerves, Plexuses, Ptomaines, etc., 
 etc., that will be found of great 
 use to the student. 
 
 Small octavo, 520 pages, Half-Dark Leather, . ^3.25 
 With Thumb Index, Half Morocco, marbled edges, 4.25 
 
 From J. M. DaCOSTA, M. D., Professor of Practice and 
 Clinical Medicine, Jefferson Medical College, Philadelphia. 
 
 "/yi»d it an excellent -work, doing credit to the learning and 
 discrimination of the author." 
 
 V Sample Pages free. 
 

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