WHtt::.-^ HXOOO 15342 i f G^ (Eolumfata litttttrrattg tit tit? (Etitj nf $>m fork (Enllrgp nf IJljgairians ann ^nrgrona l&tUtmt? lOtbranj Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/compendiumofpracOOgrub A COMPENDIUM OF PRACTICAL MEDICINE FOR THE USE OF Students and Practitioners of Medicine BY WILLIS WEBSTER GRUBE, A. M., M. D., Professor of Physiology and of Clinical Medicine in the Toledo Medical College; Visiting Physician to the Toledo Hospital ; Physician to the Toledo Medical College Dis- pensary for the Relief of the Out-door Poor ; Member of the American Medi- cal Association ; Member of the Tri-State Medical Association ; Member of the Toledo Medical Association, etc., etc. TOLEDO, OHIO: The Hadley Publishing Company. 1897. GIFT COPYRIGHTED W. W. GRUBE, 19~. PREFACE. Ill presenting this volume to the medical profession, it may not be improper to state the circumstances which led to the undertaking, and the design which it is intended to accomplish. The frequent requests on the part of medical students whom it has been my pleasure to instruct during the past few years, to prepare a compendium of practical medicine which shall aid them in acquiring established facts, is the only apology I have to offer for its appearance. This work is designed to present the leading facts and prin- ciples of medicine, in a brief, clear and concise manner, so that they may be readily comprehended. My chief aim has been to prepare a book of an essentially practical character — one neither so meager in detail as to be next to useless, nor so overladen with unnecessary matter as to be unwieldy and lacking in precise knowledge. The ever- recurring wants and requirements of the medical student and practitioner have been kept constantly in view. In the preparation of the work, the author has carefully examined all the best material at his command and freely used it; the special object being to have it abreast of the present knowledge on the subjects treated as far as such is possible in a work of this kind; and every effort has been made to give it all the freshness of interest and clearness of expression possible. The discussion or even mention of mere theories has been purposely avoided, for experience has taught us that such dis cussions serve only to confuse and discourage. In issuing a volume of this character, it is perhaps but just to say that of course it cannot and is not intended to replace the classical works. For more minute information, extended description and elucidation and other minutiae for which the work of reference is consulted, recourse must be had to more extended text -books PREFACE. and similar sources of information. Nevertheless, it is confi- dently believed that the present volume meets a distinct and im- perative need of the medical student and general practitioner, conveying in condensed and convenient form concise and practi- cal information for which they are liable to have continual use. In my endeavor to keep this book within reasonable limits, I have touched but lightly upon the pathology of disease, except in those cases in which such knowledge would aid in the treat- ment, and have purposely omitted all unimportant details. Not- withstanding my utmost efforts at condensation, the work has grown beyond the contemplated size. Much of the matter embraced in a work of this kind is the common property of the medical profession, and credit has been given for facts or opinions by merely inclosing the name of the author in parenthesis. If I have failed to give credit in any case, it is unintentional. I would gladly acknowledge my indebtedness to Prof. J. H. Pooley, M. D., of Toledo, for the preparation of Chapter IV., on "First Help in Surgical Emergencies," and to Prof. W. J. Gillette, M. D., of Toledo, for the preparation of Chapter III., on "Medical Diseases of Women." I also acknowledge my indebtedness to the standard works of Bartholow, Loomis, Flint, DaCosta, J. L. Smith, Skene, Thomas, Pozzi, Anderson, Fox, Noyes, Milton, Keyes, Bosworth, Bryant, Lusk, Habershon, Starr, Hammond, and many others. To the many kind friends who have encouraged me to un- dertake this work, I return my warmest thanks. W. W. GRUBE, M. D., 1502 Collingwood Ave., Toledo, Ohio. March, 1897. CONTENTS AND GENERAL INDEX. Examination of the patient. 17. History of. 17. Present condition. 17. Position of body. 18. General aspect. 18. PAGE. The Skin in Disease 19 The Pulse in Disease 19 The Tongue in Disease 24 The Temperature in Disease 27 Chronic Fever 30 Clinical Index 649 Fee Bill 664 Abortion 32 Abscess 37 Acidity 40 Acne 41 Acne Rosacea 45 Addison's Disease 46 A fter-pains 47 Agalactia 48 Ague (See Intermittent Fever)... 48 Ague-cake 48 Albinism 49 Albuminuria 48 Alcoholism 50 Alopecia 51 Amaurosis 53 Amblyopia 53 Amenorrhoea 610, 53 Anaemia 56 Anaesthesia 62 Anaesthetics 635 Anasarca 60 A nchy losis 62 Aneurism 58 Angina Pectoris 60 Anthrax 61 Aphasia 64 Aphonia 70 Apoplexy 64 Apthae 63 Appendicitis 66 Ascaris Lumbricoides 70 Ascites 66 Asphyxia 72 Asthenia 69 Asthma.... 67 Atheroma 72 Backache 73 Balanitis 73 Baldness 73 Basedow's Disease 73 Bed-sore 73 Biliousness 74 Bites 75 Bladder Diseases 76 Blepharitis 76 Bloody-flux 76 Blood-poisoning 77 Boils 76 Borborygmus 78 Breasts. Inflammation ol 78 Breath, Foul 77 Bright's Disease 83 Bronchitis 79 Bronchocele 78 Bubo 84 Bubonocele 78 Bunions 86 Burns and Scalds 625, 87 Calcificaiion 141 Calculi 89 Cancer 95 Cancrum Oris 132 Carbuncle 100 Cardialgia 133 Caries 99 Catalepsy 133 XII. GENERAL index. Catarrh, Nasal and Chronic Gas- tric 100 Cephalalgia 134 Cerebro-Spinal Meningitis 134 Chancre 109 Chancroid 110 Chicken-pox 135 Chilblains 112 Chiragra 220 Chloasma 141 Chlorosis 113 Cholera Infantum 116 Cholera Morbus 115 Chordee....,.,,,, 118 Chorea 120 Circumcision 135 Cirrhosis of Liver 143 Cold, Exposure to 626 Cold Feet 137 Colic 121 Coma 136 Comedones 140 Condylomata 123 Conjunctivitis 124 Constipation 125 Convulsions 127 Copper-nose 45 Coryza 128 Cough 137 Cramps 142 Croup , 128 Cystitis 131 Cysts 140 Dactylitis 164 Dandruff 164 Debility 143 Delirium 144 Delirium Tremens 145 Derbyshire Neck 164 Diabetes Insipidus 146 Diabetes Mellitus 147 Diarrhoea 149 Dislocations 627 Dyphtheria 151 Dypsomania 154 Dirt-eating 155 Dropsy 155 Drowning 627-164 Dysentery 157 Dysmenorrhea 613, 159 Dyspepsia 161 Earache 164 Eclampsia 183 Eczema 165 Embolism 184 Emissions 169 Emphysema 172 Empyema 173 Endocarditis 175 Endometritis 620, 186 Endosteitis , 392 Enteralgia 190 Enteritis 176 Enuresis 184 Ephidrosis 190 Epididjrmitis 187 Epilepsy 178 Epispadias 189 Epistaxis 180 Epithelioma 189 Eructations (Offensive) 189 Erysipelas 181 Erythema 183 Exophthalmic Goitre 213 Faintings 199 Falling Sickness 199 Fatigue 200 Felon 199 Fetor of Axilla and Feet 191 Fevers (in general) 191 Fissure of Anus 192 Fissure of Nipple 194 Fistula 195 Fits 199 Flatulence 196 Flooding 199 Flushing Heats 200 Foreign Bodies in Eye, Ear, and Nose 628 Fractures 267-201 Freckles, Sunburn and Tan 197 Frostbite 198 Furuncle 199 Galactorrhea 202 Gail-Stones ' 203 Gangrene 203 Gas, Asphyxiation from 629 Gastralgia 206 Gastric Ulcer 207 Gastritis (Toxic) 223 Giddiness 226 Gingivitis 224 Glanders 226 Glands, Enlarged Lymphatics.... 210 Glaucoma 224 Gleet ,„ 211 GENERAL INDEX. XIII. PAGE. Glycosuria 227 Goitre 213 Gonagra 227 Gonorrhoea 215 Gout ' 220 Granulating Lids 226 Gravel 226 Graves' Disease 226 Green Sickness 226 Grocers' Itch 165 Gumma 226 Gums (Spongy) 223 Hematocele 259 Hemidrosis 260 Hemoptysis 230 Hemorrhage 630, 239 Hernatemesis 227 Hematuria 228 Hay Fever 232 Headache 234 Head-injury 262 Heart-burn 237 Heart Diseases 238 Heat Stroke 255 Hectic Fever 256 Hemicrania 237 Hemiplegia 237 Hemorrhoids 242 Hepatitis 244 Hernia 630,263 Herpes 245 Hiccough 247 Hives 257 Hoarseness 257 Hodgkin's Disease 261 Hordeolum 258 Horns 262 House-maid's Knee 258 Hydrocele 259 Hydrocephalus 248 Hydronephrosis 272 Hydrophobia 274 Hydrothorax 249 Hymen-Irnperforate 261 Hyperidrosis 260 Hypochondriasis 250 Hypospadia 261 Hysteria 252 Icterus 296 Icthyosis 275 Impetigo 276 Impotence 279 Incontinence of Urine 282 PAGE. Indigestion 277 Inflammation 277 Influenza 282 In-growing Toe-nail 284 Injuries to Brain 631 Insolation 296 Insomnia 284 Intermittent Fever 286 Intertrigo 286 Intestinal Catarrh 287 Intestinal Obstruction 287 Intussusception 287 Iodism 296 Iritis 294 Irritability 297 Itch ,.... 287 Itching 297 Jaundice 297 Keratitis 299 Kidney Diseases 300 King's" Evil 300 Knee-jerk 300 Labor 301 Lactation (Excessive.) 319 Laryngismus Stridulus 302 Laryngitis 303 Lead Colic 320 Lead-poisoning 305 Lentigo 320 Leprosy 307 Leucocythemia 308 Leucoderma 320 Leucorrhoea 616, 311 Lice 313 Lichen 314 Lipoma 319 Lockjaw 319 Locomotor Ataxia 315 Lumbago 318 Lupus , 31S Lymphadenoma 310 Malarial Fevers 320 Mania 332 Mania, a potu 354 Marasmus 333 Mastitis 332 Masturbation 354 Measles 333 Melancholia 336 Meniere's Disease 357 Meningitis 337 Menorrhagia 350 Metritis 620 XIV GENERAL IXDEX. Metrorrhagia 350 Migraine 351 Milium 357 Milk-leg 357 Miscarriage 357 Mitral Disease 351 Moles 357 Morbus Coxarius 358 Morning Sickness 351 Mother's Mark 357 Mumps 352 Muscular Rheumatism 358 Myalgia 354 Myelitis 343 Nsevus 359 Nausea 364 Necrosis 360 Nephritis 360 Nettlerash 360 Neuralgia 360 Neurasthenia 366 Neuritis 364 Nightmare 365 Night Screaming 365 Nipple (Sore) 363 Nymphomania 363 Obesity 366 (Eclema 36/ (Esophageal Obstruction 379 Onanism 376 Onychia Maligna.. 36/ Opacities in Eye 377 Ophthalmia 368 Opium Habit 369 Orchitis 371 Ostitis 392 Otalgia 374 Otitis 373 Overwork 378 Oxaluria 374 Oxyuris- Vermicularis . . 376 Ozena 375 Painter's Colic... 320 Palpitation 380 Paralysis 383 Paralysis Agitans 473 Paraphimosis 468 Paraplegia 386 Paresis 383 Paronychia 199 Parotitis 352 Pediculi . 387 Pemphigus 387 PAGE. Pericarditis 388 Periostitis 392 Peritonitis 394 Pertussis 400 Phagedena 402 Pharyngitis 403 Phimosis 468 Phlegmasia Alba Dolens 404 Phthisis 406" Phthisis (Fibroid) 431 Pica and Malacia 472 Piles 242 Pityriasis 164 Pleurisy 433 Pneumonia (Lobar.) 440 Pneumonia (Lobular.) 452 Podagra 220 Poisoning ' 632 Pollution.. 170 Polyphagia 473 Polyuria 146 Posterior Spinal Sclerosis 315 Priapism 455 Prickly Heat 456 Prostatitis 456 Prostatorrhcea 458 Prurigo 459 Pruritis 460 Psoriasis 461 Pterygium 470 Ptyalism 493 Puerperal Fever 463 Purpura 465 Pyaemia 466 Pyelitis 470 Pyonephrosis 470 Pyrosis " 467 Quinsy 567 Rabies 274 Rachitis 475 Ranula 486 Rashes (Medicinal) 489 Relapsing Fever 490 Relaxed Uvula 488 Remittent Fever 329 Renal Calculi 92 Restlessness... 489 Retention of Urine 486 Rheumatism 478 Rheumatism (Chronic Articular) 483 Rheumatoid Arthritis 485 Ringworm 565 Roseola 488 GENERAL INDEX. XV PAGE. Rubeola 333 St. Vitus Dance 120 Salivation 493 Salt Rheum 165 Satyriasis 494 Scabies 494 Scalds 87 Scarlatina 495 Sciatica 361 Scorbutus 507 Sclerosis of Brain 501 Sclerosis, Cerebro-spinal 502 Scrofula 504 Scurvy 507 Sea Sickness 508 Seminal Emissions 169 Septicaemia 510 Shingles 246 Shock 633,539 Sick Headache 235 Singultus 247 Sleeplessness 284 Small Pox 594 Sneezing 537 Somnambulism. 537 Sore-feet 537 Sores 585 Spermatorrhoea 511 Spina Bifida 515 Spinal Irritation 536 Sprains 634,518 St. Anthony's Fire 181 Stenosis of (Esophagus 379 Stings 538 St. Job's Disease 542 Strangury 514 Stricture 520 Struma 504 Stye (See Hordeolum.) 514 Sudamina ■__ 539 Summer Complaint 116 SunStroke 255 Suppression of Urine 540 Sweating 190 Syncope 199 Synovitis 541 Syphilis 542 Tape-worms 560 Tetanus 562 Tic Douloureux 360 Tinea 564 Tinnitus Aurium 566 ThreadWorm 376 Thrush 564 Tongue-tie 572 Tonsilitis 567 Tooth ache 569 Torticollis.., 354 Trachoma 572 Trichinosis .__ 571 Trismus 562 Tuberculosis ,' Acute Miliary.) . . 432 Tympanites 570 Typhoid Fever 572 Typhus Fever 583 Ulcers and Sores 585 Uraemia 586 Urethritis 215 Urticaria 587 Vaccination 596 Vaginismus 588 Vaginitis 618 Valvular Diseases 596 Varicella 593 Varicocele 590 Varicose Veins 590 Variola 594 Varoiloid 595 Vertigo ' 590 Vitiligo 320 Vomiting 592 Vulvitis 589 Wakefulness 284 Warts 607 Water Brash 467 Wens 141 Whites 311, 616 Whitlow . 199 Whooping Cough 400 Worms 376. 560 Wounds (poisoned) 632 Wrist-drop 305 Wry-neck 354 Yellow Fever 60S CHAPTER I. THE EXAMINATION OF PATIENTS. To elicit the facts of a case by careful examination is the first requisite for diagnosis. There are two methods of exami- nation — the synthetical and the analytical. The synthetical method is the more scientific, but is too full, and calls for too much labor, to meet the requirements of ordinary professional life. It is the best where the symptoms are obscure and ill defined. It consists in getting the family history and the history anteced- ent to the present disease, before the present condition is ex- plored. In the analytical method the present condition is first ascertained. Da Costa uses the following plan of examination: 1. Date of examination. 2. Name. 3. Age. 4. Color. 5. Place of Birth. 6. Present abode. 7. Occupation. 8. In female, whether married or not, number of children, and date of last confinement. History — I. History antecedent to present disease: (1) Constitution and general health. (2) Hereditary predisposition (family history.) (3) Previous diseases or injuries. (4) Habits and mode of life. (5) Hygenic influences to which ex- posed. II. History of present disease: 1 Its supposed exciting cause. 2 Date of seizure. 3 Mode of invasion. 4 Subsequent symptoms in order of succession. 5 Previous treatment. Present Condition of Patient. I. General symptoms: 1. Position, in bed — mode of lying — out of bed — movements. 2. Aspect, of body — of countenance. 3. Skin. 4. Pulse. 5. Tern- 18 A COMPENDIUM OF PRACTICAL MEDICINE. perature. 6. Respiration. 7. Tongue. 8. Appetite, thirst, and condition of bowels. 9. General state of urinary secretion. 10. Sensations of the patient as to pain, etc. II. Examination of special regions. Diagnosis. Treat- ment. Position of the Body. If the patient is in bed, note how he lies; if out of bed, how he walks. If a healthy person be suddenly confined to his bed, the inference is that he will have an acute and severe disease. If the patient lies fixed upon one side, it shows, as a rule that the action of the lung of this side is impaired. The patient may be in bed but unable to lie down on account of distress in breathing. This dyspnoea is encountered especially in diseases of the heart, or where fluid is effused into the air cells or into both pleural cavities. In some diseases of the brain the gait is staggering. In one-sided palsy the movements are uncertain. General Aspect. — Expression of Countenance. The eye notices whether the body is bulky or wasted. If the bulky aspect is due to air in the tissues, they crepitate under the finger; if too fluid, the skin pits under pressure. Emaciation is a more frequent symptom than augmentation. Jt may take place rapidly or gradually. Among the counte- nances most frequently met with is that of apathy and stupor. The eye is dull and listless; the face pale or flushed with fever. This look is common in fevers of a low type and is combined with dark material on the lips, gums and teeth. Unnatural fulness and congestion of the features are some- times observed in enlargements of the heart, and oftener still in habitual drunkards. The same aspect is seen in apoplexy and in typhus fever. A pinched expression is found when there is intense anxiety or pain. The Hippocratic countenance denotes the moribund state. It is characterized by marked pallor with more or less lividity, jnnching of the nostrils, sinking of the eyes, hollowness of the temples, coldness and transparency of the ears, dropping of the lower jaw. The face of shock, with its great pallor, its anxious or frightened look, is seen after severe injuries and oj)erations. EXAMINATION OF PATIENT. 19 A dusky flush on the face, if associated with rapid breath- ing, is almost a certain indication of inflammation of the lung. Pivffiness of the eyelids in a pallid person is very apt to be expressive of Bright's disease. There is the straw-colored, anaemic hue of malignant dis- ease; the jaundice, melancholy look of an hepatic affection- Skin. — Coldness of the skin indicates a weakened capillary circulation. Protracted coldness, whether attended with dryness or with clamminess, is of evil augury. The skin is pale when- ever the blood is poor and watery. In wasting and prostrating ailments the skin feels very relaxed and soft. The skin may be dry, moist, or profusely wet and sodden. In most fevers with high temperature the skin is hot. Now, if we make the patient's skin moist, we promote his comfort and well-being. Small, often-repeated doses of tincture of aconite or tartar emetic will induce perspiration. In many cases of diabetes and Bright's disease, it is very difficult to make the very dry skin perspire. The two chief causes of sweating are weakness, and a fall in a febrile temperature, two causes often combined in the same person in exhausting febrile disease, as in phthisis. In exhausting diseases, sleep may produce sweating. Pro- fuse sweating occurs during convalescence from scarlet fever. With the exception of rheumatic fever, profuse sweating at the commencement of an acute febrile disease, when the temper- ature remains high, indicates great weakness. Duskiness of the face, ears and under the nails shows weakened heart action. Pulse. — The pulse is an accurate index of the condition of the heart, and is therefore the most valuable guide in disease. The importance of the pulse is manifest when we consider that disease kills by arresting the heart. Whilst the heart beats there is life and hope. In many instances, the pulse gives the first signs of danger, as in the case of pneumonia, in which dis- ease so long as the pulse continues good we have fair hopes of our patient. In other instances the nervous system first gives way, as shown by sleeplessness and delirium, and this depresses and weakens the heart. 20 A COMPENDIUM OF PRACTICAL MEDICINE. In any case it is the ultimate effect of the disease on the heart that destroys life. The pulse -beats may be frequent or infrequent, slow or quick; small or large; compressible or incompressible; regular or irregular; or intermittent. By the frequency of the pulse we mean the number of beats- in a given time. In a quick pulse each beat occupies less than the usual time, that is, each wave is of short duration relatively to the pause between the waves. When the volume of the pulse is greater than usual, it is- said to be large; or the volume may be less than usual, when it is said to be small. When the fingers can easily stop the pulse it is said to be compressible; when on the other hand, it can be arrested only with difficulty or not at all, the pulse is said to be incompressible. In an irregular pulse, succeeding beats differ in length, force and character. In an intermittent pulse a beat is from time to time lost. The frequency of the healthy pulse varies; thus, in some persons the normal pulse is 100, in others as low as 50 a min- ute. Five conditions produce a frequent pulse: fever, debility r excitement, hysteria, and cardiac disease. In fevers the pulse is generally accelerated in proportion to- the elevation of temperature, more in children than in adults. When a pulse is more frequent than the temperature will explain, it indicates cardiac weakness. In all febrile diseases, a pulse in adults over 120 is serious and indicates cardiac weak- ness; a pulse of 130 or 140 indicates great danger; and with a pulse at 160 the patient almost always dies. In rheumatic fever a pulse of 120 indicates great danger. In such a case, the temperature is 104° to 105° F., the patient is prostrate, the tongue dry, and sordes collect on the lips ; a, case like this often ends fatally, and when the pulse rises above 120, the patient will pretty surely die. If . pericarditis, a complication of rheumatism, causes the frequent pulse, it is of less import. EXAMINATION OF PATIENT. 21 An irregular pulse from mitral disease may be very frequent, 120, 130, or more, without indicating extreme danger. Sometimes in typhoid fever, though the temperature is high, "the pulse remains normal throughout the attack, and this shows .absence of cardiac weakness. In chronic diseases a frequent pulse very generally indicates -cardiac weakness. A weakened heart diminishes arterial tension, .and the pulse becomes soft and compressible. If the heart be- comes still more weak, the pulse becomes small as well as quick, and compressible. Smallness of the pulse, therefore, indicates still greater weakness. When the pulse is very small it is said to be thready. The more frequent, the more compressible, the smaller the pulse, the greater the cardiac weakness, and the greater the need of cardiac stimulants. The general condition of the patient may be good, but the pulse is frequent, small, compressible and quick, and indicates danger. The pulse in some persons is easily made frequent with- out this frequency indicating any danger. In some persons in perfect health we find a very small and compressible pulse. So long as the pulse remains good, we feel that our patient is com- paratively safe. An infrequent pulse occurs in some cases of blood -j)oison- ing, as in jaundice, uraemia, and in these cases, the tempera- ture is often subnormal. An infrequent pulse is met with, sometimes in fatty degeneration of the heart, and in aortic ob- struction, in irritation of the vagus or its root, as in meningitis, cerebral tumors or compression. The size of the pulse varies in disease. It is often large at the commencement of fever. The pulse is small in inanition, owing to the small quantity of blood. It is small, too, in mitral obstruction, and in mitral regurgitant disease, and in aortic stenosis; also with cardiac debility. In an intermittent pulse, an occasional beat is missed, the rhythm being otherwise regular. An intermittent pulse is very different from an irregular pulse. Some persons have a life-long intermittent pulse, but ordinarily it does not occur till after middle age. It maybe persistent or occasional; and when occa- sional only it is often due to an idiosyncrasy, and is caused by 22 A COMPENDIUM OF PRACTICAL MEDICINE. some article of food, as tea, smoking or indigestion. By the intermission some persons are made very uncomfortable and nervous, and get the sensation as if the heart stopped or rolled over. In most cases an intermittent heart is of no significance. An irregular pulse is of far more serious significance than an intermittent. The pulse is irregular, both in force and rhythm, succeeding beats differing in length, force and character. It is generally due to mitral, and rarely occurs in other forms of heart disease, though sometimes met with in great cardiac prostration, as in an acute febrile illness, a few hours before death. It occurs, too, in fatty degeneration of the heart, and in the first and sec- ond stage of meningitis. The irregular pulse indicates the need of digitalis. Whilst an irregular pulse almost always indicates mitral disease, yet a perfectly regular pulse may accompany either mitral obstruction or regurgitation. Although irregu- larity from mitral disease is rare in children, yet Ringer has seen aconite, in half- drop doses repeated hourly several times pro- duce marked irregularity of the pulse. An irregular pulse is common in children with tubercular meningitis, and it is a diag- nostic guide. In some cases of cerebral disease, with Cheyne- Stokes breathing, the pulse is irregular. An irregular pulse may be due to much smoking, to venereal excess, and to tea drinking. The condition of the blood-vessels influences the pulse. Through the action of the vaso- motor nerves on the mus- cular coat of the arteries, the small blood-vessels undergo relaxa- tion or contraction. When the vessels are relaxed the blood passes easily from the arteries to the veins, hence arterial tension is slight, and the pulse is soft, large and compressible. This pulse is met with in the early stage of some fevers. Arterial relaxation, or low tension, produces a dicrotic pulse. In this pulse one of the normal secondary waves of oscillation becomes greatly exaggerated, so that it can be easily felt by the finger. Indeed, it may be so distinct that an inexperienced per- son may mistake it for the primary wave. Ringer has known a nurse to make this mistake, and thus to double the number of true pulsations. A dicrotic pulse always indicates marked arterial relaxation, and often coincides with cardiac weakness EXAMINATION OF PATIENT. 23 and is frequently met with in typhoid fever. When the vessels are contracted the blood escapes with greater difficulty from the arteries into the veins, and we have the pulse of high arterial tension. In this case the artery is hard and cord-like; it can he rolled under the finger and is easily traced in its course up the fore-arm. With the vessels in this condition, the pulsation is often so slight that it might readily be mistaken for a weak pulse ; but its incompressibility prevents this error. In addition to be- ing small, the pulse is slow and hard. The following conditions give rise to high arterial tension: 1. Degeneration of vessels. 2. Bright's disease, especially the contracted kidney. 3. Gout, jaundice, lead-poisoning, ergot and gallic acid. 4. Affections of the nervous system. 5. The rigor of fevers. High arterial tension and hypertrophy of the heart, asso- ciated with an increased quantity of urine containing a small quantity of albumen, enables us to diagnose the contracted form of Bright's disease. During the rigor or chill of fevers the arteries contract, and produce a pulse of high arterial tension, which is frequent, small, hard, incompressible and slow. When the chill is over and the fever established, the arteries relax, and the pulse is large, full, and not easily compressed — bounding, as it is called. In well-marked aortic regurgitation, the pulse is often char- acteristic. It is a pulse of extreme low tension. If the radial artery is at all visible with the limb dependent, this visibility becomes much more marked on raising the arm. In advanced aortic regurgitation, the pulse gives to the finger a sharp, quick stroke. This is the diagnostic quality of the pulse. The pulse feels as if a small ball or shot was puffed under the finger, and is called the shotty pulse. Visible pulsation of the whole length of the carotid to the lobe of the ear, and of the tempera] and perhaps of the facial artery, is far more frequently due to aortic regurgitation than to high arterial tension, or to low ar- terial tension, or to degeneration of the arteries. Aortic regurgitation is especially a disease of middle or advanced life, being due to age and strain. In arterial degen- eration the arteries become elongated and tortuous, easily visible 24 A COMPENDIUM OF PRACTICAL MEDICINE. in the brachial just above the elbow. The arteries feel hard and corcly, and sometimes calcareous plates can be felt. The pulse of aortic obstruction is slow, generally small, in- frequent, and often hard. In marked mitral obstructive disease, the pulse, when not irregular, is small and compressible. Aneurism of the aorta often delays the pulse, and it may do this on one side more than on the other, or on one side alone. In aneurism of the aorta influencing the arteries of one arm only, the artery on this side can be felt to fill more slowly (Ringer). As the full pulse is not always strong, neither is the small pulse always weak (DaCosta). Such are the meanings attached to the various characters of the pulse. The appreciation of these different kinds of pulses requires considerable practice. Tongue. — The tongue is a mirror which reflects the condition of the digestive functions, the complexion of the nervous power and of the blood, and the state of the secretions. We examine the tongue in regard to its movements, its volume, its dryness or its humidity, its color and its coating. The movements of the tongue are impeded and tremulous in exhausted states of the system. It is protruded slowly and with difficulty in fevers of a low type. In hemiplegia one side is crippled, and the tongue turns toward one of the corners of the mouth. The volume of the tongue is changed by its own diseases Yet a broad and flabby tongue, on the sides of which the teeth leave their marks, is sometimes found in chronic ailments of the digestive organs, and as a result of the action of mercury and of certain poisons. It is observed in some diseases of the brain and heart, and in typhus and scurvy. Dryness of the tongue indicates deficient salivary secretion. The tongue is dry in acute visceral inflammations, in the exan- themata, and in typhoid fever. If the tongue be very dry, of a dark color, glazy, or furred or fissured, it denotes depraved -blood. A fissured tongue may occur in chronic affections of the liver and intestines, and in some persons it is congenital. The tongue may become dry from persistent openness of the mouth, EXAMINATION OF PATIENT. 25 as during sleep, or from coma, and has no significance. Among chronic diseases the tongue is most apt to be found dry in diabetes. A dry tongue is never a favorable sign. It is present in about fifty per cent, of fatal cases; more than any other it fore- tells death. A moist or humid tongue is a favorable sign. The dryness first invades the tip and extends up the centre. A dry tongue generally indicates nervous depression, often shown by low muttering delirium. This depression is often due to want of sleep. Narcotics, therefore, like chloral, bromide of potassium, or opium, by inducing sleep, soothe and strengthen the nervous system, and indirectly moisten the tongue. The dry tongue is often an indication for alcoholic stimu- lants. The two chief uses of alcohol are to assist digestion and to sustain the nervous system. Now sleep is the best restorative; hence fever patients who sleep well do not as a rule require stimulants. But, if in spite of sleep the tongue remains dry and delirium persists, then alcohol is indicated. Usually a patient with a dry tongue has a frequent, quick and compressible pulse calling for alcoholic stimulation. If the alcohol makes the tongue drier and more coated, it is contraindicated. In the aged, the tongue often becomes dry without, fever. The color of the tongue is a useful sign. A broad, pale, flabby teeth -indented tongue indicates anaemia with a relaxed condition of the tissues. This tongue is met with in chlorosis, and in some chronic diseases, as Bright's, and always signifies the need of iron. In diabetes the tongue becomes smooth, glazed, shiny, beefy looking, abnormally clean and often very dry. If the tongue be red, too clean, too smooth or slightly furred, it points to an irritable state of the stomach, to dyspepsia. It is met with in drunkards and in phthisis when the intestines are ulcerated, and in tubercular peritonitis. One minim of Fowler V solution given before meals will improve this tongue. The tongue is exceedingly red in scarlet fever, and is known as the "straw- 26 A COMPENDIUM OF PRACTICAL MEDICINE. berry tongue." A red, smooth tongue is a sign of failing nutrition. The " nervous tongue " is very slightly coated and covered with a slight froth, and is met with in persons of nervous tem- perament, and in cases where the nervous system has been de- pressed by overwork, and worry. The coating of the tongue is hardly discernible in health; but in disease the epithelium accumulates, and the tongue has a loaded, whitish appearance due to an excess of white epithelium. The coat is apt to be yellowish in disturbances of the liver, and of brown or very dark hue when the blood is contaminated. There are many healthy persons who wake up every morn- ing with their tongues covered, more especially at the back, with a heavy coating, which wears off after a meal. The tongue may be bare of its epithelium in certain instances of scurvy, chronic diarrhoea, dysentery, malaria, scarlet fever and typhoid fever. Local causes often coat the tongue. Enlarged tonsils often coat the back of the tongue. Decayed teeth often fur a portion of the tongue. Excessive smoking almost always coats the tongue. A coated tongue very frequently indicates derangement of the stomach, bowels or liver. If the patient be constipated, and the stools light colored^ and the tongue coated, give calomel with extract of belladonna, or hyoscyamus. If the bowels are freely open, and the tongue still coated, give in addition to the above, five drops each of tincture of mix vomica and dilute nitric acid thrice daily. After an acute illness like typhoid fever, the tongue some- times parts with its coating in flakes. The manifestations afforded by the tongue which are indi- cative of danger, are tremulous action, dryness, a livid color, a very red, shining or raw aspect, and a heavy coating of a dark or black hue (Ringer and DaCosta). Sensations of Patients. — Sick persons have many disagreeable feelings. They complain of chills, heat, languor, restlessness and of uneasiness; but their most constant complaint is of pain. Pain may be dull or gnawing, acute and lancinating, per- EXAMINATION OF PATIENT. 27 nianent or remitting. A dull pain is generally persistent. It is present in congestions, in chronic inflammations, and in acute inflammations of the parenchymatous viscera, and of mucous membranes. Acute pain is usually remittent and not so fixed to one spot. It is present in spasmodic affections, in neuralgia, and, with ex- tremely sharp and lancinating pangs, in malignant disease. Pain varies much in intensity. It is sometimes so extreme as to cause death. We have to judge of its severity partly on the testimony of the sufferer. The seat to which the pain is referred is far from being always the seat of the disease. A calculus in the bladder may produce dragging sensations extending down the thighs; inflam- mation of the hip joint gives rise to pain in the knee; disorders of the liver occasion pain in the right shoulder. The pain is either transmitted in the course of a nerve involved, or is sym- pathetic. Pain in diseases of the periosteum and bones is mostly boring and constant; in the serous membranes, sharp; in the mucous membranes, dull; and in the skin, burning or itching. Pain produced by pressure is called tenderness (DaCosta ). Temperature. — The clinical thermometer may be put under the tongue, or in the axilla, or in the rectum. The rectal tem- perature is about one degree higher than the mouth or axillary temperature. The temperature in health varies in the 24 hours. Durins; the dav, between 9 a. m. and 4 p. ]\r., the healthv tern- perature is usually about 99' F., or it may rise to 99.5° F. Any rise above 99.5° F. constitutes fever. At midnight the temper- ature is about 97° F., or even 96" F. The temperature should be taken in the morning about 7, and in the evening at the same hour. If only a single observation be taken, it is best done in the evening;. While any elevation of temperature above 99.5° F. in- dicates disease, it need hardly be pointed out that a normal temperature does not necessarily indicate health. Many diseases, both acute and chronic, during their whole courses are unat- tended with fever. As a rule, the morning temperature is Lower than the evening. In rare cases the reverse happens. In some 28 A COMPENDIUM OF PRACTICAL MEDICINE. chronic cases, as phthisis, and sub -acute rheumatism, the fever may last only a few hours during the day. In ordinary cases, the pulse and temperature rise synchron- ously, and every degree above 98 1 F. corresponds with an increase of ten beats of the pulse. When the temperature ex- ceeds 106° F., the patient may be looked upon as in danger, except the rise be due to malarial fever. Under these circum- stances, it is rapid, occurring in a person who yesterday, or but a few hours before, was healthy. In typhoid fever a tempera- ture of 105° F. is proof of grave disease. In pneumonia, a temperature above 104° F. is a symptom of very serious seizure. Stability of temperature from morning to evening is a good sign; the temperature remaining the same from evening till morning is a sign that the patient is getting worse. If, after the defervescence, the thermometer again indicates a decided rise, it shows a return of the malady or complication. Specific forms of febrile diseases have their characteristic temperature records. In measles, for instance, the temperature rises toward the breaking out of the rash, reaches its height with the period of eruption, and in twenty -four hours succeed- ing it falls rapidly. In scarlet fever the thermometer marks 105° F. or more at the beginning, and the fever gradually sub- sides. Typhoid fever has its characteristic record; so have the malarial fevers theirs. The temperature of tetanus rises to great heights before death. A temperature above 107° F. is almost certain to be the forerunner of a fatal issue. But recovery may take place. Da- Costa reports a case of cerebral rheumatism, in which the ther- mometer marked 110" F., yet the patient got well. In a case of injury to the spine after a fall, reported by Teale, the young lady lived, though the temperature reached above 122° F., and ranged for days between 112° F. and 114° F. A case of hysteria and intercostal neuralgia has been reported, in which the thermometer registered 117° F., and the patient recovered. The temperature may, also, be very high for a short time, from emotion. In children the tempera- ture is relativelv higher than in adults with the same disturbance. EXAMINATION OF PATIENT. 29 Tlie thermometer assists us in diagnosis. We should search carefully to discover the cause of the fever. The fever may be due only to the acute contagious diseases, acute inflammation of some organ, rheumatism, gout, or to the diseases causing chronic fever. In the acute specific diseases, fever and sore throat would point to scarlet fever; severe backache, headache and sore throat to small-pox; coryza, with cough, to measles. Severe fever, ushered in by a severe rigor, with severe headache, and pain in the limbs, would suggest typhus; wmilst dull, frontal headache, with diarrhoea, would strongly point to typhoid fever. If the second day passes without the occurrence of a rash, the case in all probability, is not one of scarlet fever; for the rash of this disease apj)ears on the first or second day. If the third day passes without a rash, the case is not small-pox, for this rash usually apj:)ears punctually on the third day. If the fourth day passes without a rash, the case is not one of measles. If the fifth day passes without a rash, the case is not typhus, for the rash punctually appears on this day. The diagnostic value of temperature is shown in the follow- ing : A patient is suddenly seized with severe pain on the side of the chest. The pain, shooting or stabbing in character, is in- tensified on coughing or deep breathing. This is the character- istic pain of pleurisy and of pleurodynia; one an inflammatory disease, the other a non- inflammatory disease — which is it ( Before the physical signs develop nothing but the thermometer will solve the difficulty. If the attack be pleurisy, an inflamma- tory disease, there is fever, whereas if the attack be pleurodynia, a non-inflammatory disease, fever is absent. The temperature rises rapidly in most inflammations, in typhus, scarlet fever, measles, erysipelas, etc. In some diseases the temperature rises more gradually. This happens in most cases of tuberculosis and in almost all cases of typhoid fev( r, and sometimes in rheumatism and pleurisy. The duration of the fever often aids in the diagnosis. In most acute diseases the fever usually passes away by the fifth or tenth day. In some cases of typhoid fever the symptoms are not sufficiently marked to enable the doctor to decide whether the case is one of typhoid fever, tuberculosis or phthisis. If the 30 A COMPENDIUM OF PRACTICAL MEDICINE. fever goes on beyond thirty days then probably the patient suffers from consumption, and each additional day of fever strengthens this conclusion. A sudden and considerable fall of temperature, if not due to the natural termination of the illness, means sudden collapse. It is oftenest met with in typhoid fever, and it means hemorrhage into the bowels, or perforation of the intestines. Each week in typhoid fever a great morning fall often occurs. A fall equal to that due to hemorrhage or perforation, may occur at any time, but the fall with these accidents is more persistent, and is always accompanied by the symptoms of collapse. Chronic Fever. — In some diseases fever may persist for weeks or months, and by its very duration help the diagnosis. In most cases, when the fever has lasted only a short time, the other symptoms reveal the nature of the disease; but frequently the nature of the malady remains for a long time obscure, and then the fever aids in the diagnosis. Since most acute illnesses come to an end. in the great major- ity of cases, before the thirtieth day, we may take that as the limit of acute fever. Chronic fever occurs in phthisis, abscess, syphilis, ague, rheumatism, in most cases of leucocythemia, pernicious anaemia, and chronic pyaemia. The temperature is an index of the activ- ity of the disease. If the fever be high the disease is active. In some very chronic cases of phthisis the disease advances too slowly to elevate the temperature. By the aid of the thermometer we can often diagnose phthisis, before we can- detect any physical signs, and at a period when symptoms themselves are insufficient to justify a grave diagnosis. A patient suffers from chronic fever. AVhat is the cause of it i So far as we at present know chronic fever occurs only in tuberculosis, catarrhal pneumonia, large abscesses, rheu- matism, ague, occasionally in syphilis, in some cases of leucocy- thaemia, in lymphadenoma, and in pernicious anaemia and chronic pyaemia. The discrimination of these diseases is rarely difficult. The following cases illustrate the usefulness of the ther- mometer in doubtful cases of phthisis: EXAMINATION OF PATIENT. 31 A patient is taken rather suddenly ill. His face is flushed, eyes bright, pulse quick. The temperature is very high. There is no headache, no delirium, no diarrhoea. So weak is he that he stays in bed. He continues in this state for a month or five weeks when distinct physical signs at the apices of the lungs ap- pear, accompanied by cough and expectoration, and possibly slight haemoptysis. A woman between 30 and 35 years of age, fails slightly in health, complains of slight weakness, is soon tired, but is never ill enough to be confined to bed. Her appetite is bad. There is a trifling cough with expectoration slightly streaked with blood once or twice. There may be a family predisposition to phthisis. No physical signs are aiDparent; yet the temperature, rising nightly to 101 or 102° F., declares the true nature of the disease, (Ringer and Da Costa). CHAPTER II. DISEASES IN GENERAL. ABORTION. T. Gaillarcl Thomas says, that the uterus is the organ which divides one sex from the other, that this organ has three entirely distinct and different periods of existence, that front birth to the age of thirteen, or puberty, it is undeveloped and unimportant, and that from thirteen to fifty its career is one of intense activity, and has a marked influence upon the whole being of a woman, that from the age of about fifty, to the close of life it sinks into insignificance again, and becomes an atrophied and unimportant organ — of no use whatever, that impregnation and conception are two entirely different things, that the ova may become impregnated twelve times a year, and yet conception may not result; that conception is the fixation of the impregnated ovum; that up to two and a half months there is no placenta, so far as abortion is concerned, that from the third month the placenta is the all-important element as regards abortion; that abortion is to be defined as the premature casting off of the product of concep- tion before the end of the fourth month; that between the end of the fourth month and the end of the sixth month it is called mis- carriage, and that between the end of the sixth month and the end of the ninth month it is called premature labor., When abortion occurs, one of four things may take place: First, the entire contents of the uterus — the decidua vera, the decidna reflexa, the amnion, the chorion, and the foetus may he expelled. Second, the foetus may be expelled with the amnion ABORTION. 33 and chorion, while the decidua vera and reflexa are left in the uterus. These membranes will come away later in the lochial discharge. Third, the foetus alone may be expelled. This is a complicated case. In this case the uterus must be emptied of its contents or the patient will have a violent chill and high fever, with all the signs of septicaemia. Fourth, the foetus and membranes may be expelled, and the placenta, when one is formed, left behind. Thus, we see that abortion does not always occur in the same way, and that the physician must treat each case according to its character. Causes. — 1. Carbonic- oxide gas inhaled by the mother is more certain to produce uterine contractions than ergot. The crowding together within confined quarters of pregnant women will cause a large number to abort, due to the poisoning of their blood by this gas. This gas, generated after death, produces uterine contraction, and post-mortem delivery of pregnant women. 2. The poisons in the blood produced by small-pox, scarlatina, measles and malaria. 3. Chorea, tetanus, and reflex influences, such as fright. 4. Certain drugs, such as ergot, cotton-root, etc. 5. Anything which will kill the foetus will produce an abortion, such as a twist, or knot in the umbilical cord, syphilis, a kick or blow irpon the abdomen. 6. Retroflex- ion of the uterus. In anteflexion of the uterus, sterility is com- mon, but endometritis and abortion are rare. 7. Uterine fibroids and other neoplasms, and laceration of the external os. 8. Some- times jars to the body from vomiting, coughing and straining, from railroad journeys, from violent exercise, from falls, and the like. A large proportion of abortions occur about the end of the third month. During an abortion, the attitude of the physi- cian, beyond the control of hemorrhage, should be an expectant one. In habitual abortion the most common causes are syphilis and retroflexion of the uterus. There are many women of nerv- ous temperament in whom the slightest cause is often sufficient to induce an abortion; while, in others, it is exceedingly difficult for them to get rid of the contents of the uterus before the nor- mal end of pregnancy. This is shown in attempts at criminal abortion. Lusk re- lates the case of a peasant who took his wife, while pregnant, 34 A COMPENDIUM OF PRACTICAL MEDICINE. behind Mm on horseback and started off with her at full gallop, with the view of causing her to miscarry. Having thus thor- oughly shaken her, he dropped her suddenly to the ground with- out slackening his speed. This brutal manoeuvre he repeated twice, without the least success. Thomas mentions cases of pregnant young women in Paris who attenrpted suicide by jump- ing into the Seine, and were rescued and went on to full term. Pregnant women, excited by an alarm of fire, have jumped from an upper window, breaking several bones, and have j)assed on to full term as though nothing had happened. Prognosis. — The prognosis is good, except in criminal cases. Dangers. — 1. Hemorrhage. 2. Putrid intoxication from ab- solution of the decomposing product of conception. 3. Septi- caemia and peritonitis. In this case the septic material is conveyed to the womb by the hand or instruments of the physician. 4. Suppurative arthritis. 5. Cellulitis and abscess. 6. Embolism. This may cause hemiplegia. 7. Air in the veins. The air is usually introduced through a hollow instrument used in the uterus. 8. Tetanus. This comes from putrid infection. Symptoms. — There are three essential symptoms: 1. Hem- orrhage. 2. Pain. 3. Vomiting; this last may be absent. Treatment. — The treatment is divided into: 1. Prophylaxis in cases of habitual abortion. If the cause be syphilis, give the antisyphilitics. If the cause be displacements of the uterus, correct these. If the cause be nerve irritability, give the patient teaspoonful doses of the fluid extract of viburnum prunifolium three times daily, beginning two days before the menstrual date, and continuing for eight days, with the patient in bed. 2. Ar- rest of threatened abortion. Keep the patient quiet in bed and give the following: jfc Potassii Bromidi gr. x. Chloral hydratis gr. vi. Morphinse sulphatis gr. \. — M. Sig. : One dose. Kepeat if necessary. The chloral induces sleep, the bromide has a sedative effect upon the nervous system, and the morphine robs life of its cares. If the patient be bleeding freely, apply a tampon, and remove it in twenty-four hours. In the first two ABORTION. 35 months little treatment besides rest in bed for a few days is re- quired. 3. The treatment of inevitable abortion. Get the woman through with the abortion as quickly as possible, and leave nothing in the uterus for bacteria to work on. Your hands, instruments, sponges, and tampon, if used, should all be aseptic. If the abortion is going on and the woman is losing large quantities of blood, the tampon is the best remedy. When in the third month the ovum is thrown off without rupture of the foetal membranes, the hemorrhage is rarely dangerous. The treatment is very simple — a carbolized douche morning and evening. When the sac ruptures the hemorrhage is usually pro- fuse. The treatment indicated in this case is to check the hem- orrhage by a tampon, and afterwards empty the uterus by means of the finger or curette. Do not give opium to quiet pain. Do not give ergot unless the cervix is well dilated. A good tampon is made by soaking cotton wool in carbolized water, five per cent, solution, and after pressing out the excess of fluid, make into flat pieces, and pack well around the vaginal portion then over the os. A tampon should not remain over twelve hours in the vagina. In emergency a soft towel, handkerchief, strips of cotton cloth and a roller bandage may be used for a tampon. 4. The treatment of neglected abortion is to clean out the uterus with the finger or dull wire curette and use carbolized douche (3i-Oj). The temperature, if high will soon fall after the curettage and douche. Chances of error in connection with abortion. — 1. Could a woman have an abortion, say, at the end of the third month, and at the end of six months from that time be delivered of a fully- developed living child? Yes, and the explanation is, that one of a pair of twins has been cast off and the other has gone to full term. 2. A woman has an abortion and the foetus is cast off with all its membranes entire. In a month from the date of the abortion the woman suddenly dies in collapse. An examination shows that in addition to the foetus in the uterus there lias been an extra-uterine one, and the fatal result was due to rupture of the Fallopian tube. 3. A woman has an abortion and the foetus is cast off but not all the membranes. The next month the 36 A COMPENDIUM OF PRACTICAL MEDICINE. patient does not menstruate. About the end of the ninth month, the uterus begins to contract, but instead of a living child being delivered, a bucketful of hydatids is cast off. These little cysts developed in the retained membranes. 4. The foetus is cast off with the lower portions of the foetal shell, leaving the remainder of the shell still in the uterus. This may remain for months or years constituting "molar pregnancy." Artificial Production of Abortion. — Never induce an abortion without first having a consultation. Indications. — Whenever it is felt that the prolongation of pregnancy is going to destroy the life or intellect, or to perman- ently ruin the health of a patient, abortion should be brought on. The methods by which Abortion is brought on. 1. The first method is to introduce a metallic sound into the os-uteri, and push it forcibly through the foetal shell. If there be a brutal and stupid method of producing abortion, it is certainly this. It is the one commonly practiced in criminal abortions. It will kill the foetus, but it may not come away and thereby produce putrefaction and septicaemia. This method should not be used. 2. The second method is to take sponge tents, and introduce them into the os internum. This method should be avoided. 3. Certain drugs, such as ergot, savin, pennyroyal, viscum album, and the root of the cotton plant. Xo scientific physician would ever think of placing any dependence upon them whatever. 4. The best method and the one which is sure and safe is as fol- lows: Anaesthetize the patient with ether, and place her in the Sims position. Fill the vagina with bichloride solution, (1 to 2,000). Xext you catch the cervix with a little tenaculum and dip it below the surface of the bichloride solution. "With a divulsor you stretch the cervical canal until you can introduce your finger. You next introduce a glass plug as large as the finger into the cervix. You then pack the vagina with iodoform gauze and then apjuy a tampon. This is all yoiuhave to do. The plug and the tampon may be left in position for thirty -six to forty- eight hours. You may have to stretch the os again and put in a larger plug. The plug should be an inch and a half in length with a shoulder which prevents its entrance into the uterine cavity. ABORTION ABSCESS. PRESCRIPTIONS FOR ABORTION. 37 IJ Tincturse opii, ZITxx-xxx. Sig. : Mix with three tablespoonfuls of boiled starch and in- ject into the rectum. — Parvin. 5 Misturas asafcetidse Sviij. Sig.: A tablespoonful several times daily. (In habitual abortion.) — Negri. 1J Tincturse ferri chloridi Sss. Potassii chloratis 3j • Sy rupi simplicis Sj • Aquse menthse piperita? ad Siv. — M. Sig. : A dessertspoonful in a wineglassful of water after meals. (When due to fatty degeneration of the placenta.) — Strother. IJ Auri et sodii chloridi gr. iv. Aquse destillatae Sj- — M. Sig.: Six drops in a tablespoonful of water three times daily after meals. (In habitual abortion.) — Martin. ABSCESS. A circumscribed collection of pus in any tissue is called an abscess. Pus in a preformed cavity is called empyema. An abscess is always the result of an inflammatory process. Varieties. — When an abscess forms rapidly it is called acute, hot, or phlegmenous, and its pus is living. When it is of slow formation, it is called chronic, cold, lymphatic or tubercu- lous, and its pus is dead. Symptoms. — We may have, 1. History of an injury. 2. Defective nutrition. 3. Kigor or chills. 4. Elevation of tem- perature. 5. Fluctuation. 6. The five cardinal symptoms of inflammation which are, redness, swelling, heat, pain and loss of function. If the abscess be acute or hot, the pus is thick and creamy, the walls of the cavity are tense, the surrounding tissues are indurated, and there is a tendency to burst at the point of 38 A COMPENDIUM OF PEACTICAL MEDICINE. least resistance. If the abscess be chronic or cold, the pns is thin, serons and gelatinous, the walls are flabby, the surrounding tissues are not indurated. Causes. — The tendency of late is to regard all acute abscesses as due to a special micro-organism, the staphylococcus pyogenes aureus. Chronic abscess is due to the bacillus tuber- culosis. All varieties may start from injury. The origin of pus in an abscess is emigration of white cor- puscles, proliferation of connective tissue cells, granules of fat, and debris of inflamed tissue floating in serum. Varieties of Pus. — Pus when thick and creamy is known as " healthy " or laudable pus, or living pus; when thin and watery " puriform fluid " or dead pus; when blood-stained "sanious;" gummy pus in syphilis; and contagious pus in small-pox, gonor- rhoea and venereal ulcers. Diagnosis. — Abscess must be diagnosed from: 1. Hemat- ocele. 2. Cyst. 3. Lipoma. 4. Aneurism, and 5. Malignant tumors. Hsematocele has a rapid growth, evidence of an injury, and no change in the skin. The walls of a cyst are distended by fluid which distinctly outlines it. In fatty tumor or lipoma, the skin is unchanged and may be lifted up from tumor. In an- eurism there is a distinct expansile pulsation synchronous with the heart's action. Pressure on the artery above the aneurism diminishes its size, while pressure below increases its size. An aneurism has a rasping sound like sawing wood. The pain of aneurism is very characteristic — sharp and lancinating produced by pressure on nerve. Use a hypodermic syringe to make the diagnosis. The pain in acute abscess is at first dull and heavy and then throbbing. There is not much pain in a cold abscess. We speak of an abscess according to its situation, as mam- mary, lumbar, cerebral, perineal, post-pharyngeal, etc. Prognosis. — Depends, 1. On the size of the abscess. 2. On its character. 3. On the age of the patient. 4. Situation of the abscess. 5. Condition of the patient, and 6. On its cause. Treatment. — Never squeeze an abscess but drain it freely. An acute abscess should be opened in the most dependent part, ABSCESS. 39 using a sharp bistoury for the purpose; press out gently the accumulated material, wash it with bichloride of mercury (1 to 1,000), insert a drainage tube, and place upon the outside iodo- form gauze. We do not open a chronic abscess but aspirate it. Do not allow air to go in. A small amount of pus may be ab- sorbed. Constitutional Treatment. Give tonics, such as iron, qui- nine and strychnine together with good nutritious diet and plenty of fresh air. PRESCRIPTIONS FOR ABSCESS. |fc Iodoforrai oiij. Aetheris 5 vi. — M. Sig. : Inject three to five ounces after aspirating the abscess. (In cold or tubercular abscess.) — Mosetig Moorhof. JJr Iodoformi 5ij- Glycerinae Siiss. — M. Sig.: Inject the abscess cavity, after evacuating the pus. (In cold or tubercular abscess). — Billroth. JJr Calcii sulphidi gr. ij. Sacchari lactis gr. xx. — M. In chartulas xx. div. Sig. : Take one powder every hour or two. — Ringer. |fc Emplastrum belladonnas Sig. : Apply to abscess to relieve pain. — Bartholow. Jfc Potassii permanganatis 5j- Aquse destillatse Oj. — M. Sig. : Apply to correct the fetor of abscess. — Bartholow. JJr Tincturse iodi sij- Sig.: Apply as counter-irritant, and after pus is evacuated apply to the sac. — Bartholow. Use ether sju-ay to produce local amesthesia, for opening abscesses. 40 A COMPENDIUM OF PRACTICAL MEDICINE. ACIDITY. Acidity is not a disease, but a symptom. As a symptom it has no special diagnostic value, for it is met with both in functional and in organic disease of the stomach. Excessive acidity occurs from various causes. The gastric juice may be secreted in large quantities, or it may contain an abnormal amount of acid. But excessive acidity is far' more frequently due to the de- composition of food, and to a process of fermentation dependent rather upon scarcity than over- abundance of this juice. In this case it manifests itself only after meals. At the same time car- bonic acid gas may be generated, causing great distension and eructations, or belching of sour liquid. Treatment. — Acids, given on an empty stomach, check the secretion of the acid gastric juice; given on a full stomach, they render its contents more acid; hence, if there is an excess of acid secreted by the stomach, they should be given before meals, in small doses and well diluted; while, if there is too little acid secreted, they may be given after meals, to supply the deficiency. PRESCRIPTIONS FOR ACIDITY. JJr Acidi hydrochlorici diluti Sj- Sig. : Ten drops in water twenty minutes before meals. Jfc Tincturse nucis vomica? Sj. Sig. : Five drops in water fifteen minute before meals. — Ringer. {£• Sodii bicaibonatis oiij- In pulveres no xii. div. Sig. : A powder in a wineglassful of water after meals. — Alonzo Clark. Jfc Sodii bicarbonatis 5j. Pulveris rhei Sss. Spirit! menthse piperita? 5ij- Aqua? — q. s. — ad ' 5iv. — M. Sig. : A tablespoonful after meals. (For acidity, combined with constipation). — Bellevue Hospital. ACIDITY ACNE. 41 Jfc Pulveris ipecac gr. ss. Pulveris rhei gr. ij. Sodii bicarbonatis gr. xij . In pulveres no xii. dividenda. Sig. : One powder every four to six hours to an infant one year old. — J- Lewis Smith. Alkalies after meals are only palliative. Jfc Glycerini Siv. Acidi tannici oij • — M. Sig. : A teaspoonful before, with, or after meals. — Bartholow. ACNE. Acne, called also^ Acne Vulgaris, or Varus, is an inflam- mation of the sebaceous follicles and glands, the result of accumulation and retention in them of sebaceous matter. If the sebaceous matter be retained without inflammation, the surface becomes studded with black specks, and the affection is known under the name of comedones, or black-heads. But, sooner or later, the sebum plugs give rise to irritation, act as thorns in the flesh, and excite inflammation and suppuration in the surround- ing tissues, and the patient is said to have acne. Acne is likely to occur in those whose skins are sensitive, or whose general health is disordered. It is a frequent affection and is resented by the upper classes of society on account of its disfigurement. It is rarely met with before puberty — usually be- gins between the ages of 15 and 25. Some thought that there was a connection between acne and the organs of generation, as a marriage would sometimes moderate its violence, and Rigler very rarely saw acne in eunuchs; but Hebra said, "I cannot agree with Plenck's dictum, ' Matrimonium varos curat,' but would rather say, 'Tempus varos curat.' " Symptoms. — Acne affects most frequently the face, neck. shoulders, back and chest. The starting points of the eruption is the accumulation of hardened plugs of sebum in the sebaceous follicles (comedones) which are black upon the surface, owing to admixture with particles of dust. Sometimes a small nodule surrounds each follicle, and we have acne punctata; sometimes the nodule becomes pustular, and we have acne pustulosa; some- 42 A COMPENDIUM OF PRACTICAL MEDICINE. times there is a decided induration, or tubercle, acne indurata. In severe cases some of the sebaceous glands are apt to be the seat of distinct abscesses. If these inflammatory centres are allowed to run their course unchecked, they leave cicatrices which resemble the pits of small-pox, and as the eruption tends to occur in successive croj3s, in time the disfigurement may be considerable, hence the disease, though trivial, should be treated. A burning heat is occasionally complained of, and itching is common. Diagnosis. — Tar acne may be mistaken for acne, but the history of the patient having been exposed to the influence of tarry preparations, or their external use, would make the diag- nosis. In tar acne there is a black speck in the center of each nodule, as in acne. The eruptions which frequently occur in those who are taking the bromides or iodides sometimes resemble that of acne, but in them there is a history of the taking of one of these drugs, and there is an absence of black specks in the centre of the nodules. Syphilitic eruptions may sometimes be mistaken for acne; but in the former the eruption commences after the poison enters the system, usually affects all parts, is more or less coppery in chronic stage, is often in circles or seg- ments of circles, ulceration is common, itching absent always in early syphilis, eruption easily removed by anti-syphitic treat- ment; in the latter, the eruption commences between puberty and 25, is limited to face, chest and back, is bright red, is never in circles or segments of circles, no tendency to ulceration, itch- ing often present, eruption hard to remove by any kind of treat- ment. Treatment. — Is both constitutional and local. If the patient is strumous, phosphorous and cod-liver oil in full doses should be given. If the eruption aj3pears in an aggravated form, arsenic should be given. If suppuration is a prominent feature, the sulphide of calcium may be tried. The local treatment is the most important: 1. Press out the sebum plugs (comedones). 2. Bathe the affected parts every night and morning, with water as hot as can be borne, for ten minutes, and afterwards apply friction with rough towel. 3. ACNE. 43 Acne indurata has been cured by applications of galvanism, both local and central. PRESCRIPTIONS FOR ACNE. JJr Syrupi hypophos comp Sviij. Sig. : A teaspoonful after each meal. (Acne indurata). — Bartholow. J& Liquor potassii arsenitis 5 vj . Sig. : Three drops in water after each meal. J& Liquor potassse 3j. Aquse Rosas 5iv. — M. Sig.: Apply with a soft sponge twice daily. Use mutton suet 10 face afterwards. — Bartholow. Jir Calcii sulphidi..... gr. xv. Sacchari lactis oiij • In chartulas no Lx. div — M. Sig.: Take one powder three times a day. — Anderson. J& Sulphuris iodidi 5ss. Adipis sj.— M. Sig.: Use freely over the eruption night and morning. (In acne indurate and rosacea.) — Ringer. JJr Sulphuris 5j- Gly cerini (Price) 5j • Cold cream Sj . — M. Sig. : To be applied firmly every night short of causing pain or inflammation. — Anderson. Jfc Potassii sulphureti Zinci sulphatis aa 5j- Aqua? rosse Sj. — M. Sig.: Apply to the face on muslin twice a day and wash the face with tar soap. — Anderson. Jfc Lactis sulphuris Glycerini Spirits vini rectificati Potassii carbonatis Aetheris sulphurici aa Sss. — M. Sig.: Apply to face at bed-time. — Teissl. 44 A COMPENDIUM OF PEACTICAL MEDICIXE J£ Sulpburis precipitatse 5ij- Camphor gr. x. Gum mimosa gr. xx. Aquas calcis Aquas rosas. aa 5 iij . — M . Sig. : Shake the bottle. Apply at bed-time and in the morning remove the sulphur without wetting the skin. — Kummerfeld. |£ Hydrargyri chloridi corrosivi gr. xx. Glycerini Sss. Spiriti vini rectificati Svij. Spiriti rosmarini 5iv. — M. Sig.: Apply to face. — Bartholow. J& Hydrargyri iodidi viridis gr. x. Adipis Sj • — M. Sig. : Apply to face. — Bartholow. {£ Hydrargyri iodidi rubri gr. v. Adipis Sj. — M. Sig.: Apply to face. — Bartholow. {Jr Glycerini Sj • Sig. : Half teaspoonful after meals. — Bartholow. |fc Sulphuris '• • • oj • Glycerini oj • Aquae rosse ,, oviij. — M. Sig.: Apply to face night and morning. — Ringer. J$r Hydrargyri perchloridi Sj- Aquas destillatas §iv. Ovorum xxiv albumen Succi citri oiij. Sacchari o viij. — M. Sig. : Apply to the face. — Hebra. The above is a cosmetic lotion much used by the Orientals as a beautifier of the skin, and is often of use in acne. {{r Potassii acetatis oiv. Tincturse nucis vomica? 5ij- Extracti rumicis fluidi, ad §iv. — M. Sig.: One teaspoonful, well diluted after meals. — Bulkley. ACNE ACNE ROSACEA. 45 {&• Potassii acetatis Sj. Acidi acetici 5ss. Spiriti setheris nitrosi Siss. Extracti taraxaci fluidi Sij. — M. Sig. : A teaspoonful before meals in water. — Bulkley. jfc Sulphuris prsecipitatae 5 v. Glycerini 5iss. Spiriti camphorse Sj- Aquse Siv. — M. Sig. : Apply with a brush to the affected part before retiring at night. — Lailler. {fc Sulphuris prsecipitatse 3j- Glycerinse 3j • Spiriti vini rectificati Sss. Aquse rosas ad Siv. — M. Ft. lotis. Sig.: To be painted on at night after steaming the face and washing it with sand soap. To be washed off in the morning with warm gruel, and the face powdered with the following : |fc Zinci oleatis Pulveris talc aa Sj- — M. Sig.: To be dusted on every morning. — Jamieson. ACNE ROSACEA. Called also Rosacea, or Copper-nose, is a very common affec- tion, but not so common as ordinary acne. Causes. — Intemperance is the most frequent cause in males. Debility is the usual cause in females. Those whose faces are exposed to great cold or heat, as cab -drivers, bakers and cooks, are liable to have copper-nose. In males the disease usually ap- pears about middle-life; in females about puberty, or the meno- pause. Symptoms. — The eruption always makes its appearance upon the face, as the nose, chin, cheeks or brow. The symptoms may be divided into three stages or varieties. In the first, there is simply dilatation of the small vessels and capillaries, with new formation of vessels. In the second, redness of the surface 46 A COMPENDIUM OF PRACTICAL MEDICINE. makes its appearance, which is at first congestive and transitory, but finally becomes permanent, and slight desquamation takes place. The skin has a dusky tint, especially after meals and in cold weather. In the third variety, owing to cell infiltration and the new formation of connective tissue, hypertrophy of the tissues of the skin is apparent, and the skin has a thickened and coarse appearance. Hebra describes the brandy-face and the wine-face. The brandy-face is frequently confined to the nose, where it dilates the blood-vessels, and the skin between is healthy. The wine- face is of a dark red color, and the skin has a solid redness, and the whole face has a bloated appearance. Treatment. — Constitutional treatment is very important. In cases of debility, a generous diet, tonics, especially arsenic, are indicated. The local treatment is even more important. If the blood vessels are very much dilated, they should be slit open, or punctured at each end, and touched with caustic, or they may be obliterated by electrolysis. The finest cambric needle, at- tached to the negative pole of the galvanic battery, is inserted into the lumen of the vessel, or perpendicular to the vessel at several points if a long one, and six to ten cells turned on, until the proper electrolytic action is developed. PRESCRIPTIONS FOR COPPER=NOSE. JH Hy drargy ri 5 i v. Terebinth commun 5ij- Cerse flavae 5iij- Em pi. plumbi Siss. — M. Ft. unguent. (See Acne Vulgaris). ADDISON'S DISEASE. Addison's disease is an affection of the suprarenal capsules. It is sometimes called the bronzed skin disease. Symptoms. — Extreme languor, muscles flabby, the pulse feeble, indigestion, anorexia and nausea, sometimes vomiting after eating. The skin is jrigmented, and presents the color of a mulatto. AFTER PAINS. 47 Prognosis. — It is an incurable disease. Its duration varies from one to live years. Treatment. — Sirup of the iodide of iron, cod-liver oil, chlor- ide of calcium, ojuinia, and arsenic may he tried. Faradism and galvanism have been proposed by Dr. Rockwell. Addison's disease is thought to be tuberculosis of the supra- renal bodies. AFTERPAINS. The contractions of the uterus in the first few days after the birth of the child are the causes of what are termed after- pains. They may last four days, and are more pronounced in multipara than in primiparse. They are to be regarded as a normal and favorable event. Where the uterus has been over- distended, as in twin pregnancies and hydramnios, the after-pains are especially severe. Suckling the infant produces reflex con- tractions of a somewhat severe character. PRESCRIPTIONS FOR AFTER=PAINS. Yfc Morphinee acetatis gr. i. Extracti digitalis fiuidi 2TTj . Spiriti Mindereri 3j — M. Sig. : One dose. Repeat if necessary. j& Extracti ergotse fiuidi oiij- Extracti digitalis fiuidi ZTTxxiv. Quininse Sulphatis gr. xxiv. — M. Sig.: Fifteen drops three times daily. (To aid the process of involution). The quinine may be given in capsules in gr. ii. doses, if preferred. —Sloan Maternity. Jfc Chloral Hydratis gr. xv. Sig.: One dose. May be repeated if necessary. J& Camphorae gr. x. Morphinee gr. h — M. Sig. : One dose. — Bartholow. 48 A COMPENDIUM OF PRACTICAL MEDICINE. AGALACTIA. Agalactia is imperfect lactation. PRESCRIPTIONS FOR AGALACTIA. |& Extracti pilocarpi fhiidi 5 ij . Sig. : A teaspoonful two or three times daily. — Bartholow. |Jr Decocti gossypii Oj. Sig.: A wineglassful every half hour. — Phillips. AGUE. (See Intermittent Fever). AGUE=CAKE. Is an enlargement of the spleen from malaria. Treatment. — Besides quinine in ordinary doses, there is no remedy more efficacious than the ointment of the red iodide of mercury rubbed in daily oyer the splenic region in the sunshine, until soreness of the shin compels a suspension. — Bartholow. ALBUMINURIA. Is simply albumen in the urine. It is not a disease, but a symptom. The existence of albuminuria is not proof positive of kidney disease. Albumen may be found in the urine iu the course of a great many diseases. It is frequently found in the urine of persons who are apparently in perfect health. As a rule, albumen found in the urine denotes some kidney change. PRESCRIPTIONS FOR ALBUMINURIA. |fc Sodii iodidi gr. xv. Sodii phosphatis 5ss. Sodii chloridi oiij- Aquae — q. s. — add ft. sol — M. Sig. : To be taken in the course of the twenty-four hours. — Semmola. ALBINISM. 49 {& Olei erigerontis Sss. Sig. : Five drops on a lump of sugar every three or four hours. (In the chronic forms). — Bartholow. {& Auri et sodii chloridi gr. iij. Hydrargyri chloridi corrosivi gr. v. Extracti gentiance q.s. — M. Ft. massa et in pil. no. lx. div. Sig. : One pill morning and evening. — Bartholow. ]$- Acidi gallici oi-ij • Acidi sulphurici diluti 5ss. Tincturee lupuli 5j • Infusi lupuli — add Syj. — M. Sig.: A tablespoonful thrice a day. (If urine is smoky). — Aitken. Jfc Misturse ferri et ammonii acetatis.Syj. (U. S. P.) Sig.: Two teaspoonfuls, well diluted, thrice daily. — Basham. {& Ferri sulphatis gr. xv. Magnesii sulphatis Sij- Potassii bicarbonatis oiij- Infusi buchu Sviij. — M. Sig.: A tablespoonful once or twice a day in a tumblerful 01 water. (When constipation exists). — Fothergill. The skim-milk treatment of albuminuria is a success. — Donkin. The butter-milk cure may be substituted for the milk-cure in cases of stomach disease and in albuminuria. — Bartholow. ALBINISM. Is defective pigmentation in the skin, hair and eyes. The pigment of the skin is in the mucous layer of the epidermis. In this condition there is congenital absence of the coloring matter, and the skin is milky white, the hair white, long, fine, and silky, and the iris is rose colored, the pupil being red. There is usually intolerance of light and the Albino walks with the head downwards. This deformity is met with in all races, but it occurs most among the negroes of the South. It demands no treatment. 50 A COMPENDIUM OF PRACTICAL MEDICINE. ALCOHOLISM. Is the physical and mental changes induced by alcohol. It may be acute or chronic. Mania a potu is acute alcholic delirium. Delirium tremens is a delirium with trembling occurring in the course of chronic alcoholism. Symptoms, — The symptoms are familiar to all. In the chronic form the appetite declines, the stomach becomes intoler- ant of food, and vomiting occurs. The old alcoholic suffers in the early morning before the morning dram. He strains and retches, and after great anguish, brings up only some glairy mucus and a little greenish matter. His memory grows weaker, his moral sense is blunted, he becomes morose and irritable, has headache, ringing in the ears, attacks of dizziness or vertigo, his vision grows dull, numbness, tingling, trembling, and paresis of muscles occur. He also becomes wakeful and nervous. Liver and kidney trouble supervene with ascites and puniness of face. Treatment. — Withdraw the stimulant, be careful with his diet, give tonics such as quinine, tincture of mix vomica, etc. PRESCRIPTIONS FOR ALCOHOLISM. |fc Potasii bromidi 3j- Sig. : One dose. Repeat every four to six hours if necessary. (For the horrors.) — Bartholow. Jfc Tincturae gentianae comp Tincturae calumbae comp — aa 5ij- Tincturse nucis vomicae oiss. — M. Sig.: A dessertspoonful before each meal. — Loomis. Jfc Strychniae sulphatis gr. j. Aqua font Sj— M. Sig.: Five minims increased cautiously to twenty minims hypodermically twice daily. (In both acute and chronic forms.) — Dobronravoff. J$r Sol. nitro-glycerine (1 per cent)..3ij- Sig.: One drop every two hours. (In acute form, with cerebral anaemia and intense depression.) — Van Goidtsnoven. ALCOHOLISM ALOPECIA. 51 {& Spiriti ammonii aromatici 5ij- Tincturse camphorse oiss. Tincturse hyoscy ami 3iiss. Spiriti lavandulse comp. q. s. addSij. — M. Sig. : A teaspoonful every hour until relieved. Then give |fc Pulveris capsici gr. ij. Quininse sulphatis gr. iij. — M. Ft. pulv. no. i. Sig. : To be taken before each meal for several days. — Aitken. {& Extracti lupulinse fluidi. Tincturse capsici — aa 5j • — M. Sig.: One or two teaspoonfuls as necessary. (Best substitute for alcoholic stimulants.) — Bartholow. Jfc Liquoris potassii arsenitis Sss. — M. Sig.: A half drop every half hour, for six or eight doses. (Vomiting of alcoholics.) — A. A. Smith. Jfc Sodii bromidi ..Sss. Chloral hydratis oiiss. Syrupi aurantii cort Sss. Aquse, ad Siv. — M. Sig.: A tablespoonful at night. Repeat if necessary. (For sleeplessness.) — Aitken. Give opium and chloral very cautiously to old alcoholics. For the "alcoholic paralysis," or partial paraplegia use fara- dism and galvanism. ALOPECIA. Is baldness or loss of hair or defective growth. It may be congenital or acquired. It is a common thing for children to be born with very little hair, but it soon begins to grow; in rare cases it never makes its appearance. Congenital alopecia has also been observed in the lower animals, especially in a race of horses found in Little Thibet, on whose hide not a trace of hair can be discovered; also in a race of African dogs and hogs. Treatment. — Is both constitutional and local. Cod-liver oil and tonics, especially nerve tonics, as strychnia, phosphorus, and above all arsenic are usually indicated. The local treatment resolves itself into the use of reme- dies to stimulate the hair follicles, 52 A COMPENDIUM OF PRACTICAL MEDICINE. PRESCRIPTIONS FOR ALOPECIA. ^ Tinoturse canthardis Sss. Olei ricini Siv. — M. Sig. : Rub well into the roots of the hair night and morning. — Waring. |fc Tincturse cantharidis 5iss. Tincturse capisici Ht.xx. Glycerinse Sss. Spirit! odoratse — add . Syj. — M. Sig. : Apply to head two or three times daily. — Gross J& Hydrargyri perchloridi gr. xij. Glycerini 5 vj . Spiriti rectificati Siij. Aquae destillatae — add Syj. Olei rosse ZTT.j.— M. Ft. lotio. Apply to scalp night and morning. — Anderson. Jfc Liquoris carhonis detergentis Sj. Glycerini ( Price) 5 v j • Aquse destillatse Siv. — M. Sig.: Sponge the scalp night and morning. — Anderson. JJr Pulveris cantharidis 5j Glycerini (Price) 5j • Unguenti simplicis 5vj. — M. Sig.: Apply firmly to the scalp night and morning. — Anderson. |fc Tincturse macis „..5iss. Olei olivse — add 5ij. — M. Sig.: Apply two or three times daily to affected spots. — Hebra. Jfc- Quininse sulphatis oiss. Spiriti vini rectificati Siv. Tincturse capsici Tincturse cantharidis Spiriti ammonii aromatici — aa...Sss. Glycerini Siv. Aquse q. s. — add Oj. — M. Sig.: Apply locally. — Brinton. Alopecia depending on Syphilis, Eczema and Psoriasis may be cured by the proper treatment for those affections. Pilocarpus is the most efficient remedy for alopecia which we possess. — Bartholow. AMAUROSIS AMENORKIKEA. 58 Jfc Extracti pilocarpi fluidi Sj. Tincturse cantharidis Sss. Linimenti saponis Siiss. — M. Sig.: The scalp must be well rubbed with this lotion daily. — Bartholow. AMAUROSIS. (Functional.) Amaurosis is partial or complete blindness. Amblyopia is impairment of vision. Since the ophthalmoscope has come into use, making the interior of the globe as accessible to our sight as the exterior, these terms have fallen into comparative disuse, and are used to designate conditions whose pathology is not known (functional). Causes. — 1. Traumatic. 2. By lightning. 3. Hemorrhage. 4. Toxic, such as lead, osmic acid, silver and mercury, quinine, and salicylic acid. Alcohol and tobacco, which excite a peculiar partial neuritis, may cause amaurosis or amblyopia. 5. Uraemic. 6. Diabetic. 7. Hysterical. 8. Migraine. 9. Reflex. Treatment, — Depends on the cause. For toxic causes, suita- ble antidotes and abstinence suggest themselves. Galvanization and faradization may be tried. Amaurosis of a functional kind, from lead, tobacco and alcohol, may be cured by strychnine. PRESCRIPTIONS FOR AMAUROSIS. {J- Strychnise sulphatis ,...gr. j. Alcoholis 5j • Aquse destillatse — ad Siv. — M. Sig.: A teaspoonful thrice daily before meals. — Nagel. According to Coursserant, there is no remedy comparable to pilocarpine in the amblyopia of alcoholism and of tobacco abuse. Dose, gr. iVgr. ss. AMENORRHEA. Is abnormal suppression or absence of the menses. Primary amenorrhea, called also emansio mensium, is where menstrua- tion has never occurred. Secondary or accidental amenorrhea has been called suppressio mensium. Causes. — Amenorrhea is, more frequently than to any other cause, due to anaemia of the ovaries, consecutive to chlorosis or 54 A COMPENDIUM OF PKACTICAL MEDICINE. general anaeinia, and dysnienorrhoea may depend, in one of its forms, at least, upon the same condition of the blood. — Bartholow. When the menses are absent at puberty it may be due to atresia of the uterus, vagina or vulva, or to bad hygienic sur- roundings, or to overwork at school. After the menses have become established, they may cease entirely from impoverish- ment of the blood, from debility resulting froru a chronic disease or following an acute illness. Anaemia, chlorosis, Bright's disease, diabetes, cancerous and malarial cachexia, and pulmonary tuberculosis are all potent in producing amenorrhoea. Menstruation may be suppressed from some sudden emotion, anxiety, and from taking cold. Symptoms. — Abscence of the monthly flow is of course the chief sign. There may be headache, fever, pain in the chest and pelvis, acne, eczema, herpes, and urticaria. Science has on record some curious examples what may be called substituted secretions. Jones reports the case of a young woman in whom menstru- ation was checked apparently from sudden chilling, who then suffered from amenorrhoea, and for five years had, instead of the menstrual flow, an abundant flow of milk from the breasts which lasted for thirty- six hours. Periodical diarrhoea for three days, - or leucorrhoea may replace the normal flow (Pozzi). Haemoptysis (spitting blood), haeruatemesis (vomiting blood), epistaxis (nose bleed), and rectal hemorrhages may replace the normal flow, and this is known as vicarious or ectopic menstru- ation. Treatment. — Depends on the cause. Where atresia exists, an operation is necessary. If the amenorrhcea be due to bad hygiene, or over- study, or poor health, correct these conditions. Pozzi says that it is a mistake to suppose that amenorrhoea calls for special medication supposed to have an elective action upon the uterine mucous membrane. Iron and aloes, and saline purgatives may be given in certain cases. Permanganate of po- tassium is said to be almost a specific. Apiol is sometimes of service. Mustard foot baths and mustard plasters to the thighs and l^pogastriuni, and the hot sitz-bath are important aids. AMENORRHEA. 55 Tonics and good food must be given. Electricity (faradic) with one pole npon the lumbar region and the other externally over the site of the uterus has given good results (Rockwell). During pregnancy and lactation menstruation ceases; it re- turns only when the excess of nutritive material is no longer required for these purposes. Menstruation may then be considered a safety valve; its absence indicates a lowering of nutrition when it is not the re- sult of pregnancy. PRESCRIPTIONS FOR AMENORRHEA. Jfc Tinctune aconiti radicis 5ss. Sig. : One drop every hour. (When checked by cold.) — Ringer. Jfc Potassii permanganatis 5j Ft. in no. xxx pellets. Sig.: One three times daily after meals followed by a glass of water. (Begin one week before the expected period.) — Bartholow. {& Auri et sodii chloridi gr. iij Aqua? 5 viij . — M. Sig.: A teaspoonful after meals. — Bartholow. JJr Extracti hydropiperis fluidi 5iv. Sig.: Thirty minims four times a day, for a week before the menses ought to appear, when due to functional inactivity or torpor of the uterine system. Bartholow can confirm the statement of Eberle, who reports that " with no other remedy or mode of treatment has he been so successful as with this," in amenorrhcea. jfc Apiol (parsley-camphor) 3j. Sig.: Six drops morning and evening for five days before the expected menstrual period. (When torpor of the ovaries and uterus exist.) — Biddle. Jfc TerebinthinaB albas Pulveris aloes Ferri sulphatis exsic — aa gr. xx. — M. Ft. massa et in pil. no. xx div. Sig. : One thrice daily. — Parvin. 56 A COMPENDIUM OF PRACTICAL MEDICINE. |fc Extracti aloes aq 3j- Ferri sulphatis exsic 5ij • Asafcetidae oiv. — M. Ft. massa et in pil. no. 100 div. Sig. : One pill after each meal, gradually increased to three. — Goodell. J& Tincturse ferri chloridi 5iij. Tincturse cantharidis 5j • Tincturse guaiaci ammonii Siss. Tincturse aloes Sss. Syrupi — q. s., add Svj. — M. Sig. : A teaspoonful thrice daily. — Dewees. ANEMIA. Is a ruorbid condition from diminution of blood or its nutri- tive constituents. Anaemia may be only a symptom of some other disease. It may be acute or chronic. Acute anaemia is the result of sudden and excessive loss of blood, as from wounds of arteries, post partum haemorrhage, and fevers. Chronic anae- mia may result from many forms of chronic diseases, as Bright's disease, malignant growths, tuberculosis, etc. Anaemia may also be caused by defective assimilation, an insufficient supply of food, frequent repetition of the sexual orgasm, profuse menstrual flow, prolonged lactation, pregnancy, poison in the blood from lead, malaria, etc. Symptoms. — The patient is weak and pale. His lips and tongue have lost their red color. The eye is pearly. His pulse is feeble, but generally accelerated. The appetite is deficient or depraved. The bowels are apt to be costive. Exercise induces great fatigue, shortness of breath and palpitation (DaCosta). There is mental depression. The hands and feet are always cold. Anaemic females complain of a pain in the left side and a burning sensation on top of the head. Over the jugulars, particularly the right, there is heard a continuous venous hum (Loomis). Prognosis. — Depends upon the cause of the anaemia. It is usually favorable. ANJEMIA. 57 Treatment. — The causes of anaemia are to be ascertained, and, if possible, removed. Good food is the first requisite. The appetite and digestion should be promoted by quinia and other tonic remedies. Exercise in the open air, daily sponging of the body, and sea-bathing have a favorable influence. Iron is the one drug that best combats anaemia (Loomis). It should be given after meals. Arsenic is another remedy often of much efficacy in the treatment of anaemia (Flint). It should be given in small doses for a long time. Loomis says that alcohol is food to aneemic patients, and that Burgundy, Madeira, and rich wines are to be preferred; but malt liquors are often more beneficial. Cod-liver oil, and the syrup of the lacto- phosphate of lime are of great service. The physician should encourage the patient. Central galvanization, and general faradization are of use to stimulate the functions of organic life (Bartholow). PRESCRIPTIONS FOR ANEMIA. J& Quininse sulphatis gr. xx. Ferri sulphatis exsiccat gr. xl. Stryehnise sulphatis gr. ss. — M. Ft. massa et in pil no xx. div. Sig. : One pill thrice daily. — Bartholow. J£ Tincturse ferri chloridi 5iv. Acidi phosphorici diluti 5yj. Spiriti limonis 3ij . Syrupi — q. s. add Svj. — M. Sig. : A dessertspoonful in water after meals. — Goodell. |fc Hydrargyri chloridi corrosivi gr. i-ij Liquoris arsenici chloridi 5j Tincturse ferri chloridi 3iv. Acidi hydrochlorici diluti 5iv. Syrupi Siij. Aquae — add Svj. — M. Sig.: A dessertspoonful in a wineglassful of water after meals. —A. H. Smith. |fc Ferri sulphatis exsiccat Potassii carbonatis aa 5j • Syrupi — q. s., ut. ft. massa — M. Ft. massa et in pil no. xxiv. div. Sig.: One pill after meals. — Bland. 58 A COMPENDIUM OF PRACTICAL MEDICINE. R Liquoris potassii arsenitis Sss. Tincturse gentianse composite §ivss. — M. Sig.: Half teaspoonful after each meal. (Small doses of iron may be given with the above). R Syrupi calcii lacto-phosphatis Siv. Liquoris potassii arsenitis 5j — M. Sig. : A teaspoonful three times daily. (In anaemia of lactation and of suppuration). — Bartholow. ANEURISM. Is a tumor, or sac, containing blood which communicates with the interior of an artery. Its walls are formed of the coats of an artery. Causes. — The aorta is the favorite site of aneurisms, because it is subjected to great strain. Powerful, muscular effort, syph- ilis, chronic arteritis, are the chief causes. Degeneration of the vessel walls, overaction of the heart, as in hypertrophy, gout, rheumatism and alcohol may cause aneurism. Exciting causes are: external wounds, fractures and dislocations, and sprains. It occurs most frequently between 30 and 50. Symptoms. — The earliest symptom of thoracic aneurism is pain. This may be a fixed pain, almost constant, and felt in one spot under the sternum, lancinating and tensive in character, shooting up to the neck and shoulders, down the arm to the elbows; or it is felt in the back and shoots around the chest. At times the attacks of pain are most severe, and demand the use of active anodynes (Bartholow). If erosion of vertebra?, sternum, or ribs occurs, there is a peculiar, constant "boring" pain. Pressure of the aneurism on the recurrent laryngeal nerves causes dyspncea and the voice becomes husky. Pressure on the pneumogastric may cause vomiting and pyrosis. Pressure on the pulmonary plexus gives rise to a harsh, metallic, "brassy" cough. Pressure on the cervical sympathetic causes contraction of the pupil on the affected side, and irritation causes dilation of the pupil (Loomis). Pressure on the external jugular causes the head and neck to become turgid on that side. Pressure on the trachea causes dyspnoea and a stridulous cough (with no . ANEURISM. 59 expectoration) like a nervous cough. Pressure on the thoracic duct will cause mal- assimilation, wasting and inanition. The symptoms of aneurisms in general are: 1. Expansile pulsation. 2. Pressure on the artery above destroys the pulsa- tion and diminishes the size of the aneurism. 3. Aneurismal bruit — a rasping sound, like sawing wood. 4. Pain, due to pressure on the sensory nerves. The following tumors may be mistaken for aneurisms: 1. Pulsating sarcoma and soft vascular carcinoma. 2. Abscess lying on an artery. 3. Enlarged glands lying on an artery. A clean hypodermic needle may be thrust into the sac or tumor to make the diagnosis positive (Bartholow). Prognosis. — Unfavorable. Treatment. — Is both medical and surgical. Absolute rest is the first essential. The diet must be nutritive but unstimulat- ing. Iodide of potassium and ergot are the only drugs that have stood the test of time (Loomis). Morphine must be given for the pain. For cases amenable to surgical treatment, see works on surgery. PRESCRIPTIONS FOR ANEURISM. J& Barii chloridi gr. xvij. Aqua? Sj . — M. Sig. : Six drops in a tablespoonful of water three times daily after meals, for four or five months. — Flint. {& Potassii iodidi (grs. xv. — 5ss.) Three or four times a day. (This relieves pain and promotes coagulation of blood in the sac). — Bartholow. JJr Antipyrin 3iss. Syrupi tolutan Siss. Aquse — add Siij . — M. Sig.: A tablespoonful at intervals of one to four hours until relieved. (For cardiac pain). — See. Jfy Potassii iodidi Sss. Syrupi simplicis 5j • Aquae menthre piperita? — ad Siij. — M. Sig.: A teaspoonful three times daily, gradually increased to three teaspoonfuls, but diminished on any increase of pulse rate. — Balfour. 60 A COMPENDIUM OF PRACTICAL MEDICINE. ANASARCA. Is not a disease but a symptom. It is a universal accu- mulation of serous fluid in the areolar tissue. CEdema is a localized collection of serum in the same tissue. These terms, therefore, differ in nothing but extent. (For treatment of these conditions see dropsy.) ANGINA PECTORIS. Is a neurosis of the heart characterized by pain, usually in- tense, burning, tearing or lancinating in character, in the pre- cordial region, radiating into the back, left shoulder and down the left arm, and accompanied by a feeling of constriction of the chest, and a strong sense of impending death. It is frequently associated with organic disease of the heart (Bartholow and Loomis). Treatment. — The affection is paroxysmal. There is a sud- den indescribable anguish, or "heart-pang" with a sense of suffocation, pale face, cold sweat, arterial tension high, action of heart disturbed. The paroxysms may last a few seconds only, or for hours, or even days (Bartholow and Loomis). Prognosis. — Unfavorable. Treatment. — All causes of disturbance of the heart action, as tobacco -smoking, alcohol, over -ingestion of food, and excite- ment must be removed. Five drops of nitrite of amyl should be inhaled from a handkerchief during the paroxysm. Morphine hypodermically for pain. Nitro- glycerine to prevent the attacks. Fowler's solution, cod-liver oil and the hypophosphites should be given. Electri- zation has been found useful (Bartholow, Loomis and Flint). PRESCRIPTIONS FOR ANGINA PECTORIS. 1^ Liquoris potassii arsenitis Sj- Sig. : Ten drops three times a day after meals. (Given during the interval.) — Bartholow. JJr Amyl nitritis oij- Sig.: Two to ten drops on handkerchief for inhalation. - Brunton. ANTHRAX. 61 jjr Sol. nitro-glycerine (1 per cent.). . 5ss. Sig. : One-half to two drops internally. (When pallor of face exists.) — Pepper. |& Antipyrin 5j- Syrupi tolutan 5j • A qua? — add Sij- — M. Sig.: A tablespoonful at intervals of one to four hours until relieved. — See. ANTHRAX. Commonly known as Carbuncle is a circumscribed, indurated, inflammation of the skin and cellular tissues. It is larger than a boil, and forms on the back or neck, sometimes on the face and buttock. Carbuncle is a far more serious affection than a boil, and occurs generally in men over 45. The pain is severe, sometimes intense; of a heavy, aching, throbbing, sting- ing, burning character. The inflamed area shows no disposition to become accumulated like a boil, but maintains its flat and very hard character. Little ulcers form on the dusky red skin which give it a sieve-like appearance, so numerous are the openings, and from these a whitish discharge exudes. Carbuncle, attack- ing the upper lip, is found to be an extremely fatal form of the disease, and kills by the onset of pyaemia (Flint and Anderson). Causes. — Poisonous, or irritating materials introduced into the skin; j)rolonged exposure of the skin to a scorching heat; low state of the nervous system and of the general health, pre- dispose to their occurrence (Flint and Anderson). Treatment. — Begin treatment with a calomel purge. Give tonics, such as quinine and iron in full doses. Morphine may be needed to quiet pain. Apply heat in the form of a poultice with acetate of lead and opium. Paint with tincture of iodine. Mr. O'Ferral recommends continued pressure by applying collo- dion to the inflamed skin. Some authorities advise incision. 62 A COMPENDIUM OF PRACTICAL MEDICINE. PRESCRIPTIONS FOR ANTHRAX. j& Tincturse ferri chloridi Sj. Potaseii chlora tis 5 j • Glycerinse Sj. Aquas — add Siv. — M Sig.: A teaspoonful in a wineglassful of water every two hours. — Ringer. JJr Lini farinas Aquas bullientis aa. q. s. M. et Ft. cataplasma. Sig. : Apply as hot as bearable and renew when necessary. — Rockwell. Faradization will hasten snj^pnration. ANAESTHESIA. Is loss of sensation. It is of various degrees. It may be complete, or partial, or a mere benumbing, and may be located in any part of the body. It is a symptom of some organic or functional disease of the central or peripheral nervous system. Large doses of Indian hemp, of lead, or of arsenic may cause anaesthesia. We see it in hysteria, syphilis and rheumatism, and as a result of pressure on nerve trunks, and of disturbances of the circulation and abnormal conditions of the blood. In the parts affected with anaesthesia the nutrition is less active, and there is a feeling of numbness and the temperature lowered (Loomis). Treatment. — A good nutritious diet and tonics. For the curable cases of cutaneous anaesthesia, faradization is a specific, if any remedy can be said to be a specific for anything (Rock- well). Bartholow recommends strychnine. ANCHYLOSIS. Is a bony or fibrous union of the joint ends of bones, caus- ing immobility of the joint. Anchylosis is not a disease of itself, but may be the result of any disease or injury which interferes with the normal functions and motions of a joint. Anchylosis may take place even in a perfectly healthy joint by long-con- ANCHYLOSIS APHTILE. 63 tinned rest. It may be the most favorable termination that can occur in many diseases and accidents of the joints. If anchylosis is the best result that can be obtained, then the surgeon should see that the elbow is anchylosed at a right angle, as the limb will be more useful, and the knee with the limb perfectly straight (Sayre and Bryant). Treatment. — If the anchylosis be fibrous, we resort to forcible movement to break up the adhesions. If it be bony, we divide the bone, or cut out a wedge-shaped portion. It may be necessary to divide the tendons before applying force. After breaking up the adhesions in the fibrous variety, passive motion may be resorted to. There is no treatment for bony anchylosis if the limb is already in the best position (Bryant). APHTHA. Are small white mucous ulcers of the mouth, especially of infants. Aphthous, follicular and croupous stomatitis are other names for this affection. The "aphthae," or white ulcers, are found on the internal surface of the lips, cheeks, tongue, gums, etc. The smallest of these patches are not larger than a pin's head. Causes. — Indigestion, diarrhoea, unripe fruit, candy and bad hygienic surroundings. Symptoms. — The constitutional symptoms are slight. The ulcers are painful; the child is fretful; the saliva is increased. Treatment. — Correct any intestinal disturbance that may exist with small doses of rhubarb and magnesia. Wash the mouth with a weak solution of glycerine and borax, or chlorate of potash. If the ulcers are slow to heal, touch them lightly with nitrate of silver. Bathe the feet in warm water. PRESCRIPTIONS FOR APHTHAE. Jfc Bismuthi subiritratis oj- Sig.: Apply dry to the ulcer. — Bartholow. JJr Potassii iodidi gr. iv. Aqure 3 j • — M . Sig. : Apply locally. —Bartholow. 64 A COMPENDIUM OF PRACTICAL MEDICINE. Jt Mel. boracis 5j. — M. Sig. : Apply to patches with a brush. — Ringer. Jfc Potassi chloratis gr. x. Aqua? Sj . — M. Sig.: Apply locally several times daily. — Brunton. {Jr Sodii salicylatis oiss. Aqua? destillatse Sj- — M. Sig.: Apply five or six times daily. — Hirtz. APHASIA. Is inability to use spoken language or to give vocal utter- ance to ideas. Where the memory of words is lost, it is called amnesic aphasia. Where the power of expression is lost and the words remembered, it is called ataxic aj)nasia. Aphasia is really not a disease, but a symptom. Causes. — Aphasia is associated with a number of intra- cranial lesions; with occlusion either by thrombosis or embolism of the vessels; with cerebral hemorrhage; with encephalitis, abscess, meningitis, tumors; and it may be a merely mental and moral condition (Bartholow). Treatment. — The local disease on which the aphasia depends must be removed. If the aphasia persists after the local disease has been cured, much may be done by suitable training. APOPLEXY. Is sometimes used synonymously with cerebral hemorrhage, but incorrectly, since it is a symptom merely, and not a disease (Bartholow). DaCosta says that apoplexy is coma coming on rapidly, in consequence of the compression of the brain by ex- travasated blood, by the turgescence of the vessels, or by effusion of serum. Loomis limits the term cerebral apoplexy to non-traumatic hemorrhage into the cerebral substance or meninges. Causes. — Apojjlexy is rare before 40 years of age. Miliary aneurism, periarteritis, fatty, atheromatous and fibroid degenera- tion of the walls of the vessels are causes of apoplexy, or cerebral APOPLEXY. 65 hemorrhage. Other predisposing causes are: gout, rheumatism, syphilis, chronic Bright 1 *, and chronic alcoholism. The exciting causes are: mental excitement, as in public speaking, sexual intercourse, straining at stool, and violent mus- cular exercises, and sudden stopping of bleeding piles (Flint and Loomis). Symptoms. — The seizure is generally sudden, and the coma quickly developed. The patient falls to the ground, bereft of all consciousness. In other instances, the apoplectic seizure is preceded by vertigo, dizziness, double vision, niuscse volitantes, flushing or pallor of the face, nausea, etc. During the coma the patient lies as if in a deep sleep, breathing laboriously and noisily, and each snoring inspiration is followed by a puffing sound. The pulse is slow, full, and at times irregular; the carotids throb violently. The pupils are immovable, and either con- tracted or dilated, and the eye is half open. In severe cases, the breathing becomes very irregular, of the Cheyne- Stokes variety. The coma may last from a few hours to two, three, or four days. Hemiplegia upon the side opposite to the hemorrhage is one of the most constant attendants of apoplexy, especially in the aged (Loomis). The eyes, and the head also, frequently deviate toward the side affected in the brain and from the side paralyzed; this movement constitutes a means of diag- nosis between cerebral hemorrhage and other causes of profound unconsciousness (Bartholow). Treatment. — The patient should be placed in a cool, airy apartment. Cold should be applied to the head, and heat to the feet. Attention must be directed to the bladder. An active cathartic should be given. If there are any paralyzed muscles, kneading, rubbing and electricity are the proper remedies. PRESCRIPTIONS FOR APOPLEXY. {& Olei tiglii oj- Sig. : Three or four drops may be given at once and repeated in three or four hours if free purgation be not produced, — Flint. 66 A COMPENDIUM OF PRACTICAL MEDICINE. APPENDICITIS. Is an inflammation of the appendix vermiformis. Causes. — The usual causes are foreign bodies, such as in- spissated faeces, fruit seeds, worms, gall stones, catarrhal condi- tion and traumatism. It is most frequent in males from fifteen to thirty years of age. Symptoms. — At first there are slight localized pain and ten- derness in the right iliac region. Later on, there is pain in the groin, extending down the course of the anterior crural and through the hip. The slightest attempt at palpation gives the patient great dread. The thigh is flexed on the pelvis. The following symptoms are diagnostic of perforation or acute peritonitis: a sharp, sudden, intense pain in the iliac fossa which may extend to the navel, liver, or into the back, accom- panied by nausea, vomiting and chill. Temperature 101° to 102°. A circumscribed tumor is usually detected and sometimes fluctuation. Prognosis. — When perforation has occurred, unfavorable. Treatment. — Antiphlogistic measures locally, and opium in- ternally, but according to Loomis, it is best to make an explora- tory incision. ASCITES. Is a local dropsy — an accumulation of serum in the perito- neal cavity. The amount of fluid present in ascites may vary from a few ounces to five gallons (Loomis). It is usually. of a light straw color. Ascites is a symptom, or an effect of disease, not strictly a disease in itself. Causes. — Ascites may be the result of disease of the perito- neum, or of obstruction in the main trunk of the portal vein, or in the branches of the vessel within the liver. Cirrhosis, throm- bosis, syphilitic hepatitis, abscess, cancer, and other tumors of the liver may cause ascites. Diseases of the heart or lungs may induce ascites in connection with general dropsy. Bright's dis- ease is a cause of hydremic dropsy. Symptoms. — The first is gradual enlargement of the abdo- men. There is no pain, tenderness, or any local subjective ASCITES ASTHMA. 67 symptoms. The appetite is usually impaired. There is a feel- ing of fullness. There is dyspnoea. The umbilicus is bulged out. Flatulence and diarrhoea are frequently present. The superficial veins on the abdomen or chest are enlarged and tor- tuous. The shape of the abdomen changes with a change of the position of the patient. Fluctuation is present. On percussion, there will be flatness below the level of the fluid. Ascites may be mistaken for an ovarian cyst, a distended bladder, pregnancy, and hydatid cysts of the liver. Prognosis. — In most cases unfavorable. Treatment. — First, treat the cause if known. Try to remove the fluid by means of diuretics and hydragogue cathartics; but do not continue the treatment too long. The most efficient hy- dragogue is elaterium, and the potash salts, nitre, squills and juniper are the most efficient diuretics. As little fluid as possi- ble should be taken. Tapping is the surgical method of remov- ing the fluid. The puncture is made in the median line two or three inches below the umbilicus. Loomis is in favor of tapping before the fluid has caused pressure upon the viscera. The oper- ation of tapping involves little risk. Patients have tapped themselves. For the general health give quinine, iron and cod-liver oil. PRESCRIPTIONS FOR ASCITES. |fc Elaterii gr. j. Ft. in no vi. pulveres. Sig. : One powder about 5 A. M. every other morning. — Salter. {{r Elaterii gr. ij. Ft. in no viii pulveres. Sig. : One powder at short intervals until abundant liquid evac- uations are produced. — Flint. Jfc Pulveris jalapse compositi Sj. Ft. in no viii pulveres. Sig.: One powder in early morning. — Bartholow. ASTHMA. Is a disease characterized by spasmodic difficulty of breath- ing, attended with wheezing and a sense of suffocation. It is a neuropathic affection, tonic spasms of the bronchial circular 68 A COMPENDIUM OF PEACTICAL MEDICINE. muscular fibres being induced by a morbid excitation through the nervous system (Flint). Causes. — A peculiar susceptibility in some persons constitutes the j)redisposing cause. Heredity is traced in about forty per cent. The exciting causes are: irritating inhalations, such as ipecac powder, chemical vapors, smoke, dust, fog, emanations from new mown hay, stables, roses, sulphur matches, cats, horses, etc. (Loomis). Errors in diet, bronchial catarrh and feather beds are causes. Course. — -The paroxysms last from two to six hours, but sometimes they persist for days (Bartholow). They take place, usually, during the sleeping hours. The patient is unable to lie down, but sits with the elbows on the knees near an open win- dow. A patient suffering from a severe paroxysm appears to be on the point of death. A frequent symptom is an itching sensa- tion under the chin. Sj>eech is difficult. The patient may be cyanotic (Loomis). Prognosis. — Death rarely, if ever occurs from uncomplicated asthma. Asthmatics are long-lived. Treatment. — To relieve the paroxysm, no medication is so effective as the hypodermic injection of morphine (from T2 to i gr). Chloral hydrate (gr. xx-xxx) is often equally effective (Bartholow). Nitrite of amyl by inhalation, three to five drops, sometimes affords relief. Inhalation of ether or chloro- form may be tried. Stramonium leaves may be smoked in a pipe. It often acts like a charm. PRESCRIPTIONS FOR ASTHMA. J& Potassii iodidi §ss. Tincturse gentianas comp 5iij- — M. Sig. : One teaspoonful gradually increased to two teaspoonsful, three times daily for several months. — Alonzo Clark. Jfc- Sodii iodidi gr. ij. Sodii bromidi gr. ij. Fluidi ext. euphorbia pil 7X1 iij. Glonoin gr.' i -.> o aroxysinal. In intestinal colic, jaundice is never present, while it may exist in bilary colic. In renal colic, the pain shoots from the region of the affected kidney to the inner part of the thigh and end of the penis, and the testicles are retracted; in gall-stone colic the direction of the pain is upward and backward. In renal colic, there is a constant desire to mic- turate. There is no urinary disturbance in biliary colic (Loomis). Prognosis. — Oft repeated attacks of biliary colic are bad. Treatment. — Relieve the pain by morphine hypodermically, inhalations of chloroform or ether; two or three leeches over the gall-bladder is often followed by relief. Large draughts of warm water, containing bicarbonate of soda often relieves the pain. Wrap warm clothes around the abdomen. If there are signs of collapse, give stimulants (Loomis). A gall-stone patient must not have wine or fats. He must exercise in the open air. A prolonged course of alkaline mineral water has been found the best remedy against the formation of gall-stones. Ether, turpen- tine, chloroform and hydrate of chloral have been projDosed as specifics, it being thought they have the power of dissolving the gall-stones. According to Bartholow, the most effective remedy for the removal of the conditions which lead to the formation of biliary calculi, or to bring about their solution, is sodium phos- phate. He prescribes this in drachm doses, three times daily, dissolved in sufficient hot water, and taken before meals. This remedy is continued for several weeks or months. Vichy water should be used. 92 A COMPENDIUM OF PRACTICAL MEDICIJNTE. PRESCRIPTIONS FOR BILIARY CALCULI. J& Sodii bicarbonatis 3v. In chartas no. xx div. Sig. : One powder three times daily for several months (Prophy- lactic). — Alonzo Clark. J& Chloroformi §iv. Sig. : To be inhaled, a small quantity at a time until paroxysm ceases. — Ringer. Jfc Sodii phosphatis 3ss-iss. In chartas no. xx div. Sig. : A powder before each meal continued for months (Pro- phylactic). — Bartholow. |fc Olei olivse optim Oj. Sig. : To be taken in divided doses before breakfast. |£ Morphinse sulphatis gr. -i-J. Atrophia? sulphatis gr. T ^ Aquee q. s. — M. Sig.; To be injected hypodermically during the paroxysm, and repeat if necessary. — Bartholow. CALCULI. (Renal). Renal calculi are concretions formed by precipitation of certain substances from the nrine about some body or material acting as a nucleus (Bartholow). They may be deposited in the tubes of the pyramids, in the cortical "substance, or in the pelvis of the kidney. By far the most frequent variety is uric acid. Oxalate of lime may form the starting jjoint of uric acid de- posits. Phosphatic, next touric, are the most frequently encoun- tered calculi. Mixed calculi are common. They vary in number. A kidney may contain one or a large number of concretions. They vary in size from a pin's head to a hazel nut; the larger ones may fill the whole pelvis; the smallest constitute "kidney gravel." If the larger ones obstruct the ureters, they become the cause of pyelitis, pyonephrosis, hydronephrosis, or abscess (Loomis). Causes. — Renal calculi occur at all ages, and are very fre- quent in children before the fifth year, and from five to_fifteen. CALCULI. 93 Males are nmch more liable to them than females. A sedentary life favors their development. The nuclei of renal calculi may he pus, blood, epithelium, or grains of pigment. Symptoms. — Usually there is an aching pain in the lumbar region and loins, which frequently shoots into the testicles, or labia, and down the inner side of the thighs; an itching at the end of the penis, and a frequent desire to urinate. The urine often contains pus, blood and tailed epithelium. The passage of a calculus along the ureter into the bladder is marked by sudden and intense pain in the region of the affected kidney, and is called renal colic. The urine is scanty or suppressed, and what is passed is of a smoky, high color, often bloody, and is dis- charged in drops, with a painful, burning sensation. The testi- cle of the affected side is retracted. When the calculus is washed into the ureter, an atrocious pain suddenly seizes the patient, who cries out, rolls from side to side, or rushes up and down the room. The face is pale and torn with agony, and the body is covered with a cold sweat. There may be nausea or vomiting, syncope or convulsions. The thigh of the affected side is be- numbed (Bartholow). The paroxysm, after some minutes or hours, usually terminates suddenly by the escape of the stone into the bladder. If the calculus become impacted in the ureter it will ulcerate through and give rise to a fatal peritonitis. Gravel may occasion no distress at all, or at most some little burning at micturition. After the passage of a calculus into the bladder, it will soon be found in the urine voided, or remain- ing in the bladder, it increases in size, and forms a vesical calculus. Diagnosis. — By remembering the diagnostic points the diag- nosis is easy. Prognosis. — Usually good. Treatment. — To relieve renal colic, give morphine hypo- dermically, warm baths and hot poultices to the loins and abdo- men. Inhalation of ether or chloroform will give relief. If gravel or sand of uric acid is present, probably the best prepara- tion is the officinal liquor potassii citratis, of which a table - spoonful may be taken every three hours (Bartholow). The faithful use of alkaline water not only delays, but often arrests the formation of renal calculi (Loomis). The Lithia, Carlsbad, 94 A COMPENDIUM OF PRACTICAL MEDICINE. Vicliy or Ems waters are efficacious. In five-sixths of the cases the urinary concretions consist of uric acid, and this forms the red sand which quickly collects around the sides and bottom of the vessel containing the urine. The urine in these cases is always acid. In cases of uric acid gravel, the urine is too con- centrated. The alkaline remedies above are indicated, with a large amount of water. The concretions may consist of the earthy salts, namely, the phosphate of ammonia and magnesia, and the phosphate and carbonate of lime. Ammonio-magnesian calculi are liable to form in cases of cystitis. These concretions are generally not renal but vesical. The urine in these cases is usually alkaline, and the mineral acids are indicated, either the sulphuric or hydrochloric. The nitro- hydrochloric acid is espec- ially indicated in cases of oxalate of lime gravel. The ingestion of large quantities of water form a highly important part of the treatment in all cases of gravel. PRESCRIPTIONS FOR RENAL AND VESICAL CALCULI. IJ Liquoris potassee 5ij. Infusi buch u 3 viij • — M. Sig. : Three tablespoonsful an hour after meals. (When urine acid.) — Reese. R Lithii citratis Sss. Syrupi aurantii cort Sj- Aquae ad Siij. — M. Sig. : A tablespoonful in a wineglass of water three times daily. -Guy. 5 Magnesii carbonatis 5j- Sodii biboratis Acidi citrici aa 5ij • Aquae bullientis Sviij. — M. Sig.: A tablespoonful three or four times daily. (When urine acid). — Bartholow. R Acidi nitrici diluti Acidi hydrochlorici diluti aa...5iij- Syrupi auranti cort Aquse aurantii flor .aa 3j. Aquae destillatae Sxiiiss. — M. Sig.: A wineglassful three or four times daily. (When urine alkaline). — Druitt. CARCINOMA. 95 R Acidi nitrici diluti Acidi hydrochlorici diluti aa 2JtxL Infusi serpentarise 5 viij . — M. Sig. : A half wineglassful three times daily. (When urine alka- line). — Bird. R Ammonii benzoatis 5ii-iij. Syrupi 3 iss. Aqua3 ad 5yj. — M. Sig. : A tablespoonful two or three times daily. (When urine alkaline). — Seymour. R Strychnise gr. j. Acidi nitrici diluti 5j. Aquse Sxij . — M. Sig.: Two tablespoonsful three times daily. (When urine alka- line). — Bird. CARCINOMA, OR CANCER. Is a tumor with a specific arrangement of the cells in spaces called alveoli. Theory. — Conheini has advanced the theory of the embry- onic origin of tumors, the germs of the tumor, perhaps consist- ing of misplaced embryonic cells, are brought by the individual into the world. They may remain dormant for a variable length of time, and then under the influence of some exciting cause, possibly an injury, may begin to grow. Cause. — Nothing is definitely known as to the origin of cancer, in any situation, but there is one thing certain, it is a disease of advanced life, and is more apt to appear from forty to sixty than at any other period. CARCINOMA OF THE STOMACH. Of all the organs of the body, the stomach is most frequently the seat of cancer — more frequently than the uterus, which comes, strictly, next. As regards age, the majority of cases occur at fifty, but the disease may appear at any time from forty -five to sixty. It is very rare from thirty to forty (Bartholow). Ac- cording to Loomis, the stomach, next to the liver, is the most 96 A COMPENDIUM OF PRACTICAL MEDICINE. frequent seat of internal cancer; one -third of all the cases of primary cancer have their seat in the stomach. According to Welch, quoted by Flint, the stomach, next to the uterus, is the most frequent seat of primary carcinoma. Cause. — Hereditary predisposition is undoubtedly its most important etiological factor. Beyond this its etiology is obscure (Loomis). Symptoms. — Anorexia, nausea, vomiting, pyrosis, soreness over the stomach are the earliest symptoms. After a time the pain becomes lancinating, fixed and constant. There are three prominent causes of the vomiting : First, from obstruction. When the obstruction is at the cardiac orifice, vomiting occurs immediately after eating ; when at the pylorus, the food is re- tained for one or two hours. Second, from irritation. Third, from fermentation. The absence of hydrochloric acid from the gastric juice is held to be an infallible sign of cancer. When the cancer ulcerates, the most constant symptom is hemorrhage ("coffee -ground" vomit). The stools have a dark, tarry appear- ance. Emaciation, debility, haggard look, and yellow skin are often present. By palpation, a hard, irregular and nodulated tumor may be discovered. Differential Diagnosis. — Cancer of the stomach may be mis- taken for gastric ulcer, and abdominal aneurism. Ulcer of the stomach occurs most in young adults, especially females, while cancer is seldom met with in persons under forty. In cancer there is usually a history of hereditary cancer. The pain in cancer is continuous, and described as lancinating ; while in ulcer the pain is intermittent, greatly increased by taking food. Hsematemesis, in cancer, has a sooty or "coffee -ground" appear- ance, is small in amount, and appears late in the disease, while in ulcer it is bright red arterial blood, is profuse, and appears as an early symptom. Vomiting in cancer does not relieve the pain, and is not very severe ; but in ulcer it is severe, and relieves the pain. The presence of an epigastric tumor establishes the diagnosis of cancer. An aneurismal tumor is smooth and ovoid; a cancerous tumor is hard and irregular. In aneurism, there is an expansile pulsation, while in cancer this impulse is lifting in character (Loomis). CARCINOMA. 97 Prognosis. — Is always unfavorable. Its shortest duration. is seven weeks, and its longest three and one-half years, the aver- age being one year (Loomis). Treatment. — Is altogether palliative. As to diet, milk and beef juice are the best. The burning pain is much diminished by washing out the stomach once a day with the stomach pump. Bartholow recommends equal parts of pure carbolic acid and tincture of iodine, of which one or two drops may be given in water three times daily. For the pain, give morphine hypoder- mically. Arsenic, in the form of Fowler's solution, one or two drops, three times a day, has power to allay pain and retard the growth. CARCINOMA OF THE INTESTINE. Cancer of the intestine is usually primary. The rectum is its most frequent seat, then the anus, the caecum, the sigmoid and the colon (Loomis). Cause. — The cause is obscure. It is a disease of advanced life (after forty). Males are affected three and a half times oftener than females. Symptoms. — There are pains in a fixed situation, a gradually developing cachexia, and the presence of a tumor. The pain at first is slight, then acute and sharp. The patient declines in strength and weight, has a feeling of fatigue, a fawn- color com- plexion, bluish- white lips, a skin dry, wrinkled and scurfy. In cancer of the stomach and intestines the patients usually suffer from a profuse salivary flow without apparent cause. Constipa- tion is the rule (Bartholow). In cancer of the rectum, hard nodular masses may be felt. Prognosis. — Is always unfavorable. A fatal termination will be reached in a year or two. Treatment. — The treatment is only palliative. The pain must be relieved by morphine, hypodermically. The diet should consist of milk, nutritive broths, eggs, etc. Arsenic may relieve the pain and retard the growth (Bartholow). The formation of an artificial anus is a surgical means of prolonging life. 98 A COMPENDIUM OF PRACTICAL MEDICINE. CARCINOMA OF THE LIVER. Cancer of the liver may be either primary or secondary. It is secondary to cancer of the stomach in one -half of the cases. It has been estimated that one out of every one hundred persons has cancer of the liver (Loomis). Cause. — The cause is unknown. Hereditary predisposition exists in most cases. It occurs most often between the ages of 40 and 65. Medullary cancer of the liver sometimes occurs in early life. Symptoms. — The patient gradually loses flesh and strength, complains of a sense of weight and fullness in the region of the liver. The pain soon becomes lancinating, and is localized at some j3oint over the liver, which is tender to pressure. There is loss of appetite, flatulence, nausea, vomiting. Jaundice is pres- ent in one-half of the cases. Ascites occurs more frequently than jaundice. (Edenia of the feet comes on late. The temperature is normal or sub-normal. Palpation discloses an enlarged liver, tender to pressure, with hard, smooth nodules over its surface (Loomis). Prognosis. — Cancer of the liver is a fatal disease. The aver- age duration is about one year (Loomis). Treatment. — Is palliative. Regulate the diet. Relieve the pain by a hypodermic of morphine. There is no remedy for cancer in any situation. Ascites will require attention by tap- ping. CARCINOMA OF THE KIDNEY. Cancer of the kidney may be primary or secondary. Causes. — The cause is obscure. It occurs in early life, be- fore five, and in old age. Symptoms. — There is gradual emaciation, soreness in the lumbar region, and hematuria. Prognosis. — The prognosis is always bad. The termination is invariably death. Treatment. — Is palliative. Relieve the pain and sustain the patient. CARCINOMA CARIES. 99 CARCINOMA OF THE LUNG. Cancer of the lnng is usually secondary, and very often suc- ceeds to cancer of the breast removed by amputation. It may be primary, but rarely so. It is a disease of advanced life and is extremely rare before forty (Bartholow). Cause. — The cause is obscure. Hereditary predis230sition is a most influential factor. Symptoms. — There is usually pain in the chest and a cough accompanied by a muco -hemorrhagic expectoration resembling currant jelly (Loomis). There is dyspnoea, emaciation, fever, night- sweats, with failure of strength, and haemoptysis. Prognosis. — Is always unfavorable. Treatment. — Is altogether palliative, and is restricted to the relief of symptoms. CARCINOMA IN OTHER ORGANS. Cancer of the arteries, brain, gall-bladder, heart, tongue, larynx, oesophagus, mediastinum, pancreas, pericardium, plura, and spleen is met with. In some cases it is primary, in others secondary. The cause is obscure. The prominent symptoms are pain, the cancerous cachexia, and a tumor. The prognosis is unfavorable, and the treatment is only palliative. CARIES. Is inflammation and ulceration of bone; while necrosis is its death en masse. Bones of spongy texture are more frequently attacked by caries than such as are compact. The bones of young persons are more often the seat of caries than those of old subjects. On examination, the bone is found to be soft and dark red; its cells are filled with a reddish, serous, glary fluid, or with soft granulations of feeble vitality. It is always vascular and readily bleeds on being touched. It is occasionally painful. Causes. — The predisposing cause is some constitutional dis- order, scrofula, or syphilis. The exciting cause may be a blow or injury. 100 a compendium: of practical medicine. Treatment. — Correct trie constitutional disorder and give tonics, fresh air and baths. The usual remedies employed in scrofula and syphilis are indicated. Locally, the best treatment is to freely expose and remove the diseased portion of bone. PRESCRIPTIONS FOR CARIES. B Cupri sulphatis Zinci sulphatis aa partes xv. Liquoris plumbi subacetatis partes xxx. Aceti partes CC. — M. Sig. : To be injecd through the sinuses. — Villate- B Syrupi calcis lactophosphatis ^viij . Sig. : A dessertspoonful to a tablespoonful three times daily. — Bartholow. Cod-liver oil should be given to promote constructive meta- morphosis (Bartholow). CARBUNCLE. (See Anthrax). CATARRH (Nasal, called, also, Coryza). Is a catarrhal inflammation of the nasal mucous membrane. It is commonly called "cold in the head." Causes. — Atmospherical causes are the most frequent and influential. The exjDosure of the neck to a current of cold air, of the feet and ankles to cold and dampness, passing from a warm to a cold atmosphere, and from a cold to a warm atmos- jxhere suddenly, are among the most usual causes. Irritating gases and vapors or dust may cause coryza. Epidemic influence now and then prevails on an extensive scale (Bartholow). Symptoms. — Taking cold in the head is announced by chilli- ness, weariness, headache, and general muscular soreness. An intense hypera?mia is the first change, with an arrest of secretion. This is soon followed by swelling of the membrane, and the nose feels dry, stuffed and uncomfortable, and an inclination to sneeze is often felt. Presently the nose pours out an abundant watery and saline discharge. The discharge soon assumes a purulent character. The voice has a nasal tone. The acute NASAL AND FAUCIAL CATARRH. 101 form terminates in fourteen days. The chronic may last for years. The discharge of the chronic form consists of greenish, offensive pus, or scales. If the mucous membrane is destroyed "by ulcerations, and caries of the bone has occurred, the case is then called ozsena (Bartholow). Treatment. — Where there is a strumous diathesis cod-liver oil. the phosphates, iodide of iron, etc., should be employed. Try to abort an acute attack by the administration of a full dose of quinine (gr. xv.) and morphine (gr. ss.) for an adult. When established, the best remedy is Lugol's solution, liquor iodi com- 230situs, one drop every hour or two. If there is fever, one drop of tincture of aconite root every hour will prove efficient. If the secretion is watery and profuse, tincture of belladonna may be given with the aconite, two drops every two hours. In the local treatment of chronic catarrh, the post-nasal syringe and tepid water containing a little common salt are the best materials for cleansing the passage. The tincture of iodine and carbolic acid may be readily volatilized and inhaled from a small bottle. A cocaine tablet containing gr. i-i in the form of a flattened disc, introduced alongside the septum, one on each side, twice or three times daily, is more successful. Very dilute solutions of chlorate of potassa, chloride of ammonium, sulphates of zinc, cadmium and copper, and acetate of lead, may be tried (Bartholow). According to Bartholow, the most effective application is a powder composed of tannin and iodoform (5i.-gr. x.) applied by means of an insufflator. Dobell's is an efficacious cleansing solution in chronic nasal catarrh, hypertrophic nasal catarrh, atropic nasal catarrh, and fetid nasal catarrh (ozsena). PRESCRIPTIONS FOR NASAL AND FAUCIAL CATARRH, J& Cocaine muriate gr. vj Bismuthi subcarbonatis 5ss. Talc 5iss.— M. Sig. : Enough to cover a silver five cent piece, insufflated into each nostril every two hours. (For acute coryza). — Sajous. Jfc Tinctura? aconiti radicis 3J. Tincturse Belladonna? , .31). — M. Sig.: Three drops every hour. (Pharyngitis and acute ton- silitis). — Ringer. 102 A COMPENDIUM OF PRACTICAL MEDICINE. j& Chloroformi 5ij- Glycerinse Spiritus vini galici aa Sj • — M. Sig.: One teaspoonful in water every three hours. (For acute coryza). ' — Sajous. |fc Acidi carbolici liq ITtxxx. Sodii biboratis Sodii bicarbonatis aa 5j • Glycerinse oiiiss. Aquse q. s., ad., ft Siv. — M. Sig.: To be used with atomizer. (Simple chronic rhinitis). — Dobell. |fc Sodii bicarbonatis Sj- Sig. : Insufflate or apply with the finger to the inflamed tonsil. (Tonsilitis.) — Gine. |fc Resorcin gr. v.-x. Aquse destillatse o ij • — M. Sig.: Used with atomizer twice daily, four minutes each time. — Masini and Massei. CATARRH. (Chronic Gastric.) Causes. — In many persons there is an hereditary tendency after middle life, to chronic gastric catarrh. The principal gen-' eral cause of this affection is anaemia. The most common local cause is the daily use of alcoholic stimulants. Diseases of the liver, heart and lungs which offer an obstacle to the venous return, will induce chronic gastric catarrh. Highly- seasoned foods, condiments, sauces, hasty and insufficient mastication, the frequent use of ices, and overfeeding are the principal causes. The prolonged use of arsenic, mercury, cubebs and purgatives often causes it. Finally, scrofula, syphilis and gout predispose to it (Bartholow and Loomis). Symptoms. — After taking food, the patient has a feeling of weight, or fullness, sometimes of pain. Sometimes when the stomach is empty, sometimes when it is full, the pain is greater. The symptoms of indigestion are usually present. There may be loss of appetite, nausea, vomiting of acid mucous in the morning or after meals. It is this acid material belched up into the oesophagus that causes "heart-burn." There is gaseous disten- CATARRH. 103 tion of the stomach. Palpitation, headache, and vertigo may be present. Treatment. — Regulation of the diet is the most important in all stomach diseases. When the starches, sugars and fats reach the stomach, fermentation begins. To exclude these articles, then, is the first step toward a cure. A curative measure of the highest importance is the "skim-milk cure," which consists in the exclusive use of milk, about four ounces every three hours, for some time. The stomach pump is very effective for cleansing the stomach in these cases. One or two drops of Fowler's solu- tion, three times daily before meals, continued for a month or more, is a remedy of the highest importance. When there is much acidity it may be checked by muriatic acid given before meals. Carbolic acid alone or with bismuth relieves the fermen- tation and gaseous eructations (Bartholow). PRESCRIPTIONS FOR CHRONIC GASTRIC CATARRH, Jfc Liquoris potassii arsenitis Sss. Sig. : One or two drops before meals. (Vomiting of drunkards.) — Bartholow. {& Extracti hydrastis fluidi Sss. Sig.: Five to fifteen drops before meals in water, to be continued some time. — Bartholow. {fc Tincturse cinchonas comp ,..Siv. Tincturse capsici 5ss. Tincturse mucis vomicae oij- — M. Sig.: A teaspoonful every two or three hours. (To allay the craving for alcohol.) — Loomis. J& Tincturse opii dedoratse gtt. xvj. Bismuthi subnitratis 3ij- Syrupi simplicis 5iv. Aquse cinnamomi 5iss. — M. Sig.: Shake bottle. Give one teaspoonful every two to four hours. (For child one year old.) — J. Lewis Smith. 104 A COMPENDIUM OF PRACTICAL MEDICINE. CHANCRE. I. Induration of Syphilitic Chancre. — Can always be felt when present, and in well marked cases it is absolutely pathogno- monic. It exists in three varieties : 1. A thin superficial layer of induration, aptly called '"■parchment-like," exactly underlying the ulceration. This is the commonest form. 2. The induration may resemble a split pea, situated exactly beneath the ulcer, which is upon its flat surface. This induration is easily felt, is little or not at all sensitive, freely movable over the rjarts beneath, hard like bone or wood, feels elastic, is sharply defined, ends abruptly. 3. The induration may be very extensive, far surpassing the bounds of the ulceration placed upon it, exca- vated or convex upon its surface. The skin over it is not usually red. Induration is usually greatest in chancres of the skin, lips, nipples, behind the corona glandis, and near the fraenum of the penis. In spongy tissue like the glans penis, the induration is often very slight. Again, when a syphilitic chancre becomes phagedenic, it loses its induration at once. The induration may precede the ulceration or follow it. In the latter case it comes on during the first week. Usually any form of induration will outlast the ulceration, remaining for two or three months, or more rarely for years. Eicord records one case of thirty years standing (Keyes). II Ulceration of Syphilitic Chancre. — Properly, syphi- litic chancre does not ulcerate. It consists, in more than half the cases, simply of an excoriated surface, looking red and bloody, very superficial, frequently scabbed when exposed to the air. Indeed, it may never even excoriate, the lesion consisting in a simple indurated tubercle, which scales off a little at the top. But chancre of the genitals rarely escapes more or less inflam- mation, hence it is the rule to find some shallow, occasionally deep, ulceration. When shallow, the ulcer is round or oval, with slanting borders, often a red base. When deep, the borders are never abrupt, as in chancroid, but always sloped off. The cavity is funnel-shaped. Sometimes the induration left behind on the healing of a chancre re- ulcerates (Keyes). CHANCRE. 105 III. Character of the Discharge. — Pus does not form as such on true syphilitic chancre, unless it be inflamed. Ordinarily the discharge is sero- purulent or purely serous, often bloody (Keyes). IV. Pain. — In unirritated syphilitic chancre, as a rule, there is absolutely no pain. A patient often carries a chancre some time without knowing it, and sometimes it comes and goes without being discovered at all. In this way may be explained many singular cases of undoubted syphilis, apparently not pre- ceded by any primary lesion (Keyes). V. Cicatrix. — The scar left by chancre varies. In a number of cases, there is no scar left behind. The scars left are at first discolored, of a dark, vinous hue, like the color of raw ham. This color may be followed by the true coj)per- colored. The scar is finally whiter in the center than the surrounding skin (Keyes). VI. Inoculation. — Auto -inoculations of chancre -secretion have been performed without number, the result having been invariably negative, unless the chancre had been previously irri- tated, or producing pus. Under such circumstances, the pustule and ulceration produced would be the same as the pus of any indifferent abscess would cause. The difference between the inoculation of chancroid and syphilitic chancre is illustrated in the famous case of Lindmann, who inoculated himself a number of times with chancroid pus, always with success, but with no syphilis; finally, believing himself protected (/. eriods of three months have elapsed between two successive movements, and yet the individual was apparently in good health (Loomis). 126 A COMPENDIUM OF PRACTICAL MEDICINE. Causes. — In those accustomed to large doses of opium the bowels have been known to move only four times in a year. Abuse of laxatives, diseases of the brain and spinal cord, liver, heart, diabetes, general anaemia and chlorosis, anxiety and pro- longed mental labor are causes. A sedentary life, the feeble, infirm, the bed-ridden, child-bearing, and old age, are predispos- ing causes. Disregarding the calls to evacuate the bowels, the use of food leaving no residium, deficiency of the gastric and in- testinal juices, impaired muscular contractility and loss of peris- taltic movements are causes (Loomis). Symptoms. — The patient complains of sense of fullness in the rectum, with flatulence, headache, vertigo, a foul breath and anorexia. Eruptions such as psoriasis, eczema, prurigo, ery- thema and urticaria often appear upon the surface. There are flushings of the face, dark rings around the eyes, and sometimes palpitation, A distended colon may cause pain which is located either in the chest, bladder, groin, ovaries, testicles, loins or lower extremities (Loomis). Treatment. — For temporary constipation Epsom, or Rochelle salts are efficient. For habitual constipation, regular hours for the evacuation of the bowels, articles of food which leave a bulky residue, as cracked wheat, oatmeal and fruits which have fine seeds, as figs, strawberries and prunes sweetened with molasses are sometimes very efficient. A goblet of hot or cold water just before retiring and on rising will often be of service. Daily exercise in walking or horseback riding, friction and kneading of the abdomen and the galvanic, and faradic currents are efficient means. PRESCRIPTIONS FOR CONSTIPATION. R Extracti cascarse sagradse fluidi... Elixir simplicis aa £ij . — M. Sig. : Two teaspoonsful at bed time. — Bartholow. R Extracti nucis vomicae Pulverus piper, nig ;aa .gr. xx. Pil. colocynth comp gr. 1. — M. In pil. no. xx. div. Sig.: One every night or second night. — Fothergill. CONVULSIONS. 127 R Pulveris aloes socot gr. vij . Pulveris rhei gr. xxiv. Extracti belladonna gr. i. — M. In pil. no. xii. div. Sig. : One or two pills as required. — DaCosta. CONVULSIONS. Spasm is sometimes used synonymously with convulsion; but there is this difference : the word spasm is used when we wish to express the idea of less extensive muscular contraction; and con- vulsion, when the disorder affects the muscles of the whole body. Spasms may be clonic or tonic, and so may convulsions. Convul- sions may be accompanied by a loss of consciousness and sensi- bility, as in epilepsy or not so as in tetanus. When convulsions occur in children, as they often do from reflex irritation during teething, from disordered digestion or from poison in the blood, they are then called infantile convulsions. Children often have convulsions as the precursors of febrile diseases. Convulsions may be symptomatic of any cerebral disease (Loomis). Treatment. — The discovery of a cause will indicate the treat- ment. Belladonna and the bromides may be used. Hot baths, counter-irritants to the back and neck, or cold to the head, are often of service. Chloroform is the most appropriate agent for controlling the spasms temporarily (Loomis). PRESCRIPTIONS FOR CONVULSIONS. R Olei ricini §j. Sig.: A teaspoonful or two according to age. (When due to in- digestion.) — Witherstine. R Athens fort §iv. Sig. : To be used as an inhalation until paroxysm is broken. —J. L Smith. R Misturse asafcetidse §ij. Sig.: A tablespoonful as an anema. — Waring. R Potassii bromidi 3J. Aqua? menthre piperita? §ij. — M. Sig.: A teaspoonful every three hours for a day or two. 128 A COMPENDIUM OF PRACTICAL MEDICINE. CORYZA. (See Catarrh.) CROUP. (Spasmodic.) Called also spasmodic laryngitis or false croup in contradis- tinction to true croup, is a common disease. It occurs ordinarily between the ages of two and five years. Causes. — In some families there is an hereditary tendency. The exciting cause in most cases is exposure to cold. False croup is common in the commencement of measles. Symptoms. — Spasmodic croup is usually preceded for a day or two by a slight cough and mild nasal catarrh. It commences in most patients at night after the first sleep between ten and twelve o'clock. The child awakens with a loud, barking cough. There is great dyspnoea due to swelling and tension of the vocal cords. The face is flushed and expressive of suffering. The child cries. The skin is hot, the pulse accelerated, the voice hoarse. From a half to three hours these symptoms abate. Sometimes the attack is repeated once or more during subsequent nights. Differential Diagnosis. — Spasmodic croup may be mistaken for true croup. The friends usually make this mistake before the physician arrives. True croup begins gradually. The cough becomes more harsh and the respirations more difficult by degrees, by day as well as by night. On the other hand, false croup commences abruptly at night with severe symptoms from the first. The cough in false croup possesses a loud, sonorous char- acter, while in true croup it is harsh and less full. False croup must not be confounded with laryngismus stridulous or internal convulsions. The latter is not infiammatory, but purely srmsmo- dic, suddenly commencing and abating (Smith). Treatment. — To relieve the spasmodic action of the laryngeal muscles, a warm bath should be employed at once, and the pa- tient kept in ten or fifteen minutes. In mild cases, a warm foot- bath may be sufficient. An emetic should be given at the same time with the bath. To children under three years, syrup of ipecac should be given in doses of one teaspoonful, repeated in twenty minutes, till vomiting occurs. Children over the age of ckotp. 129 three years are best treated by the compound syrup of squills in teaspoonful doses till vomiting is produced. Eochelle salts should be given after the nausea from the emetic has subsided. Inhalation of the vapor of hot water and a sinapism over the neck and upper part of the sternum are useful aids. Spraying the throat with a solution of two drachms of sodium bicarbonate to a pint of lime-water is effective. Five or six drops of syrup of ipecac, or of compound syrup of squills should be given every third hour the next day. The atmosphere in the room of the patient should be loaded with moisture. Trosseau applied a sponge soaked in water as hot as can be borne, to the larynx, repeated in ten minutes. The hoarseness, dyspnoea, and cough diminish with this treatment. PRESCRIPTIONS FOR SPASMODIC, OR CATARRHAL CROUP. |& Potassii bromidi Chloral hydratis aa gr. xx. Syrupi acacise §j . — M. Sig. : A teaspoonful or less, according to age. — Ellis, {& Tincturse aconiti radicis gss. Sig. : One drop in a teaspoonful of water every hour till urgent symptoms abate; then every two or three hours. — Ringer. JJr Pulveris aJuminis 31J. Syrupi ipecac |j . — M. Sig. : One teaspoonful every twenty minutes until vomiting is produced. A hot mustard foot-bath should be given at the same time. —J. L. Smith. Jfc Syrupi ipecacuanhas §ij. Sig. : A teaspoonful every fifteen minutes until vomiting is pro- duced. Then five or ten drops every three hours the next day. — Meigs and Pepper. CROUP. (Membranous). Called also true croup, or pseudo- membranous laryngitis, is a common and fatal disease, and occurs most frequently between the ages of two and twelve years. Some authorities regard membranous croup as only a laryngeal diphtheria. Causes. — According to J. L. Smith, the causes of croup arc, 130 A COMPENDIUM OF PRACTICAL MEDICINE. diphtheria, ''taking cold,' 1 measles, pertussis, scarlatina, typhoid fever, and irritating; inhalation. Symptoms. — Membranous croup commonly begins gradually and insidiously, revealed at first to the physician by hoarseness or huskiness of the voice, and a hoarse or harsh cough. Accord- ing to Bartholow, it is a purely local affection, and occupies the larynx exclusively. The exudation is on and not in the mucous membrane, and blood-poisoning never results. Occasionally masses of pseudo-membrane are expectorated. The dypsncea gradually increases. Whitish or grayish patches of false mem- brane may be seen on the fauces. Prognosis. — It is one of the most fatal diseases of childhood (Loomis). Treatment. — The agents which have been most employed for the purpose of dissolving the false membrane are lime-water, lactic acid, pepsin and trypsin. Smith uses the following formula? in the steam atomizer with good results : R Soclii bicarbouatis gij. Aquae calcis 0. j. — M. Liquid trypsin may be employed with lime-water. R Extracti pancreatis (Fairchilds)....3j. Sodii bicarbonatis ^iij . — M. Add one teaspoonful of this to six teaspoonsful of water, and apply ever}' half hour with a camel's hair pencil. R Liquor potassae 3J. Aquae calcis O.j. — M. This may be inhaled from the steam-atomizer. Calomel has been used with good results in doses of from five to ten grains in the commencement of the disease. PRESCRIPTIONS FOR MEMBRANOUS CROUP. R Hydrargyri sulphatis flav. .......... gr. ij-v. In pulv. no. 1. Sig. : Use as an emetic. — Fordyce Baker. R Acidi lactici ^iiiss. Aquse destillata? §x. — M. Sig.: Apply with atomizer or brush frequently. (To dissolve the membranes.) — Mackenzie. CYSTITIS. 131 CYSTITIS. Is an inflammation of the mucous membrane limno* the urinary bladder. It is acute or chronic. Causes. — Foreign bodies, especially calculi, in the bladder? blows, protracted retention of urine, scarlet, typhus, and typhoid fevers, pyaemia, septicaemia, small -pox, diphtheria, myelitis? urethritis, pyelitis, and pelvic cellulitis may cause cystitis. Ureth- ral stricture, paralysis of the bladder, gout and some forms of kidney disease are accompanied by chronic cystitis (Loonrist. Symptoms. — Acute cystitis is always accompanied by fre- quent micturition, only a few drops being voided at each attempt. After its passage the patient strains to pass more. There are dull aching pains over the pubis; sometimes the pains in the vesical region are agonizing, and there is a constant burn- ing sensation along the urethra. The urine is cloudy, deposits mucus on standing, is alkaline, and sometimes fetid. Acute cystitis lasts about one week. Chronic cystitis is often only indicated by a frequent desire to pass urine. Usually there is a constant, dull, aching pain, or a sense of weakness over the bladder. Only a small quantity of urine is passed with each act (Loomis). Treatment. — In acute cystitis, the patient must have jjerfect rest. Warm hip-baths give relief. Rectal injections of opium and belladonna are always indicated, with large poultices and very hot fomentations over the bladder. The bowels should be kept free. For the pain, chloroclyne is the best. Twenty minims of liquor potassse in mucilage may be given three times in twenty-four hours. In chronic cystitis, the catheter is to be reg- ularly and persistently used. The bladder should be washed out with weak solutions of borax. Very weak solutions of salicylic acid, carbolic acid, permanganate of potash, and chloride of sodium are also recommended. The daily use of mineral water, like Vichy, is beneficial. Drachm doses after each meal of the "Lafayette mixture" are very serviceable. 132 A COMPENDIUM OF PRACTICAL MEDICIJNTE. PRESCRIPTIONS FOR CYSTITIS. R Bals. copab Spts. etheris nitros — aa 5ss. Liquor potass* 5j • Mucilag. acacias ad giv. — M. — " Lafa} r ette Mixture.'' All stimulating drinks are forbidden (Loomis). R Atrophia? sulphatis g r -j- ■ Acidi acetici gtt. xx. Aicoholis Aquse — aa 3ss. — M. Sig. : Four drops in a wineglassful of water before each meal. (In acute cystitis.) — Goodell. R Extracti tritici fluidi Syrupi amygdala? — aa 3ij- — M. Sig.: A dessertspoonful in water five or six times daily. (In chronic cystitis.) — Thompson. R Potassii citratis Sss. Spiritus chloroformi oiiss. Tincturse digitalis ZTCLxxx. Infusi buchu o viij . — M. Sig. : Two tablespoonsful three or four times daily. — FothergilL CANCRUM ORIS. Called also gangrene of the mouth, noma, aqueous cancer of infants, is a disease of childhood occurring between two and six years. The point of attack, which is most frequently the inside of the cheek, becomes inflamed, thickened and indurated, then a purple hue appears, followed by sloughing and gangrene (J. L.. Smith). Causes. — This is a very rare disease. It occurs in debilitated and cachectic children, and in those recovering from acute dis- eases, such as scarlet fever (Loomis). Symptoms. — It commences with pain in the mouth, an ab- normal quantity of saliva, and offensive breath. Finally an ulcer appears, with a dark, ashy-brown colored slough. It may perforate the cheek. Prognosis. — Nineteen out of twenty die (Loomis). CARDIALGIA CATALEPSY. 133 Treatment. — Nitrate of silver, and even strong nitric acid, should be applied to the slough, and the mouth washed with solutions of carbolic acid and chlorate of potash. The best internal remedies are quinine, hydrochloric acid and stimulants (Loomis). CARDIALGIA. Signifies pain at the cardiac orifice of the stomach of a burn- ing character and shooting into the chest, and up the oesophagus into the throat. It is vulgarly called heartburn. Everyone has occasionally experienced this symptom. It characterizes certain cases of indigestion, and it is evidently dependent on the presence of an acid in the stomach, as it is quickly and completely re- lieved for a time by an alkaline remedy, such as lime-water, liquor potassse, bicarbonate of soda and magnesia. CATALEPSY. Is a functional disease of the nervous system, closely allied to hysteria and epilej3sy. It is characterized by loss of conscious- ness, sensation and volition, accompanied by a peculiar muscular rigidity in which the limbs remain for some time in whatever position they are placed (Loomis). Causes. — Catalepsy may occur at any age, but it is more common in females about the age of puberty. It may precede melancholia and epilepsy. Traumatism, strong emotions, fright, shock, and religious excitement may induce an attack (Loomis). Symptoms. — Catalepsy occurs in paroxysms. Consciousness is suddenly lost, and the limbs are as rigid as if : petrified. The face has a death-like appearance. The skin is cold and temper- ature is sub-normal. The attack may last a few minutes, several hours, or for days. Prognosis.— As a rule, favorable (Loomis). Treatment. — An emetic will generally cut short an attack. The faradic current may be employed to arouse the patient. Morphine may stop the paroxy&m, given hypodermically. Asa- foetida, valerian, camphor and turpentine may be given. 134 A C03IPEXDIU3I OF PRACTICAL 3IEDICIXE. CEPHALALGIA. (See Headache). CEREBRO=SPINAL MENINGITIS. Called also spotted, petechial and congestive fever, is an in- flammatory affection of the arachnoid and pia mater of both the brain and spinal cord. Causes. — Epidemics have occurred at all seasons, but more often in cold weather. It is most likely to attach those between ten and eighteen years of age. Cold, damp and overcrowded houses predispose to it. The real cause is not known (Loomis). Symptoms. — In some cases the patient is suddenly seized with a chill, loss of consciousness, becomes comatose, and dies in a few hours. Headache in most cases is prominent, and even in a condition of coma, causes the patient to groan. Pain in the back and upper part of the spine is a characteristic symptom of the disease. Attempts to flex the head on the chest increase the pain, and pressure against the back of the neck often induces excruciating agony. Soon the muscles at the back of the neck become stiff, and the head extended (opisthotonos). Attempts to swallow are painful. The temperature, as a rule, is low. The pulse is from 120 to 150. The pupils are often unequal in size. The face is pale and anxious, and has a dusky hue. Delirium comes on. The pains are shooting and lancinating in character. The eruption is usually limited to the face, neck and lips; it is herpetic in character. There is photophobia. Prognosis. — Unfavorable. From 30 to 80 per cent. die. Treatment. — The patient should be put to bed in a dark, cOol, well- ventilated room, away from noise. The diet should be milk. Opium, bromide of potassium, quinine, and ergot in proj>er doses are useful. Cold applications to the head, mustard foot-baths, and mustard to back of neck are serviceable. PRESCRIPTIONS FOR CEREBRO=SPINAL MENINGITIS. R Morphise sulphatis gr. ss. Acidi sulphurici aromat... 3j. Elixir cinchona? ad gvj — M. Sig. : A teaspoonful every two hours for a child twelve years old. — Meigs and Pepper. CEEEBRO-SPIXAL MENINGITIS — CIRCUMCISION. 135 R Acidi hydrocyanici diluti UT. xx-xl. Sodii bicarbonatis gi iss. Syrupi simplicis Aquse aa q. s., ad siiss. — M. Sig. : A teaspoonful every three or four hours for severe vomit- ing. — Delafield. R Hydrargyri chloridi mitis • Pulveris jalaps Sacchari albi aa 3j. — M. In pulv. no. x. div. Sig.: A powder every hour until free purgation occurs. — Robert. CHICKEN=POX. (See Varicella.) CHIN=COUGH. (See Whooping-cough.) CIRCUMCISION. Was instituted as a religious rite by Abraham, about 2,000 years before Christ. Several Eastern nations still practice it as a hygienic measure. The chosen j>eople preserve the custom as a religious ceremony, performing it on the eighth day. Operation. — Mark off with an aniline pencil the limits of the integument which it is proposed to remove. This line should follow the curve of the corona glandis at a short distance in front of it. Now seize the redundant prepuce with the forceps so that the aniline line shall lie just in front of the closed blades, taking care not to include the glans in the grasp of the forceps. With scissors cut off the outer portion. After the forceps has been removed, the inner layer of the prepuce is to be slit down to the corona upon the dorsum of the glans and the entire mucous membrane to be trimmed away on either side up to the frenum, leaving only enough tissue to serve to hold the sutures. Primary union seems always to occur. In the infant no suture is re- quired. The parts coapt naturally, and healing is accomplished usually in about forty-eight hours. In the adult, horse hair has proved the best material with which to suture the cut edge-. The first suture should be applied at the raphe. The ends of the suture are to be cut off about an inch long, to prevent the wound 136 A COMPENDIUM OF PEACTICAL MEDICINE. from rolling in during the swelling of the first two clays. It heals in from fonr to eight clays. An opiate for sleep and a lax- ative are the only medicines usually required (Keyes). COMA. Is complete loss of consciousness, and there is the appear- ance of the profoundest sleep. The face wears a confused look ; the pupils are sluggish, often dilated ; the mouth is open, the tongue dry. Sensation may be blunted, but is not destroyed ; nor is motion, for the patient moves when his skin is pinched or tickled. Coma always betokens a serious disturbance of the functions of the brain (DaCosta). Causes. — The cranial causes are : Hyperemia, anaemia, ceclema, compression, tumors, thrombosis, embolism, apoplexy, abscess, softenings, shock, and concussion. The most thorough coma is seen in apoplexy; it comes on quickly, and is attended with a noisy respiration and a slow pulse. The extra cranial causes are : Hysteria, epilepsy, uraemia, cholseruia, poisons of drags, narcotics and anaesthetics, anti-spasmoclics, alcohol, poisons of fevers, malaria, etc. (Loomis). Treatment. — Discover and treat the canse. CORNS. Are small callous thickenings of the skin, especially on the toes, the result of occasional pressure. Dr. Sayre writes that a corn is infinitely more painful than a cancer, and is capable of inflicting torment and agony sufficient to destroy the sweetest disposition, and upset the best regulated families. There are two varieties of corns, the hard and the soft. The soft corn is found between the toes, is exceedingly tender, and is liable to become inflamed. The hard corn has a hard, white core in the centre. The irritation produced by pressure upon these forma- tions may give rise to reflex muscular contractions which will draw the toes up. Treatment. — Shoes must be worn which will permit expan- sion of the foot. Pare the corn as much as possible without drawing blood. Then rub the surface with solid stick of nitrate COLD FEET COUGH. 137 of silver, and in a few days another layer will come off. Now surround the corn with narrow strips of adhesive plaster to pro- tect it from pressure. To the soft corn apply concentrated nitric acid or the solid stick of nitrate of silver, and place a pledget of cotton between the toes. In a few days the hardened mass will come away. Glacial acetic acid, and carbolic acid, are good applications. According to Bartholow, no application is so cer- tain, prompt and effective, for the cure of corns, as liquor potas- sse. It should be applied by means of a glass rod to the summit of the corn and the tissue softened by it scraped off. By suc- cessive applications the callosity is removed without pain or dis- comfort. COLD FEET. Many persons, especially women, are troubled with cold feet, particularly at night; so cold, indeed, as to effectually pre- vent sleep for hours. This condition, which may rank as a dis- tinct ailment, is best treated by immersing the feet nightl}' for a few minutes in cold water, rubbing them whilst in the foot-bath diligently until they become warm and glowing, and then, after thorough drying, clothing them in thick, over-large woolen or "fleecy hosiery" socks. The feet may be sponged first with water as hot as can be borne, and then for a few seconds with a sponge wrung out of cold water (Ringer). Dr. Chapman asserts that the ice-bag, applied along the lower dorsal and lumbar ver- tebrae, by increasing the flow of blood to the legs, proves very comfortable to jDersons harassed with cold feet; and he has often seen the feet become comfortably warm a few minutes after the application of ice. According to Dr. Anstie, strychnia promotes capillary circulation, and he recommends it in troublesome cold- ness of the feet and hands. COUGH. Is a sudden and violent expiration, having usually for its object the expulsion of some annoying substance from the air passages. But it may be purely nervous. A nervous cough sometimes occurs in children and in chlorotic girls. The cough is usually in paroxysms, has a peculiar barking tone and resem- 138 A COMPENDIUM OF PRACTICAL MEDICINE. bles whooping cough.. It is short, painless, and without expec- toration. Causes. — In children, it may result from diseases of the brain, from dentition, from worms, and spinal irritation. In others, anaemia, hysteria and nervous excitement may be the cause. It may be induced by involuntary imitation. A school for girls was suspended on account of the large number of cases (Flint and Smith). Treatment. — Tonic remedies, a nutritious diet, out- door life, cjuinia and small doses of strychnia are useful. No remedy is so useful in ordinary cases as iron. Dr. Cameron used the follow- ing prescription : R Ferri subsulphatis §ss. Acidi nitrici 3ss. Aquae destillatse , , , , £ss. — M. Sig. : Three drops four times daily in sweetened water. R Tincturse belladonna? gtt. xxxij. Potassii bromidi Ammonii bromidi — aa 3j. Syrupi simplicis 5ij. — M. Sig.: One teaspoonful three times daily. (For a child three years.) — J. L. Smith. There are several kinds of cough ; according to the amount of expectoration, a cough is dry or moist ; according to its ori- gin, it is laryngeal, tracheal, bronchial, sympathetic, etc. A dry cough is indicative of irritation either in the larynx, trachea, bronchi, or in the lung substance. An elongated uvula, pleurisy, and the earlier stages of phthisis may give rise to a dry cough. But the irritation may not be situated at all in the respiratory system. Affections of the liver, stomach, intestine, uterus or brain will occasion an obstinate dry cough. Cough is frequently preceded by a sensation of tickling in the larynx. Lying down often increases its intensity. PRESCRIPTIONS FOR COUGH. R Misturse asafoetida §iv. Ammonii muriatis 3j. — M. Sig.: A tablespoonful as necessary. (For sympathetic and cough maintained by habit.) — Bartholow. COUGH. 139 R Chloral hydratis Camphora? — aa 3ss. — M. Triturate in a mortar till a clear fluid is formed. Sig.: Paint with a camel's hair brush over the larynx to allay spasmodic cough. — Bartholow. R Extracti gelsemii fluidi giij. Sig. : Three to five drops in water every two hours until droop- ing of the eyelids and dilation of the pupil takes place. (For nervous, spasmodic, reflex and irritative cough.) — Bartholow. R Acidi hydrocyanici diluti sj. Tincturse sanguinariaB giv. Syrupi senegas gss. Syrupi tolutan §ij. Aquas lauro-cerasi 3vij — M. Sig. : One or two teaspoonsful, according to age, every three or four hours. (For irritable, nervous, and cough by habit.) — Bartholow. Syrup of wild cherry and syrup of lactucarium are excellent vehicles for cough mixtures. R Aluminis 33. Aquee gvj. — M. Sig.: Use in the form of a spray for chronic coughs and hoarse- ness. — Ringer. R Chloroformi 3j . Morphia sulph gr. iss. Glycerinse gij . — M. Sig.: A teaspoonful when cough is troublesome. R Olei morrhuse O.j. Sig. : A teaspoonful three times daily, tor a while, then increase to tablespoonful. (For chronic cough.) A drop of pure beech -wood creosote may be given with the cod-liver oil. A teaspoonful of glycerine added to water or a little lemon - juice, is often useful in coughs, even the cough of phthisis. This dose, taken at night, often lessens morning cough (Ringer). Glycerine of tannin is a very useful application to the throat when chronically inflamed and so productive of cough, which is often the case in children. 140 A COMPENDIUM OF PRACTICAL MEDICINE. The tincture of iodine may be used as an inhalation in the chronic forms of phthisis to allay the troublesome cough; and. as an inhalation for children with hoarse, hollow cough, accompanied by hoarseness and wheezing at the chest. Use as follows : Pour twenty to thirty drops of the tincture of iodine in a half or a pint of boiling water; then direct the patient to put his face over the mouth of the vessel and breathe the iodized steam for five or ten minutes night and morning with the head covered with a towel to prevent escape of the steam (Ringer). According to Eummo a four per cent, solution of iodoform in spirits of turpentine, used as an inhalation or spray, will diminish the cough of phthisis and chronic bronchial catarrh. According to Ringer, in the obstinate winter cough with difficult breathing and wheezing, the wine of ipecac applied as a spray to the fauces once or twice daily is very efficacious. The wine may be used pure or diluted. COMEDONES.— (See Acne.) CYSTS. Are developed in many ways : some are possibly new growths, some are formed in an accidental way by simple effu- sion of fluid into connective tissue, and others are produced by a dilatation of occluded ducts, or natural gland orifices, the cysts enlarging by the secretion of the ducts or gland contents. Of these the mucous cysts of the mouth and vagina, the sebaceous cysts of the skin, and the milk cysts of the breasts are the best examples (Bryant). Varieties. — Serous cysts, mucous cysts, sebaceous cysts, oil cysts and dermoid cysts. Serous Cysts are most commonly found connected with the kidney, ovary, thyroid or breast. They are sometimes seen in the neck. They contain a limpid, watery fluid, and are painless. Treatment. — It is dangerous to tajD or extirpate a cervical cyst. Let it alone. Mucous Cysts are found wherever mucous glands exist, and are caused by some obstruction to the escape of the gland con- tents. They are found on the lips, within the cheeks, on the CALCIFICATION CHLOASMA. 1-11 tongue and gums, and beneath the tongue when they are called ran iila. They contain a thick ropy fluid. Treatment. — They ma}" be excised, or their walls cut into. Sebaceous Cysts appear as congenital and acquired tumors. Some are caused by obstruction to the orifice of the sebaceous glands. The congenital sebaceous cyst is deeply placed, and is more common about the orbit and brow. They contain a whitish or yellowish liquid secretion and sometimes hair. The acquired sebaceous cyst may be found on an)' part of the body, but it is more common on the head and face. When on the scalp, they are known as wens. Treatment. — The only correct treatment is their removal. Dermoid Cysts are frequently met with situated deeply be- neath the skin and mnscle. They are congenital, filled with sebaceous matter, and often contain hair. Treatment. — They should be dissected out. Oil Cysts are met with but rarely, and are probably always dermoid. CALCIFICATION. Called, also, calcareous degeneration, or cretefaction, is an infiltration of the tissues with the phosphate and carbonate of lime. Calcified tissues are recognized by their hard, sometimes stony consistence. Tissues which have undergone fatty degen- eration are especially prone to calcification. In the vast majority of cases of calcification, the lime is deposited in tissue previously
  • eased. Of great practical importance is the calcification of the cardiac valves in chronic endocarditis, and of the internal and middle coats of the arteries in old age (Flint). Removing tumors from the pelvic or abdominal cavity, when the tissues and arteries are calcified, gives rise to troublesome or even fatal hemorrhage. CHLOASMA. Is a diffuse form of excessive pigmentation. It is most fre- quently met with in women during pregnancy, and also in un- married females between the ages of thirty and tin- cessation of the menses, as a result of disordered menstruation, and of dis- 142 A COMPENDIUM OF PKACTICAL MEDICIJSTE. eases of the sexual organs. It has the appearance of a dirty yellow or brown discoloration, generally implicating the face, and often extending across the forehead from temple to temple, and from near the eye -brows to near the roots of the hair. Treatment. — Careful attention must be paid to the general health and sexual organs. The local treatment is most import- ant. Some local applications, such as mustard, cantharides, and croton oil, are apt to be succeeded by new epidermis which is more deeply pigmented than that which it has replaced, and are, therefore, to be avoided; while others, such as perchloride of mercury solutions, have exactly the opposite tendency. We may use a perchloride of mercury solution of the strength of five grains in an ounce of alcohol in the following manner: Place the patient in bed and apply compresses dipped in the above solution. Moisten the compresses from time to time with the fluid without displacing them. The compresses are removed in four hours, when the skin is found to be reddened or blistered. If blistered, let out the fluid and dust the surface with starch powder. CRAMP. In writers' cramp, the flexor muscles of the thumb and fingers become rigidly contracted. Pianists, violinists, printers, tailors, etc., are sometimes similarly affected. In the treatment of writers' cramp and allied affections, discontinuance of acts which occasion the spasm is essential. Galvanism is most useful. It seems to be a central, not a peripheral affection. Some persons are liable to suffer much from cramp of the muscles of the leg or feet, occurring especially at night. Bardsley's treatment con- sists in sleeping on an inclined plane, the bed being twelve inches higher at the head than at the foot. Galvanism is very effective in these cases (Flint). Cramp may occur in any muscle. Occasionally the stomach is the seat of cramps, and causes great pain, and ejection of food. Galvanism seems to be more effective than other forms of treat- ment. CIRRHOSIS DEBILITY. 143 CIRRHOSIS. (Of Liver.) Called also interstitial hepatitis, is an inflammation of the connective tissue of the liver. It has been named sclerosis of the liver, "Gin -drinkers" liver, "hob-nailed" liver, etc. Causes. — The chief cause of cirrhosis is the intemperate use of alcohol. When it is taken in a concentrated form without food, it acts as a direct irritant to the hepatic circulation. If this irritation is long continued cirrhosis is the result. Those who take alcohol before breakfast as well as through the day are almost certain to develop cirrhosis of the liver. Those who partake freely and daily of highly seasoned food, even though they may not use alcohol, are also liable to develop cirrhosis. Syphilis, gout and rheumatism cause it (Loomis). Symptoms. — Dull pain and tenderness in the hepatic region, dyspnoea, apathy, headache, nausea and furred tongue, and loss of appetite, esj^ecially for meats, are the chief symptoms. There may be slight jaundice. Tympanites as well as intestinal catarrh usually precedes ascites. Before the ascites, the abdominal veins, especially of the right side, are sometimes enormously distended. Ascites is sometimes absent. The stools in cirrhosis are charac- teristic. They are clay- colored in the centre; surrounding this there is a dull pinkish ring, and around this a slate grey ring tinged with mucus. The urine is scanty and very dark colored (Loomis). Prognosis. — Unfavorable. Treatment. — All spirituous liquors must be abstained from. Nitro- muriatic acid and cod-liver oil are useful. Dilute nitric acid and columbo assist stomach digestion. Creosote and sul- phite of sodium are of service, when acid fermentation is a dis- tressing symptom. For the ascites and general dropsy, squills and digitalis are effective; but when they fail, tapping must be resorted to (Loomis). DEBILITY. Dr. Anstie highly extolled alcoholic stimulants in the debil- ity of old age, especially in the condition of sleeplessness, at- tended often with slow and ineffectual digestion and a tendency 144 A COMPENDIUM OF PRACTICAL MEDICINE. to stomach cramps. He employs a generous and potent wine containing much ether. According to Ringer, the good old- fashioned remedy, rum or brandy and milk taken before break- fast, is useful in phthisis and in exhausting diseases, and is a good prop to town -living women who suffer from morning ex- haustion. Arsenic is useful for the swollen feet of old or weakly persons ; or for old people with a weakly acting heart and feeble circulation, who often suffer from breathlessness on exertion. Cod-liver oil is useful in chronic degenerative diseases of old age. In nervous and general debility, cod-liver oil and the hypo- phosphites are highly useful. Quinia is of great benefit to pale and badly fed town dwellers. Sea bathing is recommended in chronic illness with debility. PRESCRIPTIONS FOR GENERAL AND SENILE DEBILITY. R Tinctura? ferri cbloridi Syrupi simplicis — aa sj. Aqua? cinnamomi §ij . — M. Sig. : A teaspoonful three times daily. — Charity Hospital. R Spiritus chloroformi 5v. Acidi hydrochlorici dil giiss. Infusi cinchona? §x v. — M. Sig. : Two tablespoonsful three times daily. — Fothergill. R Quinia? sulphatis gr. xxx. Acidi sulphurici diluti q. s., ad. ft. sol. Aqua? §ij . Tinctura? ferri chloridi £ss. Spiritus chloroformi 3yj . Glycerina? §iv. — M. Sig. : A teaspoonful three times daily. — Loomis. DELIRIUM. This is a wandering of the mind, the patient muttering incoherent words. It is more common in the young and nervous than in the old. The delirium may be quiet or active. It may be brought on by acute diseases, especially fevers. DELIRIUM. 145 DELIRIUM. (Tremens.) Occurs most frequently in old topers after a severe drinking bout, or it follows the sudden withdrawal of stimulants, or an attack may be induced by some strong moral emotion or excite- ment, or by an accident or injury (Loomis). Symptoms. — The appetite is lost and even the drink is rejected. The trembling increases ; the manner grows excited and irritable. Insomnia is an early symptom. Hallucinations and illusions come on. The delirium usually begins at the moment of falling asleep or in awaking. He then sees frightful objects — goblins, demons and monsters — but fully awake they vanish. This preliminary state is often called "the horrors." As the case progresses the hallucinations become constant. The patient sees snakes on the wall and bed, and endeavors to escape from them. He may be noisy, furious, and dangerous. There may be illusions of smell and hearing. Delirium tremens usu- ally lasts about two weeks, by which time recovery or death will have taken place (Bartholow). Treatment. — Provide suitable aliment for the patient and try to procure sound sleep. Milk and lime-water may be given freely, to which it may be advisable to add whiskey or brandy.. E^o'-noa;, beef-iuice and other animal broths should be well for- titled with red-pepper. For securing sleep, one-fourth of a grain of morphine and fifteen grains of chloral may be given, if the heart is not weak. Bromide of potassium in full doses may be given for "the horrors.' 1 Pilocarpine, tincture of digitalis in drachm doses, tincture of cannabis indica, and chloroform inter- nally may be used with advantage. PRESCRIPTIONS FOR DELIRIUM. JJr Potassii bromidi Sodii bromidi aa gr. xv. Chloral bydratis gr. x. Tincturae zingiberis ITtx. Tincturse capsici ITTv. Spiritus ammonii aromat gj. Aquse q. s., ad gij. — M. Sig. : Dose, 3ij. — Starr. 146 A COMPENDIUM OF PRACTICAL MEDICINE. Jfc Chloral hydratis £ss. Syrupi aurantii corticis Aqua? aa gss. — M. Sig. : To be taken in one dose, and repeated if necessary. — Liebreich. {Jr Potassii bromidi §ss. Syrupi simplicis 5j . Aquse foeniculi q. s., ad giij. — M. .Sig. : Two teaspoonfuls every two hours — Ringer. J$ Potassii bromidi 3j. In pulv. no. vii. div. Sig.: A powder dissolved in one-half tumblerful of water every four to six hours (In "the horrors.") — Bartholow. DIABETES INSIPIDUS. Called, also, polyuria, hyperuresis, and polydipsia, is char- acterized by extreme thirst, and the secretion of a large quantity of colorless urine, of low specific gravity, free from sugar and albumen (Loomis). Causes. — Diabetes insipidus may occur at any age and in either sex. Disturbance of the sympathetic ganglia causes dila- tation of the capillary vessels of the kidney, and produces dia- betes. Blows on the head, injuries to the medulla and spinal cord, and violent emotions have all apparently caused its development. Drinking large quantities of ice -water when over- heated, and exposure to cold and wet, are among its supposed causes (Loomis). Bartholow gives syphiloma of the brain as the most usual cause. Symptoms. — Its chief symptom is the passage of a large quantity of limpid urine; the quantity varies from thirty to sixty pints per day. Its specific gravity ranges from 1003 to 1008; it is remarkably clear, and faintly acid. It contains no sugar or other abnormal ingredients. There is intense thirst. The skin becomes harsh and dry; and the temperature sub- normal. There may be salivation (Loomis). Prognosis. — Recovery from diabetes insipidus is rare. It may last many years. Treatment. — At all times the body should be warmly clothed, and the skin kept active. According to Bartholow, the iodides DIABETES. 147 and mercury have quickly cured cases of syphilitic origin. Jaborandi and ergotin have been successful. A course of iodide of potassium should be at first administered, and if the disease does not yield, galvanism should be tried. PRESCRIPTIONS FOR DIABETES INSIPIDUS. Jfc Extracti ergotse fluidi §ij. Sig. : A teaspoonful three times daily, increased to two tea- spoonfuls. — DaCosta. {& Auri chloridi 3j. Confect. rosse gr. xx. — M. Ft. massa et in pilulas no. xx. div. Sig.: A pill after meals thrice daily. — Bartholow. |$r Pulv. Valerianae rad oii" lv - In chart, no. xii. div. Sig.: A powder three times daily. — Demange. DIABETES MELLITUS. Called also glycosuria, is a chronic disease characterized by the constant presence of grape-sugar in the urine, by an increased urinary discharge, and by progressive wasting of the body. It has at various times been regarded as a disease of the kidney, alimentary canal, liver, and nervous system, but its exact path- ogeny has never been determined (Loomis). Causes. — Diabetes occurs at all ages, but is most frequent in middle life. It appears to be hereditary in some cases. Shock or concussion of the whole body, or of the brain and spinal cord, blows upon the hepatic and renal regions, mental shocks, anxiety and chagrin may cause it (Bartholow). Pregnancy, impaired digestion, and immoderate use of sugar, new wine, and alcohol have also been named as causes (Loomis). Excessive activity in the glycogenic function of the liver may so overload the blood with sugar as to cause it to appear in the urine (Loomis). Symptoms. — Diabetes may be acute and result fatally within two or three weeks from the time the increased flow of urine is noticed. But it usually comes on insidiously; the patient notices for some time that he has been passing more urine than usual, 148 A COMPENDIUM OF PRACTICAL MEDICINE. and has been unusually thirsty. While his appetite is good, yet he is losing flesh and strength; and there is an abnormal dryness of the mouth, throat and skin, with intolerable itching, followed by desquamation. There is loss of sexual desire. The tongue is red or coated ; the gums are pale, retracted and bleed easily, and the teeth become carious. There are nausea and vomiting, with constipation. The temperature, pulse-rate and respirations are below the normal. In some cases, there will be little thirst or loss of appetite and no emaciation (Loomis). The Urine. — Very rarely the amount of urine passed is but little increased; generally it rises to twenty or fifty pints in twenty-four hours. The urine is acid, of a light straw color, without sediment. The specific gravity varies from 1030 to 1070 with an average of 1040. In rare cases a low specific gravity of 1008 or 1010 is recorded (Loomis). Prognosis. — The disease may last from a few weeks to ten or twelve years. Boils and carbuncles may complicate it (Loomis). Treatment. — Dieting is of the first importance. All sacch- arine form of food, or any article that can be converted into sugar should be avoided. Hence, starchy foods, bread, arrow- root, tapioca, sago, such vegetables as potatoes, parsnips, turnips, carrots, beans and peas, are to be absolutely avoided. Salads, greens, acids, fruits, all kinds of flesh and fowl, eggs, cheese and butter, unsweetened tea and coffee, can be taken. Baths and moderate exercise should be taken. Extract of opium, morphia, and codeia in small doses are useful. Mineral waters are given. If there is anaemia, iron, cod-liver oil, strychnia, and quinine should be given. Surgical operations should on no account be undertaken on diabetic patients. PRESCRIPTIONS FOR DIABETES MELLITUS. R Sodii salicylates 3iv-vj. Glyceri nee §j . Aquse ad §iij. — M. Sig.. Two teaspoonfuls three times daily. — DaCosta.. R Tincturse opii 5j Tincturse ferri muriatis oix. — M. Sig.: Twenty drops three times daily. — Weller.. DIAEEIIGEA. 149 R Soclii salicylatis .-5iij- Liquor potassii arsenitis 5j. Glycerinse oj- Aquas cinnamomi ad Siij • — M. Sig. : A dessertspoonful three times daily. — J. C. Wilson. DIARRHEA. Is the frequent discharge of fluid or semi-fluid faeces. It may Ibe acute or chronic. Varieties, — I. Irritative Diarrhoea is that form induced by improper and unseasonable food, foul water, tainted meats, and drugs. II. Symptomatic Diarrhoea is a part of the natural history of typhoid fever, intestinal ulcerations, all forms of cholera, and other diseases. III. Mechanical Diarrhoea is that form in which the fasces are made fluid by a large amount of serum poured into the intestinal canal, by the action of Epsom and Rochelle salts. IV. Nervous Diarrhoea may be caused by fright, grief, great anxiety, and severe pain. V. Vicarious Diarrhoea occurs when the functions of the skin, kidneys or lungs are suppressed; the flux from the bowels affords relief. Chilling the body suddenly, or intense heat, brings on a vicarious flux. VI. Fatty Diarrhoea is the result of faulty pancreatic di- gestion. VII. Colliquative Diarrhoea is a copious flux occurring in wasting diseases toward their close, e. g., phthisis, cancer and Bright 1 s disease. VIII. Chronic Diarrhoea is always associated with some form of chronic organic disease as chronic enteritis, intestinal ulcers, syphilis, malaria, scurvy and phthisis (Loomis). Prognosis. — Depends on the cause. In fatty diarrhoea 50 per cent die. Treatment. — Depends on the causes which produce it. If it depends on undigested food, a full dose of castor oil, or rhubarb and soda should be given. The diet should be restricted to milk and lime-water. Camphor, kino, bismuth, or dilute sulphuric 150 A COMPENDIUM OF PRACTICAL MEDICIiSTE. acid may be given. If there is griping, opium may he combined with the bismuth and camphor. In the treatment of chronic diarrhoea, bismuth is the most reliable drug (Loomis). PRESCRIPTIONS FOR DIARRHEA. Jfc Spiritus lavandulse comp Sij. Tincturse opii 31J . Tincturse rhei gss. Olei sassafras gtt. x. — M. Sig. : A teaspoonful after each meal. — Loomis. J£ Olei ricini ^ij. Pulveris acacia? — Pulveris sacchari aa ^ij. Tincturse opii ITT.xxi. A quae cinnamomi ad giv. — M. Sig. : A teaspoonful every three or four hours. (For children.) —West. {fc Magnesii sulphatis Tincturse rhei Syrupi zingiberis aa 5j. Aqua? carui oix. — M. Sig. : A teaspoonful three times daily, to a child one year old. —West. Jfc Tincturse opii deodoratse gtt. xvi. Bismuthi subnitratis 3ij- Syrupi simplicis Sss. Misturse cretse Siss. — M. Sig.: Shake well and give teaspoonful every three hours to a child one year old. — J. L. Smith. JJr Pulveris ipecac gr. ss. Pulveris rhei gr. ij. Sodii bicarbonatis... gr. xij. — M. In pulv. no. xii. div. Sig.: One powder every four hours to an infant one year old. (In indigestion with acidity.) — J. L. Smith. Jfc Cretse prsep 5ij. Tincturae catechu Sss. Tincturse opii XH.lxxx. Aquse cinnamomi ad 5 viij. — M. Sig.: Two tablespoonfuls after each motion. — Fothergill. DIPHTHERIA. 151 DIPHTHERIA, Is one of the most dreaded, one of the most fatal, and, un- fortunately, one of the most common maladies of childhood. It is an acute, specific, contagious disease, beginning by an infec- tion of the throat, and characterized by a local exudation, glandular enlargements, and systemic poisoning, and having for its sequelae various paralyses (Barthelow). Causes. — Diphtheria is a contagious disease, propagated by a specific poison, the form of which is not known. It may pre- vail as an epidemic, or occur sporadically. Filth, bad sewerage and drainage, overcrowding, and a general bad hygienic condi- tion favor the development and spread of diphtheria. It is first a local, then a constitutional disease. The stage of incubation usually varies from one to eight days. No age is exempt, but from the second to the fifth year is the period of greatest suscep- tibility. Previous attacks afford no immunity against subsequent ones (Loomis). Symptoms. — Are both local and constitutional. The local symptoms begin with a sensation of dryness, prickling and pain in the throat. There is hyperamiia of the fauces, and on the palate or tonsils, minute grayish -white patches appear. The false membrane is sometimes dark-red or even black. There may be swelling of the glands of the neck. The Eustachian tubes, (esophagus, posterior nares, larynx, vagina, and rectum may be involved. The constitutional symptoms are chill, fever, pain in the head and back, nausea, vomiting, and even convul- sions. The temperature may be 103° or 104° F., the pulse 120 to 130. The patient's condition grows worse each day. until about the end of one week, when the membrane is thrown off. The loss of tendon reflex often occurs as early as the first, sec- ond or third day. It is a symptom of diagnostic value. Dr. McDonnell made the following statement: "Knee-jerk is absent from the very first day of the illness, in many cases of diph- theria.' 1 Symptoms which indicate danger: 1. Diarrhoea may cause exhaustion. 2. Nausea and vomiting coming on late in the dis- ease. 3. Albuminuria, and coma may occur as a result of the 152 A COMPENDIUM OF PRACTICAL MEDICINE. nephritis. 4. An irregular and intermittent pulse throughout the entire course of the disease. 5. If the temperature falls to the normal, or below, and the exudation shows no sign of ex- foliating. 6. Convulsions occurring late in the disease. Sequelae. — After the exudation disappears and convalescence is apparently established, sequelae may develop, which may con- tinue for months, and even years. The commonest is paralysis of some of the voluntary muscles ; the muscles most frequently affected are those of the soft palate and pharynx. There is diffi- culty in swallowing and inability to articulate clearly. As the pharyngeal paralysis is disappearing — or from two to ten days after — the muscles of the lower or upper extremity may be in- volved. Before the occurrence of the paralysis there will be a sensation of coldness, pricking, crawling and numbness in the part about to be affected. There maybe paralysis of any muscle. Paralysis of the heart may occur. Diphtheritic paralysis is always entirely recovered from. These paralyses may follow the mildest as well as the more severe cases. In mild cases its dura- tion is two or "three weeks, while in others it has continued one or two years. Other sequels are nephritis and, endocarditis (Loomis). Differential Diagnosis. — The diagnosis of diphtheria rests on the presence of a membranous exudation. Ordinary sore throat or catarrhal pharyngitis is sometimes confounded with diphtheria. Membranous croup is a local affection, while diphtheria is a con- stitutional disease. Croup is not contagious or inoculable, while diphtheria is markedly so. In croup the exudation is on the surface of the mucous membrane; in diphtheria it is in its sub- stance as well as on its surface. The submaxillary glands may be, and often are, enlarged in diphtheria, but never in croup. An erythematous eruption sometimes makes its appearance on the upper part of the chest and back in diphtheria (Loomis). Prognosis. — Death rate is from twenty to fifty per cent. Duration varies from three to fourteen days. Cases that are apparently doing well sometimes terminate very unexpectedly and suddenly by paralysis of the heart. Complications make the prognosis more unfavorable. Death may occur from diph- theritic blood-poisoning. DIPHTHERIA. 153 Treatment. — The patient should be kept in bed, and the room well ventilated, and have a temperature of 70 to 75 degrees. The patient should be kept scrupulously clean. Hot poultices should be applied externally to the throat ; steam inhalation should be constant fiom the onset of the disease, until the exuda- tion has disappeared ; iron and brandy should be given freely; and the diet should be fluid, milk preferably (Loomis). Accord- ing to Bartholow, a solution of lactic acid — strong enough to taste sour — frequently applied by means of a mop, gives excel- lent results. He also recommends highly the inhalation of the vapor, as it arises from the slacking of lime. The false mem- brane may be dissolved by very frequent inhalations of atomized lime-water and lactic acid. Bartholow gives the following to prevent systemic infection: Jfc Liquor iodi comp 3ij. Acidi carbolici oj — M. Sig. : One-fourth of a drop to two drops in water every four hours. Also, moderate doses of whiskey or brandy for the same pur- pose. He also recommends iron, quinine, strychnine, galvanism and faradism for the paralytic affections of diphtheria. As a solvent for the false membrane, Dr. J. L. Smith recommends the following : Jfc Olei eucalypti oij- Sodii benzoat oj • Sodii bicarbonatis oij- Glycerines Sij • Aquas calcis... 0. j. — M. Sig.: To be used with the hand atomizer from three to five minutes every half hour, or with the steam atomizer almost con- stantly. PRESCRIPTIONS FOR DIPHTHERIA. {& Papayotin 5j. Aquas 5iv. Glycerinas 5 viij . — M. Sig.: Apply locally to membrane. — Jacobi. fy Trypsin gr. xxx. Sodii bicarbonatis gr. x. Aquse destillatse 5j. — M. Sig. : Apply locally to membrane. — Fernald. 154 A COMPENDIUM OF PRACTICAL MEDICINE. |Jr Acidi carbolici gtt. x. Liq. ferri subsulph oiij- Gtycerinae 5j. — M. Sig. : To be applied every three to six hours with a camel's hair brush. — J. Lewis Smith. JJ- Tincturse ferri chloridi oii-iij- Potassii chlorat 3j. Acidi muriatic! dil ...gtt. x. Syrupi simplicis oiv. — M. Sig.: A teaspoonful every hour or two. — J. Lewis Smith. DIPSOMANIA. Is a term commonly applied to an uncontrollable desire for alcoholic drinks. In cases of dyspepsia there may be a morbid craving for alcohol. The habitual drunkard feels a desire for continued indulgence, and lacks moral strength enough to govern an acquired appetite which represents a morbid condition. Dip- somania is to be treated as a disease of body and mind. The treatment consists in withdrawing the patient from the use of alcohol in any form, and in the employment of medicinal and hy- gienic measures. This morbid craving for alcohol is the sad inheritance from drunken parents (Flint). According to Ringer, ten -minim closes of tincture of capsicum obviate the morning vom- iting, remove the sinking at the pit of the stomach, the intense craving for stimulants, and promote appetite and digestion in dipsomaniacs. PRESCRIPTIONS FOR DIPSOMANIA, J$r Tincturae capsici IRx. Potassii bromidi gr. x. Spiritus ammonias 3j- — M. Sig.: This to be taken at one dose, and repeated several times daily. Jfc Tinctures gentianae comp Tincturae columbas comp...aa Sij- Tincturae nucis vomicae... ilt.Lxxx. — M. Sig. : A dessertspoonful before each meal. — Loomis. DIET-EATING DEOPSY. 155 DIRT=EATING. Is a morbid habit which heretofore prevailed to a consider- able extent among the plantation negroes of the Southern States. The kind of earth selected is loam or clay. According to Dun- can, a very common disease among negroes on plantations is a state of anaemia, very often attributed to the pernicious habit of dirt- eating. Almost every large j3lantation has three or four such cases. With negroes, dirt- eating proceeds from the same propensity which leads white females to resort to chalk, mag- nesia, and slate pencils, etc., in order to relieve a disordered acrid condition of the stomach. Discover and treat the cause (Flint). DROPSY. Is an abnormal collection of watery fluid in the areolar tissue, or in the serous cavities of the body. Dropsy is not a disease, but a symptom. It is associated with various disorders. Dropsies may be external or internal. To internal dropsy be- long hydrocephalus, or dropsy of the brain, hydrothorax, or dropsy of the chest, and ascites, or dropsy of the abdomen. Ex- ternal dropsies are illustrated by anasarca and oedema: the first is a universal accumulation of serous fluid in the areolar tissues; the second, a localized collection in the same tissue, differing in nothing but extent. Both exhibit painless swelling of the sur- face, devoid of redness; a skin often stretched and shining, pitting upon pressure, and both, if punctured, allow a watery fluid to run out. (Edema is most commonly perceived around the ankles. Anasarca is usually dependent upon disease of the kidneys, or of the heart. The swelling ordinarily begins at the feet and ankles in diseases of the heart, in the face in disease of the kidneys. (Edema may be due to the same causes, or the cause may be purely local, as when we see oedema happening if a bandage be applied too tightly, or if swollen glands press upon the main vein of a limb. We see oedema in venous inflam- mation, in milk-leg, or as a sequel of typhoid fever, in conse- quence of the blocking up of the femoral vein by coagulum. In these cases, the oedema is one-sided. A circumscribed oedema, 156 A COMPENDIUM OF PRACTICAL MEDICINE. also accompanies erysipelas of the .skin. Another source of double-sided oedema is anaemia (DaCosta). Causes of General Dropsy. — The most common are diseases of the heart, of the kidneys, or of the liver. Cardiac dropsy begins in the feet and ankles. Renal dropsy is usually much more general than cardiac, and does not, like cardiac, begin in the most de- pendent parts, but is often first noticed in the face and eye -lids. The proof that dropsy is renal is furnished by the presence of albumin and casts in the urine. The most usual kind of dropsy, dependent upon an affection of the liver, is abdominal dropsy (DaCosta). Dropsies may be divided into three classes : Inflammatory, mechanical, and cachetic or hydrsemic. Inflammatory dropsy is due to a moderate degree of inflammatory alteration in the coats of the blood vessels, and produces collateral oedema. Of this nature are cases of oedema glottidis, of hydrocele, and of hydro- cephalus. Mechanical dropsy is the result of some obstruction to the current of blood in the veins. The most frequent of the mechanical causes of general dropsy is valvular diseases of the heart. Hydraemic or cachectic dropsy is the result of an impover- ished and abnormally watery state of the blood. The most important cause of hydraenric dropsy is Bright's disease. PRESCRIPTIONS FOR DROPSY. J& Spiritus chloroformi HI xx. Tinctune digitalis ITC.x. Infusi buchu Sj. — M. Sig. : To be taken three or four times daily, and followed by a good drink of water. (In renal dropsy.) — Fothergill. Jfc Infusi digitalis si v. Sig.: A tablespoonful two or three times daily. — Bartholow. J& Potassii bicarbonatis gr. x. Ferri et amnion, citrat gr. v. Tincturas digitalis ITT x. Infusi buchu sj. — M. Sig.: To be taken three times daily. (In cardiac dropsy with gouty tendency or debility. — Fothergill. DYSENTERY.- 157 DYSENTERY. Called also " bloody flux," is an ulcerative colitis. It is a disease characterized by tormina, tenesmus, mucus, and mucus and blood stools, burning pain, with more or less constitutional disturbance (Bartholow).' Causes. — It occurs in both sexes and at all ages. Sudden arrest of perspiration by exposure to cold and dampness is one of the. most common causes. It occurs in late summer and autumn and in warm rather than in a cold climate. It is preva- lent in malarious regions. Impure air and water, bad or insuffi- cient food are causes (Bartholow). Symptoms. — In the epidemic form, dysentery may begin suddenly, but in the other forms it conies on gradually. There is more or less catarrh of the intestines, diarrhcea, chilliness, fever, and a feeling of malaise. In two or three days, pain in the descending colon is felt. It is described by the term tor- mina — "colicky pains." There is pain of a burning character in the rectum, with the sense of the presence of a foreign body, and with the desire to strain for its expulsion. Nothing comes away but mucus, either alone or tinged with blood. The tenesmus con- tinues. There may be ten to fifty stools daily. The patient becomes weak early. His skin is dry, harsh and wrinkled, his pulse small, quick and feeble. The discharges emit a horribly fetid odor. In the severe cases, the patient passes into the stage of collapse, the jmlse ceases at the wrist, hiccough comes on, the skin is covered with a cold sweat, the hands become cold and livid, the face is shrunken, the eyes deeply sunk, and the voice husky. In mild cases convalescence is established about the eighth day. In the more severe cases, the duration is more pro- tracted (BartholoAv). Prognosis. — Is good in mild cases, but in severe cases bad. Treatment. — 1. Food. If the stomach is irritable, milk, with one-fourth lime- water, is the best food. If the digestion remains good, the patient can take milk, eggs, beef-juice, ice-cream, boiled custard, oyster- soups, mutton, chicken and beef -broth. Where there is much depression of the powers of life, egg-nog may be freely given. 2. Medicine. According to Bartholow,. 158 A COMPENDIUM OF PRACTICAL MEDICINE. the sulphate of magnesia in solution with dilute sulphuric acid is entitled to the first j3lace as a remedy. It must be given in laxative doses, early. It serves a triple purpose : it empties the canal of retained faeces, it lessens hyperemia by setting up an outward diffusion ; its after effect is astringent and sedative. Ipecac is an excellent remedy, and must be given in the first stage, before the mucous membrane is stripped off, and in scruple to drachm doses, every four to six hours. The first doses empty the stomach, and the following ones produce copious bilious evacuations, called "ipecac stools.' 1 The utility of ipecac ceases when these stools are produced. It is best given in milk in twenty grain doses with aromatic powder added. Castor- oil, in purgative doses, in the first stage is very efficient. After the first stage is passed, an emulsion of oil (almond oil) and turpentine combined with opium is very serviceable. When destruction of the mucous membrane is beginning, the most effective remedies are corrosive sublimate, sulphate of copper, sulphate and oxide of zinc, acetate of lead, bismuth, arsenic, etc. Of this list, sul- phate of copper and arsenic, combined with opium, are most effective. One drop of Fowler's solution and five to twenty drops of deodorized tincture of opium, every three hours, gives excellent results. One-twentieth of a grain of sulphate of copper with one- eighth of a grain of morphine every three hours is good treatment (Bartholow). Bismuth in large doses (gr. xxx.-xl.) every four hours with carbolic acid is 2-ood. Excellent results are obtained by washing out the bowels with warm water. Very great relief is affected by the injection of starch and laudanum. Eight ounces of a strong solution of silver nitrate (gr. xx. to the ounce), thrown into the sigmoid flexure, is effective. Morphine hypodermically is effective. External Applications. — The cold, wet jDack, the ice-bag, but generally hot applications afford more relief. The turpentine stupe is useful. If collapse comes on, active stimulation is neces- sary. DYSE^TEEY DYSMEISTOREHCEA. 159 PRESCRIPTIONS FOR DYSENTERY. Jfc- Tinctura? opii deodorat 3ss. Bismuth subnitrat 3ij. Aquse mentbse pip S yrupi zingiberis — aa §j . — M. Sig. : Shake bottle. Give one teaspoonful every two to four hours, to a child five years old. Half dose for a child one year old. — Smith. J£ Vini ipecac §ss. Sig. : One drop every hour. (In acute or chronic form of chil- dren, with slimy stools.) — Ringer. {$r Piumbi acetat gr. xxiv. Pulv. ipecac gr. iij. Pulv. opii gr. iij. — M. Ft. massa et in pil. no. xii. div. Sig. : One pill every two hours until blood ceases, then at longer intervals. — DaCosta. Jfc Hydrargyri chloridi mitis..., 3j. In pulv. no. vii. div. Sig.: A powder two or three times daily. (In epidemic form.) —Hull. Jfr Cupri sulphatis gr. ss. Magnesii sulphatis sj . Acidi sulphurici dil 3j. Aqua? §iv. — M. Sig. : A tablespoonful every four hours. (In acute form.) — Bartholow. DYSMENORRHCEA. Is painful menstruation. At the menstrual period women normally feel unwell, have a few vague pains in the loins, and an irritable temper. Varieties and Causes. — 1. Neuralgic or sympathetic dysrnen- orrhoea is seen in nervous or hysterical women, and is accom- panied by neuralgia in other localities. 2. Congestive or inflam- matory dysmenorrhea occurs where there is excessive congestion of the uterus and ovaries from any cause. 3. Mechanical or obstructive dysrnenorrhcea is due to some cause which mechani- cally obstructs the outflow of blood, as stenosis of the os uteri, 160 A COMPENDIUM OF PRACTICAL MEDICINE. or sharp flexions. 4. Membranous dysmenorrhea is sometimes associated with endometritis. 5. Ovarian (Pozzi). Symptoms. — Pain occurs preceding, during, or following the menstrual flow. In the mechanical, the pain occurs with the appearance of the flow, and consists of a series of uterine cramps due to the effort of the uterus to expel blood clots from its in- terior. In the congestive, the pain precedes the flow, and is re- lieved when the latter becomes free. In the neuralgic, the pain is referred to the hypogastrium, left ovarian, and intercostal regions. It often occurs in the intermenstrual period, but is always aggravated at the time of the sickness. In the membran- ous, the pain lasts throughout the period, and until the expulsion from the uterus of the more or less complete membranous cast. Treatment.. — In the mechanical or obstructive, dilate the sten- osis, correct the flexion, and prevent its recurrence. In the con- gestive, give saline laxatives, hot foot- and sitz-baths, vaginal in- jections, and ergot, with bromide of potassium. Instead of the ergot and bromide, fifteen to twenty grain doses of phenacetine every six to eight hours may be given. In the neuralgic, let the patient exercise in the open air, and give, iron, quinine, and other tonics. Pozzi has found the tincture of pulsatilla, given some days before the period, in five -drop doses, three times daily, quite efficient in the neuralgic form of young women. In the membranous, dilatation of the cervix just before the menstrual period, is sometimes effective. In the ovarian type, the bromides are the most serviceable. In any variety, where the pain re- quires it, potassium bromide and chloral may be given, with mustard plasters applied. As palliative treatment for the pain, give asafceticla, musk, tincture of cannabis indica, belladonnae or hyoscyamus. Oxalate of cerium has been extolled. Wylie praises electricity, he inserts the positive pole in the cervix. Laudanum and valerian douches often afford relief when all other remedies fail. Nitro- glycerine and amyl nitrite are excel- lent for spasmodic cases (Pozzi). DYSMENORRHEA DYSPEPSIA. 161 PRESCRIPTIONS FOR DYSMENORRHEA, R Tincturse cardamonii comp 5ss. Spiritus chloroformi ZTT.xx. Liq. ammonii acetatis ^ss. Tincturse belladonna? ITC.x. Aquse cinnamomi q. s., ad oj- — M. Sig. : For one dose. (In congestive and spasmodic). — Pozzi. R Liq. ammonii acetatis £iv. Sig. : A tablespoonful every two or three hours, with the fol- lowing: R Pulv. ipecac gr. iv. In pil. no. xii. div. Sig. : One every two or three hours. — Emmet. R Extracti opii gr. v. Extracti cannabis indica Extracti byoscyami aa gr. x. Pulv. Camphora? gr. xxv. — M. Ft. massa et in pil. no. x. div. Sig.: A pill two or three times daily. — McLane. DYSPEPSIA. Is difficult or painful digestion. It is usually chronic. A disordered digestion, lasting for a short time, is called indiges- tion. Causes. — Dyspepsia is often an inherited condition. It may result from a deficiency in the quantity of gastric juice secreted, due to exhausting discharges, venereal excesses/ masturbation, leucorrhoea and phthisis, and from the excessive use of narcotics, the tannin of tea, and the nicotine of tobacco. It may result from an excess in the gastric secretion, due to chronic hepatic and cerebral diseases, and to gout. It may result from a change in the quality of the gastric juice, due to ulcer and cancer of the stomach, gout, rheumatism, diseases of the kidneys, uterus and gall-bladder. Dyspepsia may result from pressure on the stom- ach by tight lacing, from positions assumed by shoemakers, needlewomen, writers, etc. It may result from mental emotion, 162 A COMPENDIUM OF PRACTICAL MEDICINE. prolonged mental labor, anxiety, deficient or excessive physical labor, excess of starchy food, or from deficiency of meats, badly cooked food, too rapid eating, etc. (Loomis). Symptoms. — The most constant s}'mptom is an abnormal appetite; it may be lost, increased, or perverted. There is a weight, dull pain, and a sense of burning in the epigastrium after the ingestion of food, accompanied by flatulence, heartburn, gastralgia, constipation or diarrhoea, a dull headache, and languor. Indiscretion in eating or drinking is apt to bring on an attack of sick headache. There is frequently a bitter taste in the mouth. In some dyspeptics the breath has a very offensive odor. Py- rosis, palpitation, dyspnoea and a severe pain referred to the heart (which makes the patient think he has heart disease), may be present. In some cases there is ringing in the ears, spots before the eyes, and vertigo. When in any case the dyspepsia has lasted a long time, chronic gastric catarrh will almost always be developed (Loomis). Prognosis. — Dyspepia in most cases can be cured, but the cure depends for the most part on the will of the patient. Treatment. — First, if possible, remove the cause. When the gastric juice is deficient in quantity, hydrochloric acid and pepsin are indicated. The vegetable bitters are efficient in these cases, and may be combined with alcoholic stimulants. When acid risings occur after ingestion of food, and are due to active fer- mentation, the sulphite of soda, or salicylic acid immediately after meals may prevent such changes. Saline waters will aid. When there is great irritability of the stomach, bismuth acts almost as a specific, and should be given in twenty grain doses before eating. Creosote, codeia, oxalate of cerium, and morphia may be employed to arrest vomiting. Dyspeptics should never wear corsets or belts about the abdomen. They should retire and rise early, eat slowly, and masticate well. No mental or phvsical work should be performed directly after or before eating. Horseback riding and walking in the open air should be insisted upon. A change of scene and climate works rapid cures in many instances. Dyspeptics should take a cold sponge - bath morning and evening (Loomis). A small quantity of acid wine at dinner is a good stimulant to the digestive function. A DYSPEPSIA. 163 moderate dose of whiske} T , taken before nieals, is a capital remedy to promote the appetite and the digestion (Bartholow). PRESCRIPTIONS FOR DYSPEPSIA. R Ammonii salicylates 5ij- Syrupi aurantii cort §j. Aquae mentha? pip ad 5iv. — M. Sig. : A tablespoonful half an hour before meals. (In fermentative dyspepsia.) — Sullivan. R Tincturse capbici IH.xvj. Tinctura? nucis vomica? •■3 1 j- Tinctura? gentiana? comp ad...3ij. — M. Sig. : A teaspoonful in water three times daily, with i gr. aloin at bedtime, avoiding starchy diet. (For aggravated dyspepsia with constipation.) — DaCosta. R Bismuthi subnitratis Sodii bicarbonatis Pul v. cubebse — aa 3j . Pulv. zingiberis gr. xx. — M. In pulv. no. xii. div. Sig. : A powder in a wineglassful of water before each meal. —Clark. R Tincturse opii deodorat gtt. xij. Magnesii calcinat gr. xij.-xxiv. Sacchari albi oj- Aqua? anisi §iss. — M. Sig.: Shake bottle. One teaspoonful every two hours to a child one year old, until relieved. — J. Lewis Smith. R Bismuthi subnitratis...., ^iss. Mucil acacia? §j. Sodii bicarbonatis giss. Infusi calumba? ad oviij. — M. Sig.: Two tablespoonfuls before meals. (Irritative dyspepsia with raw tongue.) — Fothergill. Buttermilk- cure may be substituted for the milk- cure in cases of stomach disease (Bartholow). Actaea (cimicifuga) is recommended for the dyspepsia of drunkards. 164 A COMPENDIUM OF PRACTICAL MEDICINE. DACTYLITIS. (Syphilitic). Is guininy in character, and hence belongs to the later stages of syphilis. It is a rare affection. The swelling usually termin- ates abruptly, and is sometimes very great. There is no com- plaint of pain. The skin is natural or bluish from venous obstruction. Treatment. — Is that of tertiary syphilis. DANDRUFF. (See Pityriasis). DERBYSHIRE NECK. (See Goitre.) DROWNING. Remove from the mouth and nostrils all obstructions to the free passage of air to the lungs ; loosen clothing about the chest. Extend the arms in the direction of the body above the head, and when the capacity of the chest is thus enlarged, throw fresh air into the lungs by a flexible tube passed into the trachea, and then replace the arms, pressing firmly upon the sides and sternum. These motions may be repeated ten or fifteen times per minute. A strong solution of ammonia may be passed under the nose. EARACHE. Treatment. — An excellent application in earache is the fol- lowing: R Morphia sulphatis gr. iv. Aquse destillatse Sj. — M. Sig. : Fill the external meatus with the solution. — Bartholow. Cocaine, five to ten per cent, solution, is the most effective remedy for earache (Bartholow). The external auditory meatus filled with water as hot as can be borne is effective. Counter -irritation by blistering fluid or croton-oil liniment behind the ear often removes earache (Ringer). ECZEMA. 165 ECZEMA. Is a non-contagious, vesicular, cutaneous eruption, with cedeuia, pustules, exudation, or fission, and usually much itching. Eczema is catarrh of the skin (Tilbury Fox). It may safely be affirmed that very few persons pass through life without suffering from it in some measure. It is by far the most frequent of the diseases of the skin. Causes. — May be constitutional or local, or both combined. It often happens that the constitutional cause has disappeared before the patient is seen, and the affection remains, owing to the skin having contracted a bad habit. The chlorotic, the rach- itic, the scrofulous, and the debilitated, are very liable to be at- tacked. Eczema may be caused by digestive derangement, and the parts most frequently attacked are the face, lips, arms and hands. Improper, insufficient or bad food, is very apt to call it forth. It is often seen in infants whose mothers have a deficient or watery secretion of milk. A fruitful cause of eczema is de- ficient excretion, constipation, or defective elimination by the kidneys. A predisposing cause is rheumatism. Diabetes mel- litus may cause an eczema of the genital organs. Long- continued mental excitement, anxiety, grief, or over -study, may cause it. Eczema is met with at all periods of life, but occurs most fre- quently in children. Derangement of the uterus or its append- ages, irritation of ascarides, or tapeworm, stricture of the urethra, dentition, internal medicines, exposure to great heat, or to ex- treme cold, or to acrid substances (as in the case of grocers, bakers, bricklayers, washerwomen, cooks, smiths, etc.), may cause eczema. Varicose veins, pressure by tumors, garters, and trusses, stimulating liniments, as croton-oil, lice, fleas, bugs, irri- tation of the razor, and of discharges from the genito- urinary organs, anus, meatus auditorius, nostrils and mouth, are common causes of eczema. The irritation of poisonous dyes used in some of the colored socks in the market, is apt to give rise to a variety of eczema of the feet. Symptoms. — There are four symptoms which are almost in- variably present to a greater or less extent, namely: 1. Infiltra- tion of the skin. 2. Exudation on the surface of the skin. 3. 166 A COMPENDIUM OF PRACTICAL MEDICINE. Formation of crusts. 4. Burning heat, or itching. The infiltra- tion is due to the transudation of serum from the blood-vessels into the tissues. The exudation, or "weeping" may take place constantly, or at intervals; it is then called moist eczema. If there is no exudation, it is called dry eczema. The crusts, com- posed of hardened exudation, are more or less present. If the patient be cleanly in his habits, the exuded matter is washed off, and the crusts may be wanting; and, vice versa, the crusts may be thick. When the patches of eruption are acutely inflamed, burning heat is complained of. When the disease becomes chronic, the burning heat is replaced by itching. The use of stimulating food or drink, or on getting warm in bed, or the slightest touch of the part, gives rise to an irresistible desire to scratch. Patients derive much positive pleasure from scratch- ing the part. Instead of itching, formication is sometimes com- plained of. Scratching always aggravates the disease. The elementary lesion is of great importance. This may be: 1. An erythematous state of the skin. 2. A vesicle. 3. A pustule. 4. A papule, or a mixture of all these lesions. When the ele- mentary lesion is an erythematous state of the skin, the disease commences as a simple inflammatory redness of the surface, with- out, at first, infiltration or exudation. The vesicular and pustular forms of eczema often form upon an erythematous ground. Prognosis.— Is rarely serious. Attacks of eczema vary much in their duration. Some cases get well without treatment in a few weeks, others last for months or even years. When the eruption is localized it is more difficult of cure. Relapses are very much to be 1 feared. Treatment. — Some cases may be cured by either constitu- tional or local treatment, but generally it is advisable to employ a combination of both. Constitutional Treatment.— Purgatives and aperients are often useful, but are merely aids to Other treatments If the tongue is loaded, the appetite bad, the liver torpid and the bowels costive, the following formulae may be used : R Hydrargyri chloridi mitis gr. xx. Pulv. scammonii comp gr. xL. — M. Div. in pulv. iv. Sig.: One every week. — Anderson. ECZEMA. 167 R Quinias sulphatis gr. xij. Pulv. rhei gr. xxxvj. Hydrarg. cum cretse , gr. xx. Sacchari purificati gr. xx. — M. In pulv. no. xii. div. Sig. : Two daily. The dose to be so regulated that the patient has at least one full natural evacuation per day. Or the following may be given : B Quinine sulphatis gr. xLviij. Ferri sulphatis 3iij . Acidi sulphurici dil . ...giss. Magnesii sulphatis siij . Sy rupi zingiberis Tinct. aurantii — aa giss. Infusi calumbas ad sxxiv. — M. Sig. : A tablespoonful in a wineglassful of water thrice daily. In some cases of eczema, diuretics are indicated. In strum- ous subjects, nourishing food, stimulants in moderation, and tonics are our sheet anchors. Severe cases of eczema have been cured by the administration of cod-liver oil and syrup of the iodide of iron. Twenty drops of the syrup of iodide of iron in a teaspoonful of cod- liver oil thrice daily, and the dose to be gradually increased to a tablespoonful, may be given. Cod-liver oil may be applied locally with benefit. Of nerve tonics, those which are most likely to be useful are strychnia and arsenic (in form of Fowler's solution). In chronic eczema, electricity is used with some benefit. The diet is of great importance, and must be carefully regulated. Local Treatment. — Some cases of eczema are local diseases throughout their whole course, being due to local irritation, and "are benefited more by local than constitutional treatment. The disease sometimes remains from habit. Our skins have the same tendency as ourselves to contract bad habits. The first thing is to remove the crusts with oil. Then dust the parts with absorb- ent powder two or three times daily. Soothing ointments are indicated, such as follows : R Zinci oxidi 5J- Acicli oleici §viij . Vaselini §ix. — M. Sig.: Apply to parts. — Anderson. 168 A COMPENDIUM OF PRACTICAL MEDICINE. R Pulv. camphorse gr. xx. Pulv. zinci oxidi 3ij. Glycerini 3.j. Adipis benzoati §j . Cochinillini .. gr. j . Oleirosse ZH-j— M. Sig. : Apply to face two or three times daily. — Anderson. R Hydrargyri perchloridi gr. xij. Acidi hydrocyanic! dil gij. Glycerini 3iij . Eau de cologne ad 5yj. — M. Sig.: Sponge the parts two or three times daily. — Anderson. Of all the local means for the removal of limited eczematous eruptions, none are superior to blistering. The best and safest blistering agent is cantharides. The local varieties of eczema are: of the head, hairy portions of the face, lips, edges of the eyelids, nostrils, auricle, and external auditory passage, the flexor surfaces of the joints, the hands and feet, the legs and the geni- tal organs. PRESCRIPTIONS FOR ECZEMA. R Acidi citrici gr. xv. Aquae lauro-cerasi 3] . Olei rusci (birch) gtt. xv. Ungt. aquae rosse 3x. — M. Sig.: Use thrice daily. Use starch powder between the applica- tions. Carefully attend to diet. (For acute eczema.) — Monin. R Glyceriti amyli £viiss. Acidi tannici Hydrargyri chlo. mit aa gr. xv. — M. Sig.: Apply morning and evening. (In dry eczema with itching.) — Vidal. R Ungt. hydrargyri oxidi rubri ^ij. Ungt. sulphuris 3ij- Acidi carbolici... gr. iij. Unguenti simplicis §ss. — M. Sig.: Apply to the afiected parts. (In chronic eczema.) — DaCosta. R Tincturae belladonnas 5ss. Sig. : Five drops thrice daily to a child of two years. (In in- fantile eczema.) — Bartholow. ECZEMA EMISSIONS. 169 R Pulv. acidi salicylici gr. xv.-xxx. Pulv. zinci oxidi Pulv. amyli aa giij. Vaselini puri 3vj . — M. Ft. nngt Sig. : Apply locally, and cover with cotton after rubbing oint- ment in. (In papulous or squamous eczema.) — Lassar. R Infusi cinchonas |vj. Aquas calcis gixss. Tinct. lupulinae Succi conii aa gij . — M. Sig. A wineglassful thrice daily. (In chronic eczema of the aged.) — Neligan. R Ferri et ammonii citratis gj. Potassii citratis gij. Liquor potassii arsenitis 5!— ij . Tinct. nucis vomicae gij. Tinct. cinchonas corap ad §iv. — M. Sig.: A teaspoonful in water after meals, as a tonic and altera- tive. (In eczema.) — Bulkley. R Resorcin Zinci oxidi aa 3j. Ungt. aquas rosse gx. — M. Ft. ungt Sig. : Apply locally. (In chronic indurated eczema of infants.) — Fleisburg. EMISSIONS. (Involuntary Seminal.) By involuntary seminal emissions is meant the ejaculation of semen and the venereal orgasm without any voluntary effort, either natural or unnatural. Involuntary emissions occurring during sleep are common, taking place with erotic dreams. Occurring after intervals of several days in persons of continent habits, they are physiologi- cal rather than pathological. They denote simply a certain amount of functional activity of the generative organs. They do not imply a morbid condition nor do they lead to any morbid effects. They occur especially when habitual sexual intercourse is interrupted from any cause. Under these circumstances they are manifestations of health rather than of disease. 170 A COMPENDIUM ; OF PRACTICAL MEDICIJSTE. Occurring more frequently, the emissions denote a morbid erethism and weakness of the organs of generation. They occur sometimes nightly and sometimes even repeatedly during the same night. They then call for remedial measures. Occurring in persons debilitated from any cause, they may take place without any erection and with little or no venereal excitement. They occur sometimes during the day, and are called diurnal. Venereal excesses, or unnatural abuse, are the causes of this morbid frequency. The mind becomes depressed. The patient fancies he is impotent, his constitution ruined, and that there is clanger of insanity. They go from one physician to an- other, and upon jDatients of this class quacks prey largely (Flint). Pollution is a term applied to involuntary seminal emis- sions, attended by venereal orgasm, more or less marked. Dr. Keyes writes as follows of pollution : " Nocturnal pollutions are exceedingly common. They usually accompany erotic dreams." Nocturnal emissions in moderation are entirely natural, and by no means a sign of disease. Their frequency compatible with health varies with the purity of mind and sexual vigor of the patient. A man who is happily married rarely has noctur- nal emissions while living with his wife, but, if he leaves her for several weeks, it is natural and entirely the rule that there should be a formation and collection of semen, which distending the seminal vesicles, excites erotic fancies, and escapes at the conclusion of a dreain. Any man suffering from un gratified sexual desire is normally in a condition demanding relief for his over distended seminal vesicles, and, if that relief be not afforded in some way by the patient, it will come spasmodically during sleep. Occasionally nocturnal emissions may be over-frequent, and indicate a condition of irritation in the deep Urethra which requires treatment (Keyes). Treatment.— When emissions do not exceed three times weekly they. should be disregarded. Where they become very frequent, as nightly or several times a night for a considerable time, there should be an attempt made to correct the habit. Purify his thoughts, elevate his tone, and get him if possible happily married. The patient should endeavor to sleep soundly EMISSIONS.. 171 by tiring himself out through the clay by physical work. Dry friction, cold bath and cold douche locally are useful. He should sleep on a hard bed lightly covered. The stomach should not be full on retiring. Lying on the back with the bladder full of urine, tends to beget erections. To avoid this, the patient should tie a towel around his waist on retiring, with a hard knot in the back over the spine. Besides the above means, bromide of potassium, camphor and lupulin may be given internally, with strychnine and a mineral acid, and locally decided advan- tage may be derived from the gentle use of the steel sound, as in neuralgia of the vesical neck. Mechanical devices appear from time to time for treating pollution, but they usually do more harm than good. Keyes used an appliance which started a battery and gave an electric shock in the back when erection came on. Verneuil used a similar instrument which caused a bell to ring when erection came on. A ring which lightly encir- cles the penis, but when distended by erection causes pain and awakens the j)atient has been used. Marriage is always remedial in physiological cases (Keyes). PRESCRIPTIONS FOR EMISSIONS. B Potassii brornidi 3j. Sodii bicarbonatis gr. xv. Infusi digitalis 5ss. Atropine sulphatis gr. ^ . — M. Sig.: To be taken at bedtime. — Gross. ft Lupulinse gr. x. Pulveris camphorre gr. vj. . Extracti belladonnse gr. ij. — M. In pil. no. xii. div. Sig.: One pill thrice daily. — Bartholow. R Tincturae cantharidis gij. Tincturse ferri chloridi gvj. — M. Sig.: Twenty drops in water thrice daily. — Wood. 172 A COMPENDIUM OF PRACTICAL MEDICINE. EMPHYSEMA. ( Pulmonary. ) Enrphvsenia in general signifies the presence of air in the interstitial connective tissue. In the lungs, however, there are two kinds of emphysema — interlobular and vesicular; the former arises from rupture of the air-cells, causing a communication be- tween them and the interlobular connective tissue, and the latter, the more common, consists in an abnormal accumulation of air within the air-cells. Emphysema is essentially a chronic affection; it comes on slowly, and when once developed is permanent (Loomis and Flint'). Causes. — Are forced expiratory efforts, the glottis being closed or narrowed, as in violent coughing, straining at stool, etc. It is developed in the upper lobes of the lung. Various injuries and diseases of the chest which limit the movements of the lungs, as curvature of the spine, pleural adhesions, hydro - thorax, tumors, pneumonia, perforating wounds of the chest, or injury of the lung by the extremity of a fractured rib, may cause emphysema of the lung (Loomis and Flint). Symptoms. — The most prominent and constant subjective symptom of emphysema is dyspnoea, which is increased by physi- cal exercise. It is worse during the cold of winter. There is often a smothering sensation in the chest. There is no fever. The pulse is feeble, and the body cool and cyanotic. In extreme cases, lividity is marked. Usually there is no pain in the che>t. The nostrils are distended, the voice is feeble, and the capillary circulation is imperfect. The temperature of the body is usually sub-normal. There is distension of the jugular veins, and ver- tigo is common. There may be oedema of the feet and ankles. Emphysematous patients are especially liable to hemorrhoids. Physical Signs. — On inspection, it will be noticed that the chest is "barrel- shaped." The lower portion of the chest seems contracted. The apex of the heart will be found beating lower down than normal, and more toward the median line. On pal- pation, the vocal fremitus, varies. In senile emphysema, the vocal fremitus is usually increased. The percussion sound is vesiculo- tympanitic. On auscultation, the inspiratory sound is either EMPHYSEMA EMPYEMA. 173 short or feeble, or actually suppressed, while the expiratory is greatly prolonged (Looruis). Prognosis. — It rarely, if ever, destroys life, but when once developed, is never recovered from. Treatment. — As this disease is incurable, our treatment must be palliative. Iron and the sulphate of quinine in small doses, may be given with benefit. Cod-liver oil, bitter infusions, min- eral acids and stimulants are all useful. The diet should be of the most nutritious character, and composed largely of animal food. Exercise in the open air should be taken. Quebracho is a useful drug for emphysema. For the bronchitis which accom- panies emphysema, iodide of potassium in five to ten grain doses thrice daily is serviceable. For the asthmatic attacks, morphine and atropine are useful. PRESCRIPTIONS FOR EMPHYSEMA. B Liquoris potassii arsenitis gtt. ij. Potassii iodidi gr. x. Syrupi tolu 5ss. Aquas 5ss. — M. Sig.: This dose t. i. d. R Ammonii iodidi 5j- Liquoris potassii arsenitis 5ss. Syrupi tolutan Sj • — M. Sig.: A teaspoonful every four hours. — Bartholow. EMPYEMA. Called, also, suppurative pleurisy, or pyothorax, is charac- terized by the accumulation of a purulent liquid in the pleural cavity. It is usually confined to one side. Cause. — Is not always known. It may be of traumatic ori- gin.* It may result from exhausting diseases or debility. It often complicates acute and chronic infectious diseases. Chronic tuber- cular pleurisies are very apt to be suppurative in character. It may be secondary to abscess of the liver, or in the abdominal cavity, or to chronic phthisis. It is sometimes secondary to lobar pneumonia (Loomis). 174 A COMPENDIUM OF PRACTICAL MEDICINE. Symptoms. — If the inflammatory process . is acute there will be chills, fever, a rapid pulse, severe pain in the affected side, great prostration, anxious expression and typhoid-symptoms; these cases usually terminate fatally within two or three weeks. The symptoms of chronic empyema are very often obscure. The patient rarely suffers from local pain — there is simply a sense of uneasiness, or weight in the affected side, loss of flesh and strength, pale countenance, diurnal chill followed by profuse sweats. There are cough, weak voice, dyspnoea, etc. A positive diagnosis may be made by an exploratory puncture. If an em- pyema is about to open externally, it will protrude between the ribs, and give a sense of fluctuation, and become red. It may open into a bronchial tube and be followed by profuse purulent expectoration. The chest walls gradually retract. It may open into the peritoneal cavity and be followed by a fatal peritonitis (Loomis). Prognosis. — U nf a vorable . Treatment. — An opening should be made at the bottom of the pleural sac, allowing the pus to escape freely. The pleural cavity should be daily cleansed by the injection of tepid water to which a very small quantity of carbolic acid (one per cent.) is added. Aspiration should first be tried. In children simple aspiration frequently effects a cure (Flint). If aspiration is re- sorted to, a large- sized needle should be used, and only a small portion of the fluid removed the first time. Aspirate every third, fourth or fifth day. Never continue the removal of pus in em- pyema after the patient complains of constriction in breathing. If a permanent opening is to be made, let it be made in the ax- illary line in the seventh or eighth intercostal space, and a quarter -inch rubber drainage tube should be introduced, and so fastened that it will remain. The pleural cavity should not be washed out (Loomis). Tonics, such as quinine, cod-liver oil and iron are always indicated and exercise in the open air. PRESCRIPTIONS FOR EMPYEMA. R Misturse ferri et ammon acetat §iv. Sig.: One to two teaspoonfuls four times daily, with quinine and stimulants. (In chronic cases.) — DaCosta. ENDOCARDITIS. 175 R Liquor iodinii corap %j. Aquae destillata? §xv. — M. Sig. : Inject after aspirating the pus. — Bartholow. R Quinise sulphatis ^ij. Aqua? Sxij . — M. Sig. : Inject after evacuating the pus. — Ringer. R Aqua? chlorinii 5J. Aqua? destillata? six, — M. Sig.: To wash out the pleural cavity after the evacuations of the pus. — Ringer. ENDOCARDITIS. Is an inflammation of the endocardium. In adults the left heart is oftenest affected. The inflammation is, in the majority of cases, situated on the valves and chordae tendineae. Vegeta- tions appear upon the endocardium. These vegetations may attain the size of a pea and are favorable points for the detach- ment of emboli (Flint). Causes. — Primary, or idiopathic endocarditis is extremely rare. It is secondary to pleuritis, pneumonia and pericarditis, but, very more frequently, secondary to acute rheumatism. About one -third of the cases of acute rheumatism are complicated by endocarditis (Bartholow). It is produced by the same cause that produced the rheumatism, and not by metastasis (Flint). Symptoms. — The patient may complain of an obscure sense of distress in the praecordia, not amounting to pain. The action of the heart may be morbidly excited — palpitation. There is an endocardial murmur. The murmur is of a soft, or bellows char- acter. It accompanies the first sound of the heart. It is heard loudest at or near the apex of the heart (Flint). There may be paroxysmal dyspnoea, the face may be flushed and even cyanotic (Looniis). Prognosis. — The danger is not immediate, but remote. Treatment. — Sinapisms and stimulating liniments to the praecordia are indicated. Alkaline remedies lessen the liability to fibrinous deposits upon the valves. The patient should avoid physical exertion, mental excitement, a stimulating diet, and the use of alcohol. A tablespoonful of the infusion of digitalis should be given every four hours (Flint and Bartholow). 176 A COMPENDIUM OF PRACTICAL MEDICINE. PRESCRIPTIONS FOR ENDOCARDITIS. R Tincturse digitalis 3J • Sig.: Ten or fifteen drops every four hours. (When heart's ac- tion is irregular). — DaCosta. R Tincturse aconiti radicis Sss. Sig. : One drop every hour or two. — Ringer. R Lini farinse Aqua? bullientis aa q. s. — M. Ft. cataplasma. Sig.: Apply over the heart as hot as can be borne. — DaCosta. ENTERITIS. Is a general term applied to a catarrhal inflammation of the intestinal mucous membrane. It may be acute or chronic. Causes. — Direct irritation of the mucous membrane by im- proper, or decomposing food, impure water, or irritating medi- cines, or by exposure to wet or cold, will cause intestinal catarrh. Extensive burns will cause it. Chronic malarial infection, and chronic Bright's disease may cause it. Predisposing causes are cirrhosis of the liver, chronic valvular lesions, and pulmonary emphysema. It occurs at all ages. The two great predisposing causes in children are dentition and bad hygiene during the hot months (Loomis). Symptoms. — Diarrhoea is its earliest and most constant symp- tom. Watery mucus may be discharged from the bowels, or there may be bilious diarrhoea, with pains and cramps in the calves of the legs, vomiting, headache, furred tongue, and green- ish stools. Serous diarrhoea is the most common, and at first the dejections contain undigested food. There is pain, colicky and griping in character, or it may be dull. Food increases the pain. There is a sense of fullness and distension of the abdomen, and tenderness on pressure. There are flatulence and gurgling. Nausea and vomiting indicate that gastric catarrh is associated with the intestinal. There is usually a mild, remittent type of fever, with loss of appetite, offensive breath, scanty and dark urine. Thirst is intense (Loomis). ENTERITIS. 177 Treatment. — Kee]3 the patient in bed. It is safe to begin the treatment in every case of acute intestinal catarrh by the admin- istration of castor oil. The diet should consist of milk with lime-water. The yolk of eggs may be given with the milk. Prepared meats and light broths are useful. No fats should be allowed, or bread or any form of starchy food. Stimulants may be given when there is prostration. The abdomen should be covered with warm fomentations. Opium is the most efficient agent and must be given in half grain doses every two or three hours. When the catarrh is of malarial origin, quinine must be given in large doses. If it is the result of exposure to wet and cold, diaphoretics are indicated. Chronic intestinal catarrh may be treated by astringents; the best are nitrate of silver, acetate of lead, and sulphate of copper. Sponging the abdomen with cold salt water is good (Loomis). PRESCRIPTIONS FOR ENTERITIS. R Pulv. ipecac comp 3j*. Bismuthi subnitratis ^ij. — M. In pulv. no. xxiv. div. Sig. : A powder every two to four hours for a child five years old. — J. Lewis Smith. R Pulv. opii gr. v. Bismuthi subnitratis.. 31J. — M. In pulv. no. xx. div. Sig. • A powder every two to four hours for a child five years old. — J. Lewis Smith. R Liq. potassii arsenitis gtt. L. Tincturae opii .5j . Aquae ad giij, Sig.: A teaspoonful before meals thrice daily. (In chronic and malarial form.) — Bartholow. R Tinct. opii deodorat 3j. Sig.: Ten drops every second or third hour, according to age, to the point of tolerance. — DaCosta. 178 A COMPENDIUM OF PRACTICAL MEDICINE. EPILEPSY. (Falling Sickness.) Is a chronic paroxysmal affection. The paroxysms are char- acterized by loss of consciousness and convulsive movements of the muscles. Convulsions similar to those of epilepsy are symp- tomatic of different cerebral affections, of anaemia, of injuries of the head, and of strychnia, and are distinguished as epileptiform. Epilepsy is a functional affection. In the majority of cases, the loss of consciousness is as sudden as if produced by a stunning blow upon the head, and the person falls. In a minority of •cases, there is a brief warning of the approaching fit. It is a isense of a "cold vapor" emanating from some part of the body and mounting to the head, and has been called the aura epilep- tica (Flint). Cause. — Thirty per cent, of epileptics give a history of an inherited tendency. Children of consanguineous marriages are often epileptics. It most frequently develops between the ages of ten and twenty. Puberty and injury to the peripheral nerves, the skull, meninges, and diseases of the brain substances are ex- ■citing causes. It may arise from irritation of the genital organs, anomalies of menstruation and phimosis (Loomis). It is very generally believed that the immediately exciting cause of an epi- leptic paroxysm is cerebral anaemia resulting from vaso- motor sj)asin. Venereal excesses, and habits of masturbation have been supposed to be frequent causes. Flint relates the case of a female patient who experienced the first j)aroxysm during the first act of sexual congress after marriage. Subsequently, a paroxysm occurred at each marital connection, and she became a confirmed ejDileptic. It is well known that dogs, cats and other domestic animals are liable to epilepsy (Flint). Symptoms. — (Of grand mal.) — The onset of the paroxysm is often marked by a loud, sharp cry, and the epileptic falls heavily. Drawing the head toward one shoulder is sometimes a warning of an epileptic seizure. There is complete loss of consciousness. The face is extremely pale. The pupil is invariably dilated at the onset and does not contract on exposure to bright light and the eyes are fixed and staring, and the muscles of the face, trunk and extremities are rigid. Opisthotonos may occur. The face EPILEPSY. 179 soon becomes dark from asphyxia. Clonic convulsions succeed the tonic spasms. The tongue is thrust between the teeth. The teeth are sometimes broken. The patient froths at the mouth, and from the injuries to the tongue the saliva is often bloody. The body is often bathed in a profuse sweat. The fit may ter- minate suddenly or gradually. The patient has no recollection of the attack, and appears as if waked out of a deep sleep. (Of petit mal). — There is momentary loss of consciousness, the patient suddenly stops; has a fixed gaze for a second or two, his mind is confused, and then proceeds as if nothing had hap- pened. There may be nocturnal attacks of epilepsy. The only evidence of these attacks may be the tongue which shows indents of the teeth, and the pillows may be blood-stained. Number of Fits. — The first fit may also be the last. They may occur once a year, or two or three times in twenty -four hours. In women it sometimes seems to be connected with the menstrual epoch. Eighty per cent, of all epileptics are attacked oftener than once a month. Results of Epilepsy.— There may be impairment of the mental or physical condition. Of the mental faculties, memory is most often impaired. A subnormal temperature is very common (Loomis). Treatment. — When an epileptic fit is once established there is little to be done but to prevent the patient from injuring himself. Try to discover the cause and remove it. The bromides are at the pre&ent time used more than any other remedies. Cod- liver oil is useful. Nearly all the drugs of the materia medica have been tried (Loomis). PRESCRIPTIONS FOR EPILEPSY. R Ferri bromidi gr. iv. Potassii bromidi 5j . Sy rupi simplicis ^ij . Aquae ad o v iij- — M. Sig. : A tablespoonful twice daily. (In anaemic patients.) — Bartholow. R Extracti conii fluidi (Squibbs)....gij. Sig. : Fifteen to sixty minims three times daily. — Spitzka. 180 A COMPENDIUM OF PRACTICAL MEDICINE. R Lobelinse hydrobromat gr. ^-j. Aquse destillatae Siiss. — M. Sig. : A teaspoonful three or four times a day. — Bartholow. R Potassii bromidi ,,,, Sodii bromidi Ammonii bromidi aa oiij • Potassii iodidi Ammonii iodidi aa 5iss. Ammonii carbonat 5j- Tincturse calumbse oiss. Aquse q. s., ad. ft Sviij. — M. Sig. : A teaspoonful and a half before each meal, and three at bed time. — Brown-Sequard. EPISTAXIS. Is nasal haemorrhage. Causes. — The mucous membrane of the nose is full of blood vessels, and bleeds easily. It may be caused by ulceration of the membrane, by vascular tumors, and by mechanical causes, as valvular disease of the heart (Bartholow). Symptoms. — There may be a sense of fullness of the head, headache, noises in the ears, and vertigo. The blood may come drop by drop from a single nostril, or from the posterior nares. The quantity of blood discharged varies; it may be an ounce or even a pint or quart. Epistaxis may occur periodically as a manifestation of malaria, or take the place, vicariously, of the menstrual or hemorrhoidal flux (Bartholow). When the bleeding occurs in sleep from the posterior nares,. and is swallowed, there may be, if vomiting of the blood occurs, much difficulty in ascertaining the true source (Bartholow). Treatment. — Small pellets of ice may be introduced into the nares, while a block of ice, hollowed out to tit the nose, may be put on outside. Simply pressing the nares together, to enable the blood to coagulate, may often suffice. If pressure and cold fail, a solution of tannic acid, or of .alum, or of acetate of lead, may be thrown into the nares, and if these fail, a solution of Monsel's salts. All other expedients failing, the posterior nares must be plugged (Bartholow). EPISTAXIS ERYSIPELAS. 181 Small doses of aconite, given frequently, will often quickly check the nose-bleeding of children and of plethoric people. Cocaine may be used locally. Digitalis controls epistaxis, haem- optysis, and menorrhagia. A hot foot-bath, with or without mustard, is efficient. Spinal hot-water bag to the cervical and and ujDper dorsal vertebrae is serviceable (Ringer). PRESCRIPTIONS FOR EPISTAXIS. R Pulv. alurainis Pulv. acidi tannici aa 5j- — M. Sig. : To be insufflated into the nares anteriorly and posteriorly. — Sajous. R Extracti geranii mac. fluidi §j. Aquse ,§iij. — M. Sig. : Syringe the nostrils, or plug with cotton saturated with the fluid. — Shoemaker. R Antip yrin 31J . In capsules no. xxiv. div. Sig. : One, two or three to be taken as required. To be used with local treatment. — Robinson. ERYSIPELAS. Is a self- limited febrile affection, characterized by a local inflammation of the skin, and accompanied by constitutional symptoms. It is contagious (Bartholow). Causes. — The streptococcus erysipelatis is regarded as its specific cause. It prevails in hospitals and epidemics follow in the paths of armies. There are two kinds: idiopathic and trau- matic. It is a disease, of all ages, and occurs at all seasons. An abrasion of the surface or wound is the usual starting point. Symptoms. — -The initial symptom is a chill. Headache comes on with the fever; and there are nausea, bilious vomiting, and entire loss of appetite. A sense of heat and tension is felt in the skin, which becomes red, cedematous and shiny. The red color disappears on pressure. The inflammation reaches its highest point on the second or third day, and on the fourth, fifth or sixth day the redness is fading. Desquamation of the skin takes place. The margin of the redness is not sharply defined, 182 A COMPENDIUM OF PRACTICAL MEDICINE. but the swelling forms an abrupt ridge (Bartholow). Trauma- tic erysipelas begins as a bright red blush about the point of injury. Idiopathic erysipelas is most commonly facial, starting from either the nose, eyelid or ear (Loomis). Differential Diagnosis. — Erysipelas may be confounded with erythema and urticaria. Erythema is a superficial redness with- out inflammation — without heat and swelling — is without fever, and does not desquamate. Urticaria occurs in the form of. wheals that itch a good deal and disappear in a few hours (Bartholow). Treatment. — In the more severe cases quinine combined with belladonna is good treatment. R Quininas sulphatis gr. xL. Extraoti belladonna? gr. iij. — M. Ft. pil. no. x. Sig. : One pill every four hours. Tincture of the chloride of iron, in half- drachm doses every four hours, is much commended. Milk, eggs, animal broths, and when necessary stimulants should be given. The bowels and kidneys should be kejyt active. Local Applications. — As a rule, irritating applications do more harm than good. Bartholow has seen mercurial ointment diluted ten times with lard very successful ; or vaseline o], acid carbolic 5ss, or less, which should be brushed over the inflamed area three or four times a day. PRESCRIPTIONS FOR ERYSIPELAS. R Tincturse ferri chloridi Syrupi simplicis — aa §j . A quae 51J . — M. Sig. : A teaspoonful well diluted every two or three hours. — Charity Hospital. R Plumbi acetatis 3J. Tincturse opii 5J. Aquae ad 0. j. — M. Sig. : Shake the bottle well, and wet cloths with the lotion and apply to the affected parts. — Charity Hospital. R Acetanilidi 5j. Ft. in no. xv. capsules. Sig. : Two capsules as required for fever. — Osier. ERYTHEMA ECLAMPSIA. 183 ERYTHEMA. By this term is meant simple, superficial inflammation of the corium, the most trifling of all inflammations of the skin, and under it we must include roseola, strophulus and pityriasis. Symptoms. — There is no fever. The local symptoms are not severe. There is no distinct abrupt line of demarcation between the healthy and diseased skin. It does not usually spread rapidly. The itching is moderate. The color of the eruption is usually pink. The causes are very various. Erythema capitis or pityriasis is usually a very chronic affection and attacks the scalp and hairy parts of the head. Chilblain is a form of erythema which occurs in cold weather, and attacks the fingers, toes, ears, nose and cheeks. PRESCRIPTIONS FOR ERYTHEMA. R Zinci acetatis gr. ij . Aqua? rosse 3j- Ungt. aquas rosse 5j*. — M. Sig. : Apply locally. — Fox. R Pulveris camphorse 5ss-j. Spiritus vini rectificati Sj. Sodii boratis gr. xl. Aquas rosse oviij. — M. Ft. lotio. Sig.: Apply locally several times daily. — Tilbury Fox. R Pulveris camphorse 5ss-j. Zinci oxidi oiv. Pulveris amyli 5j . — M. Sig.: Dust on lightly and do not allow to cake upon the skin. — Bulkley. ECLAMPSIA. Is the term applied to convulsions, tonic and clonic in char- acter, the foundation of which is laid in processes connected with pregnancy, labor, and childbed. It occurs once in about five hundred pregnancies. The attack resembles that of epilepsy, the cry only lacking (Lusk). 184 A COMPENDIUM OF PRACTICAL MEDICINE. Terminations. — In favorable cases, after the expulsion of the ovum, the attacks cease or diminish in frequency and intensity. Prognosis. — Is always serious. The earlier the convulsions occur in labor the more unfavorable the prognosis (Lusk). Treatment. — The urine of pregnant women should be exam- ined occasionally. If convulsions threaten, the nervous irrita- bility should be held in check by rectal injections of chloral and bromide of potassium (thirty grains each). From one -sixth to one -fourth of a grain of morphia should be injected hypodermi- cally. The lower bowel should be cleaned out by an enema, and a cathartic should be given by the mouth (Lusk). EMBOLISM. An embolus is any solid body floating in the blood current. Embolism is the occluding of a vessel by an embolus. Arteri- oles and capillaries are the usual seats of embolism. In general an embolus is part or all of a dislodged thrombus. Causes. — A slowing of the blood current, or a change in the walls of the vessels, a weak vis-a-tergo, vegetations on the valves of the heart, a foreign body introduced into a vessel, or a frac- ture, may cause embolism (Bartholow). Symptoms. — Embolic obstruction of a member is announced by a sudden and often intense pain and a chill, with numbness, loss or diminution of tactile sense, coldness, pallor of the skin, and a feeling of deadness and weight, and paralysis of the muscles (Bartholow). Treatment. — Ten grains of the carbonate of ammonia may be administered in a tablespoonful of the solution of the acetate, three or four times each day. Another remedy is the phosphate of soda, in drachm doses, three times daily for many weeks (Bartholow). ENURESIS. Called, also, incontinence of urine, is a common and trouble- some infirmity of children. It occurs both in boys and girls, but is more common in the former. In many children it dates back to infancy, but in others it begins at six or seven years. There ENURESIS. 185 is an increase in the circular muscular fibres at the urethral ori- fice which constitutes the sphincter vesicae, an unstripecl muscle and not under the control of the will. A second sphincter which aids materially in the retention of the urine is formed by the compressor urethral, surrounds the whole membranous portion, and is a striped muscle and therefore controlled by the will (Smith). Causes. — In all cases the urine should be examined. The chief causes are: 1. Too great acidity of the urine, which will irritate and cause the bladder to contract. 2. Increased quantity of urine. This occurs from the free use of water or milk, or renal disease. 3. A vesical calculus. This will cause pain in passing water. Sound for stone. 4. Excessive irritability of the muscu- lar fibres of the bladder. This is the most frequent cause of enuresis in children. Belladonna relieves this condition. 5. Weakness of the muscular fibres which constitute the sphincter. This occurs in run down conditions. 6. Reflex action. This may be from phimosis, stricture of the urethra, irritation of as- carides, fissure of the anus, onanism, or vulvitis. 7. A psychical cause to which Bartholow alludes. The patient dreams that he is in a convenient place to pass water. 8. Malformation of the bladder. These are various (Smith). Prognosis. — Depends on the cause or causes. Treatment. — For the excessive acidity of the urine, three to five drops of the liquor potassse should be given three or four times daily in a wineglassful of water. In belladonna we rx>s- sess an agent which diminishes the functional activity, or inherent irritability of the bladder when the latter is in excess. Five drops of the tincture may be given every evening, to a child of five years, and the dose increased by one drop every second day. If the enuresis be due to an abnormally large secretion of urine, the liquid ingesta in the latter part of the day should be re- stricted. If it be due to diabetes, or chronic nephritis, treat these conditions. If it be due to a vesical calculus, lithotomy is indicated. If the cause of the enuresis be due to irritation in contiguous parts, as the rectum, penis or vulva, treat these con- ditions. If the cause be due to atony of the sphincter, mix vomica and ergot are indicated. 186 A COMPENDIUM OF PRACTICAL MEDICINE. PRESCRIPTIONS FOR ENURESIS. R Tinturse belladonna? Sj • Sig. : Ten to twenty drops thrice daily. — Ringer. R Acidi benzoici 3ij. Aquse cinnamomi 3 vj . — M. Sig. : A tablespoonful thrice daily. — Hartshorne. R Tincturse ferri muriatis 3J. Decocti uvae ursse Svj. — M. Sig.: A tablespoonful two or three times daily. — Hillis. R Santonini gr. xvj. Olei ricini oj • — M. Sig. : One or two teaspoonfuls before breakfast for two or three mornings. — Ringer. R Collodii S ss. Sig.: Put a drop in the meatus to seal it at bed time. Remove with finger-nail in morning. — Corrigan. R Chloral hydratis 3J. Sy rupi tolutani 5 iiss. — M. Sig.: A teaspoonful thrice daily. (For infantile incontinence). — DaCosta. R Atropinse sulphatis gr. j. Aquse destillatae Sj . — M. Sig.: Four to eight drops in water. (For children). — Bartholow. ENDOMETRITIS. Is an inflammation of the endometrium. It is acute and chronic. The acute is a rare disease. The chronic is a frequent disease. Causes of the Acute. — This form occurs in young girls after acute fevers, or it may be due to taking cold during menstrua- tion, or to an extension of inflammation from other parts, to chronic catarrh, or laceration of the cervix. Symptoms. — Leucorrhcea. The discharge is thick, and often profuse, and resembles the white of an egg. Menorrhagia may be present. There is a sense of fullness or pain in the pelvis and loins. Treatment. — Treat the cause. Warm mucilaginous injec- tions, salines and rest will give the best results. EPIDIDYMITIS. 18 ( The chronic form is divided into corporeal and cervical. Causes. — It may follow the acute disease, or start as a chronic affection from specific or other constitutional causes. It may be due to lacerated cervix, violence during coitus, ill-fitting pessa- ries, etc. Symptoms. — Leucorrhoea is the principal symptom. Treatment. — Treat the cause. If from lacerated cervix, reduce the size of the uterus by leeches, scarifications, iodine, hot-water injections and glycerine tampons. If the leucorrhoea still persists operate for laceration of the cervix. If there is eversion of the cervical mucous membrane scarify it. If there be chronic catarrh of the cervix, relieve the congestion by .local measures, and use astringent applications to the cervical mucous membrane. If the body of the uterus is involved, the patient is usually sterile. In this case dilate the uterus with tents left in for twenty -four hours. After dilatation wash the cavity with carbolic acid water (40 per cent.) and apply to the endometrium by means of cotton on an applicator, solutions of corrosive subli- mate, zinc sulphate, or Monsel's solution and glycerine, repeating the application every three or four days. There should be absence from sexual intercourse (Pozzi, Skene and Gooddell.) EPIDIDYMITIS. Is an inflammation of the epididymis. It is the most common of all the diseases of the testicle. It occurs at all ages. One attack predisposes to another. It is often double. Fournier states that epididymitis occurs once for every eight or nine cases of gonorrhoea. In some individuals every attack of gonorrhoea is attended by a swollen testicle (Keyes). Causes. — Traumatic violence and cold may cause it. Pro- longed sexual excitement may cause it; but urethral inflamma- tion or irritation from gonorrhoea, stricture, or the passage of in- struments is by far the most active cause. It is an extension of the inflammation from the orifice of the ejaculatory duct to the epididymis. Symptoms. — First attacks, like first attacks of gonorrhoea, are usually the most severe. If there be a gleety or gonorrhceal 188 A COMPENDIUM OF PRACTICAL MEDICIJSTE. discharge, it stops after the testicle begins to swell, but soon re- turns. There is a feeling as if the cord were being pulled upon, and pain in the back. There is frequent desire to urinate, and intense pain in the testicle, which is swollen. The pain is of the sickening variety, making patients feel faint. Rest on the back with the testicle raised modifies the pain. Epididymitis lasts about two weeks. Hardness of the epididymus may remain be- hind for months or even years. Sterility may be produced if the epididymitis be double. The testicles do not atrophy. The pa- tient is by no means impotent. He ejaculates semen, but it contains no spermatozoa. Treatment. — A suspensory bandage should be worn during the existence of urethral disease. Rest on the back, elevation of the testicle, hot flax-seed poultice, and a laxative, may be all that is necessary. In severe cases, the testicle is enveloped from the start in a tobacco poultice. The poultice is made by mixing a paper of any fine -cut tobacco (oj.) in about (sx.) of hot water, bringing the whole to a boil, and then adding ground flax seed until the proper consistence. The poultice is sprinkled with laudanum and placed upon the testicle as hot as can be borne, and covered with oiled silk. This poultice should be renewed every eight hours, until the indurated epididymus has lost its sensitiveness to pressure. Powdered opium (si-ii.) mixed with stramonium ointment (Si.) may be used instead of the tobacco poultice. According to Keyes, the tobacco poultice is more ser- viceable than any other agent. Ice is not good. In extreme pain, when the cord has become strangulated, ten to fifteen leeches above the groin will often calm the pain as by magic. When pain is caused by extreme distention of the tunica vagin- alis with fluid, puncture it, and let out the fluid. Patients should stay in bed about one week in mild cases, and ten to twelve days in worst cases. Tonics and cod-liver oil do good (Keyes). EPISPADIAS EPITHELIOMA EKUCTATIONS. 189 EPISPADIAS. Is a fissure of the superior wall of the urethra, with ectopia of the canal. It is very rare. The urethral opening may be upon the glans, or anywhere along the top of the penis, as far back as its root. When the membranous and prostatic urethra are involved, there is also exstrophy of the bladder. Epispadias is an arrest of development in the upper wall of the urethra. Treatment. — A cure cannot be promised from operative pro- cedure. Operations which have been undertaken very often fail, erections and contact of urine, with smallness of flaps, being the chief causes. A proper urinal is the best treatment. EPITHELIOMA. Is a form of cutaneous cancer. These tumors affect the skin or mucous membrane, and never originate in any other tissue. They infiltrate the parts with which they come in con- tact, and do not, as innocent tumors, simply separate them. They are the common forms of cancer found in the lips, tongue, oesophagus, rectum, scrotum, penis, clitoris, os uteri, vulva, etc. As a local disease, epithelioma may progress slowly for years, and cause little pain, and five, six, or even fifteen years may elapse before advice is sought. The surface of an epithelial cancer may be dry and warty, or ulcerating; when ulcerating the discharge will be a thin or creamy fluid (Bryant). Treatment. — These cancers should always be removed; and the sooner this is accomplished, the better the prospects of a cure. ERUCTATIONS. ( Off ensi ve ) . Patients are sometimes greatly annoyed by eructations of an offensive gas, with the odor and flavor of rotten eggs — a gas consisting largely of sulphurretted hydrogen. In such cases the urine is loaded with oxalic acid, and to correct the oxaluria on which the eructations depend, the mineral acids should be given in the proper doses (Ringer). 190 A COMPENDIUM OF PRACTICAL MEDICINE. ENTERALGIA. (See Colic.) EPHIDROSIS. Called also hyperidrosis, is an augmented sudoriparous secretion. Causes. — It may accompany any disease, and especially phthisis, as the result of debility. It may occur from excitement of the body or mind. In some cases there is no apparent cause. The perspiration may be general or local. It is sometimes lim- ited to one side of the body or face, when it is supposed to result from faulty innervation of the sympathetic. The sweating is often limited to the soles, palms, axillae, groins and genital organs. The hands are moist, clammy and cold from rapid evaporation of the sweat. In the feet, the secretion is confined by the stockings and shoes, and is apt to inflame the soles, leav- ing them very tender, so that walking or standing is painful. A species of bacteria which grows and multiplies in this sweat is the sonrce of the offensive odor (Anderson). Treatment. — For the general sweating from wasting diseases, tonics, such as quinine, the mineral acids, strychnia and arsenic are recommended. Atropia in doses of t~ot gr. is the most power- ful of all remedies for general sweating. Some benefit may come from sponging the body with vinegar and cold water. For the local sweating, Dr. Thin advises the changing of the stockings twice daily. Dr. Marten advises washing the feet night and morning with soap and water, and sponging with the following lotion : R Plumbi acetatis 3J Aceti destillati §j. Spiritus vini methylati |ij. Aquae ad sxvj . — M. Dr. Simonton recommends the use of finely pulverized alum. The feet and socks are thoroughly dusted with the powder. Repeat this process every two or three days, and the feet will become hardened. In mild forms, tannic acid 5j. to Svj. of alco- hol may be rubbed on several times daily. Dust the feet thor- oughly with pulverized salicylic acid before putting on the FETOE OF AXILLiE FEYEES. 191 stockings, and wash them with permanganate of potassium (gr. xxx.-Oj.) evening and morning and apply belladonna lin- iment before going to bed to the feet. FETOR OF AXILLA, BREATH AND FEET. These are very annoying conditions and the physician is often consulted concerning them. Permanganate of potassium is an elegant toilet preparation for destroying the odor of a foul breath, the smell of the axillae, and the fetor of the sweat of the feet, and may be used as follows: R Potassii permanganatis gr. x.-xxx. Aquse §viij. — M. Sig. : Apply locally frequently. — Bartholow. The following formulae may be used for the above condi- tions: R Sodii bicarbonatis .giij . Aqua? §viij. — M. Sig.: Apply as a lotion frequently. — Bartholow. R Atropia? sulphatis..... gr. iv.-viij. Aquse rosae §ij. — M. Sig.: Apply to the part with a brush, — Bartholow. R Acidi salicylici gr. xLv. Pulv. amyli , gv. Pulv. talc o xx ij- — M. Sig. : Dust over feet. Jfc Sodii biboratis gr. xv. Thyraoli gr. viiss. Aquse destillatse o xij . — M. Ft. sol. Sig.: A mouth wash. (For fetor of breath). — Magitot. FEVERS. (Classification of.) Fevers are distinguished as essential and symptomatic. A symptomatic fever is one which is secondary to some local affec- tion, such as an acute inflammation. An essential fever is one which is not secondary or symp- tomatic, but is primary or idiopathic. The essential fevers are as follows : 192 A COMPENDIUM OF PRACTICAL MEDICINE. I. Febricula, a form of fever characterized by its short duration and mildness. II. Continued Fevers, which are distinguished by the un- broken continuity of the febrile phenomena, such as typhoid, typhus, relapsing and erysipelatous fevers. Ill Periodical Fevers, which are distinguished by the occurrence of distinct paroxysms of the febrile phenomena, such as intermittent, remittent, typho- malarial and yellow fevers and dengue. IV. Eruptive, or exanthematous fevers, in which an erup- tion on the surface of the body is a prominent feature, as in small-pox, scarlet fever, measles, roseola and typhus. When the decline of a fever is rapid, occupying only a few hours, or a day or two, the fever is said to terminate by crisis. When the decline is protracted the termination is by lysis. (Each of the above fevers will be considered in its proper place.) Causes of Essential Fevers. — Micro-organisms are among the most important of fever-exciting agents, and are probably in- volved in the causation of all the essential fevers. Animal heat is the result of chemical processes, especially processes of oxida- tion, which are constantly going on within the body; but it is not known in what way the abnormal elevation of temperature is produced in fever (Flint). FISSURE OF THE ANUS. Produces more misery than any other local disease, and renders the natural act of defecation an agonizing one. Causes. — It is usually caused by the mechanical splitting of the orifice of the anus, from the passage of a large or indurated motion. It may be due to scratching the parts when highly irritable. Constipation, high feeding, sedentary habits, and want of local cleanliness are the common causes. Symptoms. — There is pain during \he passage of the motion. The motion may be streaked with a line of pus or blood. There is an unnatural contraction of the sphincter, and great pain is caused by attempting to introduce the finger. A careful exam- ination will often reveal the presence of an ulcer on the verge of FISSUEE OF ANUS. 193 or within the sphincter. Simple fissures are often associated with piles (Bryant). Treatment. — Happily for patients, the treatment of the dis- ease is as successful as it is single. Simple fissures are readily treated by the administration of a laxative, the local application of nitrate of silver, or of lead lotion mixed with the extract of opium, and local cleanliness. When the parts are indolent, black wash may be used, or calomel dusted over the part. When an ulcer has existed for some time and has a hard base, the most efficient means of cure is division of the base of the ulcer with the superficial fibres of the S23hincter, or forcible dilatation of the sphincter, and its laceration with the thumbs in the rectum. After=Treatment, — The bowels must be kept slightly loose, and for this purpose the following may be used: JJr Olei olivse §j . Potassii carbonatis gr. xLv. Aquse Mentha? piperita? oviij. — M. Sig. : One ounce three times daily. PRESCRIPTIONS FOR FISSURE OF ANUS. J{r Iodoformi Acidi tannici aa 5j • — M. Sig. : Unfold or open the fissure, and fill with and dust over the powder. — Bartholow. J{r Potassii bromidi oiss. Glycerina? Sj • — M. Sig. : Apply with a brush locally. — Ringer. J& Acidi tannici 5j- Gly cerina? o ij • — M. Sig.: Introduce into the rectum night and morning on a tent. — Waring. |fc Extracti hydrastis fiuidi Sj Sig.: Apply to the fissure. — Bartholow. 194 A COMPENDIUM OF PRACTICAL MEDICINE. FISSURES OF THE NIPPLE, Are excruciatingly painful, and are capable of exciting even a high degree of fever. They occur with greatest frequency in nipples which have been flattened by the pressure of corsets (Lush). Treatment. — The nipple should be kept clean, and all irri- tating matter removed. When one nipple only is affected, the child need only be applied to the sound side. The healing pro- cess may be promoted by lead-lotions, by a solution of tannin, or by some astringent ointment. Keep upon the nipple a rag wetted with Goulard's extract, a teaspoonful to a tumbler of water. If the child be troubled with sprue, its mouth and the nipples of the mother must be washed with a solution of boracic acid. PRESCRIPTIONS FOR FISSURE OF THE NIPPLES. |fc Cocaini muriatis gr. x. Aquas destillata? 5ij- — M. Sig. : Apply with a brush to the fissure half an hour before nursing, and wash well with warm water just before nursing. — L. Starr. jfc Plumbi nitratis gr. iv-x. Gly cerinse 3J . — M. Sig. : Apply after nursing, and wash the nipple carefully before the next nursing. — Bartholow. JJr Acidi carbolici gr. xxiv. Aquae Sj. — M. Ft. lotio. Sig.: Apply several times daily to the nipples. — Parvin. JJr Acidi boracici gr. xx. Mucilag. acacias 5J- — M. Sig.: Use a nipple shield, and, after nursing, dry the nipple well with absorbent cotton and apply the lotion with a camel's hair brush. Should this fail, touch the fissure with a point of nitrate silver every other day. — Starr. Jfc Tincturse benzoini composite §ss. Glycerini Sss. — M. Sig. : Appty to affected parts. — Stille. FISTUL.E. 195 FISTULA. Is an unnatural communication between a normal cavity or canal and the outside of the body or with a second body or canal. According to their situation, they are named vesico-vaginal, and recto-vaginal in women, and recto-vesical in men, gastric, biliary, faecal, anal, salivary and urinary fistulas. Causes. — They may be congenital or acquired. The acquired fistulae are either due primarily to some suppurative or ulcerative process or to mechanical violence, operative or otherwise, and subsequently to a want of repair. The fistula may be a short or a long narrow tract. When the fistula is of recent origin, the walls will be soft; when old, hard (Bryant). Treatment. — In a general way, it may be asserted that so long as the cause of a fistula exists repair cannot go on; so that in urinary fistula, when stricture is the cause, the stricture must be treated before the fistula. When the cause of the fistula has been cured or removed, then the fistula itself may be treated, and various are the means that can be employed for the same. Vaginal and rectal fistulae usually require plastic operations. The whole margin of the fistula must be pared with nicety and accuracy, and the raw surfaces brought into ap23osition. The constitutional treatment resolves itself into tonics, good food and fresh air. PRESCRIPTIONS FOR FISTUL4E. Jfc Cupri sulphatis gr. ii.-iv. Aquae siv. — M. Sig. : Inject once a day. — Sir A. Cooper. J$r Argenti nitratis gr. ij. Aqua? destillatffi 5 viij . — M. Sig.: Inject once a day. (Fistula in ano.) — Druitt. |fc Tinctura? iodini gj. Sig.: Inject once daily. — Waring. J& Extraeti sanguinarijc fluidi sij. Sig.: Inject a sufficient quantity to fill and distend the fistula, —Phillips. 196 A COMPENDIUM OF PRACTICAL MEDICINE. FLATULENCE. The gas in the intestinal canal may he merely air which is swallowed; or it may result from fermentation or decomposition of food. It causes a disgust for eating, a feeling of distention, and sometimes actual pain, shortened breathing, palpitation of the heart, eructation or belching of gas with or without an odor (DaCosta). Treatment. — According to Wood, the remedy most effective to remove and permanently cure a disposition to the accumula- tion of flatus in the bowels is an infusion made with half an ounce of calumba, half an ounce of ginger, a drachm of senna, and a pint of boiling water, and given in the dose of a wine- glassful three times a day. PRESCRIPTIONS FOR FLATULENCE. Ji Aquse camphorse siij. Tincturse lavandulse comp §j. — M. Sig. : A tablespoonful every hour or two. (For hysterical flatu- lence and flatulent colic occurring at climacteric.) — Bartholow. {& Spiritus chloroformi Tinctune cardamonii comp...aa...3ij. Sig.: A teaspoonful every half hour in water. — Bartholow. Jfc Misturse asafoetidae 5iij. Sig.: A teaspoonful when necessary. (For the flatulent colic of infants.) — Bartholow. J& Spiritus setheris compositi ^ij. Aquse camphors? 5ij . — M. Sig.: Two teaspoonfuls to expel flatus from stomach. — Bartholow. |fc Spiritus setheris comp Tincturse ammonii valerian... aa.. .5]. — M. Sig : A teaspoonful in water every fifteen minutes until re- lieved. (For hysterical flatulence and globus hystericus.) — Bartholow. {fc Olei terebinthinae oj. Sig.: Three to five drops on a lump of sugar. — Bartholow. FEECKLES. 197 FRECKLES. Called also lentigo, is the most circumscribed form of pig- mentation, and the deformity to which in well marked cases it gives rise, is so well known as to require no description. It is most apt to appear in persons with delicate skins, and in those who have fair complexions, but above all in red-haired people. It is always aggravated by exposure to the sun, hence it is met with on the face, neck and hands more particularly, and is most 23ronounced during the summer months. Treatment. — Avoid unnecessary exposure to the sun. Ac- cording to Bartholow the following lotion is useful in freckles, sunburn and tan : {&• Potassii carbonatis giij. Sodii chloridi 3ij. Aquse rosse 5viij . Aquse aurantii flor §ij. — M. Sig. : Apply to part. Yfc Liquoris potassse gj. Aquas rosse §ij- — M. Ft. lotio. Sig.: Face-wash. (In tan and freckles.) — Todd. J£ Hydrargyri chloridi corr gr. j. Zinci oxidi 31J . Zinci carbonatis ,...§ss. Glycerinse 31J. Aquas rosse 5 viij . — M. Ft. lotio. Sig.: Apply with a sponge. (In freckles and sunburn). — Fox. JJr Lactis recenti* gxiiss. Glycerinse gviiss. Acidi hydrochlorici ZTT.Lxxv Ammonii muriatis 3J. — M. Ft. lotio. Sig.: Apply morning and evening with camel's hair brush. (In tan and freckles). — Monin. 198 A COMPENDIUM OF PRACTICAL MEDICINE. FROST=BITE. When concentrated cold is apjDlied for a period sufficient to arrest the circulation in a part, a frost-bite is the result. The first effect of cold upon a part is a sense of numbness and weight and a feeling of tingling. If the cold continue, the part will become stiff and at last insensible, feeling dead. The frozen part is white and waxy. The constitutional effects of cold are at first stimulating, and subsequently depressing. Treatment.- — Sudden alteration of temperature is most in- jurious. The aim of the surgeon should be to recall the affected parts gradually to their normal condition by gentle friction in the course of the veins with furs or flannels. Stimu- lants should be administered internally. Friction with snow or ice-water is most useful. On reaction the parts may be raised, and warm milk with a little brandy given. Should reaction be too severe, it must be checked by lead or spirit lotions. When gangrene follows, carbolic acid and oil are probably the best ajjplications. If a whole foot be frozen, amputation may be called for, the surgeon always waiting until the line of demarcation is formed. PRESCRIPTIONS FOR FROST=BITE. R Acidi carbolici 3J. Tinct. iodinii 3ij . Acidi tanici £i j . Cerati simplicis |iv. — M. Ft. ungt. Sig. : Apply locally. — Bartholow. R Linimenti camphorse. Linimenti saponis comp Olei caj uputi aa §j . — M. Ft. linimentum. Sig.: Apply to the unbroken skin. — Brande. R Camphorse 3.j . Olei cajuput gij. JEtheris 3j. — M. Ft. linimentum. Sig.: Apply locally to the unbroken skin. — Tortual. FURUNCLE — FITS FELON FAINTING. 199 FURUNCLE. (See Boil.) FALLING SICKNESS. (See Epilepsy.) FITS. (See Convulsions.) FLOODING. (See Menorrhagia.) FELON. Called also paronychia, or whitlow, is an abscess of the thumb or fingers. The superficial whitlow or felon consists of inflammation of the surface of the skin of the last phalanx. It is generally seated immediately around and beneath the nail. It is attended with great pain and throbbing, and suppuration at the root of the nail, which may come off. The deep-seated variety is attended with a severe throbbing pain, great tenderness, tense and resisting swelling, and great constitutional disturbance. The inflammation usually begins in or beneath the j)eriosteuin. It may lead to suppuration, and leave the fingers stiff and useless. Treatment. — If purgatives and fomentations do not speedily bring relief, the finger must be freely laid open. The knife should be carried deep enough to feel the resistance of the bone or tendon. A strong solution of nitrate of silver in nitric ether applied over the part may abort the affection, if at the beginning (Bartholow). FAINTINGS. Treatment. — In the threatened fainting, it is a good plan to direct the patient, whilst sitting down, to lean forward, and place the head between the legs as low down as possible, so that the blood may gravitate to the brain. Brandy or wine are the best remedies, when the heart is suddenly enfeebled from fright, loss of blood, accidents or other causes. Salts of ammonium, applied to the nose, and breathed into the air-passages, are coimnoiilv used in fainting. Cold water smartly sprinkled on the face of a swooning person is a familiar way of restoring consciousness (Ringer). 200 A COMPENDIUM OF PRACTICAL MEDICINE. FATIGUE. Treatment. — The sitz-bath greatly relieves fatigue and soothes an irritable, restless state of the nervous system. A pedestrian, after great exertion and fatigue, will find it an agree- able restorative, preventing stiffness and aching muscles, to strip and wrap himself in a dripping wet cold sheet, well rubbing himself afterwards; but if stiffness still remains, a few drops of tincture of arnica taken internally will remove it. Tea and coffee are especially useful in a fatigued state of the system, and under ordinary circumstances are preferable in this respect to alcoholic drinks (Ringer). FLUSHING HEATS. The distressing symptoms occurring during the "change of life " are very various. There are heats and flushings, followed by free perspiration, and prostration is sometimes extreme. These symptoms will generally give way to bro- mide of potassium. Eucalyptol is given in the various symp- toms connected with the change of life, as flatulence, palpitation and flushings. A woman, from the sudden arrest of menstrua- tion, or through depraved health, or nervous depression, or more frequently at the "change of life," suffers from frequent attacks of flushings or heats, starting from various parts, as the face, epigastrium, etc., and thence spreading over the greater part of the body. These heats may last a few minutes only, or an hour or more, and may be repeated many times a day. The least ex- ertion or excitement may bring on these heats, and such a patient generally complains of cold feet, and sometimes of cold hands. The flushings are occasionally abruptly limited, reach- ing to the thighs, knees or elbows, and while all the parts above these feel burning hot, the parts below feel icy cold. In many of these cases palpitation or flutterings at the heart occur on the slightest excitement. Nitrite of amyl will prevent or greatly lessen these flush- ings or heats, and should be given in doses of a tenth to a sixth of a minim, in thirty times its volume of rectified spirit, every FRACTURES. 201 three hours, with an additional dose as soon as the flush begins. Both men and women, but chiefly women about forty or fifty years of age, are apt to complain of a sensation of great weight and heat on the top of the head, with frequent flushings of the face, suffusion of the eyes, hot and cold perspirations, and some- times shooting pains passing up the back of the head In these cases, a drop of laudanum, with two of the tincture of mix vomica, repeated three or four times a day, will give great re- lief. Valerianate of zinc, given in three to five grain doses in a coated pill, will usually remove the flushings of the face, hot and cold perspirations, fluttering at the heart, and heat, and weight on top of the head (Ringer). FRACTURES. A fracture is a solution of continuity of bone, while dislo- cation is a solution of contiguity. Kinds, — 1. Complete. 2. Incomplete. 3. Epiphyseal sep- aration. A complete fracture is where division completely traverses the thickness of the bone.' An incomplete fracture is where division does not completely traverse the thickness of the bone. The epiphyseal is where the epiphysis becomes separated from the bone or diaphesis. Complete fractures may be of the following kinds: 1. Simple. 2. Compound. 3. Comminuted. 4. Complicated. 5. Impacted. 6. Multiple. 7. Gunshot. 1. Simple is where the bone is broken in one place only, and with no communicatioD with the external air. 2. Comrjound is where there is communication with the external air. 3. Com- minuted is where there are a great many small pieces of bone. 4. Complicated is where the fracture is associated with the main vessels, nerves, veins, or some internal organs. 5. Impacted is where compact tissue is driven into the cancellous tissue. 6. Multiple is where the bone is broken into several pieces. 7. Gunshot is where the fracture is the result of the explosion of fire-arms. Any fracture may be oblique, transverse, longitudinal or dentated. Incomplete fractures are the following: 1. Green - stick. 2. Partial. 3. Fissured. 4. Punctured. 5. Stellate. 6. 202 A COMPENDIUM OF PRACTICAL MEDICINE. Spiral. 7. Gunshot. Epiphyseal separations occur in early life, under twenty years. The causes, symptoms and treatment are the same as fractures. Most fractures occur between the ages of twenty-five and sixty. More common in men than in women. More occur in winter than in summer. The clavicle and radius are more often broken than any other bones. Symptoms. — 1. False point of motion. 2. Rotary displace- ment. 3. Angular deviation from the normal axis. 4. Crepitus. 5. Tenderness on pressure. 6. Unnatural mobility. 7. Retrac- tion of muscles. 8. Ecchymosis and swelling. 9. Shortening. Crepitus is the most important sign, but may be absent some- times, because of something between the fragments. General Management. — Give every fracture proper and dili- gent attention. When called to see a case: 1. Do not move the patient to a vehicle and clo not set him upright. 2. Put on a temporary splint at once and carry home in a horizontal position. 3. Put patient on a hard mattress and not on a feather bed. 4. Cut off the trousers, boot and shoe, and do not pull them off. 5. Inspect the fracture, have a good assistant to make strong ex- tension of the limb in the long axis, and then he may raise the limb. You may then inspect it to a better advantage. 6. Make extension. Get the great toe in a line with the inner margin of the inner malleolus and patella and then have the foot at right angles with the limb. Give a hypodermic injection of morphine to relax muscles. You may divide every tendon in case you can not keep the muscles from contracting. Diagnosis. — Three signs are sure: 1. Mobility. 2. Crepitus. 3. Displacement. In cases of doubt, give an anaesthetic. Treat any injury as you would a fracture when there is doubt as to what it is. (For the treatment of special fractures, see works on surgery.) GALACTORRHEA. Is a constant dribbling of milk from the nipple. It is an affection which may continue long after lactation has been sus- pended. It acts like any other profuse discharge in exhausting the strength and producing a wasting of the tissues. GALACTORRHEA — GALL- STONES GANGRENE. 203 Treatment. — Consists in interrupting lactation, in compres- sion of the breasts with bandages, and tonics to repair the gen- eral health. Of special measures, saline laxatives and the inter- nal administration of iodide of potassium are of most repute (Lusk). PRESCRIPTIONS FOR GALACTORRHEA. J&- Olei camphorati §vj. Sig. : Apply externally to breasts. — Waring. Jfr Potassii iodidi |j. Aquas 5J . — M. Sig.: Twenty-five to thirty drops in water, once or twice daily. — Roussell. Ifr Atropines sulphatis gr. iv. Aquas rosas §j .-— M. Sig. : Apply on lint around the breasts, and remove when the throat becomes dry. — Bartholow. GALL=STONES. (See Biliary Calculi.) GANGRENE. Called also mortification, is the death of any part of the body in consequence of disease or injury. It is divided into acute and chronic. The acute is known as moist gangrene. The chronic, as dry or senile gangiene. Causes. — Predisposing and exciting. The predisposing causes are: Defective nervous power, as in palsied limbs, or division of large nerve trunks; general debility from poor food and improper nourishment; use of alcoholic drinks; atheroma- tous changes in the arteries of old people. The exciting causes are produced by whatever interferes with or arrests the circula- tion of a part. The arterial blood to a part may be cut off by accident, by ligature, by thrombosis or embolism of the arteries. The circulation through a part may be obstructed by the growth of a tumor or by the formation of bed-sores. Extreme weakness of the heart's action may produce gangrene, or whatever de- stroys the cells of a part, as injuries, chemical agents, prolonged use of mercury or excessive heat or cold (Bryant). 204 A COMPENDIUM OF PRACTICAL MEDICINE. Symptoms. — Are local and constitutional. Locally, at the beginning, the pain and tenderness of the part become most acute; it is of a severe, burning character; the discoloration is of a vivid-red color; the local heat is increased. The constitu- tional symptoms are of a low typhoid cast. There is a profuse perspiration. "When the part is dead, the pain and tenderness cease: it becomes cold, the bright redness disappears, and large blisters form which burst and leave a greenish discoloration beneath. The limb becomes greatly swollen, soft and boggy; a sickening fetid smell is exhaled. When the progress of the dis- ease is arrested, the line of demarcation forms which separates the living from the dead tissue. Treatment. — To avert the threatened gangrene the patient, if young and robust, with a full hard pulse, should be purged. If there is a great deal of inflammation, incisions should be made into the part, and lead water with laudanum applied. The timely use of a blister over the entire surface will sometimes bring about healthy action, and set aside the tendency to gangrene. Iron, quinine, strychnine, stimulants and nutritious diet should be prescribed. The limb should be put in an aseptic condition by washing it with T oVo solution of corrosive sublimate, and then applying cotton wool and a bandage. It should be elevated and at rest. To allay fetor, permanganate of potassium, carbolic acid and the chlorides must be resorted to. Cleanliness and thorough ventilation of the apartments must be insisted upon (Bryant). CHRONIC, DRY OR SENILE GANGRENE. Causes. — Diseased state of the arteries, weak heart and con- sequent feeble circulation may cause it. In many cases it begins without any apparent exciting cause. In old people, diabetes is a fertile cause of gangrene of the toes and feet. Symptoms. — There will be a sensation of weight in the part, with coldness, numbness, itching and tingling of the feet, and cramps of the calves are complained of. On examination, a small dark or purplish spot will be found on the inside of one of the toes, not larger than a mustard seed. This is followed by a vesicle which exposes a black surface on bursting. This grad- GANGREXE. 205 u ally spreads until the whole foot is involved. It may begin on several toes at the same time, or it may show itself on the instep or heel. The part destroyed becomes black, dry, withered, cold and insensible. Treatment. — As soon as the line of demarcation forms be- tween the dead and living tissue, the health of the patient im- proves. Tonics with stimulants should be given early. Locally cotton wool in thick layers around the foot and limb must be used. Question of Amputation. — If the gangrene is the result of a severe injury, and it is rapidly spreading, or if it arises from a wound or ligature of an artery, the rule is to amputate at once. In the above cases, do not wait for the line of demarcation to form. In chronic gangrene, due to diabetes, or ergotism, wait for the line of demarcation to form. In cases of frost-bite, or burn, or disease of the arteries, wait for the line of demarcation (Bryant). PRESCRIPTIONS FOR GANGRENE. R Brominii §j. Sig. : Apply to the slough with a glass rod. — Bartholow. R Cerati resinas comp 5J. Extracti opii aquos 3j. Olei olivre gij. — M. Ft. ungt. Sig. : Apply locally after the slough has separated. — Witherstine. R Liqour hydrogenii peroxidi siv. Sig.: Apply locally, pure or diluted. R Acidi nitrici 5J. Sig.: Apply to the ulcer with a glass rod until it is converted into a firm, dry mass. — Waring. R Sodii sulphitis oj-ij- Aquas 5x. — M. Ft. lotio. Sig.: Use as a lotion, or apply on compresses. — Waring. R Pulv. acidi salicylici §j. Sig.: Use locally as a dusting powder. (To destroy fetor and change morbid action). — Bartholow. 206 A COMPENDIUM OF PRACTICAL MEDICINE. GASTRALGIA. Is a painful state of the sensory nerves of the stomach, induced by irritation, and without fever. Causes. — The neurotic temperament, malaria, and the abuse of tea and coffee have no little influence in causing the disease (Bartholow). Strawberries, or honey, or other ingesta, or cold may bring on an attack (Flint). Symptoms. — Severe paroxysmal pain in the epigastrium, radiating upward over the chest and downward through the ab- domen, and through to the back is the most characteristic symptom. The pain is diminished by pressure, and the patient instinct- ively lies or presses firmly on the abdomen. In the severest cases the pain is excessive. The duration of the attacks may be a few hours, or a day or two, or a month with intermissions. Usually the attacks are of short duration, and terminate with eructations of gas and with vomiting. Persons of sedentary habits are more likely to be affected than those engaged in active pursuits (Bartholow). Treatment. — During a paroxysm, the first point is the relief of pain by the hypodermic injection of morphine.. The pain and also the nausea and vomiting may be arrested by creosote or carbolic acid. Equal parts of tincture of iodine and carbolic acid, of which a drop may be given every hour in a little cold water, will often stop the pain and vomiting. The paroxysms may be relieved by one drop of Fowler's so- lution and two to five drops of tincture of opium. The long continued use of arsenic in a small dose — one drop ter in die of Fowler's solution — is more effective according to Bartholow's ex- perience than any remedy mentioned. Salicylic acid is sometimes serviceable for intermittent cases. When attacks of gastralgia are due to indigestible food, the first duty is to empty the stomach. Excellent results are often ob- ■ tained from the use of muriatic acid, combined with tincture of mix vomica. The diet should be regulated. A sinapism and fomentations to the epigastrium are useful as aids. Mild cathar- tics may be given (Bartholow). Bismuth in doses from a scruple GASTBALGIA GASTRIC ULCER. 207 to a drachm three or four times a day, lias been found to be curative, according to Flint. The constant current in the hands of Leube, Beard, and Rockwell has proved efficacious. Change of habits from those of sedentary to active life is of the first importance. Alcoholic stimulants in moderation with meals may be ad- vised for a time (Flint). PRESCRIPTIONS FOR GASTRALQIA. R Tincturse conii 3J. Tincturre Valerianae Tincturse opii camphoratae Aquse lauro-carasi — aa gij . — M. Sig. : Seven drops in a little milk when the pain appears. — Monin. R Extracti coca? fluidi 3J. Syrupi aurantii flor 3v. Aquas ad gij. — M. Sig.: A teaspoonful every hour till relieved. — D'Ardenne. R Liq. chloroformi aq. sat 3xv. Aquse aurantii flor 3xiv. Tincturse anisi stellati 3j . — M. Sig. : A teaspoonful every quarter of an hour. — Dujardin-Beaumetz. R Liquoris potassii arsenitis |j. Sig. : One drop in water three times daily continued for months. — Bartholow. GASTRIC ULCER. Causes. — Ulcer of the stomach is a comparatively common disease, and is found to exist in five per cent, of the deaths from all causes. It occurs in females oftener than in males. The lia- bility to it is greatest between the ages of fourteen and thirty, although no age is exempt; it has been found in the new born babe and in the octogenarian. Amenorrhea, anaemia, chlorosis, the puerperal state, prolonged lactation, and tuberculosis are predisposing causes. Ulcer of the stomach may result from an habitual stooping position, as in milliners, seamstresses and shoe- makers. Burns of the chest and abdomen sometimes causes ulceration of the duodenum (Bartholow and Loomis). Symptoms. — It is a chronic malady usually. There are . three important symptoms of gastric ulcer— pain, indigestion, 208 A COMPENDIUM OF PRACTICAL MEDICINE. and vomiting (hseniateniesis). Pain is one of its constant symp- toms; at first it is dnll and heavy, then it becomes burning, gnawing, and fixed, boring through from front to bach, and occupying a space which the finger may cover. It usually comes on soon after the ingestion of food, and lasts during the entire period of stomach digestion; occasionally it is not present until an hour or so after eating. Very great tenderness is experienced on pressure over the vertebrae behind and the seat of pain in front. Attacks of gastralgia occasionally come on. Nausea and vomiting may accompany the pain; in some instances there is pyrosis, or "water-brash;" usually the vomiting occurs when the pain is most severe, and temporarily relieves the pain. The matter vomited consists, first of the food taken into the stomach, which has a strong acid reaction; later it is mingled with bile. Vomiting of blood is the most characteristic single symptom, but is not pathognomonic. It is absent in about one -third of the cases, and may occur only at the monthly period. Cachexia is a late symptom, the appetite is rarely impaired, sometimes it is even increased. The face, when the pain is intense, is "drawn" and haggard, which by some is regarded as characteristic of ulcer of the stomach. Obstinate constipation is the rule in ulcer of the stomach, but hemorrhage may cause diarrhoea. The blood gives to the dejections a dark color, and a tarry consistence (Bartholow and Loomis). Differential Diagnosis. — Gastric ulcer may be mistaken for cancer of the stomach, hepatic colic, cardialgia, or gastralgia, and chronic gastric catarrh. In cancer there is usually a history of hereditary cancer. Cancer is seldom met with in persons under forty; while ulcer of the stomach occurs most in young adults, and is usually associated with anaemia, chlorosis, pro- longed lactation, or compression of the stomach, as in cases of shoemakers and sewing- girls. The pain in cancer is continuous, and described as lancinating; while in ulcer the pain is inter- mittent, greatly increased by taking food, often referred to the lower dorsal vertebras, and described as. gnawing or burning. In cancer,, hamiateniesis has a sooty or coffee -ground appearance, while in ulcer it is a bright red arterial blood. Vomiting, in cancer does not relieve the pain, is not very severe, and comes on GASTRIC ULCER. 209 late; but iu ulcer it is severe, comes ou early, and affords tem- porary relief from the pain. The cancerous cachexia and de- bility are present early and steadily progress in cancer; while in ulcer there may be pallor, but no characteristic cachexia. The presence of an epigastric tumor establishes the diagnosis of cancer. In hepatic colic, the pain is in the region of the gall- bladder, and shoots to the right shoulder and back, comes on suddenly and suddenly ceases. In cardialgia or gastralgia, the pain is not excited or in- creased by the introduction of food into the stomach, but often comes on when the stomach is empty, while in ulcer the pain is associated with ingestion of food. In cardialgia or gastralgia, pressure over the epigastrium, and the ingestion of food, relieve the pain; the reverse is the case in ulcer. Cardialgia or gastral- gia is relieved by the constant current and faradization, which increases the pain of gastric ulcer. In cardialgia there will be a history of neuralgia in other parts of the body. In chronic gastric catarrh with hemorrhage there is the his- tory of diseases of the liver, heart, lungs or kidneys; while in gastric ulcer there is usually no such history. The pain in gas- tritis is not so intense as in ulcer. A coated tongue, great thirst r malaise, and pyrexia are prominent in cases of chronic gastritis, and absent in ulcer. The vomiting in chronic gastritis conies on in the morning, and the matter vomited is stringy mucus; while in ulcer the attacks of vomiting usually follow the taking of food (Bartholow and Loomis). Prognosis. — Must be regarded as serious (Bartholow). Treatment. — Rest the stomach by keeping the patient in bed, and restricting the diet to peptonized milk — a tablespoonful to a teacupful may be given every two hours during the clay and night. Digested beef-juice may also be given. All vegetables, tea, coffee, starchy foods and fruits must be prohibited. If all kinds of food are rejected, rectal alimentation must be practiced, four ounces of denbrinized blood (containing four grains of chloral to prevent its decomposition) may be thrown into the rectum every six hours (Loomis). Bartholow regards one to three drops of Fowler's solution three times daily the most im- portant remedial agent. He also gives half- grain doses three 210 A COMPENDIUM OF PRACTICAL MEDICINE. times a day of nitrate of* silver. Fifteen grains three times daily of sub-nitrate of bismuth are effective. The flatulence may be mitigated by sulphite of soda, carbolic acid, or the alkalies. The constipation may be relieved by the saline mineral waters, or by castor- oil where the patient will bear it. After some im- provement has been made, rice, soft-boiled eggs, animal broths, .stale bread and cocoa may be allowed. PRESCRIPTIONS FOR GASTRIC ULCER. R Creasoti ITIiv. Aquae gij. — M. .Sig.: A tablespoonful three or four times daily. — Niemeyer. R Liquoris potassii arsenitis gss. Sig.: One drop, repeated as required to relieve the pain and vomiting. — Bartholow. R Skimmed milk two parts and liquor calcis one part, mixed as a steady diet. — DaCosta. R Bismuthi subnitratis gij. Pulv. opii , gr. iij. — M. In pulv. no. xii. div. Sig. : One powder thrice daily, followed continuously by the fol- lowing: R Argenti nitratis gr. v. Tincturse opii 5iss. Aqua? anisi ad §iiss. — M. Sig.: A teaspoonful thrice daily with rest to the stomach. — W. H. Thomson. GLANDS, (Enlarged Lynrphatic.) Chronic glandular enlargement is a very common affection. It is found in the strumous and feeble child as a chronic and slightly painful enlargement of a gland or glands, more particu- larly those beneath the jaw and about the neck. At times these glands suppurate and leave ugly sores. Treatment. — For the ordinary or strumous enlargement of the glands in children there is no drug equal to cod-liver oil, the syrup of the phosphate, or of the iodide of iron, or the tincture of quinine. Good food and fresh air are also essential points in the treatment of these cases (Bryant). ENLARGED GLANDS GLEET. 211 PRESCRIPTIONS FOR ENLARGED GLANDS. R Potassii iodidi 3J--iv. Syrupi aurantii cort ,§j. Aqua? cinnamomii ad §iij. — M. Sig. : A teaspoonful in water three times daily. — Ringer. R Calcii sulphidi gr. vj. In pil. no. xxiv. div. Sig.: One pill every four to six hours. — Ringer. R Syrupi ferri iodidi 3j. Sig.: Five to forty minims, according to age, well diluted, after meals. — Bartholow. R Ungt. plumbi iodidi ,$j. Sig.: Apply to gland. — Bartholow. R Ungt. iodi comp 5j. Sig.: Apply to gland. — H. B. Sands. GLEET. Is a mueo-purulent discharge from the urethra,, the chronic stage of gonorrhoea. In gleet, a certain amount of sticky bluish fluid, often only a drop at the meatus in the morning — continues to be secreted after gonorrhoea, from altered patches of the urethra, or coming from the congested membrane behind a stricture. Gleet, then, is a symptom of two structural lesions, and signifies that there are patches of congestion in the canal, covered or not by granulations, or that stricture exists, and that the discharge comes from behind it. Prostatic congestion and enlargement are also liable to be attended by a slight gleet. Gleet tends to last indefinitely, and an individual so affected is a ripe subject for bastard gonorrhoea. The simple congested patches which furnish the gleety discharge, are kept from getting well by alcohol, malt liquors, sexual excesses, fatigue, violent exercise, anaemia, gouty or strumous habit. Gleet is contagious when purulent, but only if it contains gonococci. All urethral discharges become gleety before they cease (Keyes). Treatment. — Eyerything earthly has an end, even a gleet, as Thiry has sagely remarked, and no treatment will succeed where over-treatment has only served to keep up the evil. As stricture 212 A COMPENDIUM OF PRACTICAL MEDICINE. already present or forming is the most common of all causes for continued gleet, it should be sought for and treated. Where no lesion is discovered, the urine must be kept mildly alkaline, sexual intercourse avoided, and copabia or oil of sandal-wood or cubebs may be given. Stimulating or astringent injections should be employed, such as follows : R Zinci chlpridi gr. j. Aquae oj- — M. Or, R Cupri sulphatis gr. j. Aqua; 5J- — M. Or, R Ferri persulphatis 3ss. Aquas o vj — M. Or, R Zinci sulphatis gr. l-ii]. Liquoris plumbi subacetatis..dil...Sj- — M. Or, R Aluminis exust gr. x. Aquas 5j- — M. Or, R Acidi tannici gr. v-x. Aqua; oj- — M. Or, R Zinci permanganatis gr. ss-ij. Aqua? oj- — M. 0r ' R Hydrargyri chloridi corrosi gr. ss. Aqua; oxij . — M. Alcohol is often efficient, and may be used as follows : To commence with two parts of rose water to one of red wine, and continue increasing the latter until pure wine can be used. Glycerine may be combined with any of the above formulas. Three points must be remembered in regard to injections : 1. They must not be too strong. 2. They must be continued for at least ten days after the discharge ceases. 3. They may produce a hypersecretion of the urethral mucus, and thus keep up the discharge. Any injection, thrown too deeply into the canal, may light up epididymitis, or cystitis. Deep urethral injections may be used, if the discharge comes from the membranous urethra. Locate the granulating area with a bulb, and there deposit three minims of a solution GLEET. 218 of nitrate of silver of a strength, of gr. i. to grs. xx. to the ounce of water. Repeat the application three times a week. Occasionally a fifty per cent solution in water of the gly- cerole of tannin will arrest a deep urethral discharge after the nitrate of silver fails. Sometimes the passage of a well-oiled smoothly-polished sound as large as the meatus will admit, re- 23eated every third day will cure the discharge (Keyes). PRESCRIPTIONS FOR GLEET. R Potassii permanganatis gr. i iij. Aquae destillatre 3j . — M. Sig. : Use as injection. — Keyes. R Zinci sulphatis gr. vj. Tinct. opii 3j. Tinct. catechu 31J . Aqua? rosre ad §ij . — M. Sig.: Use as an injection three times a day. — Witherstine. GOITRE. (Simple and Exophthalmic). Simple goitre, or Derbyshire neck, as it is generally known in England, is very common. In its most usual form it appears as a simple bronchocele, or hypertrophy of the thyroid gland. They may press upon surrounding parts and cause dyspnoea, cough, and difficult deglutition. All these tumors rise and fall with the larynx in deglutition (Bryant). Cause. — In the Derbyshire district it is generally believed that it is from the water impregnated with chalk, lime, and mag- nesia, that the disease is produced (Bryant). Treatment. — Simple goitres are to be treated on ordinary principles by tonics, fresh air, etc. The air of the room should be kept iodized by means of solid iodine put into a box with a jjerforated lid. Bryant has seen goitres rapidly disappear under this treatment. "With the above treatment he, at times, rubs in an ointment of the iodide of ammonium, a drachm to an ounce. To paint a goitre with the tincture of iodine is useless. Dr. Mouat of Bengal, spoke very highly of an ointment of the binio- dide of mercury (three drachms to a pound of lard)rubbedin for 214 A COMPENDIUM OF PRACTICAL MEDICTJSTE. ten minutes in the sunshine. He gives his cases of recovery by the thousands. Of late years, Bryant injects 20 or 30 drops of a mixture of equal parts of tincture of iodine and alcohol, with success. In some cases, he reports a cure with one injection. Exophthalmic Goitre is a disease characterized by exophthal- mus (protrusion of the eyeballs), enlarged thyroid, dilatation of the arteries, palpitation of the heart, and anaemia. In Germany it is known as Basedow's disease; in England as Graves' disease. Causes. — Bartholow gives moral emotions, fright, chagrin, reverses of fortune and a peculiar condition of the nervous sys- tem as causes. DaCosta says, "This disease is most commonly observed in females, and connected with hysteria, neuralgia, and uterine disturbance, and is considered to be due to an affection of the cervical sympathetic nerve." According to Loomis the enlargement of the thyroid body is due to dilatation of its vessels and protrusion of the eyeball to a dilatation of the vessels behind the globe. Symptoms. — This disease may come on suddenly or slowly. Palpitation is most often the first symptom. The heart beat is always above normal and may reach 200 per minute. A soft blowing, murmur is heard at the base and over the carotids. Sometimes the goitre is the first symptom observed. The thyroid gland occasionally enlarges in pregnancy, but this is accidental. Exophthalmus may be the first symptom. There is a staring ex- pression. There is more or less fever followed by sweat. The patient is nervous, apprehensive, irritable and lachrymose. The patient is pale, anaemic, and amenorrhcea is present in most cases (Bartholow and Loomis). Prognosis. — Must always be guarded (Loomis). Treatment. — Traube achieved great success with five grains of quinine one da} r , and ten grains of iron, in the form of Val- let's mass, the following day. Good results have been obtained from belladonna and ergot. Bartholow has found galvanization of the cervical -sympathetic and the pneumogastric, by placing the of anode under the ear, and the cathode at the epigastrium to be of the highest efficiency. GOITRE GONORRHOEA. 215 PRESCRIPTIONS FOR GOITRE. R Tincture iodinii corap 5J. Sig. : Apply locally with a brush. Also five to fifteen minims in water three times daily internally. (In simple goitre). — Bartholow. R Ungt. hydrarg. iodidi rubri Bj. Sig.: Rub in a piece the size of a pea and expose to the sun. (In simple goitre). — Ringer. R Potassii bromidi §ss. In pulv. no. xii. div. Sig.: A powder in half a tumblerful of water three times daily. (In exophthalmic goitre). — Hutchinson. GONORRHEA, Is a urethral inflammation, a strictly local affection, exerting no poisonous action upon the blood, and is the most venereal of all the venereal diseases. Urethritis signifies simply inflammation of the urethra, consequently gonorrhoea is urethritis, but ureth- ritis may not be gonorrhoea. Gonorrhoea alone produces gonorrhoea. The term urethritis shoulol be reserved for all inflammatory urethral olischarges having another origin, and for all cases of doubt. "It is better that a hundred of the guilty should escape than that one innocent person should be accused. 11 Experience proves beyonol a doubt that urethral inflammation attended by an abundant discharge may be acquired by a healthy young lover from his equally healthy young mistress, by a young husband from his wife, and presenting nothing to differentiate it from gonorrhoea (Keyes). Causes. — Gonorrhoea is a notoriously contagious disease, and it may be acquired from any person having it, by the mere con- tact of the discharge with the mucous membrane of the urethra. The only mucous membranes of the body capable of taking on inflammation from the contact of gonorrhoeal pus are, the ureth- ral, vesical, vaginal, uterine, tubal, conjunctival and rectal. A peculiai vegetable parasite, called the gonococcus, is the real cause of gonorrhoea. The three most common forms of urethral flow are urethritis, bastard gonorrhoea, and gonorrhoea. Mechan- ical violence, such as the rough use of instruments in the urethra, 216 A COMPENDIUM OF PRACTICAL MEDICINE. chemical violence, such as acid urine, cantharides, strongly acid or alkaline injections, leucorrhceal discharges, lochial and the menstrual flow may be sufficient to cause urethritis in a perfectly healthy subject. In these cases the patient has a slight uneasy sensation at the meatus, a little smarting, and a pearly drop in the morning (Keyes). BASTARD GONORRHEA. A patient who has previously had gonorrhoea, comes with a little oozing from the meatus, perhaps with no itching sensation, nor any smarting on urination, and states that (perhaps after copious, libations of ale, beer, or champagne) he sinned with a suspicious party, and that while examining himself on the fol- lowing morning, found the little opaline drop. Such a person has a damaged urethra, a patch of chronic congestion, or a stric- ture, and he has irritated this surface and given himself a dis- charge. This is not true gonorrhoea; it is bastard (Keyes). Symptoms. — The period of incubation varies from a few hours to fourteen days. The first symptom in true gonorrhoea is usually noticed on the fifth to seventh day. A tickling, teasing, itchy irritation is first felt at the orifice of the urethra. A slight, bluish discharge is seen between the lips of the meatus, which swell a little and become reddened. A slight stinging is felt on urination. The quantity of the discharge increases, and it becomes opaline. Greater pain is felt in passing water. The meatus feels hot and sore. After the fifth day from its appear- ance the discharge becomes much more copious. It gets thick and purulent, and soon acquires a greenish color. Pain is now felt all along the pendulous portion of the urethra, and the canal is very sensitive to pressure. Pain may be complained of in the groin, testicle, perineum, cord and back. The stream of urine is small, forked, and dribbling on account of the inflammation of the urethra, and retention may come on if the patient has pre- viously had a stricture. The prepuce may become cedematous, occasioning phimosis or paraphimosis. Erections, also, at this time become painful, threatening chordee. Chordee is most fre- quent during the night and toward morning. After the disease BASTARD GONORRHOEA. 217 has continued at its height for from one to three weeks, the pain on urination ceases, and the discharge becomes more watery, and finally diminishes to a drop in the morning. The Duration of Gorlorrhwa is Variable. — A well-managed case lasts from three to six weeks as a rule; but the discharge may continue for months and even years. A first gonorrhoea is the most severe, but is the most certain to get perfectly well. ■ If the disease does not get well, it passes into the gleety stage (Keyes). Complications. — Balanitis, phimosis, chordee, possible reten- tion, haemorrhage, epididymitis, orchitis, gonorrhoeal cystitis, gonorrhoeal rheumatism, gonorrhoeal ophthalmia and gonorrhoeal conjunctivitis are the most important (Keyes). Treatment. — There are two methods of treatment, the abor- tive and the rational. The Abortive Treatment. — Consists in hot irrigation to soothe the membrane and wash out the poison, and in the use of anti- septic, or antiparasitic drugs to destroy the gonococcus. Nitrate of silver and chloride of zinc do more harm than good. The present favorites are prolonged irrigation and varying strengths of the bichloride of mercury. If the abortive treatment is to be tried, it should be used within the first twenty-four hours of the commencement of an attack. The method by anterior irrigation is simply to put a quart of tepid or hot water, at a strength of half a grain of bichloride of mercury in twenty-two ounces (about 1 in 20,000), into a fountain syringe, and press the blunt glass nozzle into the urethra, so that the water shall trickle out slowly alongside of the glass nozzle. Instead of the fountain syringe a little red soft rubber irrigator, called the universal in- jector, may be used. This irrigation is repeated three times a day. The Rational Method. — Consists first in observing the hy- giene of gonorrhoea, which is as follows: Absolute continence until at least ten days after the entire cessation of the discharge, and avoidance of anything liable to induce sexual excitement. No alcoholic stimulants of any sort, and, above all, no malt liquor should be drunk during the treatment. 218 A COMPENDIUM OF PRACTICAL MEDICINE. Increasing Stage. — If the case is seen early enough, mild bichloride irrigation may be tried. The bicarbonate of soda, or better still, the citrate of potash may be given in doses of gr. x-xx. during the second hour after each meal throughout the entire treatment, to keep the urine alkaline. Occasionally twenty grain doses of the bromide of potassium will moderate the ardor urinse better than the citrate. The following is a good combination: R Potassa? citratis 5ii--vj. Bals. copabia? 3iii--yj. Extracti hyocyami fluidi 5ss.-ij. Syrupi acacia? §iss. Aqua? mentha? piperita? q. s....oiij- — M. Sig. : Shake. Teaspoonful in water. Another aid to easy micturition is Milton's plan of immers- ing the penis in hot water before and during the act. A suspen- sory bandage should be worn. When injections are used in the increasing stage, they should be very mild ones, as follows: R Liq. plumbi subacetatis dil §j. Morphia acetatis gr. j . — M. Or, R Zinci sulphocarbolat gr. i-ij. Aqua? §j- — M. Or, R Zinci sulphatis gr. i-iij. Aqua? 5j • — M. (In less acute fom s). Or, R Zinci sulphatis gr. i.-iij. Liq. plumbi subacetatis dil Sj- — M. Or, R Aluminis exust gr. x. Aqua? 5j. — M. Or, if more astringency is required, R Acidi tannici gr. v.-x. Aqua? 3J- — M. A suitable injection may be used two or three times a day. Stationary Stage. — This stage lasts from one to three weeks with very little change. The treatment of the first stage, with- out any injections, must be kept up. Prolonged and frequent warm baths are beneficial in this stage. The most difficult part of the treatment of this stage is to soothe the painful erections GONOEKHCEA. 219 and keep off chordee. The best course is for the patient to keep his urine dilute and alkaline, and to immerse the penis for a long time in very hot water before retiring. He should sleep, lightly covered, on his side, on a hard bed, after a small evening meal. Bromide of potassium, in doses of from thirty to sixty grains at night in water, repeated once, if necessary, will control chordee in some cases. When a patient wakes with chordee, the penis should be plunged into the coldest water which is at hand, or laid along a piece of iron which has been exposed to the cold. He must not " break the chordee." Decreasing Stage. — Injections are of great service in the stage of decline. Any of those already given may be used. If copaiba is well borne and properly administered, it is the most efficient of the anti-gonorrhceal internal remedies. Pills or tablets containing copaiba, sandal -wood oil, cubebs and oil of turpen- tine sometimes act better than any one alone. They may cause an eruption to appear (Keyes). The treatment of the compli- cations of gonorrhoea will be found in the proper order. PRESCRIPTIONS FOR GONORR(EHA. R Balsami copaiba?. Spiritus retheris nitrosi. Spiritus lavandulae comp, aa 3ss. Liquoris potassas 3j. Mucil. acacias, q. s., ad §iv. — M. Sig.: Shake, and take one teaspoonful. ("Lafa}^ette Mixture.") — Charity Hospital. R Balsami copaiba? ^ss. Tinct. ferri muriatis. Tinct. cantharidis aa 5 ij • Glycerinae £ss. Syrupi q. s., ad $iv. — M. Sig.: A teaspoonful after meals. — Burnstead. R Potassii citratis o^s-j. Sp iritus limonis 5ss. Syrupi simplicis §ij. Aquas 5j. — M. Sig.: A dessertspoonful well diluted three or four times daily, fasting. (In the first stage). — Keyes. 220 A COMPENDIUM OF PKACTICAL MEDICINE. R Liq. hydrarg. chlor. corros..( T¥ Vo) Qj- Sig. : Distend the vagina with a speculum and cleanse thor- oughly with the above solution. Then dust over and rub in iodo- form, and tampon the vagina with iodoform gauze. Repeat in three or four days. (In female.) — Schwartz. GOUT. In a constitutional malady, inherited and characterized by paroxysms of severe pain in small joint — the great toe usually — - due to the presence of uric acid in the blood, and the deposit of the urates in the structure of the joints and throughout the body. Gout in the foot is called podagra; in the hand chiragra; in the knee gonagra. (Bartholow.) Causes. — The gouty diathesis may be inherited or acquired. Gout is a disease of middle life. The direct exciting cause is over- eating and the use of alcohol. Of the alcoholic beverages, the sweet wines and malt liquors are considered more gouty than spirits. Lack of exercise, and failure of the excretive power of the kidney and lead -poisoning are influential factors. Men suf- fer from attacks of gout much more frequently than women. As a disorder of the upper classes, gout has had a position of dis- tinction, and S}Tlenham consoled himself for his sufferings from gout by the reflection that it is an eminently respectable dis- ease, by which more rich men than paupers, more wise men than fools are afflicted. It is the large consumption of beer which de- velojDS gout in the laboring classes. Attacks are sometimes at- tributed to prolonged intellectual exertion, anxiety of mind, bodily fatigue, and exposure to cold, and are more likely to oc- cur in the spring and autumn than at other seasons of the year. (Bartholow, Flint and Loomis.) Symptoms. — Acute Gout. — Usually between midnight and four or five in the morning the patient wakes with a burning, throbbing pain in the ball of the great toe, which the slightest j)ressure greatly intensifies. The affected joint becomes red, swollen, hot and shining; the veins are distended, and it resem- bles a joint about to supi3urate. The temperature may in a severe attack reach 105° F. The pulse is full and bounding, but compressible. The pain in the affected joint is so great that the GOUT. 221 patient cannot move it. He tosses about for hours, until finally, in a profuse perspiration, falls asleep. In a few hours he awakes almost free from pain, and remains so during the day; but about the same hour the next night there is a recurrence of the local pain and the fever. These nocturnal attacks continue for two or three days, then the maximum of pain is reached. At the end of a week, they have gradually subsided. Following the attack, there is a feeling of well-being. During an attack, there are anorexia, coated tongue and constipation. The urine is scanty and high-colored. The bladder is irritable, and there is a scalding sensation on urination. An individual may have only a single attack, but usually a second supervenes within a year. Chronic Gout. — When tophi (deposits of urate of sodium) form around the joints, and they become distorted or crippled so that walking becomes difficult, it is called chronic gout. Nodules of the deposit are frequently seen on the helix of the ear, some- times on the eyelids and occasionally on the face. When the stomach, intestine, lungs, heart, liver, kidneys and brain are gouty, it is called irregular and misplaced gout. Gout is a very chronic disease. It sometimes produces subluxation of the joints, and this combined with the tophaceous nodules give rise to striking deformities (Flint and Loomis). Differential Diagnosis. — Gout may be mistaken for rheuma- tism. Gout attacks the small and rheumatism the large joints. A rheumatic attack is of longer duration than a gouty paroxysm. In gout the fever is slight, in rheumatism it is high. In acute rheumatism, the heart is frequently involved, in gout rarely. The gouty attack coming on at night in the great toe joint is in marked contrast to the onset of rheumatic fever. Acute articu- lar rheumatism is a disease of early adult life, while gout is rare before thirty-five. In gout there is a history of high living, in rheumatism there will be a history of exposure or exhaustion. In gout there is an excess of uric acid in the blood (uricsemia ), this is never the case in rheumatism, but is pathogmonic of gout. Tophaceous masses occurring in the external ear, varying in size from that of a pin's head to that of a split pea, are often of great assistance in the diagnosis (Loomis). 222 A COMPENDIUM OF PRACTICAL MEDICINE. Treatment. — 1. General Hygiene. — Gouty subjects should take systematic exercise in the open air, especially horse-back riding, walking, rowing, etc. A country residence, a warm, dry climate, are preferable. The patient should be warmly clad in flannel, retire and rise early, and avoid severe physical and mental strain. 2. Dietetics. — Starving will not cure gout. The principal articles of diet should be beef, mutton, chicken, bread, milk and fruits. All pastry, eggs, tea, coffee, alcohol, cheese, dried meats, tomatoes and strawberries should be avoided. Alkaline mineral waters, seltzers, vichy and lithia may be taken with and after meals. 3. External Treatment. — The affected part should be raised above the body and wrapped in flannel. When the pain is intense opium may be applied to the joint. Vapor and Turk- ish baths should be taken weekly. 4. Internal Treatment. — Colchicum and the alkalies are our chief remedies during the paroxysm. For thirteen centuries colchicum has been used in this disease. Loomis gives one of the following pills every three hours until the specific purgative action of the colchicum is obtained: R Pulv. ipecac Extracti colchi acet Hydrarg. protochlor (calomel) ... Ext. aloes fld aa gr. j. Ext. nucis vomicae gr. \. — M. Carbonate of potash, Rochelle salts and citrate of lithia are important adjuvants to the colchicum treatment. In chronic gout tonics, as iron, arsenic, etc., are usually demanded (Loomis). PRESCRIPTIONS FOR GOUT. R Magnesii sulphatis §j. Magnesias optima? oij- Vini colchici rad §j. Aquas menthse pip §x. — M. Sig. : A tablespoonful every hour until it operates. — Scudmore. R Tinct. iodini 3ijss. Gly cerinee §ij . — M. Sig.: A tablespoonful thrice daily. — Granville. GUMS GASTRITIS. 223 R Paraldehyde 5ss. Syrupi simplicis Siss. — M. Sig. : A teaspoonful to a tablespoon ful, well diluted when re- quired (for gouty insomnia). — Hodgson. R Granulated efferv. lithii citrat §iv. Sig.: One or two teaspoonfuls in water three times daily. — Mattison. GUMS. (Affections of). When the gums are spongy and ill-conditioned, and mani- fest a tendency to recede from the teeth, the following local application is very serviceable: R Aluminis 5j. Vini O.j. Tinct. cinchona? '. ....§ss. Tinct. myrrhse 5ij- Mel. rosse Sij. — M. Sig.: As a mouth wash. — Bartholow. The glycerite of tannin is a useful application for spongy and bleeding gums. When fetor is present, carbolic acid and iodoform are most serviceable. The tincture of benzoin, with or without glycerine, is very effective. PRESCRIPTIONS FOR SPONGY OR BLEEDING GUMS. R Chloral hydratis Tinct. cochlearise aa 5 iss. — M. Sig.: Apply to gums, by means of a pleget of cotton every day or two. (For gingivitis of pregnancy). — Pinard. R Tinct. myrrhse oih-iv. Aquse vel. infusi cinchonas siv. — M. Sig.: Use as a gargle. (For spongy or ulcerated gums). —Phillips. R Glycerite acidi tannici 3j. Sig. : Apply with camel's hair brush. — Bartholow. GASTRITIS. (Toxic.) Is an acute inflammation of the stomach, caused by the in- gestion of irritant and corrosive poisons. 224 A COMPENDIUM OF PRACTICAL MEDICINE. Symptoms. — Besides the vomiting which occurs immediately or very soon after swallowing the irritant, corrosive or toxic sub- stance, purging sets in and the same sloughs of the tissues dis- charged by vomiting pass also by stool. In the case of corrosive sublimate and the metallic salts generally there occur intense colic and tenesmus, and the discharges consist of mucus and blood and strongly simulate dysentery. Arsenic, the salts of mercury, copper, zinc and nitrate of potash, produce an intense inflammation. Sausages, hams, cheese, fish, etc., that have under- gone decomposition produce, in a few minutes or hours after swallowing them a violent gastritis. There is great anxiety and depression, a weak, rapid pulse, cold skin, covered with cold sweat, intense internal heat and thirst and burning in the gullet and fauces (Bartholow). Prognosis. — Death may occur from the immediate effects of the poison. Recovery may ensue if the injury done is not too great for repairs. Treatment. — Vomiting is to be encouraged by the free use of demulcent drinks. If the toxic agent consists of an acid, as speedily as possible, weak alkalies, lime water, soda, common soap, etc., should be given. The other poisons require their proper antidotes. The stomach pump should be used not only to remove the poison remaining, but to thoroughly wash out the stomach. To allay the pain, give a hypodermic injection of morphine. Ice should be given freely and an ice-bag applied to the epigastrium. No food should be given, but a little cold milk at short intervals (Bartholow ). GINGIVITIS. (See Gums, Affections of.) GLAUCOMA. This term is used to express a morbid condition character- ized by an increase in the hardness of the eye-ball. The word glaucoma, literally signifies green, and was employed because in certain advanced cases the pupil acquires a greenish hue. The standard of ocular tension varies in its physiological limits. In women it is normally less than in men, in children than in ad- ults. An average of twelve inches of water is normal. The sense GLAUCOMA. 225 of touch must be relied upon for the tension, and one finger of each hand is to be lightly pressed upon the e}^e as when feeling for fluctuation in an abscess. When the tension is increased it is called plus, when diminished minus tension (Noyes). Varieties. — 1. Glaucoma simplex. 2. Glaucoma with inflam- mation. 3. Glaucoma hemorrhagicum. 4. Secondary glaucoma (Noyes). Symptoms. — The simple is the most frequent variety, is in- sidious and very slowly progressive, occurs most often after mid- dle age and in hypermetropic eyes. The external appearance of the eye may be normal except a notable whiteness of the sclera. The field of vision will be restricted on the nasal side to a greater or less degree. The tension of the eye will be increased.:. Un- commonly strong glasses for reading will be needed. Attacks of sudden obscurity of sight for some minutes have taken place. At times colored rings will be observed around a lamp or gas flame. It is usual for one eye to be affected sometime before the other. It may occupy five to fifteen years for its development, and in old persons be mistaken for senile cataract. When the glaucoma becomes chronic there will be greatly increased hardness with the pupil widely and unequally dilated and fixed, the cornea more or less anaesthetic, the pupil will have a dusky or even greenish hue, and the globe enlarged tortuous arteries. In the inflammatory variety, the person is apt to be taken during the night with severe pain in the eye and forehead. There may be rise of temperature-, rapid pulse and vomiting. On inspection of the eye, the cornea may be hazy, the aqueous will be turbid, the iris and lens pressed toward the cornea, the pupil will be obscured and dilated, and the iris discolored, and diminished to a narrow ring. It is not easy to feel the tension through the swollen lids, and the pressure will be painful. Vis- ion is impaired or wholly lost in a few hours. In the hemorrhagic variety, there is effusion of blood in the retina, or optic nerve, and sometimes in the vitreous. There is a sudden loss of sight, followed by j)ain and inflammation. In the secondary variety, there is increased ocular tension, due to some other disease (Noyes). 226 A COMPENDIUM OF PRACTICAL MEDICINE. Prognosis. — The disease tends to total loss of sight. Treatment. — The merit of having discovered that iridectomy is capable of curing glaucoma, stamps the name of Graefe with undying honor. Up to his time no remedy was known, and now no remedy, except an operation, is of positive value, and the most favorable results are gained when it is done at an early period. Acute attacks occur in chronic glaucoma, and these are controlled by combining a 4 per cent, solution of cocaine muri- ate with solution of eserine sulphate (gr. i. to si. ) Each may be put up in gelatine wafers, and put in the eye every hour. Extremely hot fomentations will give relief, and morphine may be given at night. Atropia and all mydriatics should be avoided, .as they tend to aggravate the symptoms (Noyes). GRANULAR LIDS. (See Trachoma). GRAVES' DISEASE. (See Exophthalmic Goitre). GRAVEL. (See Calculi Eenal ). GREENSICKNESS. (See Chlorosis). GUMMA. (See Syphilis). GIDDINESS. Treatment. — Cod-liver oil and quinine is the best treatment for giddiness in the aged, that is, when this symptom is not as- cribable to serious organic brain disease, but probably to ather- omatous changes in the brain vessels, or to a weak heart. GLANDERS. Is a contagious disease of horses, which may be transmitted to man. The nodules of glanders are most frequently found in the nose of the horse, but in this animal, as well as in man, the nodules may be found in the skin, the mucous membranes, and viscera. The nodules usually suppurate (Flint). Treatment. — There is no drug which has any influence on the disease. Fresh air, tonics, such as quinine and iron, should be GLYCOSURIA GOINTAGRA HAEMATEMESIS. 227 given. When the nose or throat is the source of trouble, it should be washed with water rendered antiseptic by iodine, car- bolic acid, Condy's fluid or creosote, nitrate of silver solution, tannic acid, etc. Nitro- muriatic acid lotion, and a gargle of chlorate of potash should be used in the throat (Bryant). GLYCOSURIA. (See Diabetes Mellitus.) GONAGRA. (See Gout.) MMATEMESIS. Is vomiting of blood. It is a symptom in a variety of diseases. Rupture of a blood vessel is one of its essential con- ditions. Causes. — Injury to the mucous membrane of the stomach by traumatism or poisons, diseases of the wall of the stomach, ob- struction to the portal circulation, blood-poisoning, cancer and ulcer of the stomach, stoppage of the menses in the female, and sudden arrest of hemorrhoidal discharges may cause it (Loomis). Symptoms. — If the hemorrhage is profuse, the patient has a sense of heat and distention in the epigastrium, with nausea and vomiting, becomes pale, has a cold clammy skin. If the blood is vomited in large quantities immediately after the bleeding has occurred, it will be partly fluid and partly coagulated; but if re- tained for a time, it will be fluid and have a black or brownish - black appearance, with an acid reaction (Loomis). Differential Diagnosis. — Haemateruesis may be confounded with haemoptysis or blood- spitting. Haemoptysis is preceded by bronchial or pulmonary symptoms, and haematemesis by gastric symptoms. In haemoptysis there is a sense of constriction across the chest, with dyspnoea and cough. In haematemesis there is nausea, with a sense of oppression and distention in the epigas- trium. In haemoptysis, blood is coughed up in mouthfuls, bright red, frothy, alkaline and mingled with sputa. In haematemesis, blood is vomited more or less profusely, is dark colored, mixed with food, coagulated, and often acid. In haemoptysis there is a sense of trickling behind the sternum, and for a few days after the hemorrhage, small blood-spittings (Loomis). 228 A COMPENDIUM OF PEACTICAL MEDICINE. Treatment. — During the hemorrhage the patient must be kept absolutely quiet, in a horizontal position. Ice should be taken freely, and ice-bags applied to the epigastrium. Morphine and ergotin may be given hypodermically. Brandy may be given by the rectum or hypodermically. Milk is the only diet allowed for the first week (Loomis). PRESCRIPTIONS FOR H/EMATEMESIS. R Liquor ferri subsulphatis §ss. Sig.: One or two drops in ice water frequently. — Bartholow. R Ferri et ammonii sulphatis gr. xL. Aqua? cinnamomi liv. — M. Sig. : A teaspoonful every two or three hours. — Hartshorne.. R Ergotin gr. xij. Aqua? destillata? 3j . — M. Sig.: Five to ten minims hypodermically every three hours. — Ringer. R Acidi gallici gr. x. Acidi sulphurici dil XH. x. Aqua? §j.— M. Ft. haustus. Sig : To be repeated in four to six hours if necessary. — Bruton. R Tinctura? hamamelis §ss. Sig. : Two to four drops every two hours. — Ringer. R Acidi tannici 5j- Aqua? Sj • — M. Sig.: A teaspoonful frequently. — Bartholow.. HEMATURIA. Is the passage of urine containing blood. The origin of the blood may be at any point from the meatus to the malpighian tuft. It is a symptom and not a disease. Causes. — Active and passive hyperaemia of the kidney, acute suppurative nephritis, tuberculosis and stone in the kidney and pyelitis are causes. Turpentine, cubebs, copaiba, cantharides, etc., may cause blood in the urine. The causes in the ureter are cancer, polypi, ulcers and calculi. The causes in the bladder are cystitis, cancer, abscesses in the wall, polypi, stone, rupture,. HEMATURIA. 229 tuberculosis, etc. The causes in the urethra are urethritis, chor- dee, cancer, fracture of the penis, enlarged prostate, polypi, caustic injections, chancre and chancroids, phimosis, impacted stone, etc. The general causes of haematuria are acute infectious diseases, as fevers, especially malarial, scurvy and purpura. Haeniaturia is endemic in some localities, as South America and Isle of France, due to a parasite (Loomis). Symptoms. — The urine may be almost black and loaded with clots, or it may be only slightly smoky or pinkish in color. It is albuminous. The blood usually comes from the urethra, the bladder, or the kidneys. To determine the source of the blood the following rules may be observed: Urethral hemorrhages are independent of micturition, as only a residue of blood is washed out at the beginning of the flow of urine, and some of the blood will reach the meatus between the acts of micturition. Blood effused into the urethra clots there and assumes the shape of a leech, and usually comes with the first gush of urine. If the bladder is the source of the hemorrhage, the blood flows only at the time of micturition, and follows the discharge of urine. The blood does not equally diffuse through the urine, so that the first passed is clear or nearly so, but at the end of the act the urine is much more deeply colored, or pure blood, in a liquid form, or in clots is voided. There is usually pain over the bladder, with a frequent desire to pass water, and a stoppage in doing so. In renal hemorrhage, there is pain in the lumbar region, and the blood is mingled with the urine, and is commonly as profuse at the commencement as at the end of micturition. Should blood globules, albumen, casts, and blood moulded in the form of renal tubules be found in the urine, renal disease may be regarded as the cause of the haematuria. Treatment. — When the haematuria is profuse or persistent, the patient should be placed in a recumbent position, ice-bags applied over the seat of the hemorrhage, and haemostatic reme- dies used, such as gallic or tannic acid, ergot, acetate of lead, and astringent ferric preparations (Loomis). 230 A COMPENDIUM OF PRACTICAL MEDICINE. PRESCRIPTIONS FOR HEMATURIA. R Mucil. acacise q. s Syrupi simplicis Siij . Olei gaultherise gtt. viij. Olei terebinthinse Sss. — M. Ft. emulsio. Sig. : One to three teaspoonfuls every three hours. — Hunter. R Acidi gallici 5ss. Acidi sulphurici dil 5j- Tinct. opii deodorat 5j- Infusi digitalis 5iv. — M. Sig. • A teaspoonful every four hours. — Druitt. R Tinct. ferri muriat XHxxx. Tinct. digitalis 21Tx v. Aqua? menthte pip siss. — M. Ft. haustus. Sig.: To be repeated every four hours. — Aitkern. HEMOPTYSIS. Is the spitting of pure blood. The sputa are streaked with blood in bronchitis, intimately admixed with blood in pneumonia, (the rusty colored matter), yet we do not call this haemoptysis (Loomis). Causes. — Pulmonary congestion, pulmonary apoplexy, and inflammation of the lungs and bronchi may cause spitting of blood; but hemorrhage from the bronchial tubes is by far the most frequent cause of blood spitting or haemoptysis. Ulcera- tion, over distension, and weakness of the capillary walls of the bronchial mucous membrane are the chief causes of bronchial hemorrhage. Bronchial catarrh, phthisis, inhalation of irritating gases or vapors, passive hyperemia of the lungs from obstructive heart disease, intense active hyperaemia, the violent coughing of bronchitis, pertussis, and pneumonia, and suppression of the menses may cause it. Ulceration of an exposed vessel in ad- vanced phthisis will cause it (Loomis). Symptoms. — All bronchial hemorrhages are attended by the spitting of bright red, frothy, arterial blood. They may come on suddenly without any warning, but usually there is a sense of HAEMOPTYSIS. 231 constriction at the upper portion of the chest. Cough may or may not precede the hemorrhage. Usually the patient feels as if some fluid had suddenly commenced trickling under the ster- num, and he notices an unusually sweetish or saltish taste in the mouth. The blood in the throat brings on fits of coughing. Blood may be expectorated only for a few hours, or for several days. The amount varies from an ounce to a pound. The patient has an anxious expression, becomes tremulous and often faints. Hemorrhage from the lungs weakens a patient. The patient goes on coughing for a few days, expectorating small dark coagulated masses of blood, or blood- streaked sputa. Sometimes the hemorrhage is so profuse that the blood spouts out at the mouth and nose, and this points to rupture of an aneurism (Loomis). Differental Diagnosis. — Haemoptysis may be confounded with epistaxis, pulmonary apoplexy, hseinateniesis, and aneurisms rupturing into the air passages. In epistaxis, the blood is always coagulated and dark- colored. It is not attended or ^followed by a cough, and blood can always be detected in the nostrils and posterior nares. In hgematemesis, the blood is black, contains no air, has an acid reaction, is mixed with articles of food, and is vomited; in haemoptysis the blood is bright red, contains air, has an alkaline reaction, and is coughed up, while there is no nausea. When an aneurism ruptures into a bronchial tube, the hemorrhage is gen- erally profuse, and it is soon followed by death. The blood spurts out in jets. There is a history of aneurism. If the blood comes from the mouth or fauces close inspection will reveal the fact. Haemoptysis should always excite a strong suspicion of tub- erculous disease (Loomis and Flint). Prognosis. — As to final result is always unfavorable, but haemoptysis rarely proves immediately fatal (Loomis). Treatment. — Absolute rest in a cool room, with the patient in bed and not allowed to sit up, turn over, or even speak above a whisper, is of the greatest importance. If the cough continues, full doses of opium must be given. Ergot, tannin, gallic acid, acetate of lead, spirits of turpentine, persulphate of iron, or a 232 A COMPENDIUM OF PRACTICAL MEDICINE. mouthful of common salt may be administered. When the pulse is full and strong Loomis uses aconite; when it is weak, he em- ploys morphia hypoderniically. Ice -hags may be applied to the chest, and the patient urged to eat ice, and drink freely of cold drinks. Counter irritants are serviceable, such as mustard plas- ter, nvino- blister, or turpentine (Loomis and Flint). PRESCRIPTIONS FOR HEMOPTYSIS, JJr Extracti ergotse fid 5J. Olei gaultherise gtt. iv. — M. Sig. : A teaspoonful every hour at first ; then every four to six hours. —Ringer. J& Infusi digitalis §iv. Sig.: A tablespoonful every hour until the pulse is reduced. — Brinton. {Jr Sodii chloridi §ij. Sig.: Take half teaspoonful dry. Repeat till nausea occurs. — Ringer. fy Pulv. aluminis 3j. Sacchari albi 3!?s. Pulv. ipecac comp gr. xx. — M. In pulv. no. vi. div. Sig.: One powder every two hours. — Skoda. J& Plumbi acetatis gr. xx. Pulv. digitalis gr. x. Pulv. opii gr. v.— M. Ft. massa et in pil no. x. div. Sig.: One pill every four hours. — Bartholow. HAY=FEVER, Called also summer catarrh, hay-asthma, rose-cold, June- cold and autumnal catarrh, is an acute catarrh of the upper air passages chiefly, occurring at a fixed period annually, and disap- pearing after a variable duration (Bartholow). Causes. — Emanations from roses, and new mown hay, or grasses, and the pollen of wheat, rye, oats and barley may excite the disease. When the neurotic temperament is present and a special tendency exists, various exciting causes, as heat, dust, etc., may excite summer catarrh (Bartholow). HAY -FEVER. 233 Symptoms. — There are two forms in which the disease mani- fests itself — the catarrhal and the asthmatic. Hay-fever is dis- tinctly periodical. It occurs at certain seasons only. In the catarrhal form, the onset is sudden in the majority of cases. The first symptom is an itching of the eyes, nose, behind the posterior nares, and the palate. This is followed by the now of a trans- parent serous fluid, and then sneezing begins. Henry Ward Beecher, himself a sufferer from the disease, describes the sneez- ing as follows: "You never before even suspected what it really was to sneeze. If a pane of glass is gone, you sneeze. If you look into the sunshine, you sneeze. If you sneeze once, you sneeze twenty times. It is a riot of sneezes. First a single one, like a leader in a flock of sheep, bolts over; and then, in spite of all you can do, the whole flock, fifty by count, come clashing over in twos, in fives, in bunches of twenty." The eyes water, and the conjunctiva reddens; the nasal mucous membrane swells and becomes hypersernic; the breathing is carried on by the mouth. There is a sense of heat and burning in the nose and eyes, and pain shoots through the orbits. The throat is hot, dry and swollen. In the asthmatic form, the larynx and bronchial tubes are swollen and hypersemic. There is a croupy, or a wheezy bron- chial cough. The patient is unable to lie down, struggles for breath, is pale, and covered with a cold sweat. The duration of hay-fever is from a few days to three months, the average being about six weeks (Bartholow). Treatment. — There is no remedy so effectual as removal from the hay fever zone in time to prevent the attack. The patient may be exempt from the attack if on the ocean. The White Mountains, the Catskills, the Adirondacks, the Rocky Moun- tains, and the highest points of the Alleghenies, and many places by the seashore can be resorted to with confidence of re- lief. Quinine has been more useful than any other agent, and should be given in five grain doses three times a day for a week before the attack, and when the first symptoms of irritation of the nares are felt, a solution of the muriate should be applied to the nares. 234 A COMPENDIUM OF PRACTICAL MEDICINE. When the disease has begun, the best results are obtained from fifteen grain doses of iodide of potassium every four to eight hours. Morphine gr £ and atropine gr 2 w are good when there is much secretion. Local applications are more effectual than internal remedies. R Acidi carbolici ^iij. Tinct. iocli 3v. — M. Sig. : Add from one to five minims to a gill of water, and apply to the nose by means of a syringe. A few drops of the tincture of iodine may be placed in a warm vial, and cautiously inhaled. Cocaine in solution or in the form of a pellet placed along- side the septum and allowed to dissolve slowly, has proved to be the most effective agent for affording relief. The dose will be $■-£ gr (Bartholow). e> PRESCRIPTIONS FOR HAY=FEVER. R Cocaine muriatis gr. v. Aquae destillatse oij- — M. Sig.: Apply to nasal passages with a camel's hair brush. — Sajous. R Syrupi acidi hydriodici §iv. Sig. : A teaspoonful every two hours. — Judkins. R Quinine muriatis gr. iv.-viij. Aqua? gj . — M. Sig.: Apply to the nares with an atomizer. — Bartholow. R Antipyrin 5ss. Syrupi aurantii cort Bj. Aqua; ad §iij. — M. Sig.: A teaspoonful one to three times a day. — Cheatham. HEADACHE. Called also cephalalgia, is properly a form of neuralgia, as it can only be referred to the sensory, nerves supplying the men- inges and scalp. It is a symptom occurring in many affections, such as active cerebral congestion, cerebral meningitis, the essen- tial fevers, acute dyspepsia, syphilitic periostitis of the head, in- tracranial tumors, etc. Headache is extremely common. It HEADACHE. 235 occurs in paroxysms, lasting usually from twelve to twenty-four hours (Loomis and DaCosta). Varieties. — 1. Congestive. 2. Astigmatic. 3. Headache from poisoning. 4. Headache in diseases of the brain. 5. Nervous, or neuralgic. 6. Sick-headache. 7. Sympathetic. 8. Uraemic. 9. Anaemic (DaCosta). Causes. — An optical defect, as hyperopia, or astigmatism may cause an intense headache. A severe headache may be depend- ent upon decayed teeth, and will disappear with their removal. In acute inflammation of the brain, the pain is agonizing and continuous, and is associated with fever, vomiting and delirium. In abscess of the brain, and in softening, the headache is less violent, and is accompanied by signs of disturbed intellection and of deranged motion. In tumor of the brain, the headache is apt to be severe and paroxysmal, but intellection is not at first much affected. In congestion of the brain the pain is dull, increased by stooj)ing or lying clown, by long sleep, and by bodily or mental fatigue, with flushed face and throbbing of the arteries of the neck. A form of congestive headache, apt to be relieved by bleeding at the nose, is often seen in young people at the age of puberty; the attacks are brought on by running or other violent exercise. In diseases of the meninges, the pain is constant and fixed, and sometimes very sharp. Nervous or neuralgic headache is most common in women, especially in anaemic women. It is very severe, yet of short duration. Sympathetic headache is found mainly in connection with disorders of the alimentary tube, and of the uterus, and is often worse in the morning, before food has been taken. Headache may be dependent upon various poisons, as in Bright's disease, the retention of a large quantity of urea in the blood becomes the source of persistent pain in the head. Headache is common in lead poisoning, in opium-eaters, in drunkards, and after the use of strychnine and quinine. Headache increased by the erect posture and relieved by lying down bespeaks an anaemic condi- tion of the brain. Sick-headache, or hemicrania, or migraine, or 236 A COMPENDIUM OF PRACTICAL MEDICINE. megrim, lias symptoms which set it apart. The pain is usually attended by nausea and vomiting, is generally at first one-sided, and the patient vomits bile (DaCosta). The vomiting often ends the attack. The face is flushed and red and light is hurtful to the eyes. The paroxysms may last for a few hours, or a day or two. Women are especially liable to attacks about the men- strual period. Attacks may occur every few days, every week, or every month, and in many they are induced by errors of diet. They usually disappear after the age of fifty. Headache of gastric or hepatic origin is commonly frontal and throbbing in character. Headache at the vertex is symp- tomatic of cerebral disturbances, or it is due to reflex irritation, starting in the pelvic organs of the female. Pain in the occipital region is mostly an accompaniment of disorders of circulation, and vaso motor spasm and anaemia in particular. The pain of cerebral compression, or tumor, is generally localized, persistent, and very intense (Loomis and Bartholow). Treatment. — In anaemic headache the inhalation of nitrite of amyl is serviceable. In congestive headache, ergot affords relief. The bromides and hydrate of chloral are sometimes efficacious. The inhalation of a little chloroform is sometimes efficient. Evaporating lotions to the head — alcohol, spirits, vinegar, or ether — in some cases afford marked relief. Hot water to the head sometimes relieves. Strong coffee or tea affords marked relief in some cases. The faradic and galvanic currents may be tried. During the intervals, nux vomica in small doses, arsenic, or small doses of quinia may be tried. The hypophosphites and cod-liver oil, continued steadily for months, have done good in debilitated subjects. Tobacco smoking should be prohibited. PRESCRIPTIONS FOR HEADACHE. R Potassii citratis gr. xx Spiritus juniperi 3j- Spts. aatheris nitrosi 21 (xx. Infusi scoparii oj- — M. Sig.: To be taken thrice daily. (Ureemic form.) — W. H. Day. R Potassii acetatis 5yj. Infusi digitalis Svj. — M. Sig. : A tablespoonful every third hour. (Urcemic headache.) HEART BURN HEMICEANIA HEMIPLEGIA. 237 R Gran, efferv. bromo caffeine Siv. Sig. : A teaspoonful in half glass of water — cold. Repeat in half an hour if necessary. (Nervous form.) — R. V. Mattison. R Zinci phosphidi • gr. iij. Ext. nucis vomica? gr. x. Confect. rosse q. s — M. Ft. massa et in pil. no. xxx. div. Sig. : One after each meal. (Nervous form.) — Fordyce Baker. HEART BURN. (See Acidity.) HEMICRANIA. (See Headache.) HEMIPLEGIA. (See also Paralysis.) Is a motor paralysis of one side of the body. It is generally the result of the lesion above the medulla, and most frequently of the corpus striatum, but may result from injury to a cerebral hemisphere or crus. It occurs on the side opposite to the dis- ease or injury. (Loomis). Causes. — Its most frequent cause is apoplexy, but it may be due to other cerebral injuries or disease, and is frequently func- tional. The cerebral causes are : Compression from bone, blood, pus, or inflammatory exudations, tumors, especially carcinoma sarcoma and gummata. Partial anaemia from thrombosis, embol- ism, softening, aneurism and apoplexy. Encephalitis, abscess, atrophy and sclerosis. The spinal causes are as above, or any disease affecting a, lateral half of the cord. The functional causes are : Hysteria, chorea, epilepsy, diph- theria, malaria, poisons, etc. The muscles of the arm and leg are chiefly affected, while those of the trunk and neck often escape entirely. Of the cranial nerves the third, fourth, fifth, sixth and seventh and twelfth may suffer. If the fifth nerve suffers there will be anaesthesia of the face and cornea and paralysis of the muscles of mastication on the affected side. If the facial nerve suffers, the face becomes a blank and motionless, and the mouth is drawn toward the healthy side. If the twelfth nerve suffers the tongue will then be protruded with the tip pointed toward the affected side. The history of the case, the matter of inva- 238 A COMPENDIUM OF PRACTICAL MEDICINE. sion, and other symptoms, will usually give a clue to the location of the lesion. It has been noticed that paralysis caused by lesions in the motor tract above the ganglionic cells in the anterior cornua of the cord is seldom followed by much muscular atrophy or more than would be caused by inactivity, while disease affecting these cells or the peripheral nerve -trunks produces marked muscular atrophy as well as paralysis (Loomis). Hemiplegia may be feigned: but the results of electricity, and the test proposed by Hughlings Jackson, that the arms do not, as in real hemiplegia, fall forward when the patient stoops, but are retained at the side, will usually detect the fraud (Da Costa). Treatment. — In hemiplegia the constant current may be ap- plied to the brain, for the purpose of improving its nutrition, and the faradic current to the muscles, to prevent wasting and loss of function from disease. In faradizing the muscles in a case of hemiplegia, a current of just sufficient intensity to cause contractions should be used. The hypodermatic injection of strychnine into the paralyzed muscles, after the local troubles have ceased, is very efficacious. In hemiplegia and other forms of paralysis due to intracranial lesions, the indications for the treatment by massage are a lowered state of the nutrition of the paralyzed parts, coldness and blueness of the skin, wasting and contracted muscles, ulcerations, etc (Bartholow). HEART DISEASES. (See each particular affection). Treatment in General. — Overaction of the heart, Avith hyper- trophy, and without valvular lesion, is benefited by a quantity of aconite sufficiently large to moderate the cardiac movements (Bartholow). In simple hypertrophy of the heart, without valvular lesion, the tincture of veratrum viride diminishes the overaction and gives relief. The irritable heart dependent on the excessive use of tobacco, on mental excitement, and on overstrain, is relieved by five drops of the tincture of veratrum viride three times daily (Bartholow). Digitalis is indicated when the action of the heart is rapid and weak, and the arterial tension low. HEART DISEASES — HEMORRHAGES. 239 |fc Extracti ergotae fluidi siiiss. Tincturse digitalis §ss. — M. Sig. : A teaspoonfal three times a day. (In enlarged heart with- out valvular lesion). — Bartholow. {fc Ferri redacti Quininae sulphatis Pulveris digitalis (English). ...aa...gr. xx. Pulveris scillae gr. x. — M. Ft. pil. no. xx. Sig. : One pill three or four times a day. (In irritable heart of anaemia and chlorosis, and in fatty heart). — Bartholow. In dilated heart, with difficult breathing, and general oedema, the hypodermic injection of morphine, the eighth to the sixth of a grain, two or three times a week, possesses a high degree of utility (Bartholow). To stimulate the action of the heart when it flags, the am- monia 2 3re P ara tions have an undoubted effect. It is a most common practice to inhale ammonia to prevent that depression of the heart's action called fainting (Bartholow). |fc Cocaini hydrochloratis gr. yj. Aquae destillatae §iij. — M. Sig. : A teaspoonful three times daily. (In nervous cardiac de- bility). — Rosenbach. |& Tincturse digitalis 5ij. Spiritus chloroformi 5 v. Infusi buchu ad 3xij. — M. Sig.: Two tablespoonfuls in a wineglassful of water three times daily. (In simple cardiac debility). — Fothergill. Jfc Strychnia? sulphatis gr. j. Aquae 3J. — M. Ft. sol. Sig. : Eight to fifteen minims hypodermically. (For exhausted heart muscle and its nerves). — Habershon. {& Vini cocae Mariani 0. j. Sig.: A wineglassful three or four times daily (In overstrain of heart). HEMORRHAGES. Treatment. — Digitalis has an undoubted power to arrest hemorrhage. The mechanism of its action is similar to that of 240 A COMPENDIUM OF PRACTICAL MEDICINE. ergot; it slows the action of the heart and contracts the arte- rioles. R Infusi digitalis §ij- Tincturse kramerise Ext. ergotse fluidi aa §j. — M. Sig. : A tablespoonful pro re nata. — Bartholow. Active hemorrhage, occurring in the plethoric, is sometimes stopped by full medcinal doses of veratrum viride (tincture XII v). The value of acetate of lead in various forms of hem- orrhage has been attested by an immense clinical experience. In haemoptysis and haeinatemesis it is a most useful haemostatic, given in live grain doses every three hours. Chloride of barium in close of gr., 1-10-gr., ss. has proved very useful in hemorrhage. Ipecac is a most valuable remedy in haemoptysis, epistaxis, men- orrhagia, postpartum hemorrhages, etc. It arrests all kinds of hemorrhage, and should be given in frequently repeated doses until vomiting occurs. R Extracti ipecac fluidi sij. Extracti ergotse fluidi giv. Extracti digitalis flcl 3ij— M. Sig.: Thirty minims to a teaspoonful at a dose as required. — Bartholow. The fluid extract of ergot will often arrest the bleeding of hemorrhoids and cause such a contraction of the vessels in recent cases, as that the symptoms may entirely disappear. Ergot is used in various forms of hemorrhage. It is used in epistaxis, haemoptysis, renal, intestinal and uterine hemorrhage. One to two drachms of the fluid extract, given every half hour or hour, will be necessary in urgent cases. In haemoptysis the ergot may be given as follows : R Extracti ergotse fluidi Siij. Extracti ipecac fluidi. Tinct. opii deodorat aa sss. — M. Sig.: A teaspoonful every half hour or hour. — Bartholow. In renal hemorrhage, the following is useful: R Extracti ergota? fluidi Tincturse kramerise — aa Sij • — M. Sig.: A teaspoonful every hour or two. — Bartholow. HAEMORRHAGE. 241 In passive haemorrhages, the following is useful: R Olei terebinthinse siij. Extracti digitalis fid 5j. Mucil acacias Sss. Aquas menthse pip Sj. — M. Sig. : A teaspoonful every three hours. — Bartholow. The following mixture is very effective in menorrhagia, hae- maturia, purpura haemorrhagica and the hemorrhagic diathesis: R Acidi gallici 5ss. Acidi sulph. dil 5j- Tincturse opii deodor 5j. Infusi rosse comp Siv. — M. Sig.: A tablespoonful every four hours or oftener. — Bartholow. Astringents, such as alum, acetate of lead, iron subsulphate and chloride, sulphuric acid, tannin, gallic acidi and the vegeta- ble astringents are employed locally and systemically in the various kinds of haemorrhage. When the blood pressure is high and cerebral haemorrhage threatened or proceeding, venesection, or leeches, or purgatives (saline) are the most effective. In uterine haemorrhage, full doses of the fluid extract of ergot will give good results. Ipecac carried to nausea merely is highly effective. Digitalis and sulphuric acid diluted in small doses frequently repeated are highly serviceable. Monsel's solution one part and water three parts may be injected into the uterine cavity to arrest bleeding, if the os is patulous (Bartholow). PRESCRIPTIONS FOR HEMORRHAGE. R Argenti nitratis fusae q. s Sig.: Wipe the wound dry, and apply locally. (In leech-bites.) — Ringer. R Acidi acetici dil Svj. Sig.: Apply locally. (For leech-bites, piles, cuts.) — Ringer. R Tinctune opii 5j- Spts. vini gallici oj- — M. Ft. haustus. Sig. : To be taken at once. (In flooding after delivery, with uterine exhaustion.) — Ringer. 242 A COMPENDIUM OF PRACTICAL MEDICLffE. R Tincturse hsemamelis Siv. Sig. : Use pure or diluted. (In cuts, leech-bites, oozing from wounds, etc.) Also internally three minims every three hours. — Ringer. HEMORRHOIDS, OR PILES. Are small tumors at the anal verge. Kinds, bleeding and non- bleeding. The bleeding piles are generally the internal, and composed of a highly vascular tissue involving the mucous membrane of the rectum and the submucous tissue with enlarged arteries and veins. If the artery is enlarged the tumor has a bright-red aspect and is called the strawberry pile. If the vein is enlarged, the tumor has a dusky hue. The non- bleeding, or external piles, are composed of loose folds of the skin that surround the anus, or a varicose, in- flamed or ruptured vein. The treatment of external piles is simple, and excision is the only radical cure. In the earlv stagre of the affection local cleanliness, and ab- stinence fi'om highly seasoned food and strong wines, are mostly sufficient. The bowels must be kept clear. When local irrita- tion exists, an ointment of zinc and the extract of belladonna is very useful (Bryant ). Causes. — Constipation, sedentary habits or occupations, and high living appear to have the strongest influence. Pregnancy and abdominal tumors are causative. Internal piles are very insidious in their growth — bleeding is often the first symptom that attracts attention. Treatment. — Is both medicinal and surgical. All piles do not require removal. The medical or palliative treatment of piles means attention to diet, the giving up of high living and strong drinks, and the taking of simple, nutritious food in mod- eration. The bowels should be kept open by purgatives, or enema. Absolute local cleanliness should always be observed. Bv these different means an attack of piles may pass away never to return. "When the piles are inflamed, hot or cold applications are useful. Surgical Treatment. — Unless the general condition of the patient forbids, all piles, external or internal, should be removed. External piles ought to be removed by abscission. Internal HEMOEETIOIDS. 243 piles ouglit never to be excised, but destroyed by the galvanic or actual cautery, crushing, or the ligature. In Paris a plan of treatment has been successful which consists of forced anal dila- tation, either by the thumbs, or by means of a dilator, the piles withering; after one full dilatation of the anus. The Ligature Method. — The surgeon grasps the base of the pile to be ligatured by a pair of forceps, and separates the pile from the skin and submucous tissue by scissors, and then trans- fixes it with a needle armed with a double silk ligature. He should then divide the cord and tie the pile tightly in halves, and cut off half of the strangulated portion. The other masses are treated similarly. The ligatures slough off about the seventh or tenth day. After Treatment. — After the operation an opiate may be given. The bowels should be left undisturbed for two days, when a dose of castor- oil or enema may be given. If oedema of the parts follow, ice may be applied or a lotion of lead and opium. The Cautery Method. — The galvanic cautery is preferable to the actual. The anus is to be forcibly dilated, and each mass is then to be seized in turn by a clamp, and the projecting half of each mass must then be cut off with scissors, the surface wiped dry, and the cautery, heated to a white heat, applied to the sur- face, the whole projecting portion being burned down to a level of the clamp. The clamp should be removed so as not to dis- turb the eschar. When all the jnles have been treated, the whole projecting mass may be returned into the rectum with the fingers well greased, and a suppository of opiuin or morphine in- troduced at this time to soothe the pain. The after treatment is the same as in ligature. Treatment by Crushing. — A clamp, is to be adjusted as in the operation for cautery, and the protruding pile cut off with scissors. The clamp which is very strong, is left on the pile for one minute. Treatment by the Subcutaneous Injectfon of Carbolic Acid. — It is applicable to internal piles alone, and one pile should be treated at a time, about a week being allowed between the operations. About one to six drops, of a solution of carbolic acid in thirty of olive 244 A COMPENDIUM OF PRACTICAL MEDICINE. oil or glycerine should be injected with a hypodermic syringe into the pile, which turns white, and in successful cases withers without pain or sloughing. Dr. A. A. Smith of Xew York, gives the following: R Acidi carbolici gr. vj. Cocaini hydrochloratis gr. x. Glycerini giij . — M. Sig.. Inject ten minims into the tumor or pile. When a fissure or painful ulcer coexists with hemorrhoids,. its base should be lacerated by forcible dilatation of the anus. In operating on piles the surgeon must be careful not to take away too much tissue. In rectal operations, it is probably advisable to use anaesthetics in all cases (Bryant). PRESCRIPTIONS FOR HEMORRHOIDS. R Ferri sulph gr. xx. Pulv. aloes Soc Extracti opii aq Sapo cast aa gr. x. — M. Ft. pil. no. xx. Sig.: One pill morning and' evening: — Fordyce Baker. R Tincturae nucis vomica? 3j. Ext. ergotaefld Jj.— M. Sig. : A teaspoonful three or four times a da}'. (For bleeding piles and post partum piles). — Bartholow. R Tinct. hamamelis §iv. Sig.: One-half to one teaspoonful in an ounce of cold water, in- jected into the rectum daily before rising. Also take internally two to five minims three times daily. — Ringer. R Acidi nitrici Bss.-j. Aqua? iviij. — M. Ft, lotio. Sig.: Apply as a wash. (In bleeding piles). — Ringer. HEPATITIS. (Interstitial). (See Cirrhosis). HEPATITIS. (Circumscribed Suppurative.) Is an abscess of the liver. Causes. — Pysemic infarction, phlebitis, the result of opera- tions on the intestines (as for prolapsus ani, hemorrhoids, and HEPATITIS HERPES. 245 strangulated hernia), and intestinal traumatism, may give rise to abscess of the liver. Hot climates, miasmatic influences and dysentery are regarded as causes of abscess of the liver. Ulcera- tion of the stomach, of the intestine, gall-bladder and appendix, ulcerative endocarditis, and cancer of the stomach are often associated with abscess of the liver. Obstruction to the common duct, by worms or calculi may lead to ulceration followed by abscess of the liver (Loomis). Symptoms. — A slight feeling of chilliness, sometimes a dis- tinct chill, is followed by dull pain and weight in the right hypocondrium, the pain often radiating to the tip of the right shoulder. The chilly sensations recur. The pain increases and is aggravated by position and pressure. The tongue is brown and furred, there is loss of appetite, slight nausea, and often vomiting. There is dyspnoea and a short dry cough resembling that of pleurisy. With the formation of the abscess, there are hectic rigors and recurring night sweats, persistent and profuse vomiting, the pain becomes sharp and localized, the temperature rises, and exhaustion and emaciation are rapidly developed. Hepatic abscesses may be discharged in a variety of ways : through the abdominal wall, into the peritoneal cavity, into the stomach, intestines, etc. (Loomis). Physical Signs. — If the abscess is large, inspection will show a bulging of the right hypochondriac region. By palpation the liver is enlarged and has an uneven feel. The pain is increased by pressure, and localized. Fluctuation may be present. By percussion the area of hepatic dullness is increased. Prognosis. — The majority of abscesses of the liver terminate fatally. Treatment. — When pus has formed, and the locality of the abscess can be determined, aspiration should be performed. The abscess should be opened as soon as possible (Loomis ). HERPES, Is an acute, non-contagious affection, characterized by the development of one or more groups of vesicles, and accompanied by burning heat, pain or itching, which runs its course in from one to three or four weeks, and may recur ( Anderson ). 246 A COMPENDIUM OF PRACTICAL MEDICINE. Varieties. — 1. Herpes facialis. 2. Herpes praeputialis. 3. Herpes iris. 4. Herpes zoster, or shingles. Herpes facialis is the most frequent, and the parts most commonly attacked are the red portions of the lips, but any part of the face, or even the mucous membrane of the nose, palate or tongue may be involved. At first there is redness and burning heat, then little elevations appear, which soon develop into vesi- cles, often of large size; these at first are filled with clear serum, which soon becomes opaque or even purulent. Causes. — In many cases it is consequent upon catching cold, or upon digestive derangement. It is also, a very frequent ac- companiment of febrile affections, especially pneumonia in which disease its occurrence may even aid the diagnosis. Herpes preputial is is most often met with on the prepuce, but may be seated upon the glans, or even upon the skin, and in women upon the labia. The vesicles very soon rupture, so that often by the time attention is directed to the part by the burning heat, only a group of little excoriations is to be seen. These are irritated by the secretion and may be mistaken for soft chancres, especially as the eruption sometimes follows connection. This variety of herpes is often very troublesome, and may recur half dozen times in the course of a year. It is said to be more apt to occur in those who have suffered from venereal diseases. Herpes iris is rare, and is met with in young persons. It occurs in spring and autumn, and attacks most usually the dorsum of the hands and feet, and the fingers and toes. All the colors of the rain- bow may usually be observed at one time or another in the course of the disease. Herpes zoster 1 or Shingles, is the most serious of the forms of herpes, and differs from the others in that the erup- tion follows the course of certain cutaneous nerves. In its most typical form, it affects one side of the chest. It may attack other parts of the trunk as well as the extremeties, the head and neck, where it also follows the course of a nerve. Neuralgic pains usually accompany it (Anderson). Treatment. — In all varieties of herpes the part must be dusted with some soothing powder. Arsenic is the best internal remedy. The diet should be light, and saline aperients should HERPES — -HICCOUGH. 247 be used. Dr. Meredith recommends the painting of the part with oil of peppermint to relieve the pain (Anderson.) PRESCRIPTIONS FOR HERPES. |fc Zinci oxidi 31J. Glycerin* gij. Liq. plumbi subacetat dil giss. Liq. calcis §vi.-viij . — M. Ft. lotio. Sig. : Apply locally. — Tilbury Fox. J& Hydrargyri chloridi mitis 3J. Unguenti simplicis §j . — M. Ft. ungt. Sig. : Apply locally. — Pareira. HICCOUGH. Treatment, — Apomorphia cured a case of persistent hiccough when hypodermic injections of morphia and atropia had failed. Camphor has been recommended in hiccough. Chloroform, com- bined with opium, is said to control persistent hiccough (Ringer). A hypodermic injection of morphia often arrests persistent hic- cough. Cases of obstinate and even dangerous hiccough are reported which have been immediately cured by drinking an in- fusion made with a teaspoonful of mustard steeped in four ounces of boiling water for twenty minutes, and then strained (Ringer). PRESCRIPTIONS FOR HICCOUGH. Jfc Pilocarpine muriatis gr. ^. A que destillatse XHx . — M. Sig.: Inject hypodermically. — Ortille. Jfc Pulveris sinapis 5j- Aqua? bullientis , 3 iv. — M. Ft. infusum. Sig. : Take at one draught. — Ringer. Jfc Apomorphia? muriatis gr. -fa. Aqiue destillata.' 2.1Tx. — M. Sig.: Inject hypodermically. — Ringer. 248 A COMPENDIUM OF PRACTICAL MEDICINE. HYDROCEPHALUS. Is dropsy of the brain. It may be congenital or acquired. The congenital consists in an excess of the cerebro- spinal fluid, lying either externally to the brain, or more frequently in its in- terior (Smith). Causes. — Syphilis may be a cause of congenital hydrocepha- lus, but in many cases the cause is unknown. It may be associ- ated with spina bifida (Smith, J. L.) Symptoms. — -While the volume of the head increases, emaci- ation of the neck, trunk and limbs is common. In the last stages, there is more or less vomiting. As the liquid increases, the child becomes drowsy and takes no notice of objects, and finally convulsions occur (J. L. Smith). Prognosis. — Unfavorable, Treatment. — Digitalis, squills, acetate of potassium, and iodide of potassium are the remedies for this affection. One or two grains of iodide of potassium may be given every two hours to an infant of three months. A close-fitting cap may partially prevent the expansion of the head. Tapping frequently gives temporary relief, and should be performed with a very small trocar, which should be introduced in the coronal suture about an inch external to the anterior fontanel (J. L. Smith). Causes of Acquired Hydrocephalus. — Meningeal inflammations, tumors or other causes which obstruct the venous circulation, prolonged passive congestion, affections of an exhausting nature, and protracted infantile diarrhoea. Symptoms. — The child has headache, is irritable, is delirious, drowsy, and its head seems too heavy for its body and is buried in the pillow (J. L. Smith). Prognosis. — Unfavorable. Treatment for the Acquired. — Cold applications to the head. The bowels should be kept open, and derivatives should be applied to the feet and back of the neck. The acetate and iodide of potassium may be given, and vesication should be produced behind the ears (J. L. Smith). HYDROCEPHALUS HYDEOTHOEAX. 249 PRESCRIPTIONS FOR HYDROCEPHALUS. J2r Collodii cum cantharides ^iv. Sig. : Paint the back of neck every few days. — Hartshorne. # Olei tiglii rrtij. Mucil acacise 3ij. Aquae destillatse §j. — M. Sig.: The fourth part every four hours. (Said to remove fluid from the ventricles). — Dungleson. |& Potassii iodidi 3ss-j. Syrupi aurantii cort SJ. Aqua? ad 5 iv. — M. Sig.: A teaspoonful every two hours to an infant of six months. —J. L. Smith. HYDROTHORAX. A dropsy having its seat in the pleural cavity is called hy- drothorax, or water on the chest. It differs from pleurisy in the character of the fluid and in the state of the pleura. In pleurisy the effusion is an inflammatory exudation, and the pleura is the seat of an inflammation; in hydrothorax the fluid transudes, and the pleura is unaffected (Bartholow). Causes. — It is due to an organic disease of the liver, heart, or kidneys, and the serum collects in both pleural sacs. An ef- fusion caused by an inflammation of the pleura is nearly always one sided. It may occur in any exhausting disease which causes general hydraeinia, and is usually associated with dropsies in other parts of the body. Chronic malarial poisoning and Bright's dis- ease may cause it. Symptoms. — There is no fever nor pain in the side. The first symptom referable to the thorax is increasing difficulty of breathing, until the patient reaches a condition of extreme dis- tress; the lips become livid, the finger ends blue, and the respira- tion gasping. He is unable to lie down, and can speak with dif- ficulty. There may be a short dry cough- The physical signs of hydrothorax is fluid in both pleural cavities, which is not at- tended by friction sounds or vocal fremitus (Loomis). Treatment.- — If there is much effusion, delay is unsafe and thoracentesis should be promptly performed. As scrum will 250 A COMPENDIUM OF PRACTICAL MEDICINE. flow through a fine capillary needle, but little pain and no dan- ger attend the operation of aspiration. Such remedies as hydra - gogue cathartics, and diuretics are useful. Elaterium is the best. Digitalis should be given (Bartholow and Loomis). HYPOCHONDRIASIS. Is a disorder of the mind, but the mental aberration is not regarded as amounting to insanity, and patients with this affec- tion are not proper subjects for treatment at lunatic asylums. Cases are frequent and they claim the services of the general practitioner. The characteristic feature of the affection is a morbid apprehension of either the existence of, or a liability to some serious disease (Flint). Forms. — In its mildest form it consists of a feeling of ex- treme delicacy of constitution. Existing in this form, it leads to an anxiety concerning health and over-precautions for its preser- vation. In the severest form of the affection, patients suffer from the conviction that they have an incurable malady. The hypochondriac is the victim of a delusion with respect to his condition. Disease of the heart, consumption, cancer, syphilis, tapeworm, softening of the brain and diabetes are among the diseases which in different cases are supposed to exist. Hypo- chondriacs frequently consult many physicians in succession, but no one is able to convince him of his delusion. Persons of edu- cation and strong mental powers are as liable to the affection as those who are ignorant and of feeble mind. Some patients imagine they have one particular disease, others imagine they have various diseases, or fix upon one for a time and then another (Flint). Causes. — Are both physical and mental. Some persons are constitutionally liable to morbid apprehensions in this direction. Whenever they are ill with any affection, their mental constitu- tion leads to a sense of danger, and to despondency as regards recovery. This state of mind exerts a depressing influence which may interfere seriously with the favorable progress of disease. Masturbation, excessive sexual indulgence and the intemperate use of alcoholic stimulants are causative. HYPOCHONDRIASIS. 251 The reading of legitimate medical works is to be mentioned among the causes of hypochondriasis. Want of mental occuj3a- tion may cause it; and persons who have relinquished active pur- suits often become hypochondriacs. Misfortunes are causative. The physical disorders are anaemia, neurasthenia and dys- pepsia. Treatment. — Remove the supposed causes if possible. Over- exertion, mental or physical, is to be avoided. Sexual abuses, intemperance and any violation of the laws of health are to be inquired into and reformed. Anaemia and dyspeptic ailments claim treatment. Remedies have a useful moral effect within certain limits. Patients often crave remedies. The mental treatment is the most important. It is not wise to attempt to dispel the delusions by ridicule or indifference, but by argument and assurances. The patient's attention should be diverted from himself. Change of scene and new associations should be ad- vised. PRESCRIPTIONS FOR HYPOCHONDRIASIS. R Liq. potassii arsenitis XTTxL. Tinct. opii oi • Aquae menthse pip.. ad giiss. — M. Sig. : A teaspoonful three times daily. (In aged with gloomy fancies). — Lemare-Picquot. R Morphia? sulphatis gr. i-ij. Sacchari lactis gr. x. — M. In pulv. no. xii. div Sig. : A powder three times daily for at least two months. — Hammond. R Mist asafoetidas §iv. Sig.: One to two teaspoonfuls three or four times daily. — Bartlmlow. R Potassii bromidi §ss. In pulv. no. xii. div. Sig.: A powder in cold water three times daily. — Ringer. R Auri chloridi gr. i-iss. Ext. gentianae gr. xv. — M. Ft. massa et in pil. no. xxx. div. Sig.: One pill thrice daily. — Bartholow. 252 A COMPENDIUM OF PRACTICAL MEDICINE. HYSTERIA. Is a functional nervous trouble, characterized by various motor, sensory and intellectual disturbances (Bartholow). Causes. — Hysteria is almost exclusively confined to women. It is most frequent between the ages of fifteen and twenty- five. If the neurotic type of constitution is inherited, in one genera- tion it may assume the shape of hysteria; in the next epilepsy; and in the third insanity. It is not due to derangement of the uterus and ovaries, but to a peculiar morbid state of the nervous system. This peculiar state of the nervous system may be acquired by faults of early training, by a lack of personal discip- line; by mortification or chagrin. Anaemia and an impoverished condition of the blood may cause hysteria. The disturbances may be in the digestive system, in the circulatory, in the sexual, or in the nervous. It is most liable to occur in members of families in which epilepsy, chorea, catalepsy and insanity have occurred. Fright, anger, jealousy, grief and disappointment predispose to its development. Among savage nations and hard working women it is unknown or rare. It is apparently con- tagious (Bartholow and Loomis). Symptoms. — The first symptoms are usually trivial — mere irritability of disposition, rapid changes of feeling, noisy transi- tions of sadness and joy, tears and laughter. There are quick alternations of cold and heat, that are purely subjective; numb- ness, tingling, suffocative feelings, pain around the heart, palpi- tations, quick breathing, a sense of fullness of the stomach, eruc- tations of gas, and the rising of a globe to the larynx (globus hystericus), producing a sensation of choking, restlessness, the whole ending, it may be, in prolonged laughter, but more usually in crying, and in a profuse urinary discharge, the urine being jjale and watery. In the more severe attacks, patients laugh and cry, choke, gasp for breath, sob and cough; the jaws are fixed, the face retracted, the teeth grinding together, the hands clinched, the limbs drawn up and rigid. In some cases there are tonic and clonic convulsions. There is no loss of consciousness. In some cases there is a death-like pallor of the face and half- closed eyes. The attack is more apt to occur during the menstrual HYSTERIA. 253 period. Headache is the most common form of pain. Colics are frequent. Paralysis is sometimes a symptom of hysteria. Gas- tralgia, irritable bladder and spinal irritation are frequent symp- toms (Bartholow). During their hysterical paroxysms, they always want an audience; they crave attention and sympathy. Pain in the skull, as if a nail were being driven into the head, < >r a kettle were simmering on top of it, called by the ancient phv- sicians clavus hystericus, is by many regared as jDathognonionic. The whole or only a part of the cutaneous surface may be hypersesthetic or anaesthetic. There is often pain in the joints. Differential Diagnosis. — Hysteria may be mistaken for epil- epsy, hypochondria and neuralgia. It is distinguished from epilepsy by its slow onset, by incomplete coma, a normal pupil, sobbing and crying. The tongue is not bitten in hysteria. In hypochondria the patient is alvrays morose; there are not those variations in temper that are so characteristic of hysteria. Hypochondria is rare before the thirtieth year, is more common in men than in women. The two diseases may be conjoined (Loomis). Neuralgia, if of hysterical origin, ceases when the patient 1 * attention is diverted. Treatment. — Moral and hygienic measures are most impor- tant. Self-control should be instilled into the mind. Early hours, substantial food, and plain clothing should be insisted upon, while society, the follies of dress and fashion, and dainties should be prohibited. The proper books should be selected for young ladies. Sexual abuses have an injurious effect on the ner- vous system. For anaemia, iron, arsenic, and strychnine should be given. For the seizure, a little fluid extract of valerian, or a few drops of Hoffman's anodyne repeated every few minutes will terminate the attack. In the convulsive form, inhalations of amyl nitrite or of ethyl bromide may be practiced. The mi- graine may be cured by use of mix vomica, arsenic, aconitine, and galvanism. Hysterical aphonia and dysphagia may some- times be cured instantly by faradic applications- Anaesthesia is best treated by the electric brush. The various forms of hyster- ical paralysis require faradic applications. Mitchell has devised a plan of treatment for bed fast hysterical subjects which seems very successful. It consists in the combined use of massa ge, 254 A COMPENDIUM OF PRACTICAL MEDICINE. faradization, and forced feeding. Massage consists in friction, kneading and tapping of all the muscles, in passive motion to all the joints. The diet consists at first of milk only. Xo exercise is allowed, but all movements are made for the patient. The patient is separated from all her former associations and the su- perabundant sympathy of home. She is placed in bed in charge of a nurse, and not permitted to move; the desire for action grows out of the utterly monotonous idleness (Bartholow). PRESCRIPTIONS FOR HYSTERIA. R Tinct. opii oj- Tinct. nucis vomicae 31J. — M. Sig. : Three drops in water thrice daily. (For weight on the head, flushings, hot and cold perspiration). — Ringer. R Paraldehyde rtlxxx. Syrupi simplicis 3ss. Aqua? roenthae pip 5J. — M. Ft. haustus. Sig.: To be taken at a draught. (To produce sleep). R Spiritus aetheis compositi Tinct. valerians amnion aa...§j. — M. Sig. : A teaspoonful in water every fifteen minutes until relieved. — Bartholow. R Apomorphiae muriatis gr. j . Syrupi simplicis 3iv. Aquae ad 3x. — M. Sig. A teaspoonful as required. Repeat in a few hours if necessary. — Ringer. R Ext. salicis nigri Elixir simplicis aa 3 j. — M. Sig.: A teaspoonful three times daily. — Hutchinson. R Ferri citratis oij- Syr. simplicis 5ss. Aquae aurantii flor ad Svi. — M. Sig.: A tablespoonful three times, daily. — Hartshorne. R Ammonii bromidi oij- Spiritus ammoniae aromat 5i- Aquae §iv. — M. Sig.: A dessertspoonful thrice daily. — Hartshorne. HYSTEEIA HEAT STROKE. 255 J& Liquoris potassii arsenitis gss. Sig. : Three to five drops thrice daily after meals. — Bartholow. Jfc Extracti conii fluidi. Ext. hyoscyami fild aa IHvij. Chloral hydratis gr. x. Aqua? ad §j. — M. Ft. haustus. Sig.: To be taken as a single dose and repeated as required. — Madigan. HEAT STROKE. Called also sunstroke, insolation, or heat fever, is the com- plex of symptoms occurring in jjersons exposed to extreme heat nnder unfavorable circumstances (Loomis). Causes. — It is due to the influence of excessive heat — natural or artificial. The habitual consumption of spirits, beer, and al- coholic beverages, and excessive fatigue and overcrowding pre- dispose to attacks. Workmen, soldiers on the march, cab-driv- ers, or brain workers are more liable to be overcome by the heat. Hot, wet, muggy days — our August clog- days — are the most fa- vorable for its occurrence. In Dakota men can work all day ex- posed to the sun when the temperature of the air is at least 140° to 160° while in New York on a cloudy, wet day in August, with the temperature at only 93 degrees, large numbers of men and animals are prostrated (Loomis). Symptoms. — The majority of the cases occur in the middle of the day. In mild cases the patient suddenly becomes exhausted, and probably faints, or becomes semi- comatose. He is utterly jDrostrated; the skin is pale, cold and moist; the pulse is quick and feeble, and all kinds of symptoms are referred to the head — ■ floating, swimming, vertigo, fullness and neuralgic pain. These cases may recover or terminate fatally from heart failure. In a severer form, a man may be struck down suddenly, unconscious- ness suddenly follows; the skin is cold, the jduIsc is feeble, and death may result from heart failure. In another form called thermic fever, the temperature rises to 108° or 110° F. or even higher. This is due to the influence of heat on the nerve centre. It often occurs at night and in those who are dissipated 256 A COMPENDIUM OF PRACTICAL MEDICINE. or worn out. There is great restlessness, thirst, dysjDncea, and the shin is burning hot. Delirium and epileptiform convulsions are common, and finally the patient passes into a complete coma, with sterterous breathing (Loomis). Differential Diagnosis. — It may be mistaken for acute menin- gitis. In the latter the projectile vomiting, the boat belly, the pale face, and the tense, hard, wiry pulse are in striking contrast to the symptoms of sun- stroke. Acute alcoholismus may be con- founded with sun- stroke, but the history of the case will decide (Loomis). Prognosis. — Except in mild cases, is very bad; nearly one- half die (Loomis). Treatment. — The patient must have absolute rest and plenty of cool, fresh air. Stimulants are often necessary. In most cases the cold water treatment is the best. The patient should be taken to the nearest pump, stream or water-tank and im- mersed for a considerable time, or a stream of cold water should be poured over the head, neck and back. In the thermic fever form, ice water should be applied to the surface, the bowels should be moved by a saline and morphine and quinine given. The inhalation of ether or chloroform is often of service in this form (Loomis). HECTIC FEVER. Is a fever of irritation. It accompanies many chronic dis- eases in which destruction of tissues occur, especially phthisis. It is a form of remittent fever, consisting of an exacerbation, once or sometimes twice a day, depending on suppuration in many cases (DaCosta). Symptoms. — One of the first symptoms is a slight increasing frequency of pulse, and a small degree of heat of skin, generally toward evening. The heat is especially felt in the palms of the hands and the soles of the feet. The fever reaches its height about midnight and terminates by a profuse perspiration toward morning. The respiration is quick ancl short. The appearance of the face is characteristic, there being a circumscribed blush in the centre, known as the "hectic flush." The patient loses flesh rapidly. The pulse is above 80 and is soft. The temperature HECTIC FEVER HIVES HOARSENESS. 257 as a rule varies from 99° to 101° F. Hectic fever is always symptomatic of some particular disease, of profuse discharge, as of pus or blood, or of an abscess of the brain, lungs or liver, and is in part due to the entrance of septic products into the blood, as in septicaemia. Treatment. — Remove the diseased part, or let out the pus. The diet should consist of animal and farinaceous food, eo-gs, macaroni, milk, wine, beer, etc. Quinine, sulphuric acid and iron are the medicines generally indicated. For diarrhoea, aro- matic sulphuric acid, opium, and chalk mixture are efficient. Night Sweats. — Sponge the surface with cold water, or alum and water. Fifteen drops of aromatic sulphuric acid three times daily, or an sV gr. of sulphate of atropia combined or not with oxide of zinc, two or three grains, may be given at bedtime (Compend). PRESCRIPTIONS FOR HECTIC FEVER. R Quinine sulphatis oj- In pulv. no. xii. div Sig.: A powder in water three times daily. — Phillips. R Syr. calcis lactophosphat Siv. Sig. : A teaspoonful three times daily. — Beneke. R Tinct. digitalis giij. Tinct. ferri chloridi gv. — M. Sig. : Fifteen drops in water three times daily. — Bartholow. R Antipyrin gr. xL. Aqute oviij. — M. Sig. : Two tablespoonfuls, followed by one tablespoonral every hour till temperature is normal. — Pribram. HIVES. (See Urticaria). HOARSENESS. Treatment. — Chronic bronchitis and hoarseness produced by singing and by simple acute catarrh are relieved by ten minim doses of dilute nitric acid. Aphonia due to fatigue of the vocal cords and hysterical aphonia may be removed very speedily by a 258 A COMPENDIUM OF PRACTICAL MEDICINE. morning and evening dose, (yio-sV of a grain) of atropine (Bar- tholow). Ten grains of alum to the ounce of water is used in the form of spray for chronic coughs and hoarseness (Ringer). Dr. Carson finds that a piece of borax the size of a pea, dis- solved in the mouth, acts magically in restoring the voice in cases of sudden hoarseness brought on by a cold, and frequently for an hour or so, it renders the voice "silvery and clear." Borax is useful in hoarseness common among clergymen and ■singers. In chronic inflammation of the throat, a few applica- tions of glycerine of tannin brace up the tissues and lessen or remove the hoarseness. The ipecac (wine) spray is useful in hoarseness from congestion of the vocal cords. Where the hoarseness has lasted a few days only, or one or two weeks, the spray often speedily cures. At the commencement of a feverish cold, a Turkish bath will cut the attack short, remove the aching pains, and relieve or cure the hoarseness at once (Ringer). HORDEOLUM. (See Stye.) HOUSEMAID'S KNEE. Is an inflammation of the bursa of the knee, between the patella and skin, which is common to housemaids, from kneeling. It is usually chronic, but may be acute. It causes great pain and swelling, the swelling being superficial and in front of the patella. An enlargement of the bursa at the elbow is called "miner's elbow." Bryant has seen the bursa enlarge over the acromian process in men who carry timber; over the tuberosity of the ischium in weavers; over the external malleolus in tailors; over the malleoli, and also the instep, from pressure of a boot; over the ball of the great toe in cases of bunion, etc. Treatment. — Rest, leeches, fomentations and purgatives; if these do not bring relief, an incision should be made into the swelling. After evacuating the contents of the sac, a small quantity of equal parts of tincture of iodine and alcohol should be injected into it. Dr. Lewis recommends injections of carbolic acid. It may be tapped (Bryant and others). HYDROCELE HEMATOCELE. 259 HYDROCELE. Is an accumulation of serum in the tunica vaginalis testis, and it may be of the spermatic cord. The swelling of hydrocele first shows itself at the lower part of the scrotum and gradually rises till it arrives at the abdominal ring. It is of a pyriform shape. Usually it is attended with pain. Commonly there is no discoloration of the scrotum. In hydrocele the testicle is two- thirds of the way down the tumor at the posterior part, but it may sometimes be found in front, or at the bottom. The diag- nostic signs are a sense of fluctuation, transparency, lightness and freedom from j^ain. In very old cases the transparency may be absent. Congenital Hydrocele. — When the tunica vaginalis j)reserves its communication with the abdomen, and then becomes filled with serum, it is called congenital hydrocele. On being raised and compressed the fluid is slowly squeezed into the abdomen, and slowly trickles down again afterward. Treatment. — Is either palliative or curative. The evacua- tion of the serum constitutes the palliative treatment. This is accomplished by a puncture with a small trocar and canula. Palliative treatment is sufficient for children, but rarely so in the case of adults. The radical cure is performed by injecting into the sac a fluid composed of one drachm of tincture of iodine, and one or two drachms of water, after first having withdrawn all the serum from the sac. When the inflammation subsides the fluid generally secretes no longer. Dr. Lewis recommends injec- tions of a half a drachm to a drachm of pure carbolic acid lique- fied with water or glycerine into the sac. In obstinate cases, a free incision into the tunica vaginalis, and the filling of the cavity with carbolic or iodoform gauze to make it fill up by granulation, is also to be recommended (Bryant). HEMATOCELE. Is an extravasation of blood into the tunica vaginalis. It may occur as the result of a blow, strain, or the tapping of a hydrocele, or it may arise without any assignable cause. 260 A COMPENDIUM OF PRACTICAL MEDICINE. There is swelling of the part, which comes on immediately, or soon after the receipt of the injury. It resembles hydrocele as regards shape. At first the tumor is soft, and fluctuation may he detected, but when the blood coagulates it resembles in its character a solid growth. There is testicular j)ain on pressure. It is a non- transparent tumor, smooth and tense (Bryant). Treatment. — In a recent case the first indications are to arrest the flow of blood and relieve pain. The recumbent posi- tion, with testicles raised, is necessary; the ice-bag and cold lotions must be apjDiied. If the blood remains fluid for a long time, tapping may be performed. In chronic cases where there are signs of suppuration, a free incision should be made into the vaginal sac, and the cysts and clots turned out. Then will follow the usual treatment to promote healing by granulation (Bryant). HYPERIDROSIS, (See Ephidrosis.) H^MIDROSIS. Is an affection characterized by a flow of blood from the skin independent of any pre-existing lesion as a wound, abrasion or ulcer. The term literally signifies bloody sweat. Discharges of blood from wounds, abrasions and ulcers of the skin in connec- tion with menstruation, are quite common; but cases in which the flow takes place without any lesions are exceedingly rare. Causes. — The disease occurs most frequently in females, and in connection with amenorrhcea or defective menstruation, being in fact, a species of vicarious menstruation. It has been known to occur in infants and in adult males. It has been supposed that the hemorrhage is due to debility and deterioration of the blood. Treatment. — When the disease occurs in females in connec- tion with the anomalies of menstruation, these must be corrected by the usual means. The abstraction of blood, local and gen- eral, is likely to prove serviceable and to stop the discharge. If the hemorrhage seems to be due to debilit}^, a nourishing diet,, stimulants and tonics are indicated (Anderson). HODGKIx's DISEASE — HYMEN HYPOSPADIAS. 261 HODGKIN'S DISEASE. (See Lymphadenoma). HYMEN. (Imperforate and Rigid). Imperforate hymen is a condition to be recognized and not confused with adherent labia. The hymen is more deeply placed and nearer the orifice of the vagina. When imperforate, it causes retention of the menses, the accumulation of the secre- tions, and a j3elvic tumor usually accompanied by periodic pain and constitutional disturbance (Bryant). Treatment. — Division of the imperforate membrane, or its complete excision to allow of the free escape of the secretions which are usually black, is the proper treatment (Bryant). A rigid hymen is occasionally an impediment to coitus in women who marry late in life; and Thomas Bryant has been called upon on one occasion to divide the hymen of a lady about thirty who had been married for some months and had never had complete connection. HYPOSPADIAS. Is a malformation in which the canal of the urethra, instead of opening at the apex of the glans, terminates at the base or beneath the penis. It is a congenital deformity and is due to an arrest of development of a portion of the lower wall of the urethra. Hypospadias is much more common than epispadias. In examining sixty thousand conscripts, Marchal did not find a a single case of epispadias; but among three thousand conscripts ten cases of hypospadias were found. Hypospadias may occur at any point in front of the membranous urethra, but is more fre- quently confined to the glans penis. The only disturbances caused by hypospadias are functional. The patient may not be able to pass water without wetting himself, and if the opening is too low in the canal he may be impotent (Keyes ). Treatment. — Simple hypospadias rarely calls for surgical in- terference, and hypospadias of the glans penis is unimportant. The operations which have been performed for its relief are not very encouraging in their results (Keyes ). 262 A COMPENDIUM OF PRACTICAL MEDICINE. HEAD INJURIES. Must not be neglected, however trivial. They may be fol- lowed by erysipelas, inflammation and suppuration. Treatment, — They should be sutured at once with edges carefully coapted. Care should be taken to wash away all for- eign bodies and clots with bichloride of mercury solution and a syringe. No part of the scalp however torn should be cut away. The patient should be confined to bed, or to the house, purged and put on a milk diet. The hemorrhage from small vessels is usually controlled by closing the wound and using pressure; larger vessels must be tied (Bryant). Caution. — Every scalp wound should be carefully examined with the finger and probe, to ascertain whether or not fracture of the skull exists. If suppuration occurs as indicated by rigors, chills, dry tongue, with increase of swelling and throbbing pain, the adhesions must be separated and pus let out (Bryant). HORNS. While horns occur normally on the heads of many of the lower animals, they are rarely met with in man. Causes. — We know very little with regard to the causes which induce them. It is probable that in many cases at least local irritation has something to do with their production. Situation. — They are most commonly met with on the head and face, although any part may be implicated. They are more common in females, and are usually seen in persons who have passed middle life. Usually they are solitary, but occasionally multiple. Botge has reported the case of a girl aged 19 who had a horn close to the navel about six inches in length, while on the right labium there was one but a trifle shorter. The most remarkable case is that of a Mexican porter who had a horn on the upper and lateral part of his head which was fourteen inches in circumference around its shaft and divided above that point into three branches. Horns spring from the mucous layer of the epidermis and are composed entirely of epidermic cells. Color. — Horns are usually grayish, yellowish or brownish in color. They grow slowly, years often elapsing before they attain hernia. 263 their full size. The horns themselves are quite insensitive, but by pressure may give rise to pain. Sometimes the skin at their base inflames and suppurates and they fall off ; but they are apt to recur (Anderson). Treatment. — Consists in tearing out the horn after softening it with, poultices, but in order to prevent its return, it is desira- ble to cut out the piece of skin from which it grows, or to caut- erize the bases freely with chloride of zinc or caustic potash (Anderson). HERNIA. Called also rupture, is the protrusion of any viscus from its natural or containing cavity. Rupture is the wrong term, as there is no rupture of the peritoneum; it simply forms a sac or one of the coverings. It includes hernise of the brain, testicle, lung, and mostly of the alimentary canal. Reasons for Studying Hernia. — 1. Because of its frequency; one person in eight is affected with hernia. 2. Because of the effects of the presence of hernia: (a) the individual cannot enter the army or navy; (b) he must pay a higher life insurance; (c) he cannot enjoy the privileges of charity; (d) he is deprived of many pleasures. Classification. — There are ten varieties, five above the linea ilio pectinea, and five below that line. The five above are called abdominal and are: 1. Diaphragmatic. 2. Ventral. 3. Um- bilical. 4. Inguinal. 5. Femoral. The five below are called pelvic and are: 1. Obturator. 2. Ischiadic. 3. Vaginal. 4. Pudendal. 5. Perineal. The Component Parts of a Hernia are: 1. Coverings. 2. Sac. 3. Contents. The coverings of a hernia vary according to the variety and situation. The skin, fascia, muscle, subperitoneal tissue, and peritoneum cover all herniae. The sac always consists of peritoneum. It undergoes changes and may be thin or very thick. The sac is divided into different parts: 1. Mouth. 2. Neck. 3. Body. 4. Fundus. The mouth is the opening be- tween the cavity and the sac. The neck is the narrow con- stricted portion close to the mouth. The body is the pari below the neck. The fundus is the largest portion of the body. Three 264 A COMPENDIUM OF PRACTICAL MEDICINE. Muds of adhesions exist: 1. Adhesions of the guts to each other. 2. Adhesions of the guts to the sac. 3. Adhesions of the sac to the external coverings. The contents of the sac may be the ileum, colon, sigmoid flexure, or caecum. Every viscus except the pan- creas has been found in the sac. Fluid is found in the sac, from ,one ounce to a pint. The fluid is secreted from the sac, and is generally clear, but is bloody in inflamed hernia. A hernia is named by adding " ocele " to the narne of the body contained, or may be named according^ to situation. Causes. — 1. Predisposing. 2. Exciting. — Predisposing causes are : hereditary conformation of the parts, 34 per cent, are of these, 12 per cent, of which are in the first year; structural defects, as large inguinal rings, lax peritoneum, low attachment of the mesentary, wounds and abscesses and sudden emaciation after great corpulence. Exciting Causes are : forced action of the diaphragmatic and abdominal muscles, as in straining at stool, lifting heavy weights, vomiting, crying, coughing in jmeunionia or bronchitis; distension of the alimentary canal; certain forms of violent ex- ercise, as horse-back riding without stirrups; sailors pulling at ropes, and persons riding bicycles. Signs and Symptoms. — By inspection, we observe : a tumor at a hernial opening; a tumor increasing and diminishing in size and weight in the upright and recumbent position; and a tumor with healthy skin over it. By examination, we find that the tumor is reduced by taxis and returns on coughing; that the tumor has an impulse on coughing (unless strangulated); that the tumor may be hard, re- sisting, lobulated as in epiplocele, or soft, elastic and smooth if an enterocele. By inquiry, we learn that the tumor suddenly appeared from above and never from below; that the tumor is not painful, but is uncomfortable; that the tumor is often associated with intestinal disturbance. Diagnosis. — Make the patient stand before you with his back to a table and lean backwards. If in bed make him lie with a pillow under his nates. Note if the tumor is connected with the ring. Place a finger in the ring, through the scrotum, and ask iierxia. 265 patient to cough; you will feel an impulse on the end of your finger. In women, feel for the spine of the pubes and pass your finger up a little. In femoral hernia, feel for pulsation of the femoral artery and ask the patient to cough. Inquire into the history of the patient. See if the tumor is fixed or movable. Percuss the tumor and if intestinal it will be tympanitic, if epiplocele dull, if solid, flat. Hernia is not transparent. A hy- drocele will transmit light unless it contains blood or gut and then it is opaque. In hernia only there will be an impulse on coughing. Treatment of Ordinary Reducible Hernia. — Place the hernia back into its proper cavity and prevent its return by a truss. A truss should be used and the following points observed : 1. Notice the spring — have it not too weak or not too strong; 2. Notice the pad, it should be covered with kid to prevent irrita- tion to the integument; 3. Use a rubber truss in bathing. Put the truss on while the patient is lying down, as in going to bed at night and rising in the morning. Hernia should be kept back all the time, and the patient should never go without a truss. Prof. Dennis has never seen a hernia which he could not keep back with a truss. You should never guarantee a cure by a truss, but the younger the patient, the more likely is he to be cured by the use of a truss. The neck of the sac contracts and the mouth puckers up. There is danger in wearing a truss which does not fit properly. Never allow the hernia to be pressed. Never allow constipation to exist in hernia. Pathological Conditions. — There are certain pathological condi- tions which distinguish hernise, as 1. Irreducible; 2. Incarcerated: 3, Inflamed; 4, Strangulated. An Irreducible Hernia is caused by adhesions, by the nature of the protrusion, by the shape of the hernia (hour-glass ), or by contraction of the ring, or of the abdomen. The symptoms are the same as in reducible hernia. The tumor cannot he made to go back into the cavity. This form of hernia gives rise to colicky pains, intestinal derangement, and is liable to strangulation. As to treatment, the patient should be carefully watched. Let him wear a concave pad truss. The bowels should be moved daily. 266 A COMPENDIUM OF PRACTICAL MEDICINE. Give calomel, or iodide of potassium, to reduce the fat of the patient, aud if then the hernia can be reduced, use a truss. An Incarcerated Hernia is an obstruction in the protrusive parts by fluid, solid or gaseous contents. The causes are diar- rhoea, and faulty digestion with flatulence. This form is usually found in elderly people. The signs are pain with an increase in the size of the tumor; a certain degree of fullness; no heat, ten- derness, or tension. The symptoms are eructation of gas, but seldom vomiting; no circumscribed peritonitis; little or no pyrexia. As to treatment, employ gentle taxis, and as this is being done, jmll the tumor gently from the ring. Apply hot and cold applications alternately. Give an enema high up in the bowels of warm water, castile soap and glycerine. An inflamed hernia is an inflammatory condition of the gut or the sac. The causes are external violence, pressure of a badly fitting truss, local inflammation of the intestine, or of the omentum. The signs are pain with no enlargement of the tumor, a certain degree of hardness, heat, tenderness and tension. The symptoms are, slight but not continuous vomit- ing, simply the contents of the stomach; circumscribed peritoni- tis radiating from the body and neck of the sac; considerable pyrexia. As to treatment, suspend the tumor and apply local applications to produce warmth and heat to the sac. Apply opium and lead wash to the parts. Perfect rest to the bowel should be insured. Internally, give opium to relieve peristalsis and pain. A strangulated hernia is where the sac or contents are so tightly constricted that they cannot be returned to the cavity, and where circulation is arrested. There are two varieties, active and passive. The active is Avhere the sac is suddenly en- larged, or the contents become strangulated with their first descent. The passive becomes suddenly enlarged by the descent of more intestine or omentum, gas, fluid or solid into the sac. Strangulated hernia occurs most frequently in damp weather. The egression or shock is due to the sympathetic nervous system and not to the cerebro-spinal. It simulates cholera. In all cases of severe, sudden illness, look for a strangulated hernia. heejstia. 267 The Local Signs are a tumor which has either never appeared before, or if it has, is now increased in size; a tumor which is very painful, especially to touch, and is irreducible; a tumor which has lost its impulse on coughing. The Constitutional Symptoms are obstruction in the intes- tine with beginning symptoms of circumscribed peritonitis; un- controllable vomiting stercoraceous in character, with colicky pains radiating toward the umbilicus; small, quick, pulse associ- ated with great nervous prostration. A movement from the bowels may take place in strangulated hernia. The Sructural Changes are as follows: The intestine be- comes first congested, then bright red, then mahogany brown, then ashen gray, then purulent, and then fibro- purulent. The sac becomes inflamed and has a crackling sound and feel which denotes gangrene. The Treatment of strangulated hernia admits of no delay. Believe the stricture and return the gut to the cavity if it is healthy. Before you employ taxis, give a hypodermic injection of sulphate of morphine (in and around the ring) to produce quiet and relaxation of the parts. Use a warm bath to relax the abdominal muscles, and the hernia may be reduced while in the bath. This bath is indicated in the active variety only. Vene- section may be used to produce fainting, to relax the abdominal muscles, but this is not advisable because danger may result. Elevate the feet so as to employ gravitation toward the abdomen. Use aspiration in a tympanitic gut to allow the gas to escaj3e. It should never be employed where the hernia is of more than one or two hours standing. In taxis the surgeon must overcome all resistance — flex the legs and relax all the muscles. Invert the patient if the hernia has just happened. Operation. — Operate at once if taxis has been employed by other surgeons; the sooner the better. Employ taxis just before the patient goes under the anaesthetic. There are four stages in the operation: 1. Exposure of the sac; 2. Opening tlie sac; 3. Division of the stricture; 4. Management of the hernia after ex- posure. 268 A COMPENDIUM OF PRACTICAL MEDICINE. The incision should begin above the external abdominal ring one inch, and go to the bottom of the scrotum. Make the line of incision over the mesial line of the tumor. Cut through the skin first then the fascia. Look out next for three vessels, viz : circumflex iliac, external pudic and epigastric. Next cut through the external oblique, the internal oblique, creruaster and dartos. The peritoneum is recognized by its rough cellular appear- ance, by its adhesions to surrounding parts, by having no blood vessels upon it, and by its bluish color and transparency. The intestine can be seen under it. Open the sac at its lower end by taking it up between forceps. A fluid will first appear which is normal. Pass a director into the opening audit will move about freely in the cavity. Next introduce the finger into the sac, the finger having been immersed in a bichloride of mercury solution. Cut on the finger to open the sac. Then divide the stricture at once, and examine the gut afterward. There are three points where strictures may be situated, at the first ring, neck of the sac, or within the sac. But generally it is at the ring. Protect the gut. Introduce a grooved director into the ring and divide the stricture on the director. If the hernia is at the abdominal rings, cut upward and inward toward the umbilicus. If at the umbilicus cut toward the spleen. If at the femoral ring cut inward. Do not put back gut that is gangrenous, and do not leave out healthy gut. Examine it carefully, pull it down to see how much of a stricture there has been, and how much damage is done by the stricture. Note the color of the gat. If it is bright red and elastic, it is healthy and can go back. If reddish brown or black, take the thumb and index finger and pinch the gut a little, hold for a few seconds and let go to see if the blood comes back again to the part. If so it is healthy. If the gut is ashen- gray, collapsed, and has a cadaverous odor, it is not in a condi- tion to go back. If the gut is right to return, take the thumb and index finger and push it back little by little beginning at the ring. In gangrenous gut, let it slough in the wound; because the patient is in collapse, and the gut is inflamed, engorged and not in a proper condition to go back, and the sac is septic, and the HERNIA. 269 gut may retract and then nature has to fe&tore the gut. If this method fails then later on do resection open the wound and bring together the healthy ends of the gut. Keep the parts warm. Give the patient morphine to keep the intestine quiet. Do not give, however, more than two or three doses. Give no food for several days, and then begin nourishment with peptonized milk. Give small pieces of ice to quench thirst. Move the bowels with enema of olive oil, warm water and soap. Do not use purgatives or cathartics. The abdomen may be opened and the gut relieved when obstructed with anything in the way of faeces. When the gut cannot be put back with safety, use the following treatment: Opium, cracked ice, and milk diet. Apply warmth to the sac. Let the gut slough and be drawn back into the cavity as nature may direct. If the peritoneum has adhered to the stricture treat it as best you can. Different Kinds of Hernia. I. Diaphragmatic. — Is a congenital hernia in which there is a fissure in the diaphragm. When the opening or rent in the diaphragm is caused by malformation, or the arrest of develop- ment, it is a fatal condition. It may be caused by traumatism, as the fracture of a rib, or other injuries, or by the intestine go- ing through a natural opening in the diaphragm, on the left side because the liver is on the right. Treatment — The first kind is fatal. The second may be op- erated and sewed up. The third demands no treatment. II. Ventral. — Is a hernia anywhere in the abdominal wall, except at a hernial opening, as between the recti muscles, between the ossa innominata, between the linea alba and the linea semi lunaris, and as the result of traumatism. Strangulation never takes place in hernia due to traumatism. It usually follows lap- arotomy. Treatment. — If the hernia is great cut in and stitch the per- itoneum first and then the soft parts over it. III. Umbilical. — Is a hernia where the cord is tied. It is caused by a malformation and comes in early life. It is also caused by the exertion of the infant. One kind may be situated above the umbilicus in the adult and not in it. 270 A COMPENDIUM OF PRACTICAL MEDICINE. Treatment — In children treat the hernia with a truss and one suitable for the purpose. In adults, a hernia above the umbili- cus is dangerous and is liable to strangulation. If this occurs the patient is most certain to die. If the patient does not die, he will have indigestion, which must be distinguished from acute indigestion and can be by persistent vomiting in hernia. It oc- curs four times in the female to once in the male. IV. Inguinal. Varieties. — 1. Indirect inguinal hernia, or external, is one that goes through the inguinal canal. 2. Direct inguinal hernia, or internal, is one that makes its way directly through the external ring without having passed down the in- guinal canal. When the protrusion takes place above Poupart's ligament, through the intestinal ring, but does not traverse the canal sufficiently far to appear through the external ring, the hernia is called a bubonocele. Indirect inguinal is also called oblique inguinal hernia. Occurrence. — Three-fourths of all cases of inguinal hernia are on the right side of the body, because the liver is pressing above, and the root of the mesentary is lower down on that side, and most persons are right handed. It is more common in males than in females, because the rings are larger. Out of every 100 cases of hernia, 84 are inguinal, 10 femoral, and 5 umbilical. When an inguinal hernia protrudes through the external ring into the scrotum, it is called a scrotal hernia. The tissues that cover in a hernial sac will necessarily depend upon the seat of the hernia. The treatment is the same as in other hernia. V. Femoral. — Is a hernia below Pouparfs ligament, the pro- trusion having come down through the crural ring on the inner side of the sheath of the femoral vessels. It does not appear at birth, nor in early life — about twenty years of age. It is more frequent in women than in men, because Poupart's ligament is longer and weaker, and the pelvis is wider in women. The neck of the sac appears beneath Poupart's ligament and the fundus rolls up over it. Treatment. — Femoral hernia requires an immediate opera- tion. The neck of the sac is surrounded by ligamentous tissue which is unyielding and the danger is great. HERNIA. 271 VI. Ohturator. — Is a hernia which comes out through the obturator foramen. It is most frequent in females on account of the greater inclination of the pelvis. Signs and Symptoms. — There is a tumor at the inner side of the thigh and femoral vessels. There is pain in the knee joint owing to pressure of the tumor on the obturator nerve, and the pain is increased by extending the leg, and by rotating the thigh outwards. Other signs are the same as in any other hernia. Treatment. — Gentle taxis is generally sufficient. It often becomes strangulated. VII. Ischiatic. — Is a hernia which comes out through the ischiatic notch, above or below the pyriform muscle, and under cover of the gluteus maximus. Symptoms. — Same as in any other hernia with one extra — a tumor found on a line drawn from the trochanter major to the sacro- iliac synchondrosis. Treatment. — Careful taxis. If strangulated operate. VIII. Vaginal. — Is a protrusion at the upper and posterior part of the vagina. It comes usually after parturition. Symptoms. — Has all the signs of inguinal hernia and an impulse on coughing. It is a smooth, soft tumor increasing in the upright and decreasing in the recumbent position. It causes tenesmus and cystitis. It is reduced by taxis. Diagnosis.— It may be mistaken for cystocele. The diag- nosis is made by introducing a male sound. It does not become strangulated. Treatment. — It is easily reduced and kept back by a ring pessary. It should be reduced before labor. , IX. Pudendal. — Begins like vaginal. Comes out between the vagina and the levator ani muscle, lies in the long axis of the vagina, presents at the side of the ascending ramus of the ischium. Treatment. — It is easily reduced and kept back by a truss. X. Perineal. — Is a hernia between the rectum and bladder in the male, or between the rectum and vagina in the female. It is more frequent in the female on account of a greater pelvis. Signs. — Are the ordinary ones. It forms a tumor between the tuber-ischii, which increases in size when standing. 272 A COMPENDIUM OF PRACTICAL MEDICINE. Treatment. — Use a special perineal truss after reducing it. Tumors Which Are Confounded with Hernia. — 1. Hydrocele. 2. Spermatocele. 3. Hcematocele. 4. Varicocele. 5. Undes- cended Testicle. 6. Solid Tumor of Testicle. 7. Abscess. I. Hydrocele. — Signs. — 1. Slow growth from below upwards. 2. It has a tense elastic feel. • 3. Transparency. 4. Absence of impulse on coughing. IT. Spermatocele. — Signs. — 1. Situated above the testicle. 2. Notched appear- ance from pressure on the cord. 3. Marked mental effect. 4. Sj^ermatozoa seen under the microscope. Ill Hcern a tocele. — Signs. — Sudden growth following traumatism. 2. Soft fluc- tuating feel. 3. Ecchymosis of scrotum, pain and tenderness. 4. Irreducibility. IV. Varicocele. — Signs. — 1. Slow growth from below upwards. 2. Feels similar to a bag of worms. 3. Reducible, but will return with pressure over ring. 4. It does not involve the spermatic cord. V. Undescended Testicle. — Signs. — 1. Testicular sensation. 2. Pain upon j^ressure. 3. Absence of a testicle in the scrotum. 4. Absence of an im- pulse on coughing. VI Tumor of Testicle. — Signs. — 1. Circumscribed size. 2. Doughy, lobulated feel. 3. Constant situation below inguinal canal. 4. Absence of an impulse on coughing. VII Abscess. — Signs. — 1. Sense of fluctuation. 2. Inflamed integument. 3. Returns without a gurgle. 4. Peculiar impulse on coughing. HYDRONEPHROSIS. Called, also, dropsy of the kidney, consists of an accumula- tion of urine and dilatation of the pelvis and calices, with pro- gressive atrophy of the renal structure (Bartholow). Causes. — It is caused by some obstruction in the urinary passages. The obstruction may be seated in the bladder, pelvis, HYDRONEPHROSIS. 273 ureter, bladder, or urethra. It is usually unilateral. It may be con- genital or acquired. Congenital causes are: 1. A supernumerary renal artery compressing the ureter. 2. Narrowing of the lumen of the ureter. 3. A valve-like impediment produced by an oblique insertion of the ureter into the pelvis of the kidney. 4. Insertion of the ureter into the upper, instead of the lower part of the pelvis. The congenital is often associated with mal- formations of other parts, as imperforate anus, hare -lip, etc. The acquired causes are : 1. The ureter may be blocked by a calculus, by coagula of blood, or by parasites. 2. Diseases of the walls of the ureters. 3. Pressure upon the ureter from without, by a tumor, by a displaced uterus, etc. 4. Diseases of the bladder which involve one or both of the orifices of the ureters. 5. Stricture and hypertrophy of the prostate (Bartholow, Loomis and Flint). Symptoms.- — An important diagnostic sign is the discovery of a tumor in the lumbar region. The tumor is fluctuating and usually lobulated. It causes no pain except by its pressure. In growing, adhesions form which give rise to acute stabbing pains at the time of their formation. If the tumor presses upon the colon, constipation results; if upon the diaphragm, dyspnoea will result; if upon the stomach, there will be nausea and vomiting; if the tumor rests upon the abdominal aorta, a pulsation will be communicated to it. A symptom of almost pathognomonic value is the disappearance of the tumor coincident with the discharge of a large quantity of pale liquid by the bladder. The course of the disease is chronic, and the formation of the tumor slow (Bar- tholow, Loomis and Flint). Differential Diagnosis. — Hydronephrosis may be confounded with ovarian cysts, ascites, hydatid cysts and pyonephrosis. In ovarian cysts, the tumor develops from below. Vaginal and rectal examinations will aid. In ascites, when the position of the patient is changed there is a change in the level of dullness, which never occurs in hydronephrosis. It cannot be distinguished from hydatid cysts unless hydatid vessels are found in the urine. It is distinguished from pyonephrosis by a non-purulent charac- ter of the urine, and by the absence of constitutional symptoms. Treatment. — Remove the cause of obstruction if possible. 274 A COMPENDIUM OF PRACTICAL MEDICINE. Removal of the liquid by aspiration has rji'ovecl successful. A small aspirating needle or trocar should be used. Free opening and drainage is a favorable surgical procedure. Medicine will accomplish nothing. HYDROPHOBIA. Called, also, rabies, is a specific disease due to the inocula- tion of a poison contained in the saliva of rabid animals, notably the dog, and characterized by pain and stiffness of the inoculated part; by exaltation of the reflex faculty, by spasms of the throat on the attempts to swallow, and subsequently at the sight of liquids; by delirium, exhaustion and death (Bartholow). Causes. — The inoculation of man with a specific virus con- tained in the saliva of the dog, cat, wolf, fox, and some other rabid animals, is the sole cause of the disease. A certain predis- position seems necessary, for, of all persons bitten by rabid animals, onlv a small proportion are attached by hydrophobia. The teeth, in inflicting the wound, pass through the clothing, which removes the saliva, and therefore the most of those bitten through the clothing escape infection. All ages and both sexes are liable. Apprehension, fear, excesses of all kinds, fatigue, etc., favor the occurrence of the disease (Bartholow). Symptoms. — The period of incubation varies from a few days to several months or even years. During the invasion of the disease if the wound has not healed, it takes on a livid appear- ance, and becomes painful ; if it has healed, the scar becomes red, irritable, swollen and painful. Sometimes a sensation of cold- ness and of numbness is felt in the bitten member. These local symptoms are soon followed by systemic disturbances. The pa- tient is depressed, apprehensive, melancholic and peevish. The first is called the melancholic stage. There may be slight con- striction of the throat, and difficult swallowing. These symp- toms increase in severity for two or three days, when the patient passes into the convulsive stage. In this stage, there is great restlessness, the eyes have a wild look, are bright, staring, and constantly moving. The mouth and throat are dry, congested, and covered with thick, tenacious saliva which gathers about the lips in frothy masses. HYDROPHOBIA ICHTHYOSIS. 275 Thirst is intense, but the patient cannot drink. The sight of water, or the thought of drinking brings on violent spasms of the muscles of deglutition and respiration. There is intense hyperesthesia, and convulsions follow attempts at drinking. In rare cases there is a paraplegic stage. The hawking and spitting of the patient seems like the bark of a dog. Patients often be- come violent. Duration. — Hydrophobia is a very acute disease. The whole duration of the disease is comprehended in three days to two weeks (Bartholow andLoomis). Prognosis. — Is most unfavorable. Treatment. — When the bite of a rabid animal has been re- ceived, the wound should be scarified, cauterized with a hot iron, or every part of it touched with nitrate of silver. Permanganate of potassium should be tried. There is no specific to prevent the disease, unless Pasteur's inoculations with the modified virus, have this power. Of all the remedies proposed, curare is the only one which seems to possess any power over hydrophobia. One-third grain should be given every fifteen minutes (Bartholow and Loomis). ICHTHYOSIS. Called, also, fish- skin disease, is a rare malady. It is not so much a disease as a deformity. Causes. — The cause is unknown. Symptoms. — There is excessive proliferation of the cells of the epidermis. The skin is thickened, dry, coarse, wrinkled, and discolored. There is defective action of the sudoriparous and sebaceous glands. The scales resemble those of a fish (An- derson). Treatment. — A long course of arsenic is useful. The hypo- dermic injection of ^ of a grain of pilocarpine may be used from time to time. The local treatment consists in the frequent use of baths. Oily substances may be applied to the skin to keep it soft (Anderson). 276 A -COMPENDIUM OF PRACTICAL MEDICINE. PRESCRIPTIONS FOR ICHTHYOSIS. R Cupri sulphatis gr. x. Unguenti sambuci §j. — M. Sig. : Use locally. — Wilson. R Pulv. camphora? gr. x. Ungt. zinci oxidi 5J. — M. Ft. Ungt. Sig.: Use locally. — Erasmus Wilson. R Ulmi corticis ^iiss. Aquae bullien tis Oj . — M. Ft. haustus. Sig.: A wineglassful or two thrice daily. — Lettson. IMPETIGO. Is an acute pustular, inflammatory cutaneous disease. It is the pustular form of eczema. (See eczema.) Treatment. — The glycerite of tannin is an excellent applica- tion for impetigo. Skin- diseases, as impetigo and ecthyma, usually arising from a feeble state of the assimilative function, are cured by quinine. Nitric and nitro -hydrochloric acids have been used with advantage for the cure of impetigo, when depend- ent upon indigestion (Bartholow). PRESCRIPTIONS FOR IMPETIGO, R Plumbi acetatis gr. xv. Acidi hydrocyan clil , ITIxx. Alcoholis §ss. Aqua? §vss. — M. Sig.: Apply locally. — Bartholow. R Zinci oxidi 31J. Glycerinas 5ij. Liq. plumbi subacetatis 3is s - Aquae calcis ad syj. — M. Sig.: Apply locally. — Fox. R Unguenti zinci oxidi §j. Sig.: Apply locally. — Ringer. R Syrupi hypophosphiti comp svi. Sig.: A teaspoonml thrice daily in water. — Jamieson. INDIGESTION INFLAMMATION. 277 INDIGESTION. (See Dyspepsia). INFLAMMATION. Is that nutritive disturbance which is characterized by ac- tive hyperemia or congestion, and active multiplication or pro- liferation of the cells of a tissue or organ (Gross). Causes.— Are predisposing and exciting. The predisposing are gout, syphilis, scrofula, shock, loss of blood, impaired nerv- ous action, bad habits, diabetes, anaemia, etc. The exciting causes are cold or heat, injuries, acid or alkalies, parasites, and the results of the ptomaines of micro-organisms on the tis- sues. Symptoms. — A part is acutely inflamed when it is hot, red, swollen and painful. The local symptoms are : 1. Redness, which is caused by an afflux of blood to the part. Redness is not al- ways a sign of inflammation, unless it be permanent. 2. Heat, which is always present, and is due to an iu creased flow of blood to friction against the walls of the vessels of the part and to cell proliferation. The inflamed part is a heat-producing area, thus causing fever by overheating the blood. 3. Swelling, which is due to capillary engorgement, and effusion of serum into the tis- sues. The swelling is greater where the tissues are lax. And 4. Pain, which is usually felt at the seat of the morbid action. Pain sometimes suddenly leaves a part, which is a sign of com- mencing mortification. The causes of pain, are compression, stretching, irritation and disorganization of nerves. Its charac- ter varies; it may be sharp and lancinating, as in inflammation of serous membranes; acute and throbbing, as in formation of pus; dull and heavy, as in periostitis; annoying, as in toothache; sick- ening, as inflammation of the testes, itching, as in affections of the skin; or burning and scalding, as in gonorrhoea. The pain in inflammation comes on gradually, is persistent, aggravated by pressure and muscular contraction, and is fixed; there is febrile disturbance, accompanied by redness, heat and swelling. The pain of spasm comes on suddenly, is intermittent, relieved by pres- sure; is not fixed, there is no fever, and is not accompanied by redness, heat or swelling. Theofpain neuralgia is paroxysmal, is 278 A COMPENDIUM OF PRACTICAL MEDICINE. aggravated by pressure, is not fixed, and is unaccompanied by fever, redness, heat or swelling. Constitutional Symptoms. — In mild cases there is no consti- tutional disturbance, but if the inflammation be at all severe, fever will follow. The fever is usually ushered in with a chill. The tongue becomes furred and unclean, there is great thirst, want of appetite, the bowels are constipated, the urine is scanty, the skin hot and dry, and the heart's action increased (Coin- pend). Products of Inflammation. — Are fibrin, serum, pus cells and red blood- corpuscles. The first effect of the application of an inflammatory irritant is a dilatation of the arteries, then of the veins, and last of all, of the capillaries. At the same time the velocity of the blood- current is increased. After a time the blood flows less rapidly, and in the capillaries it may come to a com- plete stagnation or stasis. At this time the white corpuscles migrate from the veins and capillaries, but not from the arteries. The red corpuscles pass through the capillary walls by a process known as diapedesis (Flint). Treatment. — Remove the exciting cause if possible. The general treatment is rest and elevation and relaxation of the affected part. The local treatment in the stage of congestion is bleeding. This may be affected by punctures, scarifications, leeching, or cupping. Leeches should not be put on the inflamed surface, but between the inflamed part and the heart. If it is desired to remove a leech after a certain time, this may be ac- complished by sprinkling salt upon it. The bleeding may be stopped by applying to the part nitrate of silver, muriated tinc- ture of iron, or styptic cotton. The flow of blood from a leech - bite may be continued by the application of warm water. The application of cold is frequently of service. It contracts the calibre of the capillaries. When the second stage, or that of effu- sion, is established, compression by bandages is useful. Acetate of lead is applicable to all cases of external inflammation (eight grains to an ounce of water). When the third stage, or that of suppuration, is reached, the application of heat and moisture by means of warm baths and poultices is the best. Constitutional Treatment. — In strong, robust individuals, INFLAMMATION— IMPOTENCE. 279 blood-letting may be resorted to in the first stage of inflamma- tion. Arterial sedatives such as tincture of veratrum viride, aconite root, gelsemium and tartar emetic are indicated in the first stage of inflammation. The diaphoretics in general use are acetate of ammonium, citrate of potassium, Dover's powders, fluid extract of jaborandi, muriate of pilocarpine and lemon juice with bicarbonate of potassium. The diuretics in use are infusion of digitalis, salts of potassium, citrate of caffein, coffee, etc. Cathartics are used to evacuate the bowels, deplete the mucous membrane, and to stimulate the absorbents, and thereby remove the inflammatory deposit. Enemata of warm water, or soap and water may be used to unload the bowels. Emetics are indicated when the skin is hot and dry, the tongue heavily coated, and great weight in the epigastrium. Anodynes.— Opium is applicable to the treatment of inflammation in all stages of the disease. It should be preceded by a cathartic. It must be given in full closes, as small doses act as stimulants, while larger doses act as sedatives. Hypnotics. — When the patient is restless, but not suffering acute pain, hypnotics are indicated, such as bromide of potassium gr. xxx., chloral gr. xx., taken at bedtime (Compend). IMPOTENCE, Is a symptom, and means inability to perform the act of coition. Impotence must be carefully distinguished from steril- ity, which signifies inability to beget offspring on account of defect in the semen, whether the individual can have sexual in- tercourse properly or not. A man may be impotent and virile, or impotent and sterile, or potent and sterile. The sexual act is a compound one, physical and mental. The physical organs may be perfect and capable in their way; but if the mental are deficient in energy, or weakened by doubt of competency, or under the influence of some emotion such as shame or fear, the sexual act will be spoilt, and failure to com- plete it must ensue. Impotence may involve absence of sexual desire, or it may exist without loss of sexual desire. Different persons in health differ widely as regards the venereal propensity; in some persona 280 A COMPENDIUM OF PRACTICAL MEDICINE. the sexual desire is intense, in others it is feeble and sometimes wanting. The propensity may be increased by indulgence and diminished by an opposite course. In the marital relation cold- ness may depend on personal antipathy and is a frequent source of domestic unhappiness (Bryant and Flint). ImpoteDce may be considered as true and false. True im- potence is exceedingly rare in the male. Causes. — 1. Absence of penis. 2. Minute size of penis is only a relative cause. 3. Extreme size of the penis is a relative cause. 4. Extreme epispadias and hypospadias. 5. Large size of the prepuce, tight and narrow orifice, tumors or growths upon or about the penis, and excess of abdominal fat. 6. Very tight stricture of the urethra. 7. Aspermatism. 8. Imperfect, irreg- ular and bent erections. 9. Eunuchs. 10. Prolonged sperma- torrhoea. 11. Partial erection, attended by rapid ejaculation, is a common variety of impotence, due usually to continence, over- excitement, etc. In this case, the patient should practice the sexual act in the early morning rather than the evening. Circumcision may sometimes be necessary to diminish the sensi- tiveness of the glans penis, which is often over -acute. Treatment. — Remove the cause if possible. FALSE IMPOTENCE. Causes. — In false impotence, the cause is always nervous, or it may be a moral one; and there is often no impotence at all, except in the mind of the individual. Sexual indifference, as a result of sudden shock, grief, excessive joy, fright, repugnance and lack of affection for the individual, is a cause. Under the two latter circumstances the patient will sometimes think of an- other person than the one with whom he is lying, and thus main- tain erection and effect ejaculation. The sudden flooding of the vagina with warm mucus will sometimes cause erection to cease .at once. Rouband speaks of a man who became impotent on drawing a prize of thirty thousand francs in a lottery. The same author mentions another curious cause of false impotence : A young man brought up in the country was, at the age of four- teen, initiated into the mysteries of Venus, by a young friend of IMPOTENCE. 281 the family, twenty- one years old. Her hair was light, and worn in curls, and for precaution's sake', she never had intercourse with the boy except when dressed — that is, wearing a corset, high boots and a silk dress. A dark beauty had no power over him, and a night-dress extinguished all his fire. In after life, he found himself utterly impotent except in the company of a light haired woman, wearing curls, with high hoots, a corset and a silk dress (Keyes). Treatment. — It is necessary to arouse the moral sentiment of carnal desire by favorable relations to the sex — opera, theatre, etc. The power of the organs is increased by general dry friction of the whole body, by massage and flesh-brush, cold- bath, sea- bathing, generous diet, tonics, the mineral acids, strychnine, er- got, and especially phosphorus and cantharides, or the two com- bined, commencing at a fair dose, one -fortieth of a grain of the former to ten drops of the tincture of the latter, three or four hours before the desired erection, and increasing the dose care- fully. Cantharides produces erection without desire, and phos- phorus with desire. Electricity, and local applications of mus- tard are sometimes serviceable in recalling erection. Nervous Impotence. — Is the most common form of false im- potence. It occurs in young men. The patient can provoke erection at will and awakes with erection, but when in the pres-- ence of a woman, and when he desires to have sexual intercourse, his organs will not respond, or if erection comes on, it lacks full energy. Causes. — This form of impotence is the result of unnatural excitement of the sexual functions. It may come from protracted chastity, ungratified desire, or excessive erotic excitement at the time. After prolonged chastity and great desire, the sufferer has probably approached a female, and at the portals of success his erection has failed him. The mental depression following an exjDerience of this sort is of the most exaggerated nature. He thinks he is impotent beyond all doubt. The cunningly con- ceived advertisements of charlatans in newspapers envelop him further in deep despair. He is now without a ray of hoj3e (Keyes). Treatment. — The best treatment for a man with nervous im- 282 A COMPENDIUM OF PEACTICAL MEDICINE. potence is to instruct nini in sexual physiology and hygiene, and get him married, with the advice to attempt no intercourse, and awaiting some morning when awakening with a vigorous erec- tion, to accomplish coitus promptly, without delay or dalliance. The act once accomplished the charm is broken. The use of the steel sound and of local applications of tannin, often of decided service where ejaculation is too rapid, are also sometimes useful here (Keves). PRESCRIPTIONS FOR IMPOTENCE. R Tinct sanguinariffi , giij. Ext. stillingise fid 5v. — M. Sig. : Fifteen or twenty drops in water thrice daily. — Bartholow. R Zinci phosphidi gr. ij. Confect rosee gr. xx. Sig.: One to three pills three times daily. — Bartholow. R Ext. cannabis indica? Ext. nucis vomicae aa gr. xv. Ext. ergotse aquosi ..•••3J- — M. Ft. massa et. in pil. no. xxx. div. Sig. : A pill morning and evening. — DaCosta. R Tinct. phosphori giss. Tinct. cantharides ^iijss. Elixir simplicis ad §v. — M. Sig. : One teaspoonful three or four hours before retiring. In- crease dose carefully. — Van Buren and Keyes. INCONTINENCE OF URINE. (See Enuresis). INFLUENZA. Called also epidemic catarrh, la grippe and catarrhal fever, is a specific epidemic disease, self -limited, characterized by ca- tarrh of the respiratory organs, and sometimes of the digestive, and by nervous symptoms and debility (Bartholow). In 1830 and 1831 a severe influenza epidemic swept over the whole civ- ilized world (Loomis ) . Causes. — All conditions and all ages suffer alike. The dis- ease has passed over the whole of Europe in six weeks. It rarely continues in one locality more than two months. The usual dur- influenza. 283 ation of an epidemic is two to four years. It seems to be clue to some special morbific principle in the atmosphere (Loomis). Symptoms. — Influenza comes on suddenly. A feeling of chilliness, flashes of heat, and a feeling of lassitude are followed by symptoms of a severe naso- pharyngeal catarrh, with frontal headache, j)ains in the limbs and back, soreness of the throat, hoarseness and a frequent racking cough, difficult breathing and constriction across the chest. The sputa are at first mucous and then scanty, later copious and muco- purulent. There is great prostration. Sudamina appear on the surface and herpes on the lips. There is anorexia. There may be nausea and vomiting. The face becomes congested and livid, the pulse increases, the tongue becomes dry and brown, and the temperature rises. In mild cases the disease is at its height on the third day. In severe cases, convalescence does not commence until the tenth or twelfth day (Loomis). Prognosis. — Is good except in the very old, very young, and the debilitated. Complications make the prognosis graver. The most frequent complications are laryngitis, bronchitis, pulmo- nary congestion, pneumonia and pleurisy. Herpes labialis occurs often (Loomis). Treatment. — Repose in- doors, and at the outset a full dose of quinine and morphia (gr. xv. — gr. ss.) exercises a favorable influ- ence. Also in the early stages, a half ounce of liquor ammonii acetatis, and one grain of pulvis ipecac, every two or three hours is all that is required. The bowels should be kept freely open with salines. If patients are restless, Dover's powders may be given in small doses. For the prostration give stimulants. For the local distress in nose and throat, inhale the vapor of hot water. Bartholow gives the following: R Extracti ipecacuanha fld 5ij- Tinct. opii deodoratte 5iv. Tinct. aconiti radicis 3j. — M. Sig. : Six to ten drops every two hours. For the violent head symptoms bromide of potassium may be given. (Loomis and Bartholow). 284 A COMPENDIUM OF PRACTICAL MEDICINE. INGROWING TOE=NAIL. This is a troublesome and painful affection. It occurs most frequently on the great toe. Causes. — Tight narrow-soled shoes and boots. The pressure causes the nail to cut its way into the tissues, the tissues become hypertrophied and ulcerate, and granulations spring up from the side of the nail (Sayre). Treatment. — Remove the exciting cause. In mild cases, insert a small piece of cotton or lint under the nail. After the application of the cotton, the granulations should be brushed over with nitric acid or nitrate of silver. Another plan of treat- ment is to cut a gutter in the center of the nail, which has a tendency, it is said, to elevate the corners. Still another plan is to divide the nail on a line with the incurved edge, and strip it off, together with the matrix (Sayre). PRESCRIPTIONS FOR INGROWING TOE=NAIL. |& Liquor potassre 31J. Aqua? 5J ■ — M. Sig. : Apply on cotton to the margin of the nail at the ulcerated surface to soften the nail. — Bartholow. J£ Acidi tannici §j. Aquse destillatae .3vj. — M. Sig.: Paint over parts daily. — Biall. Jfc Plurabi (pulv.) acjtatis sj. Tinct. opii oj- Aquas ad gviij. — M. Sig.: Shake well and apply constantly until the inflammation is reduced and pain alleviated. Then insert a pledget of cotton under nail, and apply following : Jfc Argenti nitratis gr. xxx. Aquae destillatae §j. — M. Sig.: Apply two or three times daily with a brush. — Davidson. INSOMNIA. Is sleeplessness. It occurs in cerebral congestion aud in- flammation. But a person may be sleepless from excessive pain, from exhaustion, from grief, from mental excitement or fatigue, insomnia. 285 or from the free use of coffee or tea. In several of these states, congestion is the immediate cause of the wakefulness. Insomnia attends the delirium of typhoid fever, but is most marked in delirium tremens. Treatment. — When wakefulness is due to a condition of cere- bral anaemia, a full dose of some alcoholic fluid, whiskey or brandy, will produce sound and refreshing sleep. In some persons a glass of ale or beer answers better. Sulfonal in doses of 30 to 60 grains, causes sleep that is physiological in character, but pain hinders its action. Cases of sleeplessness, due to mental over-work, anxiety or physical fatigue are entirely re- lieved by fifteen to twenty grains of chloral. The bromide of potassium is effective in the same cases. Morphine and atropine is the best sleep-producer in cases of pain, in some kinds of mania, and in melancholia. A hop-pillow has induced sleep. Galvanization will sometimes cause sleep. A tepid or warm bath at bedtime will often produce sleep (Bartholow). PRESCRIPTIONS FOR INSOMNIA. R Paraldehyde oiiss. Alcoholis (90 per cent.) Siss. Tinct. vanillas 5ss. Aquas Sij. Syr. simplicis ad oiv. — M. Sig. : One or two teaspoonfuls every hour. — Yvon. R Ext. piscidias erythrin fid 5j. Syr. simplicis 5j. Aquas auranti flor oiv. — M. Sis.: A teaspoonful to a tablespoonml at bedtime. — Payne. R Anti pyrin 5,j .-ij • -Syr. auranti cort Sj- Aquas cinnamomi ad Siij. — M. Sig.: One tablespooni'ul every hour or two till effective. — Williams. R Amyl hydratis gr. xiv. Syr. auranti cort ,~>ss. Aquas 3J • — M. Sig.: Take at bedtime. — Von Mering. 286 A COMPENDIUM OF PRACTICAL MEDICINE. R Methylol Sj. Syr. auranti flor §iv. — M. Sig. : One teaspoonful at bedtime. — Richardson. R Potassii bromidi 3iv. Chloral hydratis 5ij. Syr. pruni virgin Sj. Aquas ad $iij . — M. Sig. : A dessertspoonful in a glass of water at bedtime. INTERMITTENT FEVER. (See Malarial Fever). INTERTRIGO. Is chafing of adjacent parts. It is a form of erythema. It occurs at parts where opposed surfaces of skin are in contact with one another, as between the hips, at the flexures of the thighs, in the arm -pits, and under pendulous mamma?, the inflam- mation being favored by the heat, moisture, and friction of the parts. It is especially apt to occur in hot weather, in the case of corpulent persons, and in infants. The affected surface has a reddened glazed appearance and the itching is often intoler- able (Anderson). Treatment. — Violet powder is used to prevent intertrigo in infants. In intertrigo and in the erythema which occurs about the genitals of infants, dusting the affected surface with bismuth soothes the pain and promotes healing. Tannin in j)owder, or the glycerites of tannin, applied to the affected surface is very effective. The following lotion is useful: R Aluminus.. gr. xx. Zinci sulph gr. x. Glycerinae 5j • Aquas rosse 5iv. — M. Sig.: Apply to affected surface. — Bartholow. Camphor is a useful addition to dusting powder to allay the heat, tingling and itching of eczema and intertrigo (Ringer). INTESTINAL OBSTRUCTION. 287 PRESCRIPTIONS FOR INTERTRIGO. R Pulveris amyli ,?iv. Zinci oxidi §j- Zinci carbonatis. §ss.— M. Sig.: Use as a dusting powder. —Tilbury Fox. R Acidi boracici 3iss. Vaselim 3j— M. Sig.: Apply locally after washing and drying the parts.— Waring. R Bismuthi subcarbonatis §ij. Sig.: Use as a dusting powder. — Bartholow. R Ammonii sulphoichthyolati gr. iij. Cumarini gr. xij. Unguenti petrolei 3v. — M. Sig.: Apply with the finger after bathing and drying the child. — Lor ens. R Linimenti aquae calcis §vi. Sig.: Use locally. —Tilbury Fox. INTESTINAL CATARRH. (See Enteritis.) ITCH. (See Scabies.) INTUSSUSCEPTION. (See Intestinal Obstruction.) INTESTINAL OBSTRUCTION. Is a mechanical impediment to the movement of the bowels. It may be complete or incomplete. Inquire of the patient: 1. If lie has ever had a previous peritonitis, or intestinal troubles, as colic, pains, etc. 2. The manner in which the attack appeared, whether suddenly or grad- ually. 3. If there is any exciting cause present, as a hernia, swallowing a foreign body, etc. The obstruction may come on while the patient is asleep or in perfect health, or after an indi- gestible meal, or while straining at stool with a distended blad- der. As certain as obstruction occurs in the small intestine, acute symptoms are developed, vomiting of bile comes on sud- denly, and tympanites is absent generally. Collapse is profound. The shape of the abdomen is similar to the pregnant. If the obstruction occurs in the large intestine, chronic symptoms are 288 A COMPENDIUM OF PRACTICAL MEDICINE. developed, and there is fixed pain, and tympanites with disten- sion of the colon. Collapse is less profound. Great distension of the abdomen develops rapidly. It occurs late in life. Causes. — I. Strangulation inside of the cavity. II — Changes within the lumen of the gut. III. — Changes without tie lumen of the gut. The causes of strangulation of the bowels are: 1. Peri- toneal adhesions by bands, over loops, through apertures, or at- tachment to the viscera, (the result of acute peritonitis). 2. False diverticulum. 3. Hernia. 4. Volvulus. 5. Intussuscep- tion. 6. Kinking of the gut. The causes of changes without the lumen of the gut are: 1. Compression from anything outside of the gut. 2. Contraction of the mesentery following inflammation of the same. 3. Chronic peritonitis. 4. Retroflexed uterus especially during pregnancy. The causes of changes within the lumen of the gut are: 1 Stenosis or stricture from malignant growths or ulcerations. 2. Gall-stones. 3. Foreign bodies. 4. Enteroliths. 5. Faecal im- paction. False Diverticulum. — May be the result of the viteline duct remaining pervious in the fxetus, or of a small piece projecting from the ileum like the finger of a glove, from one to three feet above the ileo-caecal valve, or it may be formed from the mucous coat, by a rupture of the muscular coat, making a hernia of the mucous coat. Hernia. — As a cause of intestinal obstruction, is formed by weakening of the walls of the intestine, and is found on the mesentric borders of the gut. The cause may also be faecal matter. The pouch comes from the ileum three to four feet above the ileo-caecal valve. Volvulus. — Is the twisting of the gut upon its own axis, or upon the mesenteric axis. It occurs most frequently in the ileum colon, caecum and sigmoid flexure. Thirty-three of 1000 cases are due to volvulus. Russians suffer more than other nationali- ties, because they have eight feet more of ileum, and eat a more vegetable diet. In the ileum it goes from left to right and once upon the mesenteric axis. It occurs at about twenty years of age. This variety comes on very suddenly, and with no assignable INTESTINAL OBSTRUCTION. 289 cause. Give an enema early, and reach, and distend the colon and percuss it, then you will know whether the obstruction is above the ileo-csecal valve or below it. In the sigmoid flexure, it is very common in chronic constipation as the bowels become filled by faecal matter and gas, and fall over each other. Gener- ally occurs after middle life, after 40 years of age. Tenesmus is very distressing in the bowels. Volvulus may come from trau- matism, as a stabbing into the abdomen; also, from active peris- talsis when the gut twists upon itself. Intussusception. — Is where one part of the bowel is thrust into another part. It is, also, called invagination. One-third of all cases of intestinal obstruction is of this kind. Twenty-five per cent, occur before the first year, and fifty per cent, before the tenth year. It most frequently occurs in the ileum, colon, ileo- cecal valve, and rectum. It is caused by irregular contraction of the bowels, and has been produced on animals by electricity. If there be an intermittent pain, it denotes that the obstruc- tion is incomplete. If there be a continued pain it shows that the obstruction is complete. Bloody stools are seen in eighty per cent, of the cases. Stenosis or Stricture from Malignant Growths or Ulcera- tions — is due to peptic, typhoid, tubercular, catarrhal, syphilitic and dysenteric ulcers. Peptic ulcer is found in the duodenum and is said to be due to the action of the gastric juice. It occurs in middle life. Typhoid ulcers are found in the long axis of the gut of the ileum. The tubercular ulcers are found in the lower ileum, and originate in the lymphatic glands, and lie in the transverse direction of the gut. Catarrhal ulcers are found in the colon, and are produced by chronic constipation. They are in large numbers and produce gangrene of the mucous membrane. Syphilitic ulcers are usually found in the rectum, in the submu- cous tissue, and are broken down gummata. Dysenteric ulcers are found in the rectum and sigmoid flexures. Stenosis from ma- lignant growths are usually from carcinoma (epithelioma) and may be primary or secondary. It usually forms an annular stricture and there comes just above the stricture dilatation and hypertrophy of the bowel. 290 A COMPENDIUM OF PEACTICAL MEDICINE. Gall Stones — Which produce obstruction are usually small but become enlarged when passing through the intestine by co- hering together. The symptoms are not so sudden or great, as by bands or loops. There are previous hepatic colic, and the presence of jaundice usually. It is more frequent in women then in men. Foreign Bodies — Are any bodies not acted upon by the gas- tric juice. These may be swallowed for suicide or by the insane or accidentally. Enteroliths — Are intestinal calculi. They are composed of phosphorus, calcium, magnesium carbonate, with cholesterine, and are formed about a necleus. This form of trouble is fre- quent in Scotland where the peasants live on coarse oatmeal. F cecal Impaction — Is due to the faeces which become hard and tend to remain in the bowel. The bowels move very seldom once in three or four weeks, and thus it is a cause of local ob- struction. In all cases a tumor can be felt under the integument and the feeling is like that of putty. A bucketful of f secal mat- ter has been removed. It may lead to peritonitis. It is more com- mon in women than in men. It may be relieved by mechanical means, but the patient may die from exhaustion. Compression from anything outside of the Gut — May pro- duce obstruction. It may be from sarcoma of pelvis. It may be from tumor of the kidneys or abscess connected with Pott's dis- ease, or hydatid cysts of the liver, displaced spleen, etc. Con- traction and inflammation of the gut may produce it. Chronic peritonitis and tubercular peritonitis with adhesions, retroflexed uterus, and enlarged tubes due to pregnancy may cause intestinal obstruction (Dennis). Symptoms. — 1. Pain which is very severe and is present early, is usually referred to the umbilicus, because near this are the great solar and mesenteric plexuses. The situation of the pain is no criterion to the situation of the obstruction in the early stages. Note that continuous pain denotes complete obstruction and paroxysmal pain denotes incomplete obstruction, and if the pain suddenly ceases it denotes gangrene. There is a localized peritonitis. INTESTINAL OBSTRUCTION. 291 2. Vomiting comes on early when the obstruction is in the small intestine. The contents of the stomach are first ejected, then the biliary secretions, and last stercoraceous material about the fifth day. Vomiting usually occurs just after the pain, and when suddenly stopping, denotes gangrene. 3. Constipation is present and continuous. Bowels do not move above the constriction. Note the presence of blood in the stools. If there is blood, it is likely to be intussusception. The blood may come from hemorrhoids. 4. Abdominal Tenderness is important, but is absent at the beginning of the attack . It supervenes quickly, and appears about the third day, and is diagnostic as a symptom because it points to local peritonitis, and if it is diffused it denotes general peritonitis. 5. There is a tumor or swelling in the abdomen. 6. The pulse is thready and rapid, 110 to 140 per minute and small. 7. Temperature is subnormal, as a rule; if peritonitis sets in it may rise to 100° F., and if perforation takes place, it falls below normal to 97° F. 8. Respirations are more frequent, suj;)erficial and thoracic. 9. Anuria. — Urine is scanty and contains albumen and indican. 10. Physiognomy has a haggard expression from mental suffering, face is drawn, eyes are sunken, and the intellect is good to the end. Collapse finally comes on. Caution. — Do not give cathartics, because they will intensify the pain, produce more vomiting, increase shock, produce stran- gulation, causing perforation and peritonitis. It may convert a chronic into an acute, and may induce intussusception. Metalic mercury is not much used and should not be till the last. Symptoms of Perforation are : 1. Emphysema of the abdomen, which is sometimes due to a gunshot wound or some oj^ening. 2. Shock, the patient is in collapse. 3. Condition of the Pulse is diagnostic, on account of heart disturbance due to perforation. It is rapid, thready and feeble. 292 A COMPENDIUM OF PRACTICAL MEDICINE. 4. Tympanitic resonance over the liver. There are two conditions of tympanites without perforation, namely : 1. When the colon is pushed up and is adherent to the walls; and 2. Em- physema of the lower lobe of the lung. The respirations are rapid and thoracic in character. 5. Sudden tympanites at the seat of perforation. 6. Subnormal temperature. 7. Vomiting. 8. Sometimes bloody stools, especially in traumatism. 9. Retention of urine. 10. Acute peritonitis and anxious physiognomy (Dennis). Treatment. — Give morphine hypodermically. Small doses stimulate and large ones paralyze, therefore large doses and not small ones are indicated. It relieves intense pain, influences shock and relaxes the abdominal walls. It increases the secre- tion of urine, affects the pulse, respiration, temperature, and vomiting. It arrests peristalsis. Caution. — If it is continued too long, retention of the bowels is produced, which is not good. Nourishment. — We cannot nourish by way of the stomach,, for it is filled with regurgitant fluid, and the intestines are filled with gas. Nourish by the rectum and give enema of milk (4 oz.). We may use hypodermics of brandy. Let the patient have ice in his mouth to quench his thirst. It will help to control vomiting and keep the tongue moist. Local Applications.— Warm ones will relax the abdominal muscles. Turpentine stupes over the abdomen is good. Hot flannels and poultices are good. Place a pillow under the popli- teal space. Enemata. — Copious ones in intestinal obstruction are good. They must be introduced slowly. If a fountain syringe be used, it must be lower than six or seven feet for children, and lower than 15 to 18 feet for adults. Warm water with soap-suds and olive oil is good. If glycerine is added it will be better. Do not use the injection late in the disease, for gangrene will be produced. Aspirations, or Paracentesis. — Should we aspirate or not ? It is dangerous and must not be done only in extreme cases, and INTESTINAL OBSTRUCTION. 293 then must not be done without consultation of some other surgeon. Operation. — Laparotomy: Results are good when the oper- ation is done early, and before the patient is exhausted, and before peritonitis sets in. Do not operate if there is suppuration with general peritonitis, or if the cause is some malignant dis- ease. First, have the parts thoroughly cleansed with a warm solution of bichloride. In the cavity do not use a solution stronger than 1 to 10,000, and never use the same sponge twice. Always empty the bladder before the operation. Make the in- cision in the median line, and the higher we go above the umbil- icus the worse it w r ill be, for the gut cannot be easily returned. If the ileo-caBcal valve is collapsed the obstruction is in the small intestine and not in the large. If by bands strangulation is caused, cut the bands between the ligatures. If by a slit, through which the gut has gone, sew up the slit. If by a false diverticu- lum, cut it off, and bring the edges of peritoneum together, and let an adhesion form. If by hernia, cut out the damaged gut and make an artificial anus. If by volvulus, and it involves the ileum, simply untwist it, but if the sigmoid flexure is involved, do a left lumbar colotomy. If by intussusception, which occurs in childhood largely, 'and if it affects the small intestine, simply draw it out; if that cannot be done, make an artificial anus just above the obstruction. Do the operation early. If the obstruction is caused by stenosis from ulceration or malignant disease, do a laparotomy and remove the disease and make an artificial anus,, then later on re-establish the contiguity of the gut. If by gall- stones, open the gut and remove them or any other foreign bodies. If by faecal impaction, it may be removed by manipula- tion. If by growth or neoplasm, remove the growth if possible, and if not, open the gut. We have sarcoma of the pelvis, tumors of the kidneys, mesentery, omentum, and abscess of Pott's dis- ease. In chronic peritonitis, wash out the cavity with bichloride solution 1 to 10,000. It is successful where there is tuberculous disease, but not in carcinoma. In contraction of the mesentery, do a laparotomy. If the obstruction is caused by retro-flexed uterus, bring it forward. 294 A COMPENDIUM OF PRACTICAL MEDICINE. Laparotomy for Acute Intestinal Obstruction. — The results of laparotomy are encouraging. Before the clays of aseptic and antiseptic surgery, the death rate was 75 per cent.; after that time 58 per cent. The percentage of deaths is due to two causes: 1. Shock. 2. Sepsis. Shock may be diminished by an early and rapid operation. Ser^sis may be diminished by adhering strictly to aseptic and antiseptic surgery. If there is suppuration do not operate. Duration of life in acute obstruction of the in- testines is six days; so operate early. If laparotomy is done and the cause removed, the per cent, of deaths is 56. If the cause is not removed the percentage of death is 66. If the gut is gan- grenous, and is opened, and afterward sutured, the percentage of death is 86 (Dennis). PRESCRIPTIONS FOR INTUSSUSCEPTION. R Fellis bovini gr. xx. Aqua? ferventis Oij . — M. Sig. : Inject slowly into the bowel until it is full} T distended. (Knee-chest position is best.) — Hawkins. R Lobelia? .5ss. Aqua? bullientis Oj. — M. Sig.: Inject one-fourth, or one-half, and repeat if necessary. — Bartholow. R Extracti belladonna? gr. iv. Aqua? ferventis Oj. — M. Sig.: Inject into the rectum. — Waring. R Sodii bicarbonatis 3j. Aqua? 5 vj . — M. Sig.: Inject into the rectum and follow at once with, R Acidi tartarici pulv gr. xxxv. Aqua? 5 iv. — M. Sig.: Inject into the bowel at once after the preceeding. — Bartholow. IRITIS. Is an inflammation of the iris. Causes. — Are local and constitutional. It may come from functional strain, from injury, from operations, from penetration of foreign bodies or by extension of inflammation from adjacent iritis. 295 structures. The constitutional causes are syphilis, rheumatism and gout. About fifty per cent of all cases is caused by syphilis. Rheumatism and gout cause obstinate, painful and recurrent at- tacks of iritis. In syphilitic iritis, a plastic or gummy exudation is thrown out. Gonorrhoea occasionally causes iritis. Other causes are malaria, variola, scrofula, and tuberculosis (Noyes). Symptoms. — Are objective and subjective. The former are change of color of the membrane, abnormal behavior of the pupil and injected blood vessels. A blue iris will change to a dull gray, a hazel to a dirty brown. The aqueous humor is turbid, and the pupil is smoky instead of a clear jet black. The pupil will be small and will not respond to light. Adhesions will be- come apparent upon dropping a solution of atropia into the eye. In severe cases, the whole front of the eye will be intensely red. The lids will be imperfectly opened. The subjective symptoms will be, impairment of sight, intolerance of light, and pain. The pain is first situated in the globe, and is a consjncuous feature from the outset, is most severe toward night, or early morning. Iritis may attack one eye or both. It generally lasts two to six weeks, if neglected it may continue for months, with entire loss of sight. Sequelw of Iritis are: 1. Adhesions of the iris to the capsule of the lens. 2. The exudation may become organized and fill the whole pupil, and thus resemble cataract. 3. The capsule of the lens may become thickened (Noyes). Prognosis. — In simple cases, vision will be perfectly restored, but if adhesions take place, sight will be impaired (Noyes). Treatment. — Avoid use of eyes, and all sources of irritation. The patient must be kept in a dark room. The essential and master remedy in iritis is a solution of atropine; it is the begin- ning, middle and end treatment. A solution of four grains to the ounce must be used and dropped in four to six times daily. If poisonous symptoms appear from the use of the atropine it must be stoj3ped, and the ]3roper treatment instituted. Appli- cations of warm water to the eye are useful. For the nocturnal pain, hot fomentations are to be used, and morphia administered. Constitutional treatment will be necessary in cases of syphilitic, rheumatic, or gouty iritis. Gonorrhoea] iritis demands urethral 296 A COMPENDIUM OF PRACTICAL MEDICINE. treatment. For severe serous iritis with deep anterior chamber and much pain, paracentesis will be effectual. When mydriatics fail and the pupil is much bound down, iridectomy is the remedy (Noyes). PRESCRIPTIONS FOR IRITIS. {& Atropine sulphatis . ...gr. iv. Aquae destillatse 3j • — M. Sig. : A drop or two in the eye three times daily. Used with hot water, bathing for fifteen minutes every hour till pain is relieved. —Chilton. R Hydrargyri chlor. corros gr. j. Potassii iodidi 3j . Tinct. calumbse .$ij. Aqua? destillatse ad 3yj. — M. Sig.: A dessertspoonful in water three times daily. — Lawson. R Seopolinse gr. j. Aqua? destillatse 3J . — M. Sig. : Two drops into the eye three times daily. — Dunn. R Emplastri cantharidis 1 in. by 1 in. Sig.: Apply behind the ear, and poultice when blistered. — Hartshorne. R Duboisise sulphatis gr. j. Aquae destillatse 3j • — M. Sig. : One drop into the eye twice daily. — Tweedy. ICTERUS. (See Jaundice). INSOLATION. ( See Heatstroke ) . IODISM. If iodine or the iodides are administered in too large doses, or to persons of irritable stomach, and for too long a time, they will produce gastro- enteric symptoms, headache, giddiness, marasmus, sometimes discoloration of the skin, occasionally sali- vation, and frequently a wasting of the mammae and testicles. This train of symptoms is called iodism. Treatment, — Withdraw the drug and give arsenic. Atropine is quite effective as a remedy for iodism (Bartholow). IRRITABILITY JAUNDICE. 297 IRRITABILITY. Cause. — All those practices and habits which cause nervous strain, and result in nervous exhaustion, may produce irritability. Treatment. — Give five grains of chloral two or three times a day in irritability with nervousness and restlessness. A sitzbath with the water between 60° and 80° greatly relieves fatigue, and soothes an irritable restless state of the nervous system. ITCHING. (See Pruritis). JAUNDICE. Called also icterus, is a yellow discoloration of the skin due to the presence of bile or blood pigment (Loomis). Jaundice is a symptom common to many affections of the liver. Causes. — /. Of Hepatogenous Jaundice. — Duodenal ca- tarrh, biliary calculi, inspissated bile and mucus, hydatid vesicles, foreign bodies from the intestinal canal, such as stones of fruit and round worms, congenital plugging of the duct and cancer of the ducts are causes within the duct. The causes which ob- struct the duct by external pressure are : Tumors of the pyloric extremity of the stomach, of the head of the pancreas and of the kidney; pressure from a pregnant uterus, from ovarian and fibroid tumors, from omental tumors, from large impaction of f aeces, from enlarged lymphatic glands in the transverse fissure, from waxy cancerous or tubercular change, from abdominal aneurism and from hypertrophic cirrhosis of the liver. II Causes of Hematogenous Jaundice are: Yellow, typhus, typhoid and malarial fevers (Loomis). Symptoms. — Jaundice first appears in the conjunctiva, then the skin of the face appears sallow or fawn -col or. The urine early undergoes a change and becomes intensely colored with bile-pigment, which it imparts to linen and white paper dipped into it. The best test for bile in the urine is the nitric acid test. Pour into a test tube an inch of nitric acid, and drop the mine slowly on top of the acid. If bile be present, there will be a red line next the acid and green uppermost with violet and blue between. The stools in jaundice are grayish or slate-colored, 298 A COMPENDIUM OF PEACTICAL MEDICINE. sometimes quite white. Jaundice is usually unaccompanied by pain. Headache is a common symptom. There is drowsi- ness, hebetude of mind and despondency. In some cases there are nausea, a persistent harassing cough, and muscular soreness. The temperature in jaundice is usually below the normal. In many cases the pulse is slow; more or less itching of the skin; sometimes an intolerable itching is observed in many cases. The taste is bitter. The vision may be yellow (Bartholow). Differential Diagnosis. — The yellow staining is slight in hem- atogenous jaundice, but it is more intense in hepatogenous. There is great itchiug of the surface in hepatogenous jaundice which is absent in the hematogenous variety. The faeces are dark in hematogenous jaundice and white or clay- colored in hepatogenous (Loomis). Determination of the Cause. — If the jaundice comes on in the course of a gastro- duodenal catarrh, it is probably a case of simple catarrhal jaundice. If it occurs in the course of malarial fever, it is probably due to malaria. If the jaundice is preceded by sudden violent pain in the right hypochondrium, it is due to the passage of gall-stones. If the jaundice be persistent — lasting many months — and intense, and follow an attack of pain which has not been repeated since, it is probably due to a permanent occlusion by a gall-stone. If the jaundice be intense, persistent and painless with enlarged liver, it may signify obstruction by hydatids. A faint jaundice lasting many months, with ascites and enlargement of the superficial veins of the abdomen, is pro- duced by sclerosis or cirrhosis or nutmeg liver. Jaundice with persistent pain or soreness in the right hypochondrium indicates cancer (Bartholow). Treatment. — Laxatives and diuretics are useful. Grain doses of calomel given at night is the best laxative in these cases. Saline laxatives which have a diuretic action are very useful. The compound jalap powder is efficient. In malarial jaundice, ten to thirty grains each day of quinine is useful. JAUNDICE — KERATITIS. 299 RRESCRIPTIONS FOR JAUNDICE. (Catarrhal.) R Ammonii chloridi 3ss. Ext. taraxaci fluidi giij. — M. 'Sig.: A teaspoonful three times daily. — Bartholow. R Ext. hydrastis fluidi 3j. Sig.: Ten drops before meals for some weeks. — Bartholow. R Sodii phosphatis §ij. In pulv. no. xvi. div. Sig. : A powder every four hours. — Bartholow. R Ammonii iodidi 5j- Liq. potassii arsenitis gss. Tinct. calumbse §ss. Aqua? Siss. — M. Sig.: A teaspoonful before meals. — Bartholow. KERATITIS. (Phlyctenular). Is an inflammation of the cornea. It is characterized by one or more slight elevations of a grayish -white or yellow color, which are about the size of a pin head. Sometimes they are visicles and sometimes semi -solids, and soon their summit is eroded, leaving a little ulcer (Noyes). Symptoms. — Are subjective and objective. There will be hyperemia, severe pain, photophobia and lachrymation. It is especially a disease of children, and attacks the ill -fed or over- fed, the weakly and the dirty. There is usually eczema of the head or face. In bad cases the cornea may be perforated (Noyes). Causes. — Are scrofula, gout, syphilis, malaria, eczema, herpes, struma and exanthematous diseases. Treatment. — Must be both local and constitutional. If there be only one or two eruptions, and they recent and situated on the cornea, they may be scraped out clean by a sharp spud. Then tie up the eye, and wash it out once in three hours with a two per cent solution of boric acid. Instead of the scraping, the ointment of yellow oxide of mercury, gr. ij. to dr. j. maybe rubbed well into the eye once daily. If there is an iritis along with the keratitis, a solution of atropine may be dropped into the eye thrice daily. The chief remedy against photophobia is cocaine which may be 300 A COMPENDIUM OF PRACTICAL MEDICINE. used several times daily. Cold water and boric acid will be grateful. The constitutional and hygienic measures are never to be neglected. Cleanliness, pure air, exercise and a suitable diet will be needed. Mild purgatives as rhubarb and soda are some- times useful. Cod-liver oil and the syrup of the iodide of iron, are standard remedies (Noyes). PRESCRIPTIONS FOR KERATITIS. {& Atrophia? sulphatis gr. ij. Aquae destillatae §j . — M. Sig. : One or two drops into the eye three times daily. — Bartholow. Jfc Hydrarg chloridi corrosive gr. j. Aquae destillatae §iv. — M. Sig.: Apply as a bath to the eye by means of a reservoir eye- cup. — Grandmont. KIDNEY=DISEASES, (See Albuminuria, Bright's Disease and Uraemia . ) KINQS'=EVIL. (See Scrofula.) KNEE=JERK. In most, healthy individuals a vigorous contraction of the quadriceps extensor muscle is produced by striking quickly with the ulnar side of the hand, the ligamentum patellae when the leg is flexed and the muscles are relaxed. This contraction is called the knee-jerk, or patellar reflex, and may be increased, dimin- ished or abolished in certain diseases of the spinal cord. The centre for the patellar reflex is in the gray matter of the lumbar portion of the spinal cord. Disease of the gray matter in this situation, and of the posterior columns of the lumbar enlarge- ment, cause the patellar reflex to disajDpear. In various condi- tions causing spastic paralysis, the patellar reflex is increased. In posterior spinal sclerosis, knee-jerk is absent; it is also absent in disease of the anterior cornua. Kuee-jerk is absent in many cases of diphtheria from the very first day of the illness (Flint). LABOR. 301 LABOR. Is the expulsion of the foetus from the uterus. Normal labor occurs when the foetus is mature. The Pains of Labor. — The pains of labor are first felt over the sacrum, and radiate to the rectum, bladder, across the abdo- men and down the thighs. At first the pains are dull, but finally reach the point of sujxreine agony. Stages. — There are three stages of actual labor: 1. The stage of dilatation of the cervical canal. 2. The stage of expul- sion of the child. 3. The stage of placental delivery (Lusk). Duration of Labor. — The average for primiparse is seventeen hours, for multij)ar8e twelve hours. For the after-pains the fol- lowing prescription of Witherstine may be used: |fc Morphiee sulphatis . gr. ij. Aquas camphoras gij. — M. Sig. : A teaspoonful every three hours. Leishman's formula may be used for precipitate labor: J& Morphia? sulphatis gr. j.-ij. Olei theobromse 3ij. — M. Ft. massa et in suppositoria no. iv. div. Sig.: One as required. In retained placenta, Atthill's formula is useful: |fc Tinct. nucis vomicae 3j. Ext. ergotse fluidi 3vi. El ixir sim plicis ad gvi. — M. Sig. : A teaspoonful in a wineglassful of water every three hours. In hour-glass contraction of the uterus, Barnes gives three to five drops of amyl nitrite to be inhaled from a handkerchief. In protracted labor due to rigid os, Ringer gives the fol- lowing: Jfc Morphias sulphatis gr. ij. Aquse destillatte oj • — M. Sig.: Five or ten minims hypodermically, repeated as necessary. In protracted labor from atony of the uterus, Leishman gives the following: Jfc Extracti ergotse fluidi sj. Olei gaultherise gtt. iv. — M. Sig.: A teaspoonful every four hours, only if os is dilated, and soft parts not rigid. 302 A COMPENDIUM OF PRACTICAL MEDICINE. LARYNGISMUS STRIDULUS. Called, also, spasm of the glottis, internal convulsions, child crowing, etc., is spasm of the muscles of the larynx. Violent emotion, especially anger, may induce a temporary suspension of respiration in young children. In the midst of their crying, they suddenly hold their breath, but it is not fol- lowed by a stridulous inspiration as it is in true spasm of the glottis (Smith). Causes. — Laryngeal spasm is most frequently met with in children, when indigestion, teething and impressions of external cold are usually assigned as causes. Cerebral irritation is given as a cause. Scrofulous and cachectic children are said to be es- pecially subject to spasms of the glottis (Loomis). Symptoms. — There is generally previous ill-health. The at- tacks are more frequent and severe at night, in or after the first sleep, than in the day. A peculiar crowing sound is heard now and then during inspiration especially when the child is crying. In severe paroxysms respiration often ceases entirely for a mo- ment. The face becomes livid. The duration of the paroxysm may be a quarter, a half, or even a whole minute. The parox- ysms may occur almost daily for several weeks (J. L. Smith). Treatment. — During a paroxysm it is customary to employ means to produce a strong impression on the surface, as slapping the back or sprinkling cold water on the face. A ready and effective mode of arresting a paroxysm is to introduce a finger into the throat. If the stomach is overloaded an emetic is indi- cated. Employ a hot foot-bath, and warm fomentations to the neck. Laxatives should be given. From ten minims to one drachm of paregoric often arrests the paroxysm (Bartholow and Flint). PRESCRIPTIONS FOR LARYNGISMUS STRIDULUS. R Syrupi ipecac §ij. Sig. : A teaspoonful every ten or fifteen minutes until free emesis occurs. — Bartholow. R Chloroformi §j . Sig.: A few drops inhaled from a handkerchief. — Bartholow. LARYNGITIS. 303 R Tinct. aconiti rad 3ss. Sig. : One drop in a teaspoonful of water every hour for three doses, then every two hours. — Ringer. LARYNGITIS. (Acute and Chronic.) Is an inflammation of the mucous membrane of the larynx. It may occur at any age. There is an acute and chronic form of the disease. Causes. — Acute catarrhal laryngitis is caused by atmospher- ical changes, by exposure to wet and cold and by chilling of the surface, especially of the neck and feet. "Taking cold" is a fruitful cause of laryngitis. Anything that irritates the laryn- geal mucous membrane may produce a laryngitis (Loomis). Symptoms. — Usually at first there is soreness of the throat, accompanied by a sense of constriction, or a tickling sensation with a tendency to cough; the larynx is tender on pressure, there is difficulty in swallowing. The expectoration is at first tena- cious; later it may become thick, purulent and abundant. The voice is hoarse or is reduced to a whisper. The face is flushed, the skin hot and dry, there is fever and a frequent pulse (Loomis). Treatment. — The patient should be confined to bed. The air of the apartment should be kept moist by vapor of water. Tincture of aconite root — one drop for a child and two drops for an adult every two hours — is highly efficient. If there be much cough, two to five drops of the deodorized tincture of opium and one or two drops of the fluid extract of ipecac may be given to- gether. A spray of a solution of morphia to the throat is an excellent means of relieving cough. A very minute quantity of tartar emetic, with paregoric and syrup of lactucarium is also an efficient combination. A hot or cold pack should be wrapped about the throat, after a brief application of mustard; and if the case is just beginning the feet should be placed in a hot mustard foot-bath. Prophylaxis. — Those who have frequent attacks should wear flannels, and protect the feet against dampness. Avoid furs about the throat. The tendency to take cold may be obviated by a daily morning cold sponge- bath. The access of an impend- 304 A COMPENDIUM OF PRACTICAL MEDICINE. ing attack may be prevented by a full dose of quinine and mor- phine (15 grs.-gr. \ to ^) (Bartholow). Causes of Chronic Laryngitis. — It may be a sequel of acute laryngitis. It may occur from constant use of the voice in public speaking or singing. It constitutes the chief morbid condition in what is termed "clergyman's sore throat." It is frequently secondary to chronic nasal catarrh. It most frequently occurs as an accompaniment of other affections, as syphilis and pulmonary j3hthisis (Loomis). Symptoms. — Of chronic catarrhal laryngitis are local. In some the voice is hoarse and husky; in other cases, the patient is only able to speak in a husky whisper. There is a hoarse strid- ulous cough, with more or less abundant muco-purulent expect- oration frequently streaked with blood and of a fetid odor. In- spiration and expiration are often accompanied by a whistling or stridulous sound. In some cases the act of swallowing fluids or solids excites spasm of the glottis. Talking is very fatiguing. In the morning the most severe paroxysms of coughing and strain- ing are experienced : the secretion accumulates during the night, and is detached with difficulty, so that much coughiug, hawking and straining are necessary (Loomis and Bartholow). Treatment. — Mild astringent solutions of alum, perchloride of iron, tannin or sulphate of zinc, from one to twenty grains to the ounce of water may be used. For steam inhalations, a few drops of oil of creosote, oil of pine or oil of juniper, added to half a pint of water at a temperature of 150° F., maybe enrploy- ed. The spray and steam inhalations may be repeated three times daily. A solution of carbolic acid (two grains to an ounce of water) as a spray, may be used with benefit in cases where the laryngeal secretion has a fetid odor (Loomis). The treat- ment of chronic catarrhal laryngitis of phthisis and syphilis is the same as in simple chronic laryngitis, with the constitutional treatment of those affections added. LARYNGITIS LEAD POISONING. .305 PRESCRIPTIONS FOR LARYNGITIS, R Sodii biboratis gr. viij. Aqua> S i ] - Aqua? cologniensis gtt. x. — M. Sig. : Use frequently with atomizer as a spray (chronic form). — Sajous. R Potassii permanganatis gr. ij. Aqua destillatas 3ij.— M. Sig.: Use with atomizer several times daily. (In fetid variety of chronic laryngitis). — Sajous. R Tinct. aconiti radicis 3ss. Sig. : One drop in water every hour. When it has existed some days then give the following: R Vini mariani Oj. Sig.: A wineglassful every three hours, with absolute rest of voice. (In acute laryngitis). — Sajous. LEAD POISONING. Is a morbid condition produced by the introduction of the salts of lead into the 'system, either through the mucous surface or the skin (Loomis). Causes. — The sources of leadqDoisoning are numerous. Painters and workers in lead are those most frequently affected. Drinking water, wines, and ales often become impregnated with it. The application of lead powder as a cosmetic to the face and neck has caused lead-poisoning. Some persons are more suscep- tible to its poisonous influence than others. Lead taken as a medicine, a dressing for the hair containing acetate of lead, a lo- tion for the eye, and vaginal injections containing lead may pro- duce lead-poisoning. Lead may be inhaled in sufficient quanti- ties to produce lead-poisoning, as in paper staining, grinding of colors, plumbing, shot-making, etc., lead-poisoning has re- peatedly occurred from sleeping in newly- painted rooms. Soda- water may contain lead, and articles enclosed in lead foil may produce poisoning. Children may be poisoned by sucking lead toys (Flint and Loomis). Symptoms. — In chronic lead- poisoning, the general health is impaired. The skin becomes sallow, dry and harsh. There are 306 A COMPENDIUM OF PRACTICAL MEDICINE. dyspepsia, loss of appetite, and constipation. A blue line forms along the edge of the gums adjoining the teeth. The most im- portant symptom is intestinal colic. It has been called painters' colic, plumbers' colic, colica pictonum, and dry bellyache. Pain is oftenest referred to the region of the umbilicus. It is a dull aching pain, sometimes acute. Patients are inclined to lie upon the belly with a folded pillow placed under them over the seat of pain. There may be nausea and vomiting. Hiccough and eructations of gas are common. The urine is scanty, and micturition is sometimes difficult and painful. There is no fever. The most frequent of the nervous affections is drop -wrist from paralysis of the extensors of the forearm. There is no loss of sensation in the paralyzed limb. The diagnosis can be made by the history of the case, and from the symptoms (Flint and Looinis). Treatment. — Remove the patient from all sources of lead- poisoning. The bowels should be kept freely open. Five to ten grains of iodide of potassium three times daily should be given. A drachm of dilute sulphuric acid in a quart of sweetened water may be taken in twenty-four hours. Faradization for ten or fifteen minutes three times a clay for two or three months is the only effectual remedy for restoring the paralyzed muscles. Chloro- form given by the mouth and applied over the abdomen some- times acts promptly and efficiently in relieving the pain. Opium in some form may be required to relieve the pain. The warm bath is useful as a palliative soothing measure (Flint and Looinis). PRESCRIPTIONS FOR LEAD=P0IS0NING. R Magnesii sulphatis si- Acidi sulphurici dil 3,j. Aquae §iv. — M. Sig. : A tablespoonful three times daily, preceded by five to ten grains of potassium iodide. — Brunton. R Morphias sulphatis gr. iv. Aquse destillatse 3ij- — M. Sig. : Five to ten minims hypodermically repeated every fifteen minutes till relieved. — Bartholow. LEPROSY. 307 R Pulv. opii gr. xij. Ext. belladonnas gr. ij . Olei tiglii gtt. xij. — M. Ft. massa et. in pil. no. xii div. Sig. : A pill every two hours until relieved. — Loomis. LEPROSY. Is an infectious and contagious disease of very ancient date, characterized by nodules which occur most frequently in the skin. It has been endemic in Egypt, India and China. It was prevalent among the Hebrews. Leper houses, for the isolation of the diseased, were estab- lished in the seventh century. There was an intense dread of the disease, and lepers had to wear a special costume, usually' a long gray gown with a hood drawn over the face; they carried a wooden clapper to give warning of their approach. They were not allowed to enter churches, inns, mills or bakehouses, nor to touch healthy persons, nor to eat with them, nor to wash in the streams, nor to walk in narrow foot paths. A leper woman, quick with child, was buried alive. Leprosy is still common all over the east, and there are leper villages in China, Japan, Persia and Crete. The disease is also common in Africa, India, Mada- gascar, St. Helena, Maderia, Canaries, Azores, West Indies, Mexico, Brazil, Central America, Norway and the Hawaiian Islands. Sporadic cases occur in England and France. Causes. — It is an hereditary disease, and there is the strong- est repugnance to marriage into a family where leprosy is known to exist. It is an infectious and contagious disease. It never originates de novo. The lesions of leprosy contain characteristic bacilli which would seem to be the real cause. Climate, poverty and bad hygiene are predisposing causes (Anderson). Symptoms. — Leprosy appears as a constitutional disease, marked externally by the deposition of a peculiar albuminous substance in the skin, appearing as discolored patches and no- dules, and effecting the nerve centres and peripheral nerves. Leprosy has been divided into two forms, viz: the tuberculous and the anaesthetic. The tubercular is characterized by epsia, diar- rhoea, profuse expectoration and haemoptysis are all causes of tbe emaciation. The wasting occurs not only in the fat and muscle, but in the organs and blood as well. Slow, gradual wasting belongs to the history of fibroid phthisis (Loomis). Disturbances in the Alimentary Tract. — In some cases there is almost entire loss of appetite, and even a repugnance to food. This is an unfavorable feature of the disease. Disorder of diges- tion is sometimes so prominent as to appear to be the chief malady. There may be nausea and vomiting, and pain in the stomach due to gastric catarrh. Diarrhoea may occur in the first stage. It may exist with, and without a tuberculous affection of the intestinal canal. Persisting or frequently recurring diarrhoea,, accompanied by cough, be the latter never so slight, should ex- cite suspicion of pulmonary phthisis. Tuberculosis of the intes tines results from swallowing the expectoration. Tuberculous ulcerations are sometimes found in the large as well as in the small intestine. The ulcerations may lead to circumscribed per- itonitis. Perforation of the intestine may take place. The ulcer- ation may cause intestinal hemorrhage. Diarrhoea is a more prominent symptom in the second stage. It is usually most severe at night. If profuse, and watery, it is called colliquative diarrlicea. Colliquative diarrhoea occurs at an advanced period of the disease, although tuberculosis of the intestine does not PHTHISIS. 419 exist. There may be tympanites. Hemorrhoids and fistula in ano are frequent troublesome complications of phthisis, and should always be relieved by surgical interference in the early stages of the disease. The cure of a fistula in ano or the heal- ing of an old ulcer is often followed by phthisical developments (Flint and Loomis). Menstruation.- 1 — Arrest of menstruation is a very frequent occurrence in females who are consumptive. In young females this is sometimes the first noticeable symptom. In advanced phthisis, it indicates extreme exhaustion, and is often followed by a more rapid progress of the disease (Loomis). Hoarseness. — Or huskiness, and sometimes extinction of the voice denote laryngitis, which may be developed in the first as well as in the second stage. Its occurrence is presumptive proof of pulmonary phthisis, the latter, as a rule, existing prior to the laryngitis (Flint). The pharynx is sometimes the seat of tuber- culous processes. A less constant symptom is the red line around the border of the gum. In some persons this gingival line is a mere streak; in others it is more than a line in breadth (Da- Costa). Clubbed dingers . — The end of the finger is somewhat clubbed. The nails are curved and become claw like, prominent in the centre, depressed at the sides, their surface slightly cracked, their appearance bluish. This peculiar appearance is characteristic of phthisis, but is not pathognomonic. A similiar nail is seen in chronic pleurisy, and in diseases of the heart. Clubbed fingers are found in about twenty- five per cent, of the cases. Shin. — Is pale and traversed by prominent blue lines. The hair becomes thin, dry, gray and falls out. (Edema of the feet and legs is a frequent symptom of the second stage, denoting no- table failure of the circulation. At first it disappears on lying down, but at length it is permanent. Its occurrence indicates that a fatal issue is not far distant (Flint and Loomis). Cerebral Symptoms. — Are rarely pronounced in any stao-e of phthisis. There is no chronic disease in which the mind is so clear. The feelings are usually cheerful and buoyant. Patients are hopeful respecting their condition, and are readily persuaded 420 A COMPENDIUM OF PRACTICAL MEDICINE. that they are improving, and hence they fall an easy prey to quacks. They sometimes dislike to be told the truth, and take offense at an intimation that they are consumptive. The expec- tation of improvement, prolonged life, or even recovery, amounts in some cases to an insane delusion. Patients are sometimes occupied in forming plans for the future when it is obvious to an observer that they are on the verge of the grave (Flint and Loomis). Physical Signs. — 1. Of the stage of consolidation: Inspection reveals diminished expansion, on inspiration, in the supra -and infra- clavicular regions of the affected side. Palpation shows more distinctly the loss of expansion on the affected side, and increase of vocal fremitus over the consolidated lung. Percus- sion elicits relative dullness and sometimes even flatness. If the consolidation is slight, the percussion sound may remain normal. To recognize a slight consolidation at the apex of the lung, it is important to percuss from the trachea rather than toward it. In all cases percussion should be performed at the end of a full in- spiration and at the end of a full expiration. Auscultation shows increase of vocal resonance. Over the affected portion, the respiratory sounds maybe feeble or exaggerated, interrupted or wavy. In addition there are certain adventitious sounds or ■rales. The earliest of these audible is a fine, dry, crackling sound (sub -crepitant) appearing at the end of inspiration. The sub crepitant rales heard within a circumscribed space at the summit of the chest on one side are highly significant of tubercle. They proceed from secondary circumscribed bronchi- tis. A crepitant rale, in like manner limited to a small space at the summit on one side, has the same significance, being due to secondary circumscribed pneumonitis. Crumpling and crackling sounds are significant, provided they be limited to the summit on one side. A pleural friction sound limited to the summit on one side denotes a secondary circumscribed pleuritis. 2. Of the stage of softening .and excavation. — Inspection shows a greater frequency of respiration and a more marked de- pression above and below the clavicle on the affected side, as well as increased difficulty in local expansion. In fibroid phthisis the retraction is more marked than in any other variety. Palptaion PHTHISIS. 421 shows diminished expansion of the affected side, on forced in- spiration. Vocal fremitus is increased. Percussion shows more uniform and widely spread dullness. Auscultation shows bron- chial breathing, and bronchophony becomes more distinct. Numerous, moist, crackling rales are heard. When cavities form, hi spert ion shows greater depression in the infra- clavicular region and less expansive movements. Pal/pdtion shows intensified vocal fremitus over large cavities containing air and communi- cating with a bronchus. Percussion gives a tympanitic reso- nance, and the varieties of this resonance, called "cracked- pot 11 and amphoric, denotes cavities. If the cavity is filled with liquid there will be dullness on percussion. Auscultation. Over small cavities, cavernous respiration will be heard. Over large cavities near the surface amphoric respiration will be heard. The incom- ing air may bubble up and cause gurgles (Loomis and Flint). The Diagnostic Points Pertaining to Symptoms. — 1. Cough and expectoration, not succeeding an attack of acute bronchitis, and not connected with chronic pharyngitis, the cough at first dry and expectoration small and transparent, and becoming gradually more abundant and opaque. 2. Stitchpains at the summit, not connected with intercostal neuralgia. 3. Chills not referable to malaria. 4. Hcemopjtysis. 5. Accelerated breathing. 6. Loss of weight. 7. Pallor or anosmia not otherwise explicable. 8. Hoarseness, or huskiness of the voice proceeding from chronic laryngitis. 9. Chronic peritonitis not traumatic. 10. Suppres- sion of the menses. 11. Buoyancy of mind instead of despond- ency (Flint). Differential Diagnosis. — -The diagnosis of pulmonary phthisis rests mainly upon an examination of the sputum and upon physi - cal signs. Incipient phthisis may be confounded with atonic dyspepsia. A cough may be present in atonic dyspepsia, the so- called stomach cough; but in this case there is no irritation about the air- passages. In advanced phthisis, hectic fever may be con- founded with intermittent. In phthisis, the fever has been pre- ceeded by a period of cough, and loss of flesh and strength, whereas in intermittent, these symptoms have followed the access of fever. In phthisis there is not enlarged spleen and the hectic is not arrested by large doses of quinine. Laryngeal symptoms 422 A COMPENDIUM OF PRACTICAL MEDICINE. are often so pronounced in the beginning as to obscure the pul- monary affection. When tubercular deposits occur in the larynx, the tone and quality of the voice are quickly affected, so that the larynx may seem to be the only seat of tubercular deposit. The coexistence of pulmonary disease ought to be suspected, because of the relation known to obtain between them. Acute phthisis may be mistaken for croupous pneumonia, bronchiectasis and capillary bronchitis. In pneumonia the pro- longed ushering in chill, the continuous high temperature, the characteristic sputum, the dullness limited to a lobe, and the pneumonic countenance, are symptoms which readily distinguish it from acute phthisis. Bronchiectasis accompanied by wasting, fetid expectoration, hamioptysis, and night sweats with the phys- ical signs of consolidation, may well be mistaken for the ad- vanced stage of acute phthisis. But in phthisis the signs of con- consolidation precede those of cavities; in bronchiectasis they follow them. Fever and emaciation are always greater in phthisis than in bronchiectasis. In capillary bronchitis there is no dullness on percussion, subcrepitant rales are heard on both sides of the chest, and there is no bronchial character to the re- spirations. The early stage of chronic phthisis may be con- founded with bronchitis, pulmonary infarction, pleurisy, acute lobar pneumonia, anaemia with cough and expectoration and cancer of the lung. The evidence of consolidation of lung-tissue is essential to the diagnosis of phthisis. So long as bronchitis is accompanied by a temperature of 100° F., and the physical signs show that the bronchitis is general, phthisis is readily excluded; but if the temperature rises to 103° F., and localized crepitant rales develop at the apex of either lung, accompanied by dullness on percussion over the seat of the rales with a bronchial charac- ter to the respirations, then there is reason to believe that phthisis is being developed. The diagnosis between chronic bronchitis and fibrous phthisis rests upon the evidences of consolidation and retraction in phthisis, and their absence in bronchitis. Pulmon- ary infarctions are attended by haemoptysis and localized areas of dullness. Heart disease is their chief cause. The blood ex- pectorated in phthisis is of a bright scarlet color; in infarctions it is dark and in the form of coagula. Infarctions are most fre- PHTHISIS. 423 quently situated in the lower lobes; in phthisis the dullness is apical. In pleurisy with effusion, flatness will exist from the base of the lungs to the level of the fluid; the line of flatness will change with a change in the position of the patient. The cough is more hacking and is not accompanied by expectoration, and vocal fremitus is diminished or absent. A localized pleurisy at the apex of the lung, not the result of a general pleurisy, is indicative of tubercular development. A.namiia with cough and expectoration is attended by no febrile symptoms, and by none of the physical evidences of pulmonary consolidation. In cancer of the lung there is usually bulging of the chest at the seat of the cancerous development; in phthisis there is retraction. In cancer the temperature is often subnormal; in phthisis it is more or less elevated. The currant-jelly expectoration of cancer is diagnostic. Pain is constant in cancer and intermittent in phthisis. The difference between caseous and tuberculous phthisis is as follows: Tubercular phthisis is distinctly hereditary; caseous phthisis is not hereditary, but occurs in the scrofulous. Tuber- cular phthisis occurs at all ages; caseous from youth to middle age. Tubercular phthisis occurs insidiously with catarrh of the bronchi and larynx; caseous results from acute inflammations of the bronchi and lungs. In tubercular phthisis the lesions are apt to be on both sides; in caseous on one side. The laryngeal symptoms are much more common in tubercular than in caseous phthisis. Fibroid phthisis is distinguished from the other forms by its slow progress, by the long period of bronchial troubles before the pulmonary lesions begin and by the merely purulent expectoration (Bartholow, Flint and Loomis). Prognosis. — The duration of phthisis is extremely variable. In the vast majority of cases it is essentially a chronic affection, but sometimes it runs a rapid course destroying life in a few weeks. The disease in such cases has been known as "galloping consumption," or phthisis florida, or acute phthisis. The prog- nosis of acute phthisis is always unfavorable. Its average dura- tion is from five weeks to five months. Flint distributes fatal cases into groups as follows: "One group will consist of cases in which the disease continues from three to six months; in another 424 A COMPENDIUM OF PEACTICAL MEDICINE. group death takes place between six months and a year; and in a third group the career extends from one to two years; and in another group the fatal termination is held in abeyance for many years." Flint says, " The generations of bacilli may die out or be destroyed, and the tuberculous products may be either ab- sorbed or calcification may occur. Cavities may completely cicatrize. In these modes complete recovery may take place. Cavities may exist without any fresh products, giving but little inconvenience for an indefinite period, and even through a long life." Of 670 cases analyzed by Flint, 44 ended in recovery, and in 31 cases, the disease became non-progressive. He claims the es- tablishment of the fact that in a certain proportion of cases phthisis is self limited. The most rational explanation of the manner in which this disease ends by self-limitationisto suppose that the conditions which are essential for the multiplication of the bacilli and which constitute the tuberculous predisposition or diathesis, after a time cease to exist. The vegetable parasite is destroyed because the soil becomes incapable of maintaining longer its existence. Persistent frequency of the pulse, fever, anorexia, and progressive emaciation oppose reliance on self- limitation. In proportion as phthisis is well tolerated there is room for hoping that it will prove self-limited. ITwmoptysis is very rarely an immediate cause of death. The disease proves fatal generally by asthenia. Bartholow says, "Phthisis is the great enemy of the human race since nearly two - sevenths of the deaths from all causes are due to this disease." He also says, " Cures are now not uncommon." Under prognosis Loomis says, "Chronic pulmonary phthisis is not necessarily a fatal disease. Its morbid processes niay be arrested in the early stage or in the stage of cavities by proper treatment. Recovery has occurred in one- sixth of my recorded cases during the past ten years. The average duration of phthisis is three years and four months. Phthisis can in no sense be regarded as a self-limited disease. Some cases, after a period of activity, become stationary and then recover; others slowly but steadily progress to a fatal termination; others again pursue a more rapid and fatal course." The prognosis is unfavorable when there is a strong hereditary tendency, wheu phthisis de- PHTHISIS. 425 velops early in life, when scrofulous or glandular disease has ex- isted in childhood, when the patient is narrow- chested, when the ordinary pulse rate is high, and when there is great variation in weight without any apparent cause. Frequent haemoptysis in an early stage of the disease is not unfavorable. When oedema of the feet and lower extremities comes on in advanced phthisis, the j>rognosis is very unfavorable, and a fatal issue is not far off. Advanced cases may die suddenly from heart failure or syncope. The majority waste to a skeleton, but the mind is perfectly clear and the patient is hopeful of recovery, and makes plans for the future as if perfectly well (Bartholow, Flint and Loomis). Treatment. — The two main objects of treatment are the de- struction of the parasite and the removal of the tuberculous pre- disposition or diathesis. There are no known remedies which will accomplish either object. I. Prophylactic Treatment. — When a phthisical tendency exists, prophylaxis becomes highly important. It is possible to prevent the development of phthisis. Children born of phthis- ical parents should not be nourished in infancy by their own mothers, but should be placed with a healthy wet-nurse. During childhood they should be fed chiefly on good cow's milk, take systematic physical exercise in the open air, removed from the city to the country. They should not lead a sedentaiy life. They should not breathe air laden with foul vapors or fine par- ticles of dust. Their sleeping apartments should be large and well ventilated. Sudden changes in temperature must be avoided, also hot, crowded apartments. Change of climate may be necessary. All those agencies which tend to develop pulmo- nary hyperemia and bronchial catarrh should be avoided. Flannel should be worn next the skin the whole year. The diet should be simple and nutritious. Cold bathing should be prac- ticed every morning to diminish the snsceptibilny to cold. The "milk-cure" and "grape-cure" will often be useful. All milk fed to children should be boiled, and they should not be allowed to come in contact with phthisical j)arents, except under guarded conditions. //. Medicinal Treatment. — Alcohol. Clinical exj^erience shows that alcohol, in a certain proportion of cases, has a salu- 426 A COMPENDIUM OF PRACTICAL MEDICINE. tary effect. If alcoliol produces a sense of comfort, increases the strength, and does not excite the circulation or nervous system., benefit maybe expected from its use; and vice-versa. As regards quantity, some patients will tolerate a large, some a moderate, and some only a small quantity. Phthisis is one of the diseases which in certain cases induce a remarkable tolerance of alcohol. Some patients are benefited by spirits, some by wine, and some by malt liquors, but in each case alcohol is the remedial princi- ple. Bartholow says: "Small doses of alcohol after meals (half an ounce for adults) are highly useful to promote appetite and tissue formation. Large quantities of alcoholic fluids impair the function of digestion, and lessen tissue forming." Cod-liver Oil. — The utility of cod-liver oil in incipient phthisis is very great. Its usefulness consists in the fact that it is a fat, having a special digestibility, owing to its containing bile elements. It is most useful in chronic tuberculosis and fibroid phthisis. It is better to give it with a little ether (IHxx.-oj.), because of the action of the ether in promoting the flow of pancreatic fluid. If cod- liver oil be taken without great repugnance, if it do not impair the appetite or digestion, or occasion derangement of the bowels, it may be ex23ected to do good. Loomis says, "It has been claimed that if cod-liver oil is commenced very early it has the power of arresting the phthisi- cal processes. I doubt if it exerts any specific influence upon the disease. Unless the patient gains in weight while using the oil, it seldom or never proves remedial. A great gain in weight will sometimes immediately follow the administration of a small quantity of oil. It always acts remeclially with more certainty in young persons and children than the aged. In some instances diarrhoea will be arrested by its use and also vomiting of food after eating. A teaspoonf ul once or twice a day is sufficient to commence with, the dose being gradually increased to a table - spoonful three times a day. Most patients take the oil best im- mediately or soon after meals." The pure oil is better than the emulsions and may be taken in whiskey or brandy to disguise its taste. The lactophosphate of lime, if well prepared, is a most valuable agent in the treatment of incipient and the more chronic PHTHISIS. 427 cases of phthisis. It may be given in a dose of a tea- to a des- sertspoonful of the syrup three times a day after meals with cod- liver oil. The hypophosphites are valuable agents to promote the con- structive metamorphosis. Arsenic is deserving of special com- mendation, in incipient phthisis, to promote the appetite and favor tissue building, while it corrects the disordered state of the stomach mucous membrane. It must be given in small doses, two drops of Fowler's solution three times daily. The iodide of iron and cod-liver oil will control the tendency to catarrhal attacks. In tubercular and fibroid phthisis, among the earliest symptoms are stomach disorders, poor appetite, atonic or acid indigestion, and especially repugnance to fatty elements of food. The mineral acids, with a bitter, such as tincture of nux vomica, are especially serviceable. If there be acid eructations, pyrosis and heart-burn, the mineral acids, especially dilute nitric (ten to fifteen drops, well diluted t. i. d.) should be administered before meals; but if the condition be atonic indigestion, the acid should be given after meals. The nux vomica tincture should be given before meals — fifteen drops in water. Qidnine. — In some cases of phthisis sulphate of quinine is one of the most reliable and satisfactory antipyretics. One tenth of a grain of morphine combined with the quinine increases its antipyretic powers (Loomis). Loomis also gives five grains of antifebrin two or three times in 24 hours to phthisical patients whose temperature ranges much above the normal, and finds that their appetites are improved during its use, and nervousness lessened. In many cases, after the disease has passed the first stage, the fever cannot be controlled. Cough. — If the cough is very distressing, gargling the throat with a solution of bromide of potassium, or applying a mixture of chloral and camphor by means of a camel's hair brush to the fauces, and the atomization of a solution of cocaine or of mor- phine, are temporarily beneficial. Fothergill's prescription of hydrobromic acid diluted and spirits of chloroform sometimes acts well. A combination of codeine, atropine and strychnine is highly efficient as a remedy for cough, for night- sweats and reflex vomiting. Picrotoxin allays the vomiting: which accom- 428 A COMPENDIUM OF PRACTICAL MEDICINE. panies the cough almost as efficiently as strychnine. The patient should try to suppress the cough. The irritable feeling in the fauces may be allayed by a bit of gum arabic, candy, or troche. The officinal troche of licorice and opium, or of morphine and ipecac, may be used. Paregoric will often allay the cough. The inhalation of a few drops of chloroform will often control the cough. Ammonium carbonate in the infusion of wild cherry bark is one of the best stimulating expectorants, and it never nauseates. A solution of morphine in glycerine applied to the fauces with a brush, relieves the cough of phthisis. A better mixture is glycerine two parts, whiskey one part and crystalized sugar enough. This should be allowed to trickle slowly down the fauces. Tannic acid (gr. xx. to oiv. of aquas) is good in chronic throat troubles. It may be used as a spray. NiyJit- sweats are a part of hectic. When quinine does not control them, quinine and opium may do so. Oxide of zinc (gr. ij-iv.) gallic or sulphuric acids, arseniate of iron (gr. {■ to^), ex- tract of belladonna, or sulphate of atropia hypodermically, picrotoxine, ergot, all may be tried at different times. Atropia is the most reliable. Sponging the body with hot water, or vinegar and water, is sometimes effective. Sponging with as- tringent waters (alum in alcohol) is sometimes efficacious. Diarrhoea. — If the diarrhoea is dependent upon catarrh, with or without ulcerations in the small intestine, cod-liver oil and the hypophosphites of lime and soda will often be of ser- vice. Five grains of pancreatin given two hours after eating will often relieve the intestinal pain even in the later stages of the disease. Ten grains of bismuth, combined with a twelfth of a grain of morphine, after each movement, will almost certainly control the diarrhoea. If the diarrhoea depends upon ulceration of the large intestine, all that can be done is to give temporary relief by opium suppositories. When diarrhoea is persistent and accompanied by rapid emaciation, it is tubercular. For the diarrhoea, Bartholow gives two drops of Fowler's solution and ten drops of laudanum. Vomit rug after meals is often a trouble- some attendent of phthisis. Champagne with the food, hydro- cyanic acid, and pepsin are useful, but the most certain relief is PHTHISIS. 429 obtained by giving the patient a glass of hot water every two hours, followed in half an hour by a teaspoonf ul of raw scraped beef made into a sandwich. Creosote. — Bartholow thinks that from one to five minims of pure beech-wood creosote given three times daily, has distinct curative power in suitable cases of phthisis. Hcemoptysls. — The most valuable remedies for the arrest of haemoptysis are rest and opium. Lead, ergot and ice are recom- mended. Turpentine is more reliable than any remedy except opium. Local pains in the chest may be relieved by blisters, sinapisms, liniments or the belladonna plaster. Antiseptic Treatment by Inhalation.— -Bartholow says, "The value of antiseptics by the method of protracted inhalation is just being recognized. The method consists in charging the air of a suitable apartment with a volatile remedy which the patient can breathe for a half to one hour or longer. I advise the inhal- ation by the protracted method of ethyl iodide, carbolic acid, car- bolic acid and tincture of iodine, iodol, iodoform, oxygen, etc. The method of germicide treatment by rectal injection of sul- phurretted hydrogen, and carbonic acid, has fallen into disuse in this country. I hope I may not be considered egotistic and pre- judiced when I say that this mode (atomization of solutions) of using the remedies is not good — is not effective. " Loomis says, " The antiseptic treatment of phthisis has not thus far given satisfactory results. Carbolized inhalations have been quite extensively employed with very favorable results ac- cording to some observers; but, after quite an extensive trial, my experience is decidedly against their use. The injection of cav- ities through the chest walls has not been followed by satisfac- tory results. I have found the hypodermic use of antiseptics to fail, not only in counteracting the sepsis, but in reducing the high tenrperature. I believe it is utterly futile to attempt to reach the bacilli imbedded in tubercular or caseous products.' 1 Again Bartholow says, "Cases of phthisis have been recently re- lated as cured by the inhalation of highly heated air. If the air is deprived of its moisture the temperature at which it can be in- haled ranges from If 0° F. to 300° F. This method is based on the power of heat to inhibit or destroy the bacilli. It is proba- 430 A COMPENDIUM OF PRACTICAL MEDICINE. ble that this mode of treatment Trill develop into a highly suc- cessful one." Hygienic Treatment of Phthisis. — Phthisical patients should sleep in large well -ventilated and well -lighted rooms with a southerly or westerly exposure. Flannels should he worn next the shin. Cold sponging or baths often act as tonics. The patient must live as much as possible in the open air, and should avoid sedentary occupations. Diet. — The diet should be generous as regards quantity. quality and variety. The articles should be highly nutritious and adapted to the digestive powers. Phthisical j)atients should drink from one to three quarts of milk each day. Cream, butter and sugar should enter into the diet as largely as possible. Change of Climate. — Bartholow says, Ci Xo change of climate can be beneficial, as a rule, after cavities have been formed, unless of slight extent. It is in incipient phthisis that a change of climate, dry, bracing and elevated, really exerts a curative influence." Loomis says, "It is well known that some consump- tives thrive best in a warm, moist air, others in a cool, dry air; some are most vigorous in winter, others in midsummer. Each case must be carefully analyzed, before any definite directions can be giyenvas to the climate best suited to it. We know of no climate which is entirely and absolutely antagonistic to its devel- opment. It was once thought that a warm, dry atmosphere alone was beneficial, but we now know that a cold climate not only does not hasten, but often arrests phthisical processes. The purity of the air is the chief reason that elevated regions are so beneficial in phthisis. Organic germs are more abundant in the air in the city than in the country. Rain and ozone free the air from them, the latter by oxidation. Rain cleanses the air of solid particles and purifies it by washing down ammonia and carbonic acid. The presence of ozone in the air is presumptive evidence of its purity. The air of high mountains and plateaux and along the shore of the ocean is richer in ozone than that of the plains. The benefit which phthisical patients derive from living near pine forests has long been known. Turpentine exhaled from pine or hemlock forests converts oxygen into ozone, and thus the PHTHISIS. 431 air of jDine forests becomes pure. Both sea and mountain air are cooler and less subject to frequent variations in temperature than the air of the plains. The question arises, will the patient be benefited by sea or by mountain air ( Patients with exhausted nervous systems, with an overtaxed brain from excessive mental labor, or an all-absorbing business, and who still retain consider- able muscular power should go to the mountains; while those past middle life, who have developed phthisis late, who are in- capable of much muscular activity do best in sea air. The health resorts of this country are those of Colorado, Minnesota, Southern California, Georgia, South Carolina, North Carolina, the Rocky Mountain regions and New Mexico. Loomis obtained the best and most jDermanent results in Asheville, X. C, in New Mexico, and in the Adirondack region of New York state. FIBROID PHTHISIS. In typical cases the lung is shrunken in size, with a corres- ponding retraction of the chest-wall and often a lateral deviation of the spine. In the substance of the lung there are firm, dense bands and masses or nodules of fibroid tissue, frequently deeply jnginented. Tubercles with cheesy centres are also usually present. This variety of phthisis is comparatively rare (Flint). Causes. — It is a disease of mature life, after the middle period, and is extremely rare before thirty (Bartholow). In the majority of cases the age of patients is under forty years (Flint). Next to heredity, chronic bronchitis and pleurisy are the most influential causes (Bartholow). Symptoms. — Fibroid phthisis is the most chronic form of the disease; its early history is that of bronchial catarrh, or of dry pleurisy; and it is not until after months, even years, that, exten- sion taking jilace to the lungs, the progress becomes more rapid. For months there is merely a dry cough, not very troublesome, but persistent. The expectoration is slight, and is nothing but mucus. The appetite is but little impaired, and the weight ami strength are not materially reduced. The symptoms increase in severity during the fall, winter and spring months for two or three years; then fever comes on toward evening, the appetite 432 A COMPENDIUM OF PRACTICAL MEDICINE. lessens, digestion becomes poor, the weight declines, the cough is harassing and prevents sleep, the expectoration becomes more profuse and entirely purulent; there is some difficulty of breath- ing, the pulse is small and weak, and finally slight chilliness is felt in the morning, fever in evening, and sweating occurs during the night. When the bronchi dilate, the expectoration becomes profuse, especially in the morning — a cupful or more may be brought up in an hour or two. The sjDutum usually contains tubercle bacilli. The matter expectorated is often notably fetid. The fingers often become clubbed (Bartholow and Flint). Physical Signs. — As regards physical signs, they are the same in all forms of phthisis. Differential Diagnosis. — Fibroid phthisis is distinguished from the other forms by its slow progress, by the long period of bronchial troubles before the pulmonary lesions begin, by the merely purulent expectoration, and by bronchial dilatation long before the cavities by excavation form. The initial period, ter- minating in a bronchiectasis, may occupy a number of years; at first for several years, there is winter cough only, the warm season being free or nearly so (Bartholow). Prognosis. — The most chronic of all the forms of phthisis is the fibroid. The course of this disease may occupy several years, indeed, an ordinary lifetime, and prove fatal at last, as it involves lesions which do not admit of recovery (Bartholow). Treatment.- — Same as in the other forms. ACUTE MILIARY TUBERCULOSIS. * Is characterized by the presence of miliary tubercles in most of the organs of the body. The organs almost constantly affect- ed are the lungs, the liver, the spleen, the medulla of the bones, the kidneys, thyroid gland, the heart, the choroid coat of the eye, the lyniph-glands and the serous membranes (Flint). Causes. — It is caused by the entrance of tubercle bacilli into the blood current, and their transportation to most parts of the body. All varieties of local tuberculosis may be followed by acute miliary tuberculosis. It frequently develops in persons TUBERCULOSIS PLEURISY. 433 apparently in perfect health. All tubercles contain bacilli (Flint). Symptoms. — Cases of this disease are rare; they occur mostly after puberty and before the middle period of life. The general symptoms denote a febrile disease. The disease sets in with a chill, a rather rapid rise in temperature from 103° to 107° F., with remissions and a rapid pulse 120 to 150, small, soft and compres- sible. The respirations are from fifty to sixty per minute. Cough is more or less prominent. There is complete anorexia and the prostration is great. The circulation in the extremities is feeble; the finger nails are blue, the lips and nose have also a cyanotic hue, and the countenance soon becomes dusky. The tongue be- comes dry; sordes accumulate about the teeth; food is rejected; tympanites and diarrhoea supervene, the stools have a light yel- low color; there is delirium of a low muttering character and stupor comes on which soon passes into coma. The cases, as a rule, present a striking analogy to typhoid (Bartholow and Flint). Prognosis. — Is unfavorable. The duration of the disease is from a few clays to six or seven weeks, with an average of three weeks (Loomis). Treatment. — The consideration of the treatment of acute miliary tuberculosis is a rather barren subject, since it does not appear that any remedy has the least influence over the disease. The condition of the patient is hopeless, and all that the physi- cian can do is to palliate symptoms and sustain the powers of life. This is one of the diseases in relation to which recovery is proof of an error in diagnosis (Bartholow and Flint). PLEURISY. Called also pleivritris, is an inflammation of the pleural mem- brane. It may run an acute, sub -acute, or chronic course, and have for its products fibrin, serum and fibrin, serum, fibrin and pus, or new connective tissue. It may he primary or secondary to some other disease (Loomis). 434 A COMPENDIUM OF PEACTICAL MEDICINE. Pathological Anatomy. — Normally the pleural membrane is smooth, polished and covered with a single layer of en- dothelial cells. The pleural cavities contain normally a small quantity of serum. The first noticeable change in pleurisy or pleuritis is redness of the jDleura from active hypersemia of the vessels. Small extravasations of blood may take place on account of the bloocL pressure. The pleura loses its glistening appearance, and becomes dull, opaque and rough; the endothelial cells are rapidly cast off. Very soon the surface of the pleura becomes covered with a fibrinous exudation and it becomes rough and shaggy in appearance. The opposing surfaces of the pleura may be agglutinated by the fibrin. If any serum exudes it gravitates to the most de- pendent portion of the pleural sac. Those are examples of dry pleurisy, in which a very plastic exudation is thrown out on the two surfaces over a small extent of the membrane, union taking place, there being no Other effusion. More commonly, the pleu- risy is of the sero -fibrinous variety. In this variety, in addition to the fibrinous coating of the pleura, the cavity contains serum, varying in quantity from a few ounces to several pints. When pus -cells accumulate in sufficient number, the exudation becomes purulent and the disease is called suppurative pleurisy or empyema (see empyema). The red blood corpuscles may be so abundant as to stain the fluid red; it is then called hemorrhagic pleurisy. In from four to six days after the onset of the inflam- mation newly formed capillaries, which are off- shoots from the pleural capillaries, make their appearance in the deeper parts of the layer of fibrin and cells covering the pleura. The termina- tions of acute pleurisy are either in death, in resolution, in chronic pleurisy, or in empyema. It will be noted that after the most favorable termination of pleurisy the pleura does not return to its normal state, but is left with a new growth of con- nective tissue which binds the pleural surfaces together over a greater or less extent. In this way the pleural cavity may become entirely obliterated by adhesions. The adhesions are at first weak, and may be broken by active exercise or by acts of coughing. Chronic pleurisy differs only in time and extent from the acute form. In pleurisy deformans the exudations are of PLEUEISY. 435 great thickness and extent, and by adhesion and subsequent con- traction, extensive deformity of the lung may result. Pleurisy may be general or circumscribed (Bartholow, Flint andLoomis). Causes. — Pleurisy may be primary or secondary. Exposure to wet and cold has been regarded as one of the most frequent causes of primary pleurisy. It may result from a penetrating wound, or blows upon the chest wall, or fracture of the ribs. It is common in early life up to the middle period, but is uncom- mon in old age. It is secondary to lobar and lobular pneumonia, pulmonary tuberculosis, infarctions, abscesses and gangrene of the luug, bronchitis, pericarditis, etc. Pleurisy is a frequent complication of many infectious diseases, such as scarlatina, var- iola, pyaemia, septicaemia, acute rheumatism, Bright's disease, scorbutus and gout. Pus is usually formed in the pleurisies of children (Bartholow, Flint and Loomis). Symptoms. — Acute pleurisy may be mild or severe. There are three stages. The first stage is the period from the attack to the time when effusion takes place. The second stage will extend to the time when the liquid begins to diminish. The third stage is the time occupied in absorption of the liquid. The first stage rarely extends beyond twenty -four hours; the second and third stage are variable. Acute pleurisy with effusion, the ordinary form, sets in as any other acute inflammation, with chill, general malaise, and fever with pain in the side. There may be a well -pronounced chill, but more often chilly sensations for the first few days. The pain is usually acute, lancinating, circumscribed, and is increased by breathing, coughing, or abrupt movements of the body. It is felt at the side of the chest, some- times at the base of the thorax, occasionally in the lumbar and iliac junction. It may be covered with a finger or two. It is commonly called "stitch in the side." The pain may be diffused and ill- defined. It may cease in three or four days, or continue. The respiration is hurried and difficult. The fever may continue with little variation for about eight days. The temperature in ordinary cases rarely rises above 100° F.; but in very severe cases it may reach 104° F. Cough is usually present, but is sometimes wanting. It is usually suppressed on account of pain. It is a dry, short, tear- 436 A COMPENDIUM OF PRACTICAL MEDICIJSTE. ing, hacking cough. When effusion conies on, the cough de- clines. The expectoration is slight or wanting, and when pres- ent it consists only of a little frothy mucus. The decubitus of the patient is highly characteristic. Before effusion has taken place the patient lies on the sound side; but when the effusion begins to compress the lung the patient lies on the diseased side. If a considerable amount of liquid be rapidly effused the respira- tions are rapid; the patient suffers from a painful sense of tho want of air or dyspnoea, and may be obliged to maintain the sit- ting posture. The pulse is accelerated, beating from 90 to 120 per minute. The countenance has an expression of weariness, anxiety and exhaustion and may be rmle or cyanosed. It is a unilateral disease — that is, it affects the j^leura of one side only (Bartholow, Flint and Loomis). Physical Signs, — During the first 24 hours of acute pleurisy, inspection shows restrained movements on the affected side, pal- pation, percussion, and mensuration will give negative results. On auscultation the respiratory murmur will be found feeble over the affected side, and a grazing friction sound will be heard. As the plastic exudation takes place inspection will show .a greater loss of expansive motion on the affected side; pjalpation shows diminished vocal fremitus; percussion gives slight dull- ness : auscultation shows feeble respiratory murmur, and a fric- tion murmur will be heard on inspiration and expiration. If the pleurisy is confined to the pleura of the diaphragm or medias- tinum the friction sound will not be heard. When there is con- siderable effusion, inspection will show more restricted move- ments; palpation shows absence of vocal fremitus at the bottom of the pleural cavity, (on the sound side the vocal fremitus is exaggerated); on percussion, dullness or flatness is found at the base of the chest, and the finger which serves as a pleximeter, feels an increased sense of resistence. Changing the position of the patient changes the line of dullness. The resonance over the lung above the level of the liquid is increased, constituting vesiculotympanitic resonance. On auscultation the respiratory sound will be absent below the level of the fluid, and feeble above it. (In health the vocal fremitus is greater on the right side). When the pleural cavity is completely filled with fluid, PLEURISY. 437 inspection will show an enlargement of the affected side, and a bulging of the intercostal spaces. On the sound side the respir- atory movements are increased. If the effusion is in the left pleural cavity, the heart will be displaced to the right, and the apex-beat may be noticed under the right nipple; if it occupies the right pleural cavity the apex-beat will be carried to the left, beyond its normal position. The circumference of the affected side at the end of expiration, will be one or two inches greater than that of the healthy side; but at the end of inspiration the difference will be but slight. Palpation shows absent vocal fremitus, or in rare cases vocal fremitus may persist and even be increased. Percussion shows flatness. Auscultation shows entire absence of the respiratory sounds, and vocal sounds will be dis- tant and indistinct. At the upper portion of the pleural cavity bronchial respiration and bronchial voice, or bronchophony will be heard. As the fluid is absorbed the friction murmur returns, and is sometimes so loud as to be heard by the patient himself (Bartholow, Flint and Loomis). Differential Diagnosis. — Pleurisy may be confounded with pneumonia, intercostal neuralgia and pleurodynia. Pleurisy begins by chilliness, which persists for several days — pneumonia by a severe rigor, rarely two; the pain in pleurisy is a stitch, a lancinating pain, which can be covered by the finger, pneumonia by a sense of soreness and pain much more diffused; the fever in pleurisy is continuous — in pneumonia there is a distinct crisis or lysis, somewhere from the fifth to eleventh day; the duration of pleurisy is indefinite — of pneumonia self -limited; the expectora- tion of pleurisy is simply frothy mucus — of pneumonia rusty or bloody; in pleurisy the vocal fremitus is absent — in pneumonia it is not only present but exaggerated; in pleurisy there is a fric- tion sound, no crepitant rale, and the bronchophony is not so well defined — in pneumonia there is no friction sound, the crepi- tant rale is present, and bronchophony is loud and clear; in pleurisy with effusion there is more decided dullness, the inter- costal spaces are pushed out, and the thorax enlarged; in pneu- monia the percussion note is not so flat, the intercostal spaces and the size of the thorax remain normal. Tntercostal neuralgia denotes a neuralgic affection of the intercostal nerves. The term 438 A COMPENDIUM OF PRACTICAL MEDICINE. pleurodynia is applied to a painful affection of the muscles of the thorax. Both affections may be characterized by pain resem- bling that of either acute pneumonia or pleurisy; that is, a lanci- nating pain felt especially in the act of inspiration. They may be accompanied by a dry cough which is acutely painful. In cases of pleurodynia there may be pyrexia, and this may acci- dentally exist in cases of intercostal neuralgia. But intercostal neuralgia, as a rule, is not accompanied by pyrexia, and has three isolated points of tenderness, namely, behind, near the dorsal vertebra?; laterally in one, two or three intercostal sj3aces; and anteriorly, in one or more intercostal sj)aces near the sternum or over the epigastrium. In pleurisy there are signs denoting effusion and a friction murmur. Pain in pleurodynia and inter- costal neuralgia is more marked, as a rule, in movements of the body than in the respiratory movements, the reverse being true of the pain of pleurisy and pneumonia. Persons affected with intercostal neuralgia are frequently anaemic, and sometimes tubercular (Bartholow and Flint). Prognosis. — The tendency is to recover. Treatment. — In the first stage, the patient should receive a full dose of quinine (gr. xx.) and morphine (gr. ss.) for an adult, and the effect of this kept up by five grain doses of quinine combined with gr. £ of morphine every four hours. Besides the power of morphine to relieve pain, it is an effective remedy in serous inilammation. By relieving pain opium diminishes the determination of blood to the inflamed part; for pain is alone sufficient to occasion an increased afflux of blood to a part. Opium places the system in a condition to tolerate better the local affection. Aconite is a valuable sedative remedy in the early stage of this, as of other acute inflammations. It should be given in drop doses of the tincture every fifteen minutes for two hours, and then hourly. Saline purgatives should be given. When the exudation is poured out, carbonate of ammonia in a solution of the acetate (gr. v.-x. in Sss.) should be given. They should take the place of the quinine and morphine. Saline laxa- tives must be given, and once a day gr. ^ of pilocarpine may be administered to keep the skin active. PLEURISY. 439 Diuretics are sometimes effective in removing the effusion. Half an ounce of the infusion of digitalis, freshly made from English leaves, given three or four times a day, with the bitar- trate or acetate of potassium, is highly effective. The quantity of fluid ingested should be as small as possible. According to Loomis, if the patient presents the signs of anaemia, the syrup of the iodide of iron should be given in teaspoonful doses three or four times each day. Loomis says: "The remedial agent which seems to me to have the greatest power in promoting the absorp- tion of an effusion is the syrup of the iodide of iron." The diet should be nutritious, tonic remedies are useful, and a little wine or spirit may be allowed. Going out of doors and gentle exercise are to be encouraged. Counter irritation may do good. Cod-liver oil and extract of malt may be given, and the digestion stimulated by bitters and mineral acids. When a large effusion exists, especially if puru- lent, it becomes necessary to remove it by the operation of thoracentesis (see empyema). As death has occurred several times very unexpectedly after the operation of thoracentesis cer- tain precautions are necessary. When the effusion is large, the whole amount should not be withdrawn at once (Bartholow, Flint and Loomis). PRESCRIPTIONS FOR PLEURISY. R Morhpise sulphatis gr. i. Quinise s'ulphatis gr. xv.-xx. — M. Ft. pulv. no. 1. Sig. : Take at once. (To abort a beginning pleurisy) . — Bartholow. R Tinct. opii deodorata? 5vj. Tinct. aconiti radicis oij. — M. Sig. : Eight drops in water every hour. (In acute pleurisy be- fore effusion). . —Bartholow. R Tinct. iodini comp oiij. Sig.: Divide the affected surface into three sections and paint one section every day. (For chronic pleurisy with effusion). — Bartholow. R Potassii iodidi 3iv. Aqua? gvj.— M. Sig. : Take one teaspoonful in milk three times a day. 440 A COMPENDIUM OF PRACTICAL MEDICINE. PNEUMONIA. Is an inflammation of the pulmonary substance or paren- chyma. Pneumonia is the name commonly used, but pneu- monitis is the more appropriate term. The parenchyma of the lungs is composed of pulmonary lobules which are composed of air cells, infundibula, alveolar passages and bronchioles. A bronchus after it enters a lobule is called a lobular bronchus or bronchiole. It divides dichotoniously once or twice, and termi- nates in the alveolar passages, into which open the air cells, air vesicles or alveoli. The alveolar passages also divide a few times, and end in funnel shaped spaces called infundibula, the walls of which are composed of thickly placed air vesicles. Pneumonia is known in common language as " lung fever," "winter fever, 11 etc, (Flint). Varieties, — I. -Acute lobar pneumonia called by German writers croupous pneumonia, by French writers fibrinous pneu- monitis, and by others pneumonic fever. 77. lobular, catarrhal or broncho ^-pneumonia and 777". Embolic pneumonia, suppura- tive pneumonia or abscess of the lung (Flint). Acute lobar or croupous or fibrinous pneumonia or pneu- monitis is an acute general disease characterized by an inflam- mation of the vesicular structure of the lungs, with an exudation into the alveoli which renders them impermeable to air. A sin- gle lobe, the whole of a lung or both lungs may be simultane- ously involved (Loomis). Morbid Anatomy. — Lobar pneumonia may be divided into three stages. 1. A stage of congestion or engorgement, or hyperaenda. 2. A stage of consolidation or red hepatization. 3. A stage of gray hepatization. Another division is into the stage of congestion; the stage of exudation (red hepatization); the stage of resolution (degeneration and extrusion of the exu- dation); and the stage of purulent transformation (gray hepatiza- tion). Iu the stage of congestion, there are an increased blood supply and the pouring out of an exudation. The lung does not collapse when the thoracic cavity is opened, has a reddish-brown appearance, is heavier, floats in water, but sinks lower than the PNEUMONIA. 4J-1 normal lung, crepitates but little when pressed, and is no longer elastic. On section a thin, frothy, blood-stained serum exudes. It may be tenacious. In the stage of exudation or red hepatization, there is a pouring out and coagulation of the exudation. There is exuded into the alveoli and bronchioles an albuminous or fibrinous fluid of great viscidity, and with it leucocytes which have wandered from the vessels, and red- blood -corpuscles present by cliapedesis, and blood by the rupture of distended capillaries. In the cap- illaries of the inflamed area the blood current is finally stopped. The albuminous or fluid exudation remains fluid for a short time, and then solidifies or coagulates. When this process is completed, the inflamed part is solid, entirely without air, and falls immediately to the bottom when jDlaced in a vessel of water. The volume of the affected lung is increased; so much so that it often bears the impress of the ribs. The lung is friable, easily torn and non -crepitant. On section a dirty red viscid fluid oozes from the surface. The cut surface has a reddish color, and is granular, resembling liver-tissue. This granular appearance is due to the little masses of coagulated exudation filling the cavity of the alveoli. The granules can be lifted out of the mold in which they are formed by means of a fine needle. There are two directions which the inflammatory process may now assume: to- ward resolution, or toward purulent transformation. When resolution takes place, the albuminous material which had solidi-. fied undergoes liquefaction, the watery parts being absorbed and the solid expectorated. When the purulent transformation takes place, there is a change in the density and color of the affected lung. The pus- cells become numerous. The consistency becomes less and less until the tissue is a mere pulp, readily breaking down on pres- sure. On section the surface presents a uniformly dirty gray appearance. On slight pressure a reddish gray or dirty white pnriform fluid flows from the cut surface. The granular look of the second stage has disappeared. Termination. — Lobar pneumonia may terminate in: 1. Reso- lution. 2. Suppuration. 3. Abscess. 4. Gangrene. 5. Chronic pneumonia. 442 A COMPENDIUM OF PRACTICAL MEDICINE. Abscess may follow suppuration. These abscesses vary in size from that of a pea to one which may occupy an entire lobe. They may open into the pleural cavity. Gangrene occurs in about two per cent, of all cases. It is liable to occur when there is great constitutional weakness, and in chronic alcoholismus or in septicaemia. In childhood, except before the second year, croupous pneumonia is rare. Double pneumonia is more frequent than in adult life. In old age, the pneumonic process usually begins in the upper lobes. Gangrene is far more frequently a termination of lobar pneumonia in old age than at any other period. It is a law of the disease that lobar pneumonia attacks the lower lobe of the right lung most frequently; the next most frequent seat is the lower lobe of the left lung; then the upper lobe of the right, the middle lobe of this lung being least fre- quently involved. According to statistics of Juergensen the right lung was affected in 53.7 per cent., the left lung in 38.23 per cent., both lungs in 8.07 per cent. According to Bartholow, the inferior lobe of the right lung is the point of election, being the seat of the inflammation in three -fourths of the cases. Ac- cording to the analysis of 121 cases by Dr. Flint, in 29 cases it was limited to the lower lobe of the right, and in 25 cases to the lower lobe of the left lung. It extended over the whole of the right lung in 27, and over the whole of the left lung in nine cases. It was limited to the upper lobe of the right lung in eight, and to the upper lobe of the left lung in three cases. It was seated in the lower lobe of both lungs in eight cases. The name " crossed 'pneumonia' 1 ' 1 has been applied to the disease when the lower lobe of one lung and the upper lobe of the opposite lung are affected. Double 'pneumonia occurs in from 5 to 15 per cent, of cases, and is more frequent in senile than in the adult period of life. According to Loomis the stage of congestion lasts from one to three days; red hepatization from three to seven days; and gray hepatization from two to thirteen days. In old age the stages merge rapidly into each other; abscess of the lung may occur within 36 or 48 hours after the onset. Over a pneumonic lung there is usually a circumscribed pleurisy. In a strict sense, nearly every case of pneumonia is a pleuro-pneumonia (Bartholow, Flint and Loomis). ■PNEUMONIA. 443 Causes. — Among the predisposing causes age ranks first. There are three periods in life in which the liability to pneumo- nia is greatest: early childhood; 20 to 40; and after 60. From reliable data it appears that lobar pneumonia is five times more frequent in the first two years of life than in the whole succeed- ing eighteen. Nine-tenths of all deaths after the sixty-fifth year are caused by lobar pneumonia. The disease occurs much oftener among males than females. In-door life, a vitiated at- mosphere, excesses, especially alcoholic, and bad hygienic influences of every kind which induce debility favor attacks of pneumonia. Frequently the attack is excited by some unusual exposure, such as working in the cold and wet or sleeping out of doors at night. Diphtheria, measles, erysipelas, small-pox, and other acute infectious diseases must be regarded as predisposing causes. One attack of pneumonia predisposes to others; twenty- eight attacks have been noted in one individual. Pneumonia may follow a severe blow or injury to the chest or shock from any traumatic cause. In the aged, lobar pneumonia has devel- oped as soon as four hours after fracture in the hip joint. Those parts of the year characterized by humidity, high winds and low T temperature invite the disease. In this country it prevails most in winter and spring. Pneumonia is unknown in the Polar regions. North and east winds favor its development. Loomis gives the following facts which tend to prove that lobar pneumonia is not a local malady: " Cold does not influ- ence the prevalence of pneumonia as it would were it a local disease (e. g. bronchitis). Wet and cold increase a bronchitis but not a pneumonia rate. Lobar pneumonia is more prevalent in our Southern than in our Northern states, affecting especially the negro population, and often proves the scourge of cotton and sugar plantations. The prevalence of pneumonia increases from pole to equator. All acute general diseases increase with the population, pneumonia does this. Statistics show pneumonia to be more frequent in New York City now than twenty years ago. Again, there is no relation between the amount of lung involved and the intensity of the symptoms. In local inflamma- tions the reverse of this is true. No second chill occurs when another lobe is attacked. The absence of a known period of in- 444 A COMPENDIUM OF PKACTICAL MEDICINE. cubation, of a typical temperature range, and of characteristic surface phenomena, and the fact that the disease is not contagious are the reasons advanced by those who regard it as a local, not a general disease. The resemblances of pneumonia to acute general diseases are: distinct chill, an orderly pyrexia, a rather typical course, i. e. a day of abrupt crisis, a definite duration, and the symptoms following in regular sequence. There is a peculiar facies ; an oc- casional herpetic eruption; nephritis is not rare; the cerebral symptoms resemble those of the exanthemata; there are sweats and sudamina; and its mode of commencement. Coma in the old and convulsions in the young indicate that it is an acute general disease. We have abortive cases of pneumonia, just as we have abortive cases of typhoid. Pneumonia is allied to acute general diseases by the fact that certain complications occur. It is some- times a disease of intra- uterine life. No local disease occurs in the foetus. The success of modern methods of treatment based on this belief bears evidence to its being a general, self -limiting, acute febrile disease. Pneumonia is thus admitted to be a gen- eral constitutional disease with local manifestations. It seems probable that the real exciting cause is a microbe (Bartholow, Flint and Loomis). Symptoms. — /. Subjective Symptoms. — For a day or longer there may be malaise, anorexia, headache, dull pains in the limbs, back and lumbar region, vertigo, epistaxis, slight diarrhoea or jaundice, and flashes of heat and rigors. In most cases the in- vasion is sudden, and the disease is ushered in by a distinct chill. Generally the patient is seized with a chill in the night. This chill is intense and prolonged, more so than in any other disease except pygemia and malarial fever. It lasts from one-half to three hours. Its abruptness and violence are characteristic. A distinct chill is less frequent in the pneumonia of old age; yet when an old person has a marked chill pneumonia may always be suspected. The initial chill is rarely repeated. A child may awake, in the night with a burning skin, bounding pulse, flushed face and hacking cough as the first symptoms. With the initial symptoms there are rise in temperature, pain in side, accelerated breathing, dyspnoea, cough, expectoration, flushed and anxious pxeuxoxia. 445 countenance, headache, loss of appetite, intense thirst, scanty urine, and heavily- coated tongue. The symptoms increase until the day of crisis, when they either suddenly remit and the patient breaks out in a profuse sweat, or they subside by lysis. The defervescence is usually reached between the fifth and ninth day. II. Objective Symptoms. — 1. Respiration is more con- stantly increased in frequency in pneumonia than in any other acute disease, and varies from 30 to 80 per minute. The respira- tions may be 80 per minute and the pulse rate not more than 100. The acceleration is not in proportion to the amount of lung in- volved. It is panting, not catching in character. It may or may not be accompanied by dyspnoea. Expansion of the nostrils is an early symptom in the pneumonia of children. 2. Dyspnoea is by no means constant. It does not depend ivpon the amount of lung involved. It is often so great that the patient is unable to lie down. The greatest dyspnoea occurs where there is marked nervous prostration, and in complicated pneumonia. In children dyspnoea is most marked when the apex of the lung is involved. 3. Pain follows the chill. It is situated under the nipple of the affected side. It is sharp and stabbing, often located over the pneumonic spot, and is intensified by coughing, sneezing, and deep inspirations. It is the pleurisy that causes the pain. Pneumonia itself is a painless disease. Pain in the affected side rarely continues beyond the third or fourth day. If it continue beyond the eighth day it is evidence of pleuro-pneumonia. It is present in 85 per cent, of all cases. In old age pain is never severe. 4. Cough is present in over 90 per cent, of the cases. It comes on within 24 hours after the advent of the disease. At first it is short and " hacking" in character. Old people with pneumonia often have no cough. 5. Expectoration is characteristic. In the first 48 hours of the disease it is simply frothy mucus. Then it becomes semi- transparent, viscid, gelatinous and tenacious, but never opaque. So tenacious is it that the cup containing it maybe inverted without spilling the mass. This tenacity in great part causes the difficulty of expectoration. Its color varies. About the 446 A COMPENDIUM OF PRACTICAL MEDICINE. second day the "brick -dust" or "rusty" sputa may be observed. This color is due to the presence of blood. The sputa may be creamy and yellow, or of a very dark or prune juice color; the latter occurs especially in alcoholic subjects. Greenish sputa may occur in the middle of the disease and during resolution. When resolution occurs the sputum becomes abundant, and of a yellow creamy color. There may be no sputum throughout; or it may not appear until the sixth or even the twelfth day. The sputum may remain brick dust till the ninth or tenth clay. In children sputa are usually absent. In senile pneumonia expecto- ration is never an early symptom. The sputa are rusty in about 33 per cent, only of such cases; frothy or catarrhal sputa are the rule. A chocolate -looking serous sputum, appearing soon after the onset of pneumonia, shows a depraved condition and indi- cates "typhoid pneumonia." 6. Temperature-range of a typical case of lobar pneu- monia indicates that it belongs to a remittent or sub -remittent type. The temperature rises suddenly during the initial chill, and in two or three hours after it may range from 102° to 105° F. After the first twenty-four hours the temperature is subject to morning and evening exacerbations and remissions. It is usually highest on the evening of the third day. A sudden rise of tem- perature may indicate a complication. The sudden fall of tem- perature on the fifth or sixth day indicates a crisis, and the beginning of convalescence. The fever may reach its highest point just before the, crisis. Pneumonia is one of the few diseases terminating by crisis. When the temperature declines gradually ("lysis"), a normal point is usually reached by the ninth day, sometimes not until the twelfth or fourteenth. A continuously high temperature after the tenth clay indicates purulent infiltra- tion. Pneumonia at the apex has the highest temperature range. The fifth and seventh are the days of crisis in the majority of uncomplicated cases. Of 867 cases, 677 ended before the eighth day. 7, Pulse varies with the severity, extent and stage of the pneumonia. In mild cases it ranges from 90 to 120; if it con- tinue above 120 the case is severe. The pulse is soft and full at the onset. Later it becomes small and feeble. It is not the most PNEUMONIA. 447 extensive pneumonia that is accompanied by the greatest flag- ging of the heart. Heart failure may exist before, or just as hepatization is commencing. When the heart is failing the pulse shows that the artery is unequally filled by each beat. In chil- dren the pulse rate may be 200 per minute. 8. The skin is often hot and dry until the crisis, but it may be bathed in perspiration from the onset. When the parched skin becomes moist at the acme of the disease and the patient is not relieved, it is an unfavorable symptom. 9. Countenance. — In most cases the expression of the coun- tenance is characteristic. The face is anxious, and over the malar bones is a mahogany flush, not diffused as in typhus fever, but well defined and circumscribed. It is called the "pneumonic spot." The rest of the face is pale. Usually one cheek is more flushed than the other; this is due to disturbance of the vaso- motor system. The lips may be cyanosed, but at the crisis they become pale. 10. Herpetic eruption upon the cheeks, nose, lips or eyelids occurs in about fifty per cent, of cases. It is rare before the sec- ond or third day and may not occur until the crisis. Sudamina may accompany profuse sweating. In children wmile the surface of the body is hot and dry, the extremities are cool and the pneumonic flush is bluish. Cyanosis of the extrem- ities is more frequent than in adults, and herpes labialis is more constant. In old age the pneumonic flush is often the first ob- jective sign of pneumonia. The eye-lids alone are cyanotic. The face assumes a sallow hue and the surface heat is succeeded by a cold, clammy perspiration. 11. Cerebral symptoms are headache, slight delirium at night (it may be active), coma and convulsions in children. 12. Digestive symptoms may be nausea and vomiting,, anorexia and thirst. The tongue and lips may become brown, dry and cracked, and sordes collect on the teeth. The urine in pneumonia is scanty and high colored. Epistaxis is most fre- quent at the onset and at the crisis. Swelling of the veins of the hands in children is an unfavorable symptom. When pneumonia is to terminate fatally, dyspnoea increases, the patient "sinks, 11 the pulse becomes small, rapid and intermittent, moist rales are 448 A COMPENDIUM OF PEACTICAL MEDICINE. heard in the bronchi, the face is livid and the body is bathed in a profuse cold, clammy sweat. Abscess. — Acute pneumonia terminates in abscess in two per cent, of all cases. In these cases, the sputa are copious and fetid, yellowish in color, and consisting almost wholly of pus. The fever is of the hectic type, and is accompanied by rigors and sweats. Gangrene, as a termination of pneumonia, has been found in about 14 per cent, of cases. In these cases there is sudden collapse, rapid, feeble, intermittent pulse, face pale and death- like, and profuse expectoration of blackish -green masses. The breath is offensive and the body has a cadaverous smell. The sickening odor of pulmonary gangrene is most perceptible after coughing. Gangrene has its seat in the lower lobes of the lung. Purulent infiltration may be suspected when resolution does not take place at the period of crisis and the temperature remains high, accompanied by symptoms of prostration and profuse purulent expectoration. Death results from exhaustion. Typlioid pneumonia is a term that has been applied to a pneumonia attended by typhoid symptoms. There is no sputa, no dyspnoea, no pain, no cough. Sordes collect on the teeth and s;ums. The tongue is thickly coated, and later covered with thick black crusts. There is stupor, somnolence and continual low, muttering delirium. This form is common in the aged. Bilious, or gastric pneumonia, is lobar pneumonia occurring in malarial districts, accompanied by gastro- enteritis with hej^atic symptoms. Physical Signs. — I. First Stage, or Stage of Congestion. — Inspection shows diminished respiratory movements on the af- fected side. Palpation shows increased vocal fremitus over the affected lung. Percussion shows slight dullness. Auscultation shows a feeble vesicular murmur. There is broncho-vesicular breathing. Within 24 to 36 hours there is heard with or at the end of inspiration a fine crackling sound over the inilamed region — the crepitant rale. This rale is highly diagnostic of pneumo- nia. . It has been compared to the sound produced by rubbing a lock of hair between the fingers in front of the ear, and to the burning of grains of salt on live coals. As the sound is produced by the separation of the bronchioles and alveoli, adherent by the PNEUMONIA. 449 viscidity of the albuminous exudation, it is obvious that it can occur only during inspiration. When consolidation takes place, the crepitant rale ceases. II. Second, or Stage of Heal Hepatization. — Inspection shows lost respiratory movements of the affected side, and in- creased on the sound side. Palpation shows increased vocal fremitus. Percussion gives complete dullness. Auscultation gives bronchial respiration and bronchojihony is heard over the whole of the consolidated lung. If the pleural cavity be partly filled with fluid, the voice sounds may be segophonic at the level of the fluid. Pectoriloquy may be heard (i. e., when the voice sounds directly into the ear from the chest). 777". Third, or Stage of Gray Hepatization. — Inspection shows returning respiratory movements. Palpation shows vocal fremitus gradually diminishing. Percussion shows diminishing dullness. Auscultation shows broncho-vesicular breathing, and rale redux (i. e., resolving subcrepitant rale). Differential Diagnosis. — -Pneumonia may be confounded with pulmonary congestion and oedema, cajrillary bronchitis, pleurisy, hypostatic congestion, catarrhal pneumonia, pulmonary infarc- tion, meningitis and typhoid fever. Pneumonia commences with a chill, followed by a rapid rise in temperature and pain in the side. There is no chill, no fever, and no pain in pulmonary congestion and oedema. The expec- toration of pneumonia is viscid and rutsy; in pulmonary congest- ion and oedema, it is profuse, watery and blood-stained. As a rule, pneumonia is unilateral; pulmonary (edema is bilateral. In capillary bronchitis there is heard all over the chest the sub- crepitant rale, the expectoration is muco-purulent, the tempera- ture range is low, there is no dullness on percussion, no bronchial breathing, and cyanosis is marked. The breathing is labored in bronchitis, and panting in pneumonia. Acute pleurisy begins with chilliness, or several rigors, and low temperature; pneu- monia with a distinct chill followed by fever. In pleurisy the face is pale and anxious, and the pulse is firm, small, tense, and wiry; in pneumonia the face has a mahogany flush, and the pulse is full and compressible. The breathing in pleurisy is catching; in pneumonia it is panting. In pleurisy there is a dry, hacking 450 A COMPENDIUM OF PRACTICAL MEDICINE. cough with mucous expectoration; in pneumonia rusty sputum. In pleurisy with effusion, vocal fremitus is diminished, there is flatness on percussion, the respiratory sounds are feeble, and there is friction sound; in pneumonia vocal fremitus is increased, dullness on percussion, crepitant rales and bronchial breathing is present. In hypostatic congestion, the expectoration is copious, watery and blood-stained. It disappears when the patient sits up. Catarrhal or lobular pneumonia in children is usually secondary to bronchitis, is developed in both lungs, has no days of crisis, and no chill. Pulmonary infarction is rare without cardiac disease or pyaemia, is non febrile, and has intense dyspnoea. The expectoration is small black clots. Cases of pneumonia with cerebral symptoms may be mistaken for meningitis, but this can only happen should the chest not be examined. In meningitis there are no thoracic symptoms, no dyspnoea, and the face is pale and anxious. Pneumonia with typhoid symptoms is sometimes mistaken for typhoid fever. But the pneumonia which compli- cates typhoid fever does not come on until late in the fever, and the regular history of typhoid fever precedes its development (Bartholow and Loomis). Prognosis. — About twenty per cent, of cases of pneumonia die. The prognosis depends on the age of the patient. After sixty the prognosis is always unfavorable. Most "sudden deaths" in the old are from acute lobar pneumonia. Double pneumonia is rarely recovered from. Conrplications such as pleurisy, capillary bronchitis, and pericarditis render the jDrognosis unfavorable. The symptoms which are unfavorable are as follows: frequency and feebleness of the pulse; great frequency and labor of respira- tion; lividity of the prolabia and face; an abundant purulent or muco-purulent expectoration; prune- juice expectoration; active violent delirium; low muttering delirium with prostration and subsultus tendinum. The occurrence of purulent infiltra- tion, abscess, or gangrene renders the prognosis unfavorable (Bartholow and Loomis). Treatment. — Acute lobar pneumonia is a well defined, self- limited disease. It is thought to be a constitutional disease with a local lesion. Loomis says " The pneumonic lung no more re- quires treatment than the intestinal ulcers of typhoid fever. It is PNEUMONIA. 451 ♦ the general condition of the patient not the local changes, which is to govern ns in the management of each case." If a patient be seen during the stage of congestion, Bartholow would apply five to ten full-sized leeches. Flint states that full doses of quinia, that is from 20 to 40 grains, given either at once or within eight or ten hours, may arrest the disease. Aconite is an effective sed- ative. Two to five drops of the tincture of aconite root may be given every two hours in the first stage. A large mustard 'poul- tice should be put on the chest, and removed when the skin is reddened, to obtain its stimulant effect on the vaso- motor nerves within, and the feet should be immersed in a hot mustard foot- bath. Bartholow states that modern researches have shown that calomel has a sedative action on the liver; lessens bile production and probably the whole functional activity of the liver; and as all cases of pneumonia are accompanied by hepatic disorders, it is clear that calomel is indicated. Calomel acts as an antipyretic and should be given on the first, second and third days of the disease in doses of from three to five grains. When the exudation begins to coagulate a solution of the carbonate of ammonia (gr. v.-x.) in liquor ammonii acetatis (5ss) every three or four hours is very useful. The Germans prefer the muriate in the same doses. The chest may be surrounded with cotton -batting or flannel jacket. Absolute rest is essential. The sick room should be well ventilated, and its temperature between 65° and 70° F. The diet should consist of milk, eggs, beef-tea, and concentrated broths. For the first four days Loomis would kee]3 the patient under the full influence of opium by hypodermic injections of morphine. There are two sources of danger — heart failure and high temperature. Alcohol is the most efficient means for pre- venting heart failure. It is best to begin with small doses, when the pulse is frequent, feeble and irregular, and not more than six or eight ounces of brandy should be given in twenty-four hours. A dicrotic pulse, delirium, muscular tremor and collapse are indications for alcohol. To reduce the temperature there are two plans of treatment: the application of cold and internal antipyretics. Cold s]X)ngmg may be practised when it is grateful to the patient. Of the antipyretics, antipyrin and antifebrin are employed. Antifebrin 452 A COMPENDIUM OF PRACTICAL MEDICINE. is to be preferred. In some cases of pneumonia quinine is more efficacious than antif ebrin in reducing fever, given in doses of gr. x-xx. every two hours. If there is restlessness or wakefulness in the third stage, chloral hydrate serves a most useful purpose. Fifteen grains at night is usually all that is required. To jDro- mote the expectoration and to relieve the cough the proper reme- dies should be given. In weak subjects a little wine may be given from the beginning (Bartholow and Loomis). PRESCRIPTIONS FOR PNEUMONIA. |i Potassii iodidi 3j. Amrnonii muriatis jiss. Mist glyc}a'rhizae co 3yj. — M. Sig. : A tablespoonful four times a day, to promote absorption together with blisters to the chest. — DaCosta. |fc Pulv, digitalis gr. vj. Quinias sulphatis gr. xij. Ext. opii Ext. ipecacuanha? aa.... gr. iij. — M. Ft. massa et in pil. no. xii. div. Sig. : One pill three times a day with the preceding mixture. — DaCosta. J& Amrnonii carbonatis gr. xl. Infusi serpentarise. .. §iv. — M. Sig. : A teaspoonful every three hours. (As a stimulant about the crisis). — Bartholow. Jfc Tinct. veratri viridis ITTxl. Spts. setheris nitrosi gvj. Liq. potassii citratis givss. Syr. zingiberis ad §vj. — M. Sig. : A tablespoonful every three hours. (In early stage.) — DaCosta. JJr Pulv. sinapis §ss. Pulv. seminis lini oviij. — M. Ft. cataplasma. Sig. : Apply to the chest covering with oiled silk. — J. Lewis Smith. Lobular Pneumonia. — Called also catarrhal or broncho-pneu- monia is always secondary, being preceded by innammation and obstruction of the smaller bronchi, which lead to the consolidat- ed lobules (Loomis). pxeumoxia. 453 Causes. — It may be excited by an extension downward of a catarrhal process from the tubes to the air cells. It is most frequent between the ages of one and three, and in old age. The bronchitis of measles, whooping cough, influenza, etc., often leads to lobular pneumonia. Bad hygienic influences as to dress, habitations, humidity and exposure, favor its development (Bar- tholow and Looinis). Symptoms. — The beginning symptoms are chilliness, followed by fever, soreness of the chest beneath the sternum, cough, ex- pectoration of a frothy mucus and some difficulty of breathing. Soon the breathing becomes rapid, superficial and labored, and the alse of the nose work quickly and continuously. The face at first is flushed and rather animated, and the eyes have a glaring expression, but the lips soon become bluish and cyanosis spreads over the face. The cough, wmich during the preceding bron- chitis was loose, loud and bronchial, now becomes dry, hacking, and is usually very painful. The pulse ranges from 140 to 200 per minute. The temperature will gradually rise to 104°- 105° F., unlike the sudden rise of lobar pneumonia. As the dyspnoea in- creases, there is increasing restlessness, never a moment of quiet, the struggle for breath and search for an easier position being incessant. The respirations are panting and may be 100 per minute. As the struggle for breath continues, the superficial veins grow into thick black cords, the result of carbonic acid poisoning, and the patient, a child, may tear the skin about the neck and face with its nails in a vain effort to remove supposed obstructions. The tongue becomes dry; sordes collect on the gums and teeth, and aphthous stomatitis is common (Bartholow and Loomis). Physical Signs. — Inspection shows a deep depression of the abdomen from retraction of the lower ribs on inspiration. Pal- pation shows increase of vocal fremitus when a considerable number of lobules have collapsed. Percussion shows no change until the atelectasis occurs, and then slight dullness. Ausculta- tion shows abundant rales all over the chest. They consist of subcrepitant rales which are somewhat coarser and louder than the crepitant, and are audible with both inspiration and expira- tion. There are also mucous and sub- mucous rales produced in 454 A COMPENDIUM OF PEACTICAL MEDICINE. the larger tubes. There may be bronchophony (Bartholow and Loomis). Differential Diagnosis. — Catarrhal or lobular pneumonia may be mistaken for croupous pneumonia, bronchitis, acute tubercu- losis and oedema of the lungs. Croupous pneumonia is, as a rule, unilateral and limited to a certain area; catarrhal pneu- monia is bilateral and diffused over both lungs. The one is a self -limited disease, the other has no fixed duration. Capillary bronchitis may be primary; lobular pneumonia is always second- ary. The breathing is labored in capillary bronchitis and pant- ing in pneumonia. The one gives resonance on percussion, the other dullness. In acute tuberculosis the fever is higher than in pneumonia. Acute tuberculosis occurs in early adult life. Lob- ular pneumonia occurs oftenest in the child of one to four years. In oedema of the lungs there is no fever (Bartholow and Loomis). Prognosis. — Half the cases die. The average duration of acute lobular pneumonia is from ten to fourteen days (Bar- tholow and Loomis). Treatment. — To promote the expectoration Bartholow would give three to six grains of the carbonate of ammonia and four to eight grains of the iodide of ammonia in solution every two hours. Some authorities would give the muriate of ammonia. Oil of turpentine, eucalyptol and copaiba may be used for the same purpose. If there is excessive dyspnoea Bartholow would give two to three grains of the subsulphate of mercury to produce vomiting, and thus dislodge the muco-pus. For the high fever the same author would give two drops of tincture of aconite root, and one of tincture of belladonna, every two hours to a child of two years. For the continued high temperature three grains of quinine and one-fourth of a grain of digitalis can be given morn- ing, noon and evening to a child of two years. The patient should be kept in a warm room well ventilated. The air of the room may be filled with the vapor of oils of eucalyptus and tur- pentine, by heating them with water. The chest should be enveloped in linseed or mild mustard poultices, or in very young children a stimulating liniment may be rubbed on the chest two or three times a day and cotton -batting applied. The food should be fluid and nutritious. Stimulants must be given from PRIAPISM. 455 the onset of the disease. Brandy or gin in milk, ten to twenty drops every three or four hours, may be given to a very young infant. If the disease is prolonged and emaciation is marked, cod -liver oil and the syrup of the iodide of iron should be given, with a change of air (Bartholowand Loomis). PRIAPISM. Is more or less continuous erection without desire. Inter- course with ejaculation may take place in some forms of priapism (Keyes). Causes. — Erection has long been observed to follow injuries to the cerebellum and spinal cord. Out of eleven cases of cere- bellar hemorrhage, erection of the penis was noted six times by Serres. Death by hanging is often accompanied by partial erec- tion. Erections are often absent after some diseases and injuries of the spine producing paraplegia; but in other cases the disease or injury is attended by priapism. Lallemand mentions the case of an officer who was thrown from his horse, and at once became paraplegic, and had priapism. As his paraplegia gradually got well his priapism ceased. The same author states the case of a soldier, who climbing out of garrison to see his mistress, fell upon his sacrum, and became partially paraplegic with priapism. As the priapism produced retention of urine, he attempted to free himself of it by masturbation, but without success. On one occasion, he indulged in copulation with his mistress almost con- tinously for several hours, until he had exhausted his partner — but all to no effect. He had no pleasure or ejaculation. Large doses of cantharides will produce erection without desire. Prolonged mental exertion, over-anxiety, etc., are some- times attended by priapism, due perhaps to some local injury, as gonorrhoea, the passage of a stone or a sound. Some prostatic affections are atteuded by priapism. Many writers mention leucocythcemia as a cause of persistent priapism. Salzer gives as causes extravasation of blood in the corpora cavernosa, impeded circulation in the smaller vessels and the formation of thrombi. Mackie notes a case of persistent priapism lasting twenty- one days in an old man of seventy. After nineteen days the right 456 A COMPENDIUM OF PRACTICAL MEDICINE. corpus cavernosum swelled and was relieved by incising it. He thinks that a small extravasation in the corpus cavernosum was the immediate cause of the priapism. Priapism in children is often due to stone in the bladder, tight prepuce, worms in the rectum, etc. (Keyes). Treatment. — Is hygienic and symptomatic. The lower part of the spine and perinseum may be blistered. Electricity, strych- nine, ergot and bromide of potassium may be tried. Iodide of potassium has been successfully used (Keyes). PRICKLY HEAT. Called also lichen tropicus because it is met with in tropical climates in its most typical form, is a congestion or slight inflam- mation at the orfices of the sudoriparous follicles (Anderson). Cause. — Heat is the exciting cause. Symptoms. — Little, bright red, acuminated papules, about the size of pinheads, make their appearance in great numbers, giving to the skin a rough feeling. They may be closely set to- gether, but generally remain discrete, the intervening skin having a healthy appearance. Here and there little vesicles, such as are observed in sudamina, often make their appearance. This erup- tion is found chiefly upon the trunk and forehead, and is accom- panied by a tingling, pricking, or itching sensation. It is aggra- vated by the use of stimulating food and drink, as well as by heat and over- clothing. The rash frequently occurs in successive crops and the duration is indefinite (Anderson). Treatment. — Keep the patient cool. The skin may be fre- quently sponged with vinegar and water, or a weak lotion of carbolic acid followed by a soothing dusting powder, such as equal parts of oxide of zinc, lycopodium and starch. The diet should be very light and unstimulating. Saline aperients are useful, as well as diuretics and cooling acidulated drinks (Anderson). PROSTATITIS. Is an inflammation of the prostate gland. Congestion of the prostate occurs physiologically during venereal excitement. If such excitement be unduly prolonged without being gratified, PROSTATITIS. 457 or if the imagination be given np to erotic fancies, the mucous follicles of the organ secrete more or less of a peculiar, viscid, bluish mucus, without odor, which mixed with urethral mucus, finds its way out at the meatus. This is perfectly natural. It is analogous to the wateriug of the mouth of a hungry individual at the sight, smell, or even thought of food. This drop of mucus appearing during erection excites in the minds of many individ- uals whose sexual requirements are not met, the most lively alarm, and they hasten to consult a physician. Marriage, to place him in natural sexual relations, will effect a cure. If this physiological hyperseinia be kept up for a long time, the prostate is liable to remain congested, and cause frequent uriuation and a gleety discharge. Slight congestion of the prostate frequently complicates gonorrhoea and stricture, and it maypassonto actual inflammation. Congestion may be excited in the prostate by sexual excess and lead to prostatitis (Keyes). Causes. — Among the causes of parenchymatous prostatitis may be mentioned gonorrhoea, stricture, extreme and prolonged sexual excitement, acid urine, cold, injury, strong injections, and cantharides internally. Gonorrhceal inflammation after the first week, may run down the urethra and involve the prostate, if the patient indulge in alcohol, sexual intercourse, takes violent exer- cise, or uses strong injections deep in the canal. The inflamma- tion behind a stricture may run back to the prostate. Termination. — Prostatitis commences as congestion and passes on to true inflammation. It terminates by resolution with exu- dation of pus, by abscess, or it may linger indefinitely as a chronic inflammation (Keyes). Symptoms. — The prostate swells rapidly and often attains the size of an orange. The mass may be felt with the finger in the rectum, and is exceedingly sensitive to pressure, unlike hy- pertrophy of the prostate. In prostatitis, the finger in the rectum or pressure over the pubes brings on a desire to urinate. The patient is conscious of something protruding into the rectum. The perinseum feels hot and is sensitive to pressure. There is a feeling of weight and dragging in the pelvis, penis and scrotum. There may be pain in the back and limbs. The stream of urine is small and is passed with effort. The prostate may swell to 458 a compendium: of practical medicine. such an extent as to cause retention. There is a constantly recurring, never- satisfied desire to urinate. Voiding the urine causes pain, but the pain is most severe as the last drops are being expelled. The patient has fever, and is irritable, despond- ent and suspicious. Recovery is complete in from one to three weeks (Keyes). Treatment. — The main treatment is rest in bed with hips raised, some alkaline diluent for the urine, and enough anodyne to control severe pain. Rectal injections of hot water may be given. The patient may drink flaxseed- tea, infusion of triticum repens with some citrate of potash or Vichy water. If the pros- tatitis is due to gonorrhoea all active treatment and urethral injec- tions must be discontinued. Ten to fifteen leeches may be applied to the perinseum. Hot applications to the pelvis are useful. At night full doses of bromide of potassium with from gr. v.- xx. chloral hydrate maybe given to produce sleep (Keyes). PROSTATORRH(EA. Is also called follicular prostatitis: In this disease, the mucous surface of the sinus of the prostate and of the mucous follicles and ducts are inflamed, while the substance of the organ for the most part escapes. Symptoms. — It runs a chronic course. It may come on dur- incr o-onorrhcea as the inflammation extends backward. The main feature of the disease is a slight oozing from the meatus of a niuco- purulent matter. The discharge may be more profuse when at stool. The patient thinks the discharge to be semen. This discharge is exceedingly rebellious to treatment. If the prostatorrhcea, or follicular prostatitis, and the parenchymatous coexist, then a peculiar weight is felt in the perineum with pain. Walking becomes painful. Crossing the legs decidedly increases the pain, as does the sitting posture. There is frequency of urination. There is pain on passing water, which contains pus and blood. The pain may be felt at the end of the penis. The stream of urine is sometimes suddenly interrupted. The patient may be feverish and depressed. A slight gleety discharge accom- panies this condition (Keyes). PRURIGO. 459 Treatment. — Xo remedy is so efficacious as blistering of the perinseum. Cantharidal collodion may be painted on one side of the perinseum, and the patient confined to bed for forty -eight hours, then the other side may be painted. Alkaline diluents may be given, and the bowels kept regular. A good diet and tonics are necessary. If this treatment fail, nitrate of silver (gr. v.-x. to the 5j.) may be injected into the membranous urethra (Key.es). PRURIGO. Is a papular skin disease with intense itching. Causes. — Very little is known concerning its cause. The fact, however, that it is met with almost exclusively amongst the neglected children of the poor, seems tolead to the conclusion that defective diet and absence of rJroper hygienic surroundings are favorable to its occurrence (Anderson). Symptoms. — As a rule it begins in infancy, usually at first upon the legs in the form of wheals like those of nettle-rash. These come and go until the child is five to seven years of age. At this time many solitary papules, about the size of hemp- seeds, make their appearance. They may be more readily felt than seen. The papules are irritable and soon become congested by scratching. The skin assumes a dusky tint and is covered with a fine mealy dust, and short stiff hairs. In some cases the skin feels as rough as a file and is thickened. The papules may sup- purate. The eruption is more severe upon the extensor sur- faces of the legs and arms than on the flexor surfaces. The trunk suffers some but the head, neck, scrotum, penis, palms and soles are usually free. Prurigo is a most loathsome disease when fully developed. It is common in parts of Europe, but is rarely met with in England and America (Anderson). Prognosis. — Is . very unfavorable. Hebra said that the jmtient may do whatever he pleases yet his malady will follow him to his grave ( Anderson). Treatment. — The diet should be generous and the hygienic surroundings good. Tonics are indicated and a long continued course of arsenic in full <<•>. Carbolic acid internally thrice daily is beneficial. Local treatment is important. Warm, vapor 460 A COMPENDIUM OF PRACTICAL MEDICINE. or Turkish baths should be ordered. A mixture of equal parts of soft soap, rectified spirit aud oil of cade may be rubbed firmly iuto the skin in the morning and removed in the bath at bedtime, after which the following ointment may be applied: R S ulphuri? Glycerina? Olei rusci aa 3 vi. Ung. rumicis oij-— M. Ft. tfngt. Sig. : Apply locally. In some cases baths of corrosive sublimate, (oij to the bath) are beneficial (Anderson). PRURITUS. Is a functional affection of the skin characterized by irrita- tion or itching and unaccompanied by eruption. Pruritus is a common affection. It may be continuous or intermittent,*and is most complained of after getting warm in bed. It may involve the whole body, as we often see in old people whose health is failing; but more commonly it is localized, and the parts most liable to be attacked are the anus, the scrotum, and the^labia (Anderson). Causes. — In any case, it is the result of direct or reflex irrita- tion of the cutaneous nervous filaments. Derangement of the digestive organs and constipation may cause it. Diseases of the kidneys, uterus aud ovaries may produce it. It often results from impediment to the free return of venous blood from the part. It accompanies jaundice and results from the poisonous action of the bile acids, circulating with the blood, upon the nerves of the skin. A frequent source-of pruritus is the. presence of sugar in the urine, especially of that form which attacks the genital organs. Elderly women who have intenseltching in and around the vulva, probably have glycosuria. Sometimes the cause of the pruritus disappears, while the itching continues owing to the cutaneous nervous filaments having contracted a bad. habit. Finally, it may result from cold, and is then^ chiefly jnet with on the lower extremities (Anderson). PRURITUS PSORIASIS. 461 Treatment. — Try to ascertain and remove the cause. If de- pendent on haemorrhoids, jaundice, diabetes mellitus, or digestive derangement, treat these morbid conditions. If the cause cannot be discovered, the treatment will be purely empirical, and in these cases it is desirable to have a good many strings to our bow since the affection is very obstinate. In such cases carbolic acid may be tried in the following formula: Be Acidi carbolici 3ij. Sy rupi aurantii 5J . Aquse $v. — M. Sig. : A teaspoonful in a glass of water three times daily on an empty stomach. Nerve tonics, as strychnine, phosphorus, and arsenic may be beneficial. Atropine may be tried as a nerve sedative. Dr. Bulkley, of New York, would give ten drops of the tincture of gelsemium every half hour till relief is obtained, or until one drachm is taken. If these remedies fail, bromide of potassium, sodium, or ammonium may be tried. Occasionally relief is ob- tained by sponging the surface with a warm decoction of poppy heads, or by the application of a weak continuous current of electricity. Alkaline baths may be tried (Anderson). PSORIASIS. Is a chronic eruption characterized by the appearance of dusky-red, or even coppery, slightly elevated patches of various sizes, covered with silvery- white, imbricated, and very adherent scales, with slight itching, but no exudation of the surface of the skin. Frequency. — It is by far the most frequent of the affections of the skin, except eczema and scabies. Parts Attacked. — The eruption may occur on any part of the body, but in the majority of cases it commences on the elbows or knees, and is frequeutly limited to these parts. Next to the elbows and knees the head is the part most commonly attacked (Anderson). Causes. — Are very obscure. Psoriasis is an hereditaiy dis- ease. Sir E. Wilson was of the opinion that psoriasis is " a manifestation of the syphilitic poison, after transmission through 462 A COMPEXDIUM OF PRACTICAL MEDICINE. at least one, and probably through several generations. 1 ' There is a non- syphilitic and a syphilitic form. Psoriasis may be in- duced by debility, but usually patients are in ajDparently good health. Long continued mental fatigue, as from over-study, great anxiety, etc., is very apt to call out the disease. It is met with in all ranks of life. Sea- air and sea- water are apt to call out an attack in one predisposed (Anderson). It is severest in the winter season. Symptoms. — As a rule, psoriasis does not occur before the sixth year, and usually comes out before the age of twenty- five. It is throughout a dry eruption. It is a non-febrile affection. The nails of the fingers and toes are sometimes affected and fall off. At the outset of the disease, little silvery -white scattered spots about the size of pin-heads make their appearance. As the disease advances, these spots may increase in size, being two to three inches in diameter. There is scarcely any itching. It is not contagious, but can often be traced to hereditary taint. The eruption may be on any part of the body, but almost always on the elbows and knees. Relapses are the rule. Psoriasis may last five, ten, fifteen, twenty or thirty years, or even a whole lifetime (xAnderson). Prognosis. — The disease is not fatal, but relapses are common. Treatment. — The patient should take a course of baths, have plenty of fresh air, take his meals at regular hours, go to bed early, rise early, and have nothing to worry him. We should tone up the digestive powers. Nitro- muriatic acid and gentian often do good. Balsam of copaiba is occasionally of service. Tar and carbolic acid internally are often effectual. Liquor potassse in doses of from twenty to thirty drops thrice daily in water is highly praised. Acetate of potash in doses of one-half drachm thrice daily is beneficial. A course of carbonate of ammonia may be tried, also strychnia. Arsenic is the most valuable internal remedy which we possess in the treatment of 23soriasis, and few cases resist it if given long enough. Five or six drops of Fowler's solution may be given thrice daily after meals. It agrees better with the stomach if given in bitter infusion — gentian. Xext in value to arsenic comes cod-liver oil. PUERPERAL FEVER. 463 The two may be combined. The syrup of the iodide of iron may be given also. Some cases are cured by a course of Bant- ingism — i. e., by a meat diet. The patient should be urged to eschew a too sedentary mode of life, to take open air exercise, and to try change of air and scene. Local treatment is of much value. Warm baths and soothing ointments may be used. Cold cream, cucumber ointment, the benzoated oxide of zinc ointment, ointment of carbonate or subacetate of lead, or a mixture of zinc and almond oil may be employed with advantage — three or four applications daily. The hydropathic treatment may be tried. Chrysophanic acid may be used in the form of an ointment, as follows : JJr Acidi chrysophanici gr. x. A dipis 3] . Lanolini , , . . §j . — M. Sig. : Use locally night and morning. PUERPERAL FEVER. Is an infectious disease, due as a rule, to the septic inocula- tion of the wounds which resuult from the separation of the de- cidua and the passage of the child through the genital canal in the act of parturition (Lusk). Frequency. — The total number of deaths to the entire num- ber of confinements is estimated to be in the proportion of 1 to 85, or from puerperal fever alone in the proportion of 1 to 146 (Lusk). Causes. — One source of puerperal fever is a contaminated atmosphere. Another and frequent source of puerperal fever is by direct inoculation. Any material of a septic character, in- troduced into the genital passages of a woman during or after confinement, may produce a general infection of the system. Pathogenic bacteria are invariably associated with puerperal fever, and to them the infectious qualities of the disease are due. Puerperal fever is really a surgical fever modified, however, by the peculiar physiological conditions which belong to the puer- peral state. It is a matter of ordinary experience that the reten- tion of a small bit of the membranes within the uterus will pro- duce fetid lochia, and as the result of infection, a febrile condi- 464 A COMPENDIUM OF PRACTICAL MEDICINE. tiou which as a rule, subsides with the expulsion of the offend- ing body and the use of disinfectant washes (Lusk). Prevention. — The physician should insist upon the value of plenty of light and fresh air as a means of contributing to the speedy recovery of child-bed women, otherwise they may become poisoned with their own exhalations. Complete antisepsis be- fore confinement will prevent the introduction of germs and after confinement will paralyze their action. Employ means to pro- mote uterine contraction. Refrain from attending a case of labor when fresh from the presence of contagious diseases or septic material. In every case of labor the hands and forearms should be freely bathed in a carbolic solution before making a vaginal examination. All instruments employed during confinement should be disinfected. The warm carbolized douche after deliv- ery stimulates uterine retraction and promotes the rapid healing of wounds in the vaginal canal. The fountain syringe should be used (Lusk). Symptoms. — The first febrile symptoms usually occur within three days of the birth of the child. The third clay is the one upon which, ordinarily, the beginning of the fever is to be antici- pated. After the fifth day an attack is rare. In most cases the fever is ushered in by chilly sensations, or by a well-defined chill. A frequent pulse is always a suspicious symptom in childbed, even where the other symptoms are apparently normal. There may be headache, sleeplessness, pain, vomiting, anorexia, and coated tongue (Lusk). Treatment. — It is to be recommended that in every case of puerperal fever, the vagina be cleansed with a two to three per cent, solution of carbolic acid, or corrosive sublimate (1:3,000) every four to six hours. The douche in itself is absolutely harm- less. No portion of the injected fiuid should be retained in the vagina. All necrotic patches of the vagina or cervix should be touched with hydrochloric acid, or with a ten per cent, solution of carbolic acid, or with iodoform. Intra -uterine injections should be resorted to with extreme circumspection. Rarely are they indicated. Opium must be given for the pain. Purgatives (castor-oil in two or three tablespoonful doses) should be ad- ministered with caution. For the fever quinia may be adminis- PURPURA. 465 tered in five grain doses at intervals of four to six hours. Stimu- lants in the form of whiskey, rum, or brandy may be given in doses of one or two teaspoonfuls hourly. Ice-cold drinks should be freely allowed (Lusk). PURPURA. Is a general disease, characterized by circumscribed extra- vasations of blood into the skin (Loomis). Purpura may be simple, rheumatic, hemorrhagic, or symptomatic. In simple pur- pura there are only minute extravasations into the skin (petechias); in rheumatic purpura there is a combination of purpura and rheumatic pains in the joints; in hemorrhagic purpura there is great constitutional disturbance, petechias not only appear in the skin, but ecchymoses, and there may be hemorrhage from all the mucous tracts; in symptomatic purpura, the purpuric spots accompany the exanthems and contagious fevers, and are purely symptomatic (Bartholow, Loomis and Flint). Morbid Anatomy. — There are changes in the walls of the vessels, or in the blood, or in both (Loomis). Causes. — Purpura occurs more frequently in women than in men. It may appear in the healthy and robust. The leading causes are bites of insects, passive congestion, various drugs, such as iodide of potassium, phosphorus, cojDaiba, ergot, chloral, and mercury; snake-bites, embolism and thrombosis of cutaneous vessels, cachexias, as tuberculosis, cancer, Bright's disease, cirrhosis of the liver, anaemia, leucocythasmia; diseases of the nervous system, small -pox, typhus and typhoid fevers, measels, scarlet fever, malaria, cholera, yellow fever, cerebro- spinal meningitis, icterus, scorbutus, etc. Purpura may be accidentally present in the course of any disease (Flint). Symptoms, — In many cases for days before the eruption appears, there is a feeling of malaise with digestive derangement. Purpuric spots are bright-red, livid, or dark purplish -red in color, they do not disappear on pressure, and are unattended by itching or other signs of local irritation. As a rule the sj>ots are not elevated. They vary in size from a pin's head to a large pea, or a spot may measure an inch in circumference, and change in color 466 A COMPENDIUM OF PRACTICAL MEDICINE. successively from bluish -red to greenish, brown, and yellow. It is more common from fifteen to twenty than at any other age. In ordinary cases a crop of purpuric spots lasts from a week to ten days, and usually first apppear on the legs. Purpura is common in fruit seasons (Bartholow, Da Costa and Flint). Differential Diagnosis. — Purpura may be confounded with scurvy and skvn diseases. From scurvy it is distinguished by the absence of spongy gums and painful swellings. The fact that there is no itching, no desquamation, no suppuration or discharge, and no change in purpuric spots upon pressure suffices to dis- tinguish them from the eruption of any form of skin disease (Loomis). Prognosis. — Most cases terminate in recovery. Treatment. — The diet should be nutritious and varied, and digestion is to be aided by tonic remedies, together with wine or spirits in small quantities. Dilute sulphuric acid may be given in doses of from five to fifteen drops every two hours combined with quinia. Ergot, gallic acid, and tincture of the chloride of iron may be of service (Flint). PYEMIA. Is an infectious disease, characterized by the formation of infarctions, metastatic abscesses and diffuse local infiammation. Venous thrombosis and embolism are essential features of this disease, and cause metastatic abscesses in the lungs, liver, kidneys, spleen, muscles, heart and brain. Metastatic abscesses vary in size from a pea to a large walnut (Loomis). Causes. — Many regard the pyaeinic and septicaeinic poison as identical, and pyaemia as nothing but a metatistic septicaemia. Inflammation of bone is a very frequent cause of a phlebitis which leads to pyaemic infection. Cellulitis, carbuncle, erysipe- las, malignant pustule, and dissecting wounds are often compli- cated by pyaemia. Endometritis or lacerations about the genital tract are fruitful sources of pyaemia in the puerperal state (Loomis). Symptoms. — Pyaemia is ushered in by a distinct chill or rigor followed by a gradual rise of temperature to 101° or 10-1 ° F. The PYJEMIA PYROSIS. 467 chills of pyaemia occur irregularly, aucl are followed, after the first two or three, by profuse and exhausting sweats. The pulse is frequent, 120 to 140, small and often intermittent. The skin may be jaundiced. The breath has a peculiarly sweet, sickish • odor. The tongue becomes coated, glazed, dry, brown and fis- sured. Sordes collect on the teeth. There are anorexia and great thirst. There is usually diarrhoea with nausea aud vomit- ing (Loomis). Differential Diagnosis. — The diagnostic points of pyaemia are, irregularly recurring chills and sweats, great variations in tem- perature, with the signs of multiple abscess in the internal organs. Pyaemia may be confounded with septicaemia, intermit- tent fever, acute yellow atrophy of the liver, acute articular rheumatism, typhus and typhoid fever. JPywmia is ushered in by a distinct chill; septicaemia by slight shivering, or mild rigors only. In pyaemia the chills recur; in septicaemia there is but one chill. In pyaemia there are profuse sweats which recur; in septicaemia, they are slight and never recur. In pyaemia the temperature gradually rises to 102° to 104° F.; in septicaemia it is high at the onset, 105° to 107° F. In pyaemia the skin is jaundiced; not so in septicaemia. There is a sweet, sickish odor to the breath in pyaemia, absent in septicaemia. In pyaemia multiple abscesses develop, never in septicaemia (Loomis). Prognosis. — Is always unfavorable. Treatment. — Cleanliness, good ventilation, sunlight and quiet are important measures. Quinia, carbolic acid, salicylic acid and oil of turpentine may be used internally. A good diet and stimulants should be administered in large quantities (Loomis). PYROSIS. The regurgitation of a considerable quantity of a liquid which is either insipid or saltish or brackish and is sometimes acid when the stomach is empty of food and usually in the morn- ing is called pyrosis or waterbrash. This liquid consists mainly of saliva. Sometimes there is not only a feeling of oppression in the thorax but a severe pain is referred to the heart accompanied 468 A COMPENDIUM OF PEACTICAL MEDICINE. by palpitation and dyspnoea. In such cases the patient is very apt to imagine he has heart disease. Pyrosis is not a disease but a symptom of certain cases of gastric dyspepsia (Flint and Loomis). PARAPHIMOSIS. Exists where the prepuce gets behind the corona glandis and cannot be replaced (Keyes). Causes. — An unnaturally tight preputial orifice is a predis- posing cause. Young boys who retract the prepuce for. the first time often find themselves unable to replace it. Rings of metal forced upon the penis retracting the prepuce may be a cause. Inflammatory paraphimosis may depend upon balanitis, gon- orrhoea, herpes, chancroid, chancre, etc. (Keyes). Symptoms. — In rjaraphirnosis the glans penis is swollen and livid. If the patient is seen at once, there may be no inflamma- tion, either of the prepuce or the glans. If the stricture of the prepuce is tight enough to arrest the circulation it will cause gangrene (Keyes). Treatment. — /. Of paraphimosis with strangulation. In strangulation the glans penis is turgid, swollen, blue-black, cold and devoid of sensibility. Ice should be first used locally to produce shrinkage and a few small punctures may be made to let out serum from the ridge in front of the stricture. In these cases ether should always be given to relax the tissues and reduc- tion attempted. If a prolonged, careful attempt at reduction fails, the strictured point must be divided. After reduction the treatment consists in position, rest and cleanliness, syringing the preputial cavity with warm water. II. Of paraphimosis without strangulation. — In recent cases reduction must be effected or inflammation will surely set in. Reduction may be accomplished by using the above means (Keyes). PHIMOSIS. Exists where the orifice of the prepuce is so small that the glans penis can not be uncovered. Phimosis is congenital or acquired, simple or inflammatory, complicated by other diseases, phimosis. 460 or by adhesions. With very young children, phimosis is so common that it may he considered normal. The foreskin of a child is developed out of all proportion to the rest of the penis. This long prepuce is often a source of anxiety to young mothers. A positive indication for operation, in the case of a child, does exist, where the preputial orifice is smaller than that of the urethra. This condition is known to exist when the prepuce "balloons" during micturition. When the prepuce is too tight in the adult, an operation may be called for as a prophylactic against future disease, such as chancre, chancroid, gonorrhoea, or an attack of herpes (Keyes). Causes. — Phimosis may be caused by frequent attacks of preputial inflammation, leaving a thick, long, indurated, inelastic prepuce, interfering not only with sexual intercourse, but some- times with urination. Another common cause of acquired phi- mosis is the cicatrization of multiple chancroid around the orifice of the prepuce. Diabetes is said to be a cause of phimosis. Marx reported a case of phimosis where a passionate and jealous woman made her lover wear a gold padlock (sometimes two) with which she secured the preputial orifice, keeping the key herself. The victim of her charms carried his padlocks, which were replaced from time to time through new punctures, during four or five years, until such a degree of irritation had been set up as to require removal of the prepuce. Inflammatory phimosis is a transient condition, but may leave true phimosis behind (Keyes). Treatment. — It is better not to circumcise when the prepuce is inflamed, if it can be avoided. Keep the patient in bed, and elevate the penis. Evaporating lotions may be used locally, con- taining a little spirit or a (gr. x.-xx. ) solution of tannin, fre- quently washing out the cavity of the prepuce by means of a syringe with dilute lead-water or carbolic acid (gr. ij. to the gj-.). Remote Results of Phimosis. — It leads to imperfect develop- ment of the glans j^enis, is an obstacle to sexual intercourse, causes spermatorrhoea, frequent desire to urinate and cystitis. According to Dr. Sayre, of New York, phimosis may cause curvature of the spine in children, and priapism (Keyes). 470 A COMPENDIUM OF PRACTICAL MEDICINE. PTERYGIUM. Is a triangular thickening of the conjunctiva, which ad- vances from the caruncle to the cornea and encroaches more or less upon the surface. The favorite site is the inner side of the eyeball. The structure grows very slowly. It may impair sight before it reaches the pupilary area. The apex is more or less rounded and seems to dip into the substance of the cornea. The edges near the apex will be found to be rolled under and will admit a fine probe to be thrust beneath for a short distance. It appears mostly in persons who are exposed much to the weather, or to dust, and who are of advanced age. A variety of fleshy ptergium may occur at any portion of the eye (Noyes). Treatment. — Is surgical and preferably by excision. Seize the corneal portion with toothed forceps and as it is lifted, push beneath it a cataract knife and shave it from the cornea. Cut away as much of the base as may be needful. The raw surface may be covered by flaps of the adjacent conjunctiva sutured by silk. Cocaine will annul the pain. An opacity of the cornea is left, which will continue for months. It may ultimately dis- appear (Noyes). PYELITIS. Is an inflammation of the mucous membrane of the pelvis of the kidney. There is hyperemia of the mucous membrane, and exudation of pus and mucous takes place. In many cases with profuse production of pus there is an obstacle to the passage of the urine, and the pus is retained in the dilated pel vis, causing the condition known as pyonephrosis (Flint). Causes. — Pyelitis is seldom, if ever, a primary disease. Its most frequent cause is the presence of calculi in the pelvis of the kidney. Obstruction to the flow of urine is a cause of pyelitis. Such obstructions are furnished by calculi, tumors pressing on the ureter, enlarged prostate, stricture of the urethra, phimosis, and paralysis of the bladder in cases of paraplegia. In these cases the urine is retained and decomposes, and thus produces irritation. The pressure of a retroverted or pregnant uterus may cause obstruction to the flow of urine. Pyelitis may be due to PYELITIS. 471 gonorrhoea, specific vaginitis, and urethritis in females. In these cases cystitis is nearly always present. Copaiba, turpentine, and cantharides passing through the kidneys may cause pyelitis. Pyelitis may be a complication in jDysernia, puerperal fever and the exanthemata (Bartholow, Flint and Loomis). Symptoms. — Pain in the back is present in the mild as well as in the severe cases. This pain, as a rule, is severest over one or both lumbar regions, is often of an aching character, and shoots down along the course of the ureters. The voiding of urine is almost incessant, and is attended by severe pain. Acute pyelitis is usually ushered in with rigors. Symptoms of hectic fever may also mark the occurrence of permanent obstruction of the ureter and the development of that condition termed pyone phrosis. There is lassitude and more or less pain on motion. There are changes in the urine. In its early stage the urine contains blood mixed with mucus and epithelium cells from the pelvis of the kidney. The presence of these epithelial cells is its most certain diagnostic indication. The specific gravity of the urine ranges from 1025 to 1030, and usually has an acid reac- tion. The urine may be ammoniacal. Calculous pyelitis is attended with more pain and hemorrhage than the other forms. In the advanced stage of pyelitis, the discharge of pus is con- stant, but if the ureter becomes blocked, for a time the urine may be quite normal, but the removal of the obstruction is fol- lowed by a copious flow of purulent urine. If there be perma- nent obstruction in the ureter, a tumor develops in the lumbar region. The existence of the tumor is determined by the pres- ence of bulging between the crest of the ilium and the false ribs on the side involved. Palpation shows deep-seated fluctuation over the tumor and tenderness on pressure. Percussion shows dullness over the tumor. A hypodermic needle will complete the diagnosis (Bartholow, Flint and Loomis). Differential Diagnosis. — The diagnosis of pyelitis in the acute stage rests mainly on the presence of the characteristic epithe- lium of the pelvis mixed with blood and mucus. In a more advanced stage, in addition to the above, there is pus. The presence of pus and acid urine, with pain in the lumbar region, accompanied by the development of a tumor at the seat of pain, 472 A COMPENDIUM OF PRACTICAL MEDICINE. which tumor gradually increases in size and suddenly disappears at the same time that a copious discharge of pus takes place from the bladder, which discharge is attended by a sense of great relief to the patient, renders the diagnosis of pyonephrosis very certain. .Pyonephrosis may be confounded with hydronephrosis, hydatid cyst and perinephritic abscess. Hydronephrosis is dis- tinguished from pyonephrosis by the non-purulent character of the urine, and by the absence of constitutional symptoms. An aspirating needle will generally decide the diagnosis. In perinephritic abscess neither pus, blood, mucus, epithelia nor al- bumen will be found in the urine; in pyonephrosis they are common and constant. Pain on motion and fever are marked symptoms in abscess and slight or absent in pyonephrosis. In women a pyonephrotic tumor has been confounded with an ovarian cyst. The exploring trocar will very quickly remove all doubts. Pyelitis is distinguished from cystitis by the absence of vesical pain and frequent micturition and by lumbar pain. In pyelitis the urine is acid; in cystitis it is alkaline (Loomis). Prognosis, — Depends much on its causes. Treatment. — Eemove the cause if possible. In acute pyelitis if there be fever, pain, and bloody urine, wet cups should be ap- plied to the loins followed by a hot bath and a hypodermic of morphine to relieve pain. Alkaline drinks should be given and the patient kept in bed. If the urine is acid, liq. potassii citratis should be given. In ammoniacal urine benzoic acid is extremely serviceable. In chronic pyelitis, eucalyptol, oils of turpentine, copaiba and cubeb limit the formation of pus. Cod-liver oil and quinine should be given with a nutritious and non- stimulating diet. Alkaline mineral water and milk should be freely given. If a tumor exist aspiration may be performed (Bartholow and Loomis). PICA AND MALACIA. Are terms applied to perversions of appetite. Malacia de- notes a morbid craving for certain articles of food, whereas pica denotes a desire for innutritions substances. The era vino- for strange kinds of food during pregnancy and in hysterical women PICA AXD MALACIA POLYPHAGIA. 473 is familiar to all. The innutritious substances frequently craved are charcoal, chalk, slate, and certain kinds of earth. In some cases of pica the articles are at first taken with the idea of im- proving the complexion and in this way the habit is formed; but in other cases a morbid uneasiness in the stomach leads to their use. This appetite is chiefly confined to young females and is generally associated with anseinia or chlorosis. Treatment. — Treat the associated disorders and prohibit the use of the above substances (Flint). POLYPHAGIA. Called also bulimia denotes a craving for food beyond the wants of the system. These terms are not correctly applied to the increased appetite during convalescence from fevers or other acute diseases. In true bulimia the amount of food craved far exceeds the requirements for nutrition. BuMmiam&y be another name for gluttony. The love of eating may be cultivated to such an extent that little else is thought of, and persons who fall into this habit may be said to live to eat, rather than to eat to live. Habits of gluttony may lead to dyspepsia, obesity, fatty degen- eration of the heart and to various affections. Bulimia may be a symptom of mental disease, or of diabetes. Cases have been reported in which the morbid appetite appeared to be insatiable, all kinds of food — raw meat, candles etc., — being eaten in some cases with avidity and in enormous quantity (Flint). Treatment. — Recovery from this condition is to be expected. The indications are to regulate the diet, to establish the general health, to correct any disorder of digestion, and to palliate the excessive craving for food by opium, or sometimes by nauseant remedies. Swallowing pieces of ice has been found effective as a palliative measure (Flint). PARALYSIS AQITANS. Sometimes called Parkinson's disease, or shaking pals)', or the trembles, is a disease of advanced life characterized by motor weakness and tremors of the voluntary muscles, especially of the limbs, occurring independently of muscular exertion (Loomis). 474 A COMPENDIUM OF PEACTICAL MEDICINE. Morbid Anatomy. — Paralysis agitans is a neurosis, a func- tional disorder. As yet no constant changes have been dis- covered. Some authorities consider it of spinal, others of cere- bral origin (Bartholow and Loomis). Causes. — It rarely occurs before forty, and is more common in men than women. It is not known to be hereditary. The jjrincipal causes are strong emotion, fright, grief, anxiety, dis- tress of mind, great bodily fatigue, and exj)osure to cold and dampness (Bartholow and Loomis). Symptoms. — Tremor is the chief symptom of paralysis agi- tans. The trembling consists of fine small movements. Paraly- sis agitans comes on slowly, and progresses slowly. It usually begins in one foot, hand or possibly a single finger, and gradu- ally becomes general. The tremors are often confined to one side of the body for a long time — hemiplegic type; less fre- quently to both lower extremities — paraplegic type. Any effort of the will, as grasping, writing, or walking, will stop the irreg- ular motions. Sometimes the disease sets in abruptly in conse- quence of some sudden shock. Mental emotion and exercise in- crease the trembling, and sleep and chloroform narcosis suspend it. The trembling consists in muscular contractions and relaxa- tions. The hands are apt to assume a position as in writing. As a rule, the head and neck are not affected. The countenance assumes a fixed, staring look of distress, the head is drawn for- ward and the trunk fiexed. The voice is often tremulous and speech is slow, hesitating and laborious. The muscles are easily tired. The patient rises slowly and is deliberate in starting, but when under way, he goes in a dog- trot with the head and body bent forward (festination). Complaints are made of cramps, of muscular stiffness, of a sense of excessive heat, and of restless- ness. The knee-jerk is normal (Bartholow, DaCosta, Flint and Loomis). Prognosis. — Although the disease may last for twenty or thirty years, death most commonly results from some intercur- rent disease. The outlook is never favorable (Loomis). Differential Diagnosis. — Paralysis agitans may be confounded with disseminated sclerosis, senile trembling, alcoholic, lead and meruwrial trembling '. In disseminated sclerosis tremors occur RACHITIS. 475 onlv when the muscles are in use; the disease beo-insin the lower limbs, affects younger persons, and paralysis occurs early. The patient has no tendency to run forward and does not have the peculiar countenance. In paralysis agitans the tremor is not dependent on volition; it begins in the upper limbs, and per- sons under forty years are exempt from this affection. Paralysis occurs late. The patient has a tendency to run forward and has a fixed, staring countenance. In senile trembling the head is chiefly affected and there is no paresis of muscles, no stiffness, no deformity of the extremities, and no impulse to run forward. Alcoholic, lead and mercurial trembling are readily diagnosti- cated by the previous history (Bartholow, Flint and Loomis). Treatment. — Xo plan of treatment is satisfactory. Hyoscy- amine, according to Charcot, is the best remedy to moderate the trembling. Gelsemium is useful. The chloride of gold and so- dium, corrosive sublimate in small doses, nitrate of silver, and the lactophosphate of lime with arsenic may be tried. The gal- vanic current may be tried (Bartholow and Loomis). RACHITIS. Called also rickets, rachitismus and osteomalacia, is a con- stitutional disease of the first years of life, characterized by a disorder of nutrition in which the growth of the bones is irregu- lar, calcification imperfect, and deformities ensue (Bartholow). Causes. — Rickets is a common result of faulty diet and of anti-hygienic surroundings, and is therefore frequent among the poor of cities, and especially in families who dwell in crowded tenement-houses. It is more common in the great cities of England and Europe than in this country. Acute disease and troublesome dentition predispose to it. It is more apt to occur in children of rachitic, syphilitic or phthisical parents. The off- sj>ring of consaiiguinious marriages, of those too old, or of the feeble and cachectic, are, as a rule, rickety. The rickety consti- tution may also be inherited. Of the exciting causes, the most common is the use of food not sufficiently nutritive, or, if nutri- tious, not suited to the age and digestive powers of the child. Thin and poor breast-milk and artificial food of poor quality are 476 A COMPENDIUM OF PRACTICAL MEDICINE. common causes of rickets. The presence of lactic acid in the intestinal canal of the infant may produce rickets according to some authorities. The disease is rare before the fourth and after the seventh year of life. Children of well-to-do families are also liable to rickets (Bartholow, Loomis and J. L. Smith). Symptoms. — Usually gastro- intestinal disturbances are the earliest symptoms of rickets. There may be vomiting, and the stools are frequent, pasty and offensive. The stools are light in color, because of the absence of bile, and have an acid reaction. The appetite is poor. The child wastes and grows dull, listless and peevish. Pains about the joints are complained of. The anterior fontanelle remains open. Profuse perspirations of the head, neck, and upper part of the chest, appear chiefly while the child is asleep, but at the same time the abdomen and extremities are dry and hot. The child kicks off the covers from its legs. There seems to be tenderness of the whole body, and the rickety child cries out when it is taken up, or moved, or pressed on. It is languid, its counten- ance wearied, depressed, and aged, the face grows broad and square, the hair is thin, dry, and dead, the muscles are wasted, and flabby, the head sinks between the shoulders, and the abdo- men is swollen and protuberant. Now the extremities of the long bones swell and have a knobby appearance, and the bone bends readily. The child may be knock-kneed, or have bow-legs. Curvature of the spine also takes place. The lower jaw is short- ened, so that the upper teeth overlap the lower. The teeth appear' late. Rachitic children are usually pigeon-breasted, and there is often marked deformity of the pelvis. The ribs, being softened, yield to the atmospheric pressure, thus projecting the sternum forward. The head of a rickety child appears larger than that of a healthy child of the same age, is flat on top, and the forehead is large and square. The limbs of the child are short in propor- tion to the trunk. Rachitic children are anaemic and very sensi- tive to changes of temperature. As the osseous changes go on emaciation goes on at the same rate, the abdomen enlarges still more, the muscles waste and grow weaker, there is less and less disposition to voluntary exertion, the perspirations are more free, the thirst increases, the bowels become more deranged, the stools RACHITIS. 477 fetid, and the food passes unchanged. All rickety children do not emaciate. Persons who were rachitic in infancy frequently be- come very strong as they reach adult life (Bartholow, Loomis and J. L. Smith), Differential Diagnosis. — The only disease with which rickets in its early stage may be confounded is inherited syphilis. Rickets does not appear, as does syphilis, during the first days of life. The "snuffles" and cutaneous lesions do not belong to rickets; the sweats about the head, the osseous changes, the enlargement of the spleen and liver, the weakness of the legs, the rims around the cranial bones, the large, lax joints, and the gastro-intestinal disturbances are symptoms of rickets which dis- tinguish it from any other disease (Bartholow and Loomis). Prognosis. — Is usually favorable, provided no serious com- plication arises. The complications of rickets are bronchitis, pneumonia, enteritis, laryngismus stridulus, convulsions, difficult dentition, diarrhoea, and chronic hydrocephalus (Loomis). Treatment. — Good air, warm clothing, daily bathing, and a nutritious diet are essential. Children kept too long at the breast often become rickety, and should be weaned at once. Good cow's milk, diluted by one-third to one-fourth of lime- water is the most suitable aliment. Scraped raw beef, with a small amount of wine, often produces marked improvement. Pepsin with bismuth may be given for the vomiting and diar- rhoea. Pepsin with diluted muriatic acid is also useful. Cod- liver oil should be taken as early and in as large doses as the child can digest. Beef tea may be given. Rachitic children should not sleep on feather beds or high pillows. The perspira- tions may be relieved by sponging with vinegar and water. The following formula will be found useful in most cases: |fc Olei morrhme 3iv. Aqua; calcis Syrupi calcis lactophosphatis — aaoij. — M. Of this, one teaspoonful should be given four or five times daily to an infant of one year (Bartholow, Loomis aud J. L. Smith). 478 A COMPENDIUM OF PRACTICAL MEDICINE. RHEUMATISM. Is a constitutional disease characterized by certain local manifestations seated in the articulations and the fibrous tissues in other parts (Flint). Varieties. — I. Acute articular rheumatism. II. Sub- acute articular rheumatism. III. Chronic articular rheumatism. IV. Arthritis deformans. V. Muscular rheumatism, " Myalgia " (Loomis). Acute articular rheumatism frequently called rheu- matic fever and. polyarthritis rheumatica is the variety charac- terized by fever, inflammation of the joints occurring in succes- sion and by a tendency to attack the peri- and endocardium. Causes. — It is more frequent in men than in women because men are more exposed to the influences producing it. Protracted stay in damp apartments, lying between damp sheets all night, exposure of the body to cold and wet, when in a heated and per- spiring state act only as an exciting cause. A special predisposi- tion is requisite. This predisposition or diathesis may be con- genital and inherited or it maybe acquired. There is an hered- itary tendency in about thirty per cent, of cases. It occurs mostly between fifteen and thirty years of age. It is rare in old age. The seasons of greatest prevalence are winter and spring. Some claim that an excess of sulphur or lactic acid in the blood will produce rheumatism if the vice of constitution exists. Erysip- elas, dysentery, scarlatina, gonorrhoea, syphilis, pregnancy, scrof- ula, phthisis and cancerous affections seem to act as exciting causes (Bartholow, Flint and Loomis). Symptoms. — In the majority of cases, acute articular rheuma- tism begins with a sudden attack at night. In some cases the pyrexia precedes the local manifestations for a few hours to one or two days. Before the attack patients often complain of mus- cular soreness, of a good deal of pain, stiffness and soreness of certain joints, of loss of appetite, coated tongue and constipa- tion. The development of the disease is denoted by an affection of one or more of the larger joints. The local symptoms are pain, tenderness, increased heat, swelling, and redness of the skin. Pain is especially excited by movements of the affected joints, or by jarring the bed, or by pressure over the joints. RHEUMATISM. 479 Swelling is most apparent in the knee, wrist, elbow, ankle, and smaller joints of the hands and feet, and is due to an effusion into the synovial cavity and surrounding tissues. The redness is due to an erythema. In some cases several joints are affected, but in other cases a single joint. The most characteristic feature of acute rheumatism is its tendency to migrate from one joint to another. Rheumatism illustrates the law of parallelism in that corresponding joints are often affected together. In an analysis of 21 cases, Flint found but a single violation of this law. This disease, therefore, is eminently one of the bilateral or symmetri- cal diseases. The joints most frequently affected are the aukle and knee; next the shoulder, elbow and wrist; then the hip and fingers, and finally the spine, the toes and the lower jaw. Acute articular rheumatism is always accompanied by more or less pyrexia. The axillary temperature in different cases varies be- tween 102° and 110° F. The pulse rarely exceeds 100 per minute. Sweating is a symptom more or less prominent, occur- ring especially at night. The sweat emits a notably sour odor. In connection with profuse sweating, sudamina or miliary vesicles frequently appear on the neck and trunk. Urticaria, erythema aud herpes labialis sometimes occur in the course of the disease. The appetite is lost, thirst is urgent, the tongue is coated, the saliva is acid, usually the bowels are constipated, and the urine is diminished. There is sleeplessness. Endocarditis occurs in some cases of rheumatism. The inflammation, as a rule, affects the membrane situated upon the mitral valve. Pericarditis occurs less frequently. It is convenient to speak of these affections as complications, but, properly speaking, they are to be reckoned among the local manifestations of the disease. They rarely occur in patients beyond forty. Other rare complications are purulent meningitis, cerebral embolism, uraemia, insauity, bronchitis, pneumonia, peritonitis, nephritis, myocarditis, phlebitis, suppur- ative arthritis, erysipelas and pyaemia. In a small number of cases of acute rheumatism, important symptoms develop which are described under the names of cerebral rheumatism and rheu- matic hyperpyrexia. In these cases, there are very high fever, delirium, muscular twitchings, stupor, face cyanosed, etc. These symptoms seem to be referable to some profound infection or in- 480 A COMPENDIUM OF PRACTICAL MEDICINE. toxication which, acts upon the thermic and other nervous cen- tres. The disease ends by self -limitation. The duration of acute articular rheumatism is three weeks to thirty days (Bartholow, Flint and Loomis). Differential Diagnosis. — Acute rheumatism may be mistaken for gout, pycemia, synovitis, or simple acute arthritis, urethral rheumatism, and hysterical joint. Gout attacks the small and rheumatism the large joints. In gout the fever is lower, and the duration of the attack shorter than in rheumatism. Sweats and cardiac mischief distinguish rheumatism from gout. In gout the attack comes on at night in the great toe joint; there is a history of high living, and an excess of uric acid in the blood; not so in rheumatism. Gout is rare before thirty-five, while acute rheu- matism is a disease of early adult life. Tophi never form in rheumatism, but are always present late in gout. In pyamiia there are recurring chills, sickly, sweet breath, slow development, jaundice, multiple abscesses, etc. Synovitis or acute arthritis is distinguished by its persistence in one joint, by the absence of sweats, of constitutional disturbance and of cardiac lesions, and by the graver local symptoms. Urethral or gonorrhoea} rheuma- tism attacks one joint, usually the ankle or wrist, does not mi- grate, is slower to recover, is unaccompanied by fever, and is coincident with a urethral discharge. Hysterical joint is without swelling or change of temperature, and is only sensitive when the patient's attention is fixed on it (Bartholow, Flint and Loomis). Prognosis. — This disease is rarely fatal. The rule is that no crippling of the joints follows the acute attack. The worst legacy acute rheumatism leaves is a crippled valvular apparatus in the heart. Some authorities say that seventy-five pei cent, of all cases of rheumatic fever are accompanied by cardiac inflam- mations, others say five per cent. The complications — pericar- ditis, endocarditis and embolism make the disease serious. Ul- cerative endocarditis is a grave sequel of the disease, giving rise to fatal pysemia. A strange sequel of rheumatic fever is chorea (Flint and Loomis). Treatment. — Rheumatic patients should have good hygienic surroundings. The temperature of the apartment should range from 68° to 70° F.; all draughts should be avoided, and the RHEUMATISM. 481 patient should be clothed in flannel and covered with flannel sheets. The diet should be milk and seltzer-water, beef-tea and broths. Animal food and alcoholic stimulants should not be given during the active period of the disease. External Applications. — Cold, by means of ice-bags to the joints, has been strongly recommended. Friction with chloro- form and the tincture of aconite is a favorite plan with some. "Hot-packs" by means of flannel, or bathing the joints in warm laudanum and then covering them with oiled silk, is always grateful to the patient. Ethyl chloride or ether may be rubbed over the affected joints. Loomis is of the opinion that the blis- ter-treatment is no better than simply surrounding the joints with cotton -batting and oiled silk. But Dr. Greenhow finds that the blister-treatment is quite as successful as the treatment by sali- cylates, and open to less objection. The blistering- plaster should be applied about the inflamed joint, but not on it. Blisters re- lieve the pain remarkably, change the reaction of the urine from acid to neutral or alkaline, and prevent complications. Blisters may be utilized in all forms of the disease and combined with other plans of treatment. Internal Medication. — Kheumatism is the most unmanageable of all diseases so far as remedies are concerned. Garrod thinks colored water is about as potent as anything. He claims that rheumatic fever is a self-limited disease. The alkaline treatment is the treatment in which alkalies play an important part. Two drachms of the bicarbonate of either potassium or sodium may be given in a state of effervescence by means of an ounce of lemon juice, or a half drachm of citric acid in four ounces of water every three or four hours. If the urine is alkaline at the end of twenty -four hours the quantity of alkali is diminished one -half. If the urine continues alkaline at the end of forty - eight hours, three drachms of alkali only are given on the third day. If the alkalinity of the urine persists, on the fourth day three grains of quinine with a half drachm of potassium bi- carbonate may be given three times daily. Cathartics may be given as required. The alkaline treatment relieves the pain, seems to shorten the duration, lessens the violence of the disease and prevents heart complications. The average duration of the cases 482 A COMPENDIUM OF PRACTICAL MEDICINE. thus treated is put by Dr. Fuller at eleven clays. Of 439 cases subjected to this plan there was not a fatal case, and only about two per cent, of cardiac complications. Loomis thinks that if long continued the alkalies do positive harm. The alkaline treat- ment is particularly applicable to the obese, florid, but flabby drinkers of malt liquors. The iron treatments applicable to the pale, delicate anaemic young subject attacked with acute rheu- matism, in whom the alkalies are too depressing. A half drachm of the tincture of the chloride of iron to six ounces of water, may be taken through a glass tube every four hours. The salicylic or salicylate treatment is most applicable to the vigorous, able-bodied subjects of the rheumatic diathesis. Sali- cin, salicylate of soda and salicylic acid, to be effective, must be given in sufficient quantity to lower the temperature — a half- drachm of salicylate of sodium every four hours, until the pulse and temperature decline, may be taken as the standard. Al- though relief follows the administration of these remedies in two or three days, yet the tendency to relapses, heart depression and irritability of the stomach is very great. The salicylate treatment does not prevent the heart complications. The best results are obtained by the combination of the salicylate and the alkaline treatment. Loomis prefers salol to salicylic acid. He seldom uses the alkaline, or salicylate treatment, but extols anti- pyrine as the most efficient drug. Flint gives antipyrine in fifteen grain closes hourly, but does not give more than two drachms in twenty-four hours. For the intense hyperpyrexia in some cases, large doses of quinine may be given and cold spong- ing practiced. Dr. Kinnicutt gives 10 to 15 minims of the oil of winter green every two hours until eight doses have been taken. DaCosta has reported 30 cases treated with the bromide of am- monium in doses of 15 to 20 grains every three hours (Bartho- low, Flint and Loomis). Subacute Articular Rheumatism. — Is usually a sequel of the acute; it is attended by slight if any fever; the pain in joints is not severe, except on motion; swelling and redness are slight and usually limited to one or two large joints. It may last six weeks or even four months. There is always anaemia. The RHEUMATISM. 483 treatment is a milk diet, iron and cod -liver oil, a warm climate, and heat to the affected joints (Loomis). CHRONIC ARTICULAR RHEUMATISM. Is an affection of the articulations characterized by pain and stiffness, with some swelling, occurring chiefly after middle life, and influenced by atmospheric changes (Bartholow). Causes. — The chronic may succeed to the acute, or the case may be chronic from the first. It is a disease of adult and ad- vanced life. Bad hygienic surroundings, exposure to wet and cold, sudden atmospherical changes, and a residence in dark and damp dwellings predispose to it. It is often hereditary (Bartho- low and Loomis). Symptoms. — The affection remains fixed in certain joints; that is, it does not shift from joint to joint, as in cases of acute rheumatism. There is aching and constant pain in one or more of the larger joints. The affected joints are tender, painful to the touch, sometimes swollen, and their movements restrained. There is no fever. The aching and deep-seated pains are often worse at night. When it is the result of exposure, heat will give a grateful sense of relief; when a rheumatic diathesis exists, dry cold is better. Old people with rheumatic joints are great u weather prophets" often being able to foretell the coming of a storm. In the morning, on rising, the joints are stiff, their movements slow, rigid and jerking, so that dressing is accomp- lished with difficulty; but use renders them limber and supple. Movements of the joints may cause more or less creaking like rusty machinery (Bartholow, Flint and Loomis). Differential Diagnosis. — Chronic rheumatism may be mistaken for rheumatoid arthritis, or arthritis deformans. In the latter occur anatomical changes, dislocations, and distortions which do not belong to the history of chronic rheumatism. Arthritis de- formans is a steadily progressive disease, one joint after another being involved and never recovered from. In chronic rheuma- tism the large joints are mainly involved; in arthritis the small joints are usually first involved, then the large (Loomis). Prognosis. — -Chronic rheumatism never affects the duration of life. It may persist throughout life ( Loomis ). 484 A COMPENDIUM OF PRACTICAL MEDICINE. Treatment. — Chronic rheumatism is benefited most by local treatment, such as blisters, iodine, belladonna, acpnite, opium and chloroform liniments. If there is but little pain in the joints, ammonia and turpentine liniments are of service. Thick flannels should always be worn about the joints. Sponging the joints with hot water will relieve the pain and stiffness in some cases. Warm baths, the Turkish or Russian baths, with local douches, are often highly useful. Many of the hot saline springs for bathing have acquired a great reputation in the treatment of this form of rheumatism, cures being effected in cases that had resisted all other methods of treatment. The best results are obtained from the baths of the Hot Springs of Arkansas, the warm and hot springs of Virginia, the sulphurous waters of Kentucky and Saratoga, the Michigan springs, and St. Cather- ine's of Canada. Mud-baths are also employed on a large scale, for the relief of rheumatism and affections of the skin, in certain parts of Germany. Frictions of the affected parts with cod-liver oil are efficacious. The method of friction and movements, Tvnown as massage, is probably the best of the local means of treatment. Galvanism has been found serviceable. The posi- tive pole should be placed over the principal nerve-bundles above, and the negative pole brushed over the joint-region. The .electrical treatment must be kept up for a long time. Internal Medication.- — Tonics such as iron, quinine, and strychnine should be employed. Cod-liver oil, according to Loomis, is the most useful of all internal remedies, and should be given for many months. Cod-liver oil should be given with a little ether to assist its digestion. A course of iodide of potas- sium often renders important service, if given many months. Muriate of ammonia may absorb deposits about the joints but it must be given for a long time. Bartholow has had excellent re- sults from the bromide of lithium. Colchicum, arsenic, bichlor- ide of mercury, guaiacum, oils of turpentine and cajeput, com- bined with sulphur have been recommended. The diet must be highly nutritious and absolutely non- stimulating. The patient should reside in a dry, warm climate (Bartholow, Flint and Loomis). RHEUMATOID ARTHRITIS. 485 RHEUMATOID ARTHRITIS, Called also arthritis deformans, rheumatic gout, rheumatic aHhritis, nodosity of the joints, dry arthritis, etc., is a chronic inflammation of the joints, without fever and without suppura- tion, progressive, and causing enlargement and deformity of various articulations (Bartholow). Causes. — It may occur at any age, but in the majority of cases patients are in middle life. Women are more liable to it than men. The smaller joints are most often involved in women; the larger in men. Damp dwellings, poor food, and mental de- pression are powerful predisposing causes. It is not an inherited disease. It occurs in the poorer classes of society, as a rule, and among those who suffer from hardships, exposure, and depriva- tions. Garrod holds that it may have its origin in the tubercular diathesis. A state of the nerve-centres is invoked to account for this disease (Bartholow, Flint and Loomis). Symptoms. — The disease is usually from the first and during its course, sub-acute. A feature of the disease is its progressive character. There is usually no constitutional disturbance. The affected joints are painful, especially on motion. A characteris- tic deformity of the fingers is a lateral deflection in the ulnar direction. In the progress of the disease the anatomical changes lead to permanent extension or flexion of parts, subluxations, dislocations, nodulations and notable distortions. The soft parts about the joints usually atrophy. Early in the disease a friction crepitus is heard as the articular surfaces are rubbed upon each other. The skin is dry and harsh, and there is a great acidity of the stomach. In the worst cases all the joints are fixed in bony ankylosis (Bartholow, Flint and Loomis). Differential Diagnosis. — Arthritis deformansm&y be confound- ed with chronic rheumatism and chronic gout. Gout is hered- itary and occurs more in males. Arthritis deformans is rarely hereditary and occurs oftenest in females. Attacks of gout are periodic. Arthritis is progressive. Chalk-stones develop in the joints in gout and are never present in arthritis. Uric acid is al- ways in excess in gout, and never in arthritis (Loomis). Prognosis. — It is one of the most chronic of diseases. It may continue for ten, twenty or thirty years or longer. It never de- 486 A COMPENDIUM OF PRACTICAL MEDICINE. stroys life, and is never recovered from. Patients with this dis- ease may attain very old age (Bartholow and Loomis). Treatment. — Quinine, iron, cod-liver oil, arsenic and. strych- nine are indicated. Flannels should always be worn next the shin. Mineral waters and warm saline baths often do good. Bartholow recommends iodine and galvanism. He gives five minims of the compound solution three times daily. Iodine oint- ment may be rubbed into the affected joints. The galvanic cur- rent is often of great benefit (Bartholow and Loomis). RANULA. Is a sublingual cyst. Cause. — Ranula is caused by an obstruction of one of the mucous glands situated beneath the tongue. They were once thought to be clue to an obstruction of the salivary ducts. They are analogous to the mucous cysts of the lip. They contain a clear, glairy, mucoid fluid. They may be congenital. They may form a large swelling beneath the jaw. When large they press the tongue upward. They are, as a rule, painless, and merely give trouble by pressure (Bryant). Treatment. — The best treatment is to raise the upper wall of the cyst by means of a pair of pointed forceps, or a tenaculum, and with scissors to cut it off. Panas, of Paris, has lately in- jected these cysts with three to ten drops of a solution of chlo- ride of zinc (forty-five grains to the ounce) with success. In large tumors the cavity may be plugged with lint soaked in iodine, or with iodoform gauze, after it has been freely incised. Encysted tumors are also met with beneath the tongue, and may be mistaken for ranula; but these tumors have a distinct capsule and contain a cheesy, sebaceous secretion. They are probably congenital (Bryant). RETENTION OF URINE. When a patient is unable to pass his urine, he is said to have retention. When no urine comes down from the kidneys, he is said to have suppression (Keyes). Causes. — Stricture (organic or spasmodic), enlarged pros- tate, inflammation or acute congestion of the prostate, spasm of RANT LA RETENTION OF URINE. 487 the cut-off muscles, true vesical paralysis, urethral calculus aucl inflammation of the urethra are capable of producing retention. Voluntary retention, often repeated and long kept up, may result in retention. Blunted sensibility of the bladder in typhus, small -pox, coma, in some syphilitic and inflammatory brain diseases, in shock from injuries, and in all conditions of spasm of the deep urethral muscles, are causes. Excess of drinking, with or without exposure to wet and cold, is an exciting cause. Re- tention in a child is generally from stone impacted in the urethra; in an adult from stricture; and in an old man from prostatic disease (Keyes). Symptoms. — The bladder may be often seen and felt, filling up the hypogastrium, perhaps reaching the navel. Pressure upon it usually causes a desire to urinate. Fluctuation may be made out between a finger in the rectum and the hand upon the hypogastric tumor. In retention there is always flatness over the pubes (Keyes). Treatment. — In retention from atony, paralysis, fever, etc., a soft catheter of medium size should be passed as often as re- quired and the bladder should be washed out on each occasion with a hot solution of borax in water. A piece of ice about the size of a chestnut introduced into the rectum may relieve reten- tion. In retention from spasmodic st/ricture caused by exposure to wet or cold and excess of drinking, the simple passage of a large metallic catheter well warmed and oiled is indicated. If the instrument will not pass no force should be employed, but an anaesthetic should be given and then it may pass. The old rem- edy of a hot bath cannot be too highly extolled in retention. A. full opiate is also an invaluable remedy relieving the involuntary contraction of the bladder and the pain. In retention from in- flammatory stricPwre caused by gonorrhoea, the passage of a small catheter, or a hot bath and a full opiate are the best remedies. In retention from a blow in the perinceum, the simple passage of a catheter will usually suffice. In retention f rom pr essw6 of an abscess in the perinceum, the treatment is to open the abscess (Keyes and Bryant). 488 A COMPENDIUM OF PRACTICAL MEDICINE. ROSEOLA. Is a self-limited eruptive disease pursuing a course similar to measles. It is also called rose-rash, false measles, German measles, rotheln, etc. Modern German authors call this disease rubeola (Bartholow). Causes. — Roseola is contagious and is essentially a disease of childhood. The causes are in a measure obscure. The delicacy of the skin in infancy and the active cutaneous circulation no doubt predispose to roseola and erythema. Summer weather with the derangements of the system which it produces is the most frequent cause of idiopathic roseola in young children Loomis and Smith). Symptoms. — Roseola is one of the mildest of the eruptive fevers. The eruption consists of rose- colored sj)ots, varying in size from a pin's head to a large pea, slightly elevated, so that when the hand passes over the surface of the skin it feels some- what rough. Sometimes these spots occasion intense itching, are quite distinctly separated by healthy skin, and disappear under pressure. The eruption is frequently the first symptom of the disease. There may be slight soreness of the throat and mild catarrh of the air-passages. The eruption usually com- mences upon or about the neck and face. It bears considerable resemblance to that of measles. There is no fever in a majority of the cases. The whole duration of the eruption is from two to four days. There is a symptomatic roseola which appears in the course of various acute febrile diseases with the exception of syphilis (Bartholow, Loomis and J. L. Smith). Prognosis. — Is favorable. Treatment. — Regulate the diet and keep the patient in- doors. RELAXED UVULA AND PALATE. Treatment. — Tannic acid is much employed in relaxed con- dition of the mouth and throat. Elongated and relaxed uvula, relaxed palate, and follicular pharyngitis are effectively treated by insufflation of tannin. In chronic affections of the larynx mucous membrane, and of the vocal cords, no inhalation is more RASHES RESTLESSNESS. 489 frequently serviceable than a solution of tannin (grs. x.-xx. to §iv.) applied by means of the handball atomizer. In chronic inflam- mation of the throat when the mucous membrane is relaxed, swollen, granular-looking, and covered with mucous or pus, a few applications of glycerine of tannin brace up the tissues and lessen or remove the hoarseness (Bartholow and Ringer). RASHES. (Medicinal). The administration of certain drugs has a' tendency to bring out eruptions which are likely to be mistaken for diseases of the skin. Some persons are peculiarly prone to them and we know not why. Arsenic produces an erythema or an urticaria in some persons, when given in large doses. Belladonna or atropia may produce a scarlet rash. Bromides produce a rash similar to acne when given for some time in full doses. Quinine may give rise to an erythematous eruption. In some persons quinine produces large patches of erythema, and always excites a violent urticaria. Chloral hydrate occasionally gives rise to a rash not unlike that of scarlet fever. Copaiba and cubebs produce a rash in some per- sons. Iodine and the iodides given for some time will produce a rash. Opium and morphia may produce an erythematous or urticarial rash which is very itchy. Tar, creosote, carbolic, digitalis, stramonium, stry china, or salicylic acid occasionally produce an eruption in those who are taking them (Anderson). RESTLESSNESS. Ringer says, that in several cases, he has seen aconite quiet the distressing restlessness of "fidgets," which affects men as well as women, and has known a few drops at bed -time calm the patient and give sound, refreshing sleep; if one drop is insufficient, it may be repeated hourly for three or four hours. Sponging with hot water will often induce perspiration, soothe the restless ness of convalescence, and induce sleep (Ringer). 490 A COMPENDIUM OF PRACTICAL MEDICINE. RELAPSING FEVER. Called also febris recurrens, typhus recurrens, spirillum fever, five-day fever, seven- clay fever, short fever, mild yellow fever \, famine fever, hunger-pest, and dynamic fever, is an acute, infectious, febrile disease, self- limited, and characterized by the occurrence of a febrile paroxysm, lasting about one week, suc- ceeded by an entire intermission of four or five days' duration, which is in turn followed by a relapse like the first seizure, although shorter. It has never been indigenous in this country. It is by no means a new form of disease. Accounts in the writ- ings of Hippocrates leave no doubt but it prevailed 2,000 years ago in the islands off Thrace. It has prevailed as an epidemic disease in most of the countries of Northern Europe. In 1844 there were fifteen cases of relapsing fever in Philadelphia. The patients were Irish immigrants, all coming over in the same vessel. Dr. Dubois reported a few cases in 1848, and Dr. Flint fifteen cases in 1850-51. All these were among recent Irish im- migrants. It prevailed as an epidemic in New York City in 1872-3, the disease having been imported by foreign immigrants. In 1865 there was a great epidemic in St. Petersburg. The name relapsing fever is to be preferred to any of the other appella- tions, as it is based on one of the most striking of the peculiari- ties of the disease (Bartholow, Flint and Loomis). Morbid Anatomy. — The lesions are those of an acute infecti- ous disease. The spleen is enlarged, due to congestion and hyperplasia of its lymphoid elements. The liver is also enlarged and is the seat of parenchymatous degeneration. The kidneys are swollen. The mucous membrane of the intestine is inflamed. Petechise of the skin are present in about 10 per cent, of the cases. The myocardium may be affected with a fatty degenera- tion almost as intense as that in phosphorus -poisoning. The blood is dark and coagulates imperfectly. In 1873 Obermeier discovered a spiral -shaped bacterium in the blood of relapsing fever patients. This parasite has been found in the blood in no other disease (Flint). Causes. — Relapsing fever is a distinctly contagious affection. The poison acquires the greater activity the more filthy, crowded RELAPSING FEVER. 491 and unhealthy the population amid which it prevails. Articles of clothing will retain the contagious principle for a long time, and those who have been in the presence of the sick can convey the poison to the healthy at a distance. Drinking water may be contaminated and spread the poison. The disease attacks by preference the young, the liability lessening after thirty and ap- parently ceasing after fifty. One attack does not afford immun- ity against subsequent attacks. The natural home of relapsing fever is Ireland. The period of incubation ranges between five and seven days, rarely nine. Facts go to show that it is not a highly contagious disease. Considerable exposure is generally necessary. The disease is not likely to be contracted from single patients in well ventilated rooms. Destitution and deficient alimentation are auxiliary causes. That the contagium is con- tained in the blood does not admit of doubt. In accordance with the germ theory, the first paroxysm of relapsing fever is due to a brood of spirochetes. Their existence terminates in about a week, as a rule, and the first febrile paroxysm then ends. The germs remaining in the body give rise to a second brood and there is the relapse of the fever. In rare instances a third and a fourth brood are produced. The contagium is probably contained in the breath and the cutaneous exhalations (Bartholow, Flint and Loomis). Symptoms. — The recurrence of the paroxysm of fever, or the relapse, is the distinctive feature of this disease. The attack is sudden. It is marked by a distinct chill with fever, frontal head- ache, vertigo, pain in the limbs, joints and back and usually nausea and vomiting. Sweats may, at first, follow the chills. The vomit consists first of the contents of the stomach, then of a yellowish material and this may be followed by black vomit similar to that of yellow fever. The temperature usually attains its highest point within the first twenty-four hours — 104° F. to even 109° F.; and the pulse reaches 140, 150, or even 160 beats per minute. The cessation of the fever is as abrupt as its invas- ion. The duration of the primary paroxysm in the majority of cases is between five and seven days. It may be two or fourteen days. The average duration of the apyrexial period or inter- mission is about seven days. The relapse, like the primary attack, 492 A COMPENDIUM OF PRACTICAL MEDICINE. is sudden, with chilly sensations, fever, etc. The relapse also ends suddenly with profuse sweat. The duration of the relapse varies between three and five days. It may lie one or ten days. The relapse does not always occur. But two, three, four, and even fine relapses have been observed. The duration of the second intermission is eight or nine days, and that of the third paroxysm about three days. The duration of the disease aver- ages about twenty-five days. The tongue is coated and soon becomes very dry and sore. Herpes labialis may occur. Epistaxis is frequent. There may be diarrhoea or constipation. Meteorism is common. Tenderness in the epigastric and iliac regions on pressure is common. Jaundice is developed in some cases. A dirty, yellowish color of the shin is present in most cases. During the first paroxysm, pains in the loins, the calves of the legs, and the muscles in other situations are generally much complained of. They are never wanting. The muscular pains do not cease with the ending of the paroxysm, but continue dur- ing the intermission. They are more or less prominent during the relapse. The pains are sometimes referred to the bones. The mind is clear. The perceptions are not blunted in this disease as they are in typhus and typhoid fever. There is no coma- vigil, no subsultus and no carphologia. There is no characteristic erup- tion. Sudamina or miliary vesicles, sometimes are observed when profuse perspiration occurs. The face is more or less flushed but there is not that degree of capillary congestion, marked especially on the cheeks which exists in typhoid fever or the dingy complexion which characterizes typhus. Relapsing fever, when it attacks pregnant women, always leads to miscar- riage or abortion. The patient goes on from day to day gradually getting worse; the fever becomes more and more intense; loss of strength and emaciation are progressive and the muscular pains are more severe; when on the seventh day of the fever a remis- sion suddenly occurs. (Edema of the feet due to general anaemia is often quite marked during convalescence. Recovery is tedious (Bartholow, Flint and Loomis). Differential Diagnosis. — Relapsing fever may be confounded with typhus, typhoid, yellow fever, small -pox and measles. In typhus, the dusky face, contracted pupils, absence of all abdom- RELAPSING FEVER SALIVATION. 493 inal pain, peculiar smell, stupor, apathy of mind, and the path- ognomonic eruption on the fifth or seventh day will be sufficient to distinguish it from relapsing. In typhoid the slow invasion, the "step-ladder" rise in temperature, the eruption and the characteristic diarrhoea will distinguish it from relapsing. In yellow fever the pulse is rarely over 110, the spleen is normal and only a remission occurs. In small-pox, the eruption appears on the third day. In measles the eruption follows a common cold in the head. Of course the prevalence of relapsing fever will assist the diagnosis (Loomis). Prognosis. — Is always good. About three per cent, of the cases die. Sudden syncope is the greatest clanger (Loomis). Treatment. — Dr. Rutty stated more than a century ago that all those cases of relapsing fever which were abandoned to whey and the good providence of God recovered. Loomis would give very little medicine in this disease. If there is any evidence of heart- failure, he would give digitalis and stimulants, with milk diet and free ventilation. For the pains, Bartholow advises morphine hypodermically; and for the nausea, half a grain of carbolic acid in cherry-laurel water. Tonic remedies are indicated. SALIVATION. Is harmful and should not be aimed at. The greatest effect that it is allowable to produce by mercury is to "touch the gums." When the gums are touched there will be an increased flow of saliva, a faint coppery taste in the mouth, and some ten- derness of the gums, tongue and mouth (Keyes). Causes. — The cause of salivation is special idiosyncrasy with a small dose of mercury, or no idiosyncrasy with large doses. A mouth kept dirty or containing bad teeth is more apt to suffer. The influence of cold and wet during a mercurial course may produce it (Keyes). Symptoms. — In salivation, the salivary fluids How freely, sometimes to an enormous extent; the breath is fetid, the metal- lic taste is very marked; the gnms are sore; the teeth feel too long for the patient to shut his mouth; the tongue swells, show- ing marks of the teeth, and the lips and cheeks may also become 494 A COMPENDIUM OF practical medicine. tumefied. Often there is fever. The teeth may fall out, or portions of the soft or bony parts necrose. The articulation is indistinct and painful and deglutition almost impossible (Keyes). Treatment. — During salivation, or any sore mouth from mercury, ten to twelve grains of chlorate of potash to. the ounce of water, or any bland fluid, may be used as a mouth wash and gargle. At least one drachm of chlorate of potash should be taken by the stomach daily. A mild solution of carbolic acid, or of permanganate of potash,, should be occasionally used as a gargle where there is great fetor of the breath. The free use of the hot bath is of advantage, and a mild diuretic may be given. A little tincture of belladonna may be given to restrain the sali- vary flow. Astringent gargles, Labarraque's solution, tincture of myrrh, hot milk, cold tea may be used as mouth -washes (Keyes). Alcohol diluted with water may be used as an astrin- gent gargle in salivation. Bromide of potassium checks the salivation sometimes occurring in pregnancy. A gargle of two drachms of tincture of iodine to eight ounces of water has been recommended to allay mercurial salivation (Ringer). SATYRIASIS. Is constant desire with erection; erotic delirium. It is also a brain disease. Acton mentions the case of an old man who was eminently satyiiasic, so much so that he would masturbate in the presence of ladies. Dying, a tumor of the size of a split pea was found in the pons Varolii (Keyes). SCABIES. Called also "the itch" is a highly contagious disease, especi- ally in persons who are inattentive to cleanliness. It is com- municated by sleeping with, or on the beds of those who are affected, or by coming much in contact with them in any way. It may also be transmitted from the domestic animals, such as the cat. It is oftener met with in winter than in summer (Anderson). Causes.— The cause of u the itch" is an animal parasite, called cccarus scahiei. This burrows into the skin particularly SCABIES SCARLET FEVER. 495 "between the fingers and toes, about the wrists, on the buttocks, abdomen, and the upper part of the penis (DaCosta). Symptoms. — The disease is attended with excessive itching, which is increased at night, and with an eruption usually due to the irritation of scratching. At the close of our civil war we had a form of itch very prevalent in this country, the so-called army itch, which was a very chronic affection and no age or social state was exempt from it. The itching was intense (DaCosta). Treatment. — Scabies can be easily cured. The treatment should be exclusively local. The indications are: 1. To destroy the acari and their eggs. 2. To do so without irritating the skin. 3. To remove the eruptions called forth by the scratch- ing. At the Glasgow Hospital for skin diseases, each patient affected with scabies, is told to scrub the whole of his body (ex- cept the head) as firmly as possible with black soap and water, and to sit in a hot bath for twenty minutes; also to rub some of the ointment given him firmly into the skin of the whole body (except the head) for twenty minutes. Let the ointment remain on the body all night. Repeat these processes every night for three nights, hut no oftener. Besides the above, he is ordered to put all his washing clothes into boiling water, and to iron all others with a hot iron. The best parasiticide in this disease is sulphur ' but it is apt to irritate and inflame the skin. Anderson prefers an ointment of storax, for it not only kills the acari, but also has a pleasant aroma, and rather soothes than irritates the skin. Burchard strongly recommends the use of balsam of Peru. One thorough application to the dry skin is sufficient, or the bal- sam may be diluted with two parts of lard and applied oftener. Lard may alone effect a cure if applied for two weeks. SCARLET FEVER. Called also scarlatina, is an acute infectious and contagious disease, self-limited, characterized by a peculiar exanthem, an affection of the throat and albuminuria, and terminating in des- quamation of the epidermis. This name has been given on account of the bright red appearance of its eruption. It is a disease of childhood, but may occur at any age (Bartholow and Loomis). 496 A COMPENDIUM OF PRACTICAL MEDICINE. Causes. — The cause of scarlet fever is a contagion, a micro- organism, which is transferable from the sick to the healthy. No specific microbe of the disease has as yet been discovered. It occurs both in the sporadic and epidemic form, but never arises spontaneously. It may be conveyed by contact, through the atmosphere, by animals, and by clothing; it is therefore a porta- ble disease. An epidemic of scarlet fever has been traced to the milk supply. Quain says : " Milk is a great medium for carry~- ing scarlet fever, and cream even more than milk often carries.it from the sick to the well." The susceptibility to scarlatina is not universal. Some seem to have a certain idiosyncrasy which prevents them from contracting the disease. Scarlet fever can be communicated from one individual to another by inoculation with the serum from a minute vesicle on the skin of a scarlet fever patient. But those who have been inoculated for scarlet fever have suffered more severely than those who con- tracted the disease in the ordinary way. The scarlet fever poison can be conveyed by clothing, but when a physician makes a visit of ordinary length, he is not likely to so convey the disease. Nurses who have been with a scarlet fever patient for a number of days and whose clothing has become filled with the poison, may carry the disease. The poison is probably contained in the skin and its excretions and epithelium and also in the breath and exhalations from the throat. The period at which the disease is most infectious is probably the highest point of the disease; but it is present at any period from the beginning to the end. The disease but rarely occurs twice in the same individual; although it may recur from one to three weeks after the close of the first attack and is then de- scribed as a relapse. The period of incubation varies from one to fourteen days, the average duration being from three to seven days. The shortest period is that of a patient mentioned by Trousseau, in whom the disease appeared in a day after expos- ure. Within the first six months of infant life there is little lia- bility to the disease; but the greatest susceptibility to the influ- ence of the poison exists between the second and seventh years, and declines slowly to the tenth, and after this more rapidly; but it does occur in old age. Those who have .just undergone SCAELET FEVEE. 497 surgical operations seem to be especially prone to contract the disease. Women during convalescence after child-birth are very liable to contract scarlet fever. Contagiousness. — The area of the contagiousness of scarlet fever is small; it apparently embraces only a few feet. It is not so contagious as pertussis, variola, varicella, or measles. Variations in Type. — The type of scarlet fever varies greatly in different epidemics. One child may have it so mildly that little treatment is required; while another has the malignant form, and soon succumbs (Bartholow, Flint, Loomis and J. L. Smith). Morbid Anatomy. — It has no characteristic anatomical lesions except those which occur in the skin and mucous membranes. The eruption is due to an intense hyperemia, which is limited to the area of the spots, but which is general when the spots coalesce (Bartholow and Loomis). Symptoms. — There are three stages of scarlet fever: First, the stage of invasion. Second, the stage of eruption. Third, the stage of desquamation. The period of invasion is sudden and violent. A strong chill is the initial symptom in adults; in children there is a violent convulsion, or a severe attack of vom- iting, with prostration. Headache of a very intense character, general muscular pains and high fever succeed to the chill. In a short time the temperature rises to 104°, 105°, or higher; the skin is hot; the throat burns and is red and swollen; the tongue is coated. The affection of the throat is due to the efflorescence which appears in this situation before its appearance on the skin. Epistaxis is common. The average duration of this stage is about twenty-four hours, and the eruption usually appears on the second day. It may appear earlier or later. Stage of Eruption. — This stage in children is sometimes ushered in by a transient convulsion. The eruption appears on the neck and upper part of the chest first, and then on the cheeks and forehead. The first appearance is in the form of minute red ox, the eruption, if confluent, may resemble that of scarlet fever for the first twenty-four hours yet the development of the first vesicle settles the question. In erythema the redness spreads in a very irregular manner, and the throat symptoms and strawberry-like tongue of scarlet fever are absent. In roseola the throat affection is much milder than in scarlet fever. In roseola the white line that the finger leaves disappears immediately, while in scarlatina it remains (Loomis and Flint). 500 A COMPENDIUM OF PRACTICAL MEDICINE. Prognosis. — Is always uncertain in scarlet fever. The rate of mortality ranges from one death in five to one in twenty. The conditions of a favorable prognosis are early eruption, mild throat symptoms, a temperature not higher than 104° F., pulse not above 120 and mild cerebral symptoms. Autumn is the most unfavorable season. Malignant; cases of scarlet fever in which no eruption appears, prove rapidly fatal. The patient is over- whelmed by the scarlatina or active blood poison. The period of greatest mortality is from infancy to five years of age (Loomis). Treatment. — I. Prophylaxis or Prevention. — The jxrophy- laxis of scarlet fever is a system of the strictest quarantine. The sick must be removed from the healthy. Fresh air renders the contagion of scarlet fever less powerful; therefore, free ventila- tion is of the utmost importance. All the clothes and excretions of the patient, the nurse and everything contaminated by the contagion should be disinfected. The funeral of those dying of scarlet fever should not be public. The sick should not be allowed to leave their apartment until desquamation is com- pleted. Belladonna has no power to prevent this disease, as was once thought. II. Medicinal Treatment. — The medicinal treatment of scarlet fever is almost entirely expectant. It is a disease which cannot be aborted, but tends to recovery. The bed and body linen should be frequently changed. The patient should be bathed with warm water once or twice daily during the period of desquamation. The baths will relieve the kidneys by keeping the skin active. If the temperature of the patient rises above 104° F., it should be reduced by some means. Loomis says, "Unless the temperature in a case of scarlet fever ranges above 105° F., do not apply cold to the surface or give antipyretics.'" In all cases the patient is tobe sponged frequently with tepid water, and if there is intense burning of the surface, a saline is to be added to the water. Sponging in this manner will give the patient very great comfort. Of all the remedies which Loomis has employed for the throat complications, cold carbonic acid water or pieces of ice afford most marked relief. In the ad- vanced stages of the disease, hot applications may be used extern- SCLEROSIS OF THE BKAIX. 501 ally to the neck and warm water gargles and steam inhalations internally. For the ulcers sometimes seen in the throat of scarlet fever patients, a spray of carbolic acid, tincture of iron, chlorate of potash, or tannic acid maybe used. Stimulants may be given early if there is much depression. Whenever kidney symptoms are developed, dry or wet cups should be applied over the region of the kidneys, upon either side of the spine. At the same time the temperature of the sick-room is to be raised to 73° or 74° F., the body of the patient covered with flannel, hot-air or warm- baths are to be given and also diuretics. Of the diuretics, digi- talis will act most favorably. Small doses of calomel may be combined with the digitalis and continued for two or three days. The patient may drink water freely. If convulsions occur, opium may be given (Loomis). SCLEROSIS OF THE BRAIN. By the term sclerosis is meant a disease characterized by the formation of isolated patches or nodules of sclerotic tissue (har- dened tissue). We have sclerosis of the liver, of the kidney, of the lung, of the brain and spinal cord, etc. Independent of cerebro- spinal sclerosis, this is a compara- tively rare condition. Cerebral sclerosis is a chronic interstitial inflammation, following hyperemia of the neuroglia. It may be diffused or multiple (Loomis). Morbid Anatomy. — On section, masses of gray, hard, well- defined, transparent sclerotic tissue are found, varying in size from one-fourth to one inch (Loomis). Causes. — Are obscure. It is intimately connected with changes in the vascular system. Sclerosis of the brain is often found in epileptics and in the insane (Loomis ). Symptoms. — Are a gradual enfeeblement of the mental powers, especially memory, muscular tremors, headache, dizzi- ness and vertigo. One group of muscles after another becomes paralyzed. Melancholia, pains in the extremities, and a sense of formication are common. Patients may gain flesh with this disease. Strabismus may be present. A peculiar symptom is festination — the patient 1 tends forward and trots along like one 502 A COMPENDIUM OF PRACTICAL MEDICINE. trying to run after he is tired out. In rare instances the first symptoms are convulsions of an epileptiform character, followed by hemiplegia (Loomis). Differential Diagnosis. — Sclerosis of the brain may be con- founded with cerebral softening, paralysis agitans or tumors. Softening occurs in old age ; sclerosis occurs from youth to middle age. The paralysis in softening is in one set or group of muscles, and if it extends, does so in an orderly manner. There is anwsthesia, and the symptoms develop more suddenly than in sclerosis. Paralysis agitans is marked by rhythmic tremor passing from one upper to the corresponding lower limb; there is a peculiar deformity of the fingers and toes; the facial muscles are not affected, and the patient inclines to the paralyzed side in walking. Paralysis agitans occurs only after the fortieth year, and is accompanied by no cerebral symptoms. Cerebral tumors are attended by headache, convulsions and signs of brain irrita- tion without loss of mental power (Loomis). Prognosis. — Sclerosis of the brain may continue from five to eight years, but it is progressive and always fatal (Loomis). Treatment. — Little can be done for this disease except to im- prove the general health. Vulpian recommends chloride of iron, Mitchell the bi- chloride of. mercury, Hammond the chloride of barium and many the phosphate of zinc. Nitrate of silver and strychnia are said to relieve tremor (Loomis). CEREBROSPINAL SCLEROSIS. Is a disease characterized by the formation of isolated patches or nodules of sclerotic tissue (hardened tissue) in the brain, pons, medulla, cerebellum and spinal cord (Bartholow). Morbid Anatomy. — The disease in the brain and cord to the naked eye, appears as glistening nodules underneath the pia, varying in size from a minute object to that of a walnut (Bar- tholow). Causes. — The exciting causes are damp and cold, sudden chilling of the body, traumatism, severe, long-continued brain work or physical exercise, powerful and prolonged moral emo- tion, chagrin and anxiety. The most powerful predisposing CEEEBRO SPINAL SCLEEOSIS. 503 cause is heredity. Continued jarring of the body is also thought to produce the disease. It occurs in nervous people with hys- teria and after acute febrile diseases. It is essentially a disease of early life, few cases occurring outside the limits of fifteen and thirty -five (Bartholow and Looniis). Symptoms. — It may be insidious or sudden in its develop- ment. If it come on insidiously, the patient complains vaguely of headache, vertigo, muscular weakness, mental disturbances, and queer feelings as formications, itchings, burnings, etc., in the limbs. There are nausea, vomiting, cardialgia, loss of co-ordin- ating power, and impairment of the special senses. There is more or less paresis in the extremities, and shaking tremor when an attempt is made at voluntary motions. In some cases the patient becomes childish or morose. During prolonged fits of yawning, sobbing, or laughing, the respirations become stridulous. The patient talks in a low monotone or whisper, dividing his words in syllables, and empasizing them as when scanning a line of poetry. A girdle pain is felt about the abdomen. Amblyo- pia, nystagmus, diplopia, and inequality of the pupils evidence invasion of the base of the brain and optic tracts. In the ad- vanced stage acute bed-sores, loss of sexual power and control of the sphincters become marked symptoms (Bartholow and Loomis). Differential Diagnosis. — Cerebro- spinal sclerosis may be mis- taken for paralysis agitans, locomotor ataxia, and cerebral hem- orrhage. In paralysis agitans the fine tremor exists when the patient is at rest, and is not accompanied by shaking of the head; while in sclerosis the head is always involved, the symp- tom ceasing as soon as the patient is at rest. Paralysis agitans is rare before forty; and multiple sclerosis is rare after thirty - five. Changes in the voice and speech and ocular symptoms are present in disseminated sclerosis and absent in paralysis. In locomotor ataxia, the peculiar tremor, impairment of voice and speech, and nystagmus that belong to disseminated sclerosis are absent. In the former disease we notice the peculiar iron- band sensation, vesical symptoms, the Meniere's vertigo, the very slow and late appearance of paretic symptoms, the lightning-like and agonizing neuralgic pains, and the peculiar double beat in 504 A COMPENDIUM OF PRACTICAL MEDICINE. walking, the heel being put down first, all of which are in marked contrast to the symptoms of multiple cerebro- spinal sclerosis. When sclerosis is ushered in by loss of consciousness which rapidly deepens into coma, with marked hemir)legic symptoms, it may be mistaken for cerebral hemorrhage / but in sclerosis the temperature is very high during these peculiar attacks — 104° or 105° F., — the hemiplegia passes off soon (Loomis). Prognosis. — The average duration of this disease is five to ten years. The termination by death is the only one known. After six or seven years emaciation sets in, a marasmus is devel- oped, and the patient is apt to die from intercurrent disease (Bartholow and Loomis). Treatment. — Improve the nutrition. Chloride of gold, phos- phate of zinc, nitrate of silver, chloride of barium, potassium, iodide and bromide, arsenic, belladonna, calabar bean, and ergot have all been used with some success. The galvanic current benefits in some cases. For the pain morphine should be given (Bartholow and Loomis). SCROFULA. Is a constitutional dyscrasia, hereditary or acquired, charac- terized by changes inflammatory and hyperplastic, occurring for the most part in the lymphatic system, the skin, mucous mem- branes, connective tissue, osseous structures and viscera. Scrofula is also known as struma, the strumous diathesis, tuber- culosis, the tuberculous diathesis. Scrofula is a disease chiefly of infancy and childhood, but early adult life is not entirely exeunt. Scrofulous persons are liable to chronic inflammations of the lymphatic glands, especially those of the neck, which enlarge, often coalesce with each other, and undergo cheesy metamorpho- sis (Bartholow, Loomis and Smith). Morbid Anatomy. — The characteristic lesions of scrofula are to be found in the lymphatic glands, although the skin, mucous membranes, bones, joints, and organs of special sense may be in- volved. Anaemia necrosis or suppuration sometimes occurs in the glands. On the skin the lesions appear as eruptions. Im- petigo of the eyelashes and external otitis are common strumous SCROFULA. 505 diseases. Scrofulous inflammation of mucous membranes is marked by a thick, sticky exudation with a tendency to form scabs. The bones most frequently involved are those of the ankle, lower part of the femur, and the vertebrae. The scrofulous development may assume the form of synovitis, osteitis, perios- teitis, or general arthritis. A pharyngitis often gives rise to hyperplasia of the tonsils (which are lymphatic glands) in scrof- ulous individuals (Loomis). Causes. — Scrofula is congenital or acquired. The children of intenrperate, phthisical, syphilitic, cancerous and very old or very young parents, develop early all the characteristic features of the scrofulous diathesis. Children of consanguineous mar- riages are especially liable to scrofula, and to this has been attri- buted the scrofula of royal families. Healthy children may ac- qire scrofula through antihygienic surroundings, from improper food, overcrowding, lack of fresh air, exercise and sunlight. In the infant scrofula is sometimes produced by insufficiency or poor quality of the breast-milk, or too protracted nursing at the breast. Some think that scrofula is a local tuberculosis from the fact that scrofulous glands sometimes contain the tubercle bacillus. Birch -Hirchf eld found tubercles in nine out of ten lymphatic glands removed from the necks of scrofulous patients. Others think that the tubercle bacillus found in scrofulous glands is accidental. Rabl tabulates 1,000 cases of scrofula as regards the causation, as follows: 79 had scrofulous parents, 446 had tuberculous parents, 356 lived in damp dwellings, 25 were subjected to other bad hygienic surroundings, 69 could be as- cribed to acute infectious diseases, such as small-pox, measles, scarlet fever, etc., 14 to vaccination, 7 to decrepitude and 4 to consanguinity of parents. Rabl also expresses the opinion that in certain cases scrofula results from syphilis in the parent or grand-parent. He believes that syphilis in the parent causes scrofula in the child by diminishing the power of resistance to the causes which produce the latter affection. He thinks that in this matter parental syphilis gives rise in some children to symp- toms identical with those of scrofula, while in other children it gives rise to syphilitic symptoms. Dr. J. L. Smith is of the same opinion (Bartholovv, Loomis and J. L. Smith). 506 A COMPENDIUM OF PRACTICAL MEDICINE. Symptoms, — Some children with a scrofulous habit have a transparent, white skin, with delicate blue veins; large, lustrous eyes; bright red lips, etc. Others may have large heads with coarse features, a thick skin, which has a flabby, spongy feel, an enlarged abdomen, and cervical glands. Chronic inflammations of the skin about the face and scalp are frequent. Coryza, con- junctivitis, otorrhcea, laryngitis and bronchitis are persistent. Synovitis may appear. A slight injury may be the starting point of caries and necrosis. Glandular enlargements are the most common symptoms. This enlargement, which is non-inflam- matory and due to cellular hyperplasia, is very gradual, and forms a smooth, Arm tumor. These glands may inflame and sup- purate. The disease progresses slowly, but toward puberty pul- monary disease is apt to be established (Loomis and Smith). Prognosis. — Is good when the patient is seen early. Scro- fulous children may die from tuberculous intestinal disease, acute hydrocephalus or croup. Treatment. — The diet should be nutritious and easily di- gested. Cod-liver oil should be given daily during the greater part of infantile and adult life. The syrnp of the iodide of iron should be given in one to two -drop doses three times daily to a child of six months, and five drops to a child of four years. The following is a good formula: Jfc Olei morrhuse §iv. Syrupi calcis lactophosphatis Aqua3 calcis — aa §ij . — M. Sig. : One teaspoonful to a dessertspoonful four times daily. —Smith. Fresh air, outdoor exercise and daily bathing are necessary. Farm-life, sea-air and sea-bathing have been found efiicacious. The following is a useful iodine mixture for external application: Tfr Liquor iodini composita Gly cerina? — aa. 5j • — M. Sig. : To be applied over the gland as an inunction. The synovitis or strumous arthritis must be treated appropri- ately when it occurs. When it occurs in two or more joints, it may be mistaken for rheumatism (Loomis aud Smith). SCURVY. 507 SCURVY. Called also scorbutus, is a chronic blood disease, which may be regarded as a peculiar form of anseinia arising from deficiency of vegetable diet. This disease appears to have been known to the ancients. During the last five or six centuries it prevailed very entensively in armies and among crews of sailing vessels, and hence it was called sea-scurvy. It prevailed enormously in the English and French armies in the Crimean War, and also in the late Civil War in our own country (Flint and Loomis). Causes. — Deprivation of fresh vegetable food for along time will very surely induce scurvy. It is rarely met with from any other cause, although an unvaried diet of poor quality may in- duce it (Loomis). Symptoms. — The skin of the face and eyelids changes color and appears bruised and swollen. The pulse is soft and the temperature lower than normal. There is great despondency and a sense of weight in the lower limbs. The skin is dry, rough and of a muddy pallor. The conjunctivae are pearly white, the tongue is clean and pale, the teeth loosen and are surrounded by bright red ulcerated and spongy gums which bleed upon the slightest provocation. The breath is exceedingly offensive, fre- quently from necrosis of the jaws. Ecchymoses and -petechial spots cover the body. Severe darting pains are felt in the limbs. about the calf of the leg and the popliteal space. Node-like swellings occur over the tibia. Slight exertion may occasion palpitation, dyspnoea, and even syncope (Flint and Loomis). Differential Diagnosis. — Scurvy may be mistaken for mercu/r- ial poisoning and purpwa. The history of the case and a close inspection of the gums will enable one to distinguish scurvy from mercurial poisoning. Scurvy is distinguished from pur- pura by the spongy gums, painful swellings, and more profuse though less numerous hemorrhages. Purpura is not affected by lime juice, or change in diet, while scurvy is (Loomis). Prognosis. — Scurvy is not a fatal disease, if uncomplicated, and appropriate treatment applied. It Aras the cause of death in a large proportion of those who died during the potato famine in Ireland (Loomis). 508 A COMPENDIUM OF PE ACTIO AL MEDICINE. Treatment. — Iu long sea- voyages or campaigns lemon or lime juice or citric acid should be taken daily when fresh or pre- served vegetables cannot be obtained. By their use in the English navy, scurvy has been diminished nearly ninety per cent. Orange-juice is also an effectual antiscorbutic. One of the most efficient of antiscorbutic vegetables is the potato. It is most efficient when eaten raw. Pickles, onions, raw cabbage or sauerkraut, the water- cress, green corn and green apples are valuable antiscorbutics. One who is seriously ill of scurvy should be kept in bed, and his diet should be fresh vegetables and acid fruits with fresh meats. Three or four ounces of lime or lemon juice largely diluted with cold water should be taken daily. Tincture of the chloride of iron and ergot are given to arrest hemorrhage. Whiskey may be given when indicated. To arrest local hemorrhage, alum, tannin, subsulphate of iron and the chloride of iron are most useful. A wash of chlorate of potash will afford relief to the mouth symptoms. Quinine, iron and strychnine act both as tonics and appetizers (Flint and Loomis). SEA=SICKNESS. Is a peculiar form of functional disturbance of the nervous system characterized by severe depression and persistent nausea and vomiting (Loomis). Causes. — Sea -sickness is most commonly the result of the motion of a ship, but it may be the result of any unusual motions to which the person is unaccustomed, as the motion of a swing or an elevator. Waltzing, riding backwards, turning a somersault, or the sudden jerk of a railroad train as it starts or stops may each produce a similar condition. In some persons, a mild form of sickness may be produced by simply watching oscillating objects. Some persons never suffer, while others are unable to endure the slightest motion on the water or elsewhere. The nerve centres are embarrassed, and the resulting nervous irritation manifests itself through vaso-motor disturbances in precisely the same manner as is seen when persons blush under embarrassing circumstances, or pale when startled (Loomis). SEA-SICKXESS. 509 Symptoms. — Seasickness usually presents the two stages of first, depression and exhaustion, and second, reaction. It begins with a sense of weight and epigastric oppression, occuriug only during the rapid rise and fall of the vessel. It speedily becomes continuous and is accompanied by vertigo and headache. Xausea is always most intense and at the same time the vomiting is often sudden and projectile, as in cerebral vomiting. The appetite is entirely lost. The mental depression is great. In the majority of cases this condition continues from three to five days, provided the voyage is of that length during which time the nausea, vomit- ing and mental depression continue and is then followed by reac- tion. There is now a ravenous appetite and a feeling of well being. In some cases the stage of depression lasts for weeks, and the pa- tient may p ass into a stage of partial collapse and coma (Loomis). Prognosis. — It is very rarely fatal, but occasionally a condi- tion of collapse develops which, if not assiduously treated, may pass into coma and death (Loomis). Treatment. — For the vaso-motor disturbance and spinal con- gestion, counter -irritation to the spine, or ice-bags and the bro- mides and nitrite of amyl have proved the most useful. The ice- bag controls the spinal congestion. The bromides must be be- gun some time before the voyage and continued in large doses until the patient is accustomed to the motion. Amyl nitrite seems to be the most efficacious remedy yet proposed. It should be given in full doses upon the first appearance of epigastric dis- tress and repeated as necessary. Dr. Clapham reports 121 suc- cessful cases out of a total of 124 in which amyl nitrite was used. Sometimes stimulants are effective but often fail (Loomis). Ac- cording to Bartholow sea-sickness is relieved sometimes by the subcutaneous injection of atropine in small quantity. A little chloroform (ZHii-ZHv.) dropped on sugar and swallowed is some- times effective in sea-sickness. Chloral in fifteen to thirty grain doses every four hours, is probably the most effective remedy, but it must be given before decided nausea sets in. The bromide of sodium in half to one drachm doses before embarking is one of the first remedies in sea-sickness. Nitro-glycerine by the stomach may afford relief (Bartholow ). 510 A COMPENDIUM OF PRACTICAL MEDICIJSTE. SEPTICEMIA. Is a constitutional disease due to the absorption into the blood of a septic material which is developed in decomposing animal matter by the action of putrefactive bacteria. The dis- ease is closely allied to surgical or traumatic fever (Loomis). Causes, — The nature of the septic poison is still a matter of dispute. Some claim that it is a chemical substance formed in a wounded part, while others regard the bacteria the sole cause of the septic infection. Decomposing tissues which cause septi- caemia may be in the body, on the surface of the body, or outside of the body. I. Thus, a decomposing placenta in utero, sloughing ulcers in typhoid, necrotic processes in chronic phthisis, diphtheritic sloughs, ulcerative endocarditis, abscess and gangrene of the lung — these are some of the internal conditions which may induce septicaemia. II. Wounds, gangrene, decomposing membranes, or sup- puration and necrosis in small-pox, any ill-conditioned wound, especially if lacerated and contused, may cause septicaemia. III. Dissecting wounds and ^os^-mortem manipulation of those who have died of infection, even without a surface abra- sion, may induce septicaemia. The respiratory and the gastro- intestinal tracts are sometimes the mode of entrance of the infec- tion (Loomis). Symptoms. — The symptoms of septicaemia or blood-poison- ing will vary with the amount of the septic material introduced into the system and the length of the infection. In a well- marked case, after a rigor, or feeling of chilliness, but rarely a distinct chill, there is a rapid rise in temperature; 105° or 107° F. may be reached within the first twenty-four hours. The pulse is rapid, 120 to 140, feeble and thread-like. The mouth, tongue, and surface of the body become hot and dry. If sweats occur they are very slight. Vomiting is frequent. The countenance is dull, and the patient generally free from pain. There is rest- lessness and low muttering delirium. The respirations are feeble, labored, and hurried. The skin may be slightly jaundiced. Diarrhoea is present in nearly all severe cases. In severe cases SEPTICEMIA SPERMATORRHOEA 511 death may occur within twenty -four to seventy- two hours, the patient dying in complete collapse. Typhoid symptoms, a dry tongue, rise in temperature, diarrhoea and muttering delirium, following an abortion or child-birth, should always excite sus- picion (Loomis). Differential Diagnosis. — Septicaemia may be mistaken for py'cemia. Pycemia is ushered in by a distinct chill; septicaemia by a slight chill. In pyaemia the chills recur; in septicaemia there is but one chill. In pyaemia there are profuse sweats, which recur; in septicaemia there are slight, if any, sweatings, and they are never recurrent. In pyaemia the temperature grad- ually rises to 102° to 104° F.; in septicaemia it is high at the onset, 105° to 107° F. There is a sweet "sickisk" odor to the breath in pyaemia, absent in septicaemia. Pyaemia develops slowly, sejrticaemia rapidly (Loomis). Prognosis, — When the symptoms of the disease are well marked the ju'ognosis is bad. Its duration is from two days to two months. Treatment. — Discover and when possible remove the cause. Antiseptics should always be used at the seat of the infection. The bowels must be freely acted upon by salines throughout the whole course of the disease. Quinine, salicylic acid and brandy are the three drugs on which we place our reliance. Tanner recommends quinine and nitric acid. The diet must be as nour- ishing as possible. Billroth's treatment is cooling drinks, a fever diet, morphine at night to secure sleep, from six to ten grains of quinine during the afternoon and warm baths (Loomis). SPERMATORRHEA. Is an escape of seminal fluid containing spermatozoa, without ejaculation and without pleasurable orgasm, usually at stool, with the urine, or to a slight extent at all times. During pro- longed erection under intense sexual excitement, a small amount of true seminal fluid is apt to escape into the prostatic sinus, and to be passed at the next urination. This may happen to any one occasionally, and does not amount to disease (Keyes). 512 A COMPENDIUM OF PRACTICAL MEDICINE. Varieties. — I. True. Spermatorrhoea. II. False Sper- matorrhoea. True spermatorrhoea may exist, but it is a very rare disease. It falls to the lot eveu of the specialist to see but very few cases of true spermatorrhoea. False spermatorrhoea, is, however, a more common com- plaint. It is supposed to be present when nocturnal emissions are frequent, when diurnal emissions take place on any sexual thought, and urethral discharge of a glairy fluid attends defeca- tion, when erections with discharge follow the slightest irritation, such as that produced by riding or walking, from the friction of trousers, etc. Such cases are common and are usually clue to masturbation, but are not cases of true spermatorrhoea, although they often preceed it. Nocturnal emissions may be too frequent; but if associated with sexual feeling, they are natural. If too frequent, they should be checked as they may lead on to the true disease. The glairy fluid pressed out in defecation is rarely seminal, but is prostatic, of a transparent, tenacious character, and not milky. Most of the symptoms Avhich a patient usually mistakes for spermatorrhoea are a gleety discharge, phosphatic urine, vesical mucus, decomposing urine, etc. The young man into whose hands some pamphlet on " Manhood Restored " has fallen, imagines himself hopelessly doomed to impotence, paraly- sis, and idiocy, because the rjamphlet tells him that he has sper- matorrhoea, which spermatorrhoea consists in nocturnal pollution, escape of mucus during prolonged erection, of phosphates in the urine, etc. Sometimes, where the diseased mind of a youth suf- fering from ungratified sexual desire can find nothing else to con- firm its suspicions, the natural healthy flocculent cloud of mucus collecting normally in all urine, after it has stood awhile, is pointed to, in dejected triumph, as a demonstration of the never- ending loss of seminal fluid (Bryant and Keyes). Causes. — Spermatorrhoea sometimes follows excessive mas- turbation, general prostration, as after typhoid fever, imperfect digestion and general nervous distress from overwork, or other cause, or follow chronic disease of the prostatic sinus and semiual vesicles. It is sometimes associated with constipation and rectal irritation, spasmodic action of the levator ani acting on the SPEEMATOEEHCEA. 513 vesicular seminales and prostate gland. The worst cases are asso- ciated with wasting of the testicles and varicocele. It is some- times due to excess of venery. Lallemand holds that sperma- torrhoea is nearly always dependent upon irritation of the pros- tate gland and its ejaculatory ducts. Trousseau believes that spermatorrhoea or incontinence of semen is due to some imper- fection in the nervous system of organic life, since it is so commonly found in men who have had incontinence of urine in childhood (Bryant and Keyes). Symptoms. — In true spermatorrhoea it is usual for spermatic fluid in small quantity to pass from the meatus during defecation and urination; while jolting or riding, etc., cause oozing of a bluish fluid from the meatus, which contain spermatozoa. Pa- tients with true spermatorrhoea have little care for their sexual functions and are not disturbed on the subject of impotence and present in this respect, a most strongly marked contrast with the hypochondriacal patients imagining themselves impotent from false spermatorrhoea. Patients with, true spermatorrhoea are not by any means necessarily impotent, but their sexual appetite is usually morbid, excessive or feeble perhaps unnatural and per- verted, while sexual power is generally diminished. According to Bryant, spermatorrhoea commences almost always with nocturnal emissions which gradually become more frequent. These are at first attended with erotic sensation, but finally occur without erection. If copulation be attempted the ejaculation takes place at once, often before the introduction of the organ. In many cases the general symptoms are those of great lack of nervous tone, dyspepsia, headache, melancholy, neuralgia, loss of spirits, 23ains in the back, groins, testicles and vesical irritability. Such patients tend to grow thin, to lose their ambition and to fret. At last the penis shrivels, the testicles become small, flabby and very sensitive and the patient becomes truly impotent, incapable of erection. This malady does not kill. Dr. Keyes knows an old gentleman who enjoys excellent health and who has had true spermatorrhoea more than fifty years (Bryant and Keyes). Treatment. — Many cases are positively incurable, some get well — medicine is of little or no value. It is unfortuate that so many text-books ascribe value to the use of drugs in this malady. 514 A COMPENDIUM OF PRACTICAL MEDICINE. All the hygienic, general and local measures advised for cases of pollution may be tried. The use of the steel sound helps to give tone to the parts. Rouband thinks well of ergot — two to eight grains daily — in atonic cases. The use of a local astringent to the prostatic sinus is often of marked advantage. The best agent for effecting this is nitrate of silver in solution (gr. x. to 5j to the ounce), three to five drops of this thrown into the deep urethra. Bryant thinks half- grain doses of the extract of bella- donna twice a day, with some tonic such as iron, zinc, strych- nine, or quinine, are valuable. The rectum should be kept empty by a nightly injection of cold water. If a positive local treatment, with perhaps some tonics when required, fails to cure, the patient will be wise to accept his malady as he would some deformity which others cannot see, and think as little of it as possible, keeping his mind pure and his thoughts away from the subject (Bryant and Keyes). STRANGURY. Is the painful passing of urine in drops. It is not a disease but a symptom. The following prescriptions have been tried and recommended : Jfc Tincturse cannabis indicse §ij. Sig. : A half-teaspoon ful every few hours. (When strangury is due to spinal disease with bloody urine.) — Ringer. Jfc Pulv. opii gr. ii.-iv. Olei theobromse. . , 3J. — M. Ft. suppositoria no. ii. Sig.: Introduce one into the bowel, and repeat if necessary in four hours. — Hartshorne. STYE. Called also hordeolum, is a small red and painful swelling situated on the outer surface of the lid or near its margin, and consists in a circumscribed phlegmonous inflammation of the lid dependent on morbid change in the Meibonian glands. (Bryant and Xoyes). Causes. — Styes generally occur in weakly, delicate persons, and are apt to be associated with chronic blepharitis or conjunc- STYE SPINA BIFIDA. 515 tivitis, and often depend on general debility. Another frequent concomitant and favoring condition is nasal catarrh, which will also need attention. Several styes may appear simultaneously, or there may be a succession of them. They give rise to con- siderable irritation and are often extremely painful. The inflammation usually goes on to suppuration (Bryant and Noyes). Treatment. — In its inception it may sometimes be checked by applying a bit of ice wrapped in muslin for a few minutes repeatedly, or by pulling the cilium which passes through it. When suppuration is unavoidable, a poultice of ground slippery elm bark is most comforting, and a puncture should be made at an early period. Good living, general tonics, and mild astrin- gents are the proper remedies to prevent their recurrence; but it is important also to investigate the state of refraction, because what causes eye strain will provoke styes (Noyes). The follow ing lotion may be of service: JJr Acidi boracici 3iss. A quae destillatse , §v. — M. Sig. : Apply to the eyelids several times daily. — Abadie. SPINA BIFIDA. Called also hydrorachitis, is a congenital defect of the ver- tebral column, accompanied by a protrusion of the surrounding membranes of the cord, due to an arrest of ossification of the vertebras of the foetus at this point. It is essentially a congenital hernia of the membranes of the cord through an opening in the spine. It is analogous to the meningoceles of the cranium, and is similar in nature to hare-lip and cleft palate. The liquid in hydrorachitis is simply a portion of the cerebro-sjDinal fluid which normally exists in the subarachnoid space in the brain and spinal cord. It often contains the spinal cord itself or large nerve trunks (Bryant and Sayre). Characters of the Tumors. — The spinal hernia is sometimes covered by the whole thickness of integument; at others the in- tegument, though present, is very thin; while occasionally the walls are rejDresented only by a transparent membrane. The tumor may have a broad base and free communication with the 516 A COMPENDIUM OF PRACTICAL MEDICINE. central canal of the cord, or a narrow and more or less peduncu- lated one. The cord is more likely to be involved in the greater than in the less base. The tumor is always more or less globu- lar, tense and elastic. When the child is asleep or quiet the swelling may be soft; but when the child cries the tumor will rapidly fill out. The skin of the tumor may be ulcerated at birth or have a small opening (Bryant). Associated with Hydrocephalus. — The tumor is often asso- ciated with hydrocephalus and in exceptional instances is double. A ncevus is not seldom found situated over the tumor. Club- foot or paralysis of the lower limbs frequently co- exist with it, and in these cases it is tolerably certain that the cord is included in the hernia. Paralytic symptoms are more common in the broad- based hernia than in the narrow. Incontinence of urine or of feces may co- exist with the paralysis (Bryant). Situation of Tumor. — The lumbo- sacral portion of the column is more frequently affected than any other, but the cervical and dorsal portions are also liable to the defect. Of twenty -seven cases of Bryant's, thirteen occurecl in the lumbar region, four in the lumbo-sacral, and nine in the sacral, and one was double, a small tumor being in the lumbar and a large one in the sacral region. Twelve of these cases were uncomplicated with any paralysis or deformity. In eleven there was incontinence of urine and feces, associated in four with paralysis of the lower ex- tremities. Four were complicated with hydrocephalus, two with naevus, and one with talipes. Bryant has seen but two cases in which the tumor was in the cervical region. In exceptional cases the spinal hernia may protrude on the anterior part of the spine. When the tumor is complicated with hydrocephalus "fluctuation may often be felt between the two parts, pressure on the head causing a fullness of the spinal hernia, and vice versa (Bryant). Diagnosis. — In general, there is no difficulty in diagnosing a spina bifida. In any infant a congenital tumor over the spine is probably a spina bifida; if globular and tense or capable of becoming tense when the child cries, the probabilities are almost converted into a certainty. The only cases for which spina bifida is liable to be mistaken are congenital tumors, unconnected with the spine, such as cystic, fibrous, fatty or fcetal tumors. These SPINA BIFIDA. 517 may be hard and tense, but they are rarely, if ever, made so much more tense from the child crying, as is the spinal hernia (Bryant). Prognosis. — The majority of these cases prove fatal. Many of the subjects are ill -developed and die within a few days of birth; death from convulsions is very usual when the sac bursts and its fluid contents escape, more particularly when the escape is rapid. The rupture of the sac is not necessarily followed by a fatal result. Bryant had a case in which at birth the tumor was transparent and soon burst, and subsequently discharged at inter- vals for three years, and finally contracted up into a solid mass. This case is an example of a natural cure by gradual closure of the bony orifice. The more pedunculated the tumor the better the prognosis (Bryant). Treatment. — The treatment of these cases is very unsatisfac- tory. In the majority of cases, palliative treatment is all that can be adopted; although in exceptional instances operative interference promises to be of service. The tumor must always be guarded from injury by some soft protective material. Slight pressure to prevent rapid increase of the tumor is always bene- ficial. The application of collodion is sometimes useful. Aspira- tion, subcutaneous puncture with a trocar, and injection of the iodo- glycerine solution have been practiced with more or less success. Successful cases are recorded in which tapping of the hernia has been performed. The practice is dangerous, as the drawing off of the fluid has been followed by convulsions and even death; yet it is the least dangerous form of practice, and may be undertaken. The puncture should always be made at the side of the tumor, and the whole of the fluid should never be drawn off at once. Mr. W. E. Image, of Bury St. Edmund's, cured a case by puncture with a darning-needle at intervals of two or three days, four or six times, and applied a compress. In this case con- vulsions were produced whenever any pressure was applied to the tumor, but ceased after tapping. Dr. Morton, of Glasgow, lias advocated the injection at intervals of seven or ten days of half a drachm of a solution made by dissolving ten grains of iodine and thirty grains of iodide of potassium in an ounce of 51 S A COMPENDIUM OF PRACTICAL MEDICINE. glycerine. The injection should be thrown into the sac after the withdrawal of a small portion of the spinal fluid. Dr. Morton reports, in 1881, that out of twenty-nine cases operated upon, there were but six failures. This success is encouraging. In a case of Bryant's, after the second tapping, there was so much draining of the"" fluid from the cord that the child died from ex- haustion. In no case where the base or neck of the tumor is large or the cord involved should this or any other operation be per- formed. In pedunculated tumors an operation may be attempt- ed. In the case of a tumor with a small pedicle Dr. Sayre ligated the base of the sac with success. He passed a needle armed with a double ligature through the centre of the pedicle and after tying one ligature on each side, passed two circles entirely around the pedicle, drawing them so tight as to strangulate the mass and then excised it with one stroke of the knife. On the twenty-third day the ligatures came away leaving the wound entirely healed. Dr. Wilson, of Clay Cross, reports a successful case in which he removed the tumor five days after the closure of its neck by means of a clamp. In some cases of spina bifida nature effects a more or less perfect cure by closing in the defec- tive portion of the spinal canal. The child should be fed upon the most nutritious diet with the administration of the phos- phates, lime, etc. (Bryant and Sayre). SPRAINS. May be very slight or very serious indirect injuries. They include more or less severe overstretchings, if not lacerations of the muscles or ligaments that bind the bones of an articulation together, some fracture or tearing away of the bone at the attach - meut of the ligaments — "sprain fractures." In children under ten, sprains of joints are liable to be complicated with some epiphysial separation. In the more severe instances are included lacerations of the muscles, tendons, and soft parts that surround the joint. All such accidents require rest and time in their treat- ment in order that repair may be complete, since neglected sprains are often the cause of joint or bone disease (Bryant). SPKAINS. 519 Contusions of joints as direct injuries always ought to be regarded in a serious aspect, for a large amount of internal mis- chief may often be sustained with very slight external evidence of injury. Under certain conditions of health a slight blow uj3on a bone is often enough to set up severe local action or to excite chronic changes which may involve the integrity of the joint (Bryant). Sprain of the hack is an accident of common occurrence. Any twist of the spine or forcible flexion may injure some of the joints. Hemorrhage may take place iuto the spinal canal as a result of the sprain or laceration of the ligaments. Prognosis. — Sprains may be followed by acute or chronic joint disease of a serious and insidious nature; and this truth should ever be before the surgeon to influence his practice. In every case of wounded joint, however trivial, and in all doubtful cases of wounded joint, the prognosis must be very guarded and the treatment cautious (Bryant). Treatment. — About one hundred years ago John Hunter said: "In sprains of joints rest is the first 'principle!''' At the present day the same words are as pregnant with truth as when then spoken. In simple cases of sprain rest is all that is needed. When swelling and effusion into the joint ensue in the course of the second or third day after the accident, the evidence of inter- nal injury is more marked, for such effusion means inflammation or synovitis, which is to be treated by absolute rest, ensured by the application of a splint, and the local use of cold or warmth. If swelling of the articulation follows immediately upon the injury, effusion of blood into the joint is indicated with or with- out fracture, but always with severe local mischief. Such cases should be treated by the employment of a splint, to ensure im- mobility of the joint, elevation of the injured part, and local ap- plication of a bag of pounded ice until hemorrhage has ceased, and all risks of inflammation of the joint are gone. As soon as the primary effects of the sprain and all signs of inflammation have passed, the application of pressure to the joint by means of a bandage with passive movement is very striking. When the joint is rendered very tense from effused blood, it may be asjnr- ated. In children all falls upon the hip followed by pain should 520 A COMPENDIUM OF PRACTICAL MEDICINE. be treated by rest and extreme care, as hip disease may originate from such cause (Bryant). After Treatment. — When the immediate effects of the sprain have passed away the local use of a stimulating liniment and moderate friction of the part expedites the cure. A local warm bath at intervals likewise relieves the stiffness of the joint. Whenever movement excites more than a momentary pain, rest should be observed. When weakness of the joint alone remains, a good bandage or strapping around the part to give support is of great benefit. Where much laceration of ligament has taken place it is necessary for the joint to have some artificial support in the form of either a splint, felt, leather casing or bandage; for no parts are repaired with less permanent power than liga- ments. In the wrist when much swelling exists, a sprain may be mistaken for a fracture or a fracture for a sprain. Much care is necessary in the diagnosis of such cases. Many sprains of the ankle are also really cases of fracture of the fibula above the malleolus. The popular notion that a severe sprain is worse than a fracture is in the main true; and when the sprain is neglected the case is always more tedious than that of a broken bone (Bryant). STRICTURE OF THE URETHRA. An unnatural narrowness of any portion of the canal of the urethra constitutes stricture. This contraction of the canal to constitute stricture must be unnatural, for the urethra has certain points of normal contraction — namely, the meatus, the middle of the pendulous, and the beginning of the membranous urethra, and these are not strictures. They become so, if they are unduly small. Thus, an individual may have a congenital stricture of the meatus. Any inflammatory condition of the walls of the canal, or spasmodic contraction of the same, constitutes stricture, as does also any growth upon or beneath the mucous membrane, as cancerous, tubercular, syphilitic and membranous (Keyes). Varieties of Stricture. — Stricture is of two kinds : 1. Mus- cular, or spasmodic. 2. Permanent, or organic — the latter may be congenital, or acquired. Inflammatory stricture does not STRICTURE OF THE URETHRA. 521 exist as a disease of the urethra. No amount of simple inflam- mation of the urethra would occasion serious inconvenience (retention), unless occurring in connection with organic stric- ture, assisted by muscular spasm or complicated by prostatic congestion. I. Muscular or Spasmodic Stricture. — -Is of the commonest occurrence; an active predisposing cause is a sensitive, high- strung nervous organization. The exciting, causes are any local irritation, inflammation, foreign body, irritation of the rectum, (reflex action), ingestion of certain substances, as cantharides, turpentine, quinine, opium, etc., mental emotions, and malaria. Take a nervous, excitable young man with a healthy urethra, or better still with an irritable bladder or inflamed urethra, and attempt to pass a bougie for the first time, and the chances are that it will be arrested. It may be grasped and firmly held at any part of the canal, but this is more liable to occur just as the instrument is entering the membranous urethra, where its point may be detained for many minutes by an involuntary contraction of the cut-off muscles. If the end of the sound is held quietly for a few moments against the contracting muscle, the spasm will yield, and the instrument pass on into the bladder. What surgeon has not witnessed spasmodic stricture, caused by modesty, shame, anxiety, fear, and irritated mind, as shown by the total inability of some patients to pass water before a class of students or even in the presence of a. physician alone in his office? In such cases there is a failure of the compressor urethrse to relax. The patient contracts his abdominal muscles and his diaphragm, and uses all his will, but to no purpose. There are two cases on record of malarial spasm where s23asmodic stricture occurred paroxysmally every twenty -four or forty - eight hours, and was cured by quinine after other means had failed. Irritation and reflex action of neighboring parts, as inflamed hemorrhoids, ulcer or worms may cause spasmodic stricture and retention. Thompson gives a case where all the symptoms of stricture existed, and where a diagnosis of stricture of the mem- branous urethra was made, when it was discovered that the patient had tapeworm. After the worm had been discharged, 522 A COMPENDIUM OF PRACTICAL MEDICINE. the stricture disappeared. Necrosed coccyx and abscess of the right seminal vesicle have caused spasmodic stricture. Keyes saw complete retention from one application of the tincture of delphinium to the scrotum to destroy pediculi. Remote surgical lesions may occasion retention by reflex spasmodic stricture. Dr. Davenport records the case of an old man who had all the evi- dences of permanent deep urethral obstruction for ten years, and who was relieved at once and permanently by a single passage of a silver catheter. Keyes has met a large number of cases in which reflex spasmodic stricture was caused by a decidedly narrow meatus, by a very moderate organic stricture, by changes in the seminal vesicles, prostate, bladder, kidney, and strongly concentrated acid urine (Keyes). Diagnosis. — Spasmodic stricture always occurs suddenly, the stream of urine between the paroxysms being of normal size. It is occasionally continuous, and acts exactly like organic stricture (Keyes). Treatment. — Discover and remove the cause. Retention pro- duced by simple spasm can often be relieved by the hot bath, rest, an opiate, and ice in the rectum, or at once by an anaesthetic and the catheter (Keyes). II. Permanent or Organic Stricture. — If not congenital, is the result of a previous pathological process. Form of Stricture. — 1. Linear. 2. Annular. 3. Tortuous. A linear stricture is like what would be caused if a thread were tied around the canal; or it may consist of a thin membranous diaphragm, with its orifice at the centre or on one side; or be a crescentic fold or free band. An annular stricture is broader, as if a flat tape had been tied around the canal. Tortuous stric- tures include all other varieties. They may be an inch or more long. The amount of contraction in stricture varies from a slight narrowing to nearly absolute occlusion (Keyes). Number of Strictures.— Stricture is usually single; but Thompson found in a single urethra, four; Hunter, six; Lalle- mand, seven; Colot, eight; and Otis fourteen (Keyes). Seat of Stricture. — The urethra is divided into three regions: Ilegion one, the bulbo-membranous, contained 215 strictures out of a total of 320, or 67 per cent.; region two, the middle portion, STRICTURE OF THE URETHRA. 523 contained 51 strictures, or 16 per cent.; region three, the first two and one-half inches of the canal from the meatus, contained 54, or 17 per cent. (Thompson). Otis places a majority of all stric- tures within the first one and one-quarter inch from the meatus; next the middle portion, and the least number in the deep urethra (Keyes). The Lesion in Stricture. — May be a mere thickening of the mucous membrane, the surface having lost its polish, being con- gested and perhaps covered with granulations. These changes are the result of chronic inflammation. This process takes place just within and beneath the mucous membrane. If the stricture is extensive and far advanced there will be a mass of dense, fibrous callous material encircling the canal and holding it per- manently contracted. This tissue may be slight in extent, cicatri- cial in character and tightly contracted, or it may be exuberant, knobbed and excessive in amount so that it may be readily felt from the outside of the canal, having a cartilaginous or even woody hardness (Keyes). Causes of Stricture. — Omitting congenital and other varieties of stricture already alluded to (cancerous, etc.) organic stricture is always caused by inflammation or a traumatism. Inflamma- tion of the urethra is the most common cause, whether this be sim- ple urethritis or gonorrhoea. Of 220 cases of stricture studied critically by Thompson 164 (seventy-five per cent.) owed their origin to gonorrhea. The longer the duration of a given gon- orrhoea the more certain it is to be followed by stricture. This is almost surely the case where gonorrhoea prolongs itself in- definitely in the gleety stage, the latter condition being nearly conclusive proof of forming stricture. Gonorrhoea attended by chordee is more apt to be followed by stricture than otherwise. Should the chordee be "broken, 11 stricture becomes inevitable and that too of the traumatic sort. The new fibroid and cicatri- cial tissue has a tendency to contract more and more, jpraumatic stricture may be produced by falling astraddle a beam, chair, stump, fence or wheel, or a kick in the perinseum from man or beast. The only treatment of gonorrhoea which may cause stricture is the use of injections. The nozzle of a syringe, if long or 524 A COMPENDIUM OF PRACTICAL MEDICINE. roughly used against an inflamed mucous membrane, may irritate it sufficiently to keep up local inflammation, until it becomes chronic, and passes on to that cell -proliferation and thickening which constitute stricture. Too strong injections may cause strict- ure, usually situated from two to four inches down the canal, rarely lower. As a general rule, it may be stated that any in- jection strong enough to produce either blood or subsequent prolonged pain, is capable also of originating organic stricture (Keyes). Time of Occurrence of Stricture after Gonorrhoea and In- jury. — Of the one hundred and sixty-four cases of stricture fol- lowing gonorrhoea, tabulated by Thompson, in ten, symptoms appeared immediately after or during the attack; seventy -one within one year; forty-one, between three and four years; twenty- two, between seven and eight years; twenty, between eight and twenty-five years. J. D. Hill makes the shortest period of strict- ure after gonorrhcea two years; longest, thirteen years; after in- jury, shortest period four months, longest, eighteen months. Boys have been kicked at school or have fallen on a fence, and symptoms of stricture did not occur for ten or twelve years after (Keyes). Irritable and Resilient Strictures. — A stricture is said to be irritable when it is very sensitive. A resilient stricture is one which is elastic, contracting quickly after being dilated (Keyes). Diagnosis. — Organic stricture of the urethra is easy of diag- nosis. In exploring a given urethra for the first time for stricture, Keyes prefers to use a blunt steel sound which will just pass the meatus. The blunt sound causes less pain than either the bulbous bougie or the urethrameter. It should be warmed, lubricated, and introduced with all gentleness. If it is obstructed anywhere, there is stricture, for the meatus is nor- mally the smallest part of the canal. When an obstruction is encountered, a smaller blunt sound is selected, and then another, until some sound will enter the bladder. It is always well in searching for stricture to commence with a large size and work down rather than to begin with a small instrument. Keyes has had cases referred to him, as cases in which a filiform instrument could not be made to enter the bladder, and STKICTURE OF THE UEETHEA. 525 he has at once passed a full- sized blunt steel sound easily into the bladder. The explanation of this is that spasm of the deep urethra frequently fails to allow a fine instrument to pass, while srjasin in that region always yields to gentle pressure slowly and accurately applied with a blunt steel sound. Moreover, a false passage, or a pouched sinus, or a dilated follicle, will frequently catch the point of a fine instrument, while a blunt sound will escape the obstacle. Having detected stricture, it may be located, calibrated and measured either with a metallic bulbous bougie or the urethrameter in the anterior urethra, or with a flexible bulbous bougie in the deep urethra. Obstructions beyond six and a half inches may generally be set down as due , to prostatic enlargement, particularly in patients older than fifty years. There is a point of physiological narrowing at about the middle of the pendulous urethra, which is by some regarded as a stricture requiring treatment by cutting, when there is no real occasion for the operation. If this point be covered by granula- tions, and bleeds as the bulb passes it, it is in a morbid condi- tion, and may require cutting, although no true stricture exists at the point. These are the so-called strictures of large caliber so popular at the present day, so common in occurrence, a rich field for the young surgeon, and sometimes the occasion of un- necessary cutting, for the gleet they occasion may often be removed permanently by a few passages of a large sound. Just within the meatus — at an eighth to a quarter of an inch — there is very often a point of congenital narrowing which may be assumed to be a stricture, and cut if there is any occasion for using an instrument larger than this point of narrowing will admit. It is always wise to divide it if stricture exists beyond. Always when there is a pouched condition of the meatus at the lower commissure, it should be cleanly and freely cut down upon the floor of the urethra (Keyes). Symptoms and Results of Stricture. — Stricture may exist for years without giving rise to a single symptom of sufficient im- portance to attract the patient's attention. In fact, it may be said that stricture has no symptoms until it has become so tight as to sensibly obstruct the outflow of urine and semen. 526 A COMPENDIUM OF PRACTICAL MEDICINE. The symptoms usually described as those of stricture are mainly the symptoms of the results of stricture. A certain small amount of gleety discharge from the congested, or it may be granular surface usually accompanies the forming stage of strict- ure but this may be so slight as not to attract attention or may be entirely absent. Exceptionally urethral or other neuralgia depends upon stricture in the forming stage. The results of stricture are mainly mechanical. The strict- ured portion acts like a dam, and the urine coming down with great force tends to dilate the urethra behind it. If more than one stricture exists the urethra may be dilated between them. This forcible stretching of the mucous membrane behind the stricture at every act of micturition weakens the tone of the stretched portion of the canal, congests it, and leads to the for- mation locally of an excess of mucus. Soon a drop of urine is retained behind the stricture in the dilated portion of the canal, the mucus acting upon it as a ferment alkalinizes and decom- poses it, liberating carbonate of ammonia. This acts upon the stretched urethra, and produces inflammation. This mild in- flammation behind stricture is very constant. It furnishes the gleety discharge or the morning drop of muco-pus, which glues the lips of the meatus together. The gleet of stricture gets better or worse according to the general condition of the patient, the degree of acidity of the urine, and the amount of sexual indulgence or venereal excite- ment. Exacerbations of gleet from slight causes often constitute the most marked feature of the case in a patient with stricture. In fact, it is the rule in mild cases that the patient is wholly un- conscious that his urethra is at all narrowed. He applies for treatment, on account of his gleet, and often refuses to believe that he has stricture, and he repeatedly asserts that he makes as large a stream of urine as ever. Nothing so well as the bulbous bougie will convince such a patient of his condition. The gleety dis- charge, once commenced behind the stricture, rarely ceases en- tirely until the constriction has been relieved. The same dis- charge will be seen in the urine in the shape of small stringy shreds, formed of pus -corpuscles, and appear as small white threads in the voided urine. These shreds may be all caught in STRICTURE OF THE URETHRA. 527 the first gush of urine, what follows being perfectly free from them. When these white filaments are seen settling clown in a glass of urine freshly passed, they constitute strong presumptive evidence of the existence of stricture; they may he due to other lesions. As the stricture tightens, a cartilaginous hardness may often be felt from the outside of the urethra at the constricted point. The meatus urinarius looks blue and congested, as does some- times the whole glans penis, from obstructed circulation. The gleet continues, the stream of urine is small, often forked. The last few drops of urine are retained in the canal. Erection is sometimes rendered imperfect and painful. The surface congestion of the stretched urethra behind the stricture in time extends backward to the bladder, and brings on irritability of that organ. The intervals between the acts of micturition grow shorter and shorter, and symptoms of mild cystitis appear. This frequency of micturition is the symptom of stricture, next to gleety discharge, which is least often absent. A slight narrowing of the canal may occasion it. The conges- tion of the urethra behind a stricture easily becomes greater, is kindled into positive inflammation by dining out, a little excess in drink, or a chilling of the legs; the mucous membrane swells up, the stricture closes, and the patient has retention of urine. If this retention is unrelieved, the bladder becomes over-dis- tended and the contractile power of the bladder may be perma- nently injured. Retention maybe the onlg disagreeably promi- nent symptom connected with a case of stricture. The spasm and inflammation which caused the narrow canal to become oblite- rated in these cases, cease after a few hours, and then the patient goes on perhaps for a year or more, without having another retention, not suffering noticeably in the meantime. If retention does not come on, the inflammation, once aroused behind the stricture, travels back through the prostatic urethra into the bladder, and we have cystitis of the neck. No\\ r commences a frequent desire to pass water, and when the patient seeks relief, he may be passing water in a fine stream every half- hour with great pain and straining. HcematwHa maybe, excep- tionally, the most prominent symptom of stricture. Keyes has 528 A COMPENDIUM OF PRACTICAL MEDICINE. had several such, cases, and has seen the hematuria cease upon relieving the stricture. Along with symptoms of vesical irritation, are found pains in the urethra, aching of the glans penis, or in the testicle, along the cord running up into the back, pains across the lumbar region, in the perinseuin, around the anus, over the pubis, in the thighs, legs, sole of the foot, or in the great toe, all of which pains are cured by the dilatation of the stricture. The sexual appetite is often impaired, sometimes nearly obliterated, in old severe cases. But in mild cases, the congestion kept up behind the stricture may be just enough to excite and irritate the jDatient, causing frequent erections, erotic fancies, and nocturnal emissions. The constant straining in urination may cause piles. The inflammation of the bladder caused by stricture is usually superficial, and the bladder walls, as a rule, thicken and contract, but rarely dilate. The ureters enlarge in connection with old stricture, also the pelvis of the kidney. It may bring on abscess of the kidney (Keyes). Extravasation. — The thinned and inflamed urethra behind the stricture may ulcerate and during one of the violent parox- ysms of straining give way and allow a little urine to escape into the cellular tissue around the canal. If the amount of urine extra vasated is small we have abscess or perhaps blind internal fistula. Its presence is indicated by a hard lump around the urethra from the size of a pea to that of a walnut. Urethral fe- ver comes on, generally described by the patient as "dumb ague;" the appetite fails and the general health runs down, finally pus forms and finds its way out through the perinseuin, leaving a fistula behind. If the quantity of urine which escapes is a little larger acute perineal abscess forms. The pus may bur- row in all directions and find an exit through the scrotum along the body of the jDenis, upon the thighs, nates or groins, or even upon the lower part of the abdomen. Sometimes the whole perinseuin is riddled with holes through which the urine escapes. Civiale reports a case of urinary fistula with fifty-two external openings. Fistula will not close until after the stricture has been relieved. Extravasated urine should be let out as soon as possible. Normal urine does not possess septic qualities but STRICTITEE OF THE URETHRA. 529 aruinoniacal and putrid decomposing urine is deadly in its effect (Keyes). Complications of Stricture. — Infiltration of urine is a serious complication. Rupture of the bladder is a rare complication of stricture. A comparatively healthy bladder will not rupture from retention. It will become immensely distended and then be relieved by drops (overflow) through the urethra. Epididymitis is a very common complication of stricture. It may affect one or both sides, and leaves behind a good deal of knotty induration, which is slow in disappearing, and may block up the canal and entail subsequent sterility (Keyes). Constitutional Disturbance. — A patient with very tight stric- ture may enjoy robust health. But when the urethra behind a stricture begins to inflame, and the bladder to show symptoms of congestion of the neck, and cystitis; when paroxysms of urethral fever become frequent; when epididymitis and abscess come on, then the whole organism shows signs of distress. The a23petite and strength fail, the skin becomes dry, pale and harsh, the mouth coated and shiny, and the patient runs down to a shadow, a living picture of misery, while his main business in life is to pass water (Keyes). Causes of Death in Stricture Cases. — Are three: 1. Extravasation of u/rime, which, if extensive kills at once by shock, or later by exhaustion and blood-poisoning with sup- puration, abscess, gangrene and pyaemia. 2. Urcemia, from implication of the kidneys, by the exten- sion of inflammation up the ureters. 3. Cachexia and exhaustion (Keyes). ^Recapitulation of Symptoms of Stricture. — Briefly the symptoms of stricture are narrowing of the canal, with dilata- tion of the urethra behind, blueness of the meatus, irregularities in the stream of urine, shreds of pus-corpuscles in the urine, pain, neuralgia of the urethra, retention of urine, overflow, dribbling, imperfect erection, irritability of the bladder, haema- turia, and impotence. The remoter results of stricture are cystitis with changes in the bladder, ureters, kidneys mid rectum often terminating fatally, and stone in the bladder, infiltration, 530 A COMPENDIUM OF PRACTICAL MEDICIJSTE. perineal abscess, fistula, rupture of the bladder, epididymitis, and sterility (Keyes). Sexual Hygiene. — An unmarried man frequently tortures himself with fancied ailments, which he ascribes to stricture. He declares himself strictured when the canal is sound. Fancied stricture, next to fancied spermatorrhoea, is a very common hypo- chondriacal expression of perverted sexuality. The trouble is in the mind. These patients must be put right about the cause of their troubles, and their sexual hygiene must be regulated. This can be accomplished only by marriage or by purity of thought and absolute continence (Keyes). Treatment. — May be considered under three heads: 1. Treatment of Uncomplicated Stricture. — («) Of large caliber; (b) of small caliber; ( 548 A COMPENDIUM OF PRACTICAL MEDICINE. one doubts that a mother in active syphilis aborts, miscarries, or produces a diseased child. As to whether the father can pro- duce a diseased child by infecting the ovum through impregna- tion without infecting the mother (and through her the ovum), is a question not yet settled. That a father may have syphilis and still have a healthy child is proved by Mireur. He leans to- ward the belief that, if the mother escape, a syphilitic father can not produce a syphilitic child. He also demonstrates that both parents may still suffer from tertiary lesions, and produce seem- ingly healthy children. When the mother has syphilis, it has been shown that she may have a healthy child while under treatment, and a diseased one if the treatment be left off before she has passed the virulent stage of the disease. Finally, that a man himself syphilitic, with a syphilitic wife and a non- syphilitic mistress, may have a diseased child by the former and a healthy child by the latter, the two children being born within fifteen days of each other, seems to be fully proved by Charrier's case. Keyes says, "The great stumbling-blocks to me, standing in the way of my seriously accepting the fact that a child may be born syphilitic and still have a healthy mother, are the failure of direct inoculation upon such mothers, and the so-called Colles's law, namely, a child born syphilitic can not poison its own mother, but may poison a healthy wet-nurse' 1 (Keyes). The Methods of Contagion are Immediate and Mediate. — Syphilis is very often transmitted by means other than sexual contact, more so than chancroid. Surgeons and accoucheurs get chancre of the fingers by inoculating abraded spots in the exer- cise of their professional duties, and in their turn may spread the disease. A midwife, with a syphilitic lesion upon her finger of which she was aware, communicated the disease directly and indirectly to forty- five persons. She was convicted and sen- tenced to twelve months' hard labor. Chancre is frequently transmitted in kissing, a little mucous patch in the mouth of one party poisoning any fissure on the lips of the other. Both of these methods are immediate. Children acquire chancre of the lips from nursing-women with mucous patches of the nipple, and, on the other hand, syphilis. 549 health) 7 nurses get chancre of the nipple By suckling children with inherited syphilis who have mucous patches of the lips. Colles's law that a child with mucous patches of the month can not produce ulceration of the nipple if it sucks its mother, depends simply upon the fact that its mother already has syph- ilis before the child is born, and consequently can not get a new chancre of the nipple. The following are examples of mediate contagion: Puche speaks of a gentleman with a long prepuce, who, after marriage, encountered an old mistress, with whom he had intercourse. Returning home shortly, without having washed, he repeated sexual intercourse with his wife, depositing the virus from his prepuce in her vagina. He escaped, but in due course, she developed chancre and general syphilis. A simi- lar authentic instance is related of a woman who proved unfaith- ful. Her husband, embracing her shortly afterward, relieved her of the poison left in her vagina by her lover, himself devel- oped chancre, while she escaped. Smokers of a pipe sometimes get chancre of the lip>s, the virus being deposited upon the mouth -piece of the pipe by some previous smoker who had mucous patches of the lip. Toys may communicate the disease to a child; tooth-brushes and cigars to an adult. Glass-blowers get syphilis in the same manner, as they work in sets of three at the same tube, passing it from mouth to mouth. Syphilis sometimes runs through a whole family, from the use of the same spoons or cups, passed from one mouth to another. Washerwomen become infected in cracks of the fingers through the virus contained upon soiled clothes. Wet- cups, transplanting teeth and passing the Eustachian cathe- ter have proved sources of mediate contagion. Circumcision and vaccination are familiar instances of mediate contagion. In all such cases chancre precedes the development of general syphilis (Keyes). For the Induration, Ulceration and (rear nil Characters of a Chancre, see Chancre. For Syphilitic Bubo, see Bubo. 550 A COMPENDIUM OF PRACTICAL MEDICINE GENERAL SYPHILIS. Primary syphilis includes the chancre and its accompany- ing adenitis, and lymphangitis. A chancre never does nor can appear elsewhere than at that point through which the poison first entered the body. Hence, inherited syphilis has no primary stage, but is general from the start. Primary Syphilis, so far as its manifestations go, is purely local. Not so with general syphilis. There is no organ or tissue of the body through which it may not manifest its presence by symptoms. The lymphatic glands all over the body may suffer. The skin from crown to sole, the nails, the hair, and the mucous membranes have their peculiar affections due to syphilis. The eye and the testicle do not escape, and each and every viscus is liable to be invaded, as are all the tissues, connective fibrous, muscular, cartilage, bone, brain, nerve, and vessel. The all-em- bracing arms of general syphilis may destroy any function. Syphilis may destroy any special sense, produce local or general paralysis, acute or chronic mania, dementia, lunacy, idiocy, etc. General Syphilis has been divided into a secondary and tertiary stage. Secondary Syphilis includes all the earlier affections of the skin and mucous membranes, and many of the lighter affections of the eye, testicle, and other glands, with some of the varieties of nervous syphilis. Tertiary Syphilis follows secondary, and consists of the later and the ulcerative skin- affections, the deeper lesions of con- nective tissues, muscle, bone, cartilage, and of the internal or- gans and all gummy deposit. Secondary syphilis lasts often a year, sometimes two or more. Tertiary syphilis (except as malignant) does not commence till after the expiration of at least one year from the appearance of the chancre. It may never show itself, or may appear after a period of health of many years, often five or ten, sometimes as late as fifty- two (Fournier). The whole secondary stage may be skipped under treatment, or even without treatment (Keyes). SYPHILIS. 551 Syphilicles. — The most conspicuous symptoms of general syphilis affect the skin, and are known as syphilicles or syphilo- dermata. It may be papular, vesicular, or pustular syphilide (Keyes). Prognosis. — Babies with inherited syphilis suffer more than any other class. The malady is often fatal with infants. Next in severity come the cases acquired in early manhood. Excesses of every sort, of wine, of women, of work, are liable to intensify the type and duration. All local irritations tend to call out eruptions at the points irritated. A child born with inherited syphilis may give no evidence of his malady until he is vaccin- ated, when an eruption may appear. A blister may call out dormant syphilis upon an adult. Patients who work much with the hands are more liable than others to eruptions of the palms. Tobacco chewed or smoked is proverbial for its power of origin- ating and maintaining mucous patches in the mouth. The rough edge of a tooth may keep up a mucous patch of the tongue. When a bone breaks in a syphilitic subject, even in one with latent syphilis, it may fail to unite unless iodide of potassium be given. The prognosis is more unfavorable with bad hygiene (Keyes). Duration of General Syphilis. — There is no disease so protean in its form as syphilis. Its symptoms simulate those of a vast number of other diseases. So true is this that it has passed into a proverb in the face of an obscure disease, "If you do not know what to do, treat the patient for syphilis.*" It is difficult to say w x hen syphilis has ended or of deciding that it ever does end. Syphilis may occur in so mild a form that the patient may never know he has it. Syphilis may manifest itself as a mild eruption after chancre, disappearing possibly without treatment, and then lie latent for many years, as long as fifty -two years, to reappear. Keyes has a case where syphilis was latent for about forty years. Syphilis once acquired, stamps its impress upon the individuality of the patient and becomes a part of him and no power on earth in a given case can say when that impress disappears. A half century may pass away and the trail of the serpent be still visi- ble. Yet syphilis may be cured. The virulence of syphilis dis- appears in the late tertiary period and during this period neither 552 A COMPENDIUM OF PRACTICAL MEDICINE. the blood nor the pathological secretions will infect a healthy subject with the disease. Of the two diseases gonorrhoea and syphilis, the former sends more patients to the tomb than the latter. Keyes says that a man may get chancre, followed by some light eruption, consider it of no importance and get well spontaneously, marry and have healthy children, himself remain- ing entirely free from any evidence of the disease and dying in a green old age (Keyes). Syphilis and Marriage. — If a patient presents himself with syphilitic chancre, at what period may he safely marry ? He should not marry earlier than four years after chancre, and it is better not to marry for five years (Keyes). Causes of tlie Protracted Duration of SyphiUs. — 1. Those living in bad hygienic surroundings, and giving themselves up to excesses of every sort. 2. Patients peculiarly susceptible to the disease. 3. Patients possessed of a strong tendency to gout or scrofula. 4. Those who treat irregularly. General Characteristics of Syphilides. — 1. Polymorphism of the earlier eruptions. 2. Rounded form of the patches of eruption, and of the ulcers. 3. Livid color, like the meat of raw ham, then coppery (pigmented), then gray, then white. 4. Ab- sence of pain and itching. 5. The earlier eruptions are distri buted habitually all over the body, are superficial, mainly con gestive, and usually symmetrical. 6. Later eruptions in groups involving the cutis vera. 7. Scales white, usuallyjnot adherent superficial. 8. Crusts or scabs greenish, black, irregular, thick adherent. 9. Ulcers with abrupt edges, adherent, not under mined, sluggish, and bleeding easily. 10. Cicatrix rounded, de pressed, thin, non-adherent, white, smooth at first, shining, often pigmented, then clearing off from the centre toward the circum- ference (Keyes). Secondary Incubation. — Primely incubation extends from the moment of suspicious contact to the a23pearance of the chancre. This period is about three weeks. . Then primary syjDhilis is ushered in; but now there is another period of rest,Jwherein the disease seems to be purely local. This period dates from the appearance of the chancre to the appearance of general symp- toms, and is called secondary incubation. This period is on an SYPHILIS. 553 average six weeks, but may be shorter or longer. In rare cases the entire secondary period may be skipped, the disease first appearing in its tertiary form. This is termed delayed syphilis (Keyes). Syphilitic Fever. — About a week or more before the appear- ance of any eruption, the jjatient is liable to have fever. The poison of syphilis reduces the number of red blood corpuscles, and produces more or less cachexia. This syphilitic hydremia is constant, but may be slight. Fever is present in about two- thirds of all cases, and may be continuous, or it may occur only toward night, followed by sweating. With the fever there may be a sallow complexion, sunken eyes, melancholy, fatigue, shortness of breath, palpitation, and pain in various parts of the body. Among the pains of early syphilis, headache is promi- nent, and is usually worse at night. The treatment is mainly tonic doses of mercury and hygienic (Keyes). Alopecia. — Falling of the hair due to syphilis is of two kinds. Scabby sores on the scalp cause the hair-follicles to be destroyed, in which case the fallen hair is not reproduced. Or- dinarily there is a thinning of the hair generally, not only of the scalp, but of the eyebrows, eyelids, whiskers, and to a degree of the whole body. In acquired syphilis the thinning of the hair is due to one of two causes (that is, when there are no scabs): 1. The syphilitic hydrsemia which, like fever, impairs the vitality of the hair-papilke. 2. Seborrhcea, the sebaceous matter clog- ging the hair -follicle. Treatment. — Shampooing once a week with ammonia or borax in warm water (5j. to the Oj.) is useful, and rubbing the scalp nightly with a stimulating lotion, as follows: J& Tinct. capsici 3ij--v. Gly cerini 3j . Aquse cologniensis ad oj.— M. — Keyes. Indolent Glandular Engorgement. — Is a diagnostic mark of the first importance in all doubtful cases of syphilis. The en- gorgement of the glands is indolent, painless. They are hard and vary in size from a small pea t<> a marble. The coincident indolent engorgement of certain glands is almost pathognomonic 554 A COMPENDIUM OF PRACTICAL MEDICINE. of syphilis. These are the post- cervical, and epitrochlear glands on either side, just above and without the inner condyle of the humerus (Keyes). Sore Throat. — Is a concomitant symptom of all stages of general syphilis. There are three type varieties: 1. A diffuse general redness, with or without ulceration in the early second- ary stage. 2. A certain amount of chronic congestion, and brawny thickening about mucous patches or atonic ulcers in the late secondary and early tertiary. 3. Destructive ulceration from gummy deposit in the tertiary stage (Keyes). General Treatment of Syphilis. — Is hygienic, tonic and specific. Hygienic Treatment. — Includes all the ordinary laws of health. Eegularity in eating and sleeping is all -important. Excesses of any kind are bad. Warm baths should be taken frequently. Catching cold and the use of tobacco are apt to induce and prolong mucous patches in mouth and throat. Change of air may be necessary to effect a cure. Mercury and the iodides will not cure all syphilis, as many practitioners seem to believe. Tonic Treatment. — Cod-liver oil, iron, quinine and other tonics must be given, along with the specific remedies. Specific Treatment. — Most of the syphilides, especially the earlier varieties, are self-limiting, and will get well under any treatment — one might even say in spite of treatment. No treat- ment may be better than over-treatment. Sarsaparilla has no curative power, but assists digestion and promotes the action of the skin, and pleases the patient. The following formula is serviceable : |fc Hydrarg. chlorid. corros .gr. j. Aluminis 3ss. Ext. sarsaparilla §ij . Gly cerini oj . Syr. sennas §iss. S pts. anisi 3 j • Ext. glycyrrhizas 5} ■ Aquas forniculi — q. s., ad sviij. — M. Sig. : A tablespoonful several times daily. — Keyes. Keyes says that the succus alteram has very little, if any, value in the treatment of syphilis, and that the quackish and SYPHILIS. 555 pretentious manner in which it is being forced upon the profes- sion is enough to conclem it, and to make any honest man doubt its claims. The Hot Springs of Arkansas. — Keyes says the springs have a positive value in the treatment of syphilis. Patients broken down, cachectic, with faulty stomachs, who have syphilitic lesions which fail to yield at home because they can not tolerate a suffi- ciently high degree of medication — these are the patients to send to the hot springs. This is the only class of patients Keyes ever sends to the springs. The physicians who do well at the springs use most unsparingly mercury by inunction and iodide of potas- sium internally in enormous doses. The hot water internally and the baths enable a patient to tolerate large doses. For ordi- nary syphilis Keyes does not consider the springs of any value. They do not shorten the duration of the disease, prevent relapse, or cure it in any sense. The rule should be: Send no patients to the springs who do well under ordinary medication at home. Treatment of Early Syphilis. — Should be commenced as soon as the diagnosis of syphilis is positive. The rule in all cases of doubt is: Do nothing, but frankly tell the patient that he must wait; or if he has not the grace to appreciate pure honesty, and must have something to do while waiting, give a placebo while studying the nature of the sore and awaiting developments. All through syphilis mercury has power, an eliminating and con- trolling power, if not a curative one. The symptoms of syphilis are controlled by mercury better than by any other known drug, unless it be the iocliclic preparations. Keyes has shown that moderate doses of mercury continued for any length of time not only do not debilitate, but act as a tonic in health, in disease, in syphilis, augmenting the number of red cells in the blood. In the early manifestations of syphilis mercury is specially potent. Under its kindly influence the chancre heals, the early eruptions fade. Mercury properly administered may be taken for years without any injury to the individual, or to his constitution, either immediate or remote (Keyes). Bad Effects of Mercury. — Occasionally a patient appears who tolerates mercury badly. He may be unable to take a cer- tain form — the protoiodide, perhaps, because it causes pain and 556 A COMPENDIUM OF PRACTICAL MEDICIXE. diarrhoea — but can take another. Most people tolerate the bi- chloride kindly but a few patients cannot take any form of mer- cury without great mental and moral depression. Early spyhilis also produces great depression mentally and morally. When a patient positively can not take mercury at all then we have to fall back upon the iodides, gold, the vegetable remedies, tonics, mineral waters and the like. The other bad effects produced by mercury are salivation and diarrhoea with griping -pain. Mer- curial tremor and cachexia occasionally occur after unjustifiable doses of the drug (see Salivation). Diarrlteea with griping pains is apt to come on in many patients who are fairly under the influence of mercury. If kept up, the patient loses appetite, runs down, and fails to derive benefit from his mercury. In these cases it is better to lower the dose or change the preparation (Keyes). Elimination of Mercury from the Body. — Mercury gets out of the body chiefly through the intestinal canal, then through the salivary glands, the kidneys and the skin. Mercury may remain in the system for five and a half months after the patient has ceased taking it by inunction. Methods of Administering Mercury. — Are in the order of their respective value to the practitioner : 1. By the stomach. 2. Local. 8. Inunction. 4. Fumigation. 5. Hypodermic. 5. Hypodermic Injections. — From one-sixteenth to one- eighth of a grain of sublimate dissolved in fifteen minims of water, is injected once or twice daily under the skin. Abscess may follow the puncture, or a hard, painful lump, very lasting sometime. This method can never become popular. 4. Fumigation. — This method is an excellent one, but not practical. It requires time and care. It is useful where prompt and kindly action of mercury is aimed at. Fumigations may be taken daily for three or four days, then once a week is usually enough to keep up the mercurial effect. The best method of fumigation is that found in Turkish bathing establishments. Calomel is the best for fumigation, because it volatilizes readily. About a scruple is enough for a bath. The powder should be placed upon a piece of tin over the spirit-lamp. The lamp and tin are placed beneath a cane-bottom chair, upon which the syphilis. 557 patient sits naked and surrounded by blankets for fifteen minutes to naif hour. 3. Inunction. — This is perhaps, of all the best means of exhibi- ting mercury. It spares the stomach, and is thorough and efficient. Its application is very dirty and it sometimes produces a local eruption. Keyes thinks that the method of inunction practiced at the hot springs is decidedly the best. The patient takes a long bath in hot water, and after drying himself, an attendant rubs in one-eighth or one-sixth of an ounce of mercurial ointment. The friction continues for twenty minutes. The next day this is re- peated and the effects watched. Keyes does not use the oleates any more. 2. Local Use of Mercury. — Ulcerative cutaneous lesions do better under iodoform. Mucous patches upon the skin do well if kept dry and painted with bichloride solution or touched with the acid nitrate of mercury diluted, three to five times and dusted with calomel. Cleanliness is the first requisite in the treatment of lesions upon mucous membranes. The teeth should be cleaned, tobacco should be stopped and soothing mouth -washes of borax, alum, etc., may be used. The mucous patch may be touched with nitrate of silver, sulphate of copper or bichloride solution (gr. ij. to Sj) but according to Keyes the acid nitrate of mercury pure and applied sparingly with the blunt end of a glass rod is the best. The pain it produces on some persons is a drawback to its use. 1. Mercury by the Stomach. — For treating general syphilis, the method by the stomach is the best. In this way it can be taken while traveling and without making the patient conspi- cuous to his friends, and it can be so used as to act as a tonic as well as specific. The forms used by the stomach are: the pro- toiodide, bichloride, blue-pill, and gray powder. Keyes rarely uses the biniodide, as it is too irritating to the intestine. Gray powder and blue-pill are good preparations when the protoiodide proves too irritating to the intestine. The bichloride is a very tonic preparation, and is more prompt than the others. Tonic Method of Treatment by Mercury. — Consists in tin- use of mercury in such a way that the mercury, over and above its antisyphilitie effect, shall act as atonic — that is, shall increase 558 A COMPENDIUM OF PRACTICAL MEDICINE. the number of the red blood- cells, and the general health and vigor of the patient. The outline of treatment is as follows: The standard fractional dose being selected— one -sixth grain of protiodide, and one-thirtieth grain bichloride — it remains to find the "full dose" and the "tonic dose.' 1 The course is commenced by causing the patient to take one granule or tablet of the stand- ard fractional dose immediately after each meal for three days — that is, three a day. For the next three days he takes four granules a day; then for three days, five a day; then for three days, six a day; then seven, and so on, adding one granule to the daily dose each fourth day, until pernicious medicinal effects of mercury begin to show themselves, which are, with the protoio- dide, usually griping pains in the abdomen, and at least two free watery stools a day. When this occurs, write down the daily number of pills required to produce it, and name this number the "full dose. 1 ' Half the full dose is the "tonic dose," and sometimes one- third is all that is required. The " tonic dose " may be com- menced with the idea of continuing it daily, month after month, for an average of about two and a half years. Under this tonic dose, Keyes says the patient will often enjoy better health than he did before he got his chancre. If new symptoms appear then is the time to add the reserve dose or to throw in some iodide of potassium for a time. This tonic course of treatment is elimina- tive not suppressive. By this course patients can be assured that they are taking mercury in the mildest manner, that it will not hurt them if they continue taking it for several years, and that it will not remain in the system (Keyes). Treatment of Late Syphilis. — In purely gummatous deposits the iodides only are required. Mixed Treatment. — When during the tonic course there is a call on the part of the symptoms for the iodides, they may be given while the mercury is continued. The Iodides. — Often the iodides have to be used alone and pushed to the point of tolerance. The iodides are agents of the very highest value in syphilis, and in purely gummatous and many of the nervous symptoms their action in very large doses is most gratifying. The iodide of potassium is the most efficient SYPHILIS. 559 of the group. The disagreeable after-taste left in the mouth by iodide of potassium may be best masked by peppermint. The best time to take the iodides is during the third hour after eating, when the contents of the stomach are neutral and yet the organ is not empty. Even on an empty stomach the drug goes well if very largely diluted in milk. The Dose of the Iodides. — There is no limit. Keyes has given two and a half ounces daily. Begin with the small dose and work up gradually to the maximum dose. The Bad Effects of the Iodides. — The metallic taste in the mouth is always much complained of when the dose runs high. The bad effects are five : 1. Possible indirect causation of sali- vation. 2. Iodism. 3. Irritation of mucous membranes. 4. Cutaneous eruptions. 5. Anaemia with nervous prostration and debility. 6. Albuminuria. Moderate doses of arsenic certainly moderate the bad effects of the iodides. Duration of Treatment. — The duration of the virulence of the disease is believed to subside in the third year, and therefore the rational period during which to maintain continued treatment is about the same. It is impossible to say to a given patient after he has followed this course that he will never have a relapse; but he can be told that he has all the guarantee that medicine can afford him, and that if he does have late symptoms the great probability is that they will be mild, and will promptly yield to a mixed treatment (Keyes). Syphilis of the Skin and Mucous Membranes. — The syphilides are those manifestations of general syphilis found upon the cutaneous envelope. Those occurring in secondary syphilis are: 1. Roseola. 2. Papular syphilide. 3. General pustular syphi- lide. 4. Pigmentary syphilide. 5. Bullous syphilide. 6. Vesi- cular syphilide. 7. Squamous syphilide. 8. Turbercular syphilide. With these occur on the mucous membranes: 1. Erythema- tous patches. 2. Ulcers. 3. Mucous patches. 4. Scaly patches. The terftia/ry lesions of the skin are: 1. Ecthyma. 2. Rupia. 3. Pustular syphilide in grouj)S. 4. Tertian" ulceration. 5. Gummy subcutaneous tumor. 560 A COMPENDIUM OF PRACTICAL MEDICINE. \Yith these occur on the mucous membrane: 1. Mucous patches. 2. Scaly patches. 3. Deep chronic ulcers. 4. De- structive gummy ulcers (Keyes). TAPE=WORMS. Constitute the class cestoda. Varieties. — Taenia saginata, beef tape-worm, is the form most common in this country; taenia solium is occasionally encountered while the bothrioeephalus latus is rare (Bartholow). There was a time when nearly every malady was attributed to worms. Taenia solium also called "armed tape-worm " is the final devel- opment of an embryo, usually lodged in the flesh of some animal. It is from seven to thirty feet long, has a globular head and flat segments or joints. Each mature joint contains both male and female sexual organs (hermaphrodite). An ordinary sized tape- worm contains five millions of ripe ova. The larval form of this worm is the cysticercus cellulosce, the embryo being found in pork (measly pork). From one to forty may be present in the same intestinal tract, in small intes- tine and may hang far down into the large intestine; the ter- minal ripe segments are constantly falling off, and are discharged with the faeces. In a few months after swallowing; the embrvo, the tape -worm reaches considerable size. Taenia Saginata, also called "unarmed tape-worm, 11 is larger, stronger, and thicker than taenia solium. The larval form of this worm is the cysticercus saginata, the embryo being found in beef. The Bothrioeephalus latus is the largest worm infecting man. This worm sometimes reaches sixty feet in length. Its color, unlike the others, is a dull bluish- gray. Some suppose its embryo to be found in a fish or mollusk (Loomis). Causes. — Since the introduction of the Russian method of curing diarrhcea by the use of finely-scraped raw meat, and the modern taste of eating rare steaks, etc., tape-worm has become more common. Their entrance into the intestinal tract is only effected through food and drink. Butchers, and those who handle raw meat, are more subject to them than others. Filthy TAPE WORMS. 561 surroundings, squalor and personal uncleanliness are conditions which favor their development. Tape- worms occur at all ages. Bothriocephalus latus is found chiefly in Scandinavia, Russia and Poland. Tamia solium occurs wherever the pig is domesti- cated. Taenia saginata is found wherever raw beef is used for food. The Tr is an inflammatory affection, generally more or less itchy and scaly. There are small pin-head spots of eruption. On scraping the surface, scales come away loaded 566 A COMPENDIUM OF PRACTICAL MEDICINE. with the parasite. It is a disease of adult life, and never con- genital. The color of the patches of eruption is yellow or brown. The scales are scanty and very fine. Tinea versicolor always commences on the trunk. It is contagious (Anderson ». Treatment. — Is very simple and efficacious. Generally the application of a solution of bichloride of mercury (two grains to the ounce of water), or hyposulphite of soda (5i. to the Si. of water), to the affected parts twice daily, and continued for some time after the eruption has disappeared, is effectual. Mercurial or sulphur vapor baths have the same effect. A thorough scrubbing of the patient with black soap night and morning in a bath is efficacious. Instead of the black soap, the following mixture may be employed : J£ Hydrargyri perchloridi gr. xx. Saponis viridis siij. Spiritus rectificati §ij. Olei lavajndulae gtts. xx. — M. Sig. : To be used night and morning, exactly in the same way as the black soap. — Anderson. Tinea Imbricata. — Called also Tokelan Ringworm, is a scaly disease — much more like ichthyosis in its general appear- ances than any other disease. The scales run in concentric circles, and do not extend deeper than the mucous layer of the epidermis. The fungi are present in very great abundance (Anderson). Treatment. — Same as ringworm of the body. TINNITUS AURIUM. Is not a disease but a symptom of disease. It consists of imaginary sounds and ringing noises in the ear. It is a frequent accompaniment of cerebral disorders. It is a sign of little mo- ment, for it is encountered in so many different conditions, such as, disease of the cerebral vessels, congestion of the brain, Meniere's disease, affections of the heart, anaemia, etc. Its cause is some- times wax in the meatus. Various drugs will produce tinnitus aurium in some persons (Da Costa). tonsilitis. 567 Treatment. — Discover and treat the cause of the tinnitus aurium. The following formulae may be tried: Jfc Acidi h} T drobrornici dil (10 per cent) 31J. Sig. : One-half to a teaspoonful in sweetened water thrice daily. — Fothergill. I& Tinct. cimicifugae ITTcix. Aquse §ij . — M. Sig. : A teaspoonful thrice daily. — Patton. TONSILITIS. Is an inflammation of the tonsil. The most important varie- ties of tonsilitis are: 1. Acute simple tonsilitis, or catarrhal. 2. Follicular tonsilitis, or ulcerative. 3. Parenchymatous or sup- purative tonsilitis. Acute simple tonsilitis is characterized by redness with moderate swelling of the tonsils and an inflammatory exudation from the mucous membrane, composed of mucous, pus-cells, and serum. This simple tonsilitis is present in most cases of acute pharyngitis, or ordinary sore throat, and is a trivil affection. Acute follicular tonsilitis, or ulcerated sore throat, is of con- siderable clinical importance. In this affection the inflammation involves not only the mucous membrane covering the surface of the gland, but especially that lining the crypts. The tonsils present little white patches. These white deposits extend into the crypts or follicles. Acute follicular tonsilitis is often at- tended by severe constitutional disturbance. The symptoms at the onset may be as severe as in diphtheria. There may be a chill or chilly sensations. The temperature may reach 104° or 105° in twenty-four to forty-eight hours. There are often head- ache, anorexia and insomnia. The patient complains of dryness and soreness of the throat and pain on swallowing. Usually within three to five days the fever and other symptoms subside and recovery is rapid. After the attack there may be marked prostration. The prognosis is always favorable, It may be mis- taken for diphtheria. Parenchymatous tonsilitis, or ''quinsy sore throat, 11 some- times called phlegmonous pharyngitis, is an inflammation of the parenchyma of one or both tonsils. It may terminate in resolu- 568 A COMPENDIUM OF PRACTICAL MEDICINE. tion, but usually it goes ou to suppuration, constituting the dis- ease called suppurative tonsilitis or quinsy (Flint and Loornis). Causes. — Quinsy is rare in those under twelve years of age, but is more common in youth than in adult life. Certain atmos- pheric influences predispose to it. It "runs in families." Scro- fula and syphilis favor its development. Exposure almost always precedes an attack. One attack predisposes to others. Tonsilitis often occurs with scarlet fever, measles, and typhoid fever. Follicular tonsilitis with ulceration is usually preceded by disorders of digestion, and seems to depend on this for its origin. A relationship has been supposed to exist between the ovaries and tonsils, but it is by no means well defined (Bartho- low, Flint and Loomis). Symptoms. — There may be a chill or chilly sensations at the onset, followed by fever, (103° to 105° F.) The tongue and throat become dry; there are heat, pain, and swelling in the ton- sil; the fluids are often regurgitated through the nostrils. Thick mucus is expectorated. The breath is offensive, the jaws are often immovable. There is a peculiar nasal tone to the voice. The patient is unable to sleep, has a sense of suffocation, and sometimes is delirious. In four or five days, something is felt to give way in the throat, and suddenly the patient is entirely re- lieved by the discharge of fetid yellow pus. Convalescence is rapid. The abscess in the tonsil may open at one or at several points. Much suffering is experienced (Flint and Loomis). Prognosis. — Is always good. Chronic enlargement of the tonsil may result. The entire duration of the disease is eight days. Death in rare instances may result from suffocation, ex- haustion, or oedema glottidis (Loomis). Treatment. — A saline laxative should inaugurate the treat- ment unless the bowels are relaxed. Tincture of aconite -root (gtt i-iij) may be given every hour or two for the period pre- ceeding pus-formation. At the onset, calomel, in the dose of three to five grains, is superior to all other remedies. When pus has formed quinine is the best agent. Acetanilid and antipyrin are good remedies to reduce temperature. Opium or its alka- loids should not be given in quinsy. The local treatment is im- portant A hot or cold wet pack about the neck affords relief. TONSILITIS — TOOTHACHE. 569 A gargle of hot milk and water, used every few minutes, lessens inflammation and swelling. Sometimes ice and cold water are more grateful. Bicarbonate of sodium in powder, placed on the tonsil gives great relief. When suppuration occurs, warm appli- cations are to be preferred. When the tonsils are much swollen they may be scarified. When pus forms it should be evacuated. Astringent gargles at the onset may in some cases arrest the dis- ease. Loomis says "I have been able in a large number of cases to abort a quinsy by a twenty-grain dose of quinine administered at the time of the chill followed by a large dose of bromide of potassium." Guaiacum has long been celebrated for its power to arrest tonsillar inflammation, in scruple doses. Fluid extract of ergot is supposed to have specific power to arrest the disease (Bartholow and Loomis). TOOTHACHE. Is a localized dental pain, and varies in character according to the part of the tooth involved. A darting pain betokens irri- tation and probable exposure of the pulp. A violent, throbbing pain points to general inflammation of the pulp. In alveolar abscess, the pain is dull and throbbing (Bryant). Treatment. — Dentists employ arsenic as an escharotic to destroy the exposed sensitive pulp of decayed teeth. A strong infusion of capsicum applied on lint to the aching tooth is very effective. Chloral, rubbed up with an equal weight of camphor T and rubbed gently in externally or put into the cavity of an aching tooth, gives prompt relief in some cases. A few drops of chloroform on cotton-wool, inserted into the hollow of a decayed aching tooth, often gives permanent relief. Equal parts of chlo- roform and creasote constitute a useful application in toothache. A mixture of equal parts of collodion and carbolic on a small piece of cotton- wool inserted into the hollow painful tooth soon gives relief. A solution of alum in nitrous ether is said to be an effective application in toothache. Dr. Duckworth reports that toothache may be quickly allayed by holding a solution of car- bonate of soda in the mouth. A drop or two of oil of cloves inserted into the cavity of an aching tooth soon stops the pain. 570 A COMPENDIUM OF PEACTICAL MEDICINE. Xanthoxyluni (prickly ash) is a domestic remedy for toothache (Bartholow and Kinger). TYMPANITES. Is not a disease but a symptom. It is a flatulent distention of the bowels. Great prominence of the abdomen due to flatu- lent distention of the bowels, is, if at all persistent, very apt to be mistaken for ascites. But the large abdomen yields not a dull, but everywhere a tympanitic sound and there is no fluctua- tion. In most cases the gas which causes the distention, is de- rived from putrefactive or fomentative changes in the ingesta. The accumulation of gas within the stomach occasions painful dis- tension, and rarely may cause sudden death. The habit of swol- lowing air may cause tympanites of the stomach (this corresponds to wind- sucking in horses). An habitual tympanites of the stomach occasions in some persons, after the ingestion of liquid, a succussion sound in walking resembling the sound frequently heard in horses. This is a source of much annoyance and morti- fication, especially to women. It may be avoided by taking into the stomach only very small quantities of liquid at a time. Some persons suffer from an habitual tympanites. Females are more liable to it than males. Treatment : Jfc Olei terebinthime jij.-viij. Olei ricini jfij . Vitelli ovi no. j . Decocti hordei §viij .-xvj . — M. Ft. enema. Sig.: Inject into the bowel. —Bartholow. Jfc Olei terebinthinse §j. Olei olivse §iss. Camphorse gr. xx. Decocti avenre Sviij . — M. Ft. enema. Sig.: Inject into the bowel. — Copeland. JSr Pulv. capsici gr. vj.-xxiv. Sacchari lactis gr. xxx. — M. In pulv. no. xii. div. Sig.: A powder every four hours. — Phillips. TRICHINOSIS. 571 TRICHINOSIS. Is a parasitic disease. The parasite is called trichina spir? alis, in tlie form of a minute worm, measuring about one-thirty- fifth of an inch in length, which enters the human system through the intestinal tract after the ingestion of trichinous flesh (Loomis). Causes. — Trichinosis in human beings results almost exclus- ively from eating trichinous pork. The raw flesh is most dan- gerous. Sausages, smoked ham, quickly broiled ham, or any form of pork that has not been subjected to a moist heat of 170°, is liable to induce it. Each trichina may give birth to a thousand young (Loomis and Flint). Symptoms. — Are first gastro-intestmal and then muscular; associated with these there is more or less fever. Nausea, vom- iting, vertigo, anorexia and a feeling of malaise come on. There is almost always diarrhoea. After a short time there are wan- dering pains in the limbs, which become stiff and painful to the touch and the muscles are swollen and rigid. In from four to ten days oedema of the eyelids perhaps of the entire face occurs. The temperature is 101° to 105°; the pulse 110 to 120. There is photophobia and movements of the limbs or of the eyes are ac- companied by excruciating pain. The pain in the limbs becomes so great that the patient cannot sleep. (Edema of the lower ex- tremities is common. The perspiration is copious, the diarrhoea exhaustive, the limbs are paralyzed and the patient lies in a state of utter helplessness. Recovery occurs in from four to five weeks after the onset of the disease. Death may occur in the fourth week (Loomis and Flint). Differential Diagnosis. — Trichinosis may be confounded with typhoid fever, but a microscopic examination of small portions of the muscular tissue will afford a positive diagnosis (Loomis). Treatment. — Preventive treatment consists in eating no pork that has not been so prepared as to kill any trichinae that might exist. We know of no means of destroying the trichinae after they have once entered the muscles. Purgatives may be given early in the disease. Good diet, stimulants, quinine and iron are of service (Loomis). 572 A COMPENDIUM OF PRACTICAL MEDICINE. TONGUE=TIE. Is occasionally met with. It is due to a tying down of the tip of the tongue by the frsenum linguae, which prevents the infant from projecting the organ beyond the gums, thereby interfering with suckling (Bryant). Treatment. — It is easily remedied by dividing the frsenum perpendicularly downward behind the gum with a pair of blunt-pointed scissors, the point of the tongue being elevated with the finger (Bryant). TRACHOMA. Called also granular conjunctivitis, is characterized by hy- pertrophy of the conjunctiva, either in disseminated spots or diffused. The trachoma granules are small, rounded masses of various sizes. On everting the lids, we find little bodies of the size of a rape -seed lying beneath the conjunctiva. The patient complains of slight irritation of the lids and inability to use the eyes for a long period; the eyes feel weak at night; light is un- pleasant; the lids are sticky (Noyes). Treatment. — Touch the lids lightly once a day with a crystal of sulphate of copper or alum, with solutions of tannin and glycerine (gr. x.-xxx. to oj.), or with a solution of nitrate of silver (gr. v. to oj). The redundant masses of granules may be squeezed by forceps (Noyes). TYPHOID FEVER. Is an acute febrile affection, self -limited, feebly if at all con- tagious, and characterized by a peculiar eruption on the abdomen, by a form of diarrhoea, by stupor and low delirium, by thicken- ing and ulceration of Peyer's patches, by infiltration and soften- ing of the associated mesenteric glands, and by swollen spleen (Bartholow). Typhoid is the most prevalent of all fevers except malarial. It may be developed in all latitudes and in all countries, but it prevails more in the temperate zones than in the torrid or frigid. The Germans call it abdominal typhus, gastric fever, or ileo- TYPHOID FEVER. 573 typhus. It is also called common continued fever, enteric fever and pythog'enic fever (Loomis). Morbid Anatomy. — When the disease if fully established the blood becomes darker in color and coagulates imperfectly. With these blood changes, parenchymatous degeneration takes place in the organs and tissues of the body. But the characteristic lesions of typhoid fever are seated in the lymphatic structures of the intestine namely, Peyer's patches and the solitary follicles. Corresponding to the intestinal changes are alterations in the mesenteric glands. Intestines. — Four stages of the morbid process in the intes- tine may be distinguished and they correspond very closely with the four weeks of the disease. In the first week of the disease there are congestion and inflammation of the mucous membrane of the small intestine with a medullary infiltration of Peyer's patches and the solitary follicles. As a result of these processes, there is hyperemia and swelling of the mucous membranes and the affected glands become enlarged and elevated from one to two lines above the mucous surface. These glands assume a dark- red or reddish -gray color marked with fine white striations and present the so-called "shaven beard" appearance. These changes begin and are most extensive in the glands nearest the ileo-csecal valve. The number of patches involved varies from four to five near the valve to twenty or thirty throughout the Avhole intestine. In the second week the hypersemia and catarrh of the mucous membrane subside and the swelling and infiltra- tion of the solitary follicles and Peyer's patches increase. The u shaven beard " appearance disappears. During this week ne- crotic changes in the swollen follicles and patches take place. The casting off of the necrotic tissue results in the formation of the typhoid ulcer. In the third week the process of ulceration is completed. The entire gland may slough uniformly and at once form the complete ulcer. Usually the sloughing and removal of the necrotic tissue does not take place until the third week of the disease. The necrotic process may extend and involve the muscular tissue, and "lid in perforation of the peritoneal covering. These ulcers may be developed in the jejunum, ileum, stomach and the large 574 A COMPENDIUM OF PRACTICAL MEDICINE. intestine. In the lower part of the ileum, at the ileo-csecal valve, the ulcers are usually of large size and elliptical with their long axis corresponding to that of the intestine. In the jejunum, stomach and large intestine they are usually round and of small size. Sometimes the ulcers are hemorrhagic. Those ulcers re- sulting from necrosis of the solitary follicles are round. Cases have been described in which the ulcers were fully formed on the seventh or eighth day of the disease. In the fourth week the process of cicatrization is commenced. It may begin in the third week of the disease and continue during convalescence. Gradually the swollen edges of the ulcers subside and granula- tion tissue springs up from their base. The gland structure is never regenerated. These cicatrices have little tendency to cause stenosis of the intestinal lumen. Perforation of the intestine is liable to occur in one or more of the ulcers. It occurs in about one per cent, of the cases of typhoid fever, and in about eight per cent, of the deaths from this disease. It is most frequent between the third and fifth week of the disease. It is rarely caused by the primary slough- ing, but is due to secondary ulceration after the separation of the slough. The opening in the peritoneal coat may be of consider- able size or it may be no larger than a pin's point. Profuse hemorrhage may occur from the primary sloughing or from the secondary ulceration. Mesenteric Glands. — More or less enlargement of the mesen- teric glands is always associated with the intestinal lesions. They are secondary to the changes in the intestinal glands. The enlarged glands vary in size from that of a hazel-nut to a small hen's egg. In rare instances these glands slough and cause peri- tonitis. Spleen. — The organ in which parenchymatous degeneration occurs earliest and most extensively is the spleen. It is enlarged often two or three times its normal size. The enlargement goes on rapidly until the third week, and is due to congestion and to hyperplasia of the cellular elements. It is dark-red in color and softened. Hemorrhagic infarctions and rupture of the capsule of the spleen may take place. These changes in the spleen take TYPHOID FEVEK. 575 place, in a greater or less degree, in ninety -eight cases out of every hundred. Liver. — The liver is usually somewhat swollen, pale, and softened. The hepatic cells are in a condition of parenchymatous degeneration. Kidneys. — Parenchymatous degeneration of the renal epi- thelium is the rule. An acute nephritis may occur. Heart. — The heart becomes soft and flabby, and is of a grayish or brown color. The parenchymatous changes which take place in the heart are more marked than those of any other organ except the spleen. The heart loses its normal outline, and when removed from the body the walls of its cavities readily fall together. Vegetations sometimes form on the valves and chords© tendinege of the heart, and in some cases the first sound will be absent. Lungs. — Changes in the lungs are present in nearly all cases of typhoid fever. Congestion and inflammation of the bronchial mucous membrane are so constantly present, that Dr. Stokes pro- posed to call typhoid fever bronchial typhus. Hypostatic con- gestion and pulmonary oedema are common. Pneumonia is a frequent complication. Larynx. — Ulcerations of the larynx, the mucous membrane of the mouth and pharynx may occur. Salivary Glands. — The salivary glands enlarge, become firm and tense, and there are a proliferation and parenchymatous degeneration of their cells. These changes cause a diminished salivary secretion which is so marked and constant in typhoid. Abscess of the parotid gland may occur in tyjDhoid. Brain and Nervous System. — No changes have been dis- covered in the central nervous system to explain the mental dis- turbance which characterizes this disease. But it is reasonable to infer that in a disease, where such severe functional distur- bances exist, there must be constant and definite parenchymatous changes. Stomach. — Softening and degeneration of the glandular structure takes place in the stomach and this gives rise to dis- turbance of digestion. 576 A COMPENDIUM OF PRACTICAL MEDICINE. Muscles-. — The voluntary muscles undergo a hyaline or waxy degeneration (Flint and Loomis). Causes. — Typhoid is endemic in every quarter of the globe. It is possible for it to prevail as an epidemic. It prevails more in the autumn than in any other season of the year and for this reason it has been called autumnal fever. It is stated that a warm, dry summer favors the occurrence of the disease in the fol- lowing autumn. Age must be regarded as a predisposing cause of typhocl fever. It occurs most frequently between the ages of fifteen and twenty- five, next between ten and fifteen and next be- tween twenty- five and thirty. It is rare in infancy and after fifty. As a rule persons are in good health when attacked. Pregnant women when attacked with typhoid fever generally abort. Some persous are more susceptible to the typhoid pois- on than others. The typhoid bacillus is the specific cause of the disease. This micro-organism may grow readily outside of the body, as in the soil, on vegetables, milk, meat-infusions, or in liquids containing sufficient nutriment, and by the formation of spores it may preserve its vitality for a long time. There is no evidence that the typhoid bacillus exists in the exhalations from the patient. Typhoid fever is communicable but not in the same way as the strictly contagious diseases, such as small-pox, scarlet fever, etc. Washerwomen frequently contract the disease from washing linen soiled with typhoid excreta. It is probable that the typhoid stools are the chief source of infection of a locality in which the disease becomes endemic. The following instance proves this: A stranger ill with typhoid fever came to a little settlement called North Boston, consisting of nine families. Up to this time typhoid fever had never been known in that neigh- borhood. In a few days the stranger died, and in a month, more than half the population, numbering forty-three, had been affected, and ten died. Of the nine families, one family escaped which obtained its water from a source different from the others, which used a common well. The typhoid bacilli have been found in the drinking-water of regions where typhoid was pre- vailing as an epidemic. Such water may be perfectly clear and apparently pure. Sometimes the water of a well used for drink- TYPHOID FEVER. 577 iiig purposes becomes infected by a cormnunication or leakage between it and a privy-vault, cess-pool, sewer, or drain. A number of typhoid epidemics have been traced to the milk- supply. Here it is probable that the vehicle of infection is the water used in cleansing the cans or in diluting the milk. The period of incubation varies frorn fourteen to twenty days (Flint and Loomis). Symptoms. — Typhoid fever is developed gradually as a rule, and is insidious usually in its approach. The j)atient feels uneasy and uncomfortable, has no pain, but feels that he is about to be sick. The premonitory symptoms are : Headache, more or less aching of the limbs, "a tired feeling all over," chilly sen- sations, loss of appetite, occasional nausea and vomiting, epistaxis in most cases, diarrhoea or constipation. By the fifth or sixth day the patient is compelled to take to his bed. Countenance has nothing peculiar at first, except it is flushed, but later the expression is dull and there is an appearance of stupidity. B) r the second week, there is a pale, olive, leaden look, and usually there is a small rose -colored spot in the centre of each cheek. The face does not assume the dark mahogany color seen in typhus, but in the advanced stages of the fever it has more of the hectic flush of phthisis. The whole surface presents a slight capillary congestion, like that jxroduced by the action of cold, and in some cases the hue of the surface is slightly dusky. This capillary congestion is caused by paresis of the peripheral arteries. Nervous System. — - -The symptoms referable to the nervous system are: 1. Headache which is more or less complained of during the first week, but usually ceases during the second week. It is not violent, but a dull heavy pain. Pain in the back and limbs, and a general aching of the whole body is also com- plained of. Delirium is manifested in the majority of cases. The de- lirum rarely comes on before the second week of the fever and is most active at night. The delirum is usually the "low-mutter- ing,'" but it may be violent. Persisting, active delirium is an extremely unfavorable symptom. The mental condition is char- acterized by hebetude, indifference, and inanimation. Sensibility 578 A COMPENDIUM OF PRACTICAL MEDICINE. is diminished and perception blunted. The state in which the patient may be said to be both sleeping and wakeful, is called coma-vigil. Other nervous symptoms are: grasping at invisible objects or carphologia, pulling up of the bed linen, visible twitchings of the muscles of the face and of the extremities, sub- sultus tendinum, rigidity of the muscles of the neck or extremi- ties and convulsions. These denote gravity of the disease. Digestive System. — Anorexia is the rule. Thirst is promin- ent. The tongue from the very outset is covered with a light, white coat. At the end of the first week it becomes red upon its sides and tip and dry in centre. In the second and third weeks the tongue becomes more heavily coated, the coating becomes brown and dry, and sordes collect on the teeth. At any period in the course of the disease the tongue may suddenly clear off and present a shiny red, beef- colored appearance. The tongue and lips may become dry, cracked, and fissured and bleed. Nausea and vomiting are quite common during the first week of the fever. Diarrhoea is one of the characteristic symptoms, but is not always present. The discharges are of a yellowish -green color, described as "pea-soup discharges." Sometimes they resemble coffee-grounds. The diarrhoea usually appears the second week, but in some cases it is present at the very outset of the disease and in others it does not appear until the third week. Intestinal Hemorrhage. — Hemorrhage from the bowels occurs in about five per cent, of the cases. It may be slight, moderate, or profuse. These hemorrhages usually occur in the second and third weeks, and are accompanied by a sudden fall of temperature. These three symptoms, namely, meteorism, or tympanites, iliac tenderness and gurgling, especially the two former con- joined with diarrhoea and ochre -colored discharges — form a group of symptoms highly diagnostic of this form of fever. They may all be absent. Perforation. — Perforation of the intestine takes place in be- tween one and two per cent, of all cases, and in ten per cent, of fatal cases. It takes place late in the disease or during convales- cence and sometimes even after apparent recovery. It occurs as often in mild as in severe cases. Perforation gives rise to per- TYPHOID FEVER. 579 itonitis, which is generally developed abruptly. The sudden oc- currence of pain diffused over the abdomen, increased tympanitic distension rigidity of the abdominal walls, great prostration, a rapid, feeble pulse, a sunken anxious expression of countenance, nausea and vomiting quickly followed by coldness and blueness of the extremities and other signs of collapse point to peritonitis from perforation. Peritonitis does not invariably denote perfora- tion. It may be caused by rupture of a mesenteric gland. Shin. — Of the symptoms referable to the skin, the most im- portant is a characteristic eruption. It makes its appearance be- tween the sixth and twelfth days of the disease, and remains visi- ble from eight to fourteen clays. It consists of isolated papules generally limited to the trunk, of a rose or pink color, called by Louis lenticular rose-colored spots. The spots are slightly ele- vated and the redness momentarily disappears on light pressure. The number of spots varies from two or three to many. Each spot remains visible for three days and then disappears. The eruption is not invariably present. Jenner states that he found the eruption present in one hundred and forty -eight out of one hundred and fifty -two cases. Bed-sores and gangrene are liable to occur in situations exposed to pressure. Respiratory System. — Slight or moderate cough is almost invariably present, proceeding from sub -acute bronchitis. Pneumonia is a frequent complication. Hypostatic congestion and oedema of the posterior portions of both lungs are incident to the feeble circulation in the latter part of the disease. Epistaxis is a symptom of diagnostic value early in the disease. Pulse. — The danger is usually considerable if the pulse for many days exceed 120 per minute. A sudden and considerable increase of frequency of the pulse often denotes the occurrence of pneumonia or peritonitis. The pulse is quick and vibratory and often dicrotic. Failure of heart- power is indicated by an increase in the frequency and feebleness of the pulse. Temperature. — There is a daily increase of temperature for the first five or eight days. This gradual rise of temperature from day to day during the first week is diagnostic of typhoid fever. There are morning remissions and evening exacerbations. The temperature of typhoid fever does not always pursue the 580 A COMPENDIUM OF PRACTICAL MEDICINE. typical course. The temperature may reach its acme by the end of the third day, and may be of a remittent or intermittent type. A high elevation of temperature in the morning, 106° to 108° F., indicates the approach of death. A sudden and considerable fall of temperature, other symptoms not denoting convalescence or improvement, is unfavorable. This often indicates hemorrhage from the bowels. Special Senses. — The eye assumes a dull expression and the pupil is dilated. The sense of heariug is always more or less impaired. The sense of taste is perverted and patients are unable to distinguish between bitter and sweet. Hypercesthesia may be present in hysterical females. Emaciation is more marked and rapid in typhoid than in any other form of fever. Mild Typhoid Fever. — -In the mild type, the fever runs its regular course but is of low grade. Some of these cases are so mild that the patients are not confined to the bed, and are called "walking cases" of typhoid fever. All the symptoms of these cases are mild. These patients should take to the bed and re- main there until convalescence is established. The abortive form of typhoid fever is ushered in with all the symptoms of a typical case; but by the end of the second week the patient passes on to a, state of complete convalescence. If only a moderate amount of typhoid poison is introduced into the system, a mild or an abor- tive type of fever will be developed. Duration of Typhoid. — Of forty-two cases ending in recovery analyzed by Flint the average duration was sixteen days. The maximum duration was twenty- eight days and the minimum five days. Of forty-five fatal cases of Flint's the mean duration was a fraction more than fourteen days, the maximum being twenty and the minimum nine days. The average duration of conva- lescence is between one and two weeks. A temporary fever often accompanies the change of diet from liquid to solid animal food. Relapses of typhoid fever sometimes occur. A return of the fever may take place after ten days to two weeks from the date of convalescence, and the patient passes through a second career, the eruption and other characteristic symptoms being reproduced. The duration of the second career is usually shorter and the TYPHOID FEVER. 581 severity greater than the first, but a fatal termination is rare. The cause of the relapse is not known. Some hold that all re- lapses depend upon a new infection. Others hold that a part of the typhoid poison has remained in the system, undeveloped dur- ing the primary attack. In some cases, apparently, the relapse has been brought on by indiscretion in diet, or exercise (Bartho- low, Flint and Loomis). Differential Diagnosis. — The presence of fever with evening exacerbations and morning remissions, headache, diarrhoea, ab- dominal tenderness, and the presence of the characteristic rose- colored spots are sufficient for a diagnosis. Typhoid fever may be confounded with typhus and releasing fevers, continued ma- hi rial fever, mute tuberculosis, pyaemia, septicaemia, pneumonia, resenceof a peculiar jerking pulse. Pulmonic insufficiency is the rarest of all valvular lesions. MITRAL OBSTRUCTION, OR STENOSIS. 603 MITRAL OBSTRUCTION, OR STENOSIS. Stenosis of the mitral orifice probably never occurs without some insufficiency. Causes. — Mitral stenosis is most frequent in the young; it rarely occurs after fifty. It is twice as frequent in females as in males. It is frequently of congenital origin. Acute rheumatic endocarditis is its most frequent cause (Loomis). Symptoms. — The subjective symptoms of mitral stenosis are few. Usually after violent exercise there is more or less cardiac palpitation, and this will cease as soon as the auricle can empty itself, which is accomplished by the patient assuming a recum- bent position on the right side, with the head slightly elevated. This class of patients are usually pale and anaemic, and frequently experience a sharp pain in the region of the apex-beat. The pulse is regular and normal in character, so long as the auricular hypertrophy compensates for the auricular dilatation. The passive pulmonary hyperemia which attends the advanced stages of this form of cardiac disease causes habitual dyspnoea, which is exaggerated by physical exertion and by a dry, hacking, "teasing" cough, which resembles the so-called nervous cough. After severe exercise, a pint of glairy, watery mucus may be ex- pectorated. The mucus may be blood-stained, indicative of pulmonary congestion aud oedema. Haemoptysis is not infre- quent, and small quantities of pure, florid blood may be expecto- rated. Orthopncea is a rare symptom (Loomis). Physical Signs. — Inspection. — As the left ventricle does not receive its normal quantity of blood, the cardiac impulse is feeble. Palpation.— On palpation, the apex-beat is less forcible than normal, and a distinct purring thrill will be communicated to the hand. This thrill is a constant attendant of mitral steno>i>. Percussion. — The increased size of the left auricle may cause an increase in the area of cardiac dulness, upward and to the left, at the second left intercostal space. Auscultation. — Mitral stenosis is eharacterized by a loud "churning,' 1 "grinding," or blubbering" presystolic murmur. 60-4 A COMPENDIUM OF PRACTICAL MEDICIJNTE. This murmur is of longer duration than any other cardiac mur- mur. The murmur is heard with its maximum intensity a -little above the apex -beat. It is louder when the patient is erect than when in a recumbent posture. When mitral reflux and mitral obstruction coexist, the two murmurs run into each other, con- stituting a single murmur. A mitral obstructive murmur is never soft or musical (Loomis). Differential Diagnosis. — The diagnosis of mitral stenosis de- pends upon the existence of two physical signs, the "purring thrill" and aloud, long, blubbering presystolic murmur. MITRAL INSUFFICIENCY, OR REGURGITATION. Regurgitation at the mitral orifice is due to a condition of the mitral valves which allows the blood to flow back from the left ventricle into the left auricle (Loomis) - Causes. — Mitral regurgitation may occur at any age; but it is especially liable in the young to follow rheumatic endocarditis, which causes extensive thickening, induration and shortening of the mitral valves. It may be secondary to aortic lesions. Ex- cessive dilatation of the left ventricle may cause it. Diseases of the columns carneae and chordae tendineae will also cause mitral insufficiency. Ulcerative endocarditis may also cause it, either by perforation and rupture of the valves, or by rupture of the chordae tendineae (Loomis). Symptoms. — During the early stage, when the hypertrophy of the right ventricle compensates for the regurgitation, there are no rational symptoms; but when the right ventricle is unable to overcome the obstruction to the pulmonary circulation caused by regurgitant blood current, there will be more or less dyspnoea, and a short, hacking cough with an abundant expectoration of frothy serum. Sometimes the serum is blood-stained. In ad- vanced cases, the extremities, face and lips become blue, the result of the interference with the capillary return circulation. The liver becomes enlarged and hardened. There will be ano- rexia, nausea and a sense of oppression in the epigastrium. Sometimes the hepatic circulation becomes so obstructed as to interfere with bile secretion, and thus give the skin a greenish MITRAL INSUFFICIENCY OR, REGURGITATION. 605 tint. There are frequent attacks of gastric and intestinal catarrh. Headache, dizziness, vertigo and stupor result from the passive cerebral hyperemia. The urine is diminished in quan- tity, high-colored, and loaded with lithates; it sometimes con- tains albumen. There may be free haemoptysis. Another late symptom of mitral regurgitation is dropsy / it first appears in the lower extremities, and gradually extends over the whole body. The pulse of mitral regurgitation is, at first, regular in force and rhythm; later it becomes diminished in volume, irreg- ular and diminished in force (Loomis and Bartholow). Physical Signs. — Inspection. — The area of the visible cardiac impulse is increased. The epigastric pulsation is due to right ventricular hypertrophy, which is a condition always found with extensive mitral regurgitation. The jugular veins appear swol- len, especially when the patient is lying down. Palpation. — The apex-beat is displaced to the left and is felt lower than normal, Palpation sometimes reveals a systolic thrill, which is confined to the region of the second left intercostal space near the sternum. Percussion. — The area of dullness is increased. Auscultation. — Mitral insufficiency is attended by a systolic murmur. It is usually soft and blowing, but may be musical. This murmur takes the place of the first sound of the heart, and is heard with its maximum intensity at the apex-beat. A loud systolic murmur at the ap>ex, and not heard at the back, is not indicative of mitral reflux (Loomis). Differential Diagnosis. — Mitral regurgitation may be mistaken for aortic obstruction and tricuspid regurgitation. The diagnosis between mitral reflux and aortic stenosis has already been con- sidered. Both mitral and tricuspid insufficiency produce a sys- tolic murmur; a mitral regurgitant murmur has its maximum intensity at the apex, while the maximum intensity of a tricuspid regurgitant murmur is to the left of the base of the ensiform cartilage. Pulmonary symptoms are prominent in mitral reflux and absent in tricuspid regurgitation (Loomis ). 606 A COMPENDIUM OF PRACTICAL MEDICINE. TRICUSPID OBSTRUCTION, OR STENOSIS. This lesion is so rare that there are no rules for its diagnosis. But its symptoms would be general cyanosis, swollen jugulars, dilated right auricle,, headache, dizziness, vertigo, etc. TRICUSPID INSUFFICIENCY, OR REGURGITATION. This lesion is usually secondary to mitral disease. Causes. — The most frequent cause of tricuspid regurgitation is mitral stenosis and regurgitation; next chronic bronchitis, and pulmonary emphysema (Loomis). Symptoms. — There may be cardiac paljntation, dyspnoea, irregular heart action, enlarged liver, dingy skin, obstinate con- stipation and hemorrhoids. Venous stasis in the stomach is evinced by dyspepsia, nausea, vomiting and hamiateniesis. Pas- sive cerebral hyperemia is marked by headache, dizziness, vertigo, and muscse volitantes. Placing the patient in a horizontal posi- tion, after the disease has existed for some time, causes the face to become turgid and blue. Jugular and epigastric pulsation are its characteristic physical signs. A very late symptom is dropsy (Loomis). Physical Signs. — Inspection. — In extensive tricuspid disease, the area of cardiac impulse is increased more than in any other valvular lesion. This area sometimes extends from the nipple to the ensiform cartilage. There is a visible impulse in the jugulars. Palpation. — The apex-beat is indistinct. Pulsation occurs in the epigastrium. Percussion. — Shows an increase in the area of cardiac dull- ness. Auscultation. — The murmur is soft, faint and blowing, and is heard with greatest intensity over the lower part of the ster- num. It is heard with the first sound of the heart (Loomis). Pulmonic Obstruction and Regurgitation are so rare, clinic- ally, that they may be disregarded (Loomis). Prognosis in valvular disease. — The prognosis varies. In aortic stenosis life may be prolonged many years. Aortic regurgitation is a graver form of disease than aortic stenosis. Mitral stenosis admits of WARTS. 607 no compensation. It is usually grave. Mitral regurgitation is- not serious if compensated (Loomis). Treatment of Valvular Diseases. — The treatment can be summed up in rest, diet and regimen. Rest must be mental as well as physical. Straining is to be avoided. The appetite, emotions and passions must be under perfect control, hence a sedentary country life is best. The bowels should be daily gently moved. The body must be warmly clothed. Prolonged exposure to cold is to be avoided. Warm baths are beneficial. When the heart power is feeble, tincture of digitalis and tinc- ture of perchloride of iron are to be given in ten- drop doses, three times a day. In some cases arsenic acts well. The use of alcohol, strong tea or coffee, or tobacco, is to be prohibited, small doses of quinine and strychnine are useful. The dropsy may be relieved by pulvis jalapw comp., combined with calomel, squills, juniper, broom and cream of tartar, act as diuretics. For the precordial pain, a belladonna plaster and morphine will give relief. Strophanthus will be found valuable in some cases.. Nitro-glycerine may be employed to lower arterial tension, and thus relieve a laboring heart. Caffeine and spartein sometimes give relief (Loomis). WARTS. Are outgrowths of the papillae of the skin. They are com- mon on the hands and other parts of the body of the young, and more rare in the adult. When on the exposed parts of the body, they assume a horny hardness. Warts are jiat or pedunculated. They occur on the neck, orifice of the nose, mouth, eyes, ears, and anus, also on the prepuce and labia. The flat warts occas- ionally come and go in a way which cannot be accounted for. An epithelial cancer may appear in a wart. Venereal warts, so- called, are very abundant, whether they grow from the glans penis or prepuce of the male or labia of the female. They are pedunculated, moist, and highly vascular, and are clearly con- tagious. Warts, however, may occur at times in these pa its without any venereal contact (Bryant). Treatment. — Pare away the cuticle and then touch the sur- face with a glass rod moistened with strong acetic acid, carbolic 608 A COMPENDIUM OF PRACTICAL MEDICINE. acid, acid nitrate of mercury, or potassa fusa, care being taken to protect the skin around the wart. Pedunculated dry warts should be cut off with the knife or scissors. The application of some powder as oxide of zine, or even starch may cause them to dry up, and disappear (Bryant). YELLOW FEVER, Is an endemic miasmatic contagious disease, which usually appears as an epidemic. It prevails most in tropical regions, occurring only south of 48° north latitude, and is characterized by a yellowish discoloration of the skin. It has been called black-vomit (Loomis). Morbid Anatomy. — The liver is usually slightly enlarged. Its color is yellow, like butter, cheese, mustard, or chamois. The blood is of a darker color than normal, and coagulates slowly. The mucous membrane of the stomach and intestines is the seat of hemorrhagic erosion, which causes the black-vomit. Changes take place in the heart, lungs, kidneys, etc. (Loomis and Flint). Causes. — Nothing is as yet known of the nature, form and composition of the morbific principle, or specific microbe of yellow fever. It is indigenous in warm climates. Yellow fever is rarely developed south of 20° south or north of 40° north latitude. The miasm is more active at night than in the day- time. The natives of yellow-fever localities are rarely attacked. The disease is rarely experienced a second time in the same indi- vidual. The negro race seems to be singularly exempt from a liability to this disease. All ages suffer. The special cause is destroyed by cold. It is a matter of common observation that an epidemic is arrested by one or two hard frosts. Commercial seaports are pre-eminently the starting-points of great ejndemics. Crowding is one of the essentials to its development. The period of incubation varies in duration from twelve hours to fifteen days (Flint and Loomis). Symptoms.— An attack of yellow fever usually is abrupt. It is denoted generally by a chill, with or without rigor. Fever follows, varying between 102° and 110° F. The pulse seldom YELLOW FEVER. 609 exceeds 100. The tongue is coated. Vomiting may occur early but is usually a later symptom. The bowels as a rule, are con- stipated. Cephalalgia is sometimes intense. Pain in the loins and calves of the legs is sometimes a prominent symptom. The eyes are reddened, irritable, watery, or tearful. The fever con- tinues for a period varying between a few hours and three days. Then follows either a marked abatement or entire cessation of fever. The condition following the febrile paroxysm has been called "the state of calm.'" This is called the second stage of the disease. In a large proportion of fatal cases and in a few of the cases ending in recovery the blach vomit occurs. This, taken in connection with other symp- toms, is pathognomonic of the disease. The black vomit rarely occurs until after the febrile paroxysm, and usually ceases twelve to twenty-four hours before death. During the second stage the evacuations from the bowels resemble sometimes tar or molasses. Yellowness of the surface of the body occurs after the febrile paroxysm. Hemorrhage from the stomach, intestines, kidneys, bladder, nostrils, gums, uterus, etc., is often a striking feature. Patients sometimes do not take to the bed, but keep about their usual avocations, not thinking themselves much ill, often a few hours before death. The face is flushed, the eyes injected, bril- liant, transparent, fiery and glassy. The countenance is that of suffering, dejection, anxiety, anguish, despair, terror, stupidity, vacancy, astonishment, etc. The duration of the disease after the febrile paroxysm varies between twelve hours and three or four days. The third stage is called the stage of collapse or exhaustion in fatal cases. If death do not take place, the third stage is the stage of convalescence. The duration of the disease varies between three and nine clays. The average duration is less than a week (Flint and Looinis). Treatment. — There is no specific remedy for yellow fever. Patients should take to the bed at once. Free ventilation, clean- liness and cold sponging are useful. Mercury has been tried. Ice may be swallowed. The acetate of lead with opium has been much extolled to prevent black vomit. Milk with lime-water is probably the best article of diet. Great restlessness calls for opium. Alcoholic stimulants may be given (Flint and Loomis). CHAPTER III. MEDICAL DISEASES OF WOMEN. BY W. J. GILLETTE, 31. D. AMENORRHEA. The term arnenorrhoea signifies either an entire absence, a less than normal amount, or an habitual delay of the return of the menstrual discharge. To those cases in which menstruation has never become established, the term primary arnenorrhoea is applied, and secondary arnenorrhoea to those in which menstrua- tion has been once established but has either completely or in great measure disappeared. For the proper establishment of menstruation it is necessary that the sexual organs be properly developed and that there be sufficient nutrition and vigor of the general system to sustain it. The primary form of arnenorrhoea is usually due to a lack of de- velopment of the uterus and ovaries which remain in an infantile condition. It is also possible that there may be -an entire ab- sence of the ovaries and uterus. The causes that operate to pro- duce secondary arnenorrhoea will also act to produce the primary form. Secondary arnenorrhoea is occasioned by any constitu- tional derangement of the system which tends to greatly lower the vitality, as chlorosis, Bright's disease, malaria, diabetes, can- cer, tuberculosis, and any of the acute fevers as well as syphilis. The influence of the nervous system is also a great factor in the production of secondary arnenorrhoea, how else can we account for the frequently observed temporary suppressions of menstrua- tion, as a result of fright, in the insane, in prisoners, in women taking sea voyages and often in the unmarried who live irregular AMENORRHEA. 611 lives and have subjected themselves to the danger of pregnancy. Obesity and plethora are often observed coincidentally with amenorrhoea possibly, standing in a causative relation. In the consideration of any case of secondary amenorrhoea, the possi- bility of pregnancy being the cause of the suppression should never be lost sight of. Any of the inflammatory diseases of the uterus and adnexa, either chronic or acute, together with sujDer- involution or long standing sub-involution, mutilations of the uterus and ovaries and even the too vigorous use of the curette and the cautery have been followed by amenorrhoea. Menstrua- tion always disappears after the complete removal of the uterus and in a large majority of cases after the ovaries and tubes have been removed; occasionally, however, it happens that menstrua- tion continues after complete removal of the ovaries, usually ceas- ing after a year or two. Tumors of the ovary do not usually interfere with men- struation, at least not until a very late date, or unless both ovaries are involved, and finally become destroyed completely by the growths, when menstruation may cease. An imperforate hymen, cervix or vagina may prevent the appearance of the menstrual now, but these cases can easily be diagnosed from amenorrhoea due to lack of development of the uterus and ovaries, by the fact that the patient has the usual monthly re- curring symptoms of menstruation, pain, discomfort, etc., and on examination a well marked bulging may be discovered at the vulva and sometimes a tumor extending above the pubis. Most of these cases are due to imperforate hymen and are easily cured by incising the hymen under antiseptic precautions and allowing the retained menstrual blood to escape, after which the regular monthly period becomes established. The sudden discharge of a retained menstruation is not entirely free from danger, and it is best to allow it to come away slowly, afterwards washing with an antiseptic fluid, as a solution of bichloride of mercury (1 to 5000). The diagnosis as to whether a case of primary amenorrhoea is congenital or not, is of importance. If it be congenital, an examination reveals the absence or abnormality of the internal sexual organs. Externally the genitals may be normally formed, 612 A COMPENDIUM OF PRACTICAL MEDICINE. the pubes covered with hair and the mamma? well developed - This class of cases may develop masculine characteristics, the upper lip covered with hair, and the muscular and mental char- acteristics more nearly approaching the male than the female; but often there is nothing in the general appearance to indicate anything sexually wrong. In the second class of cases the pubes remain bare, the mammaB undeveloped and there seems to be a complete absence of sexual development, with always a general appearance of masculinity. These do not develop symptoms of any hind indicating the trouble. Nothing can be done to relieve the condition when distinctly congenital. Cases not congenital but of delayed development may, if treated while the patient is yet young, be benefited by removing the cause of the delay, which will usually be found to be general debility with iinpro}> er mode of living. Remedies directed to bettering the consti- tutional conditions, with sometimes local stimulation of the nterus by the use of electricity, the dilating from time to time of the cervix, etc., will be found of value. Internal remedies, such as the bitter tonics, gentian, columbo, etc., with iron, mix vomica and cod- liver oil, are very useful. Secondary amenorrhoea may be occasioned by a variety of pathological conditions, as indicated above, and the treatment of it will vary, according to the cause. When due to any of the debilitating diseases, these diseases should be treated, and little attention paid to the menstruation. As soon as health is re-es- tablished, menstruation, as a rule, will recur. The amenorrheea of chlorosis is best treated by giving iron and arsenic with saline purgatives, or by giving arsenic for a time, followed by iron and aloes pills. I have found Blaud's pill a most useful one in these cases. Manganese has been recommended, but its value is ques- tionable, and if it is of value, it is certainly not the equal of iron. Potassium permanganate, tansy, savine or saffron have been recommended, but they are not entirely free from danger, and should seldom, if ever, be given. The rjrognosis is serious or not, depending entirely on the pathological condition causing the amenorrheea. In young girls it is usually more favorable than in women who have borne children. DYSMENORRHEA. 613 Sudden suppression of the flow during a monthly period is most frequently caused by a disturbance of the circulation, by expos- ure to cold, by excessive exertion, or by great mental emotion, and this sudden stoppage may be followed by inflammation of the ovaries, uterus and tubes, if the flow is not promptly re-established. The treatment at first should be directed to the re-establishment of the circulation through its proper channels, Warm sitz -baths and hot drinks should be given, the patient placed in bed, with hot fomentations over the abdomen. A cathartic may be given with advantage. If the menstruation fails to be re-established, as soon as the period has passed means should be adopted for the relief of the uterine congestion, as hot douches, warm sitz- baths, the application of leeches to the cervix, or scarifying. Exercise should be restricted. DYSMENORRHEA. Dysmenorrhea, or painful menstruation, is due to patho- logical conditions which may be grouped roughly under four heads : 1. Defective nerve supply, or the neuralgic. 2. Inflammatory. 3. Mechanical obstruction to the flow. 4. The membranous variety, in which the mucous membrane of the uterus, instead of undergoing fatty degeneration, is cast off entire or in shreds. The neuralgic variety seems to be due entirely to a general neurasthenic condition, the uterus and adnexa presenting no dis- coverable pathological lesions that could account for the severe pain. This class of patients is usually hysterical and suffer from nervous troubles. The digestion is bad and they are usually anaemic. Hyperesthesia over the lower abdomen will usually be observed even during the inter-menstrual period. The diagnosis must be based upon the fact that no lesion of the uterus can be found and upon the general condition of neu- rasthenia. Often this trouble is associated with rheumatism. Prognosis is not very favorable but in time with careful treat- ment the trouble may disappear. The indications for treatment 614 A COMPENDIUM OF PRACTICAL MEDICINE. are general rather than local. If the patient suffer from rheu- matism, tincture of guaiac, colchicum, or salicylate of sodium will be found of benefit. Tonics, out- door exercise, and a good nourishing diet with cod-liver oil, will aid greatly. In the purely ana3inic and neurasthenic cases, very often the continued use of chlorate of potash, iron, and the bitter tonics will be found of value. For the actual suffering some of the coal tar derivatives, as antipyrin and phenacetin, or pulsatilla given every hour will greatly relieve. Opium and alcohol, although they promptly re- lieve, should not be given for the habit of their continued use may be acquired. Inflammatory dysmenorrhea is a result of inflammation of the uterus and adnexa. Whenever the uterus becomes inflamed it is seldom that this inflammation does not extend to the ovaries and tubes, sometimes producing chronic pelvic peritonitis with accumulations of pus. Whenever the inflammation is largely limited to the uterus the pain begins with the flow, and contin- ues while it lasts; but if the inflammation has attacked the tubes and ovaries the pain will begin three or four or more days before the flow starts and is usually then in a large measure relieved. The pain of menstruation clue to inflamed ovaries and tubes is usually most marked on the left side, radiating down the thigh and much increased when the patient walks about. These cases have usually a history of sterility and though much may be done for them in the way of palliative treatment, yet a complete cure aside from the removal of the ovaries and tubes, is usually not to be looked for. Headache, nervousness, and some fever usually accompany the pain, and the patient is sometimes much nau- seated. The diagnosis will be indicated by the character of the pain and the evidences of inflammation within the pelvis. The treatment will be that indicated for inflammation of the pelvic organs. The bowels should be kept open with salines and the patient kept in bed during the menstrual period, Hot fomentations may be applied to the lower part of the abdomen. To control the pain, some one of the coal-tar derivatives may be given, as antipyrin, phenacetin, etc. Opium and alcohol should be withheld. During the intermenstrual period, treatment for DYSttEXORRHCEA. 615 the pelvic inflammation should be persistently followed, as hot douches, painting the roof of the pelvis with iodine, using tampons of boro-glyceride, etc. Ichthyol is a most valuable remedy in these cases used as a suppository, or a dressing within the vagina. Any condition which interferes with the free discharge of the flow produces what is known as mechanical dysmenorrhoea. These obstructions are various, and include stenosis of the cervix at either the internal or external os, acute flexions, or 23ressure of tumors as fibroids or polypi that have found lodgment in the cervical canal. Under this head may be classed cases of imper- fect development of the uterus, and usually with anteflexion. The pain of obstructive dysmenorrhoea is spasmodic in character, blood accumulates behind the obstruction, and the contractions of the uterus to force it by the obstruction, occasion it. As soon as the blood is discharged the contractions cease, the patient is relieved and so remains until the accumulated blood is again forced off. The paroxysmal character of the pain will assist in making a diagnosis. Prognosis ma}^ be good or bad, depending entirely upon our ability to relieve the obstruction. Medicines will be of but little avail; this class of cases of necessity can only be assisted by the surgeon. If the stenosis be at either os, a thorough dilation of the canal may cure. Dilation and curettment may also be em- ployed when the uterus is flexed. Flexions of the uterus are nearly always accompanied by congestion of the mucous mem- brane. Removal of growths, if such exist, must be done. Membranous dysmenorrhoea is that form in which after a time the paroxysm of pain is followed by expulsion of a mem- brane from the uterus. These membranes show a smooth reddish inner surface upon which the orifices of the utricular glands may be seen by the naked eye and an external rough, uneven surface which appears as though torn from its connections, and at times contains small blood clots. In many cases the membrane is a complete sac containing three openings corresponding to the os uteri and orifices of the tubes. The symptoms of membranous dysmenorrhoea are not differ- ent from those of other forms of dysmenorrhoea. The pain, how- 616 A COMPENDIUM OF PRACTICAL MEDICINE ever, is extremely severe, paparoxvsnial in choracter, usually the most severe just before the membrane is expelled. In nervous patients, hysterical conditions are not uncommon. The now may be scanty in fact usually is. The membrane is cast off from the second to the fifth day. Occasionally the membrane is cast off without pain. Patients with membranous clysmenorrhcea are usually sterile, but if pregnancy should supervene, they may afterwards menstruate normally, though cases are reported where pregnancy did not effect a cure. Prognosis is not very favor- able. Treatment. — Many remedies have been employed for this trouble and sometimes with benefit. . The most popular method is thoroughly dilating and curretting the uterus. Cauterization of the uterine canal with nitrate of silver, tincture of iodine, or carbolic acid may be tried. The introduction of suppositories containing iodoform has been recommended by Skene. Dilating the uterus, curretting and cauterzing the endometrium with the Paquelin cautery, followed by packing the uterus with iodoform gauze has met with success. For the immediate relief of pain the same remedies as are employed in the other forms of dys - menorrhcea should be employed. A resort to opium is only to be thought of when all other remedies have failed to relieve. LEUCORRH(EA. By the term leucorrlicea is commonly meant any discharge other than blood coining from the genitals, though literally the term means a white discharge. These discharges from the vagina are popularly called the "whites. 1 '' They may come from any point along the genital mucous membrane, from the vulva, the vagina, the cervix, or the body of the womb, and are caused by many different pathological conditions, but there are, however, forms of leucorrhoea which may be regarded as physiological, such as the large quantities of mucus poured out often during pregnancy. The abundant discharge of mucus preceding and following menstruation cannot be considered pathological. Also in girls suffering from amenorrhcea there is in many instances from time to time profuse discharge of mucus which takes the LEUCORRIKEA. 617 place of proper menstruation and has been called " menstrual leucorrhoea.' 1 ' 1 These forms of lencorrhcea require no treatment. A very considerable number of cases of leucorrhoea may be re- garded as catarrh of some portion, or all, of the genital mucous membrane, very much of the same character, as catarrh of other mucous membranes, as of the resjnratory tracts or the alimentary canal. In the respiratory tract we have bronchitis, laryngitis and nasal catarrh; in the alimentary canal, diarrhoea. What is true of these membranes is also true of the vaginal and uterine, they alike are influenced by climatic changes and a severe leucorrhoea may be lighted up by exposure to cold, check- ing suddenly the secretions of the skin, or while attending to calls of nature, draughts of air blowing over the exposed mucous membrane of a patulous vagina may give rise to it. Leucorrhoea is not uncommon in women suffering from tuberculosis, or any strumous diathesis, and often in these cases the mucous mem- brane presents no discoverable anatomical lesion. Sometimes y however, the mucous membrane is attacked by tubercle, and then severe lesions present. Hereditary or acquired syjmilis will produce leucorrhoea of a very intractable form and it often coex- ists with gout and rheumatism. Whenever the tissues are badly nourished and the patient is greatly debilitated, mucus discharge from the vagina is easily induced. All of the foregoing influ- ences will, it is true, induce leucorrhoea, but by far the most im- portant and most frequent cause of the discharge is some uterine disorder marked by lesion of structure as the inflammatory dis- eases of the vagina and uterus, such as sj)ecific (gonorrhoea) and non-specific, tumors (malignant and non-malignant), displace- ments and lesions of structure, such as those following confine- ments. Hence, leucorrhoaa should be considered, especially if constant, as extremely significant of uterine disease. If intermit- tent entirely disappearing from time to time, it is not so likelv to be an indication of uterine disease. The occurrence of leucorrhoea in children is deserving of especial attention. It sometimes follows the acute exanthematous diseases especially scarlatina. Ascarides sometimes find their way from the rectum into the vagina, and set up a severe irrita- 618 A COMPENDIUM OF PRACTICAL MEDICINE. tion with discharge. Strumous children are very subject to this trouble. Prognosis. — This must depend upon the cause entirely. Treatment. — If the condition depend upon a constitutional cause, the treatment must be general as well as local; but if to a local cause, treatment may be confined to the seat of the disease. The digestion and the bowels should be carefully attended to. Good food, warm clothing, and plenty of out- door exercise will aid in restoring the vigor of the general constitution. Frequent bathing, and rubbing the surface thoroughly with towels should not be neglected. In strumous cases, tonics, such as gentian, Colombo, nux vomica, with iron and cod- liver oil, will be of benefit. Aletris cordial, hydrastis, and cimicifuga have been recommended as having the effect of directly checking the flow. The local treatment may consist of applications to the parts of tincture of iodine, solutions of nitrate of silver, carbolic acid, chloride of zinc, etc. I have found in certain cases great benefit from the use of suppositories made after the following formula: j& Acidi tannici Acidi gallici Bismuthi subnitratis aa gr. iij-v. Olei theobroma? q. s — M. Ft. suppositorium no. i. Sig. : Insert into the vagina after a douche of warm water at bed time. These suppositories used, one daily, for a time check the se- cretions and often effect a cure. If the trouble arises from lac- erations of the cervix, these should be restored by operations. If the trouble is due to endometritis or cervicitis a currettment of the uterus will often effect a cure. In any case the cause of the trouble should be diligently sought out and removed. VAGINITIS. Vaginitis or colpitis are terms used to designate inflamma- tion of the vagina. There are two forms, the acute and chronic. If the disease lasts a period longer than three weeks or a month, it is then spoken of as chronic, prior to this time as acute. Of the varieties of vaginitis we have the catarrhal in which inflam- VAGINITIS. 619 mation of the mucous membrane is only so severe as to occasion a discbarge of mucus or muco- purulent matter. Under this head are grouped nearly all of the ordinary inflammations of the va- gina, including the gonorrhoeal. When the inflammation is of such character that a solid exudate is thrown out or into the mucous membrane we have what is termed exudative vaginitis. This form of inflammation is due to diphtheria. Sometimes the inflammation is situated within the connective tissue about the vagina. It is then known as the phlegmonous variety and is sometimes so severe as to occasion the sloughing of a great por- tion or all of the vaginal wall. Catarrhal vaginitis may occur from exposure to cold, from infection, from the introduction of foreign substances, from irri- tating injections, etc. In children it may be caused by the pres- ence of ascarides, by neglect of cleanliness, and by improper hand- ling of the parts. Vaginitis often follows attacks of the exanthematous diseases, but its most common cause is gonorrhoeal infection. Gonorrhoeal vaginitis is very apt to extend from the cervical canal to the endometrium, and from thence to the tubes and ovaries. It is also apt to spread to the urethra. Among the causes of vaginitis are excessive coition and mas- turbation. Old women sometimes are troubled with a very intractable form, the cause of which it is difficult to ascribe to anything but old age. The symptoms of vaginitis are those of inflammation else- where, as heat, pain, redness and a feeling of general discomfort. In the acute elevation of temperature frequently happens. Urination gives a sense of smarting. On examination the mucous membrane will be found to be red and swollen. Shortly after the onset of the trouble a discharge of mucus begins from the membrane, soon followed by pus. If the urethra is involved as it is likely to be, pressure along it with the finger will usually be followed by the discharge of a few drops of pus from the meatus. If the inflammation does not subside within three or at most four weeks, it is said then to have become chronic. At this time usually the symptoms will have in large measure subsided, except the discharge, which may continue copious and purulent. 620 A COMPENDIUM OF PRACTICAL MEDICINE. Gonorrhoeal vaginitis is particularly liable to become chronic The diagnosis of vaginitis is readily made out on examination with the speculum and the vivid red membrane is at once noted with the discharge. Care should always be exercised that a diagnosis of vaginitis be not made from the discharge alone, for that may come from the interior of the womb, from a pelvic abscess, from malignant growths, etc. The question often arises, can we say with certainty whether a given case of vaginitis is of gonorrhoeal origin or not. There has been much controversy regarding the matter, but the best authorities affirm that the presence of gonoccoci is conclusive proof of gonorrhoeal origin. Prognosis. — Is good in a large proportion of cases, but when it becomes chronic it may last for years. Treatment. — Patients with acute vaginitis should remain in bed or at least keep quiet while the acute symptoms last. The bowels should be kept open with salines, the diet restricted, and hot water injections given twice daily. If the parts are much swollen, poultices of emollient substances, as linseed meal or chamomile flowers, may be applied. Tampons saturated with glycerine and laudanum may be inserted, giving much comfort to the patient. After the acute symptoms have subsided, solu- tions of mercury bichloride (1 to 5000) may be injected with benefit. Solutions of permanganate of potassium are also recom- mended as injections. In this stage of the trouble I have found suppositories containing tannic and gallic acid with sub-nitrate of bismuth to be of great value. Internally ol. santal, bals. copaiba and cubebs may be given with benefit. METRITIS. We understand by the term metritis an inflammation of the uterus. As of inflammations elsewhere we recognize the acute and chronic forms. Of these forms there has been by different authors, a variety of classifications which will not be here con- sidered. Metritis is one of the most common troubles of the uterus. A variety of terms have been applied to inflammations of the uterus designed to indicate the part of it, involved in the trouble as, endometritis, meaning inflammation of the mucous METRITIS. 621 membrane lining the uterus ; parenchymatous or corporeal metri- tis, inflammation of the muscular portion or body; cervicitis, in- flammation of the cervix and endocervicitis, inflammation of the lining membrane of the cervix. Seldom, if ever, does the body of the uterus (the muscular layer) become inflamed except as an extension of the disease from the mucous membrane. The mucous membrane of both the body of the uterus and the cervix may be quite severely inflamed for a long period of time without its extension to the muscular layer. Metritis is, in the vast majority of cases, due to either gon- orrhoea, or is a sequence of the puerperal state, but may be due to other causes as, gynecological operations, the introduction of a sound, currettment, etc., when done without proper aseptic pre- cautions; or it may be caused by exposure to cold and wet, especially at the time of menstruation. Metritis sometimes fol- lows the exanthematous diseases as well as typhoid fever and syphilis. Symptoms. — The acute stage of metritis is accompanied by fever, the uterus is painful to the touch, and the patient com- plains of cramp -like pains in the lower part of the abdomen. Nausea and vomiting are usual, and diarrhoea, with painful urination. Menstruation is often profuse, but is sometimes com- pletely suppressed. With these symptoms is an abundant dis- charge of purulent matter from the uterus. Especially is this true when the metritis is due to gonorrhoea. On vaginal exam- ination the uterus is seen to be inflamed, and is very tender to the touch. The prognosis is usually favorable, but the disease may extend to the tubes and ovaries, when it becomes difficult to cure. If it continues three or four weeks, becoming chronic, the probability of a rapid and complete cure is greatly diminished, and especially if there is evidence that it has extended to the tubes and ovaries. Treatment of Acute Metritis. — The patient should remain in bed while the acute symptoms continue. To relieve the pain, heat should be applied to the abdomen. Sometimes the applica- tion of cold in the acute stage (as an ice bag to the lower part of the abdomen) will give comfort, but cold should not be applied if there is menstrual suppression. Douches of plain hot water 622 A COMPENDIUM OF PRACTICAL MEDICINE. should be given as often as three times daily or more frequently if they give comfort. Sometimes hot water is not well borne, then tepid water should be tried. Flax-seed and slippery elm have been recommended as a valuable addition to the water. If the pain is very severe it may be necessary to administer an opiate, which is best given in the form of a suppository. Tam- pons saturated with boroglyceride and glycerine in the propor- tion of oj. boroglyceride to O.j. of glycerine, introduced into the vagina, will produce a profuse watery discharge and relieve the congestion and pain. Ichthyol and glycerine may be used in the same manner with benefit. Gonorrheal metritis is treated best by washing out the uterus once a day with bichloride solution (1 to 2,000), until the acute symptoms have subsided, when the endometrium may be painted (twice weekly) with a 10 per cent, solution of nitrate of silver. Curretting the uterus and packing with iodoform gauze is effective. The gauze acts as a drain and keeps the uterus free from pus. If these more active methods of treatment cannot be adopted in a given case of gonorrhoeal metritis, the treatment for acute metritis not of gonorrhoeal origin, as described, can be adopted, together with the internal administration of anti-blenor- rhagic drugs, as bals. copaiba?, ol. santal, etc., though these reme- dies should be given in smaller doses than to men. Chronic Metritis proceeds from the acute form, or is slowly developed from a lesion of structure at some point of the uterus, which allows of the introduction of infection. The most com- mon form of lesion productive of chronic metritis are the lacera- tions of the cervix, so frequently following child bearing. Usually in these cases the uterine tear has prevented the return of the uterus to its normal size after labor and a condition of subinvolution exists. The whole organ may be involved or only the cervix, or as often happens the inflammation is confined to the mucous membrane lining the cervix and is then called e'ndo- cervicitis, or to the mucous membrane of the body, then called endometritis. Tumors, malignant and non-malignant, may act as predisposing causes of chronic metritis. A condition of hardening sometimes follows loug continued inflammation and anaemia of the uterine structure, the tissue becoming cicatricial in METRITIS. 623 character when it is known as uterine sclerosis. The condition is incurable and function of the uterus practically ceases. With chronic metritis we have the prominent symptom of pain. The patient often complains of a "bearing down" sensa- tion, is troubled with cramps, and frequently with an irrita- ble bladder. Dysmenorrhoea is usually an accompaniment of metritis with prolonged menstruation, and frequently bloody dis- charges in the interval between the menstrual periods. Some- times, however, in very weak patients, the condition is accom- panied with menstrual suppression. Usually there is copious leucorrhoea, and the appearance of this discharge is character- istic. From the cervix it resembles much the -white of eggs, and from the uterine body is milky in appearance. The general symptoms are, loss of appetite, with nausea, dyspepsia and con- stipation. The patient often loses flesh, becoming anaemic and and weak. Backache and pain in the lower abdomen is usual. The patient is hysterical and melancholy, and usually remains sterile. On vaginal examination, if the disease is a result of child-bearing, we find the os patulous, the cervix enlarged and inflamed, possibly studded with hard nodules (the follicle of Naboth), and showing evidences of laceration. Care should al- ways be taken not to confound cancer with inflammation. When the cervix is hardened with inflammation and the follicles en- larged, they may present very similar appearances. A currette, however, will clear up the diagnosis. If the case is cancer, on curettment friable tissue is always brought away. If inflamma- tion, the tissues are firm, and the currette only makes the part bleed, and denudes it of a little mucous membrane. Prognosis — Of chronic metritis is uncertain, but a slow and tedious recovery is to be anticipated. Treatment. — Patients suffering from endometritis should take plenty of rest. Employment that requires a great deal of exer- cise should be prohibited, especially work with sewing machines. The bowels should be kept open and sexual intercourse as much as possible interdicted. Bathing frequently should not be neg- lected. A sitz-bath occasionally will be found of benefit. Hot water douches should be given twice daily. If the cervix is much eroded, painting the erosions with tinct. iodine comp., a 624 A COMPENDIUM OF PRACTICAL MEDICINE. solution of nitrate of silver, carbolic acid, chloride of iron or chloride of zinc will be beneficial. Iodine is most commonly used. Applications of iodine may also be made from time to time to the endometrium with a bit of cotton wrapped upon a probe. If the remedies above recommended fail to cure, it will be best to thoroughly dilate the uterus, currette the endometrium, and if of very long standing, cauterize it with the actual cautery; or after the curettment the uterus can be packed with iodoform gauze or a drainage tube inserted and thoroughly drained. If the cervix is lacerated the laceration should be repaired. If the treatment proves of no avail and the disease has extended to the tubes and ovaries they may have to be removed. Constitutional treatment should not be neglected, as the administration of tonics, looking after the secretions, etc. CHAPTER IV. FIRST HELP IN SURGICAL EMERGENCIES. BY J. H. POOLEY, M. D. Prefatory. — The few desultory notes on various discon- nected subjects which make up this chapter are not intended as a complete discussion of any subject, but simply hints which may be referred to in an emergency and suggest some line of conduct which may be adopted while arrangements are made for regular and permanent treatment. Nothing new is offered, nor is there any pretense to novelty, even in the presentation of the subject. But sometimes the old and hackneyed, if apposite to the case, and easy of reference, is of more value at the time than the most learned and exhaustive discussion. If these suggestions prove in any instance of assistance to the young doctor, who is generally burdened with knowledge which he does not know how to use, they will not have been written in vain. BURNS. The extent of surface affected is of more importance than the depth or destruction of tissue involved. When a very large surface, especially over the trunk, is involved the prognosis is grave. The first attention in a case of burns includes both local and general treatment. Locally, tense blisters should be evacu- ated by small punctures aud gentle pressure, and the epidermis allowed to fall down over the abraded surface. Any dressing that will exclude air will answer the purpose, though if con- venient carbolic acid may be added both for its anaesthetic and its antiseptic properties. 626 A COMPENDIUM OF PRACTICAL MEDICINE. Flour, freely sprinkled over the surface from a dredging box, is almost always available. Oil of any kind thickened with chalk, whitning, bismuth, or any similiar substance is an excellent dressing. The so-called carron-oil a mixture of linseed oil and lime water is a common application and efficient, but it is a nasty ill -smelling dressing. Prof. S. D. Gross highly recommended common white paint reduced to a proper consistence with oil and freely painted over the surface. He says that no fear need be entertained of the constitutional effects of lead. Cotton, though recommended by some, is a bad dressing, and only to be used when nothing else can be had. After the dressing, whatever it is, has been freely applied on pieces of soft old cloth, it should be retained by loose bandages. The pain of burns, especially of the superficial kind, is very severe, and demands the administration of opium or some of its preparations. These may be given freely in aduhs, but in children great care is necessary in their use. Shock, and in child- ren convulsions, are common in severe burns, and demand stimulants, such as spirits, hot beef tea, etc., by mouth or rectum. In cases where steam or heated air have been inhaled, severe inflammation of the mouth and fauces may result; the frequent administration of oil, or vaseline, or lard will give relief; if oedema of the glottis results, tracheotomy may be necessary to save life. COLD. (Exposure to). The effects of intense cold may be either general or local; the first result of general exposure to cold is stimulating, but this is quickly followed by depression, pallor and coldness of the surface, with pain and numbness, followed by drowsiness, which, if indulged, ends in coma and death. Death from cold resembles apoplexy. To restore a person insensible from exposure to cold, the patient should be placed in a cool room, the surface rubbed with snow, or flannel cloths, wet with whiskey or dilute alcohol. Arti- ficial respiration must be resorted to in extreme cases. When reaction begins, the temperature of the room may be raised, and COLD — DROWNING — DISLOCATION AND FRACTURES. 627 the body wrapped up in warm blankets. Stimulants should be administered in moderate doses, at short intervals; if the patient cannot swallow, they may be given per rectum. Persevere in these efforts, as some cases have been rescued from apparent death only after hours of vigorous treatment. The local effects of cold are divided according to their sever- ity, into chilblains, and frost-bite. The frozen part at first ap- pears red, purple, or mottled, afterwards white or waxy, and is hard and stiff. Care must be taken not to restore circulation too rapidly. First rub the part with snow, afterwards with the warm hand, or some stimulating liniment. If gangrene results, treat locally with antiseptic dressings and await results. Constitutionally good food, tonics, and anodynes to relieve pain if present, are indicated. DROWNING. To resuscitate a person in a condition of suspended anima- tion from drowning, the body should first be inverted, held head downward for a few seconds, to let the water run out of the mouth, fauces, and (esophagus; then removed to a warm room, and the surface dried and vigorously rubbed with woolen cloths. The tongue should be drawn well forward and artificial respira- tion practiced either by Marshal Hall's or Sylvester's method, care being taken not to repeat the steps of the process too rapid- ly. The great thing in these cases is perseverance. Vigorous efforts should be kept up at least half an hour, and if there is the least encouragement, much longer. When reaction begins it may be favored by mustard aj) plications to precordia and spine, and hypodermic injection of stry china ^V to ^V gr. DISLOCATIONS AND FRACTURES. Until preparation can be made for reduction and permanent dressing of these injuries the limb should be placed in a com- fortable position and adequately supported. Care and gentle- ness should be exercised in the removal of clothing; it is frequently better to cut the clothes along seams, than to attempt removal in the ordinary way. As a temporary splint in case of 628 A COMPENDIUM OF PRACTICAL MEDICINE. fracture, almost anything will answer, a pasteboard box, a maga- zine or paper- covered novel, or a bundle of newspapers. In fracture of the lower extremity the so-called comforter splints serves an excellent purpose. This is prepared by taking an or- dinary bed comfort and spreading it flat upon a table or the floor; then two persons, one on each side, roll their respective halves into as compact and even a cylinder as possible. The limb is then placed between the two cylinders thus formed, and tied tightly with strips of bandage or handkerchiefs. This makes a very efficient and comfortable splint, for the first twenty-four hours or more, while arrangements are made for permanent treatment. FOREIGN BODIES IN EYE, EAR AND NOSE. Foreign bodies such as small fragments of coal- cinders, sand, straw, stone, steel, etc., may be either lodged in the folds of the conjunctiva, particularly the superior cul de sac, or impacted in the cornea. In the first, order the patient to look up while you depress the lower lid and carefully explore the lower cul de sac. Failing to find it here you direct him to look down, then seizing the lashes of the upper lid you evert it over the end of a match, point of a pencil or your finger-tip; you thus expose the whole conjunctival surface, and cannot fail to find the particle if present, it is then easily removed with a camels hair brush, or the corner of a handkerchief. Pieces of granite or steel frequently become firmly impacted in the cornea of various workmen. The eye should be anaes- thetized by a few drops of a four per cent.solution of cocaine mur., when the body can be easily picked out with a cataract needle, point of a lancet or similar instrument. Foreign bodies in the ear are generally met with in children who often mischievously or carelessly thrust such things as but- tons, beads, pebbles, grains of corn, etc., into their own, or others ears. These bodies can almost always be removed by syringing with warm water; the auricle should be firmly drawn backward and a little upward, and the water thrown up the floor of the meatus with some force. This almost invariably succeeds if persevered in, and is perfectly safe. gas. 629 No other attempt at removal should be made without full illumination, and clear sight of the object, which may then be removed by forceps, or a probe or ear spoon introduced behind it and used as a lever. Bodies similar to those put into the ears are also sometimes thrust up their nostrils by children. With a good light, the assist- ance of the ear mirror, and a little quickness and slight of hand, they do not often give much trouble. If they cannot be extracted they can sometimes be thrust backward into the throat. If left they are apt to set up a more or less violent inflammation, some- times with profuse, ill-smelling discharge; indeed the presence of such symptoms in a child should excite suspicion, and lead to careful search for some foreign body. I have known a head of timothy grass thus retained in the nose for many months. GAS. (Asphyxiation from). Persons not infrequently become asphyxiated from breath- ing for hours an atmosphere loaded with illuminating or natural gas. This may occur either accidentally or intentionally. Such persons are generally found profoundly insensible, breathing slowly, perhaps stertorously, with a feeble pulse, perhaps no pulse perceptible at wrist, with pale or livid countenance and exhaling a strong odor of the gas. There can be no. doubt of the advisability of blood letting in these cases, if the blood can be got to flow. It relieves the strain, and gets rid of some of the gas with which the blood is loaded. Other means of re- suscitation, sprinkling water in the face, holding ammonia to the nostrils, etc., together with artificial respiration should be tried. Of course doors and windows should be thrown wide open, even in cold weather. The gravity of these cases depends upon the length of time the patient has been breathing the poisonous atmosphere; but as in similar cases of asphyxiation by drowning, etc., we should persevere while there is a ray of hope, though the directly poisonous effects upon the nerve centres makes them a very fatal class of cases. 630 A COMPENDIUM OF PRACTICAL MEDICINE. HEMORRHAGE. As the various forms of internal hemorrhage are considered elsewhere in this work, we shall confine ourselves here to hemorr- hages from wounds. Hemorrhage from wounds where no consider- able artery is opened generally ceases spontaneously in a few mo- ments if freely exposed to the air, and many of the devices resorted to serve rather to keep up the bleeding than otherwise. The tem- porary control of hemorrhage, which is all we are considering here, can generally be accomplished by pressure either directly over the wound, or over the main artery, between it and the heart. Direct pressure is generally sufficient, especially when it can be made over a bony surface, as on the skull. In wounds of the extremities accompanied Avith severe bleeding, pressure should be made over the course of the principal artery, above the wound. This is most efficiently done by means of an elastic ligature or bandage. An india-rubber cord or tube, or an elastic suspender, or garter drawn tightly round the limb, generally suffices. If the blood is dark and the now apparently increased by pressure above, it is venous, remove all bandages, and rely on direct pressure. Avoid styptics, especially cobwebs, which from the soot they often contain may leave an indelible mark, like a tattoo -mark. HERNIA. Hernia, or rupture, as it is commonly called, is a very com- mon affection. It consists in the protrusion, through natural or accidental openings, of some of the abdominal contents. The great danger in these cases is strangulation, which is j>receded by inability to return the hernial contents to the abdominal cavity, as the patient has been in the habit of doing, it may be, for many years. This returning, or reduction of the hernia, is called • taxis, and should be accomplished without force or violence. A physician or surgeon who is determined to accomplish the reduc- tion if strength of hand can do it, is a dangerous person. In performing taxis, bear in mind the anatomical direction in which the hernia must return, if at all. Then, after gently but persistently compressing the base of the tumor for a few HERNIA INJURIES TO THE BRAIX. 631 minutes, endeavor to return or push it back, remembering that the part that was last to come out must be first to go back. Should one attempt of this kind fail, the patient may be left for an hour or two with ice applied to the tumor, and then another effort made, under ether, being prepared, if this fails, to proceed with the necessary operation; the great danger in these cases being in delay. INJURIES TO THE BRAIN. Concussion or Compression. — By concussion is meant a jar to the cranial contents, a molecular disturbance of the brain sub- stance, which may lead to loss of consciousness and other symp- toms, varying in gravity from a momentary dizziness to those which threaten to be fatal. Whether there can be any such con- dition without actual injury to brain substance or blood vessels is a matter of doubt, and likely long to remain so, as cases of concussion pure and simple give no opportunity for post mortem examination. Compression, or pressure upon the cranial con- tents may be immediate from depressed bone or hemorrhage; or later from inflammatory products. With the first only are we concerned; the diagnosis is not always easy. But if there is fracture with evident depression of bone, the accompanying symptoms are due to compression. In compression we have generally contracted pupil, small thready pulse, often stertorous breathing, and generally paralysis (hemi- plegia). In concussion the pupils are dilated, or one dilated, the other contracted, in but few cases is consciousness com- pletely abolished, and there is generally nausea and vomiting. In all these cases of head injury the patient should be kept perfectly quiet, in a darkened room, and nobody allowed to ap- proach him except those that are absolutely necessary. The head should be elevated, and ice or cold water compresses ap- plied. If the vital powers are very much lowered, as indicated by pale and cool surface, small and irregular pulse, artificial heat by means of hot bottles, water-bags, etc., should be applied. Stimulants, if given at all, should be used with care in small doses, and at considerable intervals. In those cases which are accompanied with great restlessness, or convulsions, or severe 632 A COMPENDIUM OF PEACTICAL MEDICINE. pain, morphine may be given hypoclerniically with advantage. The old-fashioned practice of bleeding, or administering an active purgative in these cases, is of doubtful utility at the best, and may do more harm than good. Above all, bear in mind Percival Pott's celebrated aphorism, as true to-day as when it was first uttered: u No injury of the head is so slight as to be despised, or so grave as to be despaired of." POISONED WOUNDS. Under this head we mean especially wounds received in the dissecting room, or in making post-mortem examinations, the latter of which are the more dangerous. These wounds are gene- rally upon the hand or fingers; after letting water run over the part for a moment, or just rinsing it in water, apply to the mouth and suck with all the force possible, then cauterize thoroughly with nitrate of silver, which though of very feeble power as a caustic, coagulates the albuminous fluids in and about the wound, forming barrier to absorption, and perhaps neutralizes the poison itself. In the absence of the nitrate any strong acid or alkali, or tincture of iodine, may be used, or even strong alcohol. In snake-bite, a ligature tied tightly between the wound and the heart, with strong suction, should be practiced at once, pending the arrival of professional assistance. In bites from suspected dogs, Mr. Youmans, who is certainly high authority, places great reliance on the application of nitrate of silver. POISONING. In cases of poisoning or suspected poisoning, there are cer- tain general measures which may be taken even when the nature of the poison is unknown, or before a proper antidote can be procured. Prominent among these is the production of free vomiting by any means at hand, such as salt and water, mustard and water, tickling the fauces with a feather, or the finger. After vomiting has been produced let the patient drink large quantities of warm water, or if there is much pain and irritation diluent drinks, such as milk and water, soap and water, flax- seed tea or the like if procurable. If there is a tendency to POISONING SHOCK. 633 drowsiness this should be combatted by every means in our power, keeping the patient walking about, switching the surface etc., etc. In poisoning cases all suspicious powders, mixtures, vials etc., should be taken possession of, and preserved pending the result, as they may be of the utmost importance later on. It would always be well also to preserve the matter first vomited. Keep your eyes wide open, observe everything, and say nothing. SHOCK. This is the sudden depression of the vital powers, brought about by accident or injury- The factors which enter into the cause of shock are various. Among them may be mentioned extensive destruction of parts, pain, when severe or protracted; this is exemplified in the case of extensive burns; hemorrhage, mental impressions, and direct assault upon nerve centres. Shock, even to a fatal degree, has been the result of evil tidings suddenly communicated, or of blows upon the epigastrium, when no serious injury could be recognized. The principal symptoms are, more or less, complete loss of consciousness, with or without delirium, pain, or its complete absence even when frightful mutilation has been sustained. Palor and coolness of surface, sub -normal temperature, weak, nickering pulse, or absence of pulse at wrist, and, in extreme cases, muffled and imperfect heart sounds, sighing, irregular res- piration, cold sweat, especially about the brow; and when there has been much hemorrhage, jactitation and thirst. Death may result in a short time, or the patient may recover even after a very severe and protracted attack. Generally reaction begins in two or three hours. The treatment of shock consists entirely in efforts to restore the vital powers, or as it is technically phrased to bring about reaction. Any hemorrhage that is going on must be stopped. The patient placed in a warm bed in the horizontal position, with the head low. Sometimes it is advantageous to raise the foot of the bed. External warmth should be promoted by hot water bottles or bags; or hot bricks or irons, cart- being taken not to burn the patient, who is not in a condition to give warn- 634 A COMPENDIUM OF PRACTICAL MEDICINE. ing when applications are too hot. Stimulants should be admin- istered in extreme cases by rectum or hypodernrically. If given by the mouth, care is necessary lest an overdose be administered, as absorption as well as other functions is in abeyance, and if the stomach be filled with alcohol an injurious amount may be absorbed when reaction comes on. Where great pain or rest- lessness is present, or there has been much hemorrhage, opium in some of its forms may be freely given. As a general rule, operations should be postponed till reaction is established or at least well began; but this rule does not apply to cases of abdom- inal injury where operation may be called for. In such cases the operation should be proceeded with as speedily as possible, as the only way of preventing a fatal result. SPRAINS. By a sprain is understood a wrenching, stretching, or rupt- ure, partial or complete of the ligaments of a joint, or its partial dislocation. The ankle is the joint that most frequently suffers, and there are all possible degrees in the severity of the injury. Pain is generally severe, and somtimes accompanied by nausea or vomiting, there is always more or less discoloration (ecchymosis) sometimes quite extensive. The best immediate application is hot. water, this should be applied as hot as can be borne, and frequently changed. This application may be continued for twelve or twenty-four hours, after which it is of doubtful util- ity, and should be followed by a snug, smoothly applied flannel bandage. If swelling and pain persist after two or three days the joint should be immobilized by a plaster of Paris bandage, to be retained two or three weeks, and then reapplied if neces- sary. When pain and swelling have nearly disappeared, but there is still some stiffness and pain on motion, rubbing with some anodyne liniment may be of use. A sprain often leaves some weakness, with occasional pain in the joint for years. CHAPTER V. ANAESTHETICS AND THEIR MODE OF ADHINISTRATION. Anoesthetics are those agents wliicli are employed for the prevention of pain, especially when used in surgical practice and during labor. They are likewise used to produce relaxation of muscles, when needed in reducing dislocations and hernia, or in setting fractured bones. They may be also resorted to in making diagnosis in cases of obscure abdominial tumors and in supposed malingering. Anaesthesia may be produced by benumbing the part to be operated on by means of cold, by intercepting nervous commu- nication, and by arresting the activity of the nervous centres concerned in sensation. They may be local or general in their action (Horwitz). The Introduction of Anaesthetics. — This great event has cast a wide-spread influence upon the progress of surgery. In 1842 Crawford W. Long, of Georgia, removed a tumor with the pa- tient under the influence of an anaesthetic. ~No further attempt was made until 1844, when Wells had a tooth extracted while insensible with nitrous oxide gas. Morton, at the suggestion of Dr. Jackson, anaesthetized a patient on October 16th, 1846, while Dr. J. C. Warren removed a tumor from the patient's neck. From this time on, anaesthesia, hitherto a dream, now became a living reality. To Jackson, Morton and Wells, the profession is indebted for this great discovery, which is the greatest boon to suffering humanity. There is one sad event, however, connected with this dis- covery, and that is the melancholy termination of the life of each of the three men associated with it. Jackson died insane; 636 A COMPENDIUM OF PRACTICAL MEDICINE. Morton died without worldly means; "Wells became a pauper and was arrested in New York city as a criminal for throwing vitriol. He was sent to jail, and there committed suicide by cutting his femoral artery. It is interesting to note in this con- nection, that Sir Edward Jenner, the discoverer of vaccination, was awarded 8225,000 for his discovery by an act of Parliament, while by no act of the United States Government has anything been done to perpetuate the memory of these three men. The physicians of Hartford have erected a statue to Wells (Dennis). Important Anaesthetics. — The important anaesthetics are: 1. Ether. 2. Chloroform. 3. Nitrous oxide gas. 4. Bichloride of methylene. 5. Bromide of Ethyl. Physiological Actions. — When the vapor of ether or chloro- form is inhaled, a sense of faucial irritation and of the need of air is* experienced, and more or less cough is produced. The irrita- tation of the fauces excites the flow of mucus, and the reflex act of swallowing. The feeling of the need of air causes the patient to push aside the inhaler or sponge, and in children may lead to violent struggling. The irritation soon ceases and the inhalation then proceeds quietly. The first effect is a general exhilaration, the pulse increases in frequency, the respirations become more rapid, the face flushes, talking, laughing, crying, siDging, and sometimes praying indicate the cerebral intoxication. This stage of excitement varies in duration in different individu- als. At this period, although the patient can be easily aroused, sensibility to pain is decidedly diminished. If the inhalation be continued, the patient passes into the condition of complete insensibility. In women and children, and males reduced by illness, the production of insensibility, if the anaesthetic be not inhaled too rapidly, takes place quietly; but if the subject be a robust male, in full health, the stage of insensibility is preceded by a tetanic convulsive stage, in which the voluntary muscular system and the respiratory muscles become rigid, the breathing stertorous, and the face cyanosed. If the inhalation of the anaesthetic be pushed still further, the tetanic rigidity subsides, the cyanosis dis- appears, the breathing proceeds quietly, and a condition of com- plete muscular relaxation, and of abolition of reflex movements. ANAESTHETICS. 637 is established. When this is accomplished, the arm drops with- out resistance when let fall, the conjunctiva is insensible to irrita- tion, the pupils do not alter in size when exposed to light, and there is no consciousness of pain. The surface is cool, and bathed with abundant perspiration, the countenance is placid, the eyes closed, the pupils rather contracted than dilated; the respiration easy, but more shallow than normal; the pulse slower — it maybe feebler, it may be stronger than in health. The functions of the cerebrum are suspended; only the lower centres, 23residing over respiration and circulation, continue in action (Bartholow). Modes of Dying from Anaesthetic Vapors.— 1. By the first mode, the death is sudden and occurs very soon after the inhala- tion has begun, and is ascribed to "irritation of the peripheral nervous system, accumulation of carbonic acid in the blood, and arrest of the action of the heart." The chloroform vapor seems to paralyze the cardiac ganglia. This accident sometimes occurs in persons who have previously taken the anaesthetic without unfavorable symptoms of any kind. 2. By the second mode, death ensues in the stage of rigid- ity preceding complete muscular relaxation, and is due to tetanic fixation of the respiratory muscles. In these cases respiration ceases before the pulsations of the heart cease. 3. By paralysis of the respiratory muscles, death ensues during the stage of complete muscular relaxation, and the action of the heart continues for some seconds, or even minutes, after respiration has ceased. 4. By paralysis of the heart. This also occurs in the course of complete insensibility; the motor ganglia are para- lyzed, and the heart suddenly ceases to act, the respirations con- tinuing for a short time longer. 5. This mode of dying is made up of two factors : Deju-es- sion of the functions by chloroform narcosis, and the shock of the accident or surgical operation. Death may ensue during the inhalation, or may occur afterward (Bartholow). Conditions of the Organism Rendering the Use of Anaesthetics Dangerous. — 1. Experience has proved that old drunkards are very unfavorable subjects. 638 A COMPENDIUM OF PRACTICAL MEDICINE. 2. When a tumor or abscess of the brain exists, it is dan- gerous to administer anaesthetics. 3. Very much enlarged tonsils, swollen epiglottis, oedema of the glottis are contraindications. 4. Emphysema and fatty heart are unfavorable conditions for an anaesthetic. Experience has demonstrated that those reduced by illness, and the feeble, bear anaesthetics better than the healthy and robust; that children and women are better sub- jects than men; that anaesthetics are safer when given for opera- tions for disease than for injury. 5. Incomplete anaesthesia is a condition of danger. Many accidents have occurred from trivial operations — particularly extraction of teeth — before complete insensibility. In such cases the heart, enfeebled by chloroform narcosis, is suddenly par- alyzed by the reflex action proceeding from the peripheral injury (Bartholow). The chloroform committee of the Royal Medical and Chir- urgical Society of London formulated the following rules for the administration of anaesthetics: 1. Anaesthetics should on no account be given carelessly or by the inexperienced; and when complete insensibility is desired the attention of the administrator should be exclusively confined to the duty he has undertaken. 2. Under no circumstances is it desirable for a person to give an anaesthetic to himself. 3. It is not advisible to give an anaesthetic after a long fast or soon after a meal, the best time for its administration being four or five hours after food has been taken. 4. If the patient is much depressed, there is no objection to his taking a small quantity of brandy, wine, or ammonia before commencing the inhalation. 5. Provision for the free admission of air during the patient's narcotism is absolutely necessary. 6. The recumbent position of the patient is preferable; the prone position is inconvenient to the administrator, but entails no extra danger. In the erect or sitting posture there is danger from syncope. Sudden elevation or turning of the body should be avoided. ANAESTHETICS. 639 7. An apparatus is not essential to safety if due care be taken in giving the anaesthetic. Free admixture of air with the anaesthetic is of the first importance, and, guaranteeing this, any apparatus may be employed. If lint, or a handkerchief or a napkin is used it should be folded as an open cone or held an inch or an inch and a half from the face. 8. Chloroform should invariably be given slowly. Sudden increase of strength of the anaesthetic is most dangerous. Three and a half per cent, is the average amount, and four and a half per cent., with ninety- five and a half per cent, of atmospheric air, is the maximum of the anaesthetic which can be required, given cautiously at first, the quantity within this limit being slowly increased according to the necessities of the case, the administrator being guided more by its effect on the patient than by the amount exhibited. Ether may be given more boldly. 9. The administrator should watch the respiration of his patient, and must keep one hand free s for careful observation of the pulse. 10. When patients hold their breath, more air should be admitted; and when the movement of swallowing is seen, it should be accepted as evidence that the anaesthetic is stronger than necessary. On any sound of stertor fresh air should be admitted. 11. The j)atient who appears likely to vomit while begin- ning to inhale the anaesthetic must at once be brought fully under its influence; the tendency to sickness will then cease. 12. The occurrence during the administration of an anaes- thetic of sudden pallor, lividity of the patient's countenance, or sudden failure or flickering of the pulse, or feeble or shallow respirations, indicates danger, and necessitates immediate with- drawal of the anaesthetic until such symptoms have disappeared. The chin should be raised as much as possible from the sternum, and if this movement fail to oj)en the larynx, the tongue should be pulled forward and the head drawn back. 13. Nelaton and Marion Sims advise the inversion of the body, with the view of throwing what blood there is wholly to the brain, on the theory that death from chloroform is, as a rule, 640 A COMPENDIUM OF PRACTICAL MEDICINE. clue to syncope or to cerebral anaemia. In the more threatening cases, commence instantly with artificial respiration, whether the respiration has failed alone, or the pulse and respiration together. Galvanism may be used in addition to artificial respiration, but artificial respiration is on no account to be delayed or suspended in order that galvanism may be tried. In extreme cases, laryng- otomy may be required. Few, if any, are insusceptible to the influence of anaesthetics, from two to ten minutes being required to induce anaesthesia. The time varies according to age, temperament and habits. The mixture of alcohol one part, chloroform two parts, and ether three parts, which should be mixed fresh before use, should be given in the same way as chloroform alone, care being taken, when lint or a handkerchief is used, to prevent the too free escape of the vapor. In Vienna the favorite mixture is three parts of ether to one of chloroform. Billroth employs chloroform three parts, ether one part, and alcohol one part (Bryant). Preparation of the Patient for Taking an Anaesthetic. — Before giving ether, the kidneys should be interrogated, and the urine examined. If the kidneys are diseased, it may cause sup- pression of urine and death. In operations upon the bladder and urethra the shock of the 023eration and the effects of the an- aesthetic are very apt to produce suppression of urine. If we operate in the afternoon and the patient is aware of the operation, he should have no food after the morning meal. Always avoid solid food for six or seven hours before the time for the operation. This is to prevent vomiting which is liable to follow the administration of ether. Solid particles of food may be drawn into the larynx and produce death. Vomiting, as the narcosis subsides, is usual, and as the insensibility of the glottis persists for some time afterward, particles of food may be lodged in the chink, causing fatal suffocation. Several cases of this kind have been reported. There should be nothing binding about the patient's neck or waist. We should use certain means to anticipate vomiting. Before the inhalation is begun, it is rjroper to administer an ounce or two of whiskey or brandy. Five or six grains of the bromide of sodium are often given before the operation to prevent vomiting. But much more im- ANAESTHETICS. 641 portant is the expedient proposed by Bernard, and afterward by Nussbauin, to premise a subcutaneous injection of morphine. Bernard proposed to administer the morphine before giving the anaesthetic. If the morphine be given, there is much less likely- hood of vomiting, and if the patient does vomit, it is not so ex- hausting. When the morphine influence takes place, the inhala- tion will proceed quietly without the struggling and coughing, and spasmodic breathing, which so interfere with the administra- tion of anaesthetics, especially of ether. The use of morphine subcutaneously also lessens materially, if not prevents entirely, the stage of rigidity and spasm. The quantity of the anaesthetic required is much less, and the stage of insensibility more pro- longed, when morphine is thus given. Besides these advantages, there can be no doubt that this agent antagonizes the paralyzing action of the anaesthetic on the cardiac and respiratory centers, and prevents the subsequent shock due to the administration of the anaesthetic and the per- formance of a surgical operation. Bartholow proposed the use of morphine and atropine combined as being better than the morphine alone. When the anaesthetic is about to be administered, the operator should, by a cheerful and confident manner, remove the fears of the patient. None of the paraphernalia of the opera- tion to be performed should be exhibited before the patient, and no remarks should be made in his hearing regarding his case, the anaesthetic sleep, or the surgical procedure. Only the physi- cian having the administration of the anaesthetic in charge, and the necessary assistants, should be present in the apartment. An abundant supply of fresh air should be insured to the patient, and all appliances required for resuscitation should be at hand, but not ostentatiously paraded before the patient. Inhalers. — The simplest apparatus only is required. Com- plicated inhalers have, as frequently as a towel or handkerchief, been used in fatal cases of chloroform narcosis. A cone made of stiff paper, and a towel, with a sponge or absorbent cotton in the bottom of it, and large enough to cover the nose and mouth of the patient, is the best form of inhaler for the administration of ether. Dr. Allis, of Philadelphia, has devised an inhaler 642 A COMPENDIUM OF PRACTICAL MEDICINE. which is much commended. When ether is inhaled, the atmos- phere is, as far as possible, excluded, in order that the anaes- thetic effect may be quickly induced. The important point in the administration of chloroform is to secure such an admixture of atmospheric air as that the amount of chloroform- vapor shall not exceed three and a half per cent. If this rule be regarded, the form of inhaler is of little importance. A cloth may be laid over the mouth and nose and the chlor- forni dropped slowly on it. The mouth and nose should be pro- tected from the irritant action of the chloroform by inunction with oil or vaseline. Chloroform applied to the skin directly produces vesication, and this my be followed by permanent dis- figurement of the face. A cone made of a towel, having a large opening at the apex, and containing a suitable, very porous sponge, is now probably more employed than any other form of inhaler for giving chloroform. The typical method for admin- istering it is that of Snow: in a bag of suitable size the vapor of choloroform is mixed with air in the proper proportion, and then given directly. In administering the vapor of chloro- form by any of the modes in use, it should not be forgotten that it has a density and weight four times those of air, and that, when a cloth is held closely over the mouth, the air is displaced, and the patient may be breathing little more than chloroform - vapor. During the administration of ether, attention should be directed to the state of the respiration, for arrest of the respira- tory movements is the only source of danger. When chloroform is being inhaled, the state of the circulation, as well as of the respiratory apparatus, must be regarded (Bartholow). Indications of Danger in Giving Anaesthetics. — If the patient becomes very much cyanosed, let up on the anaesthetic, and let him breathe some pure air or oxygen. If the pulse becomes irregular, let up on the anaesthetic. A rapid and feeble pulse, especially if irregular, is a very dangerous symptom. If the respirations become rapid and superficial, let up on the anaes- thetic. If the patient vomits, see to it that all foreign particles of food are removed. If the secretion of mucus collects in the throat, it should be wiped away with a sponge on a sponge - holder. ANAESTHETICS. 643 Means of Removing Dangerous Symptoms. — If the heart fails, suspend the patient by the heels. This is to relieve the cerebral anaemia. If the respirations fail, we should have on hand a pair of forceps to grasp the tongue with, in case it falls back against the epiglottis, and the skin should be pinched over the dia- phragm to stimulate it to contraction, and the jaw should be pulled forward to get free ingress of air. The head should be only slightly raised. We should always have a Faradic battery and a few of the little pearls of nitrite of amyl at hand; the former is to perform artificial respiration, and the latter is to relieve the heart by dilating the blood-vessels, and thus dimin- ishing arterial pressure. Artificial warmth should be applied. Whiskey or brandy may be used hypodermically. Strychnine and atropine are the best respiratory stimulants, and are effective in ether narcosis (A. A. Smith and Bartholow). Choice of Anaesthetics. — Ether is safer than chloroform in prolonged surgical operations. Chloroform is more pleasant to inhale than ether, and should be used in operations about the nose, throat, tongue, or mouth, owing to the fact that ether is very irritating to the mucous membranes. Chloroform is irritat- ing to the skin, but not to mucous membranes. The stage of excitement is longer from ether than from chloroform. Chloro- form is more prompt in its effects, and the narcosis induced by it more sustained, than is the case with ether. The vapor of chloroform is not, and the vapor of ether is, inflammable, whence it follows that the former may be alone admissible at night under some circumstances. If the heart be diseased, ether is the anaes- thetic to be used. If the kidneys be diseased, chloroform is the proper anaesthetic. Vomiting and suppression of urine is more apt to follow ether than chloroform (Bartholow and A. A. Smith). A. C. E. mixture, composed of alcohol one part, chloroform two parts and ether three parts, is useful when the operation is to be a very long one. It produces no cardiac depression unless used over twenty minutes. If a man has renal disease and a broken leg, the A. C. E. mixture is the proper anaesthetic. An old alcoholic is apt to have delirium tremens if he gets a broken leg, or a fracture of the skull, or any other injury. The A. C. E. 644 A COMPENDIUM OF PRACTICAL MEDICINE. mixture is the anaesthetic, to be used in these cases. This class of patients do not bear any form of anaesthetic well. After=Effects of Anaesthetics. — The after nausea and vomit- ing, which are sometimes most depressing, and occasionally dan- gerous, produced by anaesthetics, may be prevented by the hypo- dermic injection of morphine and atropine before beginning the administration of the anaesthetic. After the patient emerges from the anaesthetic sleep, the above mentioned unpleasant after- effects may be relieved by a minute quantity of morphine (ttj of a grain) and atropine (lib of a grain) injected subcutaneously (Bartholow). After the operation, do not wake the patient, but let him sleep as long as he will. This lessens the liability to vomiting. After taking ether patients do not want anything to eat for some time Give the patient a cup of hot water as soon as he can take it after coming out from the ether. After ether taking give milk or beef-tea. It is necessary to surround the patient with warmth, as Dr H. A. Hare, quoted by Ringer, has recently shown that pro longed etherization considerably lessens the body temperature He has reduced the temperature from 8° to 10° F., and in opera tions he has seen a fall of 4.4° F. in man. Probably other anaesthetics produce the same effect. Some surgeons wrap children in cotton wool, covering not only the body, but also the extremities, before giving the anaesthetic, Anaesthetics in Midwifery. — Chloroform is to be preferred in labor, because more pleasant to inhale, more prompt in action, and without inflammability. Experience has shown that chloro- form is perfectly safe in labor when properly administered. When the labor is of short duration, and not excessively painful, anaesthetics should not be used; on the other hand, when the labor is protracted and the suffering great, they favor the pro- gress of the case and prevent exhaustion and uterine inertia. In labor, chloroform should not be given until complete dilatation of the os has taken place, the head descending and the pains propulsive. It should be inhaled only when the pains come on, and there is no doubt that its entire safety in obstetric practice is due to the intermittent plan of administering it. To relieve ANAESTHETICS. 645 the pain of labor, complete narcosis should not be produced, as cessation of uterine contractions and loss of uterine retractility may result, leading to a delay in the delivery, retention of the placenta, and even post-partum hemorrhage. The patient should take a full inspiration of the chloroform vapor during the aura of a labor pain, and then bear down- About three deep inspira- tions are all that she will be able to take during any one pain. Toward the close of the second stage of labor, when the head begins to distend the external parts, the quantity of chloroform may be somewhat increased, but the inhalation should be dis- continued when the occiput has passed under the pubic arch. Chloroform is said to favor laceration of the cervix and peri- neum, but this is not believed. Instrumental or manual interference with labor may render complete anaesthesia necessary, or it may be needed to aid in the relaxation of a rigid cervix, or to prevent the woman from bear- ing down when the perinaeuin is endangered by a too rapid de- livery. If puerperal convulsions occur at any stage of labor, the utility of chloroform is unquestionable. If the patient has valvular cardiac disease, this does not contra-indicate anaesthetics as was formerly thought. The shock, when an anaesthetic is not used, is more dangerous than the anaesthetic. Dr. A. A. Smith, of 'New York, considers organic heart disease as a special indi- cation for the use of chloroform. Give only enough to take away the acuteness of the pain. Give it during the ''aura 11 of a pain for four or five pains, and then withhold it for a pain or two, in these cases of heart disease. When forceps or version are indicated in these heart cases, it is better to use ether, because it then becomes a surgical case, and should be treated as other surgical cases. Never use forceps, or perform version, or crani- otomy with the patient only partially under the anaesthetic. Finally, it is generally conceded that no well-authenticated case of death from the use of chloroform in labor has occurred, when the administration was in the hands of a properly qualified medi- cal man (Bartholow and A. A. Smith). Chloroform insensi- bility may, with care, be maintained for hours and even days. In administering anaesthetics, the attention should be directed to the state of the jmlse, the breathing, the conjunctiva, and the 646 A COMPENDIUM OF PRACTICAL MEDICINE pupil. If the pulse become quick and weak, or irregular, then the inhalation must be withheld. The breathing often affords an earlier sign of danger than the state of the pulse. If the res- pirations become shallow, and gradually less frequent, the anaes- thetic should be suspended for a time. The surest signs of safety, and the earliest of danger, are afforded by the state of the conjunctiva and pupil. While irri- tation of the conjunctiva causes reflex action, and is followed by blinking, there is usually no danger. The pupil is much con- tracted in the stages of insensibility when no danger is to be ap- prehended; but on the approach of peril from an overdose of the anaesthetic, the pupil dilates. It should in every case be made a rule that no operative measures of any kind be allowed until the patient is in the stage of relaxation. It is important to be able to obtain early warning that vomiting during narcosis from anaesthetics is about to super- vene. The pupil will, as was pointed out by M. Budin, afford a clue. He found, and my experience confirms his statement, that when the patient is about to vomit the pupils commence gradu- ally to dilate. Efforts at swallowing air are initiated at this time, and the pulse flags slightly. If now the anaesthetic be dis- continued, the pupils widely dilate, vomiting occurs, and the patient regains consciousness rapidly. But, on the other hand, if the administrator, aware of the import of these signs, pushes the anaesthetic, the pupils regain the contraction which is normal to the state of relaxation, and vomiting is obviated, while the pulse recovers its force. The gradual dilatation spoken of above must not be confounded with the sudden dilatation which be- tokens grave danger. In this last case, stertor, shallow breath- ing, and marked lessening of the pulse -force also occur, together with cyanosis. It should be borne in mind that operations on the rectum and vagina, even when the patient is quite insensible, generally cause noisy catchy breathing, very much resembling stertorous breathing, often mistaken for it, and sometimes thought to indi- cate that too much of the anaesthetic has been inhaled; but this is not the case. The true state of things can be made out as follows: The noisy breathing does not occur until the rectum AN .ESTHETICS. 647 and vagina are manipulated, and is especially loud and noisy when the finger or an instrument is passed with any force into either orifice. Are there any conditions of age or health which forbid the use of anaesthetics? Provided due care be observed, it may be given to all persons, irrespective of their condition. It has been given in serious heart disease; in every stage of phthisis; in Bright's disease, cancer, chronic bronchitis; to patients almost dead of exhaustion from loss of blood; to children of a few weeks, and to persons close upon a hundred years old. It is safe to say that any person fit for a severe operation is a fit sub- ject for an anesthetic, but no one is so free from danger that care in watching its effects can be dispensed with. . The cases requiring the greatest vigilance are not the young and delicate, for whom a small close suffices, but the strong, who inhale deeply, and struggle much (Bartholow, Ringer and Bryant). It requires special study, combined with practice, to administer anaesthetics in the proper manner. In a great many operations, the skillful anaesthetizer is of more importance to the final success of the opera- tion than the operator himself. The experienced administrator takes a great load and responsibility from the operator's mind, reduces death from ether and chloroform to a minimum, and lessens the risks of every operation. Nitrous Oxide Gas. — Is not much used now as an anaesthetic. It is cumbersome since it requires an extensive apparatus. It is expensive. It was first used by Horace Wells, a dentist of Hart- ford. It is used at the present day principally in dentistry. It is not feasible for prolonged surgical operations. It causes cya- nosis and the pulse becomes increased in force and diminished in frequency. The patient will recover from it in three minutes. Some cases suffer for two or three days after its administration from a disturbance of the nervous system. It may cause sleep- lessness and muscular tremor. This gas is both a pleasant and efficient anaesthetic, more rapid and at the same time more tran- sitory in its action than either ether or chloroform. It is espe- cially adapted for the extraction of teeth, opening of abscesses, and similar minor operations. The amount necessary to produce anaesthesia is one to two gallons. It is best administered from 648 A COMPENDIUM OF PRACTICAL MEDICINE. an India-rubber bag, containing about eight gallons of the gas. Bichloride of Methylene. — Is similar to chloroform and was first proposed as an anaesthetic by Dr. B. W. Richardson. It produces its effects inore quickly and may be used in smaller quantity than chloroform. It is agreeable to inhale and causes no heart depression. It is not used in this country at the present day, but is used in England a great deal, esjoecially by Spencer Wells and his followers, who pronounce its vapor to be the best known anaesthetic. It does not produce any gastric disturbance. It is considered more dangerous than chloroform or ether. Bromide of Ethyl. — Is a quick anaesthetic. The odor is not unpleasant, and but little irritation of the air-passages is pro- duced. It is now seldom resorted to as an anaesthetic. It may cause almost instant death by paralyzing the heart. It is a dan- gerous anaesthetic. Ott states that it destroys life by a toxic action on the respiratory centre. Chloral as an Anaesthetic. — Dr. Bouchut recommends the use of chloral as an anaesthetic for children. He gives one dose, not exceeding forty-five grains, in children under three years of age. In half an hour the patient is asleep, and in an hour insensible. The anaesthesia lasts from three to six hours and is followed 1 > y no unpleasant consequences. Thirty grains may be given with- out danger, Bouchut says, to children between two and five years of age (Bryant). Bonwell's Method of Introducing Anaesthesia. — Take a full in- spiration and then let the expiration go by installments. This must be done slowly and regularly. By this method, the sensi- bility will be benumbed so that the rectum may be examined. It may be used in opening an abscess and in pulling teeth. It will relieve many cases of insomnia. This method depends largely on the influence of the mind over the body. Deaths from the Different Anaesthetics. — Dr. Lyman has col- lected thirty- seven fatal cases from the inhalation of ether, three hundred and ninety- three, from the administration of choloro- form, nine from the employment of bichloride of methylene, four which maybe attributed to nitrous oxide gas, and several from the use of ethyl bromide. CLINICAL INDEX. ABORTION — Chloride of gold will avert the tendency to habitual abortion. Corn- utine, an alkaloid of ergot, will increase uterine action when required in abor- tion. Opium will check uterine action. Ergot will restrain the hemorrhage. All drugs are dangerous to life when used in sufficient quantity to produce an abortion. ABSCESS — Belladonna, internally, will prevent the formation of abscesses in the neck and elsewhere, and after the onset of suppuration will check the pain and inflammation. Belladonna plaster will subdue the inflammation. Nitrate of Silver solution in nitrous ether applied over the inflamed area and adjacent region will abort the inflammation. Ointments or powder of iodol and iodoform are valuable. Counter = Irritation, byblisters or tinclure of iodine around or adjacent to the abscess, is of great utility. Caustic potash or soda is sometimes used to open abscesses with the intention of preventing scarring. Sulphides, half grain every few hours, will abort abscess or hasten the forma- tion and extrusion of the pus. Ether may be Used as a spray to produce local anaesthesia for opening abscesses. Poultices will check the formation of pus or assist in maturation. Fomentations, with a solution of 20 grs carbonate of ammonium to one pint of boiling water, are of great utility in threatened mammary abscess. Iodine solution may be injected into the cavities of large abscesses after evacuation. Carbolic acid, boracic acid and permanganate of potassium solutions may be used for washing out cavities of abscesses. ACIDITY. — Mineral acids may be given shortly before meals for acid pyrosis, and after meals for alkaline pyrosis. Sulphurous acid may be given for acid fer- •mentation with vomiting of pasty matter. Acid wine may be taken during meals. Alkalies may be given after meals for immediate relief, but are only palliative. Nux vomica in two or three drop doses just before meals is effi- cient in acidity of pregnancy. Gray powder in half grain doses three times daily may be given for acidity with clayey stools. Carbolic acid will stop the fermentation and eructation. ACNE. — Phosphorus may be given in acne indurata. Sulphur may be used inter- nally. Sulphur, dr. j., glycerine, oz. j., rose water, Oss , applied to the face, as a lotion, twice daily will be effective in acne of young women with disor- dered menstrution. Corrosive sublimate, one part; alcohol, enough to dis- solve it; water, 100 parts. A teaspoonful of this may be added to a quarter of a pint of water and the face sponged with it night and morning. Arsenic (Fowler's sol.) in two drop doses, three times daily, will prevent bromic acne. Bismuth may be dusted on the face when there are heat and redness. Sub- limbed sulphur applied as a powder to the eruption is one of the best applica- tions. Alkaline lotions, as liquor potassa? dr. j. and aqua? rosa? oz. iv., applied with a soft sponge twice daily are useful when the skin is greasy and sebaceous follicles full. Hot sponging is effective in acne indurata. ADYNAMIA. — Alcohol in the form of whisky, brandy or wine of good body, in tea- spoonful doses after meals is most useful. Give brandy when bowels are re- laxed, and whisky when there is constipation. Aliment, as beef, milk and cod- liver oil. Bitters, as quassia, gentian and calumba. Quinine in gr. ss.-gr. j. doses t. i. d. Iron may be given to stimulate digestion and promote blood for- mation. Nux vomica tincture in doses of three to five drops, t. i. d. is bene- ficial. AFTER-PAINS. — Chloral in large doses is effective. Camphor (ten grains) in a mixture with a little morphine (one-eighth of a grain) is a very efficacious remedy, florphine (gr. %) and atropine (gr. T i u ), hypodermically, will give prompt relief. AGUE. — Quinine is by far the best remedy we possess for ague. In mild forms small doses several times daily and in malignant forms large doses continued 650 A COMPENDIUM OF PRACTICAL MEDICHSTE. for a long time. Arsenic, in three to ten drop doses of Fowler's solution is the best remedy except quinine. Nitro=gIycerine may avert the cold stage. ALBUMINURIA. — The milk cure, especially butter-milk. Basham's mixture, tea spoonful t. i. d., is of service in anaemic patients. Arsenic, three drops t. i. d. of Fowler's sol. after meals for kidney changes. Gallic acid has the power to restrain the waste of albumen in cases of acute albuminuria. It may be given as follows: Acidi gallici, dr. j., acidi sulphurici dil. dr. ss., tinct. lupuli dr. j., infus. lupuli oz. vj., m. Sig.: A tablespoonful three times daily. Gold and sodium chloride, in the dose of T V-2 3 o grain, t. i. d. is of the highest utility in chronic albuminuria. Nitro=glycerine ( T ^ gr.) daily, increased gradually will relieve the high arterial tension in acute and chronic Bright's disease. Digitalis may be used when the quantity of urine is much diminished. Pilocarpine may be used cautiously. ALCOHOLISM. — Bromides in drachm doses may be given for the "horrors." Arsenic, in drop doses before breakfast for the morning vomiting. Cimicifuga for the dyspepsia of drunkards. Morphine with tonics before meals for pain, nausea and want of appetite. Capiscum and nux vomica may be given as stomachic tonics. AMAUROSIS. — Strychnine will cure amaurosis of a functional kind, from lead, to- bacco and alcohol. AMENORRHQ3A. — Aconite tincture in drop-doses every half hour, for sudden sup- pression of menses. Aloes and iron may be given when due to anaemia and torpor. Apiol in a dose of fifteen grains daily for five days before the expected period, is effective in amenorrhoea due to anaemia and torpor of the ovaries and uterus. Hydropiper in thirty minim doses of the fluid extract four times daily for a week before the menses ought to appear. Chloride of gold and sodium in Jo S r - dose thrice daily when dependent on torpor of the ovaries. Hot mus- tard sitz. baths for five days before the period. Potassium permanganate, one grain thrice daily for a week before the period. It may restore it after two years delav. AN/EMIA. — Cold sponging is useful in anaemia. Hypophosphites of lime and soda, a grain thrice daily. Phosphate of lime, a grain thrice daily, in anaemia of growing persons, and of women weakened by rapid child-bearing or excessive menstruation. Trinitrin in doses of one minim of the one per cent, solution gradually increased to many will cure many cases of anaemia. Quinine in doses of one grain three times daily, for badly fed, pale town-Hvers. Iron in all forms of anaemia. Arsenic is effective in proper doses. Wines with good body. Galvanism to stimulate the functions of organic life. ANESTHESIA.— Galvanism to the spine and affected parts. The electric brush is useful in anaesthesia. Strychnine, hypodermically, ^ gr. daily increased gradually. ANEURISM. — Potassium iodide, in full doses relieves the pain and promotes co- agulation of the blood in the sac. A low diet with absolute repose in the recumbent posture. Barium chloride one-fifth of a grain, three times a day for four weeks, then two-fifths may be given for months. Aconite slows the cir- culation and thus facilitates coagulation in the sac. Ergot, especially ergotin hypodermically has been very effective. Galvano=puncture has but rarely suc- ceeded. ANGINA PECTORIS. — Arsenic (Fowler's solution) in full doses, is very efficient to prevent attacks given during the intervals. Amyl nitrite, two to five drops by inhalation affords prompt relief in cases characterized by elevated arterial tension. Nitro=glycerine one minim of a one per cent. sol. at stated intervals is superior to amyl. Ether, in small quantity by inhalation, may abort a mild attack, hypodermically in the worst cases. Nitrite of sodium, one grain sev- eral times daily. Morphia, gr. \, may be given hypodermically for the pain. ANTHRAX.— Carbolic acid applied locally. APHONIA. — Atropine ( T -J-„ gr.) morning and evening will remove aphonia due to fatigue of vocal cords.' It will also cure hysterical aphonia. Nitric acid in ten minim doses of the dilute, is effective in the hoarseness of singers and when aphonia is reflex. Electricity (galvanism) usually cures when due to paresis of the vocal cord. APHTH/E.— Bismuth subnitrate may be applied to ulcers. Potassium chlorate (gr. x. to oz. j.) mayjbe used. locally. Iodoform dusted on is an excellent topi- CLINICAL INDEX. 651 cal application. Quinine in tonic doses (gr. ss. togr. j.) is highly useful. Car= bolic acid (pure) may be applied to the ulcers, as an anaesthetic and alterant. Alum may be applied dry a few times a day to aphthous ulcers which will not heal. Borax with honey, or as glycerine of borax may be applied to ulcer. APOPLEXY.— Croton oil in one-third minim dose, may be given every hour as a purgative. Venesection or leeches, when the blood pressure is high and hem- orrhage threatened or proceeding. ASCA.RIDES — Quassia, an infusion, as a rectal injection, is one of the most ef- fective agents for the destruction of thread worms. Carbolic acid is an efficient but unsafe parasiticide when injected into the rectum. Iron, ten drops of the syrup of the iodide, three times daily by the stomach to prevent reproduction and dr. j. of the tinct. to Oj. of water by rectal injection. Santonin in dose of five grains for adult at night with or without calomel and a laxative in the morning. ASCITES. — Copaiba resin may be used as in the following: Res. copaibae dr. iij., alco- hol dr. v., spirit chloroformi dr. j., mucil. acacise oz. ij., aqua? ad. oz. xij. — M. Sig.: A tablespooniul t. i. d. Pilocarpine very serviceable when given to pro- duce free diaphoresis. Jalap (compound powder) in teaspoonful doses taken in the early morning. Elaterium in dose of gr. T Vgr. i, must be given cautiously. Milk diet or dry diet will aid remedies. * ASTHMA. — Oxygen, pure or diluted by inhalation. Amyl nitrite four or five drops by inhalation. Nitro=glycerine (gr. T ^) by the stomach. Arsenic one drop three times daily to prevent. Alum ten grains powdered and placed on the tongue is said to arrest a paroxysm. Bromides, in spasmodic asthma, may be given as follows: Potassii bromidi oz. j., potassii iodidi oz. ss., aqua; oz. iv. — M. Sig - .: A teaspoonful in water every half hour or hour. Chloral in twenty grain doses may arrest the paroxysm but danger of the chloral habit. Chloroform by inhalation relieves. Ether by inhalation is safer than chloro- form. Atropine gr. ^ at bed time may prevent paroxysm. Morphine (gr. I -) and atropine (gr. T J^) hypodermically are the best agents to cut short a parox- vsm. Potassium iodide in full doses succeeds remarkably in some cases. Quinine may be given during the intervals in grain doses thrice daily. Strych= nine used persistently may lessen the number of attacks. Galvanization of the pneumogastric and cervical spmpathetic relieves the spasmodic difficulty of breathing and sometimes effects a cure, and faradization of the chest muscles has lately been reported successful in effecting a cure. Coffee, a very strong infusion, is often useful in a paroxysm. Lobelia tincture in ten drop doses every ten minutes till dyspnoea gives way. Stramonium, gr. xx. of the dried leaves may be smoked. Tobacco smoked sometimes gives relief. BALDNESS.— Pilocarpine may be used locally in the following formula: Extracti pilocarpin oz. j., tincture cantharidis oz. ss., linimenti saponis oz. iss. — M. Sig.: To be applied to scalp daily. BED=SORES — Alcohol in form of brandy to harden skin of parts exposed to pres- sure. Alum with tinct. of camphor and whites of eggs is a good topical appli- cation. Resorcin in form of powder may be dusted on. Copaiba and castor oil equal parts, locally. Naphthol as an ointment with vaseline is said to be the most efficient of all. Iodoform dusted over sores. Charcoal sprinkled over the black slough which is then covered with a poultice. Glycerine rubbed over the part exposed to pressure after washing morning and evening is one of the best preventives of bed-sores. Silver nitrate gr. xx. to oz. j. painted on the unbroken skin as soon as it becomes red to prevent bed-sores. BILIOUSNESS.— Mineral acids before meals in acid indigestion. Hydrochloric acid and pepsin after meals in atonic dyspepsia. Sodium phosphate in tea- spoonful doses thrice daily for a long time. Calomel and blue pill in small quantity as laxative merely. Ammonium chloride in five grain doses three times daily. Tincture of nux vomica, gtt. v., t. i. d. for three weeks. BITES. — Ammonia, weak solutions, in bites of insects to neutralize the formic acid. The strong aqua ammonia should be at once applied to the bite of ven = omous serpents and of rabid animals. Potassium permanganate, a strong- solution applied locally. Alcohol stimulants internally. BLADDER, CATARRH OF. -Alkalies after meals, when the urine is acid. Ben = zoate of ammonia in gr. v. to gr. xx. thrice daily may be given when the urine is alkaline and loaded with phosphates. Copaiba, cubebs and juniper are use- ful. Cantharides, tinct. gtt. iij. to gtt. v. very useful. 652 A COMPENDIUM OF PEACTICAL MEDICINE. BLADDER, IRRITABILITY OF.— Belladonna tinct. in ten minim doses until phys- iological effects. Alkalies when urine is acid. Benzoate of ammonia when urine is alkaline. Tinct. cantharides sometimes succeeds in irritable bladder of women. BOILS. — Arsenic, Fowler's solution, in three drop doses after meals for a long- time when there is a succession of boils. Nitrate of silver gr. xx.-xxx, dis- solved in nitrous ether, and painted on early will abort boils. Sulphide of calcium half grain three times daily will hasten maturation and prevent the formation of fresh boils. ISIo use in the boils of diabetes. Collodion may be applied in the papular or pustular stage. Belladonna with glycerine locally to allay pain. Counter=irritation by blisters or iodine around the boil. Menthol forty per cent, solution locally. Poultices assist maturation and allay pain. They may be smeared over with belladonna or opium. BRAIN, DISEASES OF.— Bromide of potassium in gr. xxx. doses at bed-hour, when over-taxed from study, or over-application to business. Phosphorus jo to gV grain thrice daily for several months in cerebral softening and over- taxation. BREASTS, INFLAMMATION OF —Belladonna, especially as liniment to check secretion of milk when inflammation is imminent. When inflammation has set in, continuous application of belladonna for twenty-hours often arrests it. It is also useful when an abscess has formed. Digitalis as an infusion locally. BREATH, FOUL. — Camphor is a common ingredient of tooth powder and is a cor- rective of foul breath. Chlorine-water properly diluted. Carbolic acid in dilute solution as a mouth-wash and by the stomach. Potassium permanganate gr. ij. to oz. j. of rose-water as a mouth-wash. Tinct. of benzoin internally and as mouth-wash. BRIOHT'S DISEASE.— Milk=cure especially an exclusive skim-milk diet, or a diet composed largely of milk, has been very successful. Water and large draughts of weak alkaline waters. Bitartrate of potassaj as lemonade, drunk freely as a diuretic. Digitalis the infusion for the dropsy. Potassium iodide in the chronic cases. Iron to relieve the anaemia. Pilocarpus highly useful in many cases of uraemia. NitrO'glycerine has proved highly useful when there is in- creased vascular tension. Cod=Iiver oil in the chronic. Tannin in chronic Bright's to lessen albumen. BRONCHITIS. — Aconite tinct. in small doses frequently in the acute form. Car= bonate of ammonia in gr. v. doses every three hours if the secretion is viscid. Morphine or Dover's powder with quinine may abort an acute attack if given early. Squills, the compound syrup with paregoric is useful. Terebene may be given for the cough. Cod=liver oil may be given in the chronic form. Iron as a tonic. Strychnine is the best remedy to check the reflex vomiting. Acids to lessen the secretion in the chronic. Tar, two grains in pill every three or four hours in chronic paroxysmal winter cough. Wine of ipecac used as a spray to the pharynx is invaluable in many cases of bronchial asthma and winter cough. BRUISES. — Capsicum, a strong tincture applied with gum is said to act like a charm on discolored bruises. Hamamelis applied on lint or cotton-wool. Sul= phurous acid a solution constantly applied. BUBO. — Iodine applied to produce vesication round a bubo relieves the inflamma- tion. Nitric acid may be applied to indolent and broken bubo. BURNS AND SCALDS.— Carbolic acid, a one per cent, solution on lint frequently renewed relieves pain. Cocaine as a lotion painted on scalds relieves the pain. Collodion painted over slight burns subdues inflammation. Lime in the form of lime-water combined with oil, enjoys a high reputation. Carbonate of soda in saturated sol. to relieve pain. Boracic acid most useful in Mr. Lister's hands. Carbonate of lead and linseed oil, white lead paint, is an excellent ap- plication to burns. CALCULI, BILIARY. — Aliment, as starches, sweets, and especially fats should be avoided. Alkaline mineral waters are highly useful. Sodium phosphate, dr. j. t. i. d. for three months. Turpentine and ether equal parts, gtt. x. t. i. d. for the solution and cure of biliary calculi. CALCULI, RENAL. — Nitric acid very dilute as an injection for phosphatic calculi. Alkalies to dissolves uric acid calculi. Alkaline mineral waters as vichy, Bethesda, etc. CLINICAL INDEX. 653 CANCER. — Arsenic relieves the pain and retards the growth of cancer of the stomach and also of epithelioma. Bismuth relieves the vomiting in cancer of the stomach. Carbolic acid, pure, as an anaesthetic before applying caustics. Arsenious acid, pure, may be used to set up active inflammation in epithelioma. Carbonic acid may be injected up the vagina in cancer of the uterus to relieve the pain. Chloral in ten grain doses t. i. d. has relieved most severe pain of cancer. Chloroform as a vapor to raw, painful surface. Conium may be ap- plied as poultice to ease pain. Glycerine of carbolic acid and glycerine of tannin combined checks the discharge and stench of uterine cancer. Iodoform applied locally relieves the pain of cancerous sores, florphia dissolved in glycerine and spread on lint, is very useful where there is much pain. Opium is also used in cancer of the stomach. Poultices of starch applied cold soothe open cancers. Warm enemata relieve the pain and straining in intestinal cancer. CANCRUM ORIS. — Arsenic in medicinal doses useful. Nitric acid applied to the surface. CANKERY TASTE. — Podophyllin small doses fo grain night and morning. Pur= gatives as mercury and podophyllin, are best. Water, half a glass of pure cold, daily, half hour before breakfast. CARBUNCLE. — Arnica as an ointment on plaster. Belladonna with equal part of glycerine as a local application to allay pain. Carbolic acid and glycerine 1 to 4 on lint to sinuses. Iodine applied round the carbuncle reduces inflammation. Menthol, ten to fifty per cent, in ether or alcohol, painted on several times daily. Opium, an extract of the consistence of treacle applied three or four times a day. CARIES. — Phosphate and carbonate of lime to furnish needed materials. Cod= liver oil to promote constructive metamorphosis. CATARRH, ACUTE— COMilON COLD.— Aconite tinct. and belladonna tinct., equal parts, two drops of the mixture every half hour for six or eight hours and then every two hours. Quinine gr. xv. and morphine g-r. ss. may at the outset, abort an attack. Dover's powder in full dose of gr. x-xv. at the incep- tion may arrest the attack. Iodide of potassium gr. v , tartar emetic gr. ss., syrup of orange peel oz. j., water oz. iij.— M. Sig.: Teaspoonful doses hourly for children. Warm foot=bath before going to bed. Turkish bath is useful in chronic catarrh. Carbolic acid is of great value by inhalation of vapor and spray. CATARRH, CHRONIC NASAL.— Alum in powder, may be insufflated. Iodoform and tannin may also be applied by insufflation. Iodine in vapor may be in- haled. Ethyl iodide five to twenty drops put on a handkerchief inhaled every three hours. Sanguinaria ten drops of the tincture t. i. d., and the local ap- plication of the powder. Cubeb in powder by insufflation. CATCH IN THE BREATH.— Cold sponging night and morning will improve or even cure this curious complaint in infants. CHANCRE. — Eucalyptol with iodoform may be applied to both kinds of sores. Iodoform may be dusted over soft chancres. Iodol dusted over sore is effective. Nitric acid applied by means of a glass rod or pine stick to the chancre is one of the most valuable caustics. Acid nitrate of mercury is the most efficient escharotic for the destruction of chancre which we possess. Carbolic acid may be applied pure in mild cases. Chlorate of potassium in powder is al.so an ex- cellent local application. Iodide of iron internally is valuable. CHANGE OF LIFE. — Aetata is one of the most useful remedies for many of the dis- tressing symptoms occurring at the change of life. Ammonia in the form of Raspail's sedative lotion to be applied to the painful part of the head in the headaches of this period. Bromide of potassium in gr. xx.-xxx. doses at bed- time, for the despondency with sleeplessness and irritability often also with heats, flushings and perspirations. Calabar bean for the flatulence of this period. Change of air and scene where other treatment fails. Eucalyptol for various symptoms as palpitations, flushings and flatulence. Iron the tincture of the chloride gtt xv. t. i. d. in fluttering of the heart with fullness of the head, heat and weight on the vertex, frequent flushings and hot and cold per- spirations. Nux vomica tinct. gtt. ij. and opium tinct. gtt. ij. combined t. i. d. are most useful. CHAPS. — Collodion is sometimes used but for chapped hands and lips glycerine of starch, arnica cerate or eau de cologne and glycerine better. Compound 654 A COMPENDIUM OF PRACTICAL MEDICINE. tinct. of benzoin and glycerine, equal parts, is the best remedy for chapped hands and lips and fissured nipples. Sulphurous acid and glycerine, equal parts, combined are most useful for chapped nipples. Vaseline and petroleum are effective. CHEST PAINS. — Iodine, as an ointment, in muscular pains of the chest. Bella= donna is better when the pain is in the skin. CHILBLAINS. — Sulphurous acid is an efficient application to chilblains, applied as follows: Acidi sulphurosi dr. iij., glycerine dr. j., aquas oz. iss.— M. Benzoin tincture applied locally is the best. Turpentine is efficient. Balsam of peru in ointment for broken chilblains. Capsicum tinct. painted over un- broken chilblains. Iodine tinct. or ointment is better painted over' the part. Carbolic acid may be used as follows: Acidi carbol. dr. j., tinct, iodi dr. ij., aciditannici dr. ij, cerat. simplicis oz. iv. — M. Sig. : Ointment. CHLOROSIS— Arsenic, gtt. iij. of Fowler's sol. t. i. d. after meals. Hypophos= phites of lime or soda may be given in grain doses, t. i. d. for some time. Iron reduced gr. v., t. i. d. gives excellent results. Iron may be given with man= ganese or arsenic or with aloes if constipation exists. Water of iron- spring most beneficial. Massage with inunctions of oil. Nux vomica may be com- bined with iron. Pepsin and pancreatin aid digestion. Galvanism and faradism to the central nervous system. CHOKING. — Bromide of potassium gr. iij. -v. t. i. d. to a child six years old, which, from the time of his birth, can swallow solids with ease, yet is choked every time he tries to drink. CHOLERA, ASIATICA.— Morphia, gr. x /%-\, hypodermically, of the greatest value even in the stage of collapse. Mercury in form of gray powder, gr. \ hourly is of the greatest service in infantile cholera. A starch injection with a minute quantity of laudanum assist the gray powder. Arsenic, Fowler's sol. with opium of service. Camphor gtt. iv.-vj. of the strong spirit, every ten minutes at first then hourly. Chloral combined with morphine as follows: Chloral hydratis dr. iij.. morph. sulph. gr. iv., aqua; laur-cerasi oz. j. — M. Sig.: Fif- teen to thirty minims. Chloroform a few drops frequently to stop vomiting. Calomel, minute doses (gr. 2V) every hour will sometimes stop vomiting. AI= cohol in form of iced brandy to stop vomiting. Acetate of lead with opium and camphor as follows: Plumbi acetat. grs. xxiv., pulv. opii grs. xij., pulv. cam- phors dr ss., sacch. alb. q. s., Ft. pulv. no. xij. Sig.: One powder every hour. Chlorodyne very effective. CHOLERA flORBUS.— Horphine and atropine (gr. i and gr. 1-120) hypodermically is the most efficient remedy. Chloral with morphine if cramps occur. Carbolic acid and bismuth as follows: Acidi carbolici grs. iv., bismuthi subnitrat. dr. ij., mucil. acaciae oz. j., aqua? menth. pip. oz. iij. — M. Sig.: A tablespoon- ful every three hours. CHOLERA INFANTUM.— Carbolic acid is very effective. Bismuth subnitrate, gr- iij. every two hours. Calomel in minute doses arrests vomiting. Oxide of zinc given in the following formula: Bismuthi subnitrat dr. iss., pepsinae sacch. dr. ss., zinci oxidi grs. vj-grs. xij. — M. Ft. pulv. no. xij. Sig.: One powder every four to six hours. Brandy is serviceable. CHORDEE.— Camphor, ten to twenty grains very successful. Potassium bromide dr. j., every four hours. Cantharides tinct. one drop thrice daily. Aconite tinct one drop each hour. Morphine gr. £ and atropine gr. 1-150, hypoder- mically will most certainly relieve. Tartar emetic will relieve if carried to nausea. Tobacco wine a few drops at bed-hour. CHOREA.— Cold effusions and cold bath. Cod=liver oil when the nutrition is poor. Iron may be given for the anaemia. Arsenic, Fowler's sol. gtt. iij. to x. t. i. d. very successful. Chloroform inhalation t. i. d. in severe cases. Strychnine in increasing doses until stiffness of the muscles of the neck and spasmodic jerk- ings. Hyoscyamus gr. 1-50 daily. Morphine in large doses. Chloral at night is highly useful. Conium is said to be good. Sulphate of zinc pushed to nausea. Galvanism to the spine. CIRRHOSIS. — Iodide of sodium or ammonium in small doses t. i. d. before meals in first stage. Phosphate of sodium, dr. j., t. i. d. for a long time. Gold and sodium chloride in doses of gr. 1-10-1-20 t. i. d. seem to have curative power if given in time. Arsenic, Fowler's sol. gtt. v. t. i. d. retards or arrests the over- growth of connective tissue. CLINICAL IXDEX. 655 COLD=FEET. — Sponging with vinegar and water or hot and cold water alternately. Ice to spine. Strychinia gr. 1-60 t. i. d. to promote capillary circulation. COLIC. — For the flatulent colic of infants no remedy is better than mistura as- afoetidaj which may be given in teaspoonful doses. Chloroform a few drops frequently useful in flatulent colic and in hepatic. Ether internally and by inhalation. Camphor, a few drops of the saturated tinct. frequently. Morphine and atropine hypodermically the most prompt and successful. Hot fomenta= tions in all kinds of colic. COLICA PICTONUM.— Sulphuric acid diluted gtt. x. t. i. d. riagnesium sulphate to overcome constipation. Morphine and atropine for pain. Iodides and bro= mides in proper doses to cause excretion of lead. COLIC, HEPATIC— Morphine and atropine hypodermically for the pain. Phos- phate of soda dr. j. doses t. i. d. for a long time to dissolve the calculi and prevent the formation of others. CONDYLOMATA.— Calomel dusted over. Nitric acid dilute solution as a wash. Iodol dusted over. Iodoform powder applied freely. Carbolic acid undiluted applied to the part. CONJUNCTIVITIS.— Calomel dusted over the membrane. Bismuth in powder ap- plied directly. Ergot fluid extract, applied undiluted, very effective. Castor oil, a drop in eye, to allay pain. Yellow oxide of mercury gr. viij.-x. to oz. j. of vaseline is a most efficient remedy for granular lids. Zinc sulphate in the following formula is one of the best remedies: Zinci sulph. gr. ij.-iv., mor- phine sulph. grs. ij.-iv., atropine sulph. gr. ss., aqua? rosas oz. j. — M. Sig.: One drop in the eye t. i. d. CONSTIPATION. — Aliment as unbolted flour, corn-meal bread, fruits and vegeta- bles. Cascara sagrada in ten to fifteen minim doses t. i d. of the liquid ex- tract. Arsenic and nux vomica may be given. Faradizations of the intestines. Aloes with iron good in chronic cases. Saline mineral waters are effective. Podophyllum and the rhubarb and soda mixture very efficacious. Compound licorice powder in milk for children. Tobacco, a smoke after breakfast some- times efficient in habitual constipation. Enemata to unload the bowel, but habitually used is harmful. CONVALESCENCE. — Alcohol before or at meals in form of whisky or brandy. Fats, as cod-liver oil. Bitter tonics as gentian, colomba, etc. Lime water is useful. Pepsin and pancreatine are of service after meals. CONVULSIONS.— Ice should be applied to the head. Morphine gr. %, hypoder- mically in uremic or puerperal. Chloroform and ether by inhalation. Choloral gr. v. for children. Bromide of potassium in all forms. Warm bath for in- fants and children. CORNS. — For the cure of corns no application is so certain, prompt and efficient as liquor potassae. It should be applied by means of a pine-wood splinter to the summit of the corn and the tissue softened by it scraped off. By successive applications the callosity is removed without pain. COUGH. — Paregoric in teaspoonful doses every three hours to a child eight years old. Cod-liver oil in chronic coughs. Creasote in winter coughs. Glycerine and lemon juice are effective. CROUP. — Ipecac the syrup, in teaspoonful doses every half hour until vomiting is produced. Alum dr. j. in honey or syrup every fifteen minutes until vomiting is produced, flercury subsulphate in grs. ij.-v. is the most efficient emetic in croup. Quinine in large doses is highly useful. Carbolic acid in solution as a spray. CYSTITIS. — Alkalies to render urine neutral. Cantharides one drop of the tinct. t i. d. Laudanum and starch injected into the rectum relieves the pain. Pereira, dr. ij.-iij. of the liquid extract every three or four hours for chronic cystitis. DANDRUFF. — Borax saturated sol. for sponging the head several times daily. DELIRIUM TREMENS.— Acohol may be of great service. Potassium bromide in dr. j. doses for the "horrors." Chloroform by inhalation to procure sleep. DIABETES. — All saccharine and starchy foods must be excluded. The milk=cure has succeeded remarkably in some cases. Butter=milk may be better. Alka= line mineral waters are of great value. Codeine restrains the waste of sugar. Gold and sodium chloride is a promising remedy. 656 A COMPENDIUM OF PRACTICAL MEDICINE. DIABETES INSIPIDUS.— Ergot in large doses is the best remedy. Dry diet. Iodide of potassium has cured cases of syphilitic origin. DIARRHOEA.— Bismuth subnitrate in dr. ss. doses t. i. d. Chalk=mixture with opium in diarrhoea of children. Calomel in small doses. Castor oil in the early stage to carry away the irritant. Camphor with or without opium for summer diarrhoea. DROPSY. — Digitalis infusion in tablespoonful doses t. i. d. Saline purgatives in general dropsy. Iodide of potassium in some cases of Bright's disease. Dry diet and milk=cure. Nitro=glycerine in gradually increasing doses in cases of high vascular tension. DYSENTERY. — Salol is highly efficient in arresting intestinal fermentation. Fowler's sol. with opium. DYSMENORRHCEA.— Hot sitz=bath two or three times daily. Aconite and pul= satilla for the congestive form. Amyl nitrite by inhalation, affords relief quickly. Gelsemium and apiol give relief in the neuralgic form. Ergot may give relief. Morphine and atropine give prompt relief. DYSPEPSIA. — Milk=cure. Pepsin, ingluvin and pancreatine assist digestion in atonic dyspepsia. Muriatic acid after meals. Alkalies may be given after meals. Simple bitters may be gi/en with acids. Fowler's sol. drop doses, re- lieve irritative dyspepsia. Nux vomica and wild cherry useful stomachic tonics. Acohol in the form of wine in small quantity before meals. EAR=ACHE.— Morphina; sulphatis grs. iv., aqua; destil. oz. j.— M. Sig.: Fill the external meatus with the solution. Cocaine, four per cent, solution, one drop in the ear is the most effective remedy. Water as hot as can be borne, fill the external meatus. Counter=irritation by blister behind the ear often relieves. ECLAF1PSIA. — Morphine subcutaneously in uremic form. Chloroform by inhala- tion. Chloral grs. xx. every two hours. Potassium bromide in dr. ss. doses every two hours. Pilocarpine in small dose must be watched. Veratrum viride dr. ss. of the fluid extract every fifteen minutes until nausea or vomiting ensue. ECTHYHA. — Quinia in full doses often effects a cure. Cod=liver oil internally and externally. Iodoform, iodol and naphthol useful topically. ECZEMA. — Arsenic, Fowler's sol. gtt. iij.-v. t i. d. after meals in chronic form. Bismuth subnitrate as a dusting powder to surface. Salicylate in powder freely to eruption. Tannin in powder dusted over. Boracic acid mixed with starch as a dusting powder. Atropine internally in acute cases. Electricity (galvan- ism) in chronic cases. Iodoform and vaseline in dry stage. Milk diet exclu- sively. Lime water and glycerine equal parts locally. Oxide of zinc ointment sometimes beneficial. EMPYEHA. — Carbolic acid, a weak sol. to be injected after evacuation. Iodine solution to be injected after tapping to prevent reaccumulation of pus. Chlorine solution for washing out the cavity. ENDOCARDITIS.— Quinine, a 20 to 40 grain dose at the onset to check the inflam- mation. Morphine gr. % to gr. y 2 , hypodermically, will sometimes abort ser- ous inflammation. Salicylic acid may be given in the rheumatic form. The potassium salts liquefy the exudation. ENDOMETRITIS.— Undiluted carbolic acid is an efficient application to ulcers of the cervix uteri, chronic endo cervicitis and endo=metritis. It may be ap- plied undiluted without risk to the mucous membrane of the uterine cavity on the cotton-wrapped probe, after preliminary dilatation of the canal. There is probably no better means of treating uterine catarrh. Iodoform and tannin applied locally. Chronic acid (grs. xv. to dr. j. of hot water) has been injected into the uterine cavity with success. ENERGY, LACK OF.— The Turkish bath, like sea-air and sea-bathing, is a true tonic in this condition. EPIDIDYMITIS. — The oleates of mercury and morphia ten to thirty drops are suf- ficient for one application. It should be applied twice daily for five days, then at. night only for five days, and afterwards every other day until a cure is ob- tained. EPILEPSY.— Potassium bromide grs. xv.-xxx. t. i. d. for the diurnal variety. Chloral full dose at bed-time may prevent nocturnal attacks. Iron to prevent anaemia. Amyl nitrite inhaled when the aura is felt may prevent the seizure. CLINICAL INDEX. 657 Nitro-glycerine may prevent an attack if given in time. Nitrite of sodium in grs. xx. doses t. i. d. EPISTAXIS. — Aconite tinct. in small and frequent doses check nose-bleed in chil- dren and plethoric people. Alum in powder insufflated or a solution injected. Cocaine four per cent. sol. applied locally to nasal mucous membrane. Tannin in solution locally applied. Compression of the facial artery Spinal hot water bag and a hot foot-bath. Ergot in grs. ij.-v., hypodermically, to con- tract blood-vessels. EPITMELIOriA. — Carbolic acid applied undiluted to the cancerous sore and a syringeful of a five per cent. sol. injected daily beneath the new formation. Salicylic acid (pure) may be applied in powder. Boracic acid finely levigated applied in powder. Dried sulphate of zinc may be dusted over the affected surface. Chloride of zinc one part and flour four parts may be dusted over the surface. Potassium chlorate (powdered) is thickly applied over the sore, and is said to allay pain and remove fetor. ERUCTATIONS, OFFENSIVE.— Mineral acids to correct the oxaluria on which the eructations depend. ERYSIPELAS,— Aconite tinct. one drop hourly until fever is reduced in facial erysipelas. Belladonna tinct. five drops every two hours along with the aconite. This has a real curative power. Quinine in full doses. Tinct. chlor- ide of iron in large doses. Carbolic acid (one per cent, sol.) applied to surface frequently on lint. Iodine tinct. paint affected surface and surrounding skin to prevent spreading. Nitrate of silver eighty grains to dr. iv. of distilled water, to be applied two or three to the inflamed surface and two inches be- yond. ERYTHEMA. — Bismuth subnitrate dusted over surface allays irritation. Hydro- chloric acid diluted gtt. x. internally t. i. d. Zinc, alum and lead as lotions. Quinine in tonic doses for some time. EXOPHTHALMIC GOITRE.— Iron for the existing anaemia. Digitalis good in some cases. Ergot of service to raise arterial tension and slow the heart. Galvan- ism in uncomplicated cases is decidedly curative. FA1NTINGS. — Cold water sprinkled on the face. Ammonia to the nostrils. Brandy for feeble heart. * FEET, FETOR OF.— Calicylic acid in powder freely dusted over the feet and stock- ing- is very effective. Sodium bicarbonate a saturated solution locally. Po- tassium permanganate in solution will remove fetor temporarily. FELON. — Nitrate of silver a strong solution in nitrous ether applied over the part may abort it. Carbolic acid to benumb the surface during incision. FEVER. - Cold=baths. Tinct. aconite, one drop, tinct. belladonna two drops every hour until fever is reduced. Antipyrine grs. v. every two hours until three doses have been taken. Quinine in large doses. Phenacetine in grs. v. doses. FISSURE OF THE ANUS.— Forcible dilatation of the sphincter under an anaesthetic. Iodoform dusted well over the fissure. Cocaine to allay irrita- bility. Hydrastis the fluid extract applied undiluted. Bromide of potassium in five parts of glycerine locally. FISSURE OF THE NIPPLES.— Collodion applied to close fissure. Lime water as a lotion. A solution of iron subsulphate and glycerine applied with a brush to fissure. Tannin in powder to part. Tinct. of benzoin with glycerine. FLATULENCE. — Avoid sugar, starchy food and tea. Asafoetida one drachm of the tinct. to oz. iv. of water, a tablespoonful for adults. Bismuth and char- coal equal parts, ten-grain doses. Chloroform in drop doses every fifteen minutes. A tumbler of hot water between meals. Camphor as follows: Aqua? camphorae oz. iij., tinct. lavendulae comp. oz. j. — M. Sig.: A tablespoonful every hour. Turpentine gtt. iij. -v. on lump of sugar. FLUSHING HEATS.— Nitrite of amyl £ of a drop in five drops of rectified spirit t. i. d. Nux vomica tinct. and tinct. of opium, equal parts, four drops t. i. d. Bromide of potassium fifteen grains t. i. d. FRECKLES. — Biborate of soda, a saturated solution, is a safe and often successful lotion. The following lotion is useful: Potassi carbonatis dr. iij., sodii chloridi dr. ij., aquae rosae oz. viij., aquae aurantii flor. oz. ij. — M. Sig.: Lo- tion. GALL-STONES.— (See Biliary Calculi). 658 A COMPENDIUM OF PRACTICAL MEDICINE. GANGRENE. — Antiseptics, as carbolic acid, salicylic acid, resorcin, salol, iodoform and thymol are most effective. GASTRALGIA. — Arsenic one or two drops t. i. d. of Fowler's solution, is the most generally effective of all remedies. Chloroform two to five minims dropped on sugar and swallowed will relieve. Alum is useful in the cases with acidity and pyrosis. Injections of water under the skin over the epigastrium affords much relief. Bismuth, creasote and glycerine are useful. Nux vomica may remove the morbid state on which the pain depends. Morphine hypodermically s^.ops the pain at once. Galvanism has been successful. Diet is of great importance. GASTRIC CATARRH.— Arsenic is the most important remedy. The milk cure is ef- fective. The bitters, as calumba, gentian, nux vomica and cinchona infusion are useful. Bismuth and alum are of service. GASTRIC ULCER. — Bismuth allays pain and arrests vomiting. Fowler's solution in drop doses lessens pain and vomiting, riorphine and atropine arrest pain and vomiting, even in very minute quantity. Milk-cure may be tried. Rectal alimentation may be necessary. Silver nitrate in solution promotes healing and relieves pain. GLEET. — Blisters to the perinaeum are very beneficial. Iron when the subject is anaemic. Turpentine, juniper and cantharides tinct. may be tried. Bismuth half an ounce, glycerine half ounce and water three ounces, as an injec- tion t. i. d. GOITRE. — Electrolysis has succeeded in some cases. Red iodide of mercury oint= ment rubbed in, in the sunshine. Tinct. iodine injected into the gland applied locally. Iodide of potassium in ten grain doses internally. GONORRHOEA. — Avoid all alcoholic drinks. Alkalies to render urine neutral. Aconite tinct. one drop each hour in acute stage. Cantharides drop doses t. i. d. Bismuth with fluid ext. of hydrastis is one of the best injections. Chloride of zinc two grains to a pint of water injected hourly often removes the disease in twenty-four to forty-eight hours. Zinc sulphate two grains to an ounce of water injected three to six times daily. GUMS, AFFECTIONS OF.— Glycerite of tannin for spongy and bleeding gums. Alum for the same condition as above. Carbolic acid when fetor is present. Benzoin tinct. may be applied to the gums. H^EflATEMESIS. — Iron subsulphate and pernitrate solutions, one or two drops, well diluted with ice-water and frequently. Alum especially useful in passive. Lead acetate may be used in all conditions. Ergot may be used in doses of half- fluid drachm. Ice to be sucked and small pieces to be swallowed. Tannin may be used in solution. Turpentine in five to ten drop doses frequently. H/EMATURIA._ — Camphor two to five grains when bloody urine is due to drugs. Cannabias indica is said to relieve this condition. Ergot may be given by the stomach. Gallic acid is one of the most useful remedies. Quinine is effective in malarial haematuria. Turpentine in very small doses. H/EMOPTYSIS. — Common salt half teaspoonful taken dry and repeated till nausea is induced. Digitalis infusion in large doses useful. Ergot thirty to forty minims overy two or three hours. Ice to be sucked. Morphia in small doses hypodermically. Gallic acid and ergot bj r the stomach. Spinal hot water bag to cervical and upper vertebrae. H/EflORRHAGE, CEREBRAL.— Venesection or leeches when blood pressure is high and haemorrhage threatened or proceeding. Purgatives may be given. Frgotine, hypodermically, in two to five grain doses. H/EflORRHAGE, INTESTINAL — Ice should be applied to the abdomen. Frgotine two to five grains subcutaneously. Opium (laudanum) in doses of thirty minims to quiet intestinal movements. Turpentine in small doses frequently. Sulphuric acid diluted in ten drop doses. Tannic acid in solution and other astringents. H/EMORRHAGE, UTERINE.— Ergot, fluid extract, in teaspoonful doses. Ipecac carried to nausea is highly effective. Turpentine one drachm every three hours. MonsePs solution diluted, injected. Tincture opium in one drachm dose with brandy. Ice or hot water in uterine cavity. Acid sulphuric diluted, small doses frequently. H/EnORRHOIDS. — Nitric acid half to one ounce in half pint of water, as a lotion to bleeding piles. Bromide potassium one part to five parts of glycerine lo- cally to ease pain. Potassium chlorate half to one ounce of a saturated solution CLINICAL INDEX. 659 with ten drops of laudanum as injection to inflamed piles. Carbolic acid six grains, cocaine ten grains and glycerine one drachm. — M. Sig.: Inject ten minims into the tumor. HAY=FEVER. — Quinine is useful at the onset as a spray locally and later in tonic doses. Aconite is efficacious in the early stage. Ethyl Iodide by inhalation of service. Morphine is most beneficial in any stage. Cocaine to the nose, as a spray, is a very effective remedy. Potassium iodide ten grains at bed-time will often cut short the attack. Atropine in doses of a sixtieth of a grain when the secretion is profuse. HEADACHE. — Tea or coffee will relieve headache from nervousness or exhaus- tion. Belladonna three minims of the tincture every three hours, when pain is over brows and in eyeballs. Arsenic in three drop doses t. i. d. for neuralgic headache. Bromide potassium in thirty grain doses for sick or nervous head- ache. Sodium phosphate teaspoonful t i. d. in bilious headache. Acetanilid in five grain doses every thirty minutes until relieved or until three doses have been taken. HEART, DISEASES OF.— Horphine, hypodermically, in dilated heart and general dropsy therefrom. Iron is of great utility in the irritable heart of anaemia. Ergot is useful in dilated heart. Digitalis is remarkably beneficial in rapid ac- tion with low tension and valvular lesions. Bromide potassium in ten grain doses t. i. d. is useful for over-action and simple hypertrophy. Quinine in tonic doses for cardiac weakness. Atropine is a prompt cardiac excitant. Acohol in form of brandy or wine, when the heart is suddenly enfeebled by fright, loss of blood, accident, etc. Arsenic Fowler's sol. in three drop doses t. i. d. after meals, for breathlessness on exertion from weakly-acting heart. Strychnine in medicinal doses strengthens the heart beats. HEMIPLEGIA. — Strychnine by hypodermic injections into the paralyzed muscles most useful. Massage. Galvanism to brain and cord and faradism to the to the muscles if they waste HEPATIC DISEASES.— Chloride of gold and sodium is effective in sclerosis. Phosphate sodium is one of the most useful and certain cholagogues. Am= monium chloride is useful in catarrh of the bile-ducts. Rhubarb, aloes and podophyllum are effective. Nitro=muriatic acid is useful in ten drop doses t. i. d. in torpor of the liver. HERNIA.— Chloroform by inhalation to assist reduction. HERPES. — Morpha oleate applied locally in herpes zoster. Iodine liniment ap- plied once. Hot fomentations will often disperse the development of herpes labialis. Calomel and zinc ointments are curative. Galvanism in cases of herpes zoster. HICCOUGH. — Morphia grs. % hypodermically. Apomorphia gr. T V, hypoder- mically, will sometimes cure. Mustard one drachm infused in four ounces of boiling water has cured obstinate cases. HOARSENESS.— Turkish bath at the onset will cut it short. Borax the size of a pea dissolved in the mouth. Ipecac wine as a spray to throat. Alum as a spray, ten grains to an ounce of water. Nitric acid is highly effective in hoarseness of singers and reflex from the stomach in ten minim doses of the dilute acid. Atropine in hysterical aphonia. HYDROCELE. — Iodine tinct. injected into the sac after removal of the fluid. Carbolic acid and nitrate silver a strong solution injected in the same way. HYPOCHONDRIASIS Patassium bromide fifteen grains t. i. d. Gold and sodium chloride in gr. xWV doses 't. i. d. gives excellent results in the hypochondria of the aged. Laudanum in small doses is a remedy of the first importance. Arsenic gives good results in the aged. Asafoetida in cases with flatulence. HYSTERIA.— Cod=liver oil and the "rest cure " are useful. Aconite tinct. for flut- tering of the heart in nervous persons. Potassium bromide in large doses pre- vents paroxysms. Opium, a drop of laudanum with two of the tinct. of nux vomica four times daily for weight on head and flushings. Valerian useful IMPETIGO. — Quinia in tonic doses very efficient. Mineral acids in cases of indi- gestion. Zinc ointment applied relieves. Sulphur internally is of service. Poultices may be applied at night to remove scabs. Glycerine of tannin is a good application. Sugar of lead in solution may be applied. IMPOTENCE. — Strychnia in large doses sometimes useful when spermatorrhoea ex- ists. Cantharides tinct. in twenty to thirty drops t. i. d. with iron and nux 660 A COMPENDIUM OF PRACTICAL MEDICH5TE. vomica very useful. Cannabis indica and phosphide of zinc stimulate the func- tion. Ergotine a hypodermic injection about the dorsal vein of the penis. Ergot by the stomach increases the vigor of the erections. Gold and sodium chloride increase sexual activity in gr. ^ t. i . d. INCONTINENCE OF URINE.— Belladonna tinct. ten to twenty drops t. i. d. is the best remedy for children. The child should be waked at midnight to pass water. Ergot said to be useful when due to paresis of bladder. _ Iron syrup of the iodide in ten drop doses t. i. d. in anaemic subjects. Collodion painted to form a cap over end of prepuce. Chloral is sometimes effective in children. Strychnia good in old people with paralysis of the bladder. Cantharides tinct. two drops t. i. d. INDIGESTION.— Acid hydrochloric ten minims t. i. d. of the diluted acid. Lactic acid good in atonic dyspepsia and indigestion. Alcohol in small doses is an ex- cellent stomachic tonic. Bismuth for painful indigestion and nausea. Aloes in indigestion with torpor of large intestine and pasty motion. INSOMNIA. — Potassium bromide in thirty grain doses at bed-hour. Paraldehyde thirty to fifty minims is said to be very effective. Chloral is the most direct and generally useful hypnotic in fifteen to twenty grain doses at bed-time. florphine and atropine hypodermically is the best sleep producer in cases of pain, mania, and melancholia. Alcohol is efficient when due to cerebral anaemia. Warm bath at bed- hour often succeeds. INTERTRIGO.— Bismuth subnitrate dusted over the surface. Tannin in powder is a useful application. Zinc ointment is very efficient in some cases. INTESTINAL CATARRH. — Ammonium chloride five grains t. i. d. is a valuable remedy. Salol is a useful drug into three to five grain doses t. i. d. after meals. Bismuth is one of the best remedies. Calomel in minute doses fre- quently is of great service. Hydrastis is a useful drug in this condition. IRITIS. — Atropine two to four grains to the ounce, a drop or two in the eye, four to six times daily to prevent adhesions. Eserine to break up adhesion and di- minish intra-ocular tension. Mercury in specific iritis. JAUNDICE. — Mercury, in form of gray powder, gr. | four times daily at the onset, is very valuable. Calomel in small doses gives good results. Benzoic acid, to remove bile from the system. Sodium phosphate, a teaspoonful t. i. d. very useful. Skim=milk cure. Ammonium chloride gr. v. t. V. d. is beneficial. Nitro= muriatic acid dil. in ten minim doses t. i. d. Rhubarb, aloes and podo= phyllum are excellent remedies in this condition. JOINTS, DISEASES OF. — Blisters, a succession of them about the joints, in cases of synovitis. Nitrate silver, grs. xx. to an ounce of nitrous ether, is an efficient application to check inflammation. Oleate of mercury and morphine rubbed into the joint is of great service in inflammatory affections of joints. Galvan= ism and massage are highly useful. LACTATION. — Atropine, four grains to the ounce of rose water, applied on lint to the gland to arrest secretion. Phosphate of lime is highly useful in the debility of lactation. LARYNGITIS.— Aconite tinct. in small doses frequently. Tannin and glycerine applied to the throat. LEUCORRHOHA. — Bicarbonate of potash, or soda one drachm to a pint of water when discharge is alkaline. Carbolic acid, one drachm to a quart of water. Alum, one drachm to a pint of water, is a useful injection. Zinc sulphate may be used also. Iodoform and tannin packed about the cervix is highly useful. Acetate of lead properly diluted is an excellent local application. Bismuth may be combined with fluid extract of hydrastis. LICE. — Bichloride of mercury solution destroys lice on all parts of the body. All the essential oils will destroy lice. LUMBAGO. — Chloroform, a few drops injected deeply, is remarkably beneficial. Galvanism usually effects a cure. Faradism is sometimes useful. Morphine, hypodermically, affords prompt relief. Heat to the back for three hours. Massage is curative in some cases. MENORRHAGIA. — Ergot is very useful in all forms. Gallic acid sometimes suc- ceeds well. Potassium bromide in fifteen to thirty grain doses t. i. d. often arrests promptly. Cinnamon, the oil in drachm doses given several times daily, is highly recommended. CLINICAL INDEX. 661 MYALGIA.— Massage will usually do good. Galvanism will surely cure. Faradism may succeed. Acetanilid is an efficient remedy. Laudanum, applied with friction, gives relief. NEURALGIA.— Morphine, hypodermically, is the most efficient remedy for the relief of pain. Galvanism is the most decidedly curative agent. Hassage gives much relief. Iron, for the existing anaemia. Bromide potassium is useful in some cases. Arsenic will benefit some cases. Strychnine long continued in depressed states of the nervous system. Anaesthetics promptly relieve. Ace- tanilid will relieve in some cases. OBESITY.— Acids, alkalies, bromides and potassium permanganate will promote destructive metamorphosis. ORCHITIS.— Mercury, the oleate painted over. Ice in a bag kept applied. Iodine tinct. locally applied. Nitrate of silver in nitrous ether painted over. PARALYSIS.— Strychnine, injected into the muscular substance, is of the greatest utility in all forms of paralysis, but must be used after local trouble in the nerve-centers have subsided. Phosphorus should be given to restore nerve- matter, and in hysterical paralysis. Cod=liver oil is useful to restore nervous matter. Ergot is useful in some cases. Iodide of potassium in paralysis due to gumma. Galvanism and faradism are first in importance in the treatment of paralysis. Massage is an important adjunct to other kinds of treatment. PEMPHIGUS.— Arsenic, Fowler's sol., five drops t. i. d. after meals, for chronic form. Belladonna tinct., five minims t. i. d. for the acute. PERITONITIS. — Morphine, hypodermically, is the most efficient drug. Must be given freely. Quinine in full closes at the onset. Turpentine when there is tympanites, especially useful in puerperal peritonitis. Aconite for the fever at onset. Locally, ice-bag to abdomen; counter-irritation; heat; poultices; leeches. PERSPIRATION, EXCESSIVE.— Belladonna, as a liniment, locally to the affected part, and tinct. internally. Ergot is said to arrest sweating. Picrotoxin, a minute dose, will stop for several nights the sweats of consumption. Atropine for " night-sweats." Pilocarpine in ^ grain doses thrice daily. Oxide of zinc in two grain doses nightly to control profuse colliquative sweating. PHARYNGITIS. — Silver nitrate two grains to the ounce of water is effective in many cases. Tannin locally, in powder or solution. Hydrastis is an excellent topical application. It may be taken internally in doses of five to ten drops t. i. d. SALIVATION.— Alcohol diluted as a gargle. Iodine two drachms of the tincture to eight ounces of water. Acids in small medicinal doses as astringents. Bro- mide of potassium very beneficial in salivation of pregnancy. SCABIES.— Carbolic acid locally to destroy the parasite. Sulphur after a warm bath with soap and water, rub in ointment composed of two parts of sulphur, one of carbonate of potash and eight of lard. Clothing, submit all clothing which cannot be boiled to a temperature between 250° and 300°. Sulphate of copper used as a lotion is successful. SCIATICA.— Methylal a twenty per cent, mixture with oil, rubbed in along the nerve is effective. Morphine hypodermically. Chloroform and ether injected deeply in old cases is beneficial. Poultices applied very hot. Galvanism very effective. Nitrate of silver inject ten to twenty drops of the solution deeply near the affected nerve. Aquapuncture is much used recently. SCLERODERHA Cod=liver oil an important remedy. Galvanism (central) is recommended. Phosphates and hypophosphites with or without cod-liver oil. SCROFULA.— Calomel ointment to sores The Phosphates are very beneficial to im- prove the nutrition. Iron long continued is useful. Tinct. of iodine applied over scrofulous glands. Cod-liver oil is of great service. Chloride of calcium in ten to twenty grain doses in milk after food is effectual in enlarged glands and chronic diarrhoea. SEA-SICKNESS.— Chloral fifteen to thirty grains every four hours. Spinal ice- bag sometimes of service. Nitro glycerine has been recommended. Chloro- form one drop by the stomach frequently repeated. Bromide of soda one-half to one drachm taken before embarking is the best remedy. Morphine in small doses hypodermically. Nitrite of amyl inhaled for prevention. Nitro-glycer- ine by the stomach is useful. SLEEPLESSNESS.— (See Insomnia). 662 A COMPENDIUM OF PRACTICAL MEDICINE. SNEEZING. — Iodine inhalations in sneezing with itching of nose. Camphor inhal- tions or the powder sniffed up the nose is useful in sneezing- with running from nose and eyes. Arsenic one drop of the liquor three times a day in sneezing of asthma Iodide of potassium ten grains several times daily. SORE-FEET. — Washing soda, one tablespoonful to one-half gallon of warm water as foot-bath. SORES. — Alum in powdered form to secreting sores. Iodoform is good used as a dusting powder over all forms of sores. Opium and glycerine as an applica- tion for pain. Sulphate of zinc is applied locally to sloughing sores with bene- fit. Carbolic acid, boracic acid and salicylic acid are applications of great value as antiseptics, deodorants and alteratives. Potassa chlorate in powder is remarkably beneficial. Camphor as a dusting powder is effective. SPERMATORRHOEA.— Nux vomica is useful as a tonic. The tincture of the chloride of iron and arsenic are remedies of value when anaemia is present. Belladonna, one-fourth grain of the extract with one and one-half grains of zinc sulphate three times a day is often of use. Camphor in large doses may be used with benefit. SPRAIN.— Cold douche with salt added is beneficial to relieve stiffness. STINGS. — Weak solutions of ammonia are effective. SUN=STROKE. — Cold douche when patient is struck down unconscious. SWEATING. — Atropine is very efficacious in sweating of phthisis, one-sixtieth of a grain at bed-time. Oxide of zinc is very effective in night-sweats of phthisis. Oxide of zinc three grains and one-half grain of belladonna, given at bed- time. Picrotoxin from one hundred and eightieth to one-sixtieth of a grain, has been very successful. Pilocarpine in one-twentieth of a grain doses thrice daily, is often useful. Sponging with acidulated water, often effective. SYNOVITIS. — Blisters every night are useful. Cod=liver oil is useful if patient is debilitated. Iodine, applied to joint in chronic cases, flassage may be tried. Nitrate of silver in nitrous ether may be applied to the joint. Mercury and Morphia, oleate of, applied locally. TETANUS. — Bromide of potassium in large doses, one drachm every three or four hours is a remedy of great value. Morphine injected into the affected muscles gives relief. Paraldehyde given in sufficient quantity has often proved suc- cessful. The maximum dose (two and one-half drachms) has been given with- out ill effect. Chloral in large doses is of great value. Ether spray to spine every two hours. THIRST. — Hot drinks are of service. Ice, allowed to melt in the mouth, is useful. Acid drinks are effective to allay thirst in fevers. THRUSH. — Boracic acid solution mixed with honey (|) is very useful. Sulphur= ous acid solution, strong or diluted, applied locally. Salicylic acid, one part (dissolved in alcohol) to 250 of water. TOE NAIL, INGROWING. — Liquor potassaj, two drachms to the ounce of water. A piece of cotton saturated with the solution is pressed under the ingrowing nail, repeated each morning; the nail becomes thin and can be pared away without pain. TOOTHACHE.— Opium or morphine (solution) dropped in the cavity. Oil of . cloves, carbolic acid or resorcin in the decayed tooth are effective. Carbonate of soda (a saturated solution) held in the mouth stops the pain. ULCERS.— See Sores. URTICARIA.— Chloroform ointment for the itching. Nitric acid, diluted, as a wash for itching. Alkaline washes should be used. Warm baths. VOMITING. — Alum in six to ten grain doses in obstinate vomiting of phthisical patients. Nux vomica and ipecac are useful when tongue is coated, riorphine hypodermically. Mercury as gray powder, one-third of a grain every two hours. Lime water and milk in vomiting of infants. Chloroform, in drop doses. Bismuth, ten to fifteen grain? every two hours, very effective in vomit- ing caused by gastric disturbance. Champagne or brandy, iced, in small doses frequently repeated, often useful. VULVITIS.— Lime water, locally. Alum, sixty grains to a pint of water, every two hours, as injection. Glycerine of Tannin can be used with advantage. WARTS. — Mercury, nitrate of, locally applied. Arsenious acid as caustic. Chromic acid, a solution of 100 grs. to the oz. applied carefully with a glass rod CLINICAL INDEX. 663 to growth; dress with dry lint. Nitric acid one drachm or two of the dil. acid to a pint of water, as wash to keep warts constantly moist. WHOOPINQ=COUQH.— Belladonna, ten minims of tinct. each hour, to child three years old, especially during- third week if no complications. Chloroform or ether to lessen violence of paroxysms. Carbolic acid inhalations are some- times useful. Castanea, fluid extract in doses of one drachm t. i. d. WORMS. — Iron, tincture of the chloride, one-half ounce in a pint of water, a good injection for thread worms, coagulating the albumen. Common salt, weak solution injected into the rectum for thread worms. Potassium bromide, five grain doses, t. i. d., in convulsions caused by worms. Areca nut, a half or Whole nut is to be powdered and mixed with some syrup and swallowed for tape- worm. Chloroform in drachm doses taken in the morning, fasting, for tape- worm. Lime water injection for thread worms. Santonin, five grains for adults at bed-time for round worm. Turpentine as a poison to tape and thread worms. RBB BIUU. Administration of aneesthetics $ 5 to § 10 Consultation visits S to SO Examination for life insurance 3 to 10 Office prescription- .. .50 to 2 Expert testimony (medico-legal) per day. - -. 10 to 50 Thorough examination in office 5 to 10 Microscopical examination of urine. 2 to 10 Urine tested chemically 2 to 10 Day visit in city 1.50 to 3 Night visit in city . 2 to 5 Country visits, extra per mile 1 Vaccination -- .50 to 1 Visit in case of poisoning _ 5 to 10 GENITO URINARY AND VEN- EREAL DISEASES. Gonorrhoea (in advance) $ 15 to $ 20 Syphilis (in advance) - 25 to 100 Sounding for stone in bladder 10 to 20 Removing stone in bladder 50 to 200 External urethrotomy -.- 50 to 250 Internal urethrotomy 25 to 75 Urinary fistula 50 to 100 Aspirating the bladder 20 to 50 Circumcision - 25 to 50 Varicocele 20 to 75 Tapping of hydrocele 10 to 15 Radical cure of hydrocele 25 to 75 Phimosis or paraphimosis . 10 to 25 OBSTETRICS AND GYNECOLOGY. Labor, ordinary cases ..$ 10 to 3 30 Abortions 10 to 50 Instrumental delivery, additional.-- 10 to 15 Delivery of placenta 5 to 10 Consultation 10 to 15 Embryotomy __. 25 to 50 Perineorrhaphv (primary) 10 to 30 Perineorrhaphy (late). 25 to 100 Laparotomy. 50 to 200 Ovariotomy 50 to 200 Hysterectomy 150 to 500 Hysterorrhaphy.. 100 to 300 Amputation of cervix 50 to 100 Colporrhaphv 50 to 100 Trachelorrhaphy.. 50 to 100 Alexander's operation 50 to 150 Curetting 25 to 75 Removal of polypi 25 to 75 Removal of tumors of labia . 20 to 50 Removal of urethral caruncle 25 to 100 Colpocleisis - 50 to 150 Examination by speculum 5 to 10 Endocervicitis, operation for.. 25 to 50 Intrauterine douche 5 to 15 Fitting of pessary 5 to 15 Replacement of uterus 5 to 15 Vesico-vaginal fissure, operation for 50 to 100 Dilation of cervix in stenosis 15 to 25 Atresia of vagina, operation for 50 to 150 OPERATIVE SURGERY. Laparotomy $ 75 to $200 Hemorrhoids, internal 25 to 75 Hemorrhoids, external 10 to 50 Hare-lip... 25 to 100 Excision of mammary gland 50 to 100 Trephining 100 to 200 Removing large tumors 100 to 300 Removing small tumors 30 to 100 Staphylorrhaphy 50 to 100 Nephrectomy 100 to 250 Necrosis Ol bone 25 to 50 Fistula in ano 25 to 50 Radical cure of hernia .... 100 to 150 Strangulated hernia 100 to 200 Strangulated hernia (reduced by taxis).. 25to 50 Polypus of rectum 25 to 50 Anal fissure 25 to 50 Hernia (Warren's operation) 25 to 75 Varicose veins (radical cure) 25 to 50 Aspiration of joints... 25 to 40 Selecting and adjusting truss 5 to 10 AMPUTATIONS. Knee $ 50 to $200 Hip-joint.. lOOto 200 Leg 50to i50 Foot _ 50 to 75 Toes... 25 to 50 Thigh lOOto 150 Shoulder-joint -. 100 to 150 Arm --_ _. 50to 100 Hand 40 to 75 Finger... 15 to 30 DISLOCATIONS. Shoulder ...$ 50 to $ 75 Hip, 50to 100 Knee 25 to 75 Ankle... 25 to 50 Arm.. _ 25 to 50 Maxillary bones.. 25 to 50 Wrist... 25 to 40 Toes... - lOto 25 Fingers 10 to 25 FRACTURES. Scapula S 25 to $ 50 Femur 50 to 100 Fibula 25to 50 Leg (both bones) 50 to 75 Ribs.... 25to 50 Humerus 25 to 50 Radius or ulna 25 to 50 Elbow-joint '. ., 25 to 50 Nose 25to 60 Smallbones - 10 to 25 Forearm (both bones) 50 to »75 Coracoid or coronoid process 25 to 50 ^Clavicle - 50 to 75 RESECTIONS. Ankle-joint or foot S 50 to S 75 Elbow $ 50to 75 Femur (head of)... 100 to 200 Knee 75 to 100 Shoulder 75 to 100 Maxilla 50 to 100 Ribs 25to 50 LIGATIONS. Brachial artery $ 50 to $ 75 Subclavian or iliac artery 100 to 200 Axillary, femoral, carotid, popliteal or poterior tibial artery _.. 50 to 100 All other arteries - 20 to 40 EYE. Sclerotomy S 50 to $100 Strabismus (each eye) 40 to 100 Trachoma (each eye)..- 50 to 100 Canthotomy (each eye) 40 to 75 Opening lachrymal duct 25 to 50 Cataract 100 to 250 Artificial pupil (operation for} 50 to 100 Pterygium (each eye) 50 to 100 Tumor of lids 25 to 75 Enucleation - 100 to 200 Astigmatism . 25 to 50 Glass fitting 10 to 20 EAR. Polypus, removal of -.. --$ 50 to $ 75 Foreign bodies, removal of 10 to 40 Opening of mastoid bone 100 to 200 NOSE, THROAT AND CHEST." Nasal tumors 5 25 to $ 75 Deflected septum 50 to 100 Tonsil, excision of 25 to 75 Uvula, excision of 25 to 50 Tracheotomy 100 to 200 Laryngeal tumors 50 to 200 Adenoid vegetations 25 to ?5 Larynx, intubation of 50 to 100 Lungs, thorough examination of .. 5 to 10 COLUMBIA UNIVERSITY LIBRARIES 0048003980 ^t^Lt^T S 2S3.S"