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HUGHES' 

COMPEND OF PRACTICE. 



PHYSICIANS' EDITION. 



TO PHYSICIANS. 

The several essential qualities which a good Visiting 
List should possess are, compactness, convenience 
of arrangement, and strength to resist the unusual 
hard wear it receives. These qualities are all com- 
bined in Lindsay & Blakiston's Physicians' Visiting 
List, which has now been published for thirty-five 
years, and no better evidence of the practical worth 
of this book can be offered than the uniform increase 
in popularity it has enjoyed with each successive issue. 
One of its chief features is its size; it measures 
6^x3^ inches, and the smallest size weighs but 3^ 
ounces and is only ^ of an inch thick. The large 
sizes are a little thicker and heavier ; it is, however, 
the smallest and lightest Visiting List published. 
Our many years' experience have enabled us to put 
it together in the best manner. It is arranged for 
25^ 50, 75 and 100 patients per day or week, inter- 
leaved and plain, dated and undated. Prices range 
from Jli to JI3. Complete circular will be sent you 
upon application. P. Blakiston, Son & Co., Medi- 
cal Publishers and Booksellers, 10 12 Walnut Street, 
Philadelphia. 



COMPEND 



OF THE 



PRACTICE OF MEDICINE. 



BY 

DANIEL E. HUGHES, M. D., 

DEMONSTRATOR OF CLINICAL HBDICINB IN THE JEFFERSON MEDICAL COLLEGE, OF PHILA- 
DELPHIA ; FELLOW OF THE COLLEGE OF PHYSICIANS, 
OF PHILADELPHIA. 



PHYSICIANS' EDITION. 



BASED ON THE REVISION OF THE QUIZ-COMPEND EDITION, 

AND 

INCLUDING A VERY COMPLETE SECTION ON SKIN DISEASES. 









PHILADELPHIA: 

P. BLAKISTON, SON & CO., 

IOI2 Walnut Street. 
1886. 



Copyright, 1885, bt P. BLAKISTON, SON & CO., PniLADBLPniA. 



• • to 

• • * 






PREFACE 

TO 

THE PHYSICIANS' EDITION. 



The favor with which the " Compends of the Practice of Medicine," 
as published in the Quiz-Compend series, have been received, together 
with the knowledge that many practitioners have made use of them, 
suggested the advisability of preparing an edition especially for Physi- 
cians. To that end the Compends have been thoroughly revised and 
enlarged, by the incorporation of the more recent improvements in 
practice and the addition of a very complete section upon Diseases of 
the Skin ; which, with the addition of a complete index, and its publi- 
cation in one volume, renders it much more convenient for reference. 

The exceptional character of the advantages afforded the Author 
for clinical work, as Demonstrator of Clinical Medicine in the Jeffer- 
son Medical College, and also as Assistant-in-charge of the Medical 
Dispensary at the College Hospital for a number of years, together 
with his system of notes employed in the Quiz room during the past 
five years, have formed the basis of this Compend, which may there- 
fore be regarded as a full set of notes upon the Practice of Medicine. 

Free reference has been made to the latest writings and teachings 
of Professors DaCosta, Bartholow, Pepper, Flint, Loomis, Reynolds, 
Duhring, Fred. T. Roberts and others, to whom acknowledgment is 
here made. 

DANIEL E. HUGHES. 

December, iSSj, 



CONTENTS. 



PAGE 

INTRODUCTION 9 

FEVERS 12 

Continued. 13 

Periodical 23 

Eruptive 32 

DISEASES OF THE MOUTH 44 

DISEASES OF THE STOMACH .'. 50 

DISEASES OF THE INTESTINAL CANAL 62 

INTESTINAL PARASITES 87 

DISEASES OF THE PERITONEUM 91 

DISEASES OF THE BILIARY PASSAGES 96 

DISEASES OF THE LIVER .' 99 

DISEASES OF THE KIDNEYS 106 

ACUTE GENERAL DISEASES 127 

DISEASES OF THE RESPIRATORY SYSTEM 157 

DISEASES OF THE NASAL PASSAGES ;. 176 

DISEASES OF THE PHARYNX 181 

DISEASES OF THE LARYNX 185 

DISEASES OF THE BRONCHIAL TUBES 194 

DISEASES OF THE LUNGS ^ 212 

DISEASES OF THE PLEURA 234 

DISEASES OF THE CIRCULATORY SYSTEM 240 

DISEASES OF THE NERVOUS SYSTEM 267 

DISEASES OF THE SPINAL CORD 287 

DISEASES OF THE NERVES 298 

CEREBRO-SPINAL NEUROSES 303 

DISEASES OF THE BLOOD... 306 

DISEASES OF THE SKIN 315 

INDEX 391 



COMPEND 



OF THE 



PRACTICE OF MEDICINE. 



INTRODUCTION. 



The Practice of Medicine embraces all that pertains to the 
knowledge of, prevention and cure of, the diseases which the phy- 
sician is called upon to treat. 

Disease may be defined as a deviation or alteration in the func- 
tions, properties or structure of some tissue or organ, whereby its 
office is no longer performed in accordance with the natural standard ; 
Organic, when associated witS ^^fflfg^nic change in the affected part ; 
Functional, when the phenomefiijw^ndependent of any structural 
lesion. The study of disease, wheaHWBJjjganic or functional in char- 
acter, is termed Pathology, 

Pathologry explains the origin, causes; cli^ji^l history and nature 
of the morbid conditions to which the economy is liable. 

JEjtiologry» or the causes of disease, are twofold, to wit : Predis- 
posing and Exciting, 

Predisposition to disease signifies a special liability or suscepti- 
bility to its occurrence, and may be either hereditary or acquire^. 

Hereditary predisposition to certain diseases is also called \^/a^ 
thesis, to wit : the offspring of phthisical parents are said to be of & 

Phthisical Diathesis. "* 

•J 

Diathesis is a morbid constitution, predisposing to the develop- 
B , .9 «*^ 



10 PRACTICE OT MEDICINE. 

nient of a. particular disease, and may be eitlier inherited or ac 

Acquired predisposition is such as arises from 

I. Habits, lo wit: Strain upon the nervous system resulting i; 
3 diseases. 



IJ. Agi, to wit ; Children are very liable to catarrhal disorders. 
Young adults, to fevers, perverted sexual disorders, etc. 
Middle age, to heart and digestive disorders, cancer, etc. 
Old age. to degeneration of the vessels and heart. 
HI. Occupalion, to wit : Miners, weavers and cutlers, lung dis- 



t.lV. Stx,Xo^\\ 
Men, as 
V. Race, to ) 
malaria, 
xciting cause 



Women, emotional nervous diseases, 
nore exposed, rheumatism, pni 
it : Negro, phthisis and scrofula 



ipt from 



of disease are divided into those acting from 
■within and those acting from without. 

Causrs from ■milhin are the emotions, passions, etc., to wit : fear 
may produce chorea; anger has caused jaundice; worry, heart 
troubles. 

Causes from without axc/odd, air and li^hl. 

The Clinical History of disease includes all the symptoms and 
signs which may occur from the period of incubation until its final 



SymptomB are such alterations of the healthy functions that g 
evidence of the existence of a diseased condition or perverted func- 
tion, and may be either objective or subjective. Objective, when ev' 
dent to the senses of the observer, as redness or swelling. Subjeclivi 
when felt by the patient, as pain or numbness. 

The Period of Incubation is the interval between the entrance 
of the poison into the system and its manifestations, and seldom pre- 
sents recognizable symptoms. 

The Prodromes are the earliest recognizable symptoms ; a 
rigors or chill during the invasion of fever, and the various auri 
ceding an epileptic fit. 

Acute disease Is one in which the invasion is rapid, and, as a rule, 
severe ; when the symptoms develop less rapidly and are less intense 
the disease is said to be subacute ; when gradual or slow in develop- 
it the disease is said to be chroi. 




INTRODUCTION. 11 

Pathognomonic is the term applied to such symptoms as belong 
to one particular disease, and are therefore characteristic of it, to wit : 
the rusty sputum of pneumonia. 

Physical signs are, strictly speaking, objective symptoms. 

The Termination of a diseased action may occur in one of three 
ways, to wit : Cure, Secondary Processes, or in Death. 

Cure may occur by 

I. Lysis, or slow return to health. 

II. Crisis, abruptly, with a critical discharge. 

III. Metastasis, or changing from one location to another. 
Secondary processes is when the diseased action is substituted by 
a new morbid process, to wit : Rheumatism followed by endocarditis ; 
apoplexy by cerebral softening. 

By Death is meant a complete cessation of tissue change occurring by 
\, Asthenia, or an ever increasing debility, to wit: phthisis, 
cancer, Bright's disease.. 

II. Ancemia, or insufficient quantity or quality of blood. 

III. Apnoea, or non-aeration of blood, to wit : acute lung dis- 

eases, or croup. 

IV. Coma, death beginning at the brain, to wit : uraemia, narcotic 

poisoning, cerebral hemorrhage. 

Morbid or Pathologrical Anatomy is the knowledge of 
diseased structure or tissue changes. 

Diagnosis of disease implies a complete, exact and comprehen- 
sive knowledge of the case under consideration, as regards the 
origin, seat, extent and nature of all the morbid conditions. 

A direct diagnosis is made when the morbid condition is revealed 
by a combination of clinical phenomena, or some one or more 
pathognomonic symptoms. 

A differential diagnosis is the result when the diseases resembling 
each other are called to mind' and eliminated from each other. 

A diagnosis by exclusion is by proving the absence of all diseases 
which might give rise to the symptoms observed, except one, the pres- 
ence of which is not actually indicated by any positive symptoms. 

Prognosis of disease is the ability or knowledge to foretell the 
most probable result of the condition present, and involves an amount 
of tact or knowledge only acquired by prolonged experience. 

Treatment. The ultimate and most important object of the 
study of medicine, in a practical point of view, is to learn how to 



12 PRACTICE OF MEDICINE. 

cure, re/iiTe, or prevent disease, and it must be borne in mind that 
this does not consist solely in the administration of medicine, but 
requires strict and faithful attention to diet and hygiene. 

When the object is to prevent disease, to wit : smallpox by v; 
tion, it is called Propkylactic or Preventive treatment. 

When disease is to be broken up, although already begun, to wit : 
aborting the chill of malaria, it is called Abortive treatment. 

Wlien the disease is allowed to run its natural course without 
attempting its removal, but being constantly on the alert for obstacles 
to its successful issue, to wit: the generally adopted plan of treating 
continued fevers, it is called Expectant treatment. 

When the disease is incurable, and removal of marked suffering is 
the indication, it is called Palliative treatment. 

When marked weakness and prostration are to 
called Restorative treatment. 



Fever is a condition in which there are present the phenomena 
of rise of temperature, quickened circulation, marked tissue change 
and disordered secretion. 

The primary cause of the .fever phenomena is a disorder of the 
sympathetic nervous system giving rise to disturbances of the vaso- 
motor filaments. 

Rise of temperature is the pre-eminent feature of all fevers, and 
can only be positively determined by the use of the thermometer. 
The term feverishness is used when the temperature is gg" to 100° 
Fahr.; slight fever if 100° or 101"; moderate loz" or 103°; high if 
104° or 105° ; and intense if it exceed the latter. 

Quickened circulation is the rule in fevers, the frequency usually 
maintaining a fair ratio with the increase of the temperature. A rise 
of one degree Fahr. is usually attended with an increase of eight beats 
of the pulse per minute. 

The tissue waste is marked in proportion to the severity and 
duration of the fever phenomena, being slight or nil in febricula, and 
excessive in typhoid fever. 

The disordered secretions are manifested by the deficiency in the 



FEVERS. 13 

salivary, gastric, intestinal and nephritic secretions, the tongue being 
furred, and the mouth clammy, anorexia, thirst, constipation, and 
scanty, high-colored, acid urine. 

An Idiopathic or Essential fever is one in which no local 
affection causes the fever phenomena, although lesions may arise 
during its progress. 

A Symptomatic or Secondary fever is one dependent upon an 
licute inflammation. 

GENERAL TREATMENT OF FEVERS. 

1. Reduce the temperature. The cold bath or cold pack will do 
this most decidedly, but entails much labor and is not altogether free 
from danger, and so its use is advised only in severe cases. Cool 
sponging is of decided advantage. Quinina, in gr. xx doses repeated, 
is usually reliable. Antipyrin, gr. xx repeated, also recommended. 

2. Lessen the circulation. If the pulse is full, strong, and rapid, 
use aconitum. If the circulation is weak, either stimulants or digi' 
talis, or both. 

3. Attend to the secretions. Remove the waste of the tissues by 
diuretics, diaphoretics, and, if particularly indicated, laxatives. The 
free use of water is beneficial in promoting the various secretions. 

, 4. Nourish the patient. '* Do n't starve a fever.** Administer 
milk, beef-tea, and other light nutritious food, in small quantities, but 
at frequent intervals. 

CONTINUED FEVERS. 

All continued fevers are characterized by a steady progress of the 
febrile movement, without either a too decided rise or fall in the tem- 
perature to modify the impression of a continuous action. 

SIMPLE CONTINUED FEVER. 

• 

Synonyms. Irritative fever ; febricula ; ephemeral fever ; synocha. 

Definition. • A continued fever, of short duration, mild in charac- 
ter, not due to a specific cause, rarely fatal, but when death does 
occur, presenting no characteristic lesion. 

Causes. Fatigue, mental and physical ; exposure to heat ; ex- 
cesses in eating and drinking ; excitement and violent emotion. 
Most common in childhoodr 



PRACTICE OF MEDICINS. 

Symptoms. An abrupt feeling' oi lassitudf, followed by a de- 
cided ckillox chi/iiness, a sudden and rapid ri'Ji? ef lemperature,qu\i:\t., 
tense pulse, headache, dry skin, intense thirst, coated tongue, and scanty, 
high-colored urine. Cases due to errDrs in diet are accompanied by 
nausea and vomiting ; those in childhood, due to excitement, fright or 
emotions, may have slight convulsions. The temperature may, within 
an hour or two, reach loj" F. or more, when slight delirium may occur. 

Duration. From twenty-four hours to six or seven days. Never 
exceeding ten days. 

Termination, Within a few hours, to a day, the temperature 
rapidly falls to the norm — {crisis) ; or it maycontinue for several days 
gradually falling — {lysis). Herpes about the lips and nostrils are 
often observed at the close of an attack. Convalescence is rapid. 

Diagrnosis. Unless the fever can be attributed to some one of 
the causes that give rise to it, a doubt as to its character may exist for 
the first twenty-four hours, after which time it can hardly be mistaken 
for any other disease. 

Prognosis. Recovery, without sequela, the rule. 

Treatment. Very little medicine. Rest in bed, A full dose of 
hydrargyri chtorid. mile, or an enema, sponging the surface with cold 
water, and the administration of saline diaphoretics and diuretics. If 
there is great arterial excitement aconitum may be added. Ughl liquid 
diet is most agreeable. Cases in which the nervous symptoms are prom- 
inent do well on Fothergill's " fever mixture of the fjiture," lo wit; — 

R. Acid, hydiobroro f,^s*-j 

Syr. simplicis I^.?^^ 

A'[UK f3ii~''j* M. 

SlG. — Evety four hours. 
Quinina sulphas in tonic doses during convalescence. 

CATARRHAL FEVER. 

Synonj'niei Influenia; epidemic catarrhal fever; contagious 
catarrh. 

Definition. A continued fever, occurring generally as an epi~ 
demic ; due to a specific cause ; characterized by a catarrhal inflam- 
mation of the respiratory organs, and sometimes of the digestive ; 
always accompanied by nervous phenomena and marked debility. 

Causes. A specific vegetable germ, uninfluenced by soil, climate 
or atmospheric changes. 




I 



FEVERS. 15 

Symptoms. The onset is sudden, a chill followed hy fever, the 
temperature reaching ioi° to 103°, a quick, compressible pulse, and 
severe shooting pains in the eyes, frontal sinuses, joints and muscles. 
The chill and fever are rapidly followed by chilliness along the spine, 
pain in the throat, hoarseness, deafness, coryza, sneezing, injected, 
watery eye, and a dry, irritative, laryngeal cough, sometimes becoming 
bronchial. The tongue is furred, there is anorexia, epigastric distress, 
nausea, vomiting, and ofttimes diarrhoea. In some epidemics the 
digestive symptoms are the most prominent, when dysentery may occur. 

The above symptoms are always associated with decided weakness 
and debility. Delirium is rare, but marked hebetude and cutaneous 
hypercBsthesia are common. 

Duration. Four to seven days, with protracted convalescence. 
Relapses frequently occur. 

Complications. Lobar or catarrhal pneumonia frequently occurs, 
which adds to the gravity of the attack. The cough may outlast the 
disease several weeks. 

Diagnosis. Isolated cases may be mistaken for a " bad cold.** 
But when epidemic, the sudden onset, marked general catarrh and 
decided prostration should prevent error. 

Prognosis. Recovery is the rule when it occurs in the healthy 
and vigorous. Grave when the very young, very old, or those suffer- 
ing from organic disease, such as Bright' s disease, fatty heart, or em- 
physema, are attacked. 

Treatment. No specific. Support the system and treat indica- 
tions. The catarrh, pains and cough are at least ameliorated by the 
following : — 

R. Quininae sulph... grs. ij-iv 

Morphinae sulph gr. -^^ 

Aquae lauro-cerasi ^ 3J. M. 

SiG. — Every four hours. 

and the frequent inhalation of tinct. benzoin, comp,, ^ss-j., agues 
bul. Oj. 

If the bronchial symptoms become troublesome, use — 

K. Ammonii muriat grs. x 

Mist, glycyrrh. comp ^\]. M. 

p. r. n. 

Should Pneumonia occur treat as an ordinary case, but never de- 
press. 



PRACTICE OF MEDICINE. 



TYPHOID FEVER. 



Synonyma. Enteric fever; gastric fever; nervous fever; ente 
mesenteric fever ; abdominal typhus. 

Deflnition. An acute, self Umited,/<'i"yt affection. Axit:a a. special 
poison; characteriiied by insidious prodromes; epistaxis; dull headache 
followed by stupor and delirium ; red tongue, becoming dry, brown, 
and cracked; tympany, abdominal tenderness, and early diarrhcea; 
a peculiar eruption upon the abdomen ; rapid prostration and slow 
convalescence; a constant lesion of Peyer's patches, the mesenteric 
glands and the spleen. 

Causes. Predisposing and Exciting. Predisposing are Age, 
wit, young adults; and Season, to wit, a hot and dr%' autumn. 

The Exciting cause is a special typhoid germ. The poison usually 
results from the decomposition of typhoid stools, although it has been 
demonstrated that the disorder may be generated under certain un- 
determined circumstances, de novo, from ordinary filth and decompo- 
sition. Klebs claims to have identified a specific "typhoid bacillus." 

Pathological Anatomy, The characteristic lesions of typhoid 
fever consist in certain changes in the Peyerian patches and solitary 
glands, which may be divided into well defined stages, lo wit: 
Swelling from proliferation of their cellular elements. II. Sloughing 
and Ulceration. III. Cicatrisation, or in rare cases. Perforation. 

Tht Mesenteric glands hccamc infiltrated, enlarged and softened, 
but seldom ulcerate. 

The spleen also enlarges and softens. There is besides, parenchy- 
ttiatous degeneration OT granular changes in al\ the tissues of the body. 

Symptoms. Stage of Prodromes — The onset is insidious, with 
malaise, vertigo, headache, disordered digestion, disturbed sleep, 
epislaxis, depression, and muscular weakness, followed by a. chill o 
chilliness. 

First Week dates from onset of the fever, when are present increas- 
ing temperature, frequent pulse, coaled tongue, nausea, diarrhceat - 
headache, and upon the seventh day a Jew reddish spots resembling 
flea biles appear upon the abdomen, chest or back. 

Second Week, the foregoing symptoms are exaggerated ; fever ci 
tinuous, frequent and compressible pulse, tympanitic tender abdomen, 
gurgling in the right iliac fossa, nocturnal delirium, severe and con- 
stant headache and stupor, a short cough, with distinct bronchial r&les 



FEVERS. 

on auscultation, irregular muscular contractions [subsiiHus tendinuin), 
sordes upon the teeth and lips, the diarrlura continuing. 

Third Week. Fe%'er changes from continuous to remittent; the 
evening exacerbations continue as high as the preceding week, and 
all the symptoms remain about the same until near the end of the 
week, when they ameliorate. 

Fourth Week. The fever decidedly remits; almost normal in morn- 
ing, the pulse becoming less frequent and more fiiU, the tongue gradu- 
ally becoming clean, the abdomen lessens in size, the diarrhoia ceases, 
the patient passing into a slow convalescence, gready emaciated, which 
condition may continue for several weeks. 

Analysis of Symptoms. The temperature record of typhoid 
fever is a charaelsristic one. The fever on the morning of the first 
day may be stated at 98.5" F., evening 100.5°; second morning 99.5", 
evening [01.5°: third morning 100, j", evening 102.5°; fourth morning 
101.5°, evening 103.5°; ''^1' evening 104.5''. from that time i 
end of the second week, the evening temperature ranges between 
103° and los^ the morning temperature being a degree or more lower. 

Diarrhoea is the principal intesrinal symptom ; if atsent, die lesion 
is slight. The stools are at lirst dark, but early in the second week 
they become fluid, offensive, ochre-yellow, resembling " pea soup," 
and may be streaked with blood. They number from three to fifteen 
in the twenty-four hours. 

Eruption is almost constant. Consists of hotnfi've to twenty smaM, 
rose-colored spots on the abdainen. chest or back, sometimes on ll 
limbs, appearing in crops, lasting about five days, disappearing i 
pressure and at death. Returning with relapses. Eruption day 
from the seventh to the ninth. 

Rarely spots of a delicate blue tint — the "' taches bleuatres" 
French authors — are observed. 

Nervous symptoms are, pronounced headache, early and seve 
Dullness soon following, passing into drowsiness and stupor, w 
great prostration. Deafness pronounced. Si^ht impaired, in grave 
cases double vision. Delirium !ow and muttering, generally pleasant 
in character, always present in marked cases, 

ConvaUscente protracted. Great debility and anaemia, causing pro- 

GomplicatioilS. Intestinal hemorrhage may occur from the four- 
teendi Co the twentieth day ; a sudden decline of the teinj>erature to tlie 



18 PRACTICE OF MEDICINE. 

norm or below precedes the passage of blood by stool. TTie hemor- 
rhage is due to the erosion of a vessel during the ulcerative action. 

Ptr/ortifion makes the case almost hopeless. Pfritonitis without 
perforation adds to the gravity, but not necessarily fatal. Lobar pneu- 
monia, kyposlalic congtition and bronehitis are frequent occurrences. 
Albuminuria may occur, as may phlegmasia dolens. 

Belapses common. The symptoms all return abruptly; duration 
half the time of the original attack; occur at the end of the fourth or 
beginning of the fifth week. Not so fatal as might be expected. 

Dia^noeie. The typhoid condition differs from typhoid fever, in 
the absence oi diarrhira, eruption, and the characteristic temperature 

Enteritis has intestinal disorders alone. 

Peritonitis, abdominal symptoms only, with constipation. 

Acute miliary tuberculosis often mistaken for typhoid fever. 

Meningitis lai:ks the intestinal symptoms and fever record. 

ProgDOBiB. A positive one cannot be made. Favorable indica- 
tions are constipation, slight diarrhcea, low temperature and moderate 
delirium. 

Treatment. No specific. Intelligent nin-sing; pure air; quiet; 
disinfecting the uritie and the stools ; liquid diet at intervals of every 
hvo or three hours. 

The following remedies have advocates, claiming that they modify 
the course of the disease ; to wit : Hydrargyrum, iodum, acidum car- 
bolieum, mineral acids, argent, nitras, and ergota. 

The acid treatmetit consists in the administration of acidum nitro- 
hydrochloricum dilutum, r\ x-xx, well diluted, every four hours. 

The present popular so-called " specific treatment" of this disease 
consists in the administration every second evening, until four doses 
are taken, of hydrargyri clilor. mile, gr. vij-x, which seemingly 
lessens the frequency of the stools in the later stages of the attack, 
although slightly increasing them at the time. Also administering 
from the beginning of the attack — 

El. Tinet. iodi _ .^ij 

Acid carbol. liq 3J. M. 

Sir.. — One, two or three drops in ice water, every two or three hours, after food. 

To reduce t/ie temperature, cold bath, cold pack, and cold sponging, 
gutHiK-T sulph., gr. xv-xx, repeated within an hour, or antipyrin, gr. 
XX, repealed. 



I 



FEVERS. 19 

Diarrhoea should not be checked unless it exceeds three stools in 
twenty-four hours, when may be used — 

R. Bismuth subnit gr. xx 

Acid carbol gtt. j 

Tinct. opii deodorat gtt. x--xv 

Mucil. acaciae 3J 

Aquae Siij* M. 

SiG. — Every three or four hours. 
Or— 

R. Cupri sulph gr. yi 

Extracti opii gr. ^. M. 

SiG. — In pill, every four hours. 

For Tympanites; cold compresses or turpentine stupes to the 
abdomen, or R. ol. terebinthince, gtt. x, morphince sulph. y gr. ^V» in 
emulsion, every third hour, or tinct, nucis vomicis, gtt. x, p. r, n. 

For Thirst; cooling drinks, in moderation, or pellets of ice slowly 
dissolved in the mouth. 

Headache ; cold to the head, mustard to the neck, and foot baths ; 
if these fail to relieve, morphina or atropina hypodermatically. 

Delirium; if from debility, increase stimulants; other causes, 
morphina. 

Restlessness and coma vigil ; chloral alone or 'w\\\\.» potassii bro- 
midum or morphina. 

Debility ; food every two or three hours; don't permit sleep to 
interfere with nourishment. Stimulants are indicated early ; the best 
guide is the heart's action ; an average amount would be § vj spts. 
vini gallici, per diem. 

The bladder should be attended to at each visit. 

Intestinal hemorrhage ; at once morphina, gr. % , hypodermatically, 
and ext. ergotcs fld.,^i, xx-xl, repeated, or MonselVs solution, gtt. 
ij-iv, every two hours. 

Perforation dind peritonitis ; at once morphina, gr. X» hypoder- 
matically, followed with extractum opii, gr. j, every hour, and bold 
stimulation. 

TYPHUS FEVER. 

Synon3niiS. Contagious fever ; ship fever ; jail fever. 

Definition. An acute febrile, epidemic disease ; contagious and 
characterized by sudden invasion, profound depression of the vital 
powers, and a peculiar petechial eruption ; favorable cases terminat- 
ing by crisis in fourteen days. No lesion. 



30 PRACTICE OF MEDICINE. 

CauBB. A special infecting genn, the character of which i 
unkrown. bill which is influenced by filth and overcrowding. 

Pathologry. Blood dark and thin, with lessened fibrin; tissue 
dark, soft and flabby. 

Symptoms. Begins abruptly ; chill followed by violent fever 
temperature within a few days reaching 104° to 105° F. ; a frequent, J 
bounding pulse, soon becoming compressible ; severe headache, 1 
followed by violent delirium ; from the fifth to the sn-enth day, a. 1 
coarse, red, measly eruption, with a mottling of the skin all over 
body, except the face, not disappearing on pressure : constipaHtm the J 
rule. End of the second week, the temperature suddenly declines ; 
and ihe case passes into a rapid convalescence. 

Complioatioiis. Pneumonia and swollen parotid g!a,nd9 a 



DiagrnoBUS. From typhoid fever, the age, season, onset of the ] 
disease, character of the eruption, and the intestinal symptoms. 

Measles begin milder, with coryza and cough, and seldom have 
such pronounced nervous phenomena, but there occurs an early 
eruption appearing on the face. 

Prognosis. Unfavorable indicaiions ; high temperature, frequent 
pulse, early stupor, presentiment of death. Favorable ; youth, mod- 
erate temperature and pulse, and mild nervous phenomena. 

Treatment. Much the same as typhoid. As typhus is distinctly 
contagious, isolation is imperative, with immediate removal and dis- 
infection of the patient's excreta. 

For high temperature, cold pack, cold bath, cold sponging, full 
doses of guinina or antipyrin. 

For the headache and delirium, cold to the head, in the young 
and strong, a few leeches to the temple, and chloral, with or without 
the bromides. 

For constipation, mild laxatives. 

Debility : alcohol early and in full doses, spirilits chloroformi in 
drachm doses, whenever danger of collapse. 

CEREBROSPINAL FEVER. 
Synonyms. Epidemic.cerebro-spinal meningitis ; epidemic cere- 
bro-spinnl fever ; spotted fever : cerebro-spinal typhus. 
Definition. A malignant epidemic fever, characterised hy pain- 
s of the muscles of the neck, retraction of tlie head. 



FEVERS. 21 

hyperaesthesia, disorders of the special senses, and frequendy an 
eruption of petechia or purpuric spots. Lesions of cerebral and 
spinal membranes are found at the post-mortem. 

Cause. Special poison, the nature unknown ; attacks the young 
by preference ; most common in winter ; not contagious, 

Pathologrical Anatomy. Hypercemia, followed by an exuda- 
tion of lymph and an effusion of serum upon the membranes of the 
brain and spinal cord, causing pressure. 

Symptoms. Divided, according to the severity of the lesion, 
into three groups ; to wit, the common form, the fulminant and the 
abortive. 

The Common Form begins with a chill, excruciating headache^ 
persistent nausea, vomiting, vertigo and an overwhelming sense of 
weakness. Within a few hours the muscles of the neck become rigid 
and retracted, with decided pain upon movin'J the head ; this rigidity 
and retraction soon extends to the back, when opisthotonos 'occurs. 
The surface of the body becomes highly sensitive [hyperossthesia) and 
convulsions or delirium occur. Intolerance of light, and in some 
cases amaurosis, more or less deafness, loss of smell and taste soon 
following. The temperature and pulse records are irregular. From 
theyfrj/ day to iht fifth an eruption of petechiae or purpura occurs in 
a majority of cases. The disease reaches its height in from three to 
eight days, and passes into stupor and coma, or ameliorates and passes 
into a protracted convalescence. 

The Fulminant Form, Severe chill, depression, and in a few hours 
collapse. The patient is overcome by the poison and never reacts. 

The Abortive Form consists of one or more pronounced character- 
istic symptoms during the course of an epidemic. 

Sequelae. Result from thickening of either the cerebral or spinal 
membranes; Persistent headache, blindness or deafness, partial or 
complete ; epilepsy, or different forms of spinal palsies, 

Diagrnosis. Typhoid' Fever begins slowly, has a characteristic 
temperature record, without intense headache, muscular rigidity, 
vomiting, early delirium, ending in coma and constipation. 

Typhus fever has higher fever, is of longer duration, and has a 
peculiar measly eruption, is not attended with rnuscular rigidity and 
retraction, hyperaesthesia, nor disorders of the special senses. 

Tubercular meningitis is not epidemic, has no characteristic eruj>- 
tion ; is preceded by long prodromes, and runs a tedious course. 



22 PRACTICE OF MEDICINE. 

A congestive chill resembles the fulminant cases in suddenness of 
depression, but the latter has not the history of the former. 

Inflammation of the meninges of the cord is due to exposure to 
cold, or syphilis, and is not attended with cerebral symptoms or an 
eruption. 

Prognosis. Varies according to epidemic ; from twenty to fifty, 
and even seventy-five per cent. die. 

Treatment. Full doses of opium. Hypodermatic use of mor- 
phina, gr. % io yi every two or three hours ; or extractum opii, gr. j 
every hour until stage of effusion, when quinina in tonic doses, and' 
potassii iodidum are indicated. Prof. DaCosta alternates potassii 
bromidum with opium, especially in children. Locally y cold to the 
head and spine. A generous diet from the onset. Y ox sequelce, potassii 
iodidum, a course of hydrargyrum, and flying blisters along. the 
spinal column. 

RELAPSING FEVER. 

Synonyms. Famine fever ; bilious typhoid fever. 

Definition. An epidemic, contagious, febrile disease, self limited ; 
characterized by a febrile paroxysm, succeeded by an entire inter- 
mission, which is in turn followed by a relapse similar to the first 
seizure. No specific lesion. 

Cause. A specific poison ,* contagious ; acquiring the greater 
activity the more filthy, crowded and unhealthy the population amid 
which it prevails. 

Pathological Anatomy. During the febrile paroxysm only, 
blood contains minute cork-screw-shaped organisms or 5^/>a/ filaments 
— spirilli, constantly twisting and rotating. 

Liver and spleen greatly swollen. 

Symptoms, ^o prodromes. Onset abrupt, with fever, io2°-io4°; 
frequent, rather weak pulse, headache, nausea, vomiting, and lanci- 
nating /rt/«^ in limbs and muscles, marked in the calf of leg ; second 
day, feeling oi fullness a.nd pressure in right and left hypochondrium, 
due to swollen liver and spleen ; jaundice is frequent ; seventh day 
fever ends by crisis ; fourteenth ^/aj/ symptoms return in milder form, 
continuing about four days, when enters slow convalescence, much 
emaciated. No eruption. Several relapses may occur. 

Diagnosis. Yellow fever has many points of resemblance, but 
has a shorter febrile stage, remission not so complete, vomiting late 



FEVERS. 23 

and characteristic, normal spleen, and late appearance of yellow 
color. 

Remittent fever begins with a decided chill, followed by fever and 
sweats, and not the progressive rise of temperature till the fifth or 
seventh day. 

Progrnosis. Recovery the rule, but protracted, and decided 
emaciation results. 

Treatment. Expectant, Act on secretions ; nourish patient and 
meet urgent symptoms. For fever, antipyretic doses of quinina which, 
however, has no power to prevent the relapses ; for pain, hypoder- 
matic injections of ;;/^;^/^/«« / nausea and vomiting, acidum carbolicum 
or cerii oxalas ; during r ermssion, ferrum and quinina in tonic doses. 

PERIODICAL FEVERS. 

These affections are characterized by the distinct periodicity of the 
phenomena, having ' intervals during which the patient is wholly or 
nearly free from fever. 

INTERMITTENT FEVER. 

Synonyms. Ague ; chills and fever ; malarial fever. 

Definition. A paroxysmal fever, the phenomena observing a 
regular succession ; characterized by a cold, a hot and a sweating 
stage, followed by an interval of complete intermission or apyrexia, 
varying in length, according to the variety of the attack. 

Cause. Malaria. Bacillus Malaria ? 

Pathological Anatomy. Blood dark, from the formation of 
pigment [MelancEmia). Spleen swollen {Ague cake). Liver engorged 
and swollen. 

Varieties. Quotidian when a daily paroxysm ; tertian when every 
other day ; quartan when it occurs first and fourth days ; octan when 
weekly ; duplicated quotidian when two paroxysms daily ; duplicated 
tertian, two every second day ; double tertian, daily paroxysm, but 
more severe every second day. Dumb ague, or masked ague, has 
irregularity of the characteristic phenomena. 

Symptoms.- Each paroxysm has three stages, to wit : cold, hot 
and sweating. 

Cold stage begins with prodromes, to wit : lassitude, yawning, head- 
ache and nausea, followed by a chill; the teeth chatter, skin pale, 
nails and lips blue, the surface rough and pale, the so-called goose- 



24 PRACTICE OF MEDICINE. 



skin or cutis anscrina. nausea and great thirst, while the ihennometer 
in the axilla or mouth shows a decided rise of temperature, 102° 
104° ; these phenomena continuing from one-half to an hour. 

Hot stage begins gradually, by the shivering ceasing, the surface 
becoming /w/and flushed, the temperature rising to 106° F., or more, 
pulse full, headache, nausea, intense thirst, dry, flushed, swollen sldn, 
scanty urine and other phenomena oi pyrexia, continuing from on 
eight or ten hours. 

Sweating stage begins gradually, first appearing on the forehead, 
then spreading over the entire surface; ihe fever lessens, the tempera- 
ture rapidly falling to gg" or g8°, pulse less full, headache lessens, and 
a feeling of comfort, sleep often fallowing; duration from one to four 
hours, when the intermission occurs, the patient apparently well, 
excepting a feeling of general debility. 

The occurrence of the next paroxsym depends upon the variety of 
the attack. 

The paroxysip may be ushered in by a decided pain in one or n 
nerves, instead of the cold stage, to wit: " 6row ague." 

Dia^TCOsis. No difficulty wlien the characteristic t-/"y/,y"«'ffr, and 
sweats occur. 

Hectic fever. Distinguished by its irregularity, and occurring 
secondary to an organic disease. 

Pyamia, produced by other causes than malaria. 

Nervous chills show an absence of the temperature rise? 

Prognosis. Recovery the rule. Without treatment many ci 
end favorably after several paroxysms ; others passing into 
chronic form or malarial cachexice. 

Treatment. Cold stage can be averted and the other stages 
greatly modified by a hypodermatic injection of either morphina sulph., 
gr. ^-%,0T pilocarpine hydrochloras, gr. ||, or chlorofomti spts., 
f 3J, by the stomacli. Hot stage, cool drinks and , cold sponging. 
Sweating stage, when excessive, sponging with alumen and hot 

Intermission ; at once a brisk purgaljve, followed by cinchona ii 
some form, the most efficient being quinina sulpk.. gr. xx-xxiv, ii 
solution or freshly-made pills, in one or Iwo doses, three to five hours 
before the expected paroxysm. Many substitutes are lauded to replace 
the salts of cinchona hark, but without avail. 

After the /arfjyjwi are broken up, use lig.poiassii arse>itl.,g^v-x. 



FEVERS. 26 

t, d., for a long time, or tinct.ferri. chloridi, gtt. xx, every four hours, 
or a combination like the following : — 

R. Ferrireducti 

Quininae sulph fta gr. xlviii 

Acidi arseniosi gr. j 

01. pip. nigr gtt. xv. M. 

Ft. Pil No. xxiv. 

SiG. — One pill after meals, continued for one month, at least. 

Relapses being common, quinina should be given oh the second or 
third ^-ac^, fourth to the sixth, twelfth to i)^^ fourteenth, and nineteenth 
to the twenty-first days. 

REMITTENT FEVER. 

Synonyms. Bilious fever ; bilious remitten! fever ; marsh fever ; 
typho-malarial fever ? 

Definition. K paroxysmal fever, with exacerbations and remis- 
sions ; characterized by a moderate cold stage (which does not recur 
with each paroxysm) ; an intense hot stage, with violent headache 
and gastric irritability ; and an almost imperceptible sweating stage, 
which is frequently wanting. 

Cause. Malaria, aided by high temperature. 

Patholp^cal Anatomy. Blood dark (Melancemid) ; spleen 
enlarged, soft, filled with blood, and of an olive color ; liver congested 
and swollen, and of a bronze hue ; the brain hypersemic and olive- 
colored ; gastro-intestinal canal markedly hypersemic. 

Symptoms. Cold stage ; moderate chill, the temperature rising 
1° to 2°, oppression at the epigastrium, slight headache, and pains 
throughout the body. 

Hot stage ; persistent vomiting, furred tongue, full pulse, rising to 
I GO or I20, flushed face, injected eye, violent headache, pains in limbs 
and loins, hurried 'respiration, the temperature rising to 104° F., or 
106°. The bowels costive, stools tarry and offensive, and the surface 
becoming yellow. Delirium occurs when the temperature is very 
high. 

Sweating stage ; after six to twenty-four hours, the above symptoms 
abate, and slight sweating occurs ; the pulse, headache and vomiting 
subside, and the temperature falls to 100° F., or 99°. 

This is the remission. 



rRACTICE OF MEDICINE. 

After some two in eight or hvelve hours the symptoms of the hot 
suge return, generally minus the chill, and this is termed the 
eiacirrbatioH, which is in turn followed by the remission. 

Dnraiion. From seven to fourteen days, the average. Frequently 
the fever ceases to remit, and instead, becomes continuous, the 
symptoms resembling, if they are not identical with, the typhoid state, 
whence the term typho-malarial fever, or foaiario-typ/wid fever. 

BequelfB. The malarial cachexia results when the poison has 
not been eliminated. 

Pertittent headache and vertigo are the results of the intense 
meningeal hypera;mia that sometimes occurs. 

DiagflloaiB. In intermittent fever each paroxysm begins with a 
chill, while the chill seldom recurs in remittent fever; a distinct 
iittermiision follows each paroxysm of the intermittent form, while a. 
reminsioH occurs in remittent, the thermometer showing that the fever 
docs not wholly disappear ; during the intermission the patient is ap- 
parently well ; such is not the case in the remission of remittent fever. 
Typhoid fever is mistaken for remittent fever, but the absence 
of characteristic temperature record, diarrhcea, eruption, tympanites, 
doafness and severe prostration, should prevent the error. 
Prognosis. Uncomplicated cases are favorable. 
Treatment. Quinince suiph.. gr. xvj-xx per diem, is the remedy. 
Best given during the remission, if possible. If an irritable stomach 
prevents its administration by the mouth, use it by the hypodermatic 
method or suppository. During the hot stage, cool sponging, cold to 
the head, and if a tendency to cerebral congestion, dry or wet cups to 
the nape of the neck and— 

U. Tinet. nconit. rad g"- Hj 

Liq. potos. citrat jij 

Lic|. ammon. BCetat. jij. M, 

Every two hours. 
Purgation during the remission, with — 

R. Hydrarg. chlor. mitis gr. v 

Sodii bicarb gr. x 

Pulv. aromat gr. v. M. 

In pulv. p. r. n. 
The same precautions are essential afler the paroxysms are broken 
up, to prevent their return on the septenary periods, that were recom- 
mended for intermittent fever. 



FEVERS. • 27 

PERNICIOUS FEVER. 

Synonyms. Congestive fever ; malignant intermittent fever ; ma- 
lignant remittent fever. 

Definition. A malignant, destructive, malarial fever, which may 
be of the intermittent or remittent form ; characterized by intense con- 
gestion of one or more internal organs, together with dangerous per- 
version of the functions of innervation. 

Cause. A high degree of malarial poison. 

Varieties. Gastro-enteric ; thoracic; cerebral; hemorrhagic; 
algid. 

Symptoms. Any of these varieties may begin either as an inter- 
mittent or remittent fever ; again, iidQ first paroxysm is rarely pernicious, 
but appears as the ordinary malarial attack. 

The gastro-enteric variety has as distinctive features, intense nausea 
and vomiting, purging of thin discharges mixed with blood, tenesmus ^ 
burning heat in stomach, intense thirst, frequent, weak pulse, face, 
hands and feet cold, with shrunken features, and intense depression 
of all the vital forces. This condition continues from half an hour to 
several hours, when either an inter- or remission occurs. 

Thoracic variety often combined with the one just described. Its 
characteristic features are due to overwhelming congestion of the 
lungs, such as violent dyspnoea, gasping for air, 50 to 60 respirations 
per minute, oppressed cough with slight amount of blood-streaked 
s^uiB,, frequent, weak pulse, cold surface, and terror-stricken features. 
Duration same as above. 

Cerebral variety, due to intense congestion of the brain ; sometimes 
effusion of serum into the ventricles, or even rupture of small blood 
vessels. Characterized by violent delirium, followed by stupor and 
coma, slow, full pulse, the surface €\\htx flushed or livid. Cases may 
either resemble apoplexy — comatose variety, or acute meningitis — 
delirious variety. Duration same as other forms. 

Hemorrhagic variety, or the yellow disease, as it has been termed, 
begins as an ordinary inter- or remittent fever, soon followed by signs 
oi internal congestion, to wit : nausea, vomiting, dyspnoea, severe pains 
over liver and kidney, continuing for a few hours, when the surface 
suddenly \.\xxxis yellow and bloody urine is voided, after which an inter- 
or remission and marked abatement occurs, to be sooner or later fol- 
lowed by a second paroxysm, which is more severe, with additional 



28 PRACTICE OF UEDICINE. 

signs ai cerebral congestion. Blood may also escape fvom other parts 
than the kidneys. 

Algid variety is charactcriied by intense coldness of the surface, 
while the rectal temperature ranges from 104° to 107° F. The attack 
begins with chill which is soon followed hy fever of variable duratiori, 
when the body becomes cold, the axillary temperature falling to 90°, 
88" or even 85° F., z.cold s-weat covers the surface, the tongue is while, 
moist and cold, the breatk is icy, the -voice feeble and indistinct, the 
pulse slow, feeble and often absent at the wrist, and with all these 
symptoms, the patient complains of a sensation oi burning -atA intense 
thirst. The taind is clear.hvi the countenance is death-like. 

Dtiration. Pernicious fever, in any of its forms, may continue 
from a few hours until one, Iwo or three days. Recovery is rare after 
a second, almost never after a third, paroxysm. 

Diagnosis. YcUotd fever is most apt to be confounded with the 
hemorrhagic variety, and as they both occur in the same localities, the 
diagnosis is difficult : the early yellowness of the surface, with kama- 
turia, and the absence of the bldck vomit, are the chief points of 
distinction. 

The cerebral variety may be mistaken for cerebral apoplexy, men- 
ingitis and urcemic cowvulsions. Nor is it always an easy matter to 
differentiate between these conditions. 

The gastro-enferic variety may be mistaken for the early stage and 
the algid variety for the latter stage of cholera, but the prevalence of 
the latter should be of material aid in deciding the question. 

PrognosJe. In all varieties the result is unfavorable, unless it can 
be controlled prior to the second paroxysm. Cases in which an inter- 
mission occurs are better controlled than where a remission follows. 
The mortality is one in e/^ht from all plans of treatment. 

Treatment. The first indication in all varieties is to bring about 
reaction. Uiht cold stage, heat to the surface, with stimulating lotions; 
if the hoi stage, cold to the surface and the hypodermatic injection of 
morphina, gr. jf , at once. After reaction, quinina sulph., not less 
than gr. xl, repeated p. r. n. ; administer bystomach, rectum, or better 
still, by hypodermatic injection. Dr. Bartholow pronounces the fol- 
lowing one of the best formulae for the hypodermatic use of quinina ;— 

B. Quininae di-sulph gr. 1 

Add sulph. dil tr\_ c 

Aqnte font .5 j 

Acid catbol licj Il\, v. M. 



FEVERS. 29 

The following fonnula, known as "Warburg's Tincture," has during 
the last few years gained considerable reputation in the various forms 
of malarial fevers : — 

R . Rad. rhei, P. aloe soc, and Rad. angelica 

officinalis 5a ^iv 

Rad. helenii, Crocus Hispai)., Sem. foeni- 
culi, and Cretae preparat fta ^i) 

Rad. gentian, Rad. zedoar, P. cubeb, G. 
myrrh, G. camphor, and Boletus Lari- 

cis aa 5j . 

Confect. damocratis* ^iv 

Quininae sulph ^Ixxxij 

Spt. vini rect Oxx 

Aquae purse Oxij 

Macerate in a water bath twelve hours, express and filter. 

Each half ounce contains Quininae sulph. gr. vijss. If the stomach 
is too irritable to retain the tincture, the tincture may be evaporated 
to dryness and administered in capsules^ each containing either one 
or two drachms. 

For the gastro-enteric variety. Prof. DaCosta suggests — 

R. Morph. sulph g^« i 

Pulv. camph gr. j 

Mass. hydrarg gr. ij 

Pulv. capsici gr. ss. M. 

In pills every half hour until the character of the stools change. 

♦ Formula of Cbnfectio damocraits : — 

Cinnamon xiv Gm 

Myrrh xj Gm 

White agaric. Spikenard, Ginger, Spanish saffron. 
Treacle, Mustard seed, Framcincense, and Chian 
turpentine && x Gm 

Camel's hay, ' Costus arabacus, Zeodary, Indian 
leaf. Mace, French lavender. Long pepper, Seeds 
of harwort. Juice of rape cistus. Strained storax, 
Opponex, Strained galbanum. Balsam of Gilead, 
Oil of nutmeg, Russian castor && viij Gm 

Water germunder, Balsam tree fruit, Cubeb, White 
pepper. Seeds of carrot of Crete, Foley mont. 
Strained bdellium && vij Gm 

Gentian root, Celtic hard. Leaves of Dittany of 
Crete, Red rose, Seeds of Macedonium, Parsley, 
Sweet fennel seed. Seeds of lesser cardamon. Gum \ 

arable, Opium && v Gm 

Sweet .flag. Wild valerian. Anise seed, Sagaper- 
num && iij Gm 

Spigrul, St. John's wort. Juice of acacia. Catechu, ^ 
Dried bellies of skunk && ijss Gm 

Clarified honey .-. cmxv Gm. 

The roots to be finely powdered and the whole mixed thoroughly. 



30 PRACTICE OF MEDICINE. 

For the thoracic variety, dry or wet cups and ammonii carbonas. 

For the cerebral variety, venesection, or cups or leeches to the 
neck, cold to the head, prompt purgation, and acting on the kidneys 
and skin. 

For the algid variety warmth to the surface, hypodermatic use of 
tnorphina and the free use of amtnonU carbonas and alcoholic stimu- 
lants. 

For the hemorrhagic vdLnety, purgatives, morphina hypodermati- 
cally, and either acid sulph. dil., cid gallic^ MonseWs solution^ or 
terebinthina, for the hemorrhages. 

The following is highly spoken of for hemorrhages : — 

R. Ext. ergot3e, fld gss 

Acid sulph., diL f^jss 

Acid gallic„ 'T^] 

Syr. zingib f^iij 

Aquae q. s ad^ ^3"J- ^* 

SiG. — Dessertspoonful every 4 hours, well diluted. 
After paroxysms are broken up, a long course oi ferrum, with qui- 
nina on the septenary days. 

YELLOW FEVER. 

Synonyms. Bilious malignant fever ; typhus icterode ; Medi- 
terranean fever ; sailors' fever. 

Definition. An acute, infectious, paroxysmal disease, of three 
^fges, to wit : the febrile, the remission, and the collapse ; character- 
ized by violent fever, yellowness of the surface, and " black or coffee- 
grdund vomit." Tendency fatal ; one attack confers immunity from 
a second. 

Cause. A specific poison, existing only with a high temperature 
and destroyed by frost. Not due to the malarial poison. 

Pathological Anatomy. Skin lemon or greenish-yellow color, 
due to dissolution of the red blood corpuscles; heart softened by 
granular degeneration ; stomach, veins deeply engorged, the mucous 
membrane softened, and containing more or less "coffee-ground** 
matter, which consists of blood corpuscles deprived of their haemo- 
globin, white corpuscles, epithelial cells and debris. Intestines much 
the same as the stomach ; liver yellow color and a fatty degeneration 
of the hepatic cells ; kidneys, granular degeneration of the epithelium 
of the tubules. 



FEVERS. 31 

Symptoms. First stage, the febrile., beginning either with the 
prodromata of malaise, headache and anorexia, or suddenly with a 
chill, high fever, in a few hours reaching 104° F., high pulse, brilliant 
eye, flushed countenance, coated tongue, irritability of the stomach, 
and severe neuralgic pains in the head, limbs, epigastrium, back, and 
large joints. The patients are restless and anxious. In severe attacks 
delirium is frequent. Albumen in the urine, and a. peculiar and char- 
acteristic odor is emitted from the patient. Duration of the first stage 
from thirty-six hours to three or four days. 

Second stage, the remission, when the temperature declines to 100° 
or 101° F., and all the distressing symptoms abate or subside and, 
with some critical evacuation, convalescence occurs, or, more com- 
monly, after from one to four days, the 

Third stage, the stage of collapse, is ushered in by a return of all 
the symptoms of the first stage in an exaggerated form, followed by 
yellowness of the skin, passing to a deep mahogany color, black vomit 
and hemorrhages from other ^2cr\s, feeble pulse, cold surface, irregular 
respiration and death from exhaustion, the mind remaining clear 
until the end. 

The above symptoms represent a sthenic case ; other varieties are 
the algid, hemorrhagic and typhus. 

Duration. Depends upon the variety ; from a few hours to a few 
days. Rarely continues longer than one week. 

Diagnosis. Pernicious fever, hemorrhagic variety, is apt to be 
mistaken for yellow fever. Yellow fever is a disease of one paroxys^ 
and one remission, epidemic, albuminuria and black vomit. Per- 
nicious fever more than one paroxysm, not epidemic, rarely black 
vomit or albumen in urine. 

Prognosis. One in four perish. Short cases unfavorable, as are 
the hemorrhagic and algid. 

Treatm.ent. No specific; a "self-limited" disease. The indica- 
tions are to treat the symptoms and nourish the patient. Good nursing, 
ventilation, early emesis and purgation, with diaphoretics and diu- 
retics, are apparently beneficial. Large doses of quinina, early in 
the attack, for high temperature ; for the irritable stomach, ice slowly 
dissolved in the mouth and acidum carbolicum, gr. % in aqua menthcB 
pip,, every two hours, alternated with liquor calcis and milk, each an 
'ounce, or — 



S2 



PRACTICE OP MEDICINE. 



U , Hydrargyri chior. mile gr. J^ 

MorphinEC sulph gr. ^. 

Every iwo hours until nausea controUed. 
For the black vomit and liemorrhages, either liquor ferri subsui- 
phatis or plumhi tuetas. The pains, restlessness or delirium are best 
controlled by the hypodennatic use of morphina and alropina. Free 
stimulation from the onset is essentia!. 

ERUPTIVE FEVERS. 
As a group, the eruptive or exanthematous feveis have many fea- 
tures in common. All have a period of incubation, are characterized 
by afever of moreorless intensity preceding the eruption, by an erup- 
tion which is peculiar to each, occurring most commonly in childhood, 
rarely attacking the same person twice, very prone to occasion serious 
sequete, and are contagious. Their origin is as yet unknown. 



SCARLET FEVER, 



\ 



Synonym. Scarlatina. 

Definition. An acute, self-limited, infictinus disease ; character- 
ized by high temperature, rapid pulse, a diffused scarlet eruption, 
terminating with desquamation, inflammation of Che throat, and 
frequently more or less grave nervous phenomena. Serious sequelse 
usually follow an attack. One attack confer? immunity from the 

Pathological Anatomy. An acute inflammatioji of the skin, 
with exudation— a true Dermatitis. A grantdar change in all glan- 
dular structure, most marked in the Peyerian glands, although occur- 
ring in the stomach and kidneys. 

CaUBS. A specific poison, maintaining its vitality for a long time. 
Eminently contagious, the contagion residing chiefiy in the desqua- 
mated epidermis. Klebs' micrococci, the " monas scarlatinosum," 
may prove to be the poison. Incubation short, one to seven days. 

Varieties, Scarlatina simplex, scarlatina anginosa and scarlatina 

Symptoms. Onset sudden with a decided chill and i/amiting 
(in infants, convulsions), -followed by high/ever, soon reaching 105°; 
a rapid pulse, iio to J40 being common. At the end of twenty -four 
hoiurs a. bright scarlet rash appears on the neck and chest, spreading 



FEVERS. 33 

over the entire body within a few hours ; the eruption is not raised, 
there is no intervening healthy skin, and scattered irregularly are points 
of a darker hue. With the appearance of the eruption occurs burning 
heat of surface, burning in the throat and difficulty in deglutition are 
complained of, the throat on inspection presenting the appearance of 
a catarrhal inf[a.Tnn\2it\on. Tongue at first furred, later, red, with promi- 
nent papillae — the " strawberry tongue." There also occurs headache, 
great restlessness, in severe cases delirium. Diarrhoea quite common. 

On the fourth or fifth day the fever declines by lysis, the eruption 
fading, and on the sixth or eighth day desquamation begins, continu- 
ing for a week or more, the convalescence being slow, the patient 
emaciated and pale. 

Scarlatina anginosa are cases with great inflammation and swelling 
of the throat, tonsils and neighboring glands, the swollen glands 
pressing upon the surrounding parts, causing difficulty of breathing 
and of deglutition. 

Scarlatina maligna are cases with decided nervous phenomena, to 
wit : convulsions, delirium and muscular twitching, the temperature 
reaching 107° to 110°, i\iQ pulse rapid, feeble and irregular, the erup- 
tion delayed, of a purplish color, and in patches, 

SequelaB. Chronic sore throat; conjunctivitis; otorrhoea; chronic 
diarrhoea ; subacute rheumatism ; endocarditis ; acute Bright' s dis- 
ease ; cutaneous dropsy. 

Diagnosis. A typical case should cause no difficulty ; the high 
fever, rapid pulse, sore throat, and early scarlet eruption, followed by 
desquamation, should leave no doubt. 

Measles ; the above symptoms are absent, and catarrhal symptoms 
present. 

Smallpox ; eruption on the third day, in spots, changing to pustules 
with secondary fever. 

Dengue or break-bone fever ; absence of the above typical symp- 
toms and presence of severe pains in the bones, 
^Diphtheria ; gradual invasion, great prostration, and no eruption. 

Meningitis may be suspected from the symptoms of scarlatina 
maligna ; the epidemic influence, eruption, and rapid pulse, are points 
of difference. 

Progfnosis. Depends upon the character of the attack. Never 
can be positive of the result. Mortality ranges from ten to twenty-five 
per cent. , 

c 



34 PRACTICE OF MEDICINE. 

Treatzn^lt. Ar' specijic. Treatment must be symptomatic. 

YoT fd^'cr and rapid pnlst, either tinct. duonit. rati, or digita/zs. If 
the temperature reaches over 106-. the cold bath, douche or pack in 
addition. 

For pruritus the local use of oiis or fats, in some form, afifords 
?reat relief, the following formula being most efficient, as well as a 
disinfectant : — 

B. Acidi carbolici .^SB-j 

Vaselini ^iv. M. 

SiG. — ^To be applied over the entire surface. 

If the surface is pale, the circulation feeble and the eruption tardy in 
making its appearance, use tm<t, belladonrttE, gtt. ij-x. according^to age. 

For the throat, ice internally, and if it does not cause chilliness, 
externally, if so, apply heat externally ; also gargles in those old 
enough, and in those too young, swabbing the throat is an efficient 
substitute. The following formula is satis£ictory for either purpose : — 

Bt. Potass, chlor o"J~Ti 

Tmct. myrrh — ^ f 5 ij 

Mel. desp ^iij 

Infos, cinchonae fo*^- M. 

From the onset, in all cases, either am mo nit carbonas, or tinct. ferri 
chlor, and quinina should be used, proportioning the dose according 
to the age and severity of the attack. 

Dr. J. L. Smith warmly lauds the following mixture for cases with 
decided throat symptoms . — 

R. Acid boracic ^ss 

Potass, chlor ^ij 

Tinct. ferri chlor. f^ij 

Glyceringe, 

Syrupi ..ia- f^j 

Aquae ., f^.^ij* M. 

SiG. — One tablespoonful every two hours, to a child of five years. 

For malignant cases bold stimulation from the onset. 

It is claimed that a characteristic micrococci is found in the blood, 
and that, consequently, the disease can be favorably influenced by 
acidum carbolicujn^ thymol or acidum boricum. 

For the various sequel ce^ the treatment is the same as if they 
occurred primarily, plus tonics. 



FEVERS. 35 

The disease being infectious, every means should be taken to 
prevent its spread, to wit: isolation, cleanliness, disinfection and 
fumigation. 

Small doses of quinina, in those exposed, is said to prevent or 
modify the severity of an attack, but no true prophylactic is known. 

MEASLES. 

Synonyms. Morbilli; rubeola. 

Definition. An acute epidemic and contagious disease ; charac- 
terized by catarrhal symptoms, referable to the naso-broncho-pul- 
monary mucous membrane, fever, and a crimson eruption which 
terminates by desquamation. 

Cause. A specific poison, with a special susceptibility to child- 
hood. Contagious by contact, and has been communicated by in- 
oculation. One attack, as a rule, protects from a second. Incubation, 
ten days. 

Symptoms. Onset gradual, irregular chills, fever, the tempera- 
ture rising to ioi° or 102°, muscular soreness, headache, and intense 
nasal, pharyngeal and laryngeal catarrh; on the evening of the 
second day a decided remission takes place in the fever, the catarrh 
continuing; on \ht fourth day occurs an eruption of a crimson color, 
on the face, soon spreading over the body, in the form of dots, slightly 
elevated, which coalesce into irregular circles or crescents, and with 

« 

the appearance of the eruption xhQ fever returns, the catarrh is aggra- 
vated, but the character of the discharge, instead of being clear and 
watery, becomes turbid, thick and yellowish, and extends to the 
bronchial mucous membrane. About the ninth day the eruption 
fades, the symptoms abate, and slight desquamation occurs. Some 
cough and catarrh may remain for a long period. 

Black measles or camp measles is a variety occurring in camps and 
jails, in which occur dangerous chest symptoms, and black spots or 
petechise from deteriorated blood, and severe prostration. 

Rather common complications are lobar and catarrhal pneumonia. 

Sequelae. In those of strumous diathesis, scrofula or phthisis 
may develop. 

Diagnosis. A typical case begins gradually, with chilliness, nasal 
catarrh, watery eye, and fever, which decline before the eruption, 
rising afterwards, the eruption crescentic in shape, and of a crimson 
color. 



36 PSACTICE OF MEDICINE. 

Scar/el fever.; absence of catarrh, and earlier appearance and dif- 
fcrenl character of the eruption with severe fever and rapid pulse. 

Prognosis. As a rule, a perfect recovery. If phthisis develop, 
the prognosis is bad. Black measles, the majority perish. 

Treatment. No specific. Mild cases require no medicine, simply 
regulating the diet and bowels, and cool sponging. 
\{ fever high,— 

B. Liq. potass, cifrat 3J 

Spts. sether nilrosi gtt. x-x» 

Tincl. aconit, rad gtt. ss-j. M. 

Every two hours, soon controls it. 
For pruritus of the eruption, the local use of oHi and fats. For 
catarrhal sympioiiis, inunction of the nose, neck and chest with cam- 
phorated oil and small doses of pul-v. ipecac el opii, at bedtime ; if 
the catarrh extends to the bronchial raucous membrane, expectorants. 
During convalescence, for the strumous, protect from exposure, and 
oi. morrkua with syr.ferri iodidi. For 6iack measles, bold stimula- 
tion, mitiferrum and guinina. 

ROTHELN. 

Synonyms. Epidemic roseola ; German measles ; French measles ; 
false measles. 

Definition. An acute, self-limited disease ; characieriied by 
mild fever, suffused eyes, cough and sore throat, enlargement of the 
lymphatic glands of the neck, and a rose-colored eruption, in patches 
of irregular size and shape, appearing on the first day. 

Cause. Propagated by infection. That a peculiar germ exists is 
probable, but thus far it has not been isolated. Incubation from one 
to three weeks. 

Symptoms. Onset sudden, with mild fever, suffused eyes, with 
little or no cotyxa. sore throat, and enlargement of the cervical glands, 
not limited to those about the angle of the jaw, as in scarlatina. 
Any time from the first to the fourth day appear rose-colored spots, 
size of a pin head, slightly elevated, which coalescing, form irregular 
shaped and sl^ed patches, with intervening healthy skin, fading on 
the upper part of the body while just appearing on the lower. Symp- 
toms all terminate within a week by lysis, the parient being none the 
worse for the attack. 



FEVERS. 37 

Diagnosis. From scarlet fever, by absence of high fever, rapid 
pulse, color and character of eruption and sequelae. 

From measles, by absence of intense catarrhal symptoms, late 
appearance of eruption and not of a crescentic shape. 

Prognosis. Most favorable. 

Treatment. Mild laxatives and restricted diet, li fever high, 
saline mixture. Itching o{ skin, sponging with vinegar and water. 

SMALLPOX. 

Synonym. Variola. 

Definition. An acute, epidemic and contagious disease ; charac- 
terized by severe lumbar pains, vomiting, and an initial fever, lasting 
from three to four days, followed by an eruption, at ^x%\. papular, then 
vesicular and afterwards pustular ; the development of the pustule 
being accompanied by a secondary fever, during the presence of which 
grave complications are prone to occur. 

Causes. A specific poison whose nature is unknown, maintaining 
its contagious vitality for a long period. There is no period, from the 
initial fever to the final desquamation, when the disease is not con- 
tagious, although the stage of suppuration is the most virulent. One 
attack, as a rule, protects from a second. Vaccination has positive 
protective influence from the disease, as extensive observation has 
fully proven that in proportion to the efficiency of vaccination is 
the rarity and mildness of variola. Incubation, fourteen to sixteen 
days. 

Patholo^cal Anatomy. A granular and fatty degeneration 
occurs in the liver, spleen, kidneys and heart. The pustules are 
found in the larynx, trachea, bronchial tubes, and on the pleura. 

Varieties. Discrete ; confluent ; malignant ; varioloid or modified 
smallpox. 

Symptoms. Discrete form. Onset sudden, with a violent chilly 
vomiting, and agonizing /a/«j in the back, shooting down the limbs ; 
fever, in short time, rising to 103° or 104° F. ; full, strong and rapid 
pulse, ranging from 100 to 130; the^^^^ red, eyes injected, intense 
headache and sleeplessness ; delirium and convulsions occur at times. 
During the third day the characteristic eruption makes its appear- 
ance, first on the forehead and lips, consisting of coarse red spots ; 
with the appearance of the eruption all the marked symptoms of the 
fever abate, the patient feeling quite comfortable. On the fifth day 



PRACTICE OF HEDICINF- 

of the disease ihc spots become fiafiH/^s ; on the si'jr/A day, trans- 
formed into vesicles, which are soon umbificaUd : on the eighth day H^e 
■vesicles change to /«j/u/«,' on the n/nM i/av the pustules are entirely 
purulent, and each suirounded with a broad red band, the halo or 
areola, the face becoming swollen, and the features distorted; on 
eleventh day, pus oozes from the pustules, and driing, forms the scab 
or crust, which, on the serenleenlh to twenty-first day drops off, leav- 
ing a red, glistening depression or pit, soon changing into a white 
cicatrix. With the formation of the pustules [eighth day) sev 
rigors anA ferer set in, and a characteristic odor is emitted, all the 
original symptoms returning; this J'voni/irf_^rv<T' is the most critical 
period of the disease, and is generally attended with violent deliriunt. 
In favorable cases the secondary fever subsides after three or four 
days, and convalescence is established. 

Confluent smallpox differs from the discrete in being more sev( 
the eruption appearing during the second day. Hie pustules coalesdng 
into large patches, causing great distortion of the features. 

Malignant smallpox is characterized by the intensity and insu- 
larity of the symptoms, death resulting before the characteristic erup- 
tion appears, by convulsions or coma. In these cases hemorrhages 
are frequent and petechise are observed. 

Varioloid, or modified smallpox, is the form modified by previous 
vaccination or by a former attack of smallpox. Its course is shoi 
and milder than the other forms, the eruption appearing a day later, 
and is not attended ■with secondary fever. 

Complications. During the course of the secondary fevfrthtxt 
is a great tendency to grave inflammations, to wit ; pleuritis, pneu- 
monitis and dysentery. During convalescence, boils and abscesses on 
the skin are frequent. 

Diagnosis. Cannot be confounded with any other disease 
if have typical symptoms, to wit; chill, voraidng, pains in back 
and legs, high fever and pulse, all declining on third day, when 
the eruption appears, first spots, then papules, then vesicles, finally 
pustules, drying and forming crusts, and with the marked secondary 
fever. 

Prognosis. Depends upon the variety of tlie attack, the age of 
the patient, and whether vaccinated or not. Discrete mortality four 
per cent. ; confluent, fifty per cent. ; titalignant, all perish ; under jiw 
yean and o^ve forty years, fifty per cent. 



hi 



FEVERS. 39 

Treatment. No specific, although cases seem to do better if 
acidutn carbolicum or thymol are used. 
For the initial fever and ih^ full pulse — 

R. Tinct. aconit. rad gtt* j~y 

Spts. aether, nitrosi ^ss 

Liq. ammonii acetat f^ij 

Aquae f^iss. M. 

Every hour or two. 
Or 

R. Acid, salicyl gr. x 

Spts. vini rect gtt. xx 

Elix. simp ^ss. M. 

Every hour or two. 

If headache and backache are intense, hypodermatic injections of 
morphina, or ice bag to the heiad and back. 

For sleeplessness and restlessness or early delirium full doses of 
potassii bromidum. 

For secondary fever the best remedy is quinina, gr. v, every three 
hours, and for cerebral excitement of this period, either full doses of 
potassii bromidu7n, by stomach, or the following by rectum : — 

R. Chloral gr. xv-xx 

Mucil. acacia f^ij 

Aquae f^ij* M. 

p. r. n. 

The secondary fever being pyaemic in character, the depression 
should be anticipated by large doses of tinct. ferri chloridi and 
judicious stimulation, brandy in tablespoonful doses the most efficient. 

From the onset, milk, eggs, animal broth, oysters and beef juice 
should be administered every three hours. Icexs always grateful and 
should be given freely, and if pustules appear in the mouth, ice should 
be held in the mouth as long as possible, and washes of potassii 
chloras or acidum carbolicum employed. 

The disease being contagious, isolation, ventilation, cleanliness and 
disinfection are imperative. 

To prevent pitting keep patient in a dark room, well ventilated. 
Masks of some unctuous material, thoroughly applied, to exclude the 
air, have a beneficial effect, a good formula being, R . Ung. hydrarg,, 
pulv. marantcB, equal parts, or glycerit. amy Hi, painted over eruption, 



40 PRACTICE OF MEDICnifE. 

chanjT^ng to tinct, iodi as vesicles ire iS?ut to develop. Cold v^af^r 
drcssinjrs constantly to face and hands are beneficial, besides allaying 
heat, pain and swelling. Net a-j.^-r can be used if more grateful. 

VACCINATIOX. 

Definition. Inoculation with the matter of z-a^cinia or cow-pox 
— b(nnne vims. The person /n'/t^/s- vaccinated is, as a rule, 
protected from an attack of smallpox, and especially from a severe or 

fatal attack. 

Vaccination should be performed at least /avlv in ever\* individual, 
to wit : during infancy and at/w^e*r.V .• and it is safer to have it again 
performed if special exposure be liable or occur. 

In practicing vaccination the skin should be rapidly scraped until 
the true skin is reached and is ready to bleed, the lymph being then 
brushed over the abraded surface ; or, instead, make three or four 
horizontal and transverse cuts, about four hnes long, and rub the 
virus over them ; a little blood, but not much bleeding, should be 
caused. 

Symptoms. If the vaccination " takes," on the third day a 
papule appears ; on the sixth day a vesicle has formed, with a central 
depression ; on the eighth day a pustule, fully formed and distended 
with lymph, with a reddish areola, which becomes ver>' wide. The 
areola begins to fade on the tenth day, the pustule begins to dry, and 
by the fourteenth day a brown mahogany scab or crust has formed, 
which is detached about the twenty-third day. The cicatrix is circu- 
lar, depressed, radiated and foveated, becoming, after a time, paler 
than the surrounding integument. 

During the course of a vaccination, more or less constitutional dis- 
turbance occurs, especially in children. 

Eczematous and papular eruptions often develop in strumous cbil^ 
drcn, for which the virus is unjustly held responsible. 

VARICELLA. 

Synonym. Chicken-pox. 

Definition. A mild, slightly contagious, febrile affection ; charac- 
tiM'i/fd by a moderate fever, and the appearance of a vesicular erup- 
ti(»ii, drying up and falling off in from three to five days. 

OauBO. A peculiar poison ; attacking only children ; occurring 
spoi.ulirally and as an epidemic. 



FEVERS. 41 

Symptoms. Moderate fever, thirst, anorexia and constipation, 
followed by the eruption of vesicles, which rapidly dry, and within the 
week drop off, leaving a slight pit. Pustules almost never occur. 
Symptoms are so slight that,were it not for the vesicles, the affection 
would be often overlooked. The eruption appears on the trunk and 
extremities, very rarely on the forehead and in the mouth. 

Progrnosis. Most favorable. 

Treatment. Entirely symptomatic. If vesicles on the face,- 
efforts may be used to prevent pitting. 

ERYSIPELAS. 

Synonyms. Erysipelatous dermatitis; the rose; St. Anthony's 
fire. 

Definition. An acute, specific, infectious disease ; characterized 
by a fever of low type, and a peculiar inflammation of the skin, gene- 
rally of the neck and face. This inflammation exhibits a marked 
tendency to spread, to induce serous infiltration and suppuration of 
the areolar tissue, and to affect the lymphatic vessels and glands. 

Cause. A poison, the nature of which is unknown. Feebly con- 
tagious. One attack predisposes to another. The etiology of idio- 
pathic (medical) and traumatic (surgical) erysipelas are identical. 

Ssnnptoms. Onset sudden ; a chill, followed by fever, which 
soon reaches 104° or \o^, frequent pulse, 100 to 130, coated tongue, 
nausea and vomiting, severe pains in the limbs, with epistaxis in 
adults and convulsions in children, and often diarrhoea. 

Delirium is frequent, and in those of alcoholic habits it resembles 
delirium tremens. 

The eruption soon follows the fever, beginning in red spots, which 
rapidly coalesce and spread ; a sense of heat, tension and tingling is 
caused by the great oedema, which presents a tense, shiny appearance, 
the swelling being so great at times as to close the eyes and distort 
the features. In many cases small vesicles develop, which may 
coalesce, forming blebs, of considerable size, containing a clear yellow 
serum. After five or six days the eruption begins to subside, the 
symptoms abate, the part affected becomes tender, and there is 
moderate desquamation. 

During the height of the attack albumen appears in the urine, so 
that the possibility of urcemic symptoms must be remembered. 

When extensive infiltration into the areolar tissue occurs, the 
C* 



PRACTICE OF MEDICINE. 

1 become greater, and it is t 



led phhgmonQUi 



42 

swelling an 
erysiptlas. 

When the eruption spreads to different parts of the body, it is 
termed erysipelas ambulans. 

OotnplicationB. Thrombosis of cerebral capillaries or sinuses, 
or as it is sometimes called, "erysipelas of the brain," is explained 
by the intimate anatomical connection of the facial vein with the 
pterygoid plexus and cavernous sinus. 

(Eiiemalous /aryngilis, from extension to the larynx. 

Pneumonia, pleurisy and meningitis are frequent complications. 

Diagnosis. Not difficult. The fever, early spreading eruption, 
with burning, swelling, tension and tingling, and albuminous urioe, 
separate it from the other eruptive feiiers and erythema. 

PrognoBis. Usually favorable. Unfavorable it it attack drunk- 
ards ; if it becomes gangrenous ; if thrombosis of si 
it extends to the larynx. 

The convalescence, even from the mildest attack, is slow, the 
patient continuing weak and anxmtc for a long ti 

Treatment. Mildest cases only require a laxative, noiuishing i 
diet, and locally vaseline or bismuth oleat., to modify the heat and \ 
burning. 

According lo Reynolds, aconituin will cut short an attack, 
administers m, ji-j. every fifteen minutes for the first two hours ; then I 
in hourly doses, until the surface is moist and the temperature lowered. 
The author corroborates this plan, from a personal experience 

In severe cases, tincl.ferri chlor., gtt. xx-xxx, every third hour, well 
diluted. Also qxiinina in gr. ij. every third hour. ExI, bc/ladoHna, i 
gr. Xp added, with benefit. The diet from the onset should be of the i 
most nourishing character, and administered at regular intervals. 

Prof DaCosta reports excellent results in cases with a rapid spread* ■] 
ing tendency, from the use of piloctrpint! kydrochloras, gr. j4. hypo- J 
dermatically or ext. pilocarpi flaiduin. gtt. xx-xl, every two hours. 

Cerebral symptoms, stimulants, opium and chloral. 

Extension to throat, argenti nitras, brushed over parts. 

Locally, soothing applications are indicated, to wit : Vaseline, ung: ^ 
zinci oxidi, ol. oliva cum glycerina, or bismuth oleat. 

In phlegmonous variety, argenti nitras, 9j, spts. celherls nifrosi 
3ij, brushed over and beyond the affected part, with the internal use 
of large doses of quinlna./errum and stimulants. 



FEVERS. 48 

DENGUE. 

SynonyiQS. Break-bone fever ; neuralgic fever ; dandy fever. 

The word dengue is pronounced dangay. 

Definition. A nacute, epidemic, febrile disease, consisting of 
two paroxysms of fever with an intermission. The first paroxysm 
is characterized by high fever; distressing pains in the joints and 
muscles, and a peculiar eruption ; the second paroxysm is charac- 
terized by a milder fever, an eruption of different character, attended 
with intense itching, by some recurrence of the joint pains, and by 
debility. 

Cause. Unknown ; but it is evident that a peculiar condition of 
the atmosphere has some influence in its development. 

Symptoms. Onset sudden, y^z/^r, 103° to 105°, intense headache 
burning pains in temples, backache, severe aching and swelling of 
the joints and stiffness of muscles, nausea, vomiting, constipation, 
and the appearance of a rash, resembling scarlatina, from which the 
disease has been mistaken for scarlatinal rheumatism. After some 
hours to two or three days, a distinct inter^nission obtains, of one or 
two days* duration. 

The onset of the second paroxysm is also sudden, but the symp- 
toms are much less severe, although the patient is greatly debilitated ; 
it is at this time that the characteristic eruption appears, being either 
erythematous or rubeolous, and attended with intense itching, re- 
maining for about two days, when desquamation occurs and con- 
valescence is established, but is prolonged by the great debility of 
the patient. Average duration of the disease eight days. Relapses 
are common. 

Diagnosis. Most apt to be mistaken for acute articular rheuma- 
tism, especially during the first paroxysm, but the course of the 
disease and the epidemic influence should prevent such an error. 

The eruption might mislead for scarlet fever or measles, were it not 
for the severe joint and muscular pains. 

Prognosis. Favorable. 

Treatment. No specific. Entirely symptomatic. 

At the onset, ix^^ purgation and diaphoresis. 

For \}[i^ fever, quinina, gr. v. every five hours. 

For the pains, opium p\ acidum salicylicum. 

For the itching, lotion of acidum carbolicum. 



44 PRACTICE OF MEDICINE. 



DISEASES OF THE MOUTH. 



CATARRHAL STOMATITIS. 

Synonyms. Simple stomatitis ; erythematous stomatitis ; catarrh 
of the mouth. 

Definition. An acute catarrhal inflammation of the whole or a 
portion of the mucous membrane of the mouth and tongue, character- 
ized by redness, swelling and disordered secretion. Mostcommon in 
infants and children. 

Causes. Introduction of hot and irritating substances into the 
mouth ; difficult dentition ; secondary to disorders of the stomach, 
measles, scarlet fever or variola. 

Pathological Anatomy. The buccal mucous membrane and 
tongue have a dark red appearance, are much swollen, the tongue 
often appearing as if too broad to lie between the teeth, the sides 
showing the impressions of the teeth ; the secretions are at first 
lessened, afterwards increased, a turbid mucus covering the cheeks, 
gums and tongue, thus giving a coated tongue. 

Symptoms. Oral catarrh begins with a burning, smarting fain, 
and tension in the mouth, in those old enough to describe their suf- 
fering. Very young children refuse to nurse or allow their mouth to 
be touched, have slight fever, disordered stomach, are fretful and 
sleepless, craving cooling drinks. 

The sense of taste is blunted, and there is usually an unpleasant 
bitter taste in the mouth. 

If the catarrh becomes chronic, the breath has a fetid odor and the 
tongue is coated in the morning, the taste is disordered, and there is 
generally more or less depression of spirits. 

Diagrnosis. If the buccal cavity be examined, the condition is 
readily discerned. 

Progrnosis. Recovery is the rule for the acute variety. 

The chronic cases are usually due to the use of tobacco or alcohol, 
and are only modified by the absolute withdrawal of the exciting cause. 

Treatment. The most important point in the treatment is the 
removal of the exciting cause, attention to the secretions and diet. 

Locally — 

R. Sodii boratis ,.. ^iss 

Aquse distillat.. fjj 

Mel. rosae f^j. 



DISEASES OF THE MOUTH. 45 

FOLLICULAR STOMATITIS. 

Synonyms. Aphthae ; vesicular stomatitis ; croupous stomatitis. 

Definition. An acute inflammation of the follicles and mucous 
membrane of the mouth and tongue, characterized by 2^ fibrinous or 
croupous exudation ; the exudation first appearing in isolated spots 
{aphthce discrete), ziitrwdirds coalescing, and forming large and irregu- 
lar-sized patches [aphthce confluens), which rupture, leaving an ulcer, 
which slowly heals. 

Causes. A disease principally of childhood. Difficult dentition ; 
disorders of digestion ; uncleanliness, such as neglect to rinse the 
child's mouth after nursing ; with measles and diseases of the buccal 
cavity. 

Pathological Anatomy. Begins as a small, whitish papulo- 
vesicular elevation, semi-transparent, hard and tender, with a distinct 
red zone about their base ; there may be as few as six or as many as 
twenty ; they may remain isolated (aphthce discrete) or coalesce 
[aphtkcB confiuens) ; they are regarded as either a peculiar deposit or 
a local croupous exudation. After a day or two they rupture, leaving 
an irregular white or grayish ulcer, which slowly heals. The seat of 
the affection is the internal surface of the lips and cheeks, the gums, 
tongue and roof of the mouth. 

Symptoms. In infants, the pain is so severe that the child 
refuses to nurse. In older children, pain from talking, mastication 
and deglutition. Salivation is marked, the saliva dribbling from 
the mouth. There is sXx^X. feverishness, fretfulness TisA sleeplessness. 
Digestion is impaired, and quite commonly diarrhoea occurs. A dis- 
agreeable, penetrating odor escapes from the buccal cavity. 

Diagnosis. Impossible to confound with any other affecdon if 
the buccal cavity is examined. 

Prognosis. Always favorable. 

Treatment. Removal of the exciting cause. Attention to the 
dietary and the secretions is paramount. 

Internally, excellent results follow the use of potassii chloras, gr. j 
to V, every three or four hours, according to the age. Protracted 
cases require tonic doses of quinince sulphas. 

Locally, good results are obtained from strong solutions of potassii 
chloras, infusum coptis or bismuth, applied directly to the ulcers. 



W PRACTICE OF MEDICINE. 

ULCERATIVE STOMATITIS. 

Synons^ms. Diphtheritic stoitiiilitis : gingivitis ulcerosa. 

Deflmtioa. An acute diphthentic inflammation of the 
membrane uf the mouth, continuing until extensive and unhealthy 
ulceration occur. It usually begins on the margin of the lower gutns, 
and often extends to the lips, cheeks or tongue. 

Oauaes. Usually seen in children only. Most frequently in the 
families of the poor, the result of unfavorable hygienic surroundings, 
personal uncleanliness and poor food. Often seen in those reduced 
by severe acute disease. Perhaps contagious, as epidetniirs are not rare. 

Pathological Anatomy. The ^tms first appear congested, 
swollen, bleeding readily and separated from the teeth; soon a 
lirmly adherent deposit in the form of patches appears, at first whttish, 
speedily becoming {jray or even black, from disintegration, becoming 
soft and pulpy, the separated slough leaving irregular-shaped ulcers, 
with raised margins, from cedema of the surrounding tissue. They are 
not deep, and their surface is covered with a pulpy, yellowish sub- 
stance. The morbid process usually extends to the inner side of the 
lips, cheeks and to ihe tongue. 

Symptoma. Pain constantly, aggravaled by masiicalioti ardegiu- 
tition ; food and drink must be of the blandest character. The 
moulh is hot, the saliva dribbles away, mixed with blood and sbrcds I 
of pulpy matter, the breath is fetid, the appetite, digestion and bowels 
disordered. The patient is feverish, fretful and sleepless 

There is always enlargement and tenderness of the submaxillary 

The affection is often associated with entero-colitis. 

Diagnosis, Apt to be confounded with gangrenous stomatitis,. 1 
than which, however, there is less constitutional symptoms and a. J 
slower course of the malady. 

Prognosis. Favorable. If proinpdy and properly treated, the I 
ulcerated surface rapidly heals, although quite commonly some teethi I 
are lost. 

Treatment. The etiology of the affection must be borne in mind \ 
and remedied. Strict attention to the diet, tn the secretions, and abso- | 
lute cleanliness. 

Internally, the prompt use oi polassii fA/oritt, gr. j-v., frequently ' 
repeated, often acts like a specific. The general health often calls 
for quiniita, ferrum and stimulants. 



DISEASES OF THE MOUTH. 47 

Locally, a strong solution of potassii chloras, or keeping the ulcer 
covered with bismuth, or frequent applications of alumen exsiccatum 
are valuable. Cases which resist these remedies should be given the 
following combination, proposed by the late Dr. Dewees : — 

R. Cupri sulphat gr. x 

Pulv. cinchonas opt ^ij 

Pulv. g. arab 3;] 

Mel. commun f^^ij 

Aquae font.... f^ "J* ^ 

Ft. sol. 
SiG. — ^The ulceration to be touched twice daily, "with the point of a 
camePs-hair pencil. 

If a spreading tendency occur, the application of argenti niiras 
dilutus, or a diluted solution of acidum nitricum is indicated. 

THRUSH. 

Synonyms. Muguet ; sprue ; white mouth. 

Definition. An inflammation of the mucous membrane of the 
mouth, associated with or caused by the growth of 2i parasitic plant, 
the otdium albicans ; characterized by pain, disorders of digestion and 
of the bowels. 

Oauses. The development of the thrush-fungus, didium albicans, 
is propioted by all those conditions designated as unhygienic, by de- 
bilitated conditions of the general system, and by neglect to thoroughly 
rinse the mouth after nursing or bottle feeding. 

The age is considered a predisposing cause, seldom being seen 
after two years of age. In adults, only toward the end of cancer or 
consumption. 

Pathological Anatomy. The mucous membrane of the mouth 
assumes a dark red appearance in isolated patches, on which whitish 
points appear, which rapidly coalesce into large areas. They closely 
resemble curdled milk, from their soft consistency. These whitish 
points consist of epithelium and fat, in which are embedded the 
sporules and filaments of the fungus. 

The deposit first appears about the angles of the mouth, soon ex- 
tending to all parts of the cavity, often to the pharynx and oesophagus. 

The mouth is usually swollen and tender, the breath often fetid. 

Symptoms. Pain, aggravated by nursing or mastication. The 
lips are swollen, the saliva is increased, the breath hot and somewhat 



PRACTICE OF MEDICINE, 

feiid. There is usually increased temperature. Diarrlitrn is frequent, 
the stools green and sour, causing an erythema of the buttocks. 

Diaernosia. The curd-hke appearance of the deposit, showinglbe 
presence of parasites upon microscopical examination, will prevent 

ProETDOBis, Favorable, unless occurs toward the termination of 
exhausting diseases. 

Treatment. Absolute cleanliness of the mouth is all important, 

Memally, remedies should be directed to the removal of the dis- 
orders of the gastro-intestinal tract. 

Locally, solutions of sotiii beras answer every indication, the best 
vehicle bang ^lycerinuin, and not mei or saccliarum, a good formula 
being— 

B. Sodii boratiB 5} 

I Glycerini fgij 

^^^^ AquK gv). M. 

^^^^^B Sic. — Thoroughly applied four or liie times daily, and continued for a 
^^^^H week after the disappearance of the atTecliao. 

II GLOSSITIS. 

Definition. An inflammation of the parenchyma of the tongue; 
characteriied by great swelling of the organ, with difficult mastication, 
deglutition and vocalization. 

The affection may be either acute or chronic. 

Causes. The acufe variety is usually the result of some direct 
irritation lo the tongue, such as direct injury, contact of boiling- 
liquids, the action of acrid or corrosive substances, or the sting of 
the tongue by an insect, such as the bee or wasp. 

The chronic variety is generally circumscribed ; it may follow the 
acute; bedue to the sharp edges ofthe teeth, or the use of a tobacco pipe. 

Pathological Anatomy. Ac-iite glossilis begins with intense 
hypersemia, redness and swelling of the organ ; the size often be- 
comes so great that the tongue is loo large for the mouth, and thus 
protrudes between the teeth ; its surface is covered with a thick secre- 
tion, and it becomes of a pale or grayish color. The swelling may 
rapidly decline, or abscesses may form, which leave a more or lesa 
decided depressed cicatrix. 

Chronic glossitis occurs usually along the edges, the cicatricial 
changes being in circumscribed hard spots. If the entire orgaji ia 



DISEASES OF THE MOUTH. 49 

affected with chronic inflammation, the action is superficial, and has 
been termed " psoriasis of the mouth." 

Symptoms. Acute glossitis begins rather abruptly with y^7/^r/ 
increased pulse^ restlessness, anxiety, enlargement of the tongue, the 
sensation of heat in the mouth, with pain, and increased flow of 
saliva. Mastication and deglutition become difficult if not impos- 
sible, the voice muffled and dyspnoea decided. The glands at the 
angles of the jaw are enlarged, which, in turn, compresses the vessels 
of the neck. 

When suppuration supervenes, the constitutional symptoms be- 
come severe and the oral symptoms are intensified. Death has 
occurred from suffocation in severe cases. 

Chronic glossitis presents pain as the chief symptom, aggravated 
by movements of the organ. 

Diagnosis. The rapid course of acute glossitis should prevent 
its being mistaken for any other affection. 

Chronic glossitis, if severe, might be mistaken for cancer of the 
tongue, although the slow and mild progress of the former contrasts 
strongly with the rapid, severe and painful course of the latter, with 
its marked constitutional symptoms. 

Prognosis. Acute glossitis usually terminates in recovery within 
a week, although the danger of suffocation must always be remem- 
bered. 

Chronic glossitis is an incurable malady in the majority of instances. 

Treatment. For acute glossitis prompt measures are demanded. 

For the fever and rapid pulse, tinctura aconiti, gtt. j to iij every 
half hour or hour until its effects are produced. 

For the enlargement of thfe organ, either ice constantly applied 
internally and externally, at the angles of jaw, or the persistent use of 
hot water held in the mouth and externally ; if prompt relief does not 
follow these measures, or if the case* is an aggravated one, the 
prompt deep scarification of the tongue must be resorted to. 

If abscesses form, promptly open them and administer quinina. 

If suffocation appear imminent, tracheotomy must be performed. 

For chronic glossitis, the removal of the exciting cause and the 
local use of argenti nitras to the ulcerated edges. 

" For psoriasis of the tongue," the local use oi argentum or acidum 
carbolicum. 

The general health must always receive due attention. 



50 PRACTICE OF MEDICINE. 



DISEASES OF THE STOMACH. 



ACUTE GASTRIC CATARRH. 

Synonyms. Acute mild gastritis; gastric fever; bilious fever; 
acute indigestion ; subacute gastritis. 

Definition. An acute catarrhal inflammation of the mucous mem- 
brane of the stomach ; characterized by feverishness, loss of appetite, 
nausea, with occasional vomiting, painful digestion, irregularity of the 
bowels, and in severe attacks, vertigo (stomachic vertigo). 

Causes. Deficient quantity of or quality in the gastric juice. 
Errors in diet, insufficient mastication of food, swallowing liquids 
which are either too hot or too cold, and especially, the abuse of 
alcoholic drinks. 

Often secondary to infectious diseases, such as scarlet fever, measles, 
smallpox, diphtheria and typhoid fever. Occasionally the result of 
sudden changes of temperature. 

Pathological Anatomy. The mucous membrane is irregularly 
congested and engorged, and covered with a grayish, semi-transparent 
and tenacious mucus, having an alkaline reaction. The true gastric 
juice is secreted in lessened amount or is entirely suspended, 

S3nnptoniS. At first, loss of appetite, at times, disgust for food ^ 
heavily coated tongue, bad taste and breath, persistent nausea, and 
at times, vomiting, first of undigested food, then viscid mucus, acid 
and bitter, and finally, bilious matter; moderate irritative fever is 
present, with headache, considerable thirst and Hashes of heat with 
sensations of burning in the palms of the hands and soles of the feet; 
acid drinks eagerly sought after ; digestion imperfect, giving rise to 
pain, tenderness, feeling of weight and eructations ; bowels often 
loose, sometimes, however, constipated. Vertigo with pain in the 
nucha, is a prominent symptom in many cases, causing great anxiety. 
The urine is scanty, containing lithates and pigment. 

The symptoms are aggravated by errors in diet, and if saccharine 
or fatty articles are taken, heartburn occurs. 

Towards the termination of an attack herpetic eruptions appear 
about the mouth. 

Diagrnosis. Acute gastric catarrh with fever, may be confounded 
with remittent and typhoid fever of the first week, but all doubts will 
disappear as these maladies develop. 






''^W* "fcW-v • w***** 



««,•»» * 






* « 



DISEASES OF THE STOMACH. 51 

The vertigo may be mistaken for cerebral disease, but the dis- 
appearance of this symptom when stomachic treatment is inaugu- 
rated dispels all doubt. 

Prognosis. Favorable. Duration about a week ; recovery slow, 
even under treatment, as far as perfect digestion is concerned. 

Treatment. Give the stomach as complete rest as possible. IT 
the stomach is overloaded, an ipecac emetic is indicated, or if vomit- 
ing has begun, it may be encouraged by swallowing large draughts of 
warm water, which will act as a sedative if the stomach be empty. 
Irritability of the stomach is readily controlled by — 

R. Hydrarg. chlor. mitis gr. -^^-^js 

Sodii bicarb gr. ij 

Pulv. aromat gr. v. M. 

Every two hours, 

which has the additional advantage of relieving the bowels, or — 

R. Bismuthi subnit...'. gr. xv 

Acid, hydrocyanici, dil TT\^ij 

Mucil. acaciae f^ss 

Aq. menth. pip f^iss. M. 

SiG. — Every two or three hours. 

Weak alkaline mineral waters or liquor calcis^ should be freely 
used. 
After the acute symptoms have subsided — 

R. Tinct. nucis. vomicis gtt. iv-x 

Acid, hydrochlor. dil gtt. x 

Glycerin^, ^ss 

Aquae lauro cerasi f^iss. M. 

Before meals, will improve the appetite and digestion. 

ACUTE GASTRITIS. 

Synonym. Toxic gastritis. 

Definition. An acute and violent inflammation of the mucous, 
submucous and muscular coats of the stomach, with loss of tissue ; 
characterized by great pain, constant vomiting of blood-streaked or 
bloody mucus and symptoms of collapse. 

Causes. Ingestion of irritant and corrosive poisons, to wit : min- 
eral acids, arsenic, corrosive sublimate, copper and carbolic acid. 



52 PRACTICE OF MEDICINE. 

4 

Pathological Anatomy. The mucous membrane is vividly red 
and injected, more marked at some portions than at others ; it is soft 
and friable; erosions are irregularly scattered, and the submucous, 
muscular, and at times serous coats show decided destructive changes. 
The gastric tubules are destroyed in large numbers. In many 
cases the oral mucous membrane presents signs of severe inflam- 
mation. 

Symptoms. Immediately or soon after swallowing the irritant 
there ensues a deadly nausea, rapid and persistent vomiting; first, of 
the contents of the stomach acted upon by the poison ; afterwards, 
shreds of mucous membrane and blood clots ; great anxiety and 
depression, a weak, rapid pulse, slow and shallow respiration, cold 
skin, covered with a cold sweat, intense burning heat at the epigas- 
trium, thirst with burning in the fauces and gullet, and exhaustive 
purging ; the features are more or less retracted or sunken ; these 
symptoms terminating in collapse and death, or slow convalescence 
and recovery with a crippled stomach. 

A diagnosis of the character o^ the poison swallowed is often 
afforded by the stain of the lips, face and mucous membrane, to wit : 
sulphuric acid, blackish eschar ; nitric acid, yellowish eschar ; caustic 
potash, spreading widely and softening the tissues ; corrosive subli- 
mate, whitish or glazed; carbolic acid, white and corrugated. 

Progrnosis. Very grave. Majority perish from shock, and de- 
struction of mucous membrane, which prevents nourishing. Early 
treatment when no perforation of the walls of the stomach and 
recovery is possible, the organ being ever after much weakened. 

Treatment. At once, hypodermatic injection of morphina, re- 
peated at regular intervals. 

Vomiting should be encouraged by the free use of demulcents. 

If the case be seen within a short period of the swallowing of the 
poison, the proper antidote should be used ; but if some hours have 
elapsed, it is useless. Ice, internally and externally, gives great 
relief. The stomach should be washed out with the stomach pump, 
thereby removing any remaining poison, while at the same time it acts 
as a sedative to the inflamed membrane; also bismuthi subnit, grs. 
xx-xxx every hour or two, is beneficial. 

Milk and lime water is the only food that should be given by the 
stomach, enemata being used to support the system. 



DISEASES OF THE STOMACH. ' 63 

CHRONIC GASTRIC CATARRH. 

Synonyms. Chronic gastritis ; chronic dyspepsia ; drunkards* 
dyspepsia. 

Definition. A chronic catarrhal inflammation of the stomach, 
with thickening of the coats and atrophy of the gastric glands ; char- 
acterized by tenderness over the epigastrium, impaired appetite, pain- 
ful and imperfect digestion, thirst, and great depression of the mental 
powers. 

Causes. Repeated attacks of acute gastric catarrh ; habitual use 
of spirituous liquors ; disease of the heart, lungs, pleura or liver, pro- 
ducing chronic congestion of the stomachic vessels ; cancerous or 
other degenerative diseases of the stomach. 

Pathologfical Anatomy. The mucous membrane is of a 
brownish or slate color, elevated into ridges from hypertrophy, the 
result of constant congestion ; the peptic glands first increase in size, 
then undergo granular change, atrophy of their cells resulting. The 
mucous membrane is covered with a thick, alkaline tenacious mucus. 
These changes may affect the entire organ or be limited in extent. 

Symptoms. Loss of appetite, disagreeable feeling oi fullness in 
the stomach, tenderness at the epigastrium, but slightly influenced by 
eating, prominence of the epigastrium, from distention by decom- 
posing gases, occasional nausea and vomiting, the latter more com- 
mon in drunkards, occurring on arising, termed morning vomiting 
and consisting of glairy mucus raised after great retching ; constant 
thirsty water and at times stimulus being craved ; often great burning 
at the pit of the stomach, the result of acidity ; bowels constipated, 
urine high colored. A feeling of mental depression and sleeplessness, 
with occasional attacks of vertigo, add to the misery of the patient 
The imperfect digestion causes more or less loss of flesh, the fat disap- 
pearing, the muscles relaxed and the skin dry. 

Prognosis. Favorable as to life, but not as to complete recovery, 
the atrophied glands more or less hindering digestion and assimil- 
ation. 

Treatment. Regulated diet. Avoid fatty, saccharine and starchy 
food. Also all tonics, bitters, or acids, unless specially indicated. 

Locally, few leeches, dry cups, a blister, or empiastrum belladonna: 

Purgatives are doubly indicated ; first, relieving the constipation ; 
and second, clearing the stomach of the tenacious mucus, which 



U PUMTICB OF MEDICIKB. 

neutraliies what gastric juice is sccrettcl. Appropriate purgadves ai 
the natural mineral watei?. such as Saratoga or Friedrichshall. or — 

B ■ Magnesii lulpb ji-'j 

Sodii et potass, lart. 3»-j 

Acid, tattnric _ gr. xx. M. 

DiESotvcd in B glass of water and drank, effervescing, an hour betaif 

Digtstion may be temporarily aided by pepsinum or lactcp^tA 

with the meals. 

Great relief follows the systematic drinking of one-half to one pi 
of hot -Wilier an hour before meals. 

For the morbid condition itself may be used, liq. petassii arseniti 
gtl. i-ij before meals, or binnuth ssibnit., gr, x-xk, before meals, 
which may be added sodti bicarb., gr. v ; or argenti nitrat., gr. X~J^» 
or argenti oxiduin, gr. %~), in pill, before meals. 

Fain is so severe in some cases that resort must be had at times to 
opium or belladonna in small doses, after meals. 

Hest of the body is almost as imperative as i est of the stomach. 

GASTRIC ULCER. 

Synonyms. Chronic gastric ulcer ; perforating ulcer. 

Definition, A solution of continuity, involving ilie mucous mei 
brane and one or more layers of which the walls of the stomach a 
composed ; characterized by pain, disorders of digestion and vomil>' 
ing of blood. 

Causea. An;cmin or its sequela; the chief factor. Most 
in young Anicmic women. Virchow claims that emboliox 
form in the nutrient gastric arteries which have lost their tonicity, a 
ulcer forminc at the point of obstruction, • 

Pathological AJiatomy. In the majority of cases the ulcer 
solitary. The pusleriDr waII nearthe pylorus isthc most commonsit 

In a typical case (here is a circular hole, with sharp borders in li 
scrtm* cnat iif the stuniach ; the loss of substance is greater in tt 
mucous membrane than in ihe muscular coal, and grc.iterin ihisOia 
in the serous coat, so lliat ihe ulcer tooks like a shallow funnd, tl 
apex at the outer wall, the bnsb Ai the Itiner wall nf the stomach; 
is first round, growing, becotfles elliptical, bulging; al porlv 
ing irrtgtilar; iiie. frotn V-'i ii<^h '" diameter. When the iili 
lw*ls hefiii^ all (he coats aie perforateH, a distinct cicatrix marks 



u 



DISEASES OF THE STOMACH. 55 

location. During its progress nutrient vessels are eroded, causing 
profuse hemorrhage. Chronic gastric catarrh complicates the major- 
ity of cases. 

Symptoms. More or less prominent symptoms of indigestion. 
Pain constant at the " pit of the stomach," increased by taking food, 
especially of an irritant kind, the pain often felt in the back, of a 
burning, gnawing c\i2ir2iCi^x. Tenderness at one or more' points, ex- 
tending from the front to the back. Vomiting is almost as constant 
as pain, coming on soon after eating, if the ulcer is at the cardiac 
orifice, an hour or so after if it is at or near the pylorus. Rejected 
matter may be undigested or partly digested food, or simply acrid 
mucus. Vomiting of blood in large quantities and arterial in color is 
almost diagnostic of gastric ulcer ; the blood may be dark in color if 
it has remained in the stomach some time before being rejected. 

Severe and frequent attacks of gastralgia may add to the suffering 
of the patient. The general condition of the patient is not significant, 
some being greatly debilitated, while in others the nutrition is but 
little deranged. 

Duration. The ulcer is slow in forming, and runs a very chronic 
course, an average duration being, perhaps, a year. Cases are 
recorded in which the disease has suddenly developed and ter- 
minated by perforation, peritonitis and death within two weeks, but 
they are rare. 

Diagnosis. Duodenal ulcer presents symptoms so akin to those 
of gastric ulcer that a differential diagnosis is impossible. 

Chronic gastritis is often confounded with gastric ulcer ; the dis- 
tinctive points are, absence of vomiting of blood, no localized con- 
stant pain aggravated by food, and no tenderness in the back ; while 
the symptoms of indigestion are marked and persistent, with, as a 
rule, a history of spirit drinking, and the age of the patient — middle 
life ; ulcer in the young. 

The points of distinction between gastric cancer and gastralgia will 
be pointed out when treating of those affections. 

Prognosis. Not very unfavorable. Recoveries are frequent. 
The dangers 2iX^ perforation , peritonitis ox fatal hemorrhage. 

Treatment. Give the stomach as complete a rest as possible ; 
this is accomplished by rectal alimentation, or where it cannot be 
carried out, exclusive milk diet, adding lime water, to enable the 
stomach to better retain the milk ; the amount of milk should be one 



66 PRACTICE OF MEDICINE. 

or two ounces every two hours. Rest in bed is paramount, and 
should be insisted upon. 

Y ox pain, small doses of morphina should be used as needed. 

For hemorrhage, hypodermatic injections of ergota are most reli- 
able. Plumbi acetas, gr. j-iij arrests the bleeding and exercises a 
favorable influence over the ulcer. 

For the ulcer, liq, potassii arsenit., gtt. j-ij every five hours, has 
given excellent results in several cases treated by the author ; bismuth, 
subnitrat,, gr. xx-xxx, combined with sodii bicarb,, gr. iij-v, three 
times a day, often does well; argenti nitras, gr. }4-/i, every four 
hours, or argenti oxidum, gr. ss, every four hours, are at times bene- 
ficial. 

\i perforation diVid. peritonitis result, full doses oi opium are indicated. 

GASTRIC CANCER. 

Synonyms. Cancer of the stomach ; gastric carcinoma. 

Definition. A peculiar malignant growth, occurring for the most 
part at the pyloric extremity of the stomach, making constant pro- 
gress, destroying the gastric tissues and infecting the lymphatic glands ; 
characterized by disorders of digestion, pain, vomiting, marked anae- 
mia, and terminating in all cases by the death of the patient. 

Cause. Hereditary. Develops after forty years, for the most part. 

Pathological Anatomy. Cancer of the stomach is the most 
common form of cancer. It is, as a rule, a primary cancer. The 
variety is most commonly the scirrhus, next in frequency, medullary, 
the least frequent, colloid. As regards the location, eighty per cent, 
occur at \hQ pylorus. 

It originates usually in the tubules, rapidly infiltrating the remain- 
ing tissues, thickening everywhere as it progresses, and either remains 
a hard nodulated mass or undergoes ulceration. The hard nodulated 
growth at the pylorus constricts the orifice, resulting in dilatation of 
the stomach. The lymphatic glands adjacent to the stomach are in- 
filtrated, secondary cancers resulting. Ulceration into an artery causes 
hemorrhage into the peritoneum, resulting in local peritonitis. 

Complications. Fatty heart ; thrombosis ; tuberculosis. 

Symptoms. Indigestion, progressive in character, with marked 
acidity, flatulency and a fetid breath. 

The majority of cases have vomiting immediately after eating, if at 
the cardiac orifice, and some hours after if at the pylorus, and if 



DISEASES OF THE STOMACH. 57 

much dilatation of stomach, some days after. The rejected matter is 
food in various stages of digestion, with frequently blacky grumons 
masses of altered blood. Pain, marked and constant, dull, heaiy, 
increased by pressure, seldom lancinating. Marked ancemia, emacia- 
tion, and towards the end dropsy, the surface having an earthy or 
fawn color. A tumor is found in three-fourths of the cases, occupy- 
ing the epigastric region, not moving with inspiration. 

The duration of the disease is about one year, the patient dying 
from exhaustion, peritonitis or hemorrhage. 

Diagrnosis. Chronic gastric catarrh differs from gastric cancer, 
in the absence of a tumor, bloody vomit, characteristic pain, peculiar 
color of the surface, dropsy and the rapid emaciation. 

Gastric ulcer differs in the character of the pain, age of the patient, 
large amount of bloody vomit, absence of a tumor and progressive 
emaciation. Still the diagnosis is often difficult. 

Abdominal tumors may raise the question of a gastric cancerous 
tumor ; the points of distinction are the characteristic symptoms of 
gastric cancer, and that abdominal tumors, especially of the liver and 
spleen, the ones most apt to cause error in diagnosis, are influenced 
by inspiration, while tumors of the stomach are not so influenced. 

When a scirrhus of the pylorus lies upon the aorta, a pulsation may 
be communicated to it, raising the question of aneurism of the abdo- 
minal aorta, but the expansile pulsation of aneurism (Corrigan's sign) 
is wanting, as are the other symptoms of the affection, and if the 
patient is made to rest upon his hands and feet, the stomachic tumor 
falls away from the aorta and pulsation ceases. • 

Mikuliez claims that, by the use of his gastroscope, regular rhyth- 
mical motions can be seen when the pylorus is not the seat of cancer, 
and that such movements are absent when it is the seat of cancer. 

Prognosis. Unfavorable, Internal medication offers no hope, 
the patient usually succumbing from starvation. 

Gastric carcinoma occurring under thirty years of age is rapidly 
fatal, not conforming to the usual symptoms as seen later in life; 
the characteristic cachexia is commonly absent and haematemesis is 
rare. 

Treatment. We possess no means of arresting the disease. 
"Six operations have been practiced for the rehef of stenosis of the 
pylorus: ist. Pylorectomy; 2d. Gastro-enterostomy ; 2d. Gastrectomy; 
4th. Gastrostomy ; 5th. Duodenostomy ; 6th. Pigital divulsion of the 

D 



58 PRACTICE OF MEDICINE. 

pylorus." Professor Billroth has excised the pylorus, thereby prolong- 
ing liife ten months. 

For acidity diXid. fetor of the breath, acidtan carbolicum, gr. X~K» ^^ 
carbo animalis purificatus, gr. x-xxx, affords some relief. 

For vomiting, bismuth and opium, or the washing out of the stomach 
with the stomach pump. 

Y ox pain, morphina. 

Avoid stimulants. 

GASTRIC DILATATION. 

Synonyms. Pyloric obstruction ; pyloric stenosis. 

Definition. An abnormal increase of the cavity of the stomach, 
with the walls either hypertrophied; or decreased in thickness ; char- 
acterized by pronounced indigestion, vomiting of partly digested and 
partly decomposed food at intervals of every few days, and moving 
of flatus in the abdomen (borborygmus). 

Causes. Most common, stricture of the pylorus, the result of 
cancer; pressure of tumor against the pylorus, preventing exit of 
stomach contents. Loss of muscular tone, occurring in anaemia. 
Prof. Bartholow cites cases resulting in excessive beer-drinkers, who 
drank thirty to forty glasses of beer habitually, every day. 

Pathologrical Anatomy. When obstruction exists at the 
pylorus, the whole organ is dilated, with hypertrophy of the muscular 
layer of the stomach. In dilatation without pyloric obstruction, the 
muscuhir layer is thinner than normal, pale in color, and presents 
signs of fatty degeneration ; the mucous membrane is also pale, thin, 
and without rugio. 

Symptoms. Those of the disease producing the obstruction plus 
those of obstinate chronic gastric catarrh, with characteristic vomit- 
ing ; the cavity having a greatly increased capacity, large accumula- 
tions take place, which are rejected every few days, partly digested 
and partly decomposed. Regurgitation of partly digested aliment, 
acrid, acid and oiTensivc, is very common. Bowels constipated, the 
stools hard and dry. 

Physical signs of gastric dilatation are : on inspection, abnormal 
prominence of the whole epigastric region, with a tumor in the pyloric 
region which seems to be connected with the stomach ; percussion, if 
empty, tympanitic note extending to or below the umbilicus, having ' 

a metallic quality ; if the stomach be filled, high pitched flat note ; 






DISEASES OF THE STOMACH. 59 

auscultation, splashing and rumbling sound, the succussion sound 
being distinct if the body be shaken. 

Diagnosis. The cause being ascertained, no difficulty is expe- 
rienced in making a diagnosis. 

Treatment. Regulated diet. Restrict the use of fluids, using a 
"dry diet ** almost exclusively. 

If the result of pyloric stenosis, one of the operations noted in 
pyloric cancer may be indicated. 

Regardless of the cause, washing out the stomach with the stomach 
pump, every day or two, gives relief, and, if no stricture, adminis- 
tering strychnina or nux vomica, and .very favorable results may 
follow. 

GASTRIC HEMORRHAGE. 

Synonjnns. Haematemesis ; gastrorrhagia. 

Definition. Gastric hemorrhage is not, strictly speaking, a dis- 
ease, but a symptom ; still, vomiting of blood, occurs under such a 
variety oT conditions, that a separate consideration is desirable. 

Causes. Ulcer of the stomach ; cancer of the stomach ; scurvy ; 
purpura ; hemorrhagic malarial fever ; congestion of the liver or 
spleen ; vicarious at menstrual period ; yellow fevet. 

Symptoms. Added to the symptoms of the cause of the hemor- 
rhage, are 3. feeling offaintness and sinking at the pit of the stomach, 
followed by the ejection of blood of a black, grumous, or coffee-ground 
appearance. Rarely, and then generally in gastric ulcer, the ejected 
blood may have a bright red appearance, the gastric juice not having 
had time to act upon it. If the amount of blood escaping into the 
stomach is large, blood will be voided by stool. 

Diagnosis. Hemorrhage from the lungs may be confounded with 
gastric hemorrhage. In the former, the blood is red, is coughed up, 
not vomited, and is associated with a history of pulmonary disease. 
The chief point of distinction between pulmonary hemorrhage and the 
vomiting of red blood is, that in the former you can discern rales on 
auscultating the chest, and they are absent in the latter. 

Prognosis. Depends entirely upon the cause, the most unfavor- 
able being the result of either gastric ulcer or cancer. 

Treatment. Perfect rest in bed. Ice, swallowed and applied 
in bladders over the epigastrium and along the spine. 

Hypodermatic of morphina quiets the patient's fear, and at the 
same time has a constringing effect upon the vessels. Extractum 



ir^oUe Jluidmn or ergolin hypodermatically after the patient is 
quieted, or liquor ffrri subsulpk.. gtt. j-v, well diluted by stomach. 

Allow no food by the stomach for several days, nourishing the 
patient by rectal alimentation. 

The hemorrhage controlled, the future treatment is guided by the 



itmg c, 



GASTRALGIA. 



; stomachic colic ; spasm 



the group of neuralgias, 
is general nervous depre 
ir gouty diathesis, anasml 



Synonsnns. Cardialgia ; gastrodyni. 
of the stomach ; neuralgia of the stomach. 

Deflnition. A painful condition of the sensory nerves of the 
stomach, induced by various sources of irritation ; characterized by 
violent paroxysms of gastric pain and s;)asm, associated with feeble 

Causes. The affection belongs to the group of neuralgias. The 
most important factor in its causatio 
other causes are malaria, rheumatic 
certain articles of diet. 

Symptoms. Like most neuroses, gastralgia is distinguished by 
its /<i^o.ir>'j-7H(t/ character. Romberg ihas describes an attack: — 

" Suddenly, or after a feeling of pressure, there is severe griping 
pain in the stomach, usually extending to Ihe back, with a feeling of 
faiHiness, shrunken countenance, cold hands and feet, and an inter- 
mitlent pulse. The pain becomes so excessive, the patient cries ouL 
The epigastrium is either puffed out, like a ball, or retracted, with 
tension of the abdominal walls. There is often pulsation in the epi- 
gastrium. External pressure is well borne, and not iinfrequently the 
patient presses the pit of the stomach against some 6rm substance, or 
compresses it with his hands. Sympathetic pains often occur in the 
thorax, under the sternum, and in the (esophageal branches of the 
pneumogastric, while they are rare in the exterior of the body." 

"The attack lasts from a few minutes to half an hour; then the 
pain gradually subsides, leaving the patient much exhausted ; or else 
it ceases suddenly, with eructation of gas or watery fluid, or with 
vomiting, and with a gentle, soft perspiration, or with the passage of 
reddish urine." 

Besides such sev'ere attacks, we often see painful sensations in the 
epigastrium, of various degrees of intensity, with passing faintness or 
sinking at the "pit of the stomach." 



J 



DISEASES OF THE STOMACH. 01 

Diagnosis. From myalgia of the abdominal muscles, by the pain 
of gastralgia being more acute and lancinating, accompanied by 
nausea and vomiting and the absence of tenderness on pressure. 

From intercostal neuralgia, by the fact that in this affection the 
pain is in the left hypochondrium, with painful spots along the course of 
the nerve trunk and at the spine, and absence of nausea and vomiting. 

From gastric cancer, by the age, character of the vomited matter, 
constancy of the pain, the cachexia, emaciation and the tumor. 

From gastric ulcer, by the localized pain and its constancy, with 
tenderness and vomiting of blood, and constant dyspeptic symptoms, 
which is not the case in gastralgia. 

Prognosis. As to perfect recovery, unfavorable, but not dan- 
gerous to life. A chronic affection, in that attacks are prone to return 
from time to time. The cause has much to influence a radical cure. 

Treatnaent. For the paroxysm, hypodermatic of morphina, gr. 
^-\, or the stomachic administration of the " compound of anodynes,*' 
the so-called chlorodyne, in doses of n\,x-xxx p. r. n. The relief 
afforded by opium in some form is so decided that it is prone to lead 
to the opium habit when the attacks are frequent. 

In the interval, regulated diet and one or more of the following 
remedies : quinina, arsenicum, bismuth, ferrum, liq. iodi, comp., or 
small doses of potassii iodidum. 

ATONIC DYSPEPSIA. 
Synonyms. Dyspepsia ; indigestion ; heartburn ; pyrosis. 

Definition. A functional derangement of the stomach, with either 
deficient secretion in the quantity or quality of the gastric juice ; char- 
acterized by disorders of the functions of digestion and assimilation. 

Causes. Imperfect mastication ; bolting of food ; eating large 
quantities of food ; same diet long continued ; depressed nervous 
system, from worry and fatigue. It is often inherited. 

Symptoms. Perverted appetite, capricious or lost ; difficult diges- 
tion, a feeling of weight or fullness in the epigastrium ; acidity, from 
the decomposition of albuminoids ; heartburn, flatulency, regurgita- 
tion, or vomiting of portions of partly digested food or acrid fluid — water 
brash ox pyrosis. Pain or soreness at the " pit of stomach " during di- 
gjestion. Tongue either clean or broad, flabby and pale, showing marks 
of the teeth. Bowels constipated ; urine generally scanty and high- 
colored, with excess of urates or oxalates, or, in persons of nervous 



G2 PRACTICE OF MEDICINE, 

type, it is pale, of low sp. gr., and contains phosphates. Drowsiness 
after meals, with •wakefulness at night, defective memory, headackt 
and absent mental vigor, with flashes of heat, followed by more or 
less perspiration. Palpitation of the heart with irregularity in rhythm. 

Prognosis, With careful living, dyspepsia, functional in char- 
acter, is curable. It has been aptly termed " remorse of the stomach." 

Treatment. The most important indication is ta regulate the 
diet. Forbid saccharine, starchy or fatty articles of food. Eat small 
amounts at a time. Perfect insalivation and mastication. Rest 
after eating, from a half to an hour. Allow but small quantities 
of liquids with the meals. In the vast majority of cases fordid the 
use of stimulants -with the meals. 

MA digestion with Jiepsinum, with or without aciduin hydrochlor- 
icutn dilulum. 

Stimulate stomachic peristalsis with wkjt vomica, gentian or cinekima. 

For acidity, alkalies at times of acidity. 

Y ox pyrosis, bismuth sjiApulvis aromaticus, in large doses. 

For constipation, pil. rkei comp., at bedtime. 

For anamia, massaferri carbonatis orferri lactas. 

Yaxflatuleticy, tinctura micis vomica, before meals, carbo aniinalis 
purificatus, or acidum carholicum. 



DISEASES OF THE INTESTINAL CANAL. 



INTESTINAL INDIGESTION. 

Synonym. Intestinal dyspepsia. 

Definition. A derangement in the functions of intestinal diges- 
tion, resulting in the more or less complete decomposition of the 
chyme, from defects in the pancreatic, biliary or intestinal secretions, 
or from deficient peristalsis, one or more, singly or combined ; char- 
acterized by abdominal pain, distention, tympanites, nervous pertur- 
bation, anaemia and emaciation. 

Causes. Imperfect diet; overeating; ana;mia; deficient exercise ; 
worry; immoderate use of tobacco; diseases of the intestinal tract, 
liver or pancreas. Frequently inherited. 

Symptoms. Intestinal indigestion may be either acuts or chronic. 



the latter the 




i 



DISEASES OF THE INTESTINAL CANAL. 63 

Acute variety^ the result of an irritant in the duodenum ; rapidly 
developed pain^ flatulency, borborygmi, slight feverishness, coated 
tongue, loss of appetite, headache, pains in the limbs, usually termi- 
nating in a mild attack of diarrhoea. 

If the attack develops rapidly, the sudden formation of gases results 
in a paroxysm oi colic. 

Severe attacks are associated with disordered hepatic function, to 
wit : light-colored stools, slight jaundice and high-colored urine, the 
bowels constipated. 

Chronic variety, resulting from a greater or less decomposition of 
the partly altered food from the stomach. Pain, varying in char- 
acter, occurring from two to four or six hours after meals, with^//^-^/ 
tenderness and some fullness in the right hypochondrium, epigas- 
trium or the umbilical region. Tympanites and borborygmi are 
marked, the result of gaseous accumulations which have resulted 
from the decomposition .of the intestinal contents. Dyspnoea, the 
result of pressure on the diaphragm, is of frequent occurrence. 
Marked nervous phenomena develop, the result of the anaemia from 
deficient assimilation and from the depressing influence on the 
nervous system of the absorption of the "gases of decomposition ; " 
depression of spirits, hypochondriasis, sleeplessness, disturbing dreams, 
headache, vertigo, buzzing in the ears, muscce volitantes, deficient 
mental application, cardiac irritability, numbness and tingling in 
the extremities, anomalous /<a!/«^ throughout the body, and in marked 
cases, attacks oi fainting, epileptiform and cataleptic attacks. 

The skin is harsh and dry, the bowels are sluggish or constipated, 
the urine is high colored, of increased density, decidedly acid, and 
on cooling deposits lithates, uric acid and oxalate of lime crystals. 

Functional derangement of the liver follows after a time, adding to 
the general distress. 

Ancemia and emaciation result if the attack is protracted. 

Diagrnosis. With our present knowledge it is usually impossible 
to designate forms of intestinal indigestion due to defects in the quan- 
tity or quality of either the pancreatic, biliary or intestinal secretions. 

Acute intestinal indigestion differs from gastric indigestion in the 
time of the various phenomena, in the latter the symptoms appearing 
almost immediately after meals, while in the former not appearing 
until two, four or six hours after. 

Chronic intestinal indigestion may mislead the physician if the 



64 PRACTICE OF MEDICINE. 

various nervous phenomena are of a marked character, and a careful 
history of the case is not developed. 

Prognosis. Favorable if proper and early treatment is inaugu- 
rated, unless the result of an organic lesion. 

Treatment. Acute variety, the result of undigested food is best 
treated by opium in some form, warmth to the abdomen, and a 
prompt cathartic to cause its rapid expulsion. 

Chronic variety. Of the first importance is the diet, which should 
be restricted in amount and confined almost entirely to such articles 
as are readily digested in the stomach. 

The hepatic, pancreatic and intestinal secretions should be stimu- 
lated by a course of alkalies, one of the most efficient being sodii 
phosphas., ,^j-ij, three times a day. 

Aid intestinal digestion by the administration of the liquor pancre- 
aticus, f^j-iv, or the extractutn pancreatis, gr. ij-vj, with sodii bicar- 
bonatis, gr. v-x, two or three hours after meals. 

For constipation, bitter waters, such as Friedrichshall, Pullna, or 
Hunyadi Janos, or th^ pilulce rhei compositce, one or two at bedtime. 

INTESTINAL COLIC. 

Synonyms. Enteralgia ; tormina ; gripes. 

Definition. A spasmodic contraction of the muscular layer of 
the intestinal tube ; characterized by acute paroxysmal pain near the 
umbilicus, relieved by pressure, and associated with feeble cardiac 
action. 

Causes. Constipation ; presence of indigestible food ; collections 
of flatus ; an abnormal amount of bile discharged into the intestines ; 
lead poisoning ; syphihs ; chronic malaria ; hysteria. 

Symptoms. Romberg thus describes a paroxysm : " There are 
attacks oi pain, spreading from the navel over the abdomen, alter- 
nating with intervals of ease. The pain is tearing, cutting, pressing, 
most frequently twitching, pinching, accompanied by peculiar bear- 
ing down pains. The patient is restless, and seeks relief m changing 
his position and in compressing the abdomen ; his surface may be 
cold and his features pinched. Ih^ pulse is small and hard. The 
abdomen is tense, whether puffed up or drawn inward. There are 
often nausea and vomiting, and desire for stool. There is usually 
constipation, but sometimes the bowels are regular or even too loose. 



DISEASES OF THE INTESTINAL CANAL. 65 

Duration from a few minutes to several hours, relaxing at intervals. 
It ceases suddenly, with a feeling of the greatest relief, although some 
soreness remains for a few days." 

Lead colic is always preceded by symptoms of lead poisoning, to 
wit : slate-colored skin, dark gums, showing blue line, heavy breath, 
with sweetish metallic taste, obstinate constipation, impaired appetite, 
slow pulse and contracted abdominal walls. 

Diagnosis. Gastralgia differs from colic, in the pain being in 
the epigastric region and associated with disorders of digestion. 

In hepatic colic, or the passage of gall stones, the pain is in the 
hepatic region, attended with soreness over the gall bladder, and 
retching and vomiting, followed by jaundice and the presence of bile 
in the urine. 

In nephritic colic the pain follows the course of one or both ureters, 
shooting to loins and thigh, with retraction of the testicle of the affected 
side, strangury and bloody urine. 

In uterine colic the pain is in the pelvis, and associated with men- 
strual disdrders, in fact, a dysmenorrhcea. 

In ovarian colic or neuralgia, pain on pressure over the ovaries, with 
hysterical phenomena. 

Inflammatory disorders of the abdomen differ from colic by the 
presence of fever and tenderness on pressure. 

Prognosis. Most favorable. Death is the rarest termination 
possible. 

Treatment. Relief of pain is the first indication, and is best ac- 
complished by a hypodermatic injection of morphina, gr. Ye-yii 
which has the additional advantage of relaxing the spasm, thereby 
favoring the action of purgatives, which should soon follow. One of 
the best in colic, no matter from what cause, is — 

K. Sodii bicarbonatis gr. viij 

Hydrargyri chloridi mite gr. viij 

Pulv. zingib gr. iij. M. 

After the relief of the pain and free action of the bowels, the cause 
of the attack should be ascertained and corrected, to prevent future 
suffering. 

For lead colic, morphina, for the pain ; magnesii sulphas, .^^j, 
every hour, for the constipation, and potassii iodidum, gr. v-x, t. d., 
to eliminate the metal from the system. 

D* 



CONSTIPATION. 

Synonyms. Inlestinaltorpor; costivenes 

Definition. A functional inactivity of the intestinal cana.1, either 
due to atony of the muscular coat, causing lessened peristalsi; 
a deficiency of intestinal and biliary secretion; characterized by a 
change in the character, frequency and quantity of the slools. 

Causes. Dyspepsia; characterof the food ; habits of the patient ; 
diseases of the stomach and Uver; malaria; lead poisoning ; syphilis. 

Symptoms. In the normal condition, the majority of persons 
have 011^ sloo/ each day, altliough it is not to be considered abnormal 
if more than that number occur. 

The bmueh are moved every three or four days, with great i^ain- 
tflf and distress, ^e face aken flushed , the cerebral vessels fuli. 

Or in other cases the bowels may be relieved once a day, but the 
stool it small and hard, causing great pain. 

Another group of cases have frequent stools during the day, sfHoll 
and nonfonned, due to retained hardened fjeces acting a: 
upon the rectum. 

The change in the character of the stools is soon followed by symp^ 
toms of dyspepsia, and in many cases with great distention of the 
abdomen. 

Prognosis. Death never results from functional co 

Treatment. The successful treatment depends upon the removal 
of the cause and the co-operaliott of the patient. 

First, the patient must have a regular hour each day for goittff to 
stool, and must remain a sufficient time to permit a thorough evacua^ 
lion of the bowels. 

Second, the diet rr 
Third, pui^ative 
used vjith caiilioi. 
harm than good. 

Fourth, either of the following formula, aided by the enforcement 
of the above rules, will give good results :- 



ust be carefully regulated, 
nineral waters or cathartic medicines are to bef 
, their reckless administratioD often doing ■okok 



Ext. belladi 
Eitract aloea aqua. 



.Ico,.. 



- ET- 'A 



Pulv, rhei gr. j 

01. cnjupiiti gll. j. M. 

la {ull, at bedlime, and after a week, every second or third nighL 



DISEASES OF THE INTESTINAL CANAL. 67 

R . Resinge podophyl., 
Ext. physostig., 
Ext. belladonnae alco., 

Aloine Sa gr. )^. 

In pill, every night, or second or third night. ^ 

R . Tinct. physostig., 

Tinct. nucis vomicae, 

Tinct. belladonnae fiS, gtt. x 

Tinct. aloes et myrrh ', gtt. xxx. M. 

At bedtime. 

DIARRHCEA. 

Synonyms. Enterorrhoea ; alvine flux ; purging. 

Definition. Frequent loose alvine evacuations, without tenesmus ; 
due to functional or organic derangement of the small intestines, pro- 
Huced by causes acting either locally or constitutionally. 

Causes. Those acting locally, such as indigestion, indigestible 
food, impure food and water, irritating matters or secretions poured 
into the bowels, or entozoa, cause the flux by a direct irritation of the 
mucous surface. 

Those due to constitutional derangement may be secondary to such 
diseases as tuberculosis, pyce^nia, albuminuria, typhoid fever, or dis- 
turbances of the functions of other organs, giving rise to vicarious 
fluxes. 

Forms. Acute and chronic. 

Symptoms. Acute diarrhoea presents itself in several forms, the 
result of its cause, to wit : — 

Feculent diarrhcea. A few hours after meals the patient feels 
colicky pains and flatulency , with a desire for stooL There is often 
nausea, coated tongue, blit seldom vomiting. The pain is generally 
relieved by the purging which ensues. The stools have a feculent 
character, are of brown fluid, containing faeces, often offensive, the 
color becoming lighter after four or five evacuations. Constitutional 
symptoms are wanting. 

This form is the result of over eating, eating too rapidly, or indi- 
gestion of different forms, or worms in the intestinal canal, and 
patients generally recover in a day or two. 

Liettteric diarrhoea. In this form there is, with the frequency of 
evacuations, a want of assimilation of food, which passes through 



68 PRACTICE OF MEDICINE. 

the intestines more or less unaltered. The s/oo/s are frequent, mucous 
or serous, more or less covered unth bile, mixed with undigested food. 
In this form the patients emaciate rapidly, owing to the deficient 
assimilation, the digested portions of the food being hurried on by the 
irritated bowel, k is usually subacute in its course. 

Bilious (fiarr/uva. The sioo/s are frequent, green or ye/law, with 
seal din i^ setisaiions at the anus and griping pains in the abdomen. 
Excessive biliary secretion is the irritating cause. 

Any of the above forms may pass into chronic diarrhoea by exciting 
permanent diseases of the intestines. Diarrhoea due to constitutional 
causes will be mentioned when speaking of those conditions. 

Chronic diarrhiva results from repeated attacks of- the acute form, 
or the result of some cachexia. The symptoms, as far as the stools 
are concerned, are much the same as the acute disease, except they 
are paler, whence it has been termed white flux ; in addition, dys- 
peptic symptoms, rt'//////(7«j condition of mouth and tongue, .^/ir^r^i-^y, 
colic, emaciation and ancemia. The appetite is at times capricious, 
again impaired. 

Prognosis. Favorable m feculent and bilious forms ; unfavorable 
in lienteric and chronic forms when emaciation begins. Diarrhoea 
occurring as a symptom, the prognosis is controlled by the original 
disease. 

Treatment. Acute diarrhiva. If caused by indigestion the indi- 
cation is for a laxatiifc ; for adults, tinct, rhei, or ol ricini, or both ; for 
children between one and two years of age — 

Ijt. I'ulv. ipecac g^- A*^ 

Tiilv. rhei gr. }i-],^ 

Sodii bicarb gr. ss-ij. M. 

Every four hours until the character of the stools change. 

After the irritant is removed, for an adult, opium in some form, 
combined with kino or tannin; or the following modification of 
" Squibb's diarrhoea mixture : " — 

R. I'inct. opii deodorat fj^viss 

Tinct. camphora; f§j 

Tinct. capsici f^ v 

Chloroformi purje f;:5iiss 

Spts. vini gallici f^^j 

AlcohoHs ad f,?^^ M. 

SiG. — One teaspoon ful, p. r. n. 



DISEASES OF THE INTESTINAL CANAL. 69 

For children — 

li. Bismuth gr. iij-v 

Cretse. praep gr. v. M. 

Every two hours. 

In adults, an opium suppository often checks a flux that is un- 
influenced by opium internally. 
For the bilious form — 

R. Hydrargyri chlor. mitis gr J^ 

Sodii bicarb gr. ij 

Pulv. opii gr. ^. M. 

In pill, every two or three hours, until eight pills are used, followed by 
large doses of bismuth and pepsinum. 

In all acute forms restricted and regulated diet^x^ imperative, milk 
bei.ng the most suitable. 

Chronic diarrhoea. Bismuth, gr. xxx-xl, in milk, every four hours ; 
Hope's camphor mixture, every four hours ; cupri sulphas, gr. y^j, 
ext. opii, gr. ^^, every four hours ; argentinitras, gr. ]^, ext. opii, gr. \, 
every five hours ; may all be used with more or less success ; when 
dry tongue 2in6, great flatulency, use — 

R. Ol. terebinthini f^j 

Ol. amygdal. express f^^ 

Tinct. opii f^ij 

Mucil.acaci£E f,^ v 

Aq. lauro-cerasi f 3 ^5* ^* 

SiG. — fg j every three or four hours. 

The diet should be nutritious in character, and moderate stimulants 
are indicated. Activity of the skin and kidneys should be encouraged. . 

CATARRHAL ENTERITIS. 

Synonyms, lleo-colitis ; acute diarrhoea ; inflammation of the 
bowels. 

Definition. A catarrhal inflammation of the mucous membrane 
of the small intestines ; characterized by fever, pain, tenderness and 
looseness of the bowels. When the catarrh is limited to the duode- 
num, it is termed duodenitis, the symptoms being of a different char- 
acter. 

Pathologrical Anatomy. There first ensues hypercemia of the 
mucous membrane and intestinal glands, manifested by redness. 



' MEDICI NH. 

swriling and a-dema ; this is followed by increased iecrgfoa and an 
miergroTvlh and desquamation of ihe epilheliuin, logelher with a 
copious generation of young cells. As a. result of the hypersemia, 
rupture of ihe capillaries and extravasation of blood often occur. 

The swollen glands show a strong tendency to ulcerate. This 
catarrhal process may involve Ihe entire tube or be limited to por- 
tions of it. 

Causes. Improper and indigestible food ; summer temperature 
and exposure to cold and wet. while perspiring. 

Symptoms. Begins with languor, followed by chilline.^s ai 
fe%'tr, (he temperature ranging at iol°-i03'', this is followed by^a; 
colicky in character, situated about the umbilicus, localized tenderness 
and loose evacuations. Nausea and vomiting often occur. The stools 
Goniain but little fecal matter, are yellow or greenish-yellow in color, 
mixed with undigested food ; if the stools a 
whitish and watery, Ihe so-called "n 
appetite is impaired, and this, with the w 
waste, soon produce extreme weakness : 
always more marked in children. 

Duration. In mild cases, four or 
Itnuc more or less marked, for a week or two. 

DiasnostB. From colic, by the absence of tenderness and fever, 
and ihe presence of constipation and its paroxysmal character. 

F"roin typhoid fever, \yj the absence of prodromes, characteristic 
temperature record and eruption. 

For points of distinction from dysentery or peritonitis, sei 
affections. 

ProernOBUI. F"avorablc, if early and proper trealment ; 

Treatment. 

rice added. 

Keep the patient quiet in lied, a difficu 
children. 

For adults, opium is the remedy, in doses 



J, they become 

'e-water" discharges. The 

It of assimilation and great 

md emaciation, which is 

; days; severe cases con- 



' the bowels by a restricted diet, to wit : miUE 
:ak mutton or chicken soups, with well boiled 






:s do well with — 
Ext. opii 

n pill, every three hours. 



DISEASES OF THE INTESTINAL CANAL. 71 

Or— 

R. Tinct. opii deodorat gtt. x 

Liq. potassii citrat ^ij. H. 

Every four hours. 

The strength and the frequency of administration of either of these 
formulae must be governed by the severity of the attack. 
For children — 

R. Tinct. opii deodorat gtt. j 

Bismuth, subnit gr. v 

Mist, cretae fpjj. M. 

Every four hours, for a child of one year. 

If the case shows the least tendency to linger, the acid treatment 
should be substituted for the above, the best of which is " Hope's 
Camphor Mixture," the formula being — 

R. Acidi nitrosi f^j 

Tinct. opii gtt. xl 

Aquae camphorae f^viij. M. 

. The dose ranging from f^j to f^ij, according to the age. 

Acidum sulphuricum dilutum may be substituted for the acidum 
nitrosum in the above formula. 

Locally, poultices, warm fomentations, or ung, belladonnce or 
oleum camphorat,, give great relief. 

CROUPOUS ENTERITIS. 

Synonym. Membranous enteritis. 

Definition. A croupous inflammation of the mucous membrane 
of the small intestines ; characterized by tenderness, paroxysmal pain, 
moderate fever, and the formation and discharge of membranous 
shreds or casts. 

CatLSes. A disease of adult life. The female sex more liable 
than the male, and neuralgic, nervous, hysterical or hypochondriacal 
subjects are more subject to it than are other types. 

A peculiar state of the nervous system seems necessary to its pro- 
duction. 

Pathologfical Anatomy. A subacute inflammation of the small 
intestines, during which the mucous membrane becomes covered with 
a whitish or grayish-white, firmly adherent, membranous deposit, 
cemented together by a coagulable exudation, and prolonged by 
rootlets from its under surface into the intestinal follicles. 



72 PRACTICE OF MEUICINE. 

Symptoms. Begins hy fei'trishness, feeling of sorrness and rfij- 
Un/ion of the abdomen ; these are followed by patin of a colicky 
character, severe and depressing, felt around ihe umHlicus, continu- 
ing for half an hour, an hour or longer, and after a longer or shorter 
interval occurring again; these phenomena continue for a day or 
two. when /ooseness of /kt bowels, with distressing pain and tenesmus 
occur, the sipols containing mucus, with or without b/ood. and skrtds 
of membritne or cylittdrical ciisis of Ike boitreL Great relief is then 
en perie need, although a. feeling ai raiuitess or soreness persists for a 
day or two. 

Prpceding the local manifestations of the disease are attacks of ' 
hysteria, hypochondriasis, neuralgia, nervousness or excitability. 

The paroxysms recur at intervals of a week or two. or after several 
months ; as long an interval as three years between attacks is recorded. 

Diagrnosis. Peritonitis may be suspected until the charaaeristic 

Dysentery is excluded when the shreds and casts of membrane 

Prognosis. Favorable as to Ufe, but one of the most difficult 
of diseases to eradicate. 

Treatment. The diet must be such as contains but a minimum 
of fecal -forming matter. 

Vat ^^ pain -AwA suffering, opium in some form is indicated, the J 
most effective being a hypodermatic injection of morphina. 

For constipation during a paroxysm, an emulsion of oleum ricini ] 
and terebinlhina is of benefit To prevent a return of the paroxysms 
either liq. polassii arsenHis, gtl. J-ij, t- d., or hydrargyri ehhridum 
corrosivum, gr. j'j, t. d., with a course of oleum morrhuie, seems to 
answer in the majority of cases. Prof. Da Costa speaks highly of J 
pix liquida in some form, as an alterative to the mucous membrane, 

Under no circumstances must the bowels become constipated. 

CHOLERA MORBUS, 

Synonyms. Sporadic cholera ; English cholera ; bilious cholera. 

Definition. An acute catarrhal inflammation of the mucous 
membranes of the stomach and intestines, of sudden onset; charac- 
teriied by violent abdominal pains, incessant vomiting and purging, J 
cold surface, rapid, feeble pulse, spasmodic contractions of the muscles J 
of the abdomen and extremities, and prostration. J 



DISEASES OF THE INTESTINAL CANAL. 73 

Causes. A disease of summer and early autumn, climatic influ- 
ence being an important factor. Irritants of all kinds, unripe fruits 
and vegetables, and fermentation of food. 

Pathologfical Anatomy. Cases in which death has occurred 
within a few hours present no pathological changes. 

Generally, however, the gastro-intestinal mucous membrane is 
congested and denuded of epithelium ; the Solitary and Peyerian 
glands are swollen and prominent. The blood is thick, and dark in 
color; the kidneys are enlarged and congested; and in prolonged 
cases there are appearances of granular changes in the muscular 
system. 

Symptoms. Onset sudden and violent, and unfortunately, gene- 
rally after midnight, >vith chilliness, intense nausea, vomiting and 
purging, accompanied with distressing burning or tearing abdominal 
pain or colic. The vomited matter 2X first consists of the ordinary con- 
tents of the stomach, and the stools of ordinary faeces, but soon the 
discharges by vomit and stool are liquid, whitish or of a green or 
yellowish tint; if the attack is severe or protracted the discharges 
partake of the " rice-water " character. The patient is rapidly emaci- 
ated and reduced in strength, the body shrinks, the surface cold and 
covered with a clammy sweat, and the pulse feeble. Intense thirst 
is present, and when drink is given it is at once rejected. 

Aggravating the distress of the patient are severe cramps of the 
muscles, and especially those of the calves, and of the flexors of the 
thighs, forearms, fingers and toes. 

Termination. Mild cases often terminate favorably without 
treatment, the patient able to be around in a day or two, although 
weak. 

Severe cases, the vomiting and purging cease after some hours, but 
the patient remains weak, with an irritable stomach and bowels for a 
week or more. 

Grave cases, the true cholera type, recover from the prostration 
very gradually ; reaction coming on slowly and usually passes into a 
typhoid condition of some weeks' duration. 

Diagnosis. Asiatic cholera and cholera morbus are easily con- 
founded during an epidemic of the former, and there are no positive 
points of discrimination, unless the comma baccilli of Koch are 
proven to be always in the true cholera stools. 

Irritant poisons, such as tartar emetic, elaterium, or other sub- 



74 PRACTICE OF MEDICINE. 

stances, cause vomiting and purging, similar to cholera morbus, and 
are only discriminated from it by the history. 

ProgBoeis, In the majority of eases favorable. The mortality 
is about five per cent. 

Treatment. A/ once, regardless of the cause, a hypodermatic 
injection of iiwrphmie sulph., gr. 'A-'/i, and atropine: sulpk., gr. jj,. 
to be repeated in half an hour if no improvement; for patients who 
object to the hypodermatic mode, opiumin some form by the mouth or 
rectum, giving the preference to the liquid preparations. 

Camphora and opium combined often act well, or the diarrhcea 
mixture mentioned on page 6B. and if much depression, small doses 
of brandy or dry champagne. 

The intense thirst must not be gratified by the use of liquids, but 
small pellets of ice by the stomach are grateful. 

If the vomiting and purging continue, make use of— 

R. Bismuth suhn it gr. xx 

Acid carbol gr. ss 

Glycerini gll, xx 

Aqu:B ad fj iv. 

Esery hour or two. 

Dr. Harishorne strongly recommends— 

a. Spls. ammon. aromal fg j 

Magnes. Qptim fg j 

Aq. menlh. pip fg \i. 

Sic. — 3 j every twenty minutes. 
If the case is seen early, and if the diarrhcea is copious, he adds , 
tittct. opii campk., f 3 iv, to the mixture. 

The closer the case approaches the true cholera type, the more 
severe are the muscular cramps, and treatment is indicated. Prof. ( 
DaCosta suggests — 

B. Chloral giv 

Cosmoline 3 J- 

To be rubbed over the affected muscles. 

Dr. Bartholow suggests — 

B. Chloral „ SiiJ 

Morphinse sulph gr. iv 

Aqu^ rgj. 

^\a. — Twenty minims, hypodermalically. 
Locally, sinapis in the form of poultices or the di7 powder, should ; 
be applied from the onset. 



DISEASES OF THE INTESTINAL CANAL. 75 

The after treatment depends upon the symptoms; generally an 
acid mixture and a regulated diet, with tonic doses of quinina, are 
indicated. 

ENTERO-COLITIS. 

# 

Synonym. Inflammatory diarrhoea. 

Definition. A catarrhal inflammation of the lower portion of the 
small — ilium — and the upper portion of the large intestines, with a great 
tendency to ulceration of the intestinal glands if the catarrh becomes 
chronic; characterized by moderate fever, nausea, vomiting, diar- 
rhoea, swollen abdomen and emaciation. 

Causes. Improper and indigestible food ; summer temperature ; 
impure air ; uncleanliness ; exposure to cold and damp air. 

Forms. Acute and chronic. 

Pathologrical Anatomy. Acute variety; hyperaemia, swelling, 
oedema and softening of the mucous membrane of the lower portion of 
the small and the upper portion of the large intestines, with hyperplasia 
of the intestinal follicles, their excretory orifices enlarged and tumid, 
readily distinguished as grayish or blackish points in the middle of 
the glands; the patches of Peyer are also enlarged, tumefied and pro- 
ject above the level of the surrounding mucous membrane, the orifices 
of the follicles appearing as dark points ; these patches often have an 
ulcerated appearance, but upon close examination such is found not 
to be the case. 

Chronic variety; the thickening and infiltration has extended to the 
submucous and muscular coats, followed by induration of the tissues, 
so that the walls of the intestines are often abnormally rigid. Ulcera- 
tion occurs, which extends through the entire thickness of the mem- 
brane. " These ulcers, when isolated, are from one to one and a 
half lines in diameter, oval or circular in shape, and either have 
sharp-cut edges, as though the piece of mucous membrane had been 
cut out with a punch, or the mucous membrane bounding them is 
undermined." The small ulcers often coalesce, so that large, irregular 
ulcerated patches are formed, having for their base the submucous or 
muscular coats, and ha^e a grayish-white color. 

The mesenteric glands are enlarged, but seldom, if ever, undergo 
ulceration. 

Symptoms. Acute form ; may develop slowly, with restlessness 
and fretfulness, or suddenly with feverishness, loss of appetite, thirst, 
nausea, moderate vomiting, abdominal pain; or diarrhoea may be the 



PRACTICE OF MEDICINE. 

first indication of illness on the part of the child. Regardless of the 
character of ihe onset, thes/('o/.t soon present the characteristic appear- 
ance ; they arc semi-fluid, heterogeneous, greenish, acid, mixed with 
ycllcnvish frngmenis of ordinary fieces, and undigested casein, termed 
the "chopped spinach " stools. The abdomen is enlarged ■xaA Jendt-r. 

Emaciation is marked in proportion to the severity of the symp- 
toms, in marked cases the child is reduced to a condition of the 
greatest debility within a very few days. 

Chnmic form: usually follows the acute form, the character of Ihe 
symptoms being less severe, but decidedly persistent, the strength 
fails, the temper is very irritable, the complexion grows dark, sallow 
and unhealthy, the skin dry and harsh, and in consequence of the 
marked emaciation, either hangs in folds around the shrunken limbs, 
or is drawn tightly over the joints ; the abdomen is enlarged and 
tender, the stools numbering from six to a doien during the day and 
night, consisting of the products of an imperfect digestion mixed with 
mucus, serum, pus, and oftentimes blood, having a semi-fluid con- 
sistency, and an extremely offensive odor. 

Duration. Acute, from ten days to about two weeks, subsiding 
gradually ; chronic, from one to two or three months, or even longer. 

Diagrnoeis. The acute form can hardly be mistaken for any 
other condition, if the characteristic stools and other abdominal 
symptoms are present. The chronic form has been frequently 
mistaken for diarrhcea of tuberculosis, an error that can hardly 
occur if a physical examination of the chest has been made. 

Froefnosis. Always a very serious malady, and proves fatal if it 
attacks the weak during midsummer, or when surrounded by unfav- 
orable hygienic conditions; in vigorous children, who have passed 
through their first dentition, the prognosis is quite favorable. 

Treatment. For the acute form, restricting the amount of food ' 
for the first few days is of advantage. Fresh, pure air, cleaaliness J 
and rest are also of importance. 

Any one of the following formulie may be used with advantage. 

B . Calcii carbon, prccip jj 

TincL opii camph f_^ se 

Tinet. lovendula; comp f g ij 

Syr. gallEE aromat _ fglsa 

Syr. acaciffi f.5J. M. 

G. — Tcaspoonful, repeated every hour or two. 



\ 



DISEASES OF THE INTESTINAL CANAL. 77 

Or — R. Tinct. opii comp , fjiij 

Tinct. catechu comp f.'jiv 

Misturae cretae ^Six* M. 

SiG. — One or two teaspoonfuls, every hour or two. 

Or — U. Bismuth subnit 3iv 

Pulv. acaciae, 

Sacc. alb aa q. s. 

Syr. gallde aromat f^j 

Spts. vini gallici f^ij 

Aquae .......ad ^,?"j' M. 

SiG. — One or two teaspoonfuls, every two hours. 

Or — R. Pulv. ipecac gr* X 

Bismuth subnit gr. v 

Cretae praep gr. iij M. 

SiG. — After each stool. 

Locally, yfditTCiih. to the abdomen, with mustard, turpentine stupes or 
the spice poultice, made as follows: cloves, allspice, cinnamon and 
anise seeds, each half and ounce, pounded (not powdered) in a mortar, 
and 'placed between two pieces of coarse flannel about six inches 
square and quilted in ; soik this for a few minutes in hot brandy or 
hot whisky and water, equal parts, and apply to the abdomen, heating 
again as its becomes cool. 

For chronic form ; carefully regulated diet, rest and fresh air, and 
one of the following formulae : — 

R. Acidi carbolic! S^- H"}^ 

Tincturae iodi gtt. j-ij 

Aquae menthae 3J. M. 

SiG. — Every three or four hours. 
Or— 

R. Tinct. calumbae f^iij 

Liq. ferri nitratis TT\^xxvij 

Syrupi zingib ^^"J* ^* 

SiG. — One or two teaspoonfuls, according to age, every three or foui 
hours. 

CHOLERA INFANTUM. 

Synonyms. Choleriform diarrhoea ; summer complaint. 

Definition. An acute catarrhal inflammation of the mucous 
membrane of the stomach and intestines, together with an irritation 
of the sympathetic nervous system, occurring in children during their 



B OP MEDICINE. 

first denlition ; charactcriicd by severe colicky pains, vomiting, 
purging, febrile reaction and prostration. 

Oatise. Age; had hygiene, or as it is now entitled, " i 
malaria ;" continuous high temperature; improper food; dentition; 
constitution, as the feeble, delicate, nervous or irritable. 

Pathological Anatomy. Resembles closely, if not identical 
with the phenomena of catarrhal gastritis and enteritis, together 
with a powerful irritation of the fibres of the sympathetic system. 

Symptoms. The onset is sudden In a child previously well, or 
in a child suffering from a bowel affection. 

Begins with ■vomilittg, purging, abdominal ^awi.^i'CT', rafiid pulse 
and inUnse thirst. 

The vomiled malUr\s partly digested food, sero-mucous, and finally 
bilious, and is accompanied with distressing retching. The thirst is 
marked phenomena of the disease, and ice and water will be taken 
incessantly, although rejected only a few moments after. 

The stools are first partly fecal, but soon watery or serous, soaking the 
clothing, leaving a faint greenish or yellowish stain ; their odor l 
musty, at times fetid ; their number is from ten to twenty in thi 

Pains precede the vomiting and purging, colicky in character. 

Theyi:i/^r begins at once, the temperature varying from loi" to 105°, 
with morning remissions. The pulse is rapid and feeble, ranging 
from 130 to 160. 

These symptoms continue but a few hour?, before rapid wasting 
ensues, the body shrinks, the eyes are sunken and partly closed, the 
mouth partly open, the lips dry. Cracked and bleeding. The child, 
at first irritable and restless, passes into a semi-comatose condition, 
the pulse becoming more and more feeble, the surface has a clammy 
coldness, the contracted pupils not resp<fnding to light, and the stupor 
deepens, death soon following, or the symptoms slowly ametioi 
convalescence being slow and tedious. 

DiagnoaiB. The entero-colilis or inflammatory diarrhiea of child- 
hood is constantly being mistaken for cholera infantum. The symp- 
toms of the former are : gradual onset, fi\\hfretfulness, loss of appetite, 
feverishtiess, nausea, and moderate vomiting, soon followed by 
diarrhasa, the stools being semi-fluid, greenish, mixed with yellowish 
particles of ficces and undigested casein, with a sour odor, the 



DISEASES OF THE INTESTINAL CANAL. 79 

'* chopped spinach "stools, the abdomen distended and tender, n\od- 

^X2X^ fever and thirst, and having a duration of about two weeks. 

Prognosis. Difficult to predict the result, and so care must be 

used in giving a prognosis. The duration of the choleraic symptoms 

is short, under five days, but relapses are common, and the sequelae 

are protracted. 

Treatment. The first indication is to arrest the vomiting and 

purging, for which, use — 

R. Bismuth subnit gr. v-x 

Mucil. acaciae jss 

Acidi carbolici gr. ^5— J 

Tinct. opii deodorat gtt. j 

Mist, cretae ^iss. M. 

Every two hours for a child between one and two years. 
Or, 

R. Hydrargyri chlor. mit gr. ^^ 

Bismuth, subnit gr. ij-v. M. 

SiG. — A powder every half hour. 
If these fail, or the stomach will not retain them, tinct, opii may be 
given by the rectum, with zinci sulph, and amylum. 

Cases that have resisted other remedies have rapidly improved 
under the following : — 

U. Tinct. verat. alb fgij 

Morphinae acetat gr. ij 

Spts. vini gallici f^^* ^^* 

Et adde 3J to 

Aquae calcis, 

Aquae menthae aS f^j M. 

SiG. — One teaspoonfuU repeated every hour, if needed. 

The diet must be restricted in amount : for the first day or two gtt. 
v-xxx brandy in barley water at frequent intervals will be all that is 
required. 

Yoxfever^ quinina or aconitum are indicated. 

For depression regulated nursing or feeding, every two hours, and 
water or ice to quench the intense thirst, and cognac brandy, gtt. 
x-xxx, every hou]:«or two, in water. 

Locally ; over epigastrium, mustard or a spice poultice, or turpentine 
stupes. 

If the nervous symptoms become aggravated, small dose oi potassii 
bromidum, or valerian, which " reduces the reflex excitability, motility 
and sensibility," is indicated. 



i, ja.ils, and tenement houses 
:eric stools, and the unfavor-1 



ACUTE DYSENTERY. 

'otitis ; colonilis ; ulcerative colitis ; bloody flux. I 

DeflniUon. An acute inflammation o( the mucous membrane q 
the large intestines, either catarrhal or croupous in character ; chai 
acteriied by fever, tormina, tenesmus and fretjueni, small, mui 
and bloody stools. 

It occurs either in Ihe sporadic, endcmk or epidemic form. 

CauSfifi. Sporadic and endemic dysentery is caused most c 
monly by atmospheric changes, to wit, hot days and cool nights ; alad 
from malarial attacks, and rarely, em 

Epidemic dysentery prevails in arm 
propagated by decomposition of dyse 
able hygienic surroundings. 

It is not contagious. 

Pathological Anatomy. Sporadic dysentery is catarrhal i 
character; congestion, swelling and cedema of the mucous membrane \ 
and sub-mucous tissue, with an over-production of mucus ; the fol- | 
lieles are enlarged, from retention of their contents, the result of the I 
swelling; the congested vessels often rupture ; the mucous membrane j 
softens in patches, and is detached, forming ulcers. Recovery fol- 
lows, if the destruction of tissue is small, smooth cicatrices, minus 
gland structure, marking the si 

Epidemic dysentery is croupous in character ; begins with intense ] 
congestion, swelling, and cedema of the mucous and sub-mucous J 
tissue, with extravasations of blood and the whole mucous mernbrane 
covered with a firm Rbrinous exudation ; the mucoui membrane 
softens and sloughs, leaving large ulcers and gangrenous spots. If 
recovery occur, large cicatrice^ form, which narrow the calibre of the 
intestinal tube. 

The mesenteric glands enlarge, soften, and abscesses form in them ; 
the liver becomes the seat of small abscesses, from embolic obstruc- 
tion of the radicles of the portal vein ; the heart muscles are flabby 
and more or less fatty. 

Symptoms. Catarrhal form begins gradually, with diarrAvai, i 
loss of cippetite, nausea, and very slight fever, which continues fi 
two or three days, when the true dysenteric symptoms set in, to w 
ptfin on pressure along the transverse and descending colon, /omuHt)^ 
or colicky pains about the umbilicus, burning pain in the rectum, ? 

n of the presence of a foreign body and a desire to expel ^ 



DISEASES OF THE INTESTINAL CANAL. 81 

or tenesmus, which is almost constant ; the stools for the first day or two 
contain more or less fecal matter, but soon they consist oi 2i grayish, 
tough, transparent mucus, containing more or less blood and pus ; 
during the tormina, nausea and vomiting may occur ; the urine is 
scanty and high colored ; the number of stools ranges from five to 
twenty or more in the twenty-four hours. 

The duration is about one week, the patient being much emaciated 
and enfeebled. 

The croupous or epidemic form sets in suddenly, the stools being 
more frequent, containing more blood and pus, with patches of mem- 
brane, even casts of the bowel, together with more or less gangrenous 
mucous membrane; nausea, vomiting, and great prostration, cold 
skin, feeble pulse and emaciation, with anxious expression, the odor 
surrounding the patient beingy^AV/. 

The duration of the g^ave symptoms is three or four days, when 
collapse and death occur, or slow convalescence begins, continuing 
for weeks. 

GomplicatioDB. Peritonitis ; hepatic abscesses ; phlebitis of the 
intestinal veins ; intestinal perforation. 

Diagnosis. Enteritis lacks the tenesmus and characteristic stools. 
Peritonitis, when idiopathic, shows higher temperature, greater 
tenderness and constipation. 

Prognosis. Catarrhal form favorable. Croupous form, the prog- 
nosis is always grave, for if recovery does occur the bowel may be 
crippled, from loss of structure, or from narrowing of its calibre, the 
result of cicatrices. 

Treatment. Emaciation being rapid, the diet must be attended 
to from the onset, and be of the most nourishing character, to which 
stimulus should be added if much prostration occur. 

The most common treatment is opium, combined with one or more 
astringents, to wit ; — 

R. Ext. opii gr. ss 

Plumbi acetat gr- ij- M. 

Every two hours ; or — 

R. Pulv. opii gr. ss 

Plumbi acetat ,., gr. ij 

Pulv. ipecac gr. j. M. 

Every two hours ; or — 

E 



F JEBDICINE. 

B- I^^lv. ipecac el opii gr. x 

Bismuth subnit gr. xx. 

In milk, every two hoats. 
If the case is seen early the very best prescription possible is 

, a. Mflgtiesii sulph ,^j 

Aci<i. sulph. dil ni,v 

Tincl. opii deoilorat _ n\_x 

Aquo; menlh „ g ij. 

Every two or three hours, until teces appear in the stools, wfa« 
small doses of opium and quinina may be used. 

ipuacuanka in gr, xx-xl, is largely used in the ^rsC stages ^ 
dysentery, until the characteristic ipecac stools appear; the first dose 
being often rapidly rejected by the stomach, the treatment b difficult" 
to pursue outside of hospital practice ; but of its efficacy in many 
cases there can be no doubt. 

Dr. Loomis speaks strongly of Ipecacuanha, gr. J^ every half-hot 
will) sufKcient opium to secure quietness. 

Ringer recommends kydrargyri chloridun 
every hour or two, which ■' rarely fails to free the stools from bio 
and shme, although in some cases a diarrhcea of a different chaiacte 
may continue for a short time longer." 
lo ohildren the fallowing combination is efficacious ; — 

. B. Pulv. ipecacuanha B^- !i 

Bismuth siibml gr. v. 

Crelic ptiep '. gr. iij. 

SlG. — Every two hours. 
The patient should be confined to bed in even the mildest altackl 
and the stools removed at once and disinfected. 

Washing out th^ rectum with either tepid, hot, cold or iced n 
as suggested by iVof. DaCosta, adds greatly to the patient's eomfo^ 
and to the decrease of the inflammatory process. 

TYPHLITIS. 
Synonyms. Infiammation of the CKcum ; catarrh of the c 
Definition. A catarrhal inflammation of the mucous inembi 
of the Ci«cum and ascending colon ; characterized by pain, t 
ness, constipation, and in certain cases a. characteristic vomiting. 

Oauses. In a majority of cases mechanical, from the lodgmi 
of seeds or hardened fxces. 



DISEASES OF THE INTESTINAL CANAL. 83 

Patholo^cal Anatomy. Similar to the catarrhal inflammation 
of dysentery. 

Symptoms. Pain and tenderness in the right iliac fossa and 
along the ascending colon, with sovae prominence of this region ; the 
bowels are usually constipated, or small liquid stools may occur from 
time to time, due to the accumulation of hardened faeces in the saccu- 
lated periphery of the caecum, leaving a central canal through which 
the liquid contents of the upper bowel can pass. 

In severe cases, " the local ^^/«, tenderness and swelling 2Xt. greater, 
there are impaction q{ fceces and no movements. There are decided 
fever, restlessness, and also nausea and vomiting. The vomited 
matters, at first the contents of the stomach, then the duodenum, with 
bilious matter, and ultimately, if the impaction persists, of material 
having the odor of faeces. With these symptoms occwr great depres- 
sion of the vital powers. Peritonitis is finally developed by con- 
tinuity of tissue or by rupture of the bowel." 

Duration. The mild form lasts about one week. The severe 
form may terminate in acute peritonitis, continuing about two weeks. 

Diagrnosis. The mild form is distinguished from other intestinal 
affections, by the localized pain, tenderness and prominence, and the 
constipation. 

The severe form can only be distinguished from the other forms of 
intestinal obstruction by the history of the case and attack, and the 
results of treatment. 

Progrnosis. Mild forjn i2ivor2ih\^. Severe form gr3ive, although 
not necessarily fatal. 

Treatment. The patient should be kept in bed, and placed on 
a strictly milk diet. 

In mild cases, act upon the bowels, with either oleum ricini or 
magnesii sulphas in small doses, followed by an opium influence, to 
be maintained until convalescence is well pronounced. 

In severe cases, begin an opium influence at once, by hypodermatic 
injections of morphina guarded with atropina, continued until all 
symptoms of inflammation have subsided, when attempts to remove 
the accumulated faeces may be made by irrigation of the bowel with 
warm soapsuds, and the cautious administration of magnesii sulphas 
in drachm doses, every two hours. 

Locally, Leeches over the caecum followed by hot fomentations 
or ice bags, or cold compresses. 



abscess ; charac- 



r the caecum ; and also 
m by perforation. Often 



U PRACTICE OF MEDICINE. 

PERITYPHLITIS. 

Bynonym. Perityphlitic abscess. 

Definition. An acute inflammation of the 
around the caecum, tending la the formation of ai 
leriictl by pain, swelling, and febrile r 

Gausee. Injuries ta the abdomen ( 
extensiitn of the inflammation from theca 
occurs with typhlitis. 

Symptoms. Uegins with a feeling of ivfight, 
piiriKtysms of acuU pain extending into the hip, thigh and abdomen, 
with the development of a hard swelling in the right iliac region. 
Its special tendency is toward suppuration, which is announced by 
irregutar chills, feverishni-ss, and sweats, and a feeling of tension and 
throbbing. Its development is slow, and if associated with typhlitis 
the symptoms of that affection are added. 

Diagnosis. Differs from typhlitis by the absence of the colicky 
pains, dyspeptic symptoms, costive bowels and tympanites preceding 
the development of a tumor; in perityphlitis the tumor is present 
with the development of the symptoms. 

Psoas abscess is not associated with intestinal symptoms, and the 
discharge is free from a fecal odor. Renal and ovarian tumors should 



It be SI 



sofei 



Treatment. If not associated with typhlitis, the ti 
allay the inflammation in the first stage, by either ire. locally, or freely 
painting with tinct. iadi ; if suppuration is evident, hasten by foul- 
tices, and follow by evacuation of the pus with the aspirator or a. free 
opening, conjoined with the use of opium and quiuina. 

PROCTITIS. 

Synonyms. Catarrh of the rectum ; dysentery ; rectitis. 

Definition. A catarrhal inflammation of the mucous membrane 
of the rectum and anus ; characterised by pain, tenesmus and frequent 
stools of hardened fgeces, or of mucus, pus and blood. 

Causes. Chief cause constipation ; also sitting on damp ground I 
or stone steps ; habitual use of enemata or of purgatives ; diseases of | 
die liver. 

Pathological Anatomy. Similar !■ 
rhal dysentery. 



those oceuning in caiar- 



DISEASES OF THE INTESTINAL CANAL. 85 

SymptomB. Uneasy sensations and burning in the rectum, with 
a constant desire for stool, or tencstnus, often so severe as to cause a 
prolapse of the mucous membrane. The stools may be either har^i- 
ened faces or scybala from the distended colon, which cause intense 
pain when they reach the rectum ; or the stools may be of mucus, 
muco-pus, or bloody or blood-streaked. Generally there are present 
nausea, especially during the tenesmus, headache, feverishness and 
malaise. In severe cases there is strangury, and with the tenesmus, 
straining with urination. 

If the case be protracted and severe, inflammation of the con- 
nective tissue around the rectum occurs, causing periproctitis, which 
usually terminates in various kinds of fistula. 

Complications. Periproctitis : peritonitis : hepatic abscesses, 

DiagnoBis, In mates, the disease cannot Jie confounded with any 
other affection, save, perhaps, hemorrhoids. Va females, displacements 
of the uterus may somewhat simulate the symptoms of proctitis. 

Prognosis. Uncomplicated cases favorable. Either of the com- 
plications add greatly to the gravity of the affection. 

Treatment. In cases due to constipation the chief indication is 
to empty the bowels, for which the magnesia mixture mentioned for 
dysentery is the most suitable remedy ; after which emollient cne- 
mata, with opium, are indicated. Irrigation of the bowel with warm 
water once or twice daily assists in the liquefaction of the hardened 

Cases other than those due to constipadon, emollient enemata and 
opium, one of the best being — 

B. 01. olivie gij 

Tinct. opii deodoral n^Jiv. M. 

Every three or four hours. 
If symptoms oi periproctitis occur, use ice to the parts, and if suppu- 
ration ensue, evacuation by a free opening and guinina. 

INTESTINAL OBSTRUCTION. 
SynonymB. Intestinal occlusion ; strangulated hernia ; invagi- 



Deflnition. A sudden or gradual closure of the intestinal canal ; 
characterized by pain, nausea, vomiting, constipation, and finally 
collapse. 



ies are arranged as follows :- 
I withiH the ti&lOi-l. of hardened faeces, o' 



foreign 



80 PRACTICE OP MEDICINE. 

GauBes. Tt 

1. Accumulate 

2. Strictures, the result of cancer, ulceration, i 

3. Pr^ssun against tlu bewd. from peritoneal adhesions, tumors, 
and abnormal growths. 

4. SirangulatipHS. due to the numerous forms of hernia. 

5. Iimaginalion or intussusception, the most common. 

6. Twisting, volvulus or rotation of the bowel. 
Pathologrical Anatomy. In-L^aginalion is the only form calling 

for special description. It is usually caused by the lower portion of 
the ileum slipping down into the ciecum, as the finger of a glove 
might he invaginated, causing thus an actual mechanical obstruction ; 
this is produced by a spasm of the ileum, whereby its calibre is greatly 
diminished, thus permitting its descent into the lower bowel. Result* 
ing from this occlusion or compression, arc congestion, inflammation, 
with secondary constitutional reaction and death, or more rarely the 
invaginated bowel sloughs off, and is voided by stool, union taking 
place at its site and recovery following. 

Symptoms. The onset'of the symptoms may be either i«i/dbn 
at gradual, and are as follows \— 

Constipation, with more or less severe colicky pains, not relieved by 
either purgatives or injections ; feeling of weight and soreness, with 
distention of the abdomen and nausea and vomiting; the symptoms 
all grow more pronounced, the pain becoming violent, tenderness in 
limited areas, the vomiting ^acomva^stercoraceous, the abdomen hard 
and tense, the eyes sunken, the pulse quick and feeble, the skin cold 
and covered with a clammy sweat. The above continue more or less 
pronounced for a week to ten days, when collapse and death occur, 
or more rarely gradual return to health. 

Cases occur rarely in which small, fecal, muco-purulenl stools con- 
taining more or less blood exist, instead of constipation. 

Diagnosis. One of the most difficult, and can only be solved by 
a careful study of the case along with the different causes producing the 
affection. The site ofthe occlusion can rarely be determined positively. 

Intestinal obstruction may be mistaken for intistiniil colic, hernia, 
enteritis, peritonitis, hepatic or renal colic. 

Prognosis. Always grave, but guided by the cause. Impacted 
faces favorable. Invagination less favorable, but r 



INTESTINAL PARASITES. 87 

the longer the symptoms continue, the more favorable the outlook. 
Strangulations unfavorable, but many recoveries recorded. Stric-^ 
tures, due to cancer, cicatrized ulcers and the like, are the most 
unfavorable. 

Treatment. Stop all forms of purgatives as soon as the diagnosis 
of obstruction is determined. 

Opium is indicated in all forms, and is best administered in the 
form of morphina, combined with small doses of atropina, hypoder- 
matically. 

Several recoveries are reported from washing out the stomach re- 
peatedly, Kiissmaul reporting to it as many as five times within twelve 
hours in one case, with recovery. 

If impacted fcBces is the cause, irrigation by tepid soapsuds seems 
beneficial. 

If invagination, raising the buttocks and lowering the chest, and 
repeated injections of warmed oil, are recommended. 

Distention of the bowel by pumping air through long rectal tubes, 
or disengaging carbonic acid gas in the bowel, by first injecting a 
solution of sodii bicarbonas, and follow this with a solution of acidum 
tartaricum, about one drachm of each, pressure being made against 
the anus, to prevent escape ; but the danger of rupture of the bowel 
must not be overlooked. 

Flatulent distention can be removed by the long aspirator needle. 

Laparotomy is no doubt the operation of the future, when our means 
of diagnosticating the location of the trouble is more perfect. 

The nutrition of the patient is best attained by injections of either 
peptonized foods or defibrinated blood, or both. 



INTESTINAL PARASITES. 



TAPE WORMS. 

Varieties. Tcenia solium; Tcenia saginata; Bothriocephalus 
latus. 

Causes. The Tcenia solium, the " armed tapeworm,*' is the most 
common in this country. It is derived from the embryos contained in 
pork, known as the cysticercus cellulosus. 



The Taniii saghiata, the "unarmed lapeworni," a not uncommon 
variety, is derived from the embryos contained in beef, known as 
cysticcrcus bovis. 

The Bothriocepkalui iatiis, also an "unarmed lapeworni." the 
largest parasite infesting man, is supposed to be derived from an em- 
bryo found in fisk. 

The embryo or ova is introduced into the intestinal canal with the 
food and drink. The parasite reaches its final growth after its en- 
trance into the intestines. 

Those handling fresh meats or eating uncooked animal food are 
most liable lo be affected. 

Uncleanliness is also an important factor. 

Deaoription, The lania solium is from six to iliirty feet in 
length, has a globular head, or scolex. a slender neck connecting 
its r\\\\nema% flal segrmnis otjoinls. The head, or scolex, measures 
about ^ of an inch, has a double circle of booklets. — whence the term 
" armed tapeworm," — and is provided with from two lo four suckers. 
The segments or joints {stroliila) are flat, and vary from one-eighth lo 
one-half an inch in length, and each contain both male and female 
sexual organs, the uterus being a long, numerously branched tube, 
in which the ova develop ; the ova measure about yVsn of an inch in 
diameter. An ordinary tapeworm contains some five million ova. 

The parasite is firmly imbedded in the mucous membrane of the 
upper third of the small intestines by its booklets and suckers. 

The lower or Terminal sefftnetUs represent the adult and complete 
animal, and are termed the proghtlides, which separate from the 
parasite and are discharged either alone or with the fieces. 

The icenia saginala is from ten to forty feet in length, has a 
rounded or oval-shaped head, measures about y'g of an inch and has 
four strong and prominent suckers, but no booklets, — whence the 
term " unarmed tapeworm;" the neck is short and thick and the 
segments are larger, stronger and thicker than those of the T. sollum- 

The BothriocephcUus lalus is the largest of the tliree Cestoda, the 
length ranging from fifteen to sixty feet, the head oval, measuring 
about y', of an inch, a short neck, the segments or joints being nearly 
three times as broad as they are long. Its color is a dull, btuish-gray. 
Zoologically considered, this variety is not a true tapeworm. 

Symptoms. Nut unfrequently a l<enhx produces no symptoms 
whatever. 



i 



INTESTINAL PARASITES. 89 

Usually, however, there are colicky pains throughout the abdomen, 
inordinate appetite, disorders of digestion, emaciation, constipation, 
attacks oi cardiac palpitation, faintness, disorders of the special senses 
and pruritus of the anus and nose. Any or all of these symptoms 
may be present. 

A large meal will often remove the majority of the symptoms 
present. 

In a large number of cases the discovery of the segments is the first 
intimation of the presence of the parasite. 

Treatment. A number of remedies — ^termed taeniafuges — are 
used more or less successfully for the expulsion of the tapeworm, to 
wit:, extractum granati rad, cort, fluidum, fjss-ij, or a decoctum 
granati rad. cort. ( ^ ij bark of root, aquae Oj), wineglassful every hour 
until all is taken, as suggested by Prof. Bartholow. ; or oleoresina 
aspidii, ^ss doses repeated, or oleum pepo express, 3j-iv, followed by 
oleum ricini. 

A much pleasanter remedy is pelleterine, the active constituent of 
granatum, used in the form of the tannate, gr. x-xx, or Tanref.s 
solution of pelleterine. 

Cases which resist these means are often cured by the following : — 

B . Chloroformi, 

Ext. aspidii fld aa f^j 

Emul. olei ricini (B. Ph.) ^iij. M. 

SiG. — To be taken in the early morning ; no food until after thorough 
action of the bowels. 

« • 

An important precaution in the management is close attention to 
the " preparatory treatment " rendered essential to remove the mucus 
in which the head (scolex) is imbedded. It consists in the adminis- 
tration of a good purgative for one or two days, and a light diet, such 
as milk and broths, preceding the use of the taeniafuge. 

ROUND WORMS. 

Varieties. Ascaris lumbricoides ; oxyuris vermicularis. 

Causes. The ascaris lumbricoides is one of the most common of 
the parasites affecting the human family, and develops in the intes- 
tines, either after the entrance of the ova of the same, or from the 
so-called '* intermediate parasites." Their entrance is effected by 
means of the food and drink. 
E* 



PRACTICE OF MEDICINE, 

The oxyiiris ■vermiailaris develops in the large inlestines, from either 
its peculiar ova, or Ihe so-called " intermediate parasite," these find- 
ing their way into the bowel with the food and drink, or by direct 
contact. 

Description, The ascaris himMceiiics, or the rouni/ worm, is of 
a brown color, a cylindrical body, from ten to twenty inches in length 
and from an eighth to a fourth of an inch in circumference; the head 
terminates in three semilunar lips, each having about two hundred 
teeth. The CJ/a are oval-shaped, are produced in immense numbers, 
some sixty million in a mature female, have wonderful vitality, resist- 
ing extreme heat or cold. 

The roundivomt inhabits principally the small inlestines, although it 
often migrates to other parts. They are found in numbers from one 
to several hundred. 

The oxyuris I'fnnicularis, thread or srai worm, resembles an ordi- 
nary piece of white thread, measuring from a sixth to a half inch in 
length, the head terminating in a mouth with three lips, the tai/ termi- 
nating as a sharp point. " The ova are oval, produced in large num- 
, bers, each female containing about ten thousand, are surrounded by 
a stout envelope, which increases their vitality. 

The seal worm, as its name indicates, inhabits the large intestines, 
especially the rectum, although they frequently migrate to the sexual 
organs. They vary in number, sometimes the parts frequented being 
entirely covered. 

Symptoms. The ascnris lumbricoidcs, or ro, 
present in great numbers and yet produce no char 
oilier i^sn gastric and intestinal irrilali 
foul breath, colicky pains, nausea and 
turijcd sleep, such as tossing from side t 
the teeth. Any or al! of these symptor 
the only positive proof being the passage of the parasite. 

The oxyuris vermiciilaris, or seat worm, produce inlensg itthiiig 
about the anus, with a desire for stool, the passages often containing 
much mucusjithe result of the irritation produced by their presence. 
Should they migrate to the sexual organs, intense itching of these 
parts results, which, unless speedily corrected, leads in children lo 
masturbation. 

Treatment. The .umm lumbrkmdes art readily removed by 
the following " worm powder" ; — 



in. may be 

<i, such as picking the nose, 
omiting, diarrhcES and dis- 
D side of bed and grinding 
s may be present or absent, 



'I 



DISEASES OF THE PERITONEUM. 91 

R. Santonini gr. X~J~U 

Hydrargyri chlot. mite gr. ^-ij. M. 

Ft. chart. 
SiG. — At bedtime, followed by a dose of oleum ricini before breakfast. 

For the oxyuris vemiicularis the above santoninum powder, with 
the use of enemata of quassia^ aiumefif sodii chloriduvi^ or R., acidi 
carbolici, gr. v-x, aquae, Oj, according to the age, the injection not to 
be retained. Washing the anus and external genitals with a solution 
of acidum carbolicum should also be used. 



DISEASES OF THE PERITONEUM. 



PERITONITIS. 

Synonym. Inflammation of the peritoneum. 

Definition. A fibrinous inflammation of the peritoneum, either 
acute or chronic in character, characterized by fever, intense pain, ten- 
derness, tympanites, vomiting and prostration. It may be limited to a 
part — locals or it may involve the whole membrdine—^^enera/, peritonitis. 

Causes. Acute variety: Intense cold ; protracted irritation by 
blisters ; blows upon the abdomen ; inflammation or perforation of 
the stomach, intestines, gall or urinary bladder ; inflammation of the 
pelvic viscera ; septicaemia or pyaemia ; erysipelas. 

Chronic* variety: Tuberculosis; albuminuria; scrofula; cancer; 
cirrhosis of the liver. 

Patholo^cal Anatomy. Acute fonn ; hyperaemia of the serous 
membrane, the capillaries distended and occasional extravasations of 
blood from their rupture ; the normal secretion is arrested, and the 
shiny membrane becomes dull and opaque, from an exudation of pure 
fibrin, which is adhesive, glueing the parts together ; if the inflam- 
matory action is now arrested, it is termed adhesive peritonitis; if, 
however, the action progress, an effusion of serous fluid is poured 
out into the peritoneal cavity, the amount varying from a few ounces 
to several gallons ; this is termed exudative peritonitis. If recovery 
result, the fluid is absorbed, with much of the solid exudation, the 
unabsorbed portions forming adhesions between the membrane and 
the different abdominal organs, often causing great deformity and 
irregularity in their relations. 



PRACTICE OP MEDICINE. 

Till- ckronk form follows the acute, or is associated with tubercu- 
losis, scrofula, Bright's disease, or cirrhosis of the liver. 

The membrane is irregularly thickened and opaque, with strong 
adhesions to one or more coils of the intestine, the liver or spleen : the 
quantity of fluid present is small, purulent or sero-purulent in char- 
acter, and encysted by the agglutinated membrane. 

Bymptoms. Acule form ; when idiopathic, the onset is sudden, 
with a c kill, fever, 102-3°, P'tl^i^ 100-140, wiry and tense, sei'etv pain, 
cutting or boring in character, and tenderness, becoming so great that 
the slightest touch aggravates it, the decubitus being on the back, with 
flexed thighs ; the abdomen is distended and rigid, from trmistipalion, 
fusion and meteorism ; the diaphragm is pushed up as far as the 
third or fourth rib in severe cases, causing compression of the lungs, 
and displacement of the heart, liver and spleen. There is impaired 
appetite, and nausea and vomiting' !ae almost constant, as is hiccough. 

Secondary form, from extension, begins with local and gradually 
increasing pain, the temperature increases, tense pulse and vomiting. 
If front perforation, it is announced by severe pain and all the 
Bymptoms of shock. 

These symptoms continue from six lo eight days, when they begin 
to ameliorate and a tedious convalescence ensues, or pain and tender- 
ness grow more marked, strength fails, surface cold, pulse rapid, and 
collapse, with hippocralic face, to wit ; anxious expression, pinched 
features, sunken eyes and drawn upper lip. 

Chronic fonn : irregular chilis,fever and sweats; disthided ahdo- 
wen, constipation, alternating with diarrkwa ; diffused tenderness, 
with Points of intenscness and hardness; colicky pains during diges- 
tion, rapid emaciation and failure of strength. Usually, the lower 
portions of the abdomen give a dull note on percussion, from the 
presence of fluid, or scattered points of dullness, showing the presence 
of encysted fluid. 

DiagnosiB. Acute gastritis differs from peritonitis in having a 
history of corrosive poisoning, severe pain, limited lo the stomach, with 
early and severe vomiting; while the latter has fever, diffused ab- 
dominal pain and tenderness, with decided distention. 

Acute enteritis has localized pair\ and tenderness with marked 
diarrhcea ; constipation being the rule in peritonitis. 

Rheumatism of the abdominal miisclen occurs with a rheumatic 
history, is subacute, lacks the great abdominal distention of peri' 



DISEASES OF THE PERITONEUM. 93 

tonitis, and while tenderness exists, it is not aggravated by deeper 
pressure. 

Biliary colic, or the passage of a gall-stone, has, as a prominent 
symptom, excruciating pain, localized over the common bile duct, 
which is of a paroxysmal character and followed by jaundice. In 
renal colic the acute pain follows the course of the ureters, with 
retracted testicle and altered urinary secretion. 

PrognoBis. Idiopathic cases favorable, and especially if they 
continue longer than a week, as fatal cases usually end during the 
first week. Cases from perforation unfavorable. 

Chronic peritonitis being generally of tuberculous origin, the prog- 
nosis is unfavorable, although partial or complete recovery results in 
the cases following the acute form of the disease. 

Treatment. Acute form : Idiopathic and robust cases, locally, 
leeches or wet rups, followed by cold or hot applications, as most 
agreeable to the patient ; adynamic cases, dry cups, followed by 
warm applications medicated with tinctura opii. 

Opium and quinina are the remedies indicated at the onset of the 
disease, to wit: at once hypodermatic of morphina, gr. X~/4» main- 
taining the effect by hourly doses of either morphina or opium, by 
the mouth. Prof. Clark ascertained the tolerance of opium in this 
disease, by the tremendous amounts used in a case under his care ; 
the first day he gave 206 grs., the second day 472 grs., the third day 
236 grs., fourth day 120 grs., fifth day 54 grs., sixth day 22 grs., and 
on the seventh day 8 grains. Prof. Clark found that, as a rule, how- 
ever, morphina, gr, yi-.^, every two hours, would maintain the 
effects of the drug. The opium should be guarded with yOifficient 
doses oi atropina, Quinina, gr. v, every four hours until ^xtidfttion, 
after which gr. ij, four times a day, is of marked benefit. ^ 

The decline of the vital powers must be averted by regulated- nutri- 
tion 2Si^free stimulation. 

During convalescence, perfect quiet, nourishing aliment, moderate 
stimulation, scattered flying blisters, and the following : — 

R. Potassii iodidi gr. v-x 

Ferri pyrophos gr. ij 

Tincturi lavandulae comp n\^xy 

Syr. aurantii corticis ad 3;ij M. 

Every six hours, 
should constitute the treatment, with tonic doses of quinina. 



94 PRACTICE OF KEDICiNE, 

Pcrilonitis from perforation, absolute quiet, hypodermatic injections 
of morphina, ice locally, and stimulants per mouth, rectum, or hypo- 
dermatically. 

ChrxmU perilonilis : locally, linct. iodi, and internally, opium, for 
pain : polassii iedidum ns an absorbent, with nourishing diet, oleum 
morrliiice and stimulants, and rest in bed. 

ASCITES. 

Synonyms. Dropsy of the abdomen ; peritoneal dropsy. 

De&mtiou. A collection of serous lluid in the abdomen, or more 
correctly in the peritoneal cavity ; characteriied by swollen abdomen, 
Itucluation. dullness on percussion, displacement of viscera, embar- 
rassed respiration, plus the symptoms of its cause. 

Causes. Ascites may form part of a general . dropsy, to wit: 
cardiac or nephritic ; the most common factor in its production is 
mechankal obstruclinn of the portal system, from cirrhosis of the liver, 
tumors, diseases of the heart or lungs. 

PatholoB'ical Anatomy. The quantity of fluid in the peri- 
toneal sac ranges from a few ounces to many gallons, it is generally 
of a straw color, or at times greenish, and is transparent, having an 
alkaline reaction. When blood is present in any great quantity, it 
points to cancer as a cause. The peritoneum becomes cloudy, sod- 
den, and thickened, from long contact with the fluid. 

Symptoms.. The onset is insidious, and considerable swelling 
of i/it al'i/fintn occurs hcioTc the disease attracts attention. Consti- 
pation, from pressure of the fluid on the sigmoid flexure. Sranfy 
urine, from pressure on the renal vessels. Embarrassed respiration 
anA rardiac action, from pressure on the diaphragm upward. The 
umbiliiHS is forced outward. 

Physical signs; on palpation, a peculiar wave-like impulse is im- 
parted to the hand laying on the side of the abdomen, while gently 
tapping the opposite side. 

Percussion; patient erect, the fluid distends the lower abdominal 
region, with dullness over the site of the fluid and a tympanitic note 
above : if the patient turns on his side the fluid changes, and dullness 
over the fluid, tympanitic over the distended intestines. 

OiagTlOSis. Ovarian tumors differ from ascites in the history, 
in that the enlargement is limited to the iliac fossa, instead of a 



i 



DISEASES OF THE PERITONEUM. 95 

uniform abdominal enlargement, not changing its position when 
the patient changes posture, and by the detection of a tumor by 
conjoined manipulation throiigh vagina, or by rectal exploration. 

Pregnancy differs from ascites in the character of the enlargement, 
the history, absence of menses, increase of mammae, change in the 
neck of the uterus, absence of fluctuation, and the presence of the 
sounds of the foetal heart. 

Distention of the bladder has been mistaken for ascites ; the points 
of distinction are, in the former the history, presence of tenderness 
over the bladder, rounded outline of the percussion dullness, and the 
relief afforded by the catheter. 

Chronic Peritonitis is differentiated by the history, pain, tender- 
ness, more or less vomiting, thickened abdominal walls, and its 
generally'being associated with tubercle or cancer. 

Chronic Tympanites presents the enlarged abdomen, but lacks the 
history, the dullness and the fluctuation, giving instead a tense 
abdomen and a ujiiversal tympanitic note. 

Progrnosis. Influenced by the causes producing it. Idiopathic 
ascites, which is most rare, terminates in health within a few weeks. 
If peritoneal, generally favorable. If from organic disease, most 
unfavorable, for while it may be removed, it as rapidly returns. 

Treatment. The first indication is to treat the cause of the ascites, 
and the second to remove the fluid. 

Three modes of removing the fluid present themselves, to wit : 
first,- by hydragogue cathartics, second, diuretics, and third, tapping. 
The first and second modes may be combined, as follows : — 

R. Pulv. jalapae comp 3J-ij 

In water, an hour before breakfast ; 
And— 

R. Potassii acetat gr. x-xx-xl 

Tinct. scillae 15 ss 

Infus. digitalis f^iss. M. 

Every six hours. 

If these fail, as they certainly will after a time, the embarrassed respi- 
ration and cardiac action will call for tapping, which may be done 
with the trocar, or better still, the aspirator. 



PRACTICE OF MEDICINE. 



DISEASES OF THE BILIARY PASSAGES. 

CATARRHAL JAUNDICE. 

BynonyiUB. Catarrh of the bile ducts ; icterus. 

Deflnitibn. An acute catarrhal inflammation of the mucous 
membrane of the bile ducts and of the duodenum ; characteriied by 
gastro -intestinal derangement, yellowness, itching of the skin, fever- 
ishness and mental depression. 

Causes. Excesses in eating and drinking; a debauch; malaria; 
chmatic, as cool nights succeeding warm days. 

Fa.ttlological Anatomy. The raucous membrane of one or 
more of the bile ducts or of the duodenum becomes hyperaemic, 
swollen and thickened, from an effusion of serum into the sub-mucous 
tissue ; the result of this condition is the closure of the biliary pas- 
sages, thereby impeding the outward flow of bile. The bile in the 
hepatic ducts being retained by the obstruction, the result is a staining 
of the liver substance and an absorption of bile, and its appearance 
in the blood. 

Symptoms. Begins by epigastric distress, coated tongue, impaired 
appetite, nausea, with, perhaps, ■vomiting and looseness of the boviels 
and slight fe-verishness, ihc phenomena of a gastro- intestinal catarrh. 
In from three to five days the eyes become yellow, and jaundice 
gradually appears over the whole body ; the feverishness disappears, 
the skin becomes harsh, dry and itchy, the bowels constipated, the 
stools whitish or clay-colored, accompanied with much fiatus and 
colicky pains ; the urine heavy and dark, loaded with urates and 
containing biliary clemenls. 

A few drops of the urine placed on a whidsh surface, and a drop 
or two of nitric acid made to flow against it, will exhibit the following 
"play of colors;" a greenish tint, from the conversion of bilirubin 
into biliverdin, quickly followed by blue, violet, red, and yellow, or 
brown. 

When the jaundice is complete, the surface is cold, the heart's 
action slow, the mind torpid and greatly depressed, and pain or 
tenderness on pressure over the hepatic region. 

Dtiration. In from three to five days after the jaundice appears, 
the symptoms subside, save the torpid bowels, depression and discol- 
ored skin, which slowly disappear, often requiring a week or two. 



i 



DISEASES OF THE BILIARY PASSAGES. 97 

Diagrnosis. After the appearance of the jaundice, mistakes are 
impossible. 

The numerous diseases, of which jaundice is a symptom will be 
differentiated when treating of them. 

Prognosis. Always favorable; if the attacks are of frequent 
occurrence, however, they are apt to lead to organic hepatic changes. 

Treatment. At the onset quinina, gr. x, morning and night, 
may modify the disease, but as soon as the diagnosis is established 
the indications are for diaphoretics^ diuretics and purgatives. 

For diaphoresis y the warm bath^ to which potassii carbonas^ ^j, 
may be added; morning and night. 

For diuresis, potassii bitartras lemonade, every four hours. 

Y ox purgation, ^lih^r sodii pyrophos,, 3j-ij, every four hours, well 
diluted, or ammonii murias, gr. xv-xx, every five hours, well diluted. 

A special plan, which is said to be effective, is with " enemata of cold 
water. By means of an irrigating apparatus the large intestine is 
well distended with water once a day for several days. The first 
enema has a temperature of 60° F., and subsequent injections are a 
little warmer. The increased peristalsis of the bowels and the reflex 
contractions of the gall bladder dislodge the mucus lining and ob- 
struct the gall ducts. When the bile flows into the intestine, digestion 
is resumed and the catarrhal inflammation subsides." Other reme- 
dies may be conjoined with the irrigation method. 

Restricted diet, avoiding all starchy, fatty or saccharine articles, 
milk being the most suitable. 

For convalescence — 

R. Acid, nitrohydrochlorici dil gr. v-x 

Elix. taraxaci comp , 3J-ij. M. 

Before meals. 

BILIARY CALCULI. 

Synonyms. Hepatic calculi ; gall stones ; hepatic colic. 

Definition. Concretions originating in the gall-bladder, or biliary 
ducts, derived partly or entirely from the constituents of the bile. 
Their presence is generally unrecognized until one or more attempt 
to pass along the ducts, when an attack of hepatic colic is produced. 

Causes. Gall stones result from the precipitation of the crystal- 
lizable cholesterine, and its combination with inspissated mucus in 
the gall bladder or ducts. 



fld PRACTirE OF MEnrciME. 

A disease of middle Life, and more rrequenc in the obese, and in 

Gal! sioncs arc said lo be common in carcinoma of the stomach or 
liver. 

Pathological Anatomy. Cholesterine is the chief constituent 
of biliary calculi. Commonly several stones exist, and rarely one ; 
as many as six hundred are recorded. They are generally found 
in the gall bladder or cystic duct, rarely in the liver or hepatic ducL 

SymptoniB. Hepatic iolU begins suddenly, at the moment a 
gall stone passes from the gall bladder into the cyst duct. 

The patient is seized with a pu-rcing, agonhing pain in the region 
of the gall bladder, and spreading over the abdomen, right chest and 
shoulder ; the abdominal muschs are cramped and tender; there is 
nautea and vomiting, a small, ^^^^ pulse, eool skin, pale, distorted, 
anxious fac^, with, may be, fainting, spasmodic trembling, chills, 
or convulsions. 

The paroxysm continues from an hour or two to several days, with 
remissions, but entire relief is not afforded until the stone reaches the 
duodenum, when the pain suddenly ceases. 

Jaundice usually follows the paroxysm of pain. When the calculi 
reaches the intestines, the pain, nausea and vomiting cease, the appe- 
tite returns, and the jaundice soon disappears. 

Should the calculi become impacted, ulcerative perforation and 
consequent peritonitis follow, the calculi discharging by the intestine, 
stomach, or through the abdominal walls, 

DiaETnOHis, The malady should not be mistaken if severe pain, 
naiisi^a, and vomiting- are present, suddenly terminating, and followed 
by slight jaundice. 

Prognosis. Usual termination is in health. The prognosis be- 
coming more unfavorable if ulcerative perforation result. 

Treatment. For the colic, hypodermatic injections of morpkina, 
gr. >i-|^->i, combined with atropina.^t. j^, and warm fomenta- 
tions over the hepatic region, are indicated. 

Prof. Bartholow strongly urges the following prophylactic treatment : 
Carefully regulated diet, abstinence from all fatty and saccharine sub- 
stances, daily exercise, stoppage of all excesses, and the long use of 
sodii phnsphas, .^j, before meals, well diluted, to which may be 
added, if gastro-intestinal catarrh be present, sodii i 
together with either Vichy or Saratoga Vichy water. 



\ 



DISEASES OF THE LIVER. 99 



DISEASES OF THE LIVER. 



CONGESTION OF THE LIVER. 

Synonyms. Torpid liver ; biliousness. 

Definition. An abnormal fullness of the vessels of the liver, 
with consequent enlargement of that organ ; it is termed active when 
arterial ; passive when venous. The condition is characterized by 
torpidity of the digestive and mental functions, and slight jaundice. 

Causes. Active congestion; malaria; excess in eating and 
drinking ; alcoholic or malt liquors. 

Passive congestion ; cardiac and pulmonary diseases. 

Pathological Anatomy. The liver is enlarged in all direc- 
tions, and is abnormally full of blood. Cases due to obstructive 
diseases of the heart or lungs present the so-called "nutmeg liver," 
to wit : " At the centre of each lobule the dilated radicle of the hepatic 
vein, enlarged and congested, may be discerned, while the neighbor- 
ing parts of the lobule are pale," the radicles of the portal vein 
containing less blood. 

Long continued congestion establishes atrophic degeneration of the 
organ ; the decrease in size is confounded with the condition of 
cirrhosis, but the "atrophic liver" is smooth, while the "cirrhotic 
liver" is nodulated. 

Symptoms. Active congestion ; following cause, rapidly pro- 
duced malaise, aching of limbs, evening feverishness, headache, 
yellowish tongue, disgust for food, nausea, and, may be, vomiting, 
constipation, scanty, high-colored urine, with a feeling of fullness, 
weight, and soreness in the hepatic region, and slight jaundice, the 
eye yellow, and the complexion muddy. 

Passive congestion ; onset gradual, with a feeling of weight and full- 
ness in the hepatic region, slight jaundice, and symptoms of gastro- 
intestinal catarrh. 

On percussion the hepatic dullness is increased in all directions. 

Diagnosis. Acute congestion is continually confounded with 
catarrhal jaundice ; the latter begins with marked gastro-intestinal 
symptoms and distinct jaundice ; in the former these are less marked. 

Obstructive congestion is diagnosticated by the clinical history. 

Atrophic or nutmeg liver will be differentiated from cirrhotic liver 
when speaking of the latter. 



PRACTICE OF MEDICINE. 

Prognosis, Active congestion favorable, unless repeated attacks 
occur, rapidly succeeding each other, when "atrophic degeneratjon " 

Passive rongesliott controlled entirely by the cause. 

Treatment. Attacks due to excess in eating and driukiti^ : — 

B. Sodii bicarb gr. v 

Pulv. ipecac gr. ss 

HydrarEyri chlor.mil gr. Uj-v 

followed by 

B. Acidi nilrohydrochloriei dil tn,viiis 

Elix. laraiad comp.„ gij. 

Before meals, and a milk diet. 

Attacks due to malaria ; the above purgative followed by guinina 
mlph., gr. iv, every four hours. 

Attacks occurring with cardiac or pulmonary diseases must be 
managed by trearing the cause. 

The tendency to constipation must be overcome by the saline laxa- 
irve waters, to wit : Congress or Halhom, Pullna or Fried richsh all, or 
sodii phosphas, 5i-ij, three or four times daily, well diluted 

Locally, in acute attacks, hot cloths or sinapisms, are of benefit. 

In chronic cases benefit follows, elix. gitinina ferri et slrychninf, 
3 j, three times a day, and great comfort and support is given by the 
use of the " hydropathic belt," which is made of stout muslin, shaped 
to the abdomen, with cross pieces of tape on the inner side, which 
keeps next to the skin a fold of cloth wrung out of cold water, and a 
piece of waterproof cloth or oiled silk, to prevent evaporation. 

ABSCESS OF THE LIVER. 

Synonyms. Parenchymatous hepatitis ; acute hepatitis ; suppu- 
lUive hepaili,. 

Definition. A diffused or circumscribed inflammation of the 
hepatic cells, resulting in suppuration, the abscesses being sometimes 
single, at times double ; characterized by irregular febrile attacks, 
hepatic tenderness and symptoms of deranged gastro- intestinal and 
hepatic functions. 

Causes. The result of the absorption of putrid material by the 
portal radicles in dysentery ; ulcers of the stomach ; malaria ; blows 
and injuries; heat; pyismia. 



DISEASES OF THE LIVER. 101 

Pathologrical Anatomy. Hyperaemia, swelling, effusion of 
lymph, degeneration and softening of the hepatic cells ; suppuration, 
beginning in points in the lobules and coalescing. The abscess walls 
consist of the liver structure, more or less changed. 

The abscess may advance toward the surface of the liver, bursting 
into the peritoneum, intestines, stomach, gall bladder, hepatic duct 
or vein, or into the pleura or lungs, or externally through the abdomi- 
nal walls ; after the discharge of pus, cicatrization occurs, or the pus 
may be absorbed, the tissues around forming a dense cicatrix. 

Symptoms. Very obscure. Fever simulating markedly inter- 
mittent or remittent fevers ; disorders of the gastro-intestinal canal, 
with obstinate vomitings debility, and great irritability of the nervous 
system, sW^i jaundice, and if of long duration, typhoid symptoms. 

Locally^ if the abscess is near the surface, prominence of the 
hepatic region, throbbing, limited tenderness, and if it tends to the 
surface, redness, oedema and fluctuation. The abscess may burst 
into the intestines, stomach, lungs, or pleura, the symptoms of which 
will be pronounced. 

Diagrnosis. Hepatic abscess may be confounded with hydatids 
of the liver, hepatic or gastric cancer, abscess of the abdominal walls, 
and purulent effusion in the right pleural cavity. 

The differentiation is most difficult, but great aid is obtained from 
the use of the aspirator, 

Progrnosis. Unfavorable. Recoveries, however, do occur. If 
the abscess bursts into the lungs, bowels, or externally through the 
abdominal wall, the case is more favorable. 

Treatment. Symptomatic, and when pus is present, the use of 
the aspirator to remove it, and sustaining treatment, to wit : quinina, 
ferrum, alcohol, and oleum morrhuce, 

ACUTE YELLOW ATROPHY. 

Synonyms. General parenchymatous hepatitis ; malignant jaun- 
dice ; hemdrrhagic icterus. 

Definition. An acute diffused or general inflammation of the 
hepatic cells, resulting in their complete disintegration : characterized 
by diminution in the size of the liver, deep jaundice, and profound 
disturbance of the nervous system ; terminating in death, usually, 
within one week. 



Mt PIUCTICE OP MEIHCIKB. 

Caoeee. Uosetiled. Ii occurs frequently in yoDng pregnant 
women, from ihe third to tlic sixth month of pregnacy. Other causes 
arc venereal excesses; syphilis; action of phosphorus, arsenic or 
antimony. 

PaUiological Anatomy. Begins with hypeiaemia of the hepatic 
cells, with a grayish exodation between ilie lobules, followed by 
softening, dull yellow color, and disappearance of the cells, fat glo- 
bules taking their place. The liver is reduced in site and in weight 
The peritoneum covering the liver is thrown into folds. The spleen 
is enlarged. The kidneys undergo degeneration. The blood con- 
tains a large aniounl of urea and considerable leucin. The urine is 
loaded with bile pigment, and contains albumen. 

Symptoms. Proiirt>mu period : begins as ^ gastre-mUslinal ca- 
tarrh, coated tongue, nausea, vomiting, tenderness over the epigas- 
trium, headache, quickened pulse, slight fever and slight /dHsf/icf. 

k Uric period : jaundice deepens, pulse slow, headache increases, 
and great and obstinate sleeplessness. 

Tox ami c period ; fever, n.<fi\A pulse, more complete Jatindtce, pain, 
nausea, vomiting of blactisk, gnimtms blood, or " coffee grounds," 
tarry stools, ecchymotic patches, convulsioTis, or epileptiform attacks, 
coma, insensibility, death. 

Percussion shows markedly decreased hepatic dullness. 

Dtiratdon. Short. After appearance of jaundice, about six days. 

Prognosis. I'nfavorable. 

Treatment. Entirely symptomatic. Prof. Bartholow "advises 
the trial of very small doses of phosphorus, as early as possible, as tliis 
remedy affects the organ specifically, and an action of antagonism 
may be discovered between them." 

SCLEROSIS OF THE LIVER. 

Synonyms. Interstitial hepatitis ; cirrhosis ; hob-nailed liver ; 
gin dniiktrs' liver. 

Definition, An inflammation of the intervening connective 
tissue of the liver, chronic in its progress, resulting in an induration 
ot hardening of the organ and an atrophy of (he secreting cells; 
characterized by gastro- intestinal catarrh, emaciation, slight ja.undice 
and ascites. 

Causes, The prolonged use of alcoholic stimulants, gin, whiskey, 
beer, or porter ; syphilis. 



DISEASES OF THE LIVER. 103 

Pathologrical Anatomy. First stage ; hyperaemia of the con- 
nective tissue (Glisson's capsule) of the liver, and the development 
of brownish-red connective-tissue elements, whereby the organ is 
increased in size and density ; this increase of the connective tissue 
presses upon the hepatic cells, causing them to undergo fatty degene- 
ration. 

Second stage ; the newly formed, imperfectly developed connective 
tissue contracts, causing decrease in the size and induration of the 
organ, its surface being nodulated. The hepatic and portal circula- 
tion is obstructed, from obliteration of their radicles. 

The hepatic peritoneum is thickened and opaque, and adhesions 
are formed to the diaphragm, gall-bladder, and stomach. 

Cases occur in which the sclerosis takes place while the organ con- 
tinues enlarged; these are known as hypertrophic sclerosis. 

Symptoms. No characteristic symptoms of the early stage of 
the affection. Persistent gastro-intestinal catarrh, with attacks of 
jaundice, in a drinking man, are suspicious. Symptoms of the second 
stage are, abdominal dropsy, enlargement of the superficial abdominal 
veins, dyspepsia, localized peritoneal pain, hemorrhages from the 
stomach or intestines ^ muddy or ^\^\\y jaundiced skin and decided 
emaciation, 

Diagrnosis. Atrophy of the liver, or the nutmeg liver, is almost 
always confounded with sclerosis ; the former occurs most commonly 
with obstructive diseases of the heart and lungs, and the surface of the 
organ is not nodulated, nor is there a history of alcoholism. 

Cancer and tubercle of the peritoneum ^^2^^^ many symptoms akin 
to sclerosis. The points of differentiation are, great tenderness 
over abdomen, rapidly developed ascites, rapid decline in strength 
and flesh, absence of jaundice, absence of long-continued dyspepsia, 
absence of hepatic changes on percussion, and the presence of 
tubercle or cancer deposits in other organs. 

Progrnosis. Terminates in death. Average duration after ap- 
pearance of the dropsy, one year. 

Treatment. For the changes in the hepatic structure, little, if any- 
thing, can be done ; the following are some of the remedies recom- 
m ended, to wit: hydrargyri chloridum corrosivum, gr. eV"?!^ three 
times a day ; hydrargyri chloridum mite, gr. yj^, three times a day ; 
aurii et sodii chloridum, gr. ^\y, after meals; sodii phosphas, 3ss-j, 
after meals. 



The diet must be regulated, milk being the most suitable, arii 
avoiding fally and saccharine foods. 

The abdominal dropsy may be temporarilj' benefited by purgiilivi 
and liiuntici, but sooner or later tapping becomes imperative. 



AMYLOID LIVER, 

Synonyms. Wasy liven lardaceous liver; scrofulous liver; 
albuminoid liver. 

Deflnitioii. A peculiar infiltration into, or a degeneration of, the 
structure of the liver, from the deposit of an albuminoid material, 
which has been termed amyloid, from a superficial resemblance to 
starch granules, 

Oauaes. The chief cause is prolonged suppuration, especially of 
the bones ; coxalgia ; syphilis; cancer. 

Pathologrical Anatomy. The liver is uniformly enlarged. It 
presents a pale, glistening, transiuceflt appearance, and has a doughy 
consistency. On section, the surface is homogeneous, is anaemic 
and whitish. The deposit begins in the arterioles and capillaries, 
finally closing them. 

The reaction with iodine and sulphuric acid affords a certain test of 
the amyloid or albuminoid deposits. After thorough cleansing, brush 
over (he parts a solution of iodine with iodide of potassium in water, 
when they will assume a mahogany color, and if diluted sulphuric 
acid be added, a violet or bluish tint is produced. 

A pretty reaction is to take a one per cent, solution of anilin violet, 
which strikes a red or pink color with the amyloid or albuminoid 
material, while the unaltered tissues are stained blue, thus showing a 
beautiful contrast. 

The amyloid change involves the spleen, kidney, intestines, and 
other organs. 

Symptoms. Nothing characteristic. Hepatic dullness increased, 
with prominence over the liver. Absence of pain. Splenic dullness 
increased. Emaciation and anamia. Urine increased in amount, 
pale, and containing some albumen, due to amyloid changes in ibe 
kidneys. Disorders of digestion, with diarrhcea, due to amyloid 
changes in the intestines. Jaundice is rare. Ascites seldom occurs. 

Prognosis. Unfavorable. The progress is rapid or slow, de- 
pending upon the cause. 



DISEASES OF THE LIVER. 105 

Treatment. No specific. Symptomatic, with prolonged use of 
ferruin; syr, calcii lacto-phosphas and oleum morrhuce, 

HEPATIC CANCER. . 

Synonym. Carcinoma of the Hver. 

Definition. A pecuhar morbid growth, progressively destroying 
the hepatic tissue ; characterized by disorders of digestion, anaemia, 
emaciation, jaundice and ascites, and terminating in the death of the 
patient. 

Causes. Hereditary, when it is termed primary cancer ; from 
extension from other organs, when it is termed secondary cancer. It 
is a disease of advanced life, from forty to sixty years. 

Pathological Anatomy. The most common variety of cancer 
of the liver is a coippound of the medullary and scirrhus. 

The cancer cells develop from the interlobular connective tissue, 
and as they grow the hepatic cells atrophy, the result of the pressure 
of the new growth.* The branches of the hepatic artery enlarge and 
permeate the growth, while the branches of the portal vein are com- 
pressed and atrophied, thereby blocking up the portal circulation. 

The cancer may develop in nodules or masses^ or may be diffused ; 
the nodules vary in size, and those on the surface are rounded, with 
a central umbilication. The peritoneum is adherent, cloudy and 
thickened. 

Symptoms. The development of hepatic cancer is preceded by 
a history of dyspepsia, flatulency and constipation. Then uneasiness, 
weight and pain, increased by pressure, are noticed ; jaundice, ascites; 
occasional intestinal hemorrhages, emaciation, feebleness, ancemia, 
cold, dry, harsh skin, pinched features, with dejected, worn expression. 
Fever never occurs. The hepatic dullness is increased, with pain on 
palpation, and the liver is indurated, irregular and nodulated. 

The duration is less than a year from the time the disease is 
recognized. 

Diagnosis. The points of differentiation are the age, cachexia, 
pain and tenderness, enlarged liver with hard nodules, and rapid 
progress. 

Prognosis. Always terminates in death. 

Treatment. Early symptomatic. Sooner or \^\.^x opium must be 
used, to relieve the terrible and persistent pain. 

F 



106 



PRACTICE OP MEDICINE. 



DISEASES OF THE KIDNEYS. 



THE URINE. 

The normal quantity of urine varies from twenty to fifty ounces 
in the twenty-four hours ; it is decreased by free perspiration and 
increased by chiUing of the skin. 

The normal color is light amber, due to urolnlin ; the color deepens 
if the quantity voided be decreased, and vice versa. 

'I'he normal reaction is slightly acid, due to the acid sodtc phos- 
phate, uric and hippuric acids. After meals It may be neutral or 
even alkaline. 

The normal specific i^ravity varies from i,oo8 to 1.020; \X.\& law 
when an increased quantity is passed and high when the quantity is 
diminished. 

The most important organic and inorganic solid constituents held 
in solution are, urea (the index of nitrogenous excretion), from 308 
to 617 grains daily ; uric aciil, from 6 to 12 grains ; urates of sodium, 
' ammoniutn, potassium, calcium and magnesium, from 9 to 14 grains; 
phosphates of sodium, etc., from 12 to 45 grains, and chlorides of 
sodium, etc., from 154 to 247 grains daily. 

Fill a graduated glass tube one-third full 
oi mercury, and add one-half drachm of the 
24 hours* urine; then fill the tube evenly 
full with a saturated solution oi hypobromite 
of sodium, and close it immediately with the 
thumb; invert the tube aSd place its open 
end beneath a sat. sol. oi chloride of sodium ; 
the mercury flows out and is replaced by the 
solution of salt ; nitrogen gas is disengaged 
from the urea in the upper part of the tube. 

Each cubic inch of gas represents .645 gr. 
of urea in the half diachm, from which 
the amount passed in 24 hours may be cal- 
culated. 



I. Quantitative test- 
for urea, by hypobro- 
mite of sodium (Davy's 
Method). 



DISEASES OF THE KIDNEYS. 



107 



II. Tests for urates 
2Lnd uric acid by nitric 
acid. 



III. Quantitativfe test 
for uric,acid by nitric 
acid. 



IV. Test for the 
earthy and alkaline , 
phosphateshy the mag- 
nesian fluid. 



Urine containing an excess of urates and 
uric acid, on coolings precipitates them (viz : 
" brickdust deposits " in " pot de chambre *'). 
Heat dissolves them to a certain extent. 

Nitric acid deprives the soluble neutral 
urates of their bases, and produces, at first, 
a faint, milky precipitate of amorphous acid 
urates ; adding more acid, the still less solu- 
ble red crystals of uric acid are deposited. 

Put a small quantity of nitric acid in a 
test tube, and pour the urine carefully down 
the sides of the tube upon it, and a zone of 
yellowish-red uric acid and altered coloring 
matter will form at their union ; and a dense, 
milky zone oi acid urates above this, which, 
however, dissolves upon agitation. (See 
albumen test.) 

• 

To three ounces of the 24 hours* urine 
(after being slightly addulated,* boiled and 
filtered while hot) add one-tenth as much 
nitric acid ; place in a cool place for 24 
hours, then collect the deposit of uric acid 
on a weighed filter, wash it thoroughly; and 
dry at 212° F. The increased weight repre- 
sents the uric acid in part excreted, approxi- 
mately. 

Heat or liquor potassa increases the 
cloudiness caused by earthy Calcium and 
magnesium phosphates. Acetic or nitric 
acid clears it, by dissolving them. 

To two ounces of urine add one-third as 
much of the following solution, to wit : R . 
Magnesii sulph., ammonii chloridum purae, 
liquor ammoniae, each one part ; aquae destil., 
eight parts ; if the precipitate has a milky ^ 
cloudy appearance, the quantity of phos- 
phates is normal ; if creamy ^ the phosphates 
are in excess. 



V. Tcsl for Ihe chlo- 
rides by nitrate of sil- 



VI. Test for mucn 
by acetic acid and li- 
quor iodi coitip. 




' MEDtClXE. 

mvenient quantity of urine add a 
small amount of nitric acid, to prevent the 
formation of the phosphates and other salts 
silver; filter this, if cloudy; add to this 
i drop of a solution of nitrate of silver ( i 
part to 8) and the precipitate of white cheesy 
lumps of chloride of iih'er denotes that the 
It of chlorides are nornial ; if, however, 
only a faint milkiness occur, the chlorides 
ire diminished. 

Muais alone is not visible, but causes 
cloudiness, from having entangled mucus or 
pus corpuscles, epithelium, granules of sodi- 
um urate, crystals of atalatc of lime and 

Add to the urine a little acetic acid, or, in 
addition, a few drops aX liquor iodi eomp., 
when threads or bands of mucin are made 
visible. The addition of nitric acid dis- 
solves them. * 

Slightly acidulate the urine, if necessary, 
by addition of nitric or acetic acid, And boil ^ 
this causes a -white deposit of coagulated 
albumen, which is fiot dissolved by nitric 
acid, unless the acid is in excess. 

Nitric acid causes a •mhite deposit of 
coagulated albumen, which is dissolved if a 
large excess of acid be added. A delicate 
test is to put the nitric acid in the tube first, 
and then gradually pour the uritie down the 
side of the tube upon it, when a white soHif, 
or ring of coagulated albumen appears. . Pre- 
y caution, see tests Nos. 3. 4, 9 and 11. 

{Add a few drops of nitric acid lo a pro- 
portion of the urine, and boil : set this away 
for 34 hours, and the proportionate depth of 
the resulting deposit is the comparative 
indication, vii., %-%, etc. 



DISEASES OF THE KIDNEYS. 



109 



IX. Test for blood 
by heat and nitric acid. 



Heat or nitric acid causes deposit of albu- 
men, with the coloring matter changed ta a 
dirty brown. 



X. Test for ^/^^^ by 
heat and caustic pot- 
ash (Heller's). 



Heat the urine, then add caustic potash 
arid heat anew. The phosphates are thus 
precipitated, taking with them the coloring 
matter of the blood, which imparts a dirty ^ 
yellowish-red color to the sediment, viewed 
by reflected light, and when seen by trans- 
mitted light, gives a splendid blood-red color. 

Neither the coloring matter of the blood, 
nor that of the bile, is precipitated with the 
phosphates, so that coloration of urine which 
shows this reaction cannot be ascribed to 
the presence of the latter pigments. 

When the quantity of blood in the urine 
is very large, it is of a dark or brownish red, 
and, after standing, forms a coagulum of 
blood at the bottom of the vessel. 



XI. Test for /«J by 
liquor potassa. 



XII. Test for ^//^ by 
"fuming** or red nitric - 
acid. 



Caution, Heat or nitric acid causes coagu- 
lation of the albumen in pus. 

Add to the urine, or preferably to its de- 
posit from standing, an equal volume of 
liquor potassa ; yfYitn well mixed, a viscid 
gelatinous fluid or mass is formed, which 
pours like the white of an t.^'g, or jelly. 

Allow a specimen of urine and a few drops 
of red "fuming** nitric acid to gradually 
intermingle on a porcelain dish, and a "play 
of colors,*' green, blue, violet, red 2in& yellow 
or brown, occur, if bihary coloring matter be 
present. 



XIII. Test for biU 
pigment b/ pure hy- 
drochloric and pure 
nitric acids (Heller's). 



■ XIV. Test for jwfa»- 
by liquor potassa and 
heat (Moore's). 



XV, Test for sugar 
by subnitrate of bis- 
muth, liquor potassa 
and heat. 



PRACTICE OF MEDICINE, 

Pour into a test tube about 1.6 f^ of pure 

hydrochloric acid, and add to it, drop by 
drop, just sufficient urine 10 distinctly color 
it. The two are mixed. Then drop down 
the side of the test lube pure nitric acid, 
which will "underlay "the mixture of hydro- 
chloric acid and urine. At the point of 
contact between the mixture and the colorr 
less nitric acid a handsome" play of colors 
appears." If the " underlying " nitric acid 
is now stirred with a g'^S rod, the set of 
colors which were superimposed upon one 
another will appear alongside of each other 
in the entire mixture, and should be studied 
by transmitted hght. 

If the hydrochloric acid, on addition of 
the biliary urine, is colored reddish-yellmv, 
the coloring matter is bilirubin : if it is col- 
ored green, it is Biliverdin. 



Add to the urine half its volume of Hguor 
Potassa. {Caution. This may give a white, 
flaky precipitate of the earthy phosphates, 
which should be removed by filtering). Now 
ioil; this causes, at first, a yellowish-brown 
color, becoming darker if much sugar is 
present, due to glucic, and finally to melas- 



Add to the urine half its volume of liquor 
potassa, and then a little bismuth svbnifrate, 
shake and thoroughly boil ; the presence of 
sugar reduces the salt and black metallic 
bismuth is deposited, or if but little sugar, a 
gray deposit occurs. 

Caution. Albumen must be absent. 



DISEAI^ES OF THE KIDNEYS. 



lU 



'XVI. Test for sug^ar 
by a solution of cupric - 
sulphate, liquor po- - 
tassa and heat (Trom- 

mer's). 



Add to the urine a few drops of a solution 
of cupric sulphate t and then its own volume 
of liquor potassa, [Caution, On first addi- 
tion a light greenish precipitate occurs, 
which, on further addition of the reagent, if 
sugar or certain other organic matters are 
dissolved, giving a transparent blue liquid). 
Now boil, and a yellowish precipitate of 
hydrated cupric suboxide , occurring at once, 
denotes the presence of sugar. 

Caution, Albumen must be absent. 



XVII. Quantitative 
test for sugar\iy Pavy's 
solution, to wit : — 

Cupric sulphate, gr. 320 
Neutral potassic 

tartrate gr. 640 

Caustic potash... gr. 1280 

Distilled water., f J 20 

Keep corked. 



XVIII. Quantitative 
test for sugar by fer- 
mentation and the 
specific gravity. 



Take of Pavy's solution of cupric protox- 
ide, recently prepared (see margin), 200 
minims or a multiple of this quantity, and 
boil in a porcelain dish ; while boiling, add, 
minim by minim, from a measured portion 
of the 24 hours' urine, and it gives z. yellow- 
ish precipitate of hydrated cupric suboxide^ 
if sugar be present. 

Note carefully the gradual disappearance 
.of the blue color, and when completed (best 
determined by looking through the margin 
of the fluid against the white porcelain dish), 
from the amount of urine used, determine 
the amount of sugar passed daily. The 
quantity of urine containing one grain of 
sugar being just sufficient, to reduce the 200 
minims of the copper solution. 

Take two measured specimens from the 
24 hours' urine, and to one add a little yeast. 
Place each specimen in a temperature of 75° 
to 80° Fah. ; in 24 hours, fermentation hav- 
ing destroyed the sugar in the one containing 
the yeast, the difference in the specific grav- 
ity of the two specimens expresses the 
number of grains in each ounce of the urine. 
Approximately. 



PRACTICE OF HEDICniE. 

CONGESTION OF THE KIDNEYS. 

SynonymB. Renal hyperemia ; catarrhal nephritis. 

Deflmtion. An increase in the amount of blood In the vessels of 
the kidneys ; when arterial, it is termed active congestion ; when 
venous, passive congestion ; characterized by pain, frequent desire for 
urination, the amount of urine scanty, high-colored, occasionally 
containing albumen or blood. , 

Causes, Active; by cold; irritating substances eliminated by 
the kidneys, to wit : turpentine, "copaiba, cantharides ; during the 
eruptive or continued fevers ; injuries over the kidneys. 

Passive ; obstruclive diseases of the heart or lungs, and pressure of 
the pregnant uterus. 

Patholo^cal Anatomy. The kidneys enlarge and increase in 
weight; increased redness (the color being bluish M passive), with 
points of vascularity, corresponding to the Malpighian bodies, and 
occasionally minute ecchymoses. The abnormal hyperfcmia causes 
a. catarrhal state of the ducts of the pyramids, with shedding of their 
epithelium. 

If mechanical (passive) obstruction continues for some time, 
increase of the connective tissue, with consequent induration and 
contraction results, or a form of chronic Brighl's disease.' 

Symptoma. Active variety ,- pain over kidneys and following 
the course of the ureters into the testicles and penis, irritable bladder, 
almost constant and pressing desire for urination, the urine scanty, 
high- colored, and occasionally bloody, with fibrin, casts and albumen. 

If lllc condition persist, inflammation of the kidney results. 

,J'assii'e ; the kidney changes are masked by the li'ig ox heart 
trouble, until dropsy, scanty, higb-colered, albuminous urine is ob- 
served. 

ProsnoBlS, Active; if recogniaed aiid properly treated, favoraU«. 

Passive, controlled by the cause, and if prolonged, terminating in 
interstitial nephritis. 

Treatment. Rest of the body ; dry or wet cups over the loins ; 
dilute the urine by increasing the quantity of bland fluids consumed ; 
saline purgatives ; warm bath or other mild diaphoretics ; if great 
irritability of the bladder, camphora, gr. i[-iv, every four hours, com- 
bined with morphinre sulpk., gr.y'i-l, or the hypodermatic injection 
of morphina, gr. ^'j. 



h-b 



DISEASES OF THE KIDNEYS. 113 

• ACUTE BRIGHT'.S DISEASE. 

S3nion3niis. Acute desquamative nephritis ; acute parenchyma- 
tous nephritis ; acute tubal nephritis. 

Definition. An acute inflammation of the epithelium of the 
uriniferous tubules ; characterized by fever, scanty, high-colored or 
smoky urine, dropsy, with more or less constant nervous phenomena, 
the result' of acute uraemia. 

Causes. The young more liable than the aged ; cold and expo- 
sure ; scarlatina ; persistent use of irritants, to wit : turpentine and 
cantharides. 

Pathologrioal Anatomy. The kidneys are greatly swollen, 
engorged, more vascular, and of a red color ; in the second stage the 
organ remains large, irregularly red, 'especially the cortex; the 
tubules are engorged and filled with epithelium, blood corpuscles and 
fibrin. The capsule is easily detached, and is more opaque than 
normal. 

. If a favorable termination, the swelling lessens, the vascularity 
diminishes, the tubules returning to a normal condition. 

S3niiptoin8. Usually begins suddenly. Fever, with nausea and 
violent and persistent vomiting, dull pain over the kidneys, following 
the ureters ; .y^/« harsh and dry; pulse quick, tense and full. Soon 
dropsy appears, the eyelids and face becoming pu% and swollen, 
followed by general oedema of the extremities, scrotum and abdomi- 
nal walls. If the attack follow scarlatina there are from the onset 
much greater pallor and general debility. 

The urine is of high specific gravity, scanty, smoky (like beef wash- 
ings) in color, due to the presence of blood. Albumen is present in 
large quantities, and the microscope reveals casts of the uriniferous 
tubules, blood corpuscles, uric acid, urates and oxalate crystals and 
epithelium. 

Duration from one to fgur weeks. 

Complications. Pericarditis, pleuritis, pneumonitis, peritonitis, 
or acute urcemia, from retention and decomposition of urea in the 
blood. 

Diagrnosis. The history, fever, scanty, smoky, albuminous urine, 
with dropsy beginning in the face, should prevent any error. 

Albuminuria may be confounded, on account 6f the presence of 
albumen in the urine, but lacks the clinical histofy, usually occurring 
F* . . . 



T 

/ 

,' PRACTICE OP MEDICINE. 

/course of some constitutional affection, to wit : diphther 
.a, yellow fever or erysipelas. 
l*i0gllosis. Favorable. Majority of eases recover under prompt 
treatment. Rarely passes into chronic Bright's disease. Urainie , 
symptoms add to the gravity of the prognosis. 

Treatment. Absolute rest in bed. Milk diet, or if much depres- 
sion, also weak animal broths and oysters. Drink freely of water, but 
neither lea. coffee nor stimulants. Counter-irritation over the kid- 
neys by dry or wet cups, and poultices of digitalis. 

Free purgation hy pulv.jalapa comp., 3j, in water, before break- 
fast, or elaieriiim, gr. \. 

Diaphoresis by warm baths, or infusum pilocarpi, 3 j-'j, every three 
or four hours, or vinum ipecacuanha, gtt. j-ij. every half hour. 
Diuresis, by — 

ft. Potass, acetas gr. x~xk 

Infus. digiial fgij 

Infus. juniperi fjij- M. 

Every two or four hours. 
As soon as the blood disappears from the urine, a course of ferr^m, 
in the shape of Basham's mixture,- until albumen disappears and 
health is restored. The following is the formula of Basham's 

B. Liq.»mtnon.a<:elat fgvj ■ " 

Acid aeeiic giij 

TincL ferri ciilor _ f^^jv 

Alcoholis _5'j 

Syrup „ „... 'f,^iv 

Aqua ■. f|iT. M. 

Sic— Dose fgj-FSJ. 

CHRONIC PARENCHYMATOUS NEPHRITIS. 

Synonyms. Chronic Bright's disease ;. chronic tubal nephritis; 
chronic albuminuria ; large white kidney. 

Definition. A chronic inflammation of the cortical and tubular 
structure of the kidneys; characterized by albuminous urine, dropsy, 
increasing ansemia, with attacks of acute iiramia. 

Causes. Occasionally follows the acute form ; syphilis ; chronic , 
malaria; chronic alcohohsm ; chronic mercurialism ; lead poisoning; 
protracted suppuration. 



DISEASES OF THE KIDNEYS. 115 

It is a disease of the young, rarely occurring after forty. 

Pathological Anatomy. A large while, or yellowish- white, 
smooth kidney, often twice the' normal she. The capsule is nowhere 
adherent to the organ. Upon section, considerable tumefaction of 
the cortical substance and the rarity of vascular stria; are recognized. 
The medullary substance shows no appreciable alteration, its color 
being normal. The convoluted tubes are irregularly dilated and 
thickened, and filled with broken-down, granulated epithelium and 
fibrinous casts. In pronounced cases there is fatty degeneration of 
the tubular epithelium. 

" The intertubular matrix is greatly thickened^a change due to 
byperpla<jia of tbe connective- tissue elements, to the migration of the 
white corpuscles and their subsequent multiplication and fatty trans- 
formation, and to a quantity of fluid exudation, the' product of the 
increased pressure in the veins." 

Symptoms. The onset is gradual and insidious, and the affec- 
tion is seldom recogni/ed until the. appearance of rfni/jv, which, 
beginning under the eyes and in the face, extends all over the body, 
causing dyspnaa from ascites or hydrotkorax. The urine is scanty, 
high-colored, albuminous, and under the microscope showing hyaline 
and granular tubecasts, granular epithelium, and if fatty degeneration 
occur, fatty tubs casts and oil globules. The increase above the 
normal amount of the urine as the disease progresses must not be for- 
gotten, when the specific gravity is low, i.oto-J.015, and the quantity 
of albumen is increased. 

An/rmia is pronounced, from the large waste of albumen. Gastro- 
intestinal disorders and vague ntural^c pains are common occur- 
rences. Cardiac Hypertrophy is of common occurrence. Sronckiai 
caliirrh, with slight adtma of the larynx, causing husky voice, are 
frequent complications. Amaurosis, the result ai neuro-relinitis, occurs 
in a greater or less degree in all pronounced cases. Urcemic symp- 
toms occur, and'especially urcemk asthma (r^na! asthma). 

Complioationa. Pneumonitis, pleuritis, pericarditis, peritonitis, 
and meningitis. 

Prognosis. Not unfavorable, unless urine persistently contains 
large number t^^ fatly tube casts and /'// glohuUs.^ Relapses are fre- 
quent, but many complete (?) recoveries are recorded. 

Treatment. It is to be borne in mind that the course of a case 
uf chronic Bright's disease is not continuously downward ; periods of 



llfl 

remission often follow the most aggravated symptoms, the patient and 
his friends being buoyed into the hope of an early and complete r 
covery, when, as suddenly, an attack of a' 

Rest and liifl are important elements in the treatrtient. 

•A patient with chronic Bright's disease should, as far as possible, be 
reheved from all cares of business and spend a goodly portion of -time 
in bed. 

The did should be entirely, or as nearly so as possible, a miik diet, 
Ihe daily amount used being from two to four quarts. The moderate 
use'of a light wine is at times of advantage if taken with the food, 
although a fair number of-cases do better without stimulants. 

The use of diapkorelics and hydrngogue cathartics are only ii 
caCed when the dropsy is marked, thesk'm harsh and dry, the urinary 
secretion seamy and ursemic symptoms are threatening. 

Diuresis should be promoted, if the secretion is small, by digitalis, 
caffein or arbvtin internally, and dry cups and pouldces over ihe 

The 
f^rrum 



SlG.- 



o be treated by oleum vwtrhtia, > 
n excellent formula for the latter being — 

StrydiniEiE sulph gr. J^ 

Tinct. ferri cliloridi f.fss 

Acidi acetici purse ; f^iss 

C.TO,.lb. (Ji 

Llq-mmmii .C0.1..;. ,.«i fSvJ. 

-Tablespoonful every five hours, followed by a gluiis of cold i 






To check the waste of albumen, a difficult matter, the follow 
remedies have been used with more or less success : ergola, guinitia, 
acidum gallicum, aciduin bensolciim, linchira canlharidis, potassii, 
iodidiim, and, lastly, the Russian remedy, blutla orieHtalis (cock- 

For dropsy, purgatives, such as.piih'is jalapir co'mfiositas, kydri* 
gogue cathartics and alkaline mineral waters. If there be great dis- 
tention of the serous cavities, interfering with the respiration, the' 
aspirator &\\.a\AA be used. Puncture of the skin may be necessary 
at times, and is well accomplished with an ordinary cambric needle. 

Cases due lo syphilis, if the loss of renal structure is slight, a 
cured by a course of hydrargyri corrosivum ckloridum AaAfietassii 
iodidiim with oleum morrh'ua. 



DISEASES OF THE iElDNEYS. 117 

INTERSTITIAL NEPHRITIS. 

SsTlonyms. Chronic Bright's disease ; sclerosis of the kidneys ; 
contraclcd kidneys ; small red kidney ; gouty kidney. 

Definition. An inflamrnation of the intervening ci 
sue of the kidney, chronic in its progress, resulting in f 
or hardening, with contracdon of the organ; characterized by fre- 
quent passing of large amounts of pale, albuminous urine, of low 
specific gravity, disorders of the gastro-intestinal and nervous sys- 
tems, and a strong tendency to cardiac hypertrophy and changes in 
the vessels. 

GauaeB. A disease of middle life, from forty to sixty years. 
Gout a very common cause; lead cachexia; syphilis; alcoholism; 
alterations in the rena! ganglionic centres (DaCosta and Longstreth-) . 

Pathological Anatomy. The kidneys are reduced in size. 
The capsule is thickened, opaque and adherent. The surface of 
the kidney . is granular, with cysts of various sizes, of transparent 
color, irregularly over the surface. On section the tissue of the 
kidney is tough and resistant. The corlical portion is thin, from 
atrophy, being only a line or two in thickness. The comsecUve tissue 
is greatly thickened, compressing the tubules into mere threads, the 
_^hiiirru/i being grouped together in tunches, owing to the wasting of 
the intermediate tubes. The color varies, from a darkish-brown to a 
yellowish-gray, according to the amount of blood in the organ. 

The left side of the heart is hyperlrophied, and there is also hyper- 
trophy of the muscular fibre of the arterioles throughout the body ; if 
the case is protracted the hypcrtrophied tissues undergo fatty degene- 

In many cases there occur fatty degeneration of the retinal tissues, 
or sclerosis- of the nerve-fibre layer, changes which are termed 
retinitis albuminuria. 

The " ganglionic centres" undergo fatty degeneration and ntrophy 
(DaCosta and Longstreth), 

Apoplexy is a frequent termination of interstitial nephritis, the 
rupture of a cerebral vessel suggesting it to be a disease of degener- 



Symptom 
the kidneys, 
recognised. 



Onset insidious, and often marked alterations ir 
lit and vessels have occurred before the disease i: 



118 PRACnCE or MEDICISE. 

Any of the followiDg symptoms may first alEr 
frequent micturition, increased amount of urine, of a ^a/e co/f**". 
containing a small amount of albuifien, which inay be absent for . 
days, occasional epilhelial cells and hyaline casts. No dropsy, but a 
\\v\cpuffiness and cedema of the conjUHtliva—iae. Bright's eye. Disor- 
ders of vision, forcible cardiac action with high arterial tension. 
And any of the following symptoms, the resolt of unrmia .■ Persis- 
tent dyspepsia, occasional i/omiting, regardless of food : htctdache, 
vertigo zxid stupor, ox drowsiness ; violent t?fAi>^ of the skin; 
convulsions, epileptic seiiures, or apoplectic altaeks. 

The body weight declines, the skin is dry and scurfy, the si 
fails, and shortness of breath on exertion is present. 

The tcnnination is usually by convulsions, coma and death. 

Complications. Bronchitis : pneumonitis ; pleurilis \ pericarditit 

Diagnosis, Differs from parencAymatous nephritis In the faJE 
lowing: large quantity of urine, clear, of low specific gravity, smal 
amount of albumen, with few hyaline casts ; the hypertrophied hea) 
and lense arteries and marked disorders of vis 

ProjrtiOBis. Pursues a very chronic et 
under observation eleven years; but the i 
fatal. 

Treatmont. Regulated diet. Diaphoreti 
alcoholic stimulants. As nearly absolute re; 
health will permit. 

To prevent the growth of the connective tissuethe folio wing- reme- 
dies are recommended, to wit :/i'ftw«'j(W/rfi/OT,^_)'i/ni/'^yr('« 
ehloridutn, gr. ^f, aurii et sodii chloridiim, gr. ^,ferri iodidum a: 



Diuretics. Avoii^ 

.s patient's gener 



For uramia, if patient is conscious, purgatives, diaphoretics a 
diuretics. If unconscious, morphina hypodermatically or ckloroforx 
inhalations. 

AMYLOID KIDNEV. 

SynonymB. Chronic Bright's disease : waxy kidney ; lardaceov 

Definition. A peculiar infiltration into, or a degeneration « 
the structure of the kidney, from the deposit of an albuminoid 
material, having a superficial resemblance to starch granules. Simi- 
. lar changes occur in the liver, spleen, intestines, and other organs. 



J 



DISEASES OF THE KIDNEYS. 119 

Causes. The chief cause is prolonged suppuration, especially of 
the bones ; coxalgia ; syphilis ; cancer. 

Pathological Anatomy. The kidney is uniformly enlarged. 
It presents a pale,, glistening, translucent appearance, and has a 
doughy consistency- On section, the surface is homogeneous,' 
anaemic and whitish. ' The deposit occurs along the renal vessels and 
in the vascular tufts of the glomeruli, progressing until all parts of 
the organ are infiltrated. When the organ is thus infiltrated, the 
proper structure undergoes an atrophic degeneration, the result of 
pressure. 

The reaction with iodine and sulphuric acid affords a certain test 
of the amyloid deposit. BVush over a sfection of the affected kidney 
a solution of iodine with iodide -of potassium in water, when a 
mahogany color will be produced-, ind if diluted sulpHuric acid is 
i\ow added, a violet or bluish tint results. A very pretty reaction is to 
take a one per cent, solution of anilin violet, which strikes a red or 
pink color with the amyloid material, while the unaltered tissues are 
stained blue, making a beautiful contrast. 

Similar changes occur in other organs of the body. With the 
amyloid, change may be associated either parenchymatous or inter- 
stitial nephritis. 

Symptoms. Associated with wasting are oedema of the lower 
extremities and ascites, with an increased flow of urine, pale, watery and 
of low specific gravity, containing albumen and hyaline ra^/j, which 
are transparent. If the amyloid change be associated with other 
forms of renal, change, the urine will show the characteristics of such 
condition. A profuse, watery and persistent diarrhoea adds to the 
suffering, caused by amyloid changes in the intestinal canal. 

Diagnosis. Differs from parenchymatous nephritis in its clinical 
history, and the fact of its always being associated with a suppurating 
disease. 

From interstitial nephritis, in its history, character of the urine, 
absence of uraemia, cardiac hypertrophy, changes in the vessels, and 
the fact of its association with suppurating diseases and similar 
changes in other organs. 

Prognosis. Controlled by the suppurating disease with which it 
is associated; the termination, when the amyloid change is fully 
developed, is unfavorable, death occurring within a few months, or 
under favorable conditions, not for one or more years. 



120 



PRACTICE or MEDICTNE. 



Treatment. Sustaining and symptomatic in character. Genero 
diet, and the persistent use oT/trrum and oleum morrkua. 

If caused by syphilis, a thorough c»\iKe of potassn iodidum./erri 
iodidum and hydrargyri corroshium chloridum. with oleum morrhua. 



PYELITIS. jl 

Synonyma. Suppurative nephritis ; pyelo -nephritis. ^K 

Definition. An acute catarrhal inflammation of ihe pelvis of the 
kidney ; the Krm pyglo-nephrilis is used when suppurative inflamma- 
(ion is superadded to the catarrhal inflammation. The disease is 
characterized by lumbar pains, irritability of the bladder, the i 
neutral, or alkaline in reaction, and milky in appearance ; if j{ 
Ufphrilis occur, symptoms of hectic fever and exhaus 
the urine containing pus, 

Causes. • Cold, or exposure ; cystitis ; obstruction of the i 
by renal calculi ; pressure from a tumor. 

Pathological Anatomy. 'The inflammation is catarrhal ; 
characterized by injection of the mucous membrane of the pelvl 
the kidney, with slight extravasadons of blood ; relaxation and s 
. ening, shedding of the epithelium, and the subsequent discharge a 
mucus and pus. If the morbid condition has existed far s< 
the kidneys, one or both, are in a prpcess of suppuration, they a 
enlarged, deeply congested, except where suppuration is 
where they are of a yellowish*while iio\or—pyelo-nephritis. 
constantly forming, and, if there he no obstruction, flpws away \» 
the urine ; should there be an impediment to its escape, pus a 
laies in the pelvis of the kidney, causing its distention, giving rise 
to the condition Vnavi-a as pyilo-nephrosis. The pressure caused by 
the obstruction finally leads to destruction of the entire organ, a mere 
saC; or rfHrt/i-fj/ remaining. 

SymptomB. If caused by cyslilis, symptoms of this condition 
occur first; if from renal calculi,''\\3, characteristic symptoms preccd&_ 
those of pyelitis. 

Begins by chilliness, feveriskness, lumbar pains followii^ 1 
cotirse of the MTcKer?,, frequent micturition, the urine milky in appc 
ance when voided, acid or neutral in reaction, and depositin|^3 
copious sediment, whitish or yellowish -white in color, < 
only a small amount of albumen, no more than is due to the^tw. 



\( pyilo-nephritis follow, symptoms of pysemia supervene, lo wit, 
fnier, typhoid "in character, low. muttering delirium, subsu/tus lendi- 
num, stupor, flecline in strength, and loss of flesh, with perhaps a 
tumor in the lumbar region. 

If both kidneys are affected an^wic symptoms are frequent. 

Diagnosis. From cyslitis, by history , lumbar pains and acidily o{ 
purulent urine, the uiine in cystitis being a.lv/a.ys. a/iii/ing. 

Peti-nepiirilh, a disease of loose tissue, around about the kidneys, 
terminating in abbess, causing lumbar pain, increased by motion 
or pressure, hectic fever, sense of fluctuation over kidneys, the urine 
remaining nonnhl. 

Prognosis. Simple cases, wliere no obstruction lo flow of pus, 
recover in a week to ten d.iys. If obstruction of theureter, the prog- 
nosis is grave. Suppurative cases unfavorable. 

Treatment. Rest in bed. Milk diet. E'ree use of water to 
dilute the urine, and free diaphoresis. Quinina to keep down tem- 
perature, prevent formation of pus, and maintain the powers of life. 

To change the character of the secretion. Prof. DaCosta strongly 
recommends pix liquida ; other remedies are oleum santali, copaiba , 
eucalyptol, ferebinlhina and citbeba. 

If mhscess results, aspiration, quinina and tiitnu/anls. 

ACUTE UREMIA. 

Synonyms. Ursemic poisoning; urscmic intoxication; ura:raic 
coma; uremic convulsions. 

Definition. A group of nervous phenomena, which occasionally 
develop during the course of acute or chronic Bright's disease, and 
other maladies, the result of the retention or accumulation in the 
blood of an excrementitious material, supposed to be urea; the flow 
of urine being either normal, lessened or increased. 

Causes. Suppression of urine, from acute or chronic liright's 
disease; cystic, tubercular or cancerous kidney; the puerperal state; 
opcratiiins on the uterus, bladder, urethra or rectum. 

Symptoms. Uncmic intoxication is the result of the failure of 
the kidneys to perform their normal function of eliminating some one 
or all of the poisonous elements of the urine. 

The loxiemia may develop suddenly, by a convulsive seizure fol- 
lowed by coma, or slowly and gradually. Usually the attack is pre- 



PRACTICE OV MEBltnVK, 



ceded by a decrease in the urinary secrelion; although it must be 
borne in mind Ihat in rare instances, during, or immediulely prior to, 
the appearance of the unemic phenomena, the normal urinary flow 
has been largely exceeded. 

The onset is usually with headache, dimness of vision, dilated, 
sluggish pupils, drowsiness, vfrtiga, deafness, dusky countenance. 
nausea, vomiting, and either a chill followed hy fever, or a coal skin 
from the onset ; the mind is dull, deepening into stupor, to be followed 
by coma, or convulsions precede the coma, which terminates in death, 
unless the poison causing the attack is rapidly eliminated. If the 
amount of accumulated urea is small the phenomena may not 
approach the pronounced coma described, the patient being able to 
be aroused. When convulsions occur they vapidly succeed one 
another, consciousness seldom being complete between the fits. 

DiagnoBis. Cerebral apoplexy may be mistaken for ursemic 
coma, or the reverse. The chief points of distinction are, in the lat- 
ter the attack is usually in patients suffering from dropsy, and that 
, the coma is not sudden in its appearance, but is generally preceded 
by other nervous phenomena, such as headache, vertigo, dimness 
of vision, obstinate vomiting, and convulsions. Again, the unemic 
slerter is a sharp, hissing sound, whilst that of apoplexy is "snoring." 
Apoplexy is followed by paralysis, unsmic coma is not. 

An epileptic seizure is preceded by the sharp cry and extreme 
pallor of the face, the countenance being dusky in uriemic con- 

Prognosia. An attack of acute urasmia is always a very grave 
condition. The prognosis depends .upon the amount of retained 
poison, the length of time it has been retained, and the condition of 
the organs of elimination. 

Treatment. The indications in acute ursemia are : first, to 
arrest the nervous phenomena; secondly, to promote elimination. 
Prof. Loomis has succeeded in meeting both of these indications by- 
hypodermatic injections of morphina, gr.>i-X-)4. repeated, if 
needed, every two hours. He says, " the most uniform elTect of mor- 
phine so administered is, first, to arrest muscular spasms ; second, to 
establish profuse diaphoresis ; third, to facilitate the action of cathar- 
tics and diuretics, especially, the diuretic action of digitalis." 

Following the injection of morphina, diaphoresis should be pro- 
moted by means of the vapor-bath, or the hot is/ct-pack, or the hypo- 



DISEASES OF THE KIDNEYS. 123 

dermatic use oi pilocarpince hydrochloras^ gr. j^'/^'X* provided no 
counter-indication to its use exists. 

Diuresis should be promoted by infusum digitalis^ and dry or ivet 
cupping, and poultices over the loins. 

Catharsis is best produced by elaterium, gr. jV-H* 

RENAL CALCULI. 

Sjmonyins. Nephro-lithiasis ; gravel; renal colic. 

Definition. Renal calculi are concretions formed by the precipi- 
tation of certain substances from the urine, around some body or 
substance acting as a nucleus. 

Their presence may not be recognized until one or more attempt to 
pass along the ureters, when an attack of renal colic results ; or, by 
irritation, pyelitis is produced ; or, more rarely, they are voided by the 
urine without exciting any symptoms. 

By gravel is meant very small concretions, which are often passed 
in the urine in large numbers. 

Causes. Occur at all ages ; frequent before the fifth year, and 
from five to fifteen. Males are more liable than females. A special 
liability seems to exist in some families, but the precise etiology of cal- 
culi is not yet determined. 

Varieties, i. Uric acid, as calculi and gravel, and especially 
associated with the gouty diathesis. 

2. Urates, chiefly urate of ammonia; nearly always in, childhood. 

3. Oxalate of lime or mulberry calculus ; characterized by hard- 
ness, roughness and very dark color. 

4. Phosphatic calculi form as fi^equently in the bladder as in the 
kidney, and present a chalky or earthy appearance. 

5. Alternating calculi, consisting of alternate layers of two or more 
primary deposits. 

Anatomical Characters. In structure, a , urinary calculus 
usually consists of a central nucleus, surrounded by the body^ and 
outside of all there may be a phosphatic crust. The nucleus may or 
may hot be of the same material as the rest of the stone, sometimes 
being a foreign body, mucus or blood. 

A section generally shows a stratified arrangement, or* it may be 
partly or completely radiated. 

Symptoms. The clinical signs of renal calculi are those con- 
sequent on the results of their presence, to wit : renal hemorrhage ^ 



124 



IRAcnCE c 



renal coHgeslion. injlammalion, terrtiinating in absciss, pyelitis 
pyeto-nephritis, cystitis or renal colic. 

The symploms of renal colic begin abruptly, by severe, agonijing 
pain in the lumbar region, following the 

ponding groin and thigh. Pain and retraction of corresponding' 
testicle, also of glans peniK, Face pale and features pinched, the 
surface cold and damp. Irritability of the bladder, the urine passed 
in drops containing some blood. So severe is the pain 
that the patient may faint or pass into unconsciousness or have a 
general convulsion. If both ureters are obstructed urcF?nic symploms 
will arise. 

The paroxysm usually terminates suddenly after 
hours, the stone escaping into the bladder. 

Prognosis. Renai calculus is attended with many dangers. It 
may produce extensive disorganization of the kidney; 
along the ureter may prove fatal. If the stone be very large, 
more than one, the prognosis is graver. Calculus is a disease very 
ajjt to recur. Renal sand [gravel] and small 
more or less delay, be voided with the urine. 

Treatment. An attack of renal colic is best relieved by a 
hypodermatic injection of morpkina and a warm bath or a sup- 
pository of ext. opii, gr. j, ext. belladonn(s alco., gr. ss., repeated 
if needed. 

For attacks of grave/, liquor potassii citratis, f 5 ss., every 
hours, and, if much \iesical irritability, adding tinct. opii camph^ 

For renal hemorrhage. Prof. Bartholow reports success with 

K . Exltacli ergol* fluidi, 

Tincture krameriie flH 3'J" 

Sic— 3J every two or more hours. 

■ For Hnirnf/rfca/ra//, as a solvent, Buffalo Lithia Springs Water i 
Rockbridge Alum Springs Water of Virginia, or potassii tartrahorateu 
" obtained by heating together four parts of cream of tartar, one part 
of boracic acid, and ten parls of water. A scruple may be giveq. 
three' or four times a day, in water, largely diluted." 

For phosphalic calculi, as a solvent, amiiwnii bensoas, well diluted 
and long continued. 



DISEASES OF THE KIDNEYS. 125 

CYSTITIS. 

Synonym. Catarrh of the bladder. 

Definition. An inflammation of the mucous membrane lining the 
urinary bladder, acute or chronic in its course, and of either a 
catarrhal, croupous or diphtheritic character ; characterized by rigors, 
moderate fever, hypogastric pain, frequent but scanty micturition and 
severe vesical tenesmus, the urine containing pus. 

Gauses. Acute variety ; long retention of urine ; foreign bodies 
in the bladder; pyelitis; urethritis; blows over the pubes; myelitis 
and secondary to fevers or diphtheria. Chronic variety ; following 
the acute variety ; retention the result of enlarged prostate or an 
urethral stricture ; calculi ; gout ; chronic Bright' s disease. 

Pathologrical' Anatomy. In (uute catarrhal cystitis, there first 
ensues hyperaemia of the mucous membrane of the entire or a por- 
tion of the bladder, manifested by redness, swelling and oedema ; 
followed by an increased secretion of the small glands at the base of 
the bladder, and an increased growth and consequent desquamation 
of the vesical epithelium, together with a copious generation of young 
cells ; if the hyperaemia be decided, rupture of the capillaries and 
extravasation of blood occur. 

If the inflammation be intense suppuration of the sub-mucous con- 
nective tissue may result, and ulceration of the mucous membrane 
permit the sub-mucous abscesses to- empty into the bladder. 

If the inflammation be of a croupous or diphtheritic character, the 
morbid anatomy does not differ from the same variety of inflamma- 
tions in other mucous membranes. 

In chronic cystitis " the mucous membrane is thick, blue gray in 
color, and very tough. Muco-pus and viscid mucus are formed in 
large quantities upon its surface. The muscular wall of the bladder 
may sometimes be half an inch thick, and the fasciculi give a ribbed 
appearance to the internal surface, called the 'columnar bladder.* 
The hypertrophy df chronic cystitis may be eccentric or concentric. 
In some cases diverticuli are formed, in whose walls arc dilated and 
tortuous veins. In nearly all cases bacteria arc found in al^un dance." 
(Loomis.) 

Symptoms. Acute cystitis ; the onset is usually abrupt, hy rij,^cm, 
slight fever, loss of appetite, sleeplessness, a feeling of depression ; 
frequent micturition, but the urine is only voided drop by drop. 



12fi 



its passage followed by distressing vesical tenesmus, Ih^ result of 
spasm of the bladder; pain over the pubis and in the iliac regions, 
of a dull character, at times becoming sliarp and agonijlng ; burnii 
along fhe urethra adds to the distress of the patient. 

The iirine is cloudy, of an alkaline reaction, and at times is fetid, 
the microscope showing epithelium, pus and red blood cnrpuscles. 

Chrome cystitis; the onset is gradual and insidious, and is excited' 
by some obstacle to the evacuarion of the urine, such as stricture,, 
the presence of a stone in the bladder, or enlargement of the 
prostate gland. There are present duU pain, frequent but scanty 
micturition, the urine is alkaline, containing large amounts of muco- 
. pits or pus; on standing, it deposits a thick, glairy, viscid sediment, 
in which, under the microscope, triple phosphates and large pua 
corpuscles, extremely regular both in contents and in shape, may 
be detected. 

Although the quantity of urine voided by the patient is'small, yet 
if immediately after micturition the catheter is used, several ounce* 
of fetid, cloudy, alkaline urine may be removed. 

Patiepts with chronic cystitis usually present decided constitutions^ 
debility. 

Severe local pain, emaciation and occasional bloody urine, indi- 
cate ulceration of the vesical mucous membrane. 

Diagnosis. Pyelitis has lumljar pains following the course of the 
ureters, frequent micturition without the severe vesical tenesmus; the 
urine, although cloudy, has an acid or neutral reaction. 

Pi'Og'noHia. The acute i/ariely is, as a rule, good, being controlled' 
by the cause. 

The chronic variety continues for years, and after hypertrophy of' 
. the bladder is incurable. 

Treatment. Rest is paramount. The diet must be restricted, 
all highly seasoned articles being particularly interdicted ; milk being 
the most suitable. 

Warm applications over the pubic region are of benefit; and leech- 
ing and cupping over the bladder an 

The urine should be well diluted by large draughts of pure 
and particularly the alkaline mineral waters, to wit : Farmville 
Buffalo lithia or the Rockbridge alum, or Vichy waters. The fi 
ing formula; are of decided benefit ; — 



k 




ACUTE GENERAL DISEASES. J27 

B . Acidi benzoic!, 

Sodii borat. .J fta ^.ij 

Infusi buchu, vel 

Infusi uvae ursse .^ ^S^j* ^* 

SiG. — Tablespoonful every 2 hours, well diluted. 
Or— 

•R. Liquor, potassse ^^ ^S^ 

Mucil. acaci'ae f^viss. M. 

SiG. — Tablespoonful every 4 hours, well diluted. 

For the pain and tenesmus x^\t{ is afforded by a suppository of 
exiractum apit ,2LTi6*extrdcium belladonna, repeated .as needed. 

The vesical tenesmus is often benefited by exiractum cannabis 
indices fluidum, f 3 ss, every three or four hours. 

Chronic cystitis. The bladdef should be com'pletely emptied with 
the catheter several times in the twenty-four hours. 

The use of eucatyptol, gtt. x-xv, every four hours, well diluted, and 
washing out the bladder with the following mixture, has been of 
decided benefit in the hands of the author : — 

R. Sodii borat ^j 

Glycerini f^^U 

Aquse /.. f^ij. M. 

SiG. — f^ss-iss added to warm water and injected into the bladder 
once or twice daily. 

The diet should be nutritious, but without spices of any kind. The 
free use of the alkaline mineral waters is of advantage. 



ACUTE GENERAL DISEASES. 



PAROTITIS. 

Synonym. Mumps. 

Definition. An acute specific infectious inflammation of one or 
both parotid glands, with a very strong tendency to migrate into the 
mamma or testes ; characterized by pain, swelling and disordered 
function of the gland. 

Gauses. A specific poison. Occurs in epidemics, although isolated 
cases are seen. Males more liable than females. The most common 
ages between five years and puberty. As a rule it occurs but once in 
the same individual. 



128 PRACTICE OF MEDICINE. 

The period of incubation is from two to three weeks. 

Pathologfical Anatomy. There is inflammation of one or both 
parotid glands, and in severe epidemics the cellular tissue pervading 
the gland is involved. 

The catarrhal inflammation begins in the gland ducts and rapidly 
extends to the gland proper. There is congestion, swelling and an 
infiltration of serous fluid, with more or less infiltration of the ad- 
jacent tissues. The swelling may suddenly reach an enormous size 
and as suddenly decline, the gland returning to its normal condition, 
or, rarely,. an abscess res.ults, with partial or complete destruction of 
the gland. Occasionally the submaxillary gland is involved, also the 
mammae and testes. 

Metastatic parotitis occurs secondary to severe blood poisoning, as in 
pyaemia, typhoid or typhus fevers or diphtheria. The usual termina- 
tion of secondary parotitis is by suppuration and destruction of gland 
structure.* 

Symptoms. The onset is rather sudden, by malaise y chill, fever ^ 
ioi°-i03° F., quick pulse y headache, dry skin, scanty unne, followed 
within a day or two, by stiffness at the angles of the jaw, swelling of 
\S\(t parotid, pain, increased by moving the jaws, yf\\^ general cede?na 
of the affected side of the face, at times the skin being reddened. 
Salivation is frequent, and occasionally deafness occurs. 

The swelling and other glandular symptoms subside about the sixth 
or seventh day, to be followed by restoration to health, or what is more 
common, the involvement of the opposite gland. 

At any time during the disease metastasis to the mammce, ovaries or 
testes is apt to occur, when the symptoms peculiar to such affection 
will be added. It has been noted that a continuance of the tempera- 
ture after the decline of the parotid symptoms has begun, usually is 
significant of metastasis, 

Diagrnosis. An error seems impossible. 

Prognosis. Simple mumps, favorable; the chief danger being 
from the altered function of the mammae, ovary or testes after 
metastasis. 

Treatment. The disease being self-limited, the indications are 
entirely symptomatic with attention to the. secretions, although ex- . 
tractum pilocarpi fiuidum, n\^x-xxx repeated, has been used with 
varying success as a specific. 

Locally, warmth to .the affected gland may be agreeable. 



/ 



ACUTE GENERAL DISEASES. 129 

DIPHTHERIA. 

Synonyms. Putrid sore throat ; malignant ulcerous sore throat ; 
malignant quinsy ; membranous angina. 

Definition. An acute, specific, constitutional disease, both epi- 
demic and contagious, beginning by an affection of the throat, char- 
acterized by a local exudation and glandular enlargements ; attended 
with great prostration of the vital powers and albuminuria, and having 
for its sequelae various paralyses. 

Causes. A specific poison, the character of which is unknown. 
It is preeminently a disease of childhood. It is apt to recur in those 
who have once been affected. All conditions of bad hygiene increase 
its virulence and diffusion, although the chief cause of its spread is 
contagion. 

The poisons exists in the exudations and secretions of the fauces 
and in the breath, and floats in the atmosphere at a considerable dis- 
tance from the original source. 

The theory of " No bacteria, no diphtheria," is not proven. 

The period of incubation is from three to five days. 

Pathologrical Anatomy. The diphtheritic inflammation differs 
from either the croupous or catarrhal form, in that the exudation is not 
only upon^ but also within, the substance of the mucous membrane. 

At first there is redness, which may begin in any part of the throat, 
associated with swelling and an increased secretion of viscid mucus. 
The redness spreads over the entire mucous surface, when the exuda- 
tion makes its appearance. The deposit may commence from one or 
several points, such as on one tonsil, the soft palate, or the back of 
the fauces, which, however, speedily extend and coalesce, forming 
extensive patches, or cover uniformly the entire surface. 

The patches are of variable thickness, which is increased by suc- 
cessive layers being formed underneath. 

The color is usually gray, white or slightly yellow, but may be 
brownish or blackish, the consistence ranging from " cream to wash 
leather." 

On removing the membrane, which is accomplished with more or 
less difficulty, a raw, bleeding surface is exposed ; at times an ulcer, 
which is speedily covered with a fresh deposit. 

If the exudation separate itself, it is either not renewed at all or 
only in thinner films. 



130 PRACTICE OF MEDICINE. 

The exudation or membrane, examined by the microscope, is 
composed of fibrin, pus corpuscles, epithelial granular cells and 
bacteria. 

If the larynx f trachea or nasal mucous membranes participate in 
the disease, the croupous and not the diphtheritic form of inflamma- 
tion occurs. 

TYi^ lymphatic glands of the neck, whose vessels originate in the 
faucial tissues, are enlarged and inflamed, and contain large numbers 
of bacteria^ probably originating as the result of decomposition. 

The muscular tissue of the heart becomes soft, is easily torn, and 
its fibrillae are far advanced in granular degeneration. Ulcerative 
endocarditis has been frequently observed. 

The kidneys undergo a granular degeneration in seve|[e attacks. 

The blood undergoes alteration, being black and fluid. 

Symptonis. Following the law of contagious diseases, the symp- 
toms vary in intensity in different cases, the prominent symptoms 
being often disproportionate to the gravity of the attack. 

The invasion may be mild^ with rigors succeeded by moderate 
fever ^ headache ^ languor ^ loss of appetite, stiffness of the neck, tender- 
ness about the angles of the jaw, or slight soreness of the throat. 

In other cases the invasion is more abrupt and severe, with chilli- 
ness followed by great febrile reaction, 103° to 105°, F., pain in the 
ear, aching of the limbs, loss of strength, painful deglutition and 
swelling of the neck, compelling the patient to take to bed from the 
onset. 

The appetite is poor, the tongue slightly coated, sometimes more or 
less exudation appearing upon it, the bowels being either regular or 
slightly relaxed. The pulse, at first full and strong, soon becomes 
either frequent or slow, but compressible. The urine is scanty, high 
colored, and contains albumen. 

The local symptoms in the majority of cases are associated with the 
throat. The patient complains of a frequent and persistent desire to 
hawk, in order to clear the throat. On inspection the fauces are seen 
red and swollen, and more or less covered with the diphtheritic exu^ 
dation : sometimes the tonsils and uvula are greatly swollen and 
spotted with exudation. In bad cases, more or less ulceration or 
sloughing may be observed. Not unfrequently fragments of exuda- 
tion, \hQ false membrane, are expectorated, with particles of the ulcer- 
ated tissues, having an offensive odor, which is transmitted to the 



ACUTE GENERAL DISEASES. l!31 

breath. The lymphatic glands of the neck are enlarged and tender ^ 
and in severe cases the tissues of the neck are greatly tumefied. 

Extension to the nasal cavities causes a sanious and offensive dis- 
charge from the nose, with attacks of epistaxis. 

Extension to the larynx is indicated by hoarseness or complete loss 
of voice, croupy cough and obstructive dyspnoea, which often become 
urgent, the breathing being noisy and stridulous, and subject to 
paroxysmal exacerbations. ' If the inflammation extend to the bron- 
chi, the breathing becomes still more embarrassed. 

Duration. Ranges from two to fourteen days, an average being 
about nine days, although complications and sequelae may prolong 
its course. 

. Relapses are not uncommon. 

SequelsB. Those who recover from a severe attack remain often 
for weeks with a pale and cachectic appearance, due to the profound 
blood alteration. 

Paralysis is a common sequelae, following the mild as often as the 
severe attacks. Usually not occurring until the patient seems fully 
convalescent. 

Pharyngeal paralysis is the most common, causing difficulty or in- 
ability of deglutition, fluids regurgitating through the nose. 

Cardiac paralysis is not unfrequent, the pulsations descending to 
60, 50, 40, and in a case seen by the author, to 20 per minute. 

Diphtheritic paralysis may affect the motor muscles of the eye, 
causing strabismus; the muscles of one side, hemiplegia; of the 
legs, paraplegia ; and of the bladder, leading to retention of urine, 
or difficulty in passing it. 

Sensation is also diminished in the paralyzed parts. 

Diagrnosis. From follicular ulceration of the tonsils, which is 
frequently termed diphtheria, by the slight or absent systemic symp- 
toms, the ulcerated condition being limited to the tonsils, often but 
one, and the absence of glandular enlargement and following palsies. 

From pharyngitis, by the absence of exudation and loss of faucial 
tissue, and constitutional symptoms. 

From scarlatina, by the presence of the eruption and the absence 
of membrane in the fauces. 

From membranous croup, by the difference in the constitutional 
symptoms; croup appears sporadically and is not contagious, diph- 
theria being highly contagious and frequently occurs in epidemics ; 



132 

in diphtheria of the larynx, the depression is dearly that of blood 
poisoning, while in croup, the depression is in proportion to the 
mechanical obstruction of the respiration, by the membranous exu- 
dation. The patliolosy of croup is simple and easy of investigation; 
diphtheria is obscure in its etiology and progress. The temperature 
record of croup is a high one until carbonic acid poisoning is imminent 
from the mechanical obstruction of respiration, while in diphtheria, 
the tendency to a dechne in the temperature after the second day is 
nearly characteristic, regardless of the amount of laryngeal obstruc- 
tion. In croup the pharynx contains no membrane, and is but 
slighdy, if at all, inflamed, and associated trouble in the nose is of 
the rarest occurrence, the very reverse obtaining in diphtheria. In 
croup the laryngeal symptoms are from the onset, while in laryngeal 
diphtheria, the pharyngeal symptoms almost always precede. In 
croup glandular involvement is a clinical novelty, as are subsequent 
palsies, whllf glandular involvement and various palsies are the rule 
in diphtheria. 

FroEnoBlB. Always grave, but more so in children than in adults. 
Its gravity, In the majority of cases, is proportionate to the local 
symptoms. The average mortality is about ten per cent. 

Favorable indications are, moderate fever, strength slightly im- 
paired, a good constitution, and moderate exudation. 

Unjavorabte indications are, great depression, spreading exudation, 
great swelling of the cervical glands, large amount of albumen, ex- 
tension to larynx and nasal mucous membranes, hemorrhages from 
the fauces and nose, and an epidemic character. 

Treatment. No specific. It is a disease of debility. The blood 
being more or less altered, it follows thai sustaining measures must 
be resorted to in all cases. 

The diet must be of the most nutritious character from the onset, 
such as milk, eggs, broths and oysters, at intervals of every two or 
three hours. If deglutition be too painful, resort must be had to 
nutritious enemata, the following formula being suitable; — 

K. Milk fgj 

Spl5. frumcnti fS'v 

Egg One. M. 

Sic — Liulc ie.\x addei], bealen up and wanned. 

Siimuianis must be used boldly from the onset, guiding the dose by 



ACUTE GENERAL DISEASES. 133 

the effect ; usually, a child of two years requires from thirty to a 
minims <i^ sfiiritus -vini gallici ai spiritus frumenii, every two or three 1 
hours ; an adult, from two la four drachms every three hours. 

Ferrum 3.nA polassii cfiloras, \n full doses, frequently repeated, have ] 
seemed, when hegun early in the attack, to modify the course of the J 
malady, and they have the additional advantage of acting locally 1 
upon the throat as they are swallowed. A good formula Is — 

R. Tinct. ferri chlor. ; gtt. v-i-m 

Polassii chlor. gr. iij-v 

Glycerini....; „ n\, xv 

Syr. zingib ad fjj-ij- M. 

SlG. — In water every three hoars, for a child of two or three years. 
The efficacy of the above is greatly enhanced, in the author's expe- 
rience, by the addition to each dose of tinctura belladonna, gtt. j-v. 

Quinina, gr. xvj-xxiv per day for a young adult, and gr. v-x 
a child, should be used throughout the disease ; if irritability of the \ 
stomach prevent its administration by the mouth, it can be used as 
Suppositorv or locally in the form of the olea/e. 

Calomel'\a small doses, combined with sodH bicarbonas every hour 
until the breath becomes fetid, is beneficial, and especially in cases 
showing a tendency to spread toward the larynx. Indeed, a. tolerance 
to calomel seems to exist in diphtheria of the larynx. 

Hydrarg. chlor. corros., gr. ^f-if, refieated every second or third J 
hour, also acts well in many cases, combined as follows ; — 

5. Hydrargyri chlorid. corroMv. g''- i'r 

Tinel. ferti chlorid Hlv-x 

Glycerini tT^x 

AquE ad 5J. ] 

SiG. — One tcaspoonful every hour or two, well liiluted. 
Locally. Cleanliness of the fauces is of the utmost importance, ( 
and if a non-irritating disinfectant be added, its value is enhanced. 
Prof, flartholow " has seen excellent results from the frequent appli- 
cation of a solution of acidum lacticum. strong enough to taste sour, 
by means of a mop." The following, used as a gargle, or applied | 



PilACTlCE OF MEDICINE. 

R. Potass, cliloras ^iv 

Acid, carbol gr. ij-iv 

Tinct. myrrh gj 

Inf. cinchonie ^ij. M. 

Or— 

E. Ext. pancreatU gj 

Sodii bicarb giij. M. 

SiG, — Add 3 j to aquae 3 vj, and apply with camcl's-hair pencil. 
Inhalations of steam and hot water, and allijwirg (he patient to suck 
pellets of ice, give relief. Sponges dipped in hat water and applied 
to the angles of the jaw are beneficial. 

For laryngeal diphtheria the same general treatment, especially the 
mercurial, with irthalations of lime by slaking freshly burned lime in 
a. vessel and directing the vapor to the child by a newspaper, or some 
similar contrivance, or using three parts of ligiior calcis and one part 
of glycerin, in an atomizer, every half liour or hour, or lig. trypsin, 
as a spray. If these means fail, resort must be had to trackeoloniy, 
which has succeeded in many desperate cases. 

For nasal diphtheria the same general treatment, and syringing the 
nose every two or three hours with a weak solution potassii chlaras, 
or acidunt carbolicum, or the following : — 

R. Sodii sulphit giij 

Gljcerini fgij 

AquEB „ fgiv. M. 

For the paralysis, strychnina and ferrum internally, or strycknina 
hypodermatically, with the galvanic current locally. 

ACUTE ARTICULAR RHEUMATISM. 

Synonyms. Rheumatic fever ; inflammatory rheumatism. 
Definition, A constitutional disease, characterised by fever, in- 
flammation in and around the joints, occurring in succession, and 
a great tendency to inflammation of either the endocardium or peri- 
Causes. The predisposing causes are inherited tendency, scarla- 
tina, and the puerperal state. 

The exciting causes, exposure to cold and chilling of the body. 
Rheumatism rarely occurs before seven or after fifty years. The" 
liability to ihe disease is increased by having had an attack. 



ACUTE GENERAL DISEASES. 135 

Pathologrical Anatomy. The blood contains an excess ot 
lactic acid. The joints bear the brunt of the attack ; the synovial 
membrane is reddened, the vascularity of the synovial fringes is 
increased, so with the synovial fluid, which is thinner, of a reddish 
color, containing some gelatinous coagula of fibrin, and under the 
microscope nucleated cells, ordinary pus cells being rarely seen. 

The swelling visible about the affected part depends mostly on 
inflammatory oedema of the connective tissue around the joint. 

The pain is probably due, in all cases, to stretching of and pressure 
on the elements of the tissue by the dilated capillaries and the in- 
flammatory oedema. For the changes which ensue when the endo- 
and peri-cardium are attacked, the reader is referred to the sections 
on those diseases. 

Symptoms. Begins suddenly, generally at night, with a chill or 
chilliness, pain and stiffness in the joints, loss of appetite, at times, 
nausea and vomiting, followed hy fever, the temperature soon reach- 
ing 102°, F., to 104°, in rare cases 108° to 110° {the hyperpyrexia), the 
pulse seldom exceeding ^^, great thirst, profuse acid sweats, scanty, 
high colored, acid urine, at times showing traces of albumen, the 
bowels constipated, Hht fever continues throughout the attack, show- 
ing marked remissions. Delirium is absent, except the hyperpyrexia 
occur. Sleep is prevented by the pain and the profuse perspirations. 
The strength is moderately well preserved. 

The skin is often covered with an eruption of miliaria rubra, red 
papulcE and miliaria alba, the result of irritation at the orifices of the 
perspiratory glands, from the excessive sweating. 

The local phenomena are pain, tenderness, increased heat, swell- 
ing and redness of one or more joints ; if but one joint, it is termed 
monoarthritis, if more than one, polyarthritis. Pain is aggravated 
by motion and pressure. Swelling is most apparent in those joints 
not covered with muscle, to wit : knee, wrist, elbow, ankle, and the 
hands and feet, and is proportionate td^the acuteness of the attack. 
The inflammation may abruptly cease at one or more joints, and as 
suddenly attack others. 

The disease is extremely irregular as regards the number of joints 
affected, although the local manifestations are controlled by an im- 
portant pathological law, to wit : the law of parallelism. Correspond- 
ing joints are often affected together, and when not, the different 
affected joints are either on one side of the body, or those on both 



l-RACTICE OF MEDICINE. 

sides which are analogous, as, the knee, elbow, wrist, ankle, hip and 
shoulder, are attacked together. 

Complications. Pericarditis, endocarditis, myocarditis, cerebral 
endarteritis, bronchitis, pneumonitis and pleuritls. 

Duration. The duration of acute rheumatism is governed entire- 
ly by the presence or absence of complications. Uncomplicated 
cases recover in from Ikirleen to twenty-one days, although they may 
be prolonged to five or six weeks. Relapses are frequent. 

Diagnosis. A typical case cannot be mistaken for any other dis- 
ease, but cases running a subacute course may be mistaken for acute 
rheumatoid arthritis, gonorrheal rheumatism, or pyiernia. 

Acute rheumatoid arthritis attacks one joint at a time and becomes 
permanent, has slight if any fever, no sweats or cardiac lesions. 

Gonorrhwal rheumatism is associated with a gleety discharge, 
attacks either the ankle or wrist only, is slowly influenced by treat- 
ment, and lacks the febrile phenomena. 

Pyemia is usually manifested at a single joint at the lime, and is 
followed by suppuration and all the symptoms of hectic fever. 

ProprnosiB. Recovery is the rule in uncomplicated cases, the 
mortality being about three per cent. When death occurs it usually 
depends upon hyperpyreua. cardiac complication, or cerebral 
endarteritis. 

Treatment. Owing to our imperfect knowledge of the exact 
nature of this most painful disease, its treatment still remains either 
empirical or is directed toward certain prominent symptoms or com- 
plications of the disease. Garrod claims that "colored water" is 
about as potent as anything else, for it is. he says, a " self-limited 
disease," sometimes running a long and sometimes a short course. 
Rest in bed, whether the pain forces it or not, is imperative. Warmth 
is as imperative, for which purpose the patient should be kept in 
blankets — no sheets^and wear woolen garments. The diet must be 
easily digested food, milk being the most suitable. 

Strong and vigorous patients do well with acidum sa/icyliciim or the 
salicylates in large and frequently repeated doses, to wit : — 
B. Acidi salieylid gr. xn 

Spis, Ertlietis, nilrosi n\,xx 

Syr. Bimplicis _ T^xv. 

Eveiy three hours, well diluted. 



ACUTE GENERAL DISEASES. 137 

Or— 

R. Sodii salicylici gr. xx 

Tin<?t. lavandulse comp TT\,xv 

Glycerini ;5ss 

Aquae ad f^ss. 

Every three hours, well diluted. 

If benefit follows, the evidence is quickly afforded in the relief of pain 
and the decline of the temperature and swelling. If, therefore, after 
three or four days* use of the salicylates or acidum salicylicum, as 
above recommended, signs of improvement are wanting, the treat- 
ment had better be changed for the alkaline treatment, which consists 
in the administration of an ounce and a half of the alkaline carbon- 
ates, either alone or with a vegetable acid, each twenty-four hours, 
until the urine becomes neutral or alkaline^ when the quantity is re- 
duced to an amount sufficient to maintain alkaline urine, to wit : — 

R. Potassii bicarbonatis gij 

Acid tartaric gr. xxx. 

Dissolved in a glass of water and drank effervescing, every three hours. 
Or— 

R. Potass, bicarb ^ij 

Succi limonis f^^iv 

Aquae cinnamomi ad f^ss. M. 

SiG. — In water, every three hours. 

After the more acute symptoms are passed, change either of the above 
for tinct.ferri chlor,^ gtt. xx every four hours, well diluted. 

Pale, feeble and anaemic patients, or attacks following scarlatina, 
are most favorably influenced with 

R. Tinct. ferri chlor gtt. xx-xxx 

Syr. limonis gtt. xx 

Aquae f^j. M. 

SiG. — Every four hours, in glass of water. 



Or— 



R. Sodii salicylici ; ^iv 

Tinct. ferri chlor f^^i^iiss 

Liq. ammonii citrat f^j 

Olei gaultherise TT\^xxxij 

Glycerini f ^iss 

Aquae ...q. s ad f^iv. M. 

SiG. — Half tablespoonful every three hours, with water. 



138 PRACTICE OF MEDICINE. 

Prof. DaCosIa reports a lessened proportion of cardiac comfilica- 
lions with atnmonii bromidtttn, gr. xv-xx, every four hours. 
Subacute attacks and lingering cases are favorably influenced by 

B . Lilhii salkylalis gr. jcv-ii 

Syr. 7.ingiberi» fgj 

Aq, laura-cerasi i^\. M. 

Every four hours. 

Whichever plan , acidum salicylicum, salicylates, alkaline or ferrum, 
is adopted, qiiminum, gr. xij-xx, per day should also be used. 

Pain and rtsllessness should be controlled by opium in some form, 
in full doses, or alropina, gr. ,'np hypodermatically. 

For the hyperpyrexia, quiniaa, gr. xxx-!k repeated p. r. n., with 
the cold bath or wet pack. 

Locally, Ihe affected joints should be wrapped in cotton-wool or 
flannel, saturated with a solution of tinct. opii, one part, and iiq. 
plumb, subacelat. dil., two parts, or— 

K. Sodii bicarbonatis _ ^ij 

Tinct. opii fgsB 

Aqure bul Oij. M. 

Dr. BarCholow finds the application of blisters an effective method. 
He says, "1 have small blisters, the size of a silver dollar, placed 
around the joint, leaving an interval between for succeeding applica- 
tions. It is by no means so painful and disagreeable as it appears at 
first sight. The blisters remarkably relieve the pain, bring about a 
more alkaline condition of the blood, and render the urine less acid, 
or bring it to neutral, or even to alkaline." 

The complications are to be treated according to their character. 

MUSCULAR RHEUMATISM. 

Synonyms. According to location, to wit : cephalodynia ; lum- 
bago ; lorticoUis ; pleurodynia. 

De&nition. An affection of the voluntary muscles, inflammatory 
in character, either acute or chronic ; characteriied by pain, tender- 
ness, and stiffness of the affected muscles. It is never complicated 
with cardiac disease. 

Cause. A disease of adult life. One attack predisposes to another. 
Almost always due to cold and damp, or direct draught of. cold &ir. 
Gout increases the tendency to attacks. 



ACUTE GENERAL DISEASES. 139 

Pathologrical Anatomy. The true nature of muscular rheuma- 
tism is not yet determined. Virchow suggests a ** hyperaemia of, and 
scanty serous exudation between, the muscular striae, and in chronic 
cases inflammatory proliferation of the connective tissue.** 

Symptoms. Theyfr^/ attack is generally acute. Onset rather 
sudden, with pain in the affected muscles, with slight tenderness, and 
considerable stiffness , and difficulty of movement, by which also the 
pain is increased. 

The suffering may be severe and constant, or only on motion. 
Spasm of the affected muscles may occur. Objective symptoms are 
wanting, except it is evident that the patient keeps the affected muscles 
as quiet as possible. Fever is absent. The pain may prevent sleep. 

Duration, acute form, about one week. Chronic returns frequently, 
and finally becomes constant and aggravated when the weather is 
damp. 

Varieties. It may affect any or all of the voluntary muscles, but 
its most frequent and important varieties are : — 

1. Cephalodynia, Situated in the occipito-frontal muscle. Distin- 
guished from neuralgia of the trifacial, or occipital nerve, by pain on 
both sides of the head, excited or aggravated by movements of the 
muscle, and by absence of disseminated points of tenderness. 

Thje muscles of the eye may be affected, and movements of that 
organ excite pain. If the temporal and masseter muscles are attacked, 
mastication excites pain. 

2. Torticollis. Wry neck, or stiff neck. Situated in the sterno- 
mastoid muscles. Generally limited to one side of the neck, toward 
which side the head is twisted, great pain being excited on attempting 
to turn to the opposite side. Rheumatism of the muscles of the back of 
the neck, cervicodynia, may be mistaken for occipital neuralgia. 

3. Pleurodynia, Situated in the thoracic muscles, and may be 
mistaken for pleuritis, or intercostal neuralgia, from which it is differ- 
entiated by the absence of the diagnostic features of each. Pain is 
excited by forced breathing, coughing and sneezing. 

4. Lumbodynia or lumbago. Situated in the mass of muscles and 
fasciae which occupy the lumbar region. Most common variety. 
Usually affects both sides. It may set in rapidly and become very 
severe. Motion of any kind aggravates the pain, often becoming 
very sharp or stabbing in character. It is sometimes complicated 
with acute sciatica, when the suffering is agonizing. 



140 

Diagnosis. The different varieties may be mistaken for any of 
the following ailments, to wit ; trifacial, occipital or intercostal neu- 
ralgia, pains of progressive muscular atrophy, syphilis, metallic 
poisons, or painful affections of the loins, arising from calculi or 
gravel in the kidney. 

A careful examination of the history is usually sufficient to arrive 
at a coriect diagnosis. 

PrognoBis. Difficult to eradicate, and in chronic cases to amelio- 
rate; but is not dangerous to life. Death never resuhs. 

Treatment. Jies/ is the first indication. This is accomplished 
in pleurodynia by firmly strapping the affected side with broad strips 
of plaster, extending from mid-spine to mid-sterum. 

The /fed /application to the affected muscles of hot poultices, made of 
two-thirds pilocarpus leaves, and one-third _;f<[.rjci?rf meal, changing 
them every two hours, is, in the opinion of the author, the most 
rapidly successful treatment in acute cases. 

Internally, soiHi salicyiat., gr. xv-xx, every two or three hours, is of 
use in many cases. 

Forthe^a/;/. and consequent sleeplessness, use — 

B . Pu!v. ipecac et opii gr. x 

Potass nil ras gr. v-x. M. 

SlG. — In powder, morning and night. 

Or, hypodermatically, at the seat of pain, morpkina, gr. %-%, and 
atropina, gr. Vs. P- r. n. 

Chronic cases : Rest, flannel 
anodyne liniment, mild galvi 
affected part with a common 
being placed next to tlie skin. 

Internally, potassii iodidum, 
arsenicum, variously combined. 

RHEUMATOID ARTHRITIS. 

SjTionyms. Arthrilitisdefonnans; rheumatic gout. 

Defluition. An inflammation of the joints, accompanied with 
but slight fever, wilhout suppuration, progressive in character, causing 
nearly symmetrical enlargement and deformity of various articula- 



next to the skin, stimulating and 
, dry heat, as ironing over the 
ron, a piece of paper, or towel, 

ias, sulphur. gnaiaeumat . 



Causes. More 



I females than i 






the 




ACUTE GENERAL DISEASES. 141 

prolonged lactation, frequent pregnancies, menopause, grief, tuber- 
cular diathesis, and following attacks of articular rheumatism. 

Pathological Anatomy. It is not rheumatism, as the blood 
contains no lactic acid. It is not gout, as uric acid is not found in the 
blood nor urate of sodium in the joints. 

At first rheumatoid arthritis is attended with hyperaemia of the 
affected synovial membrane and increase of the synovial fluid. Soon 
the capsular ligament becomes irregularly thickened, the synovial 
fluid decreasing. If the process continue, the internal ligament is 
destroyed, thus allowing dislocations to occur. The inter-articular 
fibro-cartilages ulcerate and disappear, as does the cartilages covering 
the ends of the bones, the ends of the bones becoming smooth and 
ebumated, and often greatly enlarged. 

Symptoms. Either acute or chronic, the latter most common. 

Acute form involves several jomts at the same time, and is attended 
with shght pyrexia. 

Chronic form slowly involves one joint, which seemingly soon 
recovers, and is attacked again, and may never recover, but grow 
progressively worse. 

The joint slowly enlarges, is painful, movement exciting neuralgic 
pains' along the limb. Soon the articulation becomes rigid or slightly 
movable after prolonged attempts. Redness and tenderness are 
wanting. Crepitation is distinct after ulceration has destroyed the 
cartilages. 

The hands are first involved, the disease spreading symmetrically 
from articulation to articulation, until in severe cases every joint is 
deformed. 

Diagnosis. Chronic articular rheumatism is often confounded 
with rheumatoid arthritis ; but the former lacks the marked structural 
changes and the progressive involvement of joint after joint. 

Gout differs from rheumatoid arthritis by the presence of deposits 
of urate of sodium in the joints, the ears, tips of fingers and the 
bursas over the olecranon process of the elbow, the presence of uric 
acid in the blood, and the decided history of acute paroxysms. 

Gonorrhoeal rheumatism, so-called, has symptoms akin to rheu- 
matoid arthritis, but the history of urethral suppuration clears up the 
diagnosis. 

Paralysis agitans, when pronounced, might be confounded with 
rheumatoid arthritis, if the examination were hmited to the joints, 



142 PRACTICR OF MEDICEJIE. 

but the whole history, such as the tremor, the gait, etc., should 
prevent error. 

Prognosis. If early treatment be instituted, the disease may be 
held in abeyance for several years. After pronounced structural 
changes have begun, the raalady is incurable, although it may 
remain stationary for a long time. 

Treatment. If treatment be instituted before serious structural 
lesions have occurred, the author, has seen benefit in many cases by 
the following treatment: Oleum morrhua carefully and thoroughly 
rubbed into the affected joints, three times a day, with the internal 
use of iilhii citras effirvescentes gj, three times a day, and the 
following Ionic mixture : — 

B- MassjB ferri carbonat gr. v 



Aquie 3J. M. 

After meals, well diluted. 

Sodii salicylicum is recommended early in the disease. 

Attention to diet and hygiene are also necessary. When structural 
changes have destroyed portions of the Joint, palliative treatment is 
tlie only indication. 

GOUT. 

Spnonyma. Podagra, gout in the foot; chiragra, the hand; 
gonagra. the knee. 

Definition. A constitutional disease, usually inherited ; charac- 
terized by the sudden occurrence of a paroxysni of severe pain and 
swelling in one of the smaller joints — the great toe usually — with the 
presence of uric acid in the blood, and the deposit of the urate of 
sodium in the structure of the joint. 

Causes. Predisposing ; inherited ; male more than female — 
women after menopause. 

Exciting. Malt and wine drinking, whether male or female; large 
consumption of animal food ; lead poisoning ; winter season. 

When inherited tendency, may begin early in life; when acquired 
tendency, after thirty-live years. 

Tlu pathological cause consists in the presence of an excess of 
uric acid in the blood, in the form of urate of sodium. 



ACUTE GENERAL DISEASES. 143 

Pathologrioal Anatomy. Gout is characterized by the deposit 
of urate of sodium from the blood into the structure of joints and 
tissues that are not very vascular. The deposit is associated with 
signs of inflammation, to wit: hyperaemia, redness of the surface, 
with swelling and effusion in and around the affected joint. The sur- 
faces of the joint are incrusted with chalk-like masses, consisting of 
urates, which become greater with each attack, finally causing great 
deformity. 

The deposit usually begins in the metatarso-phalangeal joint of the 
great toe, but other and many joints are soon affected. 

The deposits may also be found in the knuckles, eyelids, and car- 
tilages of the ear. 

" Crystals of urate of soda are deposited in the tubules and intra- 
tubular tissues " of the kidneys — "gouty kidney " — and may be seen 
by the naked eye, the kidneys becoming small, granular and fibrous. 

Hypertrophy of the left ventricle and of the arteries, ending in 
atheromatous changes, are results of gout. 

Symptoms. Acute Gout. Occurs in paroxysms ; one year's in- 
terval between the first and second attack ; six months usually between 
the second and third, after which may occur at any time. 

Prodromes usually precede the paroxysm for several days, to wit : 
acid dyspepsia, constipation, headache and lassitude. 

The paroxysm begins suddenly, between midnight and 2 A. M., 
with acute pain in the ball of the great toe, which becomes red, hot, 
swollen, and so sensitive that the slightest touch cannot be borne. 

The veins are filled, the foot, ankle and leg swollen, and the limb 
the seat of sudden spasmodic contractions, which increase the suffer- 
ing. Slight relief is afforded by elevating the limb. Associated with 
the local symptoms are, chill, fever, quickened pulse, thirst, coated 
tongue, constipation, and scanty, acid, high-colored urine, which de- 
posits, on cooling, a heavy brick-dust sediment. 

Towards daylight the symptoms ameliorate, to return again at sun- 
down, the severity gradually lessening, until the fourth or fifth day, 
when convalescence is established, the patient, as a rule, feeling better 
than before the attack. 

Chronic Gout. Either the result of acute attacks or with a greater 
number of joints being attacked. 

The paroxysms occur at any time, but develop slowly, with less 
pronounced local and general symptoms. Deposits are noticed, the 



144 PllACTICE OF MEDICINE. 

joints becoming hard, knobby, and often distorted. The deposits or 
chalk-stones (urate of sodium) occur about the joints, tendons and 
bursDe, and helix of the ear. 

DiaBnosis. An error cannot occur if the history of the case can 
be obtained, to wit : hereditary tendency, age, sex (females rare, until 
menopause), mode of living, character of symptoms and presence of 
the characteristic deposits. 

PrognosiB. Acute gout rarely fatal ; is prone to return, but much 
depending upon the mode of living. 

Chronic gout decidedly shortens life. The most serious signs are 
those indicating advanced renal disease, with non-elimination of uric 
acid. Gout influences unfavorably the prognosis from acute diseases 
or injuries. 

Treatment. For the acute paroxysms at once, viitum colchici 
radicis, gtt. xv-xx-xxx, every two hours, well diluted, either alone or 
in combination with a potassa salt, or sodii salycilas, gr. xx, every 
three or four hours, well diluted, or Prof, Bartholow's piO, 

R. Colchicinae „ gr, ^'j 

Ext. colocynth, comp gr. ss 

QuininK sulph gr. iij. 

Every [wo or four hours. 
Or the following, recommended by Loomis :— 
Pulv. ipecac... 




X- 



M. 



Ft. pi!. No. I. 
SlG. — Every three hours. 

For the pain, hypodermatic injection of merphina, and wrapping 
the inflamed joint in cotton wool saturated with liq. plumb, sub-acefat. 
dil. and tinctura opii. 

The diet must be restricted to liquid food. 

For chronic gout, regulated diet, free action on the secretions, and 
lithii citras effervescentfs, .^j, three or four times a day, well diluted 
with water; and perliaps a course a( giiinina.ferrum and arsenicum. 

To prevent paroxysm, keep secretions acting, by the free use of 
pure water or a good alkaline water, especially the Saratoga Vichy. 



ACUTE GENERAL DISEASES. 145 

The diet is of the greatest importance, and should consist chiefly 
of vegetables and fruit, excepting tomatoes and strawberries ; fresh 
meat may be- used once a day, as may oysters, fish and soups. 
Alcoholic and malt liquors are contraindicated, as are tea and coffee ; 
skimmed milk should replace all the above. No eggs or dishes 
containing eggs, no pastry, hot bread or cakes, no sweetmeats, spices 
or condiments. 

Systematic exercise, especially walking, is of great advantage. 

Cold bathing, with caution, while the vapor or Turkish bath are ot 
benefit. 

Changing from a cold to a warm climate in winter, and the use of 
flannel under clothing, are strongly recommended. 

LITH^MIA. 

Synonyms. Lithiasis ; uric acid diathesis ; half gout. 

Definition. A condition in which the fluids of the body are satu- 
rated with nitrogen ized waste, in the form oi lithic or uric acid ; char- 
acterized by marked dyspepsia, various nervous phenomena, muscu- 
lar and articular pains, bronchial catarrh, all or any of these associated 
with scanty, high colored, acid urine. 

Causes. High living, with little exercise ; imperfect digestion of 
nitrogenized food ; impaired elimination of uric acid. 

Symptoms. Those of dyspepsia associated with irregular bowels ^ 
scanty, high-colored, acid urine, sp.gr. i. 024-1. 028 containing neither 
sugar nor albumen, but showing an increased proportion of urates. 
Also, depressed spirits, impaired memory, loss of interest in occupation ^ 
sleepless nights, attacks of vertigo, neuralgic pains in the head, and a 
constant dread of apoplexy or cerebral disease. Also, pains in the 
joints, neuralgic in character. 

If the condition be allowed to continue, the following organic 
changes may result, to wit : fatty heart ; fibroid kidney ; enlarged 
liver, or changes in the cerebral vessels. 

Diagrnosis. From gout, by the absence of acute paroxysms and 
resulting changes in the joints. 

Prognosis. If properly recognized and treated, complete recovery 
will result, although it is a disorder of long duration. 

If not properly treated, develops some one of the organic diseases 
mentioned. 



ie|a. 



148 PRACTICE OF MEDICINE. 

Treatment. Rcgukte diet, using fresh meat once daily, poultry, 
game (plainly cooked), fresh fish, oysters, occasionally eggs, lettuce, 
spinach, celery, cold slaw and tomatoes ; avoid all stimulants, tea. and 
coffee, using milk, skimmed milk or milk and cream. Act freely on 
all the secretions. Systematic exercise. Avoid tonics, bromides, 
chloral and opium. Long course of alkaline waters. Good results 
follow lilhii cilras, gr. xx, I. d., sodii phosph., gr. xxx, ter die, or 
acidum benzoicum, gr. x. t. d., all well diluted with water. The author 
strongly urges the use of acidum nilricum di/iilum, gtt. x. in half a 
glass of water, four times a day, with the occasional use of pilulie 
rhei eomposita at bedtime. 



DIABETES MELLITUS. 

Synonyms. Glycosuria ; melituria 

Definition. A chronic affection characterized by the constant 
presence of grape-sugar in the urine, an excessive urinary discharge, 
and the progressive loss of flesh and strength. 

Causes. Most common in males. Occurs at all ages, but most 
frequently between Iwenty-five and fifty years. It is often hereditary. 
Disorders of the nervous, hepatic and renal systems. Excessive use 
of farinaceous food and malt liquors. Sexual excesses. 

The exact pathology of diabetes mellitus differs in different cases, 
and in the present state of our knowledge no exclusive view can be 
adopted. Still, there are .reasons for believing that, in a large pro- 
portion of cases, the nervous system is primarily at fault, though the 
character of the lesions may differ. 

Pathologrioal Anatomy. None peculiar to diabetes are yet 
recogniied. 

Hypera:mia and hypertrophy of the liver and kidneys are gener- 
ally present, the result of increased functional activity. 

The changes in the lungs peculiar to phthisis are often found in 
very chronic cases. 

The changes in the nervous system are not fully determined. 

Symptoms, Clinically cases differ greatly in their course and 
severity; one class presenting slight symptoms and a chronic course; 
another class having marked local and constitutional symptoms and 
an acute course. The symptoms of a typical case may be arranged 
under the fallowing heads : — * 



ACUTE GENERAL DISEASES. 147 

Urinary Organs and Urine, Micturition more frequent and the 
urine increased in quantity. Pain over the region of the kidneys. 
The quantity of urine may amount to 4, 8, 12, 20 or 30 pints in 
twenty-four hours. It is usually pale, clear and watery, having a 
sweetish taste and odor, the specific gravity ranging from 1.025 ^^ 
1.050. It ferments rapidly if kept in a warm place. It yields grape 
sugar to the usual tests, the amount present varying from an ounce to 
two pounds in the twenty -four hours. 

The urea and uric acid are increased. Albumen may be present. 

The increased passage of a large quantity of saccharine urine causes 
a constant itching, burning and uneasy sensation at the prepuce, 
along the urethra, and at the neck of the bladder ; in females, itching 
and eczema of the vulva are common ; in children, incontinence of 
urine is frequent. 

Digestive Organs. An almost constant symptom is thirst, with a 
dry and parched condition of the mouth. At times the appetite is 
excessive, again absent. The breath may have a sweetish odor, the 
tongue irritable, red, and often cracked. Dyspeptic symptoms are 
common, and occasionally vomiting. The bowels are constipated, 
the stools pale and dry. At times diarrhoea may occur. 

The patient complains of feeling very weak, languid, and oi sore- 
ness and pain in the limbs, there is more or less emaciation, a harsh 
dry skin, the countenance distressed and worn. 

The mind is often greatly altered ; depression of spirits, decline in 
firmness of character and moral tone, with irritability, are present. 
Sexual inclination and power are diminished. Defects of vision are 
present. 

The blood and various secretions contain sugar. 

Complioations. Pulmonary phthisis ; Bright* s disease ; defects 
of vision from atrophy of the retina or the formation of a soft cata- 
ract; boils and carbuncles, and chronic skin affections, such as 
psoriasis, etc. 

Course. The clinical history varies in different cases. In the 
majority of cases the course is chronic, lasting for years, the symp- 
toms beginning insidiously, and becoming progressively worse, with, 
at times, decided remissions. Occasionally the disease runs an acute 
course, death occurring within four or five weeks. 

Termination. The majority of cases ultimately prove fatal, the 
symptoms markedly changing, the urine and sugar diminishing in 



14S PRACTICE OF MEDICIKE. 

quantity, the occurrence of aibvmmuria, <fbs:ust for fend and drink, 
and the development of hectic fever or colliquative diarrhcea. 

The falal result usually arises from gradual exhaustion, from blood 
poisoning, leading tu stupor, ending in complete coma, or occasion- 
ally to delirium or conTntlsions, or from complications. 

Rarely, death occurs suddenly, from uramic convulsions or 

DiagnOBis. Diabetes mellitus only exists when grape sugar is 

permanently present in the urine. " It is not the quantity, but the 
persistence of sugar which constitutes diabetes." 

When are present grape sugar in the urine, with more or less 
increase in the urinary flow, it can be mistaken for no other affection. 

From Bright' s diseases, by the absence of dropsy, and of tube casts 
in the urine ; the amount of albumen in the urine is never so great oi 
constant in diabetes mellitus as in Bright's diseases. 

From diabetes insipidus, by the absence of si 
urine, and Che larger quantity of urine voided it 

Simple glycosuria differs from diabetic glyca 
of sugar in the urine is not constant— at one ti: 
another absent — the amount of urine voided is never in exce 
heahh; simple glycosuria is a disease of the aged; diabetic glycc 
usuaily appears under fifty years. Simple glycosuria often results i 
from the inhalation of chloroform, the use of chloral, in the insane, 
from excitement, or the result of injuries to the head. 

Prognosis. Most unfavorable, as regards a cure, it being fairly 
questionable if complete recovery has ever occurred in a typical case. 
Still, decided amelioration may take place in the symptoms, and the 
progress of the malady be greatly retarded. The younger the patient, 
the more rapid the fatal termination. 

Treatment. Impress upon patients the importance of a strictly 
regulated diet. Prohibit or restrict the consumption of such articles 
as contain sugar or starch, especially ordinary bread or flour, sugar, 
honey, potatoes, peas, beans, rice, arrowroot, etc. 

The main diet should be of animal food, including meat, poultry, 
game and fish. 

A moderate amount of fluids should be allowed, and in a majority 
of cases milk will prove beneficial, although, theoretically, ■ 
indicated. Tea. coffee and cocoa, without sugar, may be allowed i: 
moderation, glycerin being used as a substitute for the sugar. 



sugar in the blood and 

n polyuria. 

una in that the amount 

2 being present, a 





ACUTE GENERAL DISEASES. 149 

Regulated exercise is of importance. The patient should wear flan- 
nel, and have two or three warm baths every week, or an occasional 
Turkish bath. 

Therapeutical Treatment. Opium exercises an influence over the 
excretion of sugar, but the effect is not maintained. Pavy strongly 
urges the use oicodeia in -doses of gr. >^-iij, three times a day. Prof. 
DaCosta suggests the use of ergota, which has decreased the urinary 
discharge and the quantity of sugar in a number of cases. Prof. Bar- 
tholow has met with an apparent cure by ammonii carbonas. The 
author has met with decided partial success with uranii nitras, gr. 
j-iij, three times a day, the cases not yet being under observation a 
sufficient length of time to pronounce them cured, although in two the 
urine has been diminished from three quarts per day to normal, the 
quantity of sugar from nine ounces to less than half an ounce, in the 
twenty-four hours. 

Potassii bromidum, 3j during the twenty -four hours, is strongly 
urged. The following remedies are recommended by different ob- 
servers, to wit : pepsinum, liquor potassii arsenitis, iodu?n, potassii 
iodid,t sodium salicylas, acidum lacticum, glycerinum, quinina, tine- 
tura cannabis indica, etc. The evidence in favor of the majority of 
these drugs is far from satisfactory. 

Symptomatic treatment is mostly called for. For emaciation and 
anaemia, yj?rrww and oleum morrhucB ; for sleeplessness and restless- 
ness, morphina, potassii bromidum, chloral or hyoscyamia ; the dys- 
pepsia, lung symptoms, etc., must be managed on general principles. 

DIABETES INSIPIDUS. 

Synonyms. Polyuria; polydipsia. 

Definition. An affection characterized by the habitual discharge 
of a very large quantity of pale, watery urine, free from albumen and 
sugar. 

Causes. Occasionally hereditary, or diabetes mellitus may have 
existed in the parent ; more common in children or young adults ; 
men are more liable than women ; injuries and diseases of the ner- 
vous system ; exposure to cold ; drinking freely of cold water ; fatigue ; 
prolonged debility ; malaria ; syphilis. 

The probable immediate cause of the excessive flow of urine consists 
in dilatation of the renal vessels, the result of paralysis of their mus- 




PRACTICE OF MEDICINE. 

t, caused by derangement of innervation, as ihe condition 
iduced experimentally by irritating a spot in the fourth ven- 
Iby section of portions, of the sympathetic nerve. 
SymptomB. The affection is characterized hy great thirst, with an 
increased flow of pale, watery, slightly acid urine, the amount varying 
frOTa one to Jizv or six ga!/ons\n the twenty-four hours. The specific 
gravity ranges from 1.001-1.007. Sugar and albumen are absent. 
Urea and the other solids are increased. The appetite Is voracious, 
the boiueh are obstinately constipated, and the skin is dry and harsh. 
The large flow of urine is usually preceded by various nervous 
phenomena, as nervousness, irritability, inability to concentrate the 
mind, vi-uid imagination, failure of memory , and headache. 

Unless the affecdon is soon arrested, great loss of flesh and strength 

Diagnosis. It differs from diabetes melUtus by the absence of 
grape sugar in the urine. 

From paroxysmal diuresis, by the absence of the increased urine 
permanently. 

From interstitial nephritis, by the greater amount of urinary dis- 
charge and the absence of albumen, cedema, etc. 

ProguosiB. Rather unfavorable as to a radical cure, unless caused 
by syphilis. Death rarely is due to the diabetes, but to some inter- 
current malady diat the patient has been unable to withstand, on 
account of the weakness produced by the diabetes. 

Treatment. If due to sy phiWs.potassiiiirdidum and hydrargyrum 
are of real benefit. Prof. DaCosta has had success with ergota In the 
form of the fluid extract or the aqueous extract. Pilocarpus has been 
used with success. Prof. Bartholow recommends ^a/i/antim in cases 
not cured by potassii iodidum, placing "one electrode to the neck 
below the occiput, the other to the hypochondriac regions in turn," 
Valerian and potassii bromiditm have been used. The author has 
effected a cure in three cases, where other remedies had failed, by 
the use, internally, of— 

R, Sirychnilue 5ulph gr. ^ 

Acid, hydrochlor. dil Tn_)i 

Aqure lauto-cerasi 3 ij. M. 

Well diluted. 

The obstinate constipation is beat overcome by pilule ccilharliite 
compositce, one at bedtime. 



ACUTE GENERAL DISEASES. 151 

CHOLERA. 

Synonyms. Epidemic cholera; Asiatic cholera; malignant 
cholera ; spasmodic cholera. 

Definition. An acute, specific, infectious disease, epidemic in the 
majority of, although endemic in other, localities; characterized by the 
transudation of serum into the stomach and intestinal canal and violent 
purging of a peculiar, rice-water-like fluid, the persistent vomiting 
of a similar material, severe muscular cramps, and a condition of 
prostration, followed by collapse and death, or of a reaction from the 
collapse and the development of the typhoid state {cholera typhoid). 

Causes. A specific poison, probably the "comma bacillus'* of 
Kotfh. Cholera is but feebly contagious, in the usual acceptation of 
that word, but it is unquestionably •/«/J?^//(7i/^. 

The evidence seems conclusive that the cholera stools are the main, 
if riot the only, channel of infection, and that the great cause of the 
propagation of cholera is the contamination of the water used for 
drinking purposes with the stools. Milk may also be the vehicle by 
which it spreads. Little, if any, danger exists from being in the 
presence of the affected, although the emanations from the cholera 
excreta in the atmosphere may generate the disease if swallowed or 
inhaled. The dead bodies of cholera subjects apparently possess slight 
infective property, "the bacteria of decomposition " probably destroy- 
ing the cholera germs. One attack does not afford protection against 
another. 

TYi^ period of incubation is short, under a week, usually. 

Pathological Anatomy. This is, as yet, far from satisfactory. 
The morbid appearances in the majority of cases of death from 
cholera may be thus summarized : The temperature generally rises 
after death, the body remaining warm for a considerable time. Rigor 
mortis rapidly ensues, the muscular contractions being often so power- 
ful as to displace and distort the limbs. The skin is mottled and the 
body greatly shrunken. The blood is darker in color, thick, viscid, 
feebly coagulable, and slightly acid. The arteries are quite empty 
of blood, the veins, on the other hand, are distended. The organs 
are, as a rule, pale and shrunken. 

The stomach and intestinal mucous membranes are congested, and 
present evidences of extravasations and ecchymoses, or are bleached 
and pale. The stomach and intestines usually contain a quantity of 



i though! by 
.phe- 



Or MEDICINE. 

whey-like material, having an alkaline reaction, as w 
of cast-off epithelium and the peculiar bacillus. I 
many that the stripping-off of the epithelium is a pc 
nomena. The Peyer's, solitary and Brunner's glands are usually 
larged and prominent, and occasionalljvevidences of ulceration 
apparent in the solitary glands, and sections placed under the mii 
scope showed the " comma bacillus." The villi of thi 
membrane, as well as the epithelium of the small 
stripped off, leaving the basement membrane, for the most part, 
exposed. The /wer is more or less advanced in fatty degeneration, 
presenting a somewhat mottled, yellowish discoloration. The kidneys 
are congested, the epithelium of the tubules granular and detached 
from the basement membrane, blocking up the tubes. Prof. Bartholow 
observed, in all of tiis autopsies, " considerable hyperemia and dilata- 
tion of the yessels of the medulla oblongata. The constancy of this 
lesion would seem to indicate a relationship between congestion of 
the medulla and the cramps." 

Symptoms, In accordance with the law of epidemic infectious 
diseases, the onset, course and character of the symptoms vary 
different cases and at different periods in the same epidemic. 

The disease may either set in suddenly in a patient previously 
good health, or it may follow an attack of rather severe and persistent 
diarrhosa, with pain, nausea, vomiting and depression. Such 
cases termed Cholerine, the stools of which are infectious. 

In a typical case there are three stages ; first, diarrhcea ; second, 
prostration ; third, collapse, or, in favorable cases, reaction. 

First Stage. Be^ns with c/tilliness, excessive thirst, coaled tongue, 
unpleasant taste in the mouth, slight abdominal pain, and three or 
four copious, watery, yet fecal stools during the day, and a decided 
feeling of loeakness, the stools rapidly becoming ivhey-tike, easily 
voided, but with force, and only slight pain. 

Second Stage. The stools rapidly increase in number, are voided 
with a rushing force, and consisting of many quarts of grayish, or 
whitish, rice-water-like fluid, accompanied with forcible vomiting, first 
of the contents of the stomach, mixed with more or less bilious matter,. 
afterwards of the peculiar rice-water- like material; thirst becomeBFi 
most intense, increasing or diminishing with the variations in tha 
number of the vomit and stools ; severe muscular cramps soon foUowj 
most severe in the calves, although occurring In all parts of the body. 



I 



ACUTE GENERAL DISEASES. 153 

Third Slagf. Tlie stools, vomit and cramps continue. The appear- 
ance of the patient becomes frightful; the eyes are sunken and sur- 
rounded by blackish rings, the nose pinched and pointed, the cheeks 
hollow, and the lips blue (facies cholerica) ; the surface cold and 
moistened with a sticky pefspiration ; the skin of the hands and 
fingers have the sodden appearance of the " washerwoman who has 
washed al! day." and if picked up in folds, the fold but slowly dis- 
appears. The temperature rapidly falls, the puhe becomes small 
and compressible, barely perceptible at the wrist, and the heart beats 
■ are scarcely recognizable. The voice is weak, husky and sepulchral 
(vox cholerica). the tongue is like ice, the breath is cold and icy, the 
urine markedly diminished and albuminous. The mind is not cloudy, 
but most patients are apathetic and indifferent to their danger. This, 
the algid state of cholera, or cholera asphyxia, usually terminates in 
death in from three to twelve, twenty-four or fortyeight-hours, but 
reaction may be established. 

Sla^ of Reaction. The temperature of the body rises, the pulse 
gradually becomes fuller and stronger, the countenance becomes 
brighter, the stools less frequent and more fecal, the vomiting 
decreases, the thirst lessens, the urine increases in amount, but con- 
tinues albuminous, the patient entering a slow convalescence, or 
typhoid symptoms' develop, the so-called cholera typhoid, which pro- 
longs the recovery for several weeks. 

Convalescence is often prolonged and complicated by the develop- 
ment of severe bed sores, boils, bronchitis, pneumonia or parotiditis. 

Sequelffi. Suppuration of the parotid gland ; painful tetanic con- 
traction of the flexor muscles of the limbs ; abscesses or ulcers of 
the limbs ; profuse sweats ; roseola, erythema, urticaria, and rarely 
vesiculareruptions. 

DiEL^nosis. The epidemic character, and rapid spreading, and 
great mortality of the affection prevents its being mistaken for any 
other disease, although isolated cases are often confounded with 
cholerine or with cholera morbus, the points of distinction being few, 
unless the "comma bacillus" only be found in the stools of true 

Pro^noeis. Very unfavorable, the mortality ranging from twenty 
to eighty per cent. The last epidemic in this country was much 
milder than former ones. The prognosis is controlled by the general 
condition of the patient, the age, habits and the development of the 



164 PRACTICE or MEDICINE. 

algid stage ; the prognosis being more favorable in those cases w! 
develop gradually than in those in which it reaches its acme 
single bound; the very young or very old, those addicted to 
various excesses and surrounded by unfavorable hygienic conditio! 
are more apt to perish than are others. 

Treatmeiit, The success depends, to a great extent, upon 
prompt and early treatment, for experience amply attests that 
arrest of the disease in the diarrhceal stage is comparatively e; 
and that in the stage of collapse its cure by any means whatever 
altogether an exceptional occurrence ; therefore, during the preva- 
lenqe of cholera the mildest cases of diarrhoea ought to receive prompt 
treatment, for many cases have their beginning as a mild diarrhma. 

It must not be overlooked that intelligent nursing and regimen 
equally as important as medical treatment. 

Firsl Stage. The remedy of all others is opiitm in some form, 
which may be added, with benefit, pliimbi aceias, in doses of gr. 
iij-v, repeated p. r. n., oracidum sulphuricum dilulum combined with 
tinetura opii deodorata, and at the same time applying mustard over 
the abdomen. Water and food should be used with great caution, 
but ice is indicated in unlimited amounts, and at times iced dry 
champagne. The patient must be kept quiet, in bed. 

Second Stage. The opium treatment should be continued, togetht 
with the free use of stimulants. For the distressing vomiting, ieaf, 
iced chmnpagne, acidum carbolicum or acidvm hydrocyanicum 
sometimes pve relief. 

Locally either continue the mustard application to the abdomen 
: of rubber bags filled with boihng water, 



* For the cramps, hot water in bottles, hot irons or bricks appUe 

• over painful parts, or an ointment of chloroform or chloral, chloroibn 

or ether inhalations, or the use of the following hypodermatic solution 

strongly recommended by Prof Bartbolow; — 

a. Chloral .^iij. 

Morphine sulph gr. iv. 

Aq, lauro-cerasi f^j. 

Sic — Fifteen lo tfakty numms each injeclion, 

For the collapse, heat to the surface and the fi'ee use of itimulatU, 
or spiritus frumenti, or sfiiritus vini gallici hypodermalically, a 



a. 



the hot, and, in some c, 
the intravenous injeciioi 
during the 1S84 epiden 
becomes more perfect, it 

If riraciion occur, trea 
■a ferrum, quinina and a. 

AH the discharges from the patient should be thoroughly disinfected 
as soon as voided, and the stools and vomited material buried. 



ases, the cold bath has 
n of sahne fluids was 
lie in France, and as 
s success will be the m< 
t indications as they a 



been of advantage ; 
unusually successful 
the modus operandi 
ire marked, 
ise, and tonics, such 



TRICHINOSIS. 

SFnonyms. Trichina;; Trichina spiralis ; " flesh-worm disease." 

Deflnition. A typhoid condition, the result of the entrance o 
pirasite — the Trichina spiralis — into the intestinal canal, and their 
subsequent migration into the mliscular structure : characterized by 
severe gastro-inlestinal irritation, severe muscular soreness, and a low 
typhoid condition. 

Cause. The Trichina spiralis are introduced into the human body 
by eating the infected hog's flesh either raw or but imperfectly 
cooked. 

Description. The parasite is found in two forms, to wit ; intesti- 
nal trichina, which is sexually mature, and muscle trichina, which is 

The intestinal trichina is a small, hair-like worm, the male meas- 
uring y'( of an inch, and the female fS of an inch in length ; the head 
is smaller than the rest of the body ; the tail of the male has a bi-lobed 
prominence, between the divisions of which the anal opening is placed, 
and from which a single spiculum can be protruded ; the female has 
a blunt, rounded tail, Che reproductive outlet being situated toward 
the anterior part of the body ; the ova are very small, containing, 
embryos being produced viviparously at the rate of at least o 
hundred each week after the entrance of the female into the intestinal 

The muscle trichina develops its sexual apparatus after it has en- 
tered the intestinal canal of its host. 

The viable embryos discharged from the female are in a state of 
motion, and at once migrate from the intestines to the muscular struc- 
ture of the individual, and here set up inflammatory action, they be- 
coming surrounded by a capsule or shell in which they are coiled. 



156 



PRACTICE OF MEDICINE. 



After a. time, in the muscle, the trichina undergoes a further change ; 
lime salts being deposited in and about Ihe capsule and in the parasite 
itself, when minute specks of lime are seen distributed throughout 
the muscular structure. 

The development of the parasite from the period of impreg- 
nation up to the time of sexual maturity is. under favorable con- 
ditions, less than three weeks. Within two days from the ingestion 
of the infected pork occurs the maturation of the muscle larva; ; 
in six days more the birth of embryos occur, and in about two weeks 
the migrating progeny have arrived at their habitat, the muscular 



Symptoms. These depend upon the number of parasites in the. 
infected food. According to Dr. Sutton, of Indiana, a piece of pork, 
the site of a cubic inch, contained eighty thousand trichinae. There 
are three stages described, to wit: the intestinal, the migration, and 
the encapsulation. 

Intestinal stage, a gastro -intestinal inflammation, with nausea, vont~ 
iting, and a ■watery diarrhaa, the severity depending upon the Dum- 
ber of the parasites ingested. 

Migration stage, a typhoid-like fever, rapid, feeble pube, profuse 
sweats, intense thirst, dry tongue and lips, and red, swollen face, 
with soreness and tenderness of the muscular structure, increased 
by any muscular act. As a rule the mind is clear but decidedly 
apathetic. 

Encapsitlation Stage. If the number of parasites ingested have been 
fev^, recovery may occur in this stage, but if the number have been 
large, the gastro-cnteritis, fever and muscular phenomena severe, the 
patient is in a critical condition, between twenty and fifty per cent. 
succumbing, 

DiagnoBia. Unless the physician has some intimation of the 
cause, cases are readily mistaken for either ordinary ileo-colitis or 
typhoid fever. 

Prognoais. Depends upon the number of trichina in the pork 
eaten. Mortality between twenty and fifty per cent. 

Treatment. If the parasites have been recently taken, within 
the first four or five days, emetics and purgati-ves to remove them 
from the stomach and intestinal canal are indicated. After thorough ] 
action of these, attempts may be made to destroy such of the 



DISEASES OF THE RESPIRATORY SYSTEM. 157 

#■ - • ♦ 

parasites as have escaped the emetic or purgative. For this purpose 
much is said in favor of glycerini, one part, aquae, two parts ; or a 
trial can be made of acidum carbolicum and tinct. iodi, as suggested 
by Prof. Bartholow. Quinina gave the best results in the cases 
seen by Dr. Sutton. 

After migration has begun the powers of life must be sustained by 
nourishing food, stimulants and tonics. 



DISEASES OF THE RESPIRATORY 

SYSTEM. 



PHYSICAL DIAGNOSIS. 

Physical Diagnosis is the art of discriminating disease by 
means of the eye, the ear and the touch. 

The sigtts thus ascertained are connected with changes or altera- 
tions in the form, density, or condition, of the structures within, and 
are known 2,s physical signs, 

" Physical signs are^ then^ the exponents of physical conditions, and 
of nothing more.'^ 

The methods employed in the physical exploration of the chest; 
are: — I, Inspection; II, Palpation; III, Mensuration; IV, 
Percussion ; V, Auscultation ; VI, Succussion. 

Percussion and auscultation, dealing with sounds, are of the most 
importance. 

For the purposes of physical exploration, the chest is mapped off 
into regions or divisions, as follows : — 

. ANTERIORLY. 

First : — Supra-clavicular, Lying above the upper edge of the clavicle, 
usually about an inch in extent. 

Second : — Clavicular, Corresponding to the inner two-thirds of the 
clavicle. 



Third : — Infra-clavicular, From the clavicle to the lower border of 
the third rib. 

Fourth : — Mammary, Between the third and sixth ribs, 
Fifth ■.—Infra-mammary, Downward from the sixth rib. 

LATERALLY. 

First ; — Axillary, That portion above the sixth rib. 
Second; — Infra- axillary. That portion, below the sixth rib. 

KJSTERIORLV. 
First ■.—Supra-scapular, That portion above the scapula.. 
Second : — Scapular, That portion covered by the scapula. 
Third : — Interscapular, That portion between the scapula?. 
Fourth : — Iiifra^scapular, That portion below the angle of the 

INSPECTION. 

Inspection signifies "the act of looking." Views of the chest 
should be taken from the sides and behind as well as from- the front ; 
for which purpose a good light should be obtained, and the patient be 
placed in as easy and comfortable a position as is possible. 

Inspection reveals the form, she, color, and movements of the 
chest, as well as the condition of the superficial parts. 

In health the sides of the chest are for the most part jyffijwe/n'ca/ in 
form, siie, color and movements, both sides .rising equally during the 
act of inspiration, and falling equally during the act of expiration. 
During the act of inspiration the intercostal spaces in (he lower two- 
thirds of the chest become more hollow, as also do the supra-clavicular 

Inspiration is almost entirely the result of muscular action ; expira- 
tion, on the other hand, is chiefly due to the elasticity of the lungs 
and chest walls, aided somewhat in forced respiration by muscular 
action. The movement of inspiration by inspection, is of longer 
duration than that of expiration, and the pause between the acts but 
momentary. 

The respiratory movement is visible oVer the whole thorax, although 
in males and in children it is most distinct at the lower portion 
(infrrior costal breathing), vhW^ in the female it is most distinct at 
the upper portion of the chest [superior costal breathing). 




By palpation is meant the application of the palmar surfaces of 
the hands and fingers to the chest, by which means we appreciate 
impressions which are capable of being conveyed by the sense of 

The objects of palpation are : — 

Firsl : — To give more accurate information regarding what is re- 
vealed by inspection. 

Second : — To locate spots of soreness, the density and condition of 
tumors, if any be present, the slate of the chest walls, the frequency 
of the breathing, and the action of the heart. 

Third ; — To determine the existence and character of the various 
kinds o^ fremitus (vibrations). 

By fremitus is understood certain tactile impressions or vibrations 
conveyed to the surface of the chest, which are classed and produced 
as follows :— 

First ; — Vocal fremitus, produced by the act of speaking or crying. 

Second :~~Tussive fremitus, produced by the act of coughing; of 
value especially when the voice is very weak. 

Third : — Bronchial fremitus, produced by the passage of air 
through mucus, blood, or pus, in the bronchial tubes, during the act 
of respiration. 

Fourth : — Friction fremitus, produced by the rubbing together of 
the roughened surfaces of the pieurie. 

When the normal chest vibrates lightly, it is termed the normal 
■vocal fremitus. 

The vocal fremitus is more distinct upon the right side toward 
the apex. 

If the lung be consolidated (denser), the vibration is greater and 
more easily distinguished. — the vocal fremitus is increased. 

In feeble persons, or when any cause interferes with the transmission 
of the vibrations, the vocal fremitus is diminished or absent. 

MENSURATION. 

Mensuration, or measurement of the chest, is of little practical 

importance, and hence seldom performed. The only measurement 

likely to be required, is the circular or circimiferential, in different 

parts of the chest, which is performed with either an ordinary gradu- 



160 PRACTICE OF 

ated (ape measure or a double tape measure, made by uniting two 
tapes in such a manner that they start in opposite directions from the 
same point at the miil-spinal line. The tapes drawn around each 
side until they meet ac the mid-sltrmal Uiu, on a line immediately 
above the nipple, or on the level of the sixth rib near its attachment 
to the cartilage — the sixth costo-stemal joint — the padent first being 
directed to effect a complete expiration, the number of inches noted, 
and then to take a deep inspiration, the increase in inches noted, 
the difference between the two giving a rough estimate of the capacity 
of the lungs. 

In right-handed persons the right side is usually one-half to three- 
fourths of an inch larger than the left ; if larger than this it is usually 
the result of some abnormal condition. 

In we 11 -developed men the chest measures at the upper part about 
thirty-three to thirty-five inches during expiration, and is increased 
.fully three inches in inspiration. 

PERCUSSION. 
Percussion, or " The act of striking," to ascertain the composi- 
tion of structures, affords signs and information of great value in 

There are two methods employed, immediate and mediaU. 

tmmfiiiaU. or direct percussion, is performed by striking the thbrax 
directly with the points of the fingers or the palmar surface of the 
hand. This method of percussion has been generally abandoned, 
u it does not enable us to distinguish, with sufficient correctness, 
between the various shades of difference in the pitch or quality of per- 
cussion sounds. 

Mf^Alf, or indirect percussion, may be practiced in three different 
Witt's, lo wit :— 

First : — With the finger of one hand interposed between the body 
percussed and the pcrctissihg finger. 

SmmJ i — With the finger acting as a ptei.imetu' and the pctcns- 
tion hftinmrT. 

T%ir4: — With the pcrcusann hammer and the pleiimeter. 

The tiisi of these modea AfKmk the most cofrect and ready infor- 
mation itKardittf; the trsi^tmct of the pMts perci^sed. The skiUfiil 
Utv of the riivgert is more diUkull n «c<)iMTt tban that of the pkxi- 



PHYSICAL DIAGNOSIS. 161 

meter and hammer; and if the examiner has acquired sufficient 
skill in its performance, an absolutely accurate result may be 
obtained. " He who is skilled in digital percussion will be able 
to percuss equally well with the hammer, the inverse of which 
does not always hold good." In addition to being proficient in 
the technical modus operandi, it is necessary to possess a sensi- 
tive ear, educated to distinguish between the vaiious shades of the 

When the fingers are employed, it is a matter of choice whether one 
or more fingers are used as the plexlmeter. Usually the last phalanx 
of the first or second fingers of the left hand are used, thcwhep fingers 
being raised from the chest, so as not to interfere with the sound- 
vibrations ; they should be applied ^rwi/)" and evenly to the surface, 
thus preventing the sfipping of the soft parts, and also to determine the 
resistance of the chest walls when the blow is given. The rou/tded 
ends of the first and second fingers of the right hand are used as a 
hamraer.striking the pleximcler fingers in such a manner that the 
nails shall not touch the skin of the underlying fingers. The force 
employed varies in different regions, hut usually, for the chest, should 
be only of moderate degree. Forcible percussion is of use only when 
the sound of deep-seated organs is desired. 

The stroke should be made perpendicularly to the surface, and not 
slanting, as is too often done. The whole movement should prgceed 
only from the wrist-joint, and ought not to be too rapid or unequal, 
or of great force, the fingers being rapidly withdrawn, so as not to 
interfere with the vibrations. 

The objects of peroUBSion are to elicit certain sounds, and the 
amount of resistance or elasticity of the organs percussed. 

The main sounds elicited by percussion are the dull, clear and 
tympanitic. Familiarity with the intensity, character and pitch of 
each of these sounds is essential. 

When jjercussing the healthy chesl, the sound obtained is termed 
the normal pulmonary resonance. It is of variable intensity, depend- 
ing upon the force of the stroke employed and the amount of adipose 
and muscular tissues covering the thorax, and the tension of the 
chest walls. 

There is no exact standard of the normal pulmonary or vesicular 
resonance, but if the two sides of the chest are compared, the normal 
standard of each person is obtained. 



Ilj2 PRACTICE OP MEDICINE. 

The character is termed pulmonary or dear, as characteristic of 
the healthy chest wall. TXv: pitch is always relatively lirui. 

The sounds elicited by percussing a healthy chest are not, however, 
alike over all its parts. 

Anteriorly, the portion of lung above the clavicle yields a sound 
which becomes somewhat tympanitic as the trachea is approached. 

Over the ctavkU the sound is clear and pulmonary at the centre of 
the bone, but at the scapular extremity it is duller, and towards the 
sternum it becomes somewhat tympanitic. 

At the infra-clavicular region the resonance is dear and distinct, 
but litde resistance being offered to the percussing finger, and the 
sound elicited may be taken as the type of the pulmonary resonance. 
In this region, however, a shght disparity exists between the two 
sides; on the right side the sound is less clear, shorter and of a 
higher pitch flian on the left side. 

In the mammary region of the right side the resonance of the lung 
is not so clear, the sound being modified by the size of the mamma 
and the upper border of the liver. On the left side the heart deadens 
the sound from the fourth to the sixth rib, and in a transverse 
direction, from the sternum to the left nipple. This dull sound 
in the left mammary region is lessened in* extent during full in- 
spiration, and in emphysema, when the lung more completely 
covers the heart. 

In the infra-mammary region on the right side the percussion note 
is dull, except during the act of complete inspiration, when the liver 
is displaced downward by the inflated lung. In the left i«A'(i-«a»(- 
mary region the sound consists of a mixture of the dull sound of the 
heart and spleen and of the clear sound of the lung, together with 
the tympanitic sound of the stomach. 

Over the upper part of the sternum — above the third rih — the sound 
is slightly tympanitic. Below the third rib, over the sternum, the 
sound is dull, due to the presence of the heart and liver. 

The position exercises some influence on the results of percussion. 
More accurate results are obtained when the patient is standing or 
sitting than when recumbent. While the front of the chest is per- 
cussed, the arms should hang loosely by the sides;" the hands may 
be clasped across the top of the head during the percussion of the 
anillary region ; during the examination of the back the head must 
be bent forward and the arms tighdy crossed in front. 



PHYSICAl- DIAGNOSIS, 163 

On the posterior surface of the chest ihe sound also varies accord- 
ing to the part percussed. 

Over the scapula the sound is duller than between these bones or 
below their inferior angles. 

Over the infra-scapular region a clear sound is obtained as far as 
the lower border of the tenth rib on the right side, where the dullness 
of the liver begins. On the left side, below the angle of the scapuia, 
the percussion sound is tympanitic if the intestines are distended, or 
it may be slightly duU if the spleen be enlarged. 

In the axillary region the sound is clear and distinct on each side. 

In the infra-axillary region of the right side the sound is duller, 
owing to the presence of the liver ; at the corresponding si 
the left side, the sound is clear or tympanitic, from the disti 
the stomach, and at the ninth or tenth rib of the left axillary region 
dullness and the sense of resistance mark the location of the spleen. 

The sounds obtained by percussion of the unhealthy or abnormal 
chest are as follows : — 

First: — Hyper-resonance ox increase of the normal pulmonary reso- 
nance is due to the relative increase in the proportion of air to the 
solid tissues of the lung, providing the tension of the chest walls be 
not altered, to wit ; emphysema, atrophy of the lungs, or consolida- 
tion of the opposite lung. 

Second : — Dullness or absence of resonance due to the relative in- 
crease of solid tissues in proportion to the amount of air, to wit : 
different stages of phthisis, pneumonia, or pleurisy. 

The pilch is increased or heightened in proportion to the diminu- 
tion of the amount of the air and the increase of the solids. 

If there be entire want of resonance the percussion note is said to 
be flat ; if there is a slight decrease in the resonance of the part the 
note is said to be impaired. 

The sense of resistance is greater, the more marked the consolida- 
tion of the lungs and the greater the tension of the chest walls. 

Third: — Tympanitic, or the drum-like percussion note, is a non- 
vesicular sound having the character of that of the intestines ; 
wherever heard if indicates the presence of air in conditions similar 
to that of the intestines, to wit: inclosed in walls which are yielding, 
but neither tense nor very thick. 

When elicited over the chest it may be due to the transmitted 
sound of the distended stomach or colon. It is obtained over the 



PRACTICE OF MEDICINE. 

chcsl in pntumolhorax. in moderate pleural effusions above the level 
of the liquid, over the seat of cavities in the pulmonary tissues, and 
in (edema of the lungs. 

The lympnnilic percussion note differs from the normal pulmoaary 
resonance in being rrtore ringing in character and of a higher pitch. 

The amphoric or metalUc sound is in reality a concentrated tym- 
panitic sound of high pitch, and denotes a large cavity with tirm, 
elastic walls. 

The cracked-pot or cracked-metal sound is another variety of the 
tympanitic sound. The condition moat commonly occasioning this 
sound is a cavity in the lung tissue, communicating with a bronchial 
lube. It requires for its development a strong, quick blow of the per- 
cussing linger, and the patient's mouth open. 

RESPIRATORV PERCUSSION. 

The percussion sound will vary grfeatly with the respiratory move- 
ments. If a full inspiration be taken and percussion performed, then 
a full expiration taken and percussion performed, and then the chest 
percussed during the normal respiration, slight changes in the charac- 
ter and pitch of the note are obtained, which otherwise would escape 
detection. Prof. Da Costa has designated this method, rcspiratoiy 

AUSCtn-TATORY PERCUSSION. 

This method consists in listening, with a stethoscope applied to the 
parictes, to the sounds elicited by percussion. " It is a serviceable 
means of determining with accuracy the boundaries of various organs, 
as those of the lungs or heart, or of the hver or spleen, and yields 
particularly ex.ict results when carried out with the double sietho- 

AUSCULTATION. 

AuBOoltatiOQ, or listening to the sounds produced within the 
chcsl during the net of respiration, coughing, or speaking, furnishes 
ihc jiiosi [x^tiable means of studying the condition of the lungs, and 
is, therefore, the most valuable method of discriminating the various 
conditions which may afleci the organs of respiration. 

Auscultation is cither immtdiair or medialf. 

It is immtdifUf when the car is applied directly to the chest, which 
laay be either denuded or thinly covered. 



PHYSICAL DIAGNOSIS. 



165 



It is mediate when the sounds are conducted to the ear by means ■ 
of a tubular instrument, termed a stethoscope. 

For ordinary purposes, immediate, or direct auscuhation is sufficient, 
but when it is desirable to analyze circumscribed sounds, as in dis- 
eases of the heart, or where the patient objects to this method, on the 
score of delicacy, or the auscultator objects, on account of the un- 
cleanliness uf the person examined, the stethoscope is to be preferred. 
Moreover, there are certain parts of the chest which can only be ex- 
plored satisfactorily by the aid of a stethoscope, and moreover, this 
instrument has the additional advantage of intensifying ii\c sound. 

In auscultation, the following rules, formulated by Prof Da Costa, 
should be observed : — 

" I. Place yourself and your patient in a position which is the least 
constrained and permits of the most accurate application of the ear 
or stethoscope to the surface. Above all, avoid stooping, or having 
the head too low." 

" 2. Let the chest be bare, or what is better, covered only with a 
towel or a thin shirt." 

" 3. If a stethoscope be employed, apply closely to the surface, but 
abstain from pressing with it. This may be obviated by steadying the 
instrument, immediately above its expanded extremity, between the 
thumb and the index finger." 

"4. Examine repeatedly the di/Terent portions of the chest, and 
compare them with one another while the patient is breathing quietly. 
Making him cough, or draw a full breath, is, at times, of service ; 
especially the former, when he does not know how to breathe." 

SOUNDS IN HEALTH. 

If the ear be applied over the laTynx or trachea of a healthy per- 
son, a sound is heard with both the act of inspiration and expiration. 
Its intensity is -variable, i\s pitch high, and its quality tubular (to wit : 
a current of air passing through a tube — the larynx or trachea), The 
duration of the sound during inspiration being somewhat longer than 
during expirarion. A short pause follows the. act of expiration, . 

This sound is termed the normal laryngeal respiration, and is 
identical in character, duration and pitch with an important morbid 
sound, termed bronchial respiration. 

The sound heard by placing the ear over the lung tissue is differ- 
ent ; it is produced in the very finest bronchial tubes and air cells by 



i OF MEDICINE, 
their expansion and contraction, and is termed the normal •vesicular 



The inspiratory portion of the sound is, of •variable intensity, its 
pitch is low.'Vs quality soft and breesy. designaXed vesicular; its dura- 
tion is during the entire act of inspiradan. 

The expiralory portion of the sound ia not always perceptible ; it is 
xii feeble intensity, very low pitch, its character soft and blowing, and 
its duration much less than the act of expiration. 

It is to be remembered, however, that the vesicular murmur will be 
found to vary in the different regions on the same side, and in corres- 
ponding regions oii the two sides of the chest. These variations 
within the range of health are especially important, and should be 
memorized. 

Infra-clavicular Region. — The vesicular murmur in this region on 
either side is much more distinct than over any other part of the 

On the left side the inspiratory sound is of greater intensity, of 
lower pitch, and more distinctly vesicular in quality than that heard 
upon the right side. On the right side the expiratory sound \i nearly 
or quite the same in length as the inspiratory sound, and is higher in 
pilch and more tubular in quality than the expiratory sound upon the 
left side. 

Supra-scapular Region. — Owing to the small number of air vesicles 
and the large number of bronchial tubes, and their nearness to the 
surface, the respiratory murmur has an intense, high-pitched, tubular 
and expiratory quality. 

Scapular Region. — Compared with the infra-clavicular region, the 
respiratory murmur heard over the scapulEE on either side is more 
feeble, and the vesicular quality less marked. 

Inter-scapular Region. — The murmur in this region differs from the 
normal laryngeal breathing only In intensity and duration. 

Ittfra-scaptilar Region.-^liis murmur in this region very closely re- 
sembles that heard in the left' infra-clavicular region. 

Mammary and Infra-mammary Regions. — The murmur in these 
regions differs from that heard in the infra-clavicular region, in being 
of less intensity. 

Axillary and Infra-axillary Regions. — The respiratory sound in the 
axillary regions is as intense as in any portion of the chest.- In the 
infra-axillary regions- the intensity is less and the pitch lower. 



PHVSICAL DIAGNOSIS. 



VOICE IN HEALTH. 



; larynx or trachea of a healthy per- 
int " twenty- one. twenty-two, twenty- 
ith moderate force, there is perceived 
:oncnssion or shock, and a 
■ fremitus, the voice seeming to be concen- 
Often the articulated words are distinctly 



If the car he applied o 
son, and he be directed 
three," in a uniform tone 
a strong resonance, with 
sense of vibration, thrill c 
trated and near the ear. 
transmitted (iaryngophony). 

The sounds thus heard are termed the normal laryngeal n 

If the ear or stethoscope be applied over the third rib anteriorly, on 
either side of the chest of a healthy person, and he be directed to 
count" twenty-one, twenty-two, twenty-three," in a uniform tone, with 
moderate force, a confused, distant hum is perceived, of variable in- 
tensity, accompanied with more or less vibration, thrill or fremitus, 
most distinct in adults, but notably weaker in women than in men. 

This sound is termed the normal vocal resonance. 

If the ear or stethoscope be applied over the third rib anteriorly, of 
a healthy person, and he be directed to whisper, in a uniform man- 
ner, the words "twenty-one, twenty-two, twenty-three," there is heard 
a sound corresponding closely in character to the sound of expiration 
over the same region during the act of forced respiration ; or, in other 
words, a feeble, low-pitched, blowing sound. 

This sound is termed the normal bronchial whisper, and is pro- 
duced by the air in the bronchial tubes during the act of expiration. 
SOUNDS IN DISEASE. 

The vesicular munnur may undergo, in disease, changes in its in. 
tensity, its rhythm, and in its character. 

The intensity of the respiratory murmur may be : — 

1. Exaggerated or increased. 

1. Diminished ox feeble. 

3, Absent or suppressed. 

Sza^^erated reepiratlon differs from the normal vesicular 
respiration only in an increase in the intensity of the respiratory 
sounds. When general over one lung, it will usually indicate defi- 
cient action of other parts. In this manner effusion compressing one 
lung, one-sided deposits, obstnictlon of the bronchial tubes by secre- 
tion, or inflammation of the lung structure, necessitate a supple- 
mentary respiration in the healthy portion of the same lung or the 



PRACTICE OF MEDICINE. 

lung upon the opposite side. From its resemblance to the ioud, 
strong, quick respiration of young children, it has been termed 
puerilf respiration. 

Exaggerated respiration is, therefore, to be regarded as' indirect 
evidence of disease in some portion of the pulmonary tissue. 

DiminiahBd reBpiration, called also senile respiration, as being 
characteristic of old age, is characterized by diminished intensity and 
duration of the sound. In the large majority of instances the inspi- 
ration suffers the greatest, the expiratory sound not diminishing in the 
same proportion. In asthma, emphysema, diseases of the larynx and 
bronchial tubes, pleuritic pain, rheumatism or paral>sis of the chest 
walls, or in thickening of the pleural membrane, we observe super- 
ficial or diminished respiration. When one side of the chest is 
partially filled with fluid, we may hear a deep-seated, but feeble 
breath sound. 

Absent or suppressed respiration occurs whenever the actioa 
of the lung is suspended ; this may be from external pressure, as 
when the lung is compressed by the presence of fluid or air in the 
pleural cavity, or when complete obstruction of the bronchial tubes 
prevents the air from either entering or escaping from the lungs. 

The rhythm of the respiratory murmur may be — 

1 . Interrupted orjerhy. 

2. The interval between inspiration and expiration prolonged. 

3. Expiration prolonged. 

In health the inspiratory and expiratory sounds are even and 
continuous, with a short interval between each act ; this may be 
altered in disease, and both sounds, especially the inspiratory, have 
an interrupted or jerky character, termed "cog-wheel respiration." 

This jerky breathinsr is noted in some spasmodic affections of 
the air tubes, in hysteria, the earliest stages of pleurisy, pleurodynia, 
and the early stages of pulmonary phthisis. It is most frequently 
associated with phthisis, due probably to the adhering lo the walls 
of the finer bronchial tubes of tough mucus, which obstructs the 
free entrance and c.v:it of the air ; it is usually most notable under 
the clavicles. 

The interval between inspiration and expiration maybe 
proloug'ed, instead of these two sounds closely succeeding one 
another. When this occurs the inspiratory sound may he shortened, 
or the expiratory sound may be delayed in 



PHYSICAL DIAGNOSIS. 169 

If the inspiratory sound is shortened, it is the result of consolidation 
of the lungs; if the expiratory sound is delayed, it is the result of 
lessened elasticity of the lung structure, and is most commonly 
associated with emphyserna. 

Prolonged expiration denotes that the air is obstructed in its 
exit from the lungs. Il may be the result of diminished elasticity, 
the result of emphysema, or from the deposits of tubercle, which 
impair the contractile power of the lungs. If the former, it is asso- 
ciated with clearness on percussion ; if the latter, however, with 
impaired resonance on percussion. When prolonged expiration is 
detected at the apex of the lung, and is associated with impairment 
of the normal pulmonary resonance, it is for the most part the result 
of a tubercular deposit. 

The quality of the respiratory murmur may be 

1. Harsh, termed vedcule-bronckial respiration. 

2. Bronchial. 

3- Cavernous. 

4- Amphoric. 

Harsh respiration, or, as it is termed by Prof. Da Costa, vnsicti/o- 
#nJ«irA(a/ respiration, is that variety in which both the inspiratory and 
expiratory sounds have lost their natural softness. It generally indi- 
cates more or less consolidation of lung tissue. In normal vesicular 
respiration the sounds produced by the air expanding the air cells ind 
finer bronchial tubes obscures the sound produced by the passage of 
air through the larger bronchial tubes, the healthy lung being an 
imperfect conductor of sound, so that as soon as any portion of the 
lung becomes consolidated the vesicular element of the respiratory 
sound is diminished, the bronchial element becoming prominent. 
Harsh respiration is, then, a union of tlie vesicular and bronchial 
sounds, being a vesicular sound mixed with some of the quahties of 
a bronchial sound, the expiration being prolonged and tubular in 
character. It is present when the bronchial mucous membrane is 
swollen, as in the earlier stages of bronchitis, also In the earlier stages 
of phthisis and pneumonia. 

Bronchial respiration is characterized by an entire absence of 
all the vesicular quality. Inspiration is of high pitch and tubular in 
character; expiration still higher in pitch, of greater intensity, ^m- 
ionged and tubular in quality ; the two sounds being separated by a 



nil 



irriCK OF MEDICINE, 



'I'lii- liroiiiliijil ro*i»ration encountered in disease closely resembles 
tliiil lieunl In hcnltli over tlic larynx or trachea. Whenever bronchial 
ii'<|iiiiillfiii i« prenent where, in health, the nonnal vesicular murmur ■ 
Khiintil 111* hi'iird, it indiciile'i consolidation of the lung structure. 

OaVnmouB reaplrtition i> n variety of the bronchial respiration, 
til It-nxt III fitr a» the quality of the sotind is concerned. It is essen- 
lliilly » blowing smind, yet not always heard during both the act of 
ln*|ilr<itli>n und expirutinn. being often only perceptible in the one, 
uiul in the other mixed with gurgling sounds. Its fiiicA is lower than 
that of ordinary bronchial respiration, and its ckaraeter is hollow. 

l''or ill production there must be a cavity of considerable «te in 
the lung (ubstnnce. not filled with fluid, near the surface of the chest 
wallo, cumniunicaiing ivith a bronchial tube. It is met with most 
commonly in the last stages of pulmonary consumption, although 
liollow a)inces o( any kind, from abscess or dilatation of the bronchial 
tube*. OCT asiun it. 

Amphoric , r«aptrfttiOQ is a blowng respitation. having a 
miiMV;)! or metallic quality. It is a variety of bronchial re^Kration 
trnvdiii-'nl in u Urye cavity with Attn walls, permitting the rcfleciion 
nf the $«und. An imitatiaa of Ais sound, though otil; an inpofect 
nni?. i« pi^ur««t by blowinj; over the moudi of an onpCy bonle. 
Th« an))>hikrk choracKr is present with both the act of ia^araiwa 
and c^niiiAO. 

AwpbiuK or wMallic respintioo is iniBcatire of a fatige cantf. dm 
cmvmwn in phthisis, but much oftener heard at iJM apper pan of a 
luivij t>>m|)««s«(il by Ai^ and air, as in paeaoKi-hjAo-tfianK. 



RALES. 

Irillffl. «r as tbi^aiv tamed, adtvMSaStaa ^ —uh . 
Itav* M) «W*)«e«e w dw healAif ttMb. ctSDW be 
twibwwrf ^ » o wa al iwywamao. 

t>««pt<l a«Mdi«e *)* '^ MrWBMfeal ateMM 



^ tntAwSm-vM*. 



PHYSICAL DIAGNOSIS. 171 

Bales may be divided into two groups, according to their char- 
acter, to wit: dry and moisl, and maybe audible either during the act 
of inspiration or expiration, or during both. 

Dry ralea, for the most part, are produced by the vibration of 
thick fluids which the air cannot lireak up, and which, therefore, tem- 
porarily narrows the calibre of the bronchial tubes. When this nar- 
rowing exists in the smaller bronchial tubes the resulting sound is 
high-pitched, or the rale is said to be sibilant or whisding ; When the 
narrowing exists in the larger bronchial tubes, the rale is low-piUhed, 
more musical in character, or sonorous. 

Dry rales are particularly prone to be dislodged by coughing, and 
when they are uninfluenced by the acts of breathing or coughing, 
they do not depend upon the presence of secretions, but upon the 
narrowing of the air tubes frotn the pressure of tumors, or from a 
thickened fold of raucous membrane, or from a spasmodic contrac- 
tion of the air tubes. 

Moist ralas are those produced by air passing through thin fluids, 
such as mucus, blood, serum, or pus, during the respiratory move- 
ments. When the fiuid exists in the smaller bronchial tubes, the 
rales are termed small bubbling, mucous, or siibcrepitant. When the 
fluid exists in the large bronchial tubes, the r&les arc said to be 
large bubbling or mucous. 

Moist rales are not persistent, but vary in intensity, and shift their 
positions as the air drives the liquid which occasions them before 
it, or during violent attacks of coughing, or after copious expecto- 

Laryngreal and tracheal ralea are those produced within the 
larynx and trachea, and may be cither moist or dry. The moist or 
bubbling sounds, produced when mucus or other liquids accumulate 
in this part of the air tubes, frequently occur in the moribund state, 
and are then known as the " death rattles." When not due to this 
condition, they denote either insensibility to the presence of liquid, 
as in stupor or coma, or inability to re'move liquid by the acts of 
expectoration, as in croup or inflammadon of these parts in the very 
feeble. 

The dry rales produced within the larynx or trachea are generally 
caused by spasm of the glottis, to wit : laryngismus stridulus, 
whooping cough and croup, or from the presence of a foreign body 
in the part. 



PRACTICE OF MEDICINE. 

Bronchial rales, resulting from the passage of air through the 
thin liquid, occasion bubbling sounds. When the liquid is present 
in the larger-sized bronchial tubes, the rales are said to be large 
bubbling, or large mucous rales, and are heard in acute or chronic 
bronchitis. 

When the liquid is in the smaller branchial tubes, the resulting rile 
is called small bubbling, small mucous, or subcrepitant, also occurring 
in acute or chronic bronchitis. 

Bronchial rales due to the narrowing of the tube by its spasmodic 
contraction, or to the presence of tough, tenacious mucus, which is set 
in vibration by the passage of air through the bronchial tubes, are 
termed dry bronchial rales; Frequently they are suggestive of cer- 
tain familiar sounds, such as snoring, cooing, humming or wheezing, 
or they are often musical notes. When produced in the smaller 
bronchial tubes, they are termed sibilant, or high-pitched rales; when 
produced in the larger bronchial tubes, they are termed sonorous or 
low-pitched rales. They principally occur in the dry stage of bron- 
chitis, or during an asthmatic paroxysm. 

The vesicular r4le, or. as it is more commonly termed, the 
crepitant rSIe, is produced within the air vesicles or at the terminal 
portion of the smaller bronchial tubes. 

Itis to be distinguished from very fine bubbling sounds, or the sub- 
crepitant rale. " It is a -very fine sound, or ratlier series of very fine 
uniform sounds, occurring in puffs and limited to inspiration." It 
resembles the noise occasioned by throwing salt on the fire, or alter- 
nately pressing and separating the thumb and finger, moistened with 
a solution of gum arabic. and held near the ear, or nibbing together a 
lock of dry hair near the ear. 

The crepitant rale is produced by the movement of fluid in the 
air cells or in the finest extremities of the bronchial tubes, or by the 
forcing open, during the act of inspiration, of the air cells aggluti- 
nated by exuded lymph. These sounds may be defined as being 
very fine, dry, crackling sounds, heard at the end of inspiration. They 
are usually present in the first stage of pneumonia, and when limited 
to the apices, are significant of the incipient stage of phthisis. 

Cavernous rales, or, as they are commonly termed, gurgling 
rales, are produced in a pulmonary cavity of considerable siie, 
containing a large quantity of liquid communicating freely with a 
bronchial tube. The sound is occasioned by the agitation of the 



PHYSICAL DIAGNOSIS. 173 

liquid wilhin the cavity, and may be compared to the sound produced 
by the boiling of liquid in a flask or large test tube. The sound 
is sometimes high-pitched or musical, whence it has been termed 
" amphoric gurgling," but it is generally low in pitch. The rale is 
heard almost exclusively during the act of inspiration, and its diag- 
nostic importance relates to the advanced slage of phthisis. 
. Pleural r&les may be either dry or moist. 

Dry pleural raUs, or as they are more commonly termed, /n>/wj 
sounds, are occasioned when the surfaces of the pleura are covered 
with a glutinous substance preventing the unobstructed movement of 
the pleural surfaces upon each other during the respiratory acts, for 
in health these movements occasion no sound whatever. The sounds 
are generally interrupted or irregular, .occurring during the act of 
inspiration or expiration, or during both acts. The character of the 
sound is variable, being termed rubbing, grazing, rasping, grating or 
creaking, according to the intensity of the respiratory acts and the 
amount of exudation. 

They are distinguished by the apparent nearness of the sound to 
the ear, and are usually intensified by firm pressure of the stetho- 
scope upon the chest. When the chest is fixed, especially at the 
lower two-thirds, and the ear applied over the seat of the sound, it 
will be found to have disappeared. This sound is diagnosflc of the 
first stage of pleurisy. 

Moist ftiction sounds are produced in the same manner as those 
just mentioned, the exudation being softened in character. This 
sound is frequently confounded with moist bronchial rales, and its 
discrimination is often only positive by a careful study of the symp- 
toms and concomitant signs present. 

Metallic tinkling is a sign of pneumo-hydro-thorax with per- 
foration of the lung, and when found is usually diagnostic of this 
affection, although it occurs rarely in cases of phthisis with a large 
cavity, the physical conditions for its production being similar to those 
in pneumo-hydro -thorax, to wit:— -a space of considerable size contain- 
ing air and liquid, the space communicating with the bronchial tubes. 

It consists of a series of tinkling sounds, of high pitch, silvery or 
metallic in tone, and is very well imitated by dropping a small marble 
into a metallic vase. It occurs irregularlyi not being present with 
every act of breathing, and may be produced by forced, when not 
heard during tranquil breathing, 



174 PRACTICE OF MEDICINE. 

Were it not for the location and the absence of concomitant signs, 
it might be confounded with tinkling sounds sometimes produced 
H-ilhin (he stomach. 



THE VOICE IN DISEASE. 



r the third rib of 



The normal vocal resonance, as heard c 
the chest anteriorly on either side, may have it 

1. Diminished or absent. 

2. Increased or exaggerated. 

Or its resonance may be of the character of — 

3. Bronchophony. 

4. Pectoriloquy. 

5. ACgqfkony. 

6. Amfikorie voice. 

The vocal resonance may be diminished or feeble in 
bronchitis with free secretion, pleurisy with effusion, or in complete 
consolidation of the lung structure and the bronchial tubes. 

The vocal resonance is absent in pneumothorax and in 
pleurisy with effusiOH. 

Bxagrererated vocal resonance differs from the normal vocal 
resonance in a slight increase of its density. It denotes a slight 
degree of solidification of lung tissue, and is chiefly of value in the 
diagnosis of lubercle. 

Bronchophony, or the voice concentrated near the ear, raised 
in pitch and in intensity, denotes complete consohdation of the 
pulmonary tissue in those parts in which the sound is abnormally 
present. 

Pectoriloquy is a complete transmission of the voice to the ear, 
the articulated words being distinctly recogniied. It has a close 
resemblance to the resonance heard over the larynx in health. Its 
presence indicates either a pulmonary cavity or more complete con- 
solidation — in other words, an exaggerated bronchophony. 

.ffigrophony is a modification of bronchophony, consisting in 
tremulousness of the voice, its character nasal or bleating, somewhat 
suggestive of the cry of a goal. When heard, it may be considered 
a sign of pleurisy with slight effusion, or pi euro-pneumonia. 

Amphoric voice, or " the echo," as it is sometimes called, is a 
musical sound, of a somewhat hollow, metallic character, hkc that 



raVSICAI. DIAGNOSIS. 



ITS'- 



produced by blowing i 
duced in lar^e cavities 
pneumoihorax. 

Increased bronchial whisper is a sound in which the whis- 
pered words are abnormally intense, and higher in pitch than the 
normal bronchial whisper. It has the same significance as exagger- 
ated vocal ri 



1 empty bottle. It i! 

I the lung, but is especially incident tt 



SUCCUSSION. 

The succusBioQ or splashing sound is pathognomonic of one 
affection, namely, pneumo-bydro-thorax. 

It is obtained by jerking the body of the patient with a quick, some- 
what forcible movement, the ear being very near or in contact with 
the chest. 

The sound is like that produced when a jmall keg, partially filled 
with liquid, is shaken. The only liability to error is in confounding 
this splashing sound with that sometimes produced within the stom- 
ach ; but attention lo concomitant signs and the symptoms will always 
protect against this error. 

ASSOCIATION OF THE PHYSICAL SIGNS (dA COSTA.) 

"As many of the signs elicited by the various methods of physical 
diagnosis depend on the same physical conditions, they may be 
studied in groups. The following will be usually found to be asso- 



Fbkm 





lu IDDdlG- 


Bronchophony 


,™.. 


DO Lcrcawd tLui' 
from dipotiu, elt. 
Sol>dilic[lDn of pulnon 




^Sn™'''" 


AblrB. voice. 


Dimmishcd 
abtenl. 




Metric. 


cording iQ 


Amphoric ar 
meuillii:. 


MotUy di- 


L»rg= fflvUy *iih«Ia.u 


Cracked 


C=«m.„» 


C:.vernous 


Un«ruin. 


Gtncr.llyacavi^«,lBin 



PKACnCE OP MEDICINE, 



DISKASES OF THE NASAL PASSAGES. 



ACUTE NASAL CATARRH. 

SynonyniB. Acute rhinitis ; acute coryia; " cold in the head." 

Duflnitiotl. An acute catarrhal inflammation of the mucous 
inLMnbriinu Ipituitwy or Schneidcrian membrane) lining the nose and 
the cavilics comniunicaling with it; characterized by feverishness, 
fccliri),! of fullness in the head, and attended with discharges of fluid, 
wiilery, mucus, or mnco-purulcnl in character. 

Patbolo^oal Anatomy. Hypermmia of the mucous mem- 
brane, attended with redness, swelling and deficient secredon. This 
tumefaction is partly increased by an adematous infiltration, cxaswi^ a 
quantity of colorless, salty and very thin liquid to flow from the nose. 
The secretion soon becomes thicker and opaque, due to the desqua- 
iii«tion of the epithelium of the nasal mucous membrane, and a 
copious gcncrntion of young cells, the hyperemia and the* swelling 
of the mcmhrnnc diminishing. 

The rcipirntory portions of the nasal fossie are more markedly 
BtTcctcd than are the olfactory. 

Rarely, and then in newborn infants and those affected with the 
eruptive fevers, the exudation in the nasal passages is of a fibrinous 
naiure, somewhat similar to that observed in diphtheria. 

OaUseB. Atmospherical changes are the most frequent and in- 
HiiFnlial. Kxpnsure of (he neck to a draft of cold air, or of the feet 
nnd ankles to cold and dampness, or changing from a warm to a cold 
Atmosphere suddenly, are among the most usual causes. 

Irritating gases and vapors, dust, certain powders, as ipecac and 
toblLCCO, excite an irritation of the nasal mucous membrane. 



n the initial s 



f measles and 



of the iodide of 



Acute corym is usually present 
influentn. 

Epidemic influence occasionally prevails or 
The ptiisan of syphilis or the long continued 
potmium nvit unfreqtiendy act as exciting causes. 

At times the catarrh sceins to spread by conta^on. 

Symptoms. " A cold in the head " is usually preceded by a feel- 
ing of lass.ituttf or vreariness and more or less Mtadaeke ,- then occur 
itrcsulat ekUty stms»li«mt, followed by more or less fettritkmest aad 



DISEASES OF THE NASAT. PASSAGES. 177 ' 

an uncomfortable feeling of dryness in the nares, with a strong in- 
clination to sneeze. This Is soon fallowed by an abundant 'waiery 
and saline discharge, which Is continually dripping from the nostrils, 
or occasions an attack of sneezing followed by blowing the nose, 
which reheves the congested and swollen membrane for a few mo- 
ments. The relief is temporary, however, the fullness of the head 
and difficult ohstructed nasal respiration rapidly returnmg. The 
anterior nares are red and inflamed. The discharge soon assumes 
a puruleHt character. The voice has a peculiar tone, rather nasal 
and muffled in character. Within a few days the swelling subsides, 
Ihe secretion lessens, health being restored in about ten days frotn 
the beginning of the attack. 

When the attack has almost terminated hard crusts may form 
within the nostrils, either on the septum or turbinated bones, which 
are with difficulty expelled hy blowing the nose. 

Oomplications, Irritation and swelling of the upper lip, from 
repeated blowing of the nose and the constant contact of the irri- 
tating discharge. 

Extension of the catarrh to the ethmoid or sphenoid cavities or 
frontal sinus, causing increased and severe headache ; or to the 
antrum of Hightnore, causing tenderness over one or both cheeks. 

Extension to 'the Eustachian tube and middle ear, causing impaired' 
hearing ; or to the pharynx or larynx, causing cough. 

Duration. In mild cases about one week ; severe cases continue, 
more or less marked, for two weeks. 

PrognoBis. Favorable if early and proper treatment be insti- 
tuted; if neglected, the catarrh tends to become chronic. In very 
young infanta, if the catarrh is not rapidly relieved, loss of flesh and 
strength occur, from inability to take the breast. 

Treatment. Attacks the result of atmospherical causes may be 
aborted by the early administration of quininis sulphas, gr. x-xv, 
with morphints sulplias, gr. ^ , or the early use alpulvis ipecacuanha 
et opii, gr. x-xv. 

The following errhine used at the very onset has proved successful 
in aborting severe cases : — 

B. Amylii, finely powdereri 5J 

Cocaine hydrpch lor gr. ij-iv. M. 

SIG. — Every half hour. 



178 



PRACTICE OF MEDICINE. 



If the attack has already developed, relief is soon afforded by 
tinctura belladonnce, gtt. ij every hour until six doses are taken, after 
which one drop every two or three hours until the physiological actions 
of the drug are produced ; if much fever be present, tinctura aconiti, 
gtt. i-ij, nfiay be added. 

An efficient plan of treating .acute coryza is by producing free 
diaphoresis with " Dover's powder," gr. x, repeated, if need be, 
followed by — 

U, Potassii citratis 3ij-iv 

Synipi ij>ecac, 

Tinct. opii camph .tia, ^ij-i^ 

Syr. limonis , ^iv 

Aquae ad« giij. M. 

SiG. — One or two teaspoonfuls every hour or two. 

With .either of the above plans may be 'added one of the following 
lerrhines : — 

« 

R. Bismuth subnit 3 vj 

Pulv. acaciae ^ ^ ij 

Morphinae hydrochlor gr. ij. M. 

SiG. — Every hour or two. — (Ferrier). 

R. Pulv. cubebae 3J 

Bismuth, subnit gij 

Morphinae muriat .gr. ij. M. 

SiG. — ^Used by insufflation every two or three hours. 



Or— 



Or— 



Pulv. fol. belladonnae 9j 

Pulv. morphinae sulph gr: ij 

Pulv. g. acaciae ^ad ^ss. M. 

SiG. — Use, with powder blower, to anterior and posterior nares, 
(Robinson). 

Acute coryza occurring in infants at the breast is controlled by 
either one of the following errhines: throw into the nose, with a 
powder blower, finely powdered saccharum alba, or equal parts of 
finely powdered saccharum album and camphorce, or Robinson's err- 
hine of saccharum alba and camphora, each half ounce finely pow'- 
dered and acidum tannicum, gr. xl. 

Attacks of nasal catarrh due to the poison of syphilis should at 
once be placed upon the proper constitutional treatment. 



DISEASES OF THE* NASAL PASSAGES. 

Attacks of nasal catarrh associated with the eruptive or mild fevei»B 
require no special treatment. 

It is well to remember that attacks of nasal catarrh occurring ii 
very young children are generally the result of hereditary syphilis 
and should be treated accordingly. 



CHRONIC NASAL CATARRH. 



Synonyms. Chronic rhii 
Definition. A chronic in 
lining the nasal passages, with 
zed by 



chronic coryza. 

of the mucous membrane ] 
ore or less alteration of structure; 
fullness in the nares, increased 
I perversion of the special sense of smell and of 
hearing. 

Causes. The result of repeated attacks of the acute variety ; in- 
halation of irritating vapors and dust ; syphilis and scrofula. J 
. Pathological Anatomy. The mucous membrane of the nare&w 
is thickened, of a dark-red, sometimes grayish color, the superficial 1 
veins dilated and varicose, often forming polypoid enlargements. In 
many cases there is ulceration of the structure, with more or less loss 
of substance ; the secretion is thick, tough, of a greenish character, 
and often very fetid ; large collections of dried mucus are often formed _ 
upon the turbinated bones and septum. 

SymptomB. Afeehng oi fullness in the na 
secretion, the character being thick and greenish, which, droppini 
posteriorly into the pharynx, causes paroxysms of " hawking," whidt^ 
are more marked in the morning immediately after arising. 

The special sense of srnell is more or less impaired, and, 
cases, entirely abolished; the special sense of hearing is mo; 
diminished, from an extension of the inflammation to the Eustachlui \ 
tubes ; the voice has a peculiar nasal intonation. 

Sudden changes of temperature caiise acute exacerbation of these J 
symptoms, when there is superadded difficult nasal respiration. 

If ulceration of the nares occur, the discharge has a fetid o 
This condition is termed osana. 

From extension of the inflammation to the nasal duct or its 
strucrion, the tears flow over the malar eminence {epiphora), leat 
to more or less congestion of the eyes. 



DSaCDOBB. HypertrofJbr of the mlBttsaed haaes u 
pbuyniieal camrii «tc iukm ■■It; wiiiuiwMjd dnoaic nasaJ eaten)). 

l^QtflkOSBw Pemuhcst cvrc iK wirtnw sbcuBcd. t he disease 
txang so deddedlr diroiuc and otwlmatr. Ac liTMtmcnl is of seoes- 
Rt)r pnNmaed, aad the nu^ontjr of paoents tire of k before a com- 
pteie cure is efieoed. 

Trastnunt. If ii dqiead upon diatfaeik condinons. ibc cause 
BiM be asceftaioed and treatment direcUd >UHdiBg}y. 

Wben BO £alhetic cause can be detenmned, anention should be 
pud to Ac gcnoal healtfa, the secretkiiis nwataiWly anended to. and 
fli^ diet noDritJoos and d^estAJc 

(JautUKfsi of ibe nasal passages is ai' Ae itfotoa tmpoitance, and 
is best effected by the fi^st mataf sjrrimge. wiA aibet sastpie or medi- 
cated tepid waters, or a cjeansng solntion, SDch as Dobell's, to wii: 

B- Addi (aitoiki. _.,_.„ _ p. j 

Sodii l»c»ri)onit ' 

Sodii bone ^ H . p. t 

Gljtcriid . 3i 

A<|BK- 3J- **- 

Sic — Ai > i^mf or vidi ■ proper sfri^e. 
after which d^ded benefit lolknrs die use at one of the Mlomi^: — 

fi. Sodiibcoat 3ij 

KanMh. sabnit. Sq 

U<»pin» nmriiL p. j- M. 

Or— 

B- lodofonm 3i 

PuIt. campbone. _ , „ jj 

Bismoth. sibok ^j. M. 

Sic — To be tued by utni^EatiMi or as a ntjf, croy lluec or four 

Or— °™'' . 

B- Ammoiui muriat. jj 

Glyceriai_ ,. jij 

Vini pids, Jiq _ jij. M. 

Sic. — Five to ten drops, dropped iwo each nostril iwo as ihree limcK a 
■day. 



DISEASES OF THE PHARYNX. 



ACUTE CATARRHAL PHARYNGITIS. 
Synonyms, Catarrhal tonsillitis ; angina catairhalis ; acuW'^ 

Definition. An acute catarrhal Inflammation of the mucoui i 
membrane of the tonsils, uvula, soft palate and pharynx; character- 
ized by rigors, fever, painful deglutition, coughing, or constant desire 
to clear the throat, with a more or \ess decided nasal intonation of the 

Causes. Exposure to cold and damp; swallowing hot fluids or 1 
food ; during the prevalence of scarlalina, measles or variola. ] 

Pathological Anatomy. The mucous membrane and sub- 
mucous tissues of the uvula, soft palate, fauces, tonsils and pharynx 
are congested, red and swollen, the secretion is at first lessened or 
entirely arrested, later it is increased, but of a thick, tenacious, opaque 
character. The swelling is most evident at tbe uvula, due to the 
amount of relaxed sub-mucous tissue, which is especially thick and 
long, often resting on the root of the tongue (" the palate is down"). 

Frequently one or both tonsils are swollen to such an extent that 
the fauces are completely occluded, and the condition is mistaken for _ 
the graver phlegmonous tonsillitis. 

In severe attacks of catarrhal angina, white or grayish-white mem-- 
branous masses form in small, irregular, roundish spots on the red- ' 
dened mucous membrane of the tonsils, soft palate and pharynx, 
causing the affection lo be frequently mistaken for diphtheria. 

Symptoms. The onset is usually sudden, with rigors, fever, 
thirst, headache, loss of appetite, coated tongue, bad taste, fool 
breath, dryness in the throat, painful deglulilian, and constant desire \ 
to clear the throat, due to the increased length of the uvula ; 
the inflammation proceeds the secretions are increased, the fluid often 
filling the mouth and also causing a constant desire to swallow, each 
act being accompanied with pain. Not infrequently earache adds lo 
thepatient'sdistress, from extension of the "catarrh" to the Eustachian \^ 
tubes and tympanum. 

In severe attacks of catarrhal pharyngitis, cases which, from t 
intense hyperremia, have been ^rmed -erysipeiatous oi e/yihe 



^ IBS PRACTICE OF MEDICINE. 

pharyngitis, the muscles of the palate are infiltrated with serum, 
which greatly interferes with their function. Under normal condi- 
tions the contraction of the muscles of the anterior half arches of the 
palate prevents the return of the foAl and drink into the mouth; 
while the contraction of the muscles of the posterior half arches, 
together with the uvula, closes the passage to the nose : if the fiinc- 
tion of these muscles be impaired, fluids would be driven through the 
nose or back into the mouth by the contractions of the pharynx in the 
act of deglutition. 

In all affections of the pharynx a nasal tone is pathognomonic, 
especially if the muscles of the half arcljes are interfered with. 

Dia^nasis, On account of the great sweUing of the tonsils, it 
may be mistaken for acvle tonsillitis: but the mild inflammatory 
symptoms should prevent the error. 

Cases with membranous deposits upon the tonsils, soft palate and 
pharynx are no doubt often xd\%'a^vasA diphtheria ; the marked ditfer- 
ence in the constitutional symptoms should prevent the error. 

Prognosis. Favorable, the affection terminating in three or four 
days by the raising of a quantity of thick, opaque mucus. 

Treatment. Perhaps the moat successful treatment of this affec- 
tion is by insufflation, every.hour or two, with sodii bicarbonas. 

If the inflammatory symptoms are severe, tinctura aconili, gtt. j-ij, 
at short intervals, is of decided advantage- At times tinctura bella- 
donna may be added. 

Locally, small pellets of ice are useful, or heat or cold to the Angles 
of the jaw. Gargles or sfirays of aluminis, ammonii tnurias or 
potassii ckloras, used at frequent intervals, often allay the congestion 
and consequent swelling. 



ACUTE TONSILLITIS. 

Synonyms. Amygdalitis; quinsy; phlegmonous pharyngitis. 

Definition. An acute parenchymatous inflammation of one or 
both tonsils, with a strong tendency toward suppuration; character- 
ized by moderate fever, pain in the throat, a constant desire lo 
relieve the throat, painful and difficult deglutition, impeded respira- 
tion, and more or less muffling of the voice. 

Causes. Generally attributed to exposure to cold, but, in the ma- ■ 
jority of cases, the exposure is so slight that there must be a. predis- 




DISEASES OF T 




position to the affection ; for persons once affected are particularly 
prone to repealed attacks, upon the slightest exposure. 

Pathological Anatomy. One or both tonsils will be seen, on 
inspection, to project from its bed, as a rounded, deep red body, which 
may eveti extend beyond the median hne. when they may entirely 
occlude the isthmus of the fauces; the half arches and posterior border 
of the soft palate are reddened and somewhat swollen. The surface- 
of the tonsils is often covered with small, "yellowish points, which 
closely resemble patches of false membrane, but careful inspectii 
will show that they are beneath the mucous membrane, being only the 
distended follicles of the gland. The mucous membrane of the fauces 
and pharynx is more or less red and swollen. 

Byinptom8. Onset more or less sudden, with ri^^ors, rise in tem- 
ptralure 102° lo 104° F., full, frequent pulse; loo to 130, headiuht, 
thirst, pain and swellitiff at the angle tf the jaTv.vilih a constant desire 
to dear the throat, difficiilt and painful di^glutition, from the enlarged 
tonsils almost closiftg the fauces, when the respiration is more or less 
impeded : the voice is more or less muffled, and attempts at phonatioH 

Darting pains along the Eustachian tubes are of frequent occur- 
rence, the patient complaining of earache and more or less deafness. 

\i suppuration be imminent, the throat becomes moic painful, the 
character of the p3.\a throbbing, Ih^ febrile phenomena increased, with 
more or less depression, the symptpms seeming to be of great danger, 
when suddenly, after an effort at vomiting, or spontaneoilsly, the toa- 
sillar abscess bursts, a quantity of pus escapes from the mouth, and 
prompt relief follows. 

Duration. The disease lasts from three to seven days, terminat- 
ing either by suppuration or the gradual resolution of the enlarged 
glands. 

Diagnosis. Tonsillitis can hardly be mistaken for any other 
affection, if the fauces are inspected. 

PrognoBis. In the majority of cases the result is favorable, 
very rarely proving fatal, except in children, and only then by ob- 
structing the respiration, and. at the same time, so seriously interferin|f;] 
with nutrition that the child's strength fails. 

Treatment. If seen early scarification should be performed,..! 
thereby relieving the engorged gland. The external use of ii 
the site of the glands, and small pellets allowed to dissolve 



|1 

I 



mouth, afford great relief. If the application of cold be objection- 
able, heat maybe substituted, in the form of warm compresses or 
poultices. 

If administered at the very onset, the inflammation may be aborted 
by quininix sulphas., gr. x-yx, comhined with morphinte sulphas., 
gi"- ^~% : free emesis is also recommended, for the same purpose. 

After the inflammation is established, the administration of tinctura 
aconiti, in small doses, frequently repeated, rapidly reduces the tem- 
perature and frequency of the pulse, and. by its local action, lessens 
the pain and swelling. If from any cause the tnterna! use of aceitilurtt 
be contra-indicated, the linctura aconiti may be diluted with gfy- 
cerinum and painted over the affected parts. The author has seen 
excellent results follow the uSe oi sedii salicylat., gr. x-xv, in solution, 
every hour, until four doses are taken, when the remedy is omitted 
for three hours, and again administered, as at first, or relief may fol- 
low hydrargyri ckloridum mite., gr. ^, every two hours. 

The following ^afg-/tf is highly spoken of by those using it: — 

B- Tina. RUaiaci ammon. 

Tinct. cinchonjE comp s& f3ij 

Mel. despumati „ jvj. 

M. and shake together until the adea of the containing vessel are well 
greased, then 
Adde 

R. Polassii chloral 3 iv 

AquEE deslil _ Jiv. 

M, and add gradualij, coulinqing shaking. 

" This should be used by the patient at intervals of every half an 
hour to an hour. 

Insufflation with sodii bicarbonas is recommended. 

If jM/^Saraft'oB be impending y«iWna should be used, gr. iij-v, every 
three or four hours. * 

Locaily the application of poultices over the affected gland hastens 
the process of suppuration when once begun. 

The diet must be in the shape of gruels, as it is impossible for the 
palient to swallow any solid substance, and in cases where even gruels 
cause painful deglutition, thin oatmeal gruel can be used with ad- 
vantage. 



DISEASES OF THE LARYNX. 



■ACUTE CATARRHAL LARYNGITIS. 

Synonyms. Catarrhal laryngitis ; " sore throat." 

Definition. An acute catarrhal inflammation of the mucous 
membrane of the larynx ; characterized by feverishness, diminished 
or suppressed voice, painful deglutition, and mote or less impeded 
respiration. 

Causes. Atmospherical changes; the inhalation of irritating 
vapors, such as gas, smoke, or ammonia, and in children, from 
violent attacks of crying. 

Pathological Anatomy. In mild cases there is a. transient ' 
congeslian (hyperfemja) of the mucous memhrane over the entire, but 
more commonly, circumscribed portions of the larynx, with more or 
less swelling and diminished secretion ; the mucous membrane soon 
returns to its normal condition, the secretion being slighUy increased. 

Symptoms. The onset is rather sudden, with irregular rigors, 
a feeling of heal, ra-wness and tickUng, referred to the larynx and 
pharynx, with a sensation of the presence of a foreign body in the 
throat. Swallowing causes pain by the upward movement of the 
larynx and by the pressure of the food on the larynx as it passes 
along the gullet. 

Coughing, from the onset, of a noisy, harsh, hoarse, or toneless 
character; in children the cough has a ringing, son oroiis, so-called * 
"croupy" character, the act of coughing causing a sensation of 
scratching in thelaryns. The first day or two there is scanty expectora- 
tion, but in a short time the secretion is increased, giving the cotigh 
a loose character. In the early stages the sputa may be slightly 
streaked with blood. The -voice is at first decidedly hoarse, soon 
followed by complete aphonia. 

Duration. Usually about one week : if very severe two or three 
weeks may elapse before the larynx returns to its normal condition. 

PrognosiB. Simple catarrhal laryngitis never terminates fatally. 

Treatment. Confinement to an apartment of uniform tempera- 
ture, the air kept moist by the vapor of water disengaged in it. 

Local/y a hoi or cold pack should be kept constantly wrapped , 
about the throat, and if its application is preceded by the temporary < 



186 PRACTICE OF MEDICINE. 

use of a weak mustard plaster, the relief afforded is more rapidly- 
obtained. At the very beginning of an attack the feet should be 
placed in a hot mustard foot bath, and a sa/i'ne caiAar/ic a-drnmis- 
tered. 

Inlenially, Hnchira aconiti, gtt. j-ij every half hour until three or 
four doses are taken, after which every hour or two, combined with 
tiHctura opii deoilorat., ffX.]-v, relieve the inflamed mucous mem- 
brane,' or instead, the use of antimonit el potassii iartras, gr. j^tV 
every hour. If a tendency to spasm of the glottis obtains, full doses 
of the bromides should be administered at once. 



(EDEMATOUS LARYNGITIS. 

Synonjnn. Oidema of the glotljs. 

Definition. An inflammation of the mucous membrane of the 
laryns and that about the glottis, with a serous efTusion into the sub- 
mucous connective tissue; characterized by obstruction to the respi- 
ration and difficult phonalion. 

Causes. The result of acute laryngitis ; abscess in or about the 
throat or tonsils ; erysipelas of the face ; scarlatina ; smallpox ; 
Bright 's disease. 

Pathological Anatomy. Infiltration Into the loose connective 
tissue of the ary-epiglottic faWs, the glosso-epiglottic ligament, the 
base of the epiglottis, and the Inter- arytenoid space. If the true 
vocal cords are inflamed, their color changes, and instead of appear- 
ing while, glistening and brilliant, they are duii, grayish-red or violet- 
red in patches. If thp swelling be the result of purulent infiltration, 
the parts affected present a deeply congested color, with here and 
there spots of a yellowish hue. 

Serous infiltration, sufficient to cause fatal (Edema, disappears 
with death, leaving but slight traces to account for the formidable 
symptoms. 

Symptomfl. At the onset the same as tho'se of catarrhal laryn- 
gitis, soon followed by a sensation of distress anApain in the throat, 
with difficulty of breathing and paroxysms of impending suffocatioK. 
The cough at first is dry and harsh, but as the infiltration increases it 
becomes stridulous and suppressed. The voice, at first muffled. Is 
soon suppressed. The difficulty of respiration in some cases becomes 
so great that the face is blue, the eyes protruded, the patient gasping 



for breath, these symptoms continuing for a few moments, when 
relief is temporarily afforded, the paroxysms soon recurring, how- 
ever, in one of which, unless decided relief be promptly afforded, 
the patient perishes. 

Diagnosis. The points of difference between eedema of the 
glottis and capillary bronchitis, asthma and croup will be pointed out 
when discussing those affections. 

But the history of the case, the sudden occurrence of suffocative 
attacks, an examination of the throat by passing the index finger 
carefully over the base of the tongue, will generally prevent the 
disease being mistaken for any other affection. 

PrognoBiB. As a rule unfavorable ; if early and vigorous treat- 
ment be instituted, recovery is possible, but without it death is the 
inevitable result, the patient dying asphyxiated. The duration of in- 
filtration of the larynx varies from a few hours to several days. 

Treatment. At the onset, if the fever be high, the use of tirtc- 
fura aconili, gtt. ij-iv, repeated, with the administration of an active 
purgative, may prevent the serous effusion. 

If the ittfillration has already occurred and is slight In amount, 
scarification, guiding the instrument by the index linger of the oppo- 
site hand, may afford relief, or the Jiypodermatic injection o^ pilo- 
carpine nilraris,%r. %, repeated. If these means fail, iracheotomy 
is indicated; in those cases of sudden and rapid infiltration of the 
glottis or larynx occurring in Bright's disease, erysipelas or scarla- 
tina, and especially the former, tracheotomy skouiil be performed 
at once. 

In all cases of infiltration of the larynx stimulants should be boldly 
administered per rectum, if stomachic administration be impossible. 

If the infiltration be composed a{ pus, quiiiince sulphas., gr. v doses 
every four hours, and stimulants are indicated. 

SPASMODIC LARYNGITIS. 

Synonyms. Spasmodic croup ;' false croup; catarrhal croup. 

Deflnition. A catarrhal inflammation of the mucous membrane 
of the larynx, associated with spasmodic contraction of the glotrig; 
characterized by paroxysmal coughing, difficulty of breathing and 
attacks of threatening suffocation. 



I 



1B8 



PBACTICE OF 



Causes. Delayed or difficult dentition ; excesses in eating and 
drinking; excitement; violent emotion and atmospherical changes, 
are all given as causes for simple croup. It is often hereditary 

Pathological Anatomy. Omgestion of the mucous mem- 
brane c>f the larj-nx, with slight swelling and deficient secretion, are 
the only changes that have thus far been noted. 

Symptoms. The attack occurs chiefly during the night, the child 
on retiring having either its usual health, or, perhaps, being a little fever- 
ish. After several hours of sleep the child is suddenly awakened by a 
paroxysm of suffocation, and a dry, harsh, ringing cough. After half 
an hour or an hour or two the breathing becomes easier, the cough 
less " croupy," the skin is covered with more or less perspiration, and 
the child falls asleep. The next day there is present cough of a loose 
character, the respiration being about normal. If no trcatnient be 
instituted, the same phenomena occur on the second night, the child 
being apparently well during the second day, the cough being less in 
amount; phenomena of a similar character, but of jnuth less sever- 
ity, are present the third night, after which the disease usually dis- 
appears. 

If the symptoms of the first paroxysm continue pronounced for 
two or three days, there is a strong probability that the inflam- 
mation may become fibrinous in character, or that true croup may . 
develop. 

Diagnosis. The symptoms are so characteristic that it seems im- 
possible for the affection to be mistaken for any other disease. 
Prognosis. Spasmodic or simple croup always terminates favor- 
Treatment. During the paroxysm, the child should at once be ' 
placed in a hot bath and hot or cold compresses wrapped about the 
throat. These means may be preceded or followed by a mild emetic. 
The air of the room should be moistened by the vapor of steam con- 
stantly disengaged in it. 

For the prevention of an attack" of spasmodic croup, a mild 
cathartic, followed by potassii bromidum, gr. x-xv, combined with 
minute doses of antimonii et potassii tart., or ipecac, are serviceable, 
the child, of course, being confined to the house for several days, on 
an easily assimilated diet. 



DISEASES OF THE LARYNX. 

CROUPOUS LARYNGITIS. 

Bynonyms. Membranous croup ; true croup. 

Definition. An acute inflammation of ihe mucous membrane 
of the larynx, altended with the exudation of a tough secretion — the 
false membrane — and the occurrence oi spasm of tile giollis ;. c^iaxstcltt- 
iied by febrile reaction, frequent ringing cough, dyspntea, *ith loud 
inspiratory sound, and ahered or extinct voice, showing a strong ten- 
dency toward death by asphyxia. 

Causes, A disease of childhood, most common in strong, vigor- 
ous, well -no unshed males. Certain families present a strong hered- 
itary tendency. Most common during a humid winter. 

Pathological Anatomy. Intense hyfienrmia of the mucotis 
membrane of the larynx, associated with swelling, (edema and marked 
redness. There soon appears on the surface of the mucous mem- 
brane a grayish peUicIe, rapidly coalescing and becoming thicker — 
the opaque, fahf membrane — which differs in extent, thickness and 
adhesiveness in different portions of Ihe larynx. In aJl cases the 
false membrane is found on the vocal cords and inner surface of the 
epiglottis. The tirst exudation (membrane) softens by the serum 
which is exuded, and is then mechanically dislodged by acts of 
coughing or vomiting, but is followed by successive deposits upoa 
the mucous membrane. 

When Che false membrane is detached the mucous membrane of 
the larynx is found unaffected, so far .is the loss of structure is con- 
cerned. Several successive crops of membrane may occur after the 
detachment, or it may entirely cease to form after the removal of the 
lirst exudation. 

On microscopical examination the false membrane is found lo be 
composed of a fine network of fibriUie, holding in their interstices 
leucocytes of an albuminous or fibrinous nature. 

The false membrane may extend into the. pharynx, but especially 
is it liable to extend into the trachea and bronchial tubes, and, as the 
inflammation extends downward, the character of the exudation 
changes from fibrinous to muco- purulent. 

Symptoms, The onset of " true croup " is either suddenly, by 
an attack of spasmodic croup, or gradually, as an acute catarrh of 
the larynx, rapidly increasing in severity, with a feeling of A^d/ in the 
throat, A(«*/«fw of the voice. ^((«AfDM^ A, _/iTfr and Wi>-j/, the hoarse- 



1 



PKACTIC-E OF MEDICINE. 

nesssoon becuaiing marked, and the <"f*(f A having aWt'AjiVj'f.'VraK/kr" 
character, rapidly fAiwy,'/*^' to a s/ritiu/ous, Ausky sound ; every few 
niinutes the child take^i a suddeo. dee^i sfriJu/ous iHspiralioa, the 
voice becoming moru and more husky. Difficulty of breatkiMg now 
follows, the child is unable to lie down. (» if. exhausted by the efforts 
ai inspiration, it is quiet for ^ moment, it soon starts up in a fright, 
breathing more heavilyj with a shrill. tohisUing Mspaulion. Soon. 
from the narrowing of the glottis, from the presence of the memhfane, 
the expiration becomes difficult and noisy, and suffbcatioH seems iin- 
njinent. from the paroxysmal attacks of spasm of tke ghtUs, when 
the child tosses wildly about, tears at its throat, as if to remove soine 
obslAclc, the face becoming cyan4>sed, the alse of the nose working 
rapidly, the mouth wide open, the inspiratory etTorts gasping, the body 
coveted with a profuse sweat, and death seems imminent, when the 
spasm is relaxed, air enters the chest, the breathing becomes some- 
what easier, and the child, exhausted and partially siupeSed. drops 
into a dlfu\ sleep of a few moments' duration. 

The suffocative attacks return at shorter intervals, or there occur 
decided remissions between them, considerable portions of the false 
membrane being expelled, when the child falls into a refreshing sleep. 

In those cases which tend to a favorable termiiution, the appear- 
ance of improvement noted between the suffocative attacks is main- 
t^ed. the paroxysms of suffocation becoming less frequent, the 
expectoration of membrane more marked, the difficulty of breathing 
lessens, the cough looser, the voice gradually returning, the fever, 
which has been more or less high during the attack, disappearing. 

If, instead of improvement, the case tends toward a fatal termina- 
tion, the sulTocative attacks become more frequent, expectoration is 
absent, the voice and cough inaudible, although the etfbrts at speak- 
ing and coughing are visible, the diibculty of breathing continues, the 
respirations becoming more frequent and shallow, but without whist- 
ling and stridor, cyanosis deepens, the countenance has an inditferent, 
drowsy and stupid look, the eyes dull and nearly closed, with 
symptoms of depression, the pulse rapid and weak, the surface cov- 
ered with a cold, clammy sweat, the extremities cold, stupor and in- 
sensibility more marked, the child dying of carbonic acid poisoning 
or aspAyxi,!. 

Dur&tioa. The duration of true croup is about one wuek. rarely 
cwttiQuing ten days. 



DISEASES OF THE LARYNX. . 191 

Diagrnosis. (Edema of the glottis may be mistaken for croup 
until the period of the formation of the characteristic membrane. The 
chief points of distinction from Ihe onset are, however, absence of 
fever, paroxysmal attacks of difficult respiration, followed by a com- 
plete return ^o the normal condition. 

Laryngeal diphtheria differs from true croup in its history, its epi- 
demic character, the marked depression, even before obstruction of 
the larynx produces imperfectly aerated blood, the presence of albu- 
men in the urine, and the sequelae. 

Progrnosis. A very fatal disease. The danger is great, in pro- 
portion to the age and feebleness of the child. 

The unfavorable symptoms are : Loud^ stridulous, inspiratory and 
expirator^^sounds, laborious and prolonged expiration, depression of 
the base of the thorax during inspiration, whispering voice or com- 
plete aphonia, congestion of the face and neck, stupor, weak, rapid 
and irregular pulse, cold extremities, and a cold, clammy perspiration. 

The favorable symptoms are': Expectoration of false membrane, 
decrease of the stridulous respiration, voice changing from whisper- 
ing to hoarseness, looseness of the cough, moderation of the fever, 
and an improvement in the general condition. 

Treatment. The indications^ for treatment are to detach and 
remove the false membrane, to prevent its formation, to prevent the 
attacks of spasm of the glottis, and to maintain the strength. 

To detach and remove the membrane emetics are of the highest 
utility, the favorite of this class being the one first used in this (Usease 
by Dr. Fordyce Barker, consisting of hydrargyri subsulphas flavus 
(turpeth mineral), gr. ij for a child of two years of age, repeating the 
dose as often as rendered necessary by the obstructed breathing; 
but the unnecessary administration of emetics should be . avoided, as 
the strength of the patient should be sustained. 

To prevent the formation of the membranous exudation a number 
of remedies have been recommended and highly lauded by their re- 
spective proposers. If seen early, as the fever and husky voice are de- 
veloping, tincturq aconiti, v\^ X~j» every fifteen minutes, and quinina 
sulphas, g^. ij-v, every hour until cinchonism is produced, are of un- 
questionable utility; another plan strongly urged is with ammonii 
bromidum in full dos6s alternated with quinina sulphas, gr. iij-v, 
every three hours; still another and popular remedy is hydrargyrum^ 
which is certainly one of the most reliable agents we possess ; it may 



192 PRACTICE OF MEDICINE. 

be used as hydrargyri chloridum corrosi-mim, gr. ,'j- i , every two or 
three hours, or in the following formula ; — 

R. Hydrargyri chlnridi mite..._ gr-^^-^-Ji 

Sodii bicarbtinat gr.ij 

Pulvis ipecac Sr.^,— J: M, 

SlG. — One powder every two hours. 

Antimonii et potassii tartras, a remedy that some years ago was 
popular in large doses, is again brought forward in doses of gr. 
ir^V' Quinina sulphas, gr. v, every three hours until six doses have 
been taken, if given before the exudation has formed, it is claimed 
will prevent its formation. 

Topreventtheparoxymsof spasm, small doses ai opium in the form 
ol pulvis ipecac et opii (Dover's powder), or full doses of the bro- 
mides, preference being given to amtnonii bromidum, as suggested by 
Prof. Bartholow, on account of its being " eliminated by the bronchia] 
and faucial mucous membrane, thus acting locally." 

To maintain the strength of the paXieat. alcoholic slimulan Is in full 
doses, nutritious, but easily digested aliment, guinina in tODic doses, 
and ammonii carbonas, are particularly indicated. 

Locally, the use of all caustic or irritating applications to the fauces 
or larynx is emphatically contraindicated. 

The inhalation of the vapor of slaked, freshly burned lime is one 
of the most ready and efficient means for assisting in the detachment 
of the false membrane. The application of cold or hot compresses, 
according to the feelings of the patient, around the throat, have a 
strong tendency to prevent the recurrence of the spasms. After the 
formation of the membrane, great relief follows the use of the vapor 
inhalations and oxygen gas, which with stimulants and liquid 
nourishment may safely carry the patient through the disease. Cjses 
in which the membrane presents a tendency to slowly loosen itself, if 
the patient's strength does not conCraindicate it, are greatly benefited 
by the application of sinapis, or even small Jlying-blisters, to the 

If the exudation still continues, regardless of the means employed, 
the propriety of tracheotomy must be decided. 



DISEASES OP 1 

. LARYNGISMUS STRIDULUS. 

SjnionyillS. Spasm of the glottis ; pseudo-croup ; " Kopp's 
asthma." 

Definition, A temporary spasm of the muscles of the larynx 
innervated by the inferior or recurrent laryngeal nerves ; character- 
ized by 3 sudden development of dyspnoea and the appearance of 
deficient oxygenation of the blood. 

Causes. Most common in children, the result of teething, laryn- 
gitis, indigestion, scrofula or other cachexia. Attacks in adults are 

Pathological Anatomy. Death the result of spasm of the 
glottis is such a very rare occurrence that the changes in the larynx 
are illy understood. 

The mechanism consists in an irritation of the superior laryngeal 
nerve — the afferent nerve — whose function is to supply the mucous 
lining of the larynx with sensibility, whence is reflected through the 
inferior laryngeal nerve — the efferent nerve — the motor influence re- 
sulting in the spasm of the laryngeal muscles. 

Symptoms. The spasm of the laryngeal muscles is of sudden 
onset, and usually after nightfall. The child may have been in 
perfect health, to all appearances, on retiring, or it may have shown 
symptoms of catarrh of the upper air passages, been suffering from 
gastro-intestinal or dental irritation. 

The child awakes suddenly, coughing'm a metallic, resonant tone — 
the croupy cough — and with great dyspnma, with loud, crowing, stridu- 
ious inspirations, the result of narrowing of the larynx from spasm, 
with wheezy, striduimn expirations. 

The entrance of air is so greatly obstructed that all the accessory 
muscles of respiration are called Into use, the lips and finger nails 
become blue, the surface cold, the countenance anxious, and the in- 
ferior portion of the chest is drawn in. instead of being expanded, 
dftring inspiration. General convulsions occur at times, during a paf- 
oxysm, also strabismus, and involuntary discharge of the fasces and 
the urine. 

The paroxysm continues from half an hour to an hour or more, to 
return after a few hours' sleep, or during the following night ; the 
cough, during the day, has the croupy character. 



19i PRACTICE OF MEDICINE. 

DiagnoBis. The non-febrile and distinctly ii 
the affection differentiates it from croup, and its own distinctive char- 
acters, from al! other diseases. 

ProgfUDsis. Favorable. Death from suffocation, during the par- 
oxysm, may occur in very young children, but it is certainly a very 

Treatment, For the paroxysm, the inhalation of a few drops of 
chloroformum is the most prompt method, due care being exercised ; 
complete anfcsthcsia is unnecessary. Success is reported by the 
prompt inhalation of awi'/wft'if. also from «('/ri)-^/vfm«««t, in small, 
but frequently repeated doses ; the following combination is a prompt 
antispasmodic : — 

R. Polassii bromidi gij 

Chloral .-. gr.xxiij 

s,,. .mniil mnld, t Jj 

AquEC mentb f^j. M. ■ 

ScR. — One teaapOQnfnl every half hour. 
After the paroxysm has been siwpended by the above combination, 
the tendency to a recurrence of the attacks is obviated by the steady 
and continued use o^pn/assii brnmidum, in moderate doses. Emetics 
are often useful in suspending an attack, especially if it is due to 
indigestion. 

Locally, the kot, alternating with the coid pack, should be con- 
stantly applied to the throat. 



DISEASES OF THE BRONCHIAL TUBES. 



ACUTE BRONCHITIS. 



SynonymB. Bronchial catarrh ; a 
" cold on the chest." 

Definitioti. An acute catarrhal infli 
tubes of the larger, middle and third si 
substernal pain, feeling of thoracic 
ing, and at first scanty, followed by 



catarrhal bronchitis ; 



the bronchial 

character! !;ed by fever, 

I. oppression inbreath- 

or less profuse expecto- 



OF THE BRONCHIAL TUBES. 19B 

Most common in childhood and old age. More com- 
n climates characterized by considerable moisture of the atmos- 
phere, combined with a low temperature, and especially where there 
are sudden and marked variations. 

Pathological Anatomy. Hyperrsmia - oi the mucous mem- 
brane of the bronchial tubes, manifested by a diffused redness, swell- 
ing, (Edema ind diminisked secretion ,- this is followed by an increased 
secretion and overgrowth and desquamation of the epithelial cells, 
together with a copious generation of young cells, the expectoration 
then becoming of a yellowish color. As a result of the hyperasmia, 
rupture of the capillaries of the mucous membrane frequendy occurs, 
when the slight expectoration of the first stage is streaked with 

In cases of bronchitis following the exanthemata, or in scrofulous 
patients, the bronchial glands participate in the inflammation, they 
becoming hypertemic, swollen and filled with secretion, and not 
unfrequently the glandular elements undergo a hyperplasia, and 
finally the "cheesy" degeneration. 

Symptoms. The im/asion is usually characterized by the occur- 
rence of either nasal or laryngeal catarrh, or both, the patient feeling 
chilly, followed by flushes of heat, the limbs, joints, and even the 
body, are affected with pain of an aching, contused character, and a 
sense of fatigue and want of energy ; there may be a furred tongue, 
anorexia and constipation. 

In nervous, irritable persons- and in children there may be slight 
delirium, and often in very young -children, especially during the 
period of dentition, convulsions may usher in the attack. 

After a day or two of these initiatory symptoms, those characteristic 
of bronchial catarrh develop. 

Pain is experienced behind the sternum, especially toward its upper 
part, of a raiv, burning, or fearing character, aggravated by a deep 
impiration or by coughing ; the pain also radiatps toward the sides, 
following the 'course of the primary bronchial tabes. Tenderness 
over the sternum is often present. 

Cough from die onset, at first in paroxysms of a hard, dry char- 
acter, changing as the disease progresses, and becoming looser, fol- 
lowed by free expectoration. The expectbralidn at first is small in 
quandty, almost transparent, frothy, and having a salty taste, often 
streaked with blood. As the disease progresses it 'becomes more 



i 



PRACTICE OF MEDICINE. 

free, of a yellowish or a greenish-yellow color, and of a tenacious 
consistency. 

There are present slight /ever, hot, dry skin, frequent ^w/m, loss of 
appetite, moderate thirst, and constipation. 

A feeling of languor and weariness, and often considerable depres- 
sion, quite out of proportion to the febrile state, are not infrequent. 

Percuseion. Normal, except in those rare cases in which the 
bronchial glands are involved, when irregular spots of dullness c; 
be developed. 

.A-UBCUltation. First stage : The bronchial membrane being 
swollen and dry, the respiratory murmur \i liarsh ox vesiculo-bronckial 
in character, associated with diffused sonorous and sibilant rSJes. 

Second stage .■ The secretion from the bronchial mucous membrane 
being increased, the respiratory murmur is less harsh in character, 
but is associated with large and small moist ot bubbling rAles. 

CiagnosiB. The points of resemblance and differences between 
acute bronchitis and other diseases of the chest will be pointed out 
when those affections are described. 

PrognOBis. Acute bronchitis of the larger tubes usually termi- 
nates in complete resolution within two weeks. In children and the 
aged, the course is more protracted and the symptoms more severe, 
but recovery is the rule. 

Treatment. During the invasion, quininie sulphas, gr. x, com- 
bined with awrphime suiph., gr. '/(,, will usually prevent or abort an 
attack of acute bronchitis. 

In the first stage, in adults, when the mucous membrane is swollen 
and dry, either of the following prescriptions will give prompt relief ; — 



R. Anbmonii el potassii lart 

Spls. tetheris nitrosi 

CHnct. aconitl, if indicated) 

Syr. siinpliciB, .ad 

5lG. — One teaspoonful every two or three hours. 



.... gr.ij 
.... fSiv 
...„ ili 
..- f3» 
.... fSvj. 



K. Liquor, potassii dtrMis C^ ij 

Vini vel syr. ipccacuanhte „., f^ ss 

Succi limonis T^'ss. M. 

SlG. — Tablespoontul every two or three hours. 

If the cough of the dry stage be severe, or if looseness of the bowels 



DISEASES OF THE BROKCHIAL TUBES. 197 

follow the use of either of the above combinations, lincliira opH cnm- 
pkoraia may be added with advantage. 

For young children, the above in proportionately reduced doses, or 
the foliowing : — 

B. Pulv. ipecac el opii gr.x 

Puk. aciilw g'-MJ 

Hydmi^yri chlor. mite gi-iv 

Sacch. lad gr.x 

Ft. e( chart. No. xij. 
SlG.— One every two hours. 
Locally : Hot mustard foot hath, and sinapis or tereMntkina stupes 
over the chest, the patient being confined to an apartment in which 
the air is moistened by the vapor of hot water. 

Secetid Stage : The secretion of the bronchial mucous membrane 
being copious, marked benefit follows the use of — 

■ R. Ammonii muriat 9 iv 

Mist, glycyrrh. comp _^ iv. M. 

SiG. — TableEpoonrul every three or four hours. 
During the attack, attention must be given to the secretions and the 
diet of the patient. 

CAPILLARY BRONCHITIS. 

Synonyms. Broncho-pneumonia ; " suffocative catarrh." 

Definition. An acute catarrhal inflammation of the titrminal 
bronchial tubes, or bronchioles; characterized by fever, impeded and 
increased respiration, impeded circulation, slight cough and scanty 
expectoration. 

Causes. Most common in childhood, foliowing exposure to cold 
or sudden changes of temperature ; associated with measles and 
whooping cough. 

Pathological Anatomy. Hyperemia, redness and swelling of 
the Iming membrane of the bronchioles, with the exudation of a tough, 
tenacious secretion. 

The air vesicles mayremain unaffected' but in the majority of cases 
they are involved, producing the complication known as " catarrhal 
pneumonia. ' ' 

In diose cases in which the air cells are not involved in the inllam- 
matory changes, the air passes, during the act of inspiration, through 



198 PRACTICE OF MEDICINE. 

the secretion blocking tlie smaller tubes, but is prevented from 
escaping during the act of expiration, the secretion in the smaller 
tubes acting, as a valve ; the result is distendon of numerous vesicles, 
producing a circumscribed or diffused functional emphysema. If the 
secretion produces complete closure of any of the smaller tubes, the 
air previously drawn into the vesicles will be absorbed, causing 
collapse (atelectasis). 

If the inflamTnation extends to the alveoli of the lungs, it produces 



1 frequent complication 
t commonly lobular ii 



ire or less ordinary bfon- 
02-103" F., difficult and 
, which the dyspnoea is 



the condition known as broncho~pne 
in children and feeble elderly people ; 
character, whence the term " lobular pm 

Ssnnptoms. Usually preceded by n- 
chilis, followed by rise of temperature, 
increased respiration, with paroxysms i 
markedly aggravated, when cyanosis rapidly develops. 

The circulation through the lungs is impeded by the dyspncea, the 
pulse becomes feeble and flickering,. and there results general con- 
gestion of the venous system, the countenance livid, the lips and 
nails blue, the surface cold, and often covered by a clammy perspira- 
tion, the tnind dull, and in children stupor and convulsions rapidly 
supervene, the result of non-aeration of Jhe blood. The cough is 
slight, but of a suppressed character, the expectoration scanty. When 
cyanosis occurs the cough may almost entirely cease ; expectoration 
also ceases, death soon following, from apncea and depression. 

Percusaion. Normal, except over those portions of the lungs 

■ which are in a condition of collapse, when dullness rapidly develops 

and may as rapidly disappear, changing to other portions of the lung, 

AuBGultation. First stage, harsh or vesiculo-bronchial, soon 
followed by diminished respiratory murmur, associated with svb- 
crepitant rules. 

Diagnosis. Capillary bronchitis is often mistaken for true catar- 
rhal pneumonia, the points of distinction between which will be 
pointed out wheti discussing that affection. 

PrognosiB. In children, on account of their inability to expecto- 
rate, which leads to rapid cflUapse of the lungs, and in the aged, the 
prognosis is most grave. In the strong and vigorous recovery follows 
prompt and energetic treatment. 

Treatment, From the very onset of the attack the treatment 
must be supporting, with the addition of such measures as seem to 
possess a controlling influence over the cata/rhal process. 



S.OF THE BRONCHIAL TURES. 

The patient must be confined to bed, well Covered and the tem- 
perature varying between 75° and 80°, the air moistened with steam. 
In the first stage dry cups, mild sinapis applications or ierebinthina 
stupes should be applied to the chest, after which it should be covered 
with an oil-silk jacket or the jacket poultice, if the child be not too 
young to permit so heavy an application without adding to the distress 
in the breathing. 

The diet must be of the most nutritious character, the great aim 
being to sustain the powers of life until the catarrhal process has 
passed through its different stages, hence milk, eggs, chicken, mutton 
and beef broths, with the free use of stimulants, commenced early 
and in amounts large enough' to overcame the signs of depression 
which are present early in the attack. 

If the_^7'CT- be high, over 102° F., quinina sulphas is indicated in 
full doses, iov a child ; the following is a good formula : — 

B- Quinina! sulphatis...: 3J 

Acid, salphurici dilut q. s. 

Spls. Eelheris nitrosi fgiv 

Syr. lolu „ fgiv 

AquK menth. p _ fgj, M. 

SlG. — One leaspoonfol every two or three hours. 
For the catarrhal process either of the following, regulating the 
dose in accordance with tbe"age of the patient :— 

BL. Syr. ipecBC TTLv-xk 

Spts. ietheris Ditrosi tH,v-xv 

Tinct. opii camph WLv-xx 

Tinct. scilla; 1ll,y-ix 

Liq. polasdi citrat B^xl-jij. M. 

SiG. — Every two hours. 
Or— 

B- Ammonii iodidi gr.ij-v 

Ammonii carbonat/t gr.iij-v 

Syr. giycyrrh f.^^s 

Syr. tolu f^BS. M. 

SiG. — Eveiy two or Ihree houra. 

\^ suffocation is imminent the use oi smclics are indicated; the most 
suitable are ipecacuanha or hydrargyii subsulpltas Jlavus, care being 
taken not to repeat emesis so often as to produce exhausdoo. 



OF MEDICINE. 

CROUPOUS BRONCHITIS. 

Synonyma, Membranous bronchitis ; plastic bronchitis ; diph- 
tlieritic bronchitis. 

Definition. An acute inflammation of the mucous membrane 
of the larger and middle-sized bronchial tubes, attended with an 
exudation, forming a membraniform layer, which is closely adherent 
to the mucous surface ; characterised by febrile reactioti, cough, diffi- 
cult breathing, scanty expectoration, followed by the expulsion of the 
false membrane in the form of patches or casts. 

Causes. Associated with membranous laryngitis from extension 
downward ; asthma ; emphysema ; phthisis ; but most commonly the 
result of exposure to cold and damp, in those of strong and vigorous 



Patholo^cal Anatomy. Hyperemia of the mucous mem- 
brane of the bronchial tubes, associated with swelling and cederaa, 
during which the surface is covered with a whitish or grayish -white, 
firmly adherent, iiietnbranous deposit, cemented together by a coagu- 
lable exudation, and prolonged by roodets from its under surface 
into the bronchial follicles, which sooner or later is loosened and de- 
tached by suppurative process and is expectorated after a violent fit " 
of coughing or vomiting. When expectorated, the false metnbrane, 
as it has been termed, has either the form of patches or is thrown off 
entire from the bronchial tube, and may be found to consist of casts 
representing more or less of the bronchia! subdivisions, and present- 
ing an appearance not unlike " boiled maccaroni." 

On microscopical examination, the detached membrane presents 
fibrillfE which characterize fibrine or lymph in other situations, and if 
placed in a solution of acetic acid, it becomi 
ordinary mucus contracts and becomes mo 
same solution. 

Symptoms. There are no symptoms or signs by means of 
which this variety of bronchitis can be distinguished from ordinary 
catarrhal bronchitis, jir/or to the expectoration of the false membrane. 

Expectoration is -pTtceAeA and &ccomp3.ra&A'by inolent paroxysms 
of coughing, and after more or less of the membrane has been raised 
a muco-purulcnt expectoration, streaked with blood, may be present 
for several days. 



s greatly swollen, while 
e dense if added to the 



F THE BRONCHIAL TUBES. 201 

Duration, The inflammation maybe either acute, sub-acule or 
chronic, expectoration of patches or strips of the membrane being 
repealed at intervals of days, weeks, months, or even years. 

PrognoBis. In adults, favorable, if not associated with other 
grave affections, such as phthisis, pneumonia or emphysema. In 
young children it may cause obstruction to the respiration, and not 
unlreqnently proves fatal. 

Treatment. As the character of the inflammation can seldom 
be determined until the membrane or portions of it have been expec- 
torated, the treatment is at lirst the same as in cases of ordinary acute 
bronchitis. 

As soon, however, as the character of the inflammation can be de- 
termined, active rmesis is the most efTsctive means of removing the 
obstruction caused by the false membrane, the best agents of this 
class being either kydrargyri subsulphas flavus. ipecacuanha, or zinci 
iulph.. to be repeated as indicated. 

Inhalations of the vapor of water, and especially of lime water, 
are highly serviceable. 

To prevent the formation of membrane. Prof. Bartholow strongly 
urges the use of ammonii iodidum and carbonas combined, in small 
doses every hour or two. In a case treated by the author after this 
method, excellent results followed. 

In cases showing a tendency to become chronic, good results 
will follow the application of flying blisters to the chest and the 
internal administration of arsenicmn and some preparation of pix 

CHRONIC BRONCHITIS. 

Synonyms. Chronic bronchial catarrh ; winter cough ; second- 
ary bronchitis. 

Definition. A chronic inflammation of the mucous membrane of 
the larger and middle-sized bronchial tubes ; character! red by cough 
and more or less profuse expectoration, plus, in many cases, the 
symptoms of emphysema of the lungs, which complicates the major- 
ity of cases. 

Chronic bronchitis: may be either ^wnart' or secondary. 

Causes, Primary, the exposure to wet or cold, or the repeated 
inhalation of dust, vapors, or other irritants. Secondary, due to gout, 
rhetijnatism, syphilis, cardiac, renal or pulmonary diseases, or alco- 
holism. 
J 



202 PRACTICE OF MEDICINE. 

Varieties. I. Mucous catarrh, associated with moderate expecto- 
ration. II. Bronchorrhaea, profuse expectoration. 111. Dry catarrh^ 
scanty expectoration. IV. Fetid bronchitis. 

Pathologrical Anatoray. The mucous membrane of the bron- 
chial tube is discolored, being of a more or less dull red, often of a 
deeply venous hue, mingled with a grayish or brownish color. These 
changes may be either in patches or extensively diffused. The ves- 
sels of the membrane are dilated. The mucqus membrane is thick- 
ened, resulting in the reduction in the calibre of the tube a^ a 
roughening of its internal surface. The submucous tissue becomes 
infiltrated, contracted and indurated. 

The elastic and muscular coats of the tubes become hypertrophied, 
lose their elasticity, and the cartilages become the seat of calcareous 
deposits. 

As the result of the loss of elasticity and muscular tone of the tubes 
they become irregularly dilated, " bronchial dilataiiony The dilata- 
tions may be uniform in character, resembling somewhat the fingers 
of a glove, or they may be sacculated or globular, forming actual 
cavities in the bronchial structure. 

In the mucous variety the secretion consists of young cells and 
mucous corpuscles, having a yellowish color ; in the dry variety, the 
"catarrh sec" of Laennec, or "dry bronchial irritation,"* the secre- 
tion is scanty, tough, semi-transparent, and occurs in defined globular 
masses ; in bronchorrhosa, which is usually associated with bronchial 
dilatation, the secretion is abundant, greenish-yellow in color, and 
often fetid. 

Symptoms. The most characteristic symptoms of chronic bron- 
chitis are the cough and expectoration. Unless associated with other 
diseases, the general health suffers but little, if at all, constitutional 
symptoms being present only during acute exacerbations. 

Mucous catarrh, or, from its occurring most commonly during the 
winter months, " winter cough," is characterized by paroxysms of 
cough, more or less violent, followed by the expectoration of a yel- 
lowish mucus. 

Dry catarrh is characterized by a harsh cough, a feeling of sore- 
ness or rawness under the sternum, and the expectoration of small 
globular masses ; this variety occurs with emphysema, gout, rheuma- 
tism and asthma. 

Bronchorrhcea, which is associated with bronchial dilatation, and 



DISEASES OF THE BRONCHIAL TUBES, 203 

in the elderly, is characlerized by paroxyamB of severe 
cooghing, followed by the copious expecloralion of greenish -yellow, 
often fetid, mucus ; the amount expectorated often amounts to four or 
five pints in the twenty-four hours. 

Fetid bronchitis, often associated with bronchial dilatation, has an 
excessively fetid odor of the brealh and expectoration. The decom- 
■nay cause gangrene of the bronchial 
n of the lung structure^ 
mplicaled with other affections, normal ; 
r, there are diffused spots of the tym- 
lund, the physical condition being 
r and connecting with a bronchial 



position of the ; 
mucous membrane, and ev( 
^rcussion, Unless c( 
if bronchial dilatation occi 
panilic or amphoric percuss 
a circumscribed cavity containing ai 

Auscultation. Harsh, or vesiciilo-bronchial respiration, a 
ciated wilh more or less profuse, sonorous, sibilant ^nA large oaA small 
bubbling rates : in bronchial dilatation, in addition to the harsh respi- 
ration, is found broncho-cavertwus breathing, with large and small 
gurgling rales. 

If emphysema complicate chronic bronchitis, the physical signs are 
somewhat modified, and will be pointed out wheri discussing that 
affection. 

Prognosie. If unassociated with disease of the lungs or heart, 
chronic bronchitis is never dangerous to life, although the symptoms 
are present more or less continually, and aggravated upon the least 
exposure. 

If associated with phthisis, emphysema, disease of the heart, or of 
the kidneys, the prognosis is governed by those affections. 

Treatment. Cases of chronic bronchitis, of whatever variety, 
should observe the following general rules ; i. Attention to the gen- 
eral health. 2. The clothing; wearing flannel Ihe year round, or, 
what is better, silk under-clothing, taking care that the opposite ex- 
treme of too much clothing be not practiced. 

'Y\\s medical treatment \% guided \yj\^^cause,ckaracter^nA severity 
of the disease. 

If secondary to other affections, in the majority of cases remedies 
directed lo the bronchial mucous membrane are contra-indicated. 
If the result of the rheumatic or gouty diathesis, in addition to the 
remedies directed to the disease itself, should be combined change 
to a warm climate, if possible, and a more or less protracted course 



202 PRACTICK OF MEOICnJE. 

VarietieB. I. Mucous catarrh, associated with moderate expecto- 
ration, li. Bronchorrkrea, ■ptoitiic expectoration. 111. Dry lalarrh, 
scanty enpectoration. IV. Fetid bronchitis- 
Pathological Anatomy. The mucous membrane of the bron- 
chia! lube is discolored, being of a more or less dull red, often of a 
deeply venous hue, mingled with a grayish or brownish color. These 
changes may be either in patches or extensively diffused. The ves- 
sels of the membrane are dilated. The mucqus membrane is thick- 
ened, resulting in the reduction in the calibre (if the tube ayl a 
roughening of its internal surface. The submucous tissue becomes 
infiltrated, contracted and indurated. 

The elastic and muscular coats of the tubes become hypertrophied, 
lose their elasticity, and the cartilages become the seat of calcareous 

As the result of the loss of elasticity and muscular tone of the tubes 
they become irregularly dilated, " bronchial dilatation" The dilata- 
tions may be uniform in character, resembling somewhat the fingers 
of a glove, or they may be sacculated or globular, forming actual 
cavities in the bronchial structure. 

In the mucous variety the secretion consists of young cells and 
mucous corpuscles, having a yellowish color; in the ifrj" I'an'rf/y, the 
■' catarrh sec " of Leennec, or " dry bronchial irritation," the secre- 
tion is scanty, tough, semi-transparent, and occurs in defined globular 
masses ; in bronchorrhcea, which is usually associated with bronchial 
dilatation, the secretion is abundant, greenish-yellow in color, and 
often fetid. 

Symptoms. The most characteristic symptoms of chronic bron- 
chitis are the cough and expecloralion. Unless associated with other 
diseases, the general health suffers but htile, if at all, constitutional 
symptoms being present only during acute exacerbations. 

Mucous catarrh, or, from its occurring most commonly during the 
winter months, " winter cough," is characterized by paroxysms of 
cough, more or less violent, followed by the expectoration of a yel- 
lowish mucus. 

Dry catarrh is characteriied by a harsh cough, a feeling of sore- 
ness or rawness under the sternum, and the expectoration of small 
globular masses ; this variety occurs with emphysema, gout, rheuma- 
tism and asthma. 

Bronchorrhcea. which is associated with bronchial dilatation, and 



DISEASES DE THE BRONCHIAL TUBES. 20! 

most common in the elderly, is characterixed by paronysms of seven 
coughing, followed by the copious expectoration of greenish -yellow 
often fetid, mucus ; the amount expectorated often amounts to four oi 
five pints in the twenty-four hours. 

Fetid bronchilis. often associated with bronchial dilatation, has ar 
excessively fetid odor of the breath and expectoration. The decom- 
position of the secretion may cause gangrene of the bronchial 
mucous membrane, and even of the lung structure, 

Vercuseion, Unless complicated with other affections, norw/o/,- 
if bronchial dilatation occur, there are diffused spots of the />•?«- 
/aniVif or ^w/^or/f percussion sound, the physical condition being 
a circumscribed cavity containing air and connecting with a bronchial 
tube. 

Auscultatioil. Harsh, or vcsiculc-brancMal respiration, asso- 
ciated with more or less profuse, joworvuj, siii/ani ani iarge anA sniail 
bubbling rales; in bronchial dilatation, in addition lo the harsh res 
ration, is found broncko-cavertious breathing, with large and small 
gurgling rates. 

If emphysema complicate chronic bronchitis, the physical signs a 
somewhat modified, and will be pointed out when discussing that 
affection. 

PrOErnosis. If unassociated with disease of the lungs or heart, 
chronic bronchitis is never dangerous to life, although the symptoms 
are present more or less continually, and aggravated upon the least 
exposure. 

If associated with phthisis, emphysema, disease of the heart, or of 
the kidneys, the prognosis is governed by those affections. 

Treatment. Cases of chronic bronchitis, of whatever variety, 
should observe the following general rules ; I. Attention to the gen- 
eral health. 2. The clothing; wearing flannel the year round, or, 
what is better, silk under-clothing, taking care that the opposite ex- 
treme of loo much clothing be not practiced. 

"^h^medical treatmeni is guided hyxhe cause, character arA severity 
of the disease. 

If secondary to other affections, in the majority of cases remedies 
directed to the bronchial mucous membrane are contra-indicated. 
If the result of the rheumatic or gouty diathesis, in addition lo 
remedies directed to the disease itself, should be combined change 
to a warm climate, if possible, and a more or less protracted course 




204 PRACTICE OF MEDICWE. 

of fia/assii ioiiitiuin, or ///A// c/fraj, or a residence atoneof theiiWnflilj 

For mucous catarrh, with acute exacerbations : — 

Vini pida, liq _ 3J. 

Three or four limes in twenty-four hours. 
Dry catarrh is greatly benefited by — 

B ■ Polassii iodidi gr.v-ii 

01. eucalyptus - gll.j-» 

Vini picis, lii] 2J. 

Three limes a (iay. 
Or— 

B. E«t. cimicifuEEe, fld ..,. V\j.^ 

Tiuct. opii. deodorat ^ Il\,iij 

Syr. pnin. virg ad Jij. 

SlG.^Every four hours. 
For bronchorrhma, copaiba, gCt. v-x every three hours, or spls. 
terebinlhiaiT, gtt. v, every four hours, or acidum carbolUiim, gr. ss, 
four times a day. and at the same time using ol. morrhuie and 
arsenicum, or, if these means fail, inhalations of aluimn, acidum 
gai/icum or atidum tannicum. 

If the expecloration be fetid, "fetid bronchitis." Prof. Da Costa 
recommends the internal use of acidum carbolicum, gtt. j every third 
hour, with inhalations of acidum carbolicum, gr. v, aqua, 3 J, two or 
three times a day, 

Zcca/^, irritation with tlnctura iodi, or flying blisters, repeated once 
or twice weekly, is of advantage. 

ASTHMA. 

SynonymB. Nervous asthma; bronchial asthma. 

Definition. A paroxysmal spasmodic contraction of the muscular 
layer surrounding the bronchial tubes, and perhaps associated with a 
tonic spasm of the diaphragm, and more or less bronchial catarrh; 
characteriied by spasmodic attacks of great dyspntea, continuing 
usually for several hours. 

Cauaes, A true neurosis of the respiratory apparatus. 

The result of peripheral or local disturbances in the nervous sys- 
tem, often hereditary ; pressure on the pneumogastric nerve ; dyspep- 



DISEASES OP THE E 

sia and constipation, resulting in irritation of the end organs of the 
pneumogastric ; uterine, hepatic, or nephritic disease; inhalation of 
various substances, as ipecac, turpentine, or irritating dusts ; climate ; 
mental and moral influences. 

Asthma is more common in men than in women ; in childhood 
and young adults than those of middle life and old age ; in the welU 
lo-do and wealthy than in the poor. 

BymptomB. The onset of a firsi allack of asthma is abrupt and 
sudden, '^e succeeding attacks being preceded by /roifrBW^r, which 
the individual rapidly learns to appreciate, to wit ; corysa, bronchial 
irrilation. thoracic constriction, marked dyspepsia, or a large passage 
of pale, limpid urine, the " hysterical urine." 

The paroxysm begins, in the majority of cases, in the early mm 
ing hours or during the afternoon, with ^feeling of anguish and ci 
siriction in the chest and an intense desire for air. The breathing is 
accompanied with ioud wheezing, the face is flushed, a 
cyanosed, and bathed in perspiration, the eyes stare, the eyeballs pro~ 
trude, and the muscles of the neck become prominent as they aid i 
the effort for air. The dyspnma soon becomes so severe that the » 
spiralion is but a gasp, the lips are pallid, cyanosis deepens, and the 
patient feels as if death were impending. 

After some minutes or hours the respiration becomes t 
more air enters the lungs, the cyanosis disappears, and gradually 
the paroxysm ceases, the patient feeling exhausted and the chest 
fatigued. 

During the paroxysm there is a short dry cough, becoming looser 
as the attack subsides, the expectoration either consisting of white 
pellets of mucus, at times streaked with blood or profuse watery m 

The duration of an attack varies from three to ten hours. Instead 
of single paroxysms, slight remissions may occur at intervals of o 
two or three hours, lo be followed by exacerbations lasting from four 
to six hours, continuing for a week or two, preventing the patient 
lying down or taking food. 

PercUBBlon. During the paroxysm, hyper-resonance over both 
lungs, termed vesicuh-tpttpanitic, the "bandbox tone" of Bamberger. 

Ausoulfca.tion, First stage feeble a^ absent-vesicular murmur, with 
prolonged expiration associated with loud wheezing, whistling, sibilant . 
and sonorous rales ; as the paroxysm subsides the vesicular Irreatkin^ 
becomes more apparent and is associated with moisl rdJes. 



206 PRACTICE OF MEDICINE. 

Prognosis. In itself asthma is not fatal to life ; but if the parox- 
ysms ate frequently repeated there results either rmpiiysema, cardiac 
dilalalioH, with subsequent dropsy, or even cerebral hemorrliage. 

Attacks of asthma frequently occur as a complication in emphy- 
sema, chronic bronchitis and valvular diseases of the heart. 

Treatment. There are two indications, to wit ; the relief of the 
paroxysm, and to prevent its recurrence. 

To relieve the paroxysm, no medication is so effective as the hypo- 
dermatic injection of morphina sulph., gr. >i to %, combined with 
atropina suipk., gr. jjj. Chloral, gr, x. repeated, where no heart 
complication exists, is often effective ; chlomformum, eetAer or arnyl 
Hitris inhalations have been recommended ; also nauseant expector- 
ants, to wit: lobelia, ipecac, scilla, or ext. geindelia fid., gtt. xx, re- 
peated every two or three hours. ^h 

Dr. Pepper speaks highly of the following for the paroxysm : — 4H 

a. Ammonii bromidi g ij 9 ij ■ 

Ammonii muriat gjas ^ 

Tioct. lobeliffi f;^iij ^^ 

Spts. xlheris comp f^j ^| 

s,,..c^> ,......: i}iv. M^ 

SiG.— Dessertspoonful in water every hour or two. 

InhaliitioHS of the fumes of belladonna, stramonium, nitre-paper, 
chloroform, ethyl bromidum, or the use of various pastilles or cigar- 
ettes, are of immense benefit in many cases. 

If an attack is impending it may often be aborted by drinking freely 
of strong black coffee, or by full doses of the bromides. 

To prevent recurrence of the paroxysms, the general health must 
be strictly watched, any of the complications or causes of the attack 
attended to, systematic exercise, bathing, regulated diet, and change 
of climate when possible. 

Internally, good results are sometimes attained by a long course oT 
belladonna, arsenicum ot potassii iodidum. ^ 

HAY ASTHMA. ^ 

Synonyms. Hay fever; autumnal catarrh ; rose fever. 

Definition. An acute catarrhal intlanimation of the upper air 

passages, extending to the bronchial tubes, associated with spasmodic 

contraction of their muscular layer; characterized by coryia, croupj 

or wheezy cough and difficult respiration. 



DISEASEIS OF THE BRONCHIAL TUBES. 207 

CauBeB. An affection of the nervous system ; often hereditary. 

Persons in whom the predisposition exists liave attacks excited by 
the inhalation of the pollen of grasses, rye, corn, wheat or_ roses. 

Pathological Anatomy. Hypertrophy of the inferior and 
middle turbinated bones; a. peculiar hyper.eathesia of the mucous 
membrane covering the inferior and middle turbinated bones, the 
middle meatus, the floor of the nose and that part of the septum 
below the limit of the olfactory membrane are freijuently associated 
with the disease. 

Symptoma, Begins by severe corysa, with sneezing, a clear, 
watery, nasal discharge, congested eyes and Eustachian tubes, rapidly 
extending to the larynx and bronchial tubes, when occur a hoarse, 
frox;*)' and wheeling fOtt^A. awA dijiailty of breathing. The dyspnoea 
occurs in paroxysms, which are often as severe as those occurring 
during a regular asthmatic attack. 

The paroxysms remit after a few days, returning again for several 
days or weeks, and again remitting, the bronchial catarrh persisting 
for a month or more. 

The constitutional symptoms are mild, unless complications occur. 

Complicationa. The affection may extend lo the finer bronchial 
tubes (capillary bronchitis] ; congestion or oedema of the lungs and 
pneumonia are not infrequent. 

Duration, Unless a change of climate is resorted to. paroxysms 
of hay fever continue more or less severe for six, eight orten weeks 
of the year; each year the paroxysms growing more severe. 

Progrnoaia. The affection never proves fatal in itself, but one or 
more of the following sequirla may result, to wit ; Asthma, chronic 
bronchitis, or loss of the special sense of hearing or of smelling. 

Treatment. No specific, unless the hypertrophy of the turbin- 
ated bones be a constant phenomena, when removal by the galvano- 
cautery would at once produce a cure. 

An attack of hay asthma is often prevented by a change of climate 
during the season of the year when the attacks are most common, 
to wit ; the early autumn. Any of the following locations may be 
selected. While Mountains. Catskills, Adirondacks, Rocky Mountains, 
or a sea voyage. . 

Success has followed the use of guhiina, gr. v. three times a day, 
beginning one month before the expected paroxysm. After the attack 
has fairly begun, polassii iodidum, gr. xv, three times a day, seems 



208 PRACTICE OF MEDICINE. 

to modify somewhat the severity of the paroxysms; or the following 
powder, by insufflation : — 

B. .Bismuth. sabnit_ 51] 

Acid, tannic , gj 

lodoformi g'''"''. M. 

Sic— Every three or four hours. 
Prof. Bartholow " has seen several cases benefited greatly" by a 
solution of quinina applied to the nares, as suggested by Helmholti ; 
"but to achieve success the application must be thorough and 

The following applied thoroughly to the nostrils has a high re- 

U. Memhol X\ 

C"«t. simpl 3ij 

01. amygd. dulcia „ „. J iss 

Zinci oxidi purx 3J 

Acid, carbolic! sjss. M. 

SiG. — Apply every few hours. 

Cases accompanied by a profuse watery discharge have this symp- 
tom at least modified by minute doses of atropine sulph., with 
morphina sulph., every three or four hours. 

A long course of arseniirum in minute doses sometimes removes 
the susceptibility to the disease. 

WHOOPING COUGH. 

Synonyms. Hooping cough; pertussis, 

Deflnition. A convulsive, paroxysmal cough, consisting of a 
number of forcible expirations, followed by a series of deep, loud, 
sonorous inspirations (the whoop), repeated several times during each 
paroxysm, and associated with catarrh of the bronchial tubes. 

Causes. Chiefly a disease of childhood, one attack generally re- 
moving the susceptibility; contagious; the result of an unknown 
poison, perhaps atmospheric, affecting the nervous system. 

Pathology. The changes, if any, occurring in the nervous sys- 
tem are unknown. It is said that ■' irritation of the internal branch 
of the superior laryngeal nerve produces relaxation of the diaphragm, 
spasm of the glottis and a convulsive expiration, the series of phe- 
a present in a paroxysm of asthma." 



Hypertemia 0^'Aie. mucous membrajie of the nares, pharynx, larynx 
and bronchial tubes, with diminished secretion, followed by an in- 
creased secretion of a transparent mucus, afterward becoming puru- 
lent, the mucous membrane pale and anfemic. 

Symptoms. Divided into three stages, lo wit ; catarrhal, spas- 
modic and tenninal. 

C in/ai stage originates as an ordinary naso-laryngo-bronchial 
a h » h a loose cough. Duration one or two weeks. 

Spa die stage :. The cough becomes paroxysmal, consisting of a 
sue ess on of short, rapid, expiratory efTorts, the face becoming 
ed he eyes swollen and protruding, the body bending forward, 
and hen hese expiratory efforts have exhausted the breath, they 
are followed by a deep, loud, crowing inspiration — tkewhoop. Each 
paroxysm being composed of three such spells, the last one followed 
by the expectoration of a small amount of tough, viscid mucus. 

The attacks of cough may be so severe as to cause vomiting, and if 
the vomiting occur shortly after food has been taken, the nutrition 
the patient will suffer. Profuse epistaxis is not infrequent. Duration 
about four weeks. 

Terminal stage. Tlie paroxysms recur at longer intervals, are 
shi)rter duration and less intensity, the catarrhal symptoms being mi 
marked, the expectoration freer. Duration, one or two weeks, often 
followed by the " cough of habit." 

Complications. Congestion of the lungs, capillary bronchiti 
pneumonia and emphysema, or, rarely, convulsions, hydrocephalus, 
or apoplexy. 

Diagnosis. During the catarrhal stage, whooping cough can: 
be distinguished from a common cold, but on the advent of the 
characteristic whoop the diagnosis is evident. 

PrognosiB. Depends upon the age and strength of the patient, 
the severity of the paroxysms, and the presence or absence of co 
plications. Ordinary cases, favorable. Moderately severe attacks 
during infancy are followed by cerebral symptoms, while attacks 
occurring in adults are followed by chest symptoms. 

Treatm.ent. No specific. A self limited disease. Remedies will 
not cure the disease, but often modify the severity of the symptoms. 

Prof, Da Costa prefers quininis sulph., in full doses, ax chloral \n 
good-sized doses, often advantageously combined with the bromides, 
and the use of a spray of sodU bromidum,, gr. xx, and aqus, f^j, lo 

r 



210 PRACTICE OF MEDICINE. 

which may be added extrachtm belIadon«s fluidum, irLij. A remedy 
of great utility is ammonii bromidum. The paroxysms are lessened 
in severity by the following : — 

a. CodeiniEBulph. ET-iVA 

Acid, hydtocjanici dilut "IX"] 

Syr. lolu 3J. M. 

Stc — Every I wo or three hours. 
hflladonna may be added to any of the remedies named with 
advantage. 

Dr. Keating reports " remarkable improvement in four cases of 
whooping cough by the use, four or six times daily, of a spray com- 
posed of" — 

K- Ammonii bromid,, 

Polassii bromid Bfi 3J 

Tinct. bellndonnie fgj 

Glyceiini : fgj 

Aqua: rosse q. a. ad f^i"- 

The diet of the patient must be regulated, the clothing to be warm 
but not loo heavy, and the patient kept in the open air as long as 
possible. 

HEMOPTYSIS. 
Bynonyms. Bronchial hemorrhage ; broncho-pulmonary hemor- 
rhage ; bronchorrhagia. 

Definition. The expectoration of pure or unmixed blood, usually 
of a bright red color, following the act of coughing. 

CauBBH. In the majority of cases, the result of tubercular deposi- 
tion in the walls of the minute bronchial arteries; excessive cardiac 
action; bronchial congestion; excessive bodily exertion, straining, 
lifting or running ; a symptom of hamnphilia (" bleeder's disease "). 
Pathologrioal Anatomy. Hsemoptysis rarely causes death in 
itself, so that few opportunities for observing post morlem appear- 
ances are obtained, and when they do occur, the location of the 
hemorrhage is seldom found. 

The air passages are more or less filled with clotted blood, the 
mucous membrane is swollen, and of a ditk red color, rarely, pale 
and bloodless. The air cells contain blood clots, or are distended 
with air, the bronchi being filled with clots preventing its escs^. 



DISEASES OF THE BRONCHIAL TUBES. 211 

Unless the clots are rapidly removed by expectoration or absorptio 
a secondary inflammation originates around about them. 

Symptoma. "Spitting of blood" occurs suddenly; rarely, it is 
preceded by epislaxis, cardiac p.Upitation and some difliculty of 
breathing. 

It begins with a sensation of luannth under the sternum, tickling 
in tlie tliroat, a sweeiish taste in the mouth, which, upon attempting 
to remove by the act of coughing, a warm, saltisA, bright red, frothy 
liguiil gushes from the- mouth and nose. The quantity of blood 
raised varies from an ounce to a pint. The appearance of the 
blood depresses the individual, he becoming pale, tremulous, often 
fiimting. 

The attack may subside within half an hour to several hours, re- 
turning for several days, in the meantime the expectoration being 
either bloody or streaked with blood. 

A slight febrile reaction, with chest pains, supervenes upon the 
hemorrhage, the result of the inflammation at the site of the bleeding, 
which soon subsides, except where blood clots develop a secondary 
pneumonia, which may undergo the cheesy metamorphosis. 

Auscultation. Coarse, bubbling- rales are discerned in circum- 
scribed portions of the chest. 

Diagnosie. From epistaxis, or hemorrhage from the posterior 
nares, it is distinguished by the absence of air bubbles and an inspec- 
tion of the fauces and nasal cavities. 

Hamalemesis, or hemorrhage from the stomach, differs from 
hemoptysis in the blood being vomited instead of expectorated, 
of a dark color, clotted, mixed with the acid contents of the stomach, 
followed with black, tar-like stools, and the absence of rales in the 
chest. 

Exceptions to the above occur when the blood from the lungs is 
first swallowed and afterwards raised by vomiting, or when the 
hemorrhage in the stomach is caused by the erosion of a large 
artery, the result of ulcer of the stomach ; in these cases, however, 
the raising of blood is preceded by epigastric pain and the blood b 
not frothy. 

Prognosis. Hsemoptysis in itself rarely terminates fatally, al- 
though causing much depression : the patient rapidly recovers, unless 
secondary pneumonia results. In nine cases out of ten it is the 
prognostic sign of phthisis. 



212 PRACTICE OF MEDICISE. 

Treatment. Perfeclrest in bed, lie head and shoulders eleVated, 
and perfect quiet, the diet to be bland, the drinks cool, the patient 
slowly swallowing small particles of ice. Common sail, slowly dis- 
solved in the mouth, is a popular remedy, and if of no real benetit. 
serves to occupy the attention of the patient and friends until medical 
advice is obtained. 

The hypodermatic injection of ergniin, gr. x-xxx, or the internal 
administration of exl. rrgoia,Jiil., or. — 

E- Acid-Eflllic gr."v 

Acid, sulph. (Ill _ TH,x 

A<iLa cmi.araoi._ Jiv. M. 

Repealed every Qfleen or Iwenly minutes. 
Or tinctura matieo. gj, or extractutn hamamelis Jld.. Itxx-Jj, i 
alumen, gr. xx, frequently repeated. 

If the hemorrhage causes great nervous excitement, or depressioj 
opium, either hypodermatically or internally, to quiet the patieD 
is indicated. 

Inhalations. \y^ means of the steamatomiier, of either jMiff.tf/'jjc/K- 
tion or lincl./erri cklor.. arc recommended when the above means f; 
Prof Da Costa recommends, for frequent small hemorrhages, ct 
tinuing day after day, cupti sulpk., gr. I'j. ext. opii, gr. j'l, p. r. n. 



P lai 

I lal 

I lai 



DISEASES OF THE LUNGS. 



CONGESTION OF THE LUNGS. 

'Bynonym- Hyperemia of the lungs. 

Definition, An increase in, or an abnormal fullness of. the capil- 
laries of the air cells; active when the result of an acelerated circu- 
lation ; passive when caused by an impeded outflow from the capil- 

CaUBes. Active. Increased cardiac aclion; over exertion ; alco- 
hohc excesses ; mental excitement ; inhalation of cold or hot air. 

Passive. Obstruction to the return circulation. Dilated heart ; 
valvular diseases; low fevers (hypostatic congestion): Bright's disease. 

Pathologry. The hyperamic lung has a bloated, dark red ap- 
pearance, its vessels are distended to the uttermost, the tissues succu- 
lent and relaxed, blood flowing freely over the cut surface ; a bloody. 



DISEASES OF THE LUSGS. 213 

frothy liquid is present in the bronchi, and the alveolar walls are so 
much swollen that the condensed lung shows scarcely any indication 
of its cellular structure, resembling the tissue of the spleen (spUnifica- 

BfmptoniB. Active. Rapidly developing oppression of lA^ chest 
and iJifficulty of breathing, (lushed face, strong, full pulse, throbbing 
carotids and congested eyes, with a short, dry cough, followed by scanty, 
frothy expectoration slightly streaked with blood. 

Passive. Developed slowly, with difficulty of breathing, bluenesg 
of the surface, almost continuous hacking cough, followed by scanty, 
blond- streaked expectoration. 

PercusBion. The n 
quality of the sound being st 

Auscultation. The ves 
panied with sub-crepilnnt rales. 

Duration. Active. Usually from three to five days, terminating 
either by resolution, hemorrhage, or rarely, pneumonia. The onset 
may be so severe and sudden that death rapidly supervenes 

Passine. Developed slowly and subject to great variations, depend- 
ing upon the cause. 

JDiagnoeiB. Active congestion of the lungs cannot be distinguished 
from the stage of engorgement of a true pneumonia, in die majority 
of cases. 

Prog'nDB^, An 
within a few hours, bi 
favorably. 

The passive form i 

Treatment. Ac, 



of the lungs slightly diminished, the 

hat tympanitic. 

r murmur is diminished and accom- 



Lite congestion of the lungs may prove fatal 
inder prompt treatment it generally ten ninates 



controlled entirely by Che cause. 

ve. In the strong and vigorous -wet cups to the 
chest, or, if the symptoms are pronounced, a. general i/encseclion. 
Internally, tinctura aconiti. gtt. j-ij every half hour or hour, as indi- 
cated. w'x'Cti free purgation. 

Passive. Dry or ivet cups over the chest, hydragogue cathartics, 
and the internal administration of digit.tlis. 



CEDEMA OF THE LUNGS. 
Deflnition, An effusion of serum upon ths free surface of the 
lung, to wit : in the pulmonary vesicles ; characterized by dyspncea, 
cough, and frothy, biood-slreaked expectoration. 

Causee. Increased cardiac action; over exertion; alcoholic ex- 
mental excitement ; inhalation of cold or hot air. 



214 



PSACnCE OF MEDICIXE. 



Pathological Anatomy. The lung tissue is swollen, and does 
not collapse when the chest is opened. The dasticity of the tissue 
bx% dtsipp^sred. and it pits upon pressure. 

If following congestion of the lungs, the color is red; if a symptom 
of a general dropsy. Its color b pale. 

On cutting into the cedematous spots an enormous quantity of 
liquid, sometimes clear, at other times of a red color, mined more or 
less with blood, flows over the cut surface. The liquid is lilled with 
bubbles, is frothy, from being copiously mixed with air. providing the 
air cells have not been entirely filled with serum, therebv excluding 
Ihc air. 

Symptoms. Following a more or less rapidly developing hyper- 
semia of the lungs are great difficulty and extreme rapidity of breatk- 
tH^, with a strong sense of opprtsiion. great anxiety, rapid and tumul- 
tuous cardiac action, tkrobbiag carotidi and temporals, fullness of the 
head and headache, fluiked face and congested eyet. with a coHitant, 
short cough, and the expectoration of a tough, frothy mucus, streaked 
with blood. 

If the effusion into the air cells be sullicient to prevent the entrance 
of air, symptoms of cyanosis rapidly supervene, the pulse becoming 
feeble, the surface cold, the breathing shallow and hurried, the cough 
suppressed, stupor replacing the restlessness, soon deepening into 

Percuasion. Slightly impaired or vesiculo-tympanitic. 

Auscultation. The vesicular murmur is supplanted by sub-crepi- 
tani and bubbling rales. 

Diasnosis. Pneumonia in the earlier stages is the only condition 
likely to be confounded with cedema of the lungs, and the subsequent 
course of the two maladies soon determines the diagnosis. 

PrognosiB. (Edema of the lungs is always a serious malady, and 
frequently, unles's promptly relieved, terminates fatally. 

TreatmeQt. If the cedema be of an active kind, prompt blood- 
letting, either by venesection or wet cups Co 

The internal administration of tinclura 
every Rfteen minutes, until the cardiac ac 
after which every hour or two, with the use 
ntonium. cither the carbonas or iodidum, t 
duce marked relief. 

The above means may be aided by counter-irritation to the chest, 
hot muitard foot-baths, and active saline purgatives. 



the chest, is indicated. 
aconili, gtt. j-ij, repeated 
:tion is markedly reduced, 
of the preparations of ««- 
o liquefy the effusion, pro- 



DISEASES OF THE LUNGS. 21S 

CROUPOUS PNEUMONIA. 
Synonyms. Lobar pneumonia ; pneumonitis; pleuro-pneumonia; 

DeBnition. An acute croupous inflammation involving the vesi- 
cular structure of the lungs, rendering the alveoli impervious to air ; 
characterized by a severe chill, fever, pain, dyspncea, cough, lusty 
apulum. and great prostration. 

Causes. The question of pneumonia being a constitutional dis- 
ease is still nt6 judice. It is most common in winter, at times occur- 
ring epidemically, the result of atmospheric conditions ; exposure to 
draughts and coid; injuries to the chest walls ; alcoholic excesses; 
gout or rheumatism. 

Pathological Anatomy. The inflammatory changes most 
cnmmonly afled the lower right lobe, rarely the upper lobe, very rarely 
corresponding lobes in both lungs. 

The changes are, I. Hyperemia (engorgement) ; 11. Exudation 
(red hepatiiaiion) ; 111. ^«c/«ft'u« (gray hepatization) ; or it may un- 
dergo purulent transformation or the development of abscesses 
(yellow hepatization). 

I. Stage of hyperemia or engorgement consists in the vessels of the 
alveoli being distended to their utmost, encroaching upon the cavity 
of the air vesicle ; the lung has a reddish-brown color, is heavier, sink 
ing somewhat lower in water than a normal lung, and having a slight 
exudation upon the vesicular surface. The same changes are per- 
ceived in the adjacent bronchioles. 

II. Stage of exudation, consists in the exudation of a viscid, fibrin- 
ous fluid, admixed with white and red corpuscles and blood, which 
rapidly coagulates, firmly enclosing the corpuscles and completely 
filling the alveoli. When the exudation and coagulation are com- 
pleted, the lung is red, sinks at once when placed in water, and its 
elasticity is destroyed. When cut into, the color, density and granular 
appearance sp closely resembles the cut surface of a section of the 
liver, that Ljennec termed it red hepatization. 

III. Resolution, or gray hepatization, follows the above condition in 
the majority of cases, the coagulated albuminous exudation under- 
going liquefaction and absorption, the cellular element undergoing a 
fatty degeneration, the greater part being absorbed, the remainder 
expelled during acts of expectoration, the alveoli returning to their 
normal condition, both as to capacity, function and elasticity. 



PRACTICE OF MEDICINE. 



^ 



aie 

If resolution ^e retarded and portions of the coagulated exudation 
undergo purultnl transfonna/ion, changing from a yellowish to a 
greeniih-yellow color (yellow hepalizalion), pus cells arc rapidly 
formed, the part becoming a granular, fatty mass. The portions of 
the lung not undergoing this purulent transformation retain the red- 
dish color with intermixed yellowish patches, the lung structure proper 
remaining intact. The purulent contents may be ejected in part, the 
remainder undergoing fatly degeneration and finally absorption. 

Abscess of the iun^ may result from the lung structure becoming 
involved in the purulent disintegration. Abscesses may be solitary or 
in great numbers, which by disintegration of intervening structure 
form one or more large abscesses ; these abscesses either terminate 
fatally, or open into the pleural cavity, causing empyema and exhaus- 
tion, or open into the bionchi and are expectorated, or an interstilial 
pneumonia is developed and the absc^s encapsulated in a firm cica- 

Gangrene of the lungs may result from blocking up of the bronchial 
or pulmonary arteries by coagula, during any stage of the disease. 

The uninllamed portions of the lungs are hyperEemic and their 
functional activity is increased. 

Death sometimes results from a general (edema of the unaffected 
lung, such cases being often erroneously termed " double pneumonia," 

If inflammation of the pleura be associated with a pneumonia, 
the &a-Z3\\iApteuro-pneunuinia, the changes in the pulmonary pleura 
are characteristic. " An uneven, thin, downy-looking layer of plastic 
exudation covers its surface. This plastic layer may conceal the liver- 
brown color of the pneumonic lung. As the third stage is reached 
the opposing surfaces of the pleura may become agglutinated. The 
pleuritic changes follow very closely those which occur within the 
lung. The cells in the pleuritic exudation are mainly pus. The pleu- 
ritic membrane is opaque, congested and ccchymotic. It may become 



so thick 

reached.' 

Dural. 

stage of e 



J give 



I duU I 



1 percussion, after resolution i 



ingestion, from one to three days ; 
;ven days; stage of resolution, from 



of Stages: stage of c~ 
tltUiott, frotn three to si 

In severe cases or in the very young, the aged or the depressed the 
stage of red hepatization may be fully developed within forty-eight 



DISEASES or THE LUN-RS. 217 

Seal : The most frequent seat of croupous pneumonia is the lower 
righl lobe ; the next most frequent seat is the lower /eft lobe ; the 
neitt, the upper right lobe, althuugh in children and the aged this lobe 
is affected equally as often as the right lower lobe. 

Symptoms, Begins with a severe and unusuallj- protracted chill 
(in children often convulsions), followed by a rapid rise of tempera- 
lure, io3°-io5° F.p a strong, full, but rapid pulse, either a dull or sharp 
pain near the nipple, aggravated by pressure, breathing or coughing, 
shortness of breath, tlie number of respirations increasing to 40, 50, or 
more per minute, causing interrupted speech ; cough, first short, ring- 
ing and harsh, soon followed by a scanty, frothy mucus, soon becoming 
semi-transparent, viscid, and /i««i;(i«i', about the second day changing 
to the familiar rusty sputum, becoming more copious and of a yellow 
color as the disease advances. There are present headache, sleepless- 
ness, rarely delirium, save in drunkards, flushed countenance, andes- 
fiecially over the malar bones is a well defined mahogany blush ; gastric 
disturbances and scanty, high-coiored urine, with diminished chlorides. 

The above symptoms continue more or less marked until either the 
fifth, seventh, m'ntk or eleventh day, when a crisis occurs, and within 
twenty-four hours convalescence is established, recovery rapidly fol- 
lowing. 

Typhoid pneumonia is a term applied to those cases which are 
accompanied by signs of extreme prostration, vtrj high temperature 
and profuse and prolonged exudation. They may also terminate by 



Bilious pne 
liver, the result of venoL 
an accompanying acute 
pneumonia and malaria 
more or less pronounced, 
inter m iitent pneumonia. 

If purulent infiltration follow the stage of red hep; 



rs in cases accompanied by congestion of the 
stasis from pulmonary obstruction or from 
catarrhal jaundice. In malarial districts 
are frequently associated, when jaundice, 
Dccurs. Such cases are termed malarial 01 






, symptoms of exhausi 
pectoration, high temperature, severt 
dry, sordes collecting on the teeth, r 
tedious. 

Pneumonia occurring in persons 
begins with symptoms closely 1 



tremens, cough, expectoration, the pain very slight, e 



with profuse purulent ex- 
sweats; the tongue brown and 
■CO very slow and convalescence 

of intemperate habits usually 
nbling an attack of delirium 



PRACTICE OF MEDICINE, 

Inspection. First stage, deficient movement of the affected side, 
due to the pain. 

Sfconii sti\ge, llie healthy side rises normally, the affected side lag- 
ging behind. If both lower lobes are impervious to air, the diaphragm 
cannot descend and the epigastrium does not project during inspira- 
tion, the breathing being conducted by the upper part of the chest 
(superior costal respiration). 

Palpation. First stage, the vocal fremitus more distinct than 
normal. 

Second stage, the vocal fremitus is markedly exaggerated, except in 
those rare instances of occlusion of the bronchi by si 

The cardiac impulse is felt in the normal position. 

Percussion. /^rrJ/jtof.?, the percussion note is slightly impaired ; 
indeed, at times having a hollow of tympanitic quality. 

Second stage, dullness over the affected parts, with an increased 

Auscultation. FiT^t stage, over affected part, feeble vesicular 
murmur, associated wilh the true vesicular or crepitant (crackling) 
rale, most distinct during inspiration. 

.Second stage, harsh, high pitched bronchial respiration, at times 
resembling a to and fro metallic sound, except in those rare instances 
in which the bronchi are more or less tilled with secretion. 

Bronchophony, or distinctly transmitted voice, at times pectoriloquy, 
or distinct transmission of articulated sounds. 

Third stage, breathing changing from bronchial to iiesiculobrott' 
ckiat, the ir^^/('/iin/ (crepitatio redux) rale returning, and if resolution 
proceed the breath sounds are associated with large and small moist 
and bubbling rales, 

TermioatioDS. Asthenic cases recover within two weeks. When 
purulent infiltration supervenes, the disease pursues a tedious course 
of several weeks' duration, with a low exhaustive fever. 

If death occur during the first or second stages it is usually the result 
of a collateral adema of the uninflamed lung, or cardiac exhaustion. 

Death in the third stage is the result of exhaustion. It is especially 
trying for the weak, the aged or drunkards. 

If abscesses occur, there are exhausting sweats, frequent cough, wilh 
a large amount of yellowish -gray, at limes blood'Streaked, expector<L- 



Gan^ene of the lungs is a r 



i associated with 



DISEASES OP THE LUNGS. 210 

symptoms of collapse, the expectoration of a blackish, fetid sputum, 
and the physical signs of a pulmonary cavity. 

DiagaosiB. CEdema of the lungs may be confounded with the 
first stage of pneumonia, but the subsequent history, iL'; presence on 
both sides, and the waterish expectoration and absence of chill and 
pain and the physical signs of pneumonia soon determine the 
diagnosis. 

Pleurisy is oftener confounded with pneumonia than any other dis- 
ease, the points of distinction between which will be pointed out when 
discussing that alYection . 

Prog'QOBiB. Depends upon the extent of the inflammation, double 
pnuemonia being very grave, but- is not near so frequent as was at one 
time supposed. A temperature of 105° F., and a pulse above i2o are 
of bad omen. Pneumonia of drunkards almost invariably terminates 
fatally. Typhoid pneumonia, the so-called bilious pneumonia, puru- 
lent infiltration, abscesses of the lungs and gangrene, all give a grave 
prognosis. 

Treatment. First stage, wet or dry cups over the chest, followed 
by the application of poultices. Internally, either iiiicf. -verat. virid., 
gtt. j-iij, or tiitct. aconiti, gtt. ij-iv, or fittctura digitalis Itlx, repeated 
every half hour or hour, until a decided impression is made upon the 
circulation, and at the same lime quininee sulphas., gr. v, every three 
or four hours. If the patient be strong and vigorous, the circulation 
full, the arterial tension high, the dyspnosa early and marked, the 
surface flushed, and the pain severe, marked relief is obtained by a 

Second stage, the arterial sedative should be replaced by quinma, 
sulpktts.,^z. iij, every three hours, and am'noiUi carbonas., gr. v, every 
two hours, and a good, nutritious diet. Local applications are use- 
less at this stage. 

Third stage, ammonii carbonas., gr. v, every three hours, guinince, 
sulphas., gr. xij-xx, during the day, nutritious diet, stimulants, and if 
the hepatiiation shows signs of lingering, flying blisters over the 
chest. 

For typhaiil pneumonia, purulent inRltration, abscess of the lungs, 
or pneumonia in drunkards, the weak or aged, guinina. ferrum, 
strong, nourishing diet, bold stimulalian, and the free us 
carbonas, are the indications. 



CATARRHAL PNEUMONIA. 

Sjmonyms. Broncho-pneumonia; lobular pneumonia ; -capillary 
bronchitis (?) 

Definition. An acute catarrhal inflammation of the bronchioles 
and alvcoii of the lungs characterized by fever, cough, dyspnoea, 
copious expectoration and great depression. 

Causes, From an extension of a bronchial catarrh downward ; 
following the eruptive fevers, especially measles ; coitiplicating whoop- 
ing cough. Persons of the rickety or scrofulous diathesis, in whom 
there is a greater irritability of the epithelial elements, are particularly 
predisposed to this form of pneumonia on slight exposure; emphy- 
sema ; diseases of the heart ; childhood and old age. 

Pathological Anatomy, f/yperamia of the mucous mem- 
brane of the bronchi, and also of the bronchioles and air cells, with 
swelling and succulence of these tissues, accompanied by an abnor- 
mai secretion And an immense firoiiuclion of young cells from the pro- 
liferation of the bronchial and alveolar epithelium, admixed with a 
yellowish, creamy, mucoid material, which blocks up Che bronchioles 
and air cells. 

The affected parts first have a reddish-gray, soon changing to a ' 
yellowish -gray color, due to the rapid metamorphosis of the newly 
developed cells, if the fatly change be completed, absorption takes 
place, and the consolidation is removed : if it remain incomplete the 
cells atrophy, the little mass becoming caseous, and the disease passes 

The bronchial tubes also participate in the disease, the walls become 
thickened, from a hyperplasi.i of the connective tissue {peri'bron- 
chilis), and their calibre is often dilated. 

Symptoms. Catarrhal pneumonia is preceded by catarrhal bron- 
chitis. It may be either acHle, sub-acule or chronic in its course. 

Acute variety : Its onset is announced by a gradual rise of tempera- 
ture to io2''-lo3'' F.. with rapid, laborious and shallow breathing, 
as shown by the widely dilated nares and violent action of all the 
accessory muscles, while the insufficient distention of the lungs is 
shown by the great recession of the lower part of the chest walls and 
sinking in of the intercostal spaces. The inspiration is short and im- 
perfect, the expiration noisy and prolonged; ihe pulse \% freguenl, 
iix>-i20 or more, and somewhat compressible; the cough, which, 



DISEASES OF THE LIWGS. 

during the bronchitis, was [oose, now becomes short, hacking, dry 
and painful, soon followed by more or less copious muco-purvltnt 
expectoration ; the appetite is impaired, bowils somewhat loose, urine 
scanty, high-colored, and the surface frequently covered with a more 
or less profuse perspiration. 

The sub-acute and chronic varieties have the same general symp- 
toms, but the duration is longer and the exhaustion greater. 

The progress of catarrhal pneumonia is sometimes, although not 
often, a very acute one. The disease may prove fatal itr a few days, 
especially if it attack feeble children ; in such the countenance 
becomes pale and livid, the lips bluish, the eyes dull, and restless- 
ness giving place to apathy and a continually augmented somno- 

Resolution, when it occurs, is by lysis, several weeks elapsing before 
complete recovery. 

Percussion. Dullness, scattered in patches, over both lungs, the 
intervening heallhy lung often giving a more or less hollow oz tym- 
panitic note. 

Auscultation. Vesiculo-bronchial breathing, changing to moist 
bronchial breathing, associated with small bubbling (sub-crepitant) 
rales. As the disease progresses toward resolution, the rales become 
larger (large bubbling) and more copious. If pneumonic phthisis 
result physical signs indicative of that condition are soon evi- 
dent. 

BequelEB. Attacks of catarrhal pneumonia complicated with 
atelectasis, or collapse of the lobules, when recovery occurs, are fol- 
lowed by emphysema of the lungs. 

If the catarrhal products which fill the alveoli and bronchioles and 
intervening connective tissue do not rapidly undergo complete fatty 
metamorphosis and consequent absorption, pneumonie phthisis re- 
sults. 

DiagnosiB. Ordinary bronchial catarrh differs from catarrhal 
pneumonia by the absence of dyspncea, fever, and dullness on per- 
cussion, and the presence of the large bubbling rales, and also by the 
subsequent history of the two affections. 

Croupous pneumonia \k A unilateral disease ; catarrhal pneumonia 
is bilateral and diffused over both lungs; the former a self-limited 
disease, the latter having no lixed duration. 

Acute tubercnlosis a[ its onset is characterized by the presence of a. 



232 PRACTICE OF MEDICINE. 

capillary broncliitis. a differentiation being possible only by a study of 
the clinical history and course of the two maladies. 

(Edema of the lungs is a bilateral disease associated with a short, 
dry cough and dyspncea, but lacks the previous catarrhal history and 
high temperature of catarrhal pneumonia. 

Progtlosis. Fully one-half of the cases of true catarrhal pneu- 
monia terminate fatally. The prognosis must be guarded for scrofu- 
lous or rachitic subjects, or those enfeebled by olher diseases, for, 
unless prompt resolution can be effected, it will terminate fatally early, 
or develop pneumonic phthisis. 

Treatment. Confinement to bed is paramount, although the 
position of the patient is to be frequently changed. The diet must 
be of the most nutritious character, administered at frequent intervais ; 
milk, eggs, chicken, beef, mutton and oyster broths are the most suit- 
able. The steady use of brandy or -whisky throughout the attack is of 
importance regulating the amount by the age of the patient and the 
severity of the attack. 

For the fever, qiiinina sulphas, gr. xv-xx each day, is the most 
reliable of all antipyretics, or antifiyrm in full doses may be sub- 
stituted. 

For the catarrhal process, the air of the apartment should be main- 
tained at an even temperature and moistened by disengaging the 
vapor of water in it. The following combination is of great utility in 
nearly ail cases : — 

ft. Ammonii carbonat gr. v 

Ammonii iodidi _ _ gr. v-i 

Mucil. acacia q. i 

Syr. glycyrrh gi-ij 

Syr prun. virg ji-'j- M, 

SiG. — Every three hours. 

A much pleasanter way of administering the ammonia salts is in 
capsules, each containing about two and one- half grains of each with 



For convalescence, nutritious {aaA.ferri iodidum. quinina sulphas, 
and oleum morrhnx. ' 

Locally: repealed application of mustard poultices or turpentine 
stupes followed by demulcent poultices, if the JnHammalory process 
tends to become chronic, scattering blisters should be used. 



DISEASES OF THE LUNGS. 223 

PULMONARY CONSUMPTION. 

Synonyms. Phthisis pulmonalis ; phthisis ; consumption. 

Definition. Four varieties of pulmonary consumption are now 
admitted to exist: Pneumonic phthisis; tubercular phthisis; fibroid 
phthisis ; acute miliary tuberculosis. 

As these forms present differences at all points they will be de- 
scribed separately. 

PNEUMONIC PHTHISIS. 

Synon3nilS. Chronic catarrhal pneumonia ; catarrhal phthisis ; 
caseous pneumonia ; caseous phthisis. 

Definition. A form of destruction of the pulmonary tissue caused 
by the caseation or cheesy degeneration of inflammatory products in 
the lungs and the subsequent softening and destruction of the caseous 
matter, with greater or less destruction of the pulmonary tissue ; 
characterized by hectic fever, cough, shortness of breath, purulent 
expectoration, and more or less rapid prostration. 

Causes. The predisposing factor in the etiology of pneumonic 
phthisis is a strumous or scrofulous diathesis, or a condition of lowered 
health, the result of various unfavorable hygienic influences. 

The exciting causes are catarrhal pneumonia in any portion of the 
lung, but especially at the apex; inflammation occurring about a 
blood clot ; inhalation of irritant particles occurring in certain occu- 
pations, to wit: weaving, grinding, mining, hatters, millers, cigar 
makers and the like. 

Pathologrical Anatomy. When a pneumonia terminates in 
resolution the inflammatory products are absorbed by first undergoing 
2, fatty metamorphosis. If the fatty metamorphosis be incomplete, the 
cells are atrophied and undergo the caseous degeneration, which con- 
sists in the absorption of the watery parts and the fatty degeneration 
of the cellular elenaents and the granular disintegration of the fibrin- 
ous material, so that ultimately a soft, solid mass-is produced, yellowish 
in color, having the appearance of cheese. 

The destructive changes are thus described by Niemeyer : " Cells, 
the products of inflammation, accumulate in the alveoli and minute 
bronchi, crowd upon each other, becoming densely packed, and thus 
by their mutual pressure they bring about their own decay, as well as 
that of the lung textures, by interfering with their nutrition, the 



1 three forms, to wki I 

isidious. the individual being J 
t exposure; gradually a p^- 
•^pus, is established, each 



K4 PKACTICE OP 

alveolar walls being also themselves damaged by the inflammatory I 
process." 

The position of the catarrhal pneumonia resulting in the above 1 
changes is usually at the apex, but it may occur at any portion of the I 
lungs, or a whole lung becomes infiltrated, and undergoes the checsyv 
degeneration (phthisis florida). 

In many cases lubercU is deposited in the inflamed lung, hastening I 
its destruction and the formation of c 

Symptoms. Pneumonic phthisi 
chronic, subacuU and acute. 

Chronic farm. The origin is rather ir 
susceptible to "colds" on the shghtes 
tislttil cough, with the expecloralion of n 

severe cold being accompanied with fA/A'j,yi^7'^r,^/!« in the chest, 
and either slight hemorrhage or blood-streaked sputa. Finally the 
attacks become persistent, with morning chills, evening _/iw*^3 and 
rather profuse flight sweats, distressing cough, profuse mu co-purulent 
Sputa, great weakness and exhaustion, loss of appetite and feeble 
digestion, the symptoms growing persistently worse, death occurring , 
from exhaustion after one or two years' duratioi 

Subacute variety. History of an acute attack of pneumonia of oi 
or two weeks' duration, followed by a decided improvement, but noti 
complete recovery. After a lapse of some weeks or months, symp-l 
loms of pulmonary softening begin, destroying the lung si 
forming cavities, accompanied by chills, fever, night sTt-eats, emacf^ 
ation, cough, muco-purulent and blood-streaked expectoration, i 
patient dying from exhaustiori within a year. 

Acute variety, the so-called phthisis florida, runs a rapid o 
beginning as a catarrhal pneumonia, involving the whole of o 
part of both lungs, associated with rapid loss of fiesk and strength,^ 
high but variable temperature, loj'-ioj" F., with remissions, profus 
night sweats, shortness of breath, severe coug\\, profuse, purulei 
blood-streaked sputa, 'ioss of appetite, feeble digestion, rapid ex 
fton, the patient succumbing in a few weeks or months, from exhaustion. 

A decided remission in the local and general symptoms of the acute 
variety may occur, the disease afterward pursuing a more chronic 



InspeotioQ. Shows defkient respiratory m 
portion of the lungs. 



I'l of the diseased j 



DISEASES OP THE LUNGS. 225 

Palpation. Increased vocal fremitus over the consolidated lung 
tissue and cavities. 

Percussion. The percussion note varies from a slight impairment 
of the normal note to dullness, and when cavities are formed, asso- 
ciated with scattered points of the tympanitic or hpllow note. If the 
cavities communicate with a bronchial tube the cracked-pot or crctcked- 
metal sound is elicited. If the cavities are filled with pus the percus- 
sion note is dull. If the pus be expelled the tympanitic or cracked- 
pot sound returns. 

Auscultation. The vesicular murmur is unimpaired in those 
parts free from disease: it is feeble or indistinct if many bron- 
<chioles arc obstructed ; and is harsh or blowing if the bronchioles 
are narrowed. The inspiratory sound will be jerking, and the ex- 
piratory sound prolonged and blowing when the lung has lost its 
elasticity. 

Associated with the impaired vesicular murmur is difine, dry, crack- 
ling sound (crepitation), appearing at the end of inspiration. If 
bronchitis be associated, large and small moist or bubbling rales are 
heard during the respiration. 

When cavities form, either bronchial or broncho-cavernous respira- 
tion is heard, associated with more or less distinct gurgling rales. 
If the cavity be free from pus and have rather firm walls, the breath- 
ing is more amphoric in character. 

Dlaffnosis. Catarrhal bronchitis has many points of resemblance 
to pneumonic phthisis. The subsequent course of the latter, with the 
high temperature, prostration, emaciation and physical signs should 
prevent error. 

Tubercular phthisis is often confounded with. pneumonic phthisis, 
an error difficult to prevent in many cases. 

ProfiTQOSis. Acute variety, the phthisis florida, usually terminates 
fatally within a few months. 

The subacute and chronic varieties may, under judicious treat- 
ment and favorable hygienic conditions, be arrested, the caseous 
matter partly expectorated and partly absorbejd, leaving more or 
less loss of structure, cicatricial, tissue supplying its place, which 
after a time contracts causing more or less retraction of the chest 
walls. 

Cases not properly treated, either from carelessness or poverty, 
succumb after a year or two. 

K 



226 PRACTICE OF MEDICINE. 

Treatment. An attempt should always be made to remove the 
caseous matter by absorption and expectoration. The following pre- 
scriptions will sometimes prove successful : — 

R. Ammon. carb gr.v 

Ammon. iodidi gr«v— x 

Syr. tolu ....:.... ^ij 

Syr. prun. virg...., 3ij, M. 

Every five hours, alternating with 

R. Liq. potass, arsenitis V\y 

Mass. ferri carb gr.v 

Vini xerici * jj 

Aquae dist ,5"j- M.- * 

The diet should be of the most nutritious character, the clothing 
warm, and, if practicable", change of residence should be made to a 
dry and elevated climate. If the digestion will permit, oleum morr- 
hucB, 3i-ij, three times a day. 

For the fever y quinince sulphas,, gr. xv-xx, is more successful than 
the combination of quinina and digitalis in small doses. 

Night* sweats are best controlled by atropince sulphas, gr. ^^, at 
bedtime, or 

B. Extract, belladonnse •. gr.ss 

Zinci. oxidi g^.iij. M. 

At bedtiftie. 

For the cough and sleeplessness, codeince sulphas, gr. ss-j, p. r. n. 

TUBERCULAR PHTHISIS. 

Synonjnus. Tuberculosis ; consumption ; incipient phthisis. 

Definition. The deposition of tubercle in the lung structure, 
which undergoes softening, followed by more or less loss of the pul- 
monary tissue proper ; characterized by fever, cough, dyspnoea, ema- 
ciation and exhaustion. 

Causes. Chiefly hereditary ; closely associated with scrofula and 
struma ; probably Contagious under certain conditions ; secondary to 
catarrhal (caseous) pneumonia; the theory of the ''bacillus tubercu- 
losis'' of Koch is still sub judice. 

Pathologrical Anatomy. Tubercle is a grayish-white, trans- 
lucent and semi-solid granulation, about the size, of a millet seed, 
most commonly deposited in the walls of the bronchioles J exciting a 



DISEASES OF THE LUNGS. 227 

low form of inflammation, the result of its own death. The masses 
of tubercle soon undergo softening (cheesy transformation) ; the lung 
structure is secondarily affected, undergoes softening, which results 
in more br less destruction of the tissue, whence cavities are formed. 

The inflammation may extend to the small arteries, causing hem- 
orrhage. 

The deposit of tubercle is generally at one of the apices, soon 
spreading to other parts; depositions may also occur in the brain, 
intestines and liver- 

The pleura is usually the seat of a chronic inflammation (dry plea-, 
risy), resulting in the obliteration of the cavity. 

The larynx suffers from extensive tubercular ulcerations, gausing 
more or less destruction of the parts. - \ 

Symptoms. The symptoms correspond closely to the stages of 
deposition^ oi softening, and of ih^t formation of cavities. 

The development is insidious, with increasing dyspepsia, irritable 
hearty a light, dry, hacking cough, referred to the throat or stomach, 
scanty, glairy expectoration, gradual loss of weight, impaired muscular 
strength, pallid appearance, more or less copious hcemoptysis often 
following. Pain^ sharp in character, below the clavicles, is often 
present. 

The beginning of softening is announced by increased cough, freer 

expectoration, dyspnoea increased on exertion, morning chills, evening 

fever, night sweats — the so-called hectic fever, diarrhoea, increased 

emaciation and weakness, the patient however continuing very 

hopeful. 

With the formation of the cavities, the cough is more aggravated, 
with profuse and purulent expectoration, at times containing yellow 
striae, the amount depending upon the numbet and size of the cavi- 
ties; haemoptysis not common at this stage; ^t pulse rapid and 
weak, increased hectic, burning of the soles and palms, copious 
night sweats, greater debility and emaciation, with oedema of the feet 
and ankles, (denoting failure of the circulation, death soon following 
from asthenia, the mind clear and Jiopeful to the end. 

Inspection. First stage often shows slight depressions in the 
supraclavicular, and at times in the infraclavicular regions. 

Palpation. Second stage, the voczX fremitus is slightly increased. 

Percussion. First stage, slight impairment of the normal percus- 
sion resonance can sometimes be elicited. Second stage, the reson- 



s 



PRACTICE OF MEDICINE, 

•inpaired, and may be even dull. Third stage, dullness with 
:ribed spots of the amphoric, qr tympanitic or cracked-pot 

AuBOUltation. First stage, i/ispiration jerky, expirdlinn pro- 
longed, the pitch higher than normal, the inspiration associated with 
cradling, rales. 

Second stage, vesiculo-bronchial breathing, associated with sub-crepi- 
tani and large and small moist or bubbling rales. 

Third stage, bronchial, broncho-cavernous and cavernous respira- 
- tian, associated with large and small moist or bubbling, and localiied 
gurgling rdles. 

Bronchophony in its various degrees is associated with the second 
and third stages of tuberculosis. 

Gomplications. Tubercular diseases of the brain, larynx, pleura 
intestines, and periloneimi ; perineal abscess leading to fistula. 

DiagllOBis. The early diagnosis of tubercular phthisis rests 
roainly on the history, together with the symptoms and physical signs. 
In the first stage it is often mistaken for dyspepsia, anemia, malaria] 
fever, or disease of the heart. 

PrognOBiB. In the main unfavorable, although under proper 
treatment, change of climate and like favorable conditions, life may 
be prolonged for years. The question of perfect recovery is, to say 
the least, doubtful. 

Treatanent; First stage, life may be prolonged, and perhaps the 
further deposition of tubercle delayed, by achange of climate, nutritious 
food, warm clothing, out-doorexercise, and the internal administration 
t>i ol. 7Harrhua,ferri iodidum, arsenicum, hypophosphtles.ovihG elixir 
quiiUna Jerri et sfrychnina^ 

Special symptoms require treatment only when indicated, care being 
exercised to avoid everything which tends to impair the appetite, dis- 
order digestion, or lower the vital powers. 

For the fever the " Niemeyer pill " is usually recommended ; its 
formula being — 

Et. Quininie sulph gr.ij 

Putv. digitalis gr-ss-j 

Pulv. opii ET-X"** 

Pulv. ipecac _ S^'in !*■ 

From a very considerable experience with this " famous " pill, I 



DISEASES OF THE LUNGS. 229 

can recall few cases in which it proved of the least benefit. The fol- 
lowing is much more effectual : — 

R. Quinince sulph... .,,.., gr.x 

Quininse muriat gr.x 

Pulv. opii et ipecac i^-iij* M. 

Ft. capsul Ng.ij. 

SiG. — One capsule five hoursj and the other three hours before the de- 
cided rise of temperature. 

For night sweats^ not the result of the diurnal fever, atropine 
sulphas t gr. ^V^V* ^t bedtime, is an effective agent. 

For cough, if not modified by the arrest of temperature and night 
sweats, the following is of use : — 

R. Codeinae sulphat ST*/i-}4 

Acid, hydrocyanici dil Tr\^ij 

Syr. tolu ^ij. M. 

SiG. — Several times a day. 

The dyspeptic symptoms are wonderfully relieved by the following: 

R. Pepsinicryst gr.ij 

Acid, muriat. dil Tr\^x 

Glycerini Tr\^xx 

Succi limonis ". Tl\^xv 

Aquae aurantii flor. ad „ ^^ij, M. 

SiG. — ^With meals. 

FIBROID PHTHISIS. 

Synonyms. Chronic interstitial pneumonia; cirrhosis of the 
lungs ; Corrigan*s disease. 

Definition. A hyperplasia (thickening) of the pulmonary con- 
nective tissue, resulting in atrophy and degeneration of the vesicular 
structure, associated with bronchial inflammation ; characterized by 
cough, profuse expectoration, fever, emaciation, and ultimately death 
by asthenia. 

Causes. Hereditary ; inhalation of irritants ; chronic bronchitis ; 
alcoholism. 

Pathologfical Anatomy. Thickening of the bronchial mucous 
membrane and dilatation of the airtubes ; hyperplasia of the pulmon- 
ary connective tissue, resulting in the compression and consequent 
destruction of the vesicular structure, which is assisted by the contrac- 



E OF MEDICINE. 

tion of the newly formed tiuues. Sooner or later catarrhal pnea- 
monia results, the product undergoing the cheesy degeneration, cavi- 
ties being formed, and as a result of the long-continued suppuration, 
tubercular depositions occur, hastening the destruction of the lung 

SymptotnB. The course is chronic, beginning as a bronchial 

calarrk, worse In winter, better in summer, when, afiei several years, 
the L"o«f^ becomes toox^ conlinuous, Ihe expecloralion freer, and muco- 
purulent, often raised in paroxysms, in large amounts, keclic fever 
develops, nigAt sweats, dyspniea and rapid emaciation, soon followed 
by tedema of the feet and ankles, the result of failing circulation, death 
occurring by asthenia. 

Inspection. Depression of the chest wfills, 

Percnasion. Impaired resonance, followed by dullness, with 
irregular spots of amphoric or tympanitic percussion note over the 
points of depression. 

Auscultation. Kirst stage, ■vesicalo-bronckial. or harsh respira- 
tion associated with large and small moist or bubbling rales, followed 
by bronchial, broncho-cavernous and cavernous respiration, with cir- 
cumscribed gurgling r^les. 

DmgfUOSiB, Beginning as a bronchial catarrh, slowly progressing, 
with the remission of the symptoms during the summer months, 
finally becoming progressively worse, with the formation of cavities, 
and symptoms of asthenia, are the chief points in the diagnosis. 

PrognoBis. The duration of fibroid phthisis is most protracted, 
four or five years being the average duration ; death, however,, is the 
inevitable termination. 

Treatment. To prevent the hyperplasia of the connective tissue, 
kydrargyri corrosivutn chloridum.potassii iodidum or aurii et sodii 
chloriJtim, are recommended. Oleum morrhum is of benefit. 

The bronchial catarrh, hectic fever and night sweats should be 
treated only when their severity becomes marked. 

ACUTE PHTHISIS. 

Synonyms. Acute milia.ry tuberculosis ; galloping consumption. . 

Definition. An acute febrile affection, due to the rapid dcpo»- 
tion tliroughout the body, but especially in the lungs, of the gray 
tubercle-granule: characterized by high fever, cough, profuse expec- 
toration and rapid prostration. 



DISEASES OF THE LUNGS. 231 

Causes. Most common between puberty and middle life. 

" That the gray granulation is deposited throughout the body under 
the influence of certain conditions of irritation, it is necessary that a 
peculiar vulnerability of the constitution iexist, in other words, that it 
be of the scrofulous type." 

The result of caseous or suppurative changes in the lungs. 

Pathologfical Anatomy. "The gray granulation or miliary 
tubercle consists of a fine reticulation of fibres, with a mass of epi- 
thelioid cells and granules, and often having a. giant cell for its 
centre." 

The deposit is generally over both lungs and the bronchial tubes, 
and is followed by hyperaemia, increase of secretion, having a viscid 
and adhesive character, and the destruction of all the tissue with 
which it comes in contact. 

Deposits also take place in the brain, pleura, intestines, peritoneum 
and kidneys. 

SymptoEQS. The onset is usually sudden, with a chill or chilli' 
ness, followed hy fever, \q2^-io^ F., rapid, dicrotic pulse, 120-140, 
cough, with scanty, glairy sputum, increased respiration, 30-50 per 
minute, pain in the chest, hot skin, dry tongue, deranged digestion 
2Si^ great prostration, the severity of the symptoms rapidly increas- 
ing, the sputum becoming more abundant and often rusty in color, 
with more or less frequent attacks of hcemoptysis, soon followed by 
headache, vertigo, sleeplessness, often delirium, coma and death. 

If d^osits have occurred in the meninges or the intestines, symp- 
toms of these affections are superadded. 

Percussion. The percussion resonance is normal until con- 
siderable deposits have occurred, when it is either slightly impaired 
or even slightly tympanitic. With the development of cavities the 
amphoric percussion note is present. 

Auscultation. Vesiculo-bronchial breathing, associated with 
large and small, moist or bubbling rales, soon followed by bronchial 
and broncho-cavernous breathing, with large and small, moist and 
circumscribed ^^//«^ rales. 

Duration. Acute phthisis terminates fatally in from four to 
twelve weeks. 

Dia^nosid. Commonly mistaken for typhoid fever with lung 
complications, an error that is readily made unless a close study of 
the history, symptoms and physical signs be made. 



232 FRACTICE OF 

Treatment. There are no means of retarding the progress of 
this malady. The various symptoms should he met as Ihcy occur, the 
patient at the same time being supplied with lar^c quantities of stimu- 

EMPHYSEMA. 

Synonym. Vesicular emphysema. 

Definition, Dilatation of, or increase in the size and capacity of, 
the air vesicles, characterized by enlargement of the chest, difficulty 
of breathing, especially on exertion, and associated sooner or later 
with dilatation of the heart. 

Causes. The predisposing cause of emphysema is a hereditary 
nutritive derangement of the lung structure, often associated with a 
rigid enlargement of the thorax. 

The crating cause is the result either of a loo forcible and long con- 
tinued inspiration — Ihe theory of inspiration, or the excessive mechan- 
ical distention of the vesicular walls by forced expiration — the theory 
of expiration. 

What is known as vicarious emphysema is a distention of the air 
cells of the healthy portion of the lung, some other part being the 
seal of consolidation. 

Interlobular emphysema is the presence of air in thespaces between 
Ihc lobules of the lungs underneath the pulmonary pleura. 

Pathological Anatomy. The situation of vesicular emphysema 
is, in the majority of cases, the superior portions of the chest, and is 
more marked on the left side than on the righL 

Aji emphysematous lung feels remarkably soft to the touch, and 
upon cutting, a dull, creaking sound is barely perceptible. It is of a 
pale red color, the vesicular walls are thinner and slighter, the vesicles 
are greatly enlarged, sometimes to the siieof a pea or bean, and have 
an irregular shape, and traversing most of these large ^cysts (dilated 
vesicles) a few delicate bands, the remains of the lacerated inter-alveo- 
lar septa, are visible. With the destruction of the septa many of the 
capillaries are destroyed, whereby the emphysematous tissue is re- 
markably bloodless and dry. 

In consequence of the destruction of so many of the capillaries, the 
obstruction to the pulmonary circulation becomes so great that the pul- 
monary artery and right cavities of the heart are greatly distended ; 
finally, the muscular tissue of the heart undergoes granular, followed 



DISEASES OF THE LUNGS. 



1, The distention of the veins results in a. general 
: nutmeg liver, congested kidneys, and gastro- 



by fatty degeneratioi 

intestinal catarrh, 

SymptomB. The chief symptoms of vesicular emphysema are 
difficulty of breathing, greatly aggravated on exertion, more or less 
cough, the result of an attending bronchitis, and the varioussymptoms 
resulting from dilatation of the heart. The distr^sof the patient is 
often increased by paroxysms of asthma. 

Inspection. The shoulders are rounded, the intercostal spaces 
widened, the vertical diameter elongated, with circumscribed promi- 
nences between the clavicles and nipples, often increased by the act 
of coughing — the peculiar " barrel- shaped " chest characteristic of 
this disease. 

The character of the respiratory movements is marked, there being 
but slight movement observed on forcible respiration, the chest hav- 
ing the constant appearance of a full inspiration, 

Palpation. The vocal fremitus is diminished, and the cardiac 
impulse depressed and nearer to the sternum. 

Percussion. The»-«o«.iB«M/«irr^(ij^rt'(hyper-reson3nl) overall 
the emphysematous portions, and ff the whole lung be involved, ex- 
tends to the seventh or eighth rib anteriorly, and to the twelfth rib 
posteriorly. The hepatic dullness may not begin until the inferior 
margin of the ribs is reached ; the cardiac dullness is lessened, on 
account of the emphysematous lung nearly covering the heart. 

Auscultation. The vesicular murmur is weakened, and in pro- 
nounced cases almost absenl. If bronchitis be present the inspiratory 
sound may be rough or sibilant in character, but its duration is always 
shortened. Expiration is aliuays firalouged, and if bronchitis be 
present, may be associated with more or less pronounced moist or 
bubbling riles. 

The^rV jomW of the heart is lessened in intensity and duration, 
the second sound being sharply accentuated. 

Diagnos^. Bronchitis is distinguished from emphysema by the 
absence of dyspnoea, hyper- resonance of the chest, changes in its 
shape, siie and movements, and the disturbance.of the circulation. 

Spasmodic asthma by the paroxysmal character of the affection, 
emphysema being a permanent malady, with attacks of asthma. 

~ Cardiac diseases due to other causes than emphysema do not have 
the characteristic physical signs of that affection. 



« 



PrognosiB. Vesicular emphysema is essentially a chronic dis- 
ease. In itself it rarely proves fatal, but if aggravated, from any 
cause, or if associated witii frequent or prolonged asthmatic paroxysms, 
the cardiac changes are hastened, general dropsy supervenes, death 
occurring from exhaustion, or, more commonly, as the result of inter- 
current attacks of pneumonia. 

Treatment. It being impossible to restore the altered lung struc- 
ture, the indications for treatment are to relieve the symptoms and to 
endeavor to prevent its further /ro^^js, 

Fcr the relief of the asthmatic paroxysms, morphine sulphas com- 
bined with atropine sulphas may be used hypodermatically, or rxt. 
quebracho fld,, .ijss-j. every hour until relief, or large doses of ^A«m 
liremidum, frequently repeated. 

To prevent the progress of the affection, remove the bronchial 

catarrh, relieve the difficulty of breathing, and strengthen the cardiac 

ion, no one combination seems comparable with the following : — 

R. Potaasii iodidi gr.v 

Strychninie sulph ;. gr.^ 

Liq. polassii arsenit nji 

Aq. lanro-ccrasi f,:; j. M. 

SlG.— Four limes n day. 

But of all means hitherto proposed for the relief of emphysema, 
nothing has approached the />i^(i/aa'o« of compressed air, hy 1^1^9:0% 
of the apparatus of Waldenberg. 

The dropsy arising from failure of the heart to compensate for the 
circulatory derangement in the lungs, may be relieved for a time, by 
the use of digitalis, or, if this fails, scilla combined with hydragogue ' 
cathartics. 



DISEASES OF THE PLEURA. 

PLEURISY. 

Synonyms. ,Plcuritis; "stijch in the side." 

Deflmtion. A fibrinous inflammation of the pleura, either acute, 
subacute or chronic in character, occurring either idiopathic ally or 
secondarily; characterized by a sharp pain in the side, a dry cough, 
dyspncea and fever. It may be limited to a part, or may involve the 
whole of one or both membranes. 



Causes. Idiopathic pleuritis is said to be due to cold and expo- 
sure, to injuries of the chest walls, or the result of muscular exertion. 

S^eomlary pleuritis occurs during an attack of pneumonia, peri- 
caditis. rheumatism, smallpox, Bright's disease, or puerperal fever- 

Chronic pleurisy follows an acute attack, or Is the result of tuber- 
culosis, Bright's disease, or alcoholism. . 

Pathological Anatomy. The course pursued by an inflam- 
mation of a serous membrane is kyperamia frfllowed hy exudalion of 
lympk. the effusion of fluid, its absorption and the aiikusion of the 
membranes. 

The frst or dry stage of pleurisy is a hyperasmia or diffused, irreg- 
ular redness of the membrane, with little specks of exudation. The 
second stage is characterized by the copious exudation of lymph, more 
or less completely, covering the membrane, giving it a dull, cloudy, 
or shaggy appearance. If the inflammation ceases at this point, it is 
termed dry pleurisy. The third, or stage of effusion, is characterized 
by the pouring out of a sero-fibrinous fluid ; more or less completely 
filling and distending the pleural cavity, and floating in the fluid are 
fibrinous.flocculi, blood and epithelial cells. 

Absorption of the fluid and more or less of the exudative lymph 
soon occurs, the unabsorbed portion becoming organized, forming 
adhesions which obliterate the pleural cavity. 

The effusion, if on the right side, pushes tile heart further to the 
left; if on the left side, the heart is displaced to the right, the impulse 
often -being seen to the right of the sternum. The lungs are also 
compressed and displaced upward and against the spinal column, 
and, on removal of the fluid, expand again, except in cases of chronic 
pleurisy, when the functional activity of the pulmonary structure is 
more or less permanently impaired. 

Chronic pleurisy results when the fluid is not absorbed or when it is 
effused into the cavity in a slow and insidious manner. The mem- 
brane is irregularly thickened, with firm adhesions, fluid being found 
in the meshes, and depressions of tlie thoracic wiHIs also occurring. 
The fluid may be serum, pus {iinpyema), or pus and.blood. Openings 
may form, through which titere is a permanent discliargc, either e: 



lernally (fistulous enipyem 
bowels. 

SymptomB. Acu 
sharp, lancinating pai. 



1 the bronchi, or, rarely, it 



) the 



■ Begins with 
lear the nipple 



I chill, followed by a 
3r in the axilla, aggra- 



236 



PKACTfcE OF 



vated by coughing and breathing, associated with slight tenderness 
on pressure. The respiralions are rapid and shallow, 30-35 per rr 
ute, a short, dry, hacking cough, moderate fever, compressible pulse, 
90-1 20. With the effusion of liquid the dyspnma becomes aggravated, 
the cough more distressing, the cardiac action embarrassed, the ci 
tenance wearing an anxious expression, the patient usually lying on 
the affected side. With the absorption of the fiuid the symptoms 
gradually, ameliorate, convalescence being more or !ess rapid. 

Sub-acute attack; Begins insidiously after cold, exposure and 
fatigue in those enfeebled. Patients usually complain of a sense of 
iveariness, shortness of breath, aggravated on exertion, evening/ji'i 
followed by night sweats, short, harassing cough, none or very 
scanty sputum ; the pulse is small, feeble but frequent, 100-120 beats 
per minute. The characteristic pain in the side is usimlly wanting. 

Chronic variety, irregular chills, fever, night sweats, dyspncea, 
palpitation, embarrassed circulation, with more or less prostration. 

Inspectioii. First stage, deficient movement of the affected side, 
on account of the pain induced by full breathing. 

Second stage, bulging or fullness of the affected side, with oblitera- 
tion c)f the intercostal spaces and displacement of the cardiac impulse. 

Palpation. Second stage, vocal fremitus feeble or absent over 
the site of the efTusion, exaggerated above the site of the fluid. 
RATcly, ^actuation may be obtained. 

Percussion. First stage, may be slightly impaired. 

Second stage, dullness or even flatness over the site of the effusion ; 
tympanitic percussion note above the fiuid. 

Auscultation. First stage, feeble vesicular murmur over the 
affected side, the patient breathing superficially, to prevent the pain ; 
i, friction sound, slight and grating or creaking, becoming louder as 
the exudation of lymph increases, limited usually to the angle of the 
scapula of the affected side, rarely heard over the entire side, accom- 
panies the respiratory movements. 

Second stage, feeble or absent vesicular murmur on the affected 
side, depending upon partial or complete compression of the lungs by 
'the fluid. Above ihe fluid puerile breathing, and Ju^^t at the upper 
margin of the fluid a friction sound may be heard. 

'Vas -vocal resonance '\^ diminished or absent over the site of the 
fluid and markedly increased above, cegophony being present at the 
upper margin of the fluid. 



r 

I sta 



DISEASES OF THE PLEURA. 



237 



With the absorption of the fluid the vesicular murmur gradually 
associated with a moist friction sound. 

DiagnosiB. AcuU pneumonia \s often mistaken for the effusion 
stage of pleurisy. The points of distinction are, in pneuinonia there 
is the pronounced chill, high fever, and characteristic sputa, bronchial 
breathing, exaggerated vocal fremitus and resonance, and no displace- 
ment of the heart, the reverse occurring in pleurisy. 

Enlargement of Ike liver ras-y bemistaken for pleurisy with effusion, 
the chief point of distinction being that, in enlargement of the liver 
the superior line of dullness is depressed upon full inspiration, while 
in pleurisy with eRusion inspiration does not modify the location of 
the dullness. 

ProgtlOBiB. Idiopathic pleurisy usually tenninates in recovery 
within three weeks. Pleurisy the result of constitutional causes has 
its prognosis modified by the condition with which it is associated. 
Empyema, unless the result of a diathesis, terminates favorably. 
Double pleurisy is unfnvorable. 

Treatment. At the onset, in plethoric patients, wet cups over 
the affected side; if great dyspnoea, severe pain i^nd high arleri^ 
teiiKion, even venesection, and in anaemic or weak persons, dry cups. 
The severe pain is promptly relieved by the hypwdermatic injection 
of inorphina sulphas, over its site, repeated as indicated. 

Tinct. verat. virid., or tinctiira aconiti, in small doses, frequently 
repeated, in the plethoric, and digitalis in the weak, control the 
circulation, and lessen the amount of blood distributed to the affected 
membrane. 

After effusion has begun txtractum pilocarpi fluidum, gtt. xs, every 
two or three hours, or — 

R. Potassii acetal.... gr.xnx 

Infua. digitalis ; , „.' gij. M. 

Every three or four hours. 

If the effusion be uninfluenced by the above, vse potassii iodidum, • 
gr. XV, every four hours, with flying blisters over the affected side; or 
the fluid may be evacuated by aspiration, using at the same time full 
doses a{ mistura ferri et ammoHii acetatis {Bas/taiH's mixture). 

If double pleuritic effusion, evacuate the fluid at once with the aspi- 
rator, and use the potassium and digitalis mixture mentioned above. 

Chronic pleurisy : if the effusion be still serous, it is often absorbed 
by the internal use a( potassii iodidum, alternating with " Baskam's 



238 PRACTICE OF MEDICINE. 

mixture" and blisters, Ihe secretions being regularly attended t 
If, however, the liquid is pus (empyema), the aspirator should be used 
at once, the patient placed upon " Baskam's mixture," stimulants and 
quinina, and if the empyema shows a tendency to linger, the drain- 
age tube may be indicated. 

HYDROTHORAX. 

Synonym. Dropsy of the pleura. 

Definition. The. effusion of serum into the'pleural cavities {bi- 
lateral), the result of a general dropsy from renal or cardiac disease. 

Pathological Anatomy. More or less clear serous fluid in both 
pleura! sacs, compressing the lungs. No signs of inflammation are 
present. 

Symptoms. Following dropsy of the abdomen occurs dyspnasa, 
with signs of deficient blood aeration, both lungs being compressed. 

Palpation. Absent vocal fremitus over the site of the field. 

Percussion. Dullness over the site of the fluid. 

Auscultation. Absent vesicular murmur over the site of the 
fluid. 

Diagnosis. Easily determined by association of the symptoms 
with a (jeneral dropsy. 

Prognosis. Controlled by the cause producing the general 
dropsy. 

Treatment. Depetiding upon the condition causing the dropsy. 
Dry cups over the chest afford relief. If the symptoms of non-aeration 
of the blood are severe, the fluid should be at once evacuated with 
the aspirator. 

PNEUMOTHORAX. 

Synonyms. Air in the pleural cavity; hydropneumothoran. 

Definition. The accumulation of air in the pleural cavities, with 
Ihe consequent development of inflammation of the membranes; 
characterized by sharp pain, followed by rapidly developing dyspnoea 
and cough. 

Causes. Generally the result of tubercular phthisis, causing per- 
foration of the pleura. Perforation may take place from the pleura 
into the lung, in connection with empyema or abscess of the chest 
walls. Direct perforation from without, by laceration of a fractured 
rib or se> 



UISEASeS flF THK PLEUKA. 230 

Pathological Anatomy. The gas in the pleural cavity consists 
of oxygen, carbon anhydride, and nitrogen in variable proportions. It 
may fill the pleural sac cotnpletely, compressing the lung, or is some- 
times limited by adhesions. The gas lends to excite inflammation, 
the resulting effusion being either serous or purulent. 

Symptoms. Symptoms of pneumothorax, the result of perfora- 
tion, are suiidiin or sharp fain in the side, intense dyspnoea, attended 
with symptoms oi collapse, coldness of the surface and cold sweats. 

The above symptoms, in" many instances, follow a severe or violent 
paroxysm of ioughing. In severe cases there is never a moment's 
cessation of the acute pain and distressing dyspncea, causing orthop- 
ncca, from the onset until death. 

Inspection. Enlargement of the affected side, the intercostal 
spaces being widened and effaced, or even bulged out so that the 
surface of the chest is smooth. Respiratory movements of the affected 
side are dirOini shed or absent. 

PercuSBion, Immediately after the rupture the percussion note 
is hyper- re son ant, or even tympanitic or amphoric in quality. If the 
amount of air in the pleural cavity become extreme there is dullness 
on percussion, associated with a feeling of great resistance or density. 
When effusion of fiuid occttrs dullness is observed over the lower part 
of the chest, hyper-resonant or tympanitic percussion note over the 
upper portions of the chest, these sounds changing as the patient 
changes his position. 

Auscultation. The normal vesicular murmur may be diminished 
or absent. The typical amphoric respiratory sound is heard when the 
fistula is open, usuadly associated with a metallic echo. 

Melallic tinkling, or the bell sound, is sometimes distinctly produced 
by breathing, coughing or speaking, after the development of inflam- 
mation of the pleura. 

The vocal resonance may be diminished or absent, or, r.arely, it 
may be exa^erated. with a distinct metallic echo. 

After the development of inflammation in the pleura, suddenly 
shakingthe patient gives rise to a splashing sensation, the succussion ' 
sound, if both air and fluid are present in the pleural cavity. 

Prognosis. When occurring as the result of tuberculosis, the 
prognosis is extremely unfavorable ; rarely, the fistulous opening being 
■ enclosed by inflammatory action ; the case then becomes one of 
chronic pleurisy. 



240 PRACTICE OF MEDICINE. 

Treatment. At once a hypodermatic injection of mnrphiH^, 
snipkia, which relieves the severe pain and somewhat modities the 
distressing dyspntea, followed by the evacuation of the fluid and air 
with the aspirator. 

If the fistulous opening be closed by inflammatory action, the case 
resolves itself into one of chronic pleurisy, the treatment indicated for 
that aflection plus the treatment of tuberculosis, being the indication 



DISEASES OF THE CIRCULATORY 
SYSTEM. 



The methods employed in making a physical examination of tiie 
heart are: 1. Inspection. II. Palpation. III. Percussion, IV. Aus- 
cultation. 

Inapeotion indicates the exact point of the cardiac impulse, 
whether there are any abnormal pulsations or any change in the form 
of the pracordium. 

Normally the impulse is visible only in ihe fifth interspace, midway 
between the left nipple and the left border of the sternum, its area 
covering about one square inch, most distinct in the thin, while often 
barely seen in the very fleshy ; often displaced downward by fiill in- 
spiration and elevated by complete expiration. 

Disease may alter the position and area of the impulse. • 

The position oi ih^ impulse is moved to the right by left" pleuritic 
effusions ; downward by hypertrophy or emphysema ; upward by 
pericardial effusion. 

The area of the impulse is changed and enlarged by pericardial 
adhesions, cardiac dilatation, or hypertrophy. 

Palpation confirms the observations of inspection, and also de- 
termines xht force, /mguency. and regularity of the cardiacimpiUse. 

The impulse is diminished hy cardiac dilatation, fatty degeneration 
of the heart, emphysema, pericardial effusion, and adynamic diseases. 

The impulse is increased hy cardiac hypertrophy, during the first 
stage of endocarditis and pericarditis, functional cardiac disturbances 
and sthenic inflammations. 

Peroussion will indicate the boundaries of the superficial and 
deep cardiac space, the so-called /r<rirori//«w. Il is essential ihat Ihe 



DISEASES OF THE CIRCULATORY S 

upper, lower, and two lateral boundaries of the pericardial region be 
memorized, to wit : superior boundary, the upper edge of the third 
rib ; Ike Ivwer boundary is a horizontal line passing through (he fifth 
intercostal space; \^a left lateral boundary 'k, about or a little within 
a vertical line passing through the nipple, the //Hfd wnaiwd/w/ and 
the right lateral boundary is an imaginary vertical line situated one- 
half an inch to the right of the sternum. These boundaries vary 
somewhat in health, but are sufficiently accurate for all practical 

The superficial cardiac space represents that portion of the heart 
uncovered with lung ; it is triangular in forio, its apex being the junc- 
tion of the lower border of the lefl third rib with the sternum, its area 
not exceeding two inches in any direction. , 

The superficial space is increased by cardiac hypertrophy, dilaiation 
or pericardial effusion. 

Diminished at the end of full inspiration or by emphysema. 

The deep cardiac space represents thai portion of the heart covered 
by long, and extends fi-om the upper border of the third rib to the 
lower edge of the fifth interspace, and from half an inch to the right 
of the sternum to near the left nipple. 

It is increased by hypertrophy or dilaiation of the heart, left pleuritic 
effusion, and apparently increased by consolidation of the anterior 
border of the investing lung. 

AuBCultation indicates Ihe character of the normal cardiac 
sounds and the point of greatest intensity at which they are heard, 
and should be thoroughly familiarized if abnormal sounds axe to be 
fully appreciated. 

The ear or stethoscope applied to the prfEcordium distinguishes two 
sounds, separated by a momentary silence— //(* short pause, and the 
second sound followed by an interval of silence — the long pause. 

The first sound, corresponding to the contraction of the heart — ihe 
systole — is louder, longer and of lower pitch and a more booming 
quality than the second sound, and has its point of greatest intensity 
at Ihe cardiac apcK or a litde to the left. It corresponds cldsely to 
the pubations as felt in the carotid or radial arteries. 

The second sound is shorter, weaker and higher in pilch than the 
first sound, and has a clicking or valvular quality, having its point of 
greatest intensity at the second right costal cartilage and a little above, 
and corresponds to the closure of the aortic and pulmonary valves. 



242 PRACTICE OF MEDICINE. 

The sound made by the closure of the tricuspid valves is best isolated 
at the ensiform cartilage. The sound made by the closure of the pul- 
monary valves at the third left costal cartilage. 

The extent of surface over which the cardiac sounds are heard 
varies, according to the size of the heart and the condition of the 
adjacent organs for transmitting sounds. 

The cardiac sounds maybe altered m intensity, quality , pitch, seat 
arid rhythm, or they may be accompanied, preceded or followed by 
adventitious or new sounds, the so-called endocardial murmurs. 

The intensity is increased by cardiac hypertrophy, irritability of the 
heart or consolidation of adjacent lung structure. 

The intensity is diminished by cardiac dilatation or degeneration 
during the course of adynamic fevers, emphysematous lung overlap- 
ping the heart, or pericardial effusion. 

The quality and pitch of the first sound may be sharp or short and 
of higher pitch when the ventricular walls are thin and the valves 
normal ; its pitch and quality are also raised during the course of low 
fevers. The second sound becomes duller and lower in pitch when 
the elasticity of the aorta is diminished or the aortic valves thickened. 
Either or both sounds have a more or less metallic quality in irritable 
heart and during gaseous distention of the stomach. 

The seat of greatest intensity of the cardiac sound is changed by 
displacement of the heart, pleuritic effusion, pericardial effusion, and 
abdominal tympanites. 

The rhythm is often interrupted by sudden pause or silence, the 
heart missing a beat, or the sounds are irregular, confused and tu- 
multuous, the result of organic changes in the cardiac muscles, valves, 
or orifices ; or a reduplication of one or both sounds of the heart may 
occur. 

The adventitious cardiac sounds or murmurs are of two kinds, those 
made external to the heart, as pericardial, exocardial, or frictional mur- 
murs, and those made within the cardiac cavity, endocardial murmurs. 

Pericardial murmurs, or friction sounds, are made by the rubbing 
upon one another of the roughened surfaces of the pericardial mem- 
brane during the early stage of inflammation. The sounds have a 
rubbing, creaking, or grating character, and are differentiated from a 
pleural friction sound by their being limited to the praecordium, syn- 
chronous with every sound of the heart, and not influenced by respi- 
ration. 





DISEASES OF THE CIRCULATORY SYSTEM. 

They are distinguished fromaa endocardial murmur by their super- 
ficial rubbing, creaking or grating character, and by not being trans- 
mitted beyond the limits of the heart, either along the course of the 
vessels, or to the left axilla, or back. 

Endocardial murmurs are of two kinds, to wit ; organic and func- 

Futtcb'onal endocardial or blood murmnrs are the result of some 
change in the natural constituents of the blood. 

Their character is soft, they are heard most distinctly at the base to 
the left of the sternum, during the systole, are not transmitted beyond 
the limits of the heart, either to the left axilla or the back, and are 
associated with general anemia. 

Organic endocardial murmurs are produced by blood currents pur- 
suing either a normal oi an aiBorina/ direction. 

In health there are two direct blood currents upon each side of the 
heart, to wit: the current from the left auricle to the left ventricle, the 
.mitral direct current; the current from the left ventricle to the aorta, 
tke aortic direct current; the current from the right auricle to the right 
ventricle, the trisctipid direct current, and the current from the right 
ventricle to the pulmonary artery, the pulmonic direct current. 

When, from disease, the valves are not properly closed, the blood 
is allowed to flow back against the direct current, producing abnormal 
blood currents, to wit : when the mitral valve is incompetent, the blood 
flows from the left ventricle back to the left auricle during the cardiac 
systole, producing the mitral regur^tant or indirect current; when 
the aortic valves are incompetent, the blood is permitted to flow from 
the aorta into the left ventricle during the cardiac systole, producing 
ib& aortie regurgitant or indirect current ; when the tricuspid valves 
are incoiBpetent, the blood flows from the right ventricle back into 
the right auricle during the systole, producing the tricuspid regurgi- 
tant or indirect current; when the pulmonary valves are incompetent, 
the blood flows from the pulmonary artery into the right ventricle, 
producing \hc pulmonic regurgitant or indirect current. 

The mitral direct current occurs during the contraction of the left 
auricle, or just before the first sound of the heart and immediately 
after its second sound. Tkt aortic direct cu?Tent is produced by the 
contraction of the Igft ventricle, and occurs with the first sound of the 
heart. The tricuspid direct current occuts during the contraction of 
the righi auricle, or just before the first or immediately after the second 



244 PRACTICE OF MEDICINE. 

sound. The pulmonic direct current is produced by the contraction 
of the heart, occurring during its first sound. • 

The mitral direct^ or presystolic murmur^ occurs before the first 
sound of the heart and immediately after the second sound. It is 
caused by a narrowing of the mitral orifice, has a blubbering quality, 
well imitated by throwing the lips into vibration by the breath, of a 
low pitch, and it has its seat of greatest intensity at the cardiac apex, 
and 4s not transmittaed to the left axilla or to the base of the heart. 

The mitral regurgitant^ dr systolic murmur^ occurs with the first 
sound of the heart, resulting from the failure of the mitral valves to 
close the mitral orifice during the systole, in consequence of which 
the blood flows back, or regurgitates into the left auricle. It is usually 
of a blowing or churning character, and has its seat of greatest in- 
tensity at the cardiac apex, being well transmitted to the left axilla 
and inferior angle of the left scapula. 

The aortic direct murmur occurs with the first sound of the heart. 
It is caused by a narrowing of the aortic orifice, has a rough or 
creaking character, is of high pitch, having its seat of greatest in- 
tensity in the second intercost^i space, to the right of the sternum, 
and is well transmitted over the carotid artery. 

The aortic regurgitant murmur occurs with the second sound of 
the heart, and is caused by the failure of the aortic valves to close the 
aortic orifice during the diastole, whereby the blood flows back or 
regurgitates into the left ventricle. It is usually of a blowing or 
churning character and of low pitch, having its seat of greatest in- 
tensity over the base of the heart, and is well transmitted downward 
toward or below the cardiac apex. It is the only organic murmur 
produced in the left side of the heart which occurs with the second 
sound of the heart. 

The tricuspid direct murmur occurs before the first sound of the 
heart and immediately after the second sound. It is caused by a 
narrowing of the tricuspid orifice, has a blubbering quality, and is 
low in pitch, having its seat of greatest intensity near the ensiform 
cai:tilage. This murmur is exceedingly rare. 

The tricuspid regurgitant murmur occurs with the first sound of 
the heart, the result of the failure of the tricuspid valves to close the 
tricuspid orifice during the systole, thus allowing the blood to flow 
back or regurgitate into the right auricle. It is usually of a blowing 
or soft, churning character, having its seat of greatest intensity at the 



DISEASES OP THK CIRCCLATORV SVSTEM. 



245 

ensiform cartilage. This murmur is also very infrequent, and occurs 
mostly when the right ventricle is considerably dilated, without the 
existence of any valvular disease. 

The pulmonic direct murmur occurs with the first sound of the 
heart- It is gi^neratly connected with congenital lesions. It occurs 
at the same instant that the aortic direct murmur occurs, and is 
distinguished from the latter by its not being transmitted into the 
carotid artery, whereas the aortic direct murmur is alwa.ys thus trans- 

Th« pulmonic rrgtirgilant murmur occurs, like the aortic regurgi- 
tant muntiur. with the second sound of the heart. This murmur is 
exceedingly rare, and its presence is only positively differentiated 
from aortic regurgitant by the absence of aortic lesions and symptoms. 

ACUTE PERICARDITIS. 

Definition. An acute fibrinous inflammation of the pericardium ; 
characterized by slight fever, pain, precordial distress and disturbed 
cardiac action and circulation. 

GaUBeB. May follow injuries of the chest walls, but generally 
secondary to either acute articular rheumatism, pneumonia, pleurisy, 
erysipelas, Bright's disease or pyaemia. 

Pathological Anatomy, The same as serous membranes in 

Hyperemia of the membrane, most marked on the visceral layer, 
followed by the exudation of lymph scattered in irregular patches, 
giving it a rough and shaggy appearance (dry pericarditis), followed 
by the effusion of a sero-fibrinous fluid, with flocculi floating in it, and 
at times mixed with blood. Rarely, the fluid is purulent. 

The fluid and lymph undergo absorption with resulting adhesions 
identical with those described under pleurisy. 

Symptoma. Acute pericarditis may be well marked and still 
present none of the characteristic subjective symptoms. It usually 
begins with rigors, fever, prvcordial distress, acute shooting pains, 
increased by breathing and coughing, leiidemess, dry, suppressed 
cough, increased cardiac action, sometimes violent palpitation. Dura- 
tion of this early stage from a few hours to a day. 

Effusion stage : the symptoms of this stage depend upon the amount 
and rapidity of the effusion ; prcecordial oppression, tendency to syn- 
cope, dyspntea, sometimes amounting to orthopncea, dysphagia, hie- • 



246 PRACTICE OF MEDICINE. 

cough, nausea and 7/^w//i*«^, feeble, irregular /?//j^, sometimes either 
melancholia, delirium, or acute maniacal excitement. 

Absorption is generally rapid, the heart remaining "irritable** for 
a long time after. If instead of absorption, the fluid accumulates, 
and life is not destroyed, the pericardial sac becomes dilated, chronic 
pericarditis resulting. 

Inspection. Early stage, excited cardiac action is evidenced by 
the impulse. 

Effusion stage, feeble, undulatory or absent impulse, its position 
displaced upward, or rarely, downward; bulging of the praecordium 
and protruding abdomen. 

Palpation. Early stage, excited or tumultuous impulse; ^m- 
czx^dX friction fremitus rare. 

Effusion stage, feeble or absent impulse, and if present its position 
is changed. 

Percussion. Early stage, normal. 

Effusion stage, cardiac dullness enlarged vertically and laterally, 
and if considerable fluid, of a triangular shape, with the base of the 
triangle on a line with the sixth rib, extending from the right of the 
sternum to the left of the left nipple, narrowing as it proceeds upward 
-to the second rib, or above, which represents the apex of the triangle. 
The shape of the dullness is sometimes altered by changing the 
position of the patient. 

Auscultation. Early stage, excited cardiac action, and usually 
2l friction sound (exocardial murmur) synchronous with cardiac sounds 
and uninfluenced by respiration, but often increased by pressure with 
the stethoscope. 

Effusion stage, cardiac sounds feeble and deep-seated at the cardiac 
apex, becoming louder and distinct toward the cardiac base. The 
friction sound is sometimes heard at the cardiac base. 

If absorption occur the above signs gradually give place to the 
normal, the friction sound returning, of a churning, or clicking, or 
grating character, gradually disappearing. 

• Diagrnosis. Endocarditis is often confounded with pericarditis, 
the points of distinction between which will be pointed out when 
discussing that affection. 

Cardiac hypertrophy or dilatation is sometimes confounded with 
pericardial effusion ; the difference between them will be pointed out 
when discussing those affections. 



DISEASliS OF THE C 

Hydreipericardium maybe mislaken tor pericardial effusion; see 
thai afietdon. 

Prognosia. Controlled by the severily of Ihe InflaTtimation and 
coexisting affections. If slight effusion, favorable. Death has rapidly 
occurred when a lai^e tiuantity of fluid has been rapidly effused, the 
result of cardiac paralysis. Adherent pericardium is a frequent 
sequela. 

Treatment. Perfect rest in bed ; for the vigorous, the application 
of leeches or ivet cups to the pTjecordium, followed by the application 
of either (Ve or pojtitices ; in the feeble rfry cajitj to the priecordium, 
followed by poultices. 

Early stage ; in the strong, control the excited cardiac acdon by 
small doses of aconitum or veratrum virlde, in the feeble using digi- 
talis; in all cases quinina is indicated. 

Effusion stage; as the effusion progresses the free administration 
of alkalies, to wit: ammonii carb., gr, v, every two hours, with liquor 
it acetatis, or potassii acefat., or potasssi carbon, with quinina, 
i liquid diet and stimvhmts, being cautious with the use of 

If the effusion has a tendency to linger, blisters to the pracordium, 
OT paracentesis, is indicated. 

CHRONIC PERICARDITIS. 

Definition. A chronic inflammation of the pericardium, with 
either distention of the sac by fluid or adhesions of the pericardium 
(adherent pericardium); characterized by impaired cardiac action 
and disturliances of the eircularion. 

Causes. Almost always the result of an acute attack. 

Pathologrical Anatomy. If the effusion be absorbed, the peri- 
cardial surfaces are agglutinated by several layers of lymph, which 
increase the thickness of the membranes half an inch or more, and 
. the outer surface of the pericardium becomes adherent to the chest 
walls, 

If the fluid be not absorbed it may progressively accumulate, dis- 
tending the sac in all directions, displacing the diaphragm, interfering 
with the functions of the surrounding viscera, or a low grade of in- 
flammation supervenes, the fluid becoming purulent, the disease ter- 
minating fatally after a variable period. 

As much as eight to ten pints of fluid have accumulated in the sac 



r 



248 PRACTICE OF MEDICINE. 

Symptoms. PriEcordial pain and distress, irregular, ^^i/rf et 
diac action, dyspnma, aggravated by movement and disturbed ciri 

An agglutinated pericardium seriously increases the danger froia 
an attack of any pulmonary infiammation. 

Inspection. If the effusion be present, bulging of the prfecoi* 
dluin and displacement of the impulse. 

If adhesions are formed between the precordial surfaces as well aa( 
with the chest walls, inspection reveals depression of Ike pracordium, 
narrowing of the spaces, increased extent but displaced impulse, i 
influenced by deep inspiration, and recession of the intercostal spaces 
(systolic dimpling) and epigastrium with every systole of the heart, 
the result of the adhesions. 

Palpation. If effusion, displaced, feeble or absent impulse; if 
adhesion, displaced and tumultuous impulse; occasionally a peri* 
cardial fremitus is distinguished. 

Percussion. If effusion, the dullness has more cr less the char- 
acter described for acute pericarditis. 

If adhesions, the cardiac dullness is but slightly modified. 

Auscultation. If effusion, cardiac sounds feeble and* deep- seated 
at the apex, louder and more distinct at the cardiac base. 

If adhesions, cardiac sounds are heard with equal distinctness in^ 
the.ir several positions, associated with a roiigh friction sound (exO' 
cardial murmur). 

Treatanent. If effusion, blisters to the praicordium, with potassH 
iodidum to hasten absorption, the patient supported by nutritious diet, 
quinina, ferrutn and stimulants, and perfect quiet. If these c 
fail to remove the fluid, or if the fluidjie purulent, paracentesis should 
be performed at once. 

If adhesions of the pericardium have resulted, the applic. 
blisters to the prsecordium, with the administration of pofassii wrfi- 
</»ni, alternating with ^TTU/n asiA guinina are indicated, with nulri~J 
tious diet, stimtdants and perfect quiet. 

hydro-Pericardium. 

Synonym, Pericardial dropsy. 

Deflnitioa. The accumulation of water in the pericardial sac^l 
minus infiammation; characleriied by prm;cordial distress, disturbs " 
cardiac action, dyspncea and dysphagia. 



K 



DISEASES OF THE CIRCULATORY SYSTEM. 

Causes. Usually a part of a general dropsy; Bright's disease; 
sudden pneumothorax; pressure of an aneurism or other mediastinal 
tumor; disease or thrombosis of the cardiac veins. 

Pathological Anatomy. The fluid may range in quantity 
from an ounce to one or two pints, and is of a clear, yellowish or 
straw-colored serum, at times turbid or bloody, and of an alkaUne 
reaction. 

If the amount of fluid be large the sac is dilated', its walls thinned 
by the pressure, and has a sodden appearance. 

Symptoms. Dropsy of the pericardium is so generally associated 
with hydrothoraJt that the symptoms .are but an aggravation of those 
attending upon that condition, to wit: distuii)ed cardiat action, dysp- 
fttxa, dysphagia, dry cough, and feeble circulation. 

The physical signs are exactly those of the stage of effusion of 
pericarditis, minus a friction sound. 

Diaffnosia. Pericarditis with effusion and hydro -pericardium 
present nearly the same signs and symptoms, a differentiation being 
possible only by a history of the case and the symptoms of the attack. 

Progrnosis. Controlled entirely by the cause. 

Treatment. Depends upon the cause of the attack. If the 
amount of fluid in the pericardial sac be great, paracentesis will ^vc 

ACUTE ENDOCARDITIS. 

Synonym. Valvulitis. 

Definition. An acute fibrinous inflammation of the serous mem- 
brane lining the cavity of the heart and forming its valves; charac- 
terized by cough, dyspncea, nausea and vomiting, disturbed cardiac 
action, resulting in changes in the valves or orifices of the heart, 

GailBes. Usually secondary to acute articular rheumatism, pleu- 
risy, pneumonia, pericarditis or Bright's disease. 

Pathological Anatomy. Inflammation of the endocardium is 
usually limited to the left side of the heart after birth, during fcetal 
life the reverse being the case. The inflammation is limited or espe- 
cially marked at the valvular porrions of the endocardium, owing 
probably to the presence of fibrous tissue beneath the membrane in 
these situations, and to the strain which falls upon the valves during 
the performance of their functions. 

Hyperamia from congestion of the vessels beneath the membrane. 




aSO PRACTICE OP HED1CIK&. 

with considerable swelling of the valves, the result of an exuda/igt 
of lymph and serum beneath and on the free surface of Ihemembranel 
covering the valves and chordiz /^nrtVwci?, resulting in the roughening 
of the surfaces and the agglutination of the mitral valves to each other, 
and of the aorta segments to the walls of the aorta, or the praliferation 
of the endocardial connective tissue, forming the nuclei of the so-^ 
called warty excrescences or vegetations, their size being ii 
by the deposit of fibrin from the blood within the cavities of t 

These vegetations may be detached by friction, giving rise to embgl^ 
which may be washed by the blood current on the left side of t) 
brain, into the kidneys and spleen. 

Rarely, ulceration of the endocardium follows the above phe- ■ 



Symptoms. This affection is usually masked by the course of 
another disease until disturbances of the circulation direct 
to the heart. 

The ensel is often by increase of temperature, precordial distm 
short cough, slight dyspnaa, more or less persistent vomiting, 
cardiac action, often rapid and tumultuous, with throbbing carotit 
and noises in the ear. As the infiammation progresses the cardii 
action and pulse decline in rapidity, with more or less congestion 
the lungs and venous stasis. 

Auscultation. Shows a change in the character of the sounds 
or the development of murmurs at the various orifices, the character 
and points of distinction between which will be pointed out when 
discussing valvular diseases of the heart. 

Duration. Between one and three weeks. 

Diaguosia. Pericarditis is distinguished from endocarditis by 
character of the physical signs. In pericarditis the murmur or fi^ctioB 
sound is heard with either sound, is near to the ear and influenced by 
pressure of the stethoscope, besides being associated with more or 
less alteration in the size and shape of the cardiac dullness, and is 
not transmitted, while in endocarditis the murmur takes the plat 
or is associated with, the cardiac sounds, and is transmitted, with th« 
absence of change or increased dullness on percussion. 

ProffnosiB. Acute endocarditis is not very dangerous 
hence a favorable prognosis maybe given; regarding the ultimatCi 
results of valvular lesions, however, the prognosis is grave. 



th(S 



THE CIRCULATORY SYSTEM. 2S1 

Treatment. Perfect rest in bid. At the onset leeches or iiiet 
cups to the prEecordium, followed by ice, or, what is preferable, 
fiouUices. 

The excited circulation should be controlled by aconitum, -veratrum 
viride, or diffilalis. 

The free administration of alkalies, to wit: ammonii carbonas.po- 
tassii acetas, or carbonas, until the urine is decidedly alkaline, may 
prevent permanent changes about the valves or orifices. 

If alkalies fail and the inflammation shows a tendency lo linger, 
good results are often obtained by a slight hydrargyrum impression. 

If signs of oppressed circulation appear, the hands becoming blue, 
the face and extremities osdematous, with congestion of the lungs, 
the free use of ammonii carbonas, digitalis and stimulants are indi- 
cated. The free use of ammonii carbonas will often prevent or break 
up heart clots. After the acute symptoms have subsided, more or 
less absorption of the exuded lymph has been promoted by the free 
use ai potassii iodidum. During the entire course of the affection the 
diet should be of the most nutritious character. 



ACUTE MYOCARDITIS. 

Definition. An in tl am mat! on of the muscular tissue of the 
heart, by extension from an inflamed pericardium or endocardium, 
or secondary to pyjemia; characterized by pain, feeble circulation, 
symptoms of blood poisoning and collapse. 

Cau&es. The result of endocarditis or pericarditis; pyxmia; 
typhoid fever; emboli of the coronary arteries. 

Patholo^cal Anatomy. Discoloration and softening of the 
cardiac substance and the infiltration of a sero-sanguinous fluid, 
fibrinous exudation and pus, leading to the formation of abscesses in 
the muscular structure of the heart. 

The disease leads to the formation of either a cardiac aneurism or 
to rupture of the walls of the heart. If recovery occur, cicatrices or 
depressed scars may mark the site of a former abscess. 

Symptoms. The clinical evidences of inflammation of the car- 
diac muscle are very obscure. If, during the course of one of the 
maladies mentioned, there are developed pain, irregular and feeble 
cardiac action, pyrexia of a low type, with symptoms of Mood poison- 
ing, and a tendency to collapse, or the symptoms of the so-called 
typhoid state, myocarditis may be suspected. 



252 PRACTICE OF MEDICINE. 

Diagrnosis. The existence of myocarditis can scarcely ever be 
anything but a presumption, the signs being all negative rather than 
positive. If during the course of rheumatism, pyaemia, puerperal 
fever, typhoid fever, pericarditis or endocarditis, symptoms of cardiac 
failure appear suddenly, associated with signs of blood poisoning and 
collapse, inflammation of the cardiac muscle may be suspected. 

Progrnosis. The course of acute myocarditis is very rapid, death 
being the usual termination, in from three to five days. Chronic 
myocarditis pursues a very latent course^ 

Treatment. Largely symptomatic. Perfect rest of mind, gen- 
erous diet, free stimulation and the administration of quinina and 
fetTUtn* 

CARDIAC HYPERTROPHY. 

Definition. An overgrowth or increase in the muscular tissue 
which forms the walls of the heart ; characterized by forcible impulse, 
over fullness of the arteries, diminished blood in the veins and 
accelerated circulation. 

Causes. Obstruction to the outflow of blood, to wit: aortic 
stenosis; emphysema; Bright*s disease; functional over action; ex- 
cessive use of tobacco, tea, coffee, or excessive muscular action. 

Varieties. I. Simple hypertrophy, or a simple increase in the 
thickness of the cardiac walls; II. Eccentric hypertrophy ^ increase 
in the cardiac walls and dilatation of the cavities, to wit : — Dilated 
hypertrophy ; III. Concentric hypertrophy, increase in the cardiac 
walls and decrease of the cavities, a very rare form. 

Pathological Anatomy. Hypertrophy of the heart is usually 
limited to the left side, the ventricles more commonly than the 
auricles, the latter dilating. 

The shape of the heart is altered by hypertrophy; if the right 
ventricle, the heart is widened transversely and the apex blunted ; if 
the left ventricle, the heart is elongated and, as a rule, the cavity is 
dilated ; if both ventricles are hypertrophied, the heart has a globular 
shape. From increase in weight the heart may sink lower during the 
recumbent position, thereby lessening the area of cardiac dullness, 
but during the sitting or upright posture it sinks lower in the chest 
and to the left, causing more or less prominence of the abdomen. 

The increase in the size of the organ is a true increase or hyper- 
trophy of the muscular tissue, and not a hyperplasia. The tissue is 



firmer and the color brighter and fresher than when the size of the 
organ h normal. 

Symptoms, Depend upon the amount of hypertrophy. The 
most common are increased a»d forcibh cardiac action, the arteries 
becoming fuller the veins less full and the circulation accelerated, 
pulsating carotids and aorla, headache, often vertigo, frequent epis- 
tojcis, congestion of the face and eyes, tinnitus aurium, dyspncea on 
exertion, dry cough, restless nights, with more or less Jerking of the 
limbs, occasional precordial pains shooting toward the left axilla, 
full firm, bounding pulse, and pulsations in the superlicial arteries. 

A sphygmographic tracing shows the line of ascent vertical and 
abrupt, but the apex is rounded, and the line of descent is oblique, 
unless there is more or less insufficiency of the valves. 

Inspection. Often fullness or prominence of the prfficordium, 
with distinct impulse. 

Palpation. The impulse is felt one or two intercostal spaces 
lower down and to the left, and is stronger and more or less diffused — 
the heaving impulse. 

Percussion. The area of cardiac dullness is increased vertically 
and transversely upon the left side of the sternum, unless the right 
ventricle is also hypcrtrophied, when the cardiac dullness is increased 
to the right of the sternum. 

AoBCUltation. If simple bypiertrophy without any coexisting 
changes in the valves or orifices, the Grst sound has a loud and some- 
what metallic quality, the second sound being strongly accentuated. 

Sequelse. Cerebral hemorrhage; miliary cerebral aneurisms; 
dilatation of the heart; fatty changes in the cardiac tissue. 

Diagnosis. Hypertrophy of the heart can scarcely be mistaken 
for any other disease if a careful study of the physical signs be made. 

Prognosis. When the resultof valvular disease, the hypertrophy 
is said to be compensatory. If the result of Brighl's disease, emphy- 
sema of the lung, or if occurring late in life, or associated with athero- 
matous degeneration of the vessels, the prognosis is unfavorable; 
when the result of functional over action in the strong and robust, a 
further enlargement can often he prevented by active and persistent 
treatment. • 

Treatment. The indications are to lessen the force and number 
of the cardiac pulsations and to remove the cause whenever possible. 

The former indications are best met by the persistent use of aconi- 



264 PRACTICE OF MEDICINE. 

tUtR in small doses, ^. i-ij, three times a. da.y, or veratrum viridt, 
gtt. Mj, three times a day, at the same time keeping the bowels, 
kidneys and skin acting freely. 

The habits of the patient are to be corrected, all laborious or active 
exercise to be restricted, the patient to be in tbe recumbent posture 
several hours during the day if possible, the diet being restricted, 
avoiding all Torms of stimulants, to wit; liquors, tobacco, tea and 

Cases of cardiac hypertrophy associated with anemia should, in 
addition to the above, be placed upon a course aX ferrum. 

DILATATION OF THE HEART. 

'Definition. An increase in the size of one or more of Ihe cavities 
of the heart, without any increase or thickening of the cardiac walls; 
in fact, jhe walls are frequently thinner; characterized by feebleness 
of the circulation, terminating in venous stasis, osdema and exhaustion. 

CaUBes. Over-exertion in those of feeble resisting powers, as 
youths or soldiers, as first pointed out by Prof. Da Cgsta ; insufficiency 
of the valves; emphysema; chronic bronchitis; gout; Bright 's disease. 

Varieties. I. Simple dilatation, the cavities being enlarged, the 
walls normal. II. Active dilatation, corresponding to eccentric hy- 
pertrophy; the cavities being enlarged and the walls increased in 
thickness, the so-called "dilated hyperirophy." III. Passive dilata- 
tion, the cavities being enlarged and the walls thinned or stretched. 

Pathological Anatomy. The right side of the heart is far 
more frequently involved than the left side. The shape of the' organ 
is altered, according to the part affected. The weight of the organ 
is. as a rule, increased, as hypertrophy almost always accompanies 
or precedes dilatation. 

The muscular tissue is generally pale, mottled and softened, and 
under the microscope presents evidences of degeneration. The orifices 
also participate, and especially the auricula -ventricular, resulting in 
the valves becoming incompetent to close the orifices, and this latter 
effect is added to by the removal of the basis of the papillary muscles 
to a great distance from the orifice, in consequence of the extension 
of the wall. 

When the auricles dilate, the large venous trunks opening into 
them unprotected by valves commonly participate in the dilatation, 
and may become greatly enlarged. 



f THE CIHCULATORV SYSTEM. 



255 



I 



The passive congestion ol the organs that follows the feeble circu- 
lation produces changes in their structure. 

Symptoms. Those associated with enfeebled circulatia*, to wit; 
peble piihe, veins distended, arteries emptied, headache, aggravated 
by the upright position, attacks ai syncope, cough, with any of the fol- 
lowing phenomena of venous congestion; of the lungs, dyspnasa; 
VivsT, Jaundice ; stomach, dyspepsia; intestines, cOHslipaiion ; kid- 
neys, scanty oKen albuminous urine ; brain, dullness of the mind and 
■vertigo, often relieved by a copious epistaxis; and, finally, dropsy, 
beginning in the lower extremities, the patient dying from exhaustion. 

Great relief often temporarily follows any of the above symptoms 
under treatment ; sooner or later, however, the venous stasis produces 
the final symptoms noted. 

InBpBCtiOD, Veins of the surface distended and enlarged; in- 
distinct cardi.ic impulse, often diffused and wavy; if associated with 
tricuspid insufficiency, there is pulsation of the Jugular. 

Palpation. Feeble and irregular fluttering but heaving impulse. 

Percussion. Cardiac dullness extended transversely, and espe- 
cially increased on the right side. 

AuBCUltatiOQ. If no valvular lesions accompany the dilatation 
the cardiac sounds are weaker than normal, the first sound having a 
sharper quality than normal; if accompanied by valvular lesions. 
cardiac murmurs are present. 

Diagnosis, Hypertrophy of the heart shows increased cardiac 
dullness, and is a disease of powerful cardiac action, while dilatatioD 
is an affection of feeble action associated with dropsy. 

Pericardial effusion has many points of resemblance to cardiac 
dilatation, but it begins suddenly, associated with some acute malady; 
and while the heart sounds are indistinct or feeble at the apex, they 
both have their normal qualities at the cardiac base, while dilatation 
of the heart has a chronic history, results in general venous stasis, the 
cardiac sounds having the same intensity over the entire preecordia. 

Prognosia. Unfavorable, death resulting from gradual exhaus- 
tion. or suddenly by cardiac paralysis if there be undue excitement. 

Treatment. The general nutrition of the patient must be pro- 
moled to the uttermost. Generous diet, moderate exercise, with bitters 
to increase the appetite and femim to improve the blood, and, in a 
majority of cases, the more or less free use of a good red wine. 

The heart tonics are digitalis in powder or infusion ; exi. conval- 



256 PRACTICE OF MEDICINE, 

iartcBffld,, gtt. V, t. d., guinina, caffeina and morphina sulph.^ in small 
doses, the latter when the dropsy becomes great and associated with 
marked cyanosis, hypodermatically, as suggested by Prof. Bartholow, 
"often acts like magic in restoring the circulation." 
The following pill is often of great advantage, to wit : — 

J0K. Ferri redact grj-ij 

Quininse sulph gr.j-ij 

Pulv. digitalis gr.j 

Morphinae sulph g^'^V ^* 

SiG. — ^Three times a day. 

The secretions should be stimulated by purgatives, diuretics and 
diaphoretics. 

If pulmonary congestion, dry cups, digitalis and stimulants. 

For cardiac asthma, dry cups, morphince sulph. hypodermatically, 
or spts. cetheris compositus (Hoffman's Anodyne). 

For hepatic congestion, blue mass and podophyllin. 

For dropsy, dry cups over the kidney, digitalis or potassii acetas, 
with scoparius ?cn&juniperus, 2J\^ pulv. jalap ce comp., 3J--ij, in water, 
before breakfast. 

FATTY DEGENERATION OF THE HEART. 

Definition. A change in the muscular fibres of the heart, in 
which the transverse striae are replaced by granules and globules 
of fat ; characterized by feeble cardiac action, venous stasis and 
dyspnoea. 

Causes. Impaired nutrition in the elderly ; prolonged anaemia ; 
chronic gout; alcoholism; phosphorus poisoning; cancer, tubercu- 
losis and scrofiila ; disease of the coronary arteries. 

Pathological Anatomy. The distinction must be made be- 
tween a deposit of fatty tissue upon or around the heart, and the 
degeneration of its muscular tissue. 

The fatty metamorphosis may affect the whole organ, or the entire 
ventricles, or be limited to portions of them. If the degeneration be 
marked the color is yellowish, the tissues soft and easily torn, and to 
the touch have a greasy feeling, oil being yielded on pressure. 

The microscopic changes are characteristic. The striae of the 
muscle are early rendered indistinct by fat and oil globules, gradually 
becoming more and more obscured, and finally disappearing alto- 
gether, the fibres being replaced by fat granules. 



SYSTEM. 267 

Symptoms. Those of weak heart, ansemia of organs and venous 
stasis, to wit; feeble, irregular, but slow cardiac acliott, eompremible 
pulse, pracordial distress, often aggravated by attacks of angina pec- 
torb ; dyspniea, aggravated on exertion, with aramia of the various 
Cleans from the feeble propulsive power; if of brain, ■vertigo, sv/ooTang, 
or pseudo-epileptic attacks, especially marked on suddenly rising from 
a recumbent position ; if of lungs, dry, hacking cough ; if of gastro- 
intestinal tract, dyspepsia and constipation ; if of kidneys, scanty 
urine, at times albuminous; and, finally, dropsy, beginning in the 

A formidable symptom, causing much inconvenience as well as 
alarm to the patient, is what he will term his constant " sighing," 
the Cheyne-Stokes breathing— "A pause in the breathing, a com- 
plete suspension of the respiratory acts for a period of time (during 
which breathing might occur several times in the normal manner), 
then the resumption of respiration very feebly and slowly, and a 
gradual and progressive increase in the number, and depth of respi- 
rations until the maximum is reached, aJid then again a gradual and 
progressive diminution, in the same order, in the number and depth 
of the respirations, until another pause occurs" — the "oscillating 
respiration," 

Concomitant symptoms are atheromatous change in the vessels, 
and the arciis senilis. 

Palpation. Weak cardiac impulse. 

PercUBBion. Not markedly changed unless preceded by enlarge- 
ment of the heart. 

Auscultation. First sound feeble, toneless, almost inaudible, the 
second sound being normal, unless changes in the valves are present. 

DiagnoBia. If aged persons, or those exposed to the causes, 
have feeble heart, associated with atheroma of the vessels and the 
arcus senilis, the diagnosis of fatty heart is almost positive. If dropsy 
occur, however, it is difficult to distinguish from dilatation of the heart. 

PrognoBiB. Incurable, the affection pursuing a more or less 
chronic course. Life may be prolonged at times by treatment, but 
death finally results from exhaustion, or suddenly, from cardiac pa- 
ralysis or rupture of the heart. 

Treatment. Palliative. Generous diet, very moderate exercise, 
stimulants, oleum nwrrhua, and the "triple elixirs," — elixir Jerri, 
quinina et slrychnina. 



,11 

it 



268 PRACTICE OF MEDICINE. 

To sustain the cardiac action, cqffeina or morphina in small doses, 
or hypodermatically for the so-called cardiac asthma. Digitalis is 
contra-indicated. 

VALVULAR DISEASES OF THE HEART. 

Definition. Alterations in the cardiac valves or orifices, render- 
ing the former incapable of properly closing the latter, or causing the 
latter to interrupt the blood current in its normal movement. 

The lesions are of two kinds, to wit : obstructive and regurgitant. 

A regurgitant lesion, termed also insufficiency, is such change in the 
valves as to permit the blood .to flow backward instead of onward, the 
true direction of the blood current. 

An obstructive lesion, termed also stenosis, is a narrowing of the 
orifice, thereby obstructing the passage of the blood. 

Varieties. L Mitral regurgitation. II. Aortic regurgitation. 
III. Tricuspid regurgitation. IV. Pulmonic regurgitation. V. Mitral 
obstruction. VI. Aortic obstruction. VII. Tricuspid obstruction. 
VIII. Pulmonic obstruction. 

Causes. In the young, usually the result of endocarditis, and 
generally affecting the mitral orifice or valves ; in the elderly, chronic 
endocarditis or atheromatous degeneration, most commonly affecting 
the aortic orifice or valves. 

Prof. Da Costa has clearly established the production of aortic dis- 
ease in early life by overwork and strain of the heart. Syphilis ; dila- 
tation of the heart ; atrophy or contraction of the valves, and con- 
genital malformations. 

MITRAL REGURGITATION. 

Pathologrical Anatomy. The most common conditions ob- 
served are more or less contraction and narrowing of the tongues of 
the valves, with irregular thickening and rigidity ; atheroma or calci- 
fication of the segments ; laceration of one or more segments ; adhe- 
sion of one or more segments to the inner surface of the ventricle ; 
rupture of the chordoe tendinece, and also contraction and hardening 
of the musculi papillares. 

As a result of the regurgitation of the blood into the left Auricle, 
there is dilated hypertrophy. 

Symptoms. Insufficiency of the mitral valves soon leads to car- 
diac hypertrophy to compensate for the diminished amount of blood 



I 

i 



DISEASES OF THE CIRCULATORY SVSTEM. 259 

sent onward by the ventricular systole. When the '" compensation 
ruptures " occur, pracordial distress, cou^M, dyspnaa, feeble, soft, 
rapid, irregular pulse : finally pulmonary congestion, cedematoys 
limbs, the abdominal cavity filled, liver congested, urine scanty and 
albuminous, the patient dying " drowned in his own fluid." 

Inepection. Cardiac impulse lower than normal, the heart being 
enlarged. 

Palpation. Early, forcible and diffused impulse ; later, feeble 
diffused impulse. 

Peroussion. Transverse and vertical cardiac dullness increased, 

AuBcultalion. Systolic blowing or churning murmur, audible 
in the mitral area, propagated to the apex, left axilla and under the 
angle of the scapula, either occurring with or taking the place of the 
first soiiHii of the heart; the second sound markedly accentuated. 

PrognosiB. So long as the compensating hypertrophy can be 
mainLiined the prognosis is not bad; when dilatation supervenes, 
however, the patient soon perishes, either from congestion of the lungs 
or dropsy and exhaustion. 

AORTIC REGURGITATION. 

Pathological Anatomy. The valves or segments adhere to 
the wails of the aorta, or a segment is lacerated or may be perfo- 
rated, or; more commonly, the segments are shrunken, deformed and 
rigid, permitting the regurgitation of the blood. These deficiencies 
in the valves are usually associated with more or less narrowing of 
the orifices. 

The cardiac muscle rapidly hypertrophies, its cavity enlarging — 
" dilated hypertrophy." 

STmptoms. Those of marked hypertrophy, to wit: forcible car- 
diac acdon, headache, tinnitus aurium, congestion of the face and 
eyes, with pulsating vessels, even small ones pulsating that before 
were not visible to the eye ; pulsations of the retinal vessels can be 
recognized with the ophthalmoscope ; the receding pulse, which is 
particularly characteristic — forcible impulse but rapidly declining, 
called " water-hammer " pulse ; also, the " Corrigan pulse." 

When "compensadon ruptures," dyspncea, cough, hepatic enlarge- 
ment, congestion of the kidneys, with scanty, albuminous urine, ascites 
and dropsy. If mitral insufficiency is now superadded, general venous 
stasis and death rapidly occur. 



260 PRACTICE OF MEDICINE. 

Inspection. Forcible cardiac impulse. 

Palpation. Strong, full cardiac impulse. 

Percussion. Cardiac dullness increased transversely and verti- 
tically. 

Auscultation. First sound, forcible ; second sound, replaced or 
associated with a churning, rushing or blowing murmur of low pitch, 
distinct at the second right costal cartilage, but most distinct at the 
junction of the sternum and the fourth left costal cartilage, transmitted 
downward toward and below the apex. 

Prognosis. The one valvular disease most likely to occasion 
sudden death; still, so long as the compensating hypertrophy re- 
mains intact, compatible with quite an active life. 

TRICUSPID REGURGITATION. 

Patholo^cal Anatomy. This form of valvular insufficiency 
is either associated with right-sided cardiac dilatation from pulmonary 
obstruction, or is the result of mitral disease. 

The tricuspid orifice is dilated in the majority of cases ; occasionally 
the segments of the valves are contracted or adherent to the ventricle. 

Symptoms. Venous stasis with its various consequences, and 
especially pulsation of the jugular, synchronous with the cardiac 
movement, and finally general venous pulsation, especially of the 
liver, pulmonary congestion, engorgement of the kidneys and dropsy. 
These symptoms are superadded to those of the affections with which 
tricuspid insufficiency is always associated. 

Inspection. Diffused, wavy, cardiac impulse ; jugular pulsation 
synchronous with the cardiac movement, uninfluenced by respiration, 
also more or less prominent hepatic pulsation. 

Palpation. The cardiac impulse extended, but feeble. 

Percussion. Dullness on percussion, extending to the right and 
below the sternum. 

Auscultation. The first sound is accompanied by a blowing 
murmur most intense at the junctioA of the fourth and fifth ribs with 
the sternum, distinct over the xiphoid appendix, becoming feeble or 
lost in the left axillary region ; often associated, however, with a mitral 
systolic murmur. 

PULMONIC REGURGITATION. 

Patholo^cal Anatomy. Insufficiency of the pulmonary vjilves 
is of Tare occurrence, but when present the changes correspond more 
or less to those described for aortic regurgitation. 



DISEASES OF THE CIRCULATORY SYSTEM. 261 

Symptoms. Those of dilatation of the right side of the heart 
and consequeftl pulmonary congestion, to wit : dyspnffia, deficient 
aeration of the blood, and cyaoosls, distention of the superRcJal 
vessels, palpitation of the heart, prjecordial distress, sudden sulToca- 
tive attacks and dropsy. 

PercuBsion. The cardiac dullness extending to the right of the 



Auscultation. A loud blowing murmur associated with the 
second sound of the heart, most distinct at the Junction of the third 
left costal cartilage and the sternum. 

Prognosis. Death results, sooner or later, from dropsy and ex- 
haustion. 

MITRAL OBSTRUCTION. 

Pathological Anatomy. Mitral stenosis is caused by deposits 
around the orifice, the result of endocarditis, or else the segments of 
the valves are "glued together by their margins," leaving but a funnel- 
shaped opening, the so-called " button -hole " mitral valve. Vege- 
tations on the valves lead to more or less obstruction of the blood 



Symptoms. Hypertrophy of the left auricle results from ob- 
slruclion at the mitral orifice, the symptoms of stenosis being unob- 
servabie until the " compensation ruptures," when occur irregiilar, 
small and feeble puhe. dyspnaa, cough, bronchorrhcea the result of 
bronchial congestion : dilatation of the right side of the heart, soon 
leading to general venous stasis, dropsy and death. 

ZnBpeotion. Normal until hypertrophy, when an undulatory im- 
pulse is observed over the left auricle. 

Palpation. When cardiac dilatationoccurs. a diffused, feeble and 
irregular cardiac impulse is felt near the xiphoid appendix. 

Auscultation. First sound normal In character but often irregu- 
lar in rhythm. The second sound normal. A blowing, sometimes 
rasping, sound is heard, immediately after the second sound ai the 
heart ceases, and .immediately before the first JoKxrf begins^ — a pre- 
systolic murmur, heard most distinctly in the mitral area, lessening in 
intensity toward the cardiac base. The cardiac sounds are all more 
or less enfeebled if cardiac dilatation occur. 

PrognOBis. The prognosis is controlled by the hypertrophy. 
Under favorable circumstances mitral stenosis is compatible with along 
and rather active life. 



AORTIC OBSTRUCTION. 

Pathological Anatomy. Stenosis of the aortic orifice depends 
upon the projection of the valves inward, and their becoming rigid 
and thickened, or atheromatous or calcareous, so that they cannot 
pressed back by the blood, but remain constantly in the current 
the circuladon. Occasionally the vaJves are covered with fibrinous 
masses, the opening into the artery being thus more or less com- 
pletely closed, or the segments may be adherent by their lateral sur- 
faces, leaving a central opening, which maybe so contracted as to 
only permit the passage of the smallest article. 

Symptoms. Hypertrophy of the left ventricle rapidly super- 
venes upon aortic stenosis. The^«/jc is small, slow and hard. The 
supply of blood to the brain is insufficient in many cases, and hence 
attacks of virligo. syncope or slight epileptiform seizures occi 
finally, dilatation of the left ventricle and incompetence of the mitral 
valve result, with subsequent pulmonary congestion, dyspnua and 
general venous stasis, the pulse soft and feeble. 

Palpation. Lowered cardiac impulse, strong in the early sla^, 
feeble when dilatation occurs. 

Percussion. The cardiac dullness is increased vertically, the 
transverse dullness being slightly affected. 

Auscultation. The first sound replaced or associated with i 
harsh, rasping sound, whistling at times, having its greatest intensity 
at the junction of the second right costal cartilage with the sterni 
transmitted along the vessels ; the murmur may sometimes be heard 
a short distance from the patient. 

Usually aortic stenosis is associated with more or less aortic regur- 
gitation, whence a double murmur occurs, having its greatest intensity 
at the base of the heart, the so-called " see-saw " murmur. 

Prognosis. So long as compensation is maintained the symp- 
toms of aortic stenosis are nil. When the compensation is ruptured, 
the usual symptoms of dilatation, venous stasis and dropsy soon 
follow. 

TRICUSPID OBSTRUCTION. 

This condition is one of the rarest affections of the heart, and if it 
ever does occur with or following an attack of endocarditis, the 
anatomical changes are similar to those of mitral obstruction. This 
condidon soon leads to auricular dilatation ; venous stasis rapidly 



THE CIRCULATORY SYSTEM. 263 

supervenes, associated with venous pulsations similar to those de- 
scribed when speaking of tricuspid regurgitation. 

PULMONIC OBSTRUCTION. 

Pathological Anatomy. Always a congenital malady, the 
changes consisting in " constriction of tlie pulmonary artery, un- 
closed foramen ovale, unclosed ductus Botalli, stricture at the ductus 
Botalli, with hypertrophy of the right cavity and frequent association 
with tuberculosis of the lungs." 

Hypertrophy of the right ventricle may ensue, the walls becoming 
almost as thick as those upon the left side. 

Those in whom these congenital defects in the cardiac structure 
occur are otherwise weak, develop slowly, have Sabby tissues, soft 
bones and seem poorly nourished. 

Symptoms. The hypertrophy which ofien ensues may keep life 
apparently comfortable for some time, but sooner or later " compen- 
sation ruptures," when cough, dyspnoea, cyanosis and death occur. 

Prognoais. The duration of these congenital atTecrions is short, 
usually from a few days to a few months ; although several well 
authendcated cases record a much longer duration. 

DIAGNOSIS OF VALVULAR DISEASES. 

In making a differential diagnosis between the various forms of 
valvular diseases of the heart, strict attention must be paid to the 
points of greatest intensity at which the several murmurs are heard. 

A murmur occurring with or taking the place of the fint sound of 
the heart — the ventricular systole — heard most distinctiy at the apex, 
transmitted to the left axilla, and at the inferior angle of the scapula, 
signifies mitral regurgitation — « milral systolic murmur. 

A murmur occurring with or taking the place of the first sound of 
the heart, with its point of greatest intensity at the xiphoid appendix, 
signifies regurgitation at the tricuspid orifice — a tricuspid systolic 



•• heard with the first sound of the heart, high-pitched, 
rasping or grating in character, with its point of intensity greatest at 
the second right costal cartilage, signifies obstruction at the aortic 
orifice — an aortic systolic murmur. 

A murmur heard with 'iS\i first sound of the heart, soft in character, 
with its point of intensity most distinct at the junction of the third 



FKACTICE OF MEDICINB, 

left costal cartilage with the sternum, signifies obstruction at the pul- 
monic orifice — a pultnomc systolic murmur. 

A murmur occurring immediately after the second sound of the 
heart, and immediately before the beginning of the first sound of the 
heart, signifies obstruction at the mitral orifice — a presystolic mitral 



T heard with or taking the place of the second loKWi/of the 
heart, most distinct at the second costal cartilage, to the right of the 
sternum, and well transmitted toward the apex or below, signifies in- 
sufficiency or regurgitation at the aortic orifice — an aortic regurgitant 
or diasystolic murmur. 

Although eight distinct valvular murmurs have been described as 
occurring in the heart, those on the right side are of rare occurrence, 
and hence of little clinical importance. 

If a murmur be heard with ihe first sound of the heart, it is almost 
certainly aortic obsiruftivc or mitral regiirgilant ; and if heard with 
the second sound, it is probably aortic regurgitant. A presystolic 
mitral murmur is also of comparariveiy rare occurrence, the force with 
which the blood passes from the left auricle into the left ventricle 
being, under ordinary circumstances, insufficient to excite sonorous 
vibrations. 

Functional or anixmic murmurs uia.y h^ confounded with thevarioys 
forms of valvular disease of the heart. The chief points of distinction 
between them are, that an anaemic murmur, which is always heard at 
the base of the heart, is always systolic in time, not transmitted away 
from the heart, and is soft in character, low in pitch, and of variable 
intensity, now being heardj now entirely absent. 

Treatment. There is no special plan of treatment for each form 
of valvular disease. The important pqjnt to bear in mind is that they 
are associated at)\e.i with cardiac hypertrophy or dilatation, snA the 
treatment, if any at all is required, is directed toward this secondary 
condition. If compensation be complete, attention to the condition 
of the bowels, kidneys and digestion, with some general directions as 
to exercise, is ail that is required. 

If the hypertrophy become marked and excessive, it is best con- 
trolled by either aconilum or veratrum ■viride. 

If dilatation have occurred, the heart weak and feeble, the circula- 
tion impeded, and venous stasis has followed, digitalis, with more or 
less active purgation, are indicated. 



DISEASES OF THE CIRCULATORY SYSTEM. 266 

PALPITATION OF THE HEART. 

Synonym. Irritable heart. 

Definition. A functional disturbance of the heart; characteriied 
by increasing frequency of its movements and more or less irregular- 
ity of the rhythm, with a strong tendency toward hypertrophy. 

Causee. Over-exertion, " the heart strain " of Da Costa ; dyspep- 
sia; uterine diseases; excesses in tea, coffee, tobacco, alcohol or 
venery ; moral and emotional causes, grief, anxiety and fear. 

SymptomB. Usually palpitation of the heart has a sudden onset 
after some one of the causes mentioned, prateordial oppression or 
pain, rapid, hanaltuoas beating, the impulse being visible through the 
patient's clothing, dyspniea, aiixiety, and a sense of choking or full- 
ness in the throat, the recumbent position impossible, vertigo, faint- 
ness, flashes of light, the puise full and strong or feeble, the face 
flushed or pale, the patient having a feeling of anxiety with a sense of 
impending danger and a fear of sudden death. These attacks are 
paroxysmal, lasting from a few moments to several hours, or a day, 
the patient often voiding a large quantity of limpid urine after the 
paroxysm has subsided, when there is a strong tendency to sleep. 

Diagnosis. Irritability of the heart is differentiated from the 
variolas forms of cardiac disease by the absence of all the physical 
signs mentioned as occurring in those conditions. 

PrognOBis. If early ai\d properly treated, favorable. 

Treatment. The first point in the treatment of irritability of the 
heart is to remove the cause; the next, to prevent the recurrence of 
the attacks of palpitation. 

The majority of cases do well by a combination of digitalis and 
belladonna. Permanent relief is often afforded by a combination of 
potassii bramidum anA ■ueralntm viride. Chloral is also useful. If 
the patient be aiuemic, the author has had excellent results follow the 
prolonged use of the elixir ferri, guinina et strychnins. Locally, 
- emplastrmn belladonme to the prscordium affords relief. 

ANGINA PECTORIS. 

Synonym. Neuralgia of the heart. 

Definition. Paroxysms in which there occur sharp cardiac pains, 
extending usually into the left shoulder and down the left arm, accom- 
panied by a feeling of constriction of the thorax and a strong sense 
of impending death. 



OF MEDICINE. 

Causes. Often hereditary ; associated with chronic cardiac 
changes, as diseases of the coronary arteries or calcification of the 
valves ; the excessive use of tobacco ; according to Trousseau, it isa 
form of masked epilepsy, and may alternate with true epileptic attacks; 
often associated with hysteria. 

Pathological Anatomy. "The pathological changes which 
stand in a causative relation to the attacks are those of the cardiac 
plexus of the phrenic and of the pneumogastric nerves. Pressure of 
enlarged lymphatics, inflammation of parts of the cardiac plexus, with 
changes in the coronary artery, seeni to be most constant." 

Symptoins, A paroxysmal affection, the attacks occurring irregu- | 
larly; in the interval entire absence of symptoms. ' 

"The patient suddenly sits up in his bed; with a cry of horror 
indicates the sense of pain at the prEecordium. This pain is of great 
intensity, but is of a cold and sickening character ; the chest is fixed, 
the breathing quickened, and the hand placed over the epigastrium 
finds that the heart's action is slight and enfeebled. The face wears 
a look of horror, pale and slightly leadened; a cold sweat breaks out 
upon the forehead; worse than the pain is the feeling of fearful sick- 
ening and depression. The poor patient gasps, ' 1 shall die ! I shall 
die!' and sometimes his short but concentrated sufFeriags in a. few 
moments end in death." 

The unpleasant sensations of these patients dtuing an attack, and 
the nervous disorder associated with it, slowly bring about a mental 
change. They are depressed and gloomy, sometimes suicidal, often 
developing epilepsy. 

Diagnosis. The points to be remembered are that the attacks 
are always paroxysmal, the patient having a sense of coldness, and . 
frequently a cold sweat, the heart's action not increased, the chest 
fixed and the breathing slow. 

Prognosis. Unfavorable, the patient either succumbing during a 
paroxysm or by exhaustion, the result of the cardiac changes. 

Treatment. As far as possible attetnpt to remove the caus 

Prompt relief follows the use q^ amy! mirii, fiJiXj, inhaled at the 
instant, or morphiniE sulphas gr j4-/i> '" which may be added with 
advantage atropinm sulphas gr. lij, hypodermatically. To preveni 
the paroxysms, Ugucr potassii arsenilis 'mjv, three times a day, also ol. 
tnorrhuiz, or hypophosphites, and ilixir Jerri, giiinineE et strychnina. 



E. 



Mi 



DISEASES OF THE N 



DISEASES OF THE NERVOUS SYSTEM. 



CONGESTION OF THE BRAIN. 

Synonyms. Cerebral hyperiemia ; cerebral congestion. 

Definition. An abnormal fullness of the vessels oT the brain ; 
active, when arterial fullness; passvue, when venous fullness; char- 
acterized by headache, vertigo, disorders of the special senses, and if 
the hyperemia is decided, convulsions. 

Cauaes. Active. Increased cardiac action, the result of hyper- 
trophy of the iefl ventricle ; general plethora ; excesses in eating and 
drinking ; alcoholism ; sunstroke ; prolonged mental labor ; dimin- 
ished amount of arterial blood in other parts, the result of the com- 
pression of the abdominal aorta ; ligation of a large artery, and the 
suppression of an habitual bleeding hemorrhoid are examples. 

Passive. Dilatation of the right heart; pressure upon the veins re- 
turning the cerebral blood. 

Patholoirical Anatomy. The post-mortem appearances are, 
overloading of the venous sinuses and of the meningeal vessels, 
including the finer branches ; the pia mater appears vascular and 
opaque ; the gray mailer of the convolutions unduly red ; the convo- 
lutions may be compressed and the Ticnbicles contracted, with the 
displacement of a corresponding amount of cerebro-spinal fluid. 

Long continued or repeated congestions lead to enlargement and 
tortuosity of all the vessels, a moist and slimy condition (oadema) of 
the cerebral substance, and an increase in the suh-arachnoid fluid. 

Symptoms. " Rush of blood to the head " may be gradual or 
sudden in its onset, the symptoms aggravated by the recumbent 
position. Headache with paroxysmal neuralgic darts, disorders of 
vision and hearing, bu:<;[ing in the ears and sparks before the eyes, 
contracted pupils, vertigo, blunted intellect, inability to concentrate 
the mind, irritable temper and curious kallucinations. The face is 
red, the eyes congested, and the carotids pulsating. The sleep is 
disturbed by dreams and jerkings of the limbs. In children convul- 
sions occur. If the attack be sudden (apoplectiform) sudden uncon- 
sciousness with muscular relaxation occur. 

Proffnoais. Mild cases terminate favorably in a few hours to a 
day or two, but show a strong tendency to recur. Severe cases (apo- 



OF MEDICINE. 

plectiform) may terminate in health, but usually foretell cerebral 
hemorrhage. 

The pdssi've form is controlled by the lesions causing it. 

Treatment. Acliv^. Remove the cause if possible. Elevate tMe 
head and apply cold, either cold cloths or the ice cap, at the same time 
warmth to the feet. Leeches to the mastoid, or cups to the neck, or 
in the apoplectiform variety venesection, to diminish the intra-cranial 
blood pressure ; compression of the carotids, or ligatures about the 
thighs, have been recommended. 

An active purgative is also indicated, to lessen the vascular tension. 

In mild cases the application of cold and potassii bromidum, gr. 
xxx-xl, repeated, controls the congestion ; extractum ergette fluidum 
b often beneficial ; in more severe cases any or all of the above 
mentioned means, together with full doses of tinctura -veratri viridit 
or tinctura aconiti, may be needed. 

Passive form. Becomes a part of the treatment causipg the hyper* 

CEREBRAL AN.^MIA. 

Definition. An abnormal decrease in the quantity of blood in 
the cerebral vessels ; general, when the diminished supply includes 
all the vessels ; partial, when the diminished supply is limited in 
area; characterised by pallor, headache, vertigo, some loss of power, 
and, rarely, convulsions. 

Causes. Partial cerebral ansemia results from obstruction of a 
vessel, from embolism or thrombosis. General cerebral ansemia 
results from hemorrhages, wasting diseases, sudden shock, feeble 
cardiac action and general ana;mia. 

Pathological Anatomy. The cerebral vessels contain lesa: 
blood than normal; the brain is pale and milky in color, and o>i 
transverse section there are no bloody points; the ventricles and 
perivascular lymph spaces are well filled with fluid. 

In partial anaimia the local conditions differ somewhat fi:om the 

Symptoms. General: headache, relieved by the recumbent 
position ; vertigo, aggravated by exertion ; general pallor and anfe- 
mia, with attacks ai fainting; when the general cerebral 
sudden and decided, convulsions occur. 

Partial anamia; sudden loss of power, of limited muscular 
gradually returning to the normal condition. 



DISEASES OF THE NERVOUS SYSTEIf. 

ProfrnosiB. Favorable in all cases save those the result of severe 
and repeated hemorrhages. 

Treatment. Regulated nourishment, with sUmulanti. A certain 
number of hoitre daily in the recumbent ppsition is of advantage. 
When a tendency to attacks of swooning exists, stimulants or even 
the cautious inhalation of amyl nitris are indicated. To improve the 
quantity or quality of the blood — 

B. Unci, feiri chlor. tn,xv 

Add. phosph. dil r^^v 

liq. arsenici chloridi _ itLiij 

Syr.Iimonis. , ntxx 

Syr. lingiberis, q. s. ad„ gij. M. 

Sio. — Every six hours, well diluted. 
Or— 

R. Extract i eiythroxyll coca; fld_ fjss 

Vini albi fort fjss, M. 

SiG.— One hour after meals. 

CEREBRAL THROMBOSIS AND EMBOLISM. 

Synonyms. Partial cerebral anxmia ; occlusion of cerebral 
vessels; cerebral apoplexy (?) 

Definition. The occlusion of a cerebral vessel, from the forma- 
tion of a thrombui, or the presence of an embolus, thus causing 
anamia of some portion of the brain ; characteriied by the gradual^ 
when dieresultof thrombosis, and the sudden, when due lo embolism — 
development of headache, vertigo, disorders of intelligence, with 
more or less complete insensibility and paralysis. 

Caueea. Thrombosis, or the Formation of a clot in the vessel — an 
ante-mortem coagulation — is almost always the result of chronic 
endarteritis, together with a slowing and weakening of the blood 



Emboli usually results from an endocarditis — cardiac emboli ; small 
particles of the exudation are carried into the circulation and are 
deposited in the brain. Emboli may also be derived from aortic 
aneurism, or syphiloma of the great vessels. 

Pathological Anatomy. The cerebral arteries may be ob- 
structed by emboli or thrombi ; the cerebral veins and sinuses by 
thrombi only. The changes in the cerebral tissue are Ihose of anaemia 
of the part or parts supplied by the occluded vessels. The subsequent 



270 



PRACTICE OF UEDICIKE. 



changes depend upon [he anatomy of the vessels. If the obstructed* 
artery has anastomoses, the collateral circulation is soon established \ 
and the brain tissue assumes its normal condition. If, on the other 
hand, the occluded vess.el be one of " Cohnheim's terminal arteries" 
— arteries without anastomoses — the blood in the whole extent of the 
occluded vessel coagulates, thus preventing the backward flow of 
blood from the sur(ounditig capillaries and so obstructing collateral 
circulation, whence the ansemic tissue dies or undergoes mcro&iosis, 
followed by yellowish- white softening; or, if the vessel beyond the 
seat of the occlusion remains pervious, blood flows back through the 
capillaries from the nearest artery or vein ; the parts that a 
before were bloodless now become deeply engorged, the succeeding ' 
changes in the vessels permittingiAa^irrffju-of the red blood globules; 
the tissues which are undergoing disintegration are colored by the 
red globules, causing the appearances entitled " red softening," which 
after some weeks becomes "yellow softening," finally changing t 
"white softening," when there is a milky, or rather creamy fiuid 
mixed with masses or particles of broken-down nerve elements. 

The vessel most commonly occluded is the lefl SylT/ian artery, ' 
which sends branches to the second and third frontal convolutions, 
the anterior and superior portions of the three temporal convolutions, 
the island of Reil, the parietal convolutions, part of the external and 
all of the internal capsule, the lenticular nucleus, and most of the 

Symptoms. Two distinct modes of onset ; gradual, when tin 
result of thrombosis ; sudden or apoplectic, when due to embolism. 

Cerebral tkrombosis. Most common in the aged. Persistent hiad- ' 
ache and vertigo, at one time severe and at another mild. Next, 
alterations of character : irritable, morose and di^sprmdent, with periods 
<A absent-mindednesi, disorders of vision, and impairment of memory, 
speech becoming hesilating and mumbling. Impaired locomation,i 
the result of the vertigo, and of muscular iveakness and tremilittff,t 
followed sooner or later by hem-iplegia, which may be preceded \ff\ 
sudden insensibility or occur gradually, the symptoms slowly pro- 
ceeding to senile dementia and death from eshaustion ; or, rarely, the 
symptoms are not so grave, and partial or complete recovery occurs 
after the hemiplegia, fromestablishmentof the "collateral circulation," . 

Cerebral embolism. The symptoms are sudden, and cither n 
or grave in character. 



il 

d 

t. 

Is 

i 





Duration. Thrombosis, essi 
has a chronic course. Months 
various symptoms until the phi 

Embolism is of sudden on; 



NERVOUS SYSTEM. 

Mild vaiiety; sudden and severe verity, confusion of mind, musat- 
tar twilchings. usually one-sided, and vomiting, followed by hemiple- 
>t frequently of the right side. After some weeks or months 
the paralysis usually disappears and recovery is complete. 

Grave- ax apoplectic variety. Sudden headache, iierltgo, flushing 
or pallor of the face, or the patient may utter a sharp cry, fall to the 
ground with sudden utuonsciouiness and complete muscular resolution, 
followed by death, or a gradual return of consciousness with hemi- 
plegia, which is generally right-sided, remaining for several weeks or 
months, or is persistent, the mind remaining normal or enfeebled and 
the emotional nature highly excited and the reason and judgment 
clouded, continuing thus for years, or gradually developing into de- 
mentia, exhaustion and death. 

mtially an affection of the elderly, 
or years may be occupied with the 
a of senile dementia develop, 
ind may be followed by a rapid 
recovery. 

DiagTQOBis. Thrombosis is associated with changes in the vessels, 
the arcus senilis and other evidences of senile degeneration. 

Embolism may be mistaken for cerebral apoplexy, and while a 
positive differentiation cannot always be made, the chief points will 
be considered when discussing that affection. 

Prognosis. Thrombosis is a permanent and progressive con- 
dition in the majority of instances. Recovery is a rare termination. 

Embolism may be followed by a perfect recovery. Usually, how- 
ever, SQn;ie evidences of the plugging remain permanently. Death 
may be the result within a day or two, from the plugging of a large 
vessel, the patient never emerging from the coma. In other cases the 
patient arouses from the coma, the hemiplegia with aphasia persisting, 
and the case pursues the usual course of localized cerebral softening. 

Treatment. Perfect rest for some time after the attack, a plain 
but nutritious diet, and attention to the various excreta. 

Prof Bartholow "has had remarkable results from the following 
plan of treatment in thrombosis;" Ammonti carbonas, gr. x, with 
ammomi iodidi.^.Y .lYiT^c times a day, continued for several months, 
" the object being dual^ — to increase the action of the heart and arteries 
and to effect a solution of thrombi forming by maintaining the alka- 
linity of the blood." 




OF UEDtClNE. 

In the aged, presenting indications of degeneration, much benefit 
results from the use of — 

K. Liquor, potasaii arsenilis „ ll\,iij-' 

Syr. calcii lacto-phosphat SJ-ij' M. 

SlG. — -After oieaU. 
It may be combined with oleum morrhua wilii decided advantage. 
For embolism, the immediate and persistent use of the following 
may dissolve the plug : — 

B. AiQinonii carbonat _ gr.v 

Liquor, ammonii ncelalis fgj. M. 

SiG. — Three or foor limes daily. 
" In a month or two a very light galvanic current [from two cups) 
may be passed through the brain in both directions." (Bartholow,) 



CEREBRAL HEMORRHAGE. 
Synonym. Apoplexy. 

Definition. The sudden rupture of a cerebral vessel and escape 
of blood into the cerebral tissue, causing pressure and more or less 
destruction of the brain substance ; characterized by sudden uncon- 
regular, noisy respiration and complete muscular relax- 



Causes. Rare under forty years of age. The principal 
disease of the vessels — a periarteritis, resulting in miliary 
and especially if associated with cardiac hypertrophy; hereditary 
tendency; Bright's disease; syphihs; gout. More frequent in the 
spring and autumn. 

Pathological Anatomy. The most common locations of cere- 
bral hemorrhage are the corpus striatum and thalamus opticus; less 
common the anterior and middle lobes ^aA ^ii^ cerebellum ; next in 
frequency the pons and medulla oblongata; and rarely on Ihc con- 
vexity of the brain, termed meningeal hemorrhage. 

When the hemorrhage is large, the blood may break into the ven- 
tricles and pass by the iter from the third to the fourth ventricle. 

A recent clot is dark In color, and in consistency a sofl, grumous 
mass, composed of coagulated blood and brain substance in varying 
proportions, at whose centre is the opening into the ruptured vesseL 
The t/n/ excites inflammation around it, resulting in its being encysted, 
by the development of new connective tissue from the neuroglia, and 



I 



then gradually absorbed, leaving 3 cicatrix, or the brain tissue around 
the clot softens and degenerates — localized softening. 

Symptoms. Two modes of onset, to wit; with and without 
prodromes or "warnings." 

Prodroims. Headache, vertigo, transient deafness or blindness, 
sensations of numbness of the extremities, with local palsies, together 
with, or the constant dread of an attack. 

The attack begins with 'vomiting, followed by either partial or com- 
plete insensibility ; respiration slow, irregular and noisy ; during in- 
spiration the paralyzed check is drawn in and puffed out in expiration ; 
pulse slow and full ; pupils uninfluenced by light, the/iici flushed, the 
eyes congested and the carotids throbbing ; the temperature declines 
below the norm, a degree or two. 

The muscular system is profoundly relaxed, and the reflex move- 
ments are abolished. The head and eyes deviate, in many cases, 
toward the affected side in the brain or from the paralyzed side. 

If the unconsciousness continue longer than twenty-four hours, 
death is the usual termination, preceded by pale face, irregular and 
rapid pulse and respiration, and rise of temperature. 
■ Reaction obtains in from a half to three hours, consciousness re- 
turning, reflex excitability reviving, associated with headache, confu- 
sion of mind, and more or less paralysis of motion and sensibility of 
one side of the body, termed — hemiplegia. 

The electro-excitability of the paralyzed parts is preserved. 

Restoration may be delayed by inflammatory symptoms, the tem- 
' perature rising to ior''-io4° F., with tonic contractions (early rijridiiy) 
of the paralysed muscles and severe neuralgic pains. 

8eq.U8l£B, J^iralysis of the muscles of the face, tongue, body 
and extremities of one side, opposite to the location of die hemor- 
rhage, termed unilateral paralysis or right or left hemiplegia. 

Paralysis of both sides of the body, due to simultaneous hemor- 
rhage on both sides, termed bilateral hemiplegia. 

litralysis of one side of the face and the extremities of the opposite 
side, tlue to hemorrhage into the pons varolii, termed alternating or 
crossed paralysis. 

Occasionally tonic conlraclions occur in muscles long paralyzed, 
termed late rigidity, and is evidence of a secondary degeneration of 
the nerve fibres. 

Choreic movements in paralyzed muscles are termed posl-hemi- 




274 PRACTICE OF MEDICINE. 

plegic chorea, due, according lo Charcot, to changes i 
centres. 

The mental powers arc always more or iess permanendy impaired 
the patient irritable and emotional, and the same holds good c 
ceming tlie memory. 

DiagnoBis. Insensibility from drink differs from apoplexy in 
following points, to wit : insensibility is not so complete, no drawing-in 
and puffing-out of one cheek with respiration, the pulse frequent in- 
stead of slow, the pupils influenced by light ; upon raising both legs 
no difference is apparent on allowing them to drop ; the eyes and head 
are not turned to one side, and lastly, the condition is ameliorated O. 
the inhalation of ammonia. 

Opium poisoninj; differs from apoplexy by the gradual approach Q 
the coma, and that the patient can be momentarily aroused, and a~ 
by the absence of the heavy stertor of apoplexy. 

Urainia causes a coma that greatly resembles apoplexy. A historj 
of Bright's disease at once clears up the case ; also u 
is always preceded by convulsions, and has a continued depressed 
temperature. 

Cerebral embolism cannot always be differentiated from apoplexy. 
We may suspect cerebral plugging, if the patient be young ; if he be 
laboring under acute, subacute or chronic valvular trouble ; if, within 
brief periods, several incomplete attacks have occurred before a com- 
plete comatose condition obtains ; or, if hemiplegia results with pass- 
ing or slight unconsciousness ; or, if the phenomena are sotiner g 
later followed by cerebral softening, as embolism and Ihrombo 
are the most common causes of softening. 

Syncope or a fainting-fit is of sudden onset, but being due to a 
failure of the circulation, the pulse is feeble, the face pale, the respi- 1 
ration quiet, and the duration of unconsciousness short, all the v 
opposite of an apoplectic fit. 

Pro^nosiB, If the patient survive the immediate effects of a 
cerebral hemorrhage, he is always in danger of a new attack, since 
the causes of the original attack still remain. Another attack or two 
is the usual course, a fatal termination ultimately occurring. 

The hemiplegia is uncertain; a partial recovery may occur withinifl 
a few months, or it may continue for years. 

Treatment. If there are prodromal indications, the most prom{M 
means of reducing the inlra-cranial blood pressure is by venesection^ 



\ 



TEM. 375 

followed by a brisk purgative ; if the patient be weak, however, leeches 
to the mastoid, and polassii bromidum, gr. xl-bt, may be substituted. 

For the attack, loosen clothing, elevate the head, remove constric- 
tions, place in a. cool room, have perfect quiet, and at once venesec- 
tion, cold to head, mustard foot bath, and oleum tiglii. gtt.j-iij.^/j'Cf- 
rini, gtt. XV, placed on back of tongue ; if the pulse be full and strong, 
when consciousness is regained, either tinctura veratri viride or 
tinctura aconiti is indicated. 

If during the attack the face be pallid and the pulse irregular, the 
patient is prostrated by the shock and stimulants and digitalis are in- 
dicated, with, perhaps, leeches to the mastoid and an enema of tere- 
binthina. 

For the secondary fever, either tinctura aconiti or tinctura veratri 
viride ; for the headache and delirium, camphorce bromidum. 

For aiding the absorption of the clot, keep the secretions acting, 
a good diet and a course of potassii iodidum or hydrargyri chloridum 
corrosivum, alternated with — 

R. Liq. potassii arsenit gtt. y 

S)'t. calcii lacto-phosph fjij- 

Three limes a day. 

After two or three months a viea^ gah'onic current applied directly 
to the brain, by placing an electrode on each mastoid process, pro- 
motes absorption. 

For the paralyzed muscles, the Jaradic current applied by placing 
one electrode over or near the nerve innervating the muscle and the 
other over its belly, acts as a tonic, preventing wasting ; it is assisted 
by hypodermaric injections of strycknintE sulph., gr. ^ three times a 

ACUTE MENINGITIS. 

Synonyms. Cerebral fever ; arachnitis. 

Deflnition. An acute inflammation of the cerebral pia mater and 
arachnoid membranes ; characterized by headache, chill, fever, deli- 
rium, and followed by symptoms of general collapse. 

GauseB. Cerebral overwork ; prolonged wakefulness ; acute alco- 
holism ; exposure » the sun ; disease of the internal ear ; erysipelas ; 
secondary to diseases of serous membranes, and the continued and 
eruptive fevers. Most frequent in early adult -life and in yoimg chil- 
dren, and in males rather Chan females. 



276 PRACTICE OF MEDICINE. 

Pathologrical Anatomy. The inflammatory changes may be 
limited either td the convexity or to the base of the brain. 

Intense hypercemia of both membranes, followed by a purulent and 
fibrinous exudation. The ventricles may be filled with fluid, com- 
pressing and flattening the convolutions. 

Symptoms. Vary according to the stages : — 

Prodromes ; headache ^ vertigo, cerebral vomitings more or less 
feverishnesSf continuing from a few hours to one or two days, when 
occurs the 

Stage of Invasion ; onset sudden, with chill, high fever, I03°-I04°, 
pulse 100-120, face flushed, with congested eyes, headache, ringing in 
the ears, photophobia, vertigo, the nausea aggravated, and ffrojectile 
vomiting. 

Stage of Excitation ; general sensibility of the body increased, 
sensitiveness to light, and acuteness of hearing, delirium furious, 
often resembling insanity, continual jerking of the limbs, oscillations 
of the eyeballs, twitching of the muscles of the face, followed by 
powerful contractions of the flexor muscles, even to the extent of 
opisthotonus, and in children convulsions. Duration, from one day 
to a week or two. 

Stage of Depression or Collapse ; the patient gradually becomes 
more quiet ; the delirium subsides, as well as the muscular agitation ; " 
somnolence occurs, passing into coma, at times temporary conscious- 
ness, coma soon following again ; pulse irregular and slow, fever 
less ; various palsies, to wit : strabismus, ptosis, pupils uninfluenced 
by light, mouth drawn to one side, urine and faeces involuntarily dis- 
charged. ' Death following, either by convulsions or by deepening 
coma. 

Diagnosis. Cerebrospinal feuer closely resembles acute menin- 
gitis, the points of distinction between which are the first named 
occurring epidemically, associated with marked spinal symptoms and 
an eruption. 

The cerebral symptoms of rheumatism are differentiated from idio- 
pathic meningitis by the association of the joint trouble. 

Cerebral symptoms of typhoid and typhus fever have a close resem- 
blance to idiopathic meningitis, and are only determined by a'study 
of the clinical history. 

In acute urcemia the face is tiwgid, with puffiness of the eyelids ; in 
meningitis the face is pale and no oedema; uraemia has decided 



DISEASES OF THE NERVOUS SYSTEM. 

albuminuria ; ic is slight or absent in meningitis : meningitis has 
chills followed by fever ; urEemia has not. 

In ilelirium trettuits the delirium is a busy one, the patient imagin- 
ing persons and animals around him, and is wild in his gestures and 
utterances ; the temperature is normal or subnormal, the skin wet and 
clammy. In meningitis the delirium is mild but incoherent, the sur- 
face is hot and dry, and Ihere is severe vomiting and headache, 

PrognoeiB. Not very favorable. If recognized early and treated, 
a fair number of recoveries occur, but it usually leaves the patient 
subject to attacks of epilepsy or with a persistent headache. 

Treatment. Must be prompt and energetic from the onset. 

At once, active purgation by oleum iiglii, gtt. ij, glycerini, HLv, 
dropped on the tongue; and if the urinary secretion be scanty, dry 
cups or digHalis poultices over the kidneys. 

In vigorous subjects a copious veti^section or leeches applied behind 
the ears, to the temples, or the nuchal region, followed by the appli- 
cation of cold to the head, and that it may be thoroughly applied, the 
head should be shaven. 

Control the active circulation by aconiiutn in small doses, fre- 
quently repeated, combined with potassii bromidum, gr. xx-xl. The 
cerebral circulation may be markedly influenced by compression of 
the carotids. Ergota is of service in some cases. 

The apartment should be cool, the air pure, the patient's head 
elevated, and an easily digested diet. 

The secretions must be carefully attended to, the catheter being 
frequently used in the stage of collapse. 

If the case show a disposition to linger, small doses of hydrargyri 
chloridum mite, at potassii iodidum aie of benefit. 

Third stage ; Free stimulation, nutritious food, Jerri iodidum and 
flying blisters. 

PACHYMENINGITIS. 

Synonyms. Meningitis ; haimatoma of the dura mater. 

Deflnition. Inflammation of the dura mater; when the exter- 
nal layer is primarily involved it is termed pachymeningitis externa ; 
when the internal layer is primarily involved it is termed pachy- 
meningitis interna. 

Causes. Pachymeningitis externa is a. surgical malady, excited 
by fractures, penetrating wounds, and other injuries of the skull. 



I 



278 PRACTICE OF MEDICINE. 

Pachymeningitis interna is due to blows upon the head without 
injury to the skull. A predisposition may be created by chronic 
alcoholism, scurvy, Bright's disease and syphilis. 

Pathologrical Anatomy. Pachymeningitis interna. Hyper- 
semia of the membrane, followed by an exudation which develops 
into a membranous new formation, containing a great number of 
vessels of considerable size but having very thin walls. Hemor- 
rhages from these new vessels are of frequent occurrence, which in- 
crease the size and thickness of the neo-membrane. 

The usual position of the neo-membrane or new formation is on 
the upper surface of the hemispheres, extending downward toward 
the occipital lobe. The changes in the adjacent portion of the brain 
are dependent on the size and thickness of the neo-membrane. 
Bartholow observed a case in which the " cyst was half an inch in 
thickness at its thickest part, and it depressed the hemisphere corres- 
pondingly, the convolutions being flattened, the sulci almost oblit- 
erated, and the ventricle lessened one-half its size. 

Symptoms. Very obscure ; principally those of cerebral pressure. 
Cases of persistent ^^«^/j^^^, vertigo, photophobia, anorexia, insomnia, 
gr^jdMdX impairment o{ intellect diVid locomotion, followed by apoplectic 
attacks and paralysis, in the aged, in whom some one of the causes 
of the affection are present, inflammation of the dura mater may be 
suspected. 

Diagrnosis. Always problematical, as its symptoms are masked 
and indefinite. 

Progrnosis. Unfavorable. Death usually occurs within a few 
weeks after the onset. 

Treatment. Symptomatic, as there is no cure for the disease. 

TUBERCULAR MENINGITIS. 

Synonyms. Basilar meningitis ; acute hydrocephalus. 

Definition. An inflammation of the membranes of the brain, 
more particularly the basal pia mater, attended with or due to the 
deposit of gray, miliary tubercle ; characterized by gradual decline of 
the bodily and mental powers. 

Causes. Most frequently occurs in children between two and six 
years of age, although numerous cases are reported occurring be- 
tween the ages of twenty and thirty years ; scrofulous diathesis ; in- 
herited diathesis. The "gelatinous children of albuminous parents," 



// 



DISEASES OF THE NERVOUS SYSTEM. 



279 



as ihe phrase goes, possess a special susceptibility to tubercular 
meningitis. 

Pathological Anatomy. The deposition of tubercle usually 
occurs at the base of the brain. 

Depositions of grayish -white granules, of a translucent, somewhat 
gelatinous appearance — miliary tubercle, are distributed along the 
vessels of the pia mater, resulting in inflammation and the exudation 
of iymph, with the consequent thickening and opacity of the mem- 

The cerebral tissue is not usually involved, although on section the 
lines indicative of blood vessels are very much increased in nuniber. 
The ventricles are distended by a clear, or milky, or even bloody 



Tubercular deposits occur in the lungs, i 
other organs. 

The presence of the tubercles alone may give rise to no symptoms 
until the exudative products of the resultant inflammation develop. 

Symptoms. The advent is either gradual and insidious, or with 
convulsions, in which the after progress is rapid. 

Prodrome: the child grows irritable, with loss of appetite, loss of 
flesh, swollen abdomen, constipation alternating with diarrhoea, irreg- 
ular attacks of feverishness, with attacks of grinding its teeth during 
sleep. Headache occurs, as shown by the child, even when at play 
suddenly stopping and resting its head on its hand or on the floor. 
Duration of this stage is from one week to a month or two. 

Stage of excitation: the onset is rather sudden, with obstinate 
•uomUing. severe headache, convulsions, fever, 102-103° '" ^^ even- 
ing, falling to 99" in the morning, pulse soft and compressible, with 
irregular rhythm. On drawing the finger nail lightly over the sur- 
face a red line results, "the cerebral stain" of Trousseau, The 
symptoms grow progressively worse with exaltation of the special and 
general senses ; the least pinch or even touch causing exquisite pain ; 
spasmodic mmiements of the muscles, with contraction and rigidity, at 
times Opislhotonus. Duration of this stage is about two weeks. 

Stage of depression : the result of the pressure of the exudation ; the 
pulse slow and compressible, with irregular rhythm ; temperature de- 
pressed ; tendency to somnolence alternating with quiet delirium, 
mental stupor, continual movement of the fingers, as in picking up 
objects ; convulsions from time to time, strabismus, osciUation of the 



380 PKACTICE OF MEDICINE. 

eyeballs, followed by intervals of wakefulness, when the headache is 
excruciating, causing the peculiar, unearthly shrill cry or shriek, ' 
hydrocephalic cry," associated with contraction of the muscles of ibe 
&ce, as if suffering were experienced ; finally collapse, occurring with 
the "Cheyne-Stokes" respiration, the coma deepening, followed by 
death, convulsions often ending the scene. Duration, from a day or 
two to two weeks. 

DiagnoaiB. Acute meningitis and tubercular meningitis have 
closely analogous symptoms during the stage of excitation, but the 
history and clinical course of the two maladies determine the 
diagnosis. 

ProgUOEOS. Unfavorable. Usual duration, three or four weeks 
after fully developed prodromes. If ushered in by convulsions the 
duration is shorter. 

Treatment. Most unsatisfactory. No means of retarding the 
disease. Treat symptoms as they develop. Blisters, leeches, active 
purgation, pustulating ointments, folassii iodidum and hydrargyrum, 
are all useless. 

If the hereditary tendency be marked, nutritious food, oleum 
tnorrhua, iodum and quinina may somewhat delay the development 
of the affection. 

ACUTE HYDROCEPHALUS. 
Synonyms. Acquired hydrocephalus; serous apoplexy. 
Definition, Strictiy speaking, hydrocephalus signifies water in the 
brain ; but it is here restricted to the presence of a serous fluid in the 
arachnoid spaces, in the pia mater, in the ventricles, and in the brain 
substance (osdema) ; characterized by the more or less sudden de- 
velopment of cerebral excitation, followed by depression and usually 
death. 

Causes. Most common between the ages of one' and five, 
although it may occur at any age. " The predominance of the ner- 
vous system in the bodily conformation" is a strong predisposing 
cause. Among the exciting causes are unfavorable hygienic condi- 
tions, dentition, eruptive fevers, blows on the head, mechanical 
causes preventing the return of the blood from the vena Galeni and 
the right sinus, compression of the jugular vein, diseases of the right 
heart, and Bright's diseases. 

Faiboloitcioal Anatomy. The effusion may be limited to the 
ventricles, although there is usually considerable distention of the 



\ 



t 



DISEASES OF THE NERVOUS SYSTEM. 281 

subarachaoid spaces and lEdenia of the pia mater and neighboring 
portions of the brain, whence resuhs more or less softening, especially 
around the ventricles. The choroid plexus is hypcrfemic and may be 
the seat of minute extravasations. 

SymptomB. There are three varieties of acute hydrocephalus 
with characteristic symptoms, to wit: comatose, convulsive and the 
ordinary. 

Coi»aloseTiariely,\i-aovin also as "serous apoplexy," begins abruptly 
with the phenomena of apoplexy, the result of the sudden effusion. 
The pressure is usually so great on the medulla oblongata that it 
ceases to funcdonate, death resulting in a few hours, rarely lasting 
several days. 

Convulsive viiriety, the result of Bright's disease or a general 
dropsy, is ushered in with headache, nausea and vomiting, followed 
in a day or two with convulsions, passing into coma, which usually 
terminates fatally, although rarely a remission may precede death for 

Ordinary variety, the most common in children, begins with fever- 
ishness, headache, vertigo, photophobia, restlessness, nocturnal deli- 
rium, insomnia, twitching and spasmodic contractions of the muscles 
and great hypenesthesia of the skin. Such symptoms continue for 
several days, when convulsions occur, followed by death, or a con* 
tinuance of the symptoms, followed by rigidity, stupor and death, 

FroifiioBiB. Unfavorable. 

Treatment. An attempt may be made to get rid of the fluid by 
diuretics and full doses ol polassii iodidum. 

CONGENITAL HYDROCEPHALUS. 

Synonym. Chronic hydrocephalus (?) 

Definition. An excessive accumulation of the cerebro-spinal 
fluid — a cerebral dropsy — in \\\ii vdvAnzXa— internal hydrocephalus, 
or in the meshes of the pia mater — external hydrocephalus, or in both 
— mixed hydrocephalus ; characterised by enlargement of the head 
and more or less pronounced nervous phenomena. 

Causes, Imperfect development of the brain or its membranes. 
Occurs in the offspring of tubercular, scrofulous or syphihlic parents. 
Inflamm-ilory changes in the ventricles and ependyma. 

Pathological Anatomy, Enlargement of tlie head is the chief 
external pathological condition, although there is no constant ratio 



■' MEDICINE. 



the head iind the amount of fluid, the quantity 
The liquid is transparent, 
small amount uf albumen and chloride 




between the size 
varying from an i 
of a straw color, t 

If the quantity of fluid be small the ventricles are simply distended, 
if the amount be large the optic tbalami and corpus 
pressed and flaltened, the roof of the ventricles thinned and the 
foramen of Monro is greatly enlarged. The enlargement of the head 
may occur before birth and impede or prevent natural delivery, or 
the head may be normal at birth and increase after. As enlargement 
progresses the bones are so thinned as to be translucent, the fon- 
tanelles and sutures are widened, the lateral portions of the 
project, the forehead bulges out over the eyes, and the orbital plates 
are depressed, forcing the eyes outward and downward, producing 
a variety of exophthalmus ; the head has an irregular, triangular shape, 
the base of the triangle being the top of the head. The scalp being 
stretched by the pressure within, becomes tense and thin and but 
ify in it are unusually 



s elastic on pressure, from 



scantily covered with hair, the 
prominent and large, and the 
the amount of litiuid beneath, 

SymptomB, The increased size of the head, with the emaciated 
condition of the child, who seemingly eats well, is what first attracts 
the attention. The head appears too heavy, the eyes have a promi- 
nent but downward direction, the face is devoid of expression, old 
and wrinkled, the voice feeble ; the mental development is not in 
comparison with the age. When the period for standing or walking 
arrives the power is found wanting. The further history is but a con- 
tinuation and exaggeration of this, until convulsions occur, which 
sooner or later terminate fatally. 

The durtidon of acquired hydrocephalus is usually slow but pro- 
gressively worse. The majority terminate within the first year; cases 
are recorded of ten and fifteen years' duration. 

Diasnosis. In rachitis the volume of the head is increased, due, 
in part, at least, to a deposit of calcareous matter on the exterior of the 
cranial bones. Rachitis may be mistaken for hydrocephalus in cases 
in which the amount of liquid is small. The differential diagnosis is 
based on the shape of the head, round in rachitis, square or triangular 
or with prominences in hydrocephalus ; with the persistent downward 
direction of the eyes and the elasticity uf the head on pressure. 



DISEASES OF THE NERVOUS SYSTEM. 283 

Prognosis, Unfavorable. Arrest of progress and even cures are 
reported. Spontaneous cures are reported foilowing the accidental 
discbarge of the fluid. But such reports are exceptional. 

Treatment. The use of the finest aspirator needle to evacuate 
the fluid is fully justifiable, combined with the internal use of fiotassii 
iodidum. and gentle but firm compression of the cranium with adhe- 

CEREBRAL ABSCESS. 

Synonym. Acute encephalitis. 

Definition. An acute suppurative inflammation of the brain 
structure, either localiied or difl^used, prihiary or secondary ; charac- 
terized by impairment of intellect, sensibility and motion. 

Causes. Primary crrebral abscess is exceedingly rare. 

Secondary cerebral abscesses result from injuries to the cerebral 
tissues, to wit: apoplexy, embolism, thrombosis, and injuries to the 
GraniSl bones. 

Pathological Anatomy. Abscess of the brain affects the left 
side more frequently than the right. They are usually encysted or 
inclosed in a limiting membrane. Abscess of the brain may be 
single or multiple, varying in size from an almond to an egg. 

It occupies a limited and well-defined region of the cerebral tissue, 
to wit; either corpora striata, optic thalami. gray matter of the cortex, 
the cerebellum, or the white matter of the hemispheres. 

" The initial stage at the site of the abscess is hyperemia. Minute 
extravasations take place (capillary hemorrhages), giving to the in- 
flamed area a dark, reddish color, whence the term red softening. 
Migration of white corpuscles, diapedesis of some red corpuscles and 
exudation of serum holding albumen and fibre in solution, occur 
simultaneously. The brain tissue, being soft and easily broken up, 
is rapidly disassociated and its elements disintegrated, itnd in a short 
time a soft, pultaceous, red mass results, which more and more assumes 
a purulent character, becoming first red dish -ye! low, then yellow or 
greenish-yellow, ultimately almost white. The injury caused by an 
abscess is not hmited to the portion of the brain inflamed, but the 
neighboring territory is in the condition of collateral hyperuemia and 
oedema." (Bartholow.) 

Symptoms. A concise description of the symptoms of abscess 
of the brain is very difficult, on account of the wide \ 



OF MEDICINE. 

pendent on its location, and also the difficulty of isolating it from 
the affections to which it is secondary. 

The onset varies according to the cause, although all cases are 
associated with headache, irritative fever, persistent and spreading 
paralysis, and convulsions. 

If following apoplexy, thrombosis or emboli there occurs fever and 
delirium, the paralysis remaining and spreading with spasmodic cun- 
tractions of the affected muscles. 

Occasionally cases run a chronic course, the onset rather insidious ; 
dull, persistent headache, changed disposition, peevish, irritable, un- 
reliable, with decline of moral sensibility ; easily fatigued by menial 
work; inability to stand exertion; memory impaired; vertigo; dys- 
pepsia, soon followed by slight palsies, which progressively increase, 
becoming general, with involuntary discharges, death following from 
exhaustion. 

DiagnoBia, A positive diagnosis is only possible by a close study 
of the clinical history, as the symptoms at times indicate meningitis, 
cerebral congestion, epilepsy or cerebral tumor. 

Prognosia. The usual termination is in death. The course de- 
pends upon the character and extent of the injury, varying from a 
few days to several months. 

Treatment. Palliative, unless the future shall justify the pro- 
priety of trephining, or of puncturing the brain, thus to favor the 

INTRACRANIAL TUMORS. 

Synonym. Cerebral tumors, 

Deflnition. Tumor of the brain is either a growth in the cere- 
bral tissue, on the meninges, or in the vessels ; characterized by 
symptoms of pressure upon the brain structure. 

Causes. Injuries to the head; syphilis; changes in the vessels; 
tubercle and cancer; hereditary. 

Pathological Anatomy. The size of tumors vary, and may be 
as large as an orange before they will give rise to symptoms. 

Tumors of the brain are of various kinds, to wit ; vascular tumors — 
aneurisms ; parasilic tumors — cysticercus ; diathetic tumors — tubercle 
or syphilis ; accidental tumors — fibroplastic. 

Whatever the character of growth, it produces irritation of the sur- 
rounding parts, and by pressure, destruction of the tissues, or it inter- 
feres with the arterial or venous flow. 



OF THE NERVOUS SYSTEM, 283 

SymptotUB. Those common to tumors in general are, hcadackf. 
persistent and increasing in intensity, defects of vision, even blind- 
nessi defects of hearing, taste and of speech, the result of paresis of 
the vocal chords, vertigo, associated with nausea and vomiting; con- 
vulsions, epileptiform in character, usually limited to one side of the 
body, occurring at regular intervals, or confined to the eyeballs or one 
limb, with ho loss of consciousness ,■ palsies, beginning first as strabis- 
mus, ptosis and dilatation of the pupil, of the facial muscles, paraple- 
gia and general hemiplegia ; defects of sensibility, to wit ; jensations 
of numbness, and coldness in ihc limbs and body. Occasionally dis- 
turbances of equilibrium manifested by a tendency to go backward 
or turn to the right or left ; intellectual faculties well preserved until 
late in the affection, when the memory becomes impaired or lost for 
certain articles, and finally a gradually advancing imbecility. 

Diagno&iB. Rarely can a positive diagnosis be made. The fol- 
lowing points will aid : long-continued, persistent headache, without 
appreciable cause, epileptiform convulsions, unilateral, without loss 
of consciousness, difficulty of vision, hearing and speech, associated 
with nausea and vomiting, and local and genera] palsies. 

The location of the tumor may be delcrmined by the more or less 
pronounced character of certain symptoms. 

The diagnosis of the character of the growth can only be deter- 
mined by a close study of the history. 

Progrnosis. Unless of syphilitic origin, unfavorable. 

Treatment. Unsatisfactory. Mostly symptomatic. As benefit 
occasionally follows the use oi pofassii iodidum, gr. xx, three times a 
day, otext. ergotcefld., 3ss-j three times a day, continued until their 
physiological effects are produced, these remedies should be used 
in all cases, discontinuing them if no benefit follow. 

APHASIA. 
Defloition. The inabihty to use spoken language or give vocal 

Amnesic aphasia, or loss of the memory of words by which ideas 
are expressed. 

Ataxic aphasia, the inability to combine the different parts of the 
vocal apparatus for vocal expression, although the memory of words 
still remains, so that the- afflicted person can write his ideas intelli- 



PRACTICE C 

Agraphia, the inability to recognize and make the signs by which 
ideas are communicated in written language. 

AfHitisic agraphia, the loss of memory o£ written signs. 

Ataxic agraphia, the inability to combine the muscular apparatus- 
" writers' cramp." 

Paraphasia, the mental state in which the wrong words are used 
to express the idea. 

Paragraphia, the state in which wrong or meaningless written signs 
are used to express the idea. 

Fatholoerical Anatomy. The distincdon between aphasia and 
a'phonia must be clearly determined. 

Aphasia is not the result of any one specific lesion, but occurs 
during the course of several, to wit: occlusion of certain cerebral 
vessels ; cerebral hemorrhage ; cerebral abscess or softening : menin- 
gitis ; tumors ; mental or moral causes ; hysteria- 
It is now almost definitely determined that lesions of the left middle 
cerebral artery, island of Reil, third frontal convolution, and parts of 
the corpus striatum, are associated in the production of aphasia. The 
lesions are usually upon the left side of the brain, the aphasia being 
associated with right hemiplegia. 

Symptoms. The degree to which articulate language is im- 
paired varies, from the loss of a few words to complete inability to 
communicate ideas. The intellect does not suffer in proportion to the 
loss of words ; for, showing the individual an article, while he may 
miscall it, if you call it by name he will recognize it. This inabilhy 
to convey thoughts is a source of great mental suffering, in some 
leading to a suicidal tendency. 

A strange clinical fact is the strong tendency to profanity shown 
by aphasic patients. 

Diagnosis, Aphonia, or loss of voice, should not be confounded 
with aphasia, or the inability to remember words. 

Paralysis of the tongue, ax inability to move this organ, thereby 
interfering with articulate language, should not be confounded with 
aphasia, which, as a rule, is not associated with paralysis of the tongue. 

Proernosis. Controlled entirely by the cause. If the result of 
congestion of the brain or a syphihtic tumor, the prognosis is favor- 
able. If associated with hemiplegia the clot may undergo absorprion, 
and recovery follow. If associated with softening of the brain, how- 
ever, the disease grows progressively worse. 



DISEASES OF THE SPINAL CORD. 287 

Treatment. Depends upon the cause, which must be energeti- 
cally treated, as the aphasia pursues a course parallel to the asso- 
ciated malady. Cases not associated with cerebral softening have 
regained the memory of words by a course of carefully conducted 
speech lessons. 

Cases of aphasia of sudden occurrence are strongly diagnostic of 
injury due to a spicula of bone if a history of a head wound, or from 
the pressure of a clot, and the operation of trephining wiE be of 



DISEASES OF THE SPINAL CORD. 



SPINAL HYPEREMIA. 

Definition. An abnormal fullness of the spinal vessels ; 
when arterial hypera^mia ; passive when venous hypera^mia; charac- 
teriied by pain in the back, with more or less pronounced, but tem- 
porary, disorders of locotnotion. ' 

CauBBB. Cold and exposure : arrested menses ; arrest of habitual 
hemorrhoidal discharge ; malaria ; protracted erect posture ; injuries 
to the back ; certain spinal poisons, as strychnina, picrotoxinum, and 
alcoholic excesses. 

Pathological Anatomy. Active. The post-mortem appear- 
ances are congestion of the meninges and cord, the same vessels 
supplying both, with numerous points of extravasation, due to the 
rupture of capillary vessels. The spinal duid is increased in amount. 

Passive. A general bluish discoloration, owing to the abnormal 
fullness of the large anastomosing vessels ; the spinal fluid somewhat 
increased. 

Symptoms. Active. Dull pain in the back ; persistent and 
increased by pressure, tenderness on motion ; tingling sensations 
a the limbs and feet, and' sometimes in the hands and arms. 
Increased reflexes, with disorders of motility, and when the patient 
is in the recumbent position, jerking of tkr limbs. On attempting 
to walk it is accomplished with difficulty, from an incompltte loss of 
power. 

If. the upper part of the cord be affected, dysfina-a and palpila- 



There often 



painful priapism and frequt 



-nal 



The above symptoms may be followed by a more or less pro- 
nounced temporary depression, the sensation diminished and the 
lower limbs feel benumbed and heavy, the movements weak. 

The tleciro-contractilily is preserved, and in many cases even in- 
creased or exalted. 

Duration, From a few hours to several days ; if longer, myelitis 
may result. 

Diagnosis, Anamia causes more or less spinal irritability and 
tenderness ; but the history, pallor and general weakness, unasso- 
ciated with defects of motility or sensibility,- will prevent error. 

Spinal meningeal hemorrhage is more sudden in its onset, its vio- 
lence and its range of symptoms. 

Myelitis and spinal meningitis have symptoms in common with 
spinal congestion, which will be pointed out when discussing those 
afTections. 

PrognoaiB. Favorable, recovery occurring in three or four days. 

If the symptoms show a tendency to Unger, myelitis more or less 
pronounced will ensue. 

Treatment. Rest, but avoid lying on the back, cups or leeches 
along the spine, followed either by the iced or the hot douche, or hot 
sponges, with active purgation, to diminish the faldod pressure. 

If the result of suddenly arrested perspiration, pilocarpus. If 
following suddenly arrested menses, aconilum. If associated with 
an active c\rc'a\a.t\on.potassii bromidum or Jlttidum gelsemit extractum, 
m, v, every four hours ; in all cases active purgation. 

For the passive fonn, treating the cause, ergota, digitalis, tonics 
and purgatives. 

SPINAL MENINGITIS. 

Synonjon. Leptomeningitis spinalis. 

Definition. Inflammation of the arachnoid and pia mater mem- 
branes of the spinal cord, either acute, subacute or chronic ; char- 
acterized by pain in the hack, rigidity of the muscles, disorders of 
motility and sensibility. 

Causes. Exposure to cold and dampness ; injuries to the ver- 
tebra; or membranes': rheumatism ; puerperal fever ; syphilis. 

Pathological Anatomy. Acute. Hyperemia of the mem- 
branes, with swelling of the tissues, the result of serous infiltration 



DISEASES OF THE SPINAL CORD. 289 

followed by purulent and fibrinous exudations. The roots of the 
spinal nerves are covered with exudation, and are swollen and soft. 
The cord proper is more or less congested and cedematous. 

Chronic. Adhesions of the membranes, with more or less accu- 
mulation of fluid, resulting in atrophic degeneration of the cord from 
pressure. 

SymptomB. Although an inflammatory affection, yet its onset 
is usually subacute, the febrile reaction being moderate, with intense 
boring pain in the back, aggravated by motion, rigidity of the spine 
and sense of constriction around the body, " the girdle." Spasmodic 
contractions of the muscle enervated by the nerves originating at 
the seat of the lesion, with inability to straighten the limbs. If the 
lower part of the spinal membranes are the seat there occur reten- 
tion of urine and constipation; if upper part, dysphagia, dyspncea 
and feeble heart. The muscular contractions are excited or in- 
creased by motion, but uninfluenced by pressure. Reflex movements 
are not abolished. The rigidity and spasmodic contraction of the 
muscles are followed by paralysis more or less complete, death fol- 
lowing from paralysis of the muscles of respiration. 

If the inflammation extend to the medulla, the above symptoms are 
associated with disorders of speech, vomiting and delirium. 

Electro-contractility lessened or absent, both as to motility and sen- 
sibility, in the affected parts. 

Chronic form succeeds to the acute or originates spontaneously, 
and presents the same fonn and order of symptoms — excitation and 

Diagnosis. The points of importance are, deep, boring pain in 
the back, aggravated by motion but not by pressure, with spasmodic 
contraction of the muscles, followed by paralysis. 

Myelitis will be differentiated from spinal meningids when discuss- 
ing that affecdon. 

Tetanus may be confounded with spinal meningitis. The points 
of distinction are : in the former occur early trismus with rhythmical 
spasms excited by irritation of the skin, such irritation not producing 
contractions in meningitis, while movement of the limb does; pro- 
gressively increasing and not associated with fever. 

Prognosis. Grave. Death is either sudden, from paralysis of 
the respiration or of the heart, or gradual, the result of exhaustion. 

Critical discharges, such as profuse perspiradon, urinary flow or 



290 PRACTICE OF MEDICI ME. 

epistaxis occur and are followed by rapid-recovery. Cases recover- 
ing may have more or less pronounced partial or complete paralysis. 

Treatment. Rest in bed, upon the side or face. Cups or Uechts 
along the spine, followed by ice, the hot douche, hot sponges, or mus- 
tard. Active purgation. 

To reduce the amouTit of blood in the vessels of the cord, AcoHitum 
and ergola combined with an opium impression. When paralysis 
(depression) occurs, quinines sulphas, gr. iij, combined with ext, 
belladonna alcohol, gr. %, three times a day, or potassii iodidurn, gr. 
jtx-xxx, three times a day, with flpng blisters along the spine. If the 
paralysis still persist a hydrargyrum impression often benefits. 

For paralysis, the galvanic current to the spine and nerve trunks, 
and the faradic current to the affected muscles, with the deep injec- 
tion of strychnina and the use of massage. 

PACHYMENINGITIS SPINALIS. 

Synonyms. Pachymeningitis spinalis interna; hypertrophic 
pachymeningitis; pseudo- membranous pachymeningitis. 

Dsflnition. An inflammation of the spinal dura ntater; charac* 
teriied by violent pains in the head, neck, shoulders and arms, fol- 
lowed by paralysis of the upper extremities. 

Causes. Exposure to cold and damp; alcoholism; syphilis ; gout; 
injuries. 

PatholoirioEtl Anatomy. Hypertrophic pachymeningitis is 
characterized by an exudation upon the inner surface of the dura 
mater, which gradually solidifies into a layer of compact connective 
tissue, which presses upon the spinal cord and nerves, producing a 
myelitis and an atrophic neuritis, resulting in muscular atrophy. 

The most frequent seat of this form of the affection is the cervical 
region, as first demonstrated by Charcot, whence the term cervical 
hypertrophic pachymeningitis. 

In the pseudo-membranous form a membranous exudation also 
occurs, in which large numbers of blood vessels develop and rup- 
ture, the hemorrhagic extravasation forming a cyst — hsmatoma — 
which causes pressure on the cord and nerves. 

Symptoms. The onset is slow and gradual, with irregular chills 
and feverishness, violent pains in the head, neck, shoulders and 
<, continuous hut subject to exacerbations, and associated with a 

■■in/ul constriction of the upper thorax. These symptoms may con- 



DISEASES OF THE SPINAL CORD. 

tinue off and ofi for several months, when Ihe muscles of Ihe painful 
parts begin to atrophy, foUowed by spasmodic conlractions and 
paralysis. 

The general health deteriorates with the progress of the muscular 
symptoms. 

The tUctro-contractUitf is lost. 

FroenosiB. If early recognized and promptly treated, Ihe hyper- 
trophic form may be cured. 

Treatment. Rest; nutritious diet; oleum morrhum and the 
hypophosphiles ; large doses o( polassii iodidum, and repeated but 
systematic counter-irritation. 

ACUTE MYELITIS. 
Definition. An inflammation aflecting the substance of the spinal 

cord, which may be limited to the gray or white matter, and involve the 
whole or isolated portions of the cord. When ih^gray matter alone 
is inflamed, it is termed central myelitis ; when the white matter and 
the meninges, it is termed cortical myelitis; it may be ascending, 
descending or transverse in its extension. The disease is charac- 
terized by more or less sudden and complete loss of motion and 



I 



Causes. Following spinal meningitis; exposure to cold and damp; 
injuries to the vertebrE; prolonged functional activity of the cord; 
typhus fever; rheumatism; syphilis; puerperal fever, or during the 
course of the exanthemata ; arsenical or mercurial poisoning. 

Fatholo^oal Anatomy. Intense hypereemia of the substance 
of the cord, with extravasations, giving the tissues a reddish-brown 
or chocolate tint, and also serous transudations, resulting in softening 
of the structure of the cord, the color changing to yellow and white, 
the nerve elements undergoing fatty degeneration, presenting the 
appearance and consistency of cream. The membranes alao tmder- 
go more or less change. 

Symptoms. The severity of the symptoms depends upon the 
extent and location of the inflammation. 

The onset is usually sudden, with a chill, fever, \iy^, frequent pHlse, 
with alterations in sensibility and motility, to wit ; patn in the back, 
aggravated by touch and by heal and cold, with sensations of formi- 
cation ("pins and needles"), the limb feeling as if asleep, or else 
complete anasthcsia, a^oclated with severe neuralgic pains. 



PRACTICE OF MEDICINE, 



uch, and ^^M 
encircled ^H 



The distinction between ana:sthesia, insensibility to touch, 
analgfsia, insensibility to pain, must be clearly made. 

A sensation of constriction around the body and limbs, as if encircled 
by a tight cord, "the girdle pains;" rapidly developing^ora^/irfTa, 
complete in a few hours, with involuntary discharges. The rrJUx 
functions are usually abolished, as seen by attempting to cause move- 
ment of the limbs by tickling the feet or by striking the patella 
tendon; rarely are they diminished, very rarely exaggerated. The 
temperature of the affected limbs is lowered three or four degrees. 

Sloughs and bedsores and muscular atrophy result if the anterior 
cornu^ — the trophic centres — are affected. 

The above symptoms of loss of motion and sensibility are associated 
with more or less pronounced vomiting, hepatic disorders, irregularity 
of the heart, dyspncea, dysphagia, apncea and painful priapisms. The 
urine is markedly alkaline in reaction. 

Among the late manifestations are shooting fiains and spasmodic 
tmtchings oi contractions oi oaf: or allof the muscles of the paralyied 

The electro-contractility is abolished in the paralyzed parts. 

Diagnosis. Acute spinal meningitis is distinguished from acute 
myelitis by severe pains, increased by pressure, with muscular con- 
tractions increased by motion, followed by paralysis much less pro- 
found than the paraplegia of myelitis ; in spinal meningitis there 
exists cutaneous and muscular hyperfesthesia, which is absent in 

Congestion of the spinal cord a characterized by the mild character 
and short duration of all the symptoms. 

Hemorrhage in the spinal canal is abrupt, with irritative symptoms, 
slight paralysis, preserved reflexes and electro -contractility. 

The principal diagnostic points of acute myelitis are the " girdle " 
around the limbs or body, rapid and complete paraplegia, lowered 
temperature in the affected parts, early and persistent sloughing (bed- 
sores) and alkaline urine. 

Frogrnosis. Varies according to the location of the lesion. 

If the paralysis is of the ascending nariety, death -occurs within a 
few days, from paralysis of the muscles of respiration. 

If the trophic centre is affected, there occur bedsores, intense 
pylonephritis and cysritis and changes in the joints ; death from 
exhaustion in several weeks. 



I> 



4 



DISEASES OP THE SPINAL CORD. 293 

Central myelitis, or inflammation of the gray matter, is rapid in its 
progress, death occurring within a week or two. 

The morbid process may be arrested and 'the general health re- 
stored, but some spinal sy^mptoms will persist. 

Treatment. Absolute rest is essential to even secure a palliation 
of the aymptoma. 

Locally, considerable relief follows the use of hot water bags or 
sponges dipped in hot water and applied along the spine every few 

The remedies most strongly recommended are : digitalis, ergota, 
bdladmiiia, bromides, cimicifuga and qtiinina, although I have never 
observed a cure with any plan of medication, after it was fairly estab- 
lished, save those due to syphilis, by large doses ni potassii iodidum. 



INFANTILE SPINAL PARALYSIS. 

Synonyms. Poliomyelitis anterior acuta; essential paralysis of 
children. 

Definition. A rapidly developed inflammation of the anterior 
horns of the gray matter of the cord, occurring suddenly in children, 
at times in adults — acute spinal paralysis of adults ; — characterised by 
mild fever, muscular tremors and twitchings, and paralysis of groups 
of mu5des. 

Causes. Essentially a disease of early life — the second month 
to the third or fourth year. The fact of its having occurred in 
adults must be borne in mind. Cold and damp; dentition (?) ; inju- 
ries to the spine; developed during convalescence from the acute 
exanthemata. 

Pathological Anatomy. The early changes are: medullary 
hyperfemia, vascular exudation and inflammatory softening, although 
the naked eye may not recognize any changes. Microscopical exam- 
ination reveals inflammatory softening of the anterior horns of the 
gray matter. Among other constant lesions are atrophic degenera- 
tion of the multipolar ganglion -cells and the anterior nerve roots. 

The changes noted as occurring in the cord are usually Umited 
to the dorso-lumbar ind cervical enlargements. 

As a direct result of the changes in the trophic centre and the net^e 
degeneration of the muscular fibres supplied, there ensue changes in 
the bones and joints, leading to great deformities. 



SpmptomB. The onset of the aiTection varies ; it is DSuaOy sud- 
den, tuith an attack of mild fever of a reminent type, of a fen days' 
duration, on recovery from which it is noticed that (he child \s para- 
lyzed. Rarely the paralysis may be preceded by con'vulswns. 

The paralysis may affect both anns and both legs, the legs alone, 
or only one of the four extremities; it may, but very rarely, be a 
hemiplegia. The bladder and rectum are not affected, nor can 
anaesthesia or numbness be detected. The temperature of the para- 
lyzed limb is low and the appearance cyanosed. After a few days there 
is a slight tmpravement in the paralyzed parts, although the muscles 
show a rapid wasting, which is progressive until all muscular ti 
is gone. 

The rejiex nwvtmeats are impaired or abolished. 

The elecfro-conlraitility by the faradic current is abolished in the 
paralyzed parts. 

With the galvanic or constant current the " reactions of degenera- 
tion " are developed. To fully understand the meaning of this term 
a knowledge of the normal electrical reactions is necessary. 

The normal formulae for the production of muscular contraction 
in the physiological state are as follows, the strength of the current 
being barely capable of causing fair contractions :- 

First, The most effective contractions are produced by the cathode 
{negatiiie) pole on closing the cirquit. 

Second. The second most effective are produced by the aaode 
(posHii/e) pole on closing the circuit. 

Third. The next most effective is by the anode pole on opening 
the circuit. 

Fourth. Cathode Pole contractions on opening circuit are rarely 
seen in the physiological state. 

The " reactions of degeneration " are shown by any reversal of the 
regular formulse, to wit; if the anodat closure shows stronger c 
tractions than cathodal closure ; still greater degeneration is shown 
\i anodal opening contractions are stronger than either the above ; and 
almost complete degeneration is shown by the complete reversal of the 
normal formula: as shown by distinct caMoali/ opening contractions. 

Diagnosis. Hemiplegia fi:om acute cerebral affections in chil- 
dren can be distinguished from infantile paralysis by the disorders 
of intelligence and the special senses, and the perseverance of the 
normal electro-contractility. 



UlSEASES OF THE SPINAL CORD. 296 

Paralysis of myelitis occurs in older persons, and is associated 
with disturbances of the genito-urinary organs and bedsores. 

Pseudo-muscular hypertrophy^ with paralysis, begins gradually, 
becoming progressively worse with increase in the size of the limbs. 

Proguosie. Depends upon the Creatinent. If prompt and proper, 
recovery may be said to be the rule. Mild cases recover within a 
few days, others as many weeks, more severe cases a month or two. 
There is no danger to life. 

Treatment. The diagnosis during the initial fever is impossible, 
so that its treatment is symptomatic. On the appearance of the 
paralysis complete rest ; hot spinal douche, ya^A galvatiism, and in- 
temaliy, quinina, belladonna or ergola. 

With the improvement that follows the above measures, inter- 
nally, linctura mia's vomica, n\,j-iij (■ d., or hypodermatic injections 
of strychnins sulphas, gr. jj to jjj twice a week and faradism to 
the paralyzed muscles. 

CHRONIC PROGRESSIVE BULBAR PARALYSIS. 

SyilonTIIlS. Glosso-labio-laryngeal paralysis; bulbar paralysis. 

Definition, A progressive muscular paralysis of the laryngeal 
muscles, tongue, soft palate and lips. 

GauBes, Obscure. Rare before the fortieth year. Among many 
others are named cold, rheumatism, gout, syphilis and injuries about 
the neck. 

Pathological Anatomy. " Degenerative atrophy of the gray 
nuclei in the floor of the fourth ventricle ; with atrophy and gray dis- 
coloration of the nerve roots from the medulla, especially of the facial 
and hypoglossal nerves." "Atrophy and disappearance of the motor 
ganglion cells is always to be noted. It may be the sole lesion." 

"The nerves going to the muscles exhibit sclerosis of the neuri- 
lemma, and the degenerative atrophy is found in the nerve roots 
coming from the bulb." 

Symptoms. The disease begins insidiously. There is first 
noticed some difficulty in articulation, from want of precision in 
movements of the tongue, which increases till that organ is com- 
pletely paralyzed. The paralysis gradually invades the soft palate, 
pharyngeal muscles, causing difficulty in deglutition, the orbicularis 
oris, preventing closure of the lips, the laryngeal muscles interfering 
mth articulalien. When the disease is fully developed the condition 



of the patient is most pitiable, indeed ; articulation is impaired o 
impossible, deglutition interfered with, the lips remaining apart, allow-' 
ing the saliva to dribble from the mouth and Uquids to return through 
the noae if attempts are made to swallow them. The general health 
gradually suffers from insufhcient nutridon and imperfect respiration. 
The " reactions of degeneration " are present. 

DiagrnOBis. It can hardly be confounded widi any other malady, j 
PrognoBis. Unfavorable. The duration is from one to five I 

Treatment. Entirely symptomatic. 

SPINAL SCLEROSIS. 

Synonym, Duchenne's disease. 

Definition. A myelitis ; an increase in the connective tissue ofj 
the spina! cord, with atrophy of the nerve structure proper. 

Varieties. I. Antero- lateral sclerosis ; II. Cei'ebrB-sfiinal sclero-\ 
Hs ; 111. Posterior sclerosis OT locomotar ataxia. 

Causes. Generally a hereditary neuropathic diathesis; syphilis;! 
mineral poisons ; shocks or injuries to the cord ; exposure to cold and | 
wet; mostly occurring between the ages of thirty-five and fifty-five; 
males more liable than females. 

Pathological Anatomy. The changes in the cord are gradual J 
in their development and follow a longitudinal instead of a tr 
direction. 

The form, consistence and color of the cord are altered, it being I 
atrophied, indurated and of a grayish color. 

The changes are hyperplasia of the connective tissue, with granular 
degeneration, atrophy and disappearance of the proper nerve ele- 
ments. The nerve rootj undergo the same fibroid change. The joints 
undergo remarkable atrophic degeneration. 



SCLEROSIS, 

Symptoms. The chief symptom is paraplegia, or entire less a 
motion in the lower extremities. Preceding the paralysis there occui 
jerking atid I'uiitchiHg, with cramps and stiffness of the muscles o 
the affected parts. As the disease is progressing the gait is ofa pecu-J 
liar character, termed by Hammond " the waddle," the patient s 
ping on the toes and showing a tendency to fall forward. There is a 



OF THE SPINAL CORD. 297 

gradual and increasing feeling of heaviness and weakness in the 
affecled Uiiibs. Sensation is unaffected. Reflex phenomena are pre- 
served, at times even exalted. As the morbid process entends upward, 
the superior extremities suffer in the same manner as those of the 

EUclro-contractilily early impaired, and gradually declining until 



POSTERIOR SCLEROSIS, OR LOCOMOTOR ATAXIA. 

Symptoms. Gradual onset by sharp, darting, eleclrtc-Uke pains 
in the limbs, with loss of sensation in the feet, the patient being un- 
able to distinguish between hard and soft substances in walking, 
, and, if the upper portion of the spinal cord be affected is unable 
to coBrdinate the muscles of the fingers sufficiently to button his 
clothing. 

Zjiss of cedrdinafion , the subject being unable to walk upon a straight 
line with his eyes closed, and with diflliculty if his eyes are opened. 
Inability to preserve the erect position with the feet close together. 
The si^kl impaired; either double vision or inability to distinguish 
between different colors. Rifiexes abolished, and "girdle" pains 
about the body and limbs. Inordinate stimulation of the genital 
functions and frequent noctural emissions. Although the patient is 
unable to coordinate the rauscies, their power is not lost, for. on being 
supported, he can kick or strike with his usual force. 

There is generally entire absence of cerebral phenomena. 

DiaernoBiB. The symptoms are so characteristic that with care 
an error in the diagnosis seems impossible. 

- Chronic myelitis is charaaerized by paralysis, and the course of the 
two affections is otherwise so different that error should not occur. 

Disease of the cerebellum presents symptoms of incoordination, but 
they are the result of vertigo, and associated with headache, nausea 
and vomiting. 

Proefnosis. Sclerosis sooner or later ti 
may be retarded for years, but the patient is n 
out great difficulty. 

Treatment. Insist upon as complete ri 
tious dieti milk being the most desirable. 

Potassii iodidum, or Aydrargyri chloridum ci 



unfavorably. It 
,ble to walk with- 



is possible. Good, nutri- 



;, in full doses, 
'ri chlmidum, gr. j',,, three times a day, often remarkably 



PRACTICE OF HEDICIKE. 

retard the progress of the affection. The best results are obtainet 
however, from argenfi ni/ras, gr. %.-%, oz oxidum, gr. fi, three timed 
a day, withholding it at intervals of a few weeks, to prevent discoUl 
oration of the skin, argyria. 

The severe and sharp pains require treatment, at first giving prefer 
ence to any of the subsdtutes of opium, but finally opium itself willa 
have to be resorted to. 

Galvanism to the spine and faradism to the affected litnbs 3 
beneficial. 



•DISEASES OF THE NERVES. 



NEURITIS. 
Defimtdon. An inflammation of the nerve trunks; characterized! 
by pain and paresis of the parts supplied by Che affected i 

ies : cold and damp. 

Hyperaemia, followed by exudation 

softened and ultimately breaks down 

of white corpuscles takes place into 

before destruction of the 

of the exudation occurring. 



Causes. Wounds and inji 

Pathological Anatomy, 
into the nerve, " which becomi 
into a diffluent mass. Migrati 
the neurilemma. Recovery may 
nerve elements is produced, absorpti< 

" It is important to note that when inflammation occurs in a nerve it 
may extend from the point first diseased upward {neuritis ascendens), 
or downward [neuritis descendens)." 

Symptoms. The onset may be accompanied with febrile t 
action. The most decided symptom is pain along the c 
nerve trunk and its peripheral distribution, of a burning, tinglingA 
tearing, intense character, increased by pressure or motion. If 1 
aflected nerve be a mixed one — sensory and motor — spasmodic o 
tractions, and muscular crampi, occur, followed by impaired molii 
terminating in paresis of the muscles innervated by the affec 
trunk. 

If the inflammation proceeds to destruction of the nerve trunk, ^ 
ing and degeneration of the muscular tissue ensues. Variou- 
changes also occur, such as cutaneous eruptions, and dubbin 
nails. The eUctro-coHtracitliiyKs impaired or lost. 



DiagnOBia. Myalgia or muscular pain i 



t associated with 



paralysis, nor does the pain follow the ci 

Prognosis. Generally favorable, with proper ti 

Treatment. Repeated blistering along the course of the nerve, 
with full doses of potassii iodidiuii are usually successful. As the 
more acute symptoms subside the use ai galiianistn or a feeble, slowly 
interrupted /fl/Hrfi: current restores the interrupted function. 

NEURALGIA. 

Definition, A disease of the nervous system, manifesting itself 
by sudden pain of a sharp and darting character, mostly unilateral, 
following the course of the sensory nerves. 

Varieties. 1. Neuralgia of tke fifth uerve : W. Cervico-oceipital 
nettralgia; III. Cervico-bnuhial neuralgia ; IV. Dorso-intercostal 
neuralgia; V. LMtnbo- abdominal neuralgia ; VI. Sciatica, 

Causes. Heredity ; anamia ; malaria ; syphilis ; metallic poi- 
sons ; anxiety ; mental exertion ; exposure to cold and damp ; injuries 
to a nerve trunk. 

Pathological Anatomy. The old 
" the cry of the nerves for pure blood " i 
truth. The changes in the nerve trunks 
been determined. A fair number of cas 



ixiom of neuralgia being 
perhaps only part of the 
ir centres have not as yet 
s present the changes of 



NEURALGIA OF THE FIFTH NERVE. 

Synonyms. Tic-douloureux ; Fothergill's disease. 

SymptomB. Paroxysmal pain, of a sharp, darting, stabbing 
character, most common at points along the course of the supra- and 
infra-orbital branches of the fifth nerve of the left side, attended with 
increased lachrymaHon. When of any duration nutritive changes are 
observed in the nervous distribution, to wit : adema along the course 
of the nerve, gray eyebrows and convulsive Iviitches ai the muscles, 
termed " tic douloureux," tenderness at the infra- and supra-orbital 
foratnina, as well as along the course of the nerve. 

CERVICO -OCCIPITAL NEURALGIA. 

Symptoms. Paroxysmal pain, of a sharp and lancinating, or 

deep, heavy, tensive character, along the course of the occipital nerve 

upon one or both sides, extending from the vertex and on the neck 



PRACTICE OF MEDICINE. 



as far down as the clavicle, and upward and forward to the cheek. 
May be associated with hypcrsstkesia of the skin, and with cramps 
in the cervical muscles, and attacks of herpes. 



CERVTCO-BRACHIAX. 

Bymptoma. Paroxysmal pains, of a severe, boring, burning or 
tensive character, with sensations of numbness and ■weakness of the 
arm, hand, shoulder, scapula and mamma, with tenderness along the 
cervical plexus. (Kdetna of the arm and other parts along the dis- 
tribution of the cervical plexus occur if the neuralgia is of long dura- 
tion, the result of nutritive changes, the limb at limes becoming 
pale, the skin glossy, dry and harsh. 

DOBSO- INTERCOSTAL NEURALGIA. 

Symptoms, Paroxysmal pain of a sharp and lancinating char- 
acter, along the fifth and sixth left intercostal spaces, often associated 
with the development of herpes, the so-called herpes saster, or 

Tenderness at the points where the nerves emerge from the inter- 
vertebral foraniina at the sides of the chest and at points in front. 



LUMBO- ABDOMINAL NEURALGIA, 
SymptomB, Paroxysmal pain of a sharp and lancinating, at 
times heavy and dull character, following the course of the ileo- 
hypogastric nerve, ileo-ingulna! and external spermatic nerv «■"- 
plying the integument of the hip. the inner side of thigh, the S' 
and labium, 



Deflnition. Pain following the course of the sciatic nerve. The 
sacral plexus is made up of the fourth and fifth lumbar and the iirst 
two pairs of sacral nerves. 

Sjrmptoms. Sciatica usually follows an attack of lumbago, the 
pain becoming fixed in the sciatic nerve ; at times it is a true neuritis. 
The pain is sharp, tearing, shooting or lancinating in character, in- 
creased upon motion, shooting along the course of the nerve into 
the hip, inner side of the thigh, half of the l^g. ankle and heel, at 
one or all of these points, in paroxysms lasting from a few hours 



DISEASES OF THE NERVES. 301 

to twenty-four hours or longer. The tactile sensation in the foot and 
motility in the limbs are impaired, and if of long duvation, wasting 
of the limb occurs, 

Diagnosis, Rheumatism, so-called, is the only condition hkely 
to be confounded with neuralgia. 

- The history of the attack, the character of the pain, with its local- 
ized spot of tenderness, should prevent such an error. . 

PrognoBiB. If promptly and properly treated, unless the result 
of pressure of an exostosis, aneurism or other tumor, favorable. 

Treatment of NeuralBise, Rest ; easily assimilated but nutri- 
tious diet ; removal of the cause, if possible. If anEemic,/i?rraOT and 
arsenkum. If rheumatic, alkalies. If syphilitic or the result of 
metallic poisons, potassii iodidum. If malarial, guinina. 

For an attack, niffrp/tina and alropina, hypodermatically, afford the 
most prompt and ready relief 

Success usually follows the use of the well-known " Gross (Prof. S. 
D.) neuralgic piU " : — 

B, QninioK snlpliaa „ gr. ij 

Morphinie sulphas _ gr. ^ 

Sttychninte gr. ^ 

Acidi arseniosi gr. ^ 

ExIraOi aconiti gr. \. M. 

Ft. pil. No. 1. 
Sio. — One every one, two or three hours. 
In sciatica, prompt relief follows fhc deep injection of chlora- 
farmum. Locally, blisters along the course of the nerve, or a lotion 
of chloral, camphor, morphina and chlorvformuht combined, in 
solution. 

Facial neuralgia is often wonderfully benefited by the internal ad- 
ministratioQ of ext. gelsetnii Jld., git. iij-v, every three or four hours, 
■ until its physiological effects are produced. All forms of neuralgia 
are more or less benefited by — 

B. Quinince sulph .' gr. iij 

Ferri rjdaet gr. j 

Acid arsenious gr. 5^ 

AconitiiP..,. gr. ^J,. M, 

In pil! eveiy four or five hours. 



301 PRACTICE OF MEDICINE. 

FACIAL PARALYSIS. 
Ssmonym. Bell's palay. 

Deflnitdon. An acute paralysis of the seventh cranial or facial 
nerve, the great motor nerve of the inu5cles of the face — the ncr^e of 



Causes. Exposure to a current of cold air against the side of the 
face — over the pes ansen'nus— is the most frequent. Also due I 
injury or disease of the middle ear. Syphilis. 

Symptoms. The facial nerve supplies the muscles of the face, ' 
the muscles of the external ear, also the stylo-hyoid, posterior belly 
of the digastric, the platysma, one muscle of the middle ear, t 
stapedius and one palate muscle, the levator palad ; by means 
the chorda tympani branch it controls the secretion of the parotid a 
submaxillary glands, and, possibly, the sense of taste. It also fiir- J 
nishes motor power to the azygos uvulae, the tensor tympani and the ff 
tensor palati muscles. 

The onset is usually sudden, with tingling of ike lips and tgngue, 
and upon looking in the mirror the patient is surprised by the per- 
fectly blank, motionless side of the face, the comer of the mouth 
depressed, the eyelids open, the face drawn toward the well side, and 
with inabihty (o expectorate, whistle or swallow. 

Any or all the muscles innervated by the nerve may participate i 
the paresis. 

The electro-contractility is feeble or lost. The reflexes are abolished. 

DiagrnoaiB. Paralysis of the muscles of the face occurs in hetni- 
plegia : the points of differentiation are the presence of cerebral 
symptoms and the normal reflex excitability. 

Facial palsy with otorrbcea, imperfect hearing, obliquity of the ■ 
uvula and loss of taste determine its origin within the aquxductus I 
Fallopii. 

It is the result of cold if the taste be normal and the uvula straight, I 

If other nerves are also involved the origin is central. 

Prognosis. Favorable. 

Treatment, if the result of cold and damp, diaphoresis with I 
pilocarpus, or diuresis with potassii iodidum and blisters in front of I 
ear, wiih gah/anism of the affected muscles. 



r 

I 

r 

f 

I 
I 



CEREBRO-SPINAL 



CEREBRO-SPINAL NEUROSES. 



CHOREA. 

Synonyma. St. ViCus's dance; insanity of the muscles. 

Deflmtion. A functional (?) disorder of the nervous system; 
characteriiied by irregular spasmodic movements of groups of muscles, 
with muscular weakness, more or less approaching a paralysis of the 
affected parts. 

Oausea. Essentially a disease of childhood ; hereditary ; reflex 
from dentition, worms, masturbation or fright; probably the result of 
rheumatism in many cases. 

Pathological Anatomp. As yet there has been no constant 
anatomical lesion discovered, the theory of emboli having, however, 
many advocates. 

Symptoms, The onset is usually gradual, the child seemingly 
grimacing or jerking the arm or hand, as if in imitation, followed 
by decided, irregjtiar jacHlalions of the muscles of the face (histrionic 
spasm), of the eyelids (blepharospasm), eyeballs (nystagmus), and 
the shoulder, arm and hand, finally extending to the lower extremi- 
ties, interfering with motility; in severe cases, inability of self-feed- 
ing or holding anything in the hands. The speech is often unintel- 
ligible, the tongue constantly moving in an irregular manner. 

The heart's action is tumultuous and irregular, associated with a 
soft, blowing, systolic murmur, most distinct at the base. The mus- 
cles are usually quiet during sleep, although this is not always the 
case. The mind is somewhat blunted, the temper irritable, the 
memory impaired. If the irregular muscular movements are con- 
fined to one side of the body, it is termed hemi-chorea. 

DiaGrnoslB. Chorea was confounded with epilepsy until the points 
of distinction were pointed out by Sydenham. 

Paralysis agilans has general muscular tremor, beginning in one 
limb, gradually progressing, uninfluenced by treatment; a disease of 
the elderly. 



304 PRACTICE OF MEDTCIHE. 

B}st'hemiplegic fkorea is the choreic movement of a paralyzed limb.l 
PrognoBis. Tlie vast majority of cases recover; hut relapses a; 

Treatment. Remove the cause, if possible. Easily assimilated 
diet. Many cases improve rapidly by confinement to bed in a dark- 
ened room. If the muscular movements interfere with sleep, , 
phina or chloral are indicated. Regulate the secretions. 

Arsenicum is the most reliable remedy yet introduced for the ireat:4 
ment of chorea. It should be pushed to its first physiological effecti 
then gradually reducing the dose until all symptoms disappear. Thu 
form of the remedy best adapted is liquor poiassii arsem'tts. gtt. \ 
creased to a or even xv, three times a day. Exiraclum riinUifug^ 
Jluidum Ti\,xx-3J, t. d., is servicable, especially in cases fbllowmg ^ 
rheumatic attack. If ansmia be present, combine or aitemat 
arsenicuin with Jerrant. 

EPILEPSY. 

De&iitioD. A chronic disease, of which the characteristic symp^ 
toms are a su dden loss of consciousness, attended with i 
general convulsions. 

Causes. Heredity; rarely worry, anxiety, depression or fiigfila 
Pressjre from a tumor at the periphery, or thickening of the t 
branes of the brain, causing pressure; dyspepsia; syphilis; uterinM 
diseases. 

Patliological Anatomy. There are no constant anatomici 
lesions as yet. associated with epilepsy. 

Varieties. I. Epilepsia gravior, le grand mal; II. Epilt 

Symptoms. Le grand mal is preceded by a more or less prc>^ 
nounced and curious sensation, the so-called aura epileptica 

The attack proper is sudden, the subject suddenly falling, witti j 
peculiar cry, loss of consciousness , pallor of tke face, the body a: 
ing a position of tetanic rigidity, succeeded after a 
more or less pronounced clonic convulsions, followed by ci 
eral hours' duration. The subject awakens with a confused or sheep^ 
ish expression, with no knowledge of what has occurred, unless 1 
has injured himself during the attack, either by the fall, or, what | 
common, has bitten his tongue during the convulsior 

Le petit mal is manifested either by attacks of vertigo, the cofli 



CEREBRO-SPINAL NEUROSES. 

i being prtsetved, or by !^ passing- aisimt-inindedness, ckheT 
form being associated with slight cotnmlsive phenomena, followed by 
coma of short duration. 

The mental functions are not, as arule,injuredby attacks of epilepsy, 
unless they recur very frequently. Indeed, when at wide intervals the 
subject seems relieved by them, "the sudden, excessive and rapid dis- 
charge of gray matter of some part of the brain on the ciuscies," the 
so-called "electrical storm," having cleared the cerebral atmosphere. 

Diagnosis. Uremic convulsions closely resemble an epileptic 
attack ; but the dropsy or general cedema and albuminous urine of 
the former should guard against error. 

Feigned epilepsy often misleads the most practical expert. 

Prognosis. The vast majority of cases will not recover under 
treatment, but have the frequency and severity of the attacks greatly 
ameliorated, but sooner or later returning with their former severity. 
Cases the result of the various reflex causes usually recover when the 
cause is removed. 

Traatment. To avert an impending attack, inhalations of amy I 
nitpis, gtL iij-v, a few whiffs of chlorqformum, or the hypodermatic 
injection of morphina. 

To prevent the return of attacks, remove the cause, if possible ; 
attention to the secretions, atid the internal administrations oi polassii 
bromidum in doses sufficient to abolish the faucial reflex and produce 
the symptomsof bromism, has great power in diminishing the severity 
and frequency of the attacks ; better results are sometimes obtained 
by the coinhinatian of the various bromides. Cases in which the 
bromides are not serviceable are sometimes benefited by argenti 
mtras, belladonna, or cannabis indica. Weak and anfemic subjects 
usually do better with strychnina in full doses than with potassii bro- 
midum. If a history of "syphilis can be obtained, the combination of 
peiasssii todiditm ani polassti bromidum will effect a cure. 

Whichever of Che above remedies are beneficial in any particular 
case, the permanency of the relief can only be maintained by the con- 
tinuation of the drug for at least two years after the last attack. 

Gowers highly recommends the following in cases complicated with 
cardiac dilatation : — . 

B- Polassii bromid gr. xx 

Tinct digital ni,x. M. 

Slfl. — Three tiroes a day. 



t 



MEDICINE. 



306 PRACTICE O 

Another good combination is the following: — 

El . Potassii brnmid gr. »v 

Sodii bromid.., ..,„,„,„ gr. kv 

Liq. potassii Bisenit TH,ij 

Ext. eonii fld lH,iij 

Aq. cinnamomi g j 

Inf. gentim comp ad ^ 35. 

SlG. — Two hours aflec meals. 
Prof. DaCosta has used with success a. bromide of nickel, in 
that have withstood the other combinations of the bromides. 



DISEASES OF THE BLOOD. 



ANEMIA. 

SynonymB. Spantemia ; hydrsemia. 

DeSnition. A deficiency of red corpuscles and albuminoid com- 
pounds — a poverty of the blood; characterized by pallor and general 
weakness. 

Oligcemia is a lessening in the amount of blood ; Ischamia is a 
localized anaemia. 

Causee. Predisposing and exciting. 

Predisposing. Sex ; the female, pregnancy and menopause ; heredity. 

Exciting. Deficient food, air or sunshine ; exces^ve work \ menul' 
worry ; prolonged and frequent nocturnal emissions ; excessive nnis* 
ing; chronic intestinal catarrh ; Bright's disease ; malaria. 

Pathological Anatomy. Post-tnorte?n, the tissues are thin. 
shrunken and bloodless. If the anemia have been of long duration 
patches of fatty change are seen in the various organs. The blood 
has a brighter color, the result of diminution in the number of red 
corpuscles and the quantity of the hsmoglobin ; it is thinner than 
normal, and coagulates slowly and imperfectly, from diminution of' 
the tibri no-plastic constituent. 

Symptoms. Pallor, gums, tongue, car and conjunctiva pale. 
Muscular weakness, inability for exertion. Deficient appetite and 
impaired digestion, attacks of vomiting the result of aniemia of the 
medulla oblongata. Quickened respiration, irritable tefuper, vertigo 
in the erect position, attacks oi swooning, hysteria, 3.nA rarely epilepsy. 



ngo ^ 
i>sy.^ 



Irritable heart, with soft systolic basic murmars and attacks of hysteria. 
Nocturnal emissions in male and deficient menses in female. 
Marasmits in children. More or less general t^detna of the eyelids 
and ankles. Long continued, symptoms of fatty changes of various 
organs, or gastric ulcer result. 

Diagnosis. The symptoms of ansemia are so characteristic that 
an error is impossible ; the cause of it, however, may be hidden. 

Prognosis. Favorable if treated early. If protracted, results in 
more or less general symptoms of fatty degenerations or ulcer of the 
stomach. 

Treatment. Remove the cause. Easily assimilated, blood- 
producing diet. Fresh air, sunlight and exercise short of fatigue. . 
Purgatives irith stomachic tonics, to promote digestion. 

For the anaimia proper. /i'/iT/m in some form is the most valuable 
remedy, always remembering that it is not assimilated if the intestines 
and liver be torpid. 

The following alterative tonic, known as Smith's (Dr. A. H.) is 
frequently of value ; — 

R. Hydrargyri chloridi corrosivom gr. j^j 

Liq. araenici chloridj f^j 

Tinct. ferri chloridi 

Acidi hydrochlorici dil ..ftS... f^'v. 

Syrupi _.... fjiij 

Aqua ad fj vj. M. 

Sic. — One dessertspoonful in a wineglaxsful of water after each meal. 

CHLOROSIS. 

Synonym. Green sickness. 

Definition, A pronounced ana-'mia, occurring in girls about the 
age of puberty. 

Causes. Obscure; inherited ;■ menstrual irregularities. Ham- 
mond maintains " that it is an affection of the nervous system, the 
blood changes being secondary." 

Patiiological Anatomy. The blood is deficient in red cor- 
puscles, the volume of the fluid normal or nearly so. Rarely the 
mass of blood is increased. The body is well nourished and the sub- 
cutaneous fat well distributed. The organs are abnormally pale. 
The spleen, the lymphatics and the marrow of the bones are not 
affected in any manner. 




308 PRACTICE OF MEDICINE. 

Symptonui. The condition is associated with disorders of men-' 
struation. The young girl experiences a change of disposHion.^ecoxa- \ 
ing morose and despondent, or rarely hystericaL 

"As respects the actual condition of the sexua! organs, there are 
two forma of derangement wh'iA happen In chlorosis; there are the 
amenorrhmc form and the menorrkagic form." After an attack of - 
menorrhagia or after the failure of the flow to appear, the changes 
occur. The complexion changes, blondes becoming pallid, waxy and 
puffy, without cedema; bnmelles becoming muddy and grayish in 
color, with bluish-black rings under the eyes. Weariness and fatigue 
upon the least exertion ; the heart irritable, with shortness of breath, -i 
The appetite is vitiated, the digestion imperfect; attacks of gastral^a I 

A not infrequent complication is gastric ulcer. Phthisis develops 1 
in those having the slightest predisposition. 

ProgHOfiifl. As a nile, unfavorable, on account of the liability tc 
grave complications. Those recovering are always liable I 

Treatment. A generous, nutritious diet; fresh air; moderaitx ex~ | 
ercise ; change of scene ; cheerfiil surroundings, Fermm&aAai 
cum are of the greatest utility. A good combination is — 

a. Fern arsenialis : gr. ^-J 

Ext. nuds vomica gr. \--\. 

Ft. pil. No. I. 
SiG. — After meals. 

The following is Bland's formula, so highly lauded by Niemeyer — 
B- Pulv. fcmsulph., 

Potassii carbonal. pune Bft ', 

Tragacantha; (| 

Ft. pfl. No. XCYJ. 

SiG.— One to three or four pills three times daily. 



PROGRESSIVE PERNICIOUS ANEMIA. 
8ynon;i]iB. Ansmatosis ; essential anjen 

Definition. A pernicious, progressive form of 
known cause, resisting all treatment, and toward 
associated with fever. 




Pathological Anatomy. The blood is scanty and pale, with 
diminished red corpuscles, albuminates and fibrih, showing a very 
feehle tendency to coagidate. There is no increa^ in the white 
corpuscles. 

The jnarrmti in adult bones becomes fatal, red and adenoid, and 
contains microcytes; several other changes have occurred second- 
arily in the marrow. 

Secondary to the ansemia, the heart, lai^er arteries and certain 
capillary tracts exhibit circumscribed or diffused fatty degen* 

The liver, spleen, kidneys and stomach are decidedly ; 
causing fatty changes in those organs. The skin may contain petechia 
of a purplish or brownish tint, and internal hemorrhages are not in- 
frequent ; retinal hemorrhage is rarely wanting. 

There is not much emaciarion, though the pallor is pronounced. 

Symptoms. It begins insidiously, with increasing languor and 
pallor, the muscular iveakness compelling the padent to lake his 
bed. Cardiac palpitation, dyspnxif, attacks of syiuope, ai/ema and 
swelling about the ankles, with petechial spots scattered irregularly 
over the surface. 

The appetite is wanting, and nausea and vomiting are occurrences, 
with marked dyspepsia and persistent diarrhiea. As the disease pro- 
gresses a remittent form oi fever develops, the temperature frequently 
showing io2°-i04'' F. . ^ 

Disorders of vision are the result of the retinal hemorrhage. The 
cardiac sounds are feeble and associated with soft basic or ansmic 
mummrs. 

Diagnosis. Progressive pernicious anaemia is distinguished from 
simple aniemia and chlorosis by the greater severity of the former. 
From leucocythemia by the normal-sized spleen and liver, and the 
absence of increase in the white corpuscles. 

ProgTDOsis. Unfavorable. 

Treatment. Symptomatic. 

LEUCOCYTHEMIA. 

Synonyms. Leucamiia ; white cell blood ; white blood ; a 
.plenica. 

Definition. A condition in which there is 
in the number of white blood corpuscles. It may assume either a 



310 l-KACTICE OF MEDICINE. 

sfiienic, a lyntphntic. or a myelogenk form, and is chataclerizcd by 
symptoms of pronounced anaemia. 

Causes. TJie real cause and nature of the affection is unknown. 

Pathological Anatomy. The spleen is increased in siie. den- 
sity and firmness ; the lymphatic glands all over the body also en- 
large, but are soft to the touch, often fluctuating ; the marroiv of Ike 
bones changes from its normal rose color to that of a greenish -yellow ; 
the liver also enlarges enormously. The blood is paler than normal, 
its specific gravity reduced from 1.055 ^° i-040 or lower, and the 
while corpuscles increased in number and in size, the r^rffo^fwc/^j 
being lessened in number and size. 

Symptoms. The onset and early progress of the disease is 
identical with that of simple anaemia, accompanied by swelling of 
the abdomen and a feeling of fullness a.n& pain in the splenic regiiM, 
due to enlargement of that organ. 

In the lymphatic variety, enlargement of the glands in thi 
neck and axillary region are associated with xha great pallor. 

In the myelogenic variety, the bones, more particularly the ribs and 
sternum, are tender on pressure, the patient assuming a waxy 
appearance. 

In each variety the appetite is poor, the digestion feeble, the bowels 
loose, the patient easily fatigued, with cardiac palpitation, and dys- 
pncea, with cedcma of the eyelids and ankles. The urine is scanty 
and of high specific gravity — 1.020-1.030, 

Diagnosis. This should cause but little trouble if enlarged 
spleen, lymphatic glands and tender bones are associated with great 
pallor, and the characteristic appearance of the blood as democistraied 
by a " puncture of the finger of the patient and receiving the blood 
on a piece of white linen or a lawn handkerchief, and placing by 
the side of it a similar stain of blood from a healthy subject. The 
full color of the latter contrasts strikingly with the stain of the former, 
which is hardly of a blood color, and translucent." 

PrognoBis. No case of recovery has yet been recorded, 
average duration is between two and three years. 

Treatment. Symptomatic. A combination of the following 
remedies with generous diet, fresh air, sunshine, pleasant surround- 
ings, oleum morrhua and the hypophosphites have at times seemed of 
temporary utility, to wit ; guinina, arscniciim./errum and ergota. 



Th^ 






ADDISON'S DISEASE. 

Synonym, Melasma supra-renalis. 

Definition. "The bronzed-skin disease." Thus defined by Aver- 
beck ; "A well-marked constitutional disease, exhibiting itself locally 
as a chronic inflammation of the supra-renal capsules, but iri its 
essence consisting in a peculiar ansmic condition, always tending 
toward death, which is characterized by intense development of pig- 
ment in the cells of the rete malpighii and in the epithelium of the 
mucous membrane of the mouth." 

Causea. Uncertain. Tubercle, scrofula and sjTihilis have each 
been given as the cause. 

Pathological Anatomy. A low form of inflammation, termi- 
nating in degeneration of the supra-renal capsule. The blood is 
deficient In fibrin and red corpuscles, with a slight increase of the 
white corpuscles. Fatty degeneration of the heart and vessels have 
been observed in seme cases. 

"The most striking change during life— the abnormal pigmenta- 
tion — is due to the deposirion of granular pigment in the cells of 
the rete malpighii, in the papillary portion of the cutis, and even in 
the connective-tissue corpuscles. No change occurs in the proper 
structure of the skin. Similar pigment deposits occur in the 
mucous membrane of the mouth, especially along the edges of the 
teeth." 

" The disease of the supra-renal capsules excites an irritation of the 
vaso-motor system — the trophic system — which leads to the pig- 



Symptome. The onset of the disease is insidious, with a feeling 
of extreme languor, muscular fatigue, asthenia, indigestion 
dyspnisa, cardiac palpitation, vertigo, melancholia and i 
drowsiness. 

The surface is first pale, then changes to a hue like that of 
melanamia, changing to icteroid, finally resembUng the color 
of a mulatto, and then to a lustreless bronse. These changes also 
occur on the mucous membrane of the lips, tongue, gums and 
mouth, 

Progrnosis. An incurable disease. Duration, a year or two. 

Treatment, Symptomatic. 



312 

HEMOPHILIA. 

Synonyms. Hemorrhagic diathesis; "bleeder's disease." 

Daflnitdon. A congenital condition characterized by the habitual 
occurrence of hemorrhages. 

Cause. Hereditary. 

Symptoma. The bleeding appears about the period of first den- 
tition, and consists of spontaneous hemorrhages from the mucous 
membraiie of the nose, mouth, lungs, stomach, intestines, or genito- 
urinary passages, or in perfect cases, hemorrhages occur directly from 
the fingers, toes, lobes of the ears, back of the hands or arms, without 
any apparent change in the skin, and continue, in spite of the most 
powerful means, for days or weeks. Traumatic hsnterfhages occur 
if kn injury of any kind is sustained about the period of the develop- 
ment of the bleeding. 

Epistaxis is the most common form of all those named. 

As a result of the great loss of blood, the subject suffers from al! tlie 
symptoms of profound anemia. 

Diagnosis. It is impossible to confound the " bleeder's disease " 
with any other. affection. 

Prognosis. Death is the usual termination within a few weeks 
frcnn the time of its development, which may not be until adult life. 

Treatment. Entirely symptomatic. It is claimed that "potassii 
ehloras — an ounce of a saturated solution three times a day — com- 
bined with tinctura Jerri ckloridi," will eradicate the constitutional 
tendency. 

SCORBUTUS. 

Synonym. Scurvy. 

Deflnition. A peculiar condition of malnutrition or anemia, 
gradually developing upon a dietary deficient in fresh vegetable ma- 
terial ; characterized by decided antemia, debihty, mental lethargy, 
petechia and a swollen and spongy state of the gums, with a tendency 
to bleed upon the slightest irritation. 

Causes. The disease only occurs when fresh vegetable nutriment 
or some appropriate substitute has been for a time paitially or com- 
pletely withheld. 

Pathologfical Anatomy. An undetermined derangement in 
the composition of the blood, wilii diminished proportion of the pot- 
ash salts. Spleen enlarged. The tissues are wasted and present 



^ 



DISEASES OF THE BLOOD. 313 

; to either one of or the combined presence of the 
following conditions, to wit : liquid condition of the blood, allowing 
it to escape from the vessels, alterations in the walls of the vessels. 

Symptoms. General weakness, lassitude, indisposition to either 
mental or physical exertion. TTie skin is dry, rough and of a 
miidily pallor, the face pale and bloated. Sweliinj; and spongi- 
ness of the gtims, with great tendency to bleed and an exceed- 
ingly offensive breath. Looseness of the ieeth, hemorrhages from 
mucous surfaces, and extravasations of blood within and beneath 
the skin. The lips are pale, which is in striking contrast to the 
redness of the gums ; the eyes are sunken and surrounded by a dark 
blue circle. 

Hemorrhages occur from the nostrils, mouth, bronchial tubes 
intestinal canal and vagina. The skin is dry and rough, resem- 
bling that of a plucked fowl, ffidema of the face and ankles not in- 
frequent. 

Depression of the spirits Is characteristic. Palpitation and dyspncea 
on exertion. Urine high colored, speedily becoming fetid. 

The patient usually longs ioT fresh vegetables and. fruits. 

ComplicatiOQa, Dysentery. Scorbutic dysentery is a frequent 
complication. It may co-exist with typhoid and typhus fever. 

ProenosiB. Favorable, if early and properly treated. 

Treatment. The chief indication is the assimilation of the ali- 
mentary principles needed for the healthy constitution of the blood 
and the invigoration of the system. 

The juice of lemons, oranges and other fruits. Antiscorbutic vege- 
tables, to wit ; raw cabbage, cresses and raw fiotatoes, in conjunction 
with meats, milk and farinaceous food. 

Improve the appetite and digestion by the use of strychnina, 
quinina, mineral aeids and bitter infusions. IWassH chloras, locally, 
will relieve the oral symptoms. 

PURPURA. 

Synonym. Hemorrhcea Petechialis. 

Definition. An acute disease, characterized by purplish discol- 
orations of the skin, the result of hemorrhages into the upper layers 
of the cutis and beneath the epidermis. 



Varieties. Purpura simplex : purpura kenwrrha^ca ; fiurpuf 



OaUBSB. Not properly understood. It may occur at any age, but 
Is especially frequent in children and elderly people. 

Symptoms, furpura simplex is the mildest form of the affection, 
ized by the sudden appearance of small, bright red 
s hemorrhage — most commonly on the legs, asso- 
ciated with slight lassitude, mild febrile reaction, and aching pains in 
the limbs. The hue of the spots rapidly fades to a purplish color 
and slowly disappears. Relapses are common. 

Purpura hemorrhagica has in addition to the eruption of purpura 
simplen^the cutaneous hemorrhage — a flow of blood from the free 
surface of mucous membranes. The most common hemorrhage is 
epistaxis, slight or profuse. Other hemorrhages are hmmatemesis, 
vtelmna, hermaturia, hstnoptysis. menorr/iagia, and also into the sub- 
stance of the mucous membranes of the palate, cheeks and gums. 
This variety is associated with great debility and depression, moderate 
fever ail d disorders of digestion. Marked anamia results from the 
hemorrhages. 

Purpura urticans is a combination of urticaria and purpura 
simplex. It is characterized by " rounded and reddish elevations of 
the cuticle, resembling wheals, but which are not accompanied, like 
the wheals of urticaria, by any sensation of itching or tingling," 
They are usually seated on the legs, thighs, breast and arms, 
and are interspersed with petechife. They gradually form and 
subside within twenty-four or thirty-six hours. Relapses are fre- 

This variety is also associated with malaise, moderate fever, and 
pains in the limbs. 

Prognosis. Purpura simplex and puipura urticans are favorable, 
but relapses are very frequent. Purpura hemorrhagica is always a 
grave disease, often proving fatal from exhaustion, or more rarely, 
cerebral or pulmonary hemorrhage. Recovery occurs frequently, 
under judicious treatment. 

Treatment. Rest and a concentrated nutritious . diet, and the 
moderate use of stimulants, are used to combat the resulting anaemia. 

The internal use of oleum terebinthince is one of the most reliable 
remedies for all forms of the disease. The following is an eligible 
formula :— 



I 



DISEASES OF THE SKIN. 315 

B- 01. terebinthiiue f^Lj 

Ol. amygdafce express f ^j 

Tinct. apii, deodorat f.^ss 

Mucil. acacise _ f|j 

Aq. lauro-cerasi ad „ '^^ "j- M- 

SiG. — One leaspoonfni every three or four hours. 

Among the numerous rcmediea suggested, the most reliable have ' 
been acidum sulphurieum dilutum and tinclura ferri ckloridi. Good 
results have followed acidum carbolicum, gtt. ij— iij every three hours, 
in cases seen by the author, and a particularly persistent case was 
cured by full doses of potassii iodidum. 

" If hemorrhages that are threatened come on with a strong pulse, 
flushed face, headache and excitcraent, digitalis, quinina and ergola 
are the appropriate medicaments." 

Locally, to arrest bleeding, astringents and either hot or cold 



DISEASES OF THE SKIN. 



DISORDERS OF SECRETION. 

SEBORRHCEA. 

Synonymfi. Acne sebacea; pityriasis; tinea furfuracea; dand- 
ruff. 

Definition. A disease of the sebaceous glands of the skin ; char- 
acterized by an excessive and abnormal secretion of sebaceous 
matter, forming upon the skin either an oily coating, or in crusts and 

Varieties. Seborrhaa oleosa ; seierrAwa sicca. 

OaiiaeB. In newly-born infants an increased secretion of seba- 
ceous matter — the vemix caseosa — is a physiological process. 

The origin of the disease is for the most part illy understood, 
anxmia being a factor in many cases. 

Pathology. Seborrhoia is a functional derangement oT the 
glands, unless it be allowed to become very chronic, when occur 
atrophy of the glands and follicles. 



31S PRACnCB OF MEDICIHE. 

Symptoms, The affection may occur upon any portion of the 
body, its most frequent seat being, however, the scalp {seborrhiEa 
capitis), and next in frequency the face {seborrhea faciei). 

Scborrhaa oleosa ; appears as an oily, greasy coaling upon the 
skin, without hyperremia, and not attended with itching. The secre- 
tion is of an oily character, the quantity at times being so great 
as to collect in minute drops of a clear, yeUowish fluid upon the 

The most common seat for this variety is the face — seborrhiea 
faciei — and nose — seborrkcca nasi. 

Seborrhea sicca ; consists in the formation of dry, more or less 
greasy masses' of scales or crusts of a. grayish, yellmuisk, or broionish- 
yellffui color, having a strong tendency to adhere to the skin, and 
attended with decided itching Occurring upon the scalp — sebor- 
rhaa capitis — it is a frequent source oi premature baldness. 

'Di&ga.OSia. Seborrhisa capitis may be mistaken for dry eciema, 
but the former is always a dry disease, while in eczema moisture has 
dtcurred at some period of the affection. The scales in seborrhaca 
are very abundant and pale ; in eczema the scales are scanty and 
reddish, the parts infiltrated and thickened. 

Seborrhcea sicca and psoriasis have many points of resemblance, 
whether occurring on the scalp or on the body. In* seborrhcea the 
scales are minute or caked, grayish or yellowish incolor. of an unctuous 
feel and usually uniformly diffused. In psoriasis the scales are very 
dry, abundant, thitk, white, irregularly dispersed, with intervening 
healthy skin, and the surface beneath the scales is ahi/ays reddish 
and inflamed. The' clinical histories of the diseases are entirely 
different, 

PrognoBis. If properly treated, favorable, although the affection 
is obstinate. 

Treatm.ent, The secretions require attention If ansmia be 
present, ferrum ajid arsenicum are indicated. The following formula 
of Sir Erasmus Wilson, and lauded by Hebra, is valuable : — 

a. Vini fcrri fjiw 

Syr. Bimpl ,, 

Liquor, potassii arsenit. &Ek... 31] 

Aqufe deslil ._..• f.fij M. 

SiG — Teaspoonful three times a. day, with meals. 

Duhring recommends calcii sulpkid., gr. iV^, several times dmly. 



I 

I 



DISEASES OF THE SKIN. 317 

Local measures are the most important in seborrhoea. For sebor'- 
rhcea capitis the following plan will usually be successful : — 

The scales are to be thoroughly moistened with either oleum oHvcb, 
oleum morrhuce or adeps, to facilitate their removal ; it is best ap- 
plied at night and the head covered with a flannel or other cap. As 
soon as the crusts are well soaked they should be removed by washing 
with soap and warm water, or equal parts of soap and glycerine and 
water, or the following will be found valuable : — 

R. Saponis viridis (Hebra).„ f^^^ 

Spts. vini. rect • f^y* 

Solve et filtra. 
SiG. — As a soap-wash or shampoo. 

The scalp is to be thoroughly cleansed of either the above by again 
washing with warm water and then dried by means of soft towels. 
Then should be applied some oily or fatty substance, depending upon 
the condition of the scalp. 

If much irritation, either vaseline or oleum amygdalas expressum. 
If no irritation be present, a stimulating preparation will be found of 
great benefit. Either of the following may be used : — 

B, Tinct. cantharidis f^iij 

Tinct. capsici , ^i^m 

Ol. ricini f^^ij 

Alcoholis ', f^ij 

Spts. rosmarini f^^j. M. 

— DUHRING. 

Or— 

R. Bismuthi subnitratis 3J 

Ung. hydrargyri ammon 3ij-iv 

, Ung. aquae rosse ad Jj. M. 

The above should be repeated every day or two, as the symptoms 
may require, until a cure be effected. 

The seborrhoea of other portions of the body are to be treated upon 
the same general method. 

COMEDO. 

Synonyms. Acne punctata nigra ; black heads or worms. 

Definition. A disorder of the sebaceous glands ; character- 
ized by retention in the excretory ducts of an inspissated secretion 
which is visible upon the surface as yellowish or whitish pin-point 



US 



PSACnCK OP HBDICINBi 



and pin-htad sized elevations, containing in their centre blackish , 

OausBB. The true edology is unknown. Among the causes 
assigned are, anxmia, menstrual disorders, dyspepsia and consti- 
pation. 

Pathology. Comedo is an afTccdon of the sebaceous glands and 
ducts, consisting of an accumulation of sebum and epithelial cells in 
the glands and follicles, dilating the ducts to such an extent as to pro- 
duce the point or elevation upon the surface. The obstructed gland 
may relieve itself, or it may continue distending the gland until a 
papule is formed. The duct sometimes contains small hairs, and also 
the microscopic mite — demodex foilicuJorum — having a length of 
from 7-^ t" Ts '^f ^^ inch, and breadth of about ;^ of an inch, 
which was at one time erroneously supposed to be the cause of the 
affection. 

Symptoma. Essentially a chronic affection, observed for the 
most part on the face, neck, chest and back. Each single elevation 
or black-head or point is designated a comedo, or if a nmnber, in the 
plural, as comedones. 

Each comedo is , small, varying from a pin-point to a pin-head 
in size, having a brownish or blackish appearance, from the dust or 
dirt that has adhered to their unctuous extremity. If they form in 
great numbers upon the face they are disfiguring, giving the individual 
the appearance of having had minute grains of powder implanted in 
the skin. There are no evidences of inflammation unless acne be 
associated, but, on the contrary, the skin has a dirty, greasy, un- 
washed appearance. 

DiagrnOEUB. There is no condition resembling comedo, so thai its 
recognition is easy, unless complicated with acne ; but even then the 
inflammatory appearances of acne should prevent error. 

Prognosis. Favorable, although often remarkably obstinate. 

Treatment. Derangements of any of the functions of the body 
should be corrected, and strict attention given to the rules for pro- 
moling the general health. 

Local measures are usually sufficient to promote a cure of the 
affection. 

The parts affected should be thoroughly softened by bathing with 
soap and warm water, when the comedones are removed by friction 
with a Turkish towel, pressure between the thumb nails, the applies- 



I 



tion of a watch key, or the inslrurnent known as the "comedo 
extractor," and their reappearance prevented by an ungu^ntuin medi- 
cated, to meet the indications, with either sulphur, alkalies, or hydrar- 
gyrum. 

PiSard's acne appUcation I have found valuable : — 
B- Sulphur subUm., 
Alcoholis, 

Tinct. lavend, comp,, 
Glycerin], 

AquEC camphorc ai f§j. M. 

SiG.— Apply freely, after remaval of the comedones. 

MILIUM. 

Synonyma. Grutum ; tubcrcula miliaria or sebacea ; acne punc- 
tata albida. 

Definitdon. An accumulation of sebum iii the sebaceous glands 
which are minus their excretory ducts ; characterised by the formation 
of small, roundish, whitish, sebaceous, n on -inflammatory elevations, 
situated immediately beneath the epidermis. 

CauBe. The origin of the affection is not understood. 

Pathology. The sebaceous gland is distended with the sebum, 
which is unable to escape owing to the obliteration of the duct, nor 
can the contents be squeezed out, as no sign of aperture is to be 
found, the formation being completely enclosed, 

Rarely the retained secretion undergoes a metamorphosis into hard, 
calcareous, stone-like masses — sebaceous concretions or culaneous 

Symptoms. Milia may occur upon any portion of the body ; 
Ibeir usual seat, however, is upon the face, forehead, and about the 
eyes. They form gradually, are about the size of a millet seed, of a 
whitish, pearl or yellowish color, hard, and of a rounded shape, giving 
the sensation to the touch of hard bodies embedded in the skin. They 
are not associated with inflammatory symptoms. 

Dia^rnOBis. Milium and comedo are somewhat similar in appear- 
ance ; the differences are that in milium the sebaceous gland is dis- 
tended without an opening, while in comedo the duct of the gland is 
always patulous upon the surface. Milium usually exists singly, the 
akin Looking normal ; while comedo is more general, the surface 
having a soiled and greasy appearance. 



FKACnCE OF HEmCIHS. 

FrOBnOBiB. Favorable. 

Treatment. As a rule no treatment is needed, the number bein^ifl 
few and their presence of no consequence. 

If their removal be desirable, two modes suggest themselves : 
to open the cyst with a fine-bladed bistoury, and turning the o 
out, destroying the remaining sack by the application of either J 
tiKctura iodi oi acidum chromict; or, the cyst maybe destroyed byj 
tUctrefysis. If a tendency to recur is showji, the plan may be I 
repeated. 

SEBACEOUS CYST. 

SjTlonyillB. Wens ; sebaceous tumor ; encysted tumor. 

Definition. A distention of the sebaceous gland and duct, 

■ with hypertrophy of the walls, which forms a thick,, tough sack or 

cyst ; characterized by the appearance of a firm or soft, more or less 

rounded tumor, having its seat in the skin or subcutaneous connective 

Oanse. Unknown. 

Pathology. Hypertrophy of the gland and duct walls, the result 
of pressure from the accumulated contents, which consist of the 
altered products of the sebaceous secretion. 

Symptoms. The development of wens is slow and insidious. 
The localities where they are more commonly developed are the 
scalp, face, back and scrotum. 

The tumors occur singly or in numbers, in size from a ptea to a: 
walnut, or larger, in shape either rounded, flattened or semiglobular; 
in consistency they are either hard or soft, and doughy; they are 
freely movable and painless. 

Diagnosis. Sebaceous cysts may be confounded with &Ity 
tumors. 

Treatment. Excision and careful and thorough dissection of the 
cyst. 

HYPERIDROSIS. 

Synonyms. Hydrosis; ephidrosis; excessive sweating. 

Definition. Afunctional disorder of the sweat glands; charac- 
terized by aa increased flow of_sweat. 

Causes. Often undetermined; occasionally inherited; nervous 
derangements ; malaria ; diseases of the heart and lungs. 



Patholofify. A functional derangement of the sudoriparous 
glands, over which the vaso-motor system has control. The character 
of the secretion, chemically, does not differ from the normal. 

Symptoms. Universal general sweating, such as occurs during 
the course of pneumonia, rheumatism, tuberculosis, typhoid and 
other febrile maladies, can hardly be considered a distinct affection. 

Uyperidrosis may be acute or chronic, llie amount slight or large, 
being constant or paroxysmal, the extent general or local, and it may 
or may not be symmetrical. 

Bromidrosii is the designation when the secretion has an offensive 

Chroinidrosis is the designation when the fluid poured forth is 
variously colored. 

Uridrosis is the designation when the excretioD from the sweat 
glands contains the elements of the urine and particularly urea. 

Pkosphoridrosis is the designation when the perspiration appears 
luminous in the dark. 

lj>cal hypsridrosis occurs most commonly upon the palms, soles, 
axillse and genitalia. 

Hyperidrosis of the palms maybe so profuse that the fluid accumu- 
lates and keeps the parts constantly macerated, the wearing of gloves 
being impossible, for as soon as tiie parts are wiped dry they are again 
bathed in the secretion. 

Hyperidrosis of the soles is a disagreeable and often distressing 
condition, as the socks and shoes become saturated, ^nd thus keep 
the soles constantly bathed, allowing the macerated epidermis to peel 
off, leaving the more tender skin exposed, causing pain and distress 
when walking. The maceration of the epidermis, the secretion about 
the toes, together with the moisture of the socks and the soles of the 
shoes, promote the rapid development of the bacteria fcetidum ,- all 
these together produce a most disagreeable, disgusting and persistent 
odor, which is termed tromidrosis pedum. 

Hyperidrosis of the genitalia attacks males more particularly, giving 
rise to a disagreeable, penetrating odor. 

The sweating may be limited to one side — unilateral kyperi- 

Prog^osifl. The majority of cases are extremely intractable ; 
complete recovery is rare in a fair proportion, while some cases are 
easily relieved. 



322 PRACTICE OF MEDICINE. 

Treatment. The general condition of the patient must receive 

Local treatment Is the most valuable, however, in this affection. 
The parts should be cleansed and immediately dried, and then 
dusted wilh some one of the numerous dusting powders. The follow- 
ing is a valuable powder: — 

U. Addi s&hcylot^ gr. ix 

Zinci oleat J j. M. 

Perhaps the very best local application is Hnctura belladonna, 
either diluted or full strength. 

In hyperidrosis of the palms and soles, the following are valuable, 
first washing the parts with a weak solution aiacidum carbolicvm^ — 

K- Acidi aalicyliil„ gw 

CrelieprKp „ gj 

Aluminis eiuc §j. 

M. et powder ficely. 
SiG. — Apply to parts with puiF ball. 
Or— 

B- Ungl. picis liqnidse, 

Ungt. sulphnris ii Jj. 

SiG, — Spread on cloth and applied with bandage. (Wilson.) 
Or— 

R. Potassii pcrmanganat _ gr, ij 

Aqua; destil _ ',..., f^j. M. 

SiG. — Frequently npplied. 

For obstinate cases, involving the palms or soles, the following 
plan of treatment, as suggested by Hebra, will be found of the great- 
est service. It is imperative that the various steps be closely fol- 
lowed; "The parts are to he cleansed with water and soap, and the 
following ointment applied on pieces of cloth cut to the sizt of the 
region. Lint smeared with the ointment is also to be placed between 
the toes or fingers, so that every portion of the skin may be covered 
with a layer of the ointment: — 

fi. Eniplast. diachyli ^iv 

Old Qlivse fjiv. 

The plaster to be melted, and the oil added and stirred antil a ho- 
mi^eneous mass results. 
SiG,— To be used on cloths. 




DISEASES OF THE SKIN. 323 

" The cloths are to be changed every twelve hours, when the parts 
are not to be washed, but rubbed dry with hnt and starch dusting 
powder, after which new dressings are again to be apphed in the 
same manner. This proceeding is to be continued from one to two 
weeks. When the disease is upon the soles, the patient may walk 
about in loose shoes." After a week or ten days the ointment can be 
discontinued, but the dusting powder is to be continued for a consid- 
erable period. If relapses occur, the original treatment should again 
be Instituted. 

SUDAMINA. 

Synonyma. Sudamen ; miliaria crystallina (Hebra). 

Deflnition. A non-inflammatory affection of the sweat glands; 
characterized by the rapid development of millet- seed -si zed, translu- 
cent, whitish vesicles, in great numbers, upon any portion of the body. 

CauB6. A high temperature, causing unusual activity of the 
sudoriparous glands. 

Pathology. The glands being excited beyond their capacity 
for normal excretion, the excessive fluid, instead of escaping upon 
the surface, from some cause collects between the layers of the 
epidermis, in the form of minute, translucent, pin-point-siied vesicles. 

Symptoms. Each minute vesicle is distinct, but they exist in great 
numbers, very closely resembling drops of free sweat. They develop 
rapidly, never coalesce, become puriform or rupture. Fresh crops 
form from time to time. Their duration is transitory ; the fluid is 
absorbed, the covering of each dries, forming a thin, delicate mem- 
brane, which disappears as a slight desquamation. 

Treatment. The treatment is that of the disease with which 
they occur. 

ANIDROSIS. 

DeQaition. A functional disorder of the sweat glands ; charac- 
terized by a diminished or insufficient secretion of sweat. 

Cause. The result of a congenital deficiency of the sweat 
glandular apparatus. Local anidrosis may result from injury to a 
nerve, during the course of chronic diseases of the skin, as ichthy- 
osis, eczema, psoriasis, lepra and elephantiasis arabum. In rare 
cases an individual ceases to sweat entirely at times ; in such cases 
the general health is impaired, and during the hot season much suffer- 
ing may ensue. 



324 PRACTICE OF MEDICINE. 

Treatment. Means to promote the activity of the skin and glands 
is the indication, such as the ingestion of large quantities of water, 
hot baths and steam baths, friction and the use of sudorifics, the most 
valuable of which \% pilocarpus. 



HYPEREMIAS OF THE SKIN. 
ERYTHEMA SIMPLEX. 

Definition. An acute affection of the skin, in which occurs an 
abnormal quantity of blood in the dermal vessels; characterized by 
discoloration, which disappears upon pressure and with more or less 
local increase of temperature. 

Varietiea. Idiopathic erythema ; symptomatic erythema. 

Causes. Idiopathic erylhema ; heat, cold, pressure, friction, or 
the contact of irritants, such as mustard, arnica and dyestulTs. 

Symplomatie trylheina occurs most frequently in childhood, from 
diseases of the stomach and intestines \ during the course of the vari- 
ous exanthemata. 

Symptoms. A more or less rapidly developed rtdntu of the 
skin, varying in color from pink or light red to dark red, which dis- 
appears upon pressure, to rapidly return again. The CKtent and form 
of the congestion varies according to the cause, at times being as 
small as a coin and isolated, and again diffused over a large area. The 
temperature of the congested part is slightly above the normal. 

Slight itching and burning are, usually, associated with the disorder. 

Dia^rnosis. Erythema resembles acute dermatitis in color, but 
the subjective symptoms of the latter are so decided that error cannot 

Treatment. Controlled by die cause, which should be removed, 
and the local application of some one of the various dusting powders. 



ERYTHEMA INTERTRIGO. 
Definition. An acute congestion of the skin ; characterized by 
redness, heat, increased perspiration, and an abraded surface, with 
maceration of the epidermis. 

Causes. In the fleshy, from contact or friction of opposing sur- 
warmth — chafing. In children and infants, contact 
Loist clothing ; also disorders of digestion. 



DISEASES OF THE SKIN. 325 

Symptoms. Paris where the natural folds of the skin come in 
contact with one another, as the nates, perineum, groins, axillE and 
beneath the mammK, in the fleshy and in infants, become red, hot, 
painful, and have an increased flow of perspiradati, which in turn 
so/tens the epidermis, giving rise to an acrid mucoid fiuid. If not 
checked by the removal of the cause and the application of dusting 
powders, inflammalio n — derm atitis— resu Its. 

Treatment. The congested parts should be thoroughly washed 
with water and castile soap, or with bran-water, and carefully dried 
with a soft towel. The opposing folds of skin are to be kept sepa- 
rated with lint or soft linen, the parts first covered with cre/a pree- 
parata, sinci oxiduin, bismu/hi submtras. aniyhtm, lycopodivm or 
buck-wkeai Jlo ur. 



INFLAMMATIONS OF THE SKIN. 



SynonsnnB, 
Daflnition. 

terized by any c 
such as erythe' 
more or less infiltration 



ECZEMA. 
Tetter ; salt rheurn ; scall. 
A non-contagious inflammat 



of the skin, charac- 

all of the results of inflammation at or in succession, 

papulesi vesicles or pustules, accompanied by 

d itching, terminating in a serous discharge, 

n desquamation. 



with the formation of 

Foims. Acute; chronic. 

Varieties. Ecuema erylhematosum ; ecMema vesiculosum 
pustulosuin ; eczema papulosum ; eczema rubrum ; eczem 
eczema JUsum; eczema verrvcosum ; ecMema sclerosum. 

Oause. Eczema attacks persons in all spheres, the rich, the poor, 
the infant or the aged, and males or females. Many families, espe- 
cially those having the " catarrhal predisposition or pecuharity of i 
stitution," seem more liable ; indeed, it appears probable that a 
disposition to eczema may be transmitted from parent to child. 
Among the causes suggested are; dentition, improper food, gastro- 
intestinal disorders, intestinal parasites, deficient urinary 
Ihe rheumatic and gouty diathesis, vaccination, prolonged contact of 
hot fomentations, heat and cold, and contact with the poison vine 
{rhus toxicodendron) and poison tree (rhus venenata). 
' Pathology, Eczema is a catarrhal inflammation of the skin — 
a dermatitis with superficial serous exudation. There is first hyper- 




' medicine: 

amia or congestion of the vessels of the skin^czema erythematosum 
when uniformly distributed, eczema papulosum when the congestion 
is Umited to distinct points. The hyperfemia is soon followed by a 
serous exudation. If the superficial exudation be profuse enough to 
form small drops, and if the epidermis possess sufficient resisting 
power not to give away immediately before it, vesicles form, prodacing 
the variety known as eczema vesiculosum ; if the vesicles contain a 
large admixture of young cells, so thattheserumbe turbid, yellow and 
purulent, the vesicles become pustules, termed eczema pustulosum ; if 
the serous exudation be not sufficient to either elevate or break through 
the epidermis, instead of either vesicles or pustules forming there occur 
dry scales, rising from the reddened skin^-eczeraa squamosum. When 
the exudation is sufficient to detach the epidermis, thus exposing the 
red and moist corium, it is termed eczema rubrum. 

In chronic eciema the skin is subacutely inflamed ; is very much 
thickened, hardened and infiltrated with cells, which extend through- 
out the entire corium, even into the subcutaneous connective tissue. 
The papillae are enlarged and at times may be distinguished with the 
naked eye. Pigmentation may take place in the deep layers of the 
rete, and in the corium, especially about the vessels. 

SymptomB. Eczema is the most common of all cutaneous affec- 
tions, with symptoms varying in accordance with the particular variety 
of the affection and its location, although the general characteristics of 
a catarrhal inflammation are present in all; these are redness, dther 
limited or diffused, heat of the part affected, swelling, the result of the 
serous exudation, giving rise either to a ifijfA(ir^( weeping), with subse- 
quent crusting, or to the deposition of plastic material. The most 
constant annoying and troublesome symptom is the itching, or at 
times burning, which varies from that which is simply annoying to 
that which is almost unendurable. 

Eczema runs its course either as an acute affection, lasting a few 
weeks, not to return, or to return acutely at wide intervals, or, as is 
much more frequently the case, it assumes a chronic state, continuing 
with more or less variation for months, years or a lifetime. It may 
appear upon any portion of the body, or involve the whole integu- 



I 



the order 



1 



{ecsema universale). The varieties are named i; 
which the lesions assume at its ■ 

Sczema BrythematoBmn, An erythema or redness of the,. I 
surface, with a yellowish tinge. The size of the macule may be very 



small or quite extensive, with irregular outlines. There may be slight 
swelling of the patch, but no discharge occurs unless it be where 
two surfaces come into contact (ecsema intertrigo), as about the 
genitalia. Cases without dischai^e are covered after a few days with 
a thin film of dry, exfoliating epider 
When a discharge (weeping) o 
more or less crusting. 

Intense itching is a constant symptom. 

Eczema Veeiculosum. Begins with burning, pain, redness and 
swelling, followed by an immense number of minute ■vesicles, either 
discrete or confluent, rapidly distending with a clear or yellowish 
fluid and attended with intense itching. ' Soon the vesicles rupture, 
the fluid rapidly diffusing over the surface and dryiag into yelloivisA, 
honey-liki crusts. New crops of vesicles soon follow, or if subse- 
quent vesication do not occur, the fluid rapidly diffuses over the ex- 
coriated surface, which also, in turn, dries into lai^e, yellowish crusts. 
After a variable time the various symptoms gradually subside. 

/ArA/nf is the most prominent subjective symptom, is intense, and 
gives rise to an irresistible desire to scratch. 

All portions of the body are liable to this variety of eczema, the 
most frequent location, however, being the face, and when occurring 
in children is commonly known as crusta lacfea. 

Eczema Pustuloaum, or Eczema Impetieinosum. This 
variety usually begins as vesicular eczema, the fluid rapidly changing 
to pus. After a short period, during which Ihe pustules have in- 
creased in size, they burst and the escaped fluid forms thick, greenish- 
yellow crusts, which, in turn, rapidly dry and fall off, or crumble 

The location of this variety is most usually upon the scalp and face. 
It is stubborn to treatment. Itching is a prominent symptom. 

Eczema Papuloaum, or Lichen Simplex. This variety of 
ecicma appears in the form of small, rounded fiiipiilfS, the siie of a 
pin-head, of tiright red, or at times dark red color ; they may be either 
discrete or confluent. In some cases all, while in others a greater or 
less number of the papules pass into vesicles and run much the same 
course as vesicular eczema. The itching is of the most intense char- 
acter, leading to severe scratching, by which the summits of the 
papules are torn, causing them to bleed, the blood forming dark red 



328 PRACTICE OP MEDICINE, 

Eczema Bubrum, or Eczema Madidans. This is a. variety 

only from a clinical standpoint. It may result from any of the fore- 
going varieties. The surface of the skin is inflamed and infiltrated, 
reil, moist and lueeping, the profuse serum rapidly drying into thick, 
yellowish, greenish or brownish rrusis, the color depending upon the 
character of the fluid, which may be serum, pus or blood from the 
exposed and lacerated corium. The crusts adhere closely and Ri 
to the part, and, unless removed by mechanical means, may rem: 
indefinitely, the disease pursuing its course beneath. 

Eczema ruhrum, or madidans, "' then, presents two appearaaci 
as it occurs with its crust, and as it exists without this covering. In 
the one case the skin itself is altogether obscured by a dirty, yellow- 
ish or brownish crust; in the other the skin presents a bright or 
violaceous red, punctate, wounded surface, deprived in great part of 
its epidermis, and exuding a scanty or profuse, clear or opaque, 
syrupy, yellowish fluid. Sometimes this is streaked with blood. 
The itching and burning are severe. It may develop upon any poc. 
tion of the body, but is most commonly seen upon the legs, 
ticularly in elderly people. Its couree is chronic and increasing 
severity. 

Ejczema Sguamosum, This is also a clinical v^ety. 
suits from the erythematous, vesicular, pustular or papular varieties 
of the affection, but more particularly the first named. A typical 
case presents itself in the form of variously sized and shaped reddish 
patches, which are dry. or more or less scaly, the skin being more 
or less infiltrated or thickened. Its course is usually chronic. 

Bozema FiBBum, or Kimoeum. Another clinical variety. 
During the progress of the erythematous, vesicular or pustular- 
varieties of eczema, cracks oi fosures result when the lesion occi 
upon regions subject to constant motion, such as between the flngei 
loes and the various joints. At times the fissures are extensive 
deep, and of a bright red color, showing the true skin, and intense^] 
painful upon motion. Chipped hands are typical instances of fissui 

Eczem.a Scleroeum. This variety of eczema, occurring most 
commonly on the palms, soles and finger-tips, is characterised by 
hypertrophy of the papilla;, showing itself as hard, thickened, infil- 
trated, localized patches, which are most apt lo crack (i 
fissum). 



n tne 
madH 









DISEASES OF THE SKIN. 

Eczema Verrucosum, or Papillomatosutn, differs from the 
foregoing in that the thickened, infiltrated patch has a warty, verru- 
cous appearance. Its course is chronic. 

Eczema Acutum et chronieum. The line which divides 
these two conditions is drawn by means of the cUnical and patho- 
logical features. The course of eczema, in the majority of instances, 
is* chronic. It may be said that so long as the genera! inflammatory 
symptoms are high and the secondary changes slight, the affection is 
acute, and that when the process has settled itself into a definite hne 
of action, continually repeating itself and accompanied by secondary 
changes, it is chronic. 

DiagnosiB. The many varieties in which eczema manifests itself 
renders the diagnosis a matter of importance. The following charac- 
teristic features of eczema are of value in arriving at a diagnosis : 
inflammation, rnielling and tedetna, thicktning ftxim cell infiltration, 
redness, the discharge or moisture followed by crusting, on removal 
of which a moist surface is presented, and itching and burning. 

Erysipelas may be confounded with erythematous or vesicular 
eciema. Tlie points of difference are the fever and other general 
disturbances, the deep-seated inflammation of the skin, rapidly spread- 
ing, with heat, swelling and tedema without moisture, giving the sur- 
face a deep red, shining and tense appearance, are characteristic of 
erysipelas and very different from eczema. 

Herpes and vesicular eczema bear some resemblance to each other ; 
herpes zoster is distinguished by the neuralgic pains which are asso- 
ciated with it and is never associated with eczema. The other varie- 
ties of herpes occurring about the face and genitalia run their course 
in a few days, while eczema is of much longer duration and has a dis- 
charge followed by crusting. 

Seborrkcea of the scalp and squamous eczema of the same region 
closely resemble each other. In eczema, however, the skin is more 
or less red, inflamed and thickened, and the scales larger, less abun- 
dant and less greasy and drier than seborrhcea. In eczema the scales 
are usually seated upon a circumscribed patch, while in seborthcea, as 
a rule, they cover the scalp uniformly. Itching occurs with both dis- 
orders. The history of the two affections should be of material aid to 
renderthe diagnosis clear ; still, however, in many cases the difficulty 
is marked. Both are frequent affections. 

Psoriasis should never be confounded with a typical case of eczema. 



330 PRACTICE OF MEDICINE. 

but chronic eciema, with infiltrated, inflammatory, scaly patches, fte- 
quently looks very much like psoriasis. 

Treatment. There is no specific. The indications are for the 
removal of the cause, where it can be ascertained, if it be possit)le, 
and attention to the general health. The diet should be of the 
most nutritious, but easily digestible character ; fresh air and moderate 
exercise are also essential elements in the treatment, together with 
attention to the secretions. If the bowels be sluggish, much benefit 
follows the use of such laxative mineral spring waters as the Hathom, 
or Hunyadi Janos, or a morning dose a{ magnesii sulphas. For chil- 
dren, syruptis rkei, to which may be added magnesia; or what is per- 
haps more efficient, a small dose of kydrargyri chloridum mite. If 
the urinary secretion be small and the urine heavy, use should be 
made of full doses of po/assii acetas and large draughts of water. If 
either a rheumatic or gouty disposition exist, lithium salts, to which 
may be added •vittum colchici seminis. If a scrofulous tendency 
exist, use oleum nwrrhua and syrupus Jerri iodidi. If anjemia, 
ferrum, quinina, strychnina and the mineral acids are indicated. 

Locally: the most important means of treatment for all the varie- 
ties of eczema are with iocal remedies, suiting the appropriate ones 
for each particular case, as no one combination is applicable for all 
varieties. It may be staled, as a principle, that nothing irritant is ever 
to be applied to the surface in acute eczema, and that in the chronic 
fonn nothing can hardly be too stimularing. The too frequent wash- 
ing or general baths are to be avoided, as they have a tendency to 
macerate the already softened epidermis. For cleansing purposes, 
in the majority of instances, ordinary Castile soap is sufficient. 

Crusts and scales are nearly always present in eczema, and are to be 
removed before medicaments can be successfully applied. Their re- 
moval is to be secured by saturation with oily preparations, a starch or 
other mild poultice, or a saturated solution of acidum boracicum. After 
their removal the parts are to be cleansed with Casdle soap and water. 

For acute erythematous or vesicular eczema, use but little, or what 
is better, no soap or water ; instead, cover the parts with a dusting 
powder, such as — 

B- Pulv. camphors gj 

Zinci oleai 5ij 

M'-™rli - Si- M. 

SlG. — -Dusting powder. 



t 



DISEASES OF THE SKIN. 331 

For acute vesicular eczema, Dr. J. C. White recommends bathing 
the affected part with loHo nigra (hydrargyri chlor. mite, gr. viij, 
liquor calcis f^j). full strength, or diluted with equal parts of lime 
water, applied by means of a sponge or a piece of cloth, for ten or 
fifteen minutes at a time, and at intervals of a few hours or longer, 
the sediment being allowed to remain on the skin ; after which ung, 
zinci oxid. is to be gently rubbed over the part. As a rule, the itching 
and burning are relieved at once, and the affection often arrested. 
Good results follow the use of a saturated solution of acidum 
boracicum. 

There are cases which do better from the application of ointments, 
of which the following is valuable : — 

R. Zinci cleat., 

Olei olivse aS. ^iv. M. 

Or, bismuth oleat, made according to the following formula of Dr. 
McCall Anderson : — 

R. Bismuthi oxidi 3^j 

Acidi oleici ^j 

Cerge albae 3;iij 

Vaselini ^ix 

Ol. rosse .- TJJ^ij. " M. 

If the discharge be excessive, the following formula of Prof. Bar- 
tholow I have seen useful : — 

R. Plumbi acetat ^ss 

Pulv. camphorse gr. xv 

Ol. amygdal f^ij 

Cerat. fiav 3 J* M* 

The late Dr. Frank Maury was partial to the following formula in 
vesicular eczema : — 

R. Hydrargyri chlor. mite gr.xx 

Ung. zinci oxid. benz ^j. M. 

For eczema papulosum the following lotions are particularly 
valuable : — 

R. Acid, carbolici 3J-ij 

Glycerini -f^iv 

Alcoholis f^iv-vj 

Aquie destil ad Oj. M. 

— DUHRING. 



I 



f MEDICINE. 



Or— 



Thymol... 




Alcoholis _ fjj 

Aqua; destil fjj. M. 

After the disappearance of the more acute symptoms, more stimu- 
lating apphcations are indicated, among which are acidum caHtoH- 
cum, thymol, pix liquida at oleum cadinum. It is to be remembered. 
however, that the more chronic the affection and the less the inflam- 
matory symptoms, the more successful is tar in. the treatment of 

Dr. Duhring considers the following one of the most elegant of di 

R, Olei oadini fgiss 

Cemti simplicis Jj 

01. amygda! xaax gtt. i. 

FL ongt. 
Or-^ 

B- Picis tiquiilK f^j 

Gtrcerini fjj 

Aicoholis 'S'j 

01. aniygdal amar „ gtt-H- 

SlG. — To be rubbed firmly into (he skin. 
The following is Dr. Bulkley's valuable "liquor picis altcatinus"!! 

B. Picis liquida; fjij 

Fotassx caustlca; 3J 

Aquse destillaCx ,..„ f?^- 

The potassa to be dissolved in water and gradually added tc 
with rubbing in a mortar. 
SlG.— To be used diluted. 
A very elegant preparation of tar is the French mixture known as 
" Goudron de Guyot," 

For eczema rubrum, one of the inost intractable varieties of the 
disease, especially the chronic eczema of the legs, the following mode 
of treatment, first suggested by Hebra, is the treatment far excel- 

The accompanying instructions are to be adhered to. A lump of 
the sapo viridts (made originally of herring fat and polassa, and con- 
taining three per cent, of caustic potassa), the size of a small nut, ia_ 
smeared upon a piece of wet flannel and applied to the affected pubJ 



DISEASES OF THE SKIN, 

and firmly rubbed until the soap has disappeared, when the flannel Is 
to be dipped into warm water and again applied to the part and 
rubbed until an abundant lather forms, more water being added 
from time lo time until the suds are most abundant, when the surface 
is thoroughly washed and freed from all the soap and carefully dried, 
after which the following (Hebra's diachylon) ointment, having 
been spread before the application of the soap, is to be applied. It is 
prepared as follows ;^ 

" Fifteen ounces of the best olive oil are added to two pounds of 
water, and heated to boiling in the water bath. Three ounces and 
six drachms of an equally good article of litharge (plumbi oxidum) 
are dusted over the fluid in ebulhtion, which is constantly stirred 
throughout, in order to prevent the formation of fatty acids. During 
the cooking, water is occasionally added as required. TTie stirring 
is to be continued till the ointment is quite cold." 

The ointment is spread upon strips of soft muslin and the affected 
part enveloped, care being exercised that neither folds nor wrinkles 
occur, the whole being covered by a firm roller and the patient being 
able to go about as usual. The entire operation is to be repeated 
twice daily. 

A modification of the above ointment, technically known as 
" unguenium diachyli albi of Hebra" has been successful in my 
hands in a mmiber of marked cases. The formula is ; — 
B. Emplast. plumbi, 

Vaseline aa Si 

01. lavendulse „ q.s. M. 

Dissolve with heat ond'stir tilt cold. 
Sic. — Apply on strips, etc. 
Prof. Da Costa has used with success in eczema rubra, liquor 
arsenii et hydrargyri iodidi, m, ij-v, t. d., and — 

JJ. Ung. plnmbi subacet '. .5 iv 

Add. carbolici cryst gr. jij 

Ungl. pelrolei „ giv. M. 

SiG. — Apply freely on muslin strips. 
Eczema capitis is either erythematous, vesicular or pustular in 
character. If the first named, it at once tends to become chronic, 
settling into the variety known as eczema squamesuin, often involv- 
ing the entire scalp and accompanied with intense itching. The pus- 



PRACTICE OF MEDICINE. 

tular variety is the more coraraon form, occurring upon the scalp 0. 
children and young adults, existing as a few palches, or, what is 
frequent, involving the entire scalp. The pustules soon rupture, the 
liquid drying into greenish -yellow crusts, which, if the affection be 
extensive, cover the whole scalp with a cap of crust. The hair be- 
comes matted and caked, the sebaceous secretion collects, and if the 
part he not cleansed the head becomes offensive, in severe cases of 
pustular eeieina of the scalp, enlargement of the lymphatic glands of 
the back of the neck and of chose behind the ear occur; they never 
suppurate, Pediculi are frequently associated with eczema capitis of 
children, either as a primary cause or a result of the matted condi- 
tion of the hair constituting a favorable habitat for them. When 
present they call for active treatment. ^1 

Eczema capitis may be confounded with psoriasis, seborrhoesi^B 
syphilis, tinea favosa and tinea tonsurans. ^^ 

Treahrutit. If the fiusluUr variety, removal of the crusts is the 
first indication. This is accomplished by saturating the scalp either 
with oleum oliva or oleum amygdala dulcis, and then washing with 
warm water and soap, or the use of a starch poultice; after their re- 
moval the application of the following ointmetit, used by Profj 
Da Costa : — 

IJ. Hydrargyri chlor. mite gr. ix 

Acid, carbol, cryst „ gr- iij 

Ung, petrolei Jj. 

SlG— Thorougtdy applied. 

The late Prof Ellerslie Wallace was fond of the following :- 

5. Sodii carb gr.m 

Ung. pcCrolei Jj. 

Sio. — Apply thorougli'y alter removal of the Crusts. 

In cases associated •v'x'Cck pediculi, I have succeeded with the followtl 
ing, after removal of the crusts ; — 

R, Hydraigyri ammomat gr. x-ii 

Adeps. benioat ^j. 

SiG. — Thoroughly applied. 

For the squamous variety of the scalp, the following formula, i 
commended by Dr. Duhring, is excellent : — 



i SKIN. 

E, Hcis liquidas fjj 

Glycerini fgj 

Alcoholis _ f^SYJ* 

Ol. amygdalfe amar gtt. iv. M. 

SiG. — Diluted or full strength, tubbed thoroughly into scalp. 

Eczema faciei. In this location the affection may be either acute 
or chronic. In adults the erythematous variety is frequently encoun- 
tered ia patches about the forehead and cheeks. Eczema of the face 
is more common in children, however, the varieties being the vesicu- 
lar and pustular. It is seen on the forehead, nose and upper lip, and 
is associated with severe itching. 

Treatment. The same as eczema capitis, or the following : — 

B. Zinci oleat gj 

Ung. petrolei Jj. M. 

Eczema labiorum. Eczema attacks the lips, either alone or in con- 
nection with other parts of the face. One or both lips may be affected. 
The symptoms are: swelling, redness, heal, inliltration, slight scali- 
ness and fissures. The affection may be in the skin around the 
border of the mouth, or the vermilion and mucous membrane of the 
lips. The mouth may be contracted and the lips partly glued 
together by the exudation and crusts. 

Eczema labiorum may be confounded with herpes labialis and 
syphilis. 

Treatment. Very difficult and discomforting to the patient. 
Among the remedies at times successful are : argenti nitras, polassa 
nitras, acidum carbolicum, pix liquida, oleum ergota and coliodium 
Hexile. 

Ecsema palpebrarum. A frequent occurrence in scrofulous chil- 
dren, showing itself along the edges of the eyelids. Pustules in- 
volve the hair follicles, followed by the usual crusting. The symp- 
toms are swelling, redness and itching, and unless the parts arc 
frequently cleansed, the litis tend to glue together. Conjunctivitis 
frequently compUcates the affection. 

Treatment. In mild cases success follows the use of Bind oleat. or 
glyceritum acidi tannici. In severe cases the plan recommended by 
McCall Anderson should be pursued. It consists in the extraction of 
the eyelashes and touching the edges of the lids with a solution of 
patassa in water, ten grains to the ounce. The edges should be care- 



FKACIICE or HEDlCtHE. 

fuHy dried a.nd the lid everted, a very small quantity on a delicate 
brush being applied, immediately neutralizing the alkali with acidum 
acetic una or vinegar. 

Eizema barbie. Eczema of the beard is characterized by the for- 
mation of extensive pustules, with preference for about the hairs, 
drying as yellowish or- greenish crusts, matting the hairs together 
and adhering to the parts. The affection may be confined to the 
hairy portions of the face, or extend to other regions of the face, be 
localiied or general, acute or chronic. 

Eczema barbie in general features somewhat resembles both tinea 
sycosis and sycosis non-parasitica, hut sycosis is an inflammation ol 
the hair follicles only and is rarely associated with crusting, while 
crusting is abundant in eciema. 

Treatment. Must be energetic and decided. The crusts are to be 
removed by poultices or warm water and soap. Then the part is to 
be cautiously shaved ; although quite painful the first time, it is hardly 
so afterward, as it is to be repeated every two or three days. Aftei 
shaving, if the attack be acute, the same plan of medication as re- 
commended by Hebra for eczema rubrum is to be practiced, the appli- 
cation to be continuous both day and night, or only at nighL If the 
attack be chronic, the following ointment should be applied after 
cleansing and shaving the beard : — 

Bt. Hydrargyti ammoniat , _ gr. iT-m . 

Sulphur 3ss-i ^k 

Ung. petrolei gj 10 

Sio. — To be thoroughly applied. ^ 

In this variety of eczema I have seen marked benefit firom the use 
of liguor arsenii et hydrargyri iodidi, "1, ij-v, three or four times 

Eczema auriutn. Eczema of the ears may be either erythematous, 
vesicular or pustular. If the former, thickening results, with desqua- 
mation of flakes or large scales ; if either of the latter, crusts form, 
which may envelop the whole ear, the symptoms being swelling, red- 
ness and severe burning and itching, and if the process extend into 
the meatus, occlusion may result, causing temporary deafness. The 
most characteristic symptom of erythematous eczema of the external 
auditory canal, besides the appearance of small flakes, is intense and 
persistent itching. 



Treatment. For acute vesicular or pustular eciema, removal of 
the crusts and the use of hydrargyri chloridi mite as an ointment of 
the strength of thirty grains to the ounce. If chronic, the use of pix 
liquida, as already suggested. For chronic erythematous eczema of 
the external auditory canal, the following formula has generally coa- 
troUed this stubborn condition : — 

B- HydrarEyri flav. oiid gr.j-iij 

Morphina: sulph gr.j 

Vaseline 3 ij. M. 

SlG. — Apply to Ihe canal. 

Eczema genitali«m. This is a most distressing condition. In the 
male the scrotum and penis are involved alone or together, the former 
alone being the more common, and is complicated with eczema of 
the inner side of the thigh or thighs. The symptoms of eczema of 
the scrotum are, swelling, often cedema as well, moisture, crusts, and 
painful fissures, followed by extensive thickening and accompanied 
by intense itching. In the female the affection attacks the labiie, and, 
rarely, the vagina and mons veneris, and may extend to the surround- 
ing parts, especially to the perineum. The symptoms of eczema of 
the labia are, great swelling, cedema, redness, with great heat and a 
free dischai^e, forming crusts, which are apt to glue the opposing sur- 
faces together. If the variety be the erythematous, in place of a dis- 
charge with crusts, the symptoms named are followed hy slight scales. 
The itching is most violent and distressing. 

Treatment. The parts attacked should be kept constantly envel- 
oped in cloths wet with a saturated solution of aciditm boraeieum until 
the more pronounced inflammatory symptoms subside, when should 
be applied ointments of zinci oleaf. or hydrargyri chloridum mite. 
Persistent cases will often succumb to the plan of treatment suggested 
by Hebra for eczema rubrum. 

Eczema ani. The anus may be attacked alone or associated with 
eczema of the perineum and genitalia. The symptoms are : redness, 
swelling, inhltralion and thickening, with or without fluid exudation. 
Fissures of the anus are usually present, and add to the distress of the 
patient, the pain attending each stool. Persistent itching and burn- 
ing, worse after retiring, adds to the misery of the patient. 

Pruritus ani may be mistaken for eczema ani. In the former the 
itching is only associated with such symptoms of inflammation as 



338 PRACTICE OF MEDICINE. 

result from the irritation of scratching, while in the latter inflarama- 
■ tory symptoms precede the itching. 

Treatment. The more acute symptoms are reHeved by bathing 
the parts with a solution of acidum boracicum, after which a weak 
application of acidum carielicum, either as a lotion or ointment. 
The late Prof. S. D. Gross recommended the application of the 
following : — 

K. Zincioxidi gvj 

Hydrargyri chlor. conosiv gr. j 

Glycerini : „ ^ij. M. 

SlQ. — Apply thoroughly to affected parts. * 

Eczema interirigo. Parts of the body that naturally come into con- 
tact with each other, as about the joints, the inner surfaces of the 
nates, in the groins and beneath the mammee, are freqtiently attacked 
with Che erythematous eczema, which is frequently, but erroneously, 
termed erythema intertrigo or chafing. The symptoms are : redness, 
heat, and a moist, macerated surface, aggravated by movement of 
the affected parts . 

Treatment. The application of a solution of acidum boracicum, or 
the use of dusting powders, such as, zinci ohat., amylum or hydrar- 
gyri chloridunt mite. It is essential for successful treatment that &e 
opposing surfaces be separated by means of lint or cloths. 

Eczema mammarum. The nipples, and more particularly those of 
primiparse, are at times the site of a vesicular eczema, with the forma- 
tion of crusts and fissures, and unless speedily relieved developes 
eczema nibrum. The pain on nursing becomes so severe that the 
mother is compelled to refuse the child. It must be borne in mind 
that eczema mammarum occurs in women who are not nursing andin 
single women. 

Treatment. Dr. Tilbury Fox advises the following plan : — 
" I. Great cleanliness and care in washing away any remnants of 
milk after each time that the child is put to the breast; and, if the 
nipple be tender and excoriated, use — 

" 1. A little liquor plumbi and calamine powder, as follows : — 

B- Lil' plurtbi S'ss 

Pulv. caUmina! prasp Siss 

Glycerin! gj 

Adepia U gj. M. 



DISEASES OF THE SKIN. 339 

" 3. I cover over the nipple with a. lead nipple shield. This ex- 
cludes the air, keeps ihe part from being chafed, and I think the lead 
does good after the part has become less red and sore. I often use a 
little glyceral tannin, painted on night and morning 

'■ The above application can always be removed with a little cold 
cream and a little warm water, spongiog before the child goes to the 

Eczema paltnarum et planiarum. The features of the affection in 
both these regions are identical. The diagnosis is often obscured by 
the thickened state of the epidermis. The symptoms arc ; infiltra- 
tion, thickening, callosity, moisture followed by dryness, and Assur- 
ing, the last named frequently becoming so deep and painful that the 
padent is unable to use his hands, or, if on the soles, to walk. 

The affection is mostly chronic, affecting either of the parts alone, 
or all at one and the same time. Itching is a constant and annoying 
symptom. 

The diagnosis is to be made between ec/ema of these parts and 
psoriasis or syphilis. 

Treatment. The plan of Hebra for eciema rubnim will usually 
be successful for this variety. The following formula is also 
valuable ; — 

B- Hydrargyri oleaC. 5-15 per cent giv 

Olei cadini Jss 

Cerat. simp giv. M. 

Sic. — Rub well iato part morning and night, fint macerating in hot 



Eczema -unguium. The nails are seldom attacked alone, but in 
connection with eciema manuum. The symptoms are ; roughness, 
want of polish, unevenness and a punctate or honeycomb appear- 
ance, similar to that seen in psoriasis of the nails. The nail becomes 
depressed, particularly at its root, thus interfering with its nutrition, 
resulting in loss of the appendage. 

Treatment. Internally arsenicum is of the greatest value. Locally, 
the following ; — 





840 PRACTICE OF MEDICINE. 

URTICARIA. 

Synonyms. Hives ; nettle-rash. 

Definition. An inflammation of the skin characterized by tbc'j 
development of wheals of a. whitish, pinkish or reddish color, accom- 
panied by stinging, pricking and tingling sensations. 

Cauaes. Irritants and poisons produce an attack when brought 
in contact with the skin. Gastric, intestinal, hepatic, nephritic, ova- 
rian, uterine and cystic derangements are very frequent causes. 
Certain medicaments ; malaria ; nervous disorders ; associated wifli 
purpura and rheumatism ; pregnancy ; lactation ; menopause. 

PathologT. An acute inflammation of the papillary layer of the 
skin ; chacacteriied by the rapid development of a " wheal " — S' 
more or less firm elevation— consisting of a circumscribed collection. 
of a. semi-fluid material, the result of a rapid exudation into tbe 
upper layers of the skin. The production of the wheal is the imme*. 
diaie result of a disturbance of the vaso-motor system, which is showtt' 
by the interference of the circulation in the wheal, the blood being 
driven from its centre to its periphery, causing the whitish apex and 
red areola, so characteristic of the developed wheal. 

Symptoms. An attack of "hives" is characteriied by the 
sudden development of ivAeals upon the cutaneous surface, which 
usually as suddenly disappear, their site being temporarily marked 
by a spot of redness or hyperferaia. 

With the appearance of the wheal occur distressing ticking, bum' 
'"£• tickling, craviling, •pricking and stinging sensations, to relieve' 
which the patient still further irritates, tears or otherwise wounds the 
surface by scratching, whence are often developed deep-colored, flat, 
lenticular papules. 

Very frequently an attack of "hives" is associated with fever, head- 
ache and gastric disorder. The "wheals" may appear upon any 
portion of the body; their size varies from that of a pea to that of a.- 
walnut or an egg — the "giantwheals:"thenumber varying from a very 
few to being so numerous as to cover the whole surbce of the body. 
The shape, siie, color and number of the wheals- that may occur in 
any given case have given rise to a number of names to de^gnate 
the lesions. Thus, urticaria annularis occurs in rings ; uriuraria 
figurata occurs in spirals ; urticaria vesiculosa has a vesicular 
development on tbe summit of tbe wheal ; urticaria bullosa, a bul- 
lous development at the simmiit; tirticaria papulosa or Uchatta^ 



eaius, the wheal and a small papule are combined; urtiearia tuberosa, 
or giant wheals; urticaria hemorrhagica ax purpurata urticata, a 
corabiaation of urticaria and purpura ; urticaria evanida, a rapid 
appearance and disappearance of the lesion ; urticaria persians. slow 
disappearance ; urticaria conferta, when the wheals are confluent ; 
urticaria piginenloia, where the wheals are succeeded by pigmenta- 
tions of the site.the tints varying from dark-brown, greenish-yellow, to 
a chocolate color; urticaria fobrilis, vihea the wheals are associated 
with fever ; urticaria ab ingcstis, when associated with indigestion. 

Treatment. To prevent the recurrence of the disorder a thorough 
investigation of the cause must be made, and when found (not always 
possible) be removed. 

Attention should be directed to the state of the general health, the 
diet and the secretions. 

The following remedies, alone or variously combined, are often of 
benefit: quinina, sodii salicylas, pilocarpus, atropina, tinctura bella- 
donna, ammonii chloridum, arsenicum and potassii bromidum. The 
following pill is valuable in many cases ; — 
£t - Fulv. pilocarpus, 

Est. guaiaci M gr. iss 

lithii bcnioat gr. iij. M. 

SlG. — Two to four each twenty' four-hours. 

If there be atonic dyspepsia and constipadon, the following combi- 

B . Magnesii snlphat Jj 

Ferri sulphat gr.viij 

Sodii chlotidi jss 

Acidi sulphorici dil -fj^ 

Inf. caKariUBe. ad... fjir. M. 

SiG. — Tablespoonful before breakfast, diluted. 

Local measures are of the greatest value, either as baths, lotions, 

or dusting powders. The following are among the most serviceable : 

sponging with alcohol, brandy .whisky , vinegar and -water, salt -water, 

alkaline baths and acid baths. Duhring recommends the following : 

8 . Acidi carbolici...; 3 iss 

Glycerini fgij 

Alcoholis f^viij 

Aq, amygdal. aniar „ fj^'j' M. 

SlQ.^ — Use u a lotion, two 01 three times daily. 



342 PRACTICE OF MEDICINE. 

Bulkley suggests the following : — 
£^ . Chloralis, 

Camphorae 9,9, ^3 j- 

Misce, and rub and incorporate with 

Pulveris amyli , ,,, 3j-4j. 

Misce, and keep tightly corked in a wide-mouthed bottle. 
SiG. — Rub in with hand. 

A serviceable formula is the following : — 

U. Chloroformi , „ fa^j 

Ung. zinci oxid „ gij. M. 

SiG. — Apply with hand. 

HERPES. 

Definition. An acute inflammation of the skin ; characterized by 
the development of one or more groups of vesicles ^ filled with a clear 
serum, occurring for the most part about the face {herpes facialis) , 
and genitalia [herpes progenitalis). 

Causes. Herpes facialis ; during the course of febrile and ner- 
vous disorders ; in connection with digestive disorders and colds. 

Herpes progenitalis ; the origin is local, from uncleanliness or 
friction. 

Pathology. Hebra defines the various forms of herpes as "a 
series of acute cutaneous diseases of cyclical course, marked by an 
exudation which collects in drops under the epidermis and elevates 
it ; forming vesicles which are never solitary, but always appear in 
groups." 

Symptoms. The appearance of the vesicles is usually preceded 
by a feeling of heat in the region, together with slight tumefaction or 
swelling. Rarely the herpetic attack is attended with malaise and 
pyrexia. 

The eruption usually appears in the form of a small cluster of pin- 
head to split-pea sized vesicles, containing a clear fiuid, becoming 
cloudy, afterward puriform and dries in small, yellowish or brownish 
crusts ; they are few in number and may coalesce. They disappear 
without leaving a scar. 

Herpes facialis ; occur upon any portion of the face, but most 
frequently about the lips — herpes labialis. The alae of the nose, 
auricles and the mucous membrane of the mouth and tongue are 



DISEASES OF THE SKIN. 343 

frequent locations, in the latter appearing as excoriated patches from 
rupture of the vesicles. 

Herpes progenitalis ; in the male the chief site is the prepuce 
[herpes firapulialis). In the female they are comparatively rare : but 
when occurring it is upon the la.bia majora and minora and the skin. 
about the vulva. 

This variety is preceded by burning, itching or neuralgic pains, 
accompanied with redness, congestion and more or less cedema. 

The lesion in these parts Is liable to be mistaken for one form or 
Other of venereal disease. 

Herpes gesiaiionis : a rare affection of [he skin occurring during 
pregnancy, consisting of erythema, papules, vesicles and buUas, 
attended with intense burning and itching. It may appear at any 
time of pregnancy up to the seventh month, and continues until some 
time after delivery. 

Treatment. Herpes facialis seldom calls for treatment, although 
in marked cases ol herpes iadialis protection with liquor gutta-percha 
or collodium Jlexile promotes dessication. 

Herpes progenitalis ; cleanliness is all Important. Coating the 
lesion with the medicaments mentioned above or washing with a 
saturated solution of acidum boracieum, and afterward dusting with 
hydrargyri ehloridum mite, are useful. 

The parts- may be rendered less -sensitive in frequently recurring 
cases by astringent lotions, as acidum tannicum or zinci sulphas. 
Circumcision, where required, may be practiced. 



HERPES ZOSTER. 

Synonyms. Zona ; shingles ; a girdle ; intercostal neuralgia. 

Definition. An acute, inflammatory disease; characterised by 
the development of groups of firm and distended vesicles situated 
upon inflamed bases and accompanied by more or less severe 
neuralgic pains. 

CaUBea. The eruption and consequent neuralgic pains are the 
immediate result of an inflammation of the ganglia or of the nerve 
trunks and branches — a neuritis — probably of the trophic fibres of 
the affected part : but the cause producing this condition is obscure. 
Among the many that have been suggested are: cold, injuries to 
nerves, anaemia, malaria, and the medicinal usi 



34i PRACTICE OF 

Fatiholosy> An inflammation of either the ganglia, the nerve 
trunk or branches — probably the trophic system— causing the de- 
velopment of vesicles in the lower strata of the rete, with " the 
infiltration of serum and inflammatory cells" of the papillae and 

Symptoms. Begin with neuralgic pains, either of a burning or 
lightning-like character, with slight febrile phenomena, followed by 
the appearance of papulo-^esiclcs along the tract of pain .- these soon 
become vesicles situated on bright red, highly-inflamed bases. The 
vesicles are about the size of pin-heads or perhaps a little larger, 
usually discrete, although they frequently coalesce, forming irregular 
patches, coming in groups until the third to the fifth or even tenth 
day, when they gradually desiccate and at the end of the second 
week nothing remains but a slight scar, which may also disappear 
after a time or rarely is permanent. 

When the eruption is at its height it is perfect iii its anatomical 
formation, each vesicle being well shaped and seated on a bright red, 
inflamed patch of skin, and distended with a translucent, yellowish 
fluid. 

The eruption is almost invariably confined to one side (utulateral) 
of the body, although, in rare instances, it is seen upon both (bi- 
lateral) sides. It is usually found upon well-known nerve tracts. 
According to the region aflected it is termed soster capitis, sosier 
frontalis, poster faciei, sosier ophthabnicus, zoster auricuiaris, zoster 
nucha, snster brachialis, xoster pectoralis, aoster abdominalis, xoster 
fanoralis. 

In the very young the eruption may develop and pursue its course 
without the neuralgic pain'; 

DiaemoBiB. The characteristics of herpes loster or shingles are 
usually so well marked that an error in diagnosis should not occur. 
The neuralgic pain preceding the eruption and its development in 
distinct groups upon inflamed bases following a nerve tract are so 
different from simple herpes of the face, or genitalia, or from the 

Proguosia. Favorable. The aflfection is self-limited,* the dura- 
tion being about two weeks. It is said that " zoster of the orbital 
region may seriously involve the eye and prove fatal." 

Treatment. The aflection being self-limited, it follows thai 
remedies to cut it short are useless, although claims are made that 



DISEASES OF THE SKIN. 345 

** zinci fhosphidum,gr, % every three hours, control the pain and 
abort the eruption." 

Prof. Bartholow " has seen excellent results in cases of shingles 
from galvanization of the affected intercostal nerves — the positive 
pole being placed over the point of emergence of the nerves, and 
the negative brushed over the terminal filaments in the skin." 

The general symptoms are to be treated as indicated. 

For the pain no remedy seems comparable with the hypodermatic 
use oi morphincB sulph., gr. }i-}4* with atropince sulph,, gr. ^ , near 
the lesion. 

Locally, relief follows coating the "shingles" with either collodium 
flexile or liquor gutta-perchcB, to which morphincB sulph. may be added. 

MILIARIA. 

Synonyms. Lichen tropicus; miliaria rubra; miliaria alba; 
prickly heat. 

Definition. An acute inflammation of the sweat glands; char- 
acterized by the development of discrete, whitish or reddish, pin- 
point and millet-seed-sized papules, vesicles or vesico-papules, pro- 
ductive of pricking, tingling and burning sensations of a most aggra- 
vated character. 

Causes. Excessive heat, the result of excessive or tightly-fitting 
clothing, or a high external temperature. Most common in fleshy 
adults who perspire freely, and in children. Nervous prostration, 
severe dyspepsia and general debility seem to predispose to " prickly 
heat." 

Varieties. Miliaria papulosa ; miliaria vesiculosa. 

Pathology. The pathology of the two varieties is the same, 
both being inflammatory affections of the sweat glands; in the one 
papules, and in the other vesicles, develop about the orifices of the 
excretory ducts. 

In either variety occurs hyperaemia of the vascular plexus of the 
sweat gland, followed by slight exudation about the ducts, giving rise 
to the minute papule or vesicle, which remain until the cause has been 
modified or removed, when they are rapidly absorbed. 

Symptoms. Miliaria papulosa ; known as lichen trophicus and 
" prickly heat," is of sudden onset, with the occurrence of numerous 
minute, acuminated, bright red papules, about the size of a pin head 
p 



346 PRACTICE OF MEDICINE. 

or millet seed, and but slightly raised above the level of the skin. 
The papules are preceded by and accompanied with sweating (hy- 
peridrosis), and distressing tingling, pricking and burning sensations. 
If the attack be severe, vesico-papules and vesicles are freely inter- 
spersed among Che numerous papules. 

Miliaria vesiculosa; in this variety, instead of papules, immense 
numbers of vesicles develop, of the size of pin points and pin heads, 
of a whitish [miliaria alba) or yellowish-white color. The surface 
from which they arise is of a bright-red color, owing to each vesicle 
being surrounded by an areola {miliaria rubra.) The vesicles are 
preceded and accompanied with sweating (hyperidrosis) and most 
distressing tingling, pricking and burning sensations. 

Either variety may attack all parts of Che body, but the abdomen, 
chest, back, neck and arms are the regions usually invaded. 

Duration. This varies with the cause. It may appear, fiilly de- 
velop and disappear in a few hours. In those predisposed, it may 
continue more or less marked throughout the entire summer. 

Diagnosis. If the cause, nature and seat of the aifection are 
taken into consideration, no error should occur. 

Eciema papulosum has a resemblance to " prickly heat," but the 
course of eczema is slow, and the papules are larger, more elevated, 
and firmer than those of miliaria papulosa. 

Eczema vesiculosum and miharia vesiculosa are to be diflerentialed 
by the marked differences in the progress of each, the former slow, 
the latter rapid, the vesicles of the former rupturing spontaneously, 
those of the latter only when severely irritated. 

Sudamen is not an inflammatory affection, while miliaria is. 
ProgTDOais. The affection is often most rebellious in fleshy per- 
sons and children, and if neglected it passes into eczema or an 
erythematous intertrigo. 

Treatment. The patient should he kept as cool as possible, and 
undue perspiration avoided. The fears entertained by the laity, ol 
danger from retrocession of the eruption, are groundless ; the soona 
it disappears Che better for Che comfort of the patient. 

The food should be light and unstimulating ; wine, spirits and beo 
are to be avoided. 

The ingestion of water, lemcmade, Apollinaris water, Vichy water, 
together with refrigerant diuretics, as polassii citrasvel acetas, a cool 
apartment, and absolute rest will ordinarily insure speedy relief. 



ii OF THE SKIN. 

Locally ; sponging wilh alkaline lotions, liquor pliimbi subacelatis 
dilutus, exiractum grindellce Jluidum well diluted, or cupri sulphas, 
in solution, gr. jt, aqus, f^j, or dusting powders, consisting oi lycepe- 
dium, zinci dxidum and amylupt. singly or combined. 

PEMPHIGUS. 

Synonym. Water blisters. 

Definition. An inflammatory disease of the skin, either acute 
or chronic, characterized by the development of a succession of 
rounded, irregular-shaped blebs or bullae, varying in siie from a pea 
to an egg. 

VarietiBB. Pemphigus vulgaris; pemphigus faliaceus. 

Cause. Obscure. It is usually associated with a depressed slate 
of the general system ; disorders of menstruation ; during pregnancy. 

Pathology. Hebra thus describes the appearance of the blebs: 
" Sometimes a circumscribed, light-red spot appears, perhaps of the 
size of a bean or large coin ; this is paler in the centre, and may even 
present a tinge of white, indicating the point at which the bleb is to 
form, and from which it will spread outward over the surrounding 
skin, and, in fact, is at first a wheal, passing afterward into a bleb. 
In other cases the bleb is not preceded either by a red spot or by a 
wheal, but begins originally as a small collection of clear fluid be- 
neath the cuticle. Thus, hyperemia of the skin may exist before 
exudation is poured out, or the latter may be formed before any con- 
gestion of the papillary layer is discoverable." 

The contents of the blebs or bullK are yellowish or colorless serum, 
of a neutral or alkaline reaction, the older the fluid the more alkahne 
it becomes. In the late stages of a bleb the fluid becomes puriform. 
In rare instances blood is contained in the bleb (pemphigus hemor- 
rhagicus). 

Symptoms. Pemphigus vulgaris ; the onset is slow (pemphigus 
ckronicus), without constitutional symptoms, or acutely (pemphigus 
acutus) preceded by febrile reaction. The lesions are the successive 
development of blebs, usually from half a dozen to a dozen, varying 
in size from a pea to an egg, of a round or oval shape, their walls dis- 
tended with a colorless fluid, the color becoming yellowish or puri- 
form as they grow older. They develop abruptly from the sound 
akin, with a definite line of demarcation, unattended with symptoms 



348 PRACTICE OF MeoiciNE, 

of inflammation. A characteristic phenomena of the lesion is UteW 

successive appearance ; a crop no sooner disappears ihan a.nother 
forms, throughout the course of the affection, each crop running iis 
course in from three to six or ten days. With the appearance of the 
blebs occur itching and burning, usually of a mild character, although 
occasionally in a distressing degree (pemphigus pruriginosus]. 

Pemphigus malignus is characterized by the great size and number 
of the blebs, which coalesce, rupture and are succeeded by excoriated 
surfaces which occasionally take on ulcerative action, the patient's 
health being seriously impaired. 

Pemphigus foliactus differs from pemphigus vulgaris in that the 
blebs, instead of being distended or tense, are flaccid and only par- 
tially filled with fluid, as they rupture before arriving at their state of 
full development. This variety also appears and disappears in crops. 
After rupture the fluid immediately dries into thin, whitish flakes. 
which are detached in quantity, leaving a red, excoriated surface — 
the rete and corium. If the aflection has continued for some time, 
the skin presents the appearance of a superficial scald. The course 
of this variety is essentially chronic. 

AH portions of the body are liable to the lesion, as also the mucous 
membrane of the mouth and vagina. It is most common, however, 
upon the limbs. 

Diagnosis. In a typical case no difficulty should be experienced 
in making a diagnosis. The mere presence of blebs, however, does 
not necessarily constitute pemphigus, for it must be remembered that 
they are at times developed in other diseases as well as by artificial 
means ; the appearance of blebs in crops is a strong diagnostic 
point. 

PrognoBiH. The course of the affection is most uncertain, and 
relapses are frequent. In arriving at an opinion the occurrence of 
fatal cases must not be forgotten. 

Treatment, Attention to the general health of the patient is of 
the greatest moment. A careful study of the cause should be made, 
and if determined, means for its removal are of the first imparlance. 

Two remedies, arsenicum and guinina, are of great value, the 
secret of success being the persistent use of the former; or if the latter 
be used, the dose should be large. 

Local measures are also of importance. The blebs should be 
punctured and evacuated as soon as formed. The use of dusting 




J 



powders of zinci oxidum, antylum, or ■nioht-poinder, c 
liquor plumbi subacelatis dilutum, are valuable. 
Hebra recommended the coatinuous bnlb. 



IMPETIGO. 

Definition. An acute inflammatory disease, characterised by the 
development of one or more discrete, rounded and elevated firm 
pustules, about the size of a pea, unattended by itching. 

Causes. Occurs for the most part between the ages of three and 
ten years, in the well nourished and healthy. It is not associated 
with eczema. It is not contagious. 

Pathologfy. The lesion is a weil-formed, typical pustule, devel- 
oping abruptly from the surface, containing a whitish-yellow fluid, 
pus corpuscles, blood corpuscles, epithelial cells and cellular detritus. 
The abscess or pustule is about the site of a pea, circumscribed and 
superficial. 

Symptoms. The affection manifests itself by the development 
of from one or two to a doien or more distinct pustules, about the sise 
of a split pea, of a rounded shape, raised above the surface, with 
thick walls, of a yellowish or whitish color, surrounded by a distinct 
areola, which soon fades, are without a central depression or umbili- 
cation, and unattended with either itching or burning. 

The affection runs an acute course, usually lasting a couple of 
weeks. The pustules, after attaining their full size, remain stationary 
for a few days, when they disappear by absorption and desiccation, 
the crusts dropping off, displaying a reddish base, which soon dis- 
appears with pigmentation or scar. 

The pustules occur on all portions of the body, the most frequent loca- 
tions being the face, hands, fingers, feet, toes and lower extremities. 

Diagnosis. Impetigo is unassociated with general symptoms, 
and its particular lesion — the pustule — is discrete, points of import- 
ance in the diagnosis. 

Eczema pustulosum is also a pustular affection, but the large num- 
ber, their disposition to coalesce, their location upon an inflammatory 
base, their rupture and subsequent crusting and itching, are diagnostic 

The diagnostic points from ecthyma will he 'pointed out when 
describing that affection. 



f 



Prognosis. Favorable, 

Treatment. The pustules should be opened as soon as tbey 
mature, the contents removed by washing with tepid water and 
soap, and the floor covered with hydrurgyri chloridum mile or zinci 

Coating the pustules with collodium flexile or liquor gullte perchu, 
if they are located where irritation be liable, is a valuable mode 
treatment. 



ECTHYMA. 



(^ 



I 



Definition. An affection of the skin, characterized by the forma.- 
tion of one or more large, isolated, flat pastuUs, situated upon an 
inflammatory base. 

Cause. It is most common among those who live in squalor and 
poverty, and in delicate and poorly-nourished children. Improper 
and insufficient diet, want of ventilation, excessive work, and un- 
cleanliness are all prominent causes. 

Pathology. The lesion is a typical pustular process, severe but 
superficial, and not extending beyond the papillary layer of the 
corium. The pustule is situated upon a firm and highly -in flamed 
base ; the number varies horn, one to a dozen or more. 

Symptoms. The disease b characterized by the development of 
one or more round or oval, -jtx flat, pustules, about the size of a pea- 
bean, attended with moderate luat, burning and pain, and if the 
number be large, slight febrile reaction. The pustules are first 
yellowish in color, surrounded by a firm and sensitive bright-red 
areola, the pustule afterward becoming reddish, from the admixture of 
blood, soon drying into flat crusts of a brownish color. The dura- 
tion of each pustule Is between two and three weeks, new ones form- 
ing, until the cause is removed. 

The most prominent sites are the thighs, legs, shoulders and 

Diagrnosis. Ecthyma and eciema pustulosum have points of re- 
semblance, but a study of the clinical history of the latter should 
prevent error. 

Impetigo differs from ecthyma by the character of the pustule 

Prognosia- With care and removal of the 
always prompt. 




DISEASES OF T 



Treatment. The general treatment of the patient i 
importance. Nutritious and wholesome food, cleanlini 
fresh air and regulated exercise should be advised, t 
such tonics as fcrrum, aruiUcum, quinina, slrycAnina 



351 

; of the first 
ss, bathing, 
igelher with 
ind mineral 



Locally : remove the crusts by first soaking with oil or fat, or water 
dressings, and apply — 

a. Ungt.ibdoxLd.benz § ss 

Vnselini Jss 

Hydraigyri ammoniati _ g j. M. 

Ft. ungt. (DiJHRlWi.) 

Pustules showing a sluggish disposition to heal should be stimulated 
by touching with v.'^ex argenii itilras OTOcidum carbolicum. 



FURUNCULUS. 

Synonyms, Funmculosis ; furuncle; boil. 

Definition. An acute affection of the skin, characterized by the 
occurrence of one or more circumscribed cutaneous or subcutaneous 
abscesses (boils), which usually terminate by necrosis of the central 
tissue, its subsequent expulsion in the form of pus or a core, and a 
resulting cicatrix. 

Cause. The result of a depraved condition of the system, in- 
duced by general debility, excessive fatigue, nervous depression, 
improper food and exercise, anasmia, diabetes, unemla, or the result 
of local friction, pressure or contusions. 

Pathology. The process resulting in a " boil " has its origin in 
either a sebaceous gland, sweat gland, or a piliary follicle, and never 
begins in the meshes of the corium. " It begins as a small, roundish 
spot, which increases In siie until certain dimensions are attained, 
when it undergoes suppurative change, resulting in the formation of a 
central point or core, composed of the tissue of the gland in which 
the furuncle originated, which, together with pus. is east off. It shows 
no disposition to become diffuse, being always a circumscribed ia- 
flammation. After the discharge of the core, a cavity of more or less 
depth remains, showing the tissues around it to be hard and infil- 
trated. After a few days or a week it fills up by granulation, leaving 
a cicatrix, which is often permanent. The central point or core, when 
thrown off, is composed of a whitish, tough, pultaceous mass of dead 



35-2 



OP BEDICTSE. 



•.c with the e 



It and depth of the inflar 



tissue, varying ii 
(Duhring). 

Hydro- adenitis, as seen in the axilla, around the nipplea and aboirt 
the anus or perineum, differs from the ordinary " boil " merely in be- 
iny deeper seated. 

Symptoms. "Boils" may occur singly, or more commonly in 
crops of two, three or more, another crop following their disappear- 
ance (furiinciihsis). 

The abscess begins as a small, rounded, imperfectly defined, iso- 
lated, reddish spot, of a highly inflamed character, gainful on pres- 
sure, its si EC gradually increasing, its central point presenting evidences 
of suppuration, Ii reaches its full development in about a week, when 
it consists of a slightly raised, rounded and pointed inllammaiory 
swelling with a yellowish point in the centre — ihe " core." Abscesses 
with no central suppuration or core are called "blind boils." The 
si/e of a developed boil varies from a split pea to a walnut, Ihe color 
deep red. with a yellow centre, and is surrounded by a slight areola. 
The pain of a toil is dull and throbbing, painful on pressure, and is 
usually worse at night. The constitutional symptoms are mild or 
severe, according lo the number and size of the lesions. 

Any portion of the body may be attacked : its preferi 
is fnr the face, neck, hack, axillie, nipples, butlocks, a 
and labiae. 

Diagnosis. The characteristics of furuncle are so marked that 
an error seems impossible. It may be, however, mistaken for car- 
buncle, the differences between which will be pointed out when dis- 
cussing that affection. 

Prognosis. No danger results from occasional boils, but when 
occurring in crops they impair the general health and are rebellious 
to treatment. 

Treatment. The treatment of a single boil is well expressed in 
the word " time ; " warm applications are said to hasten the stage of 
suppuration, and when reached an incision permits the expulsion of 
the "core," after which the cure soon results. If the lesion is 
located where friction or pressure is likely, protection by cither cover- 
ing with adhesive or soap-plasler, smoothly spread, is ample. 

When, however, successive crops of boils occur ^furunculous), the 
treatment should he both constitutional and local. The economy 
being below par, such tonics as arsemcum, quinina and /errvm are 



e, however, 
i, perineum 



DISEASES OF THE SKIN. 353 

of value. Calcii sulphid., gr. Tj-'-ii every two or three hours, ih 
valuable in these cases. 

locally, attempts to abort the process may well claim attention, 
among which are : crucial incisions, to relieve the tension of the central 
point, will often abate tlie inflammation and prevent the gangre; 
this little operation is rendered painless by the use of the ether spray, 
Aeidum earboliaim, used in five per cent, solution, of which two to 
five drops injected into the apex of the boil is valuable. Painting 
the forming boil with argenii nilras or tinchira iodi., are also recom- 
mended. 

ANTHRAX. 

Synonyms. Carbunculus ; carbuncle. 

Definition, An indurated, more or less circumscribed, dark red, 
painful, deep-seated infiammalion of the skin and subcutaneous con- 
nective tissue, terminating' in a slough and the subsequent production 
of a permanent cicatrix. 

Causes. Not positively determined. Perhaps, as in furuncle, 
impairment of the genera) health is the important factor. It is gen- 
erally noted to occur in middle and old age, and in men more fre- 
quently than in women. A " specific " cause for anthrax is not an 
improbable discovery, 

Patbologry. Although Billroth regards furuncle and carbuncle 
as differing only in degree, the explanation of Warren, of Boston, 
seems the more probable, he being the first to call the attention of 
histologists " to the existence of small columns of adipose tissue lead- 
ing from the panniculus adiposus up to the roots of the lanugo hairs, 
taking an oblique direction in a line with the erectores pilorum. 
The inllammation resulting in suppuration of the subcutaneous adi- 
pose tissue, must either form an abscess or become diffuse. In 
phlegmonous erysipelas the latter condition is observed. But when 
the inflammation is in the dermoid texture, the exudates infiltrate the 
skin and naturally follow the canals occupied by the " columnse adi- 
posie." The pressure thus exerted upon the whole dermoid tissue 
cannot fail to strangulate the circulation, and thus produce gangrene 
of the tissue, even if the exudate be not poisonous enough to destroy 
the cell by its presence. It can, by this explanation, be easily under- 
stood why this disease is apt to affect the skin on the nape of the 
neck and the back more than on other parts of the body. At this 



854 FRACTICE OF MEDICINE. 

point the skin is dense, its fibrous element extending deep into i 
adipose layer, which is surrounded with strong band| ; hence, the p 
confined in such b. place, seeking the easiest outlet, will travel atoi 
these miniature adipose canals, producing the peculiar appearand 
pathognomonic of carbuncle." 

Symptoms. Carbuncle is recognized by its peculiar form ; com" 
mencing in the lower layers of the cutaneous tissue, it first resembles 
somewhat a phlegmon minus its bright redness. At first it i 
what rounded, with a strong tendency to the production of vesieUs o 
its surface, soon, however, becoming firm, circular and flat, i 
raisedabovethe surrounding parts, spreading through the subcutanee 
tissue and skin, becoming at times enormously large, and having a 
dark red or violaceous color. As the disease progresses, the pressure 
results in the softening of the tissues, the skin becoming gangrenous, 
breaking down at numerous points, forming perforations, through 
which centres of suppuration appear in different stages of advanci 
ment, either as whitish, fibrous plugs, or as cavities, from which* 
yellowish, sanious fluid oozes, the surface of the anthrax having | 
cribriform appearance, perforated like a sieve. The e 
minates in a slough, which, on being detached, leaves a large, opea, 
deep ulcer, with firm, everted edges, granulating slowly, a permanent 
cicatrix marking the site of the lesion. The development of the 
carbuncle is attended with severe pain of a deep throbbing and burn- 
ing character. 

The constitulinna! symptnms vary with the siie. number and sever- 
ity of the disease ; loss of appetite, coated tongue, general malaise, 
and moderate febrile reaction accompanies all cases, to which a 
added those of septicaemia in severe cases. 

The duration is fi-om two to six weeks. Its favorite site is 
of the neck, shoulders, back and buttocks. It is usually single. 

DiagnoBia, The disease is distinguished from furuncle by its 
great size, ilsjlat form, its course, multiple points of suppuration, and 
the character of the slough. Also by the pain ; in furuncle, sensitive 
and painful to the touch, carbuncle not being particularly sensidvQ^^ 
Furuncles generally occur in numbers or in crops ; carbuncle is almot' 
always single. 

Progrnoeis. A guarded opinion should always be given, as deathis 
not infrequent from anthrax, especially in elderly people with Impaired 
health. The mortality, however, is not so great as the laity suppose. 



ving^l 

lich'^ 
ingS 

istN^I 

if the 

chatfl 

ebaajB 

y its 

itivcj 
..I,';. ^ 



A great danger is septic^niia, from the action of the poison on 
the blood, or the result of secondary abscesses. 

Treatment. Constitutional and local measures are both of the 
greatest value. Nutritious diet, stimulants and full doses of such 
remedies as tinctura ferri ckloridum, guinime sulphas, arsenicum and 
amntonii carbanas are beneficial. Good results are reported from 
calcii nilphid., gr. >i| every two hours. 

Locally; the crucial incision, so generally practiced in former years, 
is seldom performed now, the frequent occurrence of hemorrhages 
being too debilitating. The following are valuable plans :— 

Caustic potash, applied to the carbuncle before an opening occurs, 
until an eschar is fully formed; or, making several small punctures with 
a scalpel and inserting a small piece of caustic potash well into the 
diseased tissue ; or, if openings have already occurred, insertion of the 
caustic stick into them, allowing it to remain until melted. By either of 
these methods I have seen the slough cast off more readily than in 
cases where the crucial incision was made or in those left to nature. 
Another method is, " a saturated solution of pure acidum carboiicum 
is injected through the several apertures in every direction into the 
sloughing tissues, by the aid of an hypodermic syringe. The pain is 
severe but short lived." 

Prof Agnew recommends painting co/ /odium cum canlharide 
around the anthrax, in the form of a broad zone, the effect of the blis- 
ter being to relieve the tension, Tinctura iodi. is also used for a 
similar purpose. Hebra advocates cloths wrung out in ice water, or 
ice bags, in the early stage, changing to warm fomentations as soon 
as suppuration has begun. Dr. Aslihurst has practiced with success 
the use of pressure by means of adhesive plaster applied in much 
the same manner as used for swelled testicle. 

The resulting ulcer, after expulsion of the slough, is to be treated 
on general principles. 






ACNE. 
'ulgaris ; acne disseminata ; 



Synonyms. 

Qeflnition, An inflammation, usually chronic, of the sebaceous 
glands; characterized by the development of papules, tubercles or 
pustules, or by a combination of such lesions, usually in various 
stages of formation, occurring for the most part upon the face. 



as ' 

tie 

d to ■ 



3W PRACTICE OP MEDICINE. 

Varieties. Aam papyhsa ; acne pusMosa ; aene artificialis. 

Causa. Not always understood, as the affection is frequently ■ 
associated with apparently the most robust health. A frequent cause 
is puberty. Among the other causes observed are gastro- intestinal 
disorders, anaemia, chlorosis, uterine disorders, scrofula, and the u 
of large doses of the bromides and iodides. Acne may exist alone 
or be associated with comedo or seborrh<ea. 

Pathology' An inflammation of the sebaceous gtand structurti 
and surrounding tissues. There first occurs retention of the sebaceflns 
secretion, which is soon followed by hyper^miaand exudation about the 
glands and in the gland wall [acne papulosa), infiltration of the con- 
nective tissue {acne luherculd), followed by suppuration (acne pustu- 
/osa). If the inflammatory action be severe, destniction of the glanAj 
with a resulting cicatrix occurs. 

Symptoms. Acnr papulosa or acne punctata. This variety « 
the affection is the earliest stage of the inflammatory action, and i» ' 
usually of short duration, being soon followed by the development 
of pus. It is characterized by the occurrence oi pin-head Xa pea-she, 
flat, more or less poinled papules, situated abi>ut the sebaceous follicles, 
lighlish in color, with a minute central black point, the opening of 
the sebaceous duct. Pustules are not infrequently observed scattered 
amongst the papules. The lesion is unaccompanied with cither local 
or constitutional symptoms. While the forehead is the most frequei 
seat for this variety, they sometimes are seen elsewhere. 

Aene pustulosa. This is the fully developed affection. Iti 
upon the face, neck, shoulders and back, as pin-head to pea 
rounded or acuminated pushih's. seated upon an infiltrated, reddt 
base of superficial or deep inflammatory product {acne indurata 
Scattered amongst the pustules may be seen numerous papulej 
There are no constitutional symptoms, nor is pain complai 
unless the lesion be handled. 

Acne arlificialis is rather a clinical variety, the result, usually, of 
large doses of the bromides or iodides, the lesion being identical w 
acne pustulosa. 

Diagnosis. The lesion is so characteristic, the course so cbroniea 
and the location so frequently upon the face, that an error seems 
possible if care be exercised. 

The resemblance of the papular and pustular syphiloderms n 
not be mistaken for acne. 



DISEASES OF THE SKIN. 357 

Prognosis. Essentially a chronic affection, lasting for a number of 
years ; but if persistent treatment be employed recovery will occur. 

Treatment. To successfully combat an attack of acne, both 
constitutional and local measures must be employed. 

Constitutional treatment. The successful treatment of a case of 
acne depends upon a knowledge of its cause and familiarity with the 
constitutional habits of the patient. Disorders of digestion and con- 
stipation should be corrected. If anaemia be present, ferrunt and 
a^senicum are indicated. Scrofula is an indication for oleum morrhucB 
and ferrum iodidum. Uterine disorders, if present, should receive 
proper attention. 

Calcii sulphid.y gr. y^-J, every two or three hours, is valuable in 
many cases, as is hydrargyri chloridum corrosivum, gr. xJ^p-ffV* three 
times daily. A remedy highly spoken of by Dr. Bulkley \sgfycerinum 
in tablespoonful doses, two or three times daily. Dr. Duhring recom- 
mends that it be given in combination with ferri et quiftince citras. 
Prof. Bartholow " has seen excellent results from the use of syrupus 
hypophosphitum co7np, in acne indurata." 

Local treatment. In acne of not very long duration I have seen 
elegant results from the following plan : Just before retiring the parts 
affected are to be thoroughly washed with water as hot as can possibly 
be borne, and after the water has partly dried the parts are to be 
thoroughly covered with sulphur subliinatum, applied by means of a 
powder puff ball, no rubbing or friction to be employed, and on 
arising in the morning the sulphur is to be washed off with hot water 
and the face lightly mopped dry, or what is better, sulphur again 
applied, if the patient is willing to permit it, during the day. 

Dr. Hyde recommends that the contents of the papules and pus- 
tules be evacuated by means of a needle, rather encouraging slight 
bleeding, after which the parts are to be bathed with water as hot as 
can be tolerated, and while the part is still wet, it is thoroughly 
scrubbed with lotio saponis viridis, then cleansed with water, care- 
fully dried and anointed with a sulphur ointment. 

Prof. Bartholow suggested, in a case of acne indurata seen with the 
author, the following successful plan. To dissolve the sebaceous 
matter — 

i^. Liquor, potassae f^j 

Aquae destil fjj. M. 

SiG. — Applied to the acne spots only. 



358 PRACTICE OF UEDICINE. 

After which they were anointed with — 

8. riumhi nilral gr. itv 

Ung. petroUi 3J. 

Stg. — Apply twice Joily. 

Dr. Duhring recommends the use of the following, after washinj 
the parts with hot water ; — 

B- SulphuriE prseeip gj 

Glycerin! _ fjss 

Adipis. beni Jj 

oi. roEc en. iij. 

Ft. aog. 
Sm. — To be thoroughly rubbed into the sliin at nighL 



ACNE ROSACEA. 

Synonyma. Gutta rosea; gutta rosacea. 

Definition. A chronic hyperemia or inflammatory affection a 
the nusc and cheeks; characterized by redness, hypertrophy of tl 
skin and dilatation and enlargement of the blood vessels supplyinj 
the part, and the development of more or less acne. The nose and 
cheeks are the most frequent location. 

Cause. Not always determined. It occurs in young women 
about puberty who are ansemic, or suffer from a general debility, 
nervous irritability or prostration, dyspepsia or menstrual irregulari- 
ties. It often appears during the menopause. In young males the 
affection can often be traced to nervous or general debility, or dys- 
pepsia. The use of spirituous liquors is a frequent cause, as i^ 
constant exposure to the weather. It is frequently associated iri^H 
seborrhcea. fl 

Pathology. There first occurs blood stasis in the vessels of th*™ 
part, producing the undue redness first noticed. As a result of the 
stasis sooner or later the capillaries are dilated and hypertrophied, 
and as a result of the interrupted circulation inflammation of the 
sebaceous gland (acne) results, with the development of papules 
pustules. This constitutes the typical acne rosacea. The affectiol 
may proceed no further, remaining at this point for years, or, rarely| 
the pathology of this stage is exaggerated, the involved ti: 
hypertrophy in g, and the connective tissue undergoing a true hyp« 
plasia, causing increased size and abnormal shape of the noe 



DISEASES OF THE SKIN. 359 

Symptoms. The onset of the affection is slow and insidious, 
characteriied at first by more or less diffuse redness of the part, the 
color aggravated by water or cold air. If the nose be the part 
attacked, it is usually greasy (seborrhosic), and is apt to be cool or even 
cold. This condition may remain for years, but sooner or later the 
evidence of dilatation and hypertrophy of the capillaries is apparent 
by the more decided and permanent redness, and upon close exami- 
nation the enlarged minute cutaneous blood vessels are seen as deli- 
cate or coarse red lines, running superficially over the skin in an 
irregidar and tortuous course. Soon are developed upon the hyper- 
Eemic and hypertrophied skin papules (acne papulosa) and pustules 
(acne pustulosa), their number never, however, being very great. 
This constitutes true acne rosacea. The disease may remain in this 
state, or, rarely, the cutaneous tissues are greatly hypertrophied, the 
blood vessels enormously dilated, the glands enlarged and the connec- 
tive tissue undergoes hyperplasia, resulting in permanent, dark red, 
bulky formations, the shape of the nose being contorted into various 
irregular forms. Duhring reports a case in which the nose was the 
sij:e of the patient's fist (rhinophyma). 

The nose and cheeks arc the usual location of the disease, although 
rarely, it involves the forehead. 

Diagrnosis. The characteristics of the disease are so marked, 
consisting of rosacea — the dilated and hypertrophic blood vessels — 
with papular and pustular acne superadded, that an error can hardly 
occur, if due care be exercised. 

Lupus vulgaris bears some resemblance to acne rosacea, as it is 
api to develop about the face, and especially the nose ; but the 
papules, tubercles and pustules of lupus vulgaris soon ulcerate, fol- 
lowed by crusts and cicatrices, which never occur in acne rosecea. 

Lupus erythematosus may be confounded with acne rosacea if it 
occiu- upon the end of the nose ; but in the former the skin is harsh 
and covered with adherent whitish and yellowish scales connected 
with the openings of the sebaceous follicles, which is never the case 

Frostbite resembles the first stage of acne rosacea, but the history 
of the two conditions soon determines the diagnosis. 

ProgrnoBiB. Favorable, if treatment be instituted during the first 
stage. After hypertrophy has occurred but little can be accom- 
plished. 



k 



860 PRACTICE OF MEDICINE. 

Treatment. The cause is to be sought after and removed, t 
the general health lo be promoted. The use of all alcoholic drinla 
are to be interdicied and but small amounts of lea and coffee a 
be ajlowed. In ihe hrsC stage good results may be obtained from A 
following formula, known as " Kummerfeld's lotion": — 

Si- Sulphur pnecipitat_ giv 

Pulv. camphors gr- x 

Pulv. tragacanlhsc 9 j 

Aqua calcis „ fgij 

AquarroSK fj ij. 

Siu. — 'Shake the battle before using and apply every few hours. 
Or— 

B. Hydra^yri chlor. corrosiv gr. ij 

Ung. petrolei gj. 

SlG. — Apjjly thoroughly. 
Or, ihe following, suggested by G. H. Fox — ■ 

li. Chtysarobini _^ss 

Collodii gj. 

SiG. — Put a brush through the cork and paint lesion every evening. ' 

For the second stage stronger applications are usually require 
The dilated capillaries should be incised with a sharp knife, ii 
hope that adhesive inflammation may close the calibre of the ve 
cold water compresses being used to control the bleeding; a few of 
the dilated vessels being thus treated every day or two, until all have 
been incised. Another plan is to paint the affected parts, once or 
twice a week, with a ten to twenty grain solution of pgtassa, following 
its application with an emollient poultice. Electrolysis has also b 
recommended. 

In the third stage the knife is the only effectual remedy. 



PSORIASIS. 

Synonyms. Lepra ; alphos ; psora ; English leprosy. 

Definition. A chronic affection of the skin, characterised bjffl 
reddish, more or less thickened and elevated, dry, inflammatory a 
somewhat wrinkled patches, variable as to size, shape and r 
and covered with abundant whitish or grayish-colored, imbric&MI 
scales. It is not contagious. 



DISEASES OF THE SKIN. 

Cause. Not knoivn. The source of the affection is. no doubt, 
limifed to the skin itself, as no external or internal factors can produce it. 
It occurs in the robust and in the feeble, and in males and females. It 
uaually first appears in early life and recurs at intervals, for years. 

Pathology. According to Dr. A. R. Robinson, of New York. 
" the disease is essentially a hyperplasia of the normal constituents of 
the Malpighian layer (mucous layer). The increase takes place 
chiefly In the intcrpapillary portion of the layer, the growth of which 
downward causes an apparent increase in the size of the papilla of 
the corium, which, however, on closer examination, are found not to 
be enlarged. In the later stages of the disease the more superficial 
blood vessels of the corium become dilated, a more or less consider- 
able emigration of white blood corpuscles takes place, and the itnme- 
diate neighborhood of the vessels, together with the connective tissue 
of the corium, becomes the seat of a round-cell infiltration, which, 
with the elTusion of serum, separates the connective-tissue bundles 
and fibres into an open mesh-work. During the period of disappear- 
ance of the disease there is a gradual return to the normal condition, 
until the hyperplasia, dilatation of the blood vessels, and cell infiltra- 
tion have completely disappeared. The hair in psoriasis is atTecled 
from the beginning of the disease, hyperplasia of the external root 
sheath, the structure corresponding lo the Malpighian layer of the 
epidermis, taking place, with extension of the hyperplastic structure 
into the surrounding cutis. The sebaceous and sweat glands arc not 
at any time .iflfected." 

SymptoniB, Psoriasis begins as small, reddish spots, of the size 
of a pin's head, which immediately become covered with scanty or 
abundantai^/V/iii ot grayish, imbricated scales. The spots gradually 
increase in diameter, forming patches of various sizes and shapes. 

If one of the scales be detached by means of the finger nail, it will 
be found to adhere q>;ite firmly to the skin, and to be about the thick- 
ness of cardboard. If the reddish patch thus made bare be pinched 
up between the finger and thumb, and compared with a similar pinch 
of the healthy skin, its inflammatory thickening will be discerned. 
Then is no watery discharge at any time. 

The skin between the patches is perfectly healthy. 

While the anatomical lesions are always identical, the eruption 
assumes such features, as to the size and shape of the patches, as to 
give rise to special names. 



PRACTICE C 



' UEDICIHE. 



is small, rounded patches 
are variety, as Che les 



Psoriaiii punctata. The eruption i 
about Che siie of a pin's head. Thi 
rapidly increases in size. 

Psoriasis guttata. The eruption occurs ia the form and size tii 
drops, and when covered with scales gives the skin the appearance 
of having been splashed with mortar, A quite frequent variety. 

Psoriasis nummularis. The eruption resembles variously -sized 
coins. This is frequently as large as the patches grow. 

Psoriasis circinata. The eruption about the si/e of the former^ 
variety, the centre clearing away, leaving the skin normal, althou] 
it may continue to enlarge at the periphery, after the 
circinata. 

Psoriasis gyrata. The erupdon in wavy hues, of the width of about 
half an inch, resembling circles and semicirtles. This variety is a 
n of Che former, from the joining of Che patches of psoriasis 



lou^l^l 



Psoriasis diffusa. The patches of eruption are large and of irregu- 
lar shape, covering a considerable amounC of surface. This variety 
occurs more frequently on the front of the leg and the- outer aspect of 
the forearm. ^k 

Pioriasis patmaris tt plantaris. In these regions the eruption ijH 
characterized by larger, thicker and less lustreless scales, and by tttijH 
occurrence of deep and painful fissures, from which exudes either s 
serous or sanguineous fluid. 

Psoriasis unguium. In psoriasis of the nails they become thick- 
ened, opaque, grayish in color, deeply grooved transversely a 
often pitted, and in rare cases the nails are replaced by a scaly it 
crustation. 

Any portion of the body is liable to be attacked with psorias 
The only discomfort the padent suffers is the itching, which a 
is very severe and distressing. 

DiagnosiB. A typical case of psoriasis presents no difficulty ii 
diagnosis. There are a few affections, however, which may be con-fl 
founding in irregular cases. 

Eczema squamosum occurring upon the legs closely resembles 
psoriasis, and if the former has been attended with a very small 
amount of moisture and the latter has been considerably irritated by* 
scratching, the diagnosis will be very difficult. 

The papula -squamous syphiloderm and psoriasis are frequentljrfl 



DISEASES OP THE SKIN. 363 

mistaken for each other, the diagnosis at times being extremely 
difficult. 

Tinea eircinala and psoriasis circinata resemble each other, but 
the patches of the latter are less inflammatory, red and infiltrated, and 
the scales more abundant and larger than in the former. Tinea cir- 
cinata is usually the result of contagion, and the scales contain a 
fungus. 

Seborrh<ea of the scaip and psoriasis of the same region frequently 
are difficult of diagnosis. In the former the scalp is paler, the scales 
are finer, smaller, more generally diffused, of a grayish or yellowish 
color, and a greasy, sebaceous character. Psoriasis of the scalp is in 
patches, ivhich are reddish and Infiltrated, and there are almost 
always patches of the disease on other parts of tlie body. 

ProffQOBis. An attack can usually be removed, hut it is always 
apt to return, so that a permanent cure can never be promised. 

Treatment. Constitutional and local measures are both needed 
in the majority of attacks of psoriasis. 

Constilulional treatment. Attention to the general health, remov- 
ing all deleterious influences, such as dyspepsia, constipation, hthiasis, 
malaria, ansemia or catarrhs. 

Among the most valuable remedies used in the treatment of psoriasis 

arsenicuin, given in full doses for a long period. It is to be borne 

mind, however, that the drug is contraindicated in all acute and 

lammatory cases, Ckrysarobin,^. ^, t. d., gradually increased, 
has been suggested, but of its utility I have had no experience. 
Pliosphorus. acldtim carbalkum and pix Uqttida have all been used 
with variable success. 

Local trealment. The character of the local measures should be 
controlled by the dur.ition of the disease, its extent, location and 
obstinacy. 

The first step is the thorough removal oF the scales. This may be 
accomplished by repeated washings with soft soap and water, by 
either plain or alkaline baths, medicated washes or caustic ointments. 

In the early stage, with highly inflammatory symptoms, soothing 
applications, such as water dressings or inunctions with oils, of which 
oleum olivit rubbed over the patch several limes each day, is very 
serviceable. 

For chronic cases nothing seems comparable with the following 
formula, suggested by Dr. G. H. Fox : — 



384 PKACTICE OF MRmciNZ. 

B- Chryaarobin gr. Jt-xi-gj 

jlClheria et alcoholis ad q. s. 

CoHodii gj. 

Sic. — Rnb Ihe chrysitobin with a liltle aicohol and ether and ai 
the callodion. 

If a cam el's hair pencil be placed through the cork, this may be 
painted over the affected patch after Ihe removal of the scales, 
after drying it will not stain the clothing. Care must be exercised 
that the strength be not loo great, or a dermatitis may result. 

Other local remedies are : pi.v li^uida, iapoms viridis, creasoitem, 
sulphur, calcium sulphureium and acidum carboKeum. 



HYPERTROPHIES OF THE SKIN. 

LENTIGO. 

Synon3nii. Freckles. 

Deflnition. A pigmentary deposit of the skin, characterized by 
irregularly-shaped, pin-head or pea-siied, yellowish, brownish, or 
blackish spots, occurring for the most part about the face and back of 
the hands. 

Cause. In the majority of instances exposure lo the s 
exciting cause. 

Patholo^ry. In anatomical structure freckles consist of 
scribed, increased amount of normal pigment, differing from 
only in the peculiar form and size of the deposit. 

Symptoms. The number of "freckles" varies from a very few 
to immense numbers. They occur as brownish or yellowish-brown, 
small, roundish, irregular spots, most commonly upon the face and 
hands. Rarely the number is very great, and they give to the skin 
an uncleanly appearance. They are apt to occur at all ages, but 
rarely before the third year. 

They are unattended with itching or other subjective symptoms. 

ProiTiiOBis. Usually favorable. Their course, when left to them- 
selves, is chronic, lasting for years or a lifetime. They ordinarily 
appear in the summer, fading away as cold weather approaches, to 
return the following summer. 

Treatment. The following application has been usually success- 
ful in my hands: — 



DISEASES OF THE SKIN. 365 

R. Hydrargyri chlor. corrosiv gr. iij 

Acid, hydrochlorici, dil fgj 

Alcoholis f 2J 

Glycerini ^3^^ 

Aquae rosae ad ^3^^* ^• 

SiG. — Apply at bedtime, and remove with soap and water in the 
morning. 

CHLOASMA. 

Synonyma. Liver spots ; moth. 

Definition. A pigmentary discoloration of the skin, character- 
ized by variously sized and shaped, more or less defined, smooth 
patches, or of a discoloration, yellowish, brownish or blackish in 
color. 

Cause. The aetiology of chloasma depends upon whether the 
pigmentation is idiopathic or symptomatic in its occurrence. 

Idiopathic chloasma results from the irritation of long-continued 
scratching, such as is practiced in severe eczema or pediculosis, the 
application of blisters and sinapisms, heat, the direct rays of the sun, 
and various medicinal and chemical substances, such as follows the 
prolonged use of argentum (argyria). 

Symptomatic chloasma occurs in connection with cancer, malaria, 
tuberculosis, disease of the supra-renal capsule (Addison's disease), 
disease of the womb, pregnancy (chloasma uterinum), neurotic dis- 
turbances, anaemia and chlorosis. 

Pathologry* The affection is an increased deposit of the normal 
pigment, having its seat in the mucous layer of the epidermis. The 
deposition of the pigment is the result of a nervous derangement, 
possibly of the trophic system. 

Symptoms. Chloasma is simply a discoloration of the skin, 
unattended with alteration of the surface. 

The patches vary in size and shape ; they may be as minute as a 
coin or as large as the hand, or much larger, even to a universal dis- 
coloration of the entire surface, and they may be roundish or irregu- 
lar in outline. 

The usual color is yellowish, brownish or muddy, or even blackish 
[melasjna, vielanodermd). 

In Addison's Disease, of a typical character, '* the coloration is 
brownish, with an olive-greenish or bronze tint, and is general. 



PRACTICE OF MBDICIHE. 

although, as a rule, especially pronounced upon regions having a dIS' 
position to normal increase of pigment, as the face, backs of the,' 
hands, axilla, areola; of the nipples, and genital organs ; the hair, 
also, may become darkened. It may, also, occur with or follow other 
pigmentary changes, as of llie hair. Gaskoin reports a case, < 
ring in a woman aged forly-five, where the patch, situated c 
cheek, near the nose, was intensely dark. It had existed nine years. 
The color of her hair had, fifteen years previously, changed from 
carroly-red to black." For additional symptoms, see page 311 

In Argyria or discoloration of the skin resulting from the internal 
use of nitrate of silver, the color is a bluish, bluish-gray, slate, 
bronze or blackish, varying as to the shade. It occurs oyer tht 
face generally, but is more pronounced upon parts exposed, s 
face and hands. 

Chloaitna uterinum occurs most frequently between ihe ages of 
twenty-five and fifty, seldom after ihe menopause, caused, 
greater number of instances, by changes, physiological and patho- 
logical, which take place in connection with the uterus, 
the married and single, although much commoner in the former. 
Pregnancy is the most frequent cause, although also associated with 
either, dysmenorrhcea, chlorosis, anemia or hyster 

It is seen in the mildest degree about the eyelids, especially during 
the menstrual epoch, as a duskiness or swarthiness of the complexion, 
either lasting a few days or being permanent. As usually e 
tered, however, chloasma of this variety consists in the presence of 
one or several patches, appearing generally about the forehead 
other parts of the face, upon ihe trunk, about the nipples and upon 
the abdomen. Rarely tlie entire face is covered with a discoloralior 
resembling a mask. Cases are recorded in which the pigmentary 
deposit was general, resembling Addison's disease. 

DiagnosiB, Tinea versicolor and chloasma resemble each other 
in the color of the patches, but otherwise they have nothinj 
mon. Tinea versicolor occurs on the trunk, while chloasma occurs 
upon the face and about the nipples, and in cases the result of preg- ■ 
nancy, about the umbilicus, except in those comparatively rare 
stances in which the discoloration is diffused. The patches 
chloasma are smooth, those of tinea versicolor furfuraceous, as c 
readily be demonstrated by gently scraping the discoloration with the 
finger nail. 



DISEASES OF THE SKIN. 367 

Prognosis. Unless the result of Addison's disease, the pro- 
longed use of argentum, tuberculosis or cancer, favorable. 

Treatment. Chloasma, not the result of organic disease, or Ihe 
use of argentum, is usually removed by either of the following 
formula : — 

R. Hydrargyri chloridi coirosiv gr.viiss 

Zinci sulpliat jss 

Plmniii acclalis ^ss 

Aquie fgiv. M. 

Sii;.— Lotion. Apply morning and evening. 

— Hardv. 
Or-- 

If. Hydrargyri chloridi corroaiv S'-V 

Addi. acelici dil „ r:5ij 

Borads g ij 

AquK rosse f jiv. M. 

SlG. — Lotion. Apply twice daily. 

— Bulk LEY. 
Or— 

B. Hydrarg. ammoniat 3J 

Bismuthi subnit gj 

Ung. pelrolei „ ^j. M. 

SlG. — Apply frequently. 
For argyria, the first step is the withdrawal of the argentum, and, 
according to Prof Bartholow, " a persistent and long-continued use 
oi polassii iodidmit and sodii hypophosphis has, in a few fortunate 
instances, caused the absorption and excretion of the silver deposits. 
The action of these systemic remedies for the discoloration may be 
aided by baths of the hypoiulpkites and by the cautious use of lotions 
containing poiassii cyanidum, which possesses a decided solvent 
power over the silver deposits." 

C.^LLOSITAS. 

SynonyniB, Tyloma; callus; callosity. 

Definition. Callositas or tyloma consists in the development of 
a hard or horny, thickened patch of skin, variable in extent, and of a 
grayish, yellowish or brownish color, and unattended with pain. The 
most frequent location is upon the hands and feet. 

Causes. The result of pressure or friction, as in the case of the 
hand of the mechanic, the effect of his tools ; or, if upon the foot. 



PRACTICE OF MEDICINE. ^H 

th; result of ill-titting shoes or from unusual walking. Calloiitiea 
are also seen upon the fingers of violin, banjo nnd harp players. 

Pathology. A hypertrophy of the horny layer of the skin, the 
corium remaining normal. The cells of the epidermis become so 
closely packed together as often to simulate horn substance. 

Symptoms, Callositas consists in an increase in the thickness 
of the skin of the affected part, presenting a fi.rra, dense, more or less 
itnicture, the extent of hardness varying considerably, 
s being horny. The patch of hardness is generally abom 
the si/e of a coin, roundish in shape and somewhat elevated above 
the surrounding skin. The color of the patch may be either grayish, 
yellowish or brownish. 

Callositas are usually upon the palms, fingers, soles and toes, 
although other parts, if exposed to the cause, may also be the seat. 
At times great pain and discomfort are experienced from the growth. 

Occasionally callositas are complicated by hyperemia, fissure, 
acute inflammation, abscess, erysipelas, and serve readily as foci for 

Course. Their formation and development is always slow and 
gradual. If the cause be removed, the prognosis is favorable. 

Treatment, If the removal of the callous growth be desirable. 
the part should be repeatedly soaked in warm water, or a poultice 
applied, or warmed oil kept in contact by compresses of flannel, 
which will soften the induration and permit its removal by paring or 
scraping, layer by layer, with a sharp knife. Success has been re- 
ported from the use of a plaster of india-rubber containing acidum 

CLAVUS. 

Synonym. Com. 

Definition. A corn is a small, circumscribed, usually flat, deep- 
seated hypertrophy of the epidermis, having a horny feel, projecting 
slightly from the skin, painful upon pressure, situated, for the mosi 
part, about the toes. 

Cause. Continued pressure or friction, usually from ill-titting or 
tight boots or shoes. 

Pathology. A clavus consists of a circumscribed, excessive 
hypertrophy of the epidermis, of the same character as occurs in 
callosity and of a central poitEon — Ike core. The core extends deeply 
into the tissues, in the shape of an inverted cone, the base of the cont 



J 



DISEASES OF THE SKIN. 369 

being directed outward and appearing upon the surface as a roundish 
elevation, its apex resting upon the papillary layer of the corium. 
The core of a clavus consists of a whitish, opaque, firm, tenacious 
body, composed of epidermic cells, arranged in concentric laminae. 

The pain attending the presence of corns results from pressure 
upon the true skin by the hard core, causing irritation of the nerve 
filaments of the papillae. 

Corns existing between two toes are constantly bathed with the 
moisture of the part, which macerates and softens the formation, 
which thus receives the name of soft corn, in contradistinction to the 
hard corn. 

Symptoms. Until the growth attains a considerable size no dis- 
comfort, as a rule, is felt. After, however, its depth has reached the 
true skin, pain of an intermittent character, aggravated by pressure, 
is the chief symptom. 

Corns are often weather-sensitive, being unusually painful before, 
during or after the occurrence of storms, and should, therefore, not 
be confounded with gouty or rheumatic deposits below the skin. 

Treatment. If freedom from these annoying formations be de- 
sired, the use of a properly fitting foot covering must be practiced. 
The pressure which results in the severe pain is limited by the use 
of the ringed protective plasters in common use. 

To remove the corn, soaking with hot water or a poultice kept in 
contact over night, will soften the part and permit of its ready removal 
with the knife. 

For soft corns, the application of argenti nitras, in solid stick form, 
is highly spoken of, to be used after the growth has been sufficiently 
softened. 

VERRUCA. 
Synonym. Wart. 

Definition. A wart consists of a circumscribed hypertrophy of 
the papillary layer, with more or less epidermal accumulation ; char- 
acterized by the appearance of a hard or soft, rounded, flat or acumi- 
nated formation, of variable size. 

Varieties. The following varieties have chiefly a descriptive 
value : verruca vulgaris ; verruca plana ; verruca filiformis ; verruca 
digitata ; verruca acu?ninafa. 

. Cause. Obscure. The various assigned causes are probably in- 
capable of producing the affection. 
Q 



370 PRACTICE OF MEDICINE. 

Patholoery> while the a.natomy of warts differs somewhat accord 
ing to their variety, in all forms there eitist as a basis of their forma- 
tion a connective-tissue growth, from which the papillary hypertrophy 
takes place. The interior of the growth is supplied by one or nuat 
vascular loops, from which their \-itality is obtained. 

Symptoms. The various forms are so different as to retjuire a 
separate description. 

Verruca vulgaris, or the ordinary wart, commonly seen on the 
hands, consists of a small, circumscribed, elevated growth, having a 
broad base seated securely upon the skin. Their consistency is 
either soft or firm, the surface smooth or rough, the color that of the 
surrounding skin, or yellowish, brownish or even blackish. 

They may develop upon any region of the body, but are most 
commonly seen upon the hands and lingers. 

yciTiira plana differs from (he vulgaris in being flat and broad in 
form and but slightly raised above the level of the surrounding skin. 
Their most common location is either on the back or forehead. 
Verruca filiforniis assumes the shape of a minute, thin, conical or 
thread-like formation, about an eighth of an inch in length. 
The most frequent location is the face, eyelids and neck. 
Vemica digitata consists of a slightly elevated, broad formation, 
about the size of a split-pea, and marked by a number of digitadons 
coming from its border, giving an appearance, in marked cases, re- 
sembling a crab. 
Their most frequent site is upon the scalp. 

Ver>-Hca acuminata, known, also, as the pointed wart, the moist 
wart, the pointed condyloma, cauliflower excrescence and venereal 
wart, consists of one or more groups of irregularly-shaped elevations, 
often so closely packed together as to form a more or less solid mass 
of vegetations (verrucie vegetantes}. Their color depends somewhat 
upon the degree of vascularity, varying from a pinkish, bright-red to 
a purple color. 

They occur, for the most part, about the genitalia of either sex. 
Upon the penis, they usually spring from the glans and the inner 
surface of the prepuce ; the inner surface of the labia and from the 
vagina in the female. They are also seen about the anus, mouth, 
axilla;, umbilicus and toes. They may be either moist or dry, ac- 
cording to their location ; about the genitalia, a yellowish, puriform 
n usually covers their surface, due to fiiction and n 



DISEASES OF THE SKIN. 371 

which, owing to the heat of the parts, rapidly decomposes, producing 
a highly offensive, penetrating and disgusting odor. 

Their size varies from that of a pea to that of an almond, an egg, 
or even the fist. Their development is rapid, attaining considerable 
size in a few weeks. 

Prognosis. Favorable. 

Treatment. For the smaller warts, excision by means of the 
knife or scissors affords the most satisfactory results. If the growth 
be large and likely to be attended with considerable hemorrhage, 
as in cases of the condyloma about the genitalia, the galvano- 
caustic wire, or the Paquelin cautery will answer perfectly. Trans- 
fixing the growth in several directions with long needles dipped in a 
fifty per cent, solution of acidum chromicum has been recommended. 
The topical application of caustics, such as acidum aceticum dilutum, 
acidum nitricum, argenti nitras ox ferri perchloridum are often satis- 
factory. I have been successful in some cases by painting the growth 
with tinctura thuja occidentalis until their size was considerably re- 
duced, and then snipping them off with the scissors. The following 
formula for warts and corns is generally sold by pharmacists : — 

R. Acidi. salicylici ^^ss 

Ext. cannab. indicse gr. v-x 

Collodii ^ss-j. M. 

SiG. — Apply once or twice daily. 

A favorite formula with me is : — 

Jjc. Acidi salicylici, 

Acidi boracici aa gr. xv 

Hydrargyri chlor. mite gr- v. M. 

SiG. — Sprinkle over twice daily. 

ICHTHYOSIS. 

Synonyms. Ichthyosis vera ; fish-skin disease. 

Definition. Ichthyosis is a congenital, chronic deformity or hy- 
pertrophic disease of the skin, characterized by dryness, harshness or 
general scaliness of the skin, or, in the outgrowth of larger masses of 
a corneous consistency. 

Varieties. Ichthyosis simplex ; ichthyosis hystrix, 

Caiise. Often hereditary, but not in all cases. It is to be re- 
garded as an affection which is born with the individual, although it 




does not usually manifest itself until after the first 
of life. 

Pathology- " The diseased, or, better, deformed skin is found 
microscopically to be hypertrophied in various degrees, according lo 
the development of the malady ; the proliferation of its elements 
occurring in the connective tissue, papilliE, stratum corneum and 
blood vessels. In well-marked cases of ichthyosis hystrix, the 
elongated papillie are surmounted by dense cones of the homy layer 
of the epidermis, more or less concentrically disposed, with sclerosis 
of the connective tissue and a relatively unchanged rete. In this last 
particular the dense plaque of ichthyosis differs in texture from the 
wTi." (Hyde.) 

Symptoms. Ichthyosis displays a wide variation in its symp- 
toms. In one individual it amounts to but a slight inconvenience, 
whilst in another it may manifest itself in so pronounced a 
to be the source of great discomfort and deformity. The tw 
named represent merely accentuated types of ihe disorder, rare in its 
fullest development, and, in its slightest, much more common than is 
generally believed. 

md harshness of the skin, with only slight fur- 
is termed xeroderma. 

is the more common variety, consisting of » 
1 of the whole surface, accompanied by the pro-^ 
duction of variously sized and shaped reticulated scales, either small, 
thin and furfuraceous. like bran, or large and thick, resembling fish 
scales. Upon the extremities the scales usually form diamond-shaped 
or polygonal plates, separated from one another by furrows or lines, 
which extend down to the normal skin. In color the scales are either 
whitish, grayish or yellowish, and often have a silvery or glistening 
appearance. Rarely the color is olive-green or blackish {ichthyosis 
Higricans). The amount of scaling depends upon the age of the 
patient, and the duration and severity of the disease. 

Ichthyosis hyslrix. With or without the developments of the abovi 
variety, in this, the hypertrophy of the skin may occur in cir 
scribed patches or lat^e areas, consisting of irregularly -shaped, 
rucous, corneous, corrugated, wrinkled or rugous masses, usually^ 
darker in color than those of the simple variety. They may 
upon the arms, as solid, warty patches, or upon the hack, in the form 
elongated, linear patches. They may constitute roughened, corru-i. 



simple dryn< 
furaceous exfoliation, 
Ichthyosis simplex 
harsh, dry c 



\ 



1 



DISEASES OF THE SKIN. 373 

gated, papillary growths, or uneven, horny, blunt or pointed, spinous, 
warty formations. In the latter case the elevations may reach several 
lines or more, and stand out from the skin like quills upon the back 
of a porcupine — Whence the name hystrix. The amount and extent of 
the hypertrophy varies ; the older the patient the more highly devel- 
oped it will usually be 

Course. Ichthyosis si?nfilex may involve the entire surface uni- 
formly or appear more marked on the extremities, from the hips to 
the ankles and the arms and forearms. The affection is always worse 
in winter than in summer ; the increased activity of the sweat glands 
at this season producing the most beneficial results. The course of the 
affection is essentially chronic, continuing throughout life, now better, 
now worse. Slight itching usually occurs. 

Diagrnosis. The characteristics of the affection are so peculiar 
that an error in diagnosis is hardly possible. It is to be distinguished 
from the inflammatory affections of the skin which terminate in des- 
quamation, by the absence of any history of inflammation. 

Progrnosis. While much can be done to alleviate the affection, 
the prognosis is unfavorable as regards permanent relief. 

Treatment. Local measures are alone of value for ichthyosis. 
The maceration of the accumulated masses of epithelial hypertrophy 
is accomplished by water baths, either simple or medicated. The 
relief thus afforded the patient, while temporary, is comforting. 
Duhring says: — "It may be stated, then, that, as a rule, the more 
frequently the ichthyotic patient bathes, and the longer he is able to 
remain in the water, the less will the deformity show itself." Vapor 
and alkaline baths are also serviceable. Another valuable agent is 
sapo mollis in conjunction with baths, or alone, as a discutient. For 
severe cases, " a sufficient quantity is to be rubbed into the skin twice 
daily, for four or six days, during which period the patient is to refrain 
from bathing. A bath is first to be taken four or five days after the 
last rubbing, when, in fact, the epidermis has begun to peel off; after- 
ward inunction with a simple ointment is to be applied, in order to 
prevent fissuring of the new skin." 

The following is a useful formula : — 

R. Adipis. benz ^j 

Glycerini TT\^xl 

SiG. — Apply daily, after washing or bathing. 

— Duhring. 



OltitNfa 



PAEtASITlC DISBASEa OF THE SKIN. 
TINEA FAVOSA- 

Synooynu. Faros ; ponigo fivesA : bonejrcooibed riogvaraL 

Deflnitkm. AconlagiffutaSKtioa cf tbedda.dtie to a vc^eiible 
parattte — Acheri^H SckdnJeinii ; ctanaaiteA by the derelofiiiieiit of 
eilbcf dncreie or coafluent. nBal). drcolar. cup-^iaped. pale ydlow. 
friable crosu. ujuaJiy perforated by faaii^ 

Cause- Tbe presence and growth of a vegetable parasite Icnovn 

as due Aik&rien SchanUinii is the cause of tinea favosa. It is 

commonei in children than in adults, attaclcing the formei, id tbe lirsl 

place, cither ^ KMw M tht(Ki|^ direct contagion, and is from them 

It is a disease confined almost exclusively 

is rare in the United Stales. 

ologT- Tiaea favosa may have its seat dther in the hair- 

r upmt the surface of the skin or the naQs ; the 

r, howevcT. are the structures most commanly attacked. 

It is purely a local afiection, due solely to the presence and growth 
of the regetable paia^te discovered by Schonlein. of Berlin, in 1839. 
aad named after hint — Ackorion Sckonleinii. The crusts are made 
up almotit entirely of fitngus, which is seen, upon section, with the 
naked eye, to be composed of a porous mass and to possess a pale- 
yellow t>r whitish color. Under the microscope it is seen to consist of 
both tnyctiliurii and spuies in great quantity, and in all stages of 
develupmeot. 

Symptoms. When the affection attacks the hairs and follicles it 
is termed //hcu favoia pilaris, when the epidermis, tinta favosa epi- 
dermis, and when the nails, tintti /invsa uiiffnium. Rarely all ihe 
structures ma^y be attacked at one and tbe same time; its usual seat. 
Iiowever, is the scalp. 

The disease bcgini by die de^ clopiiionl of one nr of several pin- 




DISEASES OF THE SKIN. 375 

head-sized, pale-yellow cnists, seated about the hair follicles. In about 
a fortnight these crusts have increased in size and are umbilicated, 
termed the favus cups, are circumscribed, circular in form and very 
slightly elevated above the level of the skin. 

In their normal condition they are of a pale-yellow or sulphur- 
yellow color, but after a time, from dust and other matters, they 
become brownish- or greenish-yellow in color. The number of crusts 
vary from a very few to immense numbers. The usual size is about 
that of a split-pea. In tinea favosa pilaris et capitis the affection is 
often accompanied with pediculi, while swelling of the glands of the 
neck and small abscesses upon the scalp are not uncommon. The 
hairs become lustreless, opaque, brittle, and at times split longitudi- 
nally, and from atrophy of the follicles and sebaceous glands per- 
manent baldness may result. 

In tinea favosa unguium the nails become thickened, yellow, opaque 
and brittle. 

The disease has a peculiar odor, fesembling that of mice, or of musty, 
stale straw. 

Diagrnosis. In a recent case the characteristic favus cups, the 
pale-yellow color, the odor and the history of contagion, should render 
the diagnosis easy. If of long standing, however, and the favi 
destroyed by scratching, some doubt may exist ; but if a small 
fragment of a crust be placed upon a glass slide with a drop of 
liquor potassce , covered with a thin glass and placed under a micro- 
scope with a power of from two hundred and fifty to five hundred 
diameters, the features of the Achorion Schotileijiii will determine the 
affection to be tinea favosa. 

Progrnosis, Tinea favosa epidermis readily responds to treat- 
men. Tinea favosa pilaris is more obstinate, and if of long dura- 
tion may result in baldness. 

Treatment. The general health, in the majority of instances, 
requires tonics. Cleanliness is essential to successful management. 

For tinea favosa pilaris et capitis, two remedies are essential — 
parasiticides and depilation. The hair should be cut as short as pos- 
sible, the crusts removed by the use of oil, or soap and hot water, or 
poultices, again well oiled and the hairs removed by means of broad- 
bladed forceps, a few hairs being removed at a time and only a small 
surface cleared at each sitting, when the following lotion is to be 
thoroughly applied : — 



376 PRACTICE OF MEDICINE. 

R. Hydrarg. chlorid. corrosiv gr- v-x 

Ammonii chlorid. pur ,^ss 

Misturie amygdalae amar ^^iv. M. 

SiG. — Apply thoroughly. 

— Bulk LEY. 

Or— 

R. Sulphur 3j 

Hydrarg. ammoniat gr. xx 

Ung. petrolei f,^ j- M. 

SiG. — Rub in well. 

Tinea favosa of non-hairy parts require the removal of the crusts 
and the application of either of the above formulae. 

TINEA CIRCINATA. 

Synonyms. Tinea trichophytina corporis ; herpes circinatus ; 
ringworm of the body. 

Definition. A contagious, parasitic affection of the skin, due to 
the trichophyton fungus ; characterized by the development of one 
or more circular or irregularly-shaped, variously-sized, inflammatory, 
slightly vesicular or squamous patches, occurring upon the general 
surface of the body. 

Cause. Ringworm of the body is caused by the presence of a 
vegetable parasite discovered by Bazin, in 1854, termed the tricho- 
phyton, the same growth or fungus that produces tinea tonsurans and 
tinea sycosis. The affection is highly contagious, and is frequently 
communicated from one member of a family to another,' although it 
has been determined that a certain unknown condition of the skin is 
requisite for its development. In children it is most frequently seen 
among the weakly and poorly nourished. In adults it is usually 
associated with a depreciation in the general health. 

Pathology. The fungus is seated between the strata of the 
epidermis, more particularly in the superior layers of the rete. The 
presence of this foreign body produces the subsequent phenomena — 
a superficial dermatitis, erythema, exudation, minute vesiculation and 
papulation, and, in the severe grades, tubercles and pustules. The 
desquamative symptoms are exfoliative — nature's efforts for relief. 

Symptoms. Tinea circinata varies greatly in the degree of its 
development, from the trivial complaint so often seen in children to 



DISEASES OF THE SKIN. 377 

the chronic, extensive and obstinate disease sometimes seen about the 
thighs in adults (tinea circinaia cruris). 

The disease usually begins as a small, reddish, scaly, rounded or 
irregularly-shaped spot of papules, which, in a very few days, assumes a 
circular form (ringworm). It continues to increase in size, the papules 
often changing to vesicles. A characteristic of the eruption is its healing 
in the centre as it spreads on the periphery. Occasionally the circles 
or rings coalesce, forming serpiginous lesions. The usual size of a 
fully developed ringworm is about that of a silver quarter of a dollar. 

Chronic tinea circinata does not present the characteristic annular 
form, but " are usually in the form of single or multiple, disseminated, 
small, reddish, slightly scaly, ill-defined spots, on a level with or but 
slightly raised above the surrounding skin. Not infrequently they are 
the size of a small or large finger nail, and are irregularly shaped, 
and, as a rule, without Hne of demarcation." 

The "eczema marginatum" of Hebra is to be looked upon as a 
severe form of tinea circinata. 

Tinea circinata cruris, or ringworm of the thighs, a variety of the 
" eczema marginatum of Hebra," is usually complicated with true 
eczema, and is a very obstinate, chronic form of the affection ; it is 
accompanied by severe itching. 

Tinea trichophytina unguium is a rare variety. The nails become 
opaque, whitish, thickened and soft or brittle, especially along their 
free border. The microscope is essential for a diagnosis. Its course 
is chronic and it is difficult to cure. 

Course. As commonly seen ringworm is very amenable to treat- 
ment. Occasionally, however, it exhibits great obstinacy, showing 
itself repeatedly in the same region, in the form of relapses, or mani- 
festing itself from time to time in new localities. 

Diagrnosis. Tinea circinata may be mistaken for squamous or 
other varieties of eczema, but the circular and often annular form, 
the well-defined margin, the slight desquamation and the course and 
history of ringworm should prevent error. Chronic ringworm is more 
difficult, however. 

Seborrhoea and psoriasis often assume a somewhat circular form, 
and then have a resemblance to ringworm ; but a study of the clinical 
history should render the diagnosis easy. 

All doubtful points in diagnosis should be determined by the 
microscoj>e. The examination can readilv be made in the following 



378 PRACTICE OF MEDICINE. 

manner : "A few of the scales may be scraped, with a blunt knife- 
blade, from the suspected patch and placed upon a glass slide con- 
taining a drop of liquor potassae, over which is laid a thin glass cover. 
The cover should be pressed down and the epidermic mass flattened 
out. Permitting the specimen to remain for a few minutes, it may be 
viewed with a power of from two hundred and fifty to five hundred 
diameters. The fungus will, in most cases, be detected here and 
there, having at first a faint outline, but becoming more distinct as 
the specimen stands." 

Progrnosis. Favorable, as a rule, although the affection is rebel- 
lious to treatment in some instances and prone to relapses. 

Treatment. Local treatment is usually all that is required for 
the cure of tinea circinata. In the majority of instances the following 
plan will be successful. Washing the patch with soft soap and water 
and the application of one of the following ointments : — 

R. Cupri acetat gr. x 

Ung. aquae rosae ^j. M. 

SiG. — Keep in contact with the patch. 
Or— 

H- Hydrargyri ammoniat gr.xx-xxx 

Ung. petrolei gj. *M. 

SiG. — Keep in contact with the patch. 

** In obstinate tinea circinata cruris the following, recommended by 
Tilbury Fox, may be employed : " — 

R. Creasoti Hi xx 

Olei cadini f^iij 

Sulphuris sublimati ^iij 

Potassii bicarb ^] 

Adipis gj. M. 

SiG. — Keep in contact with the affection. 

TINEA TONSURANS. 

Synonyms. Tinea trichophytina capitis ; herpes tonsurans ; ring- 
worm of the scalp. 

Definition. A contagious, parasitic affection of the scalp, due to 
the trichophyton fungus ; characterized by the development of cir- 



9^ 



DISEASES OF THE SKIN. .*{?.» 

cumscribed, vesicular or squamous, more or less bald patches, >how- 
ing the hair to be diseased and usually broken off close lo the scalp. * 

Cause. The result of the presence and growth of the same fungus 
giving rise to tinea circinata — trichophyton. It is an affection of 
childhood, seldom being seen after puberty. It is highly contagious, 
and may be communicated from a case of ringworm of the body. 

Pathologry* The parasite originally named " trichophyton ton- 
surans'' invades the hair, hair follicles and epidermis of the scalp, 
the hair, however, suffering the most severely, becoming in a shf>rt 
time filled with the growth to such an extent, usually, as to cause its 
disintegration and destruction. The hair follicle, also, becomes dis- 
tended and prominently raised. The hair shaft is fractured just 
above the level of the scalp, and usually presents a jagged, bristly, 
stubble-like extremity. The epidermis of the scalp may cither pre- 
sent the changes of minute vesicles and desquamation, or in severe 
cases, oedema and inflammatory symptoms with fluid exudation tinra 
kerion). 

Symptoms. Ringworm of the scalp usually begins in the form 
of small, circumscribed patches, which soon become the seat of small 
vesicles or pustules, which terminate in desquamation, or of furfur- 
aceous scales. The patches spread rapidly, soon reaching the size of 
a silver quarter to that of a silver dollar. They are circular in form, 
circumscribed, of a reddish, grayish or greenish-yellow color, coxered 
with fine or coarse scales, with the hairs broken off close to the scalp. 
The epidermis of the scalp is more or less raised and the follicles are 
prominent, giving the characteristic appearance of the disease — the 
goose-skin or plucked- fowl appearance. As a result of the lo«»^ rif 
hair, baldness, more or less complete, but temporary, exists. 

Itching, slight or severe, is a constant symptom. 

Ringworm of the face or body {tinea circinata\, may complicate 
tinea tonsurans. 

Chronic ringworm of the scalp is the same condition in a more 
chronic form, having existed for six months to a year or tw<j. 

Tinea kerion is a severe variety of tinea tonsurans, " characterized 
by oedema, inflammation, and the exudation of a viscid, glutinous, 
yellowish secretion from the opening of the hair follicles. When 
fully developed the patches are yellowish, reddish or purplish in 
color, and are more or less raised, oedematous and boggy. They are 
uneven and honeycomb-like (whence the name kerion), and studded 



380 PRACTICE OF MEDICINE. 

with yellowish, suppurative points, or, later, with small cavities or 
foramina, the openings of the distended hair follicles deprived of 
their hairs, which discharge a mucoid, gummy, honey-like fluid." 

The patches are tender, painful and at times the seat of itching. 
The course of the affection is chronic. 

Diagrnosis. The diagnosis is usually unattended with difficulty, 
if the characteristic circumscribed vesicular or scaly patches with 
stubby hair be present. 

Squamous eczema somewhat resembles tinea tonsurans, but the 
hairs are normal in eczema and firmly embedded in the follicles, 
whilst they are almost always stumpy in ringworm, and in those cases 
in which they are not broken off, if pulled, they easily fall out. Ring- 
worm is contagious, eczema is not. 

Alopecia areata presents the white, shiny, ivory-like, bald patch, 
devoid of scales or hair. Ringworm has the vesicular or scaly patch 
with broken-off hairs. 

In any case of doubt the microscope will readily determine the 
diagnosis, if ** one or two of the short, stumpy hairs should be 
placed upon a slide with a drop of liquor potasses and permitted 
to stand a few minutes, when, under a power of two hundred and 
fifty diameters the fungus, as well as the lesions of the hair, will be 
visible." 

Progrnosis. Favorable, although obstinate in chronic cases. 
Relapses are of frequent occurrence. 

Treatment. Local measures are satisfactory in the majority of 
instances of tinea tonsurans. 

Mild cases should be treated by cutting the hair as close as possi- 
ble and thoroughly scrubbing the patches with sapo viridis and water 
and the application twice daily of a six per cent, solution of oieatum 
hydrargyria or either of the following : — 

R. Sodii borat 3J 

Acetidestil gij. M. 

SiG. — Apply thoroughly several times daily. 
Or— 

R. Acidi boracici , gr. xv 

Sulphur, flos gr.xv 

Vaselini ^S^ss. M. 

SiG.— Apply morning and night. 



DISEASES OF THE SKIN. 381 

Or, use may be made of Morris' thymol solution, to wit : — 

K. Thymol ^... 355 

Chloroformi ^ ^i] 

01. olivae ^jvj. M. 

SiG. — Apply several times daily. 

A preparation very popular in London, known as Coster's paste, *s 
used by painting the patches with a brush and allowing it to remain 
on until the crust is cast off, in the course of five or six days, when it 
may be reapplied. A few applications often suffice. Its formula is — 

li. lodi 3ij 

Olei picis fjj. M. 

The iodine and oil of tar should be gradually and slowly mixed. 

Cases which resist these means are to be treated by removing the 
loose hairs about the edges of the patches, and the broken-off hairs 
over the surface, by means of small, broad-bladed, short forceps, a 
few hairs only being seized at a time ; a portion of the diseased hairs 
to be removed each day until the surface has been cleared. After 
each depilation, one of the above formulae are to be applied. 

TINEA SYCOSIS. 

Synonyms. Tinea trichophytina barbae ; sycosis parasitica ; bar- 
bers' itch ; ringworm of the beard. 

Definiticm. A contagious, parasitic affection of the hair, hair- 
follicles and subcutaneous tissues of the hairy portions of the face and 
neck in the adult male, due to the trichophyton fungus ; character- 
ized by the development of tubercles and pustules. 

Cause. Tinea sycosis is the result of the presence and grf)wth of 
the same vegetable parasite that causes tinea circinata and tinea ton- 
surans — trichophyton — which invades the hair follicle and hair. It 
is highly contagious, and is said to be acquired, in most cases, at the 
hands of the barber (?). It is not a very common affection. Like the 
other vegetable growths, it seems to require some peculiar, unknown 
condition of the skin for its development. It may develop from a 
case of tinea circinata or develop simultaneously with it. 

Pathologry* The parasite finds its way into the hair follicles and 
attacks the root and shaft of the hair, causing inflammation, followed 
by more or less follicular suppuration and general infiltraticm of the 



382 PRACTICE OF MEDICINE. 

surrounding tissues. The irritation caused by the presence of the 
fungus results in inflammation of the subcutaneous connective tissue 
and the well-known tubercular formations peculiar to the affection. 
They are firm, comparatively painless, and manifest but little dis- 
position to undergo change, remaining during the presence of the 
fungus and finally gradually disappearing without leaving a scar. 
Under the microscope the parasite is plainly discernible. 

Symptoms. Barbers' itch begins as an attack of tinea circinata 
— as one or more reddish, scaly patches. Soon the redness and des- 
quamation become more decided, attended with swelling and indura- 
tion. The hairs will also be dry, brittle, incline to break, and many 
of them are already loose. The process rapidly increases, the skin be- 
comes distinctly nodular and lumpy, and points of pustulation develop 
about the openings of the hair follicles. The subcutaneous connective 
tissue is also involved, giving rise to thick, firm masses of induration. 

The surface has a dark red or purplish color, and is studded with 
variously-sized tubercles and pustules. In some instances the num- 
ber of tubercles are in excess, whilst in others the pustules are more 
numerous, numbers of them discharging, and are succeeded by thick 
crusts, which are often so abundant as to simulate pustular eczema. 

The hairs are always diseased, and break off, either in the follicles or 
just above the level of the surface. Those not breaking drop out, 
leaving the region partly or wholly devoid of hair. 

The most frequent location attacked is the chin, neck and sub- 
maxillary region. One, or what is more common, both sides of the 
face are involved. 

Itching, burning 2i![iA pain always accompany the affection, varying 
inintensity from moderate to very severe. 

The course of the affection is usually chronic. Relapses are fre- 
quent, unless most thoroughly eradicated. 

Diagnosis. Sycosis non-parasitica occasions difficulty of diag- 
nosis at times. The points of difference, however, are usually so 
marked that error should not occur. 

Sycosis non-parasitica.is a chronic, inflammatory, non-contagious af- 
fection of the hair follicles, characterized by the development of papules 
and pustules, which are perforated with hairs, the hairs themselves 
being unaffected. The upper lip, cheeks and chin are the parts mostly 
involved. If of long duration, Some inflammatory thickening results. 

In tinea sycosis or sycosis parasitica, the skin and subcutaneous 



DISEASES OF THE SKIN. 38^ 

^^^unective tissue are extensively involved, as manifested by the in- 
^^Vi ration and formation of the characteristic tubercles. The upper 
■-ipi is rarely invaded, the hairs are diseased, broken off or loo<e. and, 
^^ Tider the microscoj>e reveal the parasite. 

Pustular eczema resembles tinea sycosis, with extensive pustulation 
^-xid crusting. But in the former the hairs are not involved, nor are 
tilie characteristic tubercles present. 

Treatment. Local measures are sufficient for the cure of tinea 
Sycosis. In the majority of instances the following procedure will 
effect a cure in three or four weeks. If crusts are present, and almost 
always some are, they are to be thoroughly saturated with inunctions 
of almond or olive oil, and removed by washing with soft soap and 
water. The part is then cleanly shaved, the tirst operation being 
more painful than subsequent ones. After shaving, the affected sur- 
face is bathed for ten minutes, in water as hot as can be borne. All 
pustules are then opened with a fine needle, after which the parts 
are sponged freely for several minutes with a solution of soiiii hypo- 
sulphitis, Z]t ciqucB, f^j, after which the parts are again thoroughly 
washed with hot water, carefully dried and smeared with an iin- 
guentum sulphur., containing 3 j-ij to the ounce. This procedure is 
preferably performed at night. The following morning the ointment 
is washed off with soap and water, the face bathed with the sodium 
solution, and dusted with any inert powder. This plan continued 
faithfully every night, omitting the shaving when the beard has not 
grown much, will usually be followed with success. 

Cases resisting the above means should, in addition to the above, 
have the hairs depilated, the shaving performed every two or three 
days, thus allowing time for the hairs to grow sufficiently to depilate, 
the operation seldom being so painful as one would suppose. Shav- 
ing and depilation upon alternate days should be faithfully practiced, 
until the new hairs show themselves to be healthy. 

In addition to the parasiticides mentioned, any of those recom- 
mended for the other vegetable parasitic diseases may be used. 

TINEA VERSICOLOR. 

Synonyms. Pityriasis versicolor ; liver-spots. 

Definition. A contagious ^ parasitic affection of the skin, due to 
the microsporon furfur ; characterized by the occurrence of variously 
sized, irregularly-shaped, dry, slightly furfuraceous, yellowish spots 
upon the chest or other portions of the body. 



384 PRACTICE OF MEDICINE. 

Cause. Pityriasis versicolor is the result of the presence upon the 
surface of the skin of a vegetable fungus termed the microsporon 
furfur. It is a mildly contagious affection seen after puberty. It is 
said to occur most frequently in those suffering from wasting diseases, 
particularly phthisis pulmonalis. It is not connected with any affec- 
tion of the liver, as supposed by the laity. 

Pathologry* The fungus permeates the horny layer of the epi- 
dermis, never the hair or nail, and gives rise to the irregular-shaped 
and sized maculae, of a yellowish or brownish color. As a rule, it 
gives rise to neither hyperaemia nor inflammatory symptoms. 

Symptoms. Tinea versicolor occurs in the form of irregular, 
roundish, circumscribed or reticulated maculae. The spots vary in 
size from that of a small silver coin to that of the hand. By coal- 
escing they often cover a greater portion of the chest, their most 
usual site. Upon close inspection the surface of the macule is seen to 
be covered with furfuraceous scales, and if the scales be not visible, 
scraping with the finger nail will demonstrate their presence. In 
color the spots vary from a delicate buff or fawn shade to a yellowish, 
deep brown, and, rarely, even blackish hue. At times mild itching 
accompanies the eruption. 

Diagrnosis. The characteristics of the eruption are so distinct 
that errors in diagnosis can hardly occur. If any doubt exist, a few 
of the scales placed upon a glass slide, with a drop of liquor potasses, 
and covered with a thin glass cover and placed under a microscope 
with a power of from two hundred and fifty to five hundred diameters, 
the fungus is readily discerned. 

Progrnosis. Favorable. 

Treatment. The parts should be cleansed with soap and water, 
and either of the following lotions applied : — 

H- Sodii sulphitis ^iij 

Glycerini f^ij 

Aquae ad ^Siv. M. 

SiG. — Apply frequently. 
Or— 

R. Hydrargyri chlorid. corrosiv gr. iv 

Alcoholis ^i5vj 

Ammonii muriat ^^ss 

Aquae rosae ad f^^j- ^^• 

SiG. — Apply frequently. 

— Tilbury Fox. 



DISEASES OF THE SKIN. 385 

SCABIES. 

Synonym. The itch. 

Definition. A contagious, animal parasitic disease of the skin, 
due to the acarus or sarcoptes scabiei ; characterized by the formation 
of cuniculi (burrows), papules, vesicles and pustules, followed by ex- 
coriations, crusts and general cutaneous inflammation, and accom- 
panied with itching. 

Cause. Contagion. The only cause is the presence of the animal 
parasite, the acarus or sarcoptes scabiei. The affection occurs at all 
ages and in every walk of life. 

Pathologfy. Scabies is an inflammation of the skin with the 
development of papules, vesicles, pustules, excoriations and subse- 
quent crusting, the result of the ravages of the animal parasite, 
together with the irritation produced by the scratching of the patient. 

The parasite — acarus or sarcoptes scabiei — is a minute creature, 
barely visible to the naked eye as a yellowish-white, rounded body. 
The female is the most commonly met with, the males being said to 
take no part in causing the affection, and so are rarely seen. They 
are said to die in about a week after copulation with the female. The 
female finds her way by boring through the horny layer into the 
mucous layer of the epidermis, and, being impregnated, begins at 
once laying her eggs and at the same time making her burrow. A 
variable number of eggs are deposited, usually about a dozen, after 
which she perishes in the skin. The ova hatch out in eight or ten 
days. 

Symptoms. Scabies being an artificial dermatitis or eczema, 
according to the amount of irritation produced by the presence of the 
parasite and the traumatism the result of the severe scratching of the 
patient. 

Immediately upon the arrival of the itch mite upon the skin it begins 
its work of burrowing, and very soon a burrow or cuniculus is formed, 
in which the eggs are'deposited and which also becomes the habitat 
of the female during the remainder of her life. The ova are hatched 
in about one week after their deposit, and they at once begin to care 
for themselves and to burrow, resulting in the formation of as many 
additional cuniculi as there are active female mites. It is the presence 
of these burrowing parasites that constitute the irritation resulting 
in the inflammation of the skin, characterized by the formation of 
minute papules, vesicles and pustules, with more or less inflammatory 



f indui 

I ihesi 



PRACTICE OF Ml'U)]C-tM-:. 



Add lo these the excarialians, scrahk marks, fissures, 
torn vesielti, and pnslults with yellow and hhody trusts, caused by 
tching, and a picture of the fully-developed disease is seen. 

The hHrro'w, or nmiculus. as it is termed, is formed by the mite 
entering and making its way beneath the homy layer of the epidermis, 
which is raised, very much as a mole undermines the ground. It 
occurs as a slight linear elevation of the epidermis, varying from a 
half a line to four or five tines in length, and having an irregular or 
tortuous course. Its color is whitish or yellowish, speckled here and 
there with dark dots. Ai either end the cuniculus terminates as 
darkish points, the more prominent of which represent tiie parasite. 

The papules are the first inflammatory lesion, are numerous, and 
of small size, and may he the extent of the disease. 

The vesicles are the next stage, varying in siie and number, having 
an inflamed base, sometimes presenting cunicnli upon their summits. 

The pusMes represent the completion of liie inflammatory action, 
their site and number varying with the severity of the 

The intense itching, which is worse at night, results i 
torn papules, vesicles and pustules, followed by crnstings. which after 
a time disguise the characteristic lesions. The regions of the body 
attacked are the hands, especially the sides of the fingers and the 
folds where they join Uie hands. After a time the wrists, penis and 
mamma.', around about and upon the nipples, are invaded. 

Persons predisposed to eczema have this affection developed ia 
addition to the simple dermatitis, by the ravages of the itch mite. 

Diagnosia, A case of scabies seen before irritated by scratching 
presents no difficulty in diagnosis. The presence of the burrows 
always suffices for the diagnosis, but these are not always discover- 
able. The location of the eruption always points strongly to scabies. 
A history of contagion is of value. All doubt can be set at rest by 
the aid of the microscope. 

Prognosis. Always favorable, relapses only occurring when the 
treatment has been imperfectly carried out or where the individual 
has re- contracted the disease. 

Treatment. Local measures are alone required in the treatment 
of scabies. The strength of the parasiticides must be controlled by 
the severity of the inflammatory symptoms present. If eczema com- 
plicate scabies, it is to be treated as an ordinary attack after the death 
of the itch mites. 



k 



DISEASES OF THE SKIN. 387 

Scabies almost always succumbs to the following plan. The patient 
is to be thoroughly washed with soft soap and water, followed by a 
warm bath, after which one of the following ointments is to be 
thoroughly rubbed into every portion of the body, special attention 
being devoted to the hands, fingers and other parts usually the seat of 
the disease. 

R. Styracis liquidis ^ij 

Ung. sulphuris ^ij-i^ 

Ung. petrolei ad ^'j. M. 

SiG. — Apply after washing. 

— BULKLEY. 

Or— 

R. Sulphuris sublimat 3J 

Balsam. Peruvian! ^^^ss 

Adipis ^'}. M. 

SiG. — For children. 

— DUHRING. 

PEDICULOSIS. 

Synonyms. Phthiriasis ; morbus pedicularis ; lousiness. 

Definition. A contagious, animal parasitic disease of the head, 
body or pubes, due to the presence of pediculi and characterized by 
the wounds inflicted by the parasite, together with excoriations and 
scratch marks. 

Varieties. Pediculosis capitis ; pediculosis corporis ; pediculosis 
pubis. 

Cause. The cause is the presence of the parasite, the result of 
contagion, direct or indirect. The view of a " spontaneous genera- 
tion " of pediculi is not accepted by the great majority of observers. 

Pathologry. The lesion produced by the presence of pediculi is 
a minute hemorrhage, caused by the parasite inserting its sucking 
apparatus, or, as it is termed, its haustellum, into a follicle, and obtaining 
blood by a process of sucking, and not by biting, as is generally sup- 
posed. The presence of the parasite in any great numbers brings 
about a peculiar irritable state of the skin, which gives rise to an 
irresistible desire to scratch, as a consequence of which the surface is 
markedly excoriated and lacerated. 

Symptoms. The symptoms which arise from the presence of the 
parasite in different localities are somewhat different, and call for 
separate consideration. 



388 PRACTICE < 

Pedii:ulosis capitis. This variety is caused by the presence of the 
pfdiaitus capitis or head louse. The ova ofm/s. are readily recog- 
nised at a distance. Their favorite seat is the occipital region, either 
upon the surface of the scalp or upon the hair. Their presence 
gives rise to considerable irritation, itching and consequent scratching, 
resulting in the wounding of the scalp, with oozing of a serous or 
purulent fluid mixed with blood, which soon mats the hair and forms 
into crusts. In those predisposed to eczema, the presence of the 
parasite will give rise to that condition. 

The general health is usually unaffected by the presence of the 
pcdiculi. 

Pediculosis corporis. This variety of pedicidosis is caused by the 
presence of the pedicuiua corporis or body louse, or more properly 
termed the pediculus veslimenti or clothes louse. Its color, when 
devoid of blood, is dirty-while or grayish, with a dark line around 
the margin of the abdomen. Its habitat is the clothing covering the 
general surface, remaining upon the skin only long enough to obtain 
sustenance. The ova are usually deposited in the seams of the cloth- 
ing, the lice being hatched within the week. Occasionally a few of 
the pediculi may be observed crawling about the surface, or in the 
act of drawing blood, As they move over the surface they give rise 
to an intensely disagreeable itching sensation, to relieve which the 
patient scratches, which in turn ^ves rise to the characteristic lesions 
' of the affection. 

The lesions are numerous. The scratch marks are scattered here 
and there, either long and streaked, in other places short and jagged ; 
the excoriadons and blood crusts varying in size from a pin head to a 
split pea or even larger, with irregularly-shaped pustules. In addi- 
tion to the lesions resulting from tiie scratching, are seen the primary 
lesions, consisting of minute reddish puncta with slight areola, the 
points at which the parasite has drawn blood. In cases of long stand- 
ing, a brownish pigmentation of the whole skin may result from the 
long-continued irritation and scratching. The favorite site of the 
lesions are the back, especially about the scapular region, the chest, 
abdomen, hips and thighs. 

Pediculosis is seen most commonly among the poorer classes, and 
especially the middle-aged and elderly. 

Pediculosis pubis. This variety of pediculosis is caused by the 
presence of the pediculus pubis or crab louse. Although having its 



k 



DISEASES OF THE SKIN. ' 389 

seat of predilection about the pubes, it may also infest the axillae, 
sternal region in the male, beard, eyebrows and even eyelashes. 

They may be found crawling about the hairs, but more commonly 
hugging the surface closely. They infest adults chiefly, and occa- 
sion symptoms similar to those described in connection with other 
species. They are usually contracted through sexual intercourse, 
although occasionally they are present in cases in which they have 
not been communicated in this way, and where no explanation as to 
the mode of contagion can be suggested. The itching varies from 
slight to severe. 

Diagnosis. When violent itching exists in any case, without 
marked eruption, the possibility of the presence of pediculi should 
always be entertained, and if carefully sought after are found. 

Prognosis. Favorable, if the treatment be thoroughly carried 
out. 

Treatment. Local measures alone are all that is necessary for 
the removal of the various forms of pediculosis. 

Pediculosis capitis. The most effective application for this variety 
is to thoroughly soak the head two or three times a day with ordinary 
petroleum or kerosene oil, and left wrapped in a cloth for twenty-four 
hours. At the end of this time the head should be thoroughly washed 
with soft soap and hot water, dried and saturated with the official 
unguentunt hydrargyri ammoniati. If required, this entire procedure 
may be repeated, but usually any pediculi escaping the petroleum are 
destroyed by the unguentum. 

Pediculosis corporis. In this variety the habitat of the parasite 
being the clothing, they must be boiled or baked at a temperature 
sufficiently high to destroy life. After this the clothing should be 
changed every day or two, carefully inspected, and if pediculi are 
seen they must again be baked or boiled. It is folly to expect satis- 
factory results unless these directions be faithfully adhered to. For 
the irritation, itching and excoriations, mild alkaline baths or lotions 
of acidutn carbolicum are sufficient. 

Pediculosis pubis. The parts should be washed twice daily with 
soft soap and water, after which the thorough application of tinctura 
cocculus indicus, full strength or diluted, or a lotion of hydrargyri 
chloridum corrosivum or unguentum hydrargyri ammoniati will be 
effectual. 



INDEX. 



PAGE 

BDOMINAL dropsy 94 

typhus 16 

-^V>scess, cerebral 283 

of the liver 100 

perityphlitic . 84 

-^one 355 

artificialLs 356 

disseminata 355 

indurata 356 

papulosa 356 

Piffard's solution for 319 

punctata 35^ 

pustulosa 356 

rosacea 358 

sebacea 315 

vulgaris....... 355 

-A.cunite in erysipelas 42 

-A.cute general diseases 127 

-A.ddison's disease 311, 365 

>£tiolog>' 9 

Ague 23 

brow 24 

cake. 23 

Agraphia 286 

amnesic 286 

ataxic 286 

Albumen, test for 108 

Albuminuria 113 

chronic 114 

Anaemia 306 

cerebral 268 

essential 308 

of fjatty heart 308 

progressive pernicious 308 

splenica 309 

Ana:matosis..... 308 

Anatomy, morbid 11 

pathological 11 

Angina pectoris 265 

Anidrosis 323 

Anodynes, compound of. 61 

Anthrax 353 

Aphasia 285 

amnesic 285 

ataxic 285 

Aphonia 286 

Aphthae 45 

discrete 45 

confluens ^ 

Apnoea 11 

Apoplexy 272 

serous 280 

Arachnitis 275 

Argyria 366 



PAGE 

Arteries, Cohnheim's terminal 270 

Arthritis, deformans 140 

mono- 135 

poly- 135 

Ascaris lumbricoides 89 

Ascites 94 

Asthenia 11 

Asthma 204 

bronchial 204 

hay 206 

Kopp's ■ 193 

nervous 204 

Ataxia, locomotor 297 

Atonic dyspepsia 61 

Atrophy, acute yellow loi 

Aura epileptica 304 

Auscultation 164, 241 

DaCosta's rules for 175 

. "DACILLA, comma 151 

'^ Bacillus tuberculosis 226 

Bacteria of decomposition 151 

Barber's itch 381 

' Bell's palsy 302 

Belt, hydropathic 100 

Bile, test for 1119 

Bile pigment, test for 110 

Bilious fever 25 

malignant fever 30 

remittent fever 25 

typhoid fever 22 

Biliousness 99 

! Black-heads 317 

, Bladder, catarrh of. 125 

, Blaud's pill 308 

Bleeders' disease 312 

'. Blepharospasm 303 

, Blisters in rheumatism 138 

Blood currents direct 244 

indirect 244 

test for IOC) 

white cell 309 

Boil 351 

I Borborygmus 58 

) Bothriocephalus latus 88 

Bowels, inflammation of 69 

Break-bone fever 43 

Bright's disease, acute 113 

chronic 114 

Bromidrosis 321 

pedum 321 

Bronchitis 194 

acute 194 

' capillary 197, 221) 



391 



392 



INDEX. 



PAGE 

Bronchitis, catarrhal 194 

chronic soi 

croupous 200 

diphtheritic aoo 

foetid 202 

membranous 200 

peri- 220 

plastic 200 

secondary 201 

Broncho-pneumonia 197 

Bronchorrhagia 210 

Bronchorrhcea 202 

Bronzed-skin disease 311 

Ci*:CUM, catarrh of. 82 
Calculi, alternating 123 

biliary 97 

hepatic 97 

oxalate of lime 123 

phosphatic *. 123 

renal 123 

uric acid 123 

Callositas 367 

Callus 367 

Cancer, gastric 56 

hepatic 105 

Carbuncle 353 

Carbunculus 353 

Carcinon[ia, gastric 56 

Cardiac dilatation 254 

fotty degeneration 256 

hypertrophy 252 

murmurs 262 

paralysis 131 

see-saw murmurs 262 

valvular diseases 258 

Cardialgia 60 

Catarrh, acute gastric 50 

acute nasal 176 

autumnal 206 

bronchial 194 

chronic bronchial 201 

chronic gastric 53 

chronic nasal 179 

contagious 14 

dry 202 

mucous 202 

of the bladder 125 

of the caecum 82 

of the rectum 84 

sec. of Laennec 202 

suffocative 197 

Catarrhal jaundice 96 

stomatitis 44 

Cephalodynia 139 

Cerebral abscess 283 

anaemia. 268 

congestion 267 

embolism 269 

hemorrhage 272 

softening 283 

thrombosis 269 

tumors 284 

Cerebro-spinal fever 20 

Cerebro-spinal neuroses 303 

Cervico-brachial neuralgia....* 300 



PAGE 

Cervico-occipital neuralgia 299 

Chickenpox 40 

Chills and fever 23 

Chloasma 365 

uterinum 366 

Chlorides, test for 108 

Chlorosis 307 

Cholera 151 

Asiatic »5* 

asphyxia i53 

bilious T* 

English P 

epidemic *5* 

infantum 77 

malignant ^5^ 

morbus 7' 

saline fluids in ^^5 

solution, Bartholow's ^^ 

spasmodic *^ 

sporadic -•• '^. 

typhoid -- *'^ 

Cholerine -- V| 

Chorea -- ^ 

hemi -- -' ^ 

post-hemiplegic --" , 

Chromidrosis - ' ' ■ 

Clark, treatment of peritonitis - " ' 

Clavus .- "" 

Cohnheim's terminal arteries -> " 

Cold on the chest *" 

in the head - " 

Colic, hepatic " 

intestinal - " 

lead -' 

ovarian .- 

renal , 

stomachic •> 

uterine 

Colitis 

Coma,uraemic * 

Comedo 3 

Comma bacillus '• 

Congestion, cerebral ^^ 

of the kidneys x' 

of the lungs a' 

Congestive fever 2 

Constipation 6< 

Consumption, pulmonary 22; 

galloping ly. 

Contagious fever u 

Convulsions, uraemic i3i 

Corns 36: 

soft 36c 

Corrigan's disease 22c 

sign 5; 

Coryza, acute X7< 

chronic i7< 

Coster's paste 38 

Costiveness 6< 

Cough, winter 20 

Crackling 21I 

Crepitatio redux 2ii 

Crisis I 

Croup, catarrhal 18 

false 18 

membranous i& 



INDEX. 


3i)8 








B==:===;!l 




EE£g 










^« 


— .3B 






■piulciinl 

iSS™.— ■ 


"»j 






r3;.::4 




•■■"■■:■■■■■: ^ 


^ .=-ziz:;..S 


■'"^ir.;::::-::- 


=:::■:£ 


tc=^'=EE« 


l.'?:;._..r.::~r"::=: :8 


■^•S^EEE" 


:::::„- j; 




































«M||m .................... 




:. e? 


:::":::::: 3l' 


















;;;::::;:.": "; 


W. w 


g«onp> 


.'7. . = 








'i^^i^-:::r"^^ 






- -J 




























i;c::. ■■"„.";.....;;: ^ 




■ ■ ■':■ 


















,li«10f...... _. •> 




^^■^us::::::;:: *3 




TM <■-' 


- 



;Sfe.:::; 



Epidemic caUirT^ kit 



Eiicalypul in cyititn.... 
pACIAL puilriu.... 






epidemic ceniwo-Apiiuil.... 






Ste= 



maUgninl inlcnnilUiU aj 

nuilignuit roidttent «. «.». 37 



er, lyphus 

yellow'.'.!'.'.; ill 
continued,-.. 

periodical..,. 






Gloltis» ccdeiqac^. 



iimpie 

indc Cuyi 







§£." 


™w.iiu.;:— .-__.: 







UiGMATEHESIS 
** Hcnuiioina of il 



Hcunuonu <i the duia iiialer 



INDEX. 



395 



PAGE 

Heart, palpitation of...... 265 

physical examination of. 240 

valvular diseases of. 258 

Heartburn 61 

Hemiplegia 273 

Hemorrhaee, bronchial 210 

cerebral 272 

gastric 59 

renal 124 

solution for 30 

Hemorrhagic diathesis 312 

Hepatic cancer 105 

Hepatitis, acute 100 

interstitial 102 

parenchymatous 100 

suppurative ; 100 

Herpes 342 

circinatus 376 

&cialis 342 

eestationis 343 

uibialis.. 342 

praeputialis 343 

progenitalis 343 

tonsurans 378 

zoster 343 

Hives 340 

Hooping cough 208 

Hydraemia 306 

Hydro-adenitis 352 

Hydrocephalus, acquired 280 

acute.. 278 

chronic 281 

congenital 281 

Hydro-pericardium 248 

Hydro-pneumothorax 238 

Hydrosis 320 

Hydrothorax 238 

Hyperaemia cerebral 267 

spinal 287 

Hyperaemias of the skin 324 

Hyperidrosis 320 

local 321 

unilateral 321 

Hypertrophies of the skin 364 

Hypertrophy cardiac 252 

TCHTHYOSIS 371 

* Icterus 96 

Ileo-colitis 1 69 

fcnpetigo 349 

Incubation 10 

Indigestion 61 

acute 50 

intestinal 62 

Inflammations of the skin 325 

Influenza 14 

Inspection 158,240 

Intermittent fever 23 

Intestinal colic 64 

dyspepsia 62 

obstruction 85 

parasites 87 

stricture 85 

torpor 66 

Intestines, diseases of. 62 

irri^tion of. 97 

Introduction 9 



PAGE 

Invagination 85 

Ipecacuanha in dysentery 82 

Ischaemia 306 

Itch 385 

barbers' 381 

JAIL fever 19 
Jaundice, catarrhal 96 

malignant loi 

If'IDNEYS, amyloid 118 

■*^ congestion of. 112 

contracted 117 

diseases of. 106 

gouty 117 

lardaceous 118 

sclerosis of. 117 

small red 117 

waxy 118 

Kummerfield's lotion 360 

T ARYNGISMUS stridulus 193 

^^ Laryngitis, acute catarrhal 185 

croupous 189 

oedematous 186 

spasmodic 187 

Law of parallelism 135 

Lentigo 364 

Lepra 360 

Leptomeningitis spinalis 288 

Leucaemia 39 

Leucocythemia 39 

Lichen, simplex 327 

tropicus 345 

Liquor picis alkalinus 332 

Lithaemia 145 

Lithiasis 145 

Liver, abscess of. 100 

albuminoid 104 

amyloid 104 

atrophic 99 

cirrhosis of. 102 

congestion 99 

diseases of. 99 

gin drinkers' 102 

hob-nailed 102 

hypertrophic sclerosis of. 103 

lardaceous 104 

nutmeg 99 

sclerosis of. 102 

scrofulous 104 

spots 383 

torpid 99 

waxy 104 

yellow atrophy of. loi 

Locomotor ataxia 297 

Lotio nigra 331 

Lousiness • 387 

Lumbago 139 

Lumbo-abdominal neuralgia 300 

Lumbodynia 136 

Lungs, cirrhosis of. 229 

congestion of. 212 

gangrene of 218 

hyperaemia of 212 

oedema of. 213 

Lysis M II 



896 



INDEX. 



II 



PAGE 

TiiTALIGNANT intermittent fever 27 

■*^'^ remittent 27 

Mai, le grand 304 

Mai, le petit 304 

Marsh fever 25 

Measles 35 

black 35 

false 36 

French 36 

German 36 

Mediterranean fever 30 

Melasma, supra-renalis 311 

Melituria 146 

Membranous enteritis 71 

Meningitis, acute 275 

basilar 278 

spinal 278 

tubercular 278 

Mensuration 159 

Metastasis 11 

Miliaria ;.. 345 

alba 345 

papulosa 345 

rubra 345 

vesiculosa 346 

Milium 319 

Mixture, Bartholow's cholera 74 

Basham's iron 114 

DaCosta's muscular cramps 74 

Hartshorn's cholera 74 

Hope's camphor 71 

Keating's pertussis spray 210 

Pepper s asthma 206 

Squibb's diarrhoea 68 

Morbid anatomy 11 

Morbilli 35 

Morphia in acute uraemia 120 

in cardiac dilatation 254 

Morris's thymol solution 381 

Moth 365 

Mouth, catarrh of 44 

diseases of. « 44 

white 47 

Mucus, test for 108 

Muguet 47 

Mumps 127 

Murmurs, aortic 262 

endocardial 242 

exocardial 246 

mitral 261 

pericardial 242 

pulmonic 263 

see-saw 262 

tricuspid 262 

Muscles, insanity of. 303 

Myelitis, acute 291 

Myocarditis 251 

^J ASA L acute catarrh 176 

^^ chronic catarrh 179 

Nephritis, acute desquamative 113 

catarrhal 112 

chronic parenchymatous 114 

interstitial 117 

parenchymatous 113 

peri- 120 



PAGE 

Nephritis, pyelo- X20 

suppurative 120 

tubal 113, 114 

Nephro-lithiasis 123 

N ephrosis-pyelo 121 

Nervous fever 16 

Nettle-rash. 340 

Neuralgia 299 

cervico-occipital 299 

dorso-intercostal 300 

intercostal 343 

lumbo-abdominal 3** 

of the fifth nerve 299 

of the heart 265 

sciatic 3* 

Neuralgic fever 43 

Neuritis ^ 

Neuroses, cerebro-spinal ^ 

Nickel, use of in epilepsy 3* 

Nystagmus 3°^ 

QBSTRUCTION, aortic '^ 

7^ intestinal -- ^ 

mitral --- ^ 

pulmonic -' 

pyloric -- , 

tricuspid -- '. 

Occlusion, of cerebral vessels -' 

Oi'dium albicans -- 

Ointment, diachylon, Hebra's - 

Oligemia , - • 

Oxyuris vermicularis - 

Ozaena - ' 

PACHYMENINGITIS « 

^ spinalis ^ 

Pains, the girdle * 

Palpation 159, 24 

Palsy, Bell's 3c 

Paragraphia 28 

Paralysis 27 

bilateral 27 

bulbar 29 

cardiac 13 

chronic progr^sive bulbar 29 

diphtheritic 13 

essential, of infants 29 

facial 3c 

glosso-labio laryngeal 29 

infantile spinal 25 

of the tongue 2I 

pharyngeal 11 

unilateral 2j 

Paraphasia 2E 

Parasitic diseases of the skin 3; 

Parotiditis la 

metastatic 15 

Paste, Coster's 3? 

Pathological anatomy 1 

Patholog>r 

Pediculosis 3S 

Pemphigus 3^ 

foTiaceus 3^ 

mali^us 3^ 

prunginosus 3^ 

vulgaris 3^ 



IN'DEX. 



3fiC 



rAGB 



'^crciission ~.. i6o. 24s 

auscultatory ._ xl« 

immediate.^ i6d 

mediate i6c 

objects of,.... I ifc 

p _ respiratory 1^4 

"ericarditis, acute 245 

chronic. 247 

p . dry _.. 245 

'^cncardium, adherent 147 

effusion of — 255 

p ^ hydro-.- 242 

^«ri-nephritis X2x 

periodical fevers 23 

^eri-proctitis £5 

peritoneal dropsy ~ >4 

peritonitis ~ >i 

^eri-typhlitb — s* 

pertussis _ — aoi 

pharyngeal paralysis _ isx 

'^haryngitis, acute catarrhal x^i 

er3rsipelatous — i£: 

phlegmonous — xsa 

I^hospnates, test for. ic- 

I^hosphoridrosis ^ 

^hthiriasis 

PhthisU ^ 



■ai 



acute 

caseous... 
catarrhal, 
chronic... 
fibroid .... 
Florida... 



3X4. 



223 

T2- 



224 



mcipient 

pneumonic 

pulmonalis... 

subacute 

tubercular ~ 

Physical diagnosis 

• signs _ 

Piffard's acne solution 

Pill, Bartholow's gout. ^ ji... 

Blaud's- _.. 

DaCosta's, for hemorriaige... 

Gross' neuralgic 

Loomb' gout 

Niemeyer's 

Pilocarpus for spreading erjsipekk*. 
Pittii^, to prevent. 

veniccAoT 

Pleurisy 

Pleuritis 

chronic ~. -. 

dry 

Pleurodynia ...^^ — 

Pleuro-pneumoiua. — . 

Pneumonia, bilious. ^ 

catarriiaL. > 

chronic catarrhal ~ — 

chronic interstitial 

croupous 

lobar -~— ... 

lobular •>. 

typhoid .^...~«. 

Pneumonitis 



234 
22( 

22} 
224 
22!£ 

«:7 



222 

3c« 



2S.3 

42 

yr 

-J* 

**• 

225 
2ir 



«5 



i-.KStznj. ... . . .. 

Podagra _... . 

Pce:-^7«LcLS iscer-i:r 

P>.lzce. jCi.wjis'i*:!- 

f^-*'JC . 

Preii^-.«^.a __— .. 



^-^ 



Pr-* — t. > 



Pn^^Mis 







r 
r 



IA15-- 



Zb-.Mr 



H -X " 

fUKTJT.M. 

rjt ^f^j- 

2i:fni 

--"■'■ 
lEAegmofCi'. ^^.Jir 



''^ 



■'i 



«; 



INDEX. 



, PAGB 

^tment, specific for typhoid fever. .~ iS 

rsiens, delirium 277 

-liinsB 155 

spiralis ~ 155 

chinosis 155 

t>erculosis 226 

acute miliary 230 

mors, intra-cranial 2S4 

Tpeth mineral in croup i^z 

"loma 367 

^mpanites, chronic 95 

rphlitis 82 

ypho-malarial fever 25 

yphus, icterode 30 

"TLCER, duodenal ~.. 55 

■^ gastric - 54 

perforating 54 

Ulcerative stomatitis 46 

Jlccrosa gingivitis * 46 

-Traemia, acute i2z 

morphia in 122 

LTraemic coma 121 

convulsions 121 

CJrates, test for ~ 106 

^-Jrea, test for lo^ 

X_Jric acid diathesis L45 

test for iiyj 

XJridrosis 321 

"VJrine i-aC 

hysterical 205 

normal color - i-A. 

normal constituents zoiC 

normal quantity ^ ~ 10^ 



Uriae, 
Urticaria 



snii 



T7ACCrXAT:OV-. . 

^ Vacdsia 

Valv-Jar iaeasea -f rue 

da^aoKa -jL 

Val-Titra- 

VarioeSa. 

Varicia _ 

Varj*.....- - 

V<Err3ca... ._ 

Verc^. fCimacaa: . . .. 
\'e%ic::iakr feimarnj- .. . 

V-.CUt. UJ&CK. 

cifise rrnuu: 



-k'. 



\MWA11-L rir. 

Wart- 



^iiaoen 



Wa«ajf . ..~ 

Wiice 3usi:=:t- 

WuTiH. r-.iaiii. 



EaOLi-SjfA 



y 



'/ 



/ 



LANE MEDICAL LIBRARY 

To avoid fine, this book should be returned 
an or before the date laat stamped below.