CIHM Microfiche Series (Monographs) iCMH Collection de microfiches (monographies) Canadian Institute for Historical Microreproductions / Institut canadien de microreproductions historlques I %J^ Technical and Bibliographic Notes / Notes techniques et bibliographiques toriques The Institute has attempted to obtain the best original copy available for filming. Features of this copy which may be bibliographically unique, which may alter any of the images in the reproduction, or which may significantly change the usual method of filming are checked below. D D D D D Coloured covers / Couverture de couleur I I Covers damaged / Couverture endommagee Covers restored and/or laminated / Couverture restauree et/ou pelliculee D Cover title missing / Le titre de couverture manque I I Coloured maps / Cartes geographiques en couleur □ Coloured ink (i.e. other than blue or black) / Encre de couleur (i.e. autre que bleue ou noire) I I Coloured plates and/or illustrations / L'Institut a microfilme le meilleur exemplaire qu'il lui a ete possible de se procurer. Les details de cet exem- plaire qui sont peut-etre uniques du point de vue bibli- ographique, qui peuvent modifier une image reproduite, ou qui peuvent exiger une modification dans la metho- de normale de filmage sont indiqu6s ci-dessous. I Coloured pages / Pages de couleur I I Pages damaged / Pages endommagees D D D D Pages restored and/or laminated / Pages restaurees et/ou pelliculees j 7| Pages discoloured, stained or foxed / I J Pages decolorees, tachetees ou piquees Pages detached / Pages detachees V Showthrough / Transparence I I Quality of print varies / Planches et/ou illustrations en couleur Bound with other material / Relie avec d'autres documents Only edition available / Seule edition disponible Tight binding may cause shadows or distortion along interior margin / La reliure serree peut causer de I'ombre ou de la distorsion le long de la marge interieure. Blank leaves added during restorations may appear within the text. Whenever possible, these have been omitted from filming / Use peut que certaines pages blanches ajoutees lors d'une restauration apparaissent dans le texte, mais, lorsque cela etait possible, ces pages n'ont pas ete filmees. GTl Additional comments / Pagination is as follows: p. [4]-259. —I Commentaires supplementaires: Qualite inegale de I'impression Includes supplementary material / Comprend du materiel supplementaire Pages wholly or partially obscured by errata slips, tissues, etc., have been refilmed to ensure the best possible image / Les pages totalement ou partiellement obscurcies par un feuillet d'errata, une pelure, etc., ont ete filmees a nouveau de fagon a obtenir la meilleure image possible. Opposing pages with varying colouration or discolourations are filmed twice to ensure the best possible image / Les pages s'opposant ayant des colorations variables ou des decolorations sont filmees deux fois afin d'obtenir la meilleure image possible. This item is filmed at the reduction ratio checked below / Ce document est filme au taux de reduction indique ci-dessous. 10x 14x 18x 22x 26x 30x / 12x 16x 20x 24x 28x 32x The copy filmed here has been reproduced thanks to the generosity of: Osier Library, McGill University, Montreal The images appearing here are the best quality possible considering the condition and legibility of the original copy and in keeping with the filming contract specifications. Original copies in printed paper covers are filmed beginning with the front cover and ending on the last page with a printed or illustrated impres- sion, or the back cover when appropriate. All other original copies are filmed beginning on the first page with a printed or illustrated impres- sion, and ending on the last page with a printed or illustrated impression. The last recorded frame on each microfiche shall contain the symbol —^ (meaning "CON- TINUED"), or the symbol V (meaning "END"), whichever applies. Maps, plates, charts, etc.. may be filmed at different reduction ratios. Those too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, as many frames as required. The following diagrams illustrate the method: L'exemplaire filmd fut reproduit grice d la g4n4rosit6 de; Osier Library, McGiM University, Montreal Les images suivantes ont 6t6 reproduites avec le plus grand soin, compte tenu de la condition et de la nettet^ de I'exemplaire film*, et en conformity avec les conditions du contrat de filmage. Les exemplaires originaux dont ia couverture en papier est imprimis sont film6s en commenpant par le premier plat et en terminant soit par la darniire page qui comporte une empreinte d'impression ou d'illustration, soit par le second plat, selon le cas. Tous les autres exemplaires originaux sont film^s en commenpant par la premiere page qui comporte une empreinte d'impression ou d'illustration et en terminant par la derniire page qui comporte une telle empreinte. Un des symboles suivants apparaitra sur la derniire image de cheque microfiche, selon le cas: le symbole — ^ signifie "A SUIVRE", le symbole V signifie "FIN". Les cartes, plenches, tableaux, etc., peuvent etre filmis d des taux de reduction diffdrents. Lorsque le document est trop grand pour gtre reproduit en un seul cliche, il est film* d partir de Tangle sup*rieur gauche, de gauche d droite, et de haut en bas, en prenant le nombre d'images n^cessaire. Les diagrammes suivants illustrent la m^thode. 1 2 3 4 5 6 AAICROCOPY RESOLUTION TEST CHART (ANSI and ISO TfcST CHART -l^. 21 1.0 I.I mil !: m t m 12.5 2.2 2.0 1.8 1.25 _J ■^PPLMO \M^GE_\nc ^=" 16S3 Las; Main Street r^ Rochester. Ne» Yrrk 14609 USA -SS (716) 482 - 0300 - Phone ^= (716) 288 - 5989 > ;■ // NOTES — ON — P ^ / PRACTICE OF MEDICiL^E. :5>v^_ liv.^ "5^511) vv^^"^ / (" MONTREAL :^. -i'^ife91^'ACLlU'Y. PKACTICK OF MKDICINE. Internal Pathol.)i,'y i.s divia, dysentery, diphtheria, mumps, influenza, whooping cough and simple cholera. 2. Malarial fevers, as ague. 3. Septic diseases— septicemia, phagadaena, pyemia, hospital gangrene, erysipelas. 4. Venereal diseases— syphilis, gonorrhoea. 5. Febrile diseases communicable from animals-glanders, farcy, anthrax and hydrophobia equina. (B) Diseases depen- dent on external agents other than morbid poisons, subdivided into 4 groups : 4 Diseases due to animal -"-nd vegetable parasites. a.s tinea, worms. 2. Poisons of animals or of vegetables, inorganic poisons, lead, arsenic, etc '6- 'iseases ot in- jury, traumatic, climatic, etc. 4. Diseases produced by em. s jf diet, as •curvy, alcoholism, starvation, ergotism. (0) Immaturity (devdopaiental dis- 5G497 PRACTICE 0? MKDICINB, 6 ensps), tniilfiirmrvtinn.^, duljility, old iij{.!. (D) Nou-clns'iifiablo, or coustitutioiml, duo t() defective iiliysiiilogy, iiH leprosy, piir.iiixi, tnlH3rcuk).sis, scivl'dla, rlieii- iimtism (acute and chronic), gout, ostco-artliiilis, aiuuinia siiiiplci and jtumicious- chlorosis, lupu.s, hii!Mi(i])liilia, diiil)«t(!s, j;];!! 'onia, nialij^nant and nun-nndignant growths, cyHts, crctiniam, rickets, luucucytlicniia, uiyxcixleina, are diseases of en, dopatliic — 3 former chtsses are exopatlii . Local Diseases are named according to organs ( " locality affected : 1. of organs as of eye, livor, lynijihitic-), sj)! i, ductless glands, 2. Urinary tract, 3. Generative tract, ni.uuin I, etc. 4, Organs of iocom )lion. 5. Diseases of cellular system. 0. Diseases of ciitaneoiis system — 16 in all. Structural chmges in tissue produce the following lesions : Hypjrtrophy, atrophy (hulk), congestion (hypcnemii) active or i)assive, aiueinia, hemorrhage, dropsy — these last 4 often nearly related. IntLmnuilion with its ciiiisions, prodnclions and terminations, as Serous and jdastic effusions, su]ipurations, ulcerations. Healing process, cica- trization, degenerations, fatty, calcareous, waxy, fibroid, mucous, colloid, amyloid, or lardaceous, ])igmentary, hyaline, this siiecially aifecting the fibrous tissue, granular, or parenchynialous or cloudy dropsical degeneration of cells. New growths, malignant or simple cysts, tuhercidosis. Mechanical, as disi)laceinent, dislocation, stricture, compression, plugging, i)erforatiou, laceration, rupture, fraction, distention. Concretions, as co.igiUa or calculi. Errors of development. MalfornuUions. Disorders of functions, as convulsions in muscle; lack of func- tion, as paralysis and perversion, as when cold seems hot. Eobcrts is best edition for students; Flint ditto for practitioner ; Uristowe ditto for practitioner. Cooper's Vade Mecuni is good for cundeiised work, lleynold's and I'epper':; systems are for reference. Gkneual Diseases to be first taken u|.: 1st groiii)— Morbid poisons or zy- motic diseases. They have certain general cliaracters : 1. Affect whole body, and appear to produc^e a morbid condition of blood, and many have following char- peters— run a definite course, have specific fever, characteristic eruptions aie communicable diseases, many protect against subsequent attacks, are apt to occur epidemically, depend on a specific body introduceil into body from wiihoul, itut some may be due to something developed in body (exceptiouid). Tiiey are pre- ventable diseases. Each morbid poison has been called a germ, is specific, pro- ducing specific eflects, has been called contagion or contagia, or metabolic conta- gia. These jioisons may be divided into 3 classes : 1. True contagia. 2. Miasm. i. 3. Miasmatic contagia. Each needs definition. 1. Contagia is poison whicii mul- tiplies only in the Ijody. After escape from l)ody does not undergo cliaii;. e (is ripe) till entered into another body, so contagia only attains full development iu living body, and are excreted alive active. Are true contagious dise.is.'s. To this class belong the exanthemata, smallpox, vaccinia, scarlatina, cliicK>-n pox, etc., etc., also typhus, relapsing fever, influenza, diphtheria, mumps, wiiooping cough, syphilis, anthrax, tuberculosis, etc. 2. 3Iiasms multii)ly outside the body, give disease on entering body, but are not communicable except U,, iiiocu . PRACTint or MEDICINE. • latinn. It is not known wludlier tin; poison is thrown off the boily, ni lUirial, intoiinittent I'l-viTs iiml (Vfi vori) of Chi»m, and some include pnouraoniii, nciite rheuiniitistn, Jiciito mycosis and siinplu mycosis. 3. Conhujlons mlanma- fic. Theso jiri'sent thi-su iniculiiuitifs, the (h^vidopmont of the poison dopends on extiTiial cirniimstancus. The oscupcul poison is inocuoiis until it liiis umhsr- iiom cliiin«t', (k'vdops and is comniunicalde. Hero Iwlongs typhoid, cliolera (Asiatic), dyHontery, yellow fovor, plague and perhaps erysipelas and sc.iticieinia, certaiidy cerehro-spinal fever, also anthrax. Theorifi^ of Morhid PolHotia.—l. Are really j,'"nns of vegetable nature, microscopic, ar.' called bacteria or microbes, multiply in lelinitely. 2. Are, strictly speaking, germs (not), but are organic l)oi9ons, Just as the pop|.y produces Morphia, but first theory is the accepted one. An old theory was the germs were really grafts implanted on body from dis- eased body. AcuTK Si'KCiFic FKVK.ns.— General are divided into essential or idiopathic, duo to introduction of morbid poisons into body, producing specific fovorajand symptoinatU; as following injury, are also called traumatic fever. EssKNTUL OK Iinoi'ATmu FEvr.us.— Ist group exanthemsto it belong moat of the communicable fevers. This year the following will be treated : typhoid, typhu.s, relapsing and cerebro-spinal fevers. Typhoid Fkvkk, also called " .slow fewer," " Dothen cnterite " (Freuch) ente- ric fever, as in U. S.. pythogeuic fever (dirt begotten). History 18:50 by Lombard of Geneva, it was distinguished from typhus. In 1313 it wa.s described as enteric, mesenteric. A- R. Stewart of Glasgow 1841 described eruption, Jenner also described it. In all these fevers there are following stages ; — 1. Incuhation while developing. 2. iNV.vaioN, 1st symptom is higher temperature than normal. 3. Develop.ment and progress. 4. Stasis. 5. Decline. -Incubation of typhoid varies from 1 to 2 days to 21 to 22 days,- 10 to 14 days is average, period not fixed. Thus, of 14 persons at one time exposed, 8 days for 1, 12 in 3, 13 in 1, 14 in 2, 15 in 2, 16 in 2, 16 to 18 in 2, 14 to ?2 in 1. One of the elements aft'ecting incubation is temperature, high, favoring incubation. Unrecognizable idiosyncrasy of the per,son also affects. When im- bibed (.swallowed), it is thought to act quicker than when inhaled. When typhoid stools are decomposed, then it is thouglit inhalation is aa active as swallowing. Typhoid.— Is : 1st Typical, 2nd Atypical. Atypical cases are nsually mild, short, often non-febrile, and are called all sorts of names, — gastric, bilioua, intes- tinal, catarrhal, etc., infantile fever, Ulious remittent fever, etc. Typical For.m has 3 modes of invasion — 2 common : 1st, by slow process of development. 2. Rapid. 3. Cases occur where invasion is sudden with symptoms of narcotic poisoning are malignant, is very rare. 1. iilow, patient feels out of sorts, chilly, pains in limbs, headache, pain in back, in bones, languid, appetite impaired, headache, fever anddiarrbrea (diarrhcea coming on sudd' idy suspect typhoid), out of spirits, perhaps slight elevation of -.emperature, hangs about, PRACTICE OF MEDICINE. " and finally goes to bed about the 14th day ; symptoms gvadiially deepen into typhoiil. 2. Rapiil, or he may become suddenly sick early fever, chilliness, diarrhfea, etc., and promptly characteristic typhoid symptoms are developed. Typhoid Symptoms. — Temperature high at night, lower in morning. First week, pains in back and limbs continue, dizziness on standing, patient is reticent, sleepy with dreams, no delirium yet, but towards end of this week may have (kdirium, on waking pupils dilated, flush on malar bones, pulse not frequent at first, 90 soft. Intestinal Tract.— Tongiie red ground, perhaps white fur, thirst, loss of appetite, stools solid brown, or loose, no griping. Careful palpation shows spleen enlarged, belly gradually enlarges, perhaps pain on pressure in right iliac fossa, with gurgling if listened for in caecum. Second week, character of eruption shows itself, pink spots raised, margin definite, appear in crops, remaining 3 to 4 days, found on chest, belly and back. EiiupTiON appears from 7 to 12 days, is composed of well-defined rose- colored spots, comes in successive crops varying in number, few to actually cover- ing, each spot is about 2 lints in diameter, appear generally first at lower part of thorax and upper of abdomen, also look on back where they are present even if wanting on front. Sometimes this eruption is preceded 24 hours by a blush of sur- face of body. Eruption declines towards end of tliird week, now sudamina appear, are sweat vesicles, occur wlien there has been profuse perspiration. About middle of second week headache subsides and typhoid symptoms appear, he is apathetic, ton^^ue dry, coated, cracked. Delirium comes on at first nocturnal, but by degrees both day and night. It may be mild, (2) low, muttering, or (3) wild, needing restraint. Towards end of secon-' -veek abdomen is tympanitic, diarrhcea sets in (5 to 10 stools a day), but may be s; at. Stools are generally fluid, drab or ochre yellow color, or commonly called peasoup stools. Large flocculi (bran stools) are observed floating about. In bad cases are dark green offensive smell, are alkaline. With a microscope, crystals of Oarb. of Amm. are observable. The flocculi (bran) will be seen to be portions of mucous membrane due to breaking up of Peyer's Patches. By end of third week the nervous symptoms become more marked, ending in nervous prostration ; patient lies on back, may slip to foot of bed, hardly can feed himself, may be tremulous, tongue projected (if asked fur) tremblingly, urine and fteces passed involuntarily. Now bubbling rales are heard over lungs, showing low form of bronchitis. This symptom may occur earlier. Cardiac, — Symptoms: Pulse frequent— 120, dicrotic feeble, heart feeble, sounds alike, feet and hands cold, skin cyanotic; patient becomes comatose, sub- sidtus is observed. These .symptoms pass into collapse and death ; but even from these recovery may Lake place. In mild cases from 15 to 20 days recovery may take place, in severe 21 to 35, In this disease a relapse is apt to occur without care, as to business anxiety, mental exertion particularly of a very small kind, improper, solid or over-abundant food, exertion, etc. A true relapse may occur from re-absorp- PRACTICE OF MEDICINE. 9 tion of the poison from the ulcerating glands of intestine and mesentery, or may be due to continuing to expose liimself li tbe primary cause of attack. You can distinguish a true relapse by getting all the symptoms of typhoid over again, and in addition a return of the rash ; this last is the important point. Rela])ses are more a))t to occur in cases where cause of the fever has Ixien checked l)y antipy- retics or cold baths, drugs, etc. Convalescence is sometimes greatly protracted 2 to 3 months, with diarrhcea and hectic fever. Patients become stout rapidly afler this disease, ai>petitf d, etc. Ee Tkmpkratukr.-- s typical, rises steadily every day about 1.1 degree, and there ia a marked di.tereace of about 2 degrees between a. m. and p. m. temp- erature. This ascent goes on 5 to 6 days to its maximum 104, 105. This is tlie stage of ascent. Evening temperature is higher than morning. Tlien there is stage of continual fever, the " stasis " or " status." In this stage variations do not vary over 1 degree. In a mild case this stage lasts a week, in other cases 2 to o weeks. Now remissions occur, distinct drops of temperature. Stage of Remissions.— May last 2 weeks ; in bad cases the stage of " status " may last 2 to 3 weeks. The stage of remission now gives place to intermittent stage, a descent down to 98 or 97. Sudden alterations in temperature may be caused by hemorrhage, diarrhea or by action of drugs. Tliese variations are apart entirely from cause of disease. PuoGNOsis keTempeuatuue.— 104 is ordinarily favorable (evening temper- ature), even 105 is not wholly unfavorable, lOG is serious, 107 is generally fatal, and 108 is almost certainly fatal. Re Atypical Typhoid.— 1. There are cases lasting full length, mild temp- erature does not go over 104. 2. Mild cases not running over 3 weeks. 3. We have abortive non-maturing cases. In these, symptoms have been as severe and may be as high, and in 2 to 3 weeks fever aborts. These may be very severe at out- set, first week temperature even 105, but only a fever storm, ending quickly. In these atypical cases the erujjtion is often absent, also the diarrhcea. The spleea may not be enlarged, but generally is. Prognosis for Atypical. — Generally favorable, and convalescence rapid, but relapses are very frequent. In some atypical fevers a subnormal temperature may be present, that is, under 98.5. All other symptoms were typhoid, and post mortem shows lesions. Sequences of Typhoid. — 1. Hemorrhage, slight" or profuse ; if the latter, it may look bright, not congealed ; if scanty, it is black, coagulated, due to acid action of bowel. Source of this hemorriiage is from ulcers of intestine, most usually happens 12th to 28th day. 2. Perforation of bowel due to ulceration, may occur during convalescence. Symptoms are acute pain in bowels, constant vom- iting, and marked collapse and great distention of abdomen. If this happens in tr,e typhoid stage, then patient is too low to sliow pain or collapse to a great extent. This is generally fatal, death in 24 to 28 hours. There is a milder form of peri- tonitis, when ulceration has only reached the peritoneum without perforation. PRACTICE OP MEDICINE. 10 Another cause of peritonitis is suppuration of mesenteric glands, generally fatal. 3. Tympanitic distention fatal in 50 per cent., may be caused by paralysis of mus- cular coats of bowels, leading to distention. May be due to loss of general nerve power. Another source is decomposition of blood, food, or sloughing mucous membrane in bowel, and gases produced. It is most apt to occur in Srd week or 4th or 5th. 4. Catarrh of fauces, middle ear, dtafness and of parotid gland, leading to abcess; but tliis is rare comparing to typhus. 5. Very important is the complication in lungs, a low form of broncliitis in small branches. May begin 8th day, but usually Srd week may lead to collapse or broncho-pneumonia, occurring along with general weakness may lead to a^lcma or hypostatic conges- tion. 6. Circulatory complications, hemorrhage, thrombi, embolism. 7. Pulmon- ary effusions, phthisis. 8, Thrombosis of veins of lower extremities may occur after patient is about, due to weak circulation, occurs about Poupart's lig. Symptom Spain along Sapiienous vein. Tiiis is always recovered from, but leg. is weak for a long time, periostitis (fever sores) on shin, ulna, etc., is a sequel. Thrombosis of legs produces " milk leg." Thrombosis of arteries very occasionally ensues, and produces gangrene. Paralysis is also rare, due to peri- liheral neuritis, prmcipally affecting ulnar nerve, due to pressure or extension. The peroneal nerve is likewise sometimes affected ; sometimes both legs or arms, or one of each, or one. Cerebro-meningitis sometimes occurs, melancholia or active insanity is sometimes a sequel, immunity is not given by one attack. Lesions.— 1. Primary, essential to this disease. 2. Secondary, other fevers have same : 1. Primary, due to the morbid poison acting on Peyer's I'atches or solitary glands, of intestine, and conseciuent on these the mesen- teric glands and spleen. It begins with catarrhal slate of lower part of ileum and begiiming of colon, concentrating itself finally in Peyer's Patches and solitary glands, grows or proliferates, leucocytes escape from vessels, dis- tending follicles, infiltrates tissue and mucous structure. In extreme cases it gets through even muscular coats, and an accumulation of these cells is found on the i)eritoneum. Peyer's Patches are congested, swollen, encircled by red ring, are of size of pin-heads, but progressively increase in size and promi- nence, are in color semi-transparent and greyish white with red zone of increased vascularity. On incision they resemble f(B:al brain, — white with red lines. Their size is now like large shot or peas. So far case is curable. But now these may undergo fatty degeneration and absorption, favorable, or they may slough, owing to growth of young cells cutting off blood supply by their crowding. Color nf slough varies, may be greenish yellow (bile or blood- stained), or may be yellow or ochre color (bile-stained alone). The ulcers are not evident in Peyer's Patches, here are irregularly placed, with nndestroyed tissue, bt'tween which may slough, also finally seen in solitary glands. A typhoid ulcer is characteristic, they attect only Peyer's Patches (oval) and solitary glands, with long diameter of boM-el corresponding, and are opposite to mesentery, the edges project 1 to 2 lines, a clean l.'.ise to ulcer, ulcers PRACTICE OF MEDICINE, 11 get more minierous nearer to ca;cum, near where perforation occurs. A tyjihoid ulcer cicatrizes without contracting lumen of bowel. The perforation is uiwaya small, size of .silver pvobe, with evidences of [)eritonitis locally. The tyi.hciii jioi-son secondarily attacks mesenteric glands absorbed from ulcers of bowel- 1 hese glands enlarge: (1) may soften and be absorbed, fatty degeneration; or (2) rarely may sujipurate leading to general jjeritonitis ; or (3) caseous degeneration of gland may result and chalky material remain. Tho spleen enlarges ni tyi>hoid through hyiK'iplasia, softens, is congested, etc. An expert at 4 to 5 days by per- cussion can detect enlargement. Its size reduces by softening and ahsoriition. 2. Secondary changes not essential. These may occur in all fevers, resulting really from impaired nutrition. These same symptoms are met with in aniumia and starvation proving above, they are jiresent, higher, the fever, and lunger it lasts, also proving above, but may be jiresent in simpler cases. It is termed parenchymatous degeneration, cells become cloudy, swell and gradually form distinct gi'anules due to escape of albumen from circulation, this tiim 1} passes into fatty degeneration, this degeneration aflects or may afiect all organs of body, principally liver cells, kidney cells (tubules), heart, all voluntary muscles, then pancreas and all the rest. Naked eye alterations are : organs are dull and cloudy and of greyi,sh look ; usually are softer, have a boiled appearance, organs are found doughy, aiuemic. These occur notably in typhoid, scarlet fever, smallpox diphtheria, etc., etc. Heart is softer, more friable, color altered (grey or greyish, yellow or red brown), but under microscope the striation of its muscle cells is lost, and in place you see granules, protean at first, fatty in advanced stage; waxy degenerations are found in muscles, resemble fish flesh, are very friable, especially affects muscles most used as adductors, pectoral, recti, diaphragm, tongue. Blood vessels also undergo fatty degeneration, blood itself degenerates, red ceJls under- going fatty changes, solitary glands thus suffer, the brain aUo suffers paren- chymatous change, shewn by sometimes a weak brain after this fever. Gross Changes.— When death ensues in any of these fevers, congestion of pia mater and brain substance takes place with serous effusions into ventricles and membranes. Causation of typhoid, no morbid poison received into body necessarily sets up disease, must have proper soil, called predisposing causes. .1. Age, may occur at all ages, generally between 15 to 25, or 52 per cent, 20 per cent, occurs under 15 years and same after 25 to 35, rare after 35 years. It is usually an endemic disease, localized, so is due to local causes, most apt to occur ufter dry and hot summers, but many exceptions at present year. It is called "autumnal fever," because it prevails especially in Sept., Oct. and Nov. Overcrowding, fatigue, intemperance, etc., have far less influence in typhoid than in typhus, but still do favor its propagation. Recent residence in an infected locality pre- disposes. This fever depends on a specific poison originating in a previous case. Its sources are: 1. Drinking water, commonest, through sewerage contaminated by FRACTICr. OF MEniCINE. 12 tyj)lioi(l stools. 2. Air, volatile matter from tyidioid stools. 3. Milk sn]>yily, bow ? Imimre water used to wash milk vessels, or the wat<'ririf,' of milk dis- iionostly. It is jjiolialile tliat milk in j.roximity to typhoid influences will imliib ' ■ ])oisoii. 4. Persons recovering from the disease should not be allowoi. t.i milk cows, as des(iuamiited cnticle may get into milk. ■". Cows themselves may snfter from tyjiboid fever, and so is milk jioisoned ; eating this flesh may give tyjihoid. G. A field manured, in wbicli manure typhoid stools are present, may contaminate a cow there grazing, clinging to the hairs, etc. 7. dilution does not lessen the jiotency of the poison. 8. The ]>oi.son retains its jiotency for a long time, a case is known for 2 years ; soTue think the germs may ].vopagate in the soil. Typhoid fever is a communicable disease chieP.y through stools, hut some change is necessary in stools (deconijMjsition) before it is coin- munical)Ie, but it is tliought that now and then the fresh poison may c >m- municate the disea.se. The rule is a nurse attending does not take the disease, but there are exceptions where it .seems to be directly communicable. The time elapsing before stools are infections is thought to be 12 to 14 hours, but there are exceptions. Certain morbid pdisons passing through a body acquire increa.sed virulence, probably true of ty})hoid, su it is thought sometimes one may take the disease from the fresh stools. Foregoing is accepted theory. Murchi.son says it may originate de novo, but science does not accept it omne vivum et ovo. Any way given, the poison needs a proper nical matter and sewerage, the latter especially, chemically jiure water will not sustain life of tyj)hoid. Some (Carpenter) think water rich in lime favors propagation. " Pettenkofer " thought a scanty supjily of suiface water was the condition favorable through concentra- tion. 2. Temperature, a certain definite range. 3. Moisture, a certain degree of. 4. Peculiarities in the individual, hence we must endeavor to destroy the germs, prevent the admixture of the poison with water and milk, keep it out of water-closets and sewers, tlush thoroughly, have a good trap to sewer outside of house. The sewers should be ventilated into the general atmosphere by means of a high tow^er at highest point of such drain or each drain. Several different Germs have been described as the typhoid germ, but scientists agree with Koch's bacillus, is rod .shajied, 2 to 4 lines in length and one-third as thick, active and mobile, have been found in the blood, albumen, urine, excreta ; after death it has been found in mesenteric glands, spleen, etc So far this bacillus lias f\iiled to give the fever to lower animals, so the bacillus is really not yet proved. Diagnosis of Typhoid.— General observations: 1. Re-atypical, mild or short, severe, yon should remember they are simulated by gastric catarrh, symp- toms of cold, indigestion, but careful palpitation will in nearly all cases of typhoid shew some enlargement of the spleen. 1. This enlargement of the spleen in acute febrile disease suggests blood-poisoning and typhoid in particular. 3. The more spots, with fever and splenic enlargement, show typhoid. 4. Or without PRACTICE OK MEDICINE. 18 rose sjiots the sjiloen cnlargcnietit nloii-^ witli the typical vaviiitions of tciiiper- atiiru yivo typliui.l. C>. If similar cases, especiiilly if typlioiil bo lUVvailiiiL;, tlie (iiayiKrsis is iiKiri! certain. 6. Fever iissuciated with Hpleiiio enlar;,'(.iiient, lieadaehe ami iliarrli-.a points to typhoid, l)tit typhus fever n'senddes typhoid to some extent, to be presently uescrilxHl. It is extremely ditHciilf to diagnose acute tuberculosi from typhoid. Will be treated of under plithisis. II. Tvriius. PuEDlsPOSiNr, CAISES OF TyiMU's.— 1. All conditions which lower the vitality, as htiiHjcr, cold, thirst, mental and bodily lati^'ue, anxi.'ty, any existing disease wliich h'.wers the vital powers, tieneral tlebility from past disease. 2. Overcrowding;, as lioiises too closely packed together, or overcrowding a house by people. 3. Defective ventilation. 4. Personal uncleanliness. 5. Intem- jierance. G. Age, 20 to 40 is commorirst period, but may occur at all aj^cs. 7. Season, especially in cold moulhs, periiaps tlirough overcrowding, ill ventilation, etc. 8. It is epidemic, extreimdy so, as iu 1847. ExciTlNO Cal'sks of Tvriius. — Viuious tlieories, Murchison and another believed in spontaneous origin of typlius llirougli overcrowding, but above not accepted. The accepted theory is : due to a specific germ from antecediuit; i.i propagated directly from patient, througii euianations from lungs, slvin, etc. It can aiso be taken from ilead body. It is doubtful whether tyiiiuis germi are in stools or not, but tak(! iireeautions as if they were. Actual contact not m.-cos- .sary. A well ventilated ward renders dau'^er less. Germs are lighter than air, hence rise to u])\»'.y rooms. Dark coloivd and woollen clothing are said to caiTv tiie germs— probably true. Tvplius cases should be isolated. A few minutes' exposure to tlie influence of disease may be sufficient to coulraet it. It is tliought emanations to end of first week are innocent. Typhus gives immunity after first attack. It lias no morbid appearances in puat mortem beyond passive cnuge--tiuu and its consequences, as tedema, infarctions, etc., but the parenchymatous and fatty changes as desciilx'd in typlioid, and due to impaired nutrition, may be found in all the orgms. The brain is especially apt to have congesti.n and cudema of substaace and membranes seen during the dis ase is tendency to coma. The blood is black and tarry, due to destruction (jf red (-ells. Lungs may be bronehitic— hypostatic. Congestion may be so great as to make luugs s[)lenic. Tleuka may be congested. iNTi'.sTiNEs shew no lesions, only periiaps patches of congestion, and this would alfect the dependent parts only, ■lue to passive congestion. IV-yer's Patches and mesenteric glands are not allectt d. Spleen undergoes enlargement and softening as iu typhoid. The spleen is best tost of an inieci.ifuiK fevei', fo!' all affect it. Infarcts may also be found, due to spots of congestion. Liver is merely congested. Kidneys may suffer a little more than in typhoid. PRACTirK OF MEDIOINB. 14 TYPHOID. Invasion Hlowly, rigor not so ro- Toniiioraturu, rise .M dfgree ilitler- enco for 5 days. Oscillations of temperature in oic o 4tli week. Decline gradual or by ly-iia. Erujition, spots 6 to 11 days, tlM»t is, in lind wock; consists of scattered sjHits, rose colored well-tletincd i-dges raised above surface, failo on iiressiirc, and last only 3 to 4 days, giving place to others. Spots are few, come in crops. Countenance, etc., bright red, flush pink, jiuiiils dilated, intellect is brighter, and delirium comes on not till end of 2nd week, and is usually more active. Tong'ie thick, large and flat, dry but not as dry as in typhus, but may be nioiit throughout the whole course. Stools fluid generally. Sloughs floc- culi, tenderness and gurgling in rigiit iliac region. Symptoms generally are abdominal. Tympanites, Temperature mounts in steps, regular variations and gradual fall. Sequences — diarrha'a, hemorrhage and perfora- tion are common. Sujipuration, bedsores, etc., are rare in typhoid. Duration 3 to 4 weeks, but is in- definite, may last 2 to 3 months. TYPHUS. Invasion abrupt, heailacho, chil- liness, or distinct rigor. A sudden ri^e, rush even to 104* Ist day. Oscillations d lu^ locur at all in typhus. It ena.-> oy crisis and sudden drdp, usually attended by an (ivaouutiim, 88 sweating, flow of urine, diarrhfi'a, Appears 1st week, 4th to fith day; is dark red color, outline fades otV, an; b«t slightly raised. Kacli spot in couple of dii\ s darkens; a spot appear/4 in centre forming a [ictechia. At first, spot disap- pears on pressure, but petechia does not disapjiear. May be very numerous. There also seems to be a subcuticle rash. Spots are numerous, and soon ure present in full force. Petechia after death do not disai)pear. Eyes injected, pupils contracted, countenance dark, dusky, s dull and stupid, and delirium is low .md mutter- ing, and appears in 1st week. Thick, contracted, pointed dry, cov- ered with sordes, never moist through- out. Ikeath bad. Stools consistence of mud, no signs of sloughing, both tenderness and gur- gling absent. Symptoms sometimes are cerebral. Yes. High, according to severity of case; steady with suddjn fall after risis. These symptoms are rare in typhu.H. Suppuration of parotid glands, - ires on sacrum, on exposed parts due to )W state of nutrition. Shortest duration 3 weeks, ofwu over in 2. I PRACTICE OF MEDICINE. 15 Cnnvalescence may have true ro- lajises or returns of sli'4ht fever. Death, generally 3rd to 4th week, or later. Lesions well known. Endemic. Indirectly contagious. Disease, not peculiar to any class. Age, 15 to 25 greatest lij,bility. Ndt very infectious. Is permanent, no relapse, for one attack protects against future attacks. About 15lh to 20th day. Usually 2nd week or 3rd. None cliaracteristic. Epidemic. Directly contagious. Disease of the poor through over- crowding, ill feeding. 20 to 40 greatest liability. Is very infectious. Treatment of Feveks. — These fevers cannot be aborted, they must run their course. We can only guide it to a successful issue by supporting the vital power from the beginning. 2. Also by moderating the reaction of the system under action of the poison. y lessening production of heat. 3. By promoting discharge of heat. Agency of cold : most prompt way in fever to reduce fever is cold bath of 64" to 70^ ; wrap patient in blanket, put him in 10 to 15 minutes till he shivers. Tliis will have nsduced fever say three degrees, lasting quite a while. This method is useful for strong robust patients in the early period of the disease. GiiADiiATED Bath.— In less strong patients, or children, or more advanced cases, use the graduated bath. Put patient in water 100 degrees, the lowest temper- ature, then add ice gradually till the temperature of the bath is 80 degrees. A cold sheet is also used, especially when the temperature is persistent and not too high. Dip the sheet in tepid water and wrap about patient. Take a second sheet and wring out of cold water and wrap about him. Patient lies on macintosh tossed about him ; change outside si jet as it gets warmer. Auotlier way is to put patient on canvas camp bed, and pour water from the pitcher a little below his temperature. It runs over him through the canvas, and if bed is inclined will run off at foot into pail. Begin ny with water at, 96 degrees. Then cot is put alongside the bed, and is convenient. Another way is to cover patient with a sheet, and rub over with ice. An- other way is with tube cap forned with rubber tubing. Have pail of water high above the bed, f--phon action will empty it. Cap can be adapted to head, abdo- men, etc. Ice cap is also used. PiiECAiTioNS, — When you resort to cold baths you need to take certain pre- cautions. If there! lie much weariness, give a stimulant before bathing — as wine, brandy, quinine. If temperature falls rapidly, remove fit 103 degrees ; but if slow keep to 101. Do not keep in bath till normal temperature is reached, as the tem- perature keeps going down after and collapse may occur. The lower tempera- ture is not permanent, .so bath may need repetition to 2 to 6 times per day. Time to u.se the cold bath is first to second week. In advanced stage employ tepid bath. When there is great prostration and later the time of fever, the warmer should be the water. But after 2 to 3 baths the temperature is more satisfac- tory, heart action is better, you can continue ; but if no improvement takes place, do not continue. Indications fou Cold Bath. — If temperature over 105 degrees, the sleep be not good, 2 to 3 days without it, give bath. When temperature has no remis- sions a tepid bath is indicated. Even presence of bronchitis, pneumonia, menstruation will not contra- indicate it, ifteniperature demands it. In pregnancy cold bath is demanded. Contra indications. — Cold external surface, a weak heart, or, perforations of bowels with last cold bath will force hemorrhage. The German school alone reconmiends general use of cold in treatment of fevers, it is not adopted in general hospital practice. Dr, Colly does not accept it. Dr, Cailey does accept it. Broadbent and Orr advise the use of cold water treatment in typhoid fever. Bmnd ofStellin, its originator, says of the cold wati fore ball clist and atit Qu 1110 reti ]ia' dn tin 1)V( thi ini an la te is ci 01 PaACTICE OP MEDICINE. 18 watoi treatment that in German military hospitals deaths were 15 per cent, be- ; U. sjtm was introduced and only 9 per cent, afterwards. Brand uses cold nil, e mlarly every day when temperature exceeds 102. He says it preven 3 r^^^^^^^^ bLn 'heart, kidneys and skin, prevents catarrh of the stomach I lowels so food can be given ; it arrests the bowel lesions and prevents ulc i- ations. It dso prevents complications if so treated from the begunung of the disease in lessening them if started later in the disease. T;Tirv.K™ M.uciHK._Besides the use of -W.water we use m.hc.ne : Quinine ingrs. 20 to 30 to 40, given at night, acts; given at bed time, takes t.U Hin'to ct. If 20 grs. does not reduce 3 deg.. give 30 If stomach wdl no " n give enema in i^ilk. Grains 20 to 15 and 10 of Sahcy.ate of Soda wdl ;reat eflect. Re Antipvrine and Antifebrine. To give Antipynne give i ':;:^:;;^3i:.;.rs fbr 3 d^s. or give 15 grs. hourly ^r 3 to 4 hour, t som. times leads to sweating, so give Atropine or Agans.ne, AnUfebru, g,. 4 to 15 7i is the average— nve in water, wine. etc.. maximum dose is 20 grs it acts ;,;, ryTvt;y rarely followed by collapse; use those last two. One impor ant S i^^oLtchiifalldisLes isthe modeof death One is asthenia, is^^^^ in. Is one way to overcome this ; 2, another is keeping down the empeiat e and . is administration of stimulants. Stimulants are indicated by dicro ic ^ rapid pulse, i. e. over 120. Yever heart sounds. Coldness of ex^-enu.s H^ te nperature associated by tremor, restlessness, sleeplessness, etc. ^y tongue is an early evidence of debility. Congestion of lungs and fever ^-1-'^^- J^^ circulation Alcohol is the most important of stimulants, is nev.- given ^ t^e onset of fevers. Keep off weakness, but only at end - -'^^ f ^^ ^^^^ cases never require it. as in children, adults and generally old P-P ; J^ ^^f^^^ cases alcohol is really called for. In dosing, better err on side o i^ nty than too little, but from 6 to 8 o^. of brandy or whiskey, 6 to 12 oz. of she. y oi poi t or 1 .int of champagne in adults, in urgent cases, per day. u h t^U the effect'is: pulse becoming stronger and fuller, ^^f '^f -■*: ^^^^;^;;;\" ^^^l t " If Alcohol is not doing duty, try Camphor or Musk, -f^'^'^^'l}^''^^^^^^^ Often U pints of brandy can be taken, and no signs of intoxication, not even smelling breath. . , . j.nnnirpd CONCEUNING NEEV0U8 TROUBLE.-Coma, insomnia, ^^^-'^^'f ^^<1 ^"^P^^^ nutrition of brain, although the morbid poison h..s some ^^^ " Jl^ J*"" or passive congestion effects alike. Treatment is to k.ep ^'^^^'^f'^^'^^^'^'Z antipyretics; give proper food ; look aft^r circulat.on; give ^^^l^^^^^;;^ ^^^^^ frequently. If coma threatens to be severe, employ ice cap o ^ 'j^rft ni T'm restlessness nothing is better than a tepid bath at bed time, or equenc s;n;::g:r::;crMorphia, or give Cmoral grs. 20. Chloral grs. 5. with Bromide g''^- ^^' , , , .. , .-;h~ Thk is bp=t met bv feeding,' and Congestion of Lungs, or low urouu.ati=. ims s ne.t - , J^,,,.,.;.' con- stimulant, for it is due to weak circulation. ^^^^ ^^^^^f^^ XtolnJ o g .cion by changing position, back to side, etc., every 4 hours. Encourage take expc or g iliiin Wilt I doe.< fill' I iiiiii war pro.' moi !Sti] Sec tics VC'l are lar< abc alv tol Ur Wil rni ab an toi iSv se ei] PRACTICE OF MEDICINE. 19 take .U-oi. inspirations, to coiij,'h. fHvo Amin. Carb. and Ipecac as stimulant, expcctoiunt, or give a g.iod emetic, tiiis last is to get rid of accumulated mucous ; ov -rive Apoinori.hine gr. ^^tli hypodennically. 15ut maintain heart. In typhoid, .liimlMca is a complication. If 3 or 4 stools per day, do not interfere, add J,ime wrttur to milk,-.l part to 3 will generally keep bowels in check. If the above does not act, give Laudanum git. 2 to 3 every 4 hours. It may be obstinate, give Lead and Ophim Till or Tulv. Kino Co. gr. 3. Improper food may bo reason for dianhcea, too much starch or animal broth. If stools are very otlensive, give animal food 2 to 3 times a day. L'uNSTii"ATioN.~Do not allow it to exist, give soap enematas of pint J to 1 in warm water. TvMi'ANiTKS is dangerous : 1, food may cause it; 2, may be evidence of great prostration ; 3, irritating medicine may be the cause. To CHECK. IT, apply Turpentine stupes and abdominal bandages, and give by mouth Turpentine mins. 10 to 1 5 every 2 to 3 hours in milk, or give enemata Tur- ],entine, barley water and gruel, or insert rectal tube to allow escape of gas. .Stimulants are generally indicated, and should be used. JlEMOKUHAGE if slight is insignificant, if profuse may lead to collapse. Secure rest by absolute quiet, and give Opium. Use ice on abdomen, or use styp- tics, perhaps Ergot is best by mouth, or Ergotine injected hypodenuicidly. If very profuse, give large enemata of ice cold water. Lead Acetate or (Jallic Acid are both used by mouth. Peufouation of Bowel.— Generally fatal through peritonitis: 1. Inject large doses of Morphia to prevent peristalsis of bowel. 2. Starvation ; if some fuou is needed, give peptonized milk by rectum. Modern surgery would perform abdominal sections, liEUSOiiES.— A well nursed patient should never have any ; bed clolhes should always be dry. If red spot appears, wash with alcohol, etc ; arrange pillows so as to take weight o« such point. A wa';r l)ed may be used. If skin gets broken, use ling. Zinc or Ung. Borac. Acid. If sloughs form, eiermans would put in warm water bath. He other fevers. III. HELArSING FEVER. Also called spirilla fever, lias licen called bilious, remittent, mild yellow fever, miliary fever, famiue fever. In 1847 was last visitation in Canada. lNCUi$ATiOx\.— Average 2 to 5 days. This poison can be inoculated, and ttd-ces above. But extremes are 2 to 14 days, feets in suddenly with extreme rigor and headache and high temperature, 104 to I08i within 24 I's. Other symp- toms are paius in bones and limbs, lassitude, vomiting of biliary matter. Kigors. Surface is pungently hot. Patient is sleepless. Tongue is thickly furred on red ground, thirst, there may be black vomicing from bleeding of stumach, pidn on second day in region of epigastrium and liver and spleen. Spleen and liver both enlarged. Tains in muscles and joints resemble rheumatism. ''% i i m ilai •t the ihc ] l'.V >1 vo ■* 21 the do Tl IJ pr Tl at Is ob Si PRACTICE OF MEDICINE. 20 PULSK.— t20tol40,but neither hii^h teiniHTature nor high puis., ii Dim miUM -Is not generally Fcsent in first attack, but may occur just U u, the crisis After 5 to 7 days a crisis is rea.;h.-a, ushered in by swei.tin^' • v - r- rhoea. and iu a few hours patient may feol w.ll. The tirst 7 to S days are h by remission, but fever recurs at 15th diy. with more symptoms of jannd.ee and vomiting than in the first attaci<. In 4 to 5 days crisis is agam reaehe.l. On 2l8t day ft second relapse occurs, and more may occur ; but ofteuer rehipses occur. the mure serious is the danger. , ^- . n Aiu.UTiVK Casks may occur through perhaps resistance of patient, small doses of poison, etc. These cases terminate perhaps after first attack vhich was li.-ht, or after second attack, and botli light. There is also a malignant variety. This is also cdled bilious typhoid, but not tyi-hoid, and is due to a spn.llum. Uinbrence from typical form is thatall the symptoms are more severe. Junndice present, vomiting more severe, diarihaa, retenaon of urine, hemorrhage, etc. These symptoms may not occur ia first attack. Again, the remission may not be a true cessation, only a less febrile state. It terminates by crisis or collapse. Is very fatal Th-re is no characteristic eruption, but on third day there is an obscure mottling of the skin, lasting 2 to 3 d ly s, ending in des^iua.u ition. CoMPLICATKiNS.— (A) Besides this mottling there may be hemorrhages : 1. Minute under the skin, petechia; 2, from uuieoas surfaces, bladder, stomach, etc., in.licates scorbutic state of blood from low diet. These are serions symptoms. (B) I'ost febrile ophthalmia, often en.ling in blindness, usually blinding only one eye. (C) Pregnant women always abort, woman recovers. (D) Map be sudden death from syncope occurring after crisis, patient dies in 24 hours. (E) Alhumimiria, urine may be reduced in amount, and sometimes sup- pressed. i (F) These account for convulsions of urgemic origin. (G) Complication common with other fevers. Bronchitis, pneumonia, bubo of parotid, local paralysis, (II) After defervescence, sometimes febrile symptoms remain, and spleen remains enlarged and may suppurate. MoRiJiu Lesions.— There is no special lesion with relapsing fever, but a group ot tuem is characteristic. 1. Spleen greatly enlarged, cells also multiplied in number, infarctions of yellowish color in veins, and is very common. In ves- sels of spleen the blood cells .shew change. 2. /.iver is also enlarged, due to fatty parenchymatous degeneration. 3. Heart ditto. 4. Boms exhibit a proli- feration and subsequent degeneration of the lymphoid cells in marrow, and the little vessels of the bones shew fatty degeneraliun. Occasionally punforra sup- puration of medulla. 5. Blood, increase of white ceUs, presence of large gran-- ular fatty cells; similar ceUs are also found in splenic and portal blood ; also 1 '; i PRACTICE or MBDIOIiTK. 2t liirce, granular nucleated cells are also found in blood. 6. There in no disoaso 111 the intesliiial. tract, no inlliiinination oi ulceration. Jvnor.odV. 1. One |iowerf'ul predisposing cause is, namely, deslitiitionor starvation (famine fever). 2. U highly contagious. 3. Ovovcrow.ling greatly favors propagation, 4. Smne think germ propagates in stagnant water. 8. Kxciting cause is a spirillum, specific, its !• bitat is not known, is introduced by air or food, is inocuahlc. one attack doos, ...a protect against tlie secou.l. ti. It stu-ms to accompany typlius. 7. Murchison thought starvation and overcrowd- ing might de novo develop the poison. 8. The s^Kjcific germs w«ire discovered by Obermeyer; are long, spiral ; they are twice hmgth diamottir of red bloo I corpusiile, are found in U'.ood, uritus and after death in all organs. lu stage of remission tliese spirilla are not found in the blood, only during attack. TUKATMENT.— Person should be isoLited, but mort^ility is slight, 4 to 5 per cent, but in tropics 18 to 20 per cont. ; the virulent kind even GO i)er cent. Ventilation shouM be good, disease is mild, needs no s[)ecial treatment. If constipated, give general purgative, Sai Uitz ; if vo nitiug. give M)i-phia, suck ice, give hypodermic injection of Morphia, gr. J to i or give Calomel. Hkadache— Apply ice cap. Dkbilitv. -Allow brandy freely. Violent muscular pain, rub with Olive oil and Chloroform equal parts, also Liu Sap )uis Co. llelapse cannot be prevented either by Quinine, Salicylic Acid or Arsenic. Ccmvalescence needs tonics, Iron and Quiiiiuj, stimulants (wine), change of air. Convalescence is tedious, good nourishing food needed. The admission of plenty of pure air, frequent washing, and generous feeding will tend to arrest spread of disease ; put patient in tent. IV. SIMPLE CONTIXUKD FEVER. Is quite a distinct fever, is still so recognized, but many so-called examples are cases of a typical typhoid. Alleged Causes— Not satisfactory, do not recognize a morbid poison. 1. Mental or bodily fatigue. 2. Exposure to cold or heat. 3. Exposure directly to sun. 4. Excesses in eating or drinking. 5. Worms. 6. Suppression of functions of skin. It is said to be most frequent in children and youths, ocjurs sporadically here, but in tropics occurs endenucally ; is severe there, called Aa/viJ- ened fever due to sun heat directly. S \ MPTOMS. —Sudden invasion with chill, perhaps malaria. Then sudden rise in temperature as in typhus, with headache, restlessness, furred tongue, thirst, coustipation, diarrhoea ; vomiting not usually present, muscular pains frequent. There is no characteristic rash. Large bluish, irregular, slight stains occur in all fuvers more or less ; are seen in this fever, but not characteristic. Heupes, especially about mouth and face, is common. Course of this Fever is mild, is called ephemeral or febricula, lasts 26 to 36 hours, in common it lasts 10 to 14 days. Defeverescence is rapid, occurs by 3 PRACTICE OF MEDICINE. 22 crisis .•hichis acccnpanied l.y some critical discharge from slrin. bowels or ki!laeys etc. In chiMr.u this fever often presents distinct renussions. called by ^"■"7«r^T ^'^le ., old or broUen-do.n people n.y si.cinnl. i:...r.v..(t^pic)is.epently.Mn..^^^^^^^^ fmm blind.iess, pavalys.s, mental h inn, etc. ^''''!'' '''^'''\,.^^ . .^ j^ Disease is not communicable, either directly or indirectly. No le.ion at all '""XKK.TMKNT.-Treat symptoms as they rise, plenty of drinks, light fool. If overly, be cause, giveloth, emetic, and purgative. lu ardent fever, give active treatment by leeching, bleeding, etc. V. CEREBRO-SI'INAL VEVFM. Germans call it cerebro-typhus, called tyi.hoid, abdominal typhus ; has been called petechid ft-ver. It occurs frequently in Canada; four clmical vane- ties, namely: 1, sitnple typical; 2, toxic ; 3. mixed ; 4, atypical or abortive, 'l SiMi'i K Foini —May be preceded by symptoms of fever, as headache, voin- itina Sometimes diarriuea, pains down back and limbs, chilliness, but usually disease sets in by .li.tiuct rigor like tyi-hus, severe headache, pains down back and limbs, vertigo, vomiting (cerebral). The intensity at onset is characteristic of this fever So'.n after signs of irritation are seen, pupils are contracted, intol- erance of li.dit, belly-ache, tetanoid spasms in limbs, etc. Temperature so far may be only 11)5, pulse 120. Soon patient gets restless, delusions alternating with periods of stupor, perhaps interrupted by loud cric-s on account of pains m limbs. At this time muscles become rigid, tetanic arms partially Hexed, legs ditto, b.Uy hard and iiead drawn back almost at right angles, as in opisthotonos. Along with these are severe neuralgic pains, twitching is seen in eyelids, spasm in their muscles. Tliere may be general hypera^sthesia, so both motor and sen- sory nerves are involved. Tempe.ature-I0.5is about as high a. it goes, no variation a m. and p. in. as in typhoid. There are partial remissions also, no typical course I'ulse is also very irregular, 120 one minute, 100 perhaps the next. Is never very slow. Tuiigue may be moist or dry. clear or furred. Bowels gen- erally constipated, but mvy be loose. Urine not much altered, may be retained. Case terminates by exhaustion, coma, apno^a. Cases have proved fatal 1 to L days. It commonly proves fatal in 7 to 8 days, may last 2 to 3 weeks. 2 Toxic FoiiM.— Sets in with great suddenness, marked depression ot vital powers and blood changes shown by hemorrhage. There are no premonitory symp- toms but lias extreme rigor passing at once into collapse. Features cyanotic. Eyes' sunken, with blue halo. May be shivering, pain m the head or back, or vomitin- (black from blood). Drowsiness or stupor speedily sets in ; may be accom- panied by delirium. Petechias form on surface, feel shot-Uke. Dark purpuric siwls, ecchyinoses. These cutaneous hemorrhages may occur at very outset, or 1st or 2nd day. Pulse rapid, falling with case. Urine albummuus. feurface cold. Loss of consciousness, convulsions. Prognosis, recovery rare. i y 1 i? PRACTICE OF MEDICINE. 23 3. Abortive Form.— Towards decline of epidemic these milder forms are more liable to occur, severe forms at first. True also of cholera. Patient may not take to bed. Complains of stiff neck, pain in the head and neck, and vomiting. In some epidemics, in malarial districts, an i-termittent type is described. Skin —no cliaracteristic eruption, but petechia), pr. use spots, etc., due to hemorrhage, greatly resembles rash of malignant smallpox. The eruption i« early. Hekpes.— Little vesicles on the face, also patches of erythema, rose rash, urticaria. These do not come on late but early in the disease. Death may be in worst cases 38 hours, 2 to 3 days, commonly 12th to Uth day. Majority who die do so in the first 5 days. Convalescence is slow, 3 to 4 weeks. Eelapse may occur, atrophy and debility may follow, lasting 3 to 4 months. Mortality 20 p.c. to 80 p.c. Most cases at onset of epidemic. May die from apnoea if in the first few days, or from destruction of blood. Complications. — Inflammation of parotids, suppuration. Inflammation of bronchi and lungs, very fatal. Inflammation, purulent, of ear, labyrinth, result, ing in deafness. Iritis, choroiditis or retinitis usually affecting only one eye. Optic neuritis. Inflammation of larger joints and effusions into them. Sloughing bedsores. This fever is often found associated with other diseases in same jatient. SequeL/E.— Deafness, blindness, hemiplegia, or local paralysis (frequently recover), chronic hydrocephalus (hopeless). This fever has special lesions,— used to be called cerebro-spinal meningitis. Post Mortem Appearances.— Acute congestion of membranes of base of brain and of cord posteriorly. Later on there will be effusions of serum and pus, substance of brain suffers, minute extravasations of blood, with halo of congestions in both brain and cord. Is graver lesion than meningitis. If patient dies early these changes need microscope to demonstrate, but with it leucocytes and pus cells can be found in inflamed area. In mild cases only meningitis is present. There are also lesions common to other fevers. Hypostatic congestion. Extravasation of blood in mucous membranes. Intestines are free from disease. Etiology, predisposing ca use, infants and children especially liable, rarely attacks after forty years of age. Climate and soil do not influence, rare in tropics, is more prevalent in cold months,— Winter and Spring. Sanitary Conditions.— Weight of evidence is that overcrowding, bodily and mental fatigue, destitution common in barracks, especially of recruits, also in poor houses, jails, etc., predispose ; unsanitary surroundings must lower vitality of body, hence lowers resistance power. Exciting Cause.— A specific morbid force, not yet isolated, source and habitat not known, believed lo be inhaled, and perhaps swallowed. Is not directly conta- gious, is placed among miasmatic contagions like typhoid, is not highly conta- gious- Ergot of wheat is not its cause. ! ;i' 24 PRACTICE OP MEDICINE. TRr.TMEMT.-Ain.ly general rules for treating fevors, as to antipyretics, diet bXr nursing .Lrventilation. But specific lesion reciun.es spec.hc treat- diet baths, etc n ^^^^^^ of meningitis : 1. At outset ;;;;:; -rXll^r^ine^atchenect. you may needhot water^U.i.et hi same time. 2. Abstract blood by leeching or c^.ppmg, apply leech behind r nostdl suitable to vigorous cases ; in authentic cases do not deplete. Z::^:^ ::T!:. do, ^ it wiU weaken. 3. Ap^y busters to occiput and back of neck, leave on long enough tc vesicale-4 to 5 hours. INTERXAL EEMKDiES._To lessen blood supply to brain and cord and lessen tendency to convulsions and spasms. SPVSMS -Any of the Bromides K. or Na, generally combined in this fever .,th e "t or bella'lonnato lessen blood supply. A child 4 to 5 years, early age, hlad retracted, pain, etc. Give K Br. 5 to 6 grs- at east and add m^ o xM -A V f.o.t Vvant or m 2 to 3 Fluid Extract Bellad. Effect will be to :;'pai nd s fn;:: ^stlessness. so giving sleep: above doses given every o'lrs. Even here you can give Pot. lodid. as antiphlogistic say to ead of Jove doses add grs. 2 to 3. When second stage appears (prostration) omit Ifpot Bromid, b^t continue the lodid to promote absorption of effused serum. E Er^otin gr. i. Extract Bellad gr. V.th, may be given alone every 2 hours Lt ad tfirst prescription. Mercury is not .sed by English or Americans, t Dr Howard would give Calomel 1 gr. every 2 hours- Quinine is valua- ble. If fever is high-105 to 106-give antipyretic .^^ov restlessn^.s^or headache nothing can compare with Opium ; give hypodermic injection of Moi ph.a I^riould k^ep patient stupid with Morphia. You may supplement treat- ment bv hot application down the spine, as mustard piaster, liniments, etc. i rom banning try and maintain nutrition. At end. when hearfs action is fading sthnulants ai^e needed, and often they will take large quantities, ^^f^ of quantity. In convalescence -tonics, quinine, iron, change of air, secuie a daik room, eleva^od position of head, freedom from noise. DISINKECTION general respecting fevers. Dnty is to destroy. Mattress and pillows should be covered with rubber sheet- Bed linen and pe-na hnen should be removed, and (at bedside) immerse in a tub "J J^^^^^V^^™^ Acid and then carry to lavatory. These clothes should be boiled. Washmg peiis, iiares and body use 1 to 40 Carbolic ; in bed-pan use ^i-fecting solnUc. I. fore ii is used. \ pound Chloride Lime to 1 gallon water, flways put p^nt o above in bed-pan before using- Afterwards put a quart on top o fa>ce and let stand for 3 to 4 hours ; 2 drs- Hyd. I'erchl. and Pot Porniang. to color to 1 gallon ^vp^.r may be used. Do not empty into water closet, but bury in the ground far from any well. Some clotliiug can be boiled to destroy germs but carpets, pil- lows, etc., need exposing in an oven to 230 degrees temperature. This wdl destroy germs- ~nnr i iii • iiiumi i -?*, PRACTICE OP MEDICINE, 25 VI. MALARIAL FEVERS. Called intermittent, remittent, pernicious, and one variety of yellow fever. The German school add continued fever to above. When these malarial fevers ))ecoii)e continued they are grave cases. Pernicious is malignant. These fevers are due to subtle miasma which arises from the soil in marshy districts and along the shores. This is inhaled or swallowed, acts as a morbid ]»,i3on, and gives rise to symptoms of malarial fever. This poison lies latent in the body (inculmtes) for a longer or shorter time. L This miasma depends on the presence of decaying vegetable matter. 2. On certain degrees of moisture and temperature, 3. Exposure to the air. The nature of this miasma is that it depends on a specific germ ; a certain algi5e is found in air and in marshes, and a certain body has also been discovered in blood of malarious i)atients. Osier has proved tliiit earlier researches (by Italians) are accurate. This germ (found in blood) is found thus in red blood corpuscles. A little hyaline body is found, possesses nma'boid movement. This body becomes progressively pigmented, grows, and filially fills the red cell, tlius destroying it. It may now escape or may undergo segmentation arranged in tlie form of a rosette. The cell wall now disappears and these bodies escape into the blood, and there are found as small pigmented bodies. Beside these bodies little crescentic bodies are found both outside and inside (smaller) the blood cells. A small pigmented body is also described either as spore or a young body. On the outside of those pigmented bodies long cilia 2 to G in number project, and are used to pro} el it. Both Osier and Ccuncilman have found that when Quinine is added to blood these bodies disappear. First they cease to move, then disai)pear. In the active stage the jiigmented bodies abound. In the chronic stage the crescentic bodies abound. It is especially the pigmented bodies which the Quinine destroys. Osier calls it an infusoria, another a fungus mycotozoa (?). A proof that both the se germs are cause of the fever is that inocu- lation of blood containing those bodies conveys another wise noncontagious fever. This theory is further favor-'d by : 1. It meets best conditions under which it would be needed to exist. 2. Reappearance of malaria long since rid of, it prov. lug local conditions without the germs are innocent. Pathology.— A slight attack of intermittent fever has spleen enlarged by congestion ; during the febrile stage red blood corpuscles are extensively destroyed. The fibrine factors are diminished, and blood loses its power to coagulate, and is dark in color. Red cells decrease, white increase. Long attack, or if patient has malarial cachexia, changes are greater. What are changes produced by long continued attacks or after cachexia ? Spleen enlarged, pale, capsule thickened and adherent, ague cake, due to hyperplastic development of cells, may undergo amyloid degeneration, may weigh 6 to 30 lbs. In late stage it may atrophy, pulp disappears, and trabeculae thicken. LiVRR suffers also, early and frequently, by hypertrophy of its connective tissue, may be pigmented, slate grey color. Cirrhosis is rare. Liver may be congested, etc. Kidneys.— Amyloid degeneration or tubular nephritis. It is doubtful if ciirhc ac kidney is so produced. FRACTIOB OF MlfiDlClNE. 26 r ATHOLOGiCAL changcB in pernicious forms ^^^^^^^.^^^ Splken enlarged, congested and softened, 1 ke a bag ot ^'^^ . ■"""7' °'"*:" Tfl^bbv and dil»to,l. BUd o,pecWly suffer,, ca„,«d by di^ These cluu.,:es apply to ell iLemalunal groups, u c, intermittent, ""''iXtnUTTPNT F.V :k ok Ague characterized by paroxysms of fever recurring •f . fovpr n...Mirs every 24 hours you have a quotidian level, n evtij' g„l,.r f„,„«, a, d„ub.o tc,tia„, double qu„t,d,a„ .ud „ /"">■. ~;*1 . i„ "" A^^^cl^'^te sudden, but frequentlyit is preceded by ™^i.e, pai^in baclct:d limbs, lassitude, weariness ^^^^.^^ ^ '-^'^^'''Z: disturbance of appetite with furred tongue is s, arly in the attack. '"'thuke Stages of Pakoxvsm.-I , Cold stage ; 2, hot stage ; 3. sweating stnga Co u STAGE is accompanied by shivering, etc., but thermonieer will show sianso? fever The extremities are cold, skin pale and cutis andenna. (goose S ) se M.ulse slow and small, may be irregular, tongue pale an -^. -J and ven vomitiug. Secretion scanty, but urine is pale, cupiou.. ^" "^ '^ Id to contain an excess of urea accounting for accompanying ^-^^^ bieadmig hurr c and irreoular, thirst. Patient is low-sp.rited. dull and depressed. Intel- hurued ana iiu„ u.i , rfj • ^^^^ ^^iiae is succeeded by lect sometimes confused, dru^v=lness, coma, xnis coi-i io8, 110 TToT STAGE —Gradually attaining a temperature of 103, 105, lUb. loo, i Tt ToTto 105 in ordinary cases. Pulse rapid, soft ; if patient prostrated, ;X I try li ILpiratioa is hurried. Urine is scanty, but contains excess 4 I PRACTICE or MtWOlKE. 27 «ive urine, etc. . .,, ..tting used to the fever in the days of f Uvor stoumch, bowels, eio., »' . ,. ^. . f,„. \e oomphealioa inllamnKaum ^^ 7;-;;^^^^^ becomes ind.st.net, foi I (■oiniili''ations occur, me continues the fever. __ ;, „,urial sulfever gets a caehex m CuKONic MM^MUX^ CacHKXU A c ^^.^ ^.^^^^^^^ ^^,,,,ny having but a lon.» resident of a n.alanal district m y o l,,d a malarial attack. ^^ , d,,,ky slate hue from pigment. SYMI-TOMS.-Color pale and sallow (livei ji^turbed, tongue coated, Coui^:il looks depressed. J^^-,^:^:::^ (liver). V^^^^^^ ^^^^ armetite poor, perhaps constipated stools c y ^,_^i^^,.^^j (,,.uo Ei^ly-tery,nrine has bile l^-^^ ,,, ,.l,.tati^^n cake) also liver, blood an.emic, ^«7""; t,;?;^^ j^ blood a dehciency of red t:L. cold extremities, dropsy of eU^^^^^^^^^^^ ^^ ^^^^^^,„„ of temperatu. is cells is seen and pigmented bodies ar. 1 ^^^^^^^.^ ,^^^^y ^..^ve fatal b erved. unless an attack of feve^ o - ^^ ^.^^^. ^^,,,^.,y_ ,, ,, «ome throu-h asthenia, dropsy, or arnyloid ^^ "^^ ^ peculiarity of mahu-al •L-rrent disease may ^^^:;^^:^ i^^^^^-^^^ hsorder is that it i.uprints aliabiUty to '^ ^'^^^^^ ? ^ ,,,a esUblish a malarial r;lcts of malaria on consUtution -y^-^^; ^;,i,g vigors. He also says diathesis, making one --^P^^^^VId b P e"ts: and if continued exposure ot .nalarial diathesis will be transm^t^^^^^^^^^^^^^ ^^.^^ degenerate physically and generations occurs in ^^^-^^''^^ '^''^'''' I be superseded by other diseases, as nentally. Ague appears Bometimes > be J ^^^^^^^ ^^ ^^^^^,^, neuralgia, hysteria. ^V^'^^iyf^'J'^T, of intermittent, but have symptoms that is. they are attacks of d«^ y^^,,, occasionally are accompanied by foreign to it. They '^^« . ««"-ff " ^;^y ^hey depend on affections o nerve moderate febrile manifestations, and ^-^^^'^ / ^ ^ ^e remissions instead of tocts. Generally they are quotidian. eie m y ^^^^^^ ^^^^^^ ,^^^^^,^ intermissions ; attacks occur ^^^^^^^J^^ by an attack of ague or may be independent, but may be P^'^.^-^^ '^ _ ^^ these cases the spleen TL, ,ttack« mav alternate with genuine ague attacks ^.^^^^^^^, ^^^^ ^^^ tnese auw-n~ " ./ „_;„o miiv "ive uu aign. '■- '- escapes enlargement, and the urine may „ frnnt but is, II erai' liiii 1.(3 ( Kv chn hl" diiJ be tl. JBACTICl! or MEDinNB. 28 % „(r,w.t..(l hi'iicf liiow nou of '^' SwK;nsa STXUK.-NO interference .^1. fo.^.^^^^^ ^^^^^^^^^^ ^,^, ,.,, , Quinine should be preceded by a V^^^^ .,,,, ,f i.udanum befo.-e attack cbgcstive system calls for it. I-^^id ' '° ^^^ ^^^.^^^^^ ,^^. L,ud,uuuu to yo". may give (Minine 3 g.'s. every . h.n rs a ^^^^ ^^^. .^^^^ ^^^.^^^^^^ ,,, .eh d<.se. You n,ay subst.tute l'"-;^^^'^ ;,,,,, bas no control over agu sinular specific action to Ciununc Q^" "> ; ,,^_ , 3 times per day, in form of long attacks, etc. Arsenic wdl then c . h - - • • ^.^^^^^.^^^ .^ ,,, ,,trate of ,„;,... Solution. Watch . -f ^ ^^es per day. U is very successiul. Ammonia, dose gr. 1 to U m l'^'-."* does not produce cinchonism as Q-" ;' _; ,^,^ ,4,1, to 21 day. Those are RKMPSES AUK AVT TO occuu otcn c.mn^ ^^^ ^.^.^ ^ ,,.,e dose tnie ^elapscs may ^J- -^^ ^^^ but if you keep up dosn^ v. h of t,)uiniuc ti hours before expccteu ^^^^^^ ^^ ,^^ ^^ ^,^j.^,, ^,i^^„. 1. ihty (,)uinine 3 grs. 3 ^^J^^^ ^""^j^^' should be light and nourishing. 3. Dose should not expose themselvi , . . .1 T,.„., \ \ sVinuld not expose iueui&ei'> t:;: QuiuiueU Iron A . .. 2. A« gT- ^^ , ,, ,„„ be w^l TUK.V1MKNT OK CACUKxa.-l. Remo ^^^^ .^ ^^ 5 ^,r day. fed. 3. Give internally Qnuune. or """^^ ' ' ^ ^ ^„„,^,e. Aeion^pany with Arsenic, give hot baU.>^ by -^^ .^ ^^^^ ,,,„ rou ENLAKOKU Spl.kn give Q "^^ J ^.^^^ ^„ths are us.fvd to tone injected into spleen. Ergotme ^^'^^^ ,,,, .pleen may be good. ,;. Cold douche over spleen is good. ^^^^^-%^^^^.^^y,,d rub externaUy When alHever has gone you cau try lodid of f.-- If TBACTICE OF MEDICINE. 29 ,„„,!, fcvor, .1» continued -"'»™; ^/j^^,^™^ ^^^^^^ i. to be „a,itunt t)l.e »th« '''"" .,''i!"\,^ ', fjf mL may affect. Any who* taken f.ito account, ov condition of lealth oi W»~ ' ^ ,^,|,i, f„,e, ,. »e loaded «iU. e«e. nu...s ai, ,i»UK .. ^^^ ^^„„„^„ jhas forms like ague. 1. yuotiman. ^. fever ™|e,c.,»i,|^.raUy^ *»« ^iU, a v^longed fcbiile stage, a sweating L:rZT:Z. -o .^^^. Muenay vo."i'>^. ^f '"tayT: accom,.anied Ijy jHiispiration. lu fi.st stogc leiuiss o I auotliei; ..roxy.ni c„,ue, *- J-™-; -...tlrfty::, "'"':::^r:^t^^:::r:::Xmo,.> ..^.^ tempetature do not exceed rtot oidina-y agne, te,n„ev»t,„.e is hig.ie, .nd ""^^'^^l^ is tuircd, coated brown. Vomiting is common, contains ether W« » ™»^™;' biood bene, -f . rr"z:r:srrn;benit:,r,,: ... 1 day,, »,dy lasting ionger «- ' ^ = ""^eve^ fo m^TJis ions sligbt exce,t : a^d »1 Tliese Lms ma, .ud in 2, 4 to 8 days ending in death. 4 li PRACTICE OF MEDICINB. UNLIKENESS TO YELLOW FEVER. 30 BEMITTENT FEVEU- Has remissions. Not contagious. Black vomit very rare. No hemorrhage from mucous sur- faces. No albumen in the urine. Not before end of week fatal in worst cases. Succumbs to Quinine. Piament granules in malarial blood, YELLOW FEVER. Is continued. Highly contagious. Tendency to hemorrhage or black vomit. Hemorrhage from various raucous surfaces, bladder, etc. Albuminuria. Early fatality 3 to 4 days. Resistance to Quinine. No pigment granules in blood. . • • .1.. arPit remedy. Do not wait for remittent TRE,VTMENT.-Qumme is the g eat emeay ^^^^^^^ ^^.^^^ ..t give Quinine at -e ", someUme^^ -^^^^^^^^ ^^^ , ^ ,,, ^,,,,, scanty,stools unhealthy, S^^; ^J^ ; Q-nine is generally given in antipyretic gvs., and after it acts give the Q""";«-J^ ^^^^^ temperature is high, spong- doses of grs. 20. but 5 grs. -s o ten 0- ^- .^ink large doses during i„g. ice cap, etc., will help to allay ^«-P ^^^^^^^j^, ,^^, fever best. Quinine the fever and small doses durmg ^'"'f "^^ ^^^'J^ ^^in liver and bowels, if .ay fail to act; if ^^^J^^^^^;^; "^ ^ 7^^^^> --•^^- ^'-' needed. Give a diaphoretic Pot Bitart 1 oz „ P n ^^ ^^^^^^ ^^,._ fo. the kidneys Salts of ^^^^^^J^ ^Zl. U Quinine again fail, tar acts on the skin and bowels at once, „ ve ^^^^^^ ^ ^^.^^^^^^ tveat for a while on general fever P-;-P^-;^ A^d t ^^^^^^ ^^^^^^^^ and Opium, et mannintr and beating just a few times ei-igastnum with towel wrun pregnancy. towel and chloroform on the par -d "- .^^^^^^^^ ^^^ J ^ ,, ,, ealled PKH.010.S ^^™^- - ;- riTfrlc^uemly intermittent from ter pernicious on account of its tatality. . ■ intermittent or continued tian type, occasionally it is quotidian. Sometimes ^^^ ^^^ ^^^^^^^^ ^^^ This disease generally begins as ague, and alter . w r tTay !et in at'the outset with pernicious symp ns. ^^^^^^ PERNICIOUS SYMPT0MS.-1. Comatose form. 2. Al^.Ue. Also convulsive, delirious, choleraic forms etc ^ ^^_ COMATOSE FORM uot due to cerebral -^-^^l^^^^^^, ,Jt 21 hours, venes from the fever. Subicteroid m time- Comatose las „ It may pass otl' rapidly. IS PRACTICE OF MEDICINE. 81 AiriDF FoRM.-Patient is cold, pallid, does not recover from chill. Heart , .T^^ diMed, collapsed, bo.els loose and very tlun. unne may be sup- '""ntMOUunvGic FoHM.-Oo^ing of blood from mucous surfaces, bladder, nose, iirMOKKn\i.n. , • ,„,,. °p.p There are forms shewing jaundice, syn- ' TrlalLnrniect 25 ™,. of Quinine l.ypoJorn.ically, apply ta water to Zt. a' St^in tc ^ -ive =tunnLant,,lb™n,,y o, whisU.y in hot »ater tlie legs anu uii^n», y , strange treatment of ruV Z7::^^Z ;:rLl' T^^tr ^f cold w^. and rub Ms^ly ! h arse towel. When giving Quinine give Opium also, or inject Morplna w 1 Qdnine ; if convulsions are predo.ninant. give the Brom.de or inject^Ch - n in th i" ctum If the secretions be scanty, give a hot water bath or hot air ndtemercmal purge. Give Digitalis and Potash for the kidneys. For con a pourC of Id waL over the head, and put mustard plaster over the nape o the ne I- avin. got patient through the first attack, do everything to preven Inot;:' • G^ QrinuiJ 5 grs. every . hours and a large dose 4 hours before ''''"H0CL..L FEVKU is typhoid in a malarial patient. Quinine is espe- cially called for for the malaria. Treat also on typhoid symptoms. ,« Vp tnVpn Non-Classifiable Group, or Constitutional Diseases now to to be taken .p. They appear to rise from some condition of the system not quite nomaU. dr inherited or acquired. Acquired diseases probably arise f-" !™P«; -^-^J some of the functions of the body, as of nutrition ^'^^''^f^^f ' ^^^J^^''^"' ^'snecific stitutional diseases are expressions of certain morbid ^^^^^^^^^ modifications of vital action. Many are generated in the body to long .mperfect performance of some function, as diabetes with the liver. ^ DIATHESIS constitutes chief factor in constitutional diseases. It is a state inherited or acquired, leading to a predisposition to acquire c-^"^/^--- This state lasts generaUy throughout life. This proclivity is capable of aggiava tion, sometimes of cure. , . 1 :„i i;„„ a\^ . I.iosvNORASY also plays a slight part. It does not imply special live da thesis or proneness to disease, but under certain well-know.. ^-?-^T^^ peculiar L the individual, and dependent on definite peculiarities ^i^^^^^^Z Lt known will produce certain results, thus 20 grs. of Quinine almost always causes headache and deafness, etc. But 1 grain will cause same Wt-s m one with idiosyncrasy to this drug. Same applies to many drugs, as Mercu.y, Arsenic, Oi)ium, morbid poisons, etc. DIATHETIC Status may. besides inheriting, be brought about by chnratic i^flneuc- a^ malarial diathesis, rheumatism, etc.; may also be brought about by food, as gout, rickets, leprosy, scrofula, etc. ; may also be induced by conslaut action of cold, as catarrhal diathesis. Hutchinson teaches that lUl intlammato y affections once exj^orienced may become habitual, as erysipelas. caUrrh, etc. 32 PRACTICE OF MEDICISK. with bodily diaease. VII RHEUMATISM. Divided into articular and muscuU^u ^„ f f^ver. local affections ..,.aou..orc/u.onic. ^y-^^2^^^^' -pulsions, causes chorea, of the joints, heart. -^''^''\^'^^^^^^^ Name meningitis and tetanus, ^cu e heu nati^m ,^,,,,, .heumatica rs .uggests a ™-b^VT°:' '; isa e r w h specific local lesions. _ an inflammatory affection ; it ^ff j;;^i^^^^i;diBorder of health, but set in sud- SYMPTOMS may set in ^;t^\«"\"« ;f2n fever, or premonitory symptoms denly. slight chill, pains in the join s -dj^en J ^^^^^ ^^^^^^^ ^^^^^,^ that of the joints. ^^ ^jn at first dry, but after- KH.UM.V.C ^^.-T^mpera - 2;,:, ;,..ding, 90 to 110, t.ugue wards perspiration free, fhust, P '^ ^ -^i^ ,^j edges, pains in ti^e Uuckly coited with white U^:^ ^^^ costive, urine febrile, high Joints, send patient to bed, ^ ^ j^/ ^^^^ J.^ism an excess of pigment and of colored, scanty, solids in excess, and n iheu ^^ ^ ^^.^^_^^^^^ ^^^^^^ sulphuric acid. As the urme cool. Ij^^'^^^^^^J^^^^^^^^ture in acute rhe.umatism Albumen may be present "^f ^^;^^';"''' ^ The sweat is highly acid, has a sum .Tine... . 1 (-If; ia il.irTnlUC'. is the average,above —/^^^^^^^fl^.t:; J inflamed. This is rare. In Local AFFKCTIONS.-Jomts may not always ^^^ ^^^^ s„chacasetheheartwillbeaffectedo.som^o^^^^^^ become inflamed untilfrom ^^^^f^^^"^ .ed.lffusion may be s/ght. pvecede or accompany the fever f^^^ ^ ^^^^l.^t. This pain varies fiom I great joints may be V^^^^^\^ '';^^Z ZlZo.nA the join, but not like uneasiness to agony; occasional!, (Baem j^ ^^^^^ g„,ooth and as in gout where the veins are swol en S meune^ ^^^ ,i,,harges it is not shining, but suppuration will not occui. rheumatism but pyeemic arthritis. .^tremities. ankles and knees. 2. OUDER OF Joints afff.cted.-1. ^^^^'^^' ^^^^^^ trilateral, the Upper extremities, wrists ^;:^-XS ^^rflnge^VL above order is ^^^^^^:^:::^ , .ervous system notdisturbed except ^^:;ir^^^t::^;er is not alwaysconfinedtotheJoiuts.butisaptt^ to the viscera,— heart principally. ;i ii • i ill CO ai h PRACTIOB OF MEDICINE. 33 ViHCKKA. COMPUCATIOKS.-Most common fomis ^^^^-^^JfX'^'jf 2c mitnl valve more common in females ; it sometimes also attacks the aort c initial vaivi in ^nrtv pxcres<-ences grow on the valves, but valves. Poricaiditis IS also common; waityexcres.,ouctsfe . „f n.u «r« ul erative form is rare. Circumstances influencing the occurring of this are r ; a pr .^^ to cardiac rheumatism up to 22 y.ars of ago. It is peculiar he tc t rheumatic form. Neither chronic nor muscular forms commonly ;!;:e r It usuaHy occurs in the early part of the fever, i; j;^'^ ^-^^;-^ fiO to 70 or 80 per cent, of cases have these complications. Th.s oiganic aHtction police lanic murmurs and also functional murmurs. The second may be t^Z^L. of the heart or blood. These murnuirs ^^^^^^^^ first attack of rheumatism is more apt to ,' tack the heart than the loll, ving atlk itut is rarely if ever affected in chron.c rheumatism or rheumatism of a Ice ion and neve in muscular rheumatism. Aflections ofthe visc..a are not e:?^^ Iplications. for they are asmuchto be expected as t-uble in^he jo . Neuvous DisORDEHS.-Disturbarces of a functional nature: 1 Rheumatic deliriu.rfl the 8th to 14th day when many joints are « ete and c.. ^^^^ severe Indicated by restlessness, talkativeness. sleeplessness, etc. Theie is eaiiy ::r;^t^..^l of vital powers, pulse rapid and weak s^- cyanotic esi cially at the extremities, temperature hyperpyrexia even 109 mil 0, but my ^ absent from this delirium ; skin dry and hot. tongue dry and b-wn. Cases un a rapid course, generaUy fatal, ending in 3i days; in coma may be fatal even '" 'cTuLic NKUVOUS DisouDKUS may be melancholic, ^^^'^^^^^ tose, not as fatal as delirious form. Convulsive, tetanic, choreic and bke oims m^; be observed, and may be fatal. In all these cases no lesion is found m the brain, at most a little congestion of the brain and membranes Causes of Nervous DisTUUBANCES.-They indicate a vulnerable stale acquired or inherited of the nervous system, are apt to occur when many joints I e nvolved. or where visceral complication is present. The hyperpyrexia ha W al ged to be the cause, but delirium may occur without hypevpyjx • J^e Lre pain, the large number of joints, visceral --pl-ation loss of^ s^^^^^^^^^ impairment of blood may all combine to cause rheumatic ^^^^ "^jf^J^^urb there be a morbid poison which causes this disturbance we would lay the distuib ^"^^::^::t:Wionaldisturbanceofthenervoussystem^M ^young children or young adults. Inflammation of the meninges of U bra n b>en observed perhaps due to endocarditis of py.^mic or embolic oi.gn. In tins '"heuia c m thigitis'the vomiting and pain may both be absent only delmum p^e n This occurrence is very rare. Sometimes functional disturbance the ^t similarly met with, inducing tetanus etc ; ^on...^^o^ ^^^ ance also. Pneumonia is alsoacompli.ation,aLsop^^^^^^^^ quent accompaniment of rheumatism, if congo.ti^u ^ cxtr..ne . - - , haematufia. ■' ■«.»i H tlies I ciyt anil thei IJ con 4th ain lua ovc (Irn fos we sli| on ra«: nu in( no mi ex cli 1. ic 1« 1 u 0' c a 1 T 1 C £ - I M i Wl W«|l>| l lli PRACTICE OP MEDICINE. S4 ccnunculy untnated cases, paina ceaso at 12th to 14U. uay, 4th to 6th week. Now-a-days 4 weeks general y cues. Signs of IIecovery.-1. Cleaning of the tongue. 2. Unne increase .noi^^lut density high. 3. Subsidence of V^i;^^^^^^^^''''- ^" any cixses recovery is prolonged, joint after P^-^^'^r;;; ^^^^ ,,„,, S.inACUTK FoK-M.-AU the symptoms are nulder. The fevc. is aoseni, o festations slight, lung comphcations also si ght. Ih s in V weak unhealthy constitutions. The case is sub-acute from outset. ^r E RHFUM^TlSM IN CuLDUKN.-The local manifestations are slight, joints ,i„h^r.lCr;:^in. pains may be tlie only complaint; ^^^^ Tthefr feet all the time; it is apt not to f^^-^^;:^:JZppZ ^ .t „nf tn be affected. Disease is apt to be sub-acute, perspiralion {»o ; r;j «i,?n* -.ty ... « J »ith Uthate,, Cardiac ..an*-- "J, acre al I to altcct a cUiW tlma an Ml. They »cUom »o«pe, the '" '"'""^^^ r. ,„ L.h in „eric«rditi, or endocarfiti.,. Endocarf.l.s » connaonct. Ihtro rcWvily wiU. childrea. Delivimn, com. and convuh.cn, n>™ly seen m "'"'■"prTHOloav OF R„EU.«T,»..-Oau,«,7perceat,ofdi*a»e «*""■"»«»■ 1. C^d nl lamp climate,, e,,.oially change.hle weathe. ra,. ■" -"-'^-r; ical conntvie., .Ln inanence. n,,t ^^:^Z^Z^A°Z imtions which expose to weather. 3. Age, disease oi eauy ir 30 years of^. 30 to 50 less fre.uent. It is ^^^^^^^'^Z under 4 years of age, but no early age is exempt. Sex has no Qirec otVer than in occu;ation. A first attack after 50 years of age is a rai.ty tlut 8 t e acl foi-m. 4. Inheritance, it cannot be denied, occurs in from 2o to 2 p r 5 OnH^tack predisposes to another, llie intervals « o^t^u -d t^^^ a tacks lengthen. Gives rise to a rheumatic diatbesus. 6. Scarlet evei pu r il^l St e Centery are apt to be complicated by ps.udo rheumatism. Also Sl^b i;:rg::^elapsi:igand cerebro-spinal ^ve. — ^ a ^d iny. litis Their relation to true rheumatism is unknown, bu. .::.=e trou -^.y :;;;.";: «igi„, ana ..y ,» c.«.sed », .henma.i™ >. ^^^ ^ articular disease besides rheumatic poison. 7. A lowering oi viia p i,'. i If'* ill will) I lire, I 8. Im of lac Liii'tii tlifiir mat is (Mite trojili the c 10. ] Dr. I lRCti( abuu the It ha ofjoi 4. V Notl: hyi-t icla] losi.s iiihc suso heall joint 8. 1 9. 1 devt I i or II does rhei Gou ill 1 gou Hei PBACTICI OF MKOICINE. I ,vl,o 1ms a mathenis to rheumatism Rives a tend-ncy t.. outbreak, fatiguo. expos- ung..., cnotiou. .leLauchory. lactation, aud traumat.H.n may I Im. aflect Uctiotid theory. A chill brin«H abet rhou.nat.m by chec .n, .hnun oflactic acid and acid vl."mi.hat..s. These -auso rheumatism (unl> . lhe...>). .^^ ." i "n in diaLes has been followed by vheumat.n, thus sun^rfng h V Ohiections, no excess of laetic acid has been found in the blood m rheu- ^L It oce«r;ence may be an evidence if found not of cause but effe.., also Zro an excess of lactic acid iu the bloud in riekets. U. Nervous tlu,o y ::::i?^ oil acti.,, peripherally disturbs the centres and thus .l^u,.te rophic action of nerves, also of the skin, caus.n, sweat.ng, but ^\^^^^ the cord, brain, etc.. are probably the ottect and not the cause of ih, uual.sm. m Due to a morbid poLn. This is a probable a^use, but not at all proved. T)v hathan sutiLa-sts a chemical cause. ... , ^u C KMlcAt^THKOBV.-Glycosin is abundantly formed m t.ssues abn, u h luetic acid and uric acid, is converted into urea .n l.vcr uornuvlly, bu- m abnormal state liver fornis it into uric acid, h.mce rheumatism. U KM TaEOKV._McLa,an's. That it is .hie to an organism tnti-oduced n.to the body, as the fevers, etc. 1. It is febrile affection and so reated 2 t ha hi 1 lesions, as typhoid, s.xrh.titia. malaria, etc. 3. Similar .ntlamn.at ion of iomts in other fevers occur, as in relapsiP, --.e, also in sep ica.n.a, > em.a. 4. Visceral complieauons ,uv analogous . corn,.: -aUons of other disease -o. Nothin.Mn symptoms or progress but is s-cu in ..her fevers, a« '^-Lm-^, ot • f • fi >Fti,.l.Hrv coldand ci-iP pvedisMoso to it, also to typhoid hyperpyrexia, b. yf.tiology, com ami >- u , i . , ., , „ „,;n, t,.l,i.v.Mi- rclL ,;.. etc 7. A predisposition to rheu > ..n-n '. inherited, as with tubc.cu- fh red posLn may act; a condu.m of tissues or of whole systems is Irited, mly Jor ciie cultivation of microbes. Cold may -^ '-y---- susceptible to their attack. Arthritic diathesis consists ol a .Ute o t„sue Stlmissible by inheritance, involving a liability to -»»-— ^j^ ioiuts • in such a state then the specific poisons find symptoms eay to atta k. rTiulcyo recurrence of attacks, as of typhoid, malaria, diphtheria et. 9. This doctrine is not opposed to the doctrine that a casas mo.6. is developed in the body, as of uric acid, lactic acid, etc. DIFFERENTIAL DIAGNOSIS. ACUTE GOUT.-I. Rheumatism generally attacks several J^^^ts at -ce or in succession; gout generally attacks but one. that of ff^^^^f^ does attack several joints they are the smaller joints, as ^ ^^^^J^ ' '^ rheumatism the larger joints and several joints are '^f''^'^^^^-^^ (;out attacks the well fed, good livers and drinkers ; ^^^^^^^^^^ - ■ J 1. „,--=Q,i 'iij^ase 01 early oi iiuuuic me, ill tP^^- ^^ii^ s,^ food else a relapse. Au.ipyrine gr. 15. dose every 3 hour.. If "^^^ '^^^.s ^;^ Sod S die reduces paiu and fever, does not occasion cmchomsra as Sod. =,al.c. at "found to best suit less febrile acute attacks. Antipyrine is better than tTsahl in non-febiile articular rheumatism. McLagans rule : G.e Sod.Sa i. 15 ^rs every hour till you can move hini without pain, or give 20 grs. cncij . h .urfoi 6 cLses, or even 30 grs. every 2 hour. ; reduce dose when you get system ' turated. Said, a combination of Carbolic Acid and Sahc Acid g- - ^^^ doses every 3 to 4 hours. Is not as good as above. Look out toi Caibulio Atid poisoning. Kelapses are more frequent than under the Salicylates. LOCAL TuE.vr.M.CNr.-No special mode of treating inrtamed joints. Tie up i„ cotton wool or put oiled silk about, or lu,t poultice, aud put^d. s. ^X^^^-^- poultice. Is soothing to paint with Tr. lodid, or take Lu.. Opii Sed. 1 o/.. 1 ot tob 4 to G drs.. Ulyc. 2 ozs. Aq. 9 oz. and soak lint in above and put about "is soothing cover with oiled silk and a light bandage. If lu .mma lou be very active pu°t ouaspliut to secure rest. Or put on a starch andage o. plaLr of Paris, very useful when wrist is affected, or it takes weight of Id off wrist Emplast Lytt;e above all affected joints often gives relie . but is ba - barons, but you may use it where a joint tends to chronic.ty. 2 1, per cent, relapses under Salicylate, treat IG per cent, under alkaline treatment lleasou is pain is so relieved that you cannot keep patients in bed. etc., aor can you make them keep up medicine long enough. Hygienic Treatment of acute rheumatism, -oom well ventilated and ^vel lighted, but no draughts, it is not wise to put patieut in blankets, put on Hanue ni.d.t.'own and cotton slieet.s. Blankets aggravate the sweating. In examiuation of heiu't^'do not expose, hurry, cover with some thin substance ; hair mattress is better than feather bed. Kub patient down oite.i with dry warm towel, c.iauge slu-ts to oet rid of perspiration. Diet, a fever diet, milk and cornstarch or aumutl s H w PRACTICE OP MEDICINE. 38 1 ; 11., ...IL.il for iis when sa icvliiles uel)U^s^5 iiuiu, un-n „ ,,atiunt be coiivaU-sceut a tall wcUv ot n. vilvuliti^ wIumi vocov- bofoiv leaviii- room, else fatigue may l.ni.g relapse. In NalviUiLu, F v.Mi a i,leiiriti.s li not a coi.tra-in.lieatiui. ol e,(,M balh. „ • • ,, „„ ■ n. aeute attack i.reviously may predispose (laie). 1 luu.po.ui) „,c |.A,.m„, «...« is .».M .ir ,la,„|,, l.u. ..1H.„ no ,«ui« »t .,11 c,i, b. . , „ ic Ksi..,i.lly .li: juH.U .u,«t «i„„c.l to th. C.U .,,.1 .U,„, «.c »n-teJ. » »"»^» '" "'""m:;:;;;;,";S™>u.-c„. = i.n ...™ ..-.. ^^ "- «■'*-' *« n:;;;:; „,„,„: -n.i, d,icU., ,i„;, ,.uy ...•..■...! - .™ U„ .,„ 1 1U..U m .1. "-'='•"; ; v..,,.;,.,,, "ty,/,y...v,a. N,,s„i,,,:,,.«,»..>=c,,r,, ..n.,.,. -■,-, a,:.,. .I..K. ..".;' -"■cni,, ofu. ,un,„.. ™ . « > y_;;;;;; l,ut in.ltuMtioii ami siibhixatioii occiu'. iin. .li.ta... i. "■''1v;iKroM«.-A simple joint is seat of pain euiistant. ami on pressure .hieken- i,,.. ,' tl e part, sw.lli.,g sometimes, elVus.ou uUo ti.e .joii.. I'.un -s no s. t i uid IS woise in damp weathei-. eveakiug may i.e beard m .an p.. d. - piLtiou. The apparent swelling of .joint may be due t. -^^ ; ^^J luuselcs ; fever, sweating and local heat are abs u.t. In protracted case, thc.c may '"T™S'!5longcontin«eduseof Salic. Sod. in dose, of 15 grs. 3 to 4 umes^" ^^ months or try .ntipynne. Treatment «f subacute rheui.d.sm n Lno as this, or Pot. ludid. in 20 gr. doses . tunes per day tor nmnth. o. Muriate uf Am in IS, or rot. loum. m ^o i;.. >^"-^-- • - i r ,,,,,, , r,,\ In to "0 .rr.. Villi Colchici 10 to 15 iii. given with the 1 ot. lo lid ^ .. - 1 .*-:»»*...... . II. ill' '.lik lilt is also often goo d. Semicifuge is also used to relieve paiu uid stillness in or aij >iit the joints. Su used in cases resu nibliu'i K" Arthritis. When an;euiia is ' "'-41 •11 6,. 1. (' 1 *} 3 ^if M PRACTICE OP MEDICINE. 89 , ^ ■ • ,.MnP and Arsenic in addition to above may be pvosont the addition of Qunune ^^'"^^ f"f,™;.i^,,,rioity. both kinds, applied ;,,,,,1., Cod Liver Oil as a ^f^^^'"^^^^^'"^^ J'.,u.n baths a long t" ^"i»^ -^y ->rr ' U:lr""t . W ttth Ltin, one honr. A series „f 30 Wtl,, of 90 ,U.g. »t even a ton„«..n,-„ of 08 uU '> » „„^ 1»,1« m.y l.an.. l>y "'""''"S "«;»'""• , ' " " ; „ ,,„„, j ,„ 1 l.our. The benefit a,„l o.l,e,l,ot spring, wl.,cl.doe» I .eg 1. ^ ^^ „„„„„,t. oi.e good „f „.,uln,g to a .iTing „ O.at you ■ « 1™ u <1 u A ,^ ^^.^^ _^^^_ ^^^^^^ ^^ ^^^j^,. ,„.,ienie Mn™,m.ling. and g.ve Ae > " ';-^^, „,^f„, „, ,,„, „„es, in „,„„la,ed away from home. J * ' '' J,,^ ,^ ,^,^,„„, „„.„„t .,,, i::x;7o:r'r„:z;"r:o:"«™ ■- - *"•■ *"-'^ -- '■' \::!;'t,,k™™. or ohronic .hen,„a.i,,n, a, a ™le. no ,ce*^^ ha. co„„U.,-i,ri.a.ion by Iodine, ^"■7''-" I);: ' n, \"r ;novi.,l hot ,.,„e„u«„n. >«*;"8j.*,,,,,^- ■ ;,, „ i„.„uve .aken inten.ally. (iuaie, Anna. Cbhii., lot. lo.n.i. ^^ „]» theumatic gout, also Eii.a-M.vro,D Auviiums e,,«al, 1.. A., c u,^ a ^^ ^^^^^ ,„,„,„,,,,„„, ,„teo a,.„nti,, aUo "^^i^^"- Z::J^,„ ,„„„; acute of ehfouie, also t„ rl.cuniat.sra, several vaiieties .1. i-o , , ,^ j,„iiti,. ,enevalov,vog,«.We;2n,o„oa,,»^ ^,„^ „„„, ,, 1. OESEliM. lOBM otlst (aoulo) ui. ) 10 .,v,„,,tou« are very ™e, re,en,bles aeute ..olyartteula,. ■'»;"" «"'-.^; 1 but on the otber kJ u,arked. less sweat, ,,"1-, ''"'■''"■:''■'' ,.r";,*e,lly begi,» in the „„„d ioi,,.. a,e tnore afcted, ,«o,e ellusaa, u, o tan. '^ -1- f = ^„, .„„a,ler joint, finger, and toe,, „t f^^^^'J^^J,, ,Z. itself to a ,heath, of tendons ate also mvolved, have '^"''""°; "". , ^his acute :r:?a ::::::'«*>« He,b, L spnlt,, etc. In„a.oven.ent ,s not pot™- „e,„, a ft^sb bitthor ^'^«;^'"';;^'^X::;:Z^^^ than acute fottn in TiiF CilitoNic Form of Isl progressive is raoitiu->i ^ »""'"'•■ ;■;'.;;:'* ;T; m!^ :: .11 lete ten,issions are observed. »■'■'•'■ '"" '""»!' .'" J™; „ ,.,„ ;, not uniform, may sliil. a Jo.ut or go Disea to the opposite side. In early stage there is a more or less elfusiou. posi- liilil I 40 TRACTICE OP MEDICINE. u 1 ,vntlv bv tl.is effusion, by swelling "f ,,„ ,u,l sba,e of .ioiiUB become J^^t-;^; F^^., -^ tendons. Asdiscase become. ,,.„,,, ov by cont.act.on ^'f"; ^^ j' , ' ^ ,,Uilage is absorbed and ne. „..,,, ,l.vonic, new bo.,, on., """' ^^ ,;,,, ,„,y „„ch relaxed, s..bluxa- masses d.v.lo, in synovial ^-^ 'J" ,^ ;,,,„,,, ^.a stiffness, muscles may ti-S "t". I-'- -^^' f '"•^," '''t s 1 . .1 i- avticlav surfaces together may ,,,,,U.vain n-V'"- '""' HW 2vt^ It f^om new glands of fibrous t...... „„s,. ,,-ati..g. S,mr,ous '-'^ ^^^ ' 7,,^^,.^ ^,,^, ,,,, ,„Uylosis occurs except .n i,„,,,l„,iM- ui .,ew bony gvo^^tl . It .. ^^ ^^^ ^j^j^^^ attenuated „ ,,,,,,.,! eohunn. Over ^1-;- J"'"^ J^^.^^ ? '^ I .i^^ase advances fresh !u.d parchment U-olcing, ov f^^^^;^:,^!^ involved, as of ^aw and ver- i.,„,s are affected, ^^^^f'':;^':'^^^^^. wiU.ont destroying life. lu.: etc. It may last for 10 l. o^_2 >uU..,^^^^^^ .^ _^^^ ,,,,,eteristic affecti^^, GESERAL Condition mch.nnic u. ^ ■ ^^^^^^ urine may be ,„,..e clean, pulse, appetite. '^^^^'^""^Z^t^i^l^n^^^^^'- '^^-^ ;,:.Inadva..cedstagespt,ej.bj.o.ne^^^^^ . P, \ " has no tendency to attack heart, to occ affections are not j;;j-.or attack brain. Oc..si,ma^yito.^^^^^^^ ,„.co....non. The vheun.atic »f '^ '"^^ ^ ,^ J^ ,,,, i„ .leveloping. occurs .vphilis I'artial for.n mo.io.art.cda .. '"^ '"^ ^ j • ,„„,,ti,„es sho.ildev, ;U in old men. se..ile -^^^ ^^^'f i: m L.. expos..re to cold. w^. U„,e or spi..e. Cause seem, to b due t ^^ ^^ ^^^ „ ^^^^^^^^ .^ ^^^,^, ,^ ae. It son.eti.nes .Hows ^tUck ^ ^ ^^^^^ ^^^^ .^ ^^^,^, ^,,„,„„ spontaneously. 2 to 3 jo...ts may ^^^,,.,_ i,,co.ni..g more or less hip hy i.Mury. it will after a ^^J^^^^^ „,;„,„, of joint. It is a ,.neral. This affection J^-dually ... ufues ^^^^^_ ^^.^ ^^^.^^ „V sore, pain in the --;'"=• '!' ^^^"'^ '^^^^^^^^^ disease. IIebe..de..'s „,vy last lU to 20 years, and P^^^l^'^'^'^/^""", ,7 ,,„„, ^ut-^rowth takes place Lsiues,-usually atlects last Jo.. it » J^^ ^ ^'^ ^ j^.^ ,,en atlect the ,,.„ „.,leof base of «-Vl''t;::tn.t^ S(^ -S'tly, but not much pain. „tber phala..geal joints. The Jo.. ts ^^^^.^ ; J^_ ^^,, ^,,y occasion These ..odosit.es may ^f^;^^:^^::r^'^: ^.^^y, in chronic rl.u- tben., ov they may be of t-"'"- ^"^ " •;; j^ ^^,Y,,t,d. either hyperplas- ,,atoid arthritis every co.npone. t ^'''^ ' "^ J ^^^^ proliferation. Warty ,,,U, or atrophically. ^^-,^:;^^ .^^ :psular^r^ also due to proli- oserescences. etc.. on me.nbianes (synovia i ,^ ^,,ation, leaving ,.atio,.. Cartilages ^f^^^^^^^ '^:^JZx^ is fo-d around ,are bo.res to rub together. But ^ ' ' " ^^-^^ „^„,braiies often in ,.eat ,,, ,in.s and heads of the bones, al. n the y' ^ ^^.^^^ „,ovements. The „,..,ers project i..to the ^^^^ ^^tfCtll , ont:ct forming osteophites l„„es also increase by ossihcatioi of a tda e ^ ^^^^ ^^^.^^^ ^^ lockiu. joint often. But the bare ^ones iibb ..g ahe l^ ^^^^^^^ ^^^^^^^ osteite. They become ^^'^ ^ .^IJ^^^^^elLs. heads of bones widen, from all these changes, capsules distenueu vy iil I Pi II! The inr I'l'V. ' and 111 yVngTCf Is nil liiivc il imUrei cuinmi is 11 si iniiliii' rliDun ^^^ ^^^^^,^^ ,^^ ,„., '■'-»-'-'- --'^^^ .;;!;:;: ^i;:r ^heunuai... ot, i-viou. a^.. :::;;:;ee;aetin. ^.1,.. ,out ";--,;,;;„. ..nnat^a J., „.„Vvin. from a-.^e vhomnafsm - ^ ^ „, J ,,, aiathesis tho „,„nit., and cases cited ave few N o^ib y. ^^^^ ^^^ ^^^ ^ ^^,^^^^ .^ ,^„,^,,, ,„ain, nvuse would not cause Ih. ' 'J . 1\..,^„ ..u.vitic di ,tlu.MS wuh ,,.v..rn:d by tvcvhie centre ,n tl. ->'^ j^^^ ^ ,,,„ ,,,,i,,,.eral irritants. >.tt- ^,.er.d state of functio,> of J^^-^^;^ ^^^Sde ,J, h-.e tvo.hic f..tu..ons ,„,ar ovarian, uterine acting rotlexly. *^' ^^^^ \^ ^he j.-it-t. Gout and ...e tuo,.e ,oorly p-for.ned, '--^J'^^ ,,,,,,). in,eutnatoid arthrtt.s eluouic a,ticular rheunmtt.n nu.y cdc Cj J ^^^^^^^^^^ s..,,a ..g.ns ,,,. Ueld to act a. merely exc.tn.g cause, ^o ^^e a ^^ ^^^^^ ^^^^^^^.^^^^ ^^^ ^^^^^^^,^^ ^, „f women.-So,..e connection «<^«"'.« « ^^^ ^ ..variti.. etc. But n>ay U not U.is disease often follows l^^^-'^//^' '';;,,„;,„ „.. ^ne tu i,n,,aired fu.ui ,., ,n..e coincidence sit.ce l-^-'^yj^^J^J ".^h lowered vitality, ,redispos.ng a.,,ility caused i.y pregnancy, leaving system^wit .^^^^^^.^^^^^ ^^^^^ ^^ „ aisease. I>r. Ord says it rs «^v">. « jcf^ x Cold and exposure, henee ,ve,nancy. etc., which -tle^y - U^T th- ^^^ ^^ ,,,,,,,,„, ,nef, etc., china' i.: influence, IS commonest uiusu .y Ion, vitahty r-^-P-' ^ ^^ ,.^,,3, i„ ^ne jo.nt which hy reBex TkV MATISM, as a wlutlow, may cause lovuis. it- lait,!} J Tvuvtinns ,l„,»«t» ot umt6 of ».la, .■*»» "' SO-'y I""'™ ^,. „j,„,„.,| life. 1„„, ...1 viulitv. Attacks livst 010 ,|..mt,^ " = J .,ea^:?;= ^^:^tSr:a.:. M... .-». t,«, ^ t* »? "!'• PBACTirt OP MKDIIINII. 42 If •'"''"■'■" '■"•"" '" '" • : tl ; A I. Iron. A,.e..ic, C-.l Liv.v <.).l. f- l^" ' l,„lia,,.ushS,.,USalicy. «-,'';^ ^T I l)..if IV^vev i. active. Toni.. an. „„,is,n ; «.aa..ally r.s. ivo.u ^ > ; j^ ^,,^ ^^,,„,,,, uuh in obst..uae cuhc. , ,.„„. A iri,. to 15.n» f'»' '^ f«^^ '""' ;,,,ent a.ul mov.-.nu.ds of lb. jo.nt. ;,.,„.,„enaca. nebular "7^" ,^*^ :7 ,,,,. n^oveu.ntB sb..«ia 1. kept (r,,cible. if uee.le.1) i. '^-"^'^" '• ^" ' u.plv n, friction to skin ns. .acoa or „,,,,,, t to n.a,nta.,. ''""^"^' ^ . ^.fj^ ,;,, i bsovptio.., i.npvovHnl ...t.a.on ,;,,,, „,v. oil. etc. Massage ^^^J^^^^^^,,^ i,,ct..icity i. abo vaU.able, ,. ay pain. etc.. but 0,.unu ^^^^ ^Zl^W^,,,^^-^' -J''^'"^ ''' '''''' Z, a.,u,...ia>.al lini.nents, certa... f-*^ jj ^;:^^L,,ie. Do not use Opnun J. ,., ,.,,,Uy, are .oo.l. or L-- ^^"'^7'"'" ^^^^ u,e Bron.i.len for sleep- . „f infants at Lo.ulon Hospital suffer from U. 28 per Rickots. 30 l-"^'^=«''^-*^f;™ t It is a disease of f-reat cues. It .3 ,ent. of .biUben u.uler 2 - ^J; ^^ " jVreneb Canadians. ^,,„„,,n in tbis country ; especully auu.i ^^^^^ ^^f^^,^,„g ^sv.o^^CA^LKsIONS.-Enlar«e,nentsattbeend ^^ .^^ ^^^^ ..nan..... Tbicke,.in, of tl. "-^-;:^:;^:i;;y:nes and muscles con- size of bead, deformities u. spine. Arre t. „ ^^^^^^^.^^ ^^,,^,1,1,3 nected, o.. ,..),. Lesions of lun.s ^^1-^ ; ., ^^^^^ ,„as of long bones occxr „,,ta,,oto.ueci.anicalderangeme,Us. L a^^^^ ^^^^^^^ ^^.^ ^,,,,^,f,,,tes and ,t tbe point Nvbere cartdage ""f 'J^ J^^^^^^ i"ore vaseidar ,,,,nges to bone. Tbc bone and J^ J'^^ ^J p,oliferatiug. tbickeuu.g the tbau ordinary. The periosteum of shaft also P . 4 i 11! lii ■M i: nil sliaft; lint ]ianii'il liy bu so soft is less. 1 causing ri l)i:i'( Tlif imvl like ]iaiif ou top, si cMi'l}' stn A lit. l''iii) lIHllltllS. cartila;_'e sjiiiic is I in it, lit of spiiiu Cl arc Ih'IiI in L'liilc In tlie liow-k'j A tr. 11 cri a;4rs tli sliajiuii fiii'iiu'd iiceiiv This t so clit ] biiliv t Aires Nunc The i oiie-t less t at7t' sevei clela; spot PRACTICE OF MEDICINE. 43 I • \ :,:r:rz; ::;:»-" nX^^^^e -^ -. » ^- ,,„„;.;.;::;;„'.;„ ,. .,, or ^^y. .,. „y,«.«o,....v •'2'::::;;l:"u:, ' S ;,:!; ,,„. „„„,„„, ,,„,„. n..y »»;^;:;7'';;;;; ,';:;;- i» »i»-, «- like valiM, .•o.itmi.J 1.. l«ima,a l..ii.«. Hi'- """" '" . ;„„ „,■ ,i|„ to canil,,,.- fonoing » ncke.y ro»,. ' " '» ^^I L °e an.Uui.,l«.r curve lost s,,i,„. i» alter,..!, eervieal enrve i„oreMe,l, , .tto dorsal " '- „„ „„ ,.« ,,,t..l. 1 ateral r.,tatio» „.ay V,e s elm.os "'«'>"^- ,3°' ....•■'^■.-' .ate a, e may rear,.. .„,„ ■-^^';I^Z.< .ear, .,ap« Al.TEKMloss IS TlloliJX owi.ig lo »,tlemiig el '"•"■ I ^i,. „.„,„,. «.e.i„n) yen get a .lat,en..,g at the «"ti -;«*;'"' ' J e ,"»„- a,e. dare may le . taUing in a„a ,ter,„„„ ,n. ' f ;„._, »u„,„ I,., .I,„,,e,l breast. A vertical gr«,ve ra see„ ou e e "^^ ^'^ ; ,_' „„„ toraredby a.n„»,,l.eric pressure. ^ •■, es» o, ua g^^^^ ^__ _^^ _,^^^ „,.c„r above Uver a.al sto.uaeh »"■ » ^'^''j * ,, ' ^^^ Tcuda to ,ull ribs ta, This -'loovc is at level of about 8lh ub. iJiapuuio Arrest of gro«tl, of boues causes loss ol »1«W«. ' «°"° ^, „„ „„i„ j. Narrowing ot chest gives b.g belly, »nsls, knees, etc , all o The arrest of deve!o|„„ont ebiell, alVcts lower cxtremrties "-'J »■• " ' ^I, „.,e.,b,r.ee„t„. Uealtby Euglisb cbildreu S'"" ;:•-—•.:; r^lt^ less Hum 2 in. is arrest. In rickets, culling ot teeth ■«a"^»«" , „i,, „,j at7tl,,„o„th,endsat24thu,onth,butinru_kc.st.^^^^^^^^^ gi>v.>nO month.-? luav elaiiso before snolavs come th.oUeU. ii y , ^ ,^ „ ^hi^- dcluvecl dentition to some illness then it is a sure sign ol '.f ^*^- '' ?; ^j ,^^^ .,,ot is seen in heart where it strikes against contractecl ribs D tto vvith spleen ileen is enlarged. Changes may occur in liver and lymphatic glanus, heavier 11 ill PRACTICE OF MEDICINE. 44 ,,„, ,,,,evplas,a. M..^...l ^^^^^^-^^^^Z^,,^,,,, cuvahlc ,,u„l>ati. glands a,....u.,ation, causing ^'yP"^-; '^'^ ,^; " i;:,ut i.cveaso of white .ovpuscles o ^,,.^. ..,,„,,t,d au.l enlarged. ''^'^rr ' netimes i. B.naller than .t ought ,, 1 and decease of ved cells. ''^^'[^'^ ^^,,X^nU.c..louMy ^---\ - ^'^-^'^'-' r T m I^Sl'^f H:::Lent, ..,ne .ay urina,- calculi i, livpevlrophical. Unne 1 ot. Laib.i.io •uv cnniim)U in rickety children childhocl, beginning 4lh to 12th SVMPIOMS.-I. Age. Is disease of ^^y^,^^,,,,;^ „,. even at 7 to 9 ,.^„„,,,,, i, ...t with at second y-'^^^^'^'nisorder of bo^els-lo-.e sto^^s, V..UTS. Not settled whether congenital o. not. ^ Feverish, dull, languid, ,...., much mucous, not. always 1'--;^^;;;^^;, ^ -.j ,,d neck, ,illuw in a. m ...lu.iKS sleepless. 4. Profvise P*;-! '"^ '^ ;^'^^^i,^, q. Extveine tenderness of I,, 5. Incessant tendency to '-;;;^ '^ •,,, ,,aer body. These ast ,„,,^ eries in lifting, should lit ^- ' ^^ ^^.^.^^,. i, „,a.r children ,,;,, ,,nptoms are characteristic cd.^^^ y ^^ ^^^^^^^._ ^^,, ,,,, ,,,ybe an absence of '"^^^^ ^^ ^.^^^^^^ ehikl h.nks prematurely ,,„„,,,„ of such ^-^y-^^-;!^^- , .;^ r :^^,UUfashioned. Kickety rosary is „M. .„d from not playing with cliddiui a ^^^^ ^^^^^ stools loose, ,.,. seen, enlarged joints of extroiuities ^^^^' ;^,^^J^ ,,,ay .Uie to Hatu- ,,,„.l..s waste (no exercise), abdomen .. -"■;'^> ^ ^^^.^^ ^,i,,,t. Skin pale and ;:„. ,„. aue to down thrust of diap r,^m in a ^^O^-t^^^^ ^^^^^^^^ ^^^^^ ^ ^^^ „,„,„,. intellect deficient. ^Hhong^ |h - ^^ ^^^^^ ^^^ ^^^^^^,,^,,,„, ,,,,,e ,„,,,„„.a, not often, but there is a dehcitncy uni hi ii'4 characteristic. f.„mntr.ms head (mly may !',• rickety, MM.KKn U.CKKTS.-N0 completo-tof symptom .11^^^^ J ^^^^^ ^^^^^^^ ^^^^.^^^ ,„, .,,,.st, or delayed dentition may ^'^ -bj'^ ,j^;„ ;, i,,. rickets. , i, cannot walk at 18 moot s. an no >-- -^^^^ J^^^^ ^^^,,,.,,„.., ., ,..Uets :c:;;:;:i;t=-^^ ,,„..,;„ut relapses are common if ^-^:^ :;^^^^ ;, uiUs many by comi^i- ,a.;KKTS, i,cr .«, does not often '^ ^^"V Irsistent bronehUis kills many. ,,,„i.,„.. 1. Rickety cachexia may k.U. - ■ ^^^ ^.^^^^^ ^„„,, f ,...,.,.. bronchitis or catarrh are common. TkH^^^ o ^ ^^^^^^^, „u, .,U..r signs. 3. Laryngismus «^-^;'^'^:.^^ ""^ i co.L on spontaneously. many. H is alm..st always caused by K^^. 1^^^^^^ ^^ y..u can exclude kill. m.ny. 4. General convulsions, -"" ""^^J ,,^,„ ....uvulsions mean r ;i. '• : .' im Ai ^1 f 'i H* PRACTICE OP MKDICISE. 45 .,11,1 limit iile pjnostitis ot loii;^ u pii>-.i. r t ; 9 to 6 is febrile, pulse vai.id, diavrhcea. etc. w..ak.'i.iii-niayvrecli8po8e. Ag.u...sypm j , / f^^ periosteum uuder- ,^,. j,,, V„.ne as rickets, ends ^^^"^^^'^^^^ '^^^y^s may become ,oes proliferation, tbickens and ^'^"^'%^;J^lZn.ti^^V^^^^^- dotu..hod, pus tnay for.n in joints. ^-^^'^'^,^^1, ,,ad. repeated child. ,,,atl.. DeUcacy in motber tends ^/ ^ ' ^J ^k . j- to lowered vitality Uearin, seems to do same, as lat^ter cb, ^e ^^^^^ ^^^^^ ,,,roper ^,,„„U„.r. or in poor, tbe larger the fana > " ^ :;;;„•, k. Deficient ventila- tood .hu.n.g dentition, albw.ng rnn oi - ^^ ^; ^^ "\^.^^^^^^ ^i,,, weaken, tion. want of fresh air, of cleanbuess, f J^^^^' ^^^^ ^^,^ i, known of lactation and after 20. . . ^ ;| „ .,f each. In some cases tbe addition of ^J^^^ ^^ „^=i„ j, ,i,, L„„s ..11 help digestion, or dr. s. bcl. - IJ^^. l) , ,,, ehildren over 6 ,ooa. The additio,! of Benger's se f-u.ge ted f d .s al o ^^ ^^^^ ^^^. ^^ ;„nths. Same of >^estle s Food. As duldren ^^ J^^^^ , ^^^ .^f with all .„ ,ivc animal broths stale bread, J-^^^ ^^^ f ^l^^ ,,,,„,, ..u. ,esh air. tiUous shreds removed is also good. Ut en ^ j ^^^^ ^^ ^^.^^^^,. ^ If ieverish. give dose of 01. It.cin. or dose of g e> p wde^ ^^^^^^^^^ ,.,... Assoonasyoudiagn..er.k.s^^a^^^^^^ ^^^^^^^^_^,^^,,^^^^^,^ oflyear. Kxa.nine napkins foi oil it pi .c ^.^^ _^ ^^^^^ _^^^^ .^^ .ddition. or ,.au be begun at once. Vm. tci. ai • " ' .j,^ Saline lutbs aie ,,,Un.ie. If curds are Ibund in stools give Urn ^ > ^ I' ^;,^_ ^..^ ,,,,e.e also good in this feverish state, ^^^^^ ''^'^2^ ^^^^ dissolve it in Cod „. ,,,u air is required. Germans ----^^" ^, ,,,, ,„d ,t dissolves. Lucr Oil, ^ oz. oil pbB i gr. I'hospbo u„ ^ ' '> -' ^.^ ,^^,, ^^^^ ^lom ,.vc regular doses as of oil above. As tbe .luldren get stiun^c 'i i it I ' I , n. il Hfi \ i ■ I -'" t9"^ T 46 PRACTICE OP MEDICINE. .,„, lot thorn roll on floor. Supports may bo needed for limbs. These curves ,,tn readily now be rectified by modern surgery. IX. an.t:mia. H vp.mia. too litde Uood ; span.mia, impoverished blool ; ---'a m^ - ,,,„,d, s! i. wrong. Oligocytluemia means pauc.ty of blood cell. (aglobuUa). AN.KMU is divided into :1. Symptomatic. 2. Idiopathic. SVM1.T0M.VTIC AN.r.Ml,v.-Hi.t.,logical characters of bloo. . Red coipu.cU^ ,. ,,hiced, buv this does not determine riclmess of eel - J-"'^;^^^^^^ , • 1 « t A^ a vnle well nourished persons make blood readil}, but A,e intluences, an«,nua is commoner in infancy yo^jth aud oW a^ l^^^y ■J, youth a diuin is set up on the blood to provide f^>r ^owU ^id f^i ^- - wasti and for conversion of fbod into t....... ^n ^^^^^J'^^^Z .aste is not as great, so they can bear imjK-v.ushed blood ^'^'l':^:^ a 1^^ pvoce.ses are impaired this impoverished .^^^te ^ 'nduced^ lio^^.K,j^^^ -^^^^ kvoring inertia and inactivity ^^ .uemj. . A.ive .^^ »» litter kbor, at niensc-s. imm n.iat, cti- 1 iixaleu 'o^^ „„„;,liv .nmuin! l..i»,„.li,i.a,AromoJii.iTii,«,..l..«.i-.l'-"uniaiia,aUca...... lii.liiai) J'»»"'i ■""'o^KJirilttms,., a riic-l «s „.«t 0, li,a,«.W.,. .onccuHu. dices of good or poor air to mamtam or uesuoy. r i I • ! f! PRACTICE OF MEPICINE. 47 „,„ia or « too mpiJ consn,,,,*...,, of tol. AU d.H,«c, l,„„| „,. l.indor il»«,»i.inlat,oi, all .mM«e. ; ^^„,,„j ,„j,p,y „t uiUi lli'iviKUC duct, uuncc m„ 'I, 1 „r ,.o *»«'" piilpitation. . ;,.rocriilar si"ns of dilatation may be AVSCULTATION.-Heart's action is often nrcg. lai siu found. Apex shoved down, ventricles not completely empty throu„ {vu<\ to increase. _ ii„„,;no dilatation. On listening Hv.KuruoPUV is a compensating change f^^^^^d at Inse are systolic, are you hear distinct murmurs. Ha-mic murmurs - - ^^^^^^^^ ^ ^ ^ard most ...rally soft .nd low ^^^^ ^^ ^^^^^^^ ^ ' ^ '''''''''' ,,„,u.tly at pulmonary carti ag . ^^^^^^ p,,nonary artery. 3. .tornum, due to enlargement of eft vcn t. c^ o J ^^^^ ^^, In advanced stages the tncuspi and^ ^^1 , ;r it this latter you will hear a „„,e regurgitations, more 7'''"""^' ; ' , J ^ii,\ jf „,itral you will hear it below nuirmur down iu the stomach, below the 4th rib , it mit y (t •«! .,, ■1 i 1 1 } ill 1 '1. MM I fi W 1 PRACTICl OF MEl.ICINK. 48 , ^,, 4. Yuu often heav a By^^uiic ™unnur ^ .^l^^^^, ^„^^,„ ,,,„ tha l„,;ier .t rmlmonury oartilugo. because uUeiy l.cn aorta H ir. ft""t. -n • w „w.. vou .ay ar in marW i."-""'^ * V,,or. M""^'^^^^--^'-^"^^;'^ 1 e .1 ooutinu.us hunnuing sound. C-»- ""-■ r 'r';r:, t 2;.e.,«nc.Uc,«ily™.o,s,.,,c,,,,,. ABlElilAL MUKMUKS-Murmur, «U«u l«lHl ov,i ur„ t;::::,rs™:/''™'«.^-, weaU ..i«»Uo„, ..tuW,,.. .n„.,..ic «ld aelicient in gastric juice. , p :,„f ,, . ,1 mn«M<>s atonic, bile deficient. " * -^ ■ f u nimnst anvwheve, nut espetuiujr ,„, „,ore. Pains are lei t almost any , ^^^^.^^^^ . ,,of , ver- rt, one luimuuvry Pains are felt almost anywueve, u. .^^^ ,,„,,,„ ..males. Palpitation, spasmodic astlnua, ceiebi.1 vomit „, l,;.ign. ul deficient capacity for mental work. ^^^^ .^ ^_^^^^ ^^^_ OUU.VNS of special sen are ^^'f- -\ ;;; ;;^^^^^^ ,,, invariably ; is .si:c«K.rK.Ks.-Urine is ''y^-^:;;^^2XA.^y, nails bloodless -"-• -'1 '^^"-^"f ■ ^!^^7 'f • In s e e f nL bLiic or an.emic fever is not ,„i, ,aay become h^'^^^' ^^^S /.V^J^qs Menses generally are scanty and „„,umnK.n. The temperature of 101 to 10 J. Mei g ,,,K,, even '^^^-"^ ; le"coiTha.a is commo„ accompaniment in AssuciA TED Diseases.— Ulcer ot stomacn ^^ .ivls up to 25 years, due to thrombosis of ^^^-^^''^''^^f'''^^' :l:Lation.' The capillaries of gastric ve^-e oft^ ^l,Uthalmi. .itre runiis.s is an occasional associate ^.^ave s disease o i ^^ ...avly always accompanied by ^^^'^'^^' De^nerations »veat excitement of heart, is a disease of « ^icU syn p ^^^^ Inn poor blood, parenchymatous degeneraos ^um aU th _^ ^^^^^ liver, Iddueys. etc. ^'f ^ ^^^-^^'^^^^^^t^is ^i^^^^^^^ ^^^^ ^^^^^ hence the tendency to hemorrhages. Cause is imi u aegeiienition of coats of arteries explains hemorrl.^c.Ju^^^^^^^^^^^^ ^^.^^ • K..XV degenerations of ^ .le. - --^ -;; ^ ,^^^,,,^, ,„, secretions and digestion. Amemia tends to tavor „ occasionally dropsy. n\ ^ ''4 !''.i'l m i „ ' MICROCOPY RESOLUTION TEST CHART (ANSI and ISO TEST CHART No 2l 1.0 I.I m 1^ S IIIIIM If m ^ 1^ 12.5 2.2 2£ 1.8 1.25 1.4 1.6 A -^PF' LIE D IM^GE _lnc =i 'bbi Las' Mo't' 51'epl r-s: Rochester. New York 14609 USA .= I'716) 182 - 0300 ~ Phone H. feeblest Ph phthisis "radual gitiulini in bad I Tf bed is a diseliar over-liii till anx by, firs of aiiin laiits 11 more n are iiec chief rations <^ive ni 10 to[ but pr to put vegeta Garb. Syr, : gr., Su symjit Sulph favovil to 3 Aloes anrem to ace stoma can to Dr. E m. of is als 1-15C iron, PRAOTICE OF MEDICINE. 49 H.EMIC Dropsy affects entire body in time, begins where circulation ia feeblest, as at feet, but will gradually affect the whole body. Pkognoris of ANvEMIA. -If cause is removable cure is easy ; if cause is cancer, phtliisis, waxy degeneration of liver, glands, etc., is incurable. Death is from crradual and induced asthenia. Syncope. Coagulation of blood in heart or lon- gitudind sinus may occur (very rare), for impoverished blood favors coagulation ; in bad cases relapses are frequent. Treatment— 1. Remove cause. 2. Eestore the quality of blood. Rest in bed is an important point in the treatment. Find out cause of anaemia, bad feeding disehaiges, chronic diarrhcea, etc., and combat them, also uterine diseases anrt over-lactation. An important point is to give rest, bodily and mentally. Men- tal anxiety is a common cause, and must be removed. Restore quality of blood by, first food, it should be highly nutritious -meats, especially red meats, all kinds of animal food, you may need to begin with broth and peptonized foods; stimu- lants may be called for, claret, Burgundy and hock, only natural wines, i pint or more may be needed, a stronger wine may l)e needed. 3. Fresh air and sunshine are necessary, seaside especially good. 4. Remedies-Iron and Arsemc are the chief ones ; if patient be feverish, headache, gasuio catarrh, give less active prepa- rations of iron, as Citrate, Carb Ferri Redactum, etc. If patient has none of these .nve more active preparations, as Sulphate and tr. Ferri Perchlor. Dialized u'on 10 to 30 grs., not as good as Sulphate, do not give in a mixture, as it decomposes, but prescribe pure thing, 10 to 30 gtt. in water. In some cases you may need to put system in order before giving iron. Give a mineral acid in 5 to 10 m. m a veoetable bitter, as Gentian, Calumba, etc. If patient is prostrate some Amnion. Carb. sliould be combined. In many cases you may combine iron and bittei-s. Syr Ferri Phosph. 1 to 2 drs. is easier way for children. Qnin. Sulph. J to i !i| ■m A i iilJ! -hi 'II ! \ 1 1 ) ( PRACTICE OF MEDICINi:. Bl the y. TERNICIOUS ANiEMLV. rroarcsive pernicious anaemia called an idiopathic disease, because cause is unknown. Some thiuk it is not a primary blood disease. ""'caJks -Misery, overwork, repeated pregnancy and prolonged d.arrh.ea. occurs chefly in nudJie life, and is commoner in males. Tins .s arare d.sease. « aL common. Symptoms are the symptoms of profbund -p--"^'- .L padent becomes profoundly weak, progressively and ms.hously. pallor .s of a yellow lemon tint like mild jaundice, but conjunctiva is vvl.ite ATO.ic dyspepsia, no appetite, disgust of food, vonutmg, flatulence, perhaps a troublesome diarrLa ; intense headache is a prominent symptoin. Unne n.ay be m e y an.emic, pale, low density and a low acidity, but may be darker colo. e cs of urea, uric acid and phosphoric acid. In.i is also increased, test for 1 icangives strong evidence, sugar is .over found, rarely blood or albumen Ha-mic Fever is apt to be present, as in the other forms ; temperature (or a, - ek at a time may be at 102 to 1U4 deg., perhaps lasting several weeks, cause not known. . . ,. ., i • i i. Morbid Anatomy.-No lesion found characteristic ; fatty changes in heart, vessels, cells, liver and kidneys, etc, are found as in many other diseases is an effect not L cause. Changes in bone marrow, the yellow fat marrow changed to a dull red ; appears to be hyperplasia of original bone matter ; microscope hn .s in it a areat number of red nucleated cells. It was suggested that this was a lesion to explain the disease. Dr. Howard shewed it was found in various dis- eases Leucacyth^mia, osteomyelitis, repeated bleedings, diseases attending maras- nuis "so is nature endeavoring to repair the loss, not the cause of d.sease. Is therefore an effect. Essence of the disease is a destruction of red blood corpuscles in portal circulation, hence changes of spleen and User. Spleen and lymphatics may be found perfectly normal. Spleen may be found enlarged if a rapid destruction of red cells is going on, but not otherwise. Rec.nt investigation has noticed an excessive deposit of iron pigment in liver, spleen, bone, maiTow some- times in tubes (cells, of kidneys, etc. Dr. Hunter of Edinburgh thinks liver is the oraan of the fault, causing destruction of red cells ; he further points out the pigment is found in peripheral cells of each liver lobule. If pigment is in excess it will be found in spleen, kidneys, etc Chemical analysis shews more iron in liver thau in any other disease, so essence of disease is destruction of red cells. Hunter says it is a distinct form of amemia, and that the essential lesion is destruction, not non-formation of the red cells, and thirdly that it is probably due to ptomaine developed in intestine, and absorbed. Some have thought it is due to a germ, all is hypothetical. Diagnosis puzzling.-l. If the anivmia has come on gradually. 2. it it pro.n-.s3e3 to a severe degree in spite of occasional improvement. '6 If no cause caifbe worked out. -1. If person still retains the adipose tissue, for generally thev are fat; person does not emaciate, hence their cachectic look must not be mistaken for malignancy. 4. If instead of white or green tint there is the t 1 'Ah iil! mH n\ rn I'l iff 1 > 1 PRACTICE OP MEDICINE. 62 yellow tint. 5. If person has suffered from repeated hemorrhages, m of nose, stomach, bowels, retinte. 6. If blood has following characters : great reduction of blood cells which are very ridi in color, especially if the several varieties "inacroeyi ^" etc., are found, white cells ore really diminished but relatively are increasea. Also Toikilocytes. 7. Schultz's granular masses generally are. H. Is very apt to be accompanied by h.emic fever. 9 and lastly, its treatment being a failure. Modes of death : 1. Asthenia. 2. Syncope. 3. Apntpa. 4. Some comatose. Pernicious anaemia is nearly always fatal, but sometimes im- provement takes place, perhaps permanent. I)[KFKKENTI.A.L DIAGNOSIS.— Leiicoeytliaemia recognized by excess of white cells in blood. ILjdgkin's disea.sp (and above too) has enlarged glands and spleen- Tkeatment.— Iron fails. Arsenic is better, begin with m. 5 T. I. D., increas- ing every 5 days 1 drop till you are giving 10, 12 to 15 drops. In some cases, stomach tolerates a drop dose hourly, better than T. I. D. doses, increase to 2 diojis, etc. If Arse-iic fails try Phosphorus, or combine all these. Transfusion is advised when other remedies fail, detibrinate the blood and inject into the arteries. Diet to be nutritions, peptonized food, rectal injections of bullock's blood, an injection of dr. 2 in like of water of common salt restores heart. Sub- cutaneous injection of defibriiiated blood has been recommended, about 2 oz., is not followed by ill effects of fever, etc Put patient under chloroform, as mas- sage has to be employed to facilitate absorj.tion— is introduced on outside of thigh in 2 to 3 places, or arm. Even injections of milk or beef tea subcutaneously are useful in (all) cases of weakness (pregnancy, etc.). Leucocytii.15.mia and Hodgkin's Disease are closely connected to each other and to anaemia. XII. LEUCOCYTH/EMIA. White cells of the blood, will be first described. Primarily it is> divided into 4 varieties: 1. Splenic, originating in spleen, common. 2. Lymphatic, originating in lymphatic glands. 3. Myelogenic in marrow. 4. Intestinal in lymph follicles of intestines Blood.— There is an excess of white cells, 1 to 50 or 1 to 20 red cells, or even 1 to 1 as many white as red. These white cells are sometimes larger than usual (s[.lenic), or smaller (lymphatic) than normal. Isaturally there are 15,000 white cells in cub. lam., but in this disease even 600,000 in cub. mm. have been seen. lied cells are less in number tnan normal, and red nucleated cells are also seen, also microcytes, poikilocytfis, but not as many as in pernicious an? ^ia. Schultz's granular masses are found even 1 to 500 in diameter. There is no conbui.^i; alteration in albumen, nbrin or salts of blood, fat is often increased, frequently hypoxanthiu, uric aeitl, lenen, gluten and others are found. And after death, Charcot's crystals are found in blood. Naked eye characters shew blood paler, move li(iuid. If ^cfilninated and let stand there will be a greyish layer above the red layer of leucocytes (buft'y coat). if I. f : f -u m { t i''^l ^ ^^ ![ 'fl r.^H ,! ^1 ^^1 \ 9H \ i'fl ^^1 s^^l T I 1 fl ' 1 i yB| H H ^^1 ^ .^^1 ' ^1 ' '^^1 . ^^H j^H i^^l f ^H : ^H f ■ PRACTICE OF MEDICINE. V 9a »TBr*"^| Symptoms.— Comes in insidiously, perlmps fullness of epigastrium rej^ion first .symi.tom. On exiiniiimtion spleen will he found enliir<4ed, is early, liver is fre- (lueiitly enlarged also. Sometimes there is pain across here. Paleiie; of surface, ull the syiuptdius of anaunia, loss of stiengtli.hnMtlih'.ssueHs.palpitation.henioivliages '..spccialiy. dropsy (passive). Fever is not usually i.resout in chronic forun, hut is in advanced chronic and acute forms. Color of skin has a yellowish tint owing to destruction of red cells, etc. In rarer forms enlargement of lymphali.! glmida is seen heginning in neck, groin, axilla, etc., rarely reach larger size. lu inyelo- ninous form, there is distinct pain in the hone (usually sternum) or long hones, hut liaiii may he ahsent. Urine at first usual (luantity of urea, but there is always excess of uric acid. No albumen, but liypoxauthin, etc.. are found. Urine is i of high sp. gr. Retinal hemorrhages are fre(iuent, with white lines in course | of vessels. Duu.vTiON OF DlSK\SE Varies from 6 months to fi to 7 years, average is 2 years. This disease is always fatal. Modes of death are various. 1. llemor- rlmg.s vomiting and epistaxi.-, 2. Hicmic dropsy from this state of blood. 3. Syncope, asthenic or tatty heart, or by 4. SiMii)le asthenia, die comatose. 5. Diarrh.ca uncontrollable. G. Pi'essure of gl.mds. Complications are dropsy, ujdema of lung.s, dilatation of heart, throinbjsisof veins, cerebral heuionh,ig3. MoiMUi) Anatomy.— Lesions divided into pviiniry and secondary. I'rimiry iifloct spleen, lymph glands, marrow of hones, and p-jrhaps intestinal lymph foUicles. Second iry lesions are partly duo to accumulation of white cells in vessels and tJR.ir inliitration into surrouuding tissues, also by hypertrophy of the glau^i tissue whicli exists everywhere. Si'LKEN is found considerably enlarged from 7 to 8 oz. normal to 7 to 8 lbs.. capsule is thickened, is due to hyperplasia of the splenic pulp. Malpighian cor- puscles not alVected. Fr.'ciuently white patches of accu.uulatel cjlls are f .uii I mottling cut surface. The liver also may he enlarg'^il to 5 to ID lbs. Left lt)bj (jitener°attacked. Cut surface has irreg.dar wiiite surface about lo'.mles. KiDN'EYS have also been found enlarged by leucftMnic neoplasms. Lymphatic Glands undergo hyperi.lasia, tissi:e is loaded with young lymphatic cells, hence source of leucocytes. iioNE Mauuow.— Kspecially in spongy bom; tissue. The marrow is hyper- plustic, color grey or greyish yellow, or yellow, sometimes is greyish red. Lyin- piiatic tissue replacing the marrow. IinTEstixal Glands.— In a few instances the lymidi follicles from stomach down to large intestines are found enlarged, also the more ditfuse adenoid tissue of this region ; the enlargement of some parts may take the form of sessile growth i, as large "even as a foetal head. The ih .. -al valve may be so thickened by .ideiiuid growth as to absolutely ob^tru^u, All the otlier orgvos of the h.dy m;iy enlarge, owing either to mere accumulation of white c.dls in tlijir vessels orinhU trated into their tissues, or from overgrowth of their alenoid tissue. May be from escape of leucocytes from blood into tissues and their multiplication th n-e !)y fission. if i 1 \ ■ ■H: i 1 1 t i - 1 , 1 1 '- r j, ■ '' '. !; ■ ■ ■ 1 1' f i f i i I 11 ^ f '* 1 • ■ i i = j I- 1 J t III I'RACTICE or MRDICINE. U ('A,.HF.9.— 01)scuro, not known. Mon auffor 2 t.) 1 wonmn (of primiivily snl.Miif foiiii). I^ most fiiMnuMit fioui liO to 50 nn.l most common tuoujjh in old a',,. 11,18 occurrod in chil.U.ood, is mie in fmnalo. aft-r 30. It has Iwcn voferrea to .-ivpliilis, nguo, etc. Not so with syphilis, hut aj^uo is a cause. Splunc tumor ,„i.ri,mtin- in ajjue has h».' mo hnicocytluiMnic. It has at once ioUowu.i agu-. M.Mistruar aisoriKTs seem i.. Iiavc an inilueuce, ilillo i.re;^nancy. Thero h no luMcaitary tr.msraidsion. Tho lym|)li.ilic form has followu.l cold and wet, a chdl . Tiie bono form has followed injury to tlio hones. As a general rule no cause e.xcitiii" or prwlisposinj^ can be definitely said to exist. l-vriloLOUY.— Some thiiili tlu^ hyperplasia of blood-forming organs is the primary cause of white cells predominance. Hut how about want of red cells ? Virchow tliere says disease is due to non-trausfr)rmation of white cells into red ••ells, l.enee lack of red cells. What sots up hyperplasia and prevents conversion into red cells is not e.xpluined. Cases are recorded in whidi no lesions are found.^ so some think the hyperplasia destruction of red cells, etc., is a cons-quence of th^- disease. Some propose a germ theory. In H.jdgkin's .lisease the hame Ip.ions are found without leucicmia, thit is .leticiency in red but no increase lu white cells. Theatmknt of Leucocyth.emu.— Find an exciting cause and endeavor to remove it. It is seldom you can find ciuse. In piire into malarial history, if it were presiMit then treat with Quinine, treat enlarged spleen as you would ague ciike Cod Liver Oil has in some cases been found good to keep up nutrition. Iron" and Arsenic have entirely failed. Pot. I.jdid. has no effect, ditto mineral acids and I'hosphorus. In fact, no cure has been found. ReUrdation by iodo- form has occurred also from employment of constant curr.;nt. Transfusion of blood has no benefit, has been followed by death, due to transfusion. Injection .,f defibrinated blood subcutaneously may be tried, or transfusion from artery to artery. Excision of spleen has failed to give benefit. XIII. HODGKIN'S DISExVSE. Hodgkin's Diseasb (progressive multiple hypertrophy of the glands) or IVseudo-Leuciemia, or Lympho Sarcoma applied to soft variety, Adamemia, etc. Symptoms.— Progressive and occasionally rapid grow'h of the lymphatic glands of body. Rarely disease originates with splenic enlargement, but it is seldom much enlarged, or mesenteric glandular enlargement. When glands become en- larged there is slow loss of strength, marked aniemia generally, but not an eaily symptom. The diseased glands form round elastic tumors not adherent to skin, after awhile when larger they may fuse ; glands in axilla may weigh 1 to 2 pounds. Glands are not as hard as in cancer generally, but one variety as hard glands from interstitial growth. These glands have no tendency to suppurate, but keep growing. In about 80 per cent, of cases spleen finally enlarges, and liver afterw°ards, also kidney. Resemblance to leuc«mia is that wheiever these i; i . -i !.it 1 iilllH ™*l»!KjaSBsfes»— .sssrtrra Ifli PRACTICE OF MEDICINE. 65 "lands exist they are att'ectecl, ovaries, testes, brain, bones, etc., and these secondary growths are in two forms, isolated and infiltration. Glands first affected are^cervical, the axillary next and then inguinal. The bronchial glands sometimes become involved, penetnite the lungs. It invades thymus gland, uivad- in- inediastrum, and grows perhaps right through ribs, by infiltration. This t .ml ncy to infiltration is in the soft variety. Cervical and axillary glands exter- nally and bronchial internally are the favorites for attack. The retro-peritoneal -lands occasionallv form tumors and pressing various structures. The mesen- unic -'lands also sometimes form large tumors. As disease advances well marked foverls seen, chills, heavy perspirations. When fever is present case i3 more rapid, prostration greater and profound anajmia well marked. The Blood is essentially same as in leucocythaeraia, except no increase in wliite cells. The red cells are reduced in numbers to 2 to 2^ millions per cub- in.ni., poikilocytes rare, microcytes common. The white cells are generally not much increased. Schultz's granular masses are in variable numbers, and the nucleated red capsules are not seen. Dr. Pye Smith says the inflammation around the glands keeps increase of white cells down ; Dr. Howard does not believe this, MoRiiiiJ Anatomy.— 1. The process consists in a hyperplasia of lymphatic tissue wherever it exists, also of thymus gland. 2. Spleen. 3. Bone Marrow. 4. Tiiere is also a formation of lymphoid growths in viscera. 5. There is an infiltra- tinii of the tissues by the lymphoid growths. The prooer lymphatic glands suffer first and mainly, but the spleen seldom escapes, it s m attains size attained m leuaemia ; if it is found enlarged you will find isolated grey white tumors lu the spleen, also in the liver, made up entirely of lymphoid elements, same also is seen in kidney. The medulla of the bones presents a hyperplasia of its elements, conversion of red marrow into greyish white growih. There are two varieties of irrowth : 1, Hard, and 2, Soft. The soft variety is composed of lymphoid elements alone, and this kind is it which infiltrates while the hard form gives distinct masses. Causes, not transmissible, males have it more than females, age 26th to 35th year, but both younger and older ages have it. Not directly connected with scrofula, but distinction not marked cleariy. Twice at least it has been found with tubercle, has also been found with syphilis (a coincidence). Ague has pre- ceded it in four cases, whooping cough in two coincidences. In a few instances local irritation has started the process. Is common among Fiench soldiers (high collars). Exposure to cold has preceded it, sore throat, etc., all seem coinci- dences, and slight causes above seem only to have acted in a latent predisposition. Prognosis liighly iinfavorabl<\ alw.ays die of the disease or the compli- cations, due to pressure of enlarged glands on various organs. Duration,— rapid course, may be (rare) 2 to 6 months, more frequently it lasts 2 to 3 years. More protracted cases have occurred. ■ ; ! B^H |,; I^l^^l !l 1 1 I"' - 1 1 \i\ : fl V\\ !■ Mi 1 w^^ ■ 1 \ I ■ ' fl^H ) ,M . . . . ' 8^H fli M II 11 PRACTICE OP MEDICINE. 56 D,rK DIAGNOSIS OF Cancek of Glanps of neck. In cancer the glands are , n .La together more apt to adhere to skin, are generally tender, seat ':X^2T2Z toV tissues, and hence i.^ovahl. Again. o? these elands is always secondary to primary cancer, as of tongue. rZ et Taah vth cancel spleen is not enlarged, nor does the disease :;;r 'all glandHf body at once.no symmetry. Blood changes are not the '""T^LMKNT-Extirpation of gl . is always too late, external glands may Push treatment steadily Iodide of iron has failed, rubb.ng and cham- , ; the Idands. or douching by hot and cold svater alternately have aU be n S!;iso pressure and blistering, bat all fail. The an.«mia calls fui uon and '""p'xut VAUIKTIKS OF LvMPH.DKNOM.v.-Simple hypertrophy of a gland ,.„,'; tn'lving other glands, is lymphoma. There is a^.o a ma hgnan I'njhoma, sarcomatous, spreads to contiguous structure, may be conveyed by "'^^'^^^^^'^^°^^'"^" XIV. ADDISON'S DISEASE. A llison's disease of suprarenal capsules is acco:npanied by ^f^-^l'^^^ SVMI'T0MS.-1. Marked anaemia leading to. 2. Profoux astheuu gia- .In.Uv induced, loss of strength is one of first symptoms, great languor, lis less- f f " pr: se it, hearth action is very feeble, palpitation of heart, sigh.ng. 2 : tc' There may be pain in lumbar region. There is no wasting, npeiie generally subnormal, extremities cold, tongue -'"-- « ^^ /^^ end y, there may be nervous symptoms, as numbness, dunuess "f «^g^'t Jtc 3 M k d digestive disturbance, disgust for food, frequent vom.ting. th.s is a vkedfeaure; on careful examination you find no enlarg.men ; m me instances phthi;is or vertebral caries ^^ been present, spleen genera^b^ enl^^^^^^ .aiuoftenLpressureofabdomen. 4. Broazingofskmcomesongradually m^ cnlor .yellowish brown), most marked where pigments most abound, axd a. groin, a-discoloratiokis darkest in parts most exposed to light and where p^- nt is natural-palms and soles, roots of nails escape bronzing In mouth ug inner mav.in of 1 ps, etc.. patches of m.lbarry color are seen tongue also along ils ?iU ni^rgin is stlined. conjunctiva always remain normd. the bron.mg m.vy resemble putty, rises versicolor. This discoloration is late to come on. DU.UTION of disease is generally U years, may care in 6 months or not until 4 years. It is common in years of adult life, from 10 to 50, commoner in nude than fom.ile sex. MOKBID AN.^T0MY.-Perhap3 only enlargement of suprarenal capsules, trans- luce,it in early stages, turning grey perhaps with caseous or earthy matter; m early stages capsules are enlarged and heavy, dividmg line between cortex and Hi' !h il I n * i « n j 1 i i B I 1 1 1 1, PRACTICE OP MEDICINE. 57 nioaulla is lost A little later the semi-translucent surface gets marb ed by fatty 7':^^l^ fibroid change. Tl>e fibroid change goes on and decreases m tf T I fatty degenerations are absorbed. In last stage capsules are nod ax ■ inv! U •! 1^' uy iill in mntoug iiitcvstiti loiil dej intlaiiim nil the si Ac liliigiaii ing the foiiiis a liuavier, easily t cloudy swell The eel tioii. I heaviei iiicisioi the str Color ^ As ear tion degene cpithe' inflam occur, bryoni liegins white caj su may 1 tion c becoii lerlui 1 massi and c of ca press conii it tei albu tion advfl rv Wff PRACTICE OP MEDICINE. 58 mntous nephritis, either primary or seconaavy to an -'-'^^'^-J' ^"^''^^ interstitial nephritis (cirrhotic), because interstitial substance is affec ed 4^ Amy l„i,l decreneration (waxy kidney). Origin of first 3 forms. These 3 aie of Imutory origin and they are difi^ise in their «-' .'^'t c^be n^ nil the structures while predominating in one tissue. No rigid division can be lud . AciT. I'AUENCHYMATOUS Nephuitis most frequently begins n. the Mai- ,,l,igian tufts, also in tubules, giving glomerulitis or tubularitis. 1 That affe^^ - „. the tubules (renal bronchitis) or acute catarrhal nephritis In nuldei rllml at first kidney is not much enlarged, a little thicker an rounder and l„avier but not much. On i.cision cortex is swollen and congested, capsiUe is : ^ ^ ;rn off. Under microscope the epithelium of tubules is found to undergo cloudy or uranular degeneration, the lumen of some may be tcuud narrowcl by jSroFthe epituriium, and some of the detached cells may '^'lock others iip The ceHs are enlarged mainly by growth of their articular ^^^^-^^T;^^ lion. In a more severe form alterations are greater kidney is '^-^ ^ ^^^ 7;'^' heavier, capsule tense, peels readily, outer surfiico «f Sidney dark and n incision the color is redder, pyramids deeper stained than v.sual, organ ^^^ . the striation is marked with lines of tubules filled with ^^--"7^1;;^ ^^° " Color varies though with severity of inflammation, being brown red Y^^ »-• ^ As early sta^e of congestion is over, the kidney becomes clearer, due to accumu a- ;•:: of infllmmatoi;. products in tubules. Under -e™-pe son. g-^^^^^^^ degeneration of epithelial cells is seen, the lumen contams granula d bi is Shed epkhelium and effused blood, blood cells, etc. Resolution as a rule takes place iiflainmatory products absorbed, balance washed out. But o^en this does n^t CHcnr. then leucocytes escape into connective tissue; this last pvohfeates, em- bryonic tissue forms, changes to fibrous, and thus the interstitial "'flamuKaon begins, kidney is firm now. The connective tissue growth gives rise to tht lai^e white kidney i^chronic). „ ,, GLOMpiuLAK F0EM._In a great many cases, the disease starts from the ca, sule of glomeruli. This is noted in scarlet fever, causing glomerulitis. 1 lo ss may be very slight, naked eye shows no change, but microscope shews an exuda- tion of albumen within ca. sule around the top. In more severe cases the kiduey becomes swollen, capsule tense. The epithelium covering top may ^^^^^^'^^^^ perhaps shrivelled, or these glomeruli may become transparent ^-^^"g -^^^ masses, larger than usual ; in other cases a cloudy swelling, S--^^ ^^^^^tm and delqualation of epithelium of tuft is seen, also a similar change to ep the lium of capsl. A large growth of young cells may occur within *'- -p e co^n- press ng the tuft and stopping circulation. Hemorrhage int. -l^f f '^^ ^.^^ ompreLing tuft. All this time little change has occurred "> tubules, a though it tends to Ipread to them. Casts will always be found in the ^vibules of an albuminous exudation. Naked eye appearances of kidney not^str.king cong - t.on of cortex and where cortex joins pyramids, but not between In mo e advanced stages, congestion passes off and exudation takes its place. Later fit ff^ rrldlllOill' iiitiTstit: )• ■ lloW, waul of wliitu li! wli' rc! tl luljules thickoiK elum!j;es ycllnw is toiigl liirye ki y L'UoW, riic till tlie epii of the V vasnili tllfll w white i C nionly tivst sti tliere % L' suddei fi'C'([Uei 1030, blood beiiii,' ave fui Liter f 'tre tl w ill a cases ; occur comiii wise ' ( weeki lasts hists PRACTICE OP MEDICINE. ,l,u,.re. ^vhen .lisea.e is chronic .uul interstitial growth has occurnHl. In both .,l,„no.ulitis and f ■ '.r nephritis there is a certain escape of leucorytes u.to ;^„„.v.titial tissue, .u chronic stage kidney is twice as hivge as nornml. white or V..II0W smo„th, capsule easily turn oil, stellate groups of vessels are seen on .,„f,t.e On incision a general pallor even of the pyramids is noticed, due to- want of blood. The cortex is distinctly thickened (connective tissue onnut.on) ; i, lines of tubules distended with intlanunatory products, also y^l'-^l^ ,,„.,.,. these products have undergone fatty degeneration. Under microscope the ,des are e .gorged with unhealthy products. The interst.tial tissue is also illlned and Malphigian tufts atrophied, swollen or -"l-'^-'^ -..us eluux^es. If this patient lives longer than you expect, a granular change .^l ui yell,; large granulations are found on the surface, capsule is .dherent. kidney s ton.h an.l atrophied, is not often seen, is :3rd stage, is reduced m si/.e from lar.-e kidney, but will still be larger than normal kidney-the granulations are yellow, for epithelium of tubules which form them are fatty-kidney is white. The tubes generally through the kidney are damaged by fatty degeneration of the epithelium, nor are cysts so common in the atr..phied form. The uppe^jrances of the kidney must depend on the stage to which the process has attained. Kidney vascular in first stages, blocked with inHammatory products m later stages, and then white, and in intermediate stages it may be mottled, congested m sp..t3 and while in spots. , . . Clinical SYMPTOMS. -Acute parenchymatous nephritis occurs most com- ,nonly after scarlet fever, 14 to 15 days after desquamation or alter a cold; lu lirst Stages there i. fever 101 to 103 deg.. pulse rapid and tense ; m severe cas.s there will be headache, vomiting and diarrhoea. UK.EMIC SYMPTOMS.-Convulsions and coma. Dropsy may come on very suddenly, acute anasarca, there is generally ascites added. Urine is diagnostic, frenuent desire, is scanty, sometimes suppressed, is of high density_1020 to 1030 is highly acid, color reddish brown, sometimes red, due to presence of blood : if allowed to stand, a thick, turbid beef-tea deposit occurs. On testing a lavcre deposit, U per cent, of albumen is found, there is a dellciency ot urea, it hei';.^ retained in blood, and chlorides are_aho largely deficient ; under microscope are found tube casts moulded in tubules, are epithelial, hyaline blood casts. la later stages we often find larger casts granular, deprived of epithelium You will also find blooxl corpuscles, broken down epithelial cells, debris. In mild cases vouhave no fever, dropsy sets in more gradually, ura^.nic symptoms do not occuv^o early, no vomiting, no suppresssion of urine. This latter form is more connn(,n than the acute form. There will be less blood in the mild forms, other- wise urine will be the same. , • 1 • , . a ^'()!'K«E OF A.ri:TK FoRM as after scarlet fever, symptoms subside in o to 4 weeks, urine more copious, dropsy disappearing, etc. In some cases this disease lasts 3 to 4 months, and may end all right, but it threatens to become chronic ; if it lasts 5 to 6 months it is passing into chronic form, and death will probably occur i • I ;. f I '! 1 if 'ii i; . iiii Ill I J ill 11 , i I- . l\ ''■Mi PRACTICE OF MKIIICINB. 60 . 1 .. ,„„„tl,s. A few cases lusting 2 to 3 years are reconled. W Inu .scarktuuvl ,.,,,l";,„i. i,. chiUheu i.. fatal it occurs generally in first month, few surviving 3, ,0 ', n.oMtl.H. The tendency of this acute forn. is to recovery, only occasumally '"''''r)"u.NortF CHKON ; Pauenchymatous NEPHRITI3.-May occur as a ...luel .,f acute form, or n.ay be primary. These persons when H rst seen are ,,ale a.ulnnc. a.nl weak, and are dropsical. The great sy.n, ton.s in only J per cent. i, dropsy absent. Urine is scantier than it ought to be. its density .s Ingh alb .- „H.n nay be as high as 5 per cent., color will be darker and nearly a ways turbid tandiug it dei:.sits a beef tea deposit, a dark tinge (brown or red) from blood „.a V be seen in some cases, urea is also diminished 250 grs. Under microscope casis are present, but only a few are epithelial casts, as nunt ol epithe una has b,.euslu.l; there may b. uo blood casts ; the oth.r casts hyahne especially grauu- ,,, dark an if 1 ' 1 ll^H 11 1^1 Mffl ^■ii M PRACTICE or MrniOINE. 61 loi.l^ (if thn 1.o.ly sclf-Konerate.! " ptoiiuii.ieH." Sugar of Diubctes soniotimos m.iscM A.uUi Nq.luilis. A ll.ir.l Kioui. of eunsos. obsciro, M coUl, roiHi.itod ,.N,,os.i!.'s to col.l and aamp, burns extensive, acting rotloxly, extensive ec/.enu ,l„tn also pregnancy, usually acute, transi.-nt f..rni. How does preKuaucy do tliis? Vvi'^Mm-. on renal vessels leading,' to .'oUf^csl 'U, also to increased I.' i -"■ ot viisoulur system, and lastly the extra work of uxoi i.on of effete matter Ciiiioxii; iNTKiiMTiTUL N KPiiuiriH.— Cirrhotic or fibroid kidney, or chronic i„,luralion of the kidney. The intlainmaliou inv.4vrs principally the interstitial tissue, and the pairnchyma secondarily. In .earliest sta-. th.. connective tissue of cortex is proliferating, a migmtion of leiicooyl.-i ftud formauon of new (ihrous tissue around the iN'alphiyian capsules-this by contraction leads to pix^kermg :,„d atn.phy of organ. At a later stage the epilheliuni ,.f' the M,ilplug>an 1.. ly iiiolirciiites, so it becomes a transparent hyaline body, or underguiog tibioid cluuv'cs wilhers-eilher change impedes fun.'lion of the Malphigian bo.ly. An exu.iation may take place into the capsule. The bloo.l vessels also sailer, the arteritis e\len(is to all the coats, walls so tliick.m as to sometimes obliterate the lun.cn, culled arteritis obliterans. Some pathologists think the disease starts^in lh>' aiti I les, n.s an endarteritis, and extends to the connective tissue. The tubu'.es al>n sailer the same changes— some remain healthy, many atrophy-epithelium dugeiierates and is stripped from them— the oth.Ms contain fatty epitlhlium. Cluircot believes .some of epithelium lining tubules proliferates ami changes t.o tilnous tissue. A variety of cirrhosis of kidney, in old age. Arteria\ cirrhotic contraction of kidney needs to be distinguisiied, due to narrowing and obliter- aling of the arteries, hence atrophy. This f.jrm i.s known by the fact, the mien. scope will discover no new eoiiuective tissue. This gives smallest kulney kuuwn. To return to Ooron. Interstit. Nephritis : Naked eye appearances- -both siz." and weight may be redu3ed, capsule is much thickened and adliereut, surface of kidney is granular, coarse or tine, color of kidney varies, red, greyish red, pale, etc, amount of blood or fat accounts for col,.r. On section the same wasted appearance, cortex is nai rowed, ;jyramids approach near to surface, and are pale, cicatrices of cysts of all sizes may be seen on surface. Cysts consist either of dilated Malplugian capsules or dilatation of tubules by their own products. Tiiese cysts abound in the interstitial nei.hritis, but are rare in pareiicliymatous nephritis, so in interstitial nephritis we have hypertrophy of matrix, wasting of parenchyma. Clinicai, Symptoms.— It is very insidious, so patient does not come for iulvice till symptoms are advanced, and generally disturbaucj of nervous system brings him. There is reason to believe there is functional stage which preceded, lliis°tage is dyspepsia, constipation, headache, alVections of pharynx and larynx, .n-idences of arteria' tension, etc. These symptoms after prevailing for some time ■ ..^ult in Briglit';^ I )ise.T.w, I'ain in region of kidneys is not constant, rare to have pain. First s°ymptom may be frequent micturition, getting up at night. Patients rst well nourished, so about their work, etc. Dropsy may be entirely are 8 :.:iiii 1 ] 1 i I,: ! i : ; ij 1 PRACTICE OF MEDICINE. 6i absent from this disease, and if present is generally slight— lids of eyes in a. m. ankles at night. May be palpitation and dyspnoja. Dyspepsia is a very com- mon complaint. Dropsy is generally a late symptom, an.l is generally due to mitral disease or effusion into cavity of chest, thus interfering with circulation, Ijiit in final stage from weakness of heart we do get dropsy. Ukixe is abundant, 4, 5 to 6 pints per 2 i hours, is of low density— 1007 to 1010 to 1014, pale in color and almost free from deposit. In the slight deposit you may tind tube casts, but they are absent for a long time ; the first ones are slender, hyaline then perhaps a few broad granular casts or waxy. Albumen is often absent at thst, but usually does appear, is small in amount— will sometimes be absent in a. 111. but present after a meal or exercise— examine repeatedly for it. The amount lost daily is small, 15 grs. per diem. Solids of urine, the per cent, of urea is small ]-er specimen, but as urine is in excess it is found the per cent, of urea is about normal, hence this form doas not kill rapidly. As disease advances tliis tliuiination of urea diminishes, and urea has then been detected in the blood. .Hypeutuophv of Left Ve.vtricle, without any valvular disease, is symp- tomatic, occurs in 50 per cent, of cases. In old parsons if they h ive not had rheu- matism, then hypertrophy indicates Brighfs Disease. High arterial tension is a svmptom. To recognize : 1, the sphygmograph miy be used ; 2, by characters of pulse under fingers ; 3, heart-pulse is slow or persistent (not meaning rate), sometimes feels corded, if you will finger acr j^^ it feels thick. If you obliterate tlie pulsation a finger below will feel the thickened vessel, for the coats of arte- ries are hypertrophied. With the sphyg uograph the prelicrotic wave is more marked. Heart evidences left ventricle is hypartrophied, and apex may be out and down a little, the impulse to hand will be stronger. Accentuation of second, sound in aorta will be noticed owing to grevter tension causing abrupt recoil on the valves, and sometimes in marked cases tliere miy be reduplication of first sound, or at least prolongation. Cardiac murmurs may be due to dilatation of aorta from tension, hence regurgitation— may be also due to atheroma of valves, etc. Atheroma of arteries is also common, an effect of this disease, due to in- creased strain on arteries inducing arteritis, heuce the atheroma. This atheroma accounts for hemorrhages, epistaxis ; always suspect a man over 50 who has nose bleeding, as he may have Brighfs Disease. It may be hemorrhage into stomach, etc., but is often into brain, hence death. Hemorrhage into brain and Blight's Disease in 95 per cent, go together— apoplexy— means look at kidneys UK.EM1C Symptoms.- Vomiting, usually in morning while fasting, fluid is watery, acid, may contain urea— diarrhcea intractable, profuse and serous. _ 01)- stiuate headache may accompany ur;e;nic vomiting, amaurosis transient, abiding dyspuffia, attacks of asthenia, due to urajmia or weak heart. Cheynes-Stokes respiration, itching of skin rare, muscular convulsions, tremors, twitehings, etc., or more commonly a semi coma, apathy, listlessness, may pass into coma. A perma- nent impairment of vision, albuminuric retinitis, white patches on retina. Bron- chitis common to this form and large white kid:iey. Poriciriitis is more frequaat III' ' ' ! . iti • ■ ■ n ■I ,11 i i! ■ s ! 1 %i i wurl li PRACTICE OP MEDICINE. 63 thati parenchymatous forms-transient attacks of pulmonary cederaa (dangerous). TeiKk'iicy t^J pneumonia. • DuiiATiov AKD TEinilNATiON-Duration indefinite as you rannot get a starting point, may last several years, 2 to 10. More frequent causes of death are : 1, apoplexy; 2, urajmic convulsions or coma; 3, inflammation of lungs or some serous membrane ; 4, erysipelas. _ e a .r.n..^ CvusEs OF Chuonic Interstitial NEPiiRiTis.-Age-is a disease of advanced life 50 and up, but may occur younger. Sex-twice as frequent m males- Oh- nnte-especially common in changeable temperate climates. Exciting causes- ovUnaucy produces other kinds, but perhaps not this disease, same with cardiac L^ase, ntther cyanotic kidney they produce. Gout and lead are well known to pvoduce this affection, lead causes gout often. The uric acid secretion of kidney !„ .out and lead poisoning is noted, may be cause of the disease. Charcot thinks 1. Jl acts as irritant, causing proliferation of the interstitial fibrous tissue Dys- pepsia and over eating-persons who are largo eaters develop this form of Bn.'hfs, ditto certain forms of dyspepsia. Reason is such kidneys have more ^vodc of elimination than normal, more urates, phosphates or oxalates are to 1„ ..linnnated, and in so being cast out they irritate the kidney tissue 1 to- ,„une. also from intestinal canal may locally irritate the kidney tissues. Syphilis as a cause is not proved. Mental anxiety is thought to be a cause of this disease, no proof of direct action, but by interfering with digestion seuin-up dyspepsia, hence causing, for dyspepsia produces a lot of effete matteis 10 '. %t rid of. Malaria chronic does seem to be occasionally a producer of this atfeotion. Those conditions of bladder, urethra, which interfere with voiding of uune, or flow from kidney, as stricture, cystitis, tumor of uterus pyelitis,_etc occasionally produce this disease. Usually th.y produce " surgical kidney, but souietimesthis form (not suppurating) an " ascending nephritis. Alcoholism is also recognized as a cause. Chronic gonorrhcea by causing cystitis and hence pvehlis, so an ascending nephritis may also be a cause. Amyloid degenerat.on inherited. Disease may be inherited probably through gout, a grandmother mnther and two of her brothers died of it. Ciironic rheumatoid arthritis occa- sionally causes it ; syphilis is said also to do so, but not proved. Amyloid DEGENERATioN-also called lardaceous kidney, or bacony kidney waxy kidney, albuminoid degeneration, suppurative degeneration, etc. Develop- ment-disease begins in arteries of Malphigian tufts, these tufts become hyaline, enlarged, glistering, and are now impermeable. This process extends to both alferJnt and efferent vessels of tuft, then basement membrane of tubules becomes allected, then epithelium of tubule, of capsule and of glomerulus imdergoes fatty defeneration, then an infiltration of leucocytes of proliferation of fibrous tissue ocmirs. kidney becomes enlarged and hardened. Naked eye appearances: In first stage little is noticed. On section a skilled examiner can see ghstening bodies, like boiled sago granules. Tliese are the hyaline Malphigian bodies. Add Iodine and these become brown. In a later stage the kidney is enlarged by growth ot f T| Mi^ ; i I H « 'U Vi] PRACTICE OP MEDICINE. 64 this fibrous tissue, kidney is pale, yellow if fatty, or pale pink. Capsule easily t„n. off b It in late stages is tliickeued and slightly adherent, cortex pale, brush over with Iodine and you get brown staining. Surface is smooth, but granular ; ki.hu.v. may weigh a. high as 10 oz., hard, easily cut into thin slices, are semi- truislucent. A third stage is the contracted stage, although this view is not ,„',,ptea, and that kidneys so found are amyloid degenerations oi other forms, ',s riirhotic kidney. Tests for amyloid kidney: 1, Tr. Iodine is rough test; 2, apply a solution of Methyl violet, gives a red violet to amyloid part a blue vii.t is given healthy parts; 3, Sulphate of Indigo stains the amy oid tissue l,lue permanently, the healthy tissue iinaUy gets green. This amyloid kidney is slow to decompose. . Clinical SvMPTOMS.-First, patient is out of health, frequent micturition, urine 4, 5 to 6 pints, increased flow, is pale and of low density, 1012 down. deposits a moderate white sediment. This on examination shews casts frequently usuallv are hyaline, and shew fat globules. At times granular casts are luund and raielv'amyloid casts (test). Albumen is sometimes absent, or occurs as mere trace" at first, but once it appears it persists, perhaps 300 grs. per day is so ost, o.,ite a quantity. Urea is about normal, although any specimens may not shev. inu.h still urine is in excess. Globulin is pp. by Epsom .salts, casts and blood aho i^resent accompanying the albumen. I^ropsy is often a late symptom, occurs in belly, etc. Often where it sets in is acute nephritis setting in. Uiar- vhoe I watery, is also common. Vomiting also. These two are due, as pathologists SUV to amyloid change of villi of intestines and mucous membrane of .stomach. This amvloid change also frequently attacks liver, spleen and lymphatic glanas. Complexion usually is of great pallor-an.«nnc. Inflammation of lungs or serous meuilManes is a common tendency, but no tendency to bronclutis, but lias a marked tendency to thrombosis. Coma and convulsions are not as common as in other foruis, as urea is execreted. Little tendency to hypertrophy of heart, atheroma of blood vessels or apoplexy. Disease is apt to be fatal. Death perhaps by intercurrent disease. u i • CvrsES -Found almost invariably in cachexia brought about by chronic suppurating disease, as of bones, syphilis, caries of spine. That is reason to excise suppurating joint, etc. But syphilis causes it without suppurating It may be a sequenc4 from loss of albumen from some other disease of kulney. Cancer growing rapidly may produce it, malaria chronic also causes it, chronic dvsentery may cause. The time which will elapse between suppuration and amvloid degeneration will depend on the height of the fever which hastens, pro- lon-ed fever also causes it. The shortest period on record is 2| months. iNa ure of amvh.id degeneration is not known, some think it a second stage of hyahne d-gen^ration, but not likely, as hyaline is sequel often of small kidney cmterstit.), auo-loid is sequel of white kidney, large. Amyloid degeneration r. not always progressive, recoveries have taken place, especially when syphilis is the cause, a fatty or molecular breaking down of amyloid matter occurring. I- til! SURfJK in all jifirts of urine in state of brci l.nrging nii wfii'se, sev( in cliills, e of 3 wec'l< involved ; secondary of urine a: in soft ca no goiid. urine, so COMV urine is oi are two — i kidney (e: disease. 2 tion arisin or infiltra genito-uri: calculus, 1 in Ilright' pus, the ai There wil source of of albume — 2 uood nitric aci albumen, hence pro disain)ear ;4ives wlii are at o\v Test— M excess of tube and tion alwi ttisl Jpjis. brine tes test fur resins, a PRACTICE OP MEDICINE. 66 Surgical KiDNEY-Suppurative Nerlintis.-:Minute abcesses ave formed in all parts of kidney, especially about glomeruli from retention of decomposition of mine in kidney. Symptoms are due to absorption of N. H., hence ammoniaca .tate of breath, sweat, nrine, a dry condition of mouth and tongue ; vomiting and ,,,u-iii.' niaj' occur in acute cases, absent always in chronic cases ; as patient gets Jvorse Severe nervous symptoms are seen, delirium, etc. ; case resembles pyaMuia in .hills etc., but no metastatic abscesses. Prognosis: almost always fatal-inside of 3 weeks frcm beginning; recovery may take place if only one kidne',' be involved • hard to diagnose. This disease cannot always be diagnosed, for it is secondary to bladder troubles, etc. To determine, it is important to get si)ecimen "of urine as it comes from kidney, hence wash out bladder carefully, and leave in soft catheter, and so gather urine as it trickles down. Treatment: medical 13 no good. I'revention is better than cure. It is due to air contamination of nrine, so treat bladder antiseptically. Common Symptoms of Bright's disease, affecting all forms. Albumen m nvine is one of most reliable signs of kidney disease, of Brighfs in part. Causes avo two-organic and functional. Organic may be in kidney (renal) or out of kidney (extra renal). Renal causes are chiefly the several forms : 1. Of bright s disease 2 The cyanotic indurated state (cardiac). 3. Parenchymatous degenera- tion arising especially from fevers. 4. Nephritis from parasites, new growths or inliltrauons. Extra renal albuminuria. Cases : When pus escapes from genito-urinary tract or neighborhood into urine as cystitis, psoas, absceso, renal calodus, hemorrhage, latter causing blood in urine. But albumen may be absent in Bricrht's disease for some time. Usually appears. If albumen be mixed with pus, the amount of albumen will be small. The microscope will shew the pus cells. Tl.ere will be an absence of tube casts if Bright's be absent. History might shew .source of pus. Blood in urine, there would be absence of casts, small proportion of albumen, red blood cells. History would exclude Bright's. Tests ^r albumen -2 ooud Nitric acid and heat are good practical tests. Nitric acid. Add i nir^ic^'leid to urine, causes a white cloud, thicker in proportion to amount of all.uniou, settles as deposit. Sometimes the acid pps. uric acid and urates, hence producing a cloud, and you might mistake for albumen, but boil, and urates disappear. Heat Test-Urine containing albumen-if boiled, latter is coagulated, gives white deposit, but heat produces phosphates ; add nitric acid, and phosphates are at once dissolved, hence these two tests act as checks on one another. Bnne Test-Mix 1 oz. H. C. L. in 1 pint Sat. Sol. of Na cL, on adding to urnie an excess of this solution it gives a pp. of albumen. Put the brine solution m tube and add a few drops of urine, and so avoid mistake. But the bnne so u- tion always throws down the peptones and albumen, also pps. globulin, hence this te,,t pp... all t]- albumen, and same test tube can be used to test for sugar, fhe brine test does not throw down urates. Johnson's Test-Picric Acid is a delicate test for albumen, it also pps. albumen, alkali, albumen, etc., also urates, oleo resins, alkaloids, peptones, but on boiling the latter four disappear. I'l!^ . Ill I ! t- sssus, li Eyk ( li:ll,iuiiiiiil si'lii.-ilieclo' iiill.ininiiit SimMI, swol most eniiui 111 lie often Ceuk nflfctcd h] nil' every severe. 1 of speecli Oilier uni may ensu furin con\ ,'iltack is shut, jiiij but at on drgrees o Di'liriimi seiisibilit 01 j)araly more ma subnormi In this s' urine. ] constant. a heniori imrtion ( jiiessure of uvioni no coma erally w e rally at plexy. •' Til ]iose(l u" tions of all thus Tu gets co' toms. PRACTICE OF MEDICINE. '*'' Eve Compmcations.— a special iliseaso diagnostic of Bright's Disease. 1. ],„|,u.„uatiou of retina, at first nearly cloudy and slightly swollen, but soon white ,„„ts arPear grouped around the yellow spot. Sometimes the fundus of eye is s ,1 .,l.ed over with gr.-at white patches, probably fatty degeneration, consequent on i',ll ,„,u..tion, is called albuminuric retinitis. In addition, opt.c neuritis may be s,...u swollen, blurred, vessels become buried in the disc. This eye ailect.on .3 most! common in the chronic from (cirrhotic). In addition, hemorrhages are discover- able often, so red spots and white patches are seen. CFUiMiiuL DisTiiuBANGKS.-Every function of nervous centres seem to be nit.Mtod by Bright's Disease, blindness, neuralgia, epilepsy, etc., for toxic snbstances ,,v everywhere in the blood. Cerebral uraemia may be acute or chronic, mild or '..vevo The chronic (mild form) is often present in cirrhotic kuluey, slowness of speech or movement, passing into torpor, there may or may not be fever. Utlu'r unvmic symptoms may or may not be present. Severe but gradual coma r,„y ensue from above. The acute invasion of unemiamay set in with epilepti- f„nn convulsions, or with sudden coma, usually both, and alternating. When aU;.,k is well marked, effects of intoxication are seen. He lies comatose, eyes slu.t, pupils contmcted or dilated, he can be roused by punching or loud calling, l,„t at once relapses ; breathing is hissing, high pitched, stridulus. There are (h.orees of loss of consciousness. If aroused gives answers in monosyllables. Delirium sometimes is present, low or maniacal, chronic or passive. General sensibility may be more or less lost. State of muscles, twitching or convulsive, or paralyse.1, or rigid, or relaxed-iray be paralysed on one side or both-may be more marked one day than next, etc. Temperature is genei-ally low, normal or sulu.ormal, but sometimes is 104 even. Uriemic vomiting or purgmg is common, lu ilus state (comatose) urine will be scanty, or rather coma is caused by scanty u.ine. If there be convulsions they rapidly recur, may be intermittent and coma constant. Local apoplexy, one side or one limb may be noted paralysed without a hemorrhacre into brain, is due to sudden oedema into area of brain supplying this portion of body, so a local dropsy may cau^e those symptoms of paralysis. Its pressure acts on arterioles, shutting off the blood supply of a part. These attacks cf urftmic paralysis, the ursemic symptoms may all be absent, only the paralysis, 1.0 coma, vomiting, headache, etc., or dropsy, or fall of temperature. But gen- erally with this paralysis there is increase of temperature. This paralysis is gen- evally attached with contraction of pupil. Old writers called this " serous apo- Theory of Ue.t.mia.-1. Urea retained. 2. Garb, of ammonia fro..i decom- posed urea and many other causes. TrutH, is uraemia is due to impaired func- tions of kidneys, they not throwing off the urinary excreta they should do. then all these retained cause the urmmic symptoms. TUE.^TMENT— If a person's tissues are filled with uraemia products, if he gets cold, skin excretions checked, then he will at once develop unemic symp- turns. t 1 . I 1 1 'M M ^ C^^l i 19 ! ^ 1 j M ':) 'S^^^l ■1 ' 1 n 'H „iM, tH^I «MMft ill bi Jaiiip Co. liy using ( us I'lilvlJ liiiiirs, ad miiiith. 01 suli-iieute or liiil ail ln'iit suvfi lor h an ! air liatli: with lihui s|iiraiiiin. [lack pati gat ion ni diuretics, (h'ojisy SI tiiiiu the loUowed sonic oc( witii mil doso III' . till it tli hearlbui coIIl'C ai be strict farinace Uric ac; of soda orally i calculii brown ( substai; rarely thiue. it" PRACTICE np MEDICINE. 67 V.TTE I'AUKNCUVMATOis Nkphu.tis. -MiM.r forms, coax kidneys to action. kidn.vs an. l.locked up, give al.u.ulanco of u mild diuretic, Digitalis Tr. or uf. are -; do...s not act directly on kidney cells. As soon as im.ler .g. d.s h kiLys act. give plenty of water; Citrate of I'ota^h .s oiten add.d to .. o. Cre.;ni^>f T..tav, or give an ounce of Cream of Tartar in Len.on^. ^ „„,-.r _St..p nitrogenous food, broths, meats, etc., even milk m severe cases. R,.t in 'bed is essential. A purge may be required if bowels need it. as lu J,l „. To. ..r. :5() to 40, for ebild.vn Castor Oil or Magnes. Sulpb. dr. 1 VuMM^.N Tui.:.vrMKNT.--Klim)nate poisonous matters by sk.n. not by kidney. 1,V n.n. diaphoretics, also by bowels by active cathartics given every other day h! Pulv- .lalap Co. The fa^orite diaphoretic Liq. Amm. Aect. ss. oz. every lou ,.„„,, adding a little antimony to each dose, riloatrpine gr. A o pei mnuth. or gv. i hypodermieally. This drug is not given in active «tage »K,t m ^b-aeute st.ge^ aJ \t is irritating to kidney. Baths are also ^^^^^^ ,„, H„ ,,, ,„th. or vapor bath. Hot water or air are ^^f^f'^^^^^^T^ heat surface or increase arler^d tension too rapidly. Have bath at U8, lease m for S an hour, put in blankets for 2 hours, then rub dry and put to b.l. Ho air Uth : put patient on high stool and two spirit lamps oeneath, and make a tent .1,1, Mankets. Or if too weak, hoop bed, etc. This method secures active pei- „,i,.uon. If temperature of skin is very high and -•-. /^7;^^ ''"*;: ^f iJack patient in sheets wrung out of hot water, and cover with ankets. 1 i- atH,n may be necessary from time to time. If above methods tad e diuretics, as Digitalis, it acts through heart, increasing b ood pres..ure ; usually dropsy subsides under this treatment, and albumen subsides. Ot eouise all this time the diet has been regulated. Cupping or leeching of loins is also practiced followed by hot ].ovdticiiig. Blood letting (venous) is httle practiced, my o some occasions aid. As acute sUige passes oif commence use of iron Beg. .ith mild preparations as Am. Fer. Cit. in. 5 to lU. increasing, giving with su.a do.e nf Anun. Citrate. Even after dropsy has disappeared test tor albumen and till it disappears keep patient on non-albuminous diet. If the milk produces heartburn or headache it may be skimmed, but the cream acts as a laxative iea colleo and alcohol are to be discontinued. It is extremely important that the uie be sDictly controlled till albumen is absent from urine, hence keep on milk and farinaceous diet ; an occasional hot bath will also do good for some time. XEi'iiliOLiTHiASis-SroNE IN KiuNEV-sevcral varieties ot eouereiions. 1. Uric acid usually smooth and small, may be in large numbers or but one ; urate of soda may be found in crystals in kidney substance. These calctili are gen- crally met with past middle life in gouty, drinkers, etc. 2. Oxalate ot lime calculus comes next in frequency. The mulberry calculus, generally single brown or black, and hard. Crystals of oxalate of lime may be found ui kidney substance. 3. Phosphatic calculi are rare in kidney. 'ih-c triple phosphate rarely composes much if any renal calculus. M'>ch rarer lorms are ot xan- thine, cystine, oxalates. etc.EIfects: if numerous andl arge, calcuh disorganize If] -A- « ! 1 L r 3 u 'Ai V -iii^ fl i PRACTICE OP MEDICINE, 68 ,.i.,n..v sul.tnn.o.sct up . pyc-litis ami su,.pnrali..n of k,.lncy.lH.n,c. i-y-nopbrusu . „„, .Us,.l,a.«nl by inothra. colon, duoaemun, loin, urnin. etc., u .,.«.. calculus m v,s„r ui^tuv nmy ol-stmct oulllow of un,. , l.cucc pyolili... etc., c.x,muMou 1 v,,ti..uof i.arenchynuvau.lco„v.ni.m of kulu.-y ...to a cy.t conta.u.ug 1 ..,.1 ......... oJ ,UH. The divisionK of original lo) -^ k.h.cy cau«c . to l,e snrc.lat.Ml ; t....u.r ...ay be very la.^, in other case, ayan .h ..ot d.latc.l h..t atronhu.l, hc.co small cyst enclosi,,. calculus is all that re...a>.,,s of k..l..ey ; any ,,,,;„„..,;t uhslvuctio., will act si.n.iu.ly, as f...m ureters, etc. I., al case. «.'Ht i 'ii..d is .listctio., of i.elvi. and cilices of kidney, then tubules, and, lastly, cni- s„Ies At this tin.e kidney is large, smooth, imlc, a..d substance ...hltrate.l by ,„„v urine. El>itbeliu.u of t.-bes alrupl.ios. h.MU'e a state of u..a-...ia ...ay ensue. I„ .o.ue cases a deei.led cl.ro.,ic interstitial nephritis is set up, cau.s.ng at.ophy „f ,„•,-... Disten.ling lluid at first is urine, but as pressure increases secretion ot „nur diminishes, Hnally ceases. The pelvis of kidney secretes pelv.c ca..cer. tu..,ors. renal cahnili prod.ice these etlecls. In this fon.i of d.seasc hyper- trn,,l.y of heart n.ay occur, stagnant deco...po.sing urine from obstr.iction from i.itul.'.s to kidney arc suttici-nt to cause. ^ Symptoms of Uknal vJALCULUS.-Thero n.ay 1« no sympton.s us. ally it has well n.a,ked sy...ptoin.s. Fii'.st initiative stage,-i.ain in reg.o.i of k.d..ey, of variable intensity, often intermittct, i..duced often by j.unping, etc. Pressure may 1„. .Hsistent and severe with sense of heat ... part. Pain is deep ... re..al reg.o.i. P is often felt in sacrum. If in right kid..ey, pain is us,.ally refened to ,i,.h! bvpochondriac running to umbilicus and ..ot found over lad..ey Isattcded Jth ,.o,.stipation. may be confounded with bilia.-y or intestina col.c 1 a... often .xtH.ds alo..g ureter to testicle, which may be retracted and swollen (rarer at this sta-e). Pain may be felt along course of ext. cutaneous nerve. Llood in uri„c. i,s"f.H:.p.e..t sy.nptom, just enough to be noticed by patient such bo j occrs after ridi.ig, running, etc. Most frequent with rough oxalate of lime calculus. Ihe.naturia n.ay be ab.sent all tl...u.gh a case, tirst ind.cat.on niay be ,a,s in urine. Frequent micturition is a common symptom. Ihe unne m this early stage is turbid ; when passed, a sediment forms in upper layers may contai.i a few blood cells, lower amorphous lithates, perhaps crystals, etc If calculi do not escape now they grow rapidly, for deposits occur on nuc eus. W lien, pvelitis ensues pain is mcreased ; signs-incieased micturition and imtation.in unaarv organs, pain in perineum, micturition more frequent at night, urine cloudy. pus iu^ It etc. If calc.ilus does not escape it enlarges ; but as long as pus escapes !ro,n kid.iey, patient does not suffer more than usually, but when occlusion occurs a renal abscess exists. Urine then becomes clear, for it is f.^om sound organ. Stone may dislodge, hence turbid urine agam, w.th less pai.dul .symptoms. Future progress of suppurating kidney v>vr.es. Com- luouly kidney becomes saceulaled. parenchyma destroyed. At tnn stage _ tu,.,«r can be easily made out in renal region, or abscess may enlarge slowly. cau.sing constitutional symptoms. Signs-hectic and inflammation extends to 1 ^^^^W, ' i 1 survonmling kiilni'V, niaj may ocour, ' vuiiiil calcul may cause i symptuius,- viMial iv,i>ic with sympi in uiiiie, e which luaj there will a renal ca, lie lice reco repeated e of uric acid diet, lessen much liii'ii and esjieci will vary to iusullic oxidation calanh, d small iiua tViods, alci breakfast, 10 I'dst ^ hence ti'c t^ym[iti>ni tu be ligli renal coli nive Chk siiUle CUJ especially driniv dil water, o it has 1 fnan cab liieini, ihuretic.'^ treatniei Quinine of air, el PRACTICE OF MEDICINE. 69 lin. tissues hence perinepluitie abscess ^vhich may communicate with rrr 2 ^ZlZuJ^^^^, -ion, alon. psoas, etc. Or hepatic ab.cess ' nihv " aim may be perforated, hence e.npye.na. etc. In other cases '":;;X;i t^l^ape'into Uadder, the commonest course. If of smaU size venal calculu. '" '^> 1 ^,^„ ,, t, ji.tend ureter you get violent ''''' ' cuZ ephrahna or renal colic, sudden access of pan. in ^^'"f :!CS;.g - ureter to groin to testicle with retractioi. ,,,,1 u.g.on Shoo ^^^ ^^^^^^ ^^^^^^ ^^ nuctuntion. blood ^^•';,,rr^ In ^;:^n: cease Uddeidy when stone slips intu bhulder "' ; , fJ minutes to a few days. If it be uric acid stone, ^'"" '7, i:;irtol r^ o;alate of imie. no more to follow. But '"" rL^iriyb^le encysted in kidney and cease to be irritating ;.;r' e^t:^ Tlment renaWalculi. Try and determine its nature 1^ nd examinations of urine, and so try and prevent increase in deposit. f '7 tidZ not cutaneous unctions and correct digestive functions, regulate trr n' nl i^od and excessive eating, avoid food causing acidity as 1 1 .tc much same as gout treatment. Give alkahes as K. Cit.. etc.. "T i!^ W tith r w t " to prouiote solution. If you h ive oxaluria, tre:itu.ent rii: : w i «. hence dLuse of hard lime water if due to that li dii3 • ,Ue Nidation of starches, sugars and fats, regulate diet and pi-o.not !^ ; !: y -rcise. etc. In the oxaluria (true fbr.u) froiii g^istvo-in es inal ;^ lil treatni;nt to cure that, have diet of pla uly cooked -unial d, u,utity of vegetables only, and avoid completely s.icchamie anl .tu hy f .rUetc. To remove catarrh give f d. of Oarls^^a. in a^ni. .^ , ^\■ f ,. Uw,n O-ivb 15 ars B.I.L). ante cibum, or Nit. Alui. Ac. ini. m. ,v„,lcJic rdio.^ l»i"«"'l i.i.a«,., I..UCO Oi««n, u, hy|«,aen uo If tl,., f. » :::::;'! ,..., .,....-.0,. .... .. ^i^^^zf-;:: .^™;; ..sneciallv di-'italis and weak sol. of K sails oi Ooucli Uia^,, luni i ^irlii;: freely, as barley water or Unseed tea and ^^^ J^^ ^ ^^ ^ ^ .,aer, or with cream tartar. Stone in k.dney-if you are sme ^^^ ^' ^ ^ ^ i. l„s lasted some time, and symptoms contiuue "l*-^^- ^^ ,^^ ^ ,..„ui calculus-rest iu bed. slow diet, leeches over groins, a ve P ^^ ^ j; P • • . iv,.lt.,H„.7 to kidnovs hot fomentations to loan, diluent,, avaui hiciui, not irritating to kiun ,ys, Jt ^^^^^_^^^,^ diuretics, for pain use Opium, Camphor, etc. It ic uids in pye uvatuient must be supporting, nutritions diet an.1 -J; ^;': ;,^' ^ .i.inine, also Buchu, Cubebs or Copaiba. «maU do.es f^.r -^ - [ ^ ^ ^' oi air, eic. These cases should be turned over to surgeon, (loi suigiuil kidney, s..'., page Go.) ^ 1 1.^ TltKV snsi>i'Cl til etc., what ami thus \ worry, etc lUseasc. ,4' -^ki"> iit til 111, w.itc iary oi'gai iuHiainiie (livfvting fro 111 skii: 111 it vapt lint salt s;i;^e of i tlamiel, e wlnive vf IumI unit Me three ui; tiuuH pe is waiiti in. 5 to hut ;^iv( Iruii ill iiici'easc Strych. Dig. m nuitters will stc 1 ii'iialvfi -A, til T (.allSe. Li(l. A I of mil with ii far iu iiouvi; fur it ratiui treat PRACTICE or MEDICINE. 70 . nr r.iPONic TSTERSTITIAL NEPUiuTis.-Tf fvom symptom, you Tkevtmkxt of OimoMC iNitu^u f,.e„aent iiucturitioti, „„pect this disease from aU.umen in -■'-'; f-^^^'^^,, ,,iek pvogress. ,,^,,,.myouao. ^--^;:;^n:i::t:::t ;out,expLi. business a,„l tluu proloHS !*• H-'tfy""' ,,.,„„„l „r- ,mi,av only susiicct tlio ,,„,„,. certai,, -•<- ■';»»- ,,;t '„.;*:. Wood and »ouo™l nu„-i- ,i„„, „,,tA mvhmy to t.r,««..a «ii'l F''*'" "' "'""' „ji„,„ o„e m«n say, ,„„;„,,.„ to u,e «"«^j°-;;t";:;iro'' " : of s:^» "..a.. .,» w "'''"'■"°n .tTt ,«u -e ™,,e ki,l„.y c„„go,tlo„ Free ,ec,et,„„ aivcrting Mood to the ^Kin >o i . ^.^^^^^ ^j.^ „„„i. ,,„, .kin relieves arterial tension so here is of bath ^^^^^^ ^^^^^_ H.. vapor bath is stimuUiting. ---^^ ? ^'^ ^J ' ^ Dry friction, mas- H,. .i water bath or tepid douches oi; pack, ^f'^'^^^^^^ should wear !;;;::f;S!is::f ^ini^rature are not common. Not necessary to conhne to l„.d unless urgent. Acet or Pilocarpine, gr. i to ^ every Medicinal 'li^l'l''-^^<^^' '^^^^"^^ "";, ^1' i, uot irritable, give 2 to 3 tuvee nights. Tl>e last is -0-- ^ li k d^^^^^^^^^ ", is unemic, and albumen U,... per week. Promote healthy <^^^ f ^\^^^^.^ ^ .^i.^ures, Tr. Fe. Chi. is w.mtin.?. .Vu.«mia is present, so give I on, a, Bi.han ,,, , ,. ,0, A. A.et. I>il m. ^^ ^; ^^imlf f i:.^ .^ve Tr. Acetate 1„„ ;,.ve itT. I. D. in water. Add Syi. L mo ^^ ^^^^^^^_^^_^ 1,„ i„ above instead of strong chloride f m. ^« ; ^^^^ ^01.... increases, or headache, then stop iron ^^ ^^^^^^^ J^ ^^....Jpower give Tr. Strvch., Qnin.ne, Hypoi^hosphates etc. If \^ ,^ ^ . f '^j"^ ^ oxidi.e etfete l,i. ,„. 5 to 10 T. I. D along with -^^^ ^^:i „„,. No agent nu.tlers, is very powerful, inhale about oOhiesi day ^^ ^_^_ ^^^^^^ ..ill stop proliferating of tissue, but try ^<^-^^^^^ '^^^ ,,,^ c,,,. Merc. gr. ,„.eakfast one hour, so that it at once loaches k d y • Th^ ^^ ^ „> Ui T. I. 1). is also highly i-ecommendedespecaU i^ ^^ J^,^,^ ,, , :. Ciaonde 01^ (^Id BW^ -^^^•^,;i;:^e«ectis not mnch Ui[. Arsenicahs m. 5 1. 1. 1-'. ^"i' ^ . , ^- ^ j exclusively :::::::'zt''^sisr::;::^;:w:>:t^«uc«:auL^ ior it you must give it_ J)^^y^,^^,r,os.-V.e-r.o^■e cause, remove supp.- TUEA.TMENT OF AMYLOID DEGENEU.MU dnina-^C etc. Alwavs nation by whatever treatment is needed, -"J^^^^^t t^n!^> Y- Wi.n treat syphilis with great care, give anti-syphilitic treatment thoiou„ y Ml i i!l ! 1 • Ml i i it' ■Mh 11'. fii II < PRACTICE OF MEDICINE. 71 e,„..,.annotl.eu>ade out, then Pot. Todicl, lodid. of Ivon, Am M«r. ^>t^c Aud : vl lodid. have been found useful. Iron is called for Uncnnc symptom. ;,, nnt oiU.n present, diarvhoon, sn.all do.es of Opium, Lead Acet., etc. '" L.rA. ov SPKCIAL SYMPTOMS Uk.kmic CONVULSIONS -Comm^ ,„,thod is to eliminate poison by all the emuctories, or by blood lettmg. T 3 „ts out a lot of effete matter and relieves arterial tension Cupping of Ion ■,,,iUiven is useful. Baths are to be employed. Inject rdocarpni gr. ^t ,u,se sweating, but is dangerous if patient is comatose, as sahva inay choke. rlXialway: given, elatorium gr. i every 2 to 3 hours till >.u have pro- L discharge. The convulsions call for sedatives, some use ^blorofovm I I vulsions L not violent give Chloral, give gr. 10 to byui, then gr^ 5 ve^2 W,vs or less, even every * hour if symptoms need it. ^^^^^"^^ ^^^^^ also be "iven,gr. 20 to 30 every 2 hours or oftener, even with Chloral Ice cap ; iJo he used. 2nd method. American, is Opium under skin to allay ma- M,.rphia -r. i every 2 hours, even double the dose if necessary i convu 1- :il.Unue:i. relaxesLerioles and sustains l.art Ch«>rm iiot^e^. It is often noticed that under this treatment the bowels wdl act, ditto kidneys. ^:^::i U^lent is weed, give purgative, aud inject Opium, useful in acute '""t .uoNic CEUEBR.L SYMPTOMB.-Couvulsious will yield to Chloral, combining wiih purges, diaphoretics, etc. p„rr,r,vp Uu.onc CoMA.-Chloral or Opium of course are not indicated Remove ,,„is„u„us principle by diaphoresis, avoiding Pilocarpin (saliva niay choke use Antipvriue, etc., purgatives also, inhalation of Oxygen, injection of di. ss. Ktla.r'to stimulate heart, keeping in life while drugs are acting. AUTKUIAL TKNSIOX.-I. 2 to 3 gtt. of 1 per cent solution of ^'^ro Glyc^ .^ u..dT I D to relax arterial tension, relieves headache, noises in ears, astlema. .i'vfo 'months together to keep tension down. Un«unc asthma sometimes ;iC^^ l^poderiiuc :njection of Morphia gr. Jthto^th. Often ana^utepnij, : mdo sani ^oscine gr. ,V.tb is also good for iusomn^, give ^^P^^^^ >; sU.p in 20 minutes, no ill effects. There is a variety of '^'^-y \ "'^ ^^^ lUi 1,1's kidney, the " cyanotic indurated kidney or the cardiac kidney due to 1 ,1,1,1 Kiuiit) , hypertrophy of the connective tissue of chioiiic venous congestion, wh.cUlcau.s 10 uyp« i j vnlv,„ln,- disease the o,.uau. Causes are central which obstruct circulation, as v ilvuki di a^e .,,r,„„c interstitial pneumonia, emphysema. Local causes: ^Wominal tu ...pressing renal veins, thrombosis of tliese veins, or of vena cava abov pr ..,„' uteru^, etc. This kidney is a large red smooth ^^^^1-^' ^r-^^^^ "^ i„hu.d redder than normal, due to congestion. Cipsule easily - -/ed^ i,„..io,. no change in relation of nnvts is seen, blood vessels are tl ick ne.l a ,,,l.„.a. tl,e opirhelium for a long time is round, but finally becomes f,dty, an tl,:.,;albumen appears in urine. In this stage urine is scanty, n^gh co o- (u,va,, and urinary pigment S. 0., high, 1025 to 1030. It contains only a ,. i p,u,.t ty of albumen. 1 per cent. Sometimes a few red cells are found. C.sts tl ;if ! U :. HI Ml I [ t Tlii.'ic is iilwi fiiV nl).stl'llCti tlmt n( valv ALlilM mill only 13 in uiiiu; i»i'^ alliiunimu'i;! iliMirilt'i's o' liiiVA'ly of (3 ,ifi)iotci'ls. iijit to have ciHi.'s lii;i)t( liiiiicture of icual n Slineks, lot td iilbiimii epilepsy ai lilnoil, pev] as iiii'.t wi uu'i'ciiiy ] >upp"se a tioiial. IJ fouiul, ilu ill, hence thought t aiv pvobii lUfU, pt'l male, ov 1)1/ ami inai •Ml absii trusiuu, any vaU present make si Ti tiiuic.-! 1 these C I'lMbah 1 1 live a eour: exeivi k. PRACTICE OP MEDICINE. 72 ^ fif nvo..nt are livaline. There is aUvay. general dropsy in these cases. hI'iiMI aVisont, it present are ny.iunv.. nlwavs find a cause tl,at of valvular disease. ^^.^^^^^^ 3^^ j^^^^ albuminuria ALUiMiNLKLV other than fiom disease, in ^^^^^ ^^^^^^^^^^^^ -'^ ""^^ '] ^?Tl^ iS lS:r- ^ ;^i:: oUlcholiim l^ cases had i„ ,„i„« aiulonly 1 had I.nglit a lUitnso. i . . , ComlWoiis me due to „„,„„„„„,i,, Al»u,m„«.i« ia -«>""S'"'^°\,'™ ';tl, ciuefly .ter eating ,,„„,„ „r dig»Uo,, •• Peptic ^^--"™;, J ; * ,„r,l.„,.,,,ilati„n '"'^*- i'''i"''*l:r:;™:e"™ s;„ X;„iai;,.ia. m u* c,«e ,... «« „,■ p,„t,.i.ls. 2. Disoutcrs oi iivei „ ^^^ 3^,^^^ »." '" '»7 '"''"Ti rto"' *:; ;:rrvii:r^. Nonvou; ..„, i,..,™ ■• oiiS'M peptones. 3. Due to ms mi. i„o,1« tn..lhuiuinuria, dtto section *■- «' «^ '-"'titr/s «:;;:« i^^^^^^^^^^ "«-■- „f ivnal nerves, also mitation ot J^^'''^ ..^„,^ ii.,i,t, also give rise Sh,.k„l..ul noises, detonations, ^^^^^^^T n 1 ta^^^^^^^^ ilows onhead, ,. .,„,,i.uria, ditto cold baths dueto ^^^^j^^^ ^:^:^t dteiations in the „,il,,,,,and ophthalmic goitre. 4. H»,nic ^^'iX.. near menses, also U I. povhapsthe same as appear -^^^-^^Z^^Jl^^^^^^^^o^v^o^n., ,. ui.t with in scurvy, purpura, malai.a. In ^f^^J^^-^' ' ^,^^,, ,,, ean ,,.,.u,v poisoning, absorbing pus or ""-^^^^^^ ^^^^^ ^i, than fanc- ^,,,,,.,, . ,,,Utintlannnat^nc,C U^jr.^ ti.mal Ditto m jaundice, o. In old •"^^J'^'y '^ I J , ^^U they take f,„.„a, due to them being large eaters, having no capaci y to 1 ., he.ice kidney is overworked and allows album u to ^J,^^ U.ught there is a ^y^^<^^ :''^!^^':;^''^;, aUt r nt forms of alba- :::';;;^C:tr ^r;:rrs::t^:.:aibumen, or gouorrhcea i. ,,,1 ,nany samples of urine may be found free from albumen. 11 nuike sure'in testing you have albumen. ^^^,^^ ^^ TiM.:.TMBNT.-As a general rule, rest of body. ^^^f^J^^ ^,^ ^^^^^, ,f .aies will remove. ^ l^P^ic albuiniiurria P^ --- ^ ^^a^ in urine. ,h.se cases the liver will be found at fault s*^^" «^^» ' ^^^m, diet. P.,ably constipation, rich animal d^e^c ^^^J^^^^ ,^,,,^ ,, lllivev is involved give a course of Me em y^ Att^.i o — , • ,^,^1 . ooui-:,« of Mur. Ac. and bitters, as Gentian, Quassia, etc. Act.n. ixL'ivise will help liver. u 11 Alliiiincii ifi fxoi'cisi', etc oxiiliito ofli urine is ii1\\ jire ^vi'll, 1)1 ui'iiH' alone It is quite ii nile vest 111 id tonics, minuriii of of tulmlos. ILkmi qiient on p disordev of are minor is a discas tiitional ta nc'ss and c jaundice a alluinien blond ]ii;4i I aiipcared ' haMiio^liil) crlls. ¥ La-tly,tvi stncted d Cau dncc it, a Amyl, ri ISO poise M cold. tiun of vf Tilil miliary i a ;_;i'm'ra.l ivnal plv tration, ( ni'y ilsel Alxj \vi caseous PRACTICE OP MEDICINE. 73 CiiKOMC Tntkrmittknt ALm-MiNrniA.-Cyclic, adole.contic, occurs from 15 t,. :i.-, .i.nost exclusively in l-ys, Imthas been met with in girls also by others Ml.nu.n is found not to he constant. Is to be looked for after a full meal, aft r Ircise ete. Urine itself has an average density, acid, aniount of alhnn,en .s smal , I ,e 'of lin,e deposits, mucous threads and sometimes a few hyalme oasts. Such s duays ri. h in urea .n> pign.ent. Health of ,atients--always say they .ell, hut friends say the, «••« pale, morbid, listless, headache, e.xammat.on of „., , ,„. n>al.l pigment has dis- : rid the urine pigment will still be in excess. ;^^^ ^:^-^^f2^^ 1 ,„o,l„binuriais that the coloring matter of the blood is present, but ot he e„lls. Fuuclioual albuminuria has been seen to pass into hnemoglobinuna. Lustlv, treatment is same for functional albuminuria and haemoglobuiuria. Re- '"1:lc:i':K^Lx,OBi.CHU._Whateverdissolvedblood^obules^^^ d.u.e it L toxic agents, Pot Chlor., Pyrogallic Acid. Oil of Naphtha, NU^te of Vnn-l 1-hosphorus, Mercury, Lead. Chlorine, Iodine. Mushrooms. - 1- poisons, ' ? ;,^1 of ini^^tive diseases, malaria, also extensive ^--' ^^^^^J^^ ., cold Als.. transfusion of blood of one animal into another leads to destrnc- tiuu of red cells, hence use human blood. Lastly, in nnexplainable cases. Tn'LlcrLO^sDrsKASEOFKmNKY.-TwoformscLMiliarytubercueinwhic^^ ,niliary nodules are scattered over and in kidney. It is P-\h'> logical a > rt of a.c,Kval tuberculosis, is not diagnosable. 2. T^bercidous kidne , sc o .km. ..nal phthisis. In this tubercles form in organ. l-:^f .^V """ e"in n kid tvation, caseation of tubercle and breaking down. This form may ^^^^ ncy it elf. usually in pelvis, and extends in, but --"^ ^^ ^?;"\"^„. ^^^^^^^ Al!o .ill be found in vas deferens, testicle, ovary, uterus. The softening of caseous tubercle leads to formation of cavities. DIAGN0SIS.-1. Patient may be scrofulous, or have been, or perhaps belong i ; 4 1 ' ' ^^^1 I ■. i,' ^^^1 i .ii; '^1 ! -It '■ ; 1 , r. \^ ) '^^1 1' - t^- iM r r;i '^'^1 ■ l!! k. .1 MMMSTH 1 ^^m ^BRB, '-. 3^M Br^ 1 ''^1 1 *• •I 1 1" 3 ^1 .^^AU-MUlUtUiiiU li (,i tiilirVCuU) tiiiiis ai'L' 1 nil [i-Y, sonv UlirtlllilKIll, All''! 1 ill mil ,1 li.lll ;iiv 111 liriollli' \Vl) III' ciiiirse o\ kidlirV Cilll l„iiis, lu'cli a iifiilule cii (litti) vesic eVi: 1.. 1>l ritilG Trka jiliiir III' Vi T. 1. D. l',,V liOlll il itlU aiHi siou nil ul CaU ttll cniirrf 111 cliiMren Sfi'oiKlni of caiK'ei C'LI cutfs cai luiial (lis iKiv will lull will jius till .vliiiwsil then no Di IS I! ilhe liyilvon cause c L'tC, hi lai i-asi cancer luai'uc PRACTICE OF MEDICINB. n , r iv 2 He may have or does suffer from pyelitis. Its symp- ;;;::::;-:;rr::;;t =;..:- j^^^^^^ .„,. not touud. 3. i.-tne NMll oe. siuiuy I » :. „,>,„..time9 cause of twilli. Time ;';; I ,.01111 m urme. M..re nuaos sulfur than females. I'UdfiNo.sis is unfavorable. "Pnr min "ive OiMuni, Oain- TuKATMENT.-ralliative. keep up nutnt.on. For pa m > *. ^ ^^ ,,,„„. „.,V,.,..nc. A ..vorite prescription ^^ ^^^^,1;'^ ^^ ,. n: ^.^, ■ ,. D. Lar,e doses grs. 5 Qunune are oood. ^"^"T^^^,,, ^^^ i.. ^.y^, ;,;.. „.,,. are usually ail^cted. Suppo^ ^^^^ ^ ^^r ..u-d. and exeU ,„a ,„i„ ^^i,s manifested in one side, then that Kidnej alone siou niiyhl be practised. cronprallv is secondary to ., I This v"f n..t l»ve bcc, preorfod l,y 2. Sy...l*«- »« cates cancer, no Clots, inis vm ■ „.;,i nr lith'ites in ur ne, or pains, ■ ' >«»■*■■.- '■''•"•rif "CL" ;— L™ ;Z«e,,t ,„ic.„HUo., „uv will gout have preceded it. Uunng nanua contains no ,„, .hen it ceases so does frequent desire to niake a^^. l- ^^^^^^^ j,us till advanced stage. At close ha^nia una is co ant. Cane ^^^^^ ^^ shows itself, and nosv a tumor can be made out, even may fill Y tlien not far off. f,„nm'in a child if not congenital DiFKEKENTiAL DiAGNOSis._A large renal tu no i a ch ^^ i. .i.Ucr a cancer or sarcoma. If tumor be -"go.u^^al "ay be cy ^^^ _^ ,,yaron..phrosis or malignant disease. Cancer of ^^ ^du by its L. diLulty, but the blood gathers in body, co^ d t s. may P ^ 1 ^^^^^^^^^ ,li;,gnosis, but seldom can you get them. Agt.u.aents for hemoirhage. TuEATMENT.-PaUiative. opiates for pam. Astun^ems s^i4ai.> if in Suri'dtnatniis llllt not HO lii cullril, lliul S CVS r It; i'n(Mi','li to pi U'twi'fii fj's Tliis i?i II ilif^ I'AUASl SOIUl'tillK'S t mill''. Hy Stiiiiii,'iiliis, cliyluriii it V.yj. Mtit liciiriii;^ I'tii": kiiliiry, but Cai'se nliiliitiiiiiiil .vliirli ilfii^ utiii. Tij^ cmscs u|i 1 kiiliu'V, or Miniiiiiii.i,' f liliiw miiy wliirli liok: 1>ia(t ill others a uuiy occui ureters as invtrr, I culla[ise n liuli- Woo iimtioii, — ri;Li';4iulio clofti' to r advisiihle walls wil Avoid CO $ Con (JLI other ut PRACTICE OF MEDiriNB. 76 . .r,.omatn,.s tu.uurs arc ulso .net witli in ki.lu..y. ImrJ to dhl\u^n\.h fn.u ^ " ^ ,_ !'^ I^ ,,„tuv..n cystH to preserve life. Cysts aue to a.stent.on ol Malph.gu.n u.,.a.. This i. a aiHtin.:t aisease fn.n. cysts formed by Unyht 8. I-M.^snis OK Kii.NK^.-Hvdati.ls of kidney often form hu^e tumo.s. .„ ji^^mlr opens into ..Ivls ..f kiancy and discba... f^^^;^^:^^^ „n„.. Hyautias of kia.iey are usnally an arcompanu..ent ol hyaatuls ol 1 ve ;..ul s a worn, is fouil in kidney. Fdarius hon.inis is found n. bl.xl n ;;ia it infests kidney. M-.vable kidney or .loat.n, '-^-^ -^^'^j ,^ 1-1 Met with especially in females 32 to U, especially u. adulU .m\ n UnlU l.J. Mtt w in esinxia. y ,,:. i,,,,, u 4 to 5 times mo.e ollen right iKMiiii'^penods, but IS met with in tUiiauu. i.s k,au.;, but sometimes both. May be congenital, but nmy be aciuned. CrsBS.- Absorption of pad of lat holding it (0 Cluet .u.se - - -^; ,,.,„u,.al walls, as after delivery, so kidney lacks support, ^oiiie i k any ,h„.h diiK's d.nvn the peritoneum may cause it, as severe hcun.t.o.pu lapsus T : t cin. is ISO given as a cause, interfe.es with action ol diaphragm, " i;^:-;;:/!..; movement, not -I— 'r-'-^^/'^";-..i:: ^^ t^ kidarv or pres.in.r of liver may push kidney down, (.real miisuda icats, ' d,;:at:Li: may not al/but -^^^^^ «'-^^. ^ ^-^"t ^^rS::; blow . inay produce it. Some think there may be congenital looseners ot tissues ^""■';.;:;:i:::;:^VMPX0.s.-The disease may be latent, no i.--,.ien. But i,.,thcrs a sense of uneasiness and weight are telt. Colic, nausea -' — - ^ ,„,iy occur. I'ains may radiate up to shoulder, as in kidney di.e , do u ,„vt,.,.asin kidney disease, or in testicle due to stretching -^ ^k ,u.c.t..r. Ficiuent desire to make water is noticed. In some ^-^ -^ ^"-'^^ collapse may thieaten. you suspect peritonitis. Unne high -loi'd peihap a hta. l,lood. Sometimes disturbed circul.- .ill cause edema ol 1^ hx. m- i,uaio,..-patient in dorsal position, kuees drawn up .i I ^^^^^^^^^ rec,.,nition ol a movable tumor. In thin persons you will see a little hodow clusf to nbs filling up if you push back tumor. „i,pp u not TK..TMENT.lEasy to replace, hard to retain, stitching into pla o not aavi.a4e. Modern stays from pubes to crest of iUum sustaining abdo al .alls will keep it in place. Sp'cial pads may be made, but are not saaJactoiy. xV.voia constipation. XVI. DISEASES OF LLNGS. Consumption causes ith of total mortality. CLINICAL ToPOUiUPHY.-Fiout-draw two horizontal lines .a.e a 3rd cth,.r ut 6th rib, and one at each acromial angle down. Then clavicle and .dges ot i i l!ii sternum niak cliiviciilav, m sujiurinr and td sidi's, (livi the liaek t\v( a suiiva sea] piila-v In f middle line Tlie light k laterally an tiien leaves lili, 8th lati rill at ridge the u] per The uii'lile level of iii] Lino into an up up oblique lli<;lit Inn: biiikwaul! |j( f i i) Afft and mem lilood vesi iiig of me " memlira meiuhrani or clirouii 1. That i FlKS iiKide of I in body. throat, li( sensation oxysnial, first is li ppots in b\it sligl duieker. '1 to 3 caiiillar; e,i>ed at ,.."^'i. 1 PRACTICE OF MEDICINE. •76 suiifiKir iUulimenorsi.uiicii. ■•- i ;„ftn-mr ixillarv rckms. On '"' ^"- '""•'^^'•t;,;f::^^,r>::^ ; ;t i "tit ^'«o,„, «k. ,l,e Lack two horizontal lines, one at levti i . ^^ .^^^^^ ^^^_ In f-"t the hn^s extena^orn U^ 2 n- W^ ^ ^_^^ ^^^^^^ ^^^ .^^^^_ .naaie line lungs do not meet till at ^^^ '\ J"' ^^^„^ ,,,3^ t, the 8th rib T,. n,ht lun, rnns down to ^^ ^/^ .^^^ ,^ ^^ ^' line to 4th cartilage, laterally and 10th rostenorly. Ihe le t 1" o' l^u '^ ™ ^j^,,,, ,, ,th ,,en Laves a notch. The " superficial - - ^^^ .^^^^ ^.,„,, ,,, ,,, .. ^:; -:;^ iL .he. .. -^-z:::^^:^:^^-'^ .p oiaiHuely behind to upper part, at ivelbehn^lo 1 ^ ^^^ 1 i,.ht Unig has another fissure, beginning ai 4th taitiia e, p tl^klaid: and intersects great fissure at middle of lung behind. XVII. BRONCHITIS. a„,:„™k. 0. BHo.cH,.-B,„„o„ui, is -'■-« ■•;'°,7°;-::;;f:i ,,U,». v..eU ; 2, ., i..™.se a« aU™ <». -. ^^ ,° „X„,,,,:c,en.. By „„„.,„l,n.no«s" .0 mc»ii a fom.at.on of '•. "" "° ' .„ ,„ b, „c„t6 „„„„,„,,„„. c...avrl.al lironchitis .n,.y bo V'™»'> "y^^^Uvo alfectod. 1. That involving larger tubes, ^.^entiai ,,„ :„volves trachea. Common l,Ksx FouM.-Larger broiichi involved, "-^^ -"^^ "^^^^^^.^ ,,,.e. .,.,ae of attack is sense of chilliness, lassitude, sb^ ftb"^ ^^^.^ i„ ,odv. Sometimes there are symptoms ot '^^^^^^^ j.^^^^^^^^^^^^^ sympto ns.- t,....a:hoarseness,etc. Coughing denotes bronchi '^"^^^^J ^^J .^ ^ .jy, ;,,„ s...at>on of distress, tightness, oppression in Iron f ^^'H' J^^lr. Then at oxv.uial, short and dry at first, no expectoration for 24 48 s «.; i. like white of raw egg, gradually becomes mcu-e f ee, cha g m 3 ^^^^^ .p„ts in sputa, then sputa becomes opaque-pus - W°«^; /^^^ , , , Httle L shght constitutional symptoms. ^^^ ^;;';'^^^^:tLn. patient. ,„„.ker. Symptoms g.a.lually subside, lasting 4 to days "r a ^^1.^^^^^^ , to 3 weeks in ^^^ ^^-SrefwlLit:;^ ^delLe persons or di. ::::!:Z:it:Z!:, ZX^ -.1. a., may even end .tally m these. hi < I < ^ ' 1 ; ill I'hI r.i i) 'l-ll PRACTICE OF MEDICINE. 71 T)inTSKGKNER.VL Bkonciiitis i3 severe, dangerous, involves whole of l„,,„.hiMl tree. Is also called capillary bronchitis. It is especially apt to occur i„ tiK. extremes of life-young and old. In adult, primary bronchitrs of larger lulKs rarely extend, down to capilUiry tubes, but secondary bronchitis from fevers, e:c does frequently extend to capillary bronchi. In children, intlammation of larger tubes constantly tends to spread down to capillaries, especially in weakhngs.. Invasion frequently sets in with distinct rigors, headache, vomiting, espe ,iallv when it begins in tlie capillary tubes ; but if it extends from larger bronchi ,l,Av;,, the attack^.f the capillary tubes is not so marked, but now and then the oxtension is marked with symptoms as al..ve. The disease may attack both Mnall and largo tubes simultaneously. Symptoms then would bo more severe, t„u|,>..ature 101 to 103, pulse more freq.umt, thirst, loss of appetite, urme ngli clnivd, etc., as in fever. In this case there is more constricted feeling in chest, , tearing sensation, dyspnoea, not noticed in ordinary bronchitis, but marked >n tl.is Urn, luinl breatldng. The relation between pulse and respiration is to be ,„„,.l. normally 4 to 1, but ratio varies in ditVuse bronchitis, perhaps changed ('•iiMiACTKR OK CouGH, in diffuse form, is almost constant, is a short bark, dn- at tirst, .rm.luallv expectoration appearing, clear, changmg to opaque, etc. In H.uiv eases oxygenation of blood is incomplete lor capillaries are swollen and air evils hssened. 'signs of want of oxygen, more or less livid.ty of ears, lingers, ete., drowsiness in children, and then du not like to be disturbe.l, constantly m childivu and adults the dysp.Kca makes patient sit up to breathe. Gradually as Co, anuamlates in blood patient beco.nes lethargic, cough diminishes, for respu- atorv .en.iv is poisoned, heart fails, pulse vapid, shallow and feeble, extrenimes .row .old, cold clan.u.y perspiration breaks out. Towards clo.se perhaps eonvu - Mon. and cou.a. When c,-" I. protracted, .edema of feet, fiice, etc., is markec . Tin. dilluse loini is particJ -!' ^atal iu children in a week, in adults 10 to U ,lavs. 1ml life has been destroyed in 48 hours. In cases of convalescence change lor lirilrr shews itself in 10 to 20 day.s. SiiiocATlVE CataKKH-'- Malignant Bronchitis "-sets in so violently patirut falls into collapse. In old persons and children great vital i.ro,tralioii. Wh,„ ivaction sets in, svmptmns of dilluse br.mehitis are found, but lever is no^. iiuuk.d. Symptoms of respiratory paralysis are seen on 2nd to 3rd ciay, due tu liUiii- up of line bronchi by mucous and conseipient Co. poisoning. MoiMui. Anat(..\iv.— " Bronchitis." Steps in catarrh of bronchi. 1. llyiier- aiiiia of inllamedtube down to 4th to 5th divisions, and at same time basement ineuroraue liegins to thicken. 2. Then is an o'.lematous state of basement mem- Iran., and submucosa, and so narrows tube. a. The cylindrical epill..l.um lno.,.u. aud des.piamates at 30 hours. At .sanic time the Hat rpithehum near la. HI membrane is proliferating. Tliis is the stage when patient com;,lams of r.uu.s., for basement membrane is raw, uncovered. In severe cases the sub- 10 liil . PRACTICE OP MEDICINE. •78 ■ ..„t oounective tissue proliferates, increasing the thickness of the wall Looking ,1,,,,.. expiration allows a certain amount of ar to e cape t o m a i. ..; J.et past plug of mucus, it ^tiug as a ^^^ ;-^^. ^ "ve^^Xs is .nulually exhausted from a.r v.sicle, hence collapse, ihisisavey """'ap^vnc. ok C0Lt.PSE OF Lu.G.-Herc and there are seen lobules in a , , overran other lobule, are dark (venous), are non-crepitant or nearly so. ,w.M l^'-.'^l;^"^^^^^ blow ..nnto bronchi in early stage. On invasion you ''^ 'r';:irS^"Xe:?teralbroncbitis. inspection. Upward movements . ^of r t' .re iic'eased -lower part of ch.st. expansion movement is of upper part of che,t are mc ta e J ^, ^ ,,g,^,„t note, no con- not increased, for air does not lush in l^"^^"^; " " ^ ^^ over-distention „,iaation, yet sometimes there is a hyper re onant '-; J^'^ ° .^^ ,,,U air. Extensive collapse would give dullness. ^;^^^''^X pitched ,„,e. gives some variety of wlustUng note bw ^[^^^^^^^ I,, i,, over small bronchi, sibilant wi.eezmg. ^^ '^ ^ ^^^Z on get moist , ,U.. due to vibratu.! ^^ ;^^^ ^i ^ ^Uo ^^^^^^^^ ^^^J^^ ^^^^^^ ^^ ^^^^^ rales, mucous rales, large and small ijuouii^ , , , ^2e cf tube, o, inspiration and at end or during expiration. Size ^l^^2Z^%r^..^n, Fuither, these rales are symmetrical, whole "^ bronchia tube atte^^^^^^ o . .11 be uniformly distributed, mucous rales ,n lower part. I alpation „ives '"" f"™ olusES,_Tl.e g,.*»t one is e«lK>™™ to cold, afr«i,.g any pa-t. Cold Z ^y » overheated d,ate, overheated air, aerial gase,. sucU a, el, le- da" til. etc. Wet feet, ntecl,an,cal irritant,, dast, especally ol ve,e.. I f 1| I ■■\ \ ' I "-^fi^" 'Ofgrnnmaimmm i ' > I PBACTICE OF MEDICINE. •79 aMr niiLiiii and cotton grain, tlion metallic dust, animal dust, laineval dust, iiiilJHs' asthma. The charcoal from uiibunit oil from a smoking lamp causes an astlimii. Tiiis sets up a broncliitis followed l)y fibroid phthisis. Epidemic inttu- oiicrs not well known, as iiitluenza, which is always complicated. Also diseases (hir to morbid poisons, as measles, whooping cougli. Local diseases in chest, as tubircle. lailmonary cancer, heart disease, valvular disease, leading to retarda- tiiiii, or bloi.d flow througli lungs, leads to bronchial catarrh, aneurism. Blood (lise'ises, as I'.right's Disease, acute and chronic parenchymatous nephritis, gout (hie to poison in lilood, acting as local poison. Diagnosis.— It may be readily confounded with acute pulmonary phthisis, bronchial pneumonia, acute tuberculosis. TuHATMKNT.—Can it be cut .sh(jrt ? Try. If in first stage try and avoid it by 11 diiiphuretic (not lemonade) and a purge. P.etter give Dover's powder gr. 10, or Antifebrine gr. 7 at night, and a saline purge in a.m. If disease re- sists tliis and develops, you have to treat bronchial catarrh. In the dry stage irive tartar emetic, gr. 1th to T^th, nothing surpa.sses it. Give it even every 2 hours if constriction is great, or put a grain in a cup of sweetened water, and "dve a teaspoonfid every 10 minutes. Vin Ipecac m. 15 is a full dose, it is usmd to add some salt. Pot. Git., Pot. Nit., Tot. Bicarb., gr. 5 to eitlior, each dose to (ithi'r Ipecac or Ant. Tart, promotes action. A se.lative is generally required. Tiiict. Camp, Co. in. 10 to 1 5 is good. Small doses if you are trying to promote socretiou. Chloral 1 to U per dose is good. Tiu-i. Hyos. um\ Hemp is also good at same time to allay irritation of throat. Air of room must be kept moist by a kettle lioiliim ill the room, or let patient inhale steam. If distress of chest is great, rovcrlt with hot poultices and hot stupes. They may be allowed to drink freely anv ..1' the mild alkaline waters. Once secretion is established reduce doses of Tart. Ant. to jVli gr.. or Vin Ipecac to lOni. r,r Ipecac U gr., still give the alka- line salts, '"'he Liq. Am. Acet. is a good addition to any cough mixture. Pot. lodid. i> a good li(iuifier of bronchial mucus, and if there be spasmodic action of bron- cliial muscles it allays spasm. Bellad. in a moist st.ge would be useful to allay spasms. Tr. Squills in 10 to 15 m. in moist stage is also good, also Am. Garb, gr- :■, to 4 is a good expectorant. Sedatives— in bronchitis of adults the fear of seda- tives is not as nece.s,sary as in children. So long as tliere is nolividity or dyspnita ,ni4 expectoration is free, you can continue the Tr. Gump. Co., but otherwise withhdld it, for he must cough, pain or no pain. Cahllauy BitoxciliTis (dangerous) at begiuuiiig needs promptest treat- inent. Aconite 1 to 2 gtt. of Tr. every two hours, or i gtt. every i hour for 4 to 5 linurs, to reduce frequency of heart's action, 'f pulse grows weak give Alcohol and ix-duce dose of Aconite. The same remedies can be employed as in treat- ment i.f ordinarv bronchitis. Spasms are apt to recur, so as .soon as the moist staue is reached add Bellad. In this form Am. Garb. gr. 5 is given early, e^lMMially in children an.l old people. In this form uatcli closely for accumula- liun .,f mucus, lividity, bubbling over back of lungs, then give an emetic. Dur- j ±Mm ? a i^mm » ji •I ! 11^ jt sx:.- . ii PRACTICE OF MEDICINE. 80 i„ ».pre*n of ,«se on,,., Co.ce, ""-^"^^^^XS ;:;;;;,, :::;t,r c:::. n„L „ot .» ,.,.,,..„. a.,.,,, i ^ . ...«o„. KXIICNAL ST.>u:l.AST8 »,e .leodeil in „11 se,^e,c « es „,,.„.,,,,,,»,,nlc,skc,t hot-care ,,..,tat,,U^^ ,„,,nuly, etc., for the chest wall ,s weak ^^^_ ^,^.^^^ lu.-T Tn firc^t sta"e weak, as muK, etc , in laiti m.Io^ Iron, mineral aculs as tonics, it st ii pci^ J ..u,.,. To,line Crotuu Oil, etc.. •UKl dryer, feed well, active couuter-irntation on chest, lodn c, u tt::;':::,::!:::: s::::rof »;;«.« a„d w.,oopi,„ co„,.-a„. „.» p,.. '' ".Zrj::i:en;ia.,yt,,o,eotac,,tefo™,o,,,,re.H,e,„^^^^^^ , „,if,»t. Tl,c „re.e„ce „. ,*.„cc of ^P'^-^^f f:^ ;« ou^ ^I ,Uv »,,rrl,, broochorrta. b,-o„cl,obbn„onte.. Tbe ,. .ecm -„ . '- - '"' ^^'•'T':;^:: 'r; -i" :.-: ::':" ireV-.., of m ly be excessive. Emphysema may exist. ,.,u,.,e vou will note tympanic resonance. membrane is MCUUP AN.TOMY.-Bronchial meinbrane -"=; ^^^f f^^f^' ™; 1,, ^ells U,v.,wn into folds and thickened ; under the microscope -^^"^^^ y\;!^^^,„„„ j^ ... ,.e. but an intermediate tr.«^ ^^ ^'ZL^:^:^^^^^ ,,;„K.hitis. In long standing cases certain el ects ^';'''''^;^^rZ:^^ ,m...io„ of bronch.; 3, occasionally fibroul degene.^on c^ ^ ^_- ^ ^^^,^„ MS begins around bronchi an.l extends into uug tissue , 4^on _ ^^ . to circulation produces dilatauon of right side of heart, and with it tucuspid ie„ citation, and finally cardiac dropsy. ;i i:.i rn iU' TllKATMK lliivct tiviitiii (diiiitci-iiTitat i|iii'iit I'liMiiiiji ] aiiit. I so ! |kir|iilll,' II 1', ft iNTKliNA iif scci'i'tiiiii.s ; ofotlii'I iipaal I states (.filisei I tcviT, till '11 ;j linatiiiii, t(ir I jatiiiit 1 li tllUSt'CTrtidllS Ilydrocyaii. j (itlu'V j.'roiii) 1 this iK.'i'ils I C(i]iiulia IT t lit' IiVotll-c, f,' t'Vtiy -4 lidui titill. TvY]iv •I'niiiiiiL' and uliitis, Oil (1 wi'll as seen Call). Ill It) 1 (li„ hctnre ilnvct ciiutac steam with • iilsi) \('i-y g(i the llil'dat i iiihalatidii.s I l',Tli>'i""l " lyiitii- Oil i: 5 tn 111 ilro] .-liasiii add 1 iff also gdod, aid. If ]iati( luivilh.ii, aiK he yiv.-n till seiiiatdiis b iheuiaatic o »i I' >v PRACTICE OF MEDICINF.. 81 sOi -*!'. l- -t i' J'i;i:\TMKNT,— First find out the cause of tmnble, ami treat it as if from gout, lulcdlinl, I'.ri.i^hl's Disease, valvular diseaao, etc. These need first treatment. I iirrrt treatment of elironic l.roncliitis. (h'eat l.enefit is derived from active uiintei-initation, rojieated small blisters every 8 to ID days. In mild cases fre- luiMMit nil.laii^' Willi Lin. of Iron, Tereb. Acct. or painting svitli Iodine St. George hiiiiit. I^'• -' to -A times ])er week. The use of these counter-irritants needs kiriiinu u]!, for disease is chronic. I.NTKliNAL l!i;.MK.iili;s.—l, Think of condition of mucous membrane ; 2, thiidi 1 .1 socictiniis ; ;], think of the .state of ^'Mieral system ; 4, think --f the condition.s |„l„tlMi oinans, especially of skin, liver and kidneys. Doctor Howartl divides slates i.f(hsenseinto2 f,'reat f^rouj.s; 1. If there be constriction, dry cou-h, slight it.ver, tlini oive e.Npectorants, Ant. Tart. gr. Jth to ^/li. Hive alkalies. ^ Com- l.iiialioii, lor they liipiify the .secretions and render them free, ns Pot. Cit. 1» laiirni 1m. old, j,nve Am". Carb., it stimulates. Sedatives to add must not dry ihrMHivtioiis in this dry stage, hence avoid Opium, I'.ellad. and ns; Chloral, Hemp llv.in.cvan. Ac, Ilyoscyamus, Apomorphine gr. ,',,th (last is good). 2. The utiier poup has little or no fever, expectoration is free, sputa now purulent, so this needs ehecking, so use stimulating expectorants, balsams as Canadian I'epail.a or turpentine or Tereb. in capsules. In elderly people, or if secretion 1.U proiuse, give Mist. Am. 4i oz., Tr. Camp. Co. i oz., Syr. Tolu. 1 o/., J oz- every 4 hours, also tar water and tar pills are good to check copious expectora- te,,,. Terpene in j^ill form is also good, gr. 15 to 30 in a day. Full doses of (.Miiiiine and Iron will .'.sometimes act as an a-tringent. In cases of fo'tid bron- rliitis, Oil of Sandalwood m. 5 T. 1. D. will often act well, elieeking fetor as ueli a. sr( ivlions. Carbolic Acid is also good for the last. Give as Ijelow Ac- Carb. in. It), Tr. Camp. Co. 2 oz., Syr. Virg. Prunes 2 oz., Glycer. 2 oz., Sig- 1 dr., before meals and at bedtime. Inhalations are also given, brings drug into iliivct eoiitact with the mucous membrane. Keep i jug of water at 14(i, and mliale ^tean. with vajior of Oil of Scotch Pine. Carbolic Acid or common turpentine is ilso verv i,M,od, but moist inlialation is not as good as dry, for hot .steam rehixe« the tliroia and leads to congestion. Use fndy in dry stage of bioi.ehitis. s<. dry inhalations are best. Coghill's Inhalation-Carb. Ac. 2 drs., Tr. l.,d. Aeth di- I'.Tl.vmol orCreasote dr. 1, rectified Spts. of Wine 3 drs., or yuu can use Luca- Ivptus Oil m. 10 to 15 on sponge, orCreasote and Alcohol. Terebine is also good, 5 to ]o drops on inhaler. In those cases of bronchitis associated with bronchial i i^asniadd 16 to 20 gr. .loses of Pot. lod. and Pot. P.rom., and addition of Pellad. I is also uood. Ill many cases of obstinate bronchitis only change of climate will ^ M<\. lt>alient be delicate, do not delay too long. A moist climate for dry expec- i.ration, and dry climate f.a' moist expectoration. Plenty of outdoor exercise to v.u th.>,n, tn„ir,H of all kinds. The inhalation of compressed air >ii emphy- lous bronchitis sometimes helps. Salicylates or Colchicum or alkaloids tor uutic or gouty cases. 1 (IcliiMtc ytii ffiiii^l fioin iiiiiiiltmue, luiiy tui'in (lisriisf i^ n tiiiiii iivi' li 111 I'll I'llSlU 1;rcsi'Ut, CO viijli'iit CO iiiti'vvnl of aciiti! I'lHiii I'MYS |i(iili()iislli llldllUMll ]> PliOC L'l Jilt! fnii TltKA livoiicliitis, stL'ai\i, of IlU'lltlod- !\ >VIUlltiiIll l,'..].,. Hi I'lit's acco Effi ciiipliysei tiirii' wa \rsicle.- i iimtiMiu, tlif body coiivulsi' tissue of iilisoibeil Thi iiver-disl vussels, ;ne affec Gk uucuvs i PRACTICE OF MiniCtNE. ^ I'lAST'c nnoN-ciiiTis (Mombmnou.) is very mro, is met with chiefly in ,,,lu.,a..'yo,"n,K unultH, especially tu».e.culon3 ; so.netl.ues occurs in children .uf. ;,.. fnnn bronchial catarrh. IV-culiurity o^ li«...e in a , ■,htlu..UH.-lno,<,ng ,.,„„.l.vauc, f..rn.. not in tn.hea hut in hn.nchi. may ccnplete y hno b, .h ' . ,„nn cylin-lers. This .nen.b.ane is f.-nne.! of cm^ulatea lyn„.h. Ih.s ai'.L,. is acf.te (rare) nr ..hmnic. The acute form is attended with fever 8,ymi.- ,,„H are like the ordinary acute bronchitis. But soon great sy.npton.s of dysp- ,„.,;, ....sue, nnroxysm ..f .•00^1., asphyxia may threaten, ha,-n.oi.tys,s n.ay i«3 ,„vs,...t co„.d,in,,' will in a few hours briuK up a tube cast in ch.on.c feu, ;.i.l,.nt' coughs. pa..oxysms of dyspncoa and expectoration of c.ts. then a^ u„erval of 10 to VI (Liys. a..d attack reFateC. it may last 1 to 2 jea..^. lb.) auiile form lustfl 8 to 10 days. , ,,,. , ,• „,4.;„ i-uv.tCAt. S.ONS.-Kales, whisll.ni. or b.onchial. or bubbling, but n. ccrtam ,,„v,io.,s there will be con.plele silence-there may be dullness the,-e also ; at any ...oineiit pneumonia might set in, with its signs compl.catn.j. aoov. PU0GN0SI8.-Acnte form is serious, chronic form is not sevy fatal, is recov- erililt! fro.... . ^ . .„ TKKVTMKNT.-Not much cau be done. In very early sta^e treat as ... acute Inouchitis. i.,halations of steam; i.i plastic stage still continue ndmlal.uns of stea.u. of sp,ay of lime wat.r, or slacked lin.e in t\,- ..mi. Pot. lod.d. is recom- „H.,ul.:d. also A,n,..on. lodid. con,l.iued with ^ u.. Carl, If any constitutional .v.upto.n be present it will need its own tre In.-n.t. (. !vnige o chmate may i:,.l„. Hroncbiectasis or dilatation of bro.ichi w a .eq.ie) o' bronchitis ; 3 van- .iw^s according to diiatation.-saccular, cylindrical • ".i -.''«' '"'^y '^'-^^ ''^'°« ^^' an egg. XVIII. EMPHYSEMA. Effects or CuoNCH.Tis.-E>,.physema is divided into : 1. Irue vesicular ..,npl,vsema,in which the air vesicles are enlarged in diameter and atrophied in ti.'iv "walls 2. Inte.lobular emphysema, in which air is extravasated outside of v...icles into the tissue. This latter emphysema occurs oftenest as result of trau- .natis.n. broken ribs, etc. It may run np mediastinum, neck, face, or all over Hi., body Besides traumatic origin, occasionally co.ighing (whooping cough) ...uvulsive may cause it; air vessel ruptures and air escapes into the connective tissue of the lung. This air may infiltrate all over the body As a rule air is ab,.o.bed, and recovery takes places. That is in the L.terlobular form. Tkue Ve.sicui.au Emphysema is divided into acute and chrome, but acute is .,ver.diste,.tion. not true emphy.sema. occurs whenever a person is asphy.x.ated, ,l,.,.,vni,.a .u.illarv bronchitis, etc. This is insufflation, as mere overh Img of air vessels, no atrophy of wall. The chronic form may be general when boll. ;...,gs aie affected, or local when a small part is affected. Geneual Emphysema may be hypertrophic or atrophic, last form only occurs iu old people. iil (Ir.N'Kl! V('s-i'ls with mill I litis pi-( iiiiiMuvity. iif iiilrrveiii At Niiiie til til 111 iiilectei liiiinu:, air ula-iu'ity, s iviM'ivinu; tl wiitcr, iii'o I Vf-iicios are II Iiiiiu' time iil'irr cxurtii ]i:llii\)-.Slll.S, flMlll ill'OUC liuruleiit. Ai'i'i;.\.ii ft'i't mv sco: )llU'-L'uliU'St failure iif ci (I I'liot Ilia In; loiiiiil. (iKN'EIi li\"]n rlio[ilii lrfi|Uently ill all rL',s[)i ciivulatidU TiiYsi with iiitt'iis iiii)\'i'UU'iit ; may ho luit hy|iri-i'c'soi iuva is hii'g. iiiqiulse ai hi'liiiul reac httli! air is iiiMiil, — his a!;- ration i 4 In 1 expi si;iia. Ag (111 iT,;d bi auil auscull PRACTICE OK MKDICINE. 83 (!i;n-i:r.\l ITYPEiiTRormc Emphysema. — It cohsi.sts of a dilatation of air vc--i'ls witli atrophy of tlieir walls. It begins liy gradually unfolding uf infundilndi, niiil Ihiis piogiussing till tlit? infundibuli connt^cted to a bronchiole all unite to form „ur cavity. This large sac, by pressing against a neighbor, by atrophy or al)Sorption ,,f intervening wall, unites with it. This process continues till large sacculi form. At Niiiie time, by stretching the vessels in the wall, circulation is impaired, nutri- tiiiii altected, hence atrophy both of lung and blood vessels. In the epithelium lining, air vesicles undergo fatty degeneration. Yellow elastic tissue loses its c!u>;icity, so during expiration lung does not contract to expel air. .MoKHiD Anatomy.— In general form lungs till chest cavity and opening. On ivmoving them are very liglit, contain but little blood, are pale, Hoat high in water, are quite spongy along edges of lobes, and large vesicles are seen ; surface vesicles are more enlarged than central, extending the symptoms. May exist for ;i luHu' time witiiout knowing; perhaps only symptom will be shortness of breath iliir exertion. Besides permanent shortness of breath he may have dyspmeal ]iiini\ysnis, due perhaps to bronchitis, asthma, over-loaded stomach. A cough fidin bronchitis may be symptom complained of. Sputa may be ceroid ur muco- liinnlciit. At'PKAUANCES IN' LvTEU Staoe.— Countenance bloated, puffy, eyes prominent, krl are scorclied, lips thick and livid. A sad depressed expression is notice 1, naiscidar strength is lowered, voice is low, cannot sp>'ak louil for long time, gradual liihiiv of circulation and respiration is also shewn by tlie livid extremities, sliape lichot may be altered, bulging where the process is barrel shape, or back may lie mund. (iKNEllAL SvMProMS are weak and slow pulse and respiration, rt. iuart is li\l.(riro[ihied, hence impulse can be felt on sternum ; urine apt to be watery, tuMiuentiy deposits oxalates, which indicate deticient combustion, look for tliese 111 ill! respiratory troubles. Albumen will be found when stage is far advanced, tirnilatiou weak. I'livsiCAL Signs.— On inspection, prominence of upper wall of chest, varying witii intensity of jirocess ; very little or no expansion is seen, only up and down ui'iviuient ; direction of ribs shew they are held up, are horizontal ; rib spaces may lie natural, levf'! or higiier, but lower in atrophic form, rercussion gives a iiyici-resonant note tympanitic, percussion shews lungs are enlarged, resonant iUiM IS larger, superficial cardiac region obliterated, heart pushed down to the left, iiiipulse ai ensiform cartilage, due to the dilatatii,u of lungs shoving heart, lungs i'lliiiul reach to level of 12th rib. Auscultation gives feeble vesicular sound, but litili' air is moving, for vesicles are already filled. Occasionally the opposite is luaiii, — hissing, roughness due to a mild degree of catarrh of finer bronclii. Also ■ignition in duration of inspiration atid cx])ivatinn. Inspiratory act is nnrniaHy 4 I'l 1 expiratory, but in emphysema it is reversed. Heaves in horses is emphy- si aia. Again sound is not heard with first movement in inspiration. Is called il'l'ired breathing,. Heart sounds are heard feebly, impulse feeble, Taipation iuid auscultation shew vocal resonance and fremitus diminished. 1 fillfi! ii Efvec bv toiiLtlieiii lll'llVl's U1US( it tririisjii Visrri'ii ii iiii] ainnl ui more oi' le elii olistnictinn; al eiitiir liiulii ill COil liv.SL'iiia n ] If nee in c full 1)1 wild 111 a lias overcc liasus, etc., le h\m, have eil'eet HlhI, etc. distention, ]iait oClun by compel Caus ilrv form 1 severe effc Then com its a modi lihvsema : eii new ijihyseii docti iif air cell out of til cause. Bi ai^'ainst c( against c( ;hitii luonc with moi In this C8 good, 1\ throat is tures in i HYi l^ PRACTICE OF MEDICINE. 84 Ffkects of Emphysema.— Eight heart liyportrophies. This is followed l,v tnu.rla.niug and tibicid change in the heart. This causes mal-uutrition of lasul'slmiscle and fatty degeneration, hence dilatation of right ventricle and with it tririi.i.id regurgitation, hence venous congcslioii (systemic). Lea.ls tu dropsy. Vi.ecra all undergo fibrous change, fibroid lungs, kidney (cardiac), cirrhotic liver, i„„,ai,vd digestion, etc., all symptoms of valvular disease of heart. All blood is „,„„. or less serous, hence general n.al-nutrition. lu later stages there are obstructions to pulmonary circulation Ijy oe.lema, hydiothora.x may cause bron- chial catarrh. - CorusE OF Disease.— Proves fatal by aspliy.xia, or by general dropsy, or by cn;,a„la in heart or great vessels. This may ensue early or be prolonged. Em- ,,1,\° cma may be produced by powerful expiratory efforts or inspiratory eilorts. llcncc in cii'onic bronchitis is caused by violent coughing. For you first take i„ a lull breath, close g'ottis, and then expire suddenly, when the expiratory act h,. overcome resistance of glottis. Hence unsupported parts of lungs, apices, Lascs etc.,.'et more air and get over-distended, ditto behind costal cartilages. But vi.ole lung suffers. The coughing act in the badly nourished lung will finally l.avc etlect. When caused by inspiratory act, in old people cartilages are ossi- tied etc. Muscles strong, so expiration is not complete, air is retained, hence distention. Compensating emphysema follows on reduction by collapse of some part of lung, otherwise a vacuum would result, so phthisis is always accompanied liv compensating einpiiy.setna. Causes of Emphysema.— Usually some form of bronchial catarrh, usually dry form from hard coughing, also in whooping cough, spasmodic asthma, even severe efforts of lifting, running, blowing wind instruments, etc., may cause it. Then compensating causes. This disease is sometimes inherited, the cliild inher- its a modified state of nutritive lung tissue, hence ordinary exertions cause em- l,h^•selna in child. Same applies to bronchius-it weakens, hence predisposes to emphysema, cough being active cause. Dr. Delafield of New York teaches a new doctrine, that emphysema is a chronic interstitial pneumonia atlectmg walls of air cells ; denies altogether inspiratory and expiratory theories of causation. Treatment.— Divided into curative, preventative and palliative. Cure is out of the question, so we should aim at prevention by guarding against the cause. Bronchitis, especially chronic, is the commonest cause, hence should guard a-aiiist cold, should accustom themselves to daily cold bath to harden themselves le.dnst cold, should wear Hannel to protect again.t cold. If already subject to bionchitis, should go to a warm climate in winter. Tine forests are good to those With moist bronchitis. The bronchitis should bo carefully and actively treated. In this case Pot. lodid. or Am. lodid. adiled to expectorant mixtures are especially good, llinger'a Ipecac Wine Spray twice or three times per day, spraying 1 ! Ti' ., 4- f-- ivi-tat-^icr dihite the wiue Amoni/ couirh mix- tlii'oat 13 good. li spray is too iiiitaii-ig, -nnu! iiic wjuc. tares in emphysematous bronchitis avoid Chloral. Hygiene and Diet.— They must not e-sert themselves too much, but I Jt '! ,! U; !!li slionlu be i fiioil, fill' a ; several efFt cmtinii, Ir( systuin Ilia l'\LLl inliiiluUdiu relieves ily not atli'ctei artiticial b ratiiiii is a] Atuo atrnpliieil. alls to (Jil MoKI tiry ]io\vei SVMP shortness c less lilood. PUYS spaces iiai iiisiiir.ttioii lleSs iiici'e. TUEA. AsTM rotie ail'ect 1 1 general smallest bi iiiiitie astli is 111! lesioi cmliac dis a iieinusis lif distiiig Symp e^peeiully is tlisturba iiilestiiie, liiL'liest c'.'A iiuin, loss ariual inv fi'jai mere ! V: MM, PRACTICE OP MEDICINE. 85 iliniild be In open air. Tliey must eat ouly atnall meals, or often concentrated fiiii'!, for a full stomach lessens breathing space. Stimulants may be needed for sevcntl effects. Try and restore general nutrition of body to prevent fatty degen- eration. Iron and Arsenic are specially indicated for this, also Quinine, Digestive -.ystiMii may need treating. Correct every disturbed function. Palliative Tueatmeht. — Keep bronchitis relieved. A direct method, the iiiliiilaliouof compressed air, hasbeun devised, a larger volume of air is so got in, relieves dyspncea, heart's action stronger, dropsy disappearing, etc. But cure is nut iilfccted. Inhale condensed air, e.xhale into rarefied air, is the perfection of artiKoial breathing, machines are made for it. Pressure on chest during expi- ratinu is also resorted to. ATinn'Hlc Emi'UVSEMA occurs in old people in whom lungs are becoming atr(i|)iiied. The tissue atrophying reduces bluod vessels, and gives room for air alls to dilate. MoiMUD Anatomy. — Lungs small, cartilages ossified, hence lack of expira- tiry ]io\ver. SY.MrroMS. — 1. Shortness of breath. 2. Reduction in size of chist. Thi .-hortiiess of breath is not much felt, for old people do not exert themselves and have le^.s lilood. I'HVsiCAL Signs. — Such lungs are as when we expire. Lower intercostal spaces narrowed. Kespiration short, recoil instantly after inspiration. B )th iiis[iir,itioii and expiration are short. Percussion nothing special. Cardiac dull- ness increased as lung is retracted. There is no hypertrophy of heart. TuEAiMENT. — Supporting treatment. Tonics, etc. Not met often. XIX. ASTHMA. Asthma. — Definition — Asthma (spasmodic) (Bronchiil A?th:av) is a n^ii- rntii' all'eution, characterized by p.iroxysuial and recurrent dyspnei, and, according 1 1 general opinion, dependent of tonic spasm of muscles surrouniiug sniill aui siiiidiiist bronchi. It is held by some to depend on spasm of diaphragm (diaphrag- iiiiUie asthma), and perhaps of other respiratory muscles. In pure asthma there is uip lesion, simply a spasm of muscles, but is often associated wit;h broncliitis ; canliiic disease is then a secondary atfection. So asthm.i is a neurosis. VVliat is a neurosis ? A functional atfection of a nerve centre or nerve, no gross lesion can be distinguished. Symptoms. — Often preceded by various prodromata, but may set in all at once, especially in that variety whicii sets in after first sleep. A common premonition is liisturbance of stomach, acidity, bad taste, coated tongue, or feeling may be in intestine, diarrhu3a, fiiatulency, or vesical desire to frequently niicturite, or liiuhest centres >uay be first disturbed, bein'.a h '..idai'.!'.:\ drow-iii'.ey.s, !u;gr!!n, il.di- runa, loss of consciousness, etc. Whether these symptoms precede or not. tlie aiiual invasion is sudden. Patient feels he is sulfocatiug. This sense may be fruai mere oppression to strangulation. Patient sits up, kuees are drawn up, 11 ! i i t I '.If 4 patient loans nary ami ex spiration slo distrcs-i, livi tenipiTiitufo face Hushed, oil', r.i'iiie <^e will be a del Air expired ami 2 to 3 da I'd i.'liiod, or many ciistJS (Inease oi' la iif after han spaces. Cii] rerciission i Vim exiiiuist cilia 1 iiui.sck vit!\ (• nuj^lo ail aeiHiniuli: cause preset: it ii'ciirs til iliici'l ill 11 astliin^i occa disease, as j caria. tuei^ri (■4 11 i vale lit. o 111' iiii'liial 111 coiilractioii 1 heme liy[ier ami S'liiiutiii acciiiml for C\i;sk; (J 1: NT It ck'liies.siiig al-iii L'aus(!S J)iin:(j' as aiieuris asliiiiia. KUCEN centres iiiv PRACTICE OP MEDICINE. 86 patient leans over, chin in hands. All muscles of respiration are acting, both orJi- iiiiry and extraordinary. The respiratory act is labored — both 3xpinition and in- siiiialiiin slow, 12 per minute. Pulse slower than normal, countenance iulioatoa (listrc-:-;, lividity, blueness of extremities, coldness, profuse per3|)iration. General ti.'iii|M'riiture falls from deficient oxidation. Voice feeble, husky, eyes staring, luce Hushed. During attack urine is limpid, cojiiousas m hysteria ; as it passes oil', urine gets scanty and deposits lithates in abundance. As a rule after tit there will bo a deficiency of urea and chlorides since metabolism was not in excess. Ail' cxiiired is loaded withCo^. This struggle for breath mavlast 10 to 15 minutes ;;!.i! 1' lo 3 days. As spasm passes off expectoration ensues, sputa may be like Jelly, r> Mood, f-rit may be more liquid, yellow, ropy mucus (humid). The sputa in iiiiuiy cases contains " Charcot's " crystals and little spiral casts. The only ilnriise Hi lu)iiTs in wiiich crystals are found. After tit patient is exhausted, sore, .'• iiilrr ' ^"d work. ^!(V^;;AL Signs. — Chest — great heaving movements, but base is drawn in .■-[jaci's, Cai)acity of chest does not vary miicii, for (jaantity of air is but little. IV'icussion normal. Auscultation, whistling rales, due to narrowing of tube. If you exiiiuist patient's chest by making him speak for a while the spasm of bron- lii.il 1 iuscles will cease, and breathing will 1); norm d for 2, 3 to 4 times. Thu Coukse of spasmodic asthma is ciiaraijterized by recurrence of spasms V :t'.i (■ )!uilete cessation of symptoms in intervals, like epilepsy ; thei'e seems to be ;,ii ;!Ci luiiulation of nerve force, spending itself in tiiis nerve storm when exciting tiuise presents. This tendency to recur is conliiied by repetition, for the oftener it iviiirs tlie oftener it will reuur. It is proi).tide some essential change is pro- lines I in nerve centres by first fit, hence recurrence. Genuine spasmodic a.>tlnnii occasionally passes off, but gives place to some severe form of otiier ili.-iL'iisti, as Angina Pectoris.. It som itimes alternates with gout, eczema, urti- Liuia. megrim, par.ilysis, epilepsy. So one luuirosis may be tlie pathological i'i[uivali'Utof an(jtlu'r. Effects of asthma: jiatient apt to l)e stoop sliouldi;retl, the liraiiiiial muscles hypertrophy; if there lie attendant bronchitis tlit-re will be cmiuaction of lumen of tubes. Emiiliysema is one of the most serious elf cts, licuii' iiypertrophy of rt. heart, dilation, tricuspid regurgitation, venous obstruction ami s-iiiietimes tlius dropsy. There is no organic change in nerve centres to iiL'counl for asthma. Cai;sks. — Divided into centric, direct or eccentric. Ckntuio Causes. — Through nerve centres, all powerful mental emotions, the depivssing passions, exhaustion, ori:auic diseases of nerve centres, as tumor; al-Mi luusi's acting through blood, as unumic asthma. DiUKUT Causes. — Pressure ui»on nerves supplying bronchial muscles, •:is iiueurisms, pressing on v.agus, or on phrenic nerve in dia[>!iin;i!iatie iijthnia. KccENTKic Causes. — Any reflex, from irritating (peripheral) a. ng in centres involved in asthma. Thus from stomach, from indigestion, b ■ lood, 'i^i. pickles, excess 01 the reHe astliiii;iti truiililed due to 8 tating S( may l)e excessivi these cii: I! lit for s posit ion tiiiii is h ri'edisjK liroiichit and delii dcpressii tiiey Ilia, mouest I coiiiinoni asthma. Di^ and iiitei children, Tiu known, : Am. Arc ciiiistipat twice in avert, ' getting r sdiue cas into seve ]'.eiiaJ., ] 20 of poi Hypodcr tiiere is iiypoderr liatent m (irindelia smoked, is a powe: PRACTICE OF MEDICINE. 87 jiiiklos, pork, also flatulence. Odors, as hay asthma, thus acting throuj^h nose, excuss of ozone in air, or changes in temperature may be the initial impulse to the reflex. Dust in atmosphere, bronchitis, em])hysema may act reflexly, causing iistlmiiitic spasm. A striiellad., Hyoscyamus, Stramonium, etc. This last is most popular. Smoke gr. 2iJ of powdered leaf, or 20 m. on blotting paper, and smoked. Acts promptly. Hypodermic injection is next best way. Belladonna is also good, especially if tiiere is weakness of heart, give Atropine gr. 1 — 100, 1 — 40 per mouth, or iiyiiodermicilly, or Tr. Bellad. m, 2 to .5, or Hyoscvamin or. 1 — 120. Various Iratent medicines are devised : Belladonna, Stramonium, Poppy Leaves, Tobacco, (ii'iudelia Kobusta aa equal parts, first steeped in Sat. Sol. of Saltpetre, dried and smoked, or take Stramonium ^ oz. Aniseed i oz., Saltpetre | dr. or gr. 5. Tobacco is a powerful agent in many cases, smoke till sick ; but tobacco smokers cannot use U , ! .mm PRACTICE or MEDtOIMB, 88 it, fill' it ia no good till sickness is brought on. It is a depressant, henne anobj linn. I'viiiline ra. 20 to 30, put on a ])liite and ignited, is advocated by French. Keep Vol nil closed and patient back from the plate. It loads to profound sleep and cli'lin'ssion, oven iiliinnin;,'— may be repeated T. 1. D. Chloroform is a promjit ;mi'iit to temjiorarily relieve spasm. Morphia is one of -'ta<,"'iil3 to shorten f>X, liiit danger of habit is too great to forgot. The de) >or motors are also iisi-fid, as Nitrite of Amvb Bromides, Ipecac, etc. A ,.)od emetic of Ii)ecac I if! I'U will cut short attack. Chloral gr. 15 to 30, ■[ ii- !.., is often useful. The I'.inrnides gr, 10 to 20 every 2, 3 to 4 hours are good, usually combined willi Cliloral or Stramonium m. 5 of Nit. of Aniyl iidialed acts rapidly. CEnEiii;o.Srix.\.L Stimulants,— Strong coffee, no milk or sugar, will sorae- tiiiios jtreveut or sliorten fit. Tlie fumes of Nitre have long been used, dip blot- liiig iiajKM' in strong solution of Nitre, dry, then burn in rouin. Smoke 4 to 5 iu sijitare at a time, either in a pipe or under nose. Spta. Ether Co. dr. 1 to 2 every two hours, or Etlur dr. ss., or a big dose of whiskey or brandy, will often -Imrten the fit. Arsenic smoked has also a good influence to allay spasm ; gr. \ .\r-i(Miious .Void in each cigarette of Nitre paper is also useful. All various c mibina- tiiins r)f cigarette are to be bought in drug stores. A dash of cold water on chest will often cause reflexly a deep breath, overcoming spasm. Putting feet in hot water mid driiilciiig cold water will often arre.st il. Above are only for relief of spasm. TuEATMKNT IN INTERVALS to prevent recurrence, etc. A change of air is nci'ded. Select climate the opjiosite to that in wliich he is, — town for country, low for high altitudes, hot for cold, etc. As a rule, atmospher-'s containing dnst iiie to be avoided, bui scoty atmospheres are bene' il. High altitudes (Colorado) ri'lieve a gr.'at many, not all. Sea air is suitable for hay a.sthma. Watch digestive organs, give dietetii; rules. Do not go to bed with a full stomach, have an early evening meal — say 6 p. ra. and Ijed at 11 p. m. This implies an early liifikfast, easily di.^'csted, etc. B)iledand roasted meats are preferable to boiled and fried starchy and saccharine foo Is should be avoided, as they tend to pro- duce acid. Tend to general constitutional states, treat gout, diabetes, skin dis- 1 ise (Arseiii':), etc., if present. Sulphur and Arsenic for skin atfections and local ' medies. Ti Oanth, i^ u-seful in asthma as.sociated with skin affections. BuoxcHlTls AND AsTHMA. — Eudeavor to protect patients against cold by wearing flanuc' , >jit in no drafts, avoid cold drafts, use cold baths, etc. If odor is caused by : iima, pei ps an inhalation of Carb. Acid and Iodine or Creosote would Itisseu liie susci 'ity of the nasal membranes. Nasal Causes of A>?i'ifM • -If you find any hyp.3rtrophy there, local treat- ment is demaniled, use of galvaaie coterie and strong solution of Iodine, such as Mandell's Sol. of Iodine, is in 3 different strengths : No. 1, 6 grs. of Iodine ; 2, 12 grs. ; 3, 24 grs. To each of these is added Pot. lod. 25 grs. to No. 1, 50 to No. 2, and 75 grs. to No. 3. Chrn'nu; Acid is also very good '^nr stomach cause, correct acidity by an Alkali, or give Carb. of Bismuth ; iect constipation. Ml! 1 ill PRACTICE or MEDirrNK. 80 Nehvoi's CAt'SER.— Sedatives nrn ijiilicuted, the Bromides, also lod. of Pot. Tlis iiist j^ives best ifsiiItH, }^r. 10 to 20 T. I. D. stu-niH to havt some specific ill iMii in ivstiuna. Uromides ullay sensibility of neive centre, hence ;^ivo combina- ti.ii (.f Pot. Biom. «r. 10, and Pot. lod. y\ 10, nnd Liq. Arseniealis. which is a nervo tonic also. Hellad., Stramonium, etc., may also be added to above niixtiire. K. l'„t. lod. j,'r. G, Licj, Arsenic m. 2J, Tr. liellad. m. d to 10, Spts.' Kilur Co. m. 40 to CO, Pot. Hromido gr. 10. A simi)Ie d.we is to be given T. 1. 1). for iiinntlis. You may call iiHlhnia an ejiileptii; iittiick of bronchi. lUh Put. lod. and ['ot. Bromides are (lej)ros.sing ; hence if it is administered fora long time, iiccil tonic to counteract, hence Iron, Quinine, Cod I.iver Oil, etc. Inhalation ok Co.Mi-ui-s.sKu x\ii{, especially if comj^icated with bronihiti.9 01 ciMphy oma, is valuable in asthma. Couutcr-irritalion down spine ia also jirautised. XX. PNKUMONIA. ihll PNKrMONiA.— Ccmgestion of lungs generally means pneumonia, but it ia used ignorantly ; true congestion is very rare. May be active, as in first stugo of I'lii'iiinoiiia; may beniei hiinical, cardiac, or passive when it attend.-? dtibility, fever, tie. I':;etmi(.nia means inflamnuttion of lungs. Forms are : 1. Croupous pneu- monia, in which an exudation is thrown out into the air cells of coagidabie lymjili, cilis not involved (loliar imeunioiiia). 2. Catarrhal pneumonia, the epithelium li'iing air vessels j>rolifeiates, undergoing inflammation (lobu'ar i»nenmonia). I'Mli of the above may be acute or chronic. 3. Interstitial i),UMimonia— the inter- stiiiid tissue is involved, giving a fibroid lung, this is generally chronic. 4. Em- I'olie when emboli produce local spots of pneumonia, an infarct first, going on to iiilliiuuiiation and abscess, this is comiiKjn as in emphysema. 5. Dissecting pneumo- 'iiii. lare. Is an acute inflammation extending from pleura along lymphatics to linigs,ends in suppuration, pus dissects out lobules from one another ; is common ill I attle, rare in man. Cnoui'ous Pneumonia— 3 stages : 1, Engorgement ; 2, red hepatization ; 3, givy hepatization. At outset there is an active congestion of capillaries. Liq. f^iiii-uiiiis is effus.d together with leucocytes. Litter on the epithelium of f '-e air vessels proliferates. lied blood cells also escape with leucocytes. This is the stii^'c of engcvaement. Lung will look redder than natural, heavier, is crepitant, pits on pres.-iure, still floats, tears easier ihau usual; ou cutting, a frothy bloody viscid serum oozes out. Stage of Eed Hepatization.— Coagulation of exudation of cells, filling vesicles, leucocytes are accumulation, also red cells increasing, and at the same -uiic the proliferntivH of epitlrjliuin continues. Li course of tiiue the uiTusiua completely fill uj lung?, hence lung is henatized. Lur.g tfien looks red, tho more recent the redder, the elder the less red, for exudation lessens blood supply to parts. Lung is also solid, nun- crepitant, sinks in water, tears very readily; torn ^H^H^K«'resses blood vessels, producing anaemia. The intianunatory products, leucocytes, blood cells, proliferated tissue cells are also undergoing fatty degeneration, hence yellow tinge ; weight, of course, is increased, sinks in water. Si r.sKQUENT ritocESSES. — Resolution is most favorable — fatty degeneration of inflanmiatory products, coagulated lynij)h undergo mucoid degeneration, and all are liquified and absorbed into the circulation again. The tension being thus taken olf the vessels, the blood current enters afresh into the ini])aired vessels, and ccdenia ensues, hence rales. Thus in 3 tc 4 days the i)roducts of iiiflammation can be absorbed. At this stage lung is yellow, friable, exudation looks like pus. Al)scess of lungs, gangrene, chronic cirrhosis or caseous transformations may result. First, snjipnration — some say suj)puration is not primary, but secondary, leucocytes degeiunating and forming pus, hence abscess of lungs. Abscess of lung after pneumonia is rare, is after 5 to 6 weeks of i:neumonia, varying in size from jicii lo fist. Abscess frequently communicated with the bronchus is evacuated, walls apjiroxiniate, and cure is effected. It is thought abscess is caused by exces- sive proliferation of ej)ithelium of walls of vesicles and great aggregation leuco- cytes. One says the cause is tubercidous, A third view is that it occurs when there is low vitality. GaN(;uene is also a rare termination of pneumonia. Occurs usually at about 6th day, generally localized, sometimes diffused, spot is dirty and greenish, tissue looks like rotting tow, odor very foetid, pleura also affected. Phoonosis. — If spot be small, recovery is just possible ; if large, impossible, fur se]itic;eniia sets in. Causes of this gangrene sometimes due to ])utreHcent iiiiilter in dilated bronchi, but in simple pneumonia will depend on the intensity (if the process ; may depend on extreme debility of the circulation of the part leading to local stasis, as from weak heart. It is also apt to occur in drunkards fiuni low vitality, also obstruction by thrombosis of some branch of the pul- monary artery. Collapse followed by cirrhosis of the lung may also follow pneumonia, caused l)y air not redilating vesicles after absori)tion of the inflammatory products lilliug tliem. Air obstruction. The bronchus would keep air out, absorption of intlanimatoiy jiroducts may be incomplete, or a chronic state of inflammation remains, as in chronic nejihritis, hence formation of fibrous tissue and cinhosis. Tli(3 induration may be in j)atches on surface or between lobules, or in larger areas, and leads to contraction and atrophy of that part of the lung. Caseous Dege.xekation may be a se(|uel. Some pathologists deny, some aliirm it occurs, is still in dispute ; a caseous spot iu the lung becomes a nidus for tubercle, some even say initiates it. A primary lobar pneumonia in a healthy man never caseates (Dr. Howard), a catarrhal pneumonia may. f( i PRACTICE OP MEDICINE. 91 Associated Morbid Appearances.— 1, blocking of smaller bronchi ; 2, cedpinii of the lungs of inflamed part ; 8, thrombus in the pulmonary arterial biiuiclK's; 4, embolism of pulmonary artery; 5, viscera may be congested; G, catarrhal stomach and bowels, diphtheritic exudation, etc. ; 7, pericarchtis by Mnijjle extension, or by blood contamination ; 8, ulcerative endocarditis ; 9, meningitis with purulent effusion (|)ya?niia) ; 10, pleurisy, ])!a8tic or (hy, occasionally effusion. Pneumonia may affect a siu^'ie lobe of one lung or both, usually it affects the lower bbe. Symptoms of Lobar Pneumonia always set in suddenly by a rigor, long and sL'vere ; now and then in a few cases there may be only a chill and sense of dis- comfort for a couple of days, or in children convulsions ; rise of temperature rapidly follows rigor, may reach 103 to 104. Vomiting may take the place of chills at beginin'ug, marked depression is connnon, pain in head may be severe, cough is usually early, and tliere is more or less dyspnoea. Patient looks ill. If pneu- monia is secondary, there is not the sudden invasion as wlien caused by some fever. In occasional cases, physical signs may precede the fevei', but only iu those of broken-down constitutions. Summary ok Symptoms.— Pungent heat of skin ; pulse frequent, 80 to 120, small, (juick, residration 40,50 to 60, thus altering jjulse resjiiration ratio ; headache continues, malar bone flushed on same side as affected lung ; deliiium is rare, may be in children and drunkards, and is commoner with apex pneumonia. Dowels usually constipated, tongue furred, appetite gone, thirst; vomiting is coimuon too, .slight or severe ; urine S. G. high, excess of urea and uiic aciil and pigment, deficiency in chloride phosphates ; albumen is also freiiuent, but, not serious, and indicates a renal catarrh. Jaundice also may be present ; if accoin- jianied by a stupor or delirium, is serious. The causes of the jaundice are various: e.xtrenie jiubnonary congestion obstructs portal circulation, sometimes there is catarrh of the bile ducts, or change may produce it (in blood) ; heipes on lip or face are common, and point to pneumonia in lung trouble. Pain,— there is always a stitch like pain in the side, lasting a day or so, but is not severe, and IS due to pleurisy. Cough occurs early, is attended by a rusty expectoiution, trans])arent, tough, vi.scid ; cough is short andfreiiueut, expectoration is scanty at first, but gets more copious, and finally gets a cake, less viscid, is not frothy, more abundant, mucopurulent. Expectoration is often absent, especially in secondary pneumonia, in delirium tremens, in old people, in apex pneumonia and feeble persons. Microscope shews casts of ultimate air vesicles, blood, etc., in exjieutor- aliou. True pus cells are rare, never white ; sputa are rusty, the bloou, in pneu- monia, contains an excess of. Sometimes actual hemorrhage occurs, even alarm- ing. The temperature runs a special course, is high from the first, iU2 to 104, oscil. lates a little, reaches its climax at 3rd to 6th day— 104 to 106. There is an evening rise and morning fall, a.q in typb.oid. This ti'!!!p'!:it .ire also declines sudden!-, a droji of 3 to 4 degs., and meaning permanent defer vescenca, but sometimes there is a slower fall. I'liVSU infliuiiod pi Iiliillniir. Till.- is due is tuiiiKiiiit air 111 tlie ai |iiriiiiiiii is > is i'iiummI 1)) 111 liriiiiuliio (ltU>ii'll, vo In SPEC Stage adi'i'ii'd siiJ piiriiiiuinia; t'li' Mime i'e frui|Ufiilly ] Fiist, liiL,'h J ca^e~ : then iiiitalile tact the Ifver do Villi may ha iiKivase in t to:il>lday, Mcal signs tli(irnii;4hly s tiiiid, iiiunin turatinn you hv, made out tliu altack is (kath limy o (i.V.NGKI l'CiNim.s of br Usually prov toiitliwii of a is tiiuiid in t uiiLuiiiiected pli'mal cavr PRACTICE OF MKDICINE. 92 riiVsiCAL Signs. — In first 2-i hours tlicro are no signs, but after that, if indiiiiK'il jiart be near surface, you will have a loud, dry, harsh, vesicular mimiiur. When exudation has taken place in air cells yoii will get dullness. Tlli•^ is (hie to absence of air and jiresence of exudation. Sonietinies tiie dullness is tviiiiiiinitic, due to infiltration of the lung tissues of part and diminishing of air 111 the air cells, that is condensation of lung tissue about ojjen launehi. lies- jiinitimi is weak, crepitation is present, but is confined to the end of inspiration, is cuuxmI by the separation of the walls of air cells stuck togetiier by effusion. In liiniichiolitis there is also cre]»itation, also an a-denia of lungs, pleurisy with ifhi^iiiu, voice may be already increased in resonance. I.NSI'KCTION will discover less movement on atfected side. Stage of Hepatization. — Inspection will shew less movement on aflccii'd side. The gnat physical sign now is dullness, varying in apex ].ii(imiunia ; when dullness surrounds the larger bronchi you get a tubular dullness, fur fame reason amply onic dullness may be noted. AiscuLTATioN. — You hear tubular breathing, blowing breathing, no more (iviitiition, voice, there is brunciiopliuny and echu reverberation caused by solid limg being a better conductor of sounds. Or vibrations of solid lung augment liuyiigtal vibrations. Crepitation is rare with children, but breathing will be wiak, iind in time there will be blowing breathin''. ]i;i!.\iix ATiON. — iiesolution ire(piently, abscess or gangrene but rarely. Death lieiiiieiitly 1 to G, in either red or grey age. This disease runs a definite cour.se. I'iisi. iiigh fever, lasting 5 to 7 days, is mild, and as long as 2 weeks in severe ta.^e-: then pulse becomes more regular and skin more moist, but the most iiiitalile fact is that the fever has left by a crisis in 4 to 10 hours; with children till' Irver does not end so rapidly, for it may take a day or two to subside. Again, vdii limy have a remission of the fever at the end of a week, but followed by au iiKivase in temperature and typlioid symptoms, the fever ending by crisis in 1-lth to l'l>i day, and patient rapidly convalesces. After a fall of tem]icrature the phy- -iial signs of consolidation will consist ; a iv^w days after expectoration has llii'i'iuiilily stopped a large iiuantity of matter may be coughed up, greenish, very lliii'l, miimmulHted, and you will tind elastic tissue, fat, etc. After this expec- ti.iaiion you will often have a cavity left, which if connected to a bronchus can lie made out. The expectoration often becomes fu3tid, and if the cavity be large the attack is very apt to prove fatal ; but if small, the walls may approximate, or (kaih may occur in 2 to 3 months from exhaustion of sup] lu ration. omre to changes iu atmosphere, fatigue, etc. Age, — often occurs under 5 years of age. Se.x, — must frequent in males (exposed), 30 to 40 years. Climate,— cold and changeable, esi)ecially if damp and windy. In Franco-l'ru.ssian war 25 per cent, of troops encamped in Mount Senis had pneumonia. Exciting Causes sometimes cannot be made out, but it is usually due to cold or exposure. This may not need to be severe, depending ou the resisting power of the individual. Thus, on^ fatigued would rcsi .t etfects of expt sure less than when rested. No other cau.\es ....'' th ■ disease may exist, but some say these are but predisposing causes, and that t:>c exciting cause is a specific germ. Still, the pneumonia following the disease (.other) is similar to the primary form, as that following measles or croup in children. It rarely follows bronchitis. It is common with delirium tremens, ouised by exposure. FriedUnder w 18S3 iso- lated a germ, a micrococcus from pneumonic lungs, a vos 1 m.'u. by 3 m.m., is usually encipsuled, and capsule may hold two in it .■• tven a colony. But these encapsuled germs are found in pleurisy. But Friei-.la'.deralso found germs or micrococci altogether ditferent from above. These he cultivated, and by inoc- ulation produced pneumonia in mice, but not iu rabbits. The first kind also liavo prcH.}uced pneumonia, biit usually pyiCiaia. But pneumonia is not always associated with these micrococci. They say that ditferent. cocci will give rise to pneumonia, ju.st as different cocci will give rise to pus, but pus formation is not a disease. And seeing that cold and exposure take such a part in briu«'in<' ou 12 ° ° iL r*i \\n PRACTICE or MEDICINE. 94 !' n 9 1 «f ■ 1 !• Mil attack of pneumonia, we may consider the germ theory unproveil. Wo cannot say tiiat jiriniary pneumonia is caused by a genu. Evidence of micrococci being cause i.s not at all conclusive. DiKKKKKNT ViKWs. — Tvvo views prevail respecting pneumonia: 1, it is a loLul iullaMiiuiition caused by cold, giving rise to fever ; 2, or it is a local lesion of a speeitic pneumonic fever. The allegjd existence of a coccus favors this last view. Tiiey say these cocci go in and out with tidal air, if they penetrate farthor the cilia drive tliein out; but if cilia are paralysed, then the cocci Hnd lodgment, JH'iice pneumonia. Reasons that pnuuinoni > is a specific fever are : 1, it is typical, cyclical, self limited course; 2, fever :.'aietimes precedes local lesion; 'i, there is no constant ruiation between fever and extent of local lesion ; 4, ordinary iiiitaiits traumatic, do not excite a true pneiiuKmia ; 5, it occurs epidemically sdiuutimes ; 6, the occurrence of a contagious form occasionally ; 7, cocci have been found in intlanied air cells, lymphatics of lungs and pleural surfaces, and by iiKiijuhition have given pneumonia to mice (?). 1, But although we cannot deny tiiat pneumonia is a, 2, specihc fever, yet epidemic pneumonia may be referred to a coiuiuon cause, — the weather; 3, contagious pneumonia. Dr. Howard does not leniendjer a case, does not spread from patient to attendant, etc. ; 4, many cases (if supposed pneumonia are not pneumonia ; 5, pythogenic or sewer gas pneu- luiiiiia lias occurred as a local epidemic, sometimes contagious, but is not onlinary piimary pneumonia. Di.VLiXosis in stage of congestion may be confounded with bronchitis, piiliuniiary coUaiise and oedema of lung. But bronchitis does not .set in as .Muldeiily, has not .so severe a rigor, temperature does not run up so rapidly, does not end i)y crisis. There is also a difl'ercnee in C(jugh anua as a rule is coar.ser and mniste.r tisan tlisit of pneiiuisnia ; 2, is not lolli)wed by positive dullness, although crepitation may be heard, so you will not have bronchial breathing. CKdema is apt to be symmetrical, but may predom- inate on one side if patient lies on one side. Sputa is thin, frothy, serous, not at all like pneumonic. It is a nou febrile state, no pain. Its causation is ditlerent, '•mmU&'^^'' \ I mm 1 M • ; pII 1 I i ^ PRArXICK OP JliKDIClNB. 96 ilvular (liHciiHc of li<'iu't, or BrigluV Diseam , or aineinia, piif -a, otc, and it ..ill u'iMi rally bo jiart of a tjianeral dropsy. In i i;^e "f hepatimu ,.iii, plciiii.sy (in ilfiisivo stag<0 and liydrutliorax inaj be coiifuHJng, will be treated of when we euiiie to them. P. ;;i'MONi\ OF Av\K occurs in old iieoplo, etc. Do not call phlhi^i.s, for |iii('unioni;i i.s an active febrile (! ise, but phthi.sis is a chronic diseas* t,, liiu'umonia you hiiv(j symptoms SI. ceodinj; i 'idly,— crepitation.dullness, U .ng Invatliing, etc. TuKATMKNT. — Modern trc; iient resembles Uiat of any fever, moi.^ly at- tempting t(» control: 1. Put patient to bed, and make him stay there, to save strongth. 2. Oive. patient a good nurse, save his strength, use a bed-pan, urinal, etc. 3. Temjterature of room, G4 is hot enough, no drafts, but ventilation should be good. During first few days fever high, give grii.d, milk, l)roth.s, etc. But in (iccurren e of hepatization (fever then subsides), then give upporting food, — meat liroths, egg nog, etc , Tt residution goes on l)etter if patient is well fed. Severe pain in side lasts only one day, apply hot stupes, or inject Morphia gr. ,V,th to Jth. Tills ]iain ison iist day. Some attach great importance to MorpI ' d! , .shock (il pneumonia to vital jiower.s, so in severe cases give Morphine to ^th by mouth T. I. D. for 2 to 3 days. As a rule this is not called fo> . Bromide will often do just as well as Morphia. Majority of cases in heal man will do with previous treatment. Not so with severe ca.se.s. .AIkuicines.— Liq. Amm. Acet. dr. 2 to 4, and Pot. Cit. gr. 5 to 10, or Pot. i'.icar' very 2 to 4 hours. Give a purgative at out.set, — 01. Ricini or Calomel i;r. r>. Bleeding and Aco ■ are not now used. In elderly or weak people, es| ■cially if in malarial dist- , give Quiniiir grs. 2 to 5 every 4 hours along with l,ii|. Amm. Acet., etc. It seems to be an antiphlogistic. If stomacli will not retain (.^lu, nine give per rectum. When pneumonia is of typhoid character you must give Quinine. Pneumonia is often accompanied by disordered stomach, vomiting, etc., m give Soda gr. ?>, and Calomel gr. J, every 4 hours. When hepatization occurs still give Salines and Quinine, imia-ove the diet and give cardiac .stimulants, as wine, Digitalis, especially if there are signs of cardiac failure. If hepatization is but slowly resolved, add Iron to Quinine, and give abundance of nourishing food. Sunu! recommend alkalies. E.Kternally apply blisters, or paint with Iodine, ur apply lurp. stupes, will ha.sten resolution. It is a special indication tin-ougli pneumonia to sustain heart, especially in old people, druidvards, etc., so give alcoholic stin;u- lants,— Musk, Camphor, Ammonia, Digitalis, for heart failure is the great danger of pneumonia. High temperature, over 105, favors heart failm ■, so antipyretics are needed ; give Quinine grs. 20, for it is also a heart tonic, or give, if it fails, Antipy- rine or Antifebrine, or if these fail give cold spongimr. cold pack, or ice cap to head. Antifebrine gr. 6, Quinine Sulph. gr. 5, mak' v ery good antipyretic. If in early stage you find marked dyspnoea, heart yet .strong, ])aiient rigorous, then he may be bled, is due to congestion of lung. Patient will have lividity, dysp- na'a not accounted for by fever, pain or extent of inflammation, breathmg will be MICROCOPY RESOLUTION TEST CHART IAN5I and ISO TEST CHART No 2l 1.0 I.I 1.25 IIM IIIIIM 1.4 IIM [12.2 [2.0 1.8 1.6 A APP L IED INA ^ GE Inc S^[ '&^5 fQ5* Mam blreel rJS ^ochtBlc. New Vork '«609 USA -^ (716) 482 - 0300 - Phone mamhmmttm ) PRACTICE OF MEDICINE. 96 rapid, and there will be abundance of frothy, bloody expectoration. It means Cdllaleral congestion of the lung, not pneumonic. A moderate bleeding, 10 to 12 oz. of blood will often lower this congestion. This state is not often found, sliould be so treated. A new treatment (French), based on doctrine of bacteria, consists of injecting directly into hepatized lung of 20 to 25 c. c. of Corrosive .Sub. sol. of strength of ^i Uo' I^o this in 3 to 4 places. Is not fashionable yet. Do not try. TuEATMENT OF GANGRENE AND PULMONARY ABSCESS. — On their occurrence, at once give stimulant treatment, — ale, wine, e'.c, strong broths, etc., and tonics, as Quinine, or Tr. Fer. Mur. m. 10 to 20, or if heart is low give Ammonia. Tur- pentine in capsules every 2 hours is valuable, checks fetor and secretion. In- halations are also used. Turps or Iodine, Carbol. Acid, Thymol or Creosote should Ix! used constantly to lessen secretion, fetor, decomposition, etc. Modern surgery opens such a gangrene or abscess. 1. Find out by percussion and ausculation the exact spot, and draw a circle over centre of zone, then define its edges to where it joins healthy lung. 2. Make an incision along lower margin of rib corresponding to centre of circle, drive in a fine silver trocar, and foetid gas escapes. Then dissect down to pleura ; if lung is not adherent to pleura wait 2 to 3 days till it is, withdrawing trocar and closing wouud. Then when adhe- sion is found to have taken place, thrust in trocar, then a sharp bistoury along it, then follow with forceps, and dilate them, put in a drainage tube, and treat anti- septically. Catarrhal Pneumonia, or lobular pneumonia or broncho pneumonia. Causation. — 1. Is especially apt to be an extension of bronchitis, espe- cially capillary bronchitis. Even a coryza may extend down. 2. Often is preceded by collapse of lung, some say it depends on lobular collapse, hence following capillary bronchitis. But collapse arising from weak inspiration, also liypostatic pneumonia, are but catarrhal pneumonia. 3. Aspiri into air vesicles of inflammation products from above as in bronchitis, l.i animals, division of vagi, larynx being insensible, allows particles of food to get into lungs, thence iuti alveoli, and cause catarrhal pneumonia. 4. Closely allied to above is pneumonia caused by inhalation of dust. 5. Conveyance of septic matters by blood vessels into lung may excite local catarrhal pneumonia. 6. Tubercular deposits, by mere extension, excite catarrhal pneumonia. 7. Even a simple cold may cause a primary catarrhal pneumonia. Predisposing Causes. — 1. Age, — is a disease of childhood, under 3, and of old age. Betwen 5 to 16, 25 per cent, of cases occur. It is a comparatively rare disease in middle life, except in paralyzed or bed-ridden. Occurs only under extraordinary circumstanct s, hence phthisis is not caused by this. But probably many cases are overlooked and calLd febrile catarrh, etc. 2. Bad ventilation and overcrowding. 3. Eickuts and aiiy affcctiori vvhieh weakens the respiratory power, perhaps by favoring collapse. 4. Various forms of atrophy in children. ii > 5 i . ' ; ) I ; 7, WIHJ ,1 PRACTICE OF MEDICINE. 97 Morbid Anatomy. — There aro the same 3 stages as croupous pneumonia, congestive, red and grey hepatization. T e main differences are : 1, In croupous pneumonia the disease spreads uniformly over a wide area, involving a lobe ; 2, the exudation is of lyinpli, red and white cells, but little cliange of epithelium of air cells, etc. But in catarrhal pneumonia the process is difi'erent, diflnsed, lobules affected, lymjih is scantier, very many wliite cells, not as many rod cells as in croupous pneumonia, and lastly the great difi'erence is in prolifer- ation of epithelium ofair cells in catarrhal pneumonia, Catarihal pneumonia is in two forms, — patchy (disseminated) or confluent. Disseminated form, when lungs are opened, little patches, violet color, not crepitant, and in lower level are collapsed lobules. In a further stage these lobiiles are red, congested, a little raised, on incision a frothy serum escapes, gradually this "ed patch becomes (greyer, even changing to yellow. Microscope at this stage in lobules will find a \'j\\ red cellS: white cells and masses of germinating epithelial cells, large nuclei, lu this stage, of course, frothy serum is not found, but thick viscid pus. In all c:isesifyou slit up bronchioles you will find them inflamed, shewing this disetise is broncho-pneumonia. The disease starts with a bronchitis, then peri bronchitis, then eH'usidu into contiguous air vesicles of fibrinous lymph and lymph corpus- cles, ej)ithelial cells proliferating, so vesicle is filled. Outer vesicles may also shew nroliferation. Besides above, little yellow bodies from size of pea to ha/el nut are >;'en on incision, are either ultimate bronchioles and air cells distended with insufHated pus, or else of pus formed there, degeneration, are tiny abscesses, do not nnstake for tuberculous no.'.des. Patches of " emphysema " compensat- ing are also found. Changes of Process of Disease. — Same as croupous, one point of differ- ence IS that caseation is often the result. To go over again, resolution may occur, products expectorated, etc. 2. Caseation may occur. Chief cause is great production of cells in alveoli and in septa, walls, etc., cutting off blood supply. This caseation is apt occur in old people, children after measles, in the debilitated, etc. This caseation is common only in special circumstances. Dry caseous necrosis (pulmonary) occurs generally as a sequel of broncho-pneumo- nia or bronchitis, but only after measles or whooping cough in children. But it may occir in adults. It most frequently occurs as result of tuberculous affection, aiso in otlier forms. So in a given healthy person caseation is not apt to occur. 3. Ulceration as softening of caseous mass, a cavity results. 4. Fibrosis, a chronic fibrosis of lung frequently originated in catarrhal pneumonia. 5. Emphysema, compensatuig, often found. 6. Miliiiry tuberculosis often a sequel. Either the broncho-pneumonia was of tuberculous origin or else gives a good nidus for tubercle bacilli. 7. Pleurisy, local. The confluent form of catiirrhaT pneumonia is apt in post mortem to be found, though lobar pneumonia is caused by junction of affected lol)ules. On close examination: I, it is not iis truly hepatized as lobar pneumonia ; 2, different part will be in different stages, a mottling of stages in the different lobules. U n hi lii ' ! 1 Cm; . .■')iu;iit(! liidiicliiti rliitis, \vl is .siiddci ll'U to 1 ])aroxysn ally cliiii 5. Valln uraihialb sliDi't. I is 14 dii} after wIk unite as Physical Apjietitc IlrJapSt'S si'vcial r Chronic nccurs ir hence ex Pir capillary cussion 1 lar and i ft'chle, n ill expin lii'catliin will ha'v f(irni \\\] may els- ailiilts. acute foi is not sii Co; ]ilicates, as lilood fjlottis. tyjihoid. disease i ajit to C( ble to le PRACTICE OF MEDICINE. 98 Cmnicai. Symptoms of Catarrhal rNEUMONiA are divided into acute, ^•'jiicutc: and chronic forms. Acute form is a.\>i to occur in course of capilhiry liiduuliitis, especially met with in measles. Symptoms are liixo capillary bron- rliitis, wliith see. 1. Invasion somotinios is ushered in by a rigor. 2. Invasion is siitiiiiii, (eni]ierature rises rppidly — 104 to 105. 3. Great fi LMiuency of ])ulse, IL'O to IGO, and respirations 40 to 60, All respiratory muscles in action. 4. The jiaroxysnial cougli changes to a short, frequent cough attended with pain. Usu- ally children will not expectorate. An emetic will biing up i)hlegin, not rusty. .". Tailor gradually changes tolividity, cough gradually ceases, heart rapid, coma ;.'ra(hiully ensues, etc., and death. It is a very fatal disease, duration of attack short. In children under 18 months will prove fatal in a week. Ordinary attack U 14 days. Recovery may take place, but relai)ses threaten. Subacute form, as after whoo]iing cough, rigcr may not be m. ked. Temperature rises, but not (|uite as high; the "kink" of whooping cougli changes to short, fre(iuent cough, riiysical signs are more marked than in acute fi.... , for more time is given. Ajijietite fails, thirst, restlessness, sleep, constijiation, desquamation of skin, etc. ]!('laiises are common, emaciation ensues. The disease (sul)acute) may last sevcial months, or may pass into chronic form, ending in fibrosis or phthisis. Chronic form may be ])rimary, or follow acute or subacute form. Generally (iccurs in adults or old people. Is very apt to be confounded witW phtliisis, hence examine sputa for bacilli. Physical Signs. — Disseminated form — if seen early you will recognize capillary bronchitis, which of all diseases is apt to jiasa into pneumonia. Per- cussion will shew scattered dull spots (stroke must be light), especially in scapu- lar and interscapular region and on both sides. Auscidtation — breath iig sounds feeble, marked by fine bubbling. But faint blowing breathing may also be heard in expiration. If a patch be close to surface you may in this spot get tubular breathing. Vocal fremitus exaggerpted — bronchophony. In confluent form you will have decided dullness, blowing breathing, increased vocal resonance. This fiirm will often be unilateral, same as lobar pneumonia, or disseminated patches may elsewhere be found. Vocal fremitus in children is not noticeable, but is in adults. This form is apt to occur in chronic cases and run chronic. The hyper- aente forms of broncho-pneumonia have only signs of acute bronchitis, for time !■> not sufficient for development of pneumonic symptoms. Complications — Capillary bronchitis is always present. Pleurisy often com- ]ilicates, hemorrhage into structure of lung, do not give rise to special symptoms, as bloody sputa. Catarrhal croup is also frequent, attended often by spasm of glottis. Pulmonary gangrene is also sometimes met with, as after measles or typhoid. Pulmonary abscesses — if a predisposition exists to phthisis, then this disease is apt to light it up, lessens the resisting power. Fibroid jihthisis is also apt to complicate, and is attended with dilatation of bronchi. This disease is lia- ble to lead to general weakening of entire body. III'' u MM TRACTtCE OP METllCrNE. 90 Tr.EATMENT.— Present capillary bronchitis developing into piimimonia. Every rliiM ortlelicato adult sufTeriug from hroiiciiitis, measles or whodpin-,' cough slio'.iid be kept in house ; if dehcate, in um warm room. In first stages lieop in liwl, ditto if attack is severe. In convalescence when chill goDS out have it warmly clad. Prevent accumulation of inflammatory proilucts in tiie l)ronchi, liciicc favor cougli and expectoration. Give an emetic in i)ad cases, one in a.m. and one in p.m. Emetics also act as expectorants. The ei^i^tic shoull be stimu- luting, as Ipec. Pulv. gr. 5 for infant under months, gr. 10 if over a year. Put ciiild in erect posture ; emetic acts readier. Give drink to fill stomacii. Add Am. ("arb. to the Ipecac. Alum, Z. Sulph., etc, may also be used. Expec- torants and alkaline salts are given from first. If chiM is weak give an Am. Salt, U([ Am. Acet., or Ipecac Vin. m. 5 to lU, and gr. 1 of an alkaline salt every 2 to 3 hour.», if dose for child. In severer cases Tr. Aconite gtt. i every hour may be given. Watch effects, and stoj). Pot. lodid. in full doses in early stages. i. g(.ud. If fever or debihty give Quinine gr. { tjvery 4 hours to child, and gr iVsth Strychnine. When expectoration is freer add Turps. In early stages first week keep air of room moist, even hoo]) bed, and introduce steam. Opiates are poison, check coughing. Annn. Anise, Senega, are good to stimulate coughing. EXTEUXAL Tkeatment.— Poultices fre(inent, not too severe or too heavy, are "ood. Mustard t)lasters to redden, cotton wool jacket. Turps and Acet. Liu. rubbed in well. Diet.— Support needed from beginning,— broth, milk, etc. Alcohol later on. In subacute and chronic forms treat as plitliisis, change of clinuite, give tonics, as Cod Liver Oil and Iron. Let diet be g(jod. Quinine, dry inhalatiims are also good. XXI. PLEUPJSY. Pleurisy is inflammation of the ;)leura, may be acute, subacute or chronic, may be dilTuse or localized. The last is at apex or diaphragmatic inter lobar or mediastinal. AH serous meniliranes suffer the same operations in iuHiinimation, as in pericarditis, perit(juitis, etc. Inflammation as it attacks pleura has following steps: 1. Congestion. 2. Exudation of sifriim, migra- tion of white cells, and occasionally proliferation of epithelium. Often connective tissue cells proliferate, or at outset of acute pleurisy the membrane is con- gested, red, has increased vascularity, then comes exudation rai)idly coagulating. At first forms little transparent liquid masses on membrane, wiuch enlarge, coagulate, fine delicate fibrils forming, thus formir a false membrane, rough to the touch and eye. There is also a migration ol v -lite cells, infiltrating and thickening the false membrane and rendering it opaque. Sometimes migration of red cells is seen, minute ecchyraoses appear as in hemorrhagic pleurisy. In plastic or dry pleurisy organization may take place, the leueoeylus forming embryonic tissue, and thence changing to cicatricial tissue, this also becoming vascularized. This vascularization is accomplished by budding of the capil- 4:. pr VCTIOE OF MEOICINE. 100 luiiis iipuil niectinj,' a siiniliir one uiid joining it. These buds are at fuHt Holiil, tli.'ii <;r,i(liiaUy suften aiul form hollow tul."0, thus vessels, somelimea by joiiiin;^ aiiil fiisioii of elongateii embryonic cells tubes, arc formed which join to buds of „n-iiiid vessels. Tluis tlie cicatricial tissue bi^conu'S i.crmaniuit. In mild castas (,| pleurisy tlio epithelium (•ither remains intact or ijroliferates, and forms new iiiiitcrial; but if iu'lammation be severe, the epithelium desquamates and perishes. Wliru new tissue is formed it is called tibrinuus pleurisy or plastic pleurisy. ]| nmvf uiMit be free, long strands uf fibrous nuiterial are formed, bridles, other- wise iulhesions are broad and Hit. In many eases, scrofulous, etc., an ellusion takes place, either serous or sero fibrinous, rich in albumen, often readily coag- ulaiile on drawing olf. It varies in quantity from 1 oz. to 2 to o pints. The tliiid is always opa(iue from leucocytes, shed epitheliun) or shreds of tibviuo (tl.ieculi). When there is etfusiou the serous parts are absorbed, the solid parts liipiify and are absorbed. So long as fluid remains the intlameil membranes are separated, but on absorption of fluid these surfaces approximate and cohere. If v,a examine an inflamed membrane you will find a cohering layc ; the outer j.ait of this liquifies, but the deeper parts are composed of proliferating epi- iheliiim. A granulation tissue wiiieh approximated to opposite siufacie unites, Miidiug lung to spot by the cicatricial forming. Another change is the luflam- iiiatuiy products may degenerate and form pus. Sometimes the exudation is primarily purulent, as in empyema, so you may have either primary or sec- ondary jjleurisy, even the pus may be absorbed, and afterwards surfaces unite. The pus may escape by ulceration and perforation of tlui parietes, leaving a fistula or perforation of lung and leaving a bronchial fistula; or it may [ieiforate the diaiihragm, setting up fatal peritonitis, or perforate a hollow viseus, and escape by stools. If chest be completely filled with fluid the lung will he completely cur like pneiinioniii, followed by typhoid symptoms, breathinj^ even 40 to 50 urging dyspncm, and unless relieveil by u.vpiijiiii)ii will (lit!. I'livsiCAL Signs — 1. Of early nr dry stage -inspection, . added to Digitalis and Squill's Pill is good. Ito not salivate. Germans use it. If in 4 weeks signs of absor[)tion are not visi- lili', then aspirate (3 weeks in children). In early stage there is another method of treatment, give Pilocarpine or Antipyrine, sometimes leails to absorption. Another is salt cure. Dr. 1 Na. CI. every hour. Do not let patient drink, take salt in J tumbler of water. The " dry " cure is resorted to if patient will not allow aspiritioii. Diet is low, broths and milk in first stages, increasing as al)sorption sets in. It does not necessarily follow that aspiration cures, especially iMily operation. Often it needs repeating. You cannot always abort by tap- ping. In advanced stage and absorption going on, you need generous diet forsup- jiort. CiiuoNic Pleurisy. — Acute form should be prevented becoming chronic, Imt given a chronic case, what is to be done ? A very vigorous sppi)orting treat- 1111; it must be started. In addition to ordinary treament, give 01. Morrh., changes of air, sea voyage, etc. If fluid is present chest must be tapped. Ee-Aspiua.tion Gkmeral — , when ordinary mji.as to promote absorp- tion have failed ; or 2, when one side is filled and threatens other side, esj^ecially if severe dyspnrea has threatened or occurred; 3, if empyema is suspected, use hypodermic syrii;ge to diagnose, and treat surgically; 4, if cheStis half full of fluid and does not go away, tap ; 5, if there is (in double pleurisy) flu. • enough to fill one lung, tap; 6, in Briglit's Disease, elderly people, phthisis, tap. WiiEHE TO Tap — 2 to 3 favorite sites for tapping: 1, in back below inf. angle of scapula, tap 2 inches above lower limit of sound lung ; 2, if drainage tube is to be put in, go to axillary line, say half way, some say post axillary line al)out 6th rib or space. Advantage of side oi)eration is patient can lie on back. D-inger of tapping : 1. Syncope. 2. Cerebral embolism from clots in com- PRACTICE OF MEDICINE. 106 press- (1 lung. Caution — never perforate where you get a resonant note on per- cussion, or loud breathing, or if space he depressed ((idhesi(jn). You use the ordiiinry aspinitdr (oiU'd). In drawing off fhiid do not try to enipiy the cavity at out' sitting. WliL'ii i)atient begins to cough (lung expanding), or pain is experi- ciiicd fi' ,k' ;" i^ PRACTICE or MKDICINB. 108 „n,l,.r.'.. lil.roi.l or mlc irooua dogenoriition. A cavity may 1)0 left by tl.e disl.Ml^ma „;oii," ,f tli.^io luaHses, not a true tuberculous cavity. 15ut tlio h.'inonluiyo may Hft M|. a InouclK.-pnuumoiiia which favors tho entrance of th-- baiulli. A iiriit.Mctcl c.ugli may bu anotlier moilu of invasion, dry at first, then scanty sputa »uv;iko.l Willi yill'w from intlam.xl broi- ! i Hut tiio physical si^-ns are not tl„H.. ofbronchitis. Miy bo couliiied • lin ureas not near base, etc. A ,atanli of apex su-^est^ phthisis. Alwavs suspect a prolonged CM.ah wUh..ut hrniicliitis si.-^ns. 'I'liis cougli n almost alvvnys attended by elevation uf tempera- tinv Ordinary bronchitis is not a mode of invasion of phthisis, f(»r it is not an unliniiry bronchit s, but speciti, Catarrh in a healthy person di>es not pass into phthisis. But a more speciHo broudiitis may jiass into a bron.hn-piuuimonia, thus l.ivoring entrance of b icilli and phthisis. H<'nce treat broii-hitis, especially i„ „lul(hen and delicate on, s with great care, ditto measles, whooping cougli, etc. I'lrurisy also appears to usher in piitiiisis, may l)e localized over apex, motlerat- but abiding fever, etfusion moderate. Tlie signs of phthisis manifest tiicm.sidvos li„m 1 to 2 months to year after this pleurisy. Occasion My tliere is pleurisy with givut etfusion. Laryngi^al catarrh may aUo be the mode of invasion. Is a Uvd sign, usually do not do well. Laryngoscope shews pyrifurm 8welling.s on nryt.'iioid cimibiges. But sometimes simple, mild laryngeal catarrh is a sign of impending lauliisrs. An auicmic state of larynx is common m plilliisis. A eomm..n mode of uivasion in the young is an enlargement of external lymphatic gland a, uf nc;k. Scrofulous glands are tubercular. When they soften and break ■i..wn then system is invaded. A statement tiiat tuber dous disease of ineseiileric glaii.ls is primary eaiise of tuberculous disease in children. Certain disease of Lu.s, nioibus coeci, ciries of vertcbrit', etc., an all tuberculous atleclions. In • a^.'s of hiemoptysis, pleurisy, bronchitis, laryngitis, -aries, etc., when they u.sher in phthisis, several explaualious are olfered, viz., that these disjases are evidences uf tuhsrcular disease already present. 2. These liseases may render part m.av liable locally to penetrability of the bacilli. '• Or the.se diseases may only lower vitility, and thus lower resisting power of tht:; individual. l'ii\rilCAL SIGN.S OF riiTHlsis.— Vary with stage. 1, In early stage, sujiiiosea few scattered nodules in apex; and 2, wiih several large masses. Witii tiist no signs would be detected, but you would get round note, butauseul- t;tt:oii gives feeble respiration or else harsh. Sometimes the expiratory sound is uii.hily long and rough. Vocal resonance, expansion, etc. give no sign. But iu second case°there would not be full expansion. Terhuus also tlatteiiing and loll/pso and fibroid sl.u'iuking of lung. Pereussion gives dull note, the degree Nuiyiug to wooden dullness with amount of tubercular coi, olidatioii. Auseulta- tiuii "ives harsh breathing or blowing or tubular wiien t usolidation is great. Yucd resonance is greater, uI,jo heart sounds. Wavy rcspi^ -tios'..-. luay be n.jted, jerky cogwheel. This sign is valuable when in apex, especially if breathing ia liaisli, in addition. May be owing to partial cousolida' jus and adhesions iutcrferiug with uniform expansion of the lung. 1 ; \ t* 1 i ' i '1 r M \ PRACTICE OF MEDICINE. 109 Second Stage ok Sokikning. — As a rule there is only one new sign for this. Tiie foregoing sounds may be present, but when you hear moist crackling 11 indicates .softening. It may be fine as at beginning, getting larger, cracking, I'lii'kiiig, — with it probably the area of dullness, fiatness and non-expansion arc laii^cr. Septic .symptoms probably are now seen, chills, hectic fever, night sweats, emiiciation, sfjuta will change, will shew bacilli, shreds of yellow elastic tissue Mild pus. Tliird stage of cavities : — Softening gradually enlarges, masses are spit up, leaving cavities, emaciation is now advancing rapidly as a rule, night sweats more frequent. Patient cannot lie indifferently, but lies on back or healthy side laiyn.K now also gets affected, also epiglottis — vomiting is also a symptom, reflex from 'he cough, or else from ulceration of stomach — mouth is apt to be raw and apiithons. Cough is now loose, mixed with blood— hfemoptysis is common, may be fatal from a small pulmonary aneurism buisting, pidse weak. In longstanding cases an alteration is seen in lingers and toes, the ends become bulbous and nails convex, indicating chronic disturbances between circulation and respiration, as in some cases of chronic aneurism, emphysema, valvular disease. Physical Signs of Cavity.— Depend on size, position, state, etc. First a moderate sized cavity in apex surrounded by consolidation is one case, another is a cavity very near surface. A third might be dee[) seated, and fairly healthy tissue int(!rvening. Where a cavity is near tiie surface there is a flattening with a di'ticieui'y of expansion in all cases of cavity. l'ercu.ssion in the first ca.se gives diilhiess, heavy strokes may give tul)ular dullness. Percussion in the second cast' may give amphoric sound. If several Ijronchial tubes open into it you will get tlio cracked pot sound when tiie patient's mouth is open. In the 3rd case you may get normal signs. Auscultation over No. 1 will give no sound if cavity is filled ; but if half full of fluid, with bronchus opening into it above the tiuid, you will get cavernous breathing. If cavity is larger, amphoric breathing may be noted, but is rare. You get it to perfection in pneumothorax. In a cavity iialf tilled with fluid, if bronchus open below the level of the fluid you get bub- bling ; UKitallic tinkling is exceptional, for it takes a very large cavity. Same with iiietallic echo. Co.\iMON Symitoms. — UiarrluBa may precede tiie local signs, but is never coiiinion during disease. Its peculiarity is its uiitreatable character, no pain, but wiiMU ulceration occurs in intestines or stomach pain is experienced and blood is t'oiMid in the stools. Peyer's Patches may ulcerate without diarrluea. An obsti- nate diurrlujea in a young person is suspicious of phthisis. Anii;niia is always IMvsiiit, andlividity, fatty degeneration of the vLscera, etc., shew failing nutrition. Tlieie is also common a local fatty degeneration of the liver which gets enlarged. Aniyhdd disease of the liver perhaps involving si)leen is caused by suppuration !!'. Mi^. lung, FLstula in ano may precede phthisi.s, but usually accompanies it, I -^I'lriidly in later stages. It is apt to be chronic, acts as a safety valve and is livoi.ilile. Do not operate. The bacilli exi.st in these fi.stulif. Best authorities 14 1: r ! ■ i ■ 1 i 1 , 1 IIW 1 1 I:. .. 1 ' 'I --ll PRACTICE OF MEDICINE. 110 aiv in favor of operating, but Dr. Howard is not. Intercurrent acute pneumonia. Srlddia very serious, not as serious as primary pneumDiiia unless in the late stiiiii's of phthisis, also local bronchitis accompanies phtliisis. I'leurisy, either plastic or elfusive, or perforative, settinj,' up pyo-pneum (thorax. This Liot is aciuinpauied by shock, intense pain, and generally is rapidly fatal, but not always. Ulceration of epiglottis is found in advanced stage, is very painful on swal- luuing. Chronic laryngitis is found in a bad stage generally, Tub.u'culai menin- gilis in adults atid tubercular pcritonilis is advanced stages, which are fatal. (jAUS.vnoN OF Phthisis. — It is an infective disease caused by a specific bacillus which can be classed in Zymotics. This bacillus is ji,,,) t^i^- to tsjjo in hiiigth and ^ as thick or i to | as long as a red blood cell. These bacilli aie found in sputa in stage of softening, free in the cavities and ulcerated walls and in caseous and catarrhous tubercular pneumonia, but are few ami far between. In miliary tubercle, but not jdentiful, and in blood. Tlicse bacilli are found in all tuberculous diseases, as strumous synovitis, sciiifidous ostitis, in tuberculous disease of testicle, scrofulous kidney, glands, bU]iiurenal capsule, etc., in larynx, peritoneum and in urine when bladder is ailectcd. They live upon the tissues, as parasites — not their worst effect. Tlu^y ahso produce leucomains, organic poison is their worst effect. The.»e S( cietions lower vitality of the cells, thus giving bacilli the advantage, and de- struction ensues. If phthisis is due to micro-organisms in air, which when ia- lialed set up phthisis, why do not all have it ? One reason is that the germs are only in the tidal air, and if bronchial membranes are healthy these bodies lind no nidus. Another is, there must be a predisposition, so that oidy c.^rtain indivi- duals (jf families are its victims. There is a predisposition to race (negro), family, or individual, and iu recovery of each individual varying with the age, which in tile adult predisposes to seat in lungs. The general or lo(>,al pr.'disposition is iiilierited or acciuired. If there be no predisposition the entrance of the bacillus lias no etl'ect. Tiie law of heredity is, modes of vital action become impaired, may be continued, and even become more manifested in the child, so size, shape, color of hair, digestion, passions, etc., may be inherited. So tiie predisp )sition, not tiie disease, is communicated to the child. A few cases are recorded where tiilirrcle has been born with foetus. In these cases it is supposed father had tu- liircle of testes, or mother of ovary. A recent view is, it only occurs from w" jq Iilacenta is tuberculous. The ratio of inh(n'itance is frjm 23 to iS per cent., or ahdut 33 per cent, of cases, but peo[)le are as ignorant of family liistory that the slury is incomplete, for this disease may skip a generation. Tiie later children nt tuberculous parents are more liable than earlier children. I'lies; are more liM'ly to manifest tuberculosis at an earlier age thaa parents, luagi may not be •illv'cted, but ineninge-j, pjiitoaeuin, etc. These ciiildruu may even dij before the liirents tVom tuberculosis. If a .son inlurit phthisis froui a mo:her he is more apt to have it earlier, and h emoptysis is more apt to be a sympto:n (cross here- ■.W I PRACTICE OF MEDICINE. Ill Jity). Parents not tuberculous may transmit a predisposition to phthisis, in this way triiusmilting a tendency to catarrh of the bronchial tubes, to lunemoptysis, etc., tliu.s leaving child witii feel)le resisting power ; so children of feeble parents, consiiiiguiiioii.s parents of the intcnrperale, diabetic, syphilitic, cancerous, etc., may l.if predisposed, having a small I'esisting power. ScuoFiiLA. — Modern view is scrofula is phthisis, that tubercle bacilli are ill .scrofulous glands; another vi(!w is that it constitutes a vulnerability, csiiLX'ially of glands aiul mucous membrane, to tubercular attack, so they luivc littl(i rosi.sting jiower — no special botiily type is given to the scrofulous. Tiiliercle attacks all ty)ies of the bodily conformation, still certain conditions iiitiueiice those with long, narrow chests, where chest capacity is small are pre- (lisjiosed. So als(j weak musc1"s, especially of respiratory muscles, for the res- piMtiiiy iiot is less in such person.s. Its intensity is le.s.s, hence not so readily Ljettiug rid of products of bronchial membranes. This mucus lodges more or less, iiml gives a nidus to bacilli. The respiration being weak, the bacilli are not dis- lodued. The foregoing is the reason why i)hthisis begins in apex, for there the itispiratioii is the feeblest. In children acute phthisis occurs behind and in liases. Itace -Negroes are most of all liable, then descendants of Spaniards, half- bivcds thirdly, between Negro, Indian and Spaniard, then Europeans, recent imini- ^laiits, and duration longer, and lastly Indians of pure descent. Freiiueiit inter- iiianiages of small tribes must be a predisposing cause. Age — is most frecpient between 25 to 35, for we reason there are more people of that age tl'.an those older. For taking prorata for dilfereiit ages, all ages are bound to have it nearly alike i'xci-[it cliildren ; in cliihlren phthisis is not common, but other tubercular alfections are. Acquirud predisposition — all cau.ses which depress the vital power.s, as over. >uuiy, depression, passions, over- work, so also general debility from whatever cause, ami all febrile allectious. If these act in early life effect is great, insnIHcient food, ail, overcrowding, al.so h)wer the vitality of the individual. Then there are phthiso- geiiic disea.ses. as diabetes, 4o per cent, dying of phthisis, measles, whoojiing cough. Syphilis predispose, l)iit typhoid and smallpox do not powerfully predispose. Inani- liuii is a powerful predispusiiig cause, persistent anorexia also. lUood inanition, roiiLieiiilal malforiualioii of the licirt, as stenosis of the pidinonary valves, also jire'ii-^pose, i)Ut mere anifmia does not predispose. All disea.ses of respiratory organs '•-^I'lri lily piedis[)os(^ Why ! In some cases, the intiaiinnatory materials form a siiit tlile nidus for bacilli, iii others dcKcient expansion of cjrtain areas of lung, in 'itheis abraided surf ic(>s olfer entrances to the disease. Then thes(> local diseases I'lWiM ihe resisting [lower of the whole iiidivi In d. 01iniate,etc. — excessive badily e.xeivise may be a |»redisposing cause— low, damp, water-logged soils are said by -mil- to be predisposing, disputed by others— tluui some say that exposure to 'lamp, chill wimls predisposes. Phthisis is rare in elevated I'cgions, as in Colo- liuln, Andes, Mexico, etc. The higher you ^o the jiurer the atmosphere. Cli- mates characterized by great alterations of temperature, especially if dam|), per- liiip- l)y eausing eatariii, predispose, .V stijady cold or hot cliinati! doei not I. >H Hi m i PRACTICE OF MEDICINE. 112 liredispose. variable toinporature do,!.s. Purity of the atmosphere, no foul air, -.Mills, (lust, etc , freodoin from overcrowding are the points to be noted, so the disease is commoner in city than in country. Fond iuHuences,— vegetable food predisposes more tlian animal food, as iU is to 3ti is the ratio l)etween lierbivora iiiid carnivora. Alcohol predisposes to phthisis. Flesli (.r milk from phthisical cattle, or milk from phtliisical nurse perhaps is a fruitful s.-urce of phthisis. Only recently have bacilli been detected in the milk. Tlie milk contains bacilli nnly wlien the udder is tubercular. CoNT.vrriof.sN-Kss OK l'l[Tmsis.--Tlie Italians liave hjug l)elieved in it, nidy lately have other nations believed tliis, it is import ml. Phthisis cannot lie iiighly communicable, for at Hrompton H .spital for Consumption only one .-servant in 21 years died of iihthisis. Other similar leports come from other spe- cial hospitals. It is admitted there are exceptional cases, for proof of sleeping with a consumptive and taking tlw disease are well known, so if it is conta* -ious man and wife should both be attected ; but this rarely c^curs. Evidence shews that lelations need to ha intimate to eifect contagion, as sleeping together in badly veutilateil rooms. Tuljercular congress atfirmed it U> be contagious, that it is commiiuicildo to tlesh an 1 milk of Ijovines. Said meat and milk should b3 inspected, tuberculous cows destroyed, boiling milk, cooking meat well destroys the bacillus. The goat is not a subject of phthisis, lience its milk is purer. It has been proved that iihthisis has been communicated by milk and tlesh to animals, but there is as yet no such jn-oof in man. FiHRosrs OF Lung.— Fibroid phthisis, cirrhosis of the lung is generally of tu- bercular origin, is one way of arresting phthisis. This fibroid change sometimes follows broncho-imeumonia, as interstitial ])neumonia ; s( metimes also follows ordinary bronchitis and capillary bronchitis. Acute primary bronchitis rarely ends ii. fibrosis; fibrosis also occurs after pleurisy, setting up interstitial i)neu- luouia,— rare. Inhalation of dust, mineral, vegetable, as collier's lung, sets up tibiosis. It is not settled whether there is an idiopathic form or not. Appear- ance of fibroid lung: — the structure is tough and firm, reduced in bulk and of a dark color— opaque strands of fibrous tissue ramify through—the bronchial tubes are dilated except the smaller ones, and these may be obliterated. The induration is not uniform. The organ is usually pigmented from chronic congestion. The pleura is also much thickened, even ^ inch. In cases of tubercular origin you will fiud cavities, etc., at the ape.x ; if from dust, the fibroid change will be bilateral ; if from pneumonia it will probably be at bases. DiKFEUKNTiAL DIAGNOSIS of phthisical from inflammatory fibro.sis. Phthisi- cal affects apex of lungs ; simple fibrosis affects one lung generally, not apex, nor will there be the other symptoms of phthisis, as hectic symptoms, sweating, tiiairli(,ea, etc. Ilieiuoptysis is more frequent in tubercular furm. The deformity to chest is greater in simple fibrosis than in tubercular. Signs of cavity occur early in phthisis. Phthisical form is common and of .short duration, while simple form is rare and of long duration. Phthisical form is inherited perhaps. In ?N.ifr \ 1 1 1 m I ■[ i ^ , , ■ 1 1 .' i^H MS] i ^1 m w : :■ '- , ! ■M ] ' ; ' 1 • ^H p) PRACTICE OK MEDICINK. 113 ciisi's fif iloul)t when, say, only oiu; apex isaHeeted, or a])f.\ and base is jihtliisis, tt:c iiivsiMico of tubercular imcilli is the only true; test. 'Jkkatmknt ok I'liTiiisis.— It is at present treated hopefully— early or pre- Miitive treatment. Prcuiote healthy blood changes by daily exercise in open air, liiit do not overdo tl.e e.\ercise, do not produce over-fatigue ; horseljack riiling, valk- iiij:, cricket are good, but not football, lacrosse, etc, E.xercise is not allowable after jihthisis has begun. Troniote full play of chest, exerci.su does this, but piactise full expansion of chest at an open window, so that even the ultimate (•ills will be ventilated ; use dumb ])ell exercise, health lifts, piirallel bars, etc., but do it only in moderation. Singing, reading aloud is good ; occupation needs to he chosen ; .sedentary indoor exercise is not advisable, ado|)t outdcjor work as farming, ranching, etc. Also try to restore and maintain nutrition by jn'oper liHid, such as milk ; meat should be plentiful, also fat ; the milk may need to be peptonized; if there b(; no appetite an (esophageal tube is ])assed, and peptonized luid introduced. Invigorate and harden the system, so as not to he susceptible to clianges, so tise cold water and cold sponging, the douche, cold bathing, etc. I'romote the appetite by tonics; do not begin them if the patient is feverish or ilyspeptie, but first examine the tongue, etc. Give blue pill, I'ot. (Jit. gr. 5 to 10 III some vegetable bitter, as Gentian, to remove catarrh of the stomach, then U\i;in tonic treatment with mineral acids, especially if the skin is ac- tive, tongue clean and urine clear — give with vegetable bitters, (Jaluinb. Quassia and Gentian. If urine is loaded, tongue routed, give alkalies iiiid vegetable bitters, then begin Cod l.ivei Oil— hit dose be small at liisi — dr. 1, best givt' after a meal— addition of a few minims of Sulphuric Ether will obviate nausea. Ga^iswell's li;inulsi(.ii of Gil, I'epsine and Quinine is best for those whn cannot take clear oil. If glands are iilfi'cted, Liq. Chlorid. Calcii given with the oil is good. Quinine is best for tunics— nervme— dose may not exceed 1 gr., give T.I.D. with a min. a<;id before luculs. Meac extract is diasta.se, is used if oil cannot be taken or starchy food not iligested; give before meals. Hoft's Ext. of Malt is good, contains also bitters of linji.s ; give wine-glass full. Iron is also good if there is no fever or no lueinop- tysis. Arsenic in m. 2 to .'? of Liq. Fowler T.l.U. is good where there is anaj- iiiiii, nervous prostration or tissue waste. Change of air and travel is a good tunic ; in first stage a long sea voyage is very good, jierhajis the best. A changi.' lit climate is the best of tonics. Protect against cold, over-fatigue, catarrh, liKinchitis, etc., anything which will lower the vitality, as tyjihoid, whooping • I'ligh, measles, etc. 2nd stage, — confirmed phthisis. Thysical sign.s locate the ilisease, the disease is active, fever, r : high, ]ierhaps night sweating. Put to I'fd and treat like pneumonia, apply jjoultices or turp. stupes to chest, counter- irritation is very valuable, and give to reduce U'vev gr. 10 Cit. Pot., Acetum dr. 1 every 2 hours, keep in bed till temperature returns to 100. In another case ilie signs are not so bad, no hif'h fever or high pulse. You cannot put this one tu 1' 'il, he is not sick enough, so first ascertain the state (jf digestive organs. Here is PRA<"ni'B (IK 114 fietitc, lirst, HO figlit this. iitiili n restore appetite ll riiiuw > present tlion Liq. i;il tiuusuii Uiol nei s carefii! If (i need in one nu'l tli sturaach till' key tn |ililliisi-t, — l(Piij(iit' red with whii. > (live Am. Ciiili >^y. 1", Uis. .Siih, Nit. tor • u'ivt' Slid. Ciirli. luul (ifnliuii for several ii Strvchniii m. '.'t to 4 k best agent iur | wiittiiini,'. Then in botli cases, after fever i> restored in other, stiirt liuihiiiig up treatment. Climate i iian^ 4 Liver Oil, tonics, etc., lire in order. Ke e.xerci.se, — in this .staf,'e do not overw. ik tjie lung, a>i it is di.si'ased, still a certain amount of exercise (not violent) is needed. 3rd ,staj,'i' — softeiiing. Sejilic fever is a symptom, due to alworption of purulent niatter. So for hectic fever give Sod. Salicylate gr. 30 1st day, 20 2nd day, 10 3rd day. Stop for 3 days and see if fever is reduced ; if not, do it over again for 3 days, etc. It is well to combine a spirit with each dose, as ss. brandy or rum, or it may be given in smaller doses T.I.D., as in rheumatism, every day as long as fever lasts. Antijiyrine or Antifelirine gr. 3 T.I.I), is good, give in little .\c[ Menth. I'ip., <|(iiiiiine gr. 20 to 30, H. Hr. once jier diiy. (Jive these auti- jpyrctics ii few hours befou! tlu^ recurrence of fever. In this stage there is great jirostration, and alcohol is indicateil for this, rye in this country. If the alcohol improves appetite, etc., it is doing good, but do not feed them on alcohol. In this stage all kinds of iidurishing food are trailed for, tonics, oil, etc. Creo-iote is attracting attention, some tiiink it a specitic Dr. Howard has not tried it; it is said to have best effects in slowly progressing chronic cases, with not much fever, but .some say it can be used in any case. It is hard to jirescribe ; here are 2 iornuilas : 1*. Heechwooil Creosote ni. 15, Tr. Gentian m. 40, S.V.K. dr. 6, Sherry ad oz. 4, Sig. oz. ss. T.I.I). R. Creosote ra. 3, Glycerine dr. I, Brandy dr. 3, Ess. Pepiierraint Q. S. Sig. T. I. 1). in 24 hours. Be sure and get Jieechwood Creosote, other forms are not good, impure. IxilAL.VTiON TiiKAT.MiONT. — Dr. Howard's e.xperien'^e is that these inhala- tions are valuable to allay cough, check expectoration, and often check the sweating, cannot do any more. They do not act as germicides, for these bacilli can remain 15 minutes in a watery solution of Carbolic Acid. And again these vapors do not jienetrate to the air cells, even Iodine, Turj)entine were the only agents which reached the air cells, so inhalation as treatment of phthisis is a failure. They are valuable for catarrhal states attending phthisis, equal parts of Creosote and S. V. R. is good inhalation. Terebine ni. 10 on iidialer i;, also good. Following is good : Iodoform 1 part, Turpentine 20 parts, put a few drojis on sponge of inhaler and use every hour, from 5 minutes to 30 minutes each hour- The inhalation of the fumes of Sulphur is very valuable. Burn in a closed room 5 drs. of Sulphur to every cub. metre of air. After burning 12 hours let patient go in and stay in room 8 hours. This is a new method. Injections of H2 S. and Carbolic Acid into rectum have fallen into disuse. Sulphur .springs v.'ill benefit where there is bronchial catarrh. Incidentai, Symptoms of Phthisis. — Cough causes are numerous, do not resort to oji'ates. Cough may be due to bronchitis, treat as such. If that only JNfr PRACTIOK or .MRniCINK. 115 ii.cdi'il to lii'ing tip s|)Utii, ))iiniiute it by lutt ton or t'ollet' or liot j)im»!li ; if from l,iiyiii;t'(il (Mtiirrh, I'lc, ticat hh hucIi. TIu- onliimry oouj^'h of plitlii.sis iumhIs ircut- iiieiil, is ciiiiMcd l)y iiritiitioii of diHeami in hiii;;. Couiitor-iiritutioii is j^ood, also ,ii'iintivo> ..tin^'). 1. Improve j,'fnt.'ra! alrt'nt^lii, as cup of buef ti-a at bud- timo.i'tf. Tim best antidiaphorotic is Litj. Atropia, .somotimus I'ulv. I pec. Co. iloi'S so. Acid Snipliur Aroni. T. I. D. will sometimes check. I'icro. Toxin. ^r. „'„tli will often Work, oi Strychnia. Wasliing diest at nij,'ht and morning with vitu't^ar 1 part, water 2 parts, is good. H/1;M01'TYSIh,— Ordinary slight h.enioptysis does not call I'oi treatment, you I iinnot do much for it. Rest in bod and no talking, plenty of ice to oat is good. If urgent, j>iit large bladder of ice over the point of hemorrhage. Internal remedies : Kirst, hypodermic of Krgotin gr. o to 8, repeatright's, diabetes, diseases of nervous system, irritability, headaciies, etc., but mental ilisorders of overwork are benefited if insomnia is a complication. Also em]iliysema and phthibis with emj 'lysenia, or where lung is reduced in cajiacity by disease, as cavities, etc. Cavity cases and li.emop lysis are not suited. Phthisis of advanced age is not suited, nor if iil,tended by great debility. Cases suitable are (for high altitude) ; inherited predis- position, disease in early stage ; hemorrhagic cases only in first stage ; if thoracic ' avity be jioorly developed ; in case of unresnlved clironic pneuniouia ; all ehroiiie form of tubercular phthisis if area of lung danuiged be no too large ; if there be little pyrexia in chronic case ; uiu'esolved pleurisy is often benefited. H wBwmpi t i IIIG Aiui'vica, W iIiIl'U •> •Mctitt'C lilVlClll. •suited to 1(11) niois a VI III fo ill autiiii til sea, ai liUt ai't'ii I'lU ivci'ived Aci ot-ciii's ii tiilu'i'cle, of tlll'SC mill U Si.l COM .Syin]iti»i ture is li bnlli or I plitliisis, before tl latcii Pa y F .sii|iL'rver lik(> |iiie CO! W jivotri iiiio clii iiillainm but sucli tciuperat aiutf or Tiu liyri'tii-s ailing' wi pyivtics, thi'oui/lu ,1,'ivt' Dig iivlt clie PRACTICE OF MEDICINE. 116 lliuii Ai.TlTUDKS. — Europe, St. Maurice, 6000 ft. ; Uaiisfiets, 5000 ft, ; Aini'rica, Colorado, BiintV; intermediate elevations as at A.shville, N. Carolina Wiililcn's Kidi,'e, E.Tennessee; also the Adirondack^. The same class who are liiiiclitcd by altitudes are also benefited by dr_v, mild climates. In Europe the Kivicia. Algiers in Africa ; Madeira is mild and moist. Inactive chronic cases are suited to Al«,'iers, Madeira, etc. ; Southern California and Florida are too relaxing, tiKi moist. Tell them in California to get back from coast 50 to 60 mile.s, and aviiid foi,'s. A long sea voyage suits same class of cases as high altitudes. Send ill iiutiimn after the eciuinox. But have patients willing to go and no objection to sea, and then let them have best of accommodation. A sailing vessel is best, liiit acciimiiiodation must be good. l'i!(ii'iiVL.\xis. — Let no one .sleej) with a phthisical patient. Let sputa be rt'CL'ived into sublimate solution, jtour boiling water on it before emptying. Act'TR Phthisis. — Acute inHammatory phthisis ore aseating jineumonia otiiirs in two forms : in one the lung is stuffed more or less with agglomerating tnliercle, in another a large patch of caseating tubercle iiiHltrates lung. In many iif these ca.ses the intervening lung will be coiigesti'd or he|)atized, or even nor- mal. Usually all other organs of bo ly are also tuberculous at the same time. S|ileou swollen, bronchial glands enlarged. Often niiliaiy tubercles are seen. Symjjtoms are often like simjile pneumonia, for it sets in suddenly, but tempera- ture is less high, respirations not so short or shallow. The disease may involve both or one, or only a patch of one lung. After 14 to 2U dayb you get signs of plithisis, the softening proving it phthisis, not pneumonia. Death may ensue before this stage. Repeated and copious hsemoptysis are not uncommon. Physical Signs are those of isolated patches of consolidation, so suspect patchy i)neumonia ; these signs beginning perhaps in base or centre ; the early .su|)ervention of signs of softening. The physical signs persist, do not clear up like pneumonia. Course (several). — 1. May prove fatal in 15 to GO days— coiuiiKm. 2. May be jirotracted, 3 to G months, galloping consumj)tion. M. May sometimes pass into chronic form. 4. Lastly may recover temporarily. Now and then this inHammatory phthisis sets in quietly, not like pneumonia; may be little fever; but such persons are very weak, pain in side, cough and moderate elevation of temperature at night. Physical signs are of mild pneumonia. It may be either aiute or chronic. Theatment of Acute Phthisis. — Treat as pneumonia. Stimulants — anti- livii'tics and counter-irritants. Diet of milk, juiimal broths, meat jelly, also iilnuu- with it claret. If patient cannot take milk, add to ([uantity claret. Anti- liyietics, Quinine gr. 30, or Antipyrine. Alcohol oz. per inl)nlic phthisis. Tiiis occurs anatomically in 2 forms : 1. When lung from apex to base of both lungs is stuffed full of miliary tubercles, intervening tissue normal or congested. In these cases all other parts of body are affected. 2. In other form localized patches are similarly stuffed with miliary tubercles. OuiGiiJ.— Till tuberculous material enters small lymphatic vesstds or thoracic duct, thence into the blood, or more often the tuberculous matter enters veins, hence embolism. Tubercles existing in any jiart of the body may thus spread, as tubercles of glands of the neck, of joints, testes, etc. It is sometimes a result of chronic phthisis, but it is very exceptional for this to occur. This form sometimes supervenes after measles, typhoid, broncho-pueumonia. Symptoms.— Depend on organs specially attacked, but in this case we are dealing with lung. It may appear patient has been quite well, or perhaps has Just suffered irom measles, etc., or may have been suffering from chronic piithi- sis, but sometimes it comes on without previous disease. The disease l)egins with a rigor, temperature lO;Uo lOo, rapid, weak pulse, 120— early disturbance of stomach, vomiting, loss of appetite, constipation, early loss of strength, urine febrih^ perspirations free, sometimes even are har.sh ; cough is not a constant synqitom, but may come on late, and is attended witli a little clear viscid ex[)ec- toration, becoming more or less opaque, and may become stained with blood,— puzzling. Hiemoptysis generally absent. An early .symptom is an excessive dyspnoea, some delirium, sleeplessness, coldness of extremities, wandering or active denruim, and patient dies asphyxiated. Morning terai)erature low, evening temperature high throughout. Physical Signs — May be those of general bronchitis. In (jther cases sometimes you think you get dullness at a spot, and there tiie respiration is slightly feeble, spots will not be symmetrical. In a few days you will get rough, harsh breathing at this spot, not blowing breathing. Duvatiiui of this form varies 2 to 3 weeks, more commonly 4 to 5 weeks. The rapid cases are apt to be complicated witli cerebral symptoms which resemble typhoid ; the prolonged ones resemble bronchitis. Bacilli are not pr(>sent in the sputa, nor no softe.iing. Prognosis is very bad. Treatment is iiopeless, still treat like typhoid fever ; support the strength, lower the temperature by antipyretics, spongings, etc., counter-irritation for chest. Alcohol is used throughout. XXIV. DISEASES OF THE NERVOUS SYSTEM. 1. Diseases of the brain. It is covered with three membranes. Cerebral menin- uitis is inflammation of these membranes. The arachnoid may be considered a part of the pia mater, as inffamuiaton of these always go together, but that of the dura snator is sopavatc. Pachy meningitis is inflammatiuii of dura mater; lepto meningitis of the jiia mater or arachnoid. Lkpto Me.vingitis.— Two forms : 1, tubercular; 2, simple, or non-tuber- cular, or purulent and simple. 15 n i j (' ■ ; h. i N ! r \ PRACTICE OF SfEDICINK. 118 Symptoms ok Simple Fokm. — Are divided into extrinsic and intrinsic, the latter l)eing mainly functional. This lepto meningitis may bo ushered in with jiiuinDuitory symptoms, us of cerebral excitement, wakefulness, restlessness, irritability, headache, but usually comes on quickly. The developed symptoms live divided into three : 1, stage of excitement ; 2, stage of transition ; 3, -tage of coma or exhaustion. Symptoms of 1st are pain in the head, iieatof the s, signs of incipient paralysis. This tiausition stage lasts from 1 to 3 days, Init may be absiMit, and first stage passes into the third stage of coma or depression. Now the surface is pale and cool, jadse frequent, respirations irregular, perhaps stertorous or Cheyne-Stokes breath- ing, contraction of abdomen and retention of urine are observed, yet sometimes relaxation of the sphincter allows tlie urine to drilible, sordes collect on tlie teeth constipation may cease, person^caniKjt be aroused, is unconscious, pinching has no ellcct, pupils large and inactive, motor signs may shew paralysis of one or more areas changing. In this advanced stage with nerves paralyzed and death nearing. the temperature goes u]) high 104 to 108. Sometimes the first symptom may lie stuiwr or coma, or severe headache, or sudden delirium or spasms, or even the luvs of speech. Sometimes the disease is quit(> latent, looks like malingering; paiii'ut taciturn. If meningitis is secondary to some other disease, tlie pain and vomiting are often absent, but the irregular pulse and respirations will be noted, countenance will l)e of marked pallor, and you will get some of tlie intrinsic symptoms, as intolerance of light, etc., but in later stages the signs will be posi- tive enough. There are three cardinal symptoms of meningitis — pain in the head, vomiting and constipation. CoURSK OF THE DISEASE It is Unfavorable, lasts 8 to 9 days, may prove fatal in 24 to 36 hours, exceptionally lasts a few weeks. Pkogngsis. — Often recovered from in early stages, but is a grave disease ^^itll a high mortality. Paciiy Meningitis is divided into external and internal forms, the latter of which is very rare, but the external form is very common. External pachy men- >!!3l I .,t .i:;l{r ' iiliii tiiii 1 fi* j . M PBACTICE OF MRUIOINE. 119 inuitis is coiumoii, (luo to injuries to head, ov caries or necrosis of the cranial bones ortoiiiHamniationof the middle ear, or to clironic disease of the petrous portion (if tlip temporal bone, so these latter medical forms are obscure. The symptoms ari' nearly tlie siunu as lopto meningitis, but have a few distinguishing points. At outset it may be obscure and latent, ofteuei' not. It is more gradual in its onset than lepto meningitis, more localization of the pain in the head. If paralysis ensues later on from abscess it will be on the opposite of the body than thr pam in tlie head. Owing to the existence of sinuses these often become iutlanied, thrombosed, hence tenderness along the jugular, or even a rope-like induration. If in the lateral sinus, the plugging may extend to the external auricular veins, hence oedema of the ear. If in the cavernous sinus, the plugging meets nerves supplying the eyeballs, hence paralysis with .squinting, may even atti'it both, ii may also cause prominence of the eyeball and oedema of the lid. Optic [luuritis never occurs in simple meningitis, but in inflammation of the ear, the iiitlammation extending along meninges to the optic nerve sets up optic neuritis, and x.istly on account of those sinuses septicemia is often set up, producing rigors, intermissions in fever, etc., being symptoms of pyannia. Internal pachy menin- gitis is divided into two forms, may be simple like foregoing, or the hemorrhagic t'liiin, as in old broken down people, called also luematoma of pia mater. MoKtiiD AWTOMV. — Inflammation of the dura mater, it becomes redder ani suiter in early stages, and loosened from its attachment to the bone ; pus may accumulate between it and the bone, and sloughing sometimes occurs. If it be tluc to an injury, you will find the inflammation at the site of the injury with (extravasation of blood between the bone and the membrane. The inflammation, uven if unilateral to begin with, may extend bilaterally. In lepto menin- gitis the sac of the arachnoid may contain fluid, but chief changes are in the pia mater. It becomes congested and is more easily separated. It has one of three t'tlusions : 1, a milky gelatinous .serum ; 2, a coagulated lymph ; 3, greenish pus. I'll slitting up the longitudinal sinus you may find puffs and coagula. Tiie pia mater is found to strip easily from the cortex, which is often redder than normal, and softer, .so the disease was meningo cerebritis. On section of the brain the ventricles are found not softened, are empty sometimes, but may contain by extension of inflammation serum or lymph. You do not have a large collection of water, as in a tubercular form. The microscope shews an inflltration of leuco- cytes along the course of the vessels. Causes of Meningitis It is most commonduringactiveperiodof life, and more fre(]uent in men that iu women. It is common also in young people, occa- .-ionally even under 10 years. External violence, intemperance, mental excitement^ vxtension of disease from bones of head and from the ears, hemorrhages, abscesses, ^■uiistroke, con.stitutional sickne.ss. It occurs occasionally in other diseases, as rheumatism, Bright's Disease, croupcus pneumonia, smallpox, erysipelas of the scalp, suppression of the menses, or of bleeding piles or healing up of a chronic eczema of the scalp. Sometimes the softening of a thrombus or suppuration of I ', ttiirtMJUlii H r: ill PRACTICE OP MBDICINl. 120 ilic eyeball may lead to it; lastly, it may follow a pyaemia, suppurative stage of |.iuumonia, pulmonary abscess, empyema, ulcerative endocarditis, etc. Some- times no apparent cause can be found, and tlien you bave tbe idiopathic form. Several diseases may need differential diagnosis, such as rheumatic delirium, ili'liriuni tremens, acute mania, tubercular meningitis. Itheumatic delirium occurs in course of rheumatic fever, meningitis is a curiosity in rheumatism. It is generally accompanying visceral rheumatism at 8tb to 1 2th day. The articular alfeetion may disappear when delirium sets in, headache and vomiting are absent, nor does the pulse shew same alterations. The pulse in the later stage is weaker Mild more rapid, before or along with delirium there is hyperpyrexia in rheumatism. Itrlirium tremc is n(it often puzzling, but active form may be. The history is of intemperance. There is not much febrile disturbance, tongue loaded, secretions foul, usually no headacht;. Again there is marked tremor, the skin is moist, patient sleepless, and delirium is peculiar, is active with frightful hallu- cii\;itioiis, with a sense of dread ; generally the delirium is inoffensive, and a firm Vdice will control the paticuit. Acute mania may be puzzling. You recognize it from meningitis by absence of fever, heat of the scalp, vomiting and pain in thf head, also absence of the three stages of meningitis ; in mania tlio excitement kfi'ps up for a long poriod, the del'i'ium is active, talkative. Trkatment of Simple MKNiNfiiiis. — It is desirable to lessen or check the inllammatiou in the l)rain, so blood-letting has been jiractised ; this is not now iisod, local blood-letting is resorted to instead, (lowers says blood-letting is only to h(! done after a sunstroke, after excessive mental exertion, after traumatism, or in idioi)athic cases. Apply leeches behind the ear or over the temples, or over parietal foramina. Germans apply leeches to the nose. Always have the ]iatient's head and shoidders raised to lessen the bkiod supply to the head, and apply cold by the ice bag or by the water coil ; let it be the duty of one to keep cold applied, as it is important ; cold to head, then keep heat to feet by water liottles, etc. Internal Tke\tmi:nt. — All give a good cathartic. Calomel gr. 10, I'odoph -r. 2 to start with, followed by a saline. For constitutional treatment, give mercury, unctions is the bi'st way to give, rub in in the groin or axilla; every 4 lunu's, do not salivate, juwi .. , gums tender; others recommend Pot. lod. gr. 10 lo 15, Pot. Brom. gr. 20, and Cidoral gr. 2. The lodid, for a specific action, the other two for sleei)lessness. Give the above every 4 hours. Some would add I'lrgot to the above to lessen congestion, so add Fid. Ext. Ergot m. 10 to 15 to ihe above dose. Instead of blood-letting. Aconite may be used 2 to o gtt. every 2 to 3 hours, and watch the action. All tlie above is for the first or active stage, hi the second stage drop blood-letting. Bromides, Mercury, Aconite, etc., but Iodine may yet be given. Blisters are now used, beginning down between the shoulders and working up the occiput. In the third stage give aliniularits,— -strong broths, wine, whiskey, etc. In septicaeraic form, Iron and Quinine in full doses are best, examine the ear for pus, also mastoid process. If you suspect abscess of the brain, trephine and put in a drainage tube. iiy< ll f .' ' 1 ^ u ■ ' . ; f II i I i II PRACTIOR OP MEDIOINK. 121 Ti'HEliGULAU Mknin<;iti8. — Basiliiv form, iioute water on tho brain. This (liscasc is always secondary to tuborclu in aotne otlier or<,'iiii, or oven in tho brain itself. Cases do occur where no such disease can I)e fouml elsewiiero, and would flien become a jiriinary meningitis. This tubercular meningitis is usually 9(f(!()iidnry to j)ulmonary tuberculosis, to tubercular pleurisy, or of tius glands, hroiicbiiil or mesenteric, or of those of the neci\, or from tul)e''cular disease of the gcnito-urinary organs, bones, etc., or it may be part of a general tuberculosia in infants, and sometimes it may arise from a solitary tubercular mass of the brain. Sy.mI'TOMs. — Usually has premonitory symptoms, impaired liealth, etc. lli-tory — has been failing, getting thinner, theinionieter shews a slight evening rise ol' temperature ; child presents recurring febrile attacks, especially in the evening^ iwed to bo called infantile remittent fever ; temperature and mind altered, is on;ss, irritable or sluggi.sh, or ' as giddy attacks, headache after exertion, — these iiiiiy be attended by vo'uiting, not referred to tiie stomach ; sometimes a cough, suiuetinies a dragging oi one leg ; symptoms come on gradually, but occasionally all signs are ab.sent. Once the disease sets in, there are the same three stages a.s in the simple form with many of the same points in common. Diagnosis hetween Simple anu Tubekoulau Meningitis. TUllERCtLAIt MENINGIIIS. Usually has premonitory symji- toms. Often a family history of tubercle. Invasion slow and insidious. Delirium develops more slowly. Headache not so severe. Excitement less acute. Convulsions not so marked. Th .re are remissions in progress. Duration 12 days as an average, sometimes 2 to 3 weeks. Tem])erature does not average as high as remissions ; at close temperature may be high or low. Eye — apt to have optic neuritis. .Sometimes tubercles can be seen in fundus of eye. SIMPLE MENIN(;iTXS. No premonitory symptoms. No failing of health. Invasion violent, prompt. Delirium develo[)S rapidly. Headache severe. Excitement more acute. Convulsions may be frightful at outset. Progress is continued and short. Duration 7 to 9 days, may be fatal in 1 to 2 days. Temperature continuously high, no remissions, high at close. Eye — not apt to have optic neuritis. A valuable symptom of meningitis is this : if you draw finger nail across eheek, a wide red mark will remain for some time, is a sign of acute disease of brain '• tache cerebrale." Tubercular meningitis occasionally involves tlie vertex. \w I 1 ) H ' ' ■5 1 Hi :"" ! 1 :: t' - I r.l H!li 1 II. " S 1 V- !) '■ 1 11 k' PRACTICE OP MRmCINE. 122 Tluu tubercles would act in motor iiiul ititellectiml centres, lionce greater delirium iimlcdiivulsionHuiid tremors in tlie intervids; will ulso' lx> ciiused liy initiition ol' tiilcrcles on motor area, hencc! tliumlis drawn in. I'ulse is ajit to be fre(iiient, ;ibs( nee of o}>tie neuritis. Those cases on the vertex are more lial)le to be violent, and run a rapid eoinse. Pathology.— The tubercle is oftMoboiic orij,'in, lieconiin^ arrested in small vrius, setting uj) a local inllanimatory process in slieatbs of pia iiiater, which ,|,ivads to surrounding (•(.unective tissue. These tulwrcles excite fi diffuse inllam- iii.it i. Ml of |iia inatrr, ami di^cuise extends to brnin cortex. The tulHM'clea at tirst are small grey translucent bodies, gradiuvUy beomc opi)(|ue to yellow, caseate, and soften rapidly. Sometimes grow into large isolated masses. Moi{iiii) Anatomy. — If you examine pia mater you will find minute tidiercles, Idund chiefly iu base in fis.surc of .sylvius ; also in .sides and convexity, less often. Are also found in velum interpositum ; floor of ventricle, even on dura mater, ivfu on substance of cortex. Sometimes mendjranes are red, congested, rare. Ill later stage fluid in ventricles by pressure lessens blood supply, and brain is anicmic. In addition frequently there is an opaque, milky, gelatinous exudation with jiatches of yidlow (lymiili) scatt(!red tliroiigli, found cliielly at ba.se, also in liasc a thicker exudation leading to name oi iiasilar m(;niiigitis. On tearing off pia mater, cortex may be gofteue discovered paralyzed, generally heiiiiplegic. Usually cerebral nerves are not iia))Iicated. The right side is oftenest affected. As child recovers, the muscles altected waste, reflexes are exaggerated, but do not exhibit reaction of degenera- tiuii under electricity. Secondary, — degeneration takes place down the cord, then muscles are rigid, or have mobile spasms, or chorea like. The affected limbs cicciisionally Lave Jacksonian epilepsy, no loss of consciousness. Such children will be idiotic or imbecile. Causes — Thought to be due to thrombosis, or embolism, or local inflam- miition, or inherited syphilis. On examining the brain, atrophy of a porti jn of cmtex of brain will be found. The atrophied part is indurated, cirrhotic. The jiiii mater is thickened and adherent. Often large cavities are found in the brain ; the.se children generally recover, permanently impaired, physically and mentally. Tki;atment. — Will depend on symptoms ; if feverish and in convulsions, then )Hit in a hot bath and cold to head. For convulsions give Bromide and I'lilgral, keep in dark room. For paralysis, nothing is better than constant gal- vanic current. Massage may be good. Bromides are now not well borne unless combined with Chloral. XXVIL BRAIN TUMORS. Tubercular tumors are most common, usually are secondary to tubercle else- where. Are found oftenest in cerebellum and medulla. '2. Syphilitic growths are next commonest, affect chiefly the meningis, the pia mater, rarely the brain suli-itance. 3. Glioma (small round celled-sarcoma) is next in freciuency, and is the only one a growth of the brain substance, not encapsuled. Is found in aiil. lobes of brain mostly, is subject to hemorrhage from rupture. 4. Sarcomatous i,'ri)wlhs, various, are next in frequency. 5. Cancer is next in freipieucy. All iitlitr forms are rare except small. 6. Aneurismal tumors. V^iolence is the only e.vciting cause of tumors we know of except tubercle and syphilis. Diagnosis of Tumor. — Depends on local symptoms ; so if tumor is in area, tint functional, will be latent as in cerebellum, in sphenuidal or frontal lobes. If luitient suffers from fixed, violent, paroxysmal, const uit pain, if there be im- l>aii ineut of any of special senses, especially of sight, and especially if this be accompaiiied by optic neuritis, also if this impairment of special senses be not aeeonij)anied by motor symptoms. Or if there be twitchiiigs, localized, and 'j-j-eeiiilly of the cerebral nerves (all indiertting local lesion), especially if the symptoms come on slowly and progressively, and if mind remain intact. If in addition there be local convulsions, unilateral without perhaps paralysis in interval, 16 :ni 4P i -* I I . ■'""■' ■*' ' PRACTICE OF MEDICINE. 126 till- probability of turayr becomes greater. Apoplectic symptoms occurring with this liistory iiulicates glioma. It is imusiial for symiitoms to set in suddenly wilii ])aralysis, ai)oi)lectic symptoms, etc. Localization of tumor — if at base, ri'iiiember the cerebral nerves lie there, hence a comman symptom is paralysis uf one or more of these. Pressure of direct pyramidal tract may lead to para- lysis of limb or hemiopia from pressure on uptic tract. Optic neuritis is almost alwiiys jiresent. These local lesions may be unilateral or bilateral. Tumors of con vexity of brain — There lie the motor convolutions, anterior lobes for mental faculties, s 'iisory centres for hearing, seeing, etc., so symi)toms would be accordingly. Pro- bibly at lirst irritation of thes^ centres leading to convulsive paralysis, impairment or loss of intellectual faculties, of speech, hearing, sight, etc., you would not have ilisliirbauce of cerebral nerves, for these are at base. Tumorof middle lobe of cere IjL'lliim— If it involved lateral lobes youget nosymptoms,but if miitdlelobj then you get most noted symptoms— is alteration in gait like a drunken man — not affected by shutting of eyes as in locomotor ata.via. 2. Giddiness, even without bad gait, even lying down. 8. Knee jerk usually absent, but not constant. 4. Often a violent pain in occipital region, soniitimes with retraction of cervical muscles. 5. Marked vomiting. If turn n- of cereb ilium pressed on medulla, we would have piralysis ; epileptic convulsions rare, but disturbances of sight common. If middle peduncle of cerebellum be alfected it gives rise to circular movements. CoOKSK OF THESE TuMOlts. — Often give rise to meningitis, sometimes to apoplexy. Atum^U' growing and halting is syphilitic or tubercular. Tkfatmkn'T. — Depends on their natures. If syphilitic or tubercular, trea, constitutionally ; if meningitis be set up, treat as such. If you are in doubt, treat with Pot. lod. .411 these brain tumors e.vcept glioma and cancer are outside of brain, in membranes, hence can be enucleated by surgery. XXVIII. CKllEBRAL SYPHILIS. Morbid Axatomy. — 1. Frequently attacks arteries, arteritis m ly be apart from a gumma or in a gumma. A quantity of fibroceUulav tissue thickens inner coat, then outer coat thickens, leads ';o narrowing of lunien, hence tends to pro- duce thrombosis, softening, etc. 2. \neurism from disease of coats of arteries may give a tumor or may lead to henu vrhage. 3. Syphilis produces neoplasms of soft grey cellular structure or caseating gumma. These begin in dura or pia, not in brain but extend into brain. May be situated at base, and then leml to involve the nerves. 4. The disease may assume form of a local chronic meningitis, producing great thickening of part of membrane, and so even acting as a growth. 5. Sometimes it sets up a chronic interstitial iiiHammation of substance of brain or cord, produces wasting of convolutions, affiects chiefly moLjr areas. 6. Frequently attacks coats of nerve, hence neuritis. Ei'TECTS. — If arteries are obstructed, uon-inHamniatory softening follows of area attected. Two vessels are especially liable to be affected, viz., internal carotid and middle cerebral artery, hence motor convolutions, optic thalamus deprived of blood by plugging of middle cerebral, so one-sided paralysis and asphasia aie m I 'I' I . .t' I PRACTICE OP MEDICINE. 127 common. An aneurism might burst, hence hemorrhage. If gumma is present, signs of a tumor are observed. If meningitis be present it is of low and chronic form. It is usually in connection with a gumma, and its effect is to add to growth of tumor. Si'KciFio Diagnosis. — Prodromal symptoms — persistent lieadache aggravated nt night, often accompanied by local pain in scalp. Also sleeplessness. Among earlier symptoms are dizziness, mental confusion, impairment of memory, slow- lU'ss of thought and speech ; or the opposites, viz., irritability, etc. The overt disease declares itself suddenly, symptoms according to locality and form of lesion. 1. A grouping might be physical and mental disturbance, incomplete epilepsy and paralysis, especially when convexity of brain is affected. End is coinn, duration of a^'tack short. 2. Apoplectic attack followed by hemiplegia iissociated with drowsiness. In addition, signs of unilateral irritation of brain, fiuu-sided convulsions, etc, or neuralgia, and usually paralysis of some of cere- bral nerves. This form may be basilar or of convexity, but this form may be sudden, par'dysis of a cerebral nerve or sudden asphasia or hemiplegia. 3. Gmup like general paralysis of the insane. Treatment. — First treat active symi)toms of the attack as of apoplexy, men- ingitis, etc. When symptoms are active, " Wood" recommends bleeding to relieve congestion. Syphilitic treatment. A course of Mercury at once by inunction. From 30 to 60 grs. of Blue Ointment, daily to rub in, with a thorough warm bath between each inunction. Continue for 2 weeks, then every other day for 2 weeks, then twioe per week for 3 to 4 months. Watch gums. Another method is by Pot. lod. Give it in enormous doses (American) 30 gr. T. I. D., run up to even dr. 2 doses— no limit to dose till results are reached. Give it in Vichy Water or as i)er Wood. Syr. Sarsa Co. and Fid. Ext. do equal parts with the lodid. Many add gr. I'^th to i>„th Hyd. Perch, to the lodid. XXIX. FUNCTIONAL AFFECTIONS.— EPILEPSY. A paroxysmal loss of consciousness of chronic character, attended with convulsions and a non-febrile disease. Two divisions : 1. Idiopathic, no morbid lesion. 2. Symptomatic, as from some organic disease. Is also divided accord- ing to severity into epilepsia major and epilepsia minor. Epilepsy is said to be jiieceded by an " aura" or prodroma — is the commencement of the fit, and which is perceived by patient. The aura may affect any part of nervous system. Premonitory symptoms : psychic, — sudden failure of memory or confusion of tlionght, strange ideas, sense of strangeness, an emotional condition, as irritable, Lioss, timid, fearful, etc. ; sensory, — as disagreeable choking in throat, lump in epigiistrium, feelings of dyspnoea, palpation, headache, dimness of vision, diplo- pia, flashes of light, hallucinations of vision, colored lights, hearing disturbed ; motor, — squinting, movements of pupils, shudderings of body, sudden move- ments, spasms. These aiirae arc really a part of the fit. A Co.MPLETE Fit (major) is often ushered in by unearthly scream, person falls down unconscious completely, and often is very pale. A tonic spasm of mus- cles is also noted at same time. This is a peculiarity of epilepsy, tonic spasm at lirst. In consequence of this the breathing is arrested, pulse gets feeble, face I pets bl liiviitlii jiiws fr tliinl si iilann, tiiiii h1( jiersiiii' sciousn lliir .ill sei.'oiid piinolil il rule I: sent ti cuuseii !•: may h iugs ; ' times. but fa ^'u no C fits nu uf cast Visua some ' ] lu'j;ica Ideptt vulitii ,-ee IV drop 1 cause yet 2 to m( ease i intell t'urms mal e pile; and ■ rave, VRACTIOE or MEDICINE. 128 cets blue ju-n.lars aistended, caiotids throb, pupils dilated. After a few seconds sinsnis become clonic, therefore respiration k-ins to return, cyanosis disappears, I'n.'.thin- is labored, K>"'-lins in throat, pupils oscillate, chewing nioven.cnts of i,ws from clouic spasm ; fr.Miuently semen, urine or fieces is discharged. A third sta.'e succeeds this, return of consciousness is gradual. He awakens in „l;vnn, astonishment or anger. He makes half voluntary movements. Uespira- ti,Mi slow and labored. Stupor present, passing iuto sleep. Face pale and cold, ...rsninilion noted. After a sleep more or less prolouged, patient recovers con- '.ioiHuess with a headache and pains in muscles, sore all over. In true idiopa- thic allection those are the only effects, still patellar reflex is gone for lust few scfouds, returning in intensity in a short time. In severe fits there may be puncliform ecchymosis on forehead. In epilepsy gravior these sequences are as 11 rule as above, indicates cortical derangement. Ix .Symptomatic Epilkpsy, as from tumor, you may have tonic spasm pre- sent liist, or clonic, or clonic altogether, no regularity, and as a rule loss of cunsciousuess is not so sudden. Ei'iLEPsiA MiNOK (Mitior) presents a great many varieties. Thus there may be only sudden loss of consciousness and no spasm, or with only twHch- iu.'s ; or the loss of consciousness may be but momentary, a mere giddiness some- tiuies. In another variety there may be spasms and no loss of consciousness, or but faint. In fact the various aurie may be looked upon as epileptic tits if *hey go no further. . . OuouPSOF Petit Mal.—I. Sudden momentary unconsciousness, fainting fits momentary, or sleepiness without spasm. This class constitutes 33 per cent, of cases. 2. Giddiness constitutes Jth of cases. 3. Jerks of muscle heads. 4. Visual sensations, etc. During these attacks patients frequently i-ass wate". In some of these cases of passing water there may be convulsions. Maskeij Forms may follow an ordinary fit, or may replace the fit, being patho- iugical equivalent. 1. Phases of mental aberration, unexplainable actions, mania, kleptomania. 2. Or there may be perversion of consciousness and a low degree of volitional power. No recollection of act afterwards. 3. Sensory aberrations, see non-existing objects, have hi.lucinations, loss of consciousness, etc. 4. Some drop asleep instantaneously. These minor forms are known to be epilepsy be- cause they alternate with the graver fits. Epileptic fits may occur at any time, yet 20 per cent, occur at night. The intervals ijetween fits vary from a few hours "to months. At menstrual pe.iods there may be an aggravation. Course of dis- ease is from bad to worse, intervals shorter, fits more frequent. In a few cases intellect deteriorates even to dementia. This is not thj rule though. Wh '. fovuis threaten dementia: 1. If tiiey set in late in life. 2. If they are of petit mal type. 3. If tit? ar frequent. (Jmsar. Petrarch, Mohammed, Napoleon were epileptic, so epilepsy is not incompatible with good brain power. CoMPUGATlONS,— Occurrence of ir.ania, furious, dull or;_'ay, setsin suddenly and violently. The most dangerous insanity is epileptic. 2. Apoplexy is very rare, even in the fit, so i^ meningitis (hopeful if it does not occur). 3. Paralysis tf^ 3 IJ a' '■ ': ull^i' ; ii: 1 1 FBACTIOB or MEniCINB, 129 imare, partial after Jacksoninn cpilopsy, disappears usually in from few miimtcs t(i ft w Weeks, Cause of jiaralysis is exhaustion of centres. I'ATHOLOOY OF Neuvous FMsK\«Ks.--Leibig (?) Theor). The funilatnental cnusci of all nt>rvou8 diseane is to be sought not in iviuuiion of peripheral norvea oi vasomotor disturbance, but i' aprimary and often iniicrited vice or raorM-l dis- position of nervous system. This vice of nervous sy,' tern consists in a tendum y on part of nervous centres to accumulation and discharge of n<-rvoua force, and the concentration of tiiis discharge from different centres determines the neurosis. The immediate antecedent of an Pttack is one of unstable equilibrium and gra- dually accumulating tension. The restoration of this eiiuilibriuin is reg,iined by tlie nerve storm expitnehiig itself, (ioweis accepts part of fon'going, but s lys instability of centres is due not to accumulation of nerve force, but to reduction in controlling power of the nerve cells over the discharge, and due to imperfect nutriticm of cells. Calsks. — It is now generally held that the cause of instability arises from a slight disturbance in nervous system, which can be ir.herited, but may also be acquired. Epilepsy is inherited in 33 to 35 per cent. It is believed other neuroses in family may predispose to epilepsy, it being an equivalent. The inti- nuicy between e[)ilepsy and insanity is greater than with I'uy other neurosis. Ke age— under 1(1, 21) per cent, of cases occur; under 10 to 2^ 46 per cent, of cases occur ; under 30, 90 per cent, of cases occur. 3o it »s a disease of ear'v lifti. .•^fter 30 it becomes a rare disease. If it attacks one after llO it will b' a ni.'ile. 'iereditary syphilis especially predisposes to epilepsy. ' iMEtUAs: Exciting Calses.— 1. All intense or oft-repeated functional distu' iiances .'. or shocks to nervous system act thus, as fright and p';^ longed nicnti' anxiety, also overwork excessive venery, masturbation, blows on head, sunstroke, etc. 2. Acute disease oecasionrdly brings about idiopathic form. Thrombosis, embolism, encephalitis after (1) scarlet fever, (2) measles. 3. Ty- jilioid, rlieuinatism may explain epilepsy wlisn it succeeds hemiplegia. The first three tire often followed by epilepsy without preceding hemiplegia. It is quite jiossible in these cases the specific poison nuiy have effected the change, sn also alcoholism, lead poLsoning, etc., may act. So does the specific virus of syphilis 2. Keflex influences, as indigestion, worms in children, delayed or absent men- stmation. When predisposition to epilepsy is strong any reflex may stmt it. 3. Occurriiig in children f of cases succeed teething convulsions, and children are generally rickety. Causes of Symptomatic Epilctsy. — 1. Such lesions are tumors, indurations, ]iressure of spiculie of bone on membranes, etc., u;ay cause epilepsy. 2. One of coniinonest causes is an adherent dura mater to the brain. 3. Brown-Sequard artificially produced epilepsy in rabbits by half dividing cord in dorsal region, and their offspring inherited epilepsy. Epilepsy is a neurosis, so no constant lesion has betii found, so it has no morbid uaatomy. In the symptomatic form you will of course find tumor, induration, etc. The seat of primary change in brain is in dispute. One says the medulla and bones is the starting point extending !. t k- I •j PRACTICE OF MEDICINE. 130 secnnilavily to cortex. The more modern view is that it is primarily from a ilis- cliaii^'c from cells of cortex. It is admitted it miiy be from the cortex or the liiisilar ganglia. Diseases wliicli most freqneutly originate convulsions are ciirtical. In idiopathic epilepsy convulsions sometimes are local, so too cortical lesions cause local manifestations, hence proving cortical origin of epilepsy. The "aura," intellectual or emotional, also point to the cortex. So weight of evi- dence is that in ordinary epilepsy the discharge is cortical. Loss of conscious- ness is owing to the sudden discharge of nerve force, temporarily aflecling con- sciousness. Tkkatment. — During the attack prevent him from injuring himself, unloose necktie, place cork between teeth to avoid biting tongue, give plenty of air, etc You cannot shorten fit. If on coming out of fit he be maniacal, give Chloral and Biomid. or Camphor and Chloric iElher. In cases of rapidly recurring fits you can rut that short by Chloral grs. 15 every 3 hours, or hypodermic of Morphia gr. ith. Inhalation of Chloroform or Ether will do same. In severe ef)ilt'ptie fit do not give Morphia, lest coma of fit and Mor])hia coincide, hence death. To ward off fits after aura is jierceived a tight ligature above aura sometimes works. Some will weiir a loose ligature about arm or leg, when aura is always given in same place. It has even worked on opposite limb, so it may work through a mental impression. A i)owerful mental emoti jn, violent exercise, etc., will sometimes l>vcvent the fit. To cure, the Bromides are the best, given for years, till fits have censed to recur. It at least will diminish frequency of tits. In some, attacks will cease while Bromide is taken — 50 per cent. There was improvement in 66 ]ier cent. It is not known how Bromides act unless to render stable the nerve cells. Kules of dosing — inci ise dose till you get results, as lessening fiequency and force- E. by Brown-Sequard. Pot. Brom. 1 oz.. Pot. Iodic', dr. 2, Am. Brom. dr. 3, Sodium Bicarbonate dr. 1, Am. Carbonate if weak jiatient, Inf. Calumbie oz. 6, Sig. dr. 1 liefore each meal and dr. 3 at bed time. As a general rule dr. 1 per day will do, given as you like. The Pot. Bromide is the best of the Bromides. The patient should not intermit a dose for years. Dr. Gowers when he has checked the disease tries very large doses to try and influence the nerve cells. He gives large doses with increasing intervals, dr. 2 every 2 days, dr. 3 every 3 days, up to oz. 1 every 5 days, the only ill effects being headache and occasionally enfeeblement of mind temporarily. Sometimes Bromides fail, but act if combined, as with Digitals m. 5 in weak heart, or Belladonna m. o to 10 if patient continues to have petit mal, and espe- cially Arsenic m. 2. Indian Hemp frequently does good combined with K. Br. Gowers says if there is anaemia to give Iron. If Bromides have failed, Borax gr. 15 to 30 T. I. D. sometimes gives good resiilts, may cause psoriasis. Nitrogly- cerine sometimes cures in dose of gr. tj ? gr.adusilly increased to i give as pill or in the 1 per cent, solution. CouNTEK-IURiTATioN. — Blisters to back of neck, use of actual cautery, setous, etc., have done good, generally fail. ifl!fP^^ li) ! I I 1 1 1 \ 1 ilii ^ 'i f z... , : ; ^- PRACTICE OP MEDICINE. 131 Surgical Treatment. — Trephining is coming into ftishion. If yon suspect a tumor, of conrse operate. If there be a depressed fracture, then operate. Yet opurations have not as a rule been successful, perhaps because too ^lute. Nerve cells have acquired the habit of discharging. Mental and Moral Treatment.— Inspire confidence, so that he will take (Inms hopefully. Avoid extreme mental and bodily work, yet still he must not be idle. If it be in a child, inculcate habits of self-control, witii a will to control eniutional nature. DiETlc Treatment.— No rules can be laid down. They require to be (li'cently fed, still in some cases meat will increase, in others decrease, the tendency. D(inot goto bed on a full stomach. XXX. CHOKEA. St. Vitus Dance is divided into magna and minor by Germans, but English do not regard magna as chorea, it is more hysterical. In l5th and IGth centuries wure supposed to be possessed by demons, hence St. Vitus' shrine at Strasbourg was favored by them. Symptoms.— May have premonitions, may not. Disease may come on sluwly. Prodromita may be indigestion, constipation, depraved appetite, or nerv- ousness, as timidity, fretfulness, etc. The state of health attendant on rheum- atism may alternate with it. Menstruation at puberty, pregnancy, may pre- dispose. The Overt Disease.— Has among first symptoms a hurried manner, clumsy movements, twitchings of face, extremities, more common on left side. IVcuIiar muscular movements are characteristic of this disease, may accompany vuhintary movements or not. If during voluntary movements tlie fact to he iiuted IS, want of co-ordination, no accuracy in movements. In walking, leg will be jerked, progression thereof difficult. A common appearance while examining is child keeps affected arm to side (note a spasmodic rotation) so as to hide it. Spontaneous movements are especially characteristic, as constant movements of muscles of ftce, especially of tongue. Speech in severe cases is impeded, diflicult or impossible, even laryngeal muscles choreic, ditto respiratory muscles. The head is often tossed or jerked. These movements usually cease during sleep, are aggravated in presence of strangers, ditto by emotions, when they speak, etc. Sometimes undergo periodical exacerbations. In time muscles are flaccid, weak^ muscular power affected or defective. Common or special sensation is seldom disturbed, still hemi-aiiasthesia has been met with (hysterical). Patient is apt to be fretful, gloomy. A common symptom is inability to concentrate, to attend to anything, failure of memory. In long standing cases mind is thus impaired, (hgaiiic functions may not be affected or may, as digestion wrong, urine high, S. G. (urea and sulphates) (piiosphates nervous). It is a non-febrile disease as a rule, but in severe cases temperature may go up to 102. Some affection of heart is frequent, due to anaemia, a systolic murmur over base, a mitral murmur 1 J 1 ■ Hi mi t 1 PRACTICE OF MEDICINE. 132 at apex. May be q.\g to vegetations on valves (has likeness to rheumatism). Heavt failure is a sequence, regurgitation along the organic disease, or muscular failure. Walsh thinks chorea of papillary luuscles causes the regurgitation. So we have anaunia causing hc-emic murmurs, heart weakness causing regurgitation. Course and Teumination.— Declines gradually and completely in 8 to 10 weeks, getting well in 2 months. If it exceed 3 months will be ditlicult to treat- Occasionally it proves fatal, only in acute forms, convulsions severe. The limbs may need tying, convulsions are continuous, no sleep, child wears out and dies in :] to 10 days, or 9 to 20 days is the range. Like other neuroses, the occurrence of an acute disease, as smallpox, typhoid, etc., will cause disease to cease, and often c'lre it. Relapses are freiiuent in chorea. If death occurs it is from exhaustion, or from other lesions, pericarditis (rheumatic). It seldom attacks okl people, if it does is incurable. Causks of Chorea.— Predisposing— age one of most striking; is a disease of later periods of childhood, 9th to loth year, but has even occurred in infants. Not over 5 per cent, of cases occur after 20. It is also met within advanced life, senile chorea, but. is of a different nature, occurs independently from rheumatism, is intractable, etc. Sex. — 3 times commoner in females. Eace.— Negroes are more exempt, ditto Indians. Heredity influences. Tiie taint may be maintained or manifested in other neuroses, as epilepsy, neuralgia, etc. Other members of family siifler fi'om chorea in 14 per cent., other neuroses are found in 50 per cent. Co-sensitive, im- pressionable, nervous habit of mind predispose, this may be inherited or acquired, as by indulgence, bad habits, etc. Nutrition,— a badly nourished state predisposes to it; exciting causes, — shock to nervous centres, fright the commonest; powerful mental emotions, especially anxiety, anger, etc. The interval between shock and disease is usually a week, but may bj longer or shorter, or no interval at all. Imitation influences, is apt to be of a hysterical form, may act by influences of habit, " mocking is catching," or it may act through fright on seeing a choreic patient. It is supposed some nutritional change in nervous centres must be brought about by fright to produce such effects, a predisposition probably existing. The special reason why shocks produce chorea in children depends on the age. They are educating tlieir motor centres. Tliose are not fully developed, yet are highly exercised, hence liability to equilibrium being disturbed. Blows upon head are also exciting causes, may be from fright accompanying the injury. Reflex causes not common. The common one is worms, also decayed teeth, but are rare causes. Irritation of peripheral nerves, as crushed finger, has been followed by chorea, so also irritation of dura mater may act. Mental strain, in child- hood, due to present system of education, is a frequent cause. EiiEUMATisM. — Acute rheumatism has a remarkable connetvion, preceding chorea in 26 per cent. The rheumatism may occur during the chorea, or it may alternate with chorea, acting like an equivalent. Acute rheumatism may also follow f^u 1 « i 1 1 1 ^1 PRACTICE OP MEDICINE. 133 chorea. Some will have iv strong vlioumatic family Fiistory, even as high as 45 per cent. Ih'avt disuuse is often assuciattid with chorea, may precede oraccompany it. riducrs says the heart disease preceded in half the cases. Endocarditis often fol- low- clinvca. No nervous theory can account for endocarditis, hence rheumatism, iiotcinirea, causes these heart troubles. Some say both chorea and endocarditis are l.iit inanifostations of iheumatism. In chorea it is the same valve damaged, initial as in rheumatism. It is generally in first attacks of chorea that endocardi- tis iircuis. Ill chnrea from pregnancy there has been either a previous attack of liioiva or rheumatism. Senile chorea occurs without rheumatism. iJr. Howard iiiis never seen chorea in a rheumatic person. Only in children can rheumatisni develop chorea, i regnancy is a rare cause of chorea. A common ai)parent cause tlieii is fright, but they have had chorea or rheumatism before. This form is niave, fatal 12 to 30 per cent. The period in pregnancy is about third mouth, is laost eonimon in first pregnancies. Is often attended by delirium. TiiKoKlKs— Embolic, that tiny emboli swept off from the valves loilgcd in liiaiii in certain areas (corpus striatum, etc.), and so cause chorea. But when peojile have died, the postmortem does not sliew this appearance often. Again, Irijilit could not produce emboli fiom heart disease in so short a time. The I's.seiice of true chorea is an unstable condition of nerve centres, together with tlieir imperfect luitrition. This may be brought about by causes already men- tioned, disturbing the equilibrium between stimuli (volitionary or sensory) and the motor response, so a sovtof iiico-ordination occurs, a delirium of motor centres. TuKAT.MKNT — Tiy and find exciting cause, as worms or irregular bowels, nervous stimuli, etc. Improve nutrition and tone up nerve centres and improve loiistitution of patient. Tonics, good food, change of air and scene are good. At once take from school and send to country. Child may need rest at first, mol- erate exercise afterwards must then be taken, never exciting exercise. If there lie iiiarkeil debility, then give alcohol. Extra sleep is needed. Arsenic and Iron seem to be curative. The Garb, of Iron, Fer. Redact., Fer. Dialyz, Vin Ferri are all "ood. But Arsenic is better than Iron. Give in large doses. Give child of (i yt'ars m. 3 T. I. D., increasing a drop per day till 12 to 15 drops are reached. It intolerance is reached, stop dose for a short time and give again. Give Arse- iiie in heroic doses. There is a marked tolerance of Arsenic in this disease. It is usually given by the mouth. In some obstinate ciises give the Arsenic hypo, derniieally, u.se Liq. Fowler (minus Tr. Lavender Co.), wliioh is iiritating. The Salts of Zinc are valuable as nervine tonics, giving in large doses, starting with gr. 1 and gradually increasing. Strychnia is sometimes useful, u?e Bromide of Arsenic or Hyoscyamus. Cod Liver Oil is needed for bodily nutrition, giving at same time as the drugs. If sleep is not obtained, give Chloral, not Morphia. Cures have been effected by Chloral, keeping asleep for two weeks. In acute cases keep patient in bed in u dark ivum. In olifonic lung st-.uuliiig c;ises, give .systematic exercise, rythmical, as dancing, to overcome the irregular movements. Gymnastics and calisthenics are useful. Moral treatment — the childrau may be 17 [STT^TFryr 1 1 .'^^1 . ^^H PRACTICE OF MEDICINE. 134 very (^inntiotiiil, indulging their passions. In extremely violent cases the limbs iiiay iiued struppiny up in cotton wool and splints applied to prevent injury. XXXr. NEURALGIA. Is defined as a functional disease of nervous system, not due to a primary li'sioii, organic, either of nerve trunks or their centres, declaring itself by pains ill tiie course of sensory nerves, usually unilateral, intermittent, sometinxes ji('rii)ili(!al. At first unaccompanied by inil.imination at seat of pain or fever. Symptoms of sreneral neiiral''ia; — Hesides above the state of health at time of attack is impaired, pitient is aiueinic or has been fatigued, or recently been sii:k and debilitated. Or if general health be good, then there is a tendency to ]Miiis, numbness, etc., in the limbs, in parts which will afterwards become neural- gic. All depressing causes aggravate the pain when present. The pain is par- oxysmal in all its stages, re>nissions occurring. The paroxysm may last sec mds, liiiiir-i, days, so may the interiiiissiims. The pain is spontaneous, is apart from liiCid stimulation. Is a darting, boring, burning, tearing pain, is excruciating in tliL' [Midxysin, duller between. The pain follows sensory nerve or a definite spoD ill its distribution. Hyperiesthetic spots may also be found : 1, as where nerves emerge from skull or vertebiiK; or 2, where they } ierce fascia; 3, or where tliey become cutaneous. These teniler spots occur only in protracted cases. Nfiiialgic pain is aggravated by sudden moverajnts, by pressure (pointed), by colli and heat. There is an absence of fever in neuralgia. If it is severe or prutiiicted there may be Segoxd.vuy EfFEcrs, due to disturbance, extending from primary nerve to others. Thus the special senses may be affected, ani.iurosis, amblyopia, dilatation III pupil, deafness, loss of taste or smell. Secretion may be increased on same side, as lai;iymatioii, salivation, unilateral sweating, uniliiteral discharge from ni.se. Aluiig with the.se .secretions is a flushing of .same side of face from disturbance of vaso motor nerves. Nutrition may also suffer, hence unilateral hypertrophy of skin, ))eriosteum, etc, blanching or falling of hair unilaterally, or glaucoma irili.'^, luMpes Zoster, patches of erethema. The motor functions may also Ite thus dis- tuiliL'il, so also sen.sation with hyperasthesia or anasthesia. Taese grave results only come from severe and prolonged cases. Causation. — 1, Symptomatic; '1, idiopathic 1. Fr-nn local lesion of a iKMve, either at central origin, in its trunk, or at its periphery, or it may be iiK're irritation, as when following bruise. The neuralgia is then symptomatic. Or by pressure of tumors, or action of new growths, local interference. Its clinical features differ somewhat from idiopathic form, for pain comets on gra- dually, remissions less marked. Serious derangements of tissue are apt to occur, p;iiii is harder to treat. 2. When nerve is seat of irritation, the manifestation inav he in some other nerve. This is seen best in eye, myojtia, astigmatism, etc.^ leailing to neuralgia ; also catarrh of nose, especially if accompanied by hyper- trnpliy of mucous membrane of inf turbinated bone ; also irritation of any .Sensory nerve, as by ovarian tumor, gallstones, cai.uii, etc., caries of teeth. But b Kl r-^f^". their t(i iii.'i ill'.' I'l Iratl, iii'iiii tioii, the n llli'^Vi lit'.-, 1 licili'. luttli will's You lU'SJl' exi^it Nni iiilie new ticia ClTV oViV if win ]H)St disc assi (lef. or to t cati .li.i ]..•! ret ilit be lUf cli 135 PRACTICE OF MFDIOINE. th..,. must l,e a pvedisimition to neuralgia wlu sH^M causes so act. 3. Shocks ,.evvous system. esiLially ;...w..,ul .nontal .ion. -vl- . ovcworM^^^ „ ..motions etc WlK.n fn.i. sho.-k, from con, ssion, an interval .nay elapse i.rannoas 4. Neuralgia from malaria. 5. Neuralgia from JMSon. : : ::;aiS;i. gout. ...: U., .^.o^.^ ..1 g^t may al-o p. nee ;„„,ins -a .lilfen.nt thing, i',. From ann-mia and malnutnt.un, thus h> ,.>,rUcta. xivs cluM.l.,.u^ng. leueorrho.a. ut... act. Neural,.a ;s the prayer of ;: f, u.ro blood. 7. Age-is a disease of adult life, but some forms , he mav occur in children. There are 3 special periods :_ I. I., early a lult t:"o years.while sexual functions arebein, developed, a|Tectu.ns em.t,.ns ;,' developed a ,d n.oral responsibilities first felt. 2. From 25 to 4o. durm, ho : f ife a ui at end of this won.an's climaeteri- occurs. 3. Tu old ago we get the ^i 1 ;neuralgia.Itmaybeepileptin.nnu.aralgia.Thisischaracter.^^^^^ .„Men onset of pain: which is atrocious, f .r.utiou <,f tender spots, «1~ ;^- You ea„ only ten.porarily relieve. These patients fre,uently go --''"■- -^ » ^ a,.,„„..lent. The disc.. e lasts for years, patient d.es worn out Cold is an :!;, -ting ca^se frequently. In many cases, no ca.se at all can be ascer une \,.ural.da is often inherited, not so often as migraine, ntdl 2. per cent, is inh.nt^d. In the family a,e f.und e^uivalnt neuroses. These persons a.3 nervuus. excitable. Neuralgia is divided into 2 vmeties: e.xterual or super- ticial and visceral varieties. .„ . , • „„;„!f,i Ektkunal Foums. -Migraine, special nerves, trifacial, cerv.co occipital, cervico brachial, intercostal sciatic, aural, eocey.odyn.a. or any nerve. VISCEUAL FOHMS.-Uastric, enteralgic, hepatic, cardiac (angina pectoi.s). „v;P uterine, renal, rectal, vesical, urethral, tesi ienlar. or any organ. i>ATHOLOOY.-Tlie seal of pain in idi.M-athic form is the n.rve ce Us lom whieh the nerves anse. It is not the ganglia of p. t fibres of cord, but of eel s ,u post horns of cord or in sensory centres in brain. Call neuralgia a nerve storm llischarging from the sensory centres. Not only is neuraL^.a he, '^.tary bu associated if not inherited directly with other aeurosc . Hence an inh rite defect in the construe, ion of or eonformation of the nerve centres a feebleness or instability of the composition of the nerve cells, which read r them unequal to the demands of everyday life, render them very susceptible. TuK.vTMENT -Find out cause, if you cin examine eye for defects nose loi ratarrh. teeth, etc.. or aseertain any constitutional disease, as syphilis. an|emia, ,lub.tes, and treat them. Their cure may cure the neuralgia, but not always. Thera- peuticslimpvove nutrit ,n of nervous system and general health, tor nutrit v emedies, fats are very good, especially Cod ,iver Oil, Gutter cream etc. Let diet be of a nutritious character. Forced feeding after Wier Mitchell s pkn may be needed. Prolonged rest of body and mind may be needed in some. Exerc.se may be needed; if too weak, massage may be substituted. Change of ha ,.ts, _ t climate, etc.. wearing of warm clothin, is necessary, l.aha and fnctiou lu tuc -Ivin. ' t^ III PRACTICE OF MEDICINE. 186 ];i;mki>ik«. — Nervine Tonics, as Iron, Quinine, Arsonio, Strychnine, or Nux Voiii., l'iio8i)lioraH and perhiipn Salts of CnpidT and '/Am: Quinine i.s especially vnliiiililr if you si'.siwct malaria, is especially valuable in iu!ural;,'ia of the (,'ll)), Arsenic is also useful, as above, or in advanced life with d('i,'oneratoJ tissues. Zinc Salts, Oxide gr. 2 to 10, and Sulpliate "jr. 1 to -i, Valerianate gr. J to 4, the last for hysteria witli neuralgia, riiosphorus is often used, onlv wme- tiiiii's gives good results. Give as a, pill, dose gr. j|,tli to ,^th. Iron i ' in aiiii'iiiiii, is a nervine! also, combine with Stryciinia and Arsenic. .Anodynk IkKMK.iilKS, as narcotics and stiinulaiitn, Opium is best- !Viorphia, W ciinful lest the habit is actpiired. Most cases of habit are formed from neu- riil<;ia. IJeliadonna, Hyoscyamine „^, gr. Hemp gixtd. Aconite, Ktlicr, Alcohol, Am, Chloride, (Jocaine. These remedies seem to act best hyiKxlorinicdly. Do not liigin with over gr. ^th Morphia, IJ. 1. D. It is well to inject into site of jiain, or in course of the nerve. This is neccissary in the gravest forms where some lesion must exist. Cocaine gr. J to 1 is also a i^ood substitute of Morphia, itiji'ft into jiart. Atropia gr. ,.^- to ,,'^th (,4 to j^^tli) injt^cted in part, or Ext. lieU hul, '^r. Ijtii, arc also good. You may alternate .Morphia and Atroiiia. Ikllad. is especially useful in pelvic neuralgia. Indiati Hemp gr. \ to J is especially useful in Migraine, also suits other forms as well. Caffeine gi\ 1 to 5 hourly. Giiiuana Powder dr. i to 1 hourly. Oelseminm, in dental neuralgia, tic, etc., pusli till physioh)gical elfects are produced. If Fid. Ext. is used, begin with gtt. 5, increasing to gtt. 15 T, I. D., or Gelsemine hypodermically will do. Tonga ri.l. Ext. dr. i to 1, T. I. I). Aconite or Aconitia in gr. ^^ in granules, this last can be given every 3 hours, up to pr. 1 to 1:^0 doses. When Migraine is auconiiiauied by flushing of face, give Ergot ; if pallid face, give Amyl. Nitrite. In some forms (hepatic) gr. 20 to CO of Am. Chloride is good. Sulphur. Ether is goud in visceral neuralgia. Angina Tectoris, Gastralgia and ovarian neuralgia. Alcohol may be good ; beware of habit. Neurotics are more apt than all others to get a love of liquor, or Opium. Alcohol without doubt is a powerful agent to relieve neuralgia, but only resort to it in extremes, lest habit be induced, for the more highly nervous the patient be, the more ai)t to get the habit. Antipyrine is a prompt and powerful anodyne, is used especially in Migraine, gr. 15 maybe repeated twice per day. Antifebrine lias also a similar power. External means — blister over seat of pain ^r over spinous process of nerve affected will often benefit. More powerful counter-irritation is sometimes used, as actual cautery to region of origin of nerve from spinal column. Anodyne liniments — Aconite ui Chloroform Lin., separate or combined, are good ; Chloral and Camphor also are good ; Aconitine Ointment is good ; Menthol is good thus : R. Menthol three parts, Chlorof. four parts, Olive Oil nine parts (sciatica). Cocaine is also good. 0.smio Acid 1 per cent. sol. in water, or Glycerine 8 to 12 drops hyiioderuiiuUiy, li:is cured obstinate cases, blackens skin at part. Electricity, galvanic, is also iMiwerful foi good, more useful than faradic. If you use faradic let current bp Weak and interruptions rapid. In epileptiform neuralgia you have to use large duses of anodynes, excision or stretching of nerve, etc. fimn boide rcgii ii sioii lib. The t left a VCIltl beliii point fidin i:-ht line visib jiinc ii litl lunr Sou At a uiiti'i m It littli 4. J its ( pint tion boa ben vill sioi and it ii UC'.l car reft the Soi "11 PRACTICE OP MEDICINE. 137 XXXII. DISEASES OF HEART. Topography— Heart'jics diagonally, base to the right, apex to left. Extcndg finin upiier border of 3rd' cart, to 6th, and transversely from i in. from right border of sternum to within inch of nipple line. This is the "deep cardiac region. " Tlie superficial cardiac region is where heart is exposed by reces- sion at 4th left cart, of lung to 5th rib, inside nipple line, dropping to 6th rib. The dimensions are 2 inches verticiilly, 2^ transversely, i e., of this area, Tlie two auricles lie under 3rd cartilages and spaces above and below these, the k.ft auricle encroaching on 2nd space, the right on the 3rd space. The right ventricle lies nearly in front, the left ventricle with exception of ant border lies behintl. The right apex beat is half way between nipple line and sternum. l*rom this point the right ventricle runs along till it meets the right 6th cart., then up i inch fi„ni right edge of sternum. So right ventricle lies one inch to left and h incli to i-,U of°stornum. Tiie apex beat in man is in 5th space, about 1 inch inside nipple line and 1 .», to 3 (2) inches below nipple. This beat produces a visible pulse, visible ovc'r one inch square. Tlie valves-Tlic pulmonary valves are l>ehmd junction of 3rd cart, at left edge of sternum. The aortic are in lower down and ii Httle toward middle of sternum. The tricuspid are in middle of sternum, runnin" obliquely from 3rd interspace to 4th. The mitral lies in 3rd mterspace. So a stethoscope would include all at once. Then look elsewhere for sounds. At aortic cartilage, second right ; at pulmonary cartilage, second left; at apex for mitral, etc. XXXIII. PERICARDITIS. May be acute, 8ub-acute or chronic. Inflammation produces same changes in it as in pleura, for it is a serous membrane. So products may be ;— 1 . Plastic, little effusion. 2. Serous. 3. Serofibrinous. Slow of absorption, much solids. 4. Pus_pyopericarditis. 5. Hemorrhage, owing to the contractions of the heart, its constant movements. The heart becomes covered with nipple-liih;ns of Effusion. — Dullness on percussion, 4 ozs. of fluid being needed. IViiiai ilium enlarges even to the clavicle in extreme cases. Outline will be triiuij^'ular, apex up, base down, reaching transversely, pushing lung back, increas- ing! tile area of dullness. Na'urally the murmur becomes inaudible as the fluid iiiciviises. still we have sound of friction continuing for a long time at the base, iil-M ill soine c-ases from 30 to 40 oz. of fl.uid ; with patient on the back the fric- tiMii is sometimes heard, H(Mirt sounds are muttled, heart's impulse lessened, ('Hen displaced upwards. One view is heart is floated up. Anotiier is you do im; feel tile effects, but the base beating with stethescojie on the chest. You find til' heart, sounds are not synchronous with the heart's impulse ou the chest wall :p:i .HI ( PRACTICE OP MEDICINE. 139 A li.i:'^ing, due to acting through a layer of water. An occasional sign in children i. a ilistinct bulging over the heart. ( 'oi-usK KTC, 01.- THE DisKASK.-Recovcry is the rule. If dry form, ndhesions „>av ror.n, or white spots. If effusion be moderate, say 10 oz , it will be absorbed i„ 1(1 to 30 days, for sometimes dullness will remain, also friction, as surlaces ,,,an approximate. Adhesions will form. In slight cases there may be al)sorp. tMi^Nvilh.mt adhesions, as in dry form. In some cases death results, as trom ..aralysis of the heart from pressure or from mild carditis, weakening the lu^rt. Douth is often sudden. Syncope, as when the patient gets up to urinate More often death is gradual, lungs congested, in venous congestion shew signs of asphy- xia as dyspnoea, pallor or cyanosis. Death is rare in acute pericardilis, but it accim.punied by pleuro-pneumonia it is very fatal. In cases where death occurs it is from 20 to 30 days. Another termination is in the chronic form, which is not uncommon, as from Brighfs Disease, or when the products are purulent, or fro,,, heart disease. Paiicnt suffers from dyspn.iea, recovers and rel;,])ses. Con- gestion of the venous system, occurs, dropsy common, heart weakens. This cluuiiic forhi rarely recovers. CONSEQUKNCES OK AcuTE Pericarditis._1. Adhesions if complete are not (lia♦' the blood beconus precipitated, increasing the size of the excrescences by a deposition of thrombus. Additional chall^'es are : ulceration may attack the valves, abscess may form on valves, aueu- risni in the valves may occur. AdWsions of the valves may liajipen, futty and especially calcareous degeneration, jjuckering of the valves by cicatrization may occur. The chordie tendinsc may unite or shorten, and prevent closure of the valves, or the weak valves may rupture, so orifices of the valves may be nar- rowed or dihited, and become blockeii by fibrin. The debris of breaking down may, if not septic, lead to mechanical couseiiuences, thus softening of the brain by emboli. If septic, then abscesses may be produced elsewhere. Symi'toms. — If in the course of acute rheumatism, or in the course of any other febrile disease, there are n(j initial symptoms, sometimes [lalpitation, now nnd then there is slight precordial pain due to irritation of the cardiac ganglia or heart muscle. So long as the circulation is unobstructed, the only sii^n is a iiiiirniur. Now and then there is headache, freijuent pulse, sliort, dry cou^h and with a slight fever. In rarer instances cardiac circulation becon>es obstructed by a rupture of the valve or cord or formation of a clot. The symptoms then will indicate shock, pulse feeble, dyspnaa, coldness of the face and extremities and their iivjulv, fitful dozing. Severe myocarditis or pericarditis complicating will eituse sii.;!; (■■ .vmptoms. Embolism from detachment of particles of throm- bus from valve is are in acute non-ulcerative cases. If embolus plugs the large vessel in the brain it causes softening, in the kidney, bloody urine, elsewhere perhaps gangrene. Small capillary emboli give but slight bloody symptoms. Acute endocarditis may be quite latent. Physical Signs. — 1. Increased cardiac action, apex area enlarged, cardiac impulse stronger. An endocardial systolic murmur will usually be heard over the HI J il 1 1» -T—rtT:' ; PRACTICE OF MEDIOfNE. 141 mitral valvo, sometimes the muniuir is presystolic, as when there are vo^'ota- tiuiis on the auricular surface of the mitral valve, and the murmur may be duuble. Endocardial Muumuus.— A mere murmur does not mean inflummation. In strmii,' emotions you may hear a murmur. In aiuumia hajinio murmur is idways lu'iinl, first at the base and better up |)ulmonary artery, or an inch to the left of till' .•sltriiuni. This murmur is always systolic, is accompanied by a musical mur- mur in the veins of the neck. There will be marked signs of amemia. In ad- vahced stages the heart is weakened, the oritice is enlarged, hence tricuspid and mitral murmurs. The heart muscle weakens from malnutrition, and cannot close the (iiitice fully during systole, hence regurgitation. A similar adynamic mur- mur is often heard after typhoid, etc. Awkwarduass in the use of the stethescope v'' cause a murmur, especially in children, by pressing too heavily on the yieliling ■. '.ii. This may often happen in thin, narrow-chested people. In almost any one you can produce a murmur in imlmonary artery just at the act of expiration. Stiipfiing onward circulation of the lungs, preventing the valves oiiening evenly as liiey should, this murmur is contined only to the first part of expiration. Pres- sure of aneurisms, etc., also dis}ilacemunt of the heart, cause murmurs- Oljstruc- tidU of the orifices may cause a murnuir, so every murmur is not a sign "f endo- carditis. You need to find out if murmur is recent or old. A recent murmur is soft, lo\v-])itclied, systolic, perhaps double. If it is juirely diastolic, it is old. This endocardial murmur will change its site, extending, hence proving it recent. At iijicx to-day, at apex and base to-morrow. In a recent murmur there will be no history of disease, as palpitation, dyspncea,etc., nor would the heart be enlarged. An old murmur is generally rough and high-pitched. It may be diastolic, as in rcguigitation of the aortti. There will be a history of previous heart trouble, on examination you will find enlarged heart. CouusE, ETC. — (valvulitis) — Rarely efTects may disappear, vegetations ab- solved or Mashed off. If emboli are small, no harm is done. In some cases the iiitlanunation is interstitial and the valve may regain its strength again, with perliaps only a slight thickening (rare). The rule is permanent damage to tlie valve, sometimes progressive, varying with the severity of the attack. It may pass tluis into chronic stage. The patient's future depeiuls now on the amount of com- iHiisation afforded by the heart. As a rule, acute endocarditis is hardly ever diieclly fatal. Death is usually long after from dilatation, absence of comjien- sation, etc., but there are exceptions, as rapid death from embolism of the Ijiain, or if a valve ruptures, or if endocarditis is complicated by severe pericarditis. A licaltiiy valve rarely ruptures. Causks ok Acute Valvulitis.— The cause is rheumatism, also Bright's I'isease and chorea, attacking the mitral valve mainly. Measles, scarlet fever may also cause it. Puerperal fever, pytumia, acute gonorrhoea, even without aitiuular afiection, or ifc may be from local inflammation, extending from the pleurisy, disease of the aorta, as blows on the chest ; violent efforts at rowing and jumping, running, etc., is a rare cause of acute form, is a common cause of chronic form. It is doubtful if the disease is ever idiopathic. 18 «ll« i^l; ■ m^ PRACTICE K MElilCINB. 148 PvnioLOGY. — Feltrile diseases are moat freiiuent caines, link .■iiildi'iirditia always is produced by irnuiiion of Imcteria on the valves acting vitidly, fitherchemically or meclmiiically, but iibovu is too wide. Tlie mcs aro ■o— bacteric an ' .on-ba(tii not allow high tenipei Mine it is apossildo cause, hence use antipyretics .u ili-umalism to protect 1 t. When it has occurred d inue salir.ylate.i and idkalii's, and add supportiii-; ag.'ii! as Ammonia ;uul Quiniii.). We have nothing which will kill the bacteria, even tor. Sub. has been iiil ,iled and injected sub^u- taneously without result. Bleeding and Pot. lod. are not now used. Treat the original disease. If then- be severe pimi apply 3 to 5 leeches over the heart, or hot stupes. When signs of pulmoiinv congestion arise from iK)()r circulation, then bleed from ihe elbow 5 to 6 ozs. The great remedy is absolute rest all throughi so as to give the heart the least amount of work. Rest should include quititness of niiud. If signs of cardiac failure arise, give Digitalis m. 5 to 10, or Tr. Stro- pauthus m. 3 T '' and Alciih(d, and give abundant supply of uourisliuient. Wiien the patient vering, your duty is harder, for you caimot keep him in hr<\ long enough. nould stay in bed till the valves are healed again, so a long rest is needei .ter a valvular lesion, as after rheuiuaiism. If heart excite- nieut be very great at any time, DigitiiHs is called for then as well as when the heart is failing. Dr. Simpson found permanent injury of the valves followed aiute rheumatism more than twice as often when rest was not insisted on as 8 is to 3, and twice as many had pericarditis also. Non-rheumatic forms— treat tliu disease of which the endocarditis is a secondary sytii|.toHi. Ulckkative ENDoc.vkDiTis occurs clinically in two forms : 1. Acute endocarditis, primary carditis, ending in ulceration. 2. More commonly it is secondary to a previous valvular lesion, as a tearing of an old valvular adhesion. SVMl'TO.vis,— Two chief types of symptoms : 1. Pyiemic form. 2. Typh)id f.irm. The pyiemic form is characterized by sudden rigors with profuse sweat- ing between them. Abrupt fever and fall of temperature, great constitutional dt.'pression. Later on aft - this fever the couse([ueuce3 of emboli in the brain lead to hemiplej'ia or sot'leuins,', or asphasia, etc. ; if in femoral, to gangrene of the leg; if in the spleen, to pain there, swelling and vomiting; if in the liver, jaundice; if in the kidney, albuminuria; if in the skin, petechia when fine emboli block up the cutaneous vessels ; in the lungs, embolic pneumoniii ; around the j .ints, embolic or secomlary abscesses ; in the typhoid form you have .symptoms like typhoid, a moderate high f«ver, diarrluBa, sometimes a hiroR spleen, i)atient also somnolent. Between the above two forms are internuuli.uc cues as like rheumatic fever, especially if you have a suppurating joint, and in #- I MICROCOPY RESOLUTION fEST CHART lANSI and ISO TEST CHART No 2| 1.25 m 1^ «" IlllM I: m •^ 14.0 1.4 I 2j_ 2.2 2.0 1.8 1.6 iiil: 11111=:: ^ /qP PLlEa IfV MGE Inc =r 161)3 Los' Mom Street =^ Rochester. Ne* -^ork U609 USA — (716) -iB^ - 0300 - Phone = (716) 288 - ^989 - Fax t i I' PEACTICE OF MEDICINE. 143 these cases the heart may have no murmur. In other cases you may have no fever. There is also sometimes suppurating meningitis when ulcerative endocar- ditis follows pneumonia. Physical Signs are those of endocarditis, but the murmur will change its site and (quality as the ulceration spreads over to valves or to other valves. As the valves get eaten away you get a diastolic murmur, yet sometimes in spite, of extensive ulceration you get no sound. CouRSii:, ETC. — The severe forms always end fatally ; minor forms do recover, lint it is difficult to prove they are geimine. They may destroy life in 3 to 4 days, more commonly in 3 to 4 weeks, but in other cases they become more chronic. Causes. — The acute primary form occurs in rheumatism, in pneumonia, in (lilihtheria sometimes, and in ordinary fevers, as smallpox, measles, pyjemia ; all varieties is the great cause, traumatic, puerperal, uteriue, etc., even from a Ljuniboil, splinter festering, etc. All affections of bone and pycemia especially are lialile to cause, and especially osteomyelitis, periostitis, also dysentery in bowels. Pathology. — It has been found by experiment that the two peculiar microbes staphlococcus aureus and streptococcus pyogenes of pyiemia injected into rabbits cause ulcerative endocarditis if valves are already damaged. Tlie bluol of this animal cultivated gives products, which injecteJ into other ani.nals caused under similar circumstances ulcerative endocarditis. Others have found the i)ueuinococci of pneumoaia would also cause ulcerative endocarditis. Hence i.atholoi'ists think endocarditis is of bacterial origin. Above proves that micro- cocci will cause ulcerative endocarditis if valves are already injured. Doctor thinks it a pyaemic disease, is one of the many manifestations of pyjemia. There may be two foruis,— one septic, malignant ; tiie other non-septic, heuce not as fatal, due to crumbling down of injured valves proiucing emboli, but not pyaemia emboli. Treatment is unsuccessful, as disease is very fatal. Treat as pyaemia siii)port by Iron, Quinine, Alcohol, fresh air, good diet, etc. A successful case in which Sulpho. Garb, of Soda was given is noted. XXXV. OPvGANIC DISEA ES OF HEART Are divided into those of valves and wall. Valvular Diseases.— Causes are : 1. Malformations, congenital, most common is obstruction of pulmonary artery, or of aorta, or of valves being luiited, or of deficiency of septum of ventricles or auricles, etc. 2. Injuries of valves, of arteries, or heart. An injury or strain may rupture, or may set up acute endocarditis, but more comuionly chronic endocarditis. For this reason auilic disease is common in laboring class, straining at work, athletics, etc. This iviieated straining sets up a low chronic valvulitis. Wherever a valve ruptures, it is diseased. A case in a child 2 and 9-12, by fright, tricuspid valves were ruptured. 3. Alterations in cavities of heart, as dilatation of ventricle leading to regurgitant mitral disease, so will shortening of the valves or their cord. ^. '- f^ i> I ill ^ 1' ■ • ) J PRACTICE OP MEDICINE. 144 Aoute inflammation ofvalves. by thickening, adhesions, etc. 5. Chronic mrlm m>ons .t:ains are the great cause, also atheromatous degeneration, or may follow "cute f.rm. Brighfs Disease acts as a strain to cause this by th. high tensi n The high tension found in profound an.cmia is recognized as a cause of valvulai diseisc 6 De.^enerative diseases, as calcareous degeneration, hyahne degener- !;::„ of ..U. i^oW age thickens it. Mucoid degeneration of valve m dd age a ..nucnce of hyaline degeneration, small spots appear and luiuify-fatty dcgener i,ti' ,1 of l:uing membrane of valves, amyloid degeneration also. 7. Deposits of fibrin will obstruct by preventir.g closure of valves. Diseases of valves are obstructive or regurgitant. AouTiG SxKriosis.-Physical signs, direct signs : stethescope at base hnds a .vstolic murmur, louder yet at second right cart., and ^^'-^^-^'^^ ^ hrlldvinrof o> neck. Palpation over base might give systolic thrill, caused by eddying of blood. This murmur might m isk first heart sound there, but net at apex, where it may be lost. Indirect signs : pulse would b . regular, size varies with size of stenosis, miaht be weak. lu time left ventricle becomes enlarged, and might in time dilate.°Breathing is not eml.arrassed, no dropsy, for mitral valve is compe- t.nt Pure stenosis is a rare disease. A mere murmur of aorta does not prove aortic stenosis, may be ha^mic, or from a shred of fibrin hanging from valve, or rou.rheniug of coat above the vaWe, or cardiac malformation. ''gk-eual ConsequlXCES of aortic stenosis-Disease may last many years provided left ventricle compensates, but at any time serious symptoms may appear, even suddenly, as fron. dilatation, or weakened by fatty degeneration, or loweredcar- diac nutrition after a long fever, or the valve may be oud.lenly ruptured, or hbi.a ,„ay accumulate, further obstructing the orifice, and this if detached forms a large embolus with its consequences. . ^ . f u.„a AoiiTic Regurgitation or permanent patency, from insufficiency ot va.ves. Sicms,-a murmur at base of heart, would be diastolic. This murmur will be hear.l all way down sternum, sometimes louder at right apex than at base (this murmur u frequently accompanied by a systoUc .mrmur). The second sound of heart may be completely obscured, usually it can be heard m vessels of neck , if distinct in carotids is invariably preceded by a systolic murmur in those arter- ies, indicates a very serious lesion. INDIUKCT EviDENCES.-i. Pulse-watcr hammer, or a collapsing pulse receded from finger so quickly. The arteries can be seen to be visibly pulsating, look at brachial at elbow. 2. Dilatation of left ventricle specially marked at apex with accompanying thickening of walls. This disease gives the largest hearts, '-^-h this dilatation you will get mitral dilatation and regurgitation, ihus, d, retardin-' pulmonary circulation, hence pulmonary congestion, cough, dyspnoea, hemorrhages. 4. The right heart is affected by the pulmonary congestion, gets dilated, hypertropbied, but in tune tricuspid dilates with regurgitation. 5. Hence venous stagnation, dropsy. The other sources of diastolic murmur are not com- mon. Aoitic aneurism the most common. Pulmonary regurgitation very rare ; HIM I ■M^ h! patent Most s over-(l lyzes i years, occurs also a The IK S t(i feel area. openii lif(! an obstru 1 qiientl betwei loud a may 1. tlirill invgu satioii nary c have pulnic right 1 obstru tricus] suffer.' may e on If standi eonipt long a coinpc lessen tolic 1 times fibrin nuiinl PRACTICE OF MEDICINE. 145 patoiit ductus areteriosus. So only aortic aneurism is to bo diagnosed from. Most sudden deaths are from fatty heart or aortic regurgitation. Left heart is over-distended alwa>^, if it miss a beat, i, e., a systole has extra work which para- lyzus its wall, hence instant death. If caused by valvular rupture lives 3 to 4 years, if from rheumatism man may last many years, provided compensation occurs. Mode of death is usually from a systole. Acute congestion of lungs ia also another mode of death. Occa iunally death is fro;n dropsy or asthenia. Tiie powerful beat of heart may rupture a cerebial artery, hence hemorrhage. Symptoms ok Failvke of Compensation — Great pallor of face. Tendency to feel faint. Attacks of angina pectoris, pain in sternum, shoulders, and down area. Dyspno-a, deficient circulation. MiTUAL Stenosis. — 1, Valves may be like a diaphragm, small button hole opening ; 2, or may be funnel-shaped, this last congenital, is generally in early life and in women. The first may be from rheumatism. So oucoming blood is obstructed. I'liYsiCAL Signs. — Murmur heard in mitral area, at left apex, or i...jre fre- quently over body of ventricle over fourth cartilage, sometimes in the auricular area, between 3rd and 4th cartilages. The rhythm is pre-systolic. Characters,— is usually loud and harsh, the last part especially terminating in first sound of heart. It may be so long as to fill up diastolic space. It is accompanied by a pre-systolic tlirill. It is not propagated to left, is localized. Indirect symptoms : pulse im (;idar if compensation be not good, pulse is apt to be small. When compen- sation is failing it is irregular in volume and rhythm. Stethescope over pulmo- nary cartilage you will find accentuation of second sound, for pulmonary valves liave higher tension from pulmonary tension, for there is obstruction at end of pulmonary circulation, i. e., mitral valve. Sometimes there is a double sound, rigbi hcait empties itself slower than left heart, for it is obstructed. From mitral obstruction the left auricle will be dilated. Right ventricle will dilate, giving tricusi)id regurgitation, venous stagnation and dropsy. The left ventricle rarely sufllTs. It may later on hypertrophy to overcome venous stasis. Mitral stenosis nuiy exist without murmur, so may any cardiac lesion. The murmur is louder on lul, side if he stand up, or after exertion; sometimes only heard after standing up, or after exertion. Heart is often irregular in rhythm. So long as compensation is good patient does not suffer. If congenital the compensation is so good the child will be able to play like others, and will never notice it. As long as second sound can be heard at its left apex and to its left it is a good sign, compensation is maintained, but disappearance of that sound at apex indicates lessened bupply of blood to aorta from loss of compensation. With this pre-sys- tolic murmur there is generally a systolic murmur from regurgitation, even some- times m.-isking the real murmur. Death may be sudden from mitral stenosis, fibrin accumulated (lesions). Mitral Eegurgitation is very common from insufiiciency of valves — is mainly cf rheumatic origin. I f J ^li..v.---' PRACTICE OF MEDICINE; 146 Physical Signs A murmur, systolic, heard loudest at apex, transmitted lia. kwards, even to lower an^de of scajiida. May bo heard all over heart. A tluill, systolic, at apex is sometimes present. CoNSKQUKNCEs are iiulmoiiiiry ent;or>,'emeiit, accentuation of p\dmonary viil- s, reduplication of second sounds. I'ulse regular and small if compensation is ,^ood, l)ut irregular in volume, rhythm and force if there be less of comjiensa- ti,,n. Dilatation of lift auricle. Dilatation somewhat of left ventricle, for it has to iiold enough blood for systemic circulation and regurgitation. Pidmonary con- gestion. Dilatation of heart, regurgitation, venous stagnation, dropsy. Effects.— As long as compensation of left ventricle and right heart are pood tlRMC are no evils, but on loss of compensati. 11 symptoms develop. Loss of comi)en- sation n:ay be from dilatation, fatty degeneration, etc. Dyspna'a is a symptom. Tiii. form of disease kills generally by dropsy, slowly, or by pulmonary congestion, active or gradual, or hemorrhage from lungs (aortic disease kills suddenly). A i.immur at left apex may not be due to mitral regurgitation, may be from rough- cuiiio of ventricular surface of mitral valves, or vegetations on edges of valves iKit hindering closure. Perhajis also choreic disturbance of pajiillary muscles. Tliese mitral murmurs are often high and musical, are heard hjudest over ventri- fk; itself, are not transmitted around chest, are not attended by alterations in heart, tlicre is no incompetence. Another murmur from curable mitral regurgitation, cuiised by adamemia, heart's muscle weakened, so base does not contract to iiiirrow valves orifice. Is met with in aniemia in all febrile diseases, Irom this impau-ed nutrition. These murmurs disappear with returning strength. Is often heard about 3rd rib at base of heart. TuicusPiD Reguugitation is fairly common, murmur systolic, is usually soft, low-pitched, heard in lower sternal region, especially along the border. It will' be feeble over the base, will be transmitted a little to the right. Is too feeble for a thrill, is in many cases marked by mitral regn-gitation as primary cause. If the right ventricle be strong you will have acctntuation of second sound, not otherwise. Indirect signs,— fullness of jugular veins, and after a time visible pulsation. A double pulsation from auricular and vent, contractions, pulsation of liver may be also noticed even before the jugulars pulsate, pulmonary ..dema, right heart auricle and vent, dilated. Pulse not affected if the left heart is all light, venous stagnation with its consequences, general dropsy. In marked tlropsy you have tricuspid regurgitation. Causes.— Not usually inflammation ; acute endocarditis does not attack these valves, but chronic endocarditis is set up if the right heart is habitually strained. Habitual strain so affects the valves, walls, arteries, etc. Exceptir lly is at- tacked by rheumatism. Obstruction in the left ventricle is the 2ud great cu,. .^e. 3id, r^l.^tructinn of pulmonary circulation, asthma, emphysema, cirrhosis, acute oronchi- tis ; 4th, adanajmia also, weakness of the ]ieart's muscle. Tricuspid regurgita- tion is often curable when disease causing it is removable, not so if from disease of the left heart. !; I. T S }■ PRACTICE OF MEDICINE. 147 TiticrspiD Stenosis.— Narrowing of this oriflc^ novor occtirs alono without mitral (liaoaso, and in 5(» per cent, of (Usoiisd of tlu; aortic valvus. Ho it cannot bi. ^^ H'" •>«ft'"t (.iiiplieH itself, symptoms iiro nil, Imt when tlie iieiirt is not emptied tiu'n yim ijet ^;r,ive symptoms ; us lonj{ us compensation keeps up, of eourso arterial tension iti hii.'h, iiene.i tlusliinK, as when stooping, Iju"™ rupture of artery, apoi.loxy, etc. An iitery must be .'.ioased to rupture, pulso of course stron,i,'. In ol.l vessels cuniliils will l)e throLhiii-,', shortness of the l.reath sonictinies, for a lar}»e^ heart PiicnMiches on the lungs. A murmur up un ffiilui of sti labdi lUt'llt CUliU rhagi gradi anil eiiiot slioil cout iiiooi toba alcol ucut imiK protl !). 1 this, is ai cans rich |)reA 12. villi not Ave colli dig( giv. dig( ure iiiu bnr i'ec( fun mo ^: i hi PRACTICE OP MEDICINE. 149 telling him of heart disease, do not blurt out to a patient on discovering any serious disease. Causes of Cardiac Failuue.--!. Any serious intercurrent disease, espe- cially acute rheumatism or bronchitis, astlinia, pneumonia or acute fever. This failure may be only temporary, and judicious treatment may save patient. Use nf stimulants, rest during convalescence. 2. Over-exertion from daily fatiguing labor or more sudden strains at athletic exercise, or blowing in wind instru- ments. The poor especially suffer from this cause. 3. The nutrition of mus- cular tissue of heart may be impaired from poor blood, as in ansBuiia, hemor- rhagcs, leucorrhcea, chronic diarrluea, want of proper food, or dyspepsia, causing (gradual cardiac failure. If a dyspeptic has a murmur, etc., first cure the trouble, iiiid the heart will often cure itself. 4. Mental worry, grief, exhaustive study, emotions are common causes. Give up your work for 6 ii.onths. 5. The gradual .shortenino of the valves of muscular tendonous attachments, from cicatricial cuiitractions of former inflammatory exudation; hence gradually increasing incompetence which is permanent and not recoverable from. 6. Tea, coffee, tobacco, alcohol may act as poisons to some, causing palpitation, etc. With alcohol you have to combat the habit very hard. Alcohol sometimes ciiuses aeiite palpitation, curable by stopping the habit, and nourishing food. 7. Preg- nancy is also a cause, cvhaustion from confinement. 8. Rupture of a valve wdl pnHluce cardiac failure. Once compensation ceases you have cardiac failure. 9. Disease of the coronary artery is also cause of heart failure. Syphihs causes this, and the degeneration is either fatty or fibroid, and leads to cardiac failure. It is amenable to treatment. If from atheroma it is not. 10. Gout is a common cause from atheromatous arteries and fatty '.■ t. 11. Indolence, sedentary habits, rich food, wines, etc., induce fatty degeneration of the heart, etc. You can l.reveut disease from advancing by living on one shilling a day, and earning it. 12. Constant valvular tension from valvular disease brings about a low val- vulitis, hence fibroid degeneration of valves, cicatricial contraction, incompetence, nut remediable. Concerning Diet.— Food should be easily digested, plain and well cookad. Avoid sou.)S, for the blood shor.ld be coueeutrated, animal f jo 1 in excess, tea, culfee and tobacco prohibited. Alcohol as a rule should not be iu thi diet. If digesiiou be bad, vital [ owers low, no appetite, dilatation great, alcohol may be ^iven ; vegetable bitters, mineral acids, pancreatiiie, etc., are ussful for weak digestion. ExEUCiSE regulated according to the nature of lesion and the extent of fail- ure of compensation, for example, in mitral valve disease if dyspnaei be present much exercise is bad. In aortic disease, stenosis, exercise is generally well liorne even in regurgitation till compensation fails. Mountain climbing has been recommended for some forms of cardiac disease. It promotes the respiratory functions and excites the cardiac muscle. But " Urtel " does not prescribj mountain climbing in severe valvular disease. Pulse irregular and feet cedematous. 19 l-iii.!; I. il!f I t ir. iiit'.i PRACTICE OF MEDICINB. 150 Ho does send gouty, fatty hearts to climb mountains, also cases of corpulent )ieo|ile, fatty accumulation about the heart. IJofore sending he reduces the fluid ill til ■ blood by diaphoretics, anseaed, vomiting, lu'ddache, suspend its use. The Tincture is the most certain preparation. Digitalis is seldom giv.n alone, give with Pot. Acet. and sweet Spts. of Echer. If a little Sipiills be added often you get effects, wh;nnot from Digitalis alone. Or give Hinitalisand Quinine equal parts. Squills 2 [tarts in pill if heart be weak. If Digitalis fails give Stropanthus; old Tr. is I in 8, new Tr. 1 in 20. (iive m. 5 to 10. It acts quicker than Digitalis, does not cause arteriole con- traction. Spartein is another drug, begin svith gr. i T. I. D., pushing up to 3 to 4 grs. per day. Calomel given alone gr. 2 T. I. D., watching gums, will some- times succeed when other agents will not. Do not give in albuminuria. Hydra L'n^ues 2 to 3 per week, as Pulv. Jalap Co. orKesiu of Scamm ony and Cream Tar- tar, or Elaterium gr. Jth every 4 hour.'is. If dropsy does not yield aspirate abl(j- luen and then sometimes Digitalis will act. Instead of tapping the abdomen i puncture of legs and scrotum with 3 connected needles is done, wash skin with ;iu autisei tic. Make 2 to 3 punctures on the inner side of the leg and apply an antiseptic bandage over these points. Bandage prevents occurrence of local iutkunmation. Patient may become weak from loss of water. Aortic Regurgitation. — When compensation is failing, treatment is needed. Put to bed for a few days to lessen the weight of the blood on the valves- Give Digitalis judiciously. There is fear that slow diastole will allow of large filling uf tiie ventricle, hence begin with m. 5 T. I. D., pushing if effects are needed ; watch that the heart is not too much slowed, vomiting, etc, intermit its use, jive 3 days, stop for 2 days the treatment, etc. It is accumulative medicine (not so Stewart). Convallaria (Lily of the valley) is also a good agent, but ^ i I ■* ' -i 1 1 1 . m !'M: I ii' 1 I "1 1K1 PRACTICE OP MEDICINE. „ot euual to Digitalis. Senega and Hyoscyaraus and Sweet Spirits Nitre T I. D h n Iht good in England. Iron is also indicated to sustain nutntion of he heart. „ nl mineral acidl Diet should be generous, do not overload, though. Give Adonic for accompanying angina. In some cases of large hearts with great pal- i.itation, Aconite has been used with advantage. ' m";u.l DISK.SE.-Ilest of heart is not so needed, but circulation may ae,nand it, so as not to overload the lungs too much. Ireat -th Di| ahs I ,,,u be here used for month after month, but intermit every 7 to 8 days, so as ,.„t to get the system accustomed to drug, taking a substitute Pulmonary on- ,,.stion may call for dry cupping on back. Give an occasional purgative. Tieat uccompanying bronchitis on general principles. XXXVI. DISEASES OF THE LIVER. Ascites is frequently part of a general dropsy, but often is separate and depends on obstruction of the portal circulation, or Hriglifs Disease, or cardiac obstruction, „r more early pulmonary obstruction. Ascites-a skin full of wme Symptoms of AsorrKS.-l. Gradual uniform enlargement of abdomen, and is .eneral- 2 Fluctuation, wave transmitted through the cavity. Nopaui. Dyspnce%. 2 Percussion, patient on the back finds a clear note, in front, for intestines are tloated, mark with clinical pencil, turn patient and clear sound changes, dullness where the tluid is- The weight of fluid on reuil veins lessens the urine ; on vena cava causes cedema of the legs, a late symptom. This passive congestion seldom l,.ads to albuminuria. This ascites may be confounded in women with cystic disease of the ovaries. In early stage there is no dirticalty. for the pain in tumor will be unilateral, menses mxy bo deranged, but when the whole b3lly .s distended by a lu-e cyst it gives difficulty. In ascites the enlargement is perfectly symm3trical. ,u ovarian disease is rarely so. Skin glazed. Percussio.i in ovarian dropsy gives dullness in front, clear notes laterally from behind -change of posture does not alter a dullness with ovarian tumor. Palpation will find generally points of irre- .-ularity, resistances, hardness, etc. In ovaria.i tumor from smdler cysts, per- cussion also is not uniform. Breathing thoracic. Measurements from umbibcus to anter superior spina of ilium gives equal results in ascites but unequal results in tumor. Under an amesthetic you can feel the fluctuations spherical. An arterial mur,nur can often be heard in ovarian tum.r if it press on aorta. Occasionally a vaginal examination will clear it up. If you are in doubt, tap Fluid of ascites is transparent, alkaline, thin, citron coh.r, no floccuh. Muid ot cvst is viscid, glutinous, usually discolored. Its viscidity is due to par albumen which does not coagulate with acetic acid and heat. Microscope detects large cranular bodies-Dr. Esadle's bodies (not fat). Other conditions may be con- Ibunded with ascites, as hydatid cyst., or an enormous cystic kidney. Preg- nancy (?). Retention of urine, a flabby belly in a very fat woman, colloid disease of omentum (rare,^. Tumor, enlarged viscera. ' 1 ■ i 1 iifi ■J iHini,: !!l!.;l iuT':: ' Hi PRACTICE OF MEDICINE. 152 of live'. Cancer of Ascites is a symptom, not a disease ; is divided into : 1. Symptomatic when due to some other disease. 2. Idiopathic, no cause known. Cause exists though. Causks— Symptomatic— 1. The one great cause is cirrhosis .Mtlier hypertrophic or atrophic form. 2. Amyloid disease of livur. 3. liver. Tumors, concretions in bile duct. 4. Cancer affecting various parts, omen- tniu, pancreas, general peritoneum. Colloid disease of same parts. 5. Enlarged (ivary, above are common. Kaue Causes arc (1) Pi'i-ihepatitis, inflammation of capsule. (2) Throra- ]mm or cancerous obstruction of or adhesive inflammation obliterating the portal vein, (3) Obstruction of inf. vena cava just above lepatic vein's entrance. (4) Kidargement of kidney or spleen interfering with portal circulation. (5) Disease of mesenteric glands, as waxy, amyloid, cancerous or scrofulous. XXXVir. CIRRHOSIS OF LIVER. Morbid Anatomy of Ciurhosis of Liver, called chronic interstitial hepatitis, chiefly of larger sheaths of Glisson's capsule which surround portal vi'in and branches. An exudation of leucocytes gradually becomes converted into connective tissue (af^er going through process of fibroblasts, embryonic tissue into fibrous tissue). Tliis fibrous tissue presses on hepatic cells leading to their atrophy, some undergo fatty degeneration. Liver is rendered firmer, less vascular, lor fibrous tissue obliterates vessels. General constipation. Bile ducts are seldom aflected, hence no jaundice, sometimes wasting of hepatic cells expose new bile ducts. This formation of fibrous tissue sometimes forms in vessels, walls also, narrowing them, thickening the walls. Cai)sule is thicbmed and often aUierent to adjacent parts. These bands of adhesion may be so vascularized as to afford collateral circulation, and hence absence of dropsy.' The liver is reduced in size in atrophied form, firm to touch, rough and granular (hob-nailed). Color vanes- yellow, purple, light blue. Organ feels tough, dense, weiglis less, edges may be puckered. On incision it resists the knife, and discovers fibrous bands, etc. Usually the hypertrophic form produces a smooth surface, the process being uni- form. When process Is induced from heart disease, then the pressure from veins leads to atrophy of centre of each lobule (nutmeg liver). At samj time the fibrous tissue proliferates. When syphilis is the cause it often changes v tside of organ, great irregularity, fissured, lobulated. Often in congenital syphilis you have atrophy with cirrhosis. If produced by perihepatitis the organ is fissured, strangled, fibrous bands extending inwards as septa, capsule greatly thickened. A rare form is from adiiesive inflammation of inf. vena cava, hepatic vein obliter- ated. There is also a rare form, red atroiihy or chronic atrophy, met with after malaria, etc. It is not granular, is of a uniform red brown color, cirrhotic, fibrous. Is deeply pigmented after malaria. Glinucal SyMProMS. — Set in usually insidiously, rarely actively and openly» Dull pain in right hypochondrium. In insidious form, indigestion, furred tongue, morning vomiting (drink), flatulency, constipation, and also a feeling about liver. In some cases actual pain about liver, and perhaps slight enlargement and slight fever. Gradually complexion becomes sallow and dry, loses appetite and loses i^ 1 1 1 I ! ! 1 j i i -'i i 1 H tf _i, '1 If PRACTICE OF MEDICINE. 1B3 flesh These symptoms may last for a longor or shorter time. Tlien symptoms (.eroud sta-Tc) of portal obstruction follow, as dilatation of veins on opisastnum and alKiuiuen, Especially on right side. Hfemorrhoids, bleeding, or vomiting of blood, slight to pre ■• V, also ascites. These symptoms may alternate, hemorrhage roliev- in" In thi. Muge blood is altered, bleeding mon, easy. Urine is scanty, high Svi'i] and deposits a pink sediment. Scivere indigestion, eructations, vomitmg. .liairhoia, and death from exhaustion. Another mode of death is poismnng by biliary matter, " acolia. " Its symptoms are slight jaundice, purpuric sjwts, dpliriuin, convulsions, coma. Jaundice not often present though. Liver l^^ -reitly enlar-'cd, but in atrophic form its dullness may almost disappear. There H correspon.ling enlargement of spleen when portal circulation is otetnicted and may even be indurated. Jaundice ensues only occasionally, comes on slowly, is seldom complete, nearly always bile in stools. It is a bad symptom. The asso- ciation of jaundice with ascites means either cirrhosis or cancer of liver. Altliough fever h not constant, yet occasionally it is prominent even for weeks, pnnc.i«lly i„ the hypertrophic form. Hypertrophic is a more active form than the atrophic, more fatty too. A symptom is a stellate group of veins on face near the eyelids. Occasionally cirrhosis is advanced, and no dropsy of the belly. In these latent cases the liver is usually large. Cirrhosis once begun usually proceeds to a fatal issue with no hindrance or arrest. Occasionally there is an arrest, as when only part of or-an was affected. 1, There are cases in which the arrest is insidious, tins class^comprises the great majority of cases ; 2, those cases with move or less rapid arrest. , Causes -1, Great cause is use of raw spirits in excess or on empty stomach, even seen in children ; 2, syphilis is also a cause. It may produce well-marked hypertrophic cirrhosis, (2) or atrophic cirrhosis, (3) more frequently a lobulated liver (4) and may deposit gummata with local spots of atrophy ; 3, products of faulty diaestion entering the blood, and also the use of stimulating food, highly spiced espedally if too little e.Kcrcise be taken. So ptomaines act, even peptones at times acquire irritating properties ; 4, due to venous obstruction, cardiac dis- ease ; 5, some think ague may cause it ; 6, biliary cirrhosis from obstruction of liile ducts, the proliferation beginning in the fibrous tissue, thence extending as an interstitial hepatitis, etc. ; 7, specific poisons, as of typhoid, cholera typhus, measles and scarlet fever ; 8, it is not infrequently associated with tulMnculous disease ■ 9, a chronic peritonitis starting a perihepatitis may so start a cirrhosis ; 10, obstruction of portal vein.-rare. Prognosis bad. Fatal in one year from iiositive diagnosis in most cases. Rarely it is arrested. Trfatment —1. If you suspect it, and patient is a drinker, make him a tee- totaler.-imperative. 2. Alter his diet, plain unstimulating, farinaceous food in excess. 3. Insist on daily exercise. 4. If there be tenderness or fullness of liver, or pain, leech over liver, or at anus, and drain portal systu.n, and also give sahne purgatives, or give a mercurial, and follow by a saline next morning. If you give laiuml waters give in a.m., fasting, instead of saline. Mercurial treatment is h:i-\ 1 1 ! ij *i 1 i i- J i ' 1 i ii,- u ;if,'ain Arivst tlir H; ciiily 1(1 T. for scv out of it fiiil iit)iro] llliubf 1 ilo not Ciillfi is oiili Si.iitli aviiiil lively ciiaiiCi 11 ]i bi! tuuioi giadu times 4. Til tioii. (laiiin 7. It eiidin divid tluc f liviT rliill, li-pat enlai'i with its sy left 1( hu!} a PRACTICE or MEDICINE. 154 ,i.;;iiii becoming prominent. (Jive aniall doses Ciilomcl gr. 1 to 2 T. I. D. Anv>t nmy ensue, keep up for 5 to 6 weeks, avoiding p> till ism— snuie prefer til,, llj,'. CI. in small doses, fir. 1 to 10 T. 1. (,'„th). (Jive Mercury in ,;iilv stiij^es. II. Hyd. IJichlor. gr. Mh, Am. Mur. gr. l5, Tr. Cinclion, m. ]iiT. I. I). Tf you lire afraid of Mercury give Tot. Toil, and Am. Chlor., n|\iii^' in Tariixicniu and Gelatine. Some give m. 10 Ac. Nitro Mur. T. I. I)., Huc with a l)itter, T nixicuni and Gelatine. Martineau continues alteratives |ni several numtl.s. Whi;n disease has advanced, dropsy present, then cure is out .. "'■ "l"^^■"• It ,1 he secondary to \>^ eniia. is from operations, dyNcntery, etc. Cieneral syinp- ,„„.> are not reliable, you infer hepatitis by pain in ri-ht hypoehon.h'.un. an.l |„lln..s« there and increase in .lullness, p^rbaps sliKht jaundice, i'.ul thr-'c principal .vn.pton.s ..f hepatitis n.ay be absent-a.^ idn, for parenchyma of or«an is not VHV sensitive ; jaundice, for only a part of organ may be involved, the rest ,1,,,;,.. the hepatic work i enlargement of liver. Kven the geneiaUymhtoms ,„av l:ave l)een absent. Yet if symptoms ..f hectic occuriu sallow individual vv lio 1m ■hail bilious attacks, etc., you may .suspect hepatitis. If abscess open into peri- toneum there will be death from general peritonitis, unless circumsc.ibed. It ,.. y burst into .stomach, and be vomited, or into thorax and i-.is discharged into u .i.hne'in inciting local pleurisy, later perforating lung and being expeclorate.l, „,ve i.h vsical signs of abscess .if lung, etc., or it may perforate e.xt.;rnally. Dia- clmrge of abscess lessens hepatic tumor, and in rare cases spontaneous recovery has occurred. Ditterences between i-ya-mic and tropical abscess of hver-])ya.. niic form occurs in temperate as well as in tropical climates, the other is always tinpieal. In pyiemic you have source of pyiEinia, as in injuries, ulceration.^, sur- ..iral uperations. etc The causes of tropical are coM, malaiia, irritating eonges- iwu etc. In py{«mic form there will be more than one abscess funned, only oi lu tn.p'ical form. There is not much enlargement of liver in i.yu-mic form, llare 13 „, tropical form, and especially in one direction, and such projection ia fluctuating. In pviemic, pain and tenderness are early and acule, are also present in tropiral, Imt not as acute, dull, only becoming severe when surface uf organ is reach, d. In i.ya'inic jaundice is present from blood causes, not obstiuclive, and spleen is tulanred ; in tropical form there ' no jaundice usually, or. if so, is not ok^tructiv, in,d spleen is not enlarged. In pysemic, course is 3 to 8 weeks, in tropical l(jnu may last six months, may become quiescent. In pyccraic form prognosis is bad, fatal, while in tropical form is much better. TuEVTMENT of circumscribed hepatitis (tropical form). In early stages before exudation and loss of strength, patient robust and symptoms acute, resort to venesection, but local bleeding is more suitable in majority of cases, as bleed- in" riaht hypochondrium ; some leech the onus. Follow by hot fomentations and poultices, and give a mercurial purge, as Calomel gr. 10. Tarax.and Sod. Biorb i. also recommended. Absolute rest in bed and restricted diet are to be insisted on. persevering for several days after subsidence of symptoms; later, blislers over liver are useful, in many cases are thus arrested before stage of abscess, but if stage of suppuration occurs, as in pyaemia and abscess stage of tropical form, then I i ' PRACTICE OF MEDICINE. 156 give stimulating treatment, broths, wine and tonics, as Ac. Nit. Mur.. etc. If a^sci'ss jioints external!} it must be opened. Amyloid disease is painless, spleen enlarged, albuminuria and liistoiy of bone disease, suppuration or syphilis. Cir- vliosis— liver may be large, nodular and tender. There may be jaundice and ascites, but alcoholic history, alcoholic dyspepsia and i)hysiognomy, emaciation is not so rapid or great. Syphilis produces interstitial hepatitis, or nodular waxy liver, with jaundice, tenderness, ascites ; history and age may lead to diagnosis. Cataniial jaundice if chronic has only little enlargement. Gall stones, paroxys- mal pain, no ascites, little hydatid eidargeinent -may be impossible to diagnose iriiiu cancer. XXXIX. LARDACEOUS DISEASE. Ur waxy, bacony liver (or scrofulous). Gioss view of amyloid liver is, liver is slowly and uniformly enlarged, heavy and dense, aniemic, of a i.ale urey color. Making slices they are translucent, bacony, but this varies, will \vei'uh 7 to 11 lbs. The disease begins in intra-lobular arteries, these become tiiickened, hyaline, lumen narrowed. Heiiatic cells resist, but finally atro- jihy from pressure, or become fatty or amyloid. Tr. Iodine gives mahog- any brown. Methyl violet a rose red. This material is albuminoid, not starchy, no'tliud in blood gives this reaction, so thore must be something in tissues, which aetuig with serous blood produces this deposit. Clinical Symptoms.— Disease is painless, insidious. There may be a sense of fullness when liver gets large. No pain unless in syphilitic form, perihepatitis. Jaundice does not occur unless glands in tissue of livev become amyloid, and press uu bile ilucts. Of course a concurrent jaundice from a biliary catarrh, etc., may be present. Ascites is not abundant, comes on slowly and late, sometimes not at all ; but if eidarged glancis under liver press on portal vein you may get ascites. A low form of jieritonitis may also cause it. Obstinate vomiting wilh a clean tongue owing to amyloid disease of m. membrane of stomach, also from amy- loid deg. of villi of intestines causes obstinate diarrhuja. Sugar has been found in ]ieritoneal effusion. Complexion pale, for blood is impoverished, white cells in excess, deficiency of red cells, liver slowly and uniformly enlarges, ahd with it of en the spleen and also often the kidney, hence albuminuria and amyloid casts. Enlarged liver and spleen and albuminuria would prove amyloid deg. Cervical glands may also be enlarged. There is a marked tendency to phlebitis, thrombosis fornung. It may occur at any age, and its causes are two— chronic suppuration and constitutional syphilis. For suppuration, caries of bones, as hip, vertebrre, scrofulous diseases as phthisis, suppuratmg cervical glands, abscesses, empyema, etc. Rare causes, as chronic albuminuria, chronic dysentery, large griiwths, malignant leuctemia. In some cases no cause can be found. As a rule, once developed, this disease progresses ; occasionally there is an arrest, especially if of syphilitic origin, rare if from suppuration. Treatment. — Try and prevent by curing abscesses, excising joints, tap em- pyema. If disease be far advanced in knee, etc., perhaps amputate. Try Tot, lid. or Tr. lod. or Am. Mur. gr. 10 to 15 T. I.' D. for a long time seems good. 1 i f M 1 ' \-' aiiM pOL't PRACTICE OF MEDICINE. 157 PiriECT Treatment If syphilitic, treat it— as Pot. lod. gr. 5 to 10 for niniitlis. A course of Nitric Acid has cured. Iron is called for in all cases, (;,.iuT(Mis diet, baths, especially the sulphur bath. In all forms you can try puuish to supply potash lost to system by suppuration. XL. CANCER OF LIVER. Malignant Disease.— The several f(jrms of cancer occur — encophaloid usually, sometimes scirrhus. Of all the organs liver ofteuest has melanotic cancer. I'liuiary cancer of liver is rare ; is secondary to cancer in neighborhood. Colloid disease (cancer) is never a primary disease (if liver, rarely secondary invasion. Clinical Facts. — In many cases an early symptom is an emaciation with- (,ut cause, usually attended by loss of strength, disordered digestion, nausea, vimiitiug, loss of appetite, diarrhiea. More fre(iuently slowly— the wan sallow look of maliguant disease is seen on face, anajinic, an expression of melancholy. 1, Enlargement of liver usually, either upward or downward, may be rapid, signifying cancer ; and 2, is apt to be nodular, except in rare infiltrated variety. Tliis enlarged organ is painful to touch, and exammation makes it more painful. Diagnosis : — Nodules have extended gall bladder, lumps of fteces in colon, deep tissure from tight lacing, etc. There is mure or less constant pain. Tain iiit-reases witli rapidity of growth and occurrence of localized perihepatitis, often .suconilary to other ci ucer, hence look fur cancer elsewhere. Jaundice is njt necessary but is common, as when a cancerous nodule presses bile duct, or when glands in fissure are cancerous and press on bile duct. When jaundice oecurs it is [lersistent. Ascites is not necessary, Ijut is common, late, caused by a low fiinu of peritonitis from cancer, or from pressure of cancerous nodule on portal vein. No eidargement of spleen as in eirrhusis or amyloid. Wherever you have iiscites and jaundice look for cancer and cirrliosis. Age helps. Cancer usually .sets in after 35 to 40 ; exclude .sy[)hilis, malaria, cirrhosis. A Viiluable fact is, spleen does not enlarge as it does in cirrliosis. Urine is rich in uric acid, ;,oor in urea. In melanotic cancer urine after 12 liuurs' standing gjts dark. In List stage blood altered— yon often get hemorrhages, by vomiting, stool, etc. Duration is siiort, 2 years for hard form, 1 year for soft kind. Constitutional symptoms are emaciation and digestive derangement, diagnose from cirrhosis, ,sy[iliiliLic and nmyloid, biliary cirrhosis, etc. TuE.VTMENT, merely palliative— for pain, Opium and rest ; for ascites, tap. XLL JAUNDICE. 2 forms : 1, obstructive ; 2, non-obstructive or icterus. Is a symiitom of many diseases, and in other cases is a disease of itself. It is a yellowness (if tlie skin and conjunctiva and of the secretions, due to circulation in body of bile iiignient. It arises sometimes from pas-cige of bile into b!o(xl by reibsur-aion, and the great cause here is (A) ohstructiun uf liile ducts (m'jchani(uil jamulice), anything which interferes with (B) full play of diaiihragm may do it, as right pleurisy, pneumonia, etc. It may also arise from (C) diminished tension in lj(jital system favoring absorption, as in yellow fever, or bycoagula in large portal 20 nil" '• -d li: t. • 1 kfi I \\ .1 (!■■' ■! i PRACTICE OF MEDICINE. 158 l,:Miirli,.s; (D) the presence of excess of pii^iucnt in the portal vc'ns f..ors it; (K' |H,lyeliolia, excessive secretion of bile also favors it. 2. Deficient oxidation of \nh in tlie l)loo(l, (chemical janndice), but we have no prouf that bile gets i,„,,il„. l,l,M,d in health, is iK^t accepted. 3. That the bile pij,mient is really tMniicd in the blood, or tliat the colorin,^ matter of the bl(.od is convertible into l.ilc pi.^inent So this would be heinorrJia^'enous jiinndice. 4. Tlie suppression (.1 tiie functions of liver, and so the accumulation in Wood of l)ile, etc. Tlu3 thcnry is false, lor liver onlv makes tlie liile, nut the blood. Janndice is met— 1st urnu|. obstructive. 1. In obstruction to outflow of bile, niechiinical form. Con- 'liiiuns for above— 2, obstrncti.m may be (A) in the tubes, as catarrh of tubes or a du.idenitis, aflectins orifice ; :\ also gall stones, cancer pressing on duct ; 4, spa^m of .lucts if continued. Hydatids, Hukes, round worms from duodenum. iiii.ly a cherry stone, siippur.uion ofliydatid cyst ulcerating into and obstructing a liu.'t. (B) Outride causes acting on duct, as i)vegnanoy, aneuiism, loa'ge thought that slowing of pulse always i iidi- ature often lowered, often unaffected. The r .■■ ' ! f^^^^H ^ 1 f ii ■ Wm i^^^^^^K . ^^^H' ! '^^^^^^^^Bi^ - r'^^^^B' -'^^^^Hl ; t W^mi^^^^^ml ' / W^^^lffi' ^ i 8 K. I^^^Hs^l! 1 m Mu B^BmKb ■ J k . ' fii B^^^^B* !^ 1 'i^ i*^HH'4^ 1 '«> r. sm^/i » ? ^ '^ ■■ ■■'* i iL PRACTICE OF MEClCrNE. 159 l.ile acvh ami bilirubin are prisons; gr. f bilirubin will destroy 35 ozs. of any iiuiinal— ten times stronger than the bile acids. Hence also as well as >lJ\viiig of pulse and respiration and lowering of temperature, languor, head- iit'hc, pe(!vi.slmess, sadness, giddiness and in some cases toxic symptoms, deli- rium, lethargy, convulsions, coma and hemorrhages. Itchiness of slcin is m 20 prv ceut.of all cases, due to elimination of bile by skin, but the itchiness is not liinportionate to depth of jaundice. The mode in which patient is preserved from toNic influences is that the pigment is ppd in tissues or eliminated by the kidneys. But i.verworked kidneys may be inflamed or stutfed with pigment, hence suppres- siiiii (jf urine and ur.-emia. Death may be from urasmia, but excess of bile may kill from chola-mia. The bile acids in blood produce atrophy of hepatic cells, fatty (le.ueneration of heart muscle,-renal cells, even blood cells, all poisoned fatty degen- eration. Tlierapeutics - when hepatic cells are destroyed no more bile is formed, but it,s ingredients are retained in the blood, and poison. This is alcholia. And since livrr I'urii s urea we have its ingredients retained. These conditions form icterus ^raviis. The liver also manufactures glycogen, tliis function is lost, hence balance of nutrition is disturbed. In jaundice there is intense itchiness of the skin, is a gdod sign of obstructive form. Its four symptoms are : Slowing of pulse and respiration, lowering of temperature and itchiness. Sometimes there is yellcw visicii, urticaria may also be noticed (boils), sometimes little growths are liHind at inner or outer canthus of eyes. A chronic systolic murmur at apex is I 'lien lieard, adynamic. A'AitiETiKS.— Catarrhal jaundice— icterus simple of duodenum or bile ducts, or lioth. It is common. Causes are': 1. It is preceded by catarrh of stomacli or duodenitis, but there may be a primary biHary catarrh, i. e., of bile ducts. What- ever causes gastric or duodenal catarrh causes catarrh of bile ducts. In children riih food (Xnias time) often causes gastric catarrh. 2. The catarrh may arise in liver itself, as is pyaemia and phosphorus poisoning, also in gout. A French author says change or increase in ptomaines in bowel absorbed affect liver by irritating, causing catarrh, but in these cases you would get graver constitutional symptoms, as fever, swollen spleen, albuminuria, etc. It is probable emotional causes thus act by producing alkaloidal poisons in intestines. Epidemic FoKM.—Catarrlial jaundice sometimes prevails epidemically,— per- haps from cold and damp, perhaps from some infectious principle inhaled. Again, it is often found in connection with specific fevers : 1. The specific germ may act directly on coloring matter of blood ; 2, or on bile ducts themselves ; 3, or liy causing production of intestinal peptones, poisonous,— above may be called infec- tious causes. Gall stones in ducts will also cause catarrh, ditto secondary sypiiilis, ditto obstruction of hepatic veins. Symptoms may be latent, only yellow skin and urine and white stools. Earelv at outset you have symptoms of duodenal catarrh (nausea, vomiting, loss "t appetite, pain in epigastrium), some fever. Usually the icterus is preceded li\ symptoms of gastric disturbance, hence anorexia, furred tongue, etc. As a I'M 1 1 PRACTICE OP MEDICINE. IGO r„l,. l.iliary citarrl. .Iocs not Mive much pain in epigastrinm or over l.vcr, unless ,a.- is ad vancea, tl>en pain abn^- n.argin of ribs over liver, then liver may even be cnlar^Ml. If tiie inllanunation involves lower end of the duct, as from """ ^■'" »«. ,.t,. TiH.n escape of bile is prevented, hence enhu-ement of the gall bladder l':,in would be referred to duodenum. If obstruction be from cancer or j-ull si. me llien great distention of gall bladder. Rk iNi-KCTiors VAIKKTIKS.-This form is accompanied by fever, also by snn.ne.s and muscular pains, by sleeplessness, eruptions of herpes swollen spleen, occasio..allv nephritis, hence albumim.ria, these preceding jaundice 4 to 5 (lavs. This icterus may be slight and even transient, may be severe. Alter a time in all cases involvement of other organs follows, as spleen, kidneys and ..mntimes lungs. In jaundice from obstruction, whoa bile How is restored, there IS a sudden increase in urine and urea. Duration- of Catauiihal Jaunuick.— Usually runs favorable course m 3 to G weeks. Those from fevers are alfected by them. Rarely ends in icterus "lavus and death. C(.Mr.lcATl0>JS (catarrhal jaundice).-!. Ocxliision by adhesion of lacerated ,n memb. of cvstic duct, hence dropsy of gill bladder or its obliteration. ■2 Occlusion of individual ducts in liver, no symptoms. 3. Occlusion of common duet, very rare, hence biliary cirrhosis, atropliy of hepatic cells, etc.. andierminato in year as icterus gravus. -4. Now and tluui gall stones form from arrested secretions, sometimes the, 5, catarrhal ducts suppurate, ulcerate. .lAi'Xi.icE i-uoM Galt. Stoni;s.-Co1. Lithiasis may arise as above, ov from tliick . ravelly material inspissated in the ducts. Clinical History. -May occur in persons of inactive habits, corpulent, con. siini.rs of ri.!h foo.l, starch, sugar, etc.. in malarial districts, in subjects of biliary catirrii (lieiice stones from arrested secretions). Is much more common m women as 3 to 2, in age generally 35 to 45, rare under 30. These stones are attended by intervals and attacks oi jaundice, preceded by symptoms of biliary colic. Tiiese symptoms are, agonizing pain in epigastrium and right hypoclion- driuni after a meal, urgent and persistent vomiting, sometimes severe rigors, reflexes, no febrile symptoms, as disease is mechanical. When stone reaches duodenum or slips back into gall bladder there is instantaneous relief. If during this attack jaundice appears in 24 to 72 hours it is proof of gall stones licing cause. Occasionally stone causes iiemorrhage. In spite of there usually being agony, often there is no pain, no symptoms. If effusion continues from ol)struction of common duct, or if stone causes complete obstruction, liver gra- dually enlarges uniformly, an 1 the gall bladder will ba c^" ' mded with h to 7 pints of dropsical iluid, hence a tumor, oval, in site of gall bh-dder— perhaps hand- ling will give a pseudo-crepitus from friction of contained calculi. Jaundice con- tinues, there may be intermittent fever, sometim;s periolical, ofteuer not, like ague attacks, rig)rs. fever, etc. Th !se attacks of hjpatic intermittent fever (of Charcot) may precede or accompany hepatic colic, or the last colic may be absent ': ) i V ;. 1 ! BK 1 i 11 i 1 % 5 1 '91 T li ^^^^■; PRACTICE OF MEDICINE. r.i Tn liittfT case tlin ohatrnction in in ducts, in tlio livor itself, hence not rem' 1,11.1 n(. icterus in latter caso. This hejiatic ague runa irreyuliir course. l.i>i :; nidutlis with intervals hetwoen attacks of 1,3 to 8 days, sometime, jam with i'iu;h case. Charcot believes it due to absorption of septic materia.. I ici'ei.s tlie rigors to nervous rdlexes. I'ltiniate course of i,'all stU)t ..linuUl 1„. span./iintMt ull li.'li. Imt milk, nrw\, liglit broths, cooked fruit, l.'.u. n.mts. ,,,,,,,„„„„.,„,,,,, ,,y J),, i-,,s.-;, mc.lmniciil metl.od of cnriiiK iH tho mj.'cUnn of :.' |.iiit«to 2.', jiidlous ofcuM w.itfv, COdc^.. slowly into bowl, aii.l letting' it i.n.iiin for 5 mhnitt's, ^^i^ mre by tiiial t'l'olU be lie tis yc bi' be foiUK be su move cases UllliU Ileal PRACTICE OF MEDICINE. 1G5 arc tense, to protect, is a valuable sign. If you touch parts it is apt to occur. Aliilonien becomes tympanitic. In second stage, serous effusion occurs, fluctua- tiim often noted, even friction. ruoCrUKSS AND CoL'KSE is rapid, 24 to iS hours may bring it up to this stage. As disease i)rogresses, pulse becomes rapid and tlu'eady, vomiting inces- sant, countenance pale, thin, vomit dark green or blackish, bowels may now ivlax, liilious or bloody stools, surface becomjs cold, covered by clammy sweat, liiccoughs, startings in sleep, and death in coma and convulsions. In bad cases it may be fatal in 24 to 48 hours (perforation). General cases last a week or longer. I'iiiu ceases in last stage. Cause of constipation is paralysis of muscular coat of bdwiil from contiguous inflauimation. Itecovery may be perfect, complete, prom[)t, liiit in other cases if effusion were sero-purulent may take months. In rare cases it becomes chronic. Local Peiutonitis. — Pelvic — below brim of pelvis common. Symptoms — \ni\n low down, extending into thighs along branches of •' .sacral plexus," vomiting not early, tumors of intl.immatory products to bj felt in examining per vaginam. ^'ot so fatal a.s general form. Peritonitis in rigiit iliac fossa. CaL'.sus. — Inflammation of appendix, from tubercular ulcers, etc., apple pits, grape .seed.s, faecal concretions in apfiendix. If from inflammation of ciecum, habi- tual constipation and inipac ion of heces in caicum initiates inflammation. In both cases inflammation extends to peritoneum. Uiecitis or typhlitis and appendi- citis are not always distinguishable ; sometimes are, if appendix lies behind. Symptoms are : Ciecum you cannot tell from tyiihlitis. If in pelvis, you may not detect tumefaction. The great group of symptoms are similar. 1. Pain re- Itrred to site, increased by pressure ; sometimes you can make out deep-seated luihiess, gradually becoming nmre prominent, ami dullness appears. Finally, a I'alpable tumor appears. This will be below level of crest of ilium, two fluger bn^adths above Poupart's. If from typhlitis you wouhlget earlier evidence of tumor than with appendicitis, and at first you can move superflcial parts over it. L'g will be drawn up, especially in typhlitis, also pains along ant. of thigh, in tustiule, scrotum, penis, — neuralgic. If it be typhlitis, patient will admit con- stipation. Marked constipation, vomiting and fever are also noticed. Incases from perforation, symptoms begin suddenly with pain at site. There will early 1"' deep-seated resistance, sometimes a tunior in right iliac fossa. In ai)pendici- tis you Seldom get a distinct tumor, never early. In both, the inflammation may hi' behind c.ecum, and inflammation products may be large and yet no tumor toiuiil. In some cases of appendicitis or posterior csecitis, a peritonitis may not bi' set up, but a phlebitis of large veins and pya'iuia. CoUKSE. — Typhlitis generally gets well, fevt r abates, pain leaves, bowels move, induration leaves. This sometimes happens in appendicitis. In other casus cure is not complete, parts bound down by adhesions. In appendicitis unfavorable issue is common, for sloughing of organ occurs. A localized perito- neal abscess. So long as this abscess does not discharge into peritoneum there 21 1 ■ '■■. PEACTICE OF MEDICINE. 166 i, hope. It may open caecum and point like a psoas abscess, sometimes into the ,it,-nis, etc. The disease may bej^in in the csecum and extend to the appendix, iiiul vice versa. Inflammation from appendicitis may extend to the pevitoneuni, tliioui^h it leaving an abscess in tlie iliac fossa, hence pointing below Poupart's li- , ov along pyHformis, and pointing back or into the hip joint, sometimes points iibu've Toupart's lig. It may pass up^jehind the ca3cam, and point in the l>ack liko a lumbar abscess. It may even perforate the diaphragm and get into the pleiira. It may open into any hollow visciis, into the peritoneum ; if suddenly, y„u get acute peritonitis; if slowly, will give local peritonitis subsiding by adhe- sions! followed by second attack, diffuse . ud fatal. Sometimes the intlamm.ition meets the ilio G^cal vein, sets up i)ldubitis, hence hepatic abscess. The unginal puritouilis may be primarily diilused, not localized. Pkuitonitis from PERKORA.TIOS.— a simple ulcer of the stomach or duode- nuui, perforates or full bladder bursts, etc., with escape of contents. Tlie invasion is .siulden, and is accompanied by shock, hence cold, pale, pulseless extremities, cvanutic, little reaction, incessant vomiting, pain rapidly spreads. If he rally, luaction is poor, death rapidly follows in 1 to 3 days. In some cases tliore is no pain complained of, as in typhoid, but there is always tenderness at that spot abdomen distends. Muituiu Anatomy is similar to pleurisy, which see. Products may b3 serous, fibrous, [lurulent, hemorrhagic, etc DiFKERKNTiAL DIAGNOSIS.— Colic sets in suddenly, not accompanied by chill or followed by fever, is spasmodic, relieved by pressure, rarely voiiiitiii,,', no tenderness on pressure, pulse not greatly affected. Catarrh A.L State of Intestinks, as muco or sero enteritis. Tlie pain is griping, not pungent or burning, is not as easily increased on pressure, for in'.li'n. mation is within the bowel. Not the .same ditference in breathing; pulse is soft, not wiry ; there is apt to be diarrhoja, not constipation ; vomiting if the affj ;cio:i is in the duodenum, not otherwise perhaps. Hysterical Abdominal Pain is not preceded by rigor or followel by fever, tenderness is exquisite on the slightest pressure, but get her interested in something ; leaving the hand there, you can press deeply without pain sometimes. Abdominal distention or constipation, nausea and vomiting generally absent, p itieiit is suggestive of hysteria, emotional. The history may show hysterical atticks. The symptoms are incongruous, do not point to inflammation. Ifindnibt, treat for peritonitis, for it does no harm any way. Treatment of Peritonitis of secondary form, as from inflamed ovary, etc , or of idiopathic cases.— If symptoms are active put on 12 to 18 leeches over the'most painful spot, and follow by hot water fuinentations, cover by batting and uil silk. Put the patient under Opium, inject Morphia -i gr., and ke.ep under the influence, but do not reduce the respiration below 12, or too drowsy to answer rightly, and watch the pupik. Opium relieves pain which may kill ; it prevents 1 ! 1 1 I N iN 1 ' ■ ■I^^^Ni \ I ' |HH } k ^^^Hni^ M ■- ^ .1.-. PRACTICE or ..lEDICINE. 167 jipristalsis, and Im"? a direct antiphlogistic etVect, reducing the nervous influence and iiitl.unin.itiun. You may apply 2 to 3 tuvpoiitiae stupe-! per day and hot water stui)e3 iu intervals. In aonio forms use Mercury with Opium, not if from perforation, as it destroys the plasticity of the lymph. Do not use in i)ymmic (ir Hright's, peritonitis or cancerous, or if the cause comes from internal strangu- lation. Give Mercury in small doses, watching gums ; avoid purgatives, do not move the b(MVc ;, for if you remove the inflammation the spasm of the bowels rela.xes and thv^ bowels move spontaneously. You might coax bowels by 1 or IJ pint injection if they are torpid after. Blisters over the abdomen are no good ill eaily stages, but are good later to prom"' absorption; f(jr tympanitis enema J fcz. of Asaftetida in a pint of gruel, or use turpentine, or leave a long rectal tube in the rectum. Turpentine by the mouth is often good, give in capsules m. 10 to 15 every 24 hours, or give it in milk. In some obstinate cases bowel is per- fnrat(!d by a fine trocar ; be careful. The hiccough may yield to Morphia or Ether by the mouth, or inhalation of Chloroform. DiETKTic TUEA.TMENT. — Allow as little food as possible by the mouth, never more than a tablespoonful at a time ; relieve the tiiirst by a teaspoonful of water, or "ive it warm, slacks t! e thirst better than cold water. Ice is better for vomit- ing, or inject 2 oz. B. I. i)., of peptonized food by tlie rectum. As strength fails give stimulants, watch deatii tendency, and combat. In Ciecitis from constipation at the beginning if early give a purgative, not when inflammation is actually set up. Trevtmkn't of Perfouation. — Give Opium at once to give rest to the bowel, and try to so get the opening sealed up. If in the stomach or duodenum give notliing by the mouth, but by the rectum and skin ; you can feed the patient well under the skin,— milk and Braid's essence of beef. If perforation is low down, as in lyplioid, you can give a little by the mouth. Surgical Treatment (peritonitis). — If from perforated appendicitis its diagnosis is comparatively easy. Its eventual treatment by laparotomy is fre- quently indispensable, urgent symptoms demand immediate exposure of appendix after recovery from shock, provided the symptoms am < general peritonitis. If delay is warranted, the resulting abscess should be opened as soouas it is evident, — that is, about the 3rd day. Removal of the appendix is not often curable. In cases confined to the ca33um with paratyphlitis in which symptoms are local, imme- diate surgical treatment is not demanded, for cases are not so active ; explore by aspirating needle a resisting tumor. Wait 6 to 7 days to allow of peritonei 1 adhesions, shutting off from peritoneal cavity, and then you can open safely. In perforation from typhoid operate at once to prevent general peritonitis and rupture of the gall bladder. In acute peritonitis ending in suppuration, open early ; if abscess is found, open and drain. Disorders involving peritoneum mt relieved by general treatment warrant exploratory incisions ; even tuberculous peritonitis is operated on, and if primary prevents death. 168 PRAOTICR OF MEDICINR. XLTIT. INTESTINAL ODSTUUCTION (MECUANICAT). In iU-.un syinntoms aro vomitin- f«=ml n>attov. co,>Htii,ati..n, pain may ,, ,, oi, C. Classification of tlu, ol.tructions : 1. F.ca . comn.on '''-:rtr"'T;;:t:i^^ "i" : ' M ia alon, with debris of UM callo.l " entvolith." Theso vary ; „ . tnnts to oran,e to 4 lbs. in sizo. In others, the stone .s as h-^^,t a lul 0.1 .pon.., contains also earthy salts, bnt not in excess ; are a so mncl ,. s T he c ..; n and rectum, but also in sumll intestines. esi>ecially .f they 1 V ;t c ir They are mostly seen in yonn, adults. There are also nu,. ncre'on.aso^ seen in chlorotic ,irls fn.u eatm, slaU- penc Is ;^^r S:iphate of m. ..m vills. sonu-tin^es chal.. ^^^^^^^ „,tv be lavre enough, stoppiut' up the ileo-cncal valve. Foreign bod es, clie y I ruit stones, etc 3. Internal strangulation, as Mv,st.ng of bowel, oi a le ^LtSe may slip into ..ran.n of Winslow. "-" ;^J;;;-^^-- r::;"'i'i-s:au:::ih;;ussusception.Au^ fpi™,ent striouve of the bowel may cause it f^^om ch.nuc mflamnutu^ i,t rrccrous forn. is the commonest, and found oftenest m the s.g.nou and / LTti e in the colon. False n>en,brane is formed across cav.ty of ;;::;;;• ^^mt^oid flexion. . -•^■^;'7---!-:;,:;r: 'ir::" ™';'C-ac..e .... C,™.. to *o «r,.,>e,o„, „.. ca., f internal stran-nilation and most cases of invagination composing, ot all the : r t ^e chronic belong i.npacte.l faeces, concretions and foreign bodies, He m-e ninors. accumulation of fat in the intestinal walls acting as tumors (raie). Sv^i Z OF ACUTK FouM.-Gene,.allysud'uli tice > jiassi is 110' caiiii and I'rpci lai'gt givei tcnti as II \vat( limii w'uu wat( (lllSt •14 \ will iiici: bow bow 101 oil ' will wat 4;i PRACTICE OP MEDICINE. no Fveal matter is <.ften streaked with Wood and pus. bowel often reduced in size, lii.: pipe stem., attended with pain. You can feel the cancer if above the pelvis or by your finger, or a bougie if in the pelvis per rectum. Oft^en m s.g- Ln\ cat.cer you have free hemorrhage of the bowel, mistaken for piles, some- times dysentery is simulated so in rectal troubles insert your finger. _ Gfnkual UiAGNOSis.-In every case of abdominal trouble examine the surgical sites for external hernia, remember obturator hernia. Let first exam- iiuuion be exhaustive before the abdomen distends, mark tumor or tender spot, percussiun on the tender spot, dullness may be noted from accumulated faeces al,ovo obstruction. This dullness will increase from day to day; if there is early and incessant vomiting obstruction is generally high up, if low d.nvn you espe- cially "et f«^cal vomiting in a few days, Insert finger into rectum. If it cannot reaei. far enough insert buugie or stomach pump; often by injecting water you caiM.ot tube up farther. Often the tube is arrested by folds of sigmoid or by >\.irton's superior sphincter. 5 inches from anus or by sacral prominence, prac- tice will pass it 12 or 18 inches into the descending colon. Some recomniend pa^sino- the hand up the rectum. If the hand is large, divide the si-hincter. This is not often done, however. May discover stricture, impacted ficces, etc. TuEATMKNT OF INTESTINAL Obstuuction depends ou the cause. 11 you cannot find a cause, adapt ren.edies for curable cases. These are, relieve the pani and chock excessive peristalsis, using Opium gr. h or Morphia gr. { by the skm, ivpeating P.ellad. also checks spasm and does not cause const.patu)n. Give in lai.'e doses E^t. A gr. every two hours, even 2 grs. hourly for 12 hours has l^eu oi^x., Opium for severe pain, Bellad. for the less severe pain. Prevent over-dis- tention of the bowel, hence collapse. Therefore attend to diet, so starve patient a. much as possible. As little fluids as possible, give ice to suck, tablcspoonful ot water as seldom as possible ; feed by rectum of peptonized milk 4 oz every 8 hnurs, for supporting treatment is needed. Stimulants may be needed, brandy or wine. Ik^odern practice is to wash out the stomach by siphon tube and tepid water. It palliates symptoms, relieves vomiting and thirst, empties bowel above obstruction, and promotes normal peristalsis. Itepeat washing 2 to 3 times every •'4 hours, runcturing the distended bowel to let ofl' the flatus is sometimes done ^vill, precautions. These precautions are previous dose of Opium to lessen move- nu.nt of bowel, pierce the most convex part of distention, avoid that part of the l,owel where there is gurgling, as fluid may escape. Flatus alone may keep a bowel locked under an adiiesion. TuFATMENi- OF F.KCAL AccuMULATioN.-Give large enemata of warm water 101 to 104 deg., from 2 to 4 pints, repeating often at one sUting. Warm olive 0.1 will often work when hot water will not. You may break down the mass with the finger or a spoon if the rectum and sigmoid be filled. TuEvrMFNTOF INVAGINATION.-Keduced often (?) by large enemata of warm water after putting patient under Ether, throw in a gallon it you can. It may s.iuirt all over the room, but keep on. Let an assistant hold a wet cloth around S : i 4 , ■ 1 1 1' '^ 1 1 1 ' ' ■ ■ i i 1 fiHj 1 I^H 1 ^^■I'l ' '-^^t 1 h 1 J'l-: PRACTICE OF MEDICINE. 171 i,lie tube in anus to keep the water from squirting out. Only a small percentage of ca-ji's successfully treated thus. Old method was filling the bowels with air. Aiidtln'r was to give Mercury or small shot by the mouth, but they did it by the \noiig end. Put it in by th(,uamaticn. Abdomen is now tympanitic, tender. In bilious form, met ■ecially in malarial districts, stools at first are covered with bile. Malignant e „v tvphoid fc.rm— tropical— is dysentery with typhoid symptoms. In this usually tvea'lment is of no avail. Opium can be given in large doses. Try mineral acids or per iSalts of Iron, try Ac. Carb. If scorbutic symptoms exist, Lreat it— use Lime Juice especially. There is marked prostration, surface muddy, dry, or damp and cool. Petechia; common, pulse feeble. If rectum bj involved there is tenes- mus. Towards close there are mai ked typhoid .symptoms, dry dirty tongue, sordes on teeth, low muttering delirium. Scurvy may complicate. Sometimes there is sup])ression of urine. Sometimes sloughing occurs, ryteuiic symptoms some- times. Ordinarv mild form recovers in a few days to a week, no lesions left, but malignant speciHc form may last weeks and months. Ulcers form in walls of out, pya'mia and hepatic abscess often form, sometimes joints are all'ected as in rluMimatism, peritonitis often ensues. Prophylaxis against epidemic dysentery :— 1. Guard against the predisposing causes. 2. Remove tilth, clean privies, drains, etc. 3. Avoid overcrowding. 4. Take good food, not likely to cause diarrhoea, indigestion, etc. Causes of Dysenteuy.— Gold to abdomen or feet, etc. Food— deficiency, as ill starvation, famine, or bad quality of food, or on salt food, hence both scurvy and dysentery ; or decomposing albuminous food frequent in infants from uuelean bottle. Accumulation of ficces is occasionally followed by dysentery, absorption of f<«cal products. Impure water, bad from sewerage, etc Kiver water with excess of mineral matter causes it in strangers, hence boil and p]). the lime. Impure air, especially if contaminated by sewage or ftecal matter, as in tilihy camps. Malaria seems to have some effect (marshy). The severe l(,riii (specific), which occurs both epidemically and endemically, has its favorite habitat in the tropics, 30 to 40 degrees on either side of the equator. It is thought these germs require certain temperature— moisture and quality of soil favorable to propagation— these conditions found in tropics- Causes of simple dysenter} will predispose to specific form. MoiiiiiD Anatomy— Dysenteric inflammation may be catarrhal or diphthe- ritic—both forms treated before. It is an affection of colon, especially lower end, ;UkI may extend all the way up, seldom into small intestine. Examine sigmoid and hepatic flexures. Its inflammation leads to ulcerations, these healing from cicatricial tissue contracting lumen of bowel. Coloring matter of blood stains ulcers bide. In profound cases atrophy of intestinal canal from mouth to 'M, >i I i 1i PRACTICE OF MEDICINE. 173 amis. Dysentery leads to hepatic abscess in tropics, not in temperate climates Did. Diag. — ulcer, polypus and cancer of lectum give blood, pus, etc. Exam- ine liy speculum. In these cases the blood, etc., may escape without stool at iiivj,Mi!ar intervals, note the pus. DifT. Diagnosis — diarrha-a. More or less fajcal iiiiittov, blood not often present, mucus not much, tenesmus and dysuria rare. Dysentery — little faecal matter, blood present, great deal of mucus, tenesmus cuniuion. TKKA.TMKNT (mild form). — 1, If you see at beginning give warm bath. 2. Tut patient to bed, important to rest. 3. Give dose Castor Oil A to 1 oz.. Laudanum in. 10 to 15, or add Spts. Chloroform ^ dr. To some you will have to 1,'iv'e Piilv. llliei Co. instead of oil, ot Calomel or Blue Pill; add Opium sinapis, or Turps fomentations to abdomen are grateful. It is necessary to keep in bed. 4. Place patient on mild diet, milk or broths (tautton), no solids. Above will often check. In severe forms begin with above. 5. Large doses of Ipecac are o>)[iecially good, gr. 20 to 30 of Pulv. Ipecac. Take no food for 1 to 2 hours before, 2 to ;J hours after. You may give it in a capsule, or in a little ice water or in pills, or in 1 dr. Syr. Aurantii, aqua J oz., or in bitters. If dysentery is mala- rious add Quinine. Some give i gr. Ipecac every J hour instead of big doses. In dysentery never begin Opium treatment till bowels are cleared out. Do not give drink, let him rinse mouth with water. You are afraid of drink, it will eiiu.se vomiting — you want Ipecac kept down one hour — if emesis now occurs only gastric juice is ejected. Ipecac will cause vomiting, thus unloads portal system. Then allow light food. In 24 horuo repeat Ipecac, or even in 12 hours in severe cases, giving nourishment some hours between. It relieves tlie tenesmus, etc. Hot cloth to anus or ice in other cases, or injection of warm oil, or hot hip bath^ all relieve the tenesmus, or enema Ac. Carb. gtt. 2, to 1 oz. starch sol. An injec- tion of Laudanum in starch giv(is comfort, relieves the tenesmus, use a small ene- ma. As disease subsides reduce Ipecac gr. 10, or if case is doing good give Dover's Powder gr. 8 at night, and return to Ipecac in a. m. During case keep warm clotlis on abdomen. Treat tenesmus with lump of ice in anus, or inject pint of warm gruel, and keep dot); on anus liot, or inject Laudanum in stare \. Even in acute dysentery in children Ipecac is good, gr. J for child 6 months oi ', gr. 1 for one year, and 1 gr. for each year after up to 18 years. Salines have boen used. 1 oz. ]\Iag, Sulph. in pint of beef tea, or alteriiate salines with Pulv. Ipecac. Co. Drink wineglass every two hours of saline, gives free evacuation ; repeat when stuols become mucoid, scybalous, etc. Is used by French instead of Ipecac. Another method is injection of i)iuts 3 to 4 of cold water up bowel. This water may be medicated, alum 1 dr. to pint, or Salic. Ac or Nit. Silver gr. 40 to pint water — use fountain syringe with ' "ps well raised. If colic occurs wait, it sub- -ides ia few minutes, then let move run in — use long tube and pass up to signsoid — repeat 2 to 3 times per day. li. 01. Kiciui J oz., Turps m. 10 to 15, Chiorotlyne 111. 10 to 15, makes a good emulsion to clean out bowels. As symptoms yield, diet is improved— avoid vegetable-j for a little time. 22 Id ' m W I > li^l K t nfiHI V ' HH \\ i f IBB: PRACTICE OF MUmCINE. 174 XLV. GASTRITIS. Acute, Subacute, Chromic— Acute form rare, is rarely idiopathic, due jiinnerally to some poison by irritants, sometimes follows drini9 4Uiintities of alcohol, or, if heated, large quantities of cold water. Then fevers often give acute gastritis, as gastric fever (t/phoid), scarlet fever, yellow fever, etc., also gout, etc. A bilious attacic means an acute gastritis. Causes of subacute gastritis common. — Eating irritating, indigestible food, excess in eating, abuse of alcoliol, decomposing food, anything which reduces iliistric juice will operate. Causes of this deficiency are niimerou.s, as any ob- stiuction in portal circulation, as lung, heart and liver di-seases, fever, nervous exhaustion, previous excesses, prolonged fasting, ..rdent spirits ; atmospheric con. (litions which give bronchial catarrh may give catarrh of stomach, moist, cold and sudden chills, and then eve., ordinary food is an irritant. Uterine troubles, also passive congestion of stomach from cardiac, puhninary or hepatic diseases I'teriue disease, deficient menses, etc., wul diminish gastric juice. Sy.mptoms bilious attack. — Patient out of sorts for a couple of days, pains in back and limbs, low-spirited, sense of fatigue, then gets bad-tempered. Tiien .stomach feels too full, tongue generally coated white, or thick and foul dirty fur, saliva viscid, thirst, nausea. Sometimes pain, even severe, cramj) like, may be felt ii; pit of stomach extending to between shoulders, and aggravated by hot ilrinks. Vomit of tenacious mucus frequen% increased by food, appetite gone, mouth sticky, urine high colored, scanty ; vomiting is followei by relief. If food passes into intestines we get colic, irrititive diarrhoea, but sora itimjs constipa- tion. Nervous .system sympathizes, hence sick headache, greatly resembling some- times migraine, sense of giddiuiss, dyspmea, astluui, palpitation, attack of ejalepsy, neuralgia, if predisposed, in children even convulsions. Acute indiges- tion is a common cause of convulsions in children. In the aged it may cause a])oiilectiform attacks. Treat.ment subacute gastritis (bilious attack).— If irritating food be retained give emetic if meal be recent, and follow by a cathartic, Castor Oil, add a little Tr. Opii ; let patient abstain from food and as far as possible from diinks to Ljive stomach rest. Take milk and lime water or thin gruel. If vomiting, give Jiicarb. Sod. and Tart. Ac. and H. 0. N". Oil. m. 2 and M^jrphia, or apply .sinapis to epigastrium. Peptonized food miy be needed. In severe cases put to bid. If {lain, uneasiness continues in stomac'i, give Bis. Sub. Nit. large doses gr. 10 to ol> T. I. D., and Sod. Bicarb, or Liq. P(j;;ass. m. 10 to 15 and Tr. llyoscy. If tlatulent, give Sod. Salic. An attack often is cut short by a blue pill and a t'olycinth pill at night followed by Seidlitz in a. m., so also will au emaic. Kiiigastric uneasiness is souietiuies relieved by small pieces of ice, or small drinks of .soda water. If th^re be much mucus vomited, and signs of fermentation, give alkalies, as Liq. Pots.ss. m. 10 to 15, Sulphurous Acid or Sol. Sulphate gr. 5 to J ' ' t:: 1 ! ^^^1 ll^^^^l '1 !: i ■. i ■ ■ i ■ I i:"j|. IIP 1 I^H 1 ■ - ■Hi 1 ^ Fwliw f ; I |W 1 i 'i| |m| i : — -i iJi'lIK ii PRACTICE OF MEDIOINK. 175 10, ftro mrely usoil to stop fenuentiitinn. TeiidiMicy to recnrronco of bilious iittiicks in elderly pooplo can bo lesM.iiieil by ivgulatiiig diut and giving a niglitly ildso (if aloes, or allow latter in pilule. DiL.VTATiON OF Stomvch.— I. Rosults from bud hygiene, as too much food (h inking loo (jfton, etc. 2. Morbiil conditions, involving habitual delay of food in -toinach, as dyspepsia, chronic gastric catarrh, obstruction of pylorus. 3. Debility ol muscular coat, as in weak neurasthenic people, hysterical. At first dilatation, is transient. This dilatation is seen in course of or after many diseases, or in those suffering from ennui, grief, exophthalmic goitre, and the recurring disten- tion becomes permanent. It is thought fatty degeneration of muscle occurs as in convalescence from typhoid, or in alcoholism, or lesions of gastric nerves. Symptoms are grouped variously, it may be latent and no symptoms. It often assumes a dyspeptic form, patient has aching in the stomach, slow diges- tion, foul or acid eructations, constipation, slight emaciation, often no vomiting. If due to obstruction of pylorus, muscle hyi) irtrophies, hunc3 visible outline of stomacli, evident dilatation by percussion, vomiting of sour smelling matter, vomit less in frequency as stomach dilates, but largm- in quantity, is yeasty (sarcina ventriculi). There is an intestinal form in 4 to 5 hours after tnuih, tliere are gastralgic pains set up by a(;id fermentation in 8tora.ich and bowel, the liver may beenbirged and feel heavy, sometimes there is jaundice from catarrh. Tiiere is a nervous form, person is fatigued and weary on waking. In the fore- noon is subject to vertigo, migraine, cramps in extremities, flushing of the faje, hypochondriasis, pseudo-angina. In 17 per C3nt. of the cases the urina is alb.i- lainous, is often alkaline or neutral, acne is common, nasal or bronchial catirrh often attend. A recent writer says he finds the enlargement of middle joints of tiie lingers in cases of dilatation of the stomich— not always confined to these joints— due to absorption of Acetic Acid, Prove the dilatation by examination, as its symptoms are like gastritis. Percuss the stomach, when empty of fluid it naturally reaches only within one inch of umbilicus down and up as high as th'3 lower border of 4th rib. If ther" l)e a (quantity of fluid in the stomach you m.y be mistaken, for the upper part is clear, the lowjr part dull ; alterations of posture will vary the dullness, or shake the person and listen for the splashing. In some cases distetid the stomach wiih Cmmon, under 30 more common. Ti.o i.gh with advanced age. Fon;'. oftenest on posterior surface ■ '} wards lesser curve, may be at pjlo- '■,:• , cdunot involve whole organ. Hungry, but afraid to eat for the pain ; jvj '.arly cuLhexia. Comes on after eating, relieved on vomiting or on completion of digestion, is intermittent. Is intense burning. Vomits when food is in, profuse hemorrhage occurs in 32 per cent., re- cover, not so much mucua. Tumor absent, but very rarely oc- curs, is from adhesion, is not movable. •i ^\ PRACTICE OP MEDICINE. 177 Absent, but chlorotic symptoms. Signs of cachexia absent for a long time. Never. There is an excess of H. CI. If symptoms last 18 months cancer may be excluded, and also if previous at- tacks of pain, vomiting, or hajmatemesis. Complexion— peculiar, earthy and pale, or greenish. Early signs of cachexia. Emaciation very rapid. Microscope sometimes shews cancer- ous cells ; in voniitus, rare. In cancer there is permanent absence of II. CI. from gastric juice, is also absent in atrophy of the stomach and chronic dyspepsia, even absent some- times in healthy men. H. CI. is de- ficient in chronic catarrh. Tost for Hydrochloric Acid— in the first 45 minutes of digesting there is nominally no Hydrochloric Acid, wait IJ hours and then usethe stomach pump ; use litmus paper ; filter the mixture. Add weak sol. of Meth. Violet — gives a beautiful blue if Hydroch. Acid be present ; or take 20 c c. of water, 3 drops of Ferri Perch., 3 gtt. of a strong sol. of Carb. Acid— this gives a steel grey color to tlie mixture if H. C. L. be present, yellow if Lactic Acid is present. To test the strength of the gastric juice, take some of the filtrate, put it in two test tubes, put a little fibrin in one and fibrin of Hydroch. Acid 1 per cec*.. sol. in the other, and keep in incubator 6 to 12 hours. If that tube without acid has no digestion but the other has, then II. CI. is absent ; if no digestion in both, it means absence of pepsine. BIAG'SOSIS— Continued. ULCER. Perforation 3 times commoner. Disease may last for years ; may be arrested by proper treatment. Not so. CANCER. Perforation rare. Duration, disease is progressive. Destroys life in 1 to 2 years, rarely more than 3 years. Colloid ; is very slow, (juick progress means soft cancer. Secondary formations appear, liver enlarged, or additional tumor found. If secondary tumor be in the om- entum it will be colloid, cancer gen- erally has coma before death. Pp,C!'l,FAU!TTF,P. Rf. SiTF,. Cardiac cancer, pain on swallow'ing, and frequently regurgitation after swallowing, though part of the food lodges above the tumor, No tumor can be felt generally, epigastrium not enlarged. Pyloric cancer leads I ■ ) 1 '«■ ^^^ PRACTICE OP MEDICINB. 178 tn ililatation of the stomach, muscular coat hypertrophies from stenosis. Vomiting at first frequent, Init less frequent and more copious as stomach dilates. sour smelling, yeasty. Infiltrated cancer — organs reduced in Fize, with either frequent or no vomiting, belly Hat, and tumor is rarely made out, perhaps more resistance to palpation in gastric region. Tkkatmknt (simple ulcer). — Eest first, in had case put to bed. To give rest to ston)ach give no solid food, milk is best, no oatmeal, bran bread, etc. If milk uill not agree add Lime Water, which prevents curdling of milk into a mass which irritates, or mix milk with arrowroot or bread or flour for same purpose. If milk disagrees, give meat digested in a strong acid solution of pepsine, this is Valen- tine's beef tea, or peptonize any beef tea or milk, etc. Sometimes buttermilk will agree when other will not, Kerniiss (fermented mare's milk) will often agree. As stomach improves, add yolk of egg, or give unfermeuted bread or biscuit, then iisji, then meat. liKCTAi. Alimentation. — Be content with 2 injections per day of temper- atiiie of 98, throw it in slowly. Hold napkin to anus for a couple of minutes after, or use a fountain syringe ; let patient lie on left side, hips raised ; attach elastic catheter, and shove up to sigmoid flexure; have reservoir not very high, so titreani is slow and gentle. Give but little first day, and gradually increase. If you can keep patient on rectal alimentation for 4 to 5 weeks cicatrization of uleer will have begun. One author gives dr. 4 Carlsbad Salt every morning in ]>iiit of water in 4 drinks before breakfast, it is to lower acidity of stomach, wliich irritates ulcer. Some use siphon tube to wash out stomach. Sometimes Jlorphia is given for pain, give with Bismuth. Chloral is also good, stimulsites ulcer, is an antiseptic. Leeching may be needed over epigastrium, followed by ice bag and then Belladon. plaster. For hemorrhage no food by mouth, ice bag over stomach, small piece of ice in mouth. Give gr. 5 Ergotin every 4 hoins hypodermically, or Gallic Acid, Pulv. Alum or Perch. Iron by mouth, or Turpentine. For stricture of eiuier orifice by cicatrization stomach has been opened and orifice dilated. XLVII. DISEASES OF PANCREAS. Hemorrhages may occur into pancreas in persons fat, perhaps in good health. Violent pain in epigastrium, syncope and death in J hour to 36 hours. Looks like poisoning. After death yoii find copious extravasation of blood, pancreas may be otherwise healthy. Cannot be diagnosed. Inflam- mation of pancreas comparatively rare. Symptoms set in suddenly violent colic in epigastrium, which is distended and tender; vomiting, constipa- tion, early collapse. Post-mortem shews enlargement of pancreas, either con- taining blood in excess, abscesses or in condition of gangrene. In hemorrhagic form death occurs in 2 to 4 days, and you find disseminated necrosis of fat ; little masses from pin's head to hen's egg, looks like tubercle, are found in pancreas, sul)peritoneal tissues, etc This fat is so't. In suppurative form often opens into duodenum or stomach, sometimes abscess extends to omentum—here there may be inflammation of portal veins- These cases may be subacute or chronic. I \n' Mi ! f m m JJ i ^rsH^^^I' i PBBi h ifli fmf^ PRACTICE OF MEDICINE. 179 may take weeks to kill. In gangi'ene pancreas sloughs, and this aLscess may ojieii into liollow vi^icus and escape. Oidy known cause of pancieatltis is from (ludiliMiitis. Hemorrhagic form not accounted for. IJIAGN'OSIS.— No rules, but has been diagnosed. It is one of modes of sudden (ieulli. Treatment, palliative as with peritonitis. XLVIII. VARIOLA, OK SMALL-POX Is a contagious disease produced by a morbid poison, running a definite cumse, exhiuisting the system of the material required to sustam the specific virus. It is characterized by various stages, or can be so divided. There are two varieties, the discrete and the confluent, according as the eruption or vesicles ill it keep distinct or run together. In rare cases "Variola sine exantheui" tluTo is no erui)tioii. Tliere is also " Variola Maligna," a malignant form, and " Variola Hemorrhagic." Variola LiscREXA.— Symptoms of its 4 stages : 1. Incubation— the poisoa is latent while it is multiplying, till at last the disease is declared in the invasion or initial fevor. The incubation stage varies according to entrance of virus by inhalation or i.y in(;ubatiou,— if inhaleil, lU to IG days ; if inoculated, 7 to 9 days. Extreme duration in aU forms is 5 to 23 days. 2. Invasion or initial fever— ter- miuatfs with the full eruption. 3. Eruption stage— begins with the ai)pearance of the eruption and lasts till the beginning of second day fever; generally begins on llrd or 4th day, and then generally -ith stage begins with secondary fever, and coin[irises all the rest. The Invasion.— The symptoms resemble those of typhus, begin abruptly, chills are prominent early, patient is shivery, but a delinite rigor is not as cum- UKiu as in erysipelas or pneumonia — more .-l.-vering than a rigor commonly. Pains are also complained of, the characteristic backache in lumbar region due tuilisturbauce of the cord. Is very severe, and in majority of cases is tlic great coiniilaint and in the groins. Headache accompanies, may be quite violent. Tiitro may also be pains in the extremities. Nausea and vomiting also now apiiear till vomit may become biliary. Nervous symptoms may also be marked, as drowsiness, stupor, sometimes delirium in bad cases, even insensibility. In cliil'lieu the vomiting is more marked, and there is more likelihood of brain alfec- tion, as drowsiness, stupor or convulsions. Indeed convulsions may be the lirst symptoms noted in invasions. Temperature rises rapidly the first day, lU-i to iOo ami t'xcept during slight morning remissions it remains high till 3rd or 4th day, whuii eruption appears. Eruption gcnerilly appears on 8rd day, as a tew tiny A pii:i[ilus, devoid of fluid, of size of pin's head— raised, forming papules like grains of shot— hard. Then little crcj'T of these papules appear, separated by several hums. First crop is oil wrists, face and neck, .second uu body, third on extrenii' !•.•§. They continue to appear till end of 5th day. The eruption is then general. The fever is now abated, and pa lent feels convalescent. Look for the eruption where :i! I 1 ill IHfi PRACTICE OF MEmciNE. 180 it slioiild first appear. Thus first place on face is along ala^ nasi and sides of the nose, and on eyebrows. Bring jwitient into a good light, for first beginnings are small, and it is important to diagnose this disease early. Then look on fronts of wrists over the flexor tendons. When jjapiiles have been forming 2 to 3 days the ctmgestion about each papule fades away. A minute vesicle is seen on apex of t'iirli jiapulo on 3rd day of eruption. The vesicle enlarge.s, but buiiig bound down by a bridlo in centre becomes umbilicated. This takes place when vesicle is 2 (lays old. When vesicle is 4 days old it matures, and the serum becomes pus and the vesicle a pustule. An iiiHanmiatory ring at same time appears around liU'li jiuslule. At this time the bridle rujitures, allowing the umbilication to beciinie spherical. At 8th day of erujition a '''irk spot appears un apex of each pustule, skin here gives way, contents escape and scab forms. Between 11th to 14lli day of eruption desquamation occurs, leaving cuticle a reddish brown, which color [)ersists for some weeks. Often skin is penetrated by the pustule, causing loss of substance, hence pitting. 4th stage is that of secondary or su))purati ve fever, due to absorption of purulent material of pustule. Begins 8th day of disease and tjtli of eruption. Face, head, neck, eyelids, etc., swell greatly, spaces between pustules inflame, get dark red, the deeper the color the milder the attack. In average cases this 4th stage of fever is proportionate to eruption. May have chills, fever snuirt, high, pulse frequent and delirium slight. In favorable cases this fever subsides in 2 to 6 days, also swelling subsides. SvMi'TOMS of 4th stage, — itchiness and tenderness of skin. Eruption appears on mucous membrane, on conjunctiva', mouth, fauces, throat, prepuce, labia; are tirra, hard, whitish spots, no pus or serum. Fauces get much swollen on 7th to 8th day, there is salivation and deglutition ditlicult, voice hoarse. When pus- tules are nuituring there is a faint, sickly, characteristic odor. If case be ad- Tuneed and take unfavorable course fact; does not swell on 8th day (so swelling is favorable), space between pustules remains whitish or pale, pustules look red, and continue eUtvated. Perspiration, liitherto free, suddenly ceases ; and secondly fever presents 1 of 2 forms, — either (1), like 2nd or 3rd stage of typhus, a typhoid state, brown tongue, pulse freciuent and delirium ; (2) in other case patient is overwhelmed by puisou, sinks, pulse and temperature are not great. The patient becomes extremely restless, coughs, has frequent micturition. Confluent Sm.\ll-Pox is more serious, 50 per cent, fatal. Initial rigor and fever are more severe and shorter. Eruptions appear early, the earlier the more confluent — delayed eruption is favorable. Instead of slow and regular development of eruption, vesication or pustulation may be found on 2nd day. The eruptii n is often preceded by erythematous or petechial rash, a prodromial rash like scarlatina, measles, etc. The papides appear irregularly — like measles, in patches — are less marked as papules than in discrete form. The eruption stage iiitMiig occurred, tiie fever does not remit su completely ; pulse 110 temperature yet high, lot). The eruption is peculiar, papules flat and irregular; vesicles form rapidly, coalesce and form bullae. Salivation is excessive. At 8th day this t : ( ^vugnp' x'faUMit' •■1 ; II^Bi f^Bi , ' ' i PRACTIOE OF MEDICrNE. 181 saliva grows viscid, and is expectoratod with diificiilly. In children diarrhmn iiiMv ri']pliice jityalisni. Tiie niucdiH iiicmhniiie niiiy infliiiiio down to hirge liiciiiL'hi, producing cougli, iii»h(iniii — are daiigin'oiis syniptoius. In 4tli stage, |i:iti«nt is first endangered in 11th day by liigh fever, destructive, unless remedied \>y medicine. Tlien 1-lth to I7th day especially — are dangerous. In advanced slagi's, ]iiieunif)nia, eaidiuc inflaniir.ation, meningitis, oidenia glottidis, niiiy be fatal. Unfavorable symptoms are paleness l)etweeii pustules, face not swollen, no ptyalism, cough, etc., a black spot in each pustule. M.VLi(;XANT ou lU.ACK Small-I'ox. — Hemorrhagic. Blood is altered, and extravasations occur into body with hemorrhages from all m. memli. Purpuric symptoms may be jnesent from the first (is very fatal), or may occur during the eruptive stage. This form usually sets in without delirium. In 18 to '6ij hours a prodromal rash — deep purple or scarlet — appears, sometimes macuLir or measly, ilisappearing on pressure, coming out on lower part of abdomen or inner sides of liiiglis, or all over body e.vcei)t face. Kapidly petechiiu and large ecchymoses shew themselves, may get large. Conjunclivie become sidVused with blood, ill ieous black-eyes produced. Hemorrhages occur internally. Pulse may run liigli or not, ilitto temperature, in fact temperature not usually Irigh, but in bad ca-,es temperature is very iiigji just before death. Vomiting (bloody) is fre(iuent. I'liue is albuminous, followed liy blond. Breath may be fietid from sloughing m. iHcml). Death may be on 3rd day or earlier, but 5th day is most freiiuent. liy this time papules are few, shew themselves best on knuckles and toes, do not run to vesicles, but abort into firm, tl.it tubercles. Tliis form is never met with in vaccinated subjects under 15, or in th jse re- vaccinated above that age. Hem- orrhagic symptoms may not develop until after eruption, appearing between jiapules. Is more protracted, but Just as fatal as other form. If patients get up, the legs get hemorrhagic, so do not confound with true hemorrliagic cases. Co,\li'LICATro.v.s OF Small-Fo.x. — Ulceration of cornea, extending rapidly, leading to perfor.ition, may occur as Lite as 8()tii day. Watch for it, as it must h'. actively treated. Oedema glottidis, serious, leads to asphyxia. If he escape this, cartilagj of epiglo'-tis may necrose. Brouc'.iitis, pujuin )ii i (citarrlul), pleurisy, lltli day, sjttiug in very smLlenly, and elfusion bacjines pustular. In "^jvere casjs we get albuminu'ia, in Ird of all cases, with hiunituria in hemji- rhagic form. Orchitis, inflammation of ovaries, renal abscess and central hemor- rhage are rare. A pregnant woman in severe cases is almost certain to abort ; is very dangerous. ItKuoviiUY. — Course of disease being run may be retarded by boils appe;i"'ng iu all parts of hotly, or abscesses, or erysi[ielas, chiefly facial, hydrarthrosis, even pyrarthrojis, be Isores. Otitis, caries of tempenil bone may occur. Severe pitting in face, the cicatrices may bicome keloid, prolueing deformity. Anas- arca general, not as common as after scarlatina. Developments of scrofula, phthisis, etc., are apt to occur. Suppuration iu eyeball may occur. This is really 23 I I i ".^pff fi - ) W^^^^^K^^m flwm ^■ . j 1^^^ ' tlH ' ttJHj ^ ^ m ^^ ^^i *Wf« PRACTICE OP MKlM.'lNE. jivn'inii;, liki! tlii^ Itoils, iiliscessos, ]iyriVitlirosi.s, etc. rmnj^reno of exhviiiities is lull — t(H!H, liii,i,'er.s. I'ampk-^iiv dm; to circuiuscribod diji.seiuimU i of myijlitin or iiir('|iliiilitifi lire obaorvtid. 1'. M. Changes difl'er in thediflinent forms. Skin lesions, etc., arc of luurse tniiinl, spocitio pustules, purulent, ititiltnitions. Catiirrhiil or nieiribranuu.s in- lliuiiniitions on ni. nienib., especially tliose expn-ed to iliu air, I'MsluleH are not I uiid in serous niemb. or stomacb, intestines, idder, urethra, but do occur in \;rjina and rectum. Liver may be granular, lu.ut futty, spleen swollen and soft eiiily in disease. If patient dies early by purpuiic form few changes found. I.MMi'NiTV KiioM SECOND Atiacic. — (iemis consumed all the pabuluiu suited !n tiiuir growth. It is pi ibable tlieac(iuired resistance is transmit led to olVspring. In lice rcHson Indians and Negroes so suffer, not being so protected. In time re- sistance wears (jiit, [jabulum accumulates. . ExcEi'TioNS. — Like other exanthems — immunity is conferred by first attack, lull one man hud it three times, a lady seven times, a ct i lain surgeon took it every time lie aMendcd a case. .Some persons seem unsusceptible. .■EnoLdOY. — Is ancient disease, probably originated in animals and sjiread to man. It is propagated by its own virus, through air l)y inoculation, as tiirougli tomites, etc. The infection is given otf l)y lungs, skin, secretions or uxeivlions. Tiie perspiration is especially infectious, blood also. Time of infec- tion dates from as soon as the fever is developed, some think even during incii- liiiiun (doubtful). It is most virulent wiien vesicles are becoming pustular, oliiers say when odor is strongest. Tlie dead body is also infectious. The inflictions distance is many yards, gre !■ tlian in any other disease ; it may sjireiid from one house to anotlier througu several feet uf air, and may be llouttid III It i II r iiy wind. PiiKDisi'osiNi; Oau.ses. — Eirly age, but any age may take it. Non- Miimunity Iroiu a lu'evioiis attajk or vaccination. Idiosyncrasy, feir, epide.nic iiilliience. Tkmi'ERA.TURK of S.\1ai.i.-Pox. — Initial fever on 1st to 2nd day, 104 m ix., lMititmayincrea.se in ord to 4th day. Remissions are slight. On eruption tem|" ature ialls from 4th to Gtli day, but not to normal, keeps moderate for several iliys. At maturation temperature again rises 102 in mo IcraLe cii^-^, liiuher ii' severe. There in ly be now low remissions, i.VGNOsr'- -Mea les and chicken pox. Measles — a; outset you get catarrhal .state se and eyes, an I teuipjrature never runs up so high at first, (hi 2ml day a maiivud ' 'uissioa of temperature occurs, two days slight fever, 'li'u a rise, different from small-pox. In small-pox temperature abates after iition, increases in inaasles, nor arj spots .so largj. In measles eruption comes at same time on face and back, ditl'erent from small-pox. Kruption in measiea appears in 4th day, smivU-pox iu 3rii day. 'tj! ill i,. PBACTICF, OK MEDICrNE. '88 CilicKKM Tox.— Knii»ti()u ai)i)oars on 1st day of invasion on buck iiiul iiftor- w.inU on faou, is u .t yu slut iiko, b'^onios vusienlaf earliur, .Iocs not l)ocon»o iiial.ilicitud, is not surroun.lod by rod areola, bnt doo.s have a distendud uryth^- Millions blnsh. Vesiclos dry before pnstulation scab, do not pit. 'I'ti-ro will bo ^wr.il st.igJi of eruption at svm i tini', sliuwing it coinjs in crop<, wliiuii last i ilays. Tvi'iius Fevku.— Rost'iublos strongly at ontsot, impossible in Hrst 3 to 4 (liys to di.i^'iiose sonutime.s. Teniperature gives no help, i)iit uniption of typhus i- iiiulliorry bhisli, disa[tpuaring on i»io3sure. .Sulisoquent course of disease ia plain. I'liDaxosifl.— Expi!ri(!nce gives good indications. Danger is increased m (■ally and advanced age. Under 5 and over 50 there is a mortality of .lO piir cent., liMwi'iMi II) and lo, 'i.'! per cent. die. Continent casos .50 per cent, die, all malignant iM's die, ciiildren unler I year die. Tliu greater the eruption the greater I ill' danger, purpuric conditi(»ns are unfavorable. Delirium especially if early i.s iiidaviaalile. Lnyngeal and tracheal involvement are bad, [n't-gnancy is unfav- uialile. Uusaiiilary c(nidilions, as non-vciililatioii, are bad. High temperature i> liad During .secondary fever il temperature is over lO-t I'or several days is bad. I r primary fever lasts over 4 days case is severe, poorly marked rcmissiou ditto. V.VKioLoii) (m xlified small-|iox).— A slight continuous fever lasting 2 days \vi;h sligiit eriijition, sometimes oidy one pock. Initial sym[)Loins miy iii> just like small-pox for 48 hours, and then sue eeds the trifling ernj)tioii, hence dilfer- eace. The eruption may appear on 2iulday, earlier than small-po.v, is preceded raivly l)y erythema, etc. It is rare for pocks to he close enough to be contliiont. In varioloid all stages (jf eniiitions may be present together. . Few pocks are regularly formed. Not umbilicated, no order, no secondary fever. TUK.VTMENT.— No specific treatment, disease will run its course. Moderate (he pustulatiou, obviate intlammatic.ns, keep up strength, relieve special .symptoms, in mild discrete ca.se.s, leave case to nature, will issue favorable. At outset give mild purge, then give cooling drinks, acidulated lemonade, etc. Cold water, ice, etc., '■ i allowable, also fruit in moderation. But see patient has large, airy room. keep him cool, not cold, so do not heai) on clothes, have room ventilated by open window, temjierature of tiO. Diet is lever diet, sago, milk, broths (light). lu .severe cases nursing is important, must be good, esiiecially if here be delirium, do not leave patient delirious. During primary fever give purge, as Pil. Coloc. •Mag. Sulph., and afterwards keep bowels free by mild laxative as Pulv. Grey. Delirium in first stams calls for cold to the h al or hot foot bath. Give fulldosea 'if I'ot. Brom. till this state is reduced. Shrunken features with delirium calls lor sup[)orting treatment, high fever calls for Antipyrine or Antifebriue. Sod. ■Salic, is also used, freipieiit sitougiiig is very good. If ca.se is confluent cut hair short at once. If primary fever does not subside, Sod. Salic or Am. Carb. or black draught is called for. Sleeplessness at 10th day needs Opium, etc. If there .', » PRACTICE OP MEDICINE. 184 lie nnieh salivation do not use <\i\mn. Ilestlossuess may V)e allayed by keeping ].;iticnt in hot bath or hot luicks. Occasional application of vaseline to sur- I'aci; is very good, ^[ania may ajspear, needs Cidoral. AXTISKITIC TuEATMKNT.— Ac. Sulph. Dil. m. 5 to 30. The Hyposulphites, Suliihites and Ac. Carb. have also been used. But experience proves that bacilli iiiv mi easily destroyed by any means. In advanced stages of secondary fever stimulants are called for. Mineral acids are also very useful. A dirty tongue aud dry, a weak pulse, and cold extremities call for stimulants of all kinds. Plans to puevknt Pittin(J.— Black recommends exclusion of light and i;iving of Arsenic— should only be employed in nuidified forms, so is not of much use. In. hemorrhagic cases cold water is only of transient value. Styptics are no use. Quinine also failed. TuE.VTMEXT OF EuLTTIOX.— Keep oft' irritation as much as possible, keep purulent matter as pure as may be. Cod and Olive Oil are used on surface. Clycerine and Rose water are used after pustules have broken. Hebra recom- mends cold water compresses, l)ut they do not moilify the eruption. Ac Carb. 1 part. Glycerine 20 i)art9, may be used twice daily till desquamation. Watch uiine lest the Ac. Carb. pois(jn. Do no>^ discharge patient till scabs have gone from surface and he has hail G baths with 2 days between each. Vaccination, Vaccinia, Cow Pox.— At site of introduction on 3rd day a papule forms, which on 6th becomes a vesicle and on 8th is perfect and umlali- .■uted. An areola then forms, and lasts 2 days. This areola is important, shew- ing vaccination has acted constitutionally. Hot shin, restlessness, swelling of iixillary glands, papular eruption, or vesicular, ai)pears on extremities, and lasts ii few days. On adults the areola is more ditl'used and the effects take longer, and the local eO'ects are more severe. Irregular course of vaccination— vesicle may lie delayed for several days. The i>apule or vesicle may be on oth or Gth day and leave a yelloNV scale or scab. More frequently the vesicle becomes conoidal aud contains a yellow lluid, aud may burst on 8th day. You may get what is .ailed a raspberry oxcres(;ence raised above skin and slow in appearing. There will be no areola, it resembles a n;i'vus. It becomes hard, black, antl withers away. There may bo absence of constitutional effect^ but you caniiot tKenatlirm there is protection against small-]iox, for you must have both local and constitu- tional ettects. The vaccine lymph sb Irave red sjiots. In some cases little pocks are loft. Eruj)tion a]i]>ears rare on taoi^ first, but rather on chest and between shoulders first. Is present on scal[i, and after on arms and legs. Comes out in cni]}s during 3 to 7 days. Spots may lu' lew, ])erhaps 10 to 200 on whole body. They appear on muc. membs. tis on palate. On lips they burst early, and leave what look like little idcers. Rarely vehicles run togetlier, hence bulhr like in jjempliigiis. Constitutiomd symptoms ale almost nil. Tom[ierature about normal. liicul)ation is doiibtfid, 4 to 27 (lays, a week perhaps is its time. Disease occurs in children rarely after 10 years, exceedingly rare in adults. It is possilile, but rare, to have secmni attack. TiiKAT.MENT — Light diet, no medicine, protect spots from sci'atching, especially on face. Isolation. — Disease is so mild that it is not necessary to practice strict i->elalioii. Ill effects are exceedingly rare. L. SCARLATINA. Forms. — S. Simplex, S. Anginosa or Ulcerosa, S. Maligna and S. F.atens. ScARL.VTlN'A SiMi'LE.N', witliout .soi'e throat, is mild, even not taking to bed. Ineiibation varies from a few (3) hours up to 7 days, the average is less than 3 I lavs, I'kodromata, chilliness, shivering, and in young children often convul- ■iw. Langiiur, pain in limbs, then reaction, fever, high teiuperature ami high I'lilse, frequent vomiting and jiurging. The rapidity of invasion is diagnostic. ' Ml first or .second day, /. «., at end of 24 hours there is a rash. The I?\8!! is a brialit red effloreseenro, cousistint! of niimerou-'i siu.'.ll briabt n d .4j)f)ts on wliite skin, th5ists and i-^ ofiK^tive form, looks like an iicute meningitis. In a couple of hours typhoid symptoms appear, tymitanitis and (ieath, Adanymic form, — vomiting and purging incessant, child may turn jiale and faint, may be slightly delirious. In very few liours extreme depression occurs, pulse 170, external temperature y i f-Wj I ^ : It PRACTICE OF MEDICINE. 1.^7 fei'ls cold. F.iint rasli may a]ipi'.'ir, but weakness is the great symiitoni. It iiiiiy lie fatal in 12 lioiirs, convulsions. Tliovo arc cases internu'diate Ix'twecn thi'se two types. Tlie ni.sh in nialignant form is laic, so you lii\c to see rasli linlv; is livid, and so you like to see a bright rash — disappears and ajjiiears again ill a few days. In worst cases no ra^h appears, lulls loo soon. . SiJ.viM,.vnN.\ L\TKNs may have no sore throat or rasli, but dropsy a])pears. Tlii-< di()[isy is more f.ital than after ordinary eases. Albuminuria and h;euiatu- lia wiihiiut dropsy may be only evidence of scarlatijia, but when eiliier appear and scarlatina be present, then suspect it. TKMrKiiATUitK OF ScAULATiNA. — In ndld cases no elevation is seen before eruption; in other cases in few hours lOo to 104 iscpiickly reached, rising slowly afterwards to Ul4 to 105-108, or may just remain higii. In either case remains till rash is at its maximum, then it declines slowly by lysis, reciuiring from '■] to ^ days ibr completion of fall. SoUE TiiitoAT is iiresent in every form, so is marked syn-.jitom. The throat is lirst part attacked, and often is last j)art to recover. Simple sore throat i^' rare ill cliildren, that is inHammation of fauces, although tonsilitis is commoner. If sore throat is accompanied by enlargement of neighboiing glands suspect di[)htheria or scarlatina, and isolate ; regai'deil as infectious. Urine in 8. is seanty and reiipirkably febrile, loaded with lithates, with jjerhaps albumen till tith to 7ih to Ttli to 14th day, after that it increases in quantity, more uric acid, etc. About 14tli to loih day, urine gets abundant, neutral, pale. Sometimes in eariy stages no alliumen, a mucous cloud app'-ars in urine of e]>itheluim degenerated from a renal catarrh. This catarrh is usually mild, declining with eruption, but may iiiiitinue and pass into more serious disease of ord week. This renal catarrh is found in measles, etc, but more fre(iuently in scarlatina than in any other disease- OoMPMCATlONS. — Coryza, nasal tone of speech, nasal diseharge, is frequently feimd, especially in cai-es with jharjngitis. Otitis media common especially witli coryza, or severe sore throat, beginning in early stage and tends to forma- tion of pus in middle ear, perforation and escape of tlie ossicles. In severer cases the tymi)anitic membrane ni",/ be destroyed, mastoiditis, caries of temporal bone, etc. Otorrhea is rare, occasic'it.(jy u le to intlammation of external meatus, occurs later in disease. Eye rarely sutu'- . Keratitis with perforation may occur, am- blyopia and retinitis are rare. Scarlatinal bubo of pervical lymphatics, and axil- la ly glands too grow tender and enhirge, but subsiii . i) decline of the angina. Ill other cases, at end of 2nd week glands eii''irgc rapidly, fever returns, and iiitlunmation may invade the surrounding cellu.:ir li^sue, h».iice brawny indura- tinu ending in deep and extensive suppuration froBt l-vJ to ear, killing Ijy exliaus- tinii, asphyxia, oedema glottidis, hemorriiage — all Vcry dangerous. Cellulitis, post pharyngeal, leading to post pharyngeal abscess, is also met with. Sore throat winch sets in with eruption attains height at bth day. Although severe it iMially gets well. But later on, at Bth to 10th day to end ofsecond week, a second Nire throat may appear, is a real diphtheria, concurrent, very fatal. The ulceration I i 1 f IB ill PRACTICE OF MEDICINE. 1?8 ixtiiKls wide and deoji, fdti.l disclinrgo, gliiiidn enlarfje, etc. Is often called iiiigina maligna, rulsc in these cases is exceedingly small, death hy syncope. Al'FKCTloNS OF Joints. — Scarlatinal ilieuinatisni. At disaijpeanince of irnjitinn, jdints of liii^'cis, wrists, knees, etc., may become swollen, I'yri'xia ivlurns and illness is iii'oIonj.;ed. A single joint only may beulTeeted, not common — syiiositis with effusion is marked. Destruction of joints by sniiiniration may iici'ur, probably a pyit-niia, fatal generally, ]\Iay have endocarditis, pericarditis. Inflammation ok Seuois AIkmukanks. — rrolmbly produced by two con- ditions: 1, as in S. iheuinalisin ; 2, or as in albuminuria. I'leuritis is most frequently of renal origin. Peritonitis may occur. I'rodncts of sueh elTnsions .>|ire{lily become pustular. Endocardial murmurs (from valvnlar lesion) may result, Miiiiiitiiia being a cause in early life. Duul'SY occurs in 5 per cent, o- m es. Circumstances may make an epi- (li laic go 70 per cent. Is most common after mild attacks. Likely to occur as late as 22 days in convalescence, and even several months have intervened. This dnijisy is jireceded by albuminuria 1 to 2 days, but occasionally this is reversed, lu rare cases, drojjsy remains after albuminuria. Some cases resemble tubular iHpliritis, with fever, anasarca, urine of high color, high sjjecilic gravity, abundant albumen, deticient of una, chlorides and often blood. Mild cases have no fever 1,'eiurally comes on at end of ord week, due jierhajis to consti]iation or fever, may be very mild. Aniemia is nipidly developed. Scarlatinal droj.sy octasidually proves fatal, even in a few hours, as by effusion (rapid) into both pleura', or by convulsions or by coma. (Edema glottidis, bronchitis, laryngitis, pneumonia, periostitis, muscuhir abscesses, caries of cervical vertebrae, jiaralysis of single nerves, acute dilatation of left ventricle, aie all rarer, and disorders of the neivcs. ifETlOLOGV. — Is du(; to specific contagion, jiropagated by contact, by air, by f"!!iites, It sur])asses all other contagia by tenacity to articles, by its trans- portability, viability, as held in clothes, transmission liy hitters, etc., hence caro needed in disinfection. It is not infections before throat is sore. As long as tiuoat is congested ('.ong after desquamation) it may lie infectious. The des- (Hiauiating skin, evacuations, etc., are contagious. All through desiiuamation it is ciintagi(jus. Previous attack prot(!cts, but if greatly e.\po.sed you may get a specific sore throat capalile of transmitting the disease. Dr. oMahomet says all persnns are contagious till end of 8 weeks or G, hence length of quarantine — 6 ui'cks is a good average. It is infections as soon as ja'imary fever occurs. S. F is inoculable, but is just as severe. Disease occurs at all seasons and ages, mostly at 3rd or 4th year ; it may be inoculated, but disease is no milder. Preg- II lut woman may infect fd'tus, or not. The jioison may be conveyed by milk : a I iinvalescent woman milking cow may infect the milk. The cow itself is subject to a disease which produces scarlatina in man, pr(jbably the same disease. The pure milk is innocuous, but during milking it gets the contagion fruin the ulcers ou the teats. K'fi t ' i*l i I fi'; r 1 PRACTICE OF MEDICINB. 189 ^f'||;llIl» Ai'i'KVRAMiKs. — InHiimmitory iiltuiiitidiM fouml in kidneys, liver, llit'ii au'l lyiiiiiliiHi.'s tniisilM, lyiiij)!! fdlliclfH about fauces uiitl tliri)ii<,'li()Ut 'istiiifs. Skill also tVfci'il. AUevnlMUs are liynlinc .guneiiitioii of ulii.siic .>! iif aiti.'1'ius. (ierminati'ii of iiiuvjulur coat of urttM'ic.-i. I'lirondiymatousi 'iii,'iiii ilioii. lutiTntitial iiilluiiiiuiUion. Hyaliue ami adenoid degeneration of l> injilial .■ ti.sniu'. In kidney tlaMe is also interstitial cliiinge.gloini'inlar neiiluitis, .;i| ^ule tilled witli ct'ili. Si'arlatina cjiniiot lie aborted. 'I'ltK.VTMKNT, — Aim i." secuiv inndt'iation of syiniitonis. In ■ case iiindcrate fcltrile syni|.t<.iiis iiv U-\'\t^ to 7f> degrees sponging, , red less as iini|ii'rature declines. InMnutinii uf bm.y by vaseline, olive oil uae butter, etc.> iiM r wholi! body night aiiu morning allay^^ itoiiing, re.'^tlessness. Mdd li'lmfuges ■ ii. \ Lii|. Am. Acet. 4 q. h. and Citrate of I'otasli. Plenty of li(inids may be iliwwed. Am. Carb. i- given in anginosed form, useful wbun prostration is ■lil'raring. TkmI'KUATUUK is liigli, ni'fds antipyn-ties. For l(J.i to lO-tdo not use wlcss tlicru are nervniH evidences of poisoning, then use Antif<'l>rine grs. 3 to 5, ami same wl (,)uinine, or Antipyrine, gr. 15 adult. Qniuino is n..t much used now. Uigi- lalisisalso u.sel'ul in .some cases, ami carry ou the spiuiging, or the wet pack may 111' used. In siu;h cases anoint after llow severe cases, but not so coiiiiuoiily. Its frcjuency varies with the epidemic, as 1 to 6 ; 10 per cent, is a good average. It does not occur in cases with albuminuria ; it comes on from 8 (liiys to 3 weeks from convalescence, but may occur just after the height oi leMr, or may he delayed 2 to 2 months after. Earliest disturbance may be fre- 'liiinl and uncontrollable vom.jng ; this may or may not be associated with retardation and weakening of cardiac action, even J4 to 16 beats per minute. The slowing is duo to loss of power of the cardiac ganglia, hence power exerted by the inhibitory nerves. As a rule muscles of the soft palate sulfer first, then niuseles ui the pharynx. The voice becomes nasal, and fluid returned by the nose, 'ilirn the pharynx is involved, swallowing is imi)aired, choking; may need rectal feeding or by a stomach tube. In those cases there is antesthesia of palate, no cuiitiaction even by faradic current. Thi« condition may be associated with OuuLAit iJisoitUKKs.— The pupil may be immovable and dilated, and iiccom- mudatiou is lost, asthenopia, amblyopia, even amaurosis may follow. Strabismus, K'-' - ffi* HLfe'ioi ii W^' A K M' >i.M m 1 "I t PRACTICE OP MEDICINE. 196 Iienee diplopia from paralysis of the ocular muscles may occur. The ophthalino- joope shews no lesion. These ocular lesions may be the first and only nervous lesions, iience for ocular paralytic affections enquire into diphtlieritic history pve- viiiusly. Muscles of the epiglottis may be involved. Aplionia from voaal eonl licing jiarlyzed. Anasthesia of the larynx. Tongue muscles paralysed. More rarely ii more extensive area is involved, as the muscles of the truid< and extremities fidiii ])arietes to complete ])aralysis of all the members. There is coldness, and filially anasthesia ailecting tiie toes and fingers. There is now a simulated locomo- tor ataxia, muscles atrophy and exhibit reaction of regeneration. Tendon reflex is l«[ even early, even during the onset of the attack. Culaneous reflexes are not iiMudly lost. Annesthesia may extend; hyperjestiiesia sometimes precedes aiucs- tliesia. Taralysis may vary from day to day. Tliere is no febrile reactions during this time. PuoGiNOSis is good. These cases generally recover unless the lieart is badly aifi-cted. In a certain number of cases these are fatal from heart atfcftion or fimn failure of respiration, from paralysis of its muscles, or from pneumonia from iiilialation of material througii antesthetic lines, from starvation, or from fatty de- generation of the heart, from intercurrent disease. Diphtheritic paralysis is fatal in 10 percent, of cases. Cause of paralysis is duo to the action of poison on iiiTvous .system, also from degeneratiun of the muscles themselves and liicir nerves; fVorn proliferation of the motor and sensory nerves and their sheaths ; from irritation of the anterior roots of the nerves, secondary to irritation of the great cornua of the cord. Some call it a nmltii)le neuritis- OruEii Complications are rare. Tliey are urticaria, embolism, ulcerative endocarditis, erysipe leuca'inia, Hodgkin's diseose, purpura. The Contagiousnkss of diphtheria is now admitted, whether the membrane or the excretions are the infectious material is in dispute. The virulence of contagion varies with virulence of case. IJiit age, impurity of air, C(jncentration of [)oisoii iiilliience, and there are also individual suscei)tibilities. The poison may be tlif- f'usi'd through the air, but not widely. It cannot be conveyed over a few yards through external open air. It adheres obstinately for months to fomites, houses, etc, It is portable by clothing without affecting the wearer, but the clothes Would need fair saturation with the virus, expectoration, excreta, etc. ; infects sewers, wells, and so infects like typhoid. Therefore drinking water, sewer gas, etc., are infections. Milk may be the medium from absorption or impure water. It liiis not been shewn whether a cow can have diiihtheria. It spr(!ads in schools from breath, and because of no eruption mild cases continue at school. Inflam- matory sore throat predisposes to it, so a person with such a throat should not expose himself. Erysipelas, scarlatina, measles, typhoid predispose, also tlie piU'rperal state to vaginal diphtheria. Dampness of dwelling favors cultivation of diphtheria, perhaps by favoring catarrh, etc. Diphtheria especially prevails in temperate climates, but is present in all. Unhygienic surroundings of the poor favor propagation of the disease. All ages are liable, but especially the young. A : !1 I\ n tl 111 V tl hi I" tl] til ;ii CO Ci vc Vf th all th 1>C3 IS vi( it( PRACTICE OF MEniCINE. 197 Family predisposition seems to exist. Diplitheria originates in developing filth, especially foecfil matter, sewerage, hence hygienic necessities. Diphtheria is one of iiidest epidemic diseases, germs are universal and under favorable conditions rradily develop. Incubation varies, 1 case was 30 iiours, some think even shorter may Miflinc — 2 to 5 days is average, may be 12 to 14 days. LoiuiU) Anato.my'. — False membranes are yet divided into two — croupous a; ■ .diphtheritic. Croupous Inflammation.— When mucous membrane is so injured that its I'pithelium is partially destroyed, and vesicles injured so that exudation is poured 'Hit oti surface of m.in., we have croupous inflammation. So a pale yellowish iiiiMiil'rane forms on surface, this is connected loosely with subjacent membranes \>y fibrous threads, separate and m.ni. beneath is found intact but red. Diphtheritic Inflammation,— If mucous membrane is injured so that its rl'itlielium dies without desquamation, vessels damaged pour out coa^^ulating fluid which involves epithelial cells and coagulates themselves. M. m. coagulates uito solid membrane. If the necrosis and coagula be superficial it is superliuial (liphtherisis ; if involving sub mucous membrane, it is parenchymatous diphthe- nsis. Diphtheritic disease is a specific one, and its local manifestation is this throat affection, etc. Its germ is introduced into membrane of throat and nose, hence alfecting .system secondarily. Breath, etc., is poisonous. Spleen is enlarged, l)roving disease constitutional. Bronchial tubes always inflamed with diph- theritic exudation about 4th to 5th day, preferiing vertical tubes. Upper lobes of lu'.igs are pale and emphysematous, base congested and back parts consolidated lierhaps. Ecchymoses and small infarctions may be f(jund posteriorly and under the pleurae. Kidneys are attacked from outset, reseml)iing acute parenchyma- tous nephritis iii well marked cases. Malphigian tufts often filled with blood and micrococci. Liver,— capillary iiemorrhages in cortex and under peritoneal covering. Stomach,— there may be extension here of rlii.hthjritic exudation. Capillary hemorrhages may be found on intestines, meninges, lymphatic glands, voluntary muscles. Fatty degeneration in protracted cases, in heart muscle and voluntary muscles, sometimes waxy degeneration. Micrococci develop not only in the diphtheritic membrane but in the blood and most organs. Nervous system- alterations here found vary witii the case ; if death is due to general toxic causes the brain and cord are congested. If severe paralysis had occurred motor nerves had beim found degenerated, also their spinal roots affected by proliferating neuritis, ^liiltiple neuritis is a general aflectiou, Diagnosis of follicular tonsilitis from diphtheria is often very difficult. Follicular Tonsilitis.— Excessive secretion of the folUcles of tonsils which is forced out, is whitish or yellowish in color, distinrlly circumscribed and ol». viously raised above the surface of the tonsil— often though exudation is so gre .t it coalesces and runs over the edge of the tonsil. They do not extend from day to day, and are easily wiped out of the follicle, leaving it as a crevice or pit. Theie 25 i, ' ^ll Hff sill im\ { %] 1 PRACTICE OF MEDICINE. 198 is ail absence of tetor of breath, swelling of the glands at the angle of the jaw is altsent, no grave constitutional disturbance, as vital depression or prostration. No tendency of the disease to extend to the larynx or nares. The exudation is limited to the tonsils. Gets well of itself. Is fatal only in young children from i edema of the (jlottis. Tenderness of '.he throat is greater in the first few days than in diphtheria. DiPiiruEiiiA. — The membrane is not limited in early stage to follicles, is not much raised, is of a greyish color rather than yellowish, and patches have a tendency to coalesce. The membrane exte nds to the tonsils, covering the fauces palate, pharynx ; if brushed off leaves a raw surface. No fcstor of the breath in mild cases. Glands at the angle of the jaw and bifurcation of the carotid eidarge and are tender. A great feeling of prostration. Tendency to extend to the n.tic'S or larynx. Exudation spreads from the tonsils to the surrounding parts. Is a very fatal disease, is infectious. Tenderness of the throat less at first. TiiEATMKNT. — No specihc treatment is known for diphtheria. Treat on general principles. Dietetic auil iiygienio treatment are important. Have the l>atient in a large rooni. This is iuipurtant both for the patient and yourself. A cool temperature is important, 65 degrees prevents development of contagion, nsist positively on the patient remaining in bed even in mild cases. Keep the strength up by strong soups, milk, eggs. If milk disagrees, peptonize it. Alcohol in severe cases from the beginning, in mild cises as experience prompts. Stan- dard remedy is Iron — Tr. Ferri I'erch. in full doses 2l) to 40 gtt. in ^ oz. Glycerine every 2 to 3 hours. Give h oz. of the Tiiict. every 21 hours. Children will need less, of course. Above is the adult dose. Keep up Iron till the tongue gets red. Pot. Clilor. is often given with the Iron. For ii child of :j years, i dr. in tlie 21 hours. Ilemember that large doses of the Pot. Chlor. tends to cause nephritis, hence care is needed in prescribing it. For headaciie, vomiting, high temperature, Iron is not well borne. For the later septic stages give Quinine for a few days in fairly full doses. In Lakyxgeal Form use Hydrarg. Bichlor., smallest (hily dose J gr. for infant of 4 months, gr. i daily to child 4 to 5 years old for 4 to 8 days. IJjses vary from ^jth to |?^th gr. hourly. This drug must be well diluted, L to i^;^ in water or milk. If intestinal irritation occurs give Opium and further dilute the Perchloride. Tracheotomy or intubation can only be avoidid if the Ilyd, Perch, be given in time ; but if you have to operate, still continue the Perch. Sod. Salicyl. is dangerous, it depresses the heart. Benzoate of Soda is used to kill the specific germs in the bloud by being even injected hypodermically, but is really no use. Local Treatment. — Cauterizing or destroying the membrane leaves a raw surface ready to be infected, hence soothing measures alone are to be employed. Solvents of the membrane have been ad /ocated, as Li(i. Potass. 1 in 4, or Lime Water or Lactic Acid. This last is most reliable. Apply with brush or swab. At outset of the case paiut membrane with 1 part of lials. Tolu. to 5 parts of I WVl \ 1 '. li,; 9 J \ ■ t'lM^^H ) j 1 '1 WKSj: ^ .■ .--.iSt-ih •. i ^, ' ■ PRACTICE OF MEDICINE. 199 Etlior, painting 5 times daily so as to exclude the air. Tliis Ins not proved li'iud. Astringent gargles are powerless to arrest the exudation, as they seem to irritate and destroy tiie appetite. Inhalations of steam, slacked fresh lime close 1(1 patient, so both lime and steam are inhaled, ; this is a good deal used. Lime water and water, equal parts of each, and Carbol. Ac. 1 to 3 per cent., makes a Liiiod spray. Inhalation of Turpentine under a tent over the bed constantly is used too. A solution of papoid with solvent properties has been tried in tlie Gen- eral Hospial, 5 per cent.oreven stronger — use it fresh, paint frequently. Dr. Ross tliinks it good, keeps the throat sweet, and seems to arrest the spread of exudation, is worth a trial- must be applied every hour, day and night, for a couple of days, lifll's solution for the tiiroat is good— Tr. Ferri. Perch, dr. 4, Sulphurous Ac. dr. 2, C^arb. Acid dr. 1, Glycerine dr. 4; apply on a brush. liyd. Perchlor. 1 in 3000 is also used. Use it very carefully in grown persons, so the solution will not be swallowed. Inhalations of steam 120 degrees for 15 minutes every i hour, but some think it increases the catarrhal state. Dr. Ross thinks it is beneficial wheu tlie nose and trachea are involved. Have a kettle over an alcohol lami). ^ gas stove in the room is bad, as it uses too much oxygen. Gresoline burnt in a liunp is good, or tar preparations, but the latter are dirty from soot. If nares be nlfected, it is of the utmost importance that they be cleansed. A weak solution of common salt or Soil. Garb, will do by injecting slowly into the anterior nares. Have the mouth open so the fluid will not go into the Eustachian tubes. Use it every 1 to 2 hours, or Garb. Ac. gr. 2 to the oz., or Permang. of Potash. If nares be obstructed pass a probe so that an injection can get in. A gooil lotion, tlie best, but needing care, is Perchlor, of Mercury sol. 1 in nnri^'hs, A new plan is to destroy tlie membrane by actual cautery. If the larynx is affected it is serious. Gonstitutional treatment is the same as pharyngeal, local treatment differs. Dr. Jacobi believes in the use of Perchlor. of Mercury in laryngeal cases ; some use Galomel. Local Treatmen-t. — Cannot arrest the extension of the membrane. Re- moval of the membrane is difficult. Inhalations may be tried or sprays of j^jfths uf Lactic Acid, or Lime Water, to liquify tlie mem'Tiiie, but do it slowly and su- perticially. Papoid spray can also be used, but its liquifying power is extremely small. Emetics are sometimes useful. Use one that has not a depressing elfect, .such as Copper or Zinc Sulphate or Alum, but not Ipecac or Antimony. There is no use in using it early, as the memlirane is still adherent ; but ...j the membrane is giving way, then is the time to use it. Mechanical interference in the larynx by brush, etc., sometimes is good, as it detaches the false m'^mbrane, but is an uncertain method. So an attempt at intubation often does good. If asphyxia threatens by filling up of the larynx, either intubation or tracheotomy may be done. Intubation is more readily assented to, and is less dangerous. Has no wound to get affected. Again the air is warmed by passing along the natural inissages, and the tube keeps quite clean. It is a delicate operation, needs to bo inserted rapidly, hence better to practice on the cadaver. Getting the tube out f W: ilVi> ,^33~iS'**''r-_"-'-!-i'.-,r" PRACTICE OP MEDICINE, 200 !ij;ain is harder than inittinr; it in. Child may stmgi^lo so as to have fatal results from heart failure. One dan<,'er of intubation is the entrance of food aiul li(ini(ls ddwn the tube, anddeatli nfteii results from septic pneumonia, hence for the first 3 days let the child drink nothing but water, and feed it by a tube into the stomach. Tracheotomy is a last resort, is not successful operation. Author- ities say that tracheotomy should be performed as soon as there are symptoms of laryngeal stenosis, before tin; vital powers have failed or the lungs have begun to collapse. But every case of laryngeal diphtheria does not need tracheotomy ; many recover. riPHTiiKiUTJC Paralysis. — If mild and limited, it recovers spontaneously in a few M-eeks. In severe cases the patient needs watching. Feed him well, give stimulants, wine, Iron and Quinine. Sometimes the i)atient cannot swallow, hence use stomach pump or feed by rectum. Sometimes semi-solids such as oysters are swallowed better than fluids. Keep affected muscles warm and use friction. When the ])rocess has ceased, use electricity. Gr. ^th of Strychnia may be now injected. Warm baths, sulphur baths are good. LIV. ASIATIC CHOLERA. Is epidemic, malignant, Oriental, Indian, spasmodic cholera, etc. Is indige- nous in India as a sporadic disease with epidemics. In 1816 a wave of cholera started from India westward, and in 15 years spread over the world. It appeared at Quebec in 1832 in an emigrant vessel from Dublin. In June, 1834, it again ajipcared, and then invaded the Maritime Provinces. In 1848 it broke out at New Orleans by a vessel from Havre, reacliing Chicago in 1849, speading east, and so reaching Canada fiom the West. In 1854 the 4th epidemic occurred in Canada. Canadian cholera if severe greatly resembles Asiatic cholera. The symptoms of cholera may vary. There are two varieties : 1, the mitior ; 2, the gravior. The first is often called by the French. Various stages are : 1. Incubation, from several hours to o days. 2. Invasion and development, which latter may be so short as not to be noticed. 3. Algide stage, patient cold and pulse- less, which stage lasts from a few minutes to 48 hours. 4. Reaction stage — this is the febrile stage, is common in Europe and America. At one time not noticed in India. This stage lasts from 4 to 8 days, so the duration of the disease is from a few hours to 1 to 4 weeks. Incubation — is ordinarily 3 to 4 days, some say it is never less than 2 days, but a case where it was only 19 hours was noted. Quarantine of vessels is from 5 to 7 days. Invasion — may be quite short, sometimes prodromata of diarrluea. Mental depression, impaired appetite, weak pulse, may occur. Indefinite symptoms are often absent. The early symptom in most cases is slight diarrbsei with colicky pains. Is ficciilant at first, then becoming bilious, then more serous, then rice water stools. The stools are copious. Often the attack is at 2 to 3 in the morning, is accompanied 1 I lif ) I 1 ^^^^^iSylpB PRACTICE OF MEDICIVB. 201 l'\ a sensation of ppigastiic tlepression, tlion vnmitipg, cliani,'ing till it rpscniblus .^tiiols, then cramps begin in the extremities. Tliirst is extreme, restlessness. (i| I'ression, anxiety, pulse weak. These symptoms more or less rapidly pass into llie Aloide Staoe. — Temperature falls rapidly, surface ioy cold, .skin insensible iven to boiling water, fingers shrunken. Patient complains of ojipressidu, wants lii>sh air, wants water for the thirst, restless, throws clothes off. Pulse 120 to 140, weak, gradually beccuning extinct at wrists till you only get it at the axilla 01 neck. The n\)v\ beat is gone, sounds weak, venous circulation languid, licuco surface gels blue and cyanotic. If the patient be now lik-d the blood merely trickles, is thick, dark and viscid. Nervous functions less di.sturbed than other systems. Spasms of the extremities, face, cramps, hence .spasmodic rliolera. he mind is apathetic, fear changing to indifference. Mu.sculur strength may be retained late. Secretions generally diminished or suppres.sed, voice feeble, liiisky to extinction from exhaustion and dryness of the vocal cord. Coiinte- iiaiice gets of a choleraic aspect, .shrunken, sharp features, eoriiefi- flat, titngiio cold, etc. This algide stage in mo.st cases may come on in a few minutes. Tempe- rature varies from 90 to 07 in the axilla, but higher, 100 to 103, in rectum. The above symptotns are present in all cases unless arrested. Vomiting and purging may cease, patient dozes. The Stage of Eeaction.— If algide stage is .survived, febrile stage or stage of reaction or recovery may eii.sue. First sign of recovery is a sound sleep with a healthy, w.irm and moist skin, respirations freer, circulation better, urine apjiears, fsoces changing, and recovery progresses. Febrile reaction is a frequent lollowing of collapse, skin gets warmer, pulse rapid, tongue get.'! dry and brown, .sordes on the teeth, diarrliiea continues, gets bilious, gieeiiisli, may beoome a dysentery, or constipation with a bilious vomiting may occur. I rine albuminous and with casts is again secreted. These typhoid symptoms may pass into coma or exhaustion from diarrluea, or after 4 to 8 days struggle convalescence sets in. Tlie above is typhoid cholera. It is due to the suppressions of the functions of tlio kidney, hence urieinic symptoms, or it may be due to cholera poison. The mine ceases to be albuminous in 2 to 10 days, no permanent damage to the kidney ensues. Inflammation with diphtheritic exudation in the intestines occurs sometimes like a dysentery. Development and Puogkess. — Slight forms begin with watery purging and vomiting, passing gradually into the other varieties — marked loss of power slowly reached— cramps do not ensue till the f;eces are rice water like algide symp- loins. Are developed gradually, are less severe, and recovery is frequent. Severer f(,rm — Poison is more energetic, often 2 to 3 stools, severe cramps follow and are continued, succeeded and accompanied by algide symptoms. After death intes- tines are filled with a thick, white mucus. Early arrest of pulmonary circulation, lience algide symptoms almost at once. There is little or no purging and arrest iiiii'i of eol lUl .sli cm 2. lilt rei ]■('( til all till all ill! fal 111 ar ac uti \K a 1.. (1( se ail \V( in ai C( L'( 01 fo w C( ni P rUAOTICE OF MEIiICINK. 203 of nil tho spci'ftions, vertij;!), coma and bliiuness of tho surfaces, imrly niul deep ciiinu. Dentil iiiiiy occur in 2 to 4 hours. Cases lusting only 5 minutes are ruconli'd in Indiii. IJuhK.i; (iK Ciifil.KliA.— May ajiiicar in tlio .stnj^'c of ri'iulion, attended \>y slii,'lit febrile symi/ionia ; other Hynipt'i-M^ Imve U'cn noted, such u.s her^ies, urti- caria, etc. Seqi'EL/I: — I. riccralion of thu iiciicafrom irritation of dn.'^t in young ones. 2, Eidarjieniiiit of the iiunnids, sn]ii'nrulion following. Boils, bedsures, iidlam- nialion of the lungs. TemI'MUTUHE. — In the 1st stage tcnijioraturc falls, \iliary tt niperature 95, rectum 98. In 2nd stage there is moderate coUajise, axillary temiieratiue 94 rei'tum 100. In advanced collnpso the axillary teniiieruture is 97, ree'.nm lo.S, — that is a|iiiroaching rea lion stage. 3th stage or reaction stiigo, axillary lemiicr- aturo 96, rectum 97. Alticuation.s okIiLOOd. — During the cold stage the blood is dark, viscul and tiir like. The s]iecific giavity of the serum is high rom diainage of water, isles alkaline than usual. Licj. sanguinous and wulei escapes from the cuj/illaries into th(! intestines, hence the relative excess of solids in the blood. The transu- dation is of short duration, maximun; reached at 36 hours, and then th.i wat i i-^ reabsoib((l fruin the intestines by the blood and the sjiecilic gravity u( the bl. . falls A transudation of constituents of the bhiod cells into the serum tak'S jdact t the same time. During intestinal transudation the fluids in most of lie tissui are attracted to the blood. These lluids are loaxternal conditions have an in- tluence in the spread of cholera. Following conditions favor development: 1, moderately elevated temperature ; 2, certain amount of moisture ; 3, stagnant atmosphere; 4, water, air or soil contaminated with decomposing animal matter; 5, overcrowding ; 6, bad ventilation. Above influences aid also indirectly by favoring lowering of personal vitality. Personal influences favoring rlisease. Those reducing powers of resistance, as fatigue, poverty, old age, chronic diseases, un- wholesome food, use of bad meat, unripe food, may induce intestinal catarrh, hence favoring arrest of cholera poison in the bowels. Pkognosls. — Always grave. Mortality averages 50 per cent., ranges from 20 to 80 per cent., greatest at beginning of epidemic. The aged, intemperate, those in unhygienic surroundings are in most danger. IKEATiMENT. — Endeavor to arrest premonitory symptoms' of diarrhoea. Re- medies are same as in diarrhoea. Astringents — Opium with others. It. Pulv. Arom. dr. 3, Tr. Catechu dr. 6, Tr. Oi)ii dr. 1, Tr. Card. dr. 6, Mist. Cret^e, ad 6 ozs. Sig. ^ oz. every hour till diarrhoea lessens, then less often. Mixtures with Tr. Opii, Tr. Kino and Mist. Crette are also uf^ed. Another is Zn. Sulph., Tr. Catechu, Tr. Opii. Another is Plumb Acet. gr. 2, Camphor gr. 1, I'ulv. Op. gr. 1, in a pill. Another is Pulv. Opii gr. 1, Plumb Acet. gr. 4, make a pill. Give a pill after each movement of bowels till 3 are given, then regulate dose afterwards. Another,— Tr. Op., Spt. Camph., Tr. Vfri lit IH ! : I i i • ; , ' 'i til III 111 oil w ca tlu OIL III 1)11 Hi,' (ir' iit into privies or sewers. Vessels used about patient must be cleansed by dis- infecting solutions. Soiled linen— plunge at once into solution of Zn. Cl^, for 24 liours, then boil, and afterwards e.xpose to sulphur fumigation. Articles which cannot be so treated should be burned, hence value of straw beds in hospitals. Purify rooms after by ventilation, wa^ihing walls and SO^ fumigation. I tisinfect the air of the room by SO,, CI. Nitrous Oxide in succession. Disinfect- ants most relied on <»,re Zn. Chlor. 2, Zn. SO^, Acid Garb., Sulphuric Acid SO,, free ventilation and high temper.iture '^2 to 250 F. Corpses should be buried in 24 hours, lime in coffin. During epidemic boil all drinking water, do not use l>urgatives. U. S. Rules for Disin-fection'.— 1. Rolled Sulplmr for fumigation, 2 lbs. in room of 10 feet square, keep room tightly closeil for 24 hours. 2. Soak bdd- clotiies at bedside in solution of Hg. Cl^ and boil subsequently. 3. Carbolic Acid is not to be trusted, for its strength varies, and odor deceives as to strength. 4. Burn all articles, this is safest plan. 5. Articles which wdl not wash fumigate with Sulphur, and then ventilate in air. 6. Discliarges from patients received into solution of Fe. S04, li lbs. to gallon. 7. Wash corpse in Zn. CI. 2, solu- tion of double strengtii, wrap in sheet wet with, and bury in 24 houra- Funeral not public. LV. CHOLERA NOSTRAS (EUROPCEA) Is met chiefly in hot weather, resembles Asiatic cholera, but it is rare for rice water stools of stage of collapse to be reached except in aged persons and children. Pkodkomata. — Uneasiness in epigastrium, flatulence, pain, but more often it begins suddenly at night, — 2 a. m. generally. Stools are fiecal, thin, vomiting soon appears. Both vomiting and purging are very frequent, and violent cramps are common both in extremities and aljJomen. In b.id case collapse foUo^vs, sluunken features, suppression of urine, etc., as in algide stage of true cholera, generally in aged or those who have poor resistance. This algiie stage may be reached very rapidly. As a rule trjatment acts readily. Sometimes in a febrile stage reaction succeeds. No matter how severe the algide stage, try auJ secure a reaction ; you will generally succeed. Causes — Prolonged heat, as after hot spell, chills, poor food, unripe fruit, unsanitary surroundings, arsenic and irritant poisons. It is chiefly sporadic, but occasionally epidemic. P. M. appearances are like in true cholera, but de.ith is rare. Treatment is much like Asiatic cholera. The great remedy is Upiuin and the combination with Calomel is very good. Calomel gr. 6, Opium gr. 1 to 2, put dry on tongue and wash down with a little water. Repeat in 15 minutes if vom- ited. Do not allow any drink. Put sinapism over epigastrium. As a rule tliese remedies promptly arrest vomiting, purging aud paiu. Tuict. of ginger, hypo- dermic injection of Morphia. After treatment is Liq. Morph. gtt. 10, Sp, Chlor. gtt. 10, Glycerine gtt. 15, in J oz. cold water. Watch diet for a day or so. If algid j . t ( MaMMiH |^B|| i VBK^St ',tl^ - - . ij i PRACTICE OF MEDICI.N'E. 207 stago is reachetl then U3u lieat to boily, etc, iis in cholera. Quarantine in cho- lera seven days fur ship. It has been reduced to five days by Frencli. English sy.stein is medical inspection and isolation rather tlian (iuarantine. Medical olU- cer examines every passenger on suspected vessel, sends sick to hospital, takes names and addres.ses of all passengers, and advises local authorities at points of destination of each of passengers who are allowed at once to proceed. LYI. PERTUSSIS (VVHOOl'IXG COUGH) Is infectious— a zymotic disease characterized by catarrh of respiratory tract and a pocular spasmodic cough occurring in paroxysms and at intervals. Incu- liition, 10 to 14 days is average, may be less or more. Disease is divided into tiiree stages : 1. Catarrlial stage, 10 to 14 days; 2, spasmodic, 3 to 8 weeks; 3, convalescent, 3 weeks. C.VTAURUAL Sr.vGK.— Symptoms of cold in hr-ad, cough dry and short, running of nose, fullness in head, slight soreness of throat. Tliere is also a very mild febrile stage, but sometimes is severe. This stage lasts 10 to 1-1 days, bul n-.ay be as short as 4 days, and peculiar ougli suts in at once, is rare, or stagj ni ly last 3 weeks. So far disease is iiard to diagiiosa, is like catarrhal bronchitis. SPASMonic Stage is jn-esent when -Cjugh is paroxysmal and foUowe 1 by characteristic whoop. At onset of cough child becomes alarmed, seizes something for support. Cough is characterized by labored inspiration and e ipiration. Tlie expiration consists of a .series (6, 8, (.0 to 12) of coughs, short and violent, rap- idly succeeding without any iusiaratiou bjtwien, and child has eyes staring an I ]irotrudiug, face gets swollen, turgid, livid. Spasraj now momentarily relieved, hence a prolonged inspiration witli characteristic crowing, whooping noise. And same is again repeated. These paroxysms are mule up of several such attacks. When prolonged, the congestion in vessels of head is so great that hemorrhage from eyes, nose and ears occurs, so that tli sre is siil)-c jujuiictival eccliyinoses. Slight convulsions may occur, vomiting is common, ejection of fiejes. Paroxysm com- monly terminates by vomiting or by expactoration of glairy clean fluid— child is left exiiausted. Circulation l)jcomes natural agiiu. In severe cases child appears fatigued, pale, refuses fo(xl, etc. Freiiuency of paroxysms is in proportion to their severity, — comnroidy they recur every U- to 2 Inurs, but thare may only be 2 in a day— are generally more frequent at night. Some excitant is generally a eause of paroxysm, as laughing, crying, drinking 'aAd w.iter— common afcer eating. After 3 to 4 weeks parox; ., diminish in frequency and severity, an 1 by 8th week convalescence se:s in. Ulceration of Frenum Linguae is a good sign of pertussis, due to scraping against teeth in paroxysm. Stage of Convalescence.— Seizure? are less severe and frequent, expecto- ration more muco-purulent, vomiting ceases, etc. ; in three weeks child is well but for months a cold may give paroxysms like wliooping cough. There remains an I I 1 n t c II li t( i: w •1 d ii: II 01 11 it S( w ll h ti \u h( 01 CI bi til eii \v ni 111 Ii lis PRACTICE OF MEni' 208 irrituMe state of air passajjcs, especially la; vii\, : ■ aco spasiD of }. 'ottis. Physical signs are absent in chest if disease Ixi not euiiipli' t«d. If hconchi.tl glands bo en- liirgcd, over their situation v ii may in young clil Iren make on prolonged rough iuspiriition. PiiociNosis. — Mild uncomplicated whooping cough ends fuvoinVilv CoMi'LiCATioNS. — Capillary bronchitis is common, most dangeroii :ate in the disease. The tougher the mucus, the more the distress. If oftiMi leads to collapse of the lobules, so increasing the dy^pnavi. Catarrhal or crouiMtua piioii- monia is rarer. Pleurisy gives frightful sufferings in the paroxysms, and is also rare, Ilupturo of air cells in violent coughing, hence acute emphysema leading to sudden death — convulsions most frequent in teething children. Tuberculous i'lflammation of the brain ending in acute hydrocephalus rare also. Gastro- cuteiitis and suppression of expectoration. Abdominal pain, cannot vomit, cannot wlioo]), hence the name " dumb kink." Kvacr.alions loose. Measles not infre- (juently co-exist with pertussLs, often modify or arrest the cough while the disease lasts, the cough reappearing after the measles is over. Ikouchial asthma and vesicular empiiysema are apt to follow a severe attack. Bronchitis, pneu- monia, phtiiisis may be sequehe. Morbid anatomy uncomplicated, and death occurs, no lesions are found. Alterations found are from complications— pul- monary collapse is usually found, acute vesicular emphysema compensating with it — larynx and trachea not affected, capillary bronchi inflamed. Plffusiou of serum or even blood into the brain. If abdominal complications existed you will find congestion there— lymjjhatics enlarged— bronchial glands at the root of lung are always enlarged, llelapse of wlioophig cough is from these glands becoming enlarged by congestion consequent on cold. Pertussis is infec- tious, depends on siiecific virus. 'I'he breath and the sputa contain it. Ouo holds the disease is due to the irritative state of the vagus. Children have been born with the disease, but the virus has not been found in the blood. An oi'ganism resembling leptothorix buccalis is thought to ba the exciting agent cultivation and inuoculation prove the germ theory. This virus seems to act .specially on the nervous system and respiratory tract. In the mucous mera- br.me of the respiratory tract it excites a specilic intlimmatory action. Also in the terminus of the vagus in the lungs and stomach. Tliis accounts for the early nasal laryngeal catarrh for vomiting, paroxysmal cough, etc. i:>evera whooping cough is often fatal, rarely mild. TiiEATMENT. — In mild cases protect from exposure, as the respiratory mucous membrane is irrit«ible, so do not expose to weather unless it is mild, and give a mild diet. Keep child in warm dry air, give mild expectorants and laxatives. In severe cases enforce the above regulations more scrupulously, and treat com- jilications ».s they arrive, you cannot aborC the disease. During catarrhal stage use expectorants and mild nauseants, as Ipecac and Antimony, dose according to age. At the beginning of the paroxysmal stage add to the above Am. Bromide It I PRACTICE OF MEDICINB. 209 or Bclliidoii. AFiM coiintor-initiition to tlin uhest is good, as liniriiont Acot. Ac. ai.il tiirpoiitiiH', or 11 .siiiii|)isiii. Do not use oviiiioriiliiij^ liiiiiiiciit, it cools. In ■<|iii,tiiio/ivii jiuusfiiiitH, us Ijujciic. To lessen tlie severity of piiroxysiu ^'ive Pot. or Am. Uroiuiiio or Cliloml oi Canii.lior ; Hellail. or Atropinu aru favor- ites. Give Tr. lUllad. <,'tt. 1(1 to oliildreti '2 to .S years every hour; watcli t'lVects, It iti not so iiselMl if hroiidiitis com|ili(;iit(^s tlie ease. Some Li(i. Atropiii. m. 1 in tlie a.m. i. ^i. ,i„lli of Atroiiin.i to ehildreii 1 to 4 yeiirs. (iivu eurly ill tlie forenoon, give oiiee a day or in severe casus give another ^ dose at ni^ht, imsli till it dilutes tlie imjiil. Dr. lioss siiys it is liest to i,'ivo it in solia form, a(l\ises to give in |io!lets. Kiistace Smith gives Atropine .j\,^t\\, Zinc Snlph. gr. „'„tli in glycerine and water morning and evening for 2 days, tluiU T. I, 1). If spasms are severe, give the night dose of Am. Piromide in addilinn. A -nvering ov(M' the hed I>y keeping olf drafts aids to lessen the spasms. Alnm gr. jj ih iu honey every o hours in declining stage. The use of Quinine in pertussis wag largely n.sed, results are not .satisfactory, hard to get the child to take it. Tan- iiiite of Quinine is the form to give it in. Salicyl. Ac. has heen u.sed with success with some. Dr. Howard recommended it. R. Salicyl. Ac. g'-. 33, Alum Snlph. gr. 50, Acid llydrocyiinic Dil. gtt. 9, Syr, Lemon 4 oz. 8ig. I dr. (^very :'. hour.s for child of 3 years. Chloral is used for severe spasms. Sprcvs of weak solu- tions of Ac. Curb, or Eucalyptohire used '.ly some. Stage of convalescence — liest treatment is change of air. It gives remarkahle results, keep from cxi»osure to the weather. (Jive nntritious diet. Cod Liver Oil. For pulmonary collap.se give stimnliints, an occasional emetic. One attack generally protects from a second, but less than in other diseases. LVII. MUMPS OK PAPOTITIS. Is an inflammation of the parotid gland. There are t'vo forms : 1. Idiopa- thic mumps, which are epidemic ; 2. metastatic, which are not epidemic. Iiaoi'ATllic Pauotitis.— This occurs in epidemics, .so resembles the other acute infectious di.seases, but is unlike them, — I, in its short duration ; 2, iu slight constitutional disturbances. There are indications of a specific contagion for the disease, which causes local manifestations, but little constitutional signs, thus resembling pertussis— epidemics are less frequent thai of the exanthems. AinowiiY. — It all'ects sexes diiferiaitly, males have it v)ftenest. Children between 2 to 15 are most fiequently affected, nurslings aie exempt, also very old people, adults have it l)ut schiom. One attack protects against anotucr; it often accoiiipauie.s, precedes or follows an ejjidemic of measles. An (qiideniic does n(jt last long. Its contagiousness is well established by tracing house or local outbreaks. Stage of incubation from 4 to 12 days. Symptom.s. — Often at first is a local pain on opening the mouth, but some- times there are prodroinata, which may last a few days. Are general and not distinct, feeling out of sorts, geud'al pains, languor, headache, slight chills, per- liaps a little fever or loss of appetite. I aiii PRACTICE OF MEDICINE. 210 Local pain about the angle of the jaw, spreads to the ear, and thus becomes iiiiiie definite, any movement of the jaw increases it; shortly swellinr; begins, and soon a distinct tumor forms — is generally on one side, but may be bilateral. This swelling occurs jiist below the lobe of the ear, and gradually raises up the lobe iiud throws it outward. This tumor is never very hard (unlike tlie metastatic Viiriety). Is composed partly of enlarged gland, but mostly of surrounding (I'dematus tissue. The swelhng is diffused and the borders not defined. As the swelling increases the infra-maxillary and sublingual regions increase in size, so the neck may measure as much around as the head. The effect is to give a fixed iind stolid expression to the face, especially if bilateral. Patient looks idiotic, stupid. If swelling goes deep, tonsils may l)e affected, hence dyspliagia or nasal warts, or sense of suffocation. Skin over the swelling is generally normal look- ing, not hot or inflamed. Occasionally it is slightly inflamed. If swelling is very great skin may be glistening and pale. Tbe i)ain is not severe. One is felt at the articulation of tiie jaw, one over the mastoid. The head of the patient is held stiffly. If swelling is great tlie mouth cannot Ix^ oi>eiied, any attempt is very painful. Other symptoms from disturbance of neighboring iKUts are obstruc- tion of the Eustachian tube, hence deafness or tinnitus. Salivary glands may liiive function suppressed, hence ptyalisin. Occasionally symptoms of cerebral liyperiemia are seen. The disease nmy be bilateral or unilateral, accord- ing to the epidemic. Pulse not much affected, fever slight and transitory, nothing typical ; j)ulse and temperature will be only 4 to 5 days abnormal. CouuSK OF THE DISEASE. — Almost always favorable, symptoms are good and subside, also the swelling, and recovery takes place in 2 weeks at the outset. The oedematous swelling disappears with great rapidity, only in the scrofulous is tliere delay and absorption ; as swelling disappears there is slight desquamation over the affected area. INFLAM.MATION of the testifies is common, genemllv occui's in youths or virile men. Is a true orchitis in the body of the testicle itself, but may be an ejiididymitis, generally with hydrocele. The orchitis is characterized by consider- able swelling, but the pain is not as great as from gonorrluea. Often there is a discharge from the urethra like gonorrhoea, sometimes with scalding. If a man with gonorrhiea gets mumps he is not more liable to orchitis than others. Treatment of orchitis is by an emetic — testicles swell 4 to 6 days, subsides in 2 weeks. Orchitis sets in at the end of the 1st week, is generally unilateral ; generally on the right s'de, althougli the left parotid is oftenest affected ; rarely in females there is swelling of the ovaries, vulva or inguinal glands. Treatment. — Keep at rest, use mild salines, purgatives. Locally warm oils, inunctions are grateful ; opiates as in liniment or Lin. Camph. nuiy be nd)bed in and covered by flannel. In severe cases apply ice bag or leeches. Some apply hot fomentations. The orchitis requires elevation of the organ and opiate fomentations. Cerebral symptoms in young children are sometimes fatal in con- vulsions; leeching behind the ears or at the back of the neck, cut off the hair, and apply cold to the head and give purgatives. *:ii r 'i '■l^ ^M^ i.r 41 PRACTICE OF MEDICINE. 211 LVIII. METASTATIC PAltOTITIS Is called malignant, and accompanies a great number of acute diseases, such iis typhus, typhoid, pyieniia, dysentery, yellow fever, etc. It is a bad symptom, signities a blood poison or pyiuniia, rapidly passes on to suppuration. It is a sur- tiical affection, and tii it as sucii. LIX. INFLUENZA. Called epidemic catarrhal fever — known for centuries. When an epidemic occurs it spares no one, so ])redi>i>osing causes cainiot be limited. Tiie contagious- ness of the disease has not been proved, as tlie disease is so rapid in spreading. It sjaiaJs exceedingly rapid over a country, and does not definitely follow the lines of travel, so it is concluded tiiat the virus is wafted about in the air. There is a sudden onset, constitutional symptoms, etc. yvMPTuMS. — Irritation of the respiratory mucous membrane, more rarely of tlie gastro-intestinal tract. Tlie onset is sudden by a chill, often very detinite- May be associated with g'ineral malaise. Teiuiicrature goes up a httle, is Jiigher at night. Sometimes the temperature is high and lemaius so for a short lime, pulse DU to 100, small and weak. Soon there are signs of catarrh of some jiart of the respiratory mucous membrane, hence a cory/a even with epista-xis- i'haryngitis, hence hoarseness, swollen tonsils. Early in the disease a cough is set u}!, is troublesome and aggravating, comes on often at night ; at lir.-,t the secretion is scanty but freer later on. Examination of tiie chest may not find anything, although symptoms are like extensive bronchitis. The only adventitious sounds may be a few dry rales. With the cough there is a sense of dyspiui-a. This d and hyper;t;iuic, the tubular L'i»itiielium is fatty, hence orgsm is soft. Lungs suiVer frequently, not from typical giey tubercle, but a chronic consolidation occupying the lower part of the iipi)er lobes instead of the very apex. Arteries — hyaline degeneration of vessels in interior of various organs, is also seen in typhoid, etc. Pancreas is often diseased. French writers think this gives a rajiid course with diarrhg tvnlr.! of infiliiUii. Dustroying syiupatliotic nurvi-s of vt!rt.rl)ral artery. Dividing trunk of .syniiMitiuitic in thorax. Komoving auporior cervical ganglion of synipatlu'tic. All abovo caused ditibetos. Above shows liv(ir receives impulses, .iireveiiting in hcnltli glycogen being converted into sugar. 2. This force is not li-ansniitted along wholt! Icngtli of cord, nor Tuainly l)y vagus. 3. Exp(!rinienl8 shew inlluences from medu.lla go by symi>athetic to liver, which also po.ssesse9 independent action, lioyond the predisposition of .igc, sex, heredity, these other cau.ses are d( ubtfid. Usually diabetes deV(dops without assignable cause, (len- eral theory is : 1, I'athological ccmversion of glycogen into sugar, or failure to assimilate sugar and convert into fat; 2, the supply of un luly oxygenated blood to liver, due to vasomotor paralysis from injury of vasomotor nerves, is possible cause. Inhalation of Nitrite of Amyl has some etYect. This undue supply of oxygen is illu.strated, inhalations of oxygen produce glycosuria. So mental emotions, etc., may act through nerves or cerebral tumors or injuries, or peri- pheral stimuli of cold, blows, injury. This vasomotor theory is not yet estab- lisheil, but looks i.lausible. A dctinite neurosis may be the true nature of diabetes. TltK.VJ'MKNT.— Diilicult and unsatisfaetory. Dietetic treatment is the most important. First point is to withhold sugar-producing food. Before beginning treatment recognize the trtie condition of the urine. Collect 24 hours' urine, esti- mate urea, specific gravity, etc , sugar. Then allow a diet free from sugar. Then in 2 weeks test urine again. If sugar has almost or altogether disappeared continue same diet for 2 months. If urine is yet free at end of 2 months from sugar, then attempt a gradual return to ordinary diet. If sugar still persists, resort to medi- cines. This dietetic treatment proves unsuccessful, for very few persons can tolerate a purely animal diet for any length of time. Vary the meat ; first, meat, fowl, but patient gets to loathe the food, hence you have sooner or later to give something else. As substitut ''or bread, give bread made of b'-an gluten, almond fluur, etc., and certain ^etubles. Among animal, substances you may give animal soups, jellies, extracts, all kinds of meat, eggs, butter, fat, cream. Vegetables are mainly prohibited, alio bread, oatmeal, arrowroot, rice, etc. Peas an- eaus are also objected to, beets are bad, turnips less so. Fruits as a rule are bad, all sweet fruits are to be exchuled. Vegetables of cellulose with little star.'h may be allowed, so only give the green parts. Vegetables allowable are tb.ose which will add ' dk to food with little starch, as cjibbage and such like, spinach, lettuce, cress, green parts of celery, tomatoes, green parts of asparagus. Bran from husk of wheat is good. Gluten if obtainable is good. Make by washing starch out of Hour, dry, grind, bake, etc. Diabetic flours as sold are unreliable. Kusks and biscuits made from starcldess meal, Hour from sweet almonds makes good cakes. Nuts except chestnuts are allowable. Milk skimmed and butter-milk, sour milk, are giiud, although lactose is present in 5 per cent. m ,LJ^;' PRACTICE OF MEDICINE. 217 A skimmed milk diet is recommended by some, give nothing else as in chronic flight's. Must be given exclusively, start early. But few persons can stand it for over a week. Those who can, either starve or get well — the hitter from semi- starvation (Brunton). Do not allow more nitrogenous food than can be used, else kidneys will be overtaxed. Drink should be tepid; tepid drinks will allay the thirst better than cold, although not as palatable. Give tea, cotfee without sugar. Beat an egg up in either, it re})laces milk— a little milk may be allowed though. You can sweeten it with a little " saccharine." Cocoa nibs are also allowable, do not use chocolate. Do not use alcoholic drinks, is better without, unless in middle-aged man, who is reduced, and has been used to spirits. Whiskey is best, well diluted — chu'ct, hock are also allowed. Mineral waters, Bethesda water (Wisconsin), not beneficial exactly, but do not harm. Vichy and Carlsbad are also used. An acid drink of Lactic Acid and Glycerine and Tr. Aurantii, equal parts. Take 1 oz. of that to 1 pint water. Phosphoric Acid Dil. is also used. Do not drink more than necessary for thirst. Medicines — Opium or some of its preparations diminishes sugar appetite and thirst. Does not assist producing diabetic coma. Begin administration gradually as gr. 1 at bedtime, increasing gradually till sugar disappears, or sugar ceases to reduce. There is a tolerance of Oi)iuni in diabetes, ^ oz. of Battley's has been taken every night for 2 years. Even gr. 3 of Morphia, or gr. 10 Opium, or gr. 9 of Codeia have been given T. I. D. Dr. Pavy prefers Codeia to Opium. Begin with gr. ^ T. I. D. It is less apt to produce headache, nausea, constipation. Increase by gr. Jth rapidly until gr. 3 to 6 per day are given. Give in pill or in sol. witli Cascara. Solution of Bimeconate of Morphia may be used. If sugar disappears for 2 niduths after the diet, very cautiously allow 2 to 3 oz. of bread or its equivalent night and moi'iiing ; watch effect on urine. If su;.'ar does not disapjiear it may be necessary to give vegetable diet to keep patient from running down. But do not give excess of starches, do not give potatoes. Increase the Ojaum when you return to mixed diet in this case. Ergot i dr. to 1 T. I. D. is sometimes useful. Should theoretically be valuable for action on vessels. Arsenic and Strychnia, Iron are given, but above are not successful. Arsenic in certain preparations is good. Clement's Bromide of Arsenic is most .satisfactory, give gr. jV^h T. I. D. at first, gradually increased until gr. Jthto |th per day is reached. The dietary treatment is continued also. This Arsenic is specially adapted to nenrog(inic diabetes in early stages. Sod. Salicylate has been much u.sed, especially in con- stitutional diabetes and es])ecially in those of gouty or rheumatic diathesis — excess of uric acid ill urine. Dr. Ross has not found this good. It is important to correct any defects in action of stomach, liver, skin, kidneys, etc, therefore use of digestives, as HGL or Pepsine, especially useful in old people in whom digestion is weak. Alkalies are favorites, as Sod. Garb, and Sod. Am. and Sod. Phosph. after meal in water, hence benefit at springs. Vapor bath is recom- mended on acct)unt of action on skiu, hence also wear flannel, take exercise, use friction to skin daily, etc. Lactic, Carbolic Acids, rennet sugar have been used ■r frnrrrimifriTrn— ' i^ I T ii i i i ii tmm i t mmmmmmmmmt^ m Bt u> PRACTICE OF MEDICINE. 218 as remedies. Ac. Carb. has been extensively tried, on siip]iosition tliat disease was due to increase of ferment in liver used in converting glycogen into sugar — not proved. Iodoform has been tried, uo good, not safe, it lessened urea, also sugar and thirst. HY(ilENK. — Protect surface from exposure, give regular exercise in open air, wet or dry, more particularly in fat persons. Give cheerful surromidiugs, seaside is good. Massage is beneficial in want of exercise. Long railway journeys are not safe. Treatment of D. Coma.— If urine become much more acid, or if the urine and sugar suddenly bei ome reduced, if lips become livid, then coma threatens. Then administer alkalies freely, and hot vapor bath and purgatives are useful. If coma sets in in spite of remedies, still try hot air bath to make skin act, and give diffusible stimulants, as Alcohol, Ether, Valerian, Camphor. If these fail, perform venesection and transfuse saline fluid of 1 per cent. Sod. Carb., 5 i)er cent, neutral Sod. I'hosph. If syncope comes on, rely on cardiac stimulants, but little avails as a rule. Tests of Uiune. — If doubtful of copper tests employ the yeast test, for umc acid, etc., will reduce copjter in absence of sugar. Robert's yeast test— take 2 bottles, 8 to 12 ozs., put 4 ozs. urine into both, put lump of yeast into one, leave mouth of this o])m, and seal the other, place both away for 2-i hours at 80 to 90 deg„ then put for 2 hours in cool place, then take s[i. gr. and difference in degrees ecpials 1 grain of sugar per oz. DiAiiKTES Insipidus — Polyuria, Diuresis, Polydipsia— may come on insid- iously. Is characterized by secretion of enormous quantity of limpid urine, 20 to 60 pints of low sp gr. 1002 to 1004, slightly acid, free from glucose and albumen. It contains normal or diminished or excessive amount of solids (call former two " Adruria," the last " Polyuria"). Total amount of solids generally is in excess, urea especially. Sulphates and Phospliates increased. Inosito is found (muscle sugar). Sometimes traces of sugar are found, — a hybrid case. Skin is dry and harsh, mouth dry, bowels often constipated. General health may be good, but if case be severe and of long standing, patient loses tlesh, gets amiemic. No exces- sive appetite. Severity of disease gtuierally declines towards death. This disease may last for years in apparent good health, virility all right. Others— young, may have arrested development. Duration Usually lasts many years, has ended in 4 months. A compli- cation generally carries oil', as pneuni'^uia. Urieinic coina from alfection of kid- neys sometimes appears. Prognosis. — Is seldom cured, but disease is not incompatible with long life. If appetite be excessive, prognosis is not favorable. In some few cases disease has passed into Diabetes Mellitus. .Etiology. — Predisposing causes— includes all ages. More fn^quent in males, 2 to 1. Is most common in adults, 20 to 50; but all ages may be affected. Hereditary— neurotic temperameut, etc., predisposes. Exciting causes, — ii II 11 i. . yi,. tiiaitJammmimmiMmmuimiA in cai vi of on CO sh afl «y Wi in ac CO ry ai is m C( o: is a PRACTICE OF MEDICINE. 219 irritation of areain4th ventricle above auditory nuclei, close to diabetic centre,wi]l cause Diabetes Insii>idus, so will injury to middle lobe of cerel jlluni. Section of syinpatlu'tic trunk in thorax or splanclinic nerve, or of vaf^us, and stnnulatum of its periiiheral end, a powerful mental emotion, tumors of brain or covd, blows on head, pressure on vagus or splanchnic nerve, neuralgia, hysteria, etc., seem connected. Alcoholic iiululgence, exposure, etc., are said by some to act. Above shews strong relationship to Diabetes Mellitus. MoitniD Anatomy.— No constant lesion found, kidneys and brain oftenest affected, as kidneys atrophy or generally congested, etc. Gross lesions of nervous system are often found, as growths, etc., congt-stions. Excessive secretion of water may depend on dilatatiim of renal blood vessels, hence increased pressure in glomeruli, with excessive secretion, caused by vasomotor paralysis, due to action of splanchnics. CONCEUNING Diagnosis.— One condition which might lead astray is the polyuria, often noted in hvstcria. It may occur in nervous people without common hysterical symptoms, look for them. There is a slight polyuria due to renal " inade.puicy," urine also of low specific gravity. The urea is reduced lu amount, and there is never excessive polyuria. The polyuria of Chronic Bnght's is known by albumen, casts, hypertrophy of heart, etc. The hydruria of hydro- nephrosis is intermittent, is rare, etc. Treatment. — Treatment is empirical and unsatisfactory. Diet.— Generous, do not try to reduce tlie quantity of water too much, it is impossible, but moderate the quantity. General health sliould ha put right. ^ A course of Tot. Iodide is given, especially if you suspect syphilis ; Ergot and 15ei. ladonna have benelited. Jaboraudi or Tilocarpin or Ac. Oarb. Large doses ^ oz. Tr. Valerian T. 1. D. have been used. Nitric Acid has also been trifd. Opniiu is not" much or an v good in this form. Look fur a special cause of disease as sypiiilis, intercrauial growths (give Tot. Iodide). For malaria give Quinine. LXIL GOUT Is divided into regular and irregular forms. The irregular gout has many names,-atypical, latent, etc. Kegular gout may be called gouty arthritis. Irregular gout may be called lithccmia. Gout may be acute or chronic. ° A CUTE ItEGULAU GoUT.— Before seizure there may be premonitions, com- monest is in reference to digestive system as indigestion. Sometimes it is cardiac, and uneasiness, inability to lie on the left si.le, fluttering of heart, palpitation, dyspnoea, etc But dyspeptic premonitions are commonest, and cardiac symptoms are probably reflexes. When gouty diathesis is weU declared by previous attacks there are always peptic disturbances, as llatulence, heart-burn and constipation. Urine becomes scanty, turbid, deposits lithates. Perspiration may be suppressed, skin dry, contra to iheumatism in which perspiration is profuse— a rash even, as nettle rash. Jn many cases thjre are no premonitions. Ill > i ?I '■ dR H PRACTICE OP MEDICINE. 220 The Attack — Tt is generully sharp and sixUlen, occurring (hiring the latter half of tho night. Tlicro is severe jiain in one of the toe joints, especially of the liig toe (I'odiigra). I'ain is severe lancinating. I'art feels stiff. Intense severity is rajiidly attained, foot is tender, cannot bear the weight of the clothes. After a few hours part becomes swollen, purple or covered with red rash like erysipe- las. Veins become distended, the saphenous veins get hard and distended. CoNSTiTuriONAL SY-MI'Toms. — Iiiid)i!ity to sleep, restlessness, fever ; symp- toms increase till the morning, then perspiration ajipears, and pain begins to subside and jiatieiit sleeps. This amelioration lasts all day till after midnight, when a return of symi)toms appear. In very severe cases no remissions of pain occur even for some days. Gastric disturbance is marked. There is fever, and l)ulsc is rapid, urine is scanty, high colored, and contains less uric and ph(wphorio acid than in health. Urea is above normal. Bile may disappear fmm stools. Attack in foot is the least painful and safest of all attacks, as in hand, shoulder, nape of the neck, fauces, stomach and diaphragm. DuKATlON. — Duration of the 1st attack is from 2 to 12 days, subsequent attacks are prolonged even to 3 months. After an attack, patient enjoys good health, better perhaps than before. But sometimes the other foot or hand is attacked, peptic sjnipUims remaining. If jiatient takes care of himself he may not have another attack for 3 to 4 years. It may return .speedily if first attack be at 40 years, a young subject, but not so speedily if in older men, is less apt to become chronic. As case jwogresses the intervals become shorter till an attack in a year is looked for, till at last gout is always present. Condition becomes chronic. When patient feels good between the attacks ii is called 1st stage of gout j but wjien he does not recover between the attacks and finds he is losing strength it is called the 2nd stage. Attacks are more frequent but not so severe. Ligaments — fibrous tissues become involved, hence loss of elasticity in g.at, etc. Appetite now is lost, digestion weak, hence craving for condiments. Heart suffers at last functionally with palpitation, intermittency of pulse, faintings, cough. Complexion loses clearness, looks muddy, eyes blurred, lips blue, venules seen on face. In last stage no decided attac'.is experienced, but disease is always present, has become chronic. Dyspepsia, ardiac complications, sense of exhaus- tion, etc., are aggravated. Stimulants are caved for. Gait is tottering, vertigo, failure of memory, timidity, listlessness, all denote loss of nerve tone. IiuiEGULAK Gout (Litha:mia). — Marked, atypical, atonic, etc. First shews itself by various forms of dyspepsia, especially by gastiodynia, flatulence, consti- pation, urine deposits lithates. The nervous system suffers most, and the patient has all sorts of sensations, vague, inexplicable. Nervous sense of gt-neial uneasi- ness, fee^s out of sorts, but cannot say definitely what it is. Patient is gloomy, perhaps hypochondriacal. Paius are frequent and painful in scalp or occiput, hemicrauia, stitches in the side, shortness of bread"., dyspncea with bronchial ex- pectoration, resembling asthenia. Any or all of these symptoms may be there- fore a long time before definite symptoms appear. A paroxysm of regular gout if at Tl. to St(l g\x ^'ia l)k cai liei pet th( wi Ft abi del he exi fui att an bu G. ai'i asl inl 1)0 Vll ur thi 111- I IS th. 10 ill ati pi, so TRACTIOE OP MEDICINE. 221 at Iftst may api)eav and relieve these synii»tom3, but sometimes it increases them. Thin gout is lens painful tiian the regular gout, but it is more tedious and diilioult to treat. If regular gout is transferred from a limb to a viscus, thus if it invades stomach, there are violent (MMmps, hiecongh, faintnoss, vomiting, even ofacolf.ie ground material, or even actual hemorriiagc It may be more chronic, as g.istral- gia with flatulence, acid eructations, hicoough. Gout may affect head, hence apo- ]ilexy or stupor in which sight and hearing are retaiut.'d, but consciousness lost, cannot understand a long sentence. I>ut these signs are all preceded by violent headaclie, di'owsiness, etc. When heart is seized, the symptoms are of angina jieetoris, constricting pain, dyspncea, pal[)itatioiis, syncopal state, etc Sometimes the attack is like syncope, may be fatal, or there may be faintness and anxiety with the irregular lieu;".. Is a treacherous state. Neuralgia may be gouty tlitto. Headache, epilepsy, hysteria, iriti?, eczema, i)soriasis, prurigo may be also due to gout, especially eczema, whicli may even alternate with gouty attack. TflK Joints. —After the first few attacks the joints recover their nitural ability and usefulness, but after a number of attacks permment dam.ige results, joints remain more or less swollen and weak, movements impeded and even actual deformity results. The etfused material bjcomes mortardike by absorption of fluid, hence chalk stones (Tophi). This is deposited in cartilages and ligaments, fornrs excrescences about bursie and the cartilages. These deposits are frequently found in cartilages of the ears, and they are valualile for diagnosis. When fresh attack occurs more e.xudation occurs, swelling increased, etc. Skin gives way and chalk stone is discharged. Suppurati(jn may continue for weeks or mouths, but outwardly this heals. While sujjpurating, patient is in good health. Gouty MANii'EST.vnoNS. — Gouty bronchitis, G. asthenia, G. tonsilitis, G. pharyngeal catarrh, (r. intestinal catarrh, (K urethral or visceral cat- arrh, G. cirrhotic kidney, G. diabetes. Vascular system suffers, hence asthenia— veins of lower extremities are attacked by symmetrical adiiesive inflammations. The same of the heart. E.xamination of blood in urine is im- portant in pathology. Blood.— Normal constituents are not changed, but in (dd cases specific gra- vity is lower than health and reaction is not so alkaline, the main difference is that uric acid is in excess. Urea may also be in excess. Normally it needs care to find these t>vo. Serum from blisters or serous effusions into cavities have excess of uric acid. A blister over an inflamed joint will not have excess of uric acid, it going to the inflamed joint. Uric acid in blood does not always cause gout, for it is found in pyrexia and difl'erent fevers, etc The urine in gout — in early stages the amount may be normal, but the solids are increased, hence ap-icific gravity is 1030 to 1035, and the acidity is increased. Calcium oxalates, etc, may be dei^sited in the kidneys or ureters, hence renal or visceral symptoms. For short time before attack of gout there is lessening of all chief .solids in urine, especially uric acid, phosi)hates, etc During attack the urea is about normal, quantity of urine scanty, acid, etc. Albumen is not uncommon. As attack subsides uric and 28 ■^^m I spei sinii ('as iiiii; atic (leK Itisl ])ar occ till! can (hi lab tha in inj Wll No elli vei tail in '. got wll IIU eas bmjhM. ill niBMriit «~' ,7 'jitS^BBHBBl VIC Th mi sot COl ini thi as PEACTICE OP MKDtCtNi:. 222 liho8iihnrio acid incroft.se. In Inter sU^es of clironic gout the iivino is piili-, low specitic j,Miivity, niul 4imntity increased, uric iicid diniiuislied, urea about normal. A Hniiill aiiioiiut ()( ,dliiiiu(;ii o(!c;isionally is louuil, ■ri.iiiiilar casts, etc., oven sn-^'iir. Casts iiiiiy 1)1'. fdiinil with iilhuiiicn in acute iiaroxysnis, and casts without albumen may Im I'omKl in j,'outy jiationts. It is not slicwn whether it is a lessened form- ation 111 uiic acid or its precipitates in joints, and thus lesscninj,' urine, or from deficient excreta, that it is lessened in urine in attack. yErioi.ofiv. — rredisposing causes, — heredity, important, 50 per cent, have history, but a ■{eneration may be skijiped. It occurs earlier in life if iidierited. Sk.x. — Males have it oftener, much so ; females have it mostly after meno- pause, and it <,'enenilly appears after maturity and Iiefore decline. It has occurred in childhood, even in infancy. From 30 to 40 years is most frequent time. Alcohol — It is most potent predisjjosing cause of gout, even the essential cause. Tlie fermented liquids are most potent. Thus Scotch and lliissians drink spirits, and f,'out is rare, so ciuantity of alcohol is not the point. Loudon Ldjorers drink porter, and suffer greatly. Tiie stronger wines are more injurious than lighter wines. Porter and stout rank next to wine. The disease is commonei" in beer-ilriidving countries — Bavaria, England. The heavier beers are the most injurious. Even cider in large (juantities may cause gout. Beverages which have a diuretic tendency have less action to cause gout. Persons who indulge in heav" wines are generally heavy eaters of anim.il fooil, etc., all tending to produce gout. Not enough exercise is taken to oxidize food taken, hence blood gets loaded with efli'te material. Dyspepsia is a common cause of gout by exeessive eating and drinking and indolent habits, so excessive food is a cause. Mental efforts, se- vere and prolonged, act iu depressing manner, and so bring out the heredita'-y taint. Climate— disease is not known in troi)ics. Occupation — gout is common in lead workers. Women employed in lead works (■Jt lead colic rather than gout. A sudden increase in any one cause will bring on an attack of gout in one who has one of above predisposing causes in operation, as a spree or atUick of indigestion, nervous exhaustion, etc. These then act as exciting cause. ExciTiiSO C.VL'SES.— Cold or mu'-^ture, local injuries to joints, depressing di::- eases. MouBiD Anatomy. — Nature of gout is still under discussion. The general view is that there is a materies morbi in the blood which causes the disease. This material is either uric acid (V something like it, a product of secondary assi- milative processes, as in liver, tissues, etc Thus excess of uric acid as urate of soda is always in blood at time of attack. The morbid effusions into joints contain urate of soda, and as attack passes off this salt is in urine. There isdiin- ini,shed excretion of this salt during attack. Predisposing causes tend to form this salt or acid. Causes reducing alkalinity of blood tend to induce an attack, as use of acid liquids. There may be a peculiar mode of vital action transmiited by heredity, which causes aptitude for fonuation of uric acid in excess. Garrod .1 > - sn h1 fe li U li ]' 11 1' ti 1 n i; f( c J. I 1 o 1 c t PRACTICE OP MEDICINE. 223 says urate of soda is dopositod in the loast vascular parts wliciv circulation is filtiggisli, hence in cartikgea and liganionts. A neurotic ih.M.ry was proposed a fuw yearn aj,'n, is an old view reviv-d, is n.M accepted. On,, of tlio functions of liver is formation of urea— if unaLle to do so uric acid is umiid, hem,, liver nmy Iw.' tti-.se of gout. Birds and ropt ''os have urio acid instead of urea formation by liver, hence a functional defect of liver may be the transmittud temUiicy. I i- liairnient of kidney, hence retention of uric acid muy be a cause. Why does not uric acid in blood always ca\ise regular -^ont i .Joints ulfected. This is lu.t ex- plainabl.!. But injuries to foot or i.ress\ire on foot from being on fcvit all the time, hence ft supposablu traumatism, may pree secondary to patient's idiosyncrasy in like manner. TliEATMKNT.— First, durin<{ attack consi'ler age, previous attack, etc. Diet is antiphlogistic— sago, arrowroot, milk, etc., and mild alkali fluiws. No animal food is allowed. Alcoholic drinks are to be complete, cut off. As disease de- clines, gradually increano the diet, giving fish, fowl, etc.. before the red meats. Alcohol had better be avoided, unless in the weak ; sj-irits, well diluted, will bo better than malt liquors or wines, these should be cut otf. If much fev(!r, keep patient in bed lest over-exertion or exposure should cause disease to attack some of viscera. Commence treatment by gnod purgt; to unload hver, a" blue pill or l)ill Colocyuth, etc. If constipated during jirogress of case try r.hubarb, Colo- cynth, ■:.(•.., gi . o Tr. with some aromatic. As disease declines give milder laxa- tives. 'as iu' lafc(;r stage of gout ; purg.itives are borne badly, inducing syncope. The ! eu'r.il salt.M issociated with v jgetable acids are also given, enough to causa diuresis shouhib given. Being converted into carbonates they make blood uore alkaline. ty also allay pain, etc. Give h dr. .loses of citrate, tartrate an I ac /i^ PRACTICE 01 MEDICINE. 227 Repeated and frequent uae of spirits, especially of undiluted si)irit3, is a well- known cause, and diseases of the circulation. Freiiuent drinking diui 11,1,' the day, as of tea, etc., weakens stomach. Indolent and sedentary pe'Ji)le ar^; ui )re subject to j^astrilis than others. Middle age, 40 to 50 is coiiiinoiKsst age. This form attended with acidity is rare below liU. I'lethora predisposes. D,) not use tobacco. Other direct exciting causes are: use of food whicli does not agree, over-eating, especially of moat, especially if health be impaired. Deiective mas- tication also favors. Chronic gastritis is often secondary to disease of stomach itself, as pyloric obstruction, ulcer, cancer, etc. Symptoms if severe, that is if large area of mucous coat be affected, for such may not be the Ciise, the symptoms vary, are not persistent, intermissions followed by exacerbations, etc. Uneasiness about epigastrium, tightness and weight coming on I hour after eating, and lasting till digestion is throngli. But some cases are relieved by eating, others aggravated by empty stomach. Tiiere may be a craving for food, but the sick feelings induced lead to avoidance of food. They desire highly spiced food. There is no fever, but a good deal of thirst. Pyrosis (water brash) is frequent, raising this colorless glairy lluid long after taking food, especially in morning, often giving great relief. Vomiting is not present, but nausea is common, especially in morning. No appetite in a, m. The vomited matters are rarely frothy or fermented,, but may be s.anelimes "^ith tarula, etc. Flatulence is frequent, a sensation of spasmodic constriction about stomach, despondency. Habitual Acid Euuctations, specially after meals, is a marked symptom. Bowels constipated, stools lumpy. Sarcina ventriculi. Urine varies, is fivciuently alkaline and cloudy, tongue is variable, moderately furred, with red pai)ilUu at tip and edges. In severe cases it is red and raw. It will look normal, especially if the cause of the disease is from chronic venous congestion, Aphtlue are com- mon on the tongue in phthisical cases, gums red and spongy. I'auces dull, red and congested. Laryngeal catarrh common with husky voice, the complexion acquires a dull pasty look. If the disease lasts a long time putieut loses flesh, with cold extremities, weak heart and a pale, dry skin. Hfcmorrhoidal conges- tion. Persons subject to chronic gastritis are subject to subacute attacks (bilious attacks). In certain cases the irritation of the terminals of the vagus in the stomach is conveyed to the brain, hence a change in the disj. osition, irritabil- ity, feelings of languor, listlessness, sleeplessness, palpitation of the heart, are inclined to be depressed in spirits, even hyi)ochondriacal. Exceptionally the vomit contains what looks like coffee grounds, but is really altered blood from diapedesis of congested vessels or even from superficial ulceration. P, M. CiiAxNtiES. — Increased vascularity of the mucous membrane, some vessels are permanently distended, certain portions are of a giey or slate color, or even black from the altered pigment. The mucous membrane is generally thickly covered with mucus and deliuitely thickened. In some cases the iriwnviiiiMiT'iTifir meir Mfui (livu lar f Sfi one jiart in 4 parts of milk of lime water. If the milk is allowed to coagulate in stomach it is at once covered by mucus and is not digested. Alkalies in the milk rests to some extent the stomach by aiding digestion. A skim milk diet for 6 to 7 weeks with no medicines will cure a good many eases. In any circumstances try milk diet for 2 to 3 weeks. In giving it take a wineglassful at a tinuj and take it frequently, so that 2 quarts is taken in a day. With some yon can add a little starchy food, but some stomachs do not like it, then try raw eggs or jiow- dered meat in its place in small (inantities. If milk will not agree at all, jiep. tonize it. As soon as imiirovement begins allow a little stale ur toasted bread, beef tea, and later allow light foods, poultry, etc. After exclusive milk diet for 2 weeks, Ur. Delafield allows one meal a day of meat alone, later on adding veget- ables, reducing the milk. Any food which disagrees is to l)e avoided. Starch, sugar, etc., may cause acetic fermentation. ]S'o one kind of food will agree with every one. If you can find out u cause for the disease then treat it : thus, if it is car- diac. Digitalis may; if conslii)ation causes it, then give purgatives. For direct me- dicinal treatment the alkaline carlionates seem to be good; if constipation exists then the alkaline mineral waters are good, esjjecially if taken at the springs, as change of air, etc , does good, llochelle Salts and Sod. I'liosph. may be substi- tuted, of course at the same time regulate the di(!t. A eomnion jilan is tiie u-^e of hot water. This is A pint of very hot water taken about an hour before break- fast. If acidity is uuirked add a little Sod. IJicarb. Some take it before each meal, diet must be regulated. A little Calomel occasionally aids. In fieble per- sons, the congestion had better be relieved by stimulating the bile, hence Taiax and Sodaandaiiill of rudophyllin, followed in the forenoon by mineral water. In tak- ing a mineral water for purgation yuu take it all in a draught ; if lor hepatic stimu- lant, sip it. Sod. Salic, is recommended as a powerful cathailio stimulant. If marked acidity, give Sod. Bicarb. If it does not cure, it relieves the syraiitonis. A good way to give is in the form of lozenges. Powdered charcoal is gootl, also Glycerine if there is much ilatulence. Take charcoal in lozenges or milk. Gly- cerine in dram doses in a little water is very good ; do not allow constipation. Give Aloes, Nux Vom., Belladonna, etc. Washing out the stomach with plain warm water is much recommended. The water may be medicated with Carbolic Acid, etc. Wash as long after a meal as possible. U.se once a day for 2 to '6 nionliis, gradually reducing the number of times for 6 months. Try it in obstinate cases. In aged or enfeebled persons, supply artificial juice, pep- sine is the foundation. The mineral acids are very useful, especially Hydroch. I ■ ■-.-..-^„^... Tl Cll ar vy ul (If ca c« v< Tl III !»' cl( ar su m in Sti di pe le de o\ to ri( P3 3 CO th P' til ar in Tl ge sc I lii PRArrUKOt' MKDICINE. 229 Tlioy serve to clciir iiway tlu mum^. Kspeciiilly iisf.il in atonic cases. Do not use in ciirly ciisu.s with irritation until tliut inflaumntion is oviTconjo. In njowt cases after a sliort In-atnieut by alkalies patient will benefit by acids. Sonu' even say it corrects acidity. 1 vr. ULCKUATION OF THE STUMACIf. Two forms : ,, lfa'inonhiij,'i(' erosions ; 2,]K'rforated nicer, liesidcs, there are in acntt- uul chronic j,MHtritis pearancc-i— shallow excavations, sharply defined Imt not elevated margins. Ulcer is very .small, under the .size of a --iilit \>v.i. T\w.y are situated mostly along the lesser eurvat\ire, in other parts ecchyino.ses are seen, vessels arc ongnrged with blond. The liiL'mnrrhagic erosions are seen after many other diseases, nrmy are mere abrasions but others are deeper. Sumo may be simph^ P. M. solutions, occurring at points where the blood is Just starting fr>"n tlie capillaries, or it may nccur in j.ist la-l few hours of life, due to disintegr.i if all deaths. In this condition tiie ulcer is generally single. The ulcer is circular, oval ov irregular, or kiibiey-shaped wiien two coalesce. Si/e varies froi It) cents to h dollar, are sometimes 3 inches, (ireat extension is found only on the poste- rior aspect of the stomach. Commonest situation for the ulcer is towards the pyloric end, next towards the lesser curvature, next the posterior walls. These 3 include S5 i)er cent, of all eases. Edges are clean cut, pui\ched out. If all coats be destroyed the mucous iitening is largest, the peritoneal the smallest, so the ulcer is bevelled. The iieritoneal opening is isually small, rounded and punched out after formation of the ulcer at first, and for a long time no alteration Uikes place around it ; but when the nicer is ..f long standing, its eilges are harii and thick. Under these circumstances edges are rouuiieiland elevated, and this induration may exteiul J or 1 inch from the uld r. This indicates chroiuc ulcer. The I the ulcer is very often ' and haid, or is Soft ,. i iiocculeiit, .seems gelatinous, with .sloughing tissue, L.t^a b ir ' 'ia.se is commoner. These ulcers sometii.ies cicatrize, even 50 percent, oi tn-j cases thus appei'V. New fibroua 29 ¥ ■■SWK a } PRACTIf'K OP MF.DinVF.. 2.10 tisH.u. forms, cmtniots, l.cnco laick.Te.l cicutiix. If tl,.. nl.rr is too lar^o for tl,n tnilly will 111! of hiuil liltrouH I'mmw. 11 fdijcH (liMwn t()trii; ulcer, so history lid not hi! inali-^niint. IJiit in the nmi m.n .1 ■h as di.stroH.sinj^ pain in the stoinacii, isi VI •nstant.and one ot the earliest symiitoins, era 11> near llu' xiplmid eavlilii^ I'ain i-t nx 'hich Is referred to a small area, gen- wt severe after meals, is of a weary, latiiiL'. Usually it hegiiis after ahout 15 borin;,', huriiin<4 kind, not usually laniwo , ... mimifs after takin- fuod, an.l so„n attains a nuxiin.im, hut soiintime.s it m delaye.l l.n.'er. The |.ain alules as the sloniaeh empties itselt. In exeepliolial cases pain does not cease now hnt remains. Hot food causes most pain, move- meuts increase it, also pressure. The eontinuance of the pain is variable nny last for weeks and then suddenly cease. This pain is usually accompanied by a corre.spondii,g pain in the back, between 'Uh and 1 1 th rilis. Gastric ulcer causes little constitutional thirst, no disturbance, no fover. Appetite i^ood, perhaps excessive. Dilfeivnt kind of pain also occur., whieh is paroxysmal, and affects the large area, may be stroiij- enough to cause syncope. Is relieved by emptying th. stomach. Is suppo.ed to indicate the t.msion of the ulcer. There are occasional eructati.ms of some stulf, and vomiting', especially if the ulcer he near the pylorus. The time of vomiting varies, may be right after ingestion or not for hours. In a few cases it is very severe. It may have small streaks of blood, and very often the hemorrhage is abundant from the opening of vessels. This is lie.iuently preceded lor a day .ir two by an increase in pain (doublful). Sometimes large artery is opened, as the coronary or splenic. If the blood is in only small quan- tities and escapes slowly, it may accumulate in the stomach and pass out by the pylorus without vomiting. If more severe there are signs of enteeblement, iliar- rhcea ensues of black, tarry stools without fever, which in.H.Mtes hemorrhage, but duodenal ulcer also has this symptom. But more frequently the hemorrhage causes vomiting following faintness, nausea, depression. Syncpe may lollow. When hemorrhage has once occurred it is apt to occur again, even after the uq.se of months or years. Hitunateiuesis even of large amount is very seldom fatal, but needs careful management. Haemorrhage is more apt to occur if the ulcer be in the posterior wall or lesser curs ature. _ rKiiKiiitATION is more frequent than hemorrhage as 13 is to i, still it is not commonly only 1 in 8 .uses or 12 per cent. If perforation happens, it is generally after a meal, from increased tension. Symptoms are agonizing pam of the ei.i- .rastrium with general peiilonitis and with death iu 18 to 3*1 hn„r.. but m some cases by peniuneal adhesions. The gastric contents do not get into the general cavity Hence abscess with hectic symptoms and death from exhaustion, or abscess may point externaUy. You may find perforations made by post mortem I iJ ■HbT* ! HiB "' E; ■' :. e il htjHg^ujjWi u ; 1 fi t 1 (1 Hh i ' ^^^H I ' IH c \ c t t t < i I 1 I iT i ygL-L___ • PRACTICE OF MEDICINE. 231 examinations. Tl.ere may be death from gastric ulcer without much hcnemor- rb-re or perforation, but by exhaustion. Tlii.s is esi)ecially the case when the ulctn' is large, pain great, vomiting frequent, or bleeding small and frequent, or when extensive adhesions form with neighboring organs, and so disturbmg their function. When a large ulcer is near the pylorus, especially if it has hard ed-e, the pyloric muscle is hindennl, hence pyloric olwtruction with gastric ddutaliou. Death may result from inflammation extending to other organs, as through tlie diaphragm, setting up empyema or affecting the lungs, liver, etc. Improvement is noted" by the lessening of the pain. Duration of the disease is variable, h.is proved fatal in 10 days. In these rapid cases perforation is generally the cause. In the majority of cases, weeks, months, or years precede the fatal issue. One characteristic of the simple ulcer is its great chronicity and diiliculty of healing. Ulcers of another nature in the stomach heal readily, so there must be a sperud cau.^^e acting in simple ulcer. Various theories are advanced to account for this —an inflammatory theory, a nervous theory of production of ulcer, a vascular theory for the disturbance of the vessals in the stomach, wliich is the accepted theory. According to this the initial cause is arrest of circulation in a part of the stonuich, and sufHciently deep to allow the acid gastric juice to exert solvent action, hence the slough, but in all ])robability a previous hemorrhage was the cause of the arrest. Virchow says most freciuent causes are : 1. Embolism, hence extravasations of the blood. 2. Obstructiou through i>ortal obstruction. 3. Contraction of the vessels as in chlorosis. 4. Violence as in vomiting. Ex- cessive acidity of the gastric juice may have some effect in producing ulcer, if there be erosion to start with or little catarrhal ulcers. Pkldisposing CvuriEs.— Sex— twice as frequent in women. Age— met with at all ages, commonest between 14 to 30 in women and 50 to 60 in men. Chlorosis, anarnia, debility, etc., predispose, because vessels are not well nourished. Amenorrhea, ague, dysmenorrhea are often found with it, also phthisis and cardiac disease and syphilis. In early stages simple gastric ulcer can hardly be diagnosed from other gastric alTections, but when gastric dis- tress, epigastric circuui'^cribcl pain finally (hmote organic disease in the stomach ; but i'u addition you have sudden lue n item wis, which no doubt exists in gistric ulcer, prrivideU there are no other causes of it. as puri)ura, scurvy, h3patic pul- monary or cardiac disease, provided also vicarious menstruation cau be ex(duded. The only organic disease capable of i)ro.luciug the sam.i symptoms as gistric ulcer is gastric cancer. Cancer may supervene on simple ulcer, but simple ulcer m ly proceed to perforation if nothing but dyspi^ptic symptoius, excessive acidity, etc. Duodenal Ui.cku.— ^Mode of development is similar to gastric ulcjr. Duodenal ulcer is rare. HvMPTOMS differ very little- from gastric ulcer. It often runs a latent course, it may therefore give rise to only few dysiieptic symptoms. Pain is less complained of. Is often in the right hypochondrium with pressure symptoms, or u n 8l |!: ■ PRAOTICE OP MEDICINE. 232 may be it is at xiphoi.nt gets irri- table and morose. Is not feverish unless cancer is growing very rapidly. At late period hi'morrhage occurs, is generally moderate in amount, giving black or coffee ground aiipearance to vomit. iMoro rarely there may be copious hicmor- rhages (lia^matemcsis), may be pure blnod, red or black, clotled, etc. About this time a tumor generally appears in epigastrium. As local symptoms increase, the cachexia augments, tongue red and glazed, and marked loss of appetite, increased debility, pnistration, anasarca, delirium and death. As disease advances secon- dary canJer iijiiiears elsesvhere. Medullary and scirrhus appear in liver, colloid in omentum and peritoneum, etc. After a time, average 12 months, patient dies worn out by vomiting, pain, loss of blood. Towards termination, aiia.sarca, jaundice, hiccough, etc., may appear. Coma is a fretoms like (Esophageal cancer. Act of swallowing causer. pain, even very severe, sense of uneasiness at epigastrium passing tln..ugh to the back. Eructations of food, and as soon after eating pain is referred to lower end of sternum, even connnouer there than in epigastrimu. The growth being high up it is difhc.dt to feel. The weight of tumor cannot drag stomach down, fi.r organ is anchored above by diaiihragmatic attachment. Stomach does not enlarge, but tends to contract, ditto intestines, hence retractiim of abdomen. Diaphragm may now descend to compensate, hence downward displacement of liver, heart, etc. When PYLORfs is affected there is more or less stenosis. This gives dilatation of stomach. In cancer there are very foul hecal eructations. The pyloric tumor can generally be felt, unless abtlomen be very tense or sensitive. It is situated generally a little to right of media line and 1 to 3 incliys below mnrgin or ribs. As it grows it gravitatijs down even as low as iliac region (rare). This tumor ficiiientry pulsates from lying on aorta. It is generally somewhat mov- able, especially in females, hence posture or full stomach affects its position. But it may lose its muvability and becnmc attadied to adjaeen.t .strm.,ture..s. When body of stomach is affected and neither end, symptoms are different, vomiting takes place soon after meals, and is moderate in amount. Physical signs I ''1 ll PI r'i."R"'^-*iM 1 ' ' ] 1 PRACTICE OF MEDICINE. 234 mo not available unless anterior wall be involvgd, when soniotiines the .listnict outline of stunuicb can bo made out. Sometimes a resistin;,' tun.-.r ..f upper and lower bord.,'r can be made out, but if of posterior wall it is well nigh nnpossible to make it out. Secondary cancerous nodules are present in nearly J of cases, ^ths in Scirrhus, ^th in medullary, rarely in colloid. Secondary cancer is rapidly growing ami generally is UKidullary, especially affecting the liver twice as often as in glands of portal fissure, 3 times as (;fton as in lungs. Cancer of stomach produces obstruction; hence hypertrophy to overcome obstruction, hence dilatation. Contraction may occur from a scirrhus cancer of wall not alfecting either orifice, arises from shrinkage, and also because vomiting keoi.s organ emjity. Ccmtraetion is more common than dilatation. i-T^VnoLodY.-Heredity.but in majority of cases you can get no such reason; other causes are Di.\GN0Sis OF Cancer of Stomach.— Gastrorrha-a (mucous flux) can be distingui.shed from that of gastric cancer by the latter having greater distur- bancertho lanceolating pain, the rapid emaciation and cachexia. There is also an epigastric tumor in most cases. Ulcer of stomach-men have cancer oftener, women ulcer. Cancer over 30, ulcer common under. Site-cancer most freiiuent at ])ylorus, ulcer at jiosterior surface and lesser curvature. Appetite in cancer is early interfered with, if followed by early enuiciation and eacbe.xia. In ulcer iii many cases appetite is too great, later he is afraid to eat, althuugli feels lik.> it. Tain in cancer is not an early sympt-mi, and is less distinctly aOected by food, is inclined to be constantly present ; opposite in ulcer. Character of pain in ulcer is more severe in degree than in cancer. The pain in career is lanceolating, but may be dull burning like ulcer. Vomiting on an empty stomach is more frequent in cancer, and vomiting of less blo.,d. Vomiting on emi.ty stomach is rare in ulcer, and hemorrhage is often profuse. Tumor— in addition in cancer vou generally (80 per cent.) find tumor. Tumor occurs very rarely in ulcer, but it indicates adhesion to adjacent parts, hence symptoms subside, tumor would then be immovable. Complexion, eachex-a in cancer, failure of strength early, independently of pain, vomiting, hemorrhage. In ulcer failure of strength is late, is iroportionate to the pain, vomiting and hemorrhage. Cachexia, late, is rarely fo'ind. Duration and progress.— Cancer fatal in (i to 24 months, progresses steaddy to fatal end. Ulcer may last many montlis or years without great loss of strength. Exacerbntions and Mitermissions often occur. Enlargement of liver suggests cancer. (Edeuia of leg or .niii from thrombosis is suggestive of visceral cancer. Never seen i> ulvr. Dilitatiou of stomach— in cancer H C L is absent. If from other causes '..•.. H C L is only temporarily absent. Its habitual presence is against cancer. Perforation of the stomach is rarer in cancer than ulcer. Enlarged glands in groins, axilla, etc., favor cancer. Hannoglobin of blood is more reduced in cancerous dilatation than in that from other catiscs, rernieious amemia sometimes resembles cancer. Abdominal aneurism. You have a pul- sating tumor as sometimes in pyloric cancer, but functions of stotoiach are not as A I '■ ■< u\ 4- PEACTtCE OF MEDICINE. 235 impaired ; the pain is dull, boring, etc., felt chiefly in the back. Often luuralj^io pains along atlticted nerves. I'ain not aggravated by f(X)d, rulsntiun oeciirn in all positions contrary to cancer. Cancer of retro-peritoneal glands, pancreas, left lobe of liver also occur. Of iiancreas, stomach is not allected. TuE.vrMENT can oidy be palliative. Diet should lie light, easily digested, nnd nutritious; meals small and freerhaps lessened, timidity. Complexion pallid or sallow after a time. Extremities cold. A chronic gastritis may be induced. In functional dyspepsia .aiuarily no alteration can be discovered, but sometimes there is T>'.^, MICROCOPY RESOLUTION TEST CHART IAN5I and ISO TEST CHART No 2) 1.0 I.I •~' III— •- IIIM I: m 1: 1^ II 2.2 2.0 1.8 1.25 1.4 1.6 A -APPLIED IM/IGE ■5fi3 r,as! Uatn iitfeet '^ocheste', New York 14609 USA (716) 482 - 0300 - Phone (716) 288 - 5989 - Fa- ^^:.':JaEilHH«U7.a«a^l.WI^A'8V-;if4)c9Ll«>-. PRACTICE OB" MEDICINE. 237 fatty degeneration of gastric tubules, sometimes combined with atroiiby of wall. iVIibro nucleated tissue may replace tlie gland tissue. Teiuloncy to decjeneration increases with advancing years, and may occur entirely independently of inflammation, yet in other cases is caused by inilanuna- tion. Causes of these degenerations are not known, yet alcohohsin may, or im- pairment of semilunar gi.nglia may lead to this fatty degeneration. This fatty degeneration is often found in plitiiisis struma, fatty liver, etc., giving no symptoms. So long as stomach can do its worl-c you m ly get no synittoins, es- pecially since intestines can supplement tlie work of stomach. \/ater poured out by impaired mucous membrane to some extent compensates for lack of gastric juice. In inllammaticn or febrile states the epithelium of glands under- goes granular degeneration, hence impairment of function. CAiiriKS of deticiency in gastric juice: 1. Organic conditions, gastritis, catarrh and general granular degeneration of stomach, m iligaant disease. 2. Hereditary predisposition to non-formation of gastric juice, weak stomach ; tliese are thin, delicate persons all their lives. 3. All forms of mental or emotional excitement, if excessive, cause arrest of secretion. 4. Excessive bodily fatigue and the febrile state, these lessen secretion and suspend feeling of hunger. 5. Glut- tony, alcoholism, etc., act by wearing out excitability of gastric lurves. G. In- dolent and sedentary habits, eating too mucli habitually. P:nough juice is secre- ted to digest sutlicient, but not too much. 7. iJeficient Jnnervation as by injury to vagus, also defective action of excretory organs. Symptoms of deti- ciency of gastri/. juice.— Food is arrested in stomacii, consequent distress after eating, especially of albuminoids. Decay of albuminoids in alimentary can il, hence evolution of f(«tid gases. Fermeiitatioi's,— alcoholic with gas, lactic acid without gas, butyric acid with H and (JO J in stoin ijli, Waen tluve is plenty of "astric juice, fooil leaves stomach in 2 to 3 hours ; but if deliciency, may remain 24 hours. Half hour after eating sense of weight and uneasiness is I'elt in abdo- men, remaining till food leaves stomach. If any portion of food remains solid there is feeling of cramp.? in epigastrium, due to these chunks getting into [lylu- ric orilice. If food remains undigested some hours it irritates mucous meiuljiana of stomach, and gives reflexes, as headache, slightly furred tongue, throbbing (jf temples, palpitation, pulsation of aorta, disturbed sleep, etc. Sallowness of com- plexion is freiiuent. If digestion be poor for some time, tiie body sutlers, s[urits depressed, cold extremities, mental depression, even hyiwcliondriasis. TUEA.TMKNT ATONIC DysI'EI'sia. — Measures to establish gastric .secretion, improve blood, etc. Diet is very important. Food must be easily assimilable, given in small iiuantities, at shorter intervals. In addition .some need a light supper at 'J p. m., as beef tea, oiitineal, gruel and milk, or biscuit and milk or arrowroot. If they sit up late they feel sinking sensation, so neetl nourishment. Bodily fatigue and nervous exhaustion must be avoided, especially while digestion is croini' on. Mastication must be good. In bad cases rest both before and after meals is advised ; actual rest in bed in very bad cases may be needed for 2 to 3 ,) ■ PRACTICE OP MBDICINE. 23S days. Excrci^e-mental and hodily-i. useful, but only when digestion is not m pitress. Exercise short of exhaustion has very great power to intluence digestion Sustain funetion of skin by tepid baths and friction. Foods to avoid. -fresh bread, rieii pastry, most sweetmeats, tough and salt meats, cheese, some veget- ables There is sometimes not enough gastric juice to digest the albm.unoid capsule of starch granules, hence need to rupture c.psule. Bake without tennon your starches, flours, etc.. slowly to hardness, and then soften m water. Bread must be stale. S^a biscuits are good. Potatoes are best vegetable ; beets asparagus, rice are good. Amount of vegetables must be small. Starchy fo.d may agree if take., alone, not so if taken in a mixed meal, fetai^ch ana fat to- getl.er are especially apt to disgree, as nuts. corn. etc. lUncid fat is bad. If Emaciation be great, fats must be fed ; still in weak digestion do not give fat meat do not fry. for oil tlien envelopes fibre of meat and prevents digestion. Win e flesh and fish (fresh water) are best, contain less fats than red meat or sea hsh. Oysters are well digested. Deficiency of g.istric juice is helped by dnnking uater. Take a small glass of water 1 to 2 hours after meals, is better than cup of tea or coffee after dinner. If person has eaten too much, cup of coffee or wn.e is oood. Do not drink tea with meat meal. Anxihary foods to promote diges- tion-small quantity of tea or coffee, wine, etc Alcohol tends to retard digestion and lessen secretion. Ale, porter and effervescing wmes are very nn- suitable, for they contain a ferment. Medicinal TKEAT.MF,XT.-Dinner pills. Ipecac in some form enters into about all of them. Budds. Ipec. Pulv. gr. h to 2, Pulv. Eh.i. g". 3, Gapsicine gr. 1 Pulv. Take before dumer- Salt and mustard are used jr «'""^ F^^P"^^- taken before meals stimulates digestion. Mineral acids.-HGL or HMO taken itof hour before meals, given in small doses of Ac. Dd. m. o to lo well diluted. They form an artificial solvent to food, '■it liave also a geueral to.iic influence on stomach and .system. Are especmlly useful if lactic acid termci- tation is occurring. Ihey neutralize the alkaline.saliva. hence give scanty gastric juice chance to work. Alkalies are given after food, to prevent acid teruie.i- tation, relieve lieartburn ; do ..t continue long, as tiiey tend to hann lepsine, etc., are much used gr. 15. Do not overdo use of Pepsine, etc. HUL Dil .nay ba .iven with small doses of Morphia or Strychnine. Nux Vomica or Strychnine in cases where mental labor is cause is good, it also may be of use m Hatulence by toning muscle coat. If patient be decidedly aiu^mic, Iron or Arsenic is needed, yet n.eas care, for may not agree with stomach, so use milder preparations, as ler. Eedact.. Cit. Am. Fer.. etc. In deficient secretion of gastric juice as after fevers, etc. Quinine is the be,«t. Give gr. 1 to 2 in pill or sol. before meals, or give some form of Cinchona The other bitters are useful when appetite is lost, as tiuassia, Geuiian, eto. while aromatic bitters promote gastric flow, as Calumba, Gascarilla, etc. Combine bitters with HCL. Stop if they fail to benefit m a lew days or cause irritation. Salicin. gr. 5 to 10 after meals. CBpaMP^s^A ii [^H^H PRAOTioE OP medicine; 230 Rklifa-e Constipation.-Do not give irritating drugs, give Ext. Aloe, or Rhubarb. For aculity or flatulence give Magnesia and Rhubarb, or Charcoal or Spts. Arora. Am., or A-i-m Month. Pip-changes of treatment are in onler. rutrefaction of food occur, when there is lessened gastric juice, when there is pvo.ric obstruction or deficient peristalsi.s, etc. Alcoholic fermentation is favore. by acid in stomach, etc. Kind of fermentation depends greatly on kind of food and ferments taken in. Thus yeast cells are often taken wth bread or beer. Putrefactive fermentation-albuminoid food becomes putrid, H . S evolved, eructations of such, heaviness in stomach, mental -lepression. furred tongue evacuations dark and offensive. This kind is common result of over-eating or ot uvloric cancer. Best treatment after over-eating is em.tic and a saline purge. Charcoal is also good, also Creosote as disinfectant. Alcoholic fernientation-is more commonly result of poor digestion, follows use of new breau, ^etables fruits, new wine, poorly fermented beer. Alcohol CO^, acetic acid are produced and sarciua ventriculi are found, There is great flatulence, i^heved momen tanly by eructations of gas. perhaps vomiting of sour smelling frothy stuff. lalp>Utiuu of heart, colic, diarrhcea are common; ifl'.is fermentation be habitual you get constitutional symptoms, less spirits and energy. This indigestion though nuy be produced by faulty state of general health brought about by overwork or worry Articles tending to this fermentation must be avoided, as succulent veoetables, new bread, bad beer or new wine. Change of air. exercse are good. For eructations the pill of Ipecac, Capsicin, etc.. is good. Sulphite of Sod gr. 15 to 30 T I D Large doses of common salt will check this fermentation. Dose of HCL Dil. m. 10, k hour before meals, and (ient. or Calumb is very useful to overcome flatulence from fermentation. There may be pain in connection with flatulence, for this give Spts. Chloroform or Spts. Ether Co., etc. LXXI. GASTRIC FERMENTATION. L\CTrc Acid Fkument\tion is more common than alcoholic. Carbohydrates changed to Lactic Acid. There is no flatulence i heartburn, cardialgia, pain in pit of stomach, etc.. are characteristic. May be vomiting, sour taste in mouth. In infants this fermentation may produce alarming colic. Vomited matters aye very acid. Infants pass cpagulated milk. Lactic Acid fermentation occurs m weak, delicate persons ; everything they eat turns sour. BuTYrao Acid Feumkntation occasionally forms from Lactic Acia; beina volatile gives eructations pungent, rancid, sour, also cau.ses heartburn Treat Lactic Acid and Butyric Acid fermentations by avmd.ng starches, cheese, fat suaar. Relieve acidity temporaiily by alkalies, as Sod. Carb., Pot. Urb. (even small doses of Nitric Acid min. 5 to 6 T. I. D. 4 hours after meals). Soda acts more on liver, increases bile. Pot. on kidneys. Amm. on skin. If tongue ,., definitely furred, Soda is best. Astringents, as Bismutli. before meals with Opium or HCN if necessary, are good. Giving of mineral acids especially H. SO 4 ' Alcohol is sometimes useful, checks lactic and butyric fermentations. ii i H' PRACTICE OP MEDICINE, 240 Pot. Io.li.1. will increase for a short time the How of .saliva, may l.o sivon if ti--e is deficient saliva. Food is to bo taken slowly, well masticatcHl. Defective acuon of excretory organs may cause functional dyspepsia, as of hver. In this there is sallowness of skin, coated tongue, impaired appetite, nausea, consti- pation, impaired sleep, i. e., a bilious attack, or it may be more severe, an acute Kftstritis. To treat, counteract indolent habits by exercise. Food must be plani; if attack sets in, secure starvati.-n fnv 2 days, and drink only water, and give medicines to act on liver, as Blue Till. Euo'.ymin. etc., at night, followed in >.. m. by salines ; may be functional or organic. Characterized by paroxysmal pains in stomach often called spasms. The.se come on when stomach is empty. While pain lasts epigastrium is tender to touch, pulse is slower, surface cooL This pain is relieved when food is taken or patient lies down. Vomiling is rare, may be in severe cases ; perhaps pyrosis, especially on movements. Ulten dyspeptic symptoms may be entirely absent, tongue is clean, appetite is gooi m intervals of pain, and digestion good unless ailment is very severe. Gastralgia occurs in both sexes between 35 to 50, never in childhood. In men common cause is worry uf l)usiness, in women profuse menstruation is conuuon cause. Occurs in convalescence from fevers, etc. Diagnose from "''^'"^'^ ;;^"^'';'e by food relieving, ditto lying down. Treatment by HON and Opium, HCN dil. ott. 3 in mucilage is best. Belladonna, Chlorudyne, Chloroform are also used. Iron preparations are also useful if au;Rmia exists, give mild preparations. Alkalies in some cases are suitable alone ; if del^ility. give mineral acids or bit- ters. Diet light, meals regular, sleep sufficient, wurry stopped. LXXII. GASTUIC CONGESTION Leading to iKGmorrhage, hence h^einatemesis. Mucous .nembranes if con- gested often allow flow of blood, serous membranes only serum. Gastric con- gestion is merely a symptom, may be from mechanical obstruction to flow of blood through heart, lungs, liver. In death by hanging, convulsions severe, there is severe gastric congestion, ditto in epilepsy, with hHemorrhages Cirrhosis of liver causes portal obstruction, and hence gastric congestion. A molecular rupture of vessels-no visible rupture leads to etfusion. Often in slight bleeding blood escapes notice, for is not vomited, yet lumnatemesis may be so profuse as to be fatal, rare. Cardiac and pulmonary diseases act to cause obstructive con- aestion Mucous membrane is dull red from capillary congestion. Small erosions may exist. 2. Congestion from altered condition of blood. So po. -- circu a- ting in blood may act, hence congestions in certain organs especially of .tomach's mucous membrane. If gastric congestion be rapid there is more tendency to luemorrhage. Habitual congestion tends to impair mucous membrane, lessens aastrip.j.-^e and tends to hinder digestion. Hie.norrhage varies, greatest from ulcer, etc., opening vessel. Yet even mere congestion without rupture may lead to excessive flow. Symptoms of ha^inatemesis. sense of uneasiness, weight, tenderness at epigastrium, with symptoms of syncope. This arrests flow. ai ii s] ei fi e t PHACTU'E OF MEMCPE. LXIir. DYSENTEllY. 241 An inlliuniiiatory aff.iction of coldti. Two vaiirties, -specific ami non-specific. Specific fuiin, duo to niicro-orgaiiisni, pivseiit in evacuations, thenco into water, and 80 it spreads. Dysentery nmy be ])rinmry or secondary, as after typlioid, 8ei)tica'nna, and many ..ncli. Tiiis senoudary form may not be speritic, a mere inflammatory colitis. There is no difVorence in symptoms of specifi.; an(. non- sjiecific forms, and morbid lesions are the same) catarrhal or croupous. Dys- entery may be acute or chronic. Acute Dyskntkuy.— Symptoms— premonitory symptoms may precede, os out of sorts, lassitude ; bowels may be constipated or not. Onset is commonly liy distinct sensation of coldness in loim, even a chill or rigor, and feculent stools follow. Soon tenesmus is felt, characteristic-feels as though rectum is not emptied, an.l there is a desire to empty it. There mi-y be pain in abdomen, colic J there may l)e fever with f-irred tongue, seldom high fever, mental activity is pre- served. Fever, if severe, generally follows local lesions. After a few days patient looks haggard, skin clammy, pulse weak, soft, strength fails, and abdomen col- lapses, and can bear pressure. Pain is paroxysmal, severe, stools fiBculent, some- times bloody, often scybalous ; character of stools differ with site of disease. It sirrnioid or rectum be aflected (commonest form) stools are very scanty, chiefly composed of mucus and blood, hardly a trace of fteces, and tenesmus is very severe. In this form the bladder generally sympathizes, hence frequent scanty micturitions. In children there is apt to be prolapsus of anus. If ca3cuin ot transverse colon be affected, stools are more copious, feculent, mixed with slimy mucus and sometimes blood, often called dysenteric diarrhaa. The tenesmus is not so severe a. first form, nor is bladder so influenced. Cause of a1)sence ot fccces in dysentery is spasmodic contraction of colon, holding f«?ces m pouches, hence scvbal.x. If disease continues, strength rapidly fails, hence exhaustion, eyes sunken, extremities cold, pulse rapid and weak, tongue dry, evacuations thinner, perhaps greenish from blood, or look like beef washings, and hi.ally stools arc serous, brownish, copious and very foetid, pain ceases, there is hiccough, rapid sinkin- and .Uno.s, hm\ .lual.ty. Suit f.md font 1..1IM tiiiu!. l).Tni„i...Hii,^' alhumiuouH fcu.l nets init.vtii.-ly, ai.-l fie- qn,.nt niuso in it.tUnt« .i. Fi.ral u.rmui.lilio.H in .m-ouui aivl col...i ciiiso im- tation. 4. In.i.urn iiir, eiHuvia of .iocomposii.g animal n.attois, sowers, etc 5, Inmure watur. 0. Maluvia niaycauHe bilious -lysent-ry, hut ju-rhaps it h rather i.npnre wat.r in nmlarial districts. Th. specific forn. is .Inc to u spcc.hc -cnn. Occurs princii-ally in the tropics, occurring -ivoii opi.lc.uically un.lcr ccrtam fuvoral.le circun.stauccs. Tho virus escapes by stools. Stools .Iry, and so virus g.,t9into air, hence infection by air as well as by drinking water. Dysentery attaclllicles which stand out. Subnu.cous and nnis- cuL- coats are also swollen by infiltration. Pus cells may l)o sec in betw.-en ll.e glands and in submucous coat. Kecovery may be perfect, pus cdls d..s..rbe>l. 2nd sta.'e is ulceration or purulent s<.ftening. follicles necrose, mucous membrane over follicles and under slough, and follicles drop out. The muscular coat at this stage is infiltrated with purulent matter. Exudation now begins to be diphtheritic. Diphtheritic dysentery is usually found post m..rteni with the catarrhal. A fresh attack of hypeia^mia takes place in catarrlial turin. a tibrinous exu.lation with extravasation of blood thickens the mucous membrane of a reddish white color. After a time patches of mucous, submucous and even muscular coats become gangrenous, from si/.e of 5 cents up. In other coats abscesses form from the ulcers, forming sinuses, even lead to perforation. Kecov- ery may occur by cicatrization. This is usually in rectum, and if it mvolves the whole colon, it usually spreads from rectum. In severe dysentery the wlu.le colon is dark with congestion, even the lower part of ileum feels thicker than normal. In chronic cases there are brownish pigmentary patches, punched out ulcers, cicatrices, etc. In complicated forms the small intestines may be afTecte.l. Pcyer's Patches involved. Dysentery lays foundation for most cases of liver disease in hot climates, hepatic abscess, etc. Spleen and pancreas may be enlarged, even abscess in spleen, lungs may suffer, vesicular bronclv.t.s, lobular pneumonia, pya3n.ic abscesses. There may be purulent etfunions mto cavities. For this subject in full see folio 171. LXXIV. MUCO ENTERITIS. Intestinal catarrh-an inflammation of small intestines, which occasionally extends to colon or duodenum. If it involves serous coat, hence peritonitis, it is called sero-enteritis. May be mild or severe. I • rli ■■ ^A ^Wl ! 4„ l' -.^l^H PRACTICE OP MEDICINE. 243 Mild FoRM.-Symptoms : feels dull, griping, abdominal pains, most fre- quently in ri-ht iliac fossa extending towards umbilicus, attended by flatulence. This last does not last long, and tlu-u diarrhcea supervenes, but this may have existed from outset. The stools are oiTensive, of various colors. Abdomen is tender on deep pressure, either general or localized. Griping aggravated by tlatus at intervals. Fever mild, pulse slightly accelerated. Some thirst, may be slight nausea. Tongue moist, Nvhite fur in centre, red edges, drowsiness, flushing of cheeks I^lorning remission of temperature, evening rise. xVfier few days symp- toms subside and attack is over. This affection is one of commonest among children. , , .... ,^ In Severe Foum similar symptoms more pronounced, chilliness, etc. Local symptoms severer, as tenderness, diarrhcea, etc. Abdomen gets full, eveu tympanitic later. Stools fetid, even streaked with blood. IMlse small, fre-iuent, compressible in diarrha.a, never firm and hard as in acute peritonitis. Tongue is apt to be red and raw, even shiny with papilU« enlarged. Patient gets pro.strate. faint drowsy. After a few days symptoms may subside, and patient gnulually aet stron-rer. Urine deposits excess of lithates, appetite returns, etc. 1 his in Favorable°cases. In other cases it passes from bad to worse, ending perhaps in death The griping pain, tenderness, diarrhoea increase, becoming constant. Vomiting sets in. and you cannot nourish patient, so emaciation is rapid, pu se threadlike, stools involuntary. In children convulsions, collapse, coma death. If serous coat is involved it is sero-enteritis, and you get symptoms added gra- dually or suddenly of peritonitis. Cmstipati. n generally replaces the diarrhcea In some cases you get jaundice from congest- extending to common bile duct, as from duodenitis. If lower part of ileum be inflamed, tongue is angry red etc. If mucous membrane be inflamed it is reddened; if only follicles, the redden- in. is punctiform, there is .ntu.iiesceiice, friability, etc., of mucous membrane. Secretion at first is sero-niucoid, later it gets tenacious, muco-pur.ilent ^ Causes —1, Cold and damp, especially of feet or overheated body ; -, irri- tatin- substances, food, medicines, worms ; 3, obstruction from invagination stran.nilati.m, fix^cal obstruction; 4, often attend fevers, pneumonia; o, often accoinpanies severe burns ; 0, suppression of menses, etc. Enteritis is more fre- quent in infants and delicate people, especially apt to occur durmg dentition, after measles and scarlatina. „ , • i r ft„„ DiAGNOSis.-From peritonitis especially, also from typhoid fevci-often mistaken. Also from colic and dysentery. Neuralgia-rheumatic affections of abdominal muscles. Acute hydrocephalus in infants. If muco enteritis be attended by vomiting and con.stipati..i.. coma, stupor, etc it resem- bles hydrocephalus, but in inflammation in brain you have paiii in head and not in abdomen, and sequence of excitement as photophobia excitement etc then sta.'e of depression and -tage of coma, in muco enteritis pain is m bowels, etc and symptoms of cerebral disorder later in case. Again, in cerebral cases vomit- ing is not attended by retching, nausea, or salivation, and keeps on when stomach \ i IHHHh IS ir o o; a I a I PRACTICE OF MEDICINE. 244 is empty. In enteritis there is nausea, salivation, etc., and relief often by emp- tying stomach. It is well in all these cases to examine well for hernia, to bear in ntiiul iwisons might be cause. Lead poisoning may be misti.ken lor enteritis. TuEATMr.NT.- If constipation exist or irritating substances be m bowels, give mild cathartics as Castor Oil or enemata. Add Laudanum. If vomiting or bilious symptoms, give Calomel A follow by Sal llochelle. If breath smell sour, give Magnesia. Some advise ;. ■ :ives all through to keep bowels open. Use only mildest laxatives. But i .isere be marked inflammation of muscular coat of bowel, as noted by constipation, also if evidence of peritonitis, purgatives will not act till inflamniatiun goes down. Hence avoid purgatives and give mild enemata. If much tenderness, apply leeches to abdomen, and give small doses oi Calomel and Opium. IMercury is useful if stools are pale and urine turbid, especially useful in children. In mild cases Mercury is not needed. Alkalies are useful, are sedatives to mucous membrane and neutralize irritating products. Sod. Bicarb.-you may add Hyoscyamus, etc. If diairhaa exist do not try to lock up bowels at once. Begin with mild measures, as Mist Cretaj, or if this fails a few small doses of Tnlv. Ipecac Co. or Laudanum or Tr. Camph. Co. Starch and gruel, or barley water by enemata 1 to 2 oz. and a few drops of Laudanum is soothing. As disease gets chronic give .small doses of mineral acids and Opium, or use vegetable astringents, as Catechu, Tannic Acid, etc. If serous coat be involved, treat peritonitis ; absolute rest is necessary in all cases. DuoDKNiTis.— Treat similaily, alkaline salts are principally used, as Pot. Tart., etc., no lilercury. Treat the emesis by ice. Iced soda water and milk iu small quantities, etc. LXXV. LEAD COLIC. Colica Pictornm, Saturnine Colic, Devonshire Colic— Occurs chiefly in painters and workers in lead, etc., as plumbers, glaziers and wurkers, type setters, etc. Cases liere are not numerous. Shot works, workers m white lead^ etc. Pood (^acid) from newly glazed vessels, cosmetics. SvMi'TOMy.—Colic often preceded by disturbance in health, loss of appetite, lanc'uor, low s])irits, odd pains in abdomen. Symptoms augment, sometimes there are no premonitory symptoms. Pain, twisting iu umbilical region, abdumen is retracted and hard. Karely is it tympanitic. Pain on pressure on abdomen. Produces restlessness, symptoms of a colic llemissiou occurs after some hours, leaving feeling of constriction, apt to be nocturnal exacerbation. Obstinate consiiiruion resisting even powerful cathartics. Sometimes tenesmus, strangury and initable bhu.lder. If abdominal pain threatens to run around loin it may mislead and make vou think of renal colic from .stone. Evacuations are scy- balous like sheep dung, tongue generally furred. There is nausea and vomiting —biliary, marked. Breath is very fetid. L'riiie is pale, generally copious. There is blue line on gums. Colic may alteruate or accompanying cramps in legs and arms and joints, and these parts may later become paralyzed. In rare cases cerebral functions are disturbed only in acute cases. If lead colic has lasted some time the complexion is sallow, ameraic, muddy. r m PRACTICE OF MEDICINE. 245 Prognosis.— 1 per cent, fatal. Symptoms subside in 3 to 25 days. Tkeatment relieves symptoms and hastens recovery. Relapses are frequent if causes remain. I, relieve p liii ; 2, evacuate bowels ; 3, get rid of l(!ad. Relieve pain by Opium. Warm bath is i^ralefiil. To ac^ on bowels use 01. Riuini or IMack Draught, or if it fail 01. Tiglii. Move bowels every hour. Hyjioderinics of Morphia will not antagonize cathartics, Opium by mouth will. Use eneuiata. To remove leail from system have frwpient baths and f-iction, also sulphur baths, use of Sulphuric Acid, etc., sulphates. Alum is used, thus gr. 20, Opium gr. 1, every 3 hours. LXXVI. CONSTIPATION. Costiveness is w]u3n secretions are deficient in amount, so absolute amount of ftcces is too small. Symptoms and eilVcts— intestine serves to remove eifeto material from blood. Their retention jiroduces general syiaptoms, as want of cerebral activity, poor sleep, drowsiness, skin unhealthy, greasy, sebaceous secre- tions excessive, complexion alters and digestion is uneasy, flatulence common. If secretion of liver is deficient, stools are otf.iiisive, pale, etc. If scybabc are retained they produce irritability lower down, lieuce diarrhi^ea simulated. Tins is especially the case in elderly people, if much mucus be formed stools are dark, slimy, gelatinous. CvuriKs OF Dkfkctive Secuktion.— 1. Obstruction of circulation of heart alters secretion of liver— sluggish circulation. 2. Deficient supply of blood does .same, as in tliose who overwork brain. Excessive perspiraticm has same eflcct. 3. Aiiivniia and chlorosis also act by tlefeetive supply of blood. 4. Use of alcohol. 5. Opium. 5. Febrile state generally, check .secretions. (Jonstipatiou means less frequent evacuation of large bowel than normil. Habit has great influence over this. EpfEOTS OF OoxsTll'.VTION'.— 1. Gradual distention of gut, so that tliere is greater contractile power required to propel its contents. 2. Not oidy are pouclies enlarged, but actual hernial protrusions of mucous coat through muscular layer, occurs, covered only by peritoneum. These protrusions contain mucus or f.eces, these are common in sigmoid. 3. General effects on .sy.stem. Reabsorption into sy.«tem of matter from bowel, hence syuq)toms like lack of excretion, as iu costiveness, but not to such an extent. 4. Accuinulitiou of ftejes produc; pres- sure on nerves, hence pain in gr(jiu, sciatica inside of knee from pressure on obturaior nerve, on veins, give varex, piles, varicocele, on bladder, frequent mictu- rition. Jaundice from pressure on common duct. Belly is aiit to become lull, tumor in ca-cuin, sigmoid, rectum or course of colon. Causes of Coxstipation. — 1. Djticient excretion. 2. Loss of contractile power in muscular coat from (a) over-use of purgatives, (/*) disease of spin.d cord, (c) over-distention by accumulation of contents, {d) from Ijad poismiing, [c) intlammatiou of intestines. 3. Pain in rectum from fissure, abs^-.ess, ulcjr, pdes, etc ; for fear of pain patient postpones going to stools, heuce misses. 4, Weakness 31 PEACTICE OP MEDICINE. 246 of auxiliary expulsive inu^icles, as of abdomen from paralysis, indolence, or pain- ful state of abdominal parieles, as abscjss, boils, etc. 5. Habitual ue;.^lect of bowels. 6. Meciiani'jal obstructions, stricture, inv.i'^inatioii, tumors, etc. TuKATMKN'T OF CosTiVKNE^s. — Pr imote excretion, especially from liver and bowels, hence blue pill followed by saline. But as a rule use slower purgative as pill Aloi! Co. or Pill Ilhei C). A Wdek of Al )es will do. all stronger (jurgatives will di) and do it m ire permanently. Use of copious drinks of v/ater is good, promotes removal of etfete matter from.system. Mineral waters (mild) are good, Selizer or Vicliy, etc. Accessory foods, as coffee, beer, wine, etc., arrest tissue waste, are unsuitable ; but milk, chocolate, soda water, etc., are good. Tkeat.mkmt OK CjnstH'.vtion.— Determine cause and remove it. Always go about it with care, and tind cause. 1. Correct deficient excretion. 2. If ])nrgatives have been abused abandon them, prohibit alcoiiol. 3. I'romote con- tractile power of abdominal muscles and bowel, hence exercise, walking and riding, cold sponging, kneading daily of abdomen. A wet compress covered by oil silk and put to abdomen and worn all night is good. Nux Vom. continued for a long time is good. May be combined with Bel- ladotma, Iron, etc. BjUadonna alone may do if effectively persisted in. Give Ext. Bjlladonna gr. ^th every m u'liing fasting, i.e., on e.npty .stomach for a week, tiien 2 pills every morning, then 3, stopping when bowels act all right. Galvanic current througli abilomen is tried. Enemata improve contractile power of intestine as well as act directly by stimulating. Try water, or glycerine a small quaniity in a small quantity of water. Glyce- rine dr. I in a(i. 3 oz., thrown in .slowly, produces in | hour a copious evacuation. Is a very favorite means. Glycerine suppositories are also mrde, are very effective. Tonics are also useful, hence Quinine, mineral acids, etc. Insist on stated hour for stool. Food should be mi.\ed— animal and vegetable, but vegetables make some flatulent. Let food be digestible, but it may contain a certain amount indigeitible for faecal bulk, as oar meal, bran brea 1, cracked wheat. Fruits are also uselnl, especially early in a.m. With some a drink of water be- fore bed will give evacuation in a.m. In giving purgatives do not give acJve ones, but persistent use of mild ones,— Aloes, lUuibarb, occasionally Ul. Kiciui. If you use mineral waters use purgative ones. LXXVII. ENTERLAGIA OR COLIC. Symptoms are : 1. Pain— paroxysmal, intermittent, but may be uniform raid continuous — violence may be very great, agony. 2. Abdominal muscles are tense, rigid, sometimes knotted by spasm. The violence of pain may produce 3, temporary depression, hence weak pulse, cold extremities, convulsions in children. The pain is gjuerally relieve! l)y pressure, and, after leaving, tlie abdo- men is soft. 4. Constipation is generally present, unless in bilious colic. 5. Vomiting is often present. 6. There is no fever, no increase of pulse, uriue varies. PRACTICE OP MEDlOtNE, 247 rRO(iKOSIS.— Tn a few cases symptoms incnmse in spite of remedies, vomit- ing increases, storcoraceous vomiting, colliipse, tympanites, hiccough and aiaking; but majori* >' cases recover. In above bad case it is spasmodic ilius, or ol> struction ot bowels or paralytic ilius. But even such desperate cases are not to be abandoned, for recovery may be had in noim of them. Divisions of Colic — I. Simple colic, flatulent, nervous or spasmodic. 2. From injurious food, 3. From morbid secretions. 4. Ixjad colic. Simple Colic— Rapid flatulence, irregular distention and contraction of intestines, borborygini, etc. Tn nervous and sjjasmodic colic there is less disten- tion by flatus. In all tlieso forms there is twisting pain in region of umhilicu-*, extending to up or down side, relieved by p'-essure. Wlien violent, countenance is pale and anxious, and collapse may lead you to fear perforation. Obstinate constipation is present. Wlien bowels move they are depraved. Tliese several forms of colic occur in hysterical, hyponchondriacal, alcoholic people, in those wealvened by hi»3morrhages or over-laotation— other causes are old, fright, etc. 2. But other causes arise, as from bad food, hejice the colic of eatables. Cjlic co'.njs on .S hours after eating. Vomiting and diarrhoex may ensue. Is often present with headaclie, costicaria, etc. Cause 1 by imperfect mastication, a^id wine-, shell fisli, cheese, sausages, some mushrooms, 3. Bilious colic (morbii secretions), furred tongue, mental depression, muddy skin, may be preceded by odd symp- toms. There may hi violent vomiting of bile and purging of dark, bilious stools, or watery and light colored. Tliere may be considerable prostration and collapse like cholera. It is almost identical with Canadian cholera, an I may end fatally. Its causes are same as summer cholera. Endemic causes— occurs in summer. 4. Retained excreta are frequent causes of colic in children. Chief symptons are ab- dominal pain (draw up legs), tense abdomen, incessant crying, watery evacua- tions, curdy, etc. It may induce muco enteritis, or from excessive action may kill from exhaustion. Diagnosis of Colic— 1. Strangulated hernia. Colic is known by absence of hernia at any natural hernial oijeniugs. Examine carefully for slight hernia, 2. Perforation of intestine or stomach. This is known by intensity and per- sistence of the collapse, by ditfereuces of the character of the pain which is pun- gent, agonizing instead of Lwis'.ing, by its spread from original site, by bjuig aggravated with pressure, progressing rapidly to fatal issue. 3. Passage of renal or'biliary calculi. Pain of gall stone is more intense, vomiting is more frequent, and jaundice sets in in 36 to 48 hours usually. There may be history of pre- vious attack. In nephralgia pain runs down to testicle, there is frequent mictu- rition, bloody urine, etc., and constipation is not so common. Intussusception m children, colic occurs after stool or action of purgative. Tliere is a constant desire to stool and discharge of only a little bloody mucus or blood, and a tumor may be detected, usually iier rectum, also inability to introduce a long tube up rectum. Remember that colic may be due to gall stones, Muco enteritis,— ab- sence of fever, tenderness on pressure, etc. 1 t i PRACTICE OF MEDICINI. -*° Treatment. — Relieve pain, cvacnivto bowds. In simple colic, Tr. Opii m. 30. Spts. Chlorofonn. Chloruilyuo ia yood. Wanulli to iibdoinen by stupes. Diffusible stiinuliints, as cup of hot gin-rcsr tea. If coiistipiitinn has existed several days iiiui no sign of iiillanimation, give enema and follow by (.'iloniel ami Opium, or 01. R- .ui 1 oz., Tr. Opii m. 15. In llatulenco Til. Asafcetida Co. If exhausted, give ..Icoholic stimulants. If colic be due to indigestible food and no vomiting, give emetic, as Iiiecac, and after e'uptying stomach give Calomel, and follow by a saline. Colic f.om morbid secretions often cure themselves by vomiting, encourage by warm water. Treat severe cases like Canadian cholera. Stupes to abdomen, warm bath sometimes is grateful. Friction to abdomen or stimulating liuiuients in children. LXXVIII. rERITONITIS May be ocn.te or chronic, general or local. AcuTK Gexkual Peuitonitis is nearly always secondary, but in some cases you cannot find cause, hence idiopathic peritonitis, but this form is exceedingly rare. SvMPTt).MS.— Distinct rigor in idiopathic form, but this is absent in secon- dary form, which is the most frequent, so rigor is rare. Pain is one of earliest and most characteristic symptoms, in all cases is acute, pungent and considerable in degree, but in some oases pain is moderate except on movement or pressure. Site of pain is most fre(|uent to begin in iliac inguinal or hypogastric region, extends all over belly, but always remains worst over site of commencing pain. Patient lies on back, knees flexed, ditto thiglis, or on side with thighs flexed. If pain is extensive and severe the respiration is (juick and short, almost altogether thoracic. Appearance of patient is : co\intenance anxious, pale, sharp, dark,, drawn features, tongue white, thirst severe, nausea common, ditto vomiting of colorless or bilious matter, especially if upper part of abdomen be affected Constipation is the rule. Urine scanty, dark, acid. Surface hot, dry, tempera- ture elev,;ted, but may not be as in traumatism, or perforation when sliock per- sists. But as a rule there is elevation of temperature. Pulse small, wiry, hard and constricted, frequent. Abdomen tense and resisting, owing to increased excitability of muscles caused by inflamed peritoneum. This rigidity is con- stant, not caused by hand, but existing before you put hand on. Abdomen becomes more or less tympanitic, in extreme cases like a drum. This distention is from relaxation of intestinal walls from paralysis of muscle coat rather than from excess of gas. In some cases no distei;tion occurs of abdomen, but it is always hard and rigid. As effusion occurs the rigidity yields somewhat, hence doughy feeling, and at length (rarely) fluctuation cannot be observed. Then dul- iiess along flanks. In general peritonitis thoro m gener.al and uniform djstfin. tion, contrary to what is found in partial peritonitis. Before ett'usiou a friction sound may be heard or felt over inflamed part, not often made out distinctly, though. i il ^ k^ PBACTICE OF MEDICINE. 240 PROonFRS AND CotusE is goiicnilly rapitl. If uiifivvomMf, nil Hymptoins bpcomn ii^u'iiviitcd fur 2 to 3 diiys, witli ifiiiisHidiis, and an death iicarH, oiico more aliiliiiiKMi m't» tytnjiuiii'ic, disiilaciii^ liver, iuiij^s, i't(!., iij), licncii ri'Mjiira- tioHH vapid, r)() to CO per iiiiii., heart jierhniw boatinj^ in 2iiti spaco ''aiii then suhsides HUildi'idy, entinteiiaiice jiiiiched, v. nititig frequent, bilii. v -i' uicoijg. Howfls may lie rclaNcd. I'nlse small, tlirc ady, rapid. Surface ''i.iil and damji, beginninj,' in e.xtromitii , which liccome livul. There is liieeoiigh, shorl lireuthing, general nsjihyxin, death from asthenia, .sonic'imes preceded by comn, C( n- vidsions. The case may be rapid, endin.' in even 48 hours, as in those uf baniniation, and even in these cases there is doubt if it does any good. It lias some power to ja-eveiit plasticity and organization of exudation. Calomel gr. 1, 2 tn 4 q. h. In puerjieral cases, septicemia or pyae- mia, give Quinine in large duses. For irrilabili^y of stomach if Opium does not allay, then give HON and Morphia or Spls. Am. Arom., or smo'l drinks of hot water, or small pieces of ice, or soda water, etc. Only give small quantities at a time, a tablesjwonful. Counter-irritation to abdomen is not employed till active stage is over, then a large fly blister may do good, then tonics, stimulants come in use. Small doses of turpentine seem good. Tynii)anites may need special treatment, as an enema of AsafeLida, or oz. of 01. Tiirp., made into emulsion and given as enema. Rectal tube may be used. In extreme tympanites punctuie intestines and allow gas to escape. Is a serious operation, may allow contents of intestines into cavity of peritoneum. In all cases absolute rest, at out.set no food whatever. Later only sm;dl (juantities of blandest lluids, as a little bai'lcy w.iter i oz. every i lionr, or gum water, gradually increasing diet. If fipcal abscess form, treatment must be supjiorting. Partial peritonitis calls for .^ame treatment. Typhlitis and appendicitis — treatment istiiesameas general peritonitis, but lately it has been advised to keep bowc';open by salines, tiiis is yet "sub judice." Uo not use salines if perforation has occurred. If cie ntis fr,jm im[)aotion of f-ejes, remove by mild purgatives, uidess an obstruction bo causj of accinnulation. If perforation peritonitis, give 0|)ium, absolute rest, stomai^li em^jty, sj only wash out mouth, stimulants by rectum orstomacli. OrEKATiVE iNTHiiFKKKNuE.— I'erforating apiiendicilis — jases are common and urgent. Case is fairly easy of diagnosis, and its treatm 'Ut by lapi.rotomy is generally indispensable — needs incision to be made as soon as possiljle after recovery from shock — the sooner it is done the better the chiucj of success. Tlie great diliiculty is early diagnosis. Ifilelay seems warranted tiie resulting ab- scess should be incised as soon as it is evident, and this is usually ou .'b'd d ly after first cliaracteristic symptoms. Ty[)hilitis, even if coaiplicited with peri or para typhlitis, there is not the same need for early surgical interference, for the peritonitis is less severe and less rapid. Sands of New Yca'k s,tys it can wait a week or 10 days to see if it needs operation. A large propi>rtion of these cases recover spontaneously, hence treat expectantly till need of operation is seen. The risk of operation is entrance of ficcal matter into piM-itoneum. Yet Dr. Weir of New York advocates early ojteration as no chance is given foi' alisc.ss to (jjien into peritoneum. Since both Ciccum and appendix are covered by the peritoneum, a suppurative peritonitis must be set np before perforation, or else adhesions form. DO £' loration occurs, and so a sub.[)erit()neal abscess forms. Some favor asjiir- ation to assist diagnosis, but many prefer an exploratory incisiijn. If perit.)niiis •62 V ■;^i \ PRACTICE OF MKDICINE. 254 \ .(: be sprciulinf; mjiidly, i. ''., a gtMioral povitonitis bo setting in, operate at once ; Init if it remain local, tben any time in a week is time euoiigh to operate, and an exploratory needle may be used to diagnose. Typhoid jjerforatioii or rupture of gall bladiler clearly need operation, there is escape of material into cavity. But results are not satisfactory. In acute suppurative peritonitis escape Ijy lapa- rotomy should be afforded — should be treated by early and suHicient drainage, according to Tait. CauoNio Pkritonitis. — Two chief fo''ms of mode of invasion : 1. Chronic following acute, — rare. 2. Disease insidious in outset. This second class ia not infrc(juent, and is usually associated with cancerous or tuber- culous diathesis. First form — may be localized or general. If local following acute, symptoms do not completely subside, temperature oscillates, swelling may remain, pain, rigid muscles over place, and later abscess forms. If general, the bowels have contracted adhesions, patient is subject to tiiirst, vomiting, nausea. There is irregidar state of Ijowels, evacuations unhealthy, skin dry and hot, I'.arsli, tongue smooth, jjain in abdomen is felt on sudtlen movement of holy There is almost always tenderness on e.xamination, and after a time suppuration is set uj) with hectic temperature. Copious effusion may now occur, and patient may die from debility. Diagnosis. — If history of this following acute attack is plain, diagnosis is very easy. But often history is vague, as illness with abdominal pains. If witli this there is abiding abdominal pain, constipation, etc., irregularity of abdominal surface, Mien diagnosis is sure. Second form is insidious, no complaints till disease is present plainly. Is oftenest tubercular, proved by following signs as foregoing of chronic peritonitis, then patient is under 30, is of mariced tubercular diatliesls, heredity, following perliaps some exanthem, deficient hygienic condi- tions previously, hectic rather than ind.immatory fever. Bowels irregular ; if diarrhoea is due to tul)erculous ulcerat' ^n, there is uneasiness and deep-seated pain. Lying on back, abdomen looks full, has lost its suppleness, wall and contents move en masse, and it seems as though you could move muscles over abdominal contents. If disease be far advanced fullness contrasts with emaciation over ribs. Fullness is less marked than ascites, yives a more or less resonant note, and effusion is generally scanty, may be bound down and simulate a cyst. Also exclude causes of ascites, as liver, cardiac, renal disease. There are probably signs in lungs of phthisis. Caxckkous Foum may be suspected if patient is beyond middle age, if co- lon be cancerous, if there is emaciation and cachexia, if nodule? '^'mi be felt. Ten- derness is not so great as in other forms, and there is more eft'u., on than tubercu- lous form. It is often associated with cancer in liver, spleen, etc., and often a, tumor can be felt in some place. Exclude cirrhosis of liver, amyloid disease, etc., and exclude other causes of ascites. In simple chronic peritonitis, adhesions of viscera may be marked. In tuberculous peritonitis intestines may be matted, bound to organs, walls, etc. Adhesions may be dry, no effusion. Tuberculous r r., Itli I < .jnii < PRACTrOE OP MEDICINE. uloeratioii is often fomid in nuicous nionibiant', and perforntions iire commf) ()|ieiiinj; into otlit'i' loftjis of intcistint's or into pouches formed by adhesions, hen ■ fft'Ciil abscess. Tiibfudes are found all over. (-ANCKI10U3 PERlTONrna. — Nodules found sown all over peritoneum, and omentum thickened and infiltrated with these nodules — is drawn up to colon. A^esentery also in same condition. There i^ abundant eiTusion of serum. Hlfused fluid may be tridy ascitic from chronic inilamm.itory action, also from adhe- sions contraclinu; and obstructing portal circulation. Mesenteric and lumbar glands eidar«;(d. TiiKATMKNT.— In sinijile form, rest, fomentations, and in later staj,'es fly blis- ters. Some pu.stulate with Croton Oil, or friction, miissa^^n to jiromote disper- sion of fluid by weak Mercury or Iodine ointment. Alternate l)y Mercury and Iodine, togetiier with diuretics. Tonics, anodynes, etc. TlfEAT.MEST OK SECOND FoitM. — Incurable, although recently some say tubercular eases have been saved by (i])eration. Avoid mercurial treatment, use tonics, fresh air, an( (lynes. If fluid accumulates too much, yon can nspirate to relieve. In tubcioiilar cases many In] arotoniies have been jierformed, relieve ,'•} nipt( niK (iiid ])rolong life, open and diain. TUKATMENT OF ClluoNic C^ICITIS. — If much tenderness and jiiiin, a few leeches, anil follow by Opium. Follow by mild counter-irritation. I'egulato bowils by mild enemata. Give tonics, liemember fascal abscess may have formed and need treating. LXXIX. FATTY DEGENERATION OF LIVER. Normally' liver contains fat, varying with quality of food, etc. It is neces- sary to distinguish primary degeneration from that following organic disease, as amyloid, etc. In this latte'", impaired nutrition of cells leads secondarily to fatty degeneration. Is a grave lesion then. PiUM\i{Y Fatty DficENERATlON. — Liver enlarged laterally chiefly, edges rounded generally. Peritoneal covering is not altered. Substance of liver is soft, pits and color of faded leaf. Section in early stages is nutmeg. Specific gra- vity reduced, floats. It leaves a greasy stain. It is pale, anajmic from enlarged fatty cells comjiressing capillaries. Microscopically i to | of cells are tilled with oil globules, nucleus disappears and in advanced cases cell disapjjears. Causes. — 1, Excess of fat in blood, hence from over-feeding or indolence ; 2, from free use of alcohol ; 3, when type of respiration is low ; 4, when exhaust- ing .symptums of disease, as rapid emaciatiuii, occurs, and blood gets loaded with fat from adipose tissue. So has been met in phthisis frequently, also after exau- theras, acute skin diseases, carcinoma, dysentery, in bed-ridden patients. %? rff i .i • i; i! h '' ;; i i PRAOTirE OF MlDIOINi. S66 r Symptoms.— None cliaracteristic, uliyht forms aro not pntliologicnl. In nd- vaiiceil (.ast'H joii Imvo uiiliir^'oinun^ i>{' livur with Hinootli siirftico. If iil)il(nrifin be lax, you iiuiy fcfl livi!r is soft u h1 doughy. Niigiitivuly tlioi'u iiro no siijiis of portiil olistriK'tioii. Tin- f(i»oeH iii" upt to ho disordore !, piilo or dark, a tuiuhjney to diiiirhocii. Skin gots smooth ami oily. Com|>'i .;rost of secretion of bile is very nire, deep Jiuindict) never occurs. So in d.agiiosia, h)ok to the cause and enliirgiMuent of liver in al)sence of ascites and jaundice. In very rare cases ex- troine aiiminia, great exhaustion and syniptonis of con»iileto suppression of bile sonnioh'iice, delirium and ..oma. 'lUK.\.TMl'".NT. — Not miicli dietetic, lessen fats and starches. Fruits allow- able in hirge quantity. I'rescrilm plenty of exercise, mild salines, laxative mineral waters, etc. Do not use chologoguoa. 1 iii lii ■ M i SB I IN" X) E X. A Addison's Disease ^° Ague 215 • 7'2 AlLiimiimna < A 46 AniKiiiia " Pernicious ^'■ Aortic Stenosis ^'''* " Rcmirgitalion ^^-l Appendicitis ' ••• '"^ Arthritis— Mono Articular • ^1 " Rheumatoid •" 1 CI Ascites ^' _ Asthma ^^ Atonic Dys^peps'ia 2.!G Atrophy of Stomach 230 B Biliary Cirrhosis ^^^ Bright's Disease •^' Broncliitis "^^ « Capillary ''S " Chronic ^0 " Diffuse T^ •« General "''^ «• Plastic ^2 « SutFocative T^ Cancerof Liver ^^' Cancer of Stomach uG Cerebral Syphilis 12G Cerebritis 123 Chicken Pox 1*<4 Chlorosis 50 Cholera — Asiatic 200 " European 20G Chorea 131 Cirrhosis ^^^ Colic— Lead 244 Congestion — Gastric 240 Conetipatiou • • • 245 D Diabetes 212 " Insipidus 218 " Mellitus 212 Diphtheria 1^3 . Disease of Pancreas l''^ Disease of Peritoneum 164 Diseases — General -^ Diseases of Heart 137 Diseases of the Liver 151 Diseases of Lungs 75 Diseases of the Nervous System 117 Drop-iy — Cardiac 150 Duodenal Ulcer 231 Duodenitis 244 Dysentery 171, 241 Dyspepsia — Atonic •• 236 E Emphysema 82 " Atrophic 85 " Hypertrophic 83 Empyema — Acute 106 " Chronic 106 Endocarditis 140 Enteralgia 246 Enteritis Maco 242 Epilepsy > 127 F Fevers — Acute Rheumatic 32 " Cerebrospinal 22 " General 7 " Intermittent 26 " Malarial 25 " Pernicioup 30 " Relapsing 19 " Remittent 29 " Rheumatic 32 " Simple Continued 21,212 " Typhoid 7 " TyphoMalarial 31 " Typhus 13 Functional Affections 127 258 INDEX G Gall Stones 1'''0 Gastric Carcinoma 2.(2 " Congestion 210 " Fermentation 2M9 " Ulcer 229 Gastritis — Acute ' ' 4 " Chronic 2'Jt; Gout— Acute regular 219 " Irregular 220 " Subacute 224 H Hucnioglobinuria "^^ . Heart— Aortic Regurgitation of U4 " Dilatation of 148 •' Diseases of l''^ " Hypertrophy of 14'^ Hepatitis , 151 Hoilgkiu's Disease 54 Hydroihorax 104 I Infantile Cerebro Paralysis 1 25 Intluenza 211 Intestinal Obstruction 108 J Jaundice 157 •' Catarrhal 159 " Non-obstructive llili " Obstructive 158 K Kidney — Amyloid 63 " Carcinoma of 74 " Cystic 75 " Movable 75 " Surgical 65 " 'J'ulierculous Disease of 73 L l,ead Colic 244 Leucocythfi'mia 52 Liver — Amyloid 156 " Cancer of 157 " Cirrhosis of 152 " Diseases of 151 " Fatty Degeneration ,.,,,, 255 Liver — Lardaceons 156 Lung Diseases in general 75 M Malarial Cachexia 27 Measles 190 Gorman 192 Meningitis — Lepto 117 Pachy 118 " Tubercular 121 Mitral Stenosis 145 " Regurgitation 145 Mumps 209 N Nephritis — Acute Parenchymatous 58 " Chronic Piirenchynuitous.. .. 60 " Chronic Interstitial 61 Nephrolilhia-^is 67 Nervous System— Disea-^es of 117 Neuralgia 134 o Obstruction — Intestinal 168 Organic Diseases of Heart 143 P Paralysis — Infantile Cerebro 125 Parotitis 209 » Metastatic 211 Pericarditis 137 Peritonitis 164, 248 " Acute general 164 " Cancerous 255 " Chronic 168, 254 " from perforation 166 " Local 165 Pertussis — Whooping Cough 207 Phthisis 106 " Acute 116 " Chronic 107 " Miliary 117 Pleurisy — Acute and Chronic 99 Pneumonia 89 R Regurgitation— Tricuspid 146 llheumfttisin ...........,. = . = .... ^ ..» ^ , . 32 " Cerebral 225 " Ch. Articular ^ 38 INDEX. 259 136 75 27 I'JO lt)2 117 118 121 145 U5 20!) ons 58 lUUoiis.. .. 60 1 til rt7 117 VU 1()8 143 125 2U!) 211 187 IM, 248 1G4 2)5 1(18, 254 16() 165 207 106 116 107 117 99 89 146 ........... 32 225 V 38 Rlieuiiiatoiil Artliritis, RicketH 4? Scarlatina Small-Pox— Continent. . . . " Malignant ... Stomach— A tropliy of . . . " Cancer of.... " Cirrhosi.s of. . " Dilatation of. " I'lceralion of Syijliiiis — Cerebral 185 17'J 181 2:!ti 176 235 175 220 126 T Tricuspid Regurgitation 116 " .Steno-^i.'< '17 Tumors — Brain 1 25 u Uncniia 66 Uneniiu Coma 71 V Vaocinatidii Valvular Disease of Heart . 1H4 143