CORNELL UNIVERSITY
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MEDICAL LIBRARY

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GIFT FROM THE LIBRARY OF

CHARLES EDWARD VAN CLEEF, M.D.
B.S. CORNELL UNIVERSITY, '71.

 

 
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A COMPLETE

HANDBOOK OF TREATMENT,

ARRANGED AS AN ttf li AhY

Alphabetical Index of Diseases

TO FACILITATE REFERENCE, AND

CONTAINING NEARLY ONE THOUSAND FORMULA,

BY

WILLIAM AITKEN, M.D. (Ep1y.), F.R.S.,

Professor cf Pathology inthe Army Medical School; Examiner in Medicine for the
Military Medical Services of the Queen; Fellow of the Sanitary Institute of Great
Britain; Corresponding Member of the Royal Imperial Society of Phsicians
of Vienna; and of the Society of Medicine and Natural History of Dres
den; Pathologist attached to the Military Hospital of the British

Troops at Scutari in Turkey during the Crimean War.

 

NEW YORK:
BERMINGHAM & CO.

I

1882,
ii
COPYRIGHTED 1882
BY

BERMINGHAM & CO.

Electrotyped and Printed by
W.L. MERSHION & CO,
37, 39. & 41 Clinton St., Rahway, N. J.
PREFACE,

THERE is, perhaps, no more striking characteristic of the
medical practitioner of to-day, and none better illustrating
the pervading spirit of the age, than the universally observed
tendency among medical men to shun, in medical literature,
the unrealities of theoretical discussion, and to appropriate
with avidity only facts which they can instantly transform
into working force, and the gain from which is conspicuously
apparent.

Now and then we meet with a writer who has in part, at
least, appreciated this demand for the practical, the utiliz-
able, and has accordingly made some effort to supply this im-
perative appetite with the proper food. We have, however,
in the whole range of medical literature, no book which is a
complete reflection of the ¢reatment of every recognized dis-
ease, no book which has taken for granted that the practi-
tioner knows what disease he has to cope with, and aimed
chiefly to supply him, ready for instant use, with the arma-
ment he must rely on to win the victory—an: armament
which should embrace chiefly the best methods of treatment.

A book which is at once concise and comprehensive, which
is arranged so that the practitioner, given a disease to treat,
may have before him in a nutshell, the latest treatment re-
commended by the best authorities; and a book which is,
above all else, a book of TREATMENT, we here offer to the
profession. Itis composed of the chapters on Treatment
taken from the seventh (latest) edition of Dr. Aitken’s Ency-
clopedic work on the Science and Practice of Medicine,
which chapters have been revised and rearranged, so as to
make them more available for reference. The reader will
find that the work does not only embrace the experience of
its distinguished author, but also that of every known
authority.
A COMPLETE

HANDBOOK OF TREATMENT.

ARRANGED AS AN

.

ALPHABETICAL INDEX OF DISEASES,

Aene.—De/finition.—Inflammation of the sebaceous glands
and hair follicles, with retention of the gland secretion.

TLreatment.—Local and general measures require to be
combined. Diet, in the first instance, should be restricted.
Wine, spirits, and coffee are to be refrained from. Milk is
to be used as a drink, and as an article of diet, combined
with light food, fresh vegetables, and succulent ripe fruits.
Emollient applications, such as an emulsion of bitter al-
monds, a decoction of bran or quince*seeds, and tepid milk,
are useful. Dr. Anderson has found sulphur (31.), mixed
with rectified spirit (3i.), to be shaken before using it; ora
mixture of hyd. corrosiv. sublim. (gr. ix.-xii.); hydrochl. am-
monie( 3 ss.)cochinillini (gr.i.); aqze. rosoe (3 vi.),particularly
serviceable. Generally, if one fails, the other succeeds.

In that form of acne common to young women at the com-
mencement of their menstrual period, Dr. Ringer recom-
mends sulphur (31.), glycerine (/31.), water (73 x.), to be
applied twice or thrice daily.

Whichever of these lotions is used, let it be applied by dip-
ping a piece of flannel into the lotion, and rubbing very
firmly over the eruption night and morning. Flowers of sul-
phur used dry to dust the parts with at bedtime is also of
service. To promote resolution of the induration, iodide of
sulphur, in the proportion of fifteen or twenty-four grains to
an ounce of lard, is of great service in dispelling the tumors.
Drastic purgation ought to be avoided. Simple baths at a
temperature of 88° or 90° Fahr. are of service. Calomel
ointment (31. of calomel to 3 ii. of lard) ‘has been found use-
ful, care being taken against salivation. If there be much
thickening of skin, Mr, Milton recommends the internal use

5
6 ADDISON $ DISEASE.—AGUE.

of liquor potassz, although inferior to arsenic, which ought tc
be used. In dysidrosis, the treatment is mainly by carron oil
to the inflamed parts, with diuretics and tonics internally.

Addison’s Disease.—Definition.—Disease of the supra-
renal capsules, with discoloration of the skin; or, a morbid
state which establishes itself with extreme insidiousness,
whose characteristic features are anemia, general langour
and debility, and extreme prostration, expressed by loss of
muscular power, weakness of pulse, remarkable feebleness of
the heart’s action, breathlessness upon slight exertion, dim-
ness of sight, functional weakness and irritability of the stom-
ach, and a peculiar uniform discoloration of the skin, which
becomes of a brownish olive-green hue, like that of a mulatto,
occurring in connection with a certain diseased condition of
the suprarenal capsules. The progress of the disease is very
slow, extending on an average over one year and a half, but
may be prolonged over four or five. The tendency to death
is by asthenia, the heart becoming utterly powerless, as if its
natural stimulus—the blood—had ceased to act.

Treatment.—lf the disease be recognized in its earliest
stages, its progress may to some extent be delayed. The
asthenia, the depression, the evidence of local irritation about
the suprarenal capsules, and the pathology of the disease gen-
erally, point to the necessity for tonic treatment and nutri-
tive diet, the avoidance of all causes of depression, and the
benefit of rest in bed, and of such medicinal agents as may
relieve the vomiting. Glycerine, in two drachm doses, com-
bined with fifteen or twenty minims of the spirit of chloro-
form, and of the tincture of the sesquichloride of iron, have
have been of service (E. H. Greenhow). This may be varied
by the substitution of twenty to thirty minims of the syrup of
phosphates of iron, quinine and strychnia, in place of the ses-
quichloride of iron. The greatest caution is necessary in
using purgative remedies as fatal collapse is apt to follow
cathartic medicine.

Ague.—Definition.—Febrile phenomena occurring in par-
oxysms, which observe a certain regular succession, charac-
terized by unnatural coolness, unnatural heat, and unnatural
cutaneous discharge, which prove a temporary crisis, usher-
ing in a remission. - These phenomena continue to be devel-
oped in an uninterrupted series or succession of paroxysms,
more or less regular, which pass into each other by insensible
steps, so long as the ague lasts,
AGUE, 7

Treatment.—It is useless to attempt the cure of inter-
mittent fever if the sufferer is permitted to remain within
the sphere of malarial influences. The old empirical treat-
ment in the English fens was first an emetic, then a sharp
purge, followed by quinine and arsenic. But an emetic
must not be given for ague, without regard to the special
circumstances of the case. Emetics are only of use when
the tongue is very foul or the stomach overloaded ; or when
there is nausea and headache with epigastric oppression. An
emetic will then give great relief, and hasten the stage of
reaction. In the simple cases, when removed from the
sphere of malarial influence, active purgatives are always
beneficial in relieving the full and congested state of the
abdomen generally ; and they prepare the way for the action
of quinine, especially combined with diureties, such as cream
of tartar (Woop). ‘There are also cases of intermittent fever
complicated with hepatic and other engorgements, which
continue to recur despite of all means, until a few doses of
calomel, followed by purgatives, are administered ; then the
quinine, which before failed,. will speedily cure the disease.
The compound jalap powder,combined with calomel, is found
very beneficial in such cases. If much urinary irritation
exist a mixture of 3 vi of bicarbonate of soda, dissolved in
& viiss. of water, to which % ss. of Sp. Atheris nitrosiis added,
given in half-ounce doses every two or three hours, with or
without tincture of opium, will relieve it. Certain morbid
conditions both of liver and spleen, may produce and main-
tain the tendency to recurrences of ague. Ramazini relates
the case of a patient harassed by an obstinate ague, and who
was cured by mercurial frictions administered for syphilis.
The influence of splenic disease in keeping up the morbid
train of actions of the original fever, and in producing re-
lapses, has been recorded by M. Piorry. In more than 500
cases of ague in which he observed the state of the spleen,
he comes to the foliowing conclusions, namely :—that the
organ is invariably enlarged during the progress of the fever,
and that by the use of quinine the spleen diminishes in size ;
that its reduction in size bears some relation to the quantity
of quinine taken ; that the effect it produces upon the fever
is in proportion to the reduction of the spleen ; that the dis-
ease is cured simultaneously with the subsidence of the
splenic enlargement ; and that the fever is apt to recur so
long:as the spleen exceeds its normal size. The treatment
of the disease as to stages is to be managed as follows :—
8 AGUE.

During the cold stage the patient generally desires to be let
alone, care being taken that he has abundance of bed-clothes.
If the stage continues unusually long without signs of reaction
the application of external warmth becomes necessary with
warm drinks ; and even ammonia, ether, camphor, and other
diffusible stimulants may be required if the vital powers are
unequal to the development of reaction. During the hot
stage, diluent drinks may be indulged in, if the patient de-
sires them, with cooling diuretics; but the danger consists
in the approach of collapse when the sweating stage com-
mences ; and when stimulants and support may be required.
The first dose of quinine should, then, be given towards the
close of the sweating stage. “I always assume,” writes
Professor Maclean, “that in first attacks the type of the dis-
ease will prove to be quotidian, and take my measures ac-
cordingly, making sure that the patient shall have thirty
grains of quinine between the termination of one paroxysm
and the hour when we may look for another; and looking
to the fact that we may look for the setting in of the cold
stage, perhaps two hours earlier than on the first day, the
last ter. grain dose of quinine should be given so as to antici-
pate that time by at least an hour.” Itis to be administered,
in solution, dissolved by a small quantity of dilute sulphuric
acid, and the dose mixed with syrup of orange peel. It may
also be administered in starch or beef-tea enemata, or by
subcutaneous injection. The object and action of quinine
are to break the system off ‘‘the habit of going through the
phenomena of an ‘ague fit.’ It counteracts the influence of
the malarial poison, and prevents the repetition of the
attacks. A moderate degree of cinchonism must still be
maintained for some days, to the extent of ‘ringing in the
ears,’ by giving three or four grains of quinine in solution
every three or four hours, anda day or two before the
interval of a month the patient must be again brought under
the influence of this remedy. Within this period (a lunar
month) there is always a tendency to the repetition of the
‘ague fit,’ the habit of which must be thus broken; other-
wise it will be strengthened by every successive attack”
(Maclean). Next to quinine in the cure of ague comes
arsenic. From six to eight drops of Fowler’s solution may be
given during the interval of freedom from fever. It should
be given in small doses, and not persevered in for more than
eight or ten days; and like quinine its use must be continued
in diminished doses for some time after cessation of the
ALBUMINURIA.—-ALCOHOLISM, 9

fever. The earliest signs of its physiological action must be
looked for to determine to what extent it mus: be pushed—
these being redness of the eyes, watering of the mouth, and a
silvery state of the tongue. ‘The dose should always be
given after food. In malarial brow-ache (brow-ague) and ma-
larial hemicrania it is more efficacious than quinine. Dueat-
tention must be paid to feeding during the intermission,
especially by beef-tea and farinaceous food.

In all complications of ague, be they cerebral, pulmonic,
hepatic, or gastric, quinine must still be the therapeutic agent
to be relied upon. Antiphlogistic measures are not to be
substituted in place of it on any account whatever. As to
the malarions cachexia, removal from the malarious locality
is the first essential condition to restoration of health; the
next is a combination of nutritious diet, abundance of exer-
cise, pure air and pure water; and clothing should be warm
on first coming into cold latitudes. The prophylactic use of
quinine must still be persevered in; and if appetite fail, a
course of syrup of the phosphate of iron, quinine and strych-
nia in ten-minim doses, in a large quantity of water (aclaret
glassful), will be of service. In the experience amongst the
invalided soldiers at the R. V. Hospital at Netley Dr. Mac-
lean has found this medicine of much use. The chronic
malaria cachexia is also much benefited by arsenic, especially
when there is diarrhoea. In such cases two minims of
Fowler’s solution with five minims of laudanum should be
given before meals. So also the use of coti bark may be of
service in diarrhoea. In the treatment of the anemic chlorosis
of malaria arsenic is especially adapted to those cases in
which iron does not agree ; while the efficacy of iron is often
also increased by its combination with arsenic.

Should the spleen continue of large size ointment of the
bin-iodide of mercury is to be rubbed in over the gland. A
portion about the size of a nutmeg is to be applied with a
smooth spatula, the patient sitting before the heat of the fire,
as long as he can bear the smarting which follows. The
remedy has a not less beneficial influence on enlarged livers
(Pror. W. C. Maclean).

Albuminuria—Sce Bright's Disease.

Alcoholism.—Defiition.—A train of morbid phenomena
produced by the slow and cumulative action of alcohol in the
various forms in which it is used as a drink. Delirium is one
of the most prominent features of the morbid state, which
is otherwise characterized by hallucinations, dread, tremors of
Io ALCOHOLISM.

the tendons and muscles of the hands and limbs, watchfulness,
absence of sleep, great frequency of pulse. A thick, creamy
fur loads the tongue, and a cool, humid, or perspiring surface
prevails ; while the patient gives forth a peculiar odor, of
a saccharo-alcoholic description; more or less strong.
Treatment—The indications are,—(1.) The elimination
of the poison ; (2.) the sustenance of the patient during this
period. The two most fatal errors which can be committed
in the treatment of delirium tremens are to bleed the patient
or to give him opiates. The greatest number of cases of
those treated by opiates are apt to terminate by convulsions
and coma (Morehead, Peddie, Law, Cahill, Laycock).
If it be true, also, that opium and alcoholic stimulants singly
__are to be deprecated in the treatment of delirium tremens, a’
fortiort in their combination there is a twofold danger,
alike in tropical as in temperate regions it is a course of
treatment attended with much hazard, and if systematically
followed, is certain of leading to unfortunate results (see
Moreheads’s “Researches on Diseases in India;” also,
“Notes on Treatment of Delirium Tremens,” by W. Hanbury,
33rd Regiment, in Madras Quarterly Journal, July, 1863).
The strength must be supported by diet of the most nutri-
tious I:ind, in a fluid and mild form, such as yolk of eggs,
soups, and the like. Food should be given in small quanti-
ties and often. Beef-tea, spiced soup, and egg-flip, are each.
to be commended at different periods of the day. If the pa-
tient continues to digest food, the danger is much diminished,
which in the first instance is from exhaustion. Careful
nursing is above all things necessary, so that protection from
all sources of danger may be adequate and the food ad-
apted to the state of the digestion, which is always feeble.
The disease must be treated as one spontaneously curable ;
not by withholding remedies, but by using them in strict
subordination to good nursing and carefully adjusted diet
and regimen (Ware, Hood, Peddie, Laycock, W. T. Gaird-
ner). Active specifics for delirium tremens appear to be
founded on the idea that the disease is one nominally of
high mortality. Hence the enormous doses of digitalis
(Jones) and of Cayenne pepper (Kinnear and Lyons of
Dublin) ; but before resorting to the use of such remedies
as digitalis, it will at least be judicious practice to adopt
such means as are calculated to restore the powers of nature
—namely, nutrients and rest ; while the stimulus of such a
spice as Cayenne pepper, given in the soup, on the atonic
ALCOHOLISM. II

stomach, will have a favorable influence on absorption.
Under the care of my friend, Dr. Lyons, of Dublin, numer-
ous cases of delirium tremens have rapidly yielded to capsi-
cum, in doses of xx. to xxx. grains, inthe form of a bolus. I
have given it in numerous cases and in all forms of chronic
alcoholism. Its influence in soothing the patient and in
securing quiet sleep has been certainly remarkable. By
some reviewers this influence has been questioned ; but the
evidence of its good effects are daily accumulating. Dr.
Ringer, in an able article in the Britt Med. Journ., in
1871, advocates the use of capsicum, “given in doses of
the tincture (five to ten drops) in a little syrup of orange
peel. Orthe powder may be formed into five-grain pills
with extract of gentian—one to be taken every four hours
till quietude is obtained ; or, twenty grains in a single dose
may be taken before meals, or whenever depression or
craving for alcohol arises.” It induces sleep in the early
stages of delirium tremens. It obviates the morning vomit-
ing, removes the sinking at the pit of the stomach, the in-
tense craving for stimulants, and promotes appetite and
digestion. Dr. Wilks prescribes it with nitric acid and nux
vomica. Dr. Lauder Brunton has given a great deal of at-
tention to this subject, and, according to his experience, a
combination of iron and nux vomica (say fifteen minims of
the tincture of the perchloride and ten of tincture of nux
vomica) is one of the most efficacious remedies for the tre-
mors of chronic alcoholism. If the stomach be deranged,as it
very frequently is, the indigestion should be treated previ-
ously to the administration of iron, by giving ten grains of
subnitrate or carbonate of bismuth with ten of magnesia,
suspended with gum tragacanth. If there be any tendency
to sleeplessness, or if the tremors should not rapidly disappear
under the use of the iron and nux vomica alone, thirty or
forty grains of bromide of potassium should be given at
night. The chalybeate mixture already mentioned, either
alone or with the addition of five or ten minims of tincture
of capsicum, tends to alleviate the craving for drink. An-
other mixture recommended for this purpose consists of
sulphate of iron, magnesia, and oil of cloves ; a third consists
of carbonate.of ammonia in infusion of gentian, to be taken
whenever the craving is felt. Should the craving come on
at intervals of several weeks, with complete intermissions
between, the case should be treated like one of epilepsy, by
the administration of bromide of potassium.
12 ALCOHOLISM.

Chloral is now a most important and valuable addition to
our remedial agents in this disease. It produces sound and
refreshing sleep, followed by relief to all the symptoms. It
now seems to serve all the purposes intended by opium.

The late Dr. Jones, of Jersey, gave as rhuch as half-ounce
doses of the tincture of digitalis till three doses had been
taken; and then, if excitement were not subdued, nor sleep
induced, two fluid drachms were repeated every three or four
hours (Med. Times and Gazette, Sept. 29, 1860). But Dr.
Ringer justly cautions against such excessive doses, and re-
cords two instances in which the patient suddenly fell back
dead. The disease no doubt proves suddenly fatal, some-
times independently of any remedy ; but the powers of digi-
talis in a tincture are much too uncertain to be relied upon
as safe in such enormous doses, Bromide of potassium has
been found of great use in calming the excitement of delirium
and procuring sleep, especially in the earlier stages of the
disease, before the delirium has become furious. The dose
may be xx. or xxx. grains every two hours. Its good effects
are, however, very uncertain when given alone ; less so when
combined as suggested by Dr. Lauder Brunton (Ringer).

In some cases purgative remedies are indicated from the
first. “These cases are known by the flushed, bloated ap-
pearance, the very foul tongue, the maakish, peculiar odor of
the breath, the fetid discharges from the bowels, and the his-
tory cf a recent surfeit of eating as well as drinking” (W T.
Gairdner, “ Clinical Medicine,” p. 271).

Opium may be administered with safety and advantage only
in protracted cases, provided the quantity given in twenty-
four hours is never allowed to exceed the full dose which
would be considered safe for a healthy person of the age and
sex of the patient. Where it appears to be indicated in pro-
tracted cases, it ought to be pushed as rapidly as possible for
two or three doses, while its effects are carefully watched.
Its use must be discontinued for at least a good many hours
as soon asa full maximum amount of 3iss. to Zii. of the
tincture, in all, has been reached, or even sooner if the pupils
have become contracted during tts use. This remedy should
always be given in the fluid form, otherwise it is apt to ac-
cumulate in the bowels, owing to the weakened state of the
digestion ; and a laxative, or even a purgative, should be al-
ternated with opium, follawed by a bitter tonic, which always
operates favorably in lingering cases of nervous and dyspep-
tic exhaustion. Narcotics are only safe in delirium tremens
ALOPECIA AREATA.—ANAMIA. 13

when they are given with the object of aiding and seconding
the natural cure of the disease, employed in moderate doses,
and given only at the latter stages. The Aerotc use of them,
as heretofore too often advocated by most eminent phy-
sicians, is now recognized as a treatment which merely sub-
stitutes zarcotic poisoning for alcoholism or delirium tremens.

Envelopment in a wet sheet, and then a blanket round the
wet sheet,.is recommended by Dr. Wilks and Niemeyer as a
valuable sedative appliance. As soon as hot vapor so gener-
ated surrounds the patient, he falls into a quiet sleep (JZed.
Times, Sept. 19, 1868).

Alopecia Areata—See Tinea Decalvans.

Anemia.—Definition—A disease in which there is
either a relative diminution of the mass of blood (Andral),
with the general composition and distribution of the blood
altered from the normal standard; or in which the mass of
blood is diminished, and the liquor sanguinis is watery, poor
in albumen, and containing an excess of salts. These con-
ditions, co-existing with relative deficiency of the red blood-
corpuscles (Vogel), and a diminution of the urine-pigment

Parkes), with altered innervation of the vascular system
en constitute anzemia.

Treatment.—The energies of the physician must be directed
to discover and counteract the cause of the anemia. Nutri-
tious substances must be supplied for diet, in the shape of
easily digested meats and broths. The purely tonic treat-
ment, in the combination of air, exercise and diet, must be
carried out as far as practicable. A change of air is abso-
lutely necessary, and generally also of diet. vom is one of
the best medicinal remedies; and it ought to be taken as
largely diluted with water as possible. The astringent pre-
parations are pre-eminently tonic ; and are especially useful
when the anemia is associated with or dependent upon inor-
dinate discharges. Solution of the perchloride of iron, in the
form of tinctura ferri perchloridi, in doses of ten to thirty
minims in water, or in an infusion of quassia, or of calumba,
has properties in common with the numerous salts of iron,
and is one of the most reliable preparations. If the anemia
is associated with diarrhoea, or menorrhagia, or leucorrheea,
the solution of the pernitrate of iron, in similar doses, is at-
tended with benefit. A preparation which is no longer new
to the pharmacopceia—the syrup of the phosphate of iron—
possesses the general properties of the ferruginouscompounds,
14 ANEMIA.

and is of great service when the anzmia is associated with
certain forms of dyspepsia, or with amenorrheea. It invigor-
ates and increases the powers of digestion, and may be given
to the extent of one to three drachms for a dose in water.
Another phosphatic preparation of very great value is that
which was devised by the late Dr. Easton, Professor of Ma-
teria Medica in the University of Glasgow. Although it is
not in the pharmacopeeia, and although its mode of prepara-
tion had not been published before Dr. Easton kindly sent
it to me for publication in the previous editions of this work,
yet the combination has become very popular throughout the
country as a valuable tonic in anemia and cachexie generally.
As such it has been largely used by my colleagues, Professors
Maclean and Longmore, amongst the used-up cachectic and
anzemic soldiers under treatment at the Royal Victoria Hos-
pital at Netley ; and I would add my testimony to its being a
most valuable medicine in general practice.*

*The following is the original formula devised by Dr. Easton for the
preparation of the phosphates of iron, quinine, and strychnia, in the form
of asyrup (‘‘Syrupos ferri, quinia et strychniz phosphatum ”’) :—.R
Ferri Sulph. 3 v.; Sodz Phosph., 3 vi. (a little more phosphate of soda
gives a better result, say 3i.); Quiniz Sulph., grs. excii. ; Acid Sulph.
Dil., q. s.; Aque.Ammonie, q. s.; Strychniz, grs. vi.; Acid. Phosph.
Dil, %xiv.; Sacchar. Alb., 3 xiv. ‘‘ Dissolve the sulphate of iron in 1
oz. boiling water, and the phosphate of soda in 2 oz, boiling water. Mix
the solutions, and wash the precipitated phosphate of iron till the wash-
ings are tasteless. With sufficient diluted sulphuric acid dissolve the
sulphate of quinia in 2 oz. water. Precipitate the quinia with ammomia
water, and carefully washit. Dissolve the phosphate of iron and the
quinia thus obtained, as also the strychnia, in the diluted phosphoric acid;
then add the sugar, and dissolve the whole, and mix without heat. The
above syrup contains about one grain phosphate of iron, one grain phos-
phate of quinia, and one thirty-second of a grain of phosphate of strych-
niain each drachm. The dose might therefore be a teaspoonful three
times a day. The amount of phosphate of quinia might be increased ac-
cording to circumstances ; and if eight grains of strychnia were employed
in place of six, as in the above, the phosphate of strychnia would be in
the proportion of the one twenty-fourth of a grain in every fluid drachm
of the syrup. I would scarcely venture on a much larger dose. In cases
of delicate children, with pale countenances and deficient appetites, I
have given, with great benefit, a combination of equal parts of the above
syrup and of that prepared by Mr. Edward Parrish, often called chemical
food. To children between two and five years of age, the dose of this
combination may be a teaspoonful three times daily. The preparation
ought to be kept as much as possible from light and air, otherwise the
preparation loses its characteristic opaline appearance, and assumes a
fawn color; a precipitate may be thrown down.” It is prepared by
Messrs. Murdoch, Chemists, in Glasgow ; by Duncan and Flockhart in
Edinburgh ; by Randall and Sons, Southampton; and by Savory and
Moore, in London.

 

 
ANAMIA, 15

_ In some cases the astringent preparations of iron are not
suitable, and are apt to irritate delicate stomachs, or those in
whom any inflammatory local disease exists. For delicate
females and children the saccharated carbonate of iron is a
most valuable preparation, in the form of mistura ferri com-
posita to the extent of one to two ounces for a dose; or in
the form of the pillula ferri carbonatis, in doses of from five
to twenty grains in the twenty-four hours. The citrate of
iron and ammonia is another remedy which possesses scarce-
ly any astringency, and may often be given in cases of anemia
when the stomach will not bear more astringent preparations.
Five to ten grains of this salt may be taken during the twenty-
four hours. It is best taken during effervescence, pre-
scribed in solution of citric acid, and not in bicarbonate of
potash solution. If it is put into the latter, carbonic acid
will be given off, and probably burst the bottle. Tincture of
orange-peel is the best flavoring agent; but as the salt will
not dissolve in the tincture alone, it is necessary to dissolve
the salt in water first, and then add the tincture, otherwise
the division into doses is impracticable (Squire). When it
is desirable to continue the use of iron for a long time, as in
the anemia of neuralgic affections or tic-douloureux, or to
give it in large doses, the magnetic oxide of iron is the best
preparation to administer in doses of five to twenty grains
twice or thrice a day in water. The reduced iron—the fer-
rum reductum of the British pharmacopceia—is also a reme-
dy which does not possess the astringent properties of the
other preparations, and is one of the most powerful remedial
agents in casés of anemia. One to five grains may be given
several times a day in powder or in pill. It has no taste, and
one grain is equal medicinally to five grains of the citrate of
iron. The citrate of iron and quinine, either in solution or
in the form of a pill, is a new and useful preparation, in doses
of five to ten grains three times a day.

Generally, such a preparation of iron must be found as
will not check the digestion of other food. If loss of -appe-
tite and feverishness follow its use, the form of the remedy
is probably unsuitable, and requires to be changed. Chlorine,
in the form of warm hydrochloric acid baths, is highly spoken
of by Dr. T. K. Chambers, as an agent of great value, and as
a directly restorative medicine in anemia (I. c., p. 332). The
bowels are to be kept regular by four grains of the pills of
aloes and myrrh taken at bedtime. Ferruginous remedies
are always of use when we have reason to believe that there
16 ANASARCA.—ANGINA PECTORIS.

is a diminished energy in the formation of blood-cells ; and
if the urine be pale and almost neutral during the whole of
twenty-four hours, it is as good an indication for the use of
iron as the pallor of the skin in cases af anemia (Parkes).
Dr. Trousseau was of opinion, however, that for anzmia,
complicated with tubercles, iron preparations were unsuit-
able, as tending to hasten their development. Dr. Clymer has
found arsenic a valuable remedy combined in the form of
chlorides of arsenic, iron, and quinine.

Anasarca.—Definition.—An accumulation of serum in
the areolar tissue throughout the body ; a general cedema or
anasarca with effusion into one or more of the large serous
cavities,

Treatment of general dropsy is regulated by the nature of
the disease which causes the dropsical state, and will be con-
sidered under Heart Disease and Kidney Diseases.

Angina Pectoris.—Definition—Pain or spasm of a
weakened heart (Chevers), referred to the lower part of the
sternum, or to the precordial region, extending through the
chest to the left scapula, and up the sternum to the root of
the neck. The pain is characterized by its suddenness, its
severity, and by a sense of constriction or of burning. It
compels the patient, if walking, instantly to stop, and almost
prevents inspiration. The pain is felt likewise in the left
shoulder, whence it sometimes reaches to the elbow, rarely
to the hand, often with a sensation of numbness in the parts.
A tendency to syncope exists, associated with intense anxiety,
and a sensation of approaching dissolution.

Treatment.—The indications are to be found in a study of
the lesions on which the paroxysms mainly. depend. Med-
icine can do little more than mitigate the severity of an at-
tack. This is generally best done by diffusible stimulants,
such as brandy, ether, chloroform, ammonia, chlorodyne. Al-
cohol, in small doses often repeated, sesqui-carbonate of am-
monia, in doses of from three to five grains, the muriate of
ammonia, in doses of from ten to twenty grains, have each
powerful stimulant effects. Hot bottles and sinapisms
should be applied to the feet. The bowels may require to
be rapidly and efficiently acted upon. Thirty minims of
tincture of digitalis, repeated at the end of half an hour, give
great relief. It has also been beneficial when the angina was
associated with fatty heart. In that form of angina pectoris
where there is distension of the right ventricle, accompanied
AORTA, ANEURISM OF. 17

by palpitation, dyspnoea, and lividity of the face (cardiac asth-
ma), the frequent use of digitalis exercises a stimulating in-
fluence on the sympathetic cardiac ganglia and muscular
fibres (Fothergill).

Aorta, Aneurism of —Defnition—A spontaneous cir-
cumscribed partial dilatation of some portion of the aorta,
consequent on lesion or degeneration of its walls.

Treatment.—Local bleeding is useful when there are pain
and tenderness over the aneurismal sac. General blood-let-
ting may be useful if the circulation is excited, and the pa-
tient be of full habit, but not on the principle advocated by
or ascribed to Valsalva. Of all remedies digitalis, aconite,
belladonna and veratrin are the most useful in tranquillizing
and regulating the action of the heart. The deposition of
fibrine from the blood is more prone to take place when the
circulation is “slowed.” It is the principle.of treatment in
the cure of aneurisms by pressure. The current of blood is
not entirely stopped, but is rendered more slow, so as to
have an amount of stagnation of blood in the sac favoring
the separation of fibrine and its coagulation. A diminution
of from ten to fifteen pulsations of the heart in the minute
will greatly tend to the filling of the sac with coagula (Ful-
ler). The medicinal agents which tend to promote this result
are, ergotine, gallic or tannic acids, tincture of steel, acetate
of lead, and iodide of potassium. Mr. Joliffe Tufnell, of Dub-
lin, has advocated the treatment of aneurisms of the thoracic
and abdominal aorta on the principle here enunciated—
namely, that of “slowing” the circulation. It consists of
restricted diet and perfect rest in the horizontal position, for
periods varying from eight to thirteen weeks, combined with
the employment of such remedies as may be necessary for
special ends. The horizontal posture must be s¢ricdly and
absolutely maintained, in a light and cheerful airy room, into
which the sun shines, and from which the patient may be
able to have as cheerful a view as possible out of the window.
The diet must be confined to ¢#ree meals, served at regular
intervals, and restricted to the following in kind and in
amount :—Breakfast—Two ounces of white bread and but-
ter, with two ounces of milk or cocoa.’ Dixzner—Three
ounces of broiled or boiled meat, with three ounces of pota-
toes or bread, and four ounces of water or light red wine.
Supper—Two ounces of bread and butter, and two ounces of
milk or tea. These diets should make, in the aggregate, ten
ounces of solid and eight ounces of fluid in the twenty-four

2
18 AORTA, ANEURISM OF.

hours and no more. The object of the special diet is to main-
tain life on as little food as possible, without inducing restless-
ness, as in some irritable constitutions, but if such restless-
ness should occur, a little more food may now and then be
allowed. Anodynes, aperients, narcotics, sedatives, and tonics
are also useful aids in the management of the case. Of
anodynes lactucarium is the most valuable, given in the form
of a pill, by itself or combined with humulin and hyoscyamus
(Med. Rep. Army Med. Dep., 1862, p. 472). The patient
must avoid everything which tends to increase the action of
the heart. Moderate living, without the plethora of excess,
but with sufficient nutrition to maintain the circulation at a
uniform flow, is the point to aim at. Fatal results may
speedily follow any marked change of diet and regimen (Cop-
land). Pain and depression will generally be subdued by
the hypodermic injection of morphia, commencing with one-
fourth of a grain. Cough is to be relieved by sedatives and
expectorants. Dyspnoea may require tracheotomy Dropsy.
may be lessened by mercury, digitalis, squills, juniper, and
decoction of broom-tops.

Since 1861, the following three special modes of treating
aneurisms have been proposed, besides Mr. Tufnell’s dietetic
method :—(z.) The introduction of a quantity of fine iron
wire into the aneurismal cavity, with the intention of supply-
ing an extensive surface over which fibrine may coagulate.
The late Dr. Murchison and Mr. Charles H. Moore practised
this method in a case of saccular aneurism of the ascending
aorta projecting through the anterior wall of the left side of
the chest. Twenty-six yards of wire were passed through a
small canula inserted into the tumor when it was evident
that the patient could not live many days. With some modi-
fications it was shown that the experiment might be justifia-
ble in some cases of sacculated aneurisms only (MJed.-Chir.
Trans., Vol. XLVII., p. 129, London, 1864). (2.) The
method of rap7d pressure treatment, as practised by Dr.
William Murray, of Newcastle-upon-Tyne, and Lecturer on
Physiology in the University of Durham. It has been ap-
plied to aneurisms of the abdominal aorta. The cure by
this method takes place rather by the coagulation of blood
in the sac from sudden cessation of the current, than to any
deposit of fibrine. The patient requires to be completely
under the influence of chloroform, so that he may suffer the
application of a powerful pressing instrument on sedative
parts, and so as to restrain all muscular movement. All
APOPLEXY, 19

movement of the.blood in the sac must be completely arrest-
ed, and maintained in a motionless state, as in the applica-
tion of a ligature to the vessel for aneurism, The duration
of the treatment and maintenance of pressure can only be
measured by the result as to the time when pulsation ceases
inthetumor. The first condition of success is, that complete
arrest of circulation in the tumor must be steadily maintained.
Arregular pressure for ten hours has been known to fail. Con-
solidation has occurred in twenty minutes in a case of Dr.
Heath’s, of Sunderland, when complete and steady pressure
was maintained, having failed in a first trial with irregular
pressure. (3.) Dr. Roberts, of Manchester, and Dr. G. W.
Balfour, of Edinburgh, have each collected cases, some
of them under their own care, in which the treatment
of aneurism of the aorta by iodide of potassium was persist-
ently carried out with remarkable beneficial results. The
dose varied from five, seven, ten, fifteen, and twenty to thirty
grains three times a day; and the relief of pain, one of the
earliest symptoms of amendment, does not follow till an effi-
cient dose has been taken. It is better to begin with twenty
or thirty grain doses at once, and intermit or suspend them
for a day or two, if circumstances indicate the necessity of
such step. The object is to saturate the system with the
drug as speedily as possible. It is believed to owe its cura-
tive agency to its power of increasing the coagulability of the
blood. A few weeks may be sufficient to bring about the
curative result; but Dr. Balfour’s experience is, that any
considerable amendment can only be. procured by keeping
the patient for many months, perhaps twelve or more, per-
sistently saturated with the drug. (Balfour, Adin. Med.
Journ. July, 1868, p. 333 Chuckerbutty, in Brit. Med.
Journ., July 19 and 26, 1862; Roberts, Brit. Med. Journ.,
January, 1863). The strict enforcement of the recumbent
position is an adjuvant of paramount necessity in the treat-
ment of all aneurisms. Tracheotomy may prolong life in
some cases where stridor exists, if the laryngeal symptoms
are the source of immediate danger (W. T. Gairdner).

Apoplexy.— Definition Hemorrhages within the skull
or spinal canal, consequent on the rupture of blood-vessels
in the membranes or substance of the cerebro-spinal nervous
system,

Treatment—It may “incline the balance to recovery or
death.” Bleeding from the veins of the arm, the jugular
vein, or the temporal artery, has been the most conspicuous
20 APOPLEXY.

method of treatment from the earliest times. It 1s now em-
ployed only under the following circumstances: (1.) When
there,is an obvious increase of intracranial pressure, It 1s
practiced so as to bring about indirectly a diminution of arte-
tialtension. With such intracranial pressure there is cerebral
hyperemia, and when a paralysis of the respiratory or vagus
centre is threatened, then it is that venesection by diminish-
ing this pressure may have the effect of prolonging life.
Patients have thus been roused from a state of coma. Clin-
ically, the indications for venesection under such conditions in
cerebral hemorrhage are: A turgid face with distended veins,
and increased pulsation of the carotids; a powerfully acting
heart; the radial artery of normal tension; the pulse of nor-
mal frequency, or slow and regular; when the respiration is
uniform, but of snorting character; when the patient is strong
and not too old. Slow and deep respiratory movements,
with stertor (indicating paralysis of the respiratory centre),
and combined with rapid pulse (indicating paralysis of the
vagus), add greatly to the necessity of immediate venesec-
tion. The beneficial action of the remedy is shown by the
pulse becoming softer, more subdued, and more regular.
Venesection is out of place in all cases which do not corre-
spond to this description (Nothnagel). Large bleedings are
to be avoided. The blood ought to be permitted to flow
from a large opening, in order more rapidly to relieve the
congestion, to check, if possible, further effusion of blood,
and to divert its active flow from the head. The head and
shoulders should be raised while the blood is flowing.

On the other hand, in some cases, bleeding during an
apoplectic fit hastens a fatal result—collapse occurring during
or immediately after venesection, from which the patient
never recovers. It is to be avoided in the old and decrepit,
where marked arterio-sclerosis is present; alsd if the pulse be
small and slow, feeble, or almost imperceptible, the skin cold
and clammy, with a tendency to death by syncope; if the
heart’s action be feeble or weak, and the pulse irregular; if
the patient has been of intemperate habits, or is suffering
from organic disease of the heart and arteries; or if there is
a gouty or rheumatic history, no advantage is to be gained
by the abstraction of blood at this time and in this way.
Blood-letting is therefore absolutely contra-indicated under
the following circumstances: (@.) anemia, (2.) aortic valvu-
lar disease, (¢.) in cases commencing with syncope. In such
cases the use of stimulants must be had recourse to in order
APOPLEXY. ar

to prevent paralysis of the heart. The clinical indications
for stimulants are: A pale collapsed expression of face, ab-
sence of venous turgidity, slight arterial tension, heart’s im-
pulse weak, respiration hesitating and intermittent. It may,
in some exceptional cases, be necessary to follow or combine
venesection with stimulants.. The stimulant agents may be
(1.) Such as will rouse the depressed activity of the respira-
tory centre,—e. g., sudden sprinkling of the skin with cold
water; the application of ammonia to the nostrils; (2.) sub-
stances which will stimulate directly the heart’s action—v. g.,
musk, strong coffee, wine, and preparations of ammonia. If
the patient cannot swallow; enemata of musk may be used
(Nothnagel). Many still believe with Trousseau, that in a//
cases; grave or slight, patients do better without either blood-
letting or purgatives. He considers the part played by con-
gestion of the brain to have been much exaggerated. Dr.
Althaus, also, is of opinion (after an experience of more than
400 cases of hemiplegia from cerebral hemorrhage) that the
former universal treatment by venesection was thoroughly
irrational: and he considers that the condition of the brain
during cerebral hemorrhage is not one of congestion (as was
formerly believed), but is one of anzmia; that the organ not
only loses blood largely, but is also, through compression
from the clot, unable to receive a fresh supply; that death
takes place chiefly from anzemia; and that by venesection
we hasten the fatal result. Instead of doing nothing, how-
ever, he recommends ergotine to be at once injected hypoder-
mically (a grain of Bonjean’s ergotine every hour, or even
every half hour), into the subcutaneous areolar tissue. Ad-
ditional chances of recovery may be given by applying to
the head cold cloths, or crushed ice in a bladder, and mus-
tard cataplasms to the feet; also, by placing a drop or two of
croton-oil on the tongue, and by throwing up a cathartic
enema of castor oil and turpentine.

After the patient has in some degree revived, some time
should be allowed for the absorption of the blood effused be-
fore deciding upon the future treatment. A few hours hav-
ing elapsed, the conduct of the practitioner should be guided
by the occurrence or not in the patient of pain of the head,
which may be taken as a measure of the fullness of the brain,
andits tendency toinflammation; but the less thatis done dur-
ing the first three or four days the better. If pain in the head
continue, ten to twelve leeches should be applied from time to
time, till that symptom is entirely relieved; or, supposing the
22 APOPLEXY.

pulse to be full and strong, and the patient free from head-
ache, yet, under these circumstances, leeches should be ap-
plied to the head, to subdue that reaction which so generally
takes place from the fourth to the seventh day. The further
treatment of the case is by moderately purging the patient,
both as a means of relieving the head and of improving the
secretions of the alimentary canal, which are often black and
fetid. Active and searching purgatives generally do good at
this stage. Five grains of calomel with a drachm of com-
pound jalap powder, given as soon as the patient can swallow,
and followed up by black draught, or by an ounce of sulphate
of magnesia with camphor mixture every four or six hours,
and continued, according to its effects, for a greater or less
length of time, are the best means we have for promoting re-
covery, and for preventing a relapse. In cases of hypertro-
phy of the heart, without valvular disease, eight to ten
minims of digitalis may be added to each dose of the purga-
tive medicine. If the power of swallowing is in abeyance,
then three or four drops of croton oil, with five grains of cal,
omel, rubbed up with fresh butter, should be put on the back
part of the tongue, and stimulating enemata thrown up the
rectum. The following are recommended by the late Dr.
Tanner:

1. Enema of Turpentine and Castor-Oil.—Yy. Olei Ricini,
Olei Terebinthine, a a 3iss.; Tincture Asafcetide, 3 ii;
Decocti Avene, % xii.; misce, fiat enema. To be thrown up
the rectum by means of a long stomach-pump tube.

2. Croton Oil Enema.—h. Olei Ricini, Olei Terebinthinz,
aa 3i., Olei Crotonis, m vi., Decocti Avene, 3 iv.: misce,
flat enema.

Although turpentine is objected to by some on account of
the intoxicating effects which it is sometimes apt to produce,
it is nevertheless an efficient remedy where torpor and insen-
sibility exist. It is of great importance to empty the rectum
and lower bowel.

If the intestines are distended by gases, an enema of castor
oil and rue may be given:

3. Castor Oil and Rue Enema.—];. Confectionis Rute,
31; Olei Ricini, 3i.; Tincturee Asafcetidee, 311; Decocti
ne % vii ; misce (Practice of Medicine, 4th edition, p.

53):
_ Apprehension of a relapse being at an end, the patient is
in general most willing to believe that the palsy which may
remain 1s a mere local disease. and to submit to any treat-
ARTERITIS.—ASCITES, 23

ment for its removal; but every attempt to act locally on the
muscular system is prejudicial so long as any central irrita-
tation exists. Such remedies are neither theoretically nor
practically useful. (See -“Paralysis.”) Active or passive
exercise of the muscles are remedies highly beneficial. The
induced current of electricity is also beneficial. It seems to
improve the nutrition of the paralyzed muscles, which tend
to atrophy from long disuse, and paralysis tends also to get
worse frorn diminished excitability of the nerves. Local
faradization by induced currents of electricity gives artificial
exercise to these muscles, and thereby improves their func-
tional and nutritive properties.

Dietetic and Prophylactic Treatment—The diet of the pa-
tient should be limited to milk, boiled vegetables, light pud-
dings, and fish. At no subsequent period ought he to in-
dulge in a full animal diet, or to drink undiluted wines. At
the same time, too lowering a regimen is to be avoided, as
thereby the irritability of the system and the heart’s action:
generally is increased. All the causes of the disease already:
fully referred to should be avoided, counteracted, or over-
come. The diet and the bowels should be carefully regu-
lated, and the patient placed under the best possible hygienic
influences. A sojourn at the moderately warm waters of
Wildbad, Pfaffers, Ragatz, and Laudeck (Teplitz with great
caution), and Rehme and Nauhein, are recommended by
Niemeyer and Nothnagel, with careful regulation of diet and
exercise.

Arteritis.— Definition.—Inflammation ot the textures of
an artery.

Treatment.—Leeches should be applied freely over the
course of the vessel; and large doses of opium, or of ether
with chloroform, may be given to relieve pain and dyspneea.
Iodide of potassium or colchicum may also be indicated, ac-
cording to the constitiitional morbid condition which has
brought about the lesion.

Arthritis, Rheumatic—Sze Ostec-Arthritis, Chronic:

Ascites.—Definition.—A collection of serum slowly ef-
fused into the cavity of the peritoneum.

Treatment.—When ascites occurs without any obvious
organic cause, and without albumen in the urine, the best
remedy is the bitartrate of potash, administered in divided
doses, as one drachm three times a day, or every six hours ;
or in one large. dose, as half an ounce, combined, if the
24 ASCITES.

paitient’s bowels be confined, with ten to fifteen grains of
jalap. When the smaller doses are used, it may be useful to
add ten grains of the citrate or tartrate of iron to each dose.
If these remedies should fail, one-sixth to a half a grain of
the extract of elaterium every night, or every other night, may
be given. When ascites is combined with anasarca, squills
afford most relief. Five to eight grains of the pulvis scillz,
three times a day, generally relieve the dropsy. If the
stomach be irritable, half a grain of opium should’ be added
to each dose. When the ascites arises from disease of the
heart, the kidneys being sound, and the urine free from albu-
men, the treatment must have reference to the nature of the
cardiac lesion. If the valves of the heart are diseased, the
patient may be greatly relieved by the administration of
tonics, stimulants, and saline or drastic purgatives. An
ounce and a half of camphor mixture, with a drachm of the
spirit of nitrous ether, fifteen minims of the tincture of hyoscy-
amus, and a drachm of the sulphate of magnesia will fozm a
draught which, taken three times a day, may greatly reduce
the ,dropsy. The tincture of squills (mx. to mxx.), with a
drachm of the acetate of potash, has occasionally succeeded.
Small doses of elaterium, as one-eighth to one-fourth of a
grain three times a day, is a medicine that is also sometimes
useful. Should the liver be inflamed or hypertrophied, with-
out other alterations of structure, the dropsy may disappear
with the cure of the hepatic disease. Bleeding by leeches,
if the hepatic lesion be due to the congestion of inflamma-
tion, and the neutral salts, such as the sulphates of magnesia or
soda, or moderate doses of calomel, may give relief. If due
to a cirrhotic liver paracentesis abdominis ought to be re-
peated as a systematic method of treatment (F. Tf. Roberts).
Abdominal pains are relieved most effectually by fomenta-
tions. The bowels are often greatly constipated, and require
drastic purgatives, as the black draught, castor or croton oil,
or even elaterium. In ascites depending on enlarged spleen
when it is simply hypertrophied, the bromide of potash, and
the iodide of potassium, in doses of five to eight grains three
times a day, have been found useful. My friend and col-
league, Professor Maclean, has found that rubbing the binio-
dide of mercury, in the form of an ointment, in the proportion
of 15 grains of the biniodide to one ounce of lard or vaseline,
on the skin over the enlarged spleen, has a marked bene-
ficial effect in reducing the enlargement. The ointment, in a
piece about as large ac a nutmeg, is to be rubbed into the skin
ASTHMA, HAY.*—ASTHMA, SPASMODIC, 25

while the patient sits before a strong fire or in the rays of an
Indian sun; in the evening of the same day, half the amount
is to be rubbed in lightly ; and the ointment is not to be re-
peated at a less interval than 14 days. The invalided sol-
diers suffering from splenic enlargement invariably ask for a
supply of the remedy when they go from hospital. The
biniodide of mercury, similarly used, has been of great service
in reducing the swelling of a goitre. The dropsy which oc-
curs in young chlorotic women, in whom the urine contains
albumen (the kidney being healthy in structure though dis-
ordered in function), is generally curable,—the most efficient
remedy is the bitartrate of potash in drachm doses three
times a day, combined with iron. :

Asthma, Hay.— Definition A peculiar catharral affec-
tion occurring during the summer months, especially during
the inflorescence of the grasses, or during the drying and
conversion of the newly-mown grass into hay in May, June,
and July.

Treatment.—Regarding it as the result of irritation (speci-
fic or mechanical) from fine particles of matter (indefinite
dust or specific powder) floating in the air, the use of a res-
pirator of fine cotton, or of crape or cambric in several folds,
should prevent the affection, and ought to be tried by those
who suffer every year about the months of May and June.
In other respects the local catarrh must be treated as de-
scribed under “ Bronchial Catarrh,” and ‘“ Bronchitis.”

Asthma, Spasmodic.—Defnition—A disease which
culminates in paroxysmal attacks of difficult breathing, of
varying duration. The dyspnoea seems to be immediately
dependent on more or less extensive contraction of the small-
er bronchi, due to spasm of their circular fibres. The breath-
ing is accompanied by a wheezing sound, a sense of constric-
tion in the thorax, great anxieties, and a difficult cough. The
attack usually terminates by the expectoration of a quantity
of mucus from the lungs, which varies considerably “in ap-
pearance and in amount. In some instances the mucus is
thick and heavy, in others it is light and frathy, whilst in the
severer forms there may be only a few dark pellets coughed
up before relief is obtained (Pridham). In the hours imme-
diately succeeding the fit, a remarkable diminution of the
urea and chloride of sodium may occur, which would imply
a considerable arrest either of formation or elimination,
probably the former (Ringer, Parkes); or to the starvation
that is generally enforced at that time (Salter).

,
26 ASTHMA, SPASMODIC.

Treatment comprises, (1.) What should be done during
the fit; and,(2.) during the intervals. When a patient is la-
boring under a fit of either form of asthma, to tranquillize
his suffering and shorten the attack isthe aim of treatment.
Any exciting case must be removed. An undigested meal,
or constipation, must be got rid of—by an emetic in one case,
or by an enemain the other. The patient should have a strictly
tonic regimen ; and camphor mixture, to the extent of about
an ounce and a half, combined with a drachm of the spirits of
nitrous ether and some morphia, may be giyen every hour, or
every two hours, for a short time. Some milder narcotic may
be substitued for morphia, as tincture of hyocyamus, to the
extent of about fifteen drops for each dose. Or asafcetida,
castor, musk, or hydrocyanic acid, to the extent of miij. every
six hours, may be substituted. If the fit should occur after
a hearty meal, and after an emetic has been given, the tinc-
ture of rhubarb, or the sulphate of magnesia, should be con-
tinued in repeated small doses. If the attack be long, arrow-
root or sago, with small quantities of wine or brandy, should
be given to support the patient underhis exhausting suffer-
ings. Ipecacuanha, tartar emetic and tobaccoare the drugs
which most rapidly relax spasm as direct depressants. There
is, however, great danger in the use of the latter, from un-
manageable and dangerous collapse. Tobacco ought never
to be indulged in by the asthmatic, except as an agent in the
cure of his disease. Then only can he look to it for relief,
and it should be smoked from a pipe. Ipecacuanha ought to
be given in a dose of twenty grains at the onset of the parox-
ysm. The feelings of the sufferer should be consulted as to
the temperature to which he should be exposed during the
paroxysm. Where there is any organic lesion the fresh air
is grateful and reviving. On the contrary, when the parox-
ysm is purely a spasm of the bronchial tubes, warmth, by
relaxing spasm at their ultimate divisions, is generally more
useful than cold. Patients learn by experience what will
give them most relief. Strong coffee, spirits and water, ice
rapidly swallowed, may suit individual cases.

The treatment during the interval is all-important. Few
cases will be found of true spasmodic asthma which are not
entirely under the control of well-regulated dietetic manage-
ment. By many physicians a rule of life as to diet is the only
certain treatment of asthma. Extremely strict dietetic treat-
ment and sedatives during the intervals of the paroxysms
must be prescribed. A plan of treatment somewhat as follows
ASTHMA, SPASMODIC. 27

may be laid down, after that suggested by Mr. Pridham of
Bideford and Dr. Hyde Salter of London :—The secretions
from the bowels are first to be corrected by Pilula Aloes cum
-Myrrha, gr. iii.; Pilule Hydrargyri, gr. i.; Extracti Tar-
axaci gr. i; Extracti Strammonii, gr. ss., made into two pills
to be taken at bedtime, followed by a saline aperient in the
morning. Or giving, every alternate night, Pil. Hyd., gr. iv.;
Pulv. Ipecac., gr. i., in the form of a pill. And on the fol-
lowing morning, Mist, Sennz comp., 3 i. ; Bicarbonatis Mag-
nesia, gr. x.; Bicarbonatis Sode, gr. viii; and during the
day small doses of compound ‘rhubarb powder. After thus
attending to the general secretions for about ten days, a strict
diet is to be commenced, which must be regularly weighed
out and adhered to, the hours of meals being fixed.  (1.)
Breakfast at eight a. M., to consist of half a pint of green tea
or coffee, with a little cream, and two ounces of dry stale
bread. Dr. Salter allows an egg or (zo¢ and) a mutton chop,
or some cold chicken or game. ‘T’ea is better than coffee,
and milk and water better than either. (2.) Dinner at one
P. M., to consist of two ounces of fresh mutton, without fat cr
skin, and two ounces of dry stale bread or well-boiled. rice.
Beef and lamb should be rarely eaten, pork or veal never.
There should be no cheese and no dessert (Salter). Three
hours after dinner (not sooner) half a pint of weak brandy
and water, or whisky and water, or dry sherry and water,
may be taken, or toast-water ad /ibitum, Water is the best
fluid to drink. (3.) Supper at seven P. M., to consist of two
ounces of meat as before, with two ounces of dry stale bread.
The patient is not to be allowed to drink any fluid whatever
within one hour defore his dinner or supper, and not until
three hours after either of these meals. At other times he is
not limited as to drinks, otherwise than that all malt liquors
are to be prohibited. Soda or seltzer-water may be indulged
in when thirsty. With this dietetic treatment, sedatives, such
as three grains of the extract of conium, are to be taken four
times a day—namely, at the hours of seven, twelve, five, and
ten,—the dose to be gradually increased to five grains four
times a day. To each of these pills a fourth of a grain of
the Extract of Indian hemp may be added, which may be
gradually increased to one grain in each dose. Under this
treatment in a few days distressing symptoms subside; and
after the regimen has been strictly persevered in for at least
a month, two ounces more of meat may be permitted, if di-
gestion is sufficient. The stools must be repeatedly seen by
28 ASTHMA, SPASMODIC

the physician ; and the stomach must not have more to do
than it can accomplish. The powers of digestion are known
to be recovering when there is a craving for food as the hour
of nourishment arrives. If flesh is gained, strength improves ;
and while the tongue cleans, the appetite improves, the dis-
tension of the stomach lessens, and the powers of digestion
recover. The patient ought to be able to sleep six or seven
hours at a time, and to lie in bed all night. If these results
follow, the ultimate cure of the disease may be looked for;
but it may at the same time be taken for granted that the
asthmatic can never with impunity eat and drink as other
people. It is only by the exercise of self-denial that the pa-
tient has it in his own power to live a life of comparative
ease and comfort. Many patients not possessed of such re-
solution, self-denial, and strength of mind, will say such
dieting does not suit their constitution, and that they cannot
or will not persevere; but no trial of the remedy can be con-
considered sufficient which does not embrace a period of at
least six months, the physician taking care to ascertain the
weight of the patient, his age and height, before commencing
any treatment. It is difficult to persuade many people to live
so abstemiously. Many cannot control their appetite; or
they believe that in so limiting themselves in regard to diet
they will injure their constitution. It is necessary to subdue
by sedatives rather than opiates the abnormal ravenousness
of appetite. Asthmatics are generally dyspeptics ; and the
most simple rule regarding diet is:—Let no food be taken
after such a time in the day as will allow digestion being
completed or the stomach empty before going to bed. The
time when the last solid food should be taken will depend
upon what the bedtime is. If ten, or half-past, then three or
four should be the dinner hour, after which no more solid
food should be eaten.

Open air exercise must be freely taken, but not within
three hours after eating animal food, and the exercise must
be always short of fatigue. The greatest punctuality is
necessary as regards the taking of food, of exercise, and of
medicine; and the bowels should act immediately after
breakfast, either naturally or by enema. Success depends
on the regularity with which all the functions of the body
can be performed ; and care should be taken to rest body
and mind, at least, for one hour after food. Smoking stra-
monium, the inhalation of chloroform, or of ether, or both, al-
though they appear to soothe and mitigate the paroxysm in
ASTHMA, SPASMODIC, 29

some cases, yet they do not appear to shorten the attack in
any. The inhalation of nitrite of amyl has been recently recom-
mended. The fumes of stramonium are to be collected in an in-
verted glass bowl with a narrow mouth. The bowl being charged
to its full, is placed under the mouth of the patient, who is
directed to inhale, to the fullest extent in his power, the
smoke which has been collected in the bowl. Or the stra-
monium may be smoked like tobacco, “then puff the smoke
into a tumbler, and inhale it cold into the lungs” (Bullar),
Or it may be smoked as an Oriental smokes the hookah, in
which the smoke is purified by being passed through water.
Cigars and cigarettes of stramonium are now sold by the
chemists. The fumes of brown paper saturated with a solu-
tion of nitrate of potash sometimes also relieve the spasms.
Indian hemp, in doses of from two to four grains of the ex-
tract, or thirty minims of the tincture, will often relieve the
spasm for the time being, but may fail ever after, (See Wat-
son, “ Lectures on the Practice of Physic,” Vol. II).

Only one remedy—jaborandi, and its alkaloid pilocarpin—
has beeh found not only to remove the urgent symptoms of
asthma, but to exercise, at the same time, a favorable influ-
ence on the disease itself. It produces a powerful revolution
in the distribution of the blood, by attracting a large volume
to the skin and salivary glands; and by diminishing its vol-
ume through copious perspiration and salivation, congested
internal organs are relieved in a proportional degree. Dr.
Berkhart has found the alkaloid preferable to jaborandi, be-
cause—(1.) It acts more rapidly; (2.) it does not produce
strangury ; (3.) the dose can be more accurately regulated.
In cases where the cardiac muscles are in a state of fatty
degeneration, the influence of pilocarpin may induce the
most alarming symptoms; which soon spontaneously subside,
the heart regaining its previous force. But if it lingered to
do so, asubcutaneous injection of +45 or yp grain of atropine,’
or one drop of liquor atropiz (B. P.), immediately restores
the balance. Pilocarpin, or muriate of pilocarpin, is more
suitable in the treatment of the younger asthmatics, but is by
no means contra-indicated in patients of more advanced age.
The dose should not exceed one-third of a grain. Dr. Berk-
hart has never used more than ten drops of a 2 per cent. so-
lution, injected under the skin of either arm. During the
action of the drug, the patient should preserve the recumbent
posture—which the almost immediate relief obtained will
enable him to do—and he should be carefully watched until
5° ATHETOSIS.—~BERI-BERI.

‘

the effect has passed off. It is desirable to have a solution
of atropine or liquor atropiz always at hand, in case of need.
It is well, also, not to use pilocarpin soon after the patient's
meals; if the dyspnceal seizure occur under these circum-
stances, there are, itis needless to say, other remedies more
suitable (Brit. Med. Journal, June 19, 1880). Similar re-
sults may be obtained in less urgent cases by the internal
administration of the powder of the leaves, in doses of 30 to
go grains, infused in boiling water—the water and grounds
being swallowed together.

Athetosis.—Dejfinition—A form of spasm hitherto ob-
served chiefly in the muscles of the hand and of the fore-
arm, characterized by the impossibility which the patients
find in keeping the fingers and toes in any desired position ;
and the inability to prevent a continuous action of them,
which is slow, regular, and never ceasing, except when the
limb is supported, or during sleep. The movements are not
disorderly, like hysteria and chorea, nor tremulous, like those
of paralysis agitans and various forms of sclerosis.

Treatment—Beyond improving the general health, any
medicinal treatment can only be determined upon by a spe-
cial study of each particular case. If syphilis has been an
antecedent, its appropriate remedies must be had recourse to.

Beri-Beri.—Definition.—A constitutional disease, expres-
sed in the first instance by anzemia, and culminating in acute
cedema. Itis marked by stiffness of the limbs, numbness,
and sometimes by paralysis of the lower extremities, op-
pressed breathing (anxietas in paroxysm), and a swollen and
bloated countenance. The urine is secreted in diminished
quantity. The cedema is general, not only throughout the
connective tissue of the muscles, but throughout the connec-
tive tissue of solid and visceral organs in every cavity of the
body. Effusion of serum into the serous cavities very gen-
erally precedes death.

Treatment.—Bleeding has been considered applicable to
those cases where there is extreme difficulty of breathing and
delirium, when the patient is robust, and when the cedema
does not pit much on pressure, where there is rapid and full
pulsation of the large arteries, and if the urine shows the
existence of albumen (Wright); but,’ judging from the
pathology of this disease, ‘the constitutional influence of
stimu'ants, of a generous strengthening diet, of tonics, diu-
retics and analeptics, ought undoubtedly to be the basis of
BERI-BERI. 3r

treatment. Should there be irritability of the stomach, an
effervescing draught, with doses of laudanum and camphor
mixture are useful. Saline drinks should be administered,
and the extremities should be rubbed with stimulating lini-
ments, and rolled in flannel bandages. In the asthenic or
chronic form of the disease, the strength must be supported
by the most nourishing diet that can be given in small bulk,
aided by tonics, and wine if necessary ; while doses of equal
quantities of squill and digifalis (ten to fifteen drops of each)
may be given twice or thrice daily. In the third and mildest
form, a native remedy called Treeak Farook is very useful.
The ingredients of this medicine are unknown ; but it pro-
fesses to be the “ Theriaca Andromachi” of old writers. It
is prepared in Venice, and transmitted to India through
Arabia, and was first recommended by Dr. Herklotts, of the
Madras Presidency, as a remedy in beri-beri. It is a thick
extract (in which some terebinthine material largely enters),
which is only to be procured from the Moghuls, and in those
towns which still keep up some communication with the
Arabian Sea. Many observers bear testimony to its good
effects in removing the cedema and subduing the pulse
(Wright, Traill, Madras Quarterly Med. Jour., 1842, Vol.
IV., p. 154, Geddes, Malcolinson). In some recorded cases
the pulse has fallenin four days from 108 to 84 beats per
minute under its use. The prescription most approved of
consists of pills of the following ingredients :—

R. Treeak Farook, 5ss.; Pulv. Rhei., 3 iiss; Confectio,
Aromat., 3ss.; Mellis, q.s., misce, et divide in pill xlviii,
(Malcolmson),

The electuary form is also much used in India. The
remedy does not seem to be an active medicine, except in
combination. Four or five stools are obtained daily under
its use, and its action is not accompanied by any violent
purging, increase of pulse, or determination to the surface ;
and after it has been used from one to two weeks, the cede-
ma generally disappears, when the numbness and paralysis
subside. If it purges, the quantity of rhubarb must be
diminished. The patient should feed on animal food,
wheaten cakes, and milk. In instances where the native
remedy has failed to produce a beneficial effect, nux vomica
has been more successful, commencing with doses of two
grains of the extract daily, and increasing the dose gradually
according to the physiological result. The extract of nux
vomica, in doses of half or a quarter of a grain, combined with
32 BLADDER, CATARRH OF.——~BRAIN, TUMORS, ETC.

iron or gentian in a pill, is the most convenient form. Local
abstractions of blood from the spine have also proved useful ;
and a blister applied over the loins has given relief in many
obstinate cases. No single rule of treatment will apply in all
cases. The anzemic condition must be counteracted on the
principles of treatment explained under that disease ; and any
specially abnormal state, such as diseased heart, must be
treated accordingly. When the disease prevailed very generally
in the Carnatic, in 1782 and 1783, some cases were most suc-
cessfully treated by a pill containing a quarter of a grain of
extract of elaterium, combined with extract of gentian, given
every hour until copious watery evacuations were procured ;
and this plan was repeated every third or fourth day, till
with others this plan of treatment was not so successful ; the
cases recovering best under large doses of spirits of nitre,
antimonial wine, frictions with warm camphorated oil, aperi-
ent medicines, wine, and a nourishing diet. Mr. Evezard’s
method of medicinal treatment consists mainly in the admin-
istration of acetate of potash in gin, in the following for-
mula :—k,. Gin, 3 ss.; Potass. Acet., gr. v.: Aqua, 3 iii. ;
misce. To be given three timesa day. If vomiting persists,
hydrocyanic acid may be useful in relieving it, to the extent
of one drop three times a day, given in milk. In the expe-
rience of Dr. Paterson of Bahia, a trip to Europe (if not had
recourse to too late) is a certain cure: and medicinally, his
patients have derived marked benefit from a combination of
ergotine, iron and extract of belladonna, in the form of a
pill, Sea-bathing is also acknowledged to be of great service,

Bladder, Catarrh of— See Cystitis.

Brain, Inflammation and Suppuration of-—See Zn
cephalttes.

Brain, Tumors, Ete., of.—Definition—New growths,
parasites, and aneurisms, implicating the cerebral substance,
the spinal cord or their membranes, or both.

Treatment—Under such circumstances medicinal treat-
ment,can be only palliative; the patient may be protected as
much as possible from hyperemia of the brain aggravating
the morbid state. His nutrition and mode of life must be
regulated, and also the functions of the bowels. Apoplectic
or local inflammatory attacks may be met by local blood-
letting and cold compresses, Hypodermic injections of mor-
phia are also to be used in suitable cases. If syphilis exists,
BRIGH'T’S DISEASE, 33

or is suspected, anti-syphilitic remedies are at once to be
adopted.

Bright’s Disease.— Definition. generic term, includ-
ing several forms of acute and chronic disease of the
kidney, associated with albumen in the urine, frequently with
dropsy, and with various secondary or intercurrent affec-
tions, resulting from deterioration of the blood.

Treatment—{a.) Of Acute Bright’s Disease-—(1.) Relieve
the kidneys as much as possible from the labor of elimina-
tion, by avoiding exposure to cold, by keeping the patient at
rest in bed, in a room of moderate uniform temperature. (2.)
The food should be scanty, consisting of gruel, arrowroot,
milk, or weak broth. Pure water is the best drink, and alco-
holic fluids are not to be taken on any account. (3.) Free
action of the skin and bowels must be maintained. The hot
air bath and antimonial remedies are the best agents to effect
the first of these conditions, and free perspiration is to be
encouraged by bedding the patient in blankets. Antimonial
wine may be given in doses of from fifteen to thirty drops
every four or five hours. The bowels are to be kept open
by the compound jalap powder, in doses of twenty to sixty
grains, repeated daily or on alternate days. It may be alter-
nated with podophyllin or with extract of colocynth. Mercury
isnot to be given. (4.) Cupping over the loins relieves pain in
the back, and the quantity of urine passed generally increases .
after eight or ten ounces of blood have been withdrawn in
this way from an adult, or two or three ounces from a child
three or four years old. (5.) When the tongue becomes clean
and the general symptoms improve, mutton broth or good
beef tea may be indulged in; and, as the digestion improves,
solid food may be eaten in small quantities, beginning with
fish and fowl, and afterwards mutton or beef. (6.) Flannel
must be worn next the skin. (7.) Iron is of great service
during convalescence, for in such cases the anzemia becomes
extreme. ,‘Phosphate of iron, in the form of syrup, or citrate
of iron and quinia, or the ferrum redactum, are the most
digestible forms, and they ought to be given in ‘small doses
repeated after every diet. (8.) Diuretics are not to be given.
In a case where the urine was suppressed, fomentations, con-
sisting of infusion of the leaves of digitalis, were found by
Christison and Vogel to increase enormously the amount of
urine. Parkes found the amount of the albumen to diminish
markedly from the use of the tincture of the sesquichloride
of iron (. C., Pp. 379).

8
34 BRIGHT’S DISEASE.

(6.) Of Chronic Bright's Diseasc, general principles only
‘can be indicated, inasmuch as every case requires a special
study, and a line of treatment in detail peculiar to itself.
Whatever treatment be adopted, a long time is necessary be-
fore any appreciable results are obtained. It is, therefore,
necessary to persist in one line of treatment steadily from
week to week,-and even from month to month; and it is ob-
viously of great importance to be as accurate as possible in
diagnosis as to the probable state of the kidney, so as to de-
fine the line of treatment from the first which may seem best
adapted for the individual case.

It is a question of grave importance how far vomiting or
diarrhoea ought to be checked. If either of these occur-
rences are suddenly stopped, the gastric and intestinal mem-
brane acting at the time as an emunctory for the urea and
other excreta of the urine, the patient may be suddenly cut
off by convulsions, apoplexy, or effusion into some of the
serous cavities, such as the pericardium, or the pleure, or the
ventricles of the brain. It is necessary, therefore, in the first
instance, to determine in all chronic cases the particular organ
or tissue which seems in each case to be acting vicariously.
‘The perspirations are often spontaneously profuse; and the
skin is by far the safest emunctory for the vicarious elimina-
tion of urinary constituents. Therefore it is important to
promote the action of the skin if it be deficient, and to en-
courage it even if it is already considerable. Diaphoretics
are always of essential service. The best are Dover’s pow-
der, the warm bath, warm clothing, and, for convalescents
especially, a moderately warm climate. In Sir Robert
Christison’s experience diaphoretics have always appeared
most serviceable when they are so given as to excite a gentle
perspiration during a part of the night. So it is also safe to
promote the discharge of secretions from the intestinal canal,
with due caution that they do not become excessive, so as to
pass into permanent diarrhea. Urea and other constituents
of the urine are found in such discharges in large proportions.
When general anasarca prevails, absorption may be promoted
by gentle pressure, which at all times must be very cautiously
applied, and the effects closely watched, for such effusions
afford great temporary relief to important symptoms which
indicate the involvement of vital organs. Bandaging to pro-
mote absorption is not justifiable so long as the anasarca is
increasing, Patients ought to be encouraged to go about as
long as they are able, care being taken that they are clothed
BRIGH'T’S DISEASE, 35

with flannel and woolen garments, and otherwise well pro-
tected from chills or draughts of cold air.

In the subacute forms of the disease the action of the skin
is especially to be promoted by such saline remedies as the
acetate or citrate of ammonia, to which may be added one,
two, or three drachms of the infusion of digitalis, and.ten or
fifteen minims of antimonial wine. In such cases, also, ten
or fifteen minims of the tincture of the perchloride of iron,
or from five to ten grains of the citrate of iron and ammonia
may be given every day with one of the meals. Every second
day a dose of the compound jalap powder may be given; and
if hyperzemia of the kidneys prevail, it may be necessary to
take from four to six ounces of blood from the loins by cup-
ping or by leeches. As the urine becomes more free from
blood corpucles and albumen, the iron medicines. may be
more frequently given, and the compound jalap powder less
frequently. A good formula for the administration of salines
and iron in the subacute and chronic cases is that given by
Dr. Basham and Goodfellow, as follows: ;

Liquor Ammoniz Acetatis, 3 ii.; Acidi Acetici diluti, 31;
Tinct. Ferri Perchloridi, 3 iv.; Aque, 3 iss.; misce. Two tea
spoonfuls for a dose.

Small doses frequently repeated seem to do better than
larger ones given at longer intervals. ‘These remedies tend
to lessen the watery state of the blood; and the action of the
chalybeate medicines is of no avail till after purgation has
been free, and when the hot air or warm baths have caused
the skin to act freely. A nutritious diet is then to be given,
combined with the chalybeate remedy.

The quantity of urea passed by the urine should be deter-
mined day by day, to ascertain how far the kidneys are capa-
ble of secreting and eliminating these excrementitious pro-
ducts. According to the results obtained the diet must be
regulated, and such measures taken as are calculated to re-
duce the quantity of urea, and other constituents formed
daily, to the capacity of the diseased kidneys for the work
they are able to do.

The further treatment of the chronic forms of Bright’s dis-
ease is influenced by the amount of the anasarca present.
If considerable anasarca is present, neither cupping nor
leeches can be had recourse to, on account of the bruising
and erysipelatous inflammation they are apt to induce. The
chalybeate mixture already mentioned is still found of ser-
vice, taken at least three times daily, and to it may be added
36 BRIGHT’S DISEASE.

from time to time fifteen or twenty minims of the spiritus
etherus nitrici (Goodfellow). ‘The citrate of iron and am-
monia, in from five to ten grain doses, with the sulphuric or
chloric ether, are also good and useful rémedies; and if the
iron medicines are found too stimulating, sulphate of zinc,
or tannic and gallic acids, may be used instead. The sul-
phate of zinc is to be given, in doses of one to three grains
three times a day, in the form of a pill, made with extract of
hop, and with or without a grain of the extract of nux
vomica; or the same dose of sulphate of zinc may be given
in a draught combined with sulphuric or chloric ether (Good-
fellow). These latter medicines relieve considerably the flat-
ulence and sensation of coldness in the stomach and bowels,
so much complained of in such cases.

If the urine is “smoky,” or if blood is seen on microscopic
examination, the gallic acid, in five or ten grain doses, may be
given, with afew drops of diluted sulphuric acid and a few

-drops of the tincture of hops, or other aromatic vegetable tinc-
ture, in an infusion of the same. The objection to these rem-
edies is the constipation they are apt to induce. ‘The bowels
should always be kept relaxed, two or three loose evacuations
being secured daily. The medicine most generally useful 1s
the compound jalap powder of the London Pharmacopeeia,
which should be taken in the morning fasting, in half drachm
or drachm doses, in a wine-glass of water. It does not induce
prostration, but by repetition it is apt to lose its effect, when
elaterium may be necessary in small but repeated doses; two
grains of elaterium being dissolved in sulphuric ether, and the
eighth of a grain given every six hours till the desired effect is
produced. Very abundant watery purgation is thus obtained,
and a sensible impression is made upon the distended dropsi-
cal parts (Basham). If elaterium may not be deemed advisa-
ble, a saline draught of the following composition may prove
efficient:

i. Magnes. Sulph. vel Sode Sulph., 3i.to 3 ij.; Astheris
Sulph., m x.; Acid. Sulph. dil., mx.; Ferri Sulph., gr. i. to i;
Aq. Menthe Vir., 3 iil. to § iv.

This draught is to be taken the first thing in the morning
once or twice aweek. It ought to produce two or three loose
and watery evacuations (Goodfellow). ~

Diuretics are a most certain and speedy remedy when the
dropsical effusions are considerable; and they are sometimes
advisable when the urine is scanty, although they are seldom
necessary in the treatment of the fundamental disease. Sir
BRiGHT’S DISEASE. 37

Robert Christison is convinced that the fears entertained by
some of injury being produced by the stimulus of diuretics on
the kidneys are visionary. In his experience, over more than
forty years, the best diuretics are digitalis, squill, and bitar-
trate of potash, taken simultaneously; and, if these fail, Hol-
lands spirits sometimes speedily establishes the diuresis.

When dyspeptic spmptoms predominate, and there is con-
siderable flatulence, the following pill is recommended byDr.
Goodfellow to be taken twice or thrice daily:

_&. Ferri Sulphatis, gr. i.; Ext. Nucis Vomice, gr. %4 to
i; Mas. Pil. Galb. Co., gr. ii. to iii; misce, fiat pilula.

And if there be co-existent bronchitis, a draught of the
acetate of ammonia, with ten, fifteen or twenty drops of the
spiritus aetheris nitrici, and half a drachm of the oxymel of
squills, is to be taken intermediately with the pills. If much
nausea prevail three minims of dilute hydrocyanic acid may
be added to the draught, with occasional application of mus-
tard to the stomach.

Want of sleep is often complained of, but opiates are in-
advisable, because they are apt to check the secretions and
to occasion constipation. Henbane may be given in place
of opium. :

The patient should select a residence where the soil is san-
dy or chalky, where the air is mild and dry, so that as much
open-air exercise may be taken as possible.

Diet should be light, but nutritious; no pastry should be
eaten; and stimulant liquors should be used with caution, al-
though, when exhaustion is great, their use may be unavoidae-
able. The principal meal should be in the middle of the
day, but not later than three o’clock; and the last meal should
be taken two or three hours before bedtime, retiring early to
bed, and rising early. Light but warm woolen clothing is to
be always worn—in summer as well as in winter.

The complications of Bright’s disease are extremely diffi-
cult to manage. The diarrhoea must not be suddenly
checked. Thirty to sixty minims in water of the spiritus
ammoniz aromaticus, with half a drachm of the tincture of
kino or of catechu, after every loose stool, will in general be
all that is necessary. If there be much griping, the applica-
tion of a linseed poultice over the abdomen, with two
drachms or half an ounce of tincture of opium sprinkled
over it, will give relief (Goodfellow). When it is found nec-
essary to use measures for checking the diarrhoea, means
should be taken that the skin acts freely, or that the urine
38 BRIGHY?’S DISEASE.

flows increased in quantity. Lead and opium pill (pilula
plumbi cum opio), in doses of five or ten grains twice or even
thrice a day, is the best remedy for checking diarrhcea. These
remedies may be aided by a suppository of the hydrochlorate
of morphia occasionally, each suppository containing a quar-
ter of agrain of the hydochlorate of morphia (morphiz hy-
drochlor. suppositoriz). Vomiting may be controlled to some
extent by bismuth, but more frequently by morphia, hydrocy-
anic acid, creasote, rectified pyroxylic spirit, chloroform, or
chlorodyne, or little fragments of ice; and if these fail, a blis-
ter over the epigastrium has sometimes succeeded (Sir Robert
Christison).

Intercurrent inflammatory attacks and cffusions into cavi-
ties are still more difficult complications to manage. ‘The ap-
plication of afew leeches, or the abstraction of a few ounces
of blood by cupping, may be borne well in cases ‘with head
complications; but the greatest care and caution are required
in the employment of similar remedies in the complication of
pericarditis, on account of the great danger of death by
syncope.

Bronchial complication are serious, and more or less con-
stantly present. They are frequently the immediate cause of
death in chronic Bright’s disease. The least stimulating ex-
pectorants may be administered under such circumstances.
The following formula is recommended by Dr. Goodfellow:

i. Liquor Ammonie Acetatis, 3ii. to Ziii.; Spiritus
(Etheris Nitrici, mxx. to 3ss.; Oxymellis Scillae (Lond.),
3ss.; Aqua Camphore et Aque aa 3 v.; misce, fiat haustus.
To be taken every four, six, or eight hours.

If the expectoration be viscid and difficult to discharge, a
few drops of antimonial wine may be added to the draught;
or if there be much spasm of the bronchial tubes, as indicated
by the asthmatic breathing, a few drops of sulphuric or
chloric ether may be given. If, on the other hand, the ex-
pectoration be purulent and difficult, a few grains of carbon-
ate of ammonia may be given with the oxymel of squills.
Every precaution ought to be taken to prevent a fresh attack
of bronchitis. So long as the patient is able to bear it, the
habit of cold sponging and dry rubbing of the surface of the
body every morning with a flesh brush or.coarse towel is the
best preventive, and being clad in warm woolen clothes.
Flannel next to the skin must be invariably insisted on.

Mercurial preparations are contraindicated in Bright’s dis-
ease—so great is the tendency to salivation and the otherwise
BRONCHIAL CATARRH. 39

injurious effects they produce. Podophyllin (the active prin-

ciple of the May apple) may be used instead. Its dose is from

4 to 1 grain; and it ought not to be given in doses larger than-
one grain. Itis best given in a fluid form (see p. go2, ante),

ora pill with soap and hyoscyamus. As an occasional mild

aperient pill, the following is found to answer well:

R. Mas. Pil. Rhei. Comp., gr. ii. to iii; Vel. Ext. Aloes,
Aquosi, gr. i; Ext. Nucis Vomice, gr. i; Mas Pil. Galb. Co.,
gr. il.; misce. fiat pilula (Goodfellow).

Bronchial Catarrh.— Definition —Infiltration and cede-
ma of the mucous membrane of the bronchial tubes, so that
tumefaction diminishes their calibre, attended first with dry-
ness of surface, followcd by a watery secretion, which subse-
quently becomes. turbid ard yellow. The, disease is some-
times attended with chilliness and the discomfort of what is
called a “ common cold.”

Treaiment.—When the symptoms of a “common cold”
first express themselves, when the attack is sudden, attended
with marked depression, aching pains in the head, back, and
limbs, and febrile disturbance (and even when the sensations
have extended to the chest, as indicated by the hoarseness
and tendency to cough), the disease may be at once subdued
in a healthy person-by a full stimulant (but not narcotic)
dose of opium or morphia. “One-third or one-fourth of a
grain of muriate of morphia, or one grain of opium, ought to
be taken at bedtime. Its influence will begin to be felt in
from twenty minutes to half an hour, by the gradual disap-
pearance of the sense of intense weakness, the relief of the
pains, and that peculiar feeling of thorough and evenly tis-
tributed warmth of the whole body which is so different from
fever on the one hand, or chilliness on the other” (Anstie,
op. cit., p. 120.) An alcoholic diaphoretic drink; or five
grains of carbonate of ammonia, or ten to twenty grains of
muriate of ammonia; or, if the appetite is unimpaired, a full
supper, followed by a hot alcoholic stimulant, may have a
similar effect to opium. Natural sleep ought to supervene,
and the morning ought to find the patient well. The follow-
ing formula has been recommended as an anticatarrhal olfac-
tory, originally prescribed by Dr. Hagner; — Carbolic acid,
5 parts; rectified spirit of wine, 15 parts; strong solution of
ammonia, 5 parts; distilled water, 10 parts. The mixture is
kept in a stoppered dark glass bottle. When a catarrh is
commencing, a few drops are placed on three or four layers
of blotting or filtering paper; the patient holding this in his
40 BRONCHIAL CATARRH.

hand, and closing his eyes, inhales deeply from it as long as
any smell is perceptible. The effect is to cut short the acute

_ Stage of the cold, to prevent the occurrence of subsequent
coryza and bronchial and laryngeal catarrh; while all trouble-
some symptoms are rendered much milder. The remedy
should be applied every two hours a E. Brand, Wiener
Med, Wochenschrift, Jane 15, 1872). Snuffs composed of
morphia and subnitrate of bismuth are also found useful when
coryza is present—e. g., muriate of morphia, gr. i.; powdered
gum arabic, 3i.; subnitrate of bismuth, 3 111.; and oxide of
zinc may be added in the proportion of 40 grains. This com-
pound powder is to be repeatedly and thoroughly snuffed
into the nostrils.

If such remedies are delayed too long, the object next to
aim at is to induce a copious perspiration and a continued
action of the skin and kidneys, by small doses, frequently re-
peated, of antimonial and ipecacuanha wines, or nitrate of
potash, or acetate of potash, as well as bicarbonate of potash
and aqua potassee, combined at a later period with tinctures
of squills and hyoscyamus. In the early stage of the disease
the bronchial membrane has its normal moist condition al-
tered to a dry state; and the object of treatment is to bring
about a return of the naturally moist condition. This is
best effected by the inhalation of the vapor of hot water, the
use of tartar emetic in doses of one-twelfth to one-sixth of a
grain, the use of ipecacuanha in one-quarter or half-grain
doses, From the frequent inhalation of steam great benefit

is derived. Opium has often been regarded as hurtfulin the
first stage, because it has been taught that it interferes with
the free secretion of mucus; so as to render expectoration
difficult. But the onset of the catarrh—i. e., free expectora-
tion, is in consequence of the abatement of the inflammation,
which opium tends to subdue, and in this respect it acts as
an expectorant. Thus itis often of great service in the first
stage of a common cold, as it is in most acute inflammations
(Flint.) The inhalation af iodine vapor every three or four
minutes for an hour is of service, each inhalation lasting one
minute, by merely holding a bottle of tincture of iodine in
the warm hand under the nose (Tanner.) Total abstinence
trom liquids for forty-eight hours, originally recommended
by Dr. Richard Lower, one hundred and forty years ago, is
a practice recently revived by Dr. C. J. B. Williams. Muri-
ate of ammonia, 3 ss. in solution, is a remedy also much in
use, combined with liquorice or simple syrup, with one grain
BRONCHIAL CATARRH. 41

of tartar emetic and one or two drachms of antimonial wine,
dissolved in six or eight ounces of water. Of this a table-
spoonful for a dose, frequently repeated, may induce relief,
when the discharge from the nose and trachea is viscid.
Copious warm drinks and abundant warm bed-clothing, to
induce diaphoresis, are efficient remedies to be used early.

The object aimed at in the treatment of a “ common cold”
is to establish a free catarrh—to soften the expectoration and
make coughing “loose” and easy. Niemeyer lays down
some practical rules, based on symptomatic indications, to
accomplish these ends :—(1.) In chronic colds or catarrhs,
where cough is incessant and distressing, and out of propor-
tion to the expectoration, narcotics are indicated—such as
ten grains of Dover’s powder at bed-time, or the camphorated
tincture of opium (paregoric elixir), External counter-irri-
tants are also of service, in the form of mustard poultice,
“mustard leaves,”’ or blistering substances, short of vesica-
tion, such as stimulating liniments. Chlorate of potass is
also a useful remedy. (2.) Dyspnoea, with extensive sibil-
lant rhonchus and irritability of the mucous membrane, are
also relieved by narcotics, combined with ipecacuanha, or
with tartar emetic. But narcotics are contraindicated if, ow-
ing to the feebleness of the patient, the efforts of expector-
ation are inadequate to prevent accumulation in the bronchial
‘tubes. Alkaline carbonates possess the property of thinning
and rendering easier of expectoration the viscid bronchial se-
cretion, and are‘on that account to be recommended, especial-
ly where the condition of the urine suggests such remedies.
Opium in its many forms is the most useful remedy, so long
as the first stage of inflammation exists, if care be taken to
watch that nothing contraindicates its administration. Pre-+
parations of conium, hyoscyamus, ‘or hydrocyanic acid, must
be used in cases where opium is contraindicated.

(3.) When secretion is profuse, with relaxation of the mu-
cous membrane of the bronchi, when large, soft, moisterales
are heard, stimulant expectorants are indicated,—senega,
squills, carbonate of ammonia, benzoin, gum ammoniac, and
oil of cubebs. Remedies in the form of gas are also of ser-
vice, such as the fumes of tar, by boiling it alone or mixed
with water; also vapor of turpentine, half a drachm being put
into a bottle of hot water, the patient inhaling for a quarter
of an hour, four timesa day. In all cases absolute rest, veg-
etable diet, demulcent drinks, and small doses of antimonials
will greatly tend to bring about relief. A pint of any demul-
42 BRONCHITIS.

cent fluid (such as linseed tea), with two drachms of anti-
monial wine, taken in small quantities, so as to be consumed
in twenty-four hours, will be found a good standard prescrip-
tion. Gum arabic, in the proportion of one ounce to the pint
of water, or decoction of marsh mallow, or of dried fruits, is
a good substitute for the linseed, and may be flavored with
anything agreeable to the taste of the patient, such as orange
or lemon syrup. If much fever exists, a very hot foot-bath,
just before going to bed, has a soothing effect. The air of
the bed-room must be kept at about 60” Fahr., not below,
and the patient must remain as quiet as possible.

_ Generally, in prescribing cough mixtures, which ought if
possible to be avoided (seeing that they so impair the func-
tions of the stomach), the following conditions ought to be
adhered to'in devising the mixture:—(1.) That the prescrip-
tion should be in the form of fluid remedies,—solution, or in-
fusion of wines or syrups of the drugs. (2) That the dose
should not exceed one teaspoonful. (3) That the propor-
tions contained in the mixture should be so arranged that a
dose may be given cvery two, three, four, or six hours, ac-
cording to the urgency and acuteness of the symptoms. Such
a mixture may contain in each dose, for an adult, from ten to
thirty minims of antimonial wine, or of ipecacuanha wine, or
of tincture of sanguinario, or of syrup of squills, or of vinegar.
of squills, with two minims to four minims of hydrocyanié
acid, or thirty to sixty minims of tincture of, hyoscyamus or
of conium; or from two to four minims of tincture of opium;
or from thirty to sixty minims of camphorated tincture of
opium.

Bronchitis.— Definition Inflammation of the air-pas-
sages leading to the pulmonary vesicles, characterized by
hoarseness, moderate cough, heat, and soreness of the chest
anteriorly—symptoms which are more and more intense ac-
cordipg to the severity of the diseage, and especially the ex-
tensive implication of the smaller tubes. The natural mu-
cous secretion is at first arrested, but subsequently it becomes
increased in amount and altered in quality, tending to assume
the corpuscular character.

Treatment——(a.) In acute bronchitis——General bleeding
uniformly weakens the patient. In severe cases of acute
bronchitis some blood may be taken from the chest, with
great caution not to take too much, either by cupping be-
tween the shoulders or by leeches, and in general from ten to
twelve ounces are sufficient. Itis only in extensive conges-

 
BRONCHITIS. 43

tion of venous circulation threatening asphyxia, that general
blood-letting is imperative. Next to blood-letting, tartarized
antimony, administered in solution in doses of a sixth ora
quarter of a grain, every three or four hours, conduces to free
secretion, and generally to mitigate the symptoms of the dis-
ease. Digitalis is a useful adjunct to the antimonial treat-
ment. When the expectoration becomes thicker and less
copious, the antimony may be decreased, and squills, or ipe-
cacuanha, with paregoric, given. After this a blister should
be applied to the chest; and on its removal a large linseed
poultice should be placed near the blistered part, and con-
tinued for many hours. The bowels should be freely evacu-
ated by a purgative dose of calomel, combined with com-
pound jalap powder, and they should subsequently be kept
in regular and gentle action by some neutral salt, such as sul-
phate of magnesia in the liquor ammoniz acetatis, combined
at the same time with some nitrate of potass. ‘The neutral
citrates, tartrates; or acetates of the alkalies are useful elim-
inating remedies. :

After the severe symptoms at the outset have been sub-
dued, expectoration should be promoted by squills, ipecac-
uanha, and tartar emetic, combined with hyoscyamus or
conium. Opium in narcotic doses (¢. ¢., above a grain) is in-
admissible, because its tendency is to paralyze the action of
the mucous passages in eliminating secretion. After secretion
has begun to diminish, in acute cases opium may be pre-
scribed with benefit in stimulant doses, in the form of solution
of the salts of morphia, added at bedtime to the doses of the
cough mixtures so usually administered. (See under Bron-
chial Catarrh.) If the disease shows a disposition to pass into
the chronic stage, quinine, with squills and conium, may be
administered, or a draught containing full doses of cinchona,
with five grains of carbonate of ammonia, or ten to twenty
grains of the muriate of ammonia, and thirty or forty minims
of the compound tincture of benzoin (Friar’s balsam), or of
the balsam of Peru, will generally facilitate expectoration
and relieve the dyspnoea. If a “hearty cough” is not at-
tended by easy and free expectoration, but the chest remains
loaded, stimulant expectorants may be given in aid of other
remedies, such as the decoction of senega, or the mistura
ammoniaci-(Fuller). The patient throughout the treatment
should remain in a room where the air is kept moist by the
evaporation of boiling water from large flat dishes near the
bed, and the temperature of the air should be maintained at
44 BRONCHITIS.

63° to 68° Fahr. Alike in acute and in chronic cases, io-
dide of potassium is of great service. It has a marked effect
in reducing the frequency of the respirations. It is best
prescribed with carbonate of ammonia, and if cough is very
troublesome, tincture of belladonna and ipecacuanha wine
may be added.

(2.) In chronic bronchitis, especially in patients who have
made considerable progress in the journey of life, a lower
tone of the system prevails. - A greater laxity of aérian mem-
brane—particularly with excessive secretion, often muco-pur-
ulent—characterizes them ; and after blistering and poultic-
ing the chest repeatedly with linseed and mustard poultices,
the treatment in general should be more tonic. The cam-
phorated mixture or paregoric and stimulant cxpectorant
remedies are indicated for occasional, but not for constant
use. Stimulating embrocations may be rubbed not only over
the chest, both before and behind, but along the sides of the
neck.

A liniment composed of the following ingredients was ex-
tensively employed by the late Drs. Graves and Stokes in the
Meath Hospital, Dublin :—

. Spt. Terbinthine, 3 iii; Acid. Acet. 3iv.; Vitelli Ovi,
i.; Aq. Rose, 3 liss.; Ol. Limon., 3i.; misce.

It is to be applied as a rubefacient, morning and evening,
when it generally reddens the skin and produces small pim-
ples. In several cases the secretion of the kidneys is increas-
ed during its use (Maclachlan). Of tonic remedies most re-
liance may be placed on the influence of nux vomica, iron,
and quinine, in the form of a syrup composed of the phos-
phates of strychnia, of iron, and of quinia; so that, in doses
of a teaspoonful three times a day, each dose shall contain
the thirty-second part of a grain of phosphate of strychnia,
and one grain respectively of the phosphates of iron and
quinia. (Formula for the preparation of this compound, see
“ Anzmia.”’) The inhalation of slightly irritant vapors has
a beneficial effect, as of vinegar, turpentine, chlorine and io-
dine. Of the fetid gums, ammoniac in particular is a useful
remedy. An emulsion of gum ammoniac in diluted nitric
acid, is a combination from which beneficial results are ob-
tained. The following is a formula for its prescription—
namely, an hundred and twenty grains of the gum ammoniac
‘dissolved in two fluid drachms of diluted nitric acid and
twelve ounces of water, compose a mixture of which an ounce
may be given in gruel or barley-water three times a day
BRONCHITIS, 45

(Easton, Glasgow Med. Jour, Oct. 1, 1863). It may also
be advantageous to administer astringent remedies, and one
of the most useful is tannic acid, in doses of one to three
grains two or three times a day; or the oil of cubebs to the
extent of ten drops three or four times a day on a piece of
sugar (see under treatment of “ Phthisis”’).

Acute bronchitis is apt to be latent in old people, and to be
complicated with gastric or gastro-enteric inflammation
(Maclachlan). The stimulants of food (by enema in the
form of soup, without salt, if unable to be taken by the
mouth) aud of alcohol are the main remedies necessary from
the very beginning. Abstinence cannot be enforced with
safety. Leeches must be applied to the pained gastric re-
gion. When the disease is associated with a tendency to
gout, colchicum must be given. “It allays the cough, pro-
motes the flow of urine, keeps up a regular alvine discharge,
and can be given much more generally than squills, because
it does not produce that feverishness which results from the
use of the latter remedy, and can therefore be employed
where there is considerable fever” (Forbes). It requires to
be administered with great caution in the aged and infirm
(Maclachlan). In the protracted bronchitic affections of the
aged, diuretics are of great service. The following formule
are recommended by Drs. Maclachlan and Stokes.

B. Decocti Senegz, f3vij.; Potasse Nitratis, gr. ili.;
Tinct. Camph. Comp. vel Tinct. Conil, m xx.; Spiriti Aithe-
ris Nitr., f3ss,; Oxymellis Scille, f3ss. Fiat haustus ter
die summendus (Maclachlan).

R. Lig. Ammon. Acet., 3 iii; Potassa Acetatis, gr. xx.;
Aceti Scilla, f 3.ss.; Spirit. Aith. Nitr., £3 ss.; Tinct. Camph.
Co., m xx.; Mist. Camph., 2 vi.; Syrupi Aurant., 3 i. (Mac-
lachlan). Fiat haustus ter die summendus.

BR. Decocti Senege, 3 v.; Tinct. Camph. Co. Tinct. Scil-
le, aa Ziti; Syrupi Tolut., 3iv. Sumat 3ss. vel. Zi. ter
die (Stokes, Maclachlan). :

When gastric irritation prevails, the administration of bal-
sams, gum resins, and terebinthine remedies must be sus-
pended.

(c.) In capillary bronchitis the treatment must be strictly
conservative ; spoliative remedies lessen, if they do not de-
stroy, the chances of recovery. The tendency to death is by
apnoea, from the imperfect oxygenation of the blood—the
area of available respiratory surface being greatly diminish-
ed, both from the morbid state of the minute bronchi and
46 BRONCHOCELE—CANCER,

the accumulation of diseased products in them. The pa-
tient must be properly and adequately nourished. Stimu-
lants are often required, and tonics should be early adminis-
tered. The chest must be covered with hot poultices, and
an oil-silk jacket worn over them. Dry-cupping has seemed
to give relief to urgent symptoms. The muriate of ammonia
—two grains every two hours—either alone or in combina-
tion with the chlorate of potash: and the carbonate of am-
monia has long had a certain reputation in capillary bron-
chitis, especially in the later stages.

(d.) In bronchiectasis opiates are required to relieve
cough; balsamic remedies (tolu, tar, benzoin, turpentine,
copaiba, cubebs) and astringents, like catechu or rhatany,
with the use of counter-irritants and the inhalation of vari-
ously medicated vapors, are all useful aids in ameliorating
the condition of the patient. Muriate of ammonia and the
alkalies are also to be recommended. Inhalation of disin-
fectants, capable of being so used, such as creosote, carbolic
acid, sulphur vapor, turpentine, , and the like, are of special
service (see under treatment of “'Phthisis ”).

(.) Plastic Bronchitis——In the acute form, muriate of
ammonia and the alkalies and iodide of potassium may be
given, with an occasional emetic, and inhalation of the vapor
of hot water. The patient should be carefully protected
against damp and sudden changes of weather.

Bronchocele—Sce Gottre.

Bronchocele, Exophthalmic—SceeGoitre, Exohpthalmic.

Cancer.— Definition —A growth consisting of a delicate
fibroid stroma, containing within its meshes aggregated but
not coherent cell-elements—cells, nuclei, or granules—gener-
ally uNn-uniform, though often similar to natural cell-ele-
ments. It tends not only to spread continuously irrespective
of the tissue invaded, and to multiply its elements indefinite-
ly, and so to infiltrate into the surrounding structures, especi-
ally in the course of the lymphatics and nerve sheaths of the
part affected ; but it also tends to infect or reproduce itself
in more remote and internal parts of the body; and finally,
it tends to progressive softening and ulceration, with ulti-
mate poisoning and exhaustion of the system. It is in this
dynamical specific force of growth, spread, infectiveness, and
multiplication, that the “malignancy” of “cancer” is ex-
pressed ; and by virtue of which it is a disease sud generis.

Treatment.—No remedy has yet been found which can in

ie
CANCER. 47

any degree be considered curative of the constitutional state
associated with cancer, and the efforts of the practitioner are
consequently limited to relieving symptoms, and to the adop-
tion of such palliative measures as may prolong life. It has
generally been believed that to remove a cancerous growth
where it is practicable must, on theoretical grounds merely,
be attended with as much benefit to the constitutional dis-
ease as would attend the removal of a leg for acute rheuma-
tism chiefly expressed in the knee-joint. The statistics of
cancer show, so far as they go, and as Dr. Walshe long ago
showed, that “ excision of a cancerous tumor seems to awaken
a dormant force. Cancers spring up in all directions, and
enlarge with a power of vegetation almost incredible.” Never-
theless, there are good reasons for removing cancers in some
cases, especially mammary cases and others accessible to the
knife. The greatest measure of good may be done, as Sir
James Paget has clearly shown, “by making a careful selec-
tion of cases fit for operation, and rejecting all the rest as
unsuited for operation” (Med. Times and Gazette, September
27, 1872, p. 319). With regard to excision of the breast for
cancer, the main objection in the first instance is, that even of
cases selected with some care, 10 per cent. (Paget) to 16 per
cent. (Lebert) die of pyzmia, or erysipelas, or tetanus, or
secondary hemorrhage, or some calamity subsequent to the
operation. On the whole, however, taking the results of some
hundreds of cases, it is certain that the average duration of life
of those operated on is not less than those in whom the disease
runs its course. In well-selected cases it will be found always
greater. A recent tabulation of hospital and private cases by
Sir James Paget showed that 85 cases operated on lived an
average of 55.6 months ; and 62 cases not operated on lived
an average of three months. It has also been said that the
recurrent disease is more painful than the primary one ; but in
very many cases Sir James Paget has found that the recurrent
disease was much less severe than the continued disease.
Considering, therefore, the danger of the operation, and the
fact that in every case a recurrence of the disease may be ex-
pected, it is reasonable to submit a patient to the risk of dying
from the primary operation for the sake of that interval of
health between the operation and the recurrence of the disease,
for the good probability of adding a year to life, and for the
chance of having a less severe disease? The average length
of the interval before recurrence is little more than thirteen
months: more’than half return within twelve months; and
48 CANCER.

two-fifths return within six months. The extremes between
which the average is drawn are very wide. In some cases the
return may be within three months ; in others not for ten,
twelve, or more years. Itis of great importance to determine
in what cases the risk of life is greater ; and in what cases the
probability of aspeedy return of the disease is greater than
the average. The old after sixty; the very large-breasted ©
in cases of mammary cancer; the fat and plethoric ; the
cachectic ; the over-fed on animal food; the drunkards ; the
gouty: the habitually bronchitic ; the albuminurious ; the
very dejected—not timid merely ; in short, those with any or-
ganic disease of the internal organs—all such cases are
“ doubly hazardous” to interfere with by operation (Paget.)
The probability of rapid recurrence is great in acute can-
cers—i. ¢. all those that are rapid in their progress—and in
those which are observed to increase very quickly before the
operation. Great pain, however, is often saved by performing
‘the operation even under suchcircumstances. In illustration,
Sir James Paget records the case of a lady “whose breast he
removed when she was five months advanced in pregnancy.
She recovered well from the operation, and the benefit pro-
cured by its performance was very great. She went to her full
term, bore her child, and was able to suckle it for a year be:
fore slie died, with her most anxious wish fulfilled in compara-
tive comfort.” Another condition unfavorable to operation
is a brawny skin, with firm cedema and wide-open hair follicles
or wide adhesion of skin, or in which the skin is cancerous,
or where there are scattered tubercles of cancer in the glands
and skin; or where there is considerable affection of the
lymph-glands in the vicinity, and especially numerous dis-
eased glands. A moderate amount of lymphatic disease is
not a serious obstacle to.an operation (Sir James Paget).
In very chronic cases the operation is needless—where the
breast is small, shrivelled, knotty, and sunk down on the pec-
toral muscle. By thus selecting with care, on the one hand,
cases fit for operation, and refusing to interfere in those cases
in which the operation would be attended with more than a
proper share of danger, Sir James Paget believes that the life
of alarge number of those who suffer from cancer may be
considerably prolonged. In whatever part the disease may
be situated, one great rule is to endeavor to restore the
healthy functions of that part, and to alleviate by opiates,
chloroform, or chlorodyne internally, the distressing pains the
patient endures. These remedies areforatime uccessful,
CANCRUM oRIS, 49

but make no impression on the disease, which silently pro-
ceeds, and the patient finally limits himself altogether to
opiates. The quantity of opium or other narcotic known to
have been taken in such cases is something enormous—five,
ten, fifteen, or twenty grains of opium at a dose, ora propor-
tionate quantity of hyoscyamos or of conium, three, four, or
more times in the twenty-four hours. But although these
large doses have occasionally been given, yet it may be ques-
tioned whether they are not more hurtful than beneficial ;
for usually they produce headache, delirium, loss of appetite,
and narcotism, so that the patient is only the more rapidly
exhausted. In general, therefore, the patient does better
under moderate doses of opiates, as one or two grains, or its
equivalent of morphine or other narcotic, every four, six, or
eight hours, than when more excessive doses are given—a
larger dose producing headache and much cerebral distur-
bance, without in any sensible degree mitigating the suffer-
ings. When the disease is seated in the colon or intestine,
the tumor is in general difficult to make out. One loop of in-
testine may open into another; and death by haemorrhage
may terminate the case. The symptoms vary greatly accord-
ing to the position of the cancer and the part of the intestinal
canal affected. Great sickness and vomiting generally attend
cancer in the duodenum. When the stomach is so irritable
that it rejects everything, it is our duty to support the pa-
tient by nutritive injections, as of strong broth, egg-flip, sago,
or other fluid substances. It has been attempted to impart
strength to the patient by means of milk baths, or baths of
strong broths ; but the skin has not generally sufficient power
of absorption, and it has been found that the heat of the bath
has exhausted the patient in a far greater ratio than its nutri-
ment supported him. As a general principle, diet has little
or no influence over the course of the disease when once es-
tablished, except it may be that total abstinence from nitro-
genous food may starve out the growth, and most likely also the
patient ; so that whatever agrees with the patient’s digestion
may be safely indulged in. Preventive treatment must be
directed to the infant life of those who are hereditarily pre-
disposed.

Cancrum Oris.— Definition —The more severe form of
inflammation of the mouth.
Treatment.—The disease is analogous to hospital gangrene,
and an early recognition of its nature will suggest an efficient
4
5° CATALEPSY—CEREBRO-SPINAL MENINGITIS.

application of strong nitric acid to the slough. The mouth
must be frequently syringed with a solution of carbolic acid,
in the proportion of half a drachm dissolved in a gallon of
boiling water, and allowed to become warm or tepid.

Tonics and antiseptics must be freely given. Beef-tea,
wine, brandy, quinine, and chlorate of potash are also in-
dicated.

Carcinoma—Scee Cancer.

Catalepsy.— Definition —A sudden suppression of con-
sciousness; but instead of falling down convulsed, as
in hysteria, the patients maintain the position in which
they were when the attack commenced. The limbs
and trunk persist in a state of balanced muscular con-
tractions; the same expression of countenance is pre-
served which may chance to be at the moment of seizure. If
sitting, the patient continues to sit; if standing, he continues
to stand; if occupied in any mechanical employment, he
continues fixed in one attitude; and if he is under the in-
fluence of any passion, the countenance retains its expres-
sion,

Treatment,—No constant line of treatment can be stated.
The individual.case must be judged of upon its own merits,
and prescribed for according to the principles which have
guided the dictates of treatment in the allied nervous affec-
tions,

Catarrh, Epidemic—Sce /nfluenza.
Cephalalgia—See Headache.
Cerebro-Spinal Fever—Sce Cerebro-Spinal Meningitis.

Cerebro-Spinal Meningitis.—Definition.—A fever be-
lieved to be of an acute specific character, of sudden inva-
sion, attended by painful contraction of the muscles of the
neck and retraction of the head. In certain epidemics it
has been accompanied by a profuse purpuric eruption; and,
occasionally, by secondary effusions into certain joints.
Lesions of the brain, the spinal cord, and their membranes,
are found on dissection. The course of epidemic cerebro-
spinal fever is rapid, attended with great prostration of the
powers of life, severe headache, and pain along the spine.
The variations of temperature are so great that no typical
range can be given; and the result is generally fatal.

Treatment.—At the outset, stimulating embrocations to
the spine and extremities with moist or dry heat to the
CHELOID—CHLOROSIS, 5T

limbs, and wrapping in blankets, give some relief. Opium
in large doses is the only drug which has appeared to be of
any Service in subduing the virulence of the symptoms,
Quinine, in cases where malaria aggravates the disorder, is
also well spoken of. Ether and chloroform inhalation have
been of use as sedatives; and tincture of cantharides has been
af service in cases marked by extreme depression. Counter-
irritation, by the actual cautery applied along the spine, or
by blisters, has been foliowed by alleviation of the pain and
other symptoms. ‘The energetic use of cold, as of ice com-
presses to the head, of leeches behind the ears, and of
calomel, as in sporadic meningitis, are measures to be recom-
mended.

Cheloid.— Definition —A tuberculated growth or swell-
ing of the true skin occurring spontaneously or upon a:
cicatrix.

Treatment is not yet defined; but the history of the dis-
ease points to cold applications and tonic remedies as the
basis of a rational treatment.

Chicken-Pox.— DefinitionA disease the result of a
specific cantagium capable of inoculation, and having a
period of incubation of eleven days (Murchison and Squire);
it consists of a specific eruption, in a series of new crops,
usually appearing for several days in succession; so that
dried and fresh vesicles are often alongside of each other, on
the breast, back, face, and extremities, preceded by fever.
The disease may be protracted for a fortnight or longer, and
may be epidemic. It affects the system only once.

Treatment consists simply in abstinence from animal food;
having recourse to a milk diet ; and careful attention to the
bowels by saline luxations if necessary. The patient is to be
kept at perfect rest and cool, by making him repose ona
mattress rather than on a feather bed, with light coverings.
It is necessary to be on the lookout against catarrh.

Chlorosis.—Definition-—A deficiency of the blood-cells
with redundancy of the serous part of the blood, occurring
in young girls at the age of puberty; in the young of both
sexes before the complete development of the distinctive
characters of the sexes towards puberty; and sometimes dur-
ing pregnancy.

Treatment is chiefly conducted by change of air and diet,
by moral and physical hygiene, and by medicines. All the
functions of the body must be carefully observed and regu-
52 CHLOROSIS.

lated. The residence of the patient must be a reputed
healthy spot, in the pure air of the country, rather than the
town. Dry frictions of the back and limbs are also recom-
mended, with bathing in the sea, where it can be borne,
The food must be regulated so as not to be too stimulating
nor disgustingly bland; frequent change is demanded, with
a due attention to the proper apportioning of nutritive and
respiratory elements. The diet should be generous, and
carefully apportioned to the powers of digestion. Any
symptoms of dyspeptic oppression, impaired digestion, or
offensive stools, demand a careful readjustment of the dietary.
Three meals, or perhaps four may be taken during the day—
the intervals between the meals being equal; and, half an
hour before each of the meals, two grains of capsicum, with
one grain of quinine, may be given ina pill. The breakfast
should consist of biscuit, dry toast, or stale bread, with fresh
butter, and perhaps an egg, and one small cupful—not more
—of hot black tea. Five or six hours after breakfast, and
hhalf-an-hour after the pill, a dinner of well-done meat, such
as mutton chops, may be eaten with potatoes—beef-tea, or
milk being taken for drink, according to taste and the powers
of digestion. The evening meal may be similar to the morn-
ing. At first there may be a loathing of all kinds of
food in the form of regular or “ordinary diets.” In such
cases no meals should be prescribed, and no solid food; but
a cup of milk, with a third part of lime-water in it, may be
given every two hours, prescribed as a medicine ; and a pint
of beef-tea in divided doses may be taken as a drink during
the day. This diet may be gradually added to as the appe-
tite improves. Trousseau observes that “there are some
chlorotic girls who would rather die from inanition than eat
ordinary food. We should not hesitate in such cdses to
make those therapeutic concessions which we are so often
obliged to submit to in the practice of our art. I allow ali-
mentary substances acknowledged to be very indigestible—
caring not for the kind of food so long as it is eaten—as
radishes, salads, fruits hardly ripe, highly seasoned sausage
meat, old cheese, vegetables, meats prepared with vinegar,
acid drinks, and the like. All I require in this whimsical
diet is, that there be sufficient variety. By such means we
often succeed in rousing the digestive functions, bringing
back the sensation of hunger, and gradually leading the pa-
tient to proper food.” Lebert insists on the importance of
artificial feeding in some cases. A mixed diet is essential,
CHLOROSIS 53

Change of air and bathing will also greatly aid in restoring
health. If the patient lives in a town, she ought to be sent
into the country ; and, best of all, to the seaside, where sea-
bathing may be prescribed, if the strength of the patient is
sufficient. Should the patient have been living in the coun-
try, a change of air and scene to a lively town, with cheerful
society; and, sometimes a little good wine with the food,
will be no less useful as remedial agents. The much-be-
quacked use of water, in its varied modes of appliance to
particular cases, will be found a powerful restorative agent,
if judiciously used by the patient under medical advice.

Of medicines, the preparations of iron have most reputa-
tion. They seem to act by promoting the formation of the
red blood-corpuscles ; and they operate best in those cases
in which the blood is rich in albumen. They also act as
stimulants to digestion ; and itis not altogether immaterial
which of the numerous officinal preparations of iron are to be
prescribed. Almost every physician has some prepara-
tion of iron he fancies better than another; and some
of them seem to be aided in their good effects by com-
bination with carbonate of potash, such as the sulphate
of iron, in doses of three to five grains, or of the ferri
sulphas exsiccata, in doses of two to five grains, pre-
scribed in pills.) The use of ferruginous remedies must
be persevered in for months, and the general.indications for
prescribing the preparations are the same as those given
_ under Anemia. In pills, the iron preparations may also
be combined with extract of nux vomica, or with strych-
nia, in suitable doses; or the syrup of the phosphates
of iron, quinine, and strychnia, may be given (see Ane-
mia); or the eliminative action of the colon is to be pro-
moted by four grains of the pill of aloes and myrrh taken
every night at bedtime, or by a grain of the watery extract of
Barbadoes aloes witha little gingerine as a pill. Simple
bitter tonics are useful adjuncts to the chalybeate treatment,
such as gentian, calumba, and the preparations of cinchona.
They, aid feeble digestion. Tartarated iron (Ferrum tar-
taratum) is also a useful remedy, and may be prescribed
with alkalies, in doses of six to twenty grains, dissolved in
water. :

Where a high degree of. serous plethora exists, and pro-
duces violent excitement of the vascular system, palpitation
of the heart, and congestion of the head, venesection may be
practised. It not only acts as a sedative, but aids the radi-
54 CHOLERA, MALIGNANT.

cal cure of the disease, inasmuch as it causes the subse-
quently adrninistered ferruginous preparations to be borne
more easily. Both general and local blood-lettings may be
used ; but the blood must be taken in small quantities, a
-ouple of ounces at a time being quite sufficient (Vogel).

Cholera, Asiatic—See Choler1, Malignant.

Cholera, Malignant.—Definition.—A disease essentially
specific, existing at all seasons of the year in certain parts of
India (its perennial endemic area), capable of being propa-
gated or disseminated over the surface of the earth through the
atmosphere, or in other ways, but chiefly by means of human
intercourse between the healthy and the sick. The seizure is
characterized in many (but not in all) cases by premanitory
diarrhcea, sudden muscular debility, tremors, vertigo, occa-
sional nausea, and spasmodic griping pains in the bowels,
depression of the functions of respiration and circulation,
and a sense of faintness and oppression in the precordial
region. A copious purging of serous fluid (alkaline when
passed, and in appearance resembling water in which rice has
been washed, sometimes containing blood) is succeeded or
accompanied by vomiting and burning heat at the stomach,
coldness and dampness of the whoie surface of the body,
coldness and lividness of the lips and tongue, cold breath, an
unquenchable thirst, a feeble rapid pulse, difficult and op-
pressed respiration, with extreme restlessness (a state ex-
pressed in physiological language by the term ‘“ anxietas”’),
suppressed urinary secretion, blueness of the entire surface of
the body, a sunken and appalling countenance, a peculiarly
suppressed voice, a peculiar odor from the body, partial heats
of the proecordia and forehead—fatal collapse, a reaction
and secondary fever. Under conditions favorable to its
propagation malignant cholera often becomes epidemic.

The College of Physicians defines cholera to be “an epi-
demic disease, characterized by vomiting and purging, with
evacuations like rice-water, accompanied by cramps, and re-
sulting in suppression of urine and collapse.’

Treatment.—There are few diseases for the cure of which
so many different remedies and modes of treatment have been
employed as in cholera. In considering the treatment of this
disease there are three periods to be provided for,—(1.) The
period of diarrhoea, which so frequently precedes cholera—
“premonitory diarrhoea.” This indication of intestinal
trouble must be distinctly recognized as the starting-point of
CHOLERA, MALIGNANT, 58

all other symptoms, and the true source of danger. (2.) The
algide period, or collapse ; and, (3.) Period of reaction,

(1.) The Period of Premonitory Diarrhcea—To check or
arrest the diarrhoea is the practical result aimed at by a va-
riety of formule. The evacuations ought to be checked as
soon as possible. Those in which opium is the main remedy
have acquired the most amount of confidence. The manage-
ment of a case embraces the following conditions = )
That the horizontal position of the body be maintained ; and
patients ought to take to bed at once. The necessity forthe
horizontal posture of the patient is, that it aids the efforts of
the circulative powers, which tend to weakness. (2.) That
the administration of opium, with or without cordial stimu-
lants, be at once commenced. With regard to opium, its
dose must be regulated by, (¢.) The extent of the nervous
prostration ; (4.) The rapidity of the dejections ; (c.) The
extent of vascular depletion. In the cases which present
these phenomena in the extreme a much larger dose of opium
is required to be given at the outset at one time than in the
casesless urgent. (3.) That the induction of perspiration be
brought about.

The extensive experience of.my friend, Dr. Fergus, of
Glasgow, in whose practice I was privileged to assist during
the epidemic of 1849, led him to the conclusion (in which I

concur) that “ there is a first stage at which cholera is cura-
ble and preventible’’-—namely, that of laxity of the bowels
previous to vomiting, spasms, or uneasiness of any kind. The
relaxation of the bowels may not even amount to diarrhcea,
and may be to the extent of only two or three stools a day,
where one only was usual. Such relaxation was generally
thought of no moment, being attended with no pain. On
the contrary, the evacuations often gave a feeling of relief.
This is the only stage at which opiumis to be given, and
that in a full dose. At this stage, in combination with a
stimulant, it is often of the highest value. It is only to be
given ‘‘if the evacuations are still bilious, the pulse fair, and
the skin warm.’”’ When vomiting, “rice-water” purging, and
cramps set in (the phenomena of collapse) it is then too late
for opium. Drs. Macpherson and Macnamara record, as the
result of their extensive experience in India, that if adminis-
tered at the proper stage no remedy is so effectual as opium;
and the drug may be safely trusted to cure the premonitory
diarrhoea of cholera. A dread has arisen of using opium from
fear of secondary effects; but the same writers ‘ustly observe,
56 CHOLERA, MALIGNANT.

that if it has a curative effect, we must not shrink from its
use from the dread of ulterior consequences. “‘ The vast
majority of practitioners have found opium extremely useful
in the early stages of the disease. Men like Twining and
Parkes, who by no means considered the disease to consist
merely in vomiting and purging, were agreed that opium is
the medicine to be given in the commencement of the great
majority of cases.” It calms the brain, relieves the excessive
feeling of constriction at the epigastrium, tends to counteract
over-secretion from the mucous membrane, favors cutaneous
transpiration, and assists the action of such other remedies
as stimulants, astringents, carminatives, or absorbents, (Gub-
ler). The following formula for pills, each containing a grain
of opium, with stimulants, is well known as a most useful
anti-spasmodic pill in the early stage of bowel evacua-
tion :—

R. Pulv. Opii, gr. xii. ; Camphor, gr. xxx. ; Pulv. Capsici,
gr. ix. ; Spt. vinc. rect., q. s.; Conserv. Rosar, q. s.; Misce
et divide in pil. xii. ;

Moderate doses of opium or morphine, either alone or
combined with stimulants (as the pulvis crete aromaticus
cum opio) are sometimes sufficient to check diarrhoea. When
medical men have charge of large numbers. of people, as in
the army, navy, prisons, workhouses, asylums, hospitals, and
the like, it is incumbent on them to make frequent inspec-
tions of those under their care, and to seek out any cases of
incipient diarrhoea. Responsible officers should be made to
take notice of those who go more than once a day to the
water-closet at times when a cholera epidemic influence pre-
vails. In military practice, frequent inspection of the men is
of cardinal importance. Every man in a regiment should be
seen at least three times a day by some medical officer, who
should also visit the various guards. By walking down the
ranks at roll-call, and picking out the men who show the
earliest symptoms, cases are thus caught in the stage of pre-
monitory diarrhoea, and saved. The following rules were
drawn up by Dr. Fergus, now President of the Faculty of
Physicians and Surgeons of Glasgow, and printed and hung
up in prominent places, for the direction and management of
large numbers of men, in the factories and offices of that city,
over which he had charge when cholera was epidemic :—

‘(z.) Do not be afraid of cholera, or make it the topic of
conversation. Fear and all the depressing passions are in-
jurious. (2.) Do not take brandy; it is not a preventative ;
CHOLERA, MALIGNANT. 57

and it does harm by disordering the action of the stomach
and bowels. (3.) Do not make any change in your usual
diet, if it is simple and of easy digestion; take it moderately,
and at regular intervals, as long fasting is injurious; and
carefully avoid excess in any intoxicating beverage. (4.)
Take no excessive fatigue; if overheated, beware of any
sudden chill, and see that the skin is kept comfortably warm.
If the disease appears in winter, much benefit may be derived
from wearing a flannel belt round the body, covering the
stomach and bowels. (5.) As soon as cholera appears in a
town, a bottle of solution of morphia or laudanum (and a
graduated measure) should be kept in every house, place of
business, factory, or wherever, in fact, there are a number of
people gathered together. Persons travelling should always
have it with them, or easy of access. During the existence
of the epidemic, one person in each factory, &c., should take
the charge of the health of the inmates, and should act as
‘house physician,’ warning all under his or her care to at-
tend to the slightest relaxation of the bowels. He should
remind them that the less pain the more danger, and there-
fore the more need of immediate and energetic action. (6.)
Should the slightest diarrhoea occur, the individual so attacked
should at once receive forty minims of solution of morphia
or laudanum.* If from home or at business, the patient
should be at once conveyed home in a cab, put to bed, and
kept warm. If chilled, warm water bottles may be put to
the feet. If the first dose has not checked the looseness,
the patient should take a second, and then have a flannel
cloth thoroughly. dipped in turpentine, placed all over the
stomach and bowels for from forty minutes to an hour, or a
large, soft, warm poultice of linseed meal and mustard for
one or two hours. If the second dose has not effectually
checked the diarrhoea, and medical assistance has not arrived,
a third dose may be taken. (7.) The patient must remain in
bed two or three days after the diarrhoea is checked. I insist
strongly on this, for the patient often feels so well that it is
difficult to get him to attend to it. (8.) To relieve the thirst,

» If a measure is not at hand, a small teaspoonful. Of course this
dose is for adults, Below that age the doses should be a drop for each
year till twelve or fifteen, and after fifteen a drop and a half for each
year, up to forty minims, or a small teaspoonful. More portable than
laudanum, and of equal efficacy, would be pills composed of a grain and
a half of opium, and a grain of cayenne pepper in each pill, three of
which may be taken with safety, till medical assistance arrives,
58 CHOLERA, MALIGNANT.

a piece of ice may be given, or a mouthful of iced water, or
soda water; but in no case must more fluid be taken at a
time, and all food should be abstained from till from fifteen
to eighteen hours after the opiate has been administered.
Then, and for two or three days, the diet should consist of
such food as rice, sago, arrow root, Indian corn flour, tea and
toast, &c.; about the third day beef-tea or chicken-soup
might be taken. (g9.) These rules are for the first stage, and
for it only—v. ¢., the diarrhoea. If a person has neglected the
first warning, and is in the second stage—/. ¢., has cramps,
vomiting, and stools like rice-water, without smell— you
should, till medical assistance arrives, place the patient in
bed surrounded with bottles of hot water, and give him a
little ice, and mouthfuls of soda and water. If the cramps
are severe, you must-rub the limbs with turpentine, or chlor-
oform and oil.” —Glasgow Med. Journal, 1866.

The following cholera mixture (as it was called) was pro-
posed by the Board of Health during the prevalence of
cholera, and was no doubt useful in many cases of diarrhcea:

BR Pulveris Arom., 3 iii; Tinct. Catechu, f3x.; Tinct.
Cardam. Comp., f 3 vi.; Tinct. Opii, 31; Mist. Crete, pre-
parat. ad f%xx. Of this mixture the dose is one ounce.

Bulky doses of remedies are obviously objectionable. The
usual remedies known as “‘astringents”’ (compared with each
other, or with opium) have no decided influence for good.
“ Astringents,” as such, have merely a negative effect.

Of the various preparations of opium, Dr. Macnamara
gives preference, as Dr. Fergus does, to the tincture. Thirty
drops of laudanum in water should be administered as soon
as possible after the first watery motion has been voided, and
this dose must be repeated if the purging does not stop after
the first dose has been given. A pill composed of one grain
of opium and two grains of the acetate of lead, to be taken
every hour till the purging stops, is a useful formula, and
more easily distributed than laudanum. Supposing thirty
drops of laudanum to have been administered ; and, that
within half an hour the patient is again purged, Dr. Macna-
mara does not hesitate to repeat the dose at once. It is not
advisable to wait until two or three motions have been passed.
Watery painless purging should be at once stopped by such
means. When the disease is endemic, and still more so when
it is epidemic, every family should have a bottle of laudanum,
to be resorted to at once after the first watery motion. If
the motion is accompanied by a feeling of exhaustion. and a
CHOLERA, MALIGNANT, 59

faintish sensation at the przecordial region, the dose of laud-
anum should be followed by “a stiff glass of brandy and
water.” “No more erroneous practice can possibly exist in
India, or any other place where cholera exists, than that of
allowing diarrhcea to go on upon the supposition that the
attack is a bilious one, and that the purging is a salutary ora
harmless process. More deaths from cholera have been
occasioned from this than from any other mistaken notion on
this subject. The issue is simply this: Supposing the attack
to be a bilious one, we stop it with opium, and may subse-
quently have to administer a dose or two of blue pills and
rhubarb; or, perhaps, a little judicious starving may answer
the same purpose. But if, under the impression that the
diarrhoea is bilious, we allow it to run on, it may become, in
the course of a few hours, the second stage of cholera, and
our opium may then be of little or no use.”

In the case of children the dose of laudanum must be
regulated by the age of the child.

But there are certain cases in which, although the diar-
rhoea may be altogether checked by such remedies, yet the
disease is not cured. Symptoms characteristic of the algide
or collapse stage supervene. These are the cases which have
been held to justify that method of treatment which has for
its object elimination by the promotion of purging and of
vomiting—excretion of the poison by the alimentary canal.
The advocates of this method of treatment also lay stress up-
on the fact that those are the worse cases in which the diar-
theea is the least; and that those cases are the most hopeful
in which diarrhoea and vomiting are the most severe. Dr.
George Johnson’s treatment by castor-oil has for its object
the elimination in this way of the specific poison; and it may
be said of it, that it is neither more nor less successful than
other remedies of its class. It, as well as purely astringent
mixtures, excites such loathing in most cases that it cannot
be persisted in. Dr. Johnson agrees that “diarrhoea during
an epidemic season ought not to be neglected even for an
hour.” He regards such diarrhoea as an indication of the
presence of offending material in the alimentary canal—e.g.,
(x.) Unwholesome, undigested food; or, (2.) A large and
unnatural accumulation of the feculent contents of the
bowel; or, (3.) Noxious secretions poured from the blood
into the bowels, in consequence of the action of a specific
blood-poison. To this latter process Dr. Johnson believes
choleraic diarrhcea to belong. Therefore he lays down the
60 CHOLERA, MALIGNANT.

following rule:—“ Not to attempt by opiates, or by other
directly repressive means, to arrest a diarrhcea while there 1s
reason to believe that the bowel contains a considerable
amount of morbid and offensive material; for, such offensive
material must come forth before diarrhoea can permanently
cease.” Purging he considers the natural way of getting rid
of the irritant cause; and the safest purgative he believes to
be castor-oil. So far as meeting the conditions of examples
(1.) and (2.) as above stated, the treatment cannot be im-
proved upon; but that it is the best possible treatment to
meet the preliminary diarrhoea or relaxation of the bowels in
cholera cannot be regarded as established nor warranted
by what we know of the pathology of the disease as set forth
in the text. Assuming it to be proven that malignant cholera
is a specific disease in which there is poisoning of the
blood; and believing, as I do, that such is the pathology of
the disease: and, seeing that the College of Physicians enter-
tain a similar belief—for malignant cholera has been classed
by the College in Section A of the General Diseases, con-
cerning which it is written, that “it comprehends those dis-
orders which appear to involve a morbid condition of the
blood, and which present the following characters:—they run
a definite course, are attended with fever, and frequently
with eruptions on the skin, and are more or less communi-
cable from person to person.” Assuming the pathology of
malignant cholera to be as here represented, I cannot admit
that the best indications for the treatment of the disease are
those which suggest an attempt to eliminate the poison by
the promotion of purging and vomiting. I do not believe
we can, by any remedy, nor by the over-stimulation of any
eliminative function, ever get rid of any such poisons as
those of small-pox, measles, scarlet fever, typhus fever, en-
teric fever, or any other general and specific disease-poison
comprehended in Section A. No method of treatment,
based on the so-called principle of eliminating a poison, has
ever effected a cure of any one of these diseases; and I do
not see any likelihood of the principle being more successful
in cases of malignant cholera than with other diseases of the
class. We have never yet been able to “cut short” any of
these diseases by emetics, purgatives, or diaphoretics. Nei-
ther emetics nor purgatives have ever cut short small-pox,
although, if we are to follow indications of treatment elimin-
ative of poison, we ought to encourage such vomiting and
purging which mark the initiative stage of most of the ex-
CHOLERA, MALIGNANT. 61

anthemata. The early attempts to cure small-pox, scarlet
fever, and measles, by promoting copious eruption on the
skin, in the belief that the poison was so eliminated, proved
a signal failure. The popular belief that “better out than
in” was not found to be a safe principle of treatment’ in the
management of those diseases. We have no eliminative
method of treatment which will rid the blood of such
specific disease-poisons; just as we have no antidote which
will destroy or counteract the influence of snake-vemon
when once it has got accidentally or artificially into the blood.
We do our best when we try only to guide the patient
through those specfiic diseases, by moderating the violence
of the expressions of the malignant phenomena, not by in-
creasing them, We cannot cure these diseases. The most
successful results in the treatment of all of them have been
got by those agencies which have led to modified and less
malignant forms of disease, such as by vaccination, in regard
to small-pox, and by sanitary improvements generally. We
do not think of, and dare not attempt to promote, diarrhoea
or specific lesion in the intestines during enteric fever. Why
should we be induced to promote diarrhoea in malignant
cholera, in the belief that we are thereby to free the blood
from the specific poison of the disease? We have no evi-
dence that the body is freed of the poison in this way.
The bowel discharges may be, and undoubtedly are, means
(but not necessarily the only means) of propagating the
disease; but it does not follow that promoting their dis-
charge frees the blood from poison either in enteric fever
or in cholera. By moderating the catarrhal flow in enteric
fever, it is not found that we aggravate the disease and
lock up specific poison in the system; certainly by mod-
erating, curtailing, or restraining the diarrhoea of cholera,
the only chance is left us of guiding the patient through
that disease; and OPIUM is the remedy which, by actual
experience, alike in India and in this country, seems most
worthy of reliance; but,—only at the commencement of
laxity, or relaxation of the bowels, in seasons when chol-
era is epidemic.

Treatment based upon conflicting theories (which are
but theories after all) as to the nature of the disease, is
greatly to be deprecated; and on this point Dr. Fergus
makes the following pertinent remarks:—

“The influence of the theories of Dr. G. Johnson and
others is to be seen in the instructions recently issued by
62 CHOLERA, MALIGNANT,

the Board of Supervision in Scotland—very excellent as to
the sanitary part, but in the medical portion (like most
things issued by a committee) an evident compromise. It is
a compromise, I believe, between the facts anda theory. .

. . Weare told, under the fourth section, to take castor oil
or rhubarb and soda for laoseness of the bowels, and after-
wards the astringent mixture or pills—the former being in-
tended as elimfnators to promote the diarrhcea, the latter to
check it. If this advice is followed during an epidemic of
cholera, the consequences may be very serious. It is well
known that during an epidemic there is a general tendency
to relaxation of the bowels, and that they become very sus-
ceptible of the smallest dose of even the mildest medicine.
Any one who has had much to do with cholera must have
frequently met with cases which appeared to be the direct
consequence or result of a slight dose of medicine. The
risk is that the castor-oil and rhubarb would drive most of
the cases into the second stage of cholera, and then the use
of astringents and opiates at that stage would increase the
danger immensely. As to the remedies ordered, the quan-
tity of laudanum—viz., five drops per dose—is too small, and
there is no necessity for the chalk and catechu. Before the
opiate could produce much effect, the stomach would be
overloaded with the chalk and catechu, to the extent of in-
ducing vomiting. The pills should be ordered after each
discharge from the bowels; but people will find it easier to
provide themselves with laudanum than to use complicated
mixtures or pills.”

“With regard to castor-oil,” writes Dr. Macnamara, ‘‘I was
acting as House Physician to King’s College Hospital, in 1854,
when Dr. G. Johnson was treating his cholera patients on
eliminative principles. I caught some of his enthusiasm on
the subject, and came out to India the same year full of con-
fidence and hope in castor-oil. These ideas were destined
soon to pass through asevere ordeal; for in the following
year I was left at Bhaugulpore in charge of a field hospital.
I was the only medical man in the place, when cholera burst
out among the Europeans and natives under my care: I
went boldly to work with castor-oil, but it absolutely and
completely failed; the mortality from the disease was fearful.
I have since on several occasions tried castor-oil in cholera,
but I have now finally abandoned it, having never seen any
benefit arise fromits use.” In the second or algide stage the
object is to promote reaction and to keep it in moderation.
CHOLERA, MALIGNANT. 63

If the patient is not seen till profuse discharges—rice-water-
like—have taken place, the time for all active treatment has
passed, and efforts must be directed solely to restoration and
repair; and, if possible to rendering the stoolsacid, by the
following draught every half hour for four hours, and then
to continue every hour (Macnamara):—

R. Dilute sulphuric acid, and dilute acetic acid, of each
m xv.; carbolic acid, half a drop; water, an ounce and a
half; and opium may be added to the first and second doses,
as existing circumstances may indicate.

To promote reaction in cholera and diarrhoea, the follow-
ing formula has met with most universal approval in this coun-
try and in India. So highly is it valued, indeed,that it is or-
dered to be always in store, and in readiness in the “ Aledical
Field Companion” of the army when on the march:—

B. Ol. Anisi., Ol. Cajeput, Ol. Juniper, aa 3 iss,; Ather.,

3 ss.; Liquor Acid. Halleri, 3ss.;* Tinct. Cinnam., § ii;
misce. The dose of this mixture is ten drops every quarter
of an hour in atablespoonful of water. An opiate may be
given with the first and second dose, but should not be contin~-
ed, for reasons already given.

The nitrite of amyl has also been recommended in the
collapse of cholera by several physicians. It ought to be
given internally, or by subcutaneous injection rather than by
inhalation (Dr. T. L. Brunton, Brit. Med Journ., of Jan. 13,
1872). The indications generally followed are to treat the
case as we should a similar state in typhoid fever, and to
moderate the affection of the bowels by milk opiates, by ene-
mata, and by sinapisms to the abdomen; also, to relieve the
head by leeches and cold lotions, and subsequently, as the
tongue becomes brown, to support the patient with wine,
sago, strong broths, and a generally cordial treatment.
During the reaction stage Dr. Andrew Clark, of the London
Hospital, employed with great success a powder composed as
follow:—

Hyd. c. Creta, gr. ii; Pulv Ipecac., gr. ss.; Pulv. Doveri,
gr. liss.; night and morning. 3

The cases most benefited by this remedy were those in
which the tongue had become dry and hard, salines, lemon-
ade, and chlorate of potash drinks being freely given. Mus-

* The Liquor or Elixir Halleri consists of one part of concentrated
sulphuric acid to three parts of rectified spirit. Itis commonly employ-
ed in Germany in the treatment of typhus and allied diseases, in doses of
five to twenty drops in solution (Murchison, 1. v., p, 266).
64 CHOLERA, MALIGNANT,

tard plasters or blisters to the nape of the neck were found to
be of use by inducing the return of the urinary secretion.

The sick-room should be supplied with fresh air. Liquids
should be assiduously applied to every surface capable of
absorbing them, and the patient should be suffered to remain
as free from officious treatment as possible. Heat applied in
the dry form is to be avoided, but cloths moistened with hot
water may bé applied; or the patient may be wrapped up in
warm, moist blankets, and hot bottles or bags of heated sand
placed around his cold and benumbed body. After the
temperature is restored, the surface should still be kept moist,
by sponging from time to time, or by the use of the wet sheet,
to moderate the reaction. Urgent thirst is one of the most
distressing symptoms in cholera. There is incessant craving
for cold water—doubtless instinctive, to correct the inspis-
sated condition of the blood, due to the rapid escape of the
liquor sanguinis. It was formerly the practice to withhold
water——a practice as cruel as it is mischievous. Water in
abundance, pure and cold, should be given to the patient,
and he should be encouraged to drink it, even should a large
portion of it be rejected by the stomach; and when the pur-
ging has ceased, some may, with much advantage, be thrown
into the bowel from time to time (Maclean). Niemeyer re-
commends cold wet compresses to be frequently laid over
the abdomen; and, also a grain of calomel every hour. Such
compresses are said to be grateful to the feelings of the pa-
tient, whose sense of heat is great, although he may be cold to
the bystander. The practice alsois consistent with the lesions,
especially the intensely pink vascularity seen in the intestines
after death. The following as a drink is generally relished
and retained upon the stomach:—“ A raw egg beat up with
half a pint of milk, and then mingled with about a pint and
a half of water, adding as much salt as will give the whole an
agreeable taste ” (Dr. Andrew Buchanan,). Or whey, milk
and water, weak chicken soup, or any similar decoction, may
be drunk ad libitum. Enemata of warm milk, repeated as
often as expelled, are of the highest importance if the evacu-
ations have ceased, by supplying an absorbable fluid, by miti-.
gating abdominal pains, and diluting acid secretions. The
secreting of urine may be premoted by dry cupping over the
loins, by the use cf solution of chlcrate of potash, and the
like. But suppression of this secretion is most to be
dreaded where opium has been too freely used in the
treatment
CHOLERA, MALIGNANT. 65

In men of intemperate habits we often see, during the stage
of reaction, obstinate vomiting of thick, tenacious, green
paint-looking matter, probably bile-pigment, acted on by
some acid in the stomach orailmentary canal. It isa symp-
tom of evil omen, and often goes on uncontrolled until the
patient dies exhausted, and this although all other symptoms
may promise a favorable issue. It may last for a week, re-
sisting all remedies,and proving fatal when the urinary secre-
tion has been restored, and all cerebral symptoms have sub-
sided. Alkalies in the effervescing form, free stimulation of
the surface,and chloroform in small doses, offer the best
hope of relief for such cases. The patient should be nourish-
ed more by the bowel than the stomach when vomiting is
present. Ice should be given ad-dbitum, where it can be
obtained, not only to dissolve in the mouth, but to swallow
in pieces of convenient size (Maclean),

A plan, perhaps peculiar to this country, which was prac-
tised to bring about reaction (when the inefficiency of medi-
cines was generally admitted), was an injection into the veins
of the patient of a solution of half an ounce of muriate of
soda, and four scruples of sesquicarbonate of sodz, in ten
pints of water, at a temperature varying from 105° to 120°
Fahr. This solution was injected slowly, half an hour being

“spent in the gradual introduction of the ten pints, and the
immediate effects of this treatment were very striking.’ The
good effects were rapid in proportion to the heat of the solu-
tion, but a higher temperature than what is stated could not
be borne. After the introduction of a few ounces, the pulse,
which had ceased to be felt at the wrist, became perceptible,
and the heat of the body returned. By the time three or four
pints had been injected, the pulse was good, the cramps had
ceased, the body, that could not be heated, had become warm,
and instead of a cold exudation on the surface, there was a
general moisture ; the voice—before hoarse and almost ex-
tinct—was now natural; the hollowness of the eye, the
shrunken state of the features, the leaden hue of the face and
body had disappeared ; the expression had become animated,
the mind cheerful, the restlessness and uneasy feelings had
vanished ; the vertigo and noises of the ear, the sense of op-
pression at the precordia, had given way tv comfortable feel-
ings; the thirst, however urgent before the operation, was
assuaged, and the secretion of urine restored, though by no
means constantly so. But these promising appearances were
not lasting: the vomiting continued, the evacuations became

5
66 CHOLERA, MALIGNANT.

even more profuse, showing that the remedy did not’ touch
the root of the evil. The patient soon relapsed into his
former state, from which he might again be roused by a rep-
etition of the injection. This amendment, ‘however, was
transient, and the fatal period was not long deferred. Of 156
patients thus treated at Drummond Street Hospital, Edin-
burgh, only twenty-five recovered,—a lamentably small pro-
portion ; and small as it is, it seems doubtful if the recover-
ies were final or complete (Mackintosh, “‘ Principles of Pathol-
ogy,” p. 365). Nevertheless, injection of fluid by the veins
ought still to be persevered in as a remedy in the right direc-
tion—with due regard to temperature—as a means of pro-
longing life. A trial made by Surgeon-Major E. Y. Kellat
at the close of an Indian epidemic is deserving of more ex-
tended experience, namely :—To inject distilled water at a
temperature of 99° Fahr. hypodermically, into the connec-
tive tissue of the body, or into the cavity of the peritoneum.
He thus aimed at establishing an artificial anasarca or an as-
cites ; experience having shown that of several instances of
cholera attacking persons suffering from such conditions, the
effused fluid became rapidly absorbed during the course of
the cholera—the patients recovering. The distilled water he
thus proposes to inject hypodermically, must filter through
the living tissue before it can reach the circulation; and”
hence be more fitted to mingle with the blood, than when
thrown into the veins directly from contact with air. Water
is the cardinal want. The supply of it fails first: and thus
introduced it avoids contact with the morbid surface and se-
cretions of the stomach and bowels, which are barriers to its
absorption in that direction.

Stimulants tend to irritate the stomach, and are of no use
in exciting the heart to any salutary action. Employed as
in typhus, they are worse than useless. All violent remedies
are greatly to be deprecated. Strychnia, prussic acid, to-
bacco, galvanism, boiling water, the actual cautery, or firing
the spine, or bags of ice to the spine, or injections of spirits,
are proven by trials to be of no use; nor can their recom-
mendation be supported except upon baseless theories, hav-
ing no rational relation to the pathology of the disease.

To generalize on the subject of remedies in cholera, the
broadest conclusion seems to be, that remedies with an acid,
rather than an alkaline or neutral reaction, have been the
most beneficial.

Prevention of Cholera.—The following summary, from the
CHOLERA, MALIGNANT. 67

writings of Dr. Parkes and Mr. Simon, will best conclude
this account of cholera. The importancé of the topics noticed,
and the uncertainty that yet enshrouds many of them, may
justify, it is hoped, the amount of space which the subject
has taken up:—

“For the first time in the history of cholera a new system
of prevention has been brought largely into play in Europe—
viz., the addition to the discharges of a presumed disinfect-
ing substance. This plan, of course, is based on the belief
that the principal (perhaps the only) mode of spread is by
means of the' putrefying evacuations; and the results ob-
tained by it give certainly some strong evidence in favor of
this opinion. In this country the diffrculty has been to make
the public (and, in some cases, even the medical men) sensi-
ble of the importance of this plan, and of the necessity of
giving it a complete trial. In some cases in which it has
really been fairly tested, it appears to have arrested the spread
of the disease, as at Bristol; and Dr. Budd’s paper in
the Brit. Med. Journ, April 13, 1867, gives good
evidence on this point. In Southampton also, I be-
lieve, the spread was limited in this way, though it was not
arrested so perfectly as at Bristol. In London, and several
provincial towns, the method was also tried more or less fully.
In Germany, owing to the influence of Pettenkofer, the dis-
infecting plan was also brought into play, and the system fol-
lowed has been described by that chemist.* Without ana-
lyzing all the evidence, I proceed to give the most important
practical rules. The dangerous period of the choleraic
stools is supposed to be when they become very ammoniacal.
This occurs sometimes immediately they are passed, but
usually not to any extent for some time. It is thought (but
of course exact scientific proof is not readily attainable) that
anything which makes and keeps them acid prevents the
changes which cause the poison. The three principal means
of doing this are the use of carbolic acid, and sulphate of iron
(with or without permanganate of potassium), and the salts
of zinc. Each has its advantages, and all may beused. The
carbolic acid, from its liquid form and from its volatility, is
excellently adapted to purify air, and to be used when sur-
faces are to be washed. It is also useful for sewers and
closets. The sulphate of iron in substance and strong solu-

* “Cholera Regulativ,” von H. Griesinger, M. Pettenkofer, and C.
A. Wunderlich, Zzetschrift. fur. Biologie, Band, II., p. 435.
68 CHOLERA, MALIGNANT.

tion is better adapted for being put in the utensils in a room.
as it has no smell, but it may be equally used for sewers and
for watering streets. The sulphate of zinc (for the chloride
is too dear) is better adapted for being put on linen or on
floors, as it does not ironmould the linen hike the sulphate of
iron. The carbolic acid has not been used much in Ger-
many, as it isstill too dear; but Pettenkofer makes an ob-
servation of importance—viz., that when added to sulphate of
iron the mixture seems to have more power of preventing
ammoniacal development than either substance separately.
If so, it might be desirable, as a matter of practice, to use
the two together as much as possible. The salts of zinc
(sulphate or chloride) may be also used, but are perhaps not
so good, and in some forms are dearer than the iron salts.
Chloride of lime does not prevent the ammoniacal change,
and appears altogether less useful. The quantity in which
these substances must be used is as follows:--For each
healthy person, daily, about three-quarters of an ounce of
sulphate of iron, or one drachm of strong (but impure) car-
bolic acid, is sufficient. This amount will entire’y prevent
any decomposition of the feces for several days. In a town,
therefore, where sewers are used, the above amount of sul-
phate of iron, or carbolic acid, multiplied by the number of
persons, should go into the sewers daily, and, if possible,
should be passed in from the houses, so as to act on the
house-drains as well as on the main sewers. If the place is
not sewered, then the disinfectants should be added to the
cesspools, middens, latrines, or whatever plans may be in use.
If both sulphate of iron and carbolic acid are used, which is
to be recommended, half the quantity of each should be
employed. The iron should be dissolved in a good deal of
water.

“Tn Southampton, is 1866, carbolic acid was chiefly used;
and the average amount was about twenty gallons daily for
a town of 50,000 people: it certainly appeared useful. If an
aerial disinfection is needed, sulphurous acid (obtained by
burning sulphur) is perhaps the best. Nitrous acid fumes
are certainly very powerful; and one or other of these sub-
stances should be used for half an hour daily in all privies or
latrines. For washing clothes the iron salts are not ap-
plicable, as they stain linen. Carbolic acid gives a disagree-
able smell. Either a watery solution of sulphurous acid, or
a solution of zinc salts, should therefore be used. Baking
the clothes, at atemperature of 250°, or boiling, should be
CHOLERA, MALIGNANT, 69

used. In hospital wards, dead-houses, &c., itis a good plan
to sprinkle sawdust on the floors, and to moisten it with the
weak carbolic acid (one part of crude acid in sixty or eighty
of water). These measures should be commenced when
cholera is apprehended. Every privy and sewer should have
twice daily the mixed carbolic acid and sulphate of iron so-
lution. If cholera is introduced, the amount should be
doubled in the privies of all the adjacent houses, while the
closet of the affected house should never act without a por-
tion of the disinfecting liquid being placed in it. If the dis-
ease breaks out, a plan recommznded by Dr. Budd is worthy
of imitation—viz., to place a layer of carbolic acid powder
(carbolic acid and lime) in the bed, under the breech of the
patient. ‘The disinfection in this way of the closets and
privies of hotels, railways, and workshops, should be com-
menced very early.”

A saline antiseptic, “chloralum, has been recently much
commended; and on the subject of prevention Mr. Simon
has also made some valuable suggestions:—

“Wherever cholera is known to exist too much importance
cannot be attached to the precaution of thoroughly disin-
fecting, without delay, all discharges from the stomach and
bowels of persons suffering under the disease, and of disin-
fecting or destroying all bedding, clothing, towels, and the
like which such discharges may have imbued; and, of course,
neither choleraic discharges, nor any slops which may con-
tain traces of them, should ever (even when supposed to be
disinfected) be cast into any position from which they may
get access into drinking water. But, although the duty of
observing those precautions is one which ought never to be
neglected, populations cannot prudently stake their lives on
the chance that it will be completely fulfilled for them.
Apart from all questions of negligence, the degrees of cholera
are too many, and the slight and incipient cases far too apt
to escape observation, for any such defence against its infec-
tion to be more than partial. And, therefore, the main object
for endeavor must be to secure everywhere such local cir-
cumstances that the infective material, though not disin-
fected, would be unable to spread its influence among the
population. The dangers which have to be guarded against
as favoring the spread of cholera infection are particularly
two. First, and above all, there is the danger of water sup-
plies which are in any (even the slightest) degree tainted by
house refuse or other like kinds of’ filth; as where there is
7O CHOLERA, MALIGNANT.

outflow, leakage, or filtration from sewers, house-drains,
privies, cesspools, foul ditches, or the like into springs,
streams, wells, or reservoirs from which the supply of water
is drawn, or into the soil in which the wells are situate; a
danger may exist on a small scale (but perhaps often re-
peated in the same district) at the pump or dip-well of a
private house, or, onalarge and even vast scale, in the source
of public waterworks. And secondly, there is the danger of
breathing air which is foul with effluvia from the same sorts
of impurity.

“Temporary security must, as far as practicable, be sought
in measures of a palliative kind:—(¢.) Immediate and search-
ing examination of sources of water-supply should be made
in all cases where the source is in any degree open to the.
suspicion of impurity; and the water both from private and
public sources should be examined, Where pollution is dis-
covered everything practicable should be done to prevent
the pollution from continuing, or, if this object cannot be at-
tained, to prevent the water from being drunk. (4.) Sim-
ultaneously there should be immediate thorough removal of
every sort-of house refuse and other filth which has oc-
cumulated in neglected places; future accumulations of the
same sort should be prevented; attention should be given to
all defects of house-drains and sinks through which offen-
sive smells are let into houses; thorough washing and lime-
washing of uncleanly premises, especially of such as are
densely occupied, should be practised again and again. (¢.)
Disinfection should be very freely and very frequently em-
ployed in and round about houses wherever there are re-
ceptacles or conduits of filth, wherever there is filth-sodden
porous earth, wherever anything else, in or under or about
the house, tends to make the atmosphere foul.

“Tn the absence of permanent safeguards no approach to
security can be got without incessant cleansings and disin-
fections, or without extreme and constant vigilance against
every possible contamination of drinking-water.”

Then again as to the risk of contagion, Mr. Simon writes:

“Cholera in England shows itself so little contagious, in
the sense in which small-pox and scarlatina are commonly
called contagious, that, if reasonable care be taken where it
is present, there is almost no risk that the disease will spread
to persons who nurse and otherwise closely attend upon the
sick. But cholera has a certain peculiar infectiveness of its
own, which, where local’ conditions assist, can operate with
CHOLARA, MALIGNANT. Vt

terrible force, and at considerable distances from the sick.
It is characteristic of cholera (and as much so of the slight-
est choleraic diarrhoea as of the disease in its more developed
and alarming forms) that all matters which the patient dis-
charges from the stomach and bowels are infective. Probably,
under ordinary circumstances, the patient has no power of
infecting other persons except by means of these discharges,
nor any power of infecting even by them, exeept in so far as
particles of them are enabled to taint the food, water, or air
which people consume. Thus, when a case of cholera is
imported into any place, the disease is not likely to spread,
unless in proportion as it finds locally open to it certain fa-
cilities for spreading by direct infection. In order rightly to
appreciate what these facilities must be, the following con-
siderations have to be borne in mind :—First, that any chol-
eraic discharge, cast without previous thorough disinfection
into any cesspool or drain, or other depository or conduit of
filth, infects the excremental matters with which it there min-
gles, and probably more or less, the effluvia which those mat-
ters gvolve ; secondly, that the infective power of choleraic
discharges attaches to whatever bedding, clothing, towels,
and like things have been imbued with them, and renders
these things, if not-thoroughly disinfected, as capable of
spreading the disease in places to which they are sent (for
washing or other purposes), as, in like circumstances, the pa-
tient himself would be ; thirdly, that if, by leakage or soak-
age {rom cesspools or drains, or through reckless casting out
of slops and wash-water, any taint (however small) of the in-
fective material gets access to wells or other sources of drink-
ing-water, it imparts to enormous volumes of water the power
of propagating the disease. When due regard is had to these
possibilities of indirect infection, there will be no difficulty
in understanding that even a single case of cholera, perhaps
of the slightest degree, and perhaps quite unsuspected in its
neighborhood, may, if local circumstances co-operate, exert
a terribly infective power on considerable masses of popula-
tion,” .

The inquiries made through the Epidemiological Society
show that special hospitals, or special wards in hospitals,
ought to be devoted (with a separate and special staff of at-
tendants for day and night duty, or more frequent periods of
relief) entirely to the management of cholera patients.

With regard to India much may still be expected from a
thorough improvement of its sanitary condition: and espec-
72 CHOLERA, SIMPLE,

ially of the filthy towns and bustees, or native villages, con-
structed without any plan or arrangement, without roads,
without drains, ill-ventilated, and never cleaned—the abodes
of misery, vice, and filth—the nurseries of sickness and dis-
ease. These are the localities within the endemic area of
cholera which require special attention and improvement in
the first instance ; and which are now receiving the attention
of the Indian authorities through their special sanitary ad-
ministration.

Cholera, Simple.—Definition—An acute catarrhal in-
flammation of the mucous membrane of the stomach, which
extends into the intestines, attended with nausea, retching,
and vomiting, followed by severe watery diarrhoea, consisting
of profuse transudation of fluid ‘containing little albumen ;
the whole system generally being affected, as evidenced by
fever.

Treatment.—lf the stomach retains undigested food be-
lieved to be unwholesome, a mild emetic may be given; but
this is rarely necessary, as the stomach usually empties itself
completely. When the solid matters have been ejected, the
subsequent treatment will depend on the acidity or acrid
nature of the matter ejected. Simple alkaline remedies, like
carbonate of soda in solution ad /bitum, will sometimes re-
lieve the nausea and sickness; and when the vomiting be-
comes liquid, opium is the remedy most to be relied upon.
It must be, however, given in solution, such as laudanum,
Battley’s solution, or with chloroform and other stimulants,
as in the form of chlorodyne. A full dose of either of these,
or a full dose of muriate of morphia, laid on the tongue,
should be administered immediately after the act of vomit-
ing. If the first dose should be immediately rejected, a sec-
ond is to be repeated ; if that too is rejected, a third may be
so given, but no more. An enema of laudanum, one to two
drachms, with starch must be given instead, directly after an
evacuation of the bowels. If this is rejected after being again
repeated, then hypodermic injection of solution of morphia
may be adopted ; and in any form when retained, the remedy
will require repetition every hour or half hour till the vomit-
ing and purging are arrested. The effects of each dose must
be carefully watched, so that narcotism may not be induced.
It is important that so much fluid may not be taken as the
greatness of the thirst desires. A table-spoonful of ice-cold
water, given at short intervals, or a bit of ice to dissolve in
CHOREA. 43

the mouth, is all that Gught to be permitted. Gruel made
from the boiled fluid in which oatmeal has been soaked, and
allowed to cool, and given with ice, isa grateful and sooth-
ing drink.

Chorea.— Definition —An irregular spasmodic convulsive
action of the voluntary muscles, ceasing during sleep, of a
clonic kind, especially a profusion of movements of the face
in smiles and frowns, and of the trunk and extremities in
gesticulations. The movements are either entirely withdrawn
from the control of volition, or but little under the direction
of the will. The disease is brought on by fear or emotion,
or without obvious exciting cause. It has special relation
to certain other nerve-disorders, also to rheumatism and to
heart affections.

Zreatment-—Having ascertained a time limit to the dis-
ease we are able to judge as to the effect of medicinal
remedies, observing by how much they shorten its duration.
The remedies given may be classed into three divisions: (1.
Anti-rheumatic remedies, as potash, iodides, bark; (2.
nervine tonics, arsenic, zinc, iron ; (3.) empirical, as ice or
ether over the spine, galvanism, sedatives.

From the use of ether to the spine—a plan: so strongly
commended by a few—Dr. Andrew Clark has seen no bene-
fit. In his experience rest andthe free use of arsenic are
the remedies which shorten most the duration of the disease.
Arsenic, in the form of Fowler's solution, is also well
spoken of by Romberg, in doses of three to five drops. Dr.
Bristowe also is in favor of arsenic, given in small doses, and
continued for some length of time. Experience also shows
that, in most simple cases, any special treatment by drugs
may be dispensed with ; and that the chief matter to attend
to is the general health and nutrition of the patients, which
may be sufficiently dealt with by good diet, the withdrawal
from causes of excitement and annoyance, and by discipline
and sensible management. There are, however, various
drugs which may prove valuable auxiliaries ; as, for instance,
the salts of iron when there is anzmia, and in all cases cold
or tepid bathing ; or the cold douche to the spine, or the
shower-bath. In the rheumatic group of cases, much the
same course of tonic treatment is generally applicable; any
special cardiac symptoms calling for appropriate remedies.
In the reflex group, the rule of action is to remove the cause
of reflex irritation. Cases with high temperature and a
74 CHOREA.

febrile condition indicate the presence of collateral disease,
only indirectly associated with choreic movements, and call
for treatment directed to the removal of the organic mischief.
In several cases of very severe chorea, tartar-emetic has been
found of great service; and in many of moderate severity,
bromide of potassium was apparently useful (Arlidge).

Generally, therefore the indications for the treatment of
chorea are—(r1.) To remove, if possible, all morbid states of
the body which may tend to aggravate the disease, such as
constipation, anemia, -amenorrhoea, worms ; (2.) By well-
regulated purgative medicines to subdue any cerebral con-
gestion ; _) To sustain the strength and improve the vigor
of the nervous system by tonic and stimulant medicines, by
food, and by the cold bath. The particular tonic is not of
much moment. Dr. Wood recommends the powder of the
black snake root (cimicifuga, in doses of from half a drachm
to a drachm, or from one to two fluid ounces of a decoction;
or from one to two drachms of a saturated tincture should
be given three or four times a day, and continued for several
weeks, the dose being gradually increased till it produces
headache, vertigo, or disordered vision. The sulphate of
zinc has also had the credit ascribed to it of curing a large
number of cases, beginning with a grain in the form of a
pill, three times a day, and increasing the dose till it reaches
seven or eight grains daily. The preparations of iron are
also frequently resorted to with benefit. But Dr. Walshe
did not find any of these remedies at all useful in the acute
case he has described. Of all the remedies he tried, the
“extract of cannabis Indica” was followed by the most
satisfactory results. It exercised a sedative influence on the
muscular action in a marked degree, and that immediately.
The Indian hemp was given in doses of one-fourth of a
grain of the extract thrice daily. The dose was subsequently
increased to half a grain, and at the same time one-grain
doses of nitrate of silver were administered, and a draught
containing eight drops of dilute nitric acid. Nitrate
of silver he found to have no mean influence in aiding
the cure. Dr. Corrigan had also previously used Indian
hemp with much success in chorea (AZed. Timesand Gazette,
1845, p. 29 ; also Dublin Hosp Gazette).

The tincture of Calabar beans (31. to 3 i. of alcohol,) be-
ginning with twenty minims three times a day, is also recom-
mended by Dr. J. W. Ogle ; the dose to be increased by ten
minims a dose, up to 31. The student is recommended to
CHOREA, RHYTHMICAL HYSTERIC, 75

consult a valuable paper * On the Uses of Indian Hemp in
Nervous Diseases,’’ by Professor Russell Reynolds, in Beale’s
Archives.

Trousseau and Niemeyer consider narcotics to be of great _
value in the form of large doses of morphine; others are of
opinion that.narcotics are not well borne in chorea.

Gentle applications of the galvanic current along the spine,
the patient standing erect, have been successful in the hands
cf Benedikt. The current should be just strong enough to
be felt distinctly without pain. Chapman’s ice-bags to the
spine are also of use.

Chloroform has been used with benefit to control the vio-
lent movements.

The best treatment is the improvement of diet, change of
surroundings, and moral discipline. Hence it is that chil-
dren with chorea improve so much in well administered hos-
pitals, where the food is abundant and discipline well maine
tained. Butchoreic patients must not be associated together,
because the disease tends to be kept up apparently by imita-
tion, especially amongst children.

Of other classes of stimuli, camphor, in five-grain doses,
has acquired much reputation, especially after the alvine dis-
charges have become healthy by the action of purgatives. .
Many young women who attribute the attack to fright, fre-
quently get well from the simple administration of the spirit
of nitrous ether in one fluid drachm doses three times a day,
combined with the officinal camphor mixture. The cata-
logue of remedies which have been proposed is endless. In
many instances, however, the above medicines may be con-
tinued for weeks without any manifest improvement. In
such cases the cold bath, or the cold shower bath, is an ex-
cellent adjuvant; and, unless the patient is suffering from
some structural disease, the case uniformly yields to this
conjoined treatment; great care and attention being bestowed
on the regulation of the diet, which should be light, nutri-
tious, and easily digested.

Chorea, Rhythmical Hysterie.— Definition — A chor-
eiform affection under the influence of hysteria, and pre-
ceded by it (Charcot).

Treatment.—P rofessor Charcot recommends that prolonged
and repeated ovarian compression might be maintained with
benefit to such cases as occur in the female by means of some
such instruments as are used for compression of large vessels
76 COLIC—COLIC, BILIARY,

like the aorta. So also the application of ice bags to the
ovarian region for half an hour at a time, repeated several
times a day for several days, has had the effect of arresting
the attacks, or of lessening their intensity. He prefers, how-
ever, the inhalation of ether or of nitriteof amyl. Professor
Trousseau has found cases of those forms of chorea to im-
prove under the influence of oil of turpentine in capsules
containing ten minims each, of which ten were taken daily
for twelve to fifteen days a month; and to use warm baths of
several hours’ duration.

Colic.—Definition.—A painful affection of some portion
or the abdomen, caused by violent contraction of the mus-
cular fibres of some portion of the intestinal canal.

The Treatment is by opiates, chlorodyne stimulants, and
purgative medicines. When the bowels are constipated,
five grains of calomel, fifteen grains of jalap, and one

“grain of opium, should be administered immediately, and
tollowed by—

BR. Mist. Camphore c. Magnesiz Sulphat., 3j.; Tinct.
Hyoscyami, m xv. to xx.; Tinct. Cardamomi, 3j. To be
repeated every five or six hours, until stools are obtained.

In mild cases a scruple of rhubarb, or half an ounce of
castor-oil, or other mild purgative, combined with a grain of
opium, may be substituted for opium, calomel, and jalap.
Some have doubted the propriety of administering opiates at
the onset of the disease; but it is certain that a mild purga-
tive, combined with a mild narcotic, will effect more than -
a drastic purgative without such combination. Opium in full
doses (gr. i. to ii.) is more generally useful in colic’ than any
other remedy. Enemata often give immediate relief. Hxter-
nally, the application of large bags filled witnnot chamomile
flowers, or of heated sand, or heated salt, or of the stémach-
warmer filled with hot water, are useful. The warm bath,
fomentations, or a large linseed or mustard poultice over the
abdomen, are also highly useful auxiliaries. The diet should
be sago and arrow-root, with a little brandy; and for some
time after the patient has recovered it should be light, and
perhaps limited to fish and puddings.

Colic, Biliary.— Definition.—Concretions of certain bil-
lary constituents in the biliary ducts, or accumulating gener-
ally in the gall-bladder, as gall-stones, the passage of which.
through the duct into the duodenum gives rise to symptoms
known as “ gall-stone colic.”
COLIC, BILIARY. 17

Treatment.—When the symptoms of gall-stone passing the
duct are present, the curative indications are to facilitate its
passage into the intestine, to relieve the intense pain which
accompanies it, and to prevent that inflammation which the
presence of an extraneous body of any magnitude is calcu-
lated to produce in the duct. The first thing to be done is to
calm the sufferings of the patient. Half a grain of solid
opium, or a quarter of a grain of morphine, or twelve drops of
laudanum, or the mistura camphorce, 3 xj., conf. opii 3 ss.
to Dij.,c. sp. eth. nitr. 3 j., should be given every hour, or
every two hours, till some relief is obtained, or till there is
slight narcotism. Similar doses may be repeated every four:
or six hours, till the pain has ceased. If the vomiting be se-
vere, and the remedies be rejected, the opiate may be given
hypodermically, commencing with not more than one-fourth
of a grain of the muriate of morphia in solution, or opium
may be administered by enemata of laudanum. Careful in-
halation of chloroform, till anaesthesia is produced, also gives
great relief, and is a valuable remedy when paroxysms are
most violent. It not only calms pain, but may lead to the ces-
sation of the spasmodic contraction of the biliary passages,
and thus favor the expulsion of the calculus (Murchison).
Chloroform also, when given internally, appears to exercise
some influence as a solvent of biliary concretions. Dr. J.
Barclay relates an instance in which m ii. to m iii. of chloro-
form, given three or four times a day, afforded great and im-
mediate relief (Brit, Med. Journal, 1870). Dr. Murchison
has seen marked benefit from the extract of belladonna, given
in half grain doses every two or three hours. The hydrate of
chloral, as it produces extreme muscular relaxation, is also a
likely remedy. Small pieces of ice in the mouth may relieve
vomiting. Emetics or laxatives are not to be given during the
attack. A warm bath should be immediately prepared, with
a temperature of 100° to 110°, or as hot as the patient can
bear it, and the immersion should continue till he is in some
degree exhausted. The intention of the bath is to relax by
means of heat the muscular fibre of the ducts, and thus re-
lieve the pain and facilitate the passage of the gall-stone. The
effect is generally so agreeable to the feelings of the patient
that, on the recurrence of the pain, he may ask for a repeti-
tion of it, and his wishes should be complied with. If awarm
bath cannot be procured, fomentations, or a large linseed
poultice, should be applied over the abdomen, Dry heat is
always at hand, and hot flannels, hot sand, or hot chamomile
78 COLIC, BILIARY.

i

flowers afford some relief. Bleedingis not calledfor. The
calculus having passed, and the patient being relieved, the se-
cretions of the liver should be rendered more healthy. A
course of neutral salts, or of the Cheltenham or Leamington
waters, ought to be taken in this country. Under the use of
the Karlsbad waters immense quantities of gall-stones are
evacuated with proportionately little difficulty (Niemeyer).
The same is true of other alkaline mineral waters, such as
Vichy, Marienbad and Kissengen.

The’ radical treatment of biliary calculi ought to be at-
tempted during the intervals between the attacks of gall-stone
colic, by—(1.) Solvents believed to act on the calculi. These
are,—(a.) Alkaline solvents, which are to be preferred above
all others. Under their influence the calculi seem to’ be
really dissolved or broken up, so as to disappear without leav-
ing any trace; or they are expelled entire in abundant bilious
evacuations. This alkaline treatment comprises the fixed
alkalies, soap-lye, salts of soda, carbonate of ammonia; but es-
pecially the waters of Vichy, Vals, Karlsbdd and Ems. These
are used as drinks and as baths; and they must be employed
perseveringly, at different periods, during several years in
succession. (4.) Durande’s remedy, which consists in the ad-
ministration of half a drachm to a drachm every day, in the
morning, of a mixture composed of fifteen grammes (7. ¢.,
about 3 iii.) of sulphuric ether, and ten grammes (7. ¢., about
3 11.) of oil of turpentine, has enjoyed a reputation since 1790,
as a solvent of biliary calculi. It has been extensively used
and recommended by many Continental physicians. In this
country Copland speaks favorably of it; but whatever virtue
the remedy may possess as a solvent, it is probably due more
to the ether than the turpentine, the former being a ready sol-
vent of cholesterine (Waring). The dose is to be gradually
increased till about a pound of this mixture has been taken.
Its mode of action is not known; but where it has succeeded,
the calculus has been expelled without being dissolved. It
seems in some way efficient in promoting the expulsion of
calculi, probably by its anti-spasmodic action, rather than
acting as asolvent. Recently various substitutes have been
proposed in place of Durande’s remedy, and also variations
from the original dose (Niemeyer). One is a popular remedy,
a mixture of oil of turpentine, Sii. with 3i. of spirits of sul-
phuric ether, which has been prescribed in drop doses by
Rademacher. (c.) Diet has a great influence upon the qual-
ity of the bile. Fresh laxative vegetable food, grapes, fruits,
CONSTIPATION. 19

and whey ought to constitute the staple articles of a regulated
diet. All fat should be as much as possible excluded from
food, and the plainest diet, in the form of roasted meats or
boiled meats, with vegetables and farinaceous food, should
be rigidly proportioned to the wants of the system. The
drinks should be water or lemonade, and an avoidance of al-
coholic or malted stimulants. (2.) Treatment which seeks to
assuage pain.—With this end in view, Lutten prescribes
opium in larger doses than those already mentioned—namely,
two and one-third to three grains of solid opium at ohce; but
he considers the hypodermic injection of solution of morphia
as preferable ( ‘Nouveau Dictionaire de Medicine et de
Chirurgie Practiques;” also, “Society Med. de Paris, 1866;”
and “ Sydenham Society’s Biennial Retrospect for 1865-66”).
The intense agony is more effectually relieved by large doses
of opium than by any other remedy, particularly if it be com-
bined with the use of the hot bath (Dr. Waring). Two grains
of solid opium, or mxl. of the tincture of opium may be
given, either by mouth orin the form of enema, to be re-
peated in half an hour if the pain is not relieved. It may
also be advantageously combined with a full dose of ether or
chloroform. care being taken in case of over-dosing with the
opiate. F

Large draughts of hot water, containing carbonate of soda
in solution (3i. to 311, to twenty ounces of water) give
more immediate relief than any other means (Dr. Prout).
The first dose or two may be rejected; but the addition of a
few drops of laudanum and steady perseverance in the rem-
edy will eventually ensure its success (Murchison). No
doubt can exist as to the efficacy of alkaline waters in re-
moving the symptoms of gall-stones. It is certain that the
salts of Vichy and Karlsbad waters relieve the symptoms of
this affection, provided they are administered in hot water,
and so as to represent nearly the strength of the natural
springs.

Constipation.— Definition —A retention of faeces beyond
the usual period, so that when they are passed it is with
difficulty, and in a comparatively hard indurated state.

Treatment.—There it no rule of health more important than
that the bowels be kept regularly open. Enemata are of the
first importance, and ought to be much more frequently em-
ployed than they are as ahabit. They may be simply a pint
of warm ‘water 100° Fahr.; or the same quantity of warm
80 CONSTIPATION.

water, with half an ounce of common salt. The common
soap enema (a strong solution of soap) is likewise a valuable
remedy; and when the constipation is great, half a pint toa
pint of castor-oil, neat, may be thrown up. For constipation
in children and young persons nothing is so efficient as an en-
ema of salt and water, repeated night and morning, or every
night, or every other night only, according to the urgency of
the symptoms. Large accumulations of scybala (stercoraceous
tumors) seem visibly to melt away under their continuous in-
fluence. These enemata ought afterwards to be followed by
one or two drachms of sulphate of magnesia, one grain of
quinia sulphatis, in aromatic sulphuric acid in an ounce of in-
fusion of gentian, every morning till the bowels assume a
healthy tone. A soap suppository, ze, a piece of common
yellow soap, shaped to an oval form, about half an inch thick
at the middle part and an inch and a half long, introduced into
the rectum, is also a useful stimulant to the action of a torpid
rectum in children. When constipation is occasional and ac-
cidental, any of the milder cathartics, in the absence of an
enema, as the sulphates of soda or of magnesia, castor-oil,
thubarb, aloes, or the confectio sennz, or the pilulz colocyn-
thidis comp., will in general open the bowels. In obstinate
constipation, tartrate of antimony, to the extent of one-fourth
of a grain, combined with a drachm of sulphate of magnesia
every hour, may often bring feeces away after nausea super-
venes. If, however, the constipation is habitual, the healthy
habit of a daily evacuation is not easy to be re-established. The
remedies, though often successful, yet occasionally fail. In
cases of habitual constipation, the combination of tonic with
laxative will often produce a more efficient action than a per-
severance in the use of purgative medicines alone. Thus,
two grains of the ferri sulphatis, or an ounce and a half of the
infusion of gentian, combined with one or two drachms of
sulphate of magnesia, given according to the urgency of the.
case, three times a day, or every six hours, will empty the
bowel when the salt alone will fail. In old persons, a combi-
nation of aromatics with the purgative, as in the decoctum
aloes, is a more useful and effective remedy than the same or
even a greater quantity of aloes alone. Aloes is a useful
remedy when the colon seems specially at fault as a result of
fever and debilitating diseases, or of sedentary habits’and oc-
cupations. The watery extract, combined with essential oil
of ginger and jalapin; or with quinia, extract of nux vemica,
ipecacuanha, are the most useful combinations. Where slow
CONSTIPATION. 81

digestion, with a deficiency of mucous secretion prevails, the
following is a formula for pills, of which one ought to be taken
an hour before dinner (and before breakfast also) if required:

BR. Pulv. Ipecacuanha, gy. viii. to xii; Ext. Aloe, gr. xii;
Sulphatis Ferri, gr. xviii. to xxiv. Misce, et divide in pil. xii.

Or, the ipecacuanha may be omitted; or the aloes may be
combined. only with some bitter extract, such as gentian.
Such pills ought to be continued regularly till the occurrence
of a “loose motion,” after which one only, an hour before
the principal meal, will be sufficient. ;

Another formula for a pill of a similar nature is of use in
habitual constipation, namely:

B. Pil. Rhei. Co., vel Pil. Coloc. Co., vel Aloe, gr. il. to ili;
Pul. Capsici, gr.i. To be taken with the food, and repeated
daily as occasion may require (Pavy).

Drastic purgatives ought never to be given. The diet
ought to be especially attended to. More food, both slid
and liquid, may require to be taken. When constipa-
tion is obstinate, and has resisted the stronger purgative rem-
edies, a full dose of opium sometimes seems to relax the
spasm of the muscular coat of the bowels, on which the con-
stipation may depend. Belladonna also may be given with
advantage, in doses of 4 to 4 of a grain every morning at
rising, combined with the extract of gentian (Trousseau);
or 10 minims of the tincture of belladonna may be similarly
taken. All medicines for the relief of constipation ought to
given just before or with food; and are to be regarded as act-
ing with the food in bringing about the result. Pills or
draughts at bedtime are. not so useful. In the constipation
of children the sulphate of potass is recommended alike by
Drs. Hiller and West. The following are useful formule:

B. Potas. Sulphatis, gr. xl.; Syrup Rhei. 3 ss.; Aq. Carni
Ad. Ziii.; Misce. Dose—A table-spoonful for a child six
years of age (Hiller).

R.. Potas. Sulphatis, gr. xii.; Infus. Rhei. 3 vss.; Tinct Au-
rant., 3ss.; Aq. Carni, 3ii; Misce. Dose—A table-spoon-
ful for a child three years of age (West).

Asevere case of colic with constipation, in the practice
of Dr. Murchison recovered under the use of one-haif grain
of the extract of belladonna ever$ four hours, with belladon-
na ointment to the abdomen, a warm bath and castor oil
enemeta (Lancet, Jan. 19, 1871). When constipation arises
from torpor of the colon, equal parts of compound gamboge
pill and the compound colocynth pill is recommended by the
82 CONSTIPATION,

late Dr. Symonds of Bristol (“ Lib. of Medicine,” Vol IV., p-
139). The compound extract of colocynth, or compound
colocynth pill variously combined with small doses of blue
pill, or with ipecacuanha, or with podophyllin, or with
nux vomica, is a safe and useful form for the relief
of the bowels. Colchicum (tincture of the root) has been
found of service in doses of ten drops several times
daily (Chapman). When constipation does not yield to
the simple treatment which has been mentioned, re-
course must be had to more active remedies. Thus calo-
mel, gr. v.; c. jalape, gr. xv., is a dose which rarely fails
to produce motions, and this if necessary, may be followed up
four hours after, either by the neutral salts in divided doses,
or by ablack draught in one dose. If a stronger medicine
‘than the above be necessary, elaterium is of greater power,
and from 7 to + grain, combined with henbane, is sufficient
to begin with, so as to avoid hypercatharsis. When the stools
indicate a deficiency of bile, inspissated ox-gall has been
recommended. It may be given in the following formula:

. Fel. Bov. Purificat., 3ii; Ol. Carni, mx.; Magnes.
Carb., q-s.; Misce. Divide in pil. xxxvi. Dose—Two to be
taken daily (Waring); or,—

R. Fel. Bov. Purificat., Pil. Asafoetid. Co., aa. gr. xxx.;
Ex. Aloes, gr. xx.; Sapon. Dur. gr. x; Pulv. Ipecac., gr.
vili.; Misce. Divide in Pil. xxx. Dose—One or two may
be taken daily before dinner (Copland).

The resin of podophyllin, to the extent of $ to} of a
grain combined with compound rhubarb pill, acts similarly
to the combination of rhubarb pill with calomel. A length-
ened period sometimes elapses before it operates. The
tincture of benzoin, to the extent of gtt. xx. three times a
day, will, it is said, keep the bowels active and regular (Hast-
ings, Streetan). -

Sometimes the feecal matter accumulated in the colon is
so large in quantity, and so hard and impacted, that manual
assistance is necessary to relieve the patient. Women some-
times suffer for years from constipated bowels; and a con-
trary state of the bowels may take place from the irritation
of hardened feeces, when they are much harassed by purg-
ing, existing more or less for many months. At length a
violent tengsmus comes on, with a bearing down most intol-
erable, much worse than a woman suffers in her confine-
ments. On examining the rectum, a mass of hard matter
may be found, which cannot be broken to pieces’ without
CONSUMPTION—CONVULSIONS, INFANTILE, 83

the aid of an instrument. This mass consists of a variety
of undigested substances, which when broken down, may
be washed away by injections, to the perfect relief of the
patient.

Dietetic Treatment—Patients suffering from constipation
should avoid port wine or brandy, and should eat freely of
sub-acid fruits, drink more water, and in some cases eat
more food of a kind likely to stimulate the colon, such as
bran bread; and oatmeal, in the form of cakes, or well-
boiled porridge, should be eaten for breakfast. They should
go daily at the same hour to stool ; for such is the periodical
regularity of all the functions of the body, that they are more
readily performed at accustomed hours than irregularly,

Consumption—See Phthisis.

Convulsions, Infantile.—De/inition.—Convulsive seiz-
ures, consisting of contraction of muscles by gradual but
rapid shortening of the muscular fibres, causing such hard-
ness and stiffness of the muscle or limb that it cannot be over-
come. This period of tonic contraction is followed by clonic
spasmodic phenomena, characterized by the occurrence of
alternating movements of contraction and relaxation inde-
pendent of the will, which is as powerless to suspend or mod-
erate them as to excite them (Trousseau.)

Treatment.—Of all the causes mentioned i connection
with convulsions, none are so common or universal as indi-
gestion. Hence the quantity and quality of the food and
condition of the evacuations, by vomiting or by stool, ought
to be inquired into at the first. If some unwholesome diet
has been given, a good purgative of calomel, mixed with pow-
dered sugar, should be put on the back of the child’s tongue.
If indigestion is traced as the source of the fits in an infant
or young child, a'few drops of aromatic spirit of ammonia, or
the same quantity of ether, may be given in a teaspoonful of
water; or a drop or two of anise oil, rubbed up with sugar,
may be given from time to time, by laying the powdered
sugar so saturated on the tongue of the child. Itis in such
cases that mere flatus in the bowels may cause a fit in a pre-
disposed child. The belly will be found tumid, when gentle
friction over the abdomen (following the direction of the cos
lon), combined with the warm bath and those soothing aro-
matics, will give relief.

The clothing must be loosened completely, so as to admit
air freely, and anti-spmasmodics, such as ether alone, or com-
84 CONVULSIONS, INFANTILE.

bined with musk or belladonna, may be given, till the pro-
gress, duration, seat, or probable cause of the convulsions
may be ascertained. An emetic, a purgative enema, a search-
ing purgative, such as calomel, combined with jalup or rhu-
barb, may be indicated; or the removal of a pin in the dress,
which had been long pricking the skin, or too tight a dress,
may, on removal or rectification, cause the convulsions to
cease.

In all cases, however, when a child we have never seen be-
fore is found in a fit, it is best to order a warm bath to be
prepared, and to have the room freely ventilated. The next
points to inquire into are the condition of the pulse and of
the .child’s head as to form and completion of its bones.
“Pass one hand quietly and carefully over the child’s head
while the pulse is felt with the other. Fulness or weakness
of the pulse will be a guide to diagnosis; so also if the head
be hot or cold, if the anterior fontanelle be tense and pro-
truding, or sunk and retracted, and if the face be flushed or
pale” (Ellis, Diseases of Children).

When the child is completely stripped of its clothing, it
should be observed if the legs are drawn upwards to its belly,
and if so, and the head be hot, and the fontanelle prominent;
there is congestion of the head, which may either vc the
cause or the consequence of the fits. In any case the child
should be placed first with its feet in the bath, in which a
handful of mustard may be mixed (two ounces of mustard to
four gallons of water). At the same time vinegar and water,
or spirits and water lotion, may be applied to the child’s head;
while hot flannel cloths wrung out of the hot mustard and
water bath (with more mustard sprinkled on the surface of
the flannel) should envelop each leg and foot. If the head
be cold or the fontanelle depressed, the entire body of the
child should be immersed in the mustard and water bath
(temperature about 98° Fabr.); and friction employed over
the whole skin. A little sal-volatile map be held to the nose,
and a few drops of brandy in a teaspoonful of water may be
used to moisten the lips. It is possible the child may be in
a state of faint or syncope, and not in a fit.

During these proceedings it is important to find out the
previous medical history of the child, as to,—(z1.) Which of
the acute specific diseases it may have had. (2.) State of
dentition, and also condition of gums to be determined, by
passing the finger along them. (3.) What the child may have
been eating recently. (4.) The previous existence of diar-
CONVULSIOS, INFANTILE, 85

rhoea. (5.) The ‘previous occurrence of carpopedal twitch-
in ngs, or drawing in of the hands and feet, with general irri-

ility. If this latter condition is found to have existed,
and if the fontanelle be prominent, there is some abnormal
conditioft of the nervous system. A calomel purgative may
be required, or leeches, or a rubefacient behind the ear or
over the vertex. With headache, vomiting, and some fever-
ishness, a pulse of 130 would rather point to stomachal dis-
turbance; whereas with a slow pulse (say at 40), these symp-
toms would rather indicate an early manifestation of tuber-
cular meningitis, where bromide of potassium or ammonium
may be required after suitable purgation. If recently con-
valescent from ‘scarlatina, and there be albuminuria or an-
asarca, a hydragogue cathartic may be required, in the form
of twenty grains of compound jalap powder with a grain of
scammony, to a child five years of age, repeated every two
or three hours till the desired result is produced. It may be
necessary at the same time to dry-cup the loins. If convul-
sions come on during hooping-cough, apply ice or cold tothe
head, with free purgation, and use a sedative cough mixture
(Ellis, lc. p.

A clyster of one part vinegar and three parts water, the ap-
plication of cold compresses to the head, or of leeches be-
hind the ear, if the convulsions do not subside, are remedies
advocated by Niemeyer.

If symptoms denote stupor, cold affusion should be pre-
scribed; if, on the other hand, they denote some collapse,
wine, camphor, musk, and other stimulants must be used.

If dentition is causing the convulsions, the dense tissue of
the gums over the tooth ought to be relieved by lancing it, or
cutting it across over the crown of the tooth.

Dr: Tanner advises the administration of bromide of po-
tassium as a medicine from which more may be hoped for
than from any pther. If there be inability to swallow, it
ought to be given in enemata of beef-tea.

Where great restlessness prevails, dilute hydrocyanic acid,
with tincture of hyoscyamus, may be given.

Compression of the carotid arteries and chloroform inhal-
ation, or a mixture of ether and chluroform, are only to be
had recourse to in cases of prolonged duration, depending on
such irritation as that of dentition. Anesthesia thus induced
is of great value.

Trousseau is strongly opposed to blisters and general “
yulsions to the skin,” except in some cases of “ yaward fits” :
86 CONVULSIONS, PUERPERAL,

involving the diaphragm or the heart. In such cases the ac-
tion of the remedy, as ammonia, must be immediate.

Convulsions, Puerperal—Definition —An acute affec-
tion of the nervous system, characterized by loss of conscious-
ness and sensibility, by tonic and by clonic spasms. It occurs
only as an accessory phenomenon of another disease (gener-
ally Bright’s, in an acute form) which, under certain circum-
stances, spreading its toxeemic effects on the nutrition of the
brain and the whole nervous system, gives rise to convul-
sions. The blood-poisoning is generally to be referred to
anzemia, or to the products of the changes in urea which are
_ retained in the blood, or to the retention of other excremen-
titious constituents of the urine (Braun).

Treatment.—\f oedema with albuminuria and tube casts
in the urine are observed during the course of pregnancy,
the morbid condition may be kept in check, and the exten-
sion of the disease may be prevented by hygienic manage-
ment and medicinal remedies. The watery and otherwise
deteriorated condition of the blood is to be ameliorated by a
liberal -and properly assorted dietary, and by ferruginous
tonics; and a good general effect is often produced by the
use of tepid and vapor baths (Caxeaux, Leishman). It has
also been suggested by Frierichs that tartaric acid, benzoic
acid, or lemon juice should be regularly given, with the idea
that these will prevent decomposition of the urea in the blood,
or neutralize the carbonate of ammonia already formed.
The functions of the bowels must be regulated with care.
Purgation as a prophylactic must be resorted to with cau-
tion. Compound jalap powder, in electuary, with or with-
out guaiacum, are the most efficient and least depressing
medicines for this purpose. The quantity and the micoscopic
appearances of the urine furnish the best indications as to
the necessity for the use of diuretics. When, exudation has
taken place into the Malpighian capsules and the tubes, it is
desirable to clear them of the obstruction, and prevent its
reformation. The copious use of diluents may effect this
desirable result. But if the secretion of urine be scanty,
and uremic intoxication threaten to come on, the secretion
of urine must be increased. The acids already named, and
the mineral waters of Seltzer and Vichy, are the remedies
best adapted for this purpose (Braun, Leishman). I find also
frequently repeated small doses of bicarbonate of soda com-
bined with spirits of nitrous ether in large quantities of cold
COUP DE SOLEIL.—-CRETINISM. 87

barley water, an efficient diuretic in such circumstances.
Pills of tannin and extract of aloes may be used for restor-
ing the normal tone. Labor should only be provoked when
the symptoms are such that the life of the mother is in dan-
ger (Braun, Leishman).

In the treatment of the fits, procedure is different accord-
ing as they happen during pregnancy, during labour, or after
delivery. During the paroxysm, the indications are the same
in all cases. As to blood-letting, there are certain cases in
which the constitution and temperament of the woman, the
violence of the attack, combined with evidence of vascular
tension within the cranium (such as throbbing carotids,
marked suffusion of the eyes and face), warrant us in believ-
ing that by venesection we give the patient the best chance
of recovery, or in such cases leeches may be freely applied
to the temples and ice to the head. In cases which do not
present these indications for blood-letting, the administra-
tion of chloroform, ether, and other anesthetic agents, pro-
duces a berteficial effect. Symptoms which suggest the ap-
proach of a first seizure, or a repeated paroxysm, are a suffi-
cient warrant to adopt this method of treatment. It is the
premonitory symptoms which must be held in control by
anzesthetics,—their use is too late when the respiration is
impeded. Chloral hydrate has also been strongly recom-
mended, and it has this further advantage, that “when it is
pushed further it produces an anesthetic effect, under the
influence of which a woman may be delivered without expe-
riencing the slightest suffering” (Leishman). In ordinary se-
dative doses—not more than thirty grains—its effect is safe,
and in most cases efficacious; but if larger and repeated
doses are required, its cumulative action is such that very
alarming symptoms are occasionally produced, and death
has even been the result of what might be considered quite
an ordinary dose. Four drachms have been administered by
enema within three days. Sponging with warm water, or te-
pid vinegar and water, has been found useful. Opium is not
to be administered in cases where albuminuria is present.
(For obstetri¢ details, see Leishman’s “System of Midwif-
ery,” 3d Edition, p. 776.)

Coup de Soleil—Sze Sunstroke.

Cretinism:—Definition.—A condition of imperfect devel-
opment and deformity of the whole body, especially of the
head. It is endemic in the valleys of certain mountainous
88. CROUP.

districts, and is attended by feebleness or absence of the
mental faculties, and sometimes of the special senses.. It
is often associated with goitre.

Treatment.——The indications of treatment are those which
suggest improvement in all hygienic measures for the pre-
vention of the disease. Dr. Gubbenbuhl, of Zurich, was the
first to recognize the fact that the mental state of cretins
could be improved by improving the growth and condition of
the body. In 1842 he succeeded in buying the mountain of
Abendberg, which incloses the plain of Interlaken, and there
he established an hospital for these unfortunate children.
The infant cretins, removed from the low close valleys (in
which the malady too often finds the circumstances most
congenial for its development), are there fed and trained in
“the free, dry, cool, and bracing air of the open but sheltered
and sunny slopes of the Abendberg.” Once established, |
the condition of the cretin can only be ameliorated by insti-
tutions similar to those founded by Dr. Guggenbuhl. The
condition is beyorfd medicinal remedies. -

Croup.—Definition—A “non-infectious inflammation of
the mucous membrane of the trachea, occurring in children,.
differing from other inflammations in like tissue in the pres-
ence of plastic exudation” (Barclay) ; or it is a disease ac-
companied by the exudation of a fibrino-albuminous material
which rapidly coagulates upon the mucous membrane of the
epiglottis, glottis, larynx, or trachea, and sometimes over all
of these parts; indicated by accelerated, difficult, wheezing,
or shrill respiration ; short, dry, constant, barking cough,
voice altered by hoarseness, with spasm of the interior lar-
yngeal muscles, and pain and constriction above the sternum,
frequently followed, towards the close of the disease, by ex-
pectoration of a membranous albuminous substance, or even
of a cylindrical cast of some portion of the breathing tube.
The disease occurs in children, and may terminate fatally,
either in suffocation or exhaustion of the vital powers.

Treatment.—Every case of croup demands the most active,
efficient, and energetic treatment. Great and diametrical as
are the pathological differences of croup and diphtheria, the
treatment most effectual in either is not the less decided and
opposite. While calomel in purgative doses, tartar emetic,
and blood-letting may each and all of them be demanded in
croup, these. agents would be most baneful in diphtheria,
which is most successfully combated by the administration of
the mineral acids (especially the nitric and hydrochloric),
CROUP. 89

chlorate of potash, quinine, and iron (See Diphtheria), Bleed-
ing, especially local, should be employed in most cases to a
considerable extent (an ounce of blood for every year of
age) ; and two to twelve leeches, according to the age of the
patiént, should be applied over the trachea and larynx. The
bleeding should be encouraged by the application of a lin-
seed poultice to the throat. This first bleeding often gives
great relief, and sometimes averts the danger. If not, the
leeching after a few hours may be repeated. As soon as
some relief is obtained, a blister should be applied along the
lateral aspect of the neck on each side, and not over the tra-
chea. The blistered surface should be dressed with mercu-
rial ointment. Many practitioners prescribe emetics also;
first, because their emetic effects, and the large evacuations
they produce, favor the resolution of the inflammation; and
second, because the effort of vomiting may be the means of
detaching and of expelling the false membrane, should it
have formed. So soon as croupy cough and dyspneea occur,
an emetic of ipecacuanha with tartar emetic ought at once to
be given in doses suited to age. Four to six grains of ipeca-
cuanha, combined with a quarter or a third. of a grain of tar-
tar emetic, will be sufficient for a child of two or three years
of age. The action of the emetic may be aided by a warm
bath of 98° to roo? Fahr. If it becomes obvious that the
exudation has assumed the form of a membrane, especially if
indicated by a diphtheritic coating over the fauces, a solution
of the nitrate of silver, varying in strength from forty to one
hundred and twenty grains to the fluid ounce of distilled
water, should be applied to as much of the fauces and larynx
as can be reached. A sponge on the end of a piece of whale-
bone should be loaded with the weaker solution, and squeezed
against the r¢ma g/ottidis two or threetimes a day. Bleeding
has no effect in removing or modifying the false membrane ;
but the system must be brought as speedily as possible under
the influence of mercury. Two, three, or four grains of calo-
mel, with two or three grains of James’s powder, may be
given at short intervals every two or three hours ; and a dose
of castor-oil occasionally, till the full effect of the calomel as
a purgative is obtained. Green fecal stools, like chopped
spinach, are characteristic of this result. Mercury appears a
powerful resource in these cases; and, introduced either in-
ternally or by inunction, so as to affect the mouth, but with-
out inducing salivation, uniformly gives relief as soon as its
constitutional action is established.
go CROUP.

Bleeding, blistering, and mercury, although the rule of
treatment in idiopathic infantine croup, are, forthe most
part, entirely inefficient in those cases in which the affection
begins in the fauces, as in the case of many epidemics, espe-
cially after scarlatina, which are really cases of diphtheria.
Expectorant medicines should be given with the mercurials,
and be continued after them. Ipecacuanha and senega are
most efficient.

Tracheotomy, when not too long delayed, has saved many
a life in croup, while it has proved utterly abortive in diph-
theria, which is beyond the reach of any such topical
remedy. M. Trousseau has saved one-third of his patients
by its means ; and of twenty cases Bretonneau saved six.
Perhaps the experience of the profession generally is some-
what discordant on this point at present. Those who oper-
ate early save some of their patients, while those who wait
till a case is advanced, and beyond medical treatment, before
they resort to this measure, for the most part lose all their
patients. The evidence, however, is daily accumulating
which shows that tracheotomy ought to be resorted to much
oftener as a remedy for croup than it has hitherto been, and
that at a much earlier period in the disease,—not as a last
resource, when death from asphyxia appears imminent, and
after treatment of the most depressing kind. That this is
the secret of success in France and in this country, is shown
by the experience of able physicians and good surgeons, of
whom the names of M. Trousseau, the late Mr. Jones, of
Jersey, Mr. Henry Smith and Dr. Fuller, of London, the late
Dr. Cruickshank, of Dalmellington, in Scotland, and Mr.
Spence, Professor of Surgery in the University of Edinburgh,
Dr. George Buchanan, in Glasgow, and Professor Roser, of
Tubingen, may be stated as authorities by experience. In
country districts the performance of trachectomy in a case
of croup is almost imperatively called for in the majority of
cases, if some symptoms of amelioration do not follow the
steady use of bleeding, emetics, the warm bath, and calomel
purgation, pursued for twelve or sixteen hours. I know
from personal knowledge in a wild country district of Scot-
land, where croup was very common and fatal, that the late
Dr. Cruickshank saved eight out of eleven cases during two
years. A. valuable paper by Mr. Smith, in Zhe Medical
Times and Gazette, January 26, 1856; another by the late
Mr. Jones, of Jersey, in the 8th November of that year;
and, lastly, a paper by Dr. Conway Evans, in the The Edin-
CROUP. gI

burgh Medical Journal for January and May, 1860, go to
support the same conclusion,—namely that an earlier intro-
duction of air, by the operation of tracheotomy, for croup,
would not only give a larger percentage of recoveries in this
country, but would place the operation in the same favorable
light in which it is now regarded in Paris and other parts of
France. Tracheotomy in croup is undoubtedly gaining
ground ; and it cannot be denied that children perish, in the
first instance, almost always from suffocation. Tracheotomy
is therefore indicated in croup as soon as there are urgent
symptoms of obstruction of the glottis, When the respiration
is so impeded that the demand for oxygen is only satisfied by
difficult forced respirations, dreadful anguish is depicted on
the reddened countenance covered with sweat; there is
extreme restlessness ; the patient tosses from side to side,
gets out of bed one minute and into it the next, clutching
spasmodically at those around him, as if seeking everywhere
for help. This is the proper period for the operation of
tracheotomy in croup,—the time when success may be
expected (RosER). Should the operation be longer delayed,
symptoms of asyhyxia appear, overloading of the blood with
carbon ensues, the face suddenly becomes blue, with fixed
and staring eyes, convulsive exertions are made, and anxious
struggles for breath follow the stage of suffocative agony. In
some cases the symptoms of asphyxia come on more slowly,
and are apt to make considerable progress before the danger
is fully appreciated. This insidious form of asphyxia is
denoted by symptoms of great weariness and weakness, rest-
lessness, oppression, anxious startings out of short slumbers,
loss of consciousness and of feeling, approaching stupor, the
face pale, and tending to become cedematous. If tracheotomy
is delayed till these symptoms become expressed, it may still
enable the child to breathe more freely, and thereby may
promote the chances of recovery ; but the child has usually
no longer power to resist the advancing bronchitis. The causes
of death after the operation are mainly pneumonia, bronchitis,
or the severity of the constitutional febrile state (Syden.
Society Year-Book, 1863, p. 278). In diphtheria the fatal
result depends on a cause acting generally on the system,
which ultimately destroys the patient, and which tracheo-
tomy willnot prevent. Age influences success to a consider-
able extent. Under two years of age few cases recover; but
between the ages of six and twelve nearly one-half are saved
(Conway Evans).
92 CROUP, SPASMODIC——CYSTITIS.

Croup, Spasmodic—Scee Laryngismus Stridulus.

Cyanosis.— Definition —A peculiar blue condition of the
skin, symptomatic of various malformations or derangements
of the heart and great vessels, so that a small portion only
ot the blood is subjected to aération in the lungs.

Treatment must depend upon the nature of the lesion or
disease which gives rise to the cyanosis. The inhalation of
oxygen gas has given relief in some cases.

Cynanche Tonsillaris—See Quinsy.

Cystitis.— Definition—Inflammation of the urinary plad+
der.

Treatment.—The causes must, if possible, be removed.
Purging, together with opiates, diluents, and the warm bath,
are the best means of curing the acute affections. Chronic
inflammation of the bladder, and especially catarrh, is very
difficult of cure, and often our best directed efforts are un-
successful. Opium is the remedy of the greatest value,
especially aided by hot hip-baths, hot fomentations over the
abdomen, and linseed-meal poultices, with or without mus-
tard or turpentine, over the hypogastric region. Supposi-
tories of morphia are of great use, containing half a grain to
a grain of opium ; but if the pain be very great, much larger
doses may be given—as much as two to four grains of opium,
with ten to fifteen grains of extract of hyoscyamus, in a sup-
pository, at the hour of sleep. Alkaline and demulcent
drinks should be at the same time given. The state of the
urine is one of the surest guides in our attempts to cure the
patient. If the urine be acid, the best medicines are the
neutral salts or the pure alkalies, with opiates ; while, if the
urine be alkaline, or greatly loaded with mucus, the mineral
acids are of the most service, combined with an opiate.
Thus the infusio rose c. acidi sulph. dilut. mij. to v., c. mag-
nesiz sulphatis, 3j., c. tinct opii, miij. to v., every sixth
hour, is one of our best and most useful remedies. Tonics
often succeed when other remedies fail, and of these salicine
is one of the best. It may be given in doses of ten grains
every six hours. It must be admitted that much ‘difference
of opinion prevails as to the best tonic remedy, some pre-
ferring uva ursi, others pareira, others the turpentines, as the
Canadian balsam, and others again the infusio diosme. In
chronic catarrh, when the discharge is copious, the decoction
of uva ursi, in doses of not less than half a pint daily, is very
soothing. It is of most advantage in cases of irritability
DELIRIUM 1REMENS—DENGUE. 93

rather than of inflammation, prescribed in large doses, from
one to two drachms of the extract daily, or from eight to
sixteen ounces of the infusion as a drink, made as follows:—

Ri. Fol. uve ursi, 3i.; Aq. Fervid., f 3 xviii. Macerate
for two hours, and boil down to 15 ounces, and strain (Sir
Benjamin Brodie).

Delirium Tremens—Sce Alcoholism.

Dengue.— Dejinition.— A specific continued fever or féb-
ricula, eminently contagious, and having an incubation-
period of a few hours to one to seven days (Charles), charac-
terized by frontal headache, by severe pains in the limbs and
trunk, and sometimes by an eruption, resembling that of
measles, over the body. The disease occurs chiefly in the
West Indies.

Treatment.—Time is an essential element in the treatment-
Emetics and purgation may be given if indicated. Calumba
and rhubarb with soda form a useful alterative medicine.
Emetics of tartrate of antimony and ipecacuanha bring away
large quantities of bile, relieving the pains of the head and
limbs almost immediately ; and the eliminative action ought
afterwards to be maintained by sulphate of magnesia and
tartar emetic. It may be necessary to repeat the emetic
till bile is discharged from the stomach. Dr. Charles’ ex-
perience leads him to say that most patients get on better
without any emetic, which ought only to be given where the
tongue is much Joaded and where there is gastric derange-
ment and nausea. Colchicum, sweet spirits of nitre, nitrate
of potash, and antimony, in proportions sufficient for dia-
phoresis, given every two hours, with an additional efferves-
cing draught, exercise a beneficial influence on the pains.
After the acute symptoms subside, forty to sixty drops of the
wine of colchicum, with twenty-five drops of laudanum, to
which thirty drops of antimonial wine may be added, always
ensure a good night’s rest. Dr. Christie treated his cases by
purgation during the first day, and.in other respects as he
would a case of malarious fever, by five-grain doses of
quinine. When the febrile symptoms subsided iodide of po-
tassium, in four-grain doses, was given, and continued dur-
ing the remission, and for a few days after desquamation of
the cuticle had taken place. Dr. Charles considers purga-
tion ought not to be used in dengue, as it adds to the tor-
tures of the disease and is too lowering. He considers bella-
94 DIABETES MELLITUS,

donna a sovereign remedy in the pains of dengue, and pre-
scribes it thus,—To one drachm of the tincture of belladonna
he adds five drachms of orange syrup, and directs a sixth
part to be taken every hour by an adult till the third dose is
given, which may give so marked relief that no more need be
taken. Less than three such doses seldom is sufficient, and in
very severe pains two or three doses may be given in one.
One-third to half grain doses of the extract, repeated twice
or thrice in the twenty-four hours, will also generally suffice.
Atropia may be used hypodermically in solution of one grain
of the sulphate to an ounce of water; of which 8 minims are
sufficient for most cases, while 10 minims (containing 2g of
a grain) is a full dose for a powerful, well-developed adult.
Such a dose must not be exceeded in any case ; and atropia
is only to be used thus to afford rapid relief when pain is very
intense, and has lasted: for some time. Five minims of the
solution is enough for a child of twelve years (containing 7,
of a grain). Cold water in the form of cold sponging has
been found of great service in the hyperpyrexia of dengue ;
and the cold bath is worthy of consideration.

Diabetes Mellitus. —Defixction—A constitutional dis-
ease produced through errors in the processes of assimila-
tion either in the stomach, in the solid organs, or in the
blood, and cha:acterized especially by an excessive thirst, an
excessive discharge of urine, more or less constantly saccha-
rine, to an extent of over 10 grammes (154 grains) of sugar
per litre (35.3 ounces) of urine (Laséque), and associated
with progressive emaciation of the body, often ending sud-
denly by coma from acetonzemia or by convulsions.

Treatment.—There are few diseases in which the treat-
ment has been more varied than in diabetes mellitus. Every
conceivable medicine has been given, but exact determina-
tions of their effects on the sugar have rarely been made.
The emaciated state of the patient presents an insurmount-
able obstacle to bleeding. Nevertheless, this mode of treat-
ment has often been practised: but the pathology of diabe-
tes, as given in the text, does not sanction general blood-
letting as a mode of cure.

Mercury alike with lead, antimony, zinc, silver, and cop-
per, are indifferent as to their influence on the formation of
sugar (Parkes), Opium has been given to the extent of roo
grains in the twerity-four hours; but with an equal want of
success, although it does seem to lessen the sugar, probably
by lessening the appetite and hindering the taking of food
DIABETES MELLITUS, 95

(Parkes). Nevertheless opium and its preparations, especi-
ally codeia, have among all known remedies the most decis-
ive influence on the excretion of sugar; but the duration of
the action is only exceptionally an enduring one (Seegen).
The whole materia medica has been exhausted in search of
a remedy for this disease. The metals, the fixed and the
volatile alkalies, the vegetable and mineral acids, the astrin-
gents, purgatives, tonics, diaphoretics, and diuretics, have
each in their turn been administered, and each has perhaps
afforded some relief ; but the disease has proceeded, and
finally, it may be said, nearly every patient dies whose treat-
ment is left entirely to drugs. Dr. Prout, who considered
diabetes merely as a form of dyspepsia, conceived that each
case requires a special treatment. In the early stages of the
disease some have found great benefit from the tincture of
the muriate of iron, now called the tincture of the perchlo-
ride of iron. Dr. Camplin speaks of the citrate of ammonia
in the effervescent form, generally combined with the citrate
of iron as more useful than any other medicine ; while bit-
ters and alkaline remedies did him great service at one
period of his attack. Amongst remedies, alkalies, as recom-
mended by Miahle and Contour, and mineral waters have
proved themselves the best. The use of Carlsbad water
has always a favorable influence, the amount and duration
of the influence varying with the severity of the disease (See-
gen). The quantity of sugar in diabetes decreases under
the use of alkalies, and at the same time the patient is better
nourished. This action of the alkalies depends probably
upon an increased oxidation of the hydrates of carbon in the
blood of the non-muscular tissues, by which partly the want
of oxygen in the muscles may be compensated. If the un-
“known cause cannot be removed, in consequence of which
the muscles cease to decompose sugar, there are no re-
medies by which we might decompose the sugar in a diabetic
diseased organism. But we may partly supply, in the blood
of diabetic patients, what is wanted. Besides alkalies, we
may use paralactic acid; and as glycerine acts in a similar
manner as paralactic acid,—. ¢., is easily consumed in the
blood—it deserves to be taken into consideration in such
cases. It has been given with benefit to the extent of six
to eight drachms daily; and its administration should be
continued uninterruptedly for at least one month. In place
of paralactic acid, there may be used lactic acid, as it is also
consumed in the blood. :
96 DIABETES MELLITUS.

Opium, combined with ipecacuanha, is eminently useful
as a sedative, especially in the form of Dover’s powder ;
while exercise, warm clothing, friction of the surface, hot
bathing, and diaphoretics, improve the cutaneous functions,
The functions of the skin must always be inquired into, and
must be kept active. The nitro-muriatic acid baths, and the
internal administration of the acid, might also be employed
with some prospect of benefit in cases requiring acid tonics.
This is more generally the case in the young, and in the
early stages of the disease, in which the tincture of the per-
chloride of iron is also of service, prescribed in the infusion
of quassia or of calumba. But each case requires to be
made a special study, considering that many, or at least sev-
eral, organs are concerned in the disorded working of the
system (Prout, Camplin). The mistura ferri composita is
another of the iron preparations which has been found of
service. With the view of diminishing the morbid ferment
in the stomach, Drs. W. Ebstein and Julius Muller, of Bres-
lau, have prescribed carbolic acid with advantage. It was
given dissolved in peppermint water (the strength being x
gramme to 300 grammes), about six to seven tablespoonfuls
of this solution being taken in a day. It has also been
found of use in the treatment of the acetonzmia (B. Foster).
One to three grains may be given in glycerine or in a pill,
twice or thrice a day. Valerian has also been found of use
in diminishing the excretion of urea (Bouchardat), and so
lessening thirst. He gives it in repeated small doses, and
gradually increases the amount taken until he has, in some
cases, reached a dose of 30 grammes (450 grains) in twenty-
four hours (ed. Times and Gazette, Vol I., p. 568). With
regard to the acetonemia, transfusion has failed in this
country and abroad. So also has the injection of a saline
solution into the blood, as practised by Drs. E. H. Fagge
and F. Taylor, of Guy’s Hospital (Guy's Hosp. Report, XIX.,
p. 173 and 521). Salicylic acid and its salts are also worthy
of trial, so is thymol (B. Foster, Burdon Sanderson). In
the severe form of cardialgia, I have found great benefit to
result from the use of Seller’s Bismuth Mixture, prepared by
Messrs. Mackay, Sellers & Co., 1 and 2 Bouverie street, Lon-
don, in half-drachm doses, mixed with water, three or. four
times a day. Dr. Garrod writes favorably of the sulphide of
ammonium as useful, in so far as it controls the morbid appe-
tite; and Dr, S. Ringer finds sulphide of calcium of use.
In the affections of the genitals in the female, I have found
DIABETES MELLITUS. 97

the intense pruritus to be best relieved by bathing in solution
of Condy’s fluid (permanganate of potash) in copious and
frequent ablutions, or by vaginal injections without soap.
Winckel has found a solution of one part of salicylic acid in
300 of water; but glycerole of lead, zinc ointment, white
precipitate ointment, glycerine and tannin, sitz baths with
bran, carbolic acid solution (z grain to 4 ounces of water as
a vaginal injection, or 5 grains to the ounce as a lotion),
may cach in their turn be of use in relieving these
most distressing of the symptoms and complications of
diabetes.

The little benefit derived from medicine induced Dr.
Rollo to try the effects of an entirely azoted or animal diet ;
and now it is found that the regulation of the diet is of the
first and primest importance in the treatment of diabetes.
A full and generous diet is unquestionably useful; but the
patient soon gets disgusted with mutton or beef, or both, for
breakfast, dinner, and supper: he consequently nauseates a
meat diet, and abandons it altogether, A diet of salt fish
has been attempted, but the patient in a short time so
loathes it that it has to be givenup. A mixed diet, therefore, if
contraindicated by some theories, is at least the best to
adopt in practice, if duly regulated and aided by other
means. It will be evident, however, that those vegetables
which contain a large quantity of saccharine matter should
be avoided, as potatoes, grapes, or other very ripe fruit, and
a fortiori, sugar itself.

“ However surely an exclusive animal diet may lessen or
entirely remove, the sugar in the urine of a diabetic patient, it
is certain that it cannot long be tolerated.’”’ In this opinion
Niemeyer, Trousseau, and many other physicians now con-
cur: “Under its use the appetite fails, and a loathing of all
food soon happens. The necessity of a mixed diet for man
is as necessary for him when suffering from diabetes as in a
state of health. In this disease the nervous system is un-
doubtedly implicated, and arigid adherence to animal food
alone, were it practicable, would soon be followed by an
aggravation of the nervous troubles. There is, from the very
beginning, and throughout the course of the disorder, a
strong tendency to devitalization, and this too must be
guarded against. Fortunately the sugar in the urine may
be kept down, and at the same time the general strength of
the system maintained, by a properly adjusted diet of mixed
food. Along, then, with the carnivorous dietary, whose im-

7
98 DIABETES MELLITUS,

portance is not to be undervalued, certain vegetables may be
permitted, not only with impunity, but with advantage.
These are, cabbage, cauliflowers, onions, spinach, water-
cress, sorrel, endive, lettuce, &c. Trousseau has found no
ill consequences from eating acid fruits, as strawberries,
gooseberries, cherries, and he has allowed apples, pears and
grapes. He even suffers his diabetic patients to eat a sma
quantity of bread, if they greatly crave for it. As he re-
marks, there are many persons who are unable to make a
meal without it. Such a regimen is more likely to keep the
disease stationary, and secure the general comfort of the
patient, by upholding his strength, than by confining him to
one kind of diet, which his stomach soon revolts against, and
which must result in innutrition, general debility, the devel-
opment of intercurrent affections, and sooner or later death.
Enforced daily exercise in the open air, when possible, just
short of fatigue, is as of much importance in the treatment
of diabetes as diet. In Professor Bouchardat’s estimation
exercise is the most efficacious of agents. Gymnastics should
be practiced. ‘Trousseau says that he has repeatedly seen,
during the hunting season, diabetic patients, abroad with
their gun and dog, cease both to drink and urinate to excess,
and regain their strength, and even their virile powers. A
suit. of flannel or buckskin should be worn next the skin.
Warm alkaline baths should be frequently taken, and an
occasional Turkish bath will be found serviceable, if it pro-
duces no disposition to boils; or daily packing with the wet
sheet may be tried, carefully watching the effects. The
whole body should be hand-rubbed daily. Cream, so long
as it agrees, may be permitted, and cod-liver oil is in many
cases well borne, and would seem, as anourisher, to do good.
The benefit of small doses of the alkalies, not continued
longer than a week or ten days at a time, is incontestable.
They are the best given in the form of Vichy, Marienbad
Kreutzbrun, or Carlsbad Sproudel water. Legroux thought
- he derived benefit from the administration of arsenic. Dr.
Richardson, of London, has recommended the respiration of
oxygen, and Bérenger-Féraud has shown that during its use
there is great diminution in the amount of sugar in the urine
(Bul. de Ther., t. \xvii). The ethereal solution of the
peroxide of hydrogen (ozonic ether) has been given with as-
serted benefit in half-drachm doses in an ounce of distilled
water. Dr. T. K. Chambers has prescribed iodide of potash
on purely empirical grounds. The preparations of iron are
DIABETES MELLITUS. 99

indispensable, and should be varied from time to time. To
lessen the thirst and craving for food, small doses of opium
are useful. By the use of the mixed diet recommended, par-
ticularly if fatty articles can be taken, the obstinate consti-
pation, so common in the earlier stages of the disorder, may
be obviated without a recourse to drugs. Should this not
be the case,castor-oil in capsules, or rhubarb and podophyllin,
must be prescribed.

“This mode of treatment, which secures a proper but 'va-
tied diet, one that will not disgust the patient, but will nour-
ish his body, though it may not remove the symptom glyco-
suria, will, in a large number of cases, give the diabetic a fair
share of conditional health; so that, as Dr. Trousseau re-
marks, he would not know he had sugar in his urine, if an
occasional chemical analysis did not remind him of its pres-
ence.” (Dr. Clymer’s American edition).

Nevertheless, there are, as Dr. Camplin justly observed,
‘certain fixed broad principles upon which the disease is to
be treated.” In all cases the various influences of the stom-
ach, liver, skin, and kidneys on the nervous system and on
each other, ought to be sought out and determined, and the
basis of treatment arranged accordingly. It is necessary to
abstain from all amylaceous food, as well as from every solid
and liquid containing sugar, or any substance readily con-
vertible into sugar. Fat meat and eggs may be taken, if
biliary derangement is not induced by them, and fish is a
most important article with which to vary the monotony of
the dietary. Milk may also be indulged in occasionally, as
it is not found that the sugar it contains is readily converted
into glucose. Its influence, however, requires watching.
The name of Dr. Donkin is associated with a special treat-
ment of this disease in the use of skim-milk as the sole and
only diet. He shows that in accordance with the teachings
of chemistry and physiology we ought to expect advan-
tageous results from it. Dr. Donkin contends that milk-sugar
differs so essentially from cane sugar, grape sugar, and pure
diabetic sugar, that it is not converted into it, and does’ not
appear again in that form in the renal excretion. “ Belong-
ing to a different class of sugars, milk-sugar does not undergo
alcoholic fermentation in contact with yeast; and, in addi-
tion, it does not precipitate the oxide of copper when treated
with the reduction test. On the other hand, it is subject to
lactic fermentation by the action of ferments. On account
of these intrinsic differences, lactose, as an ingredient of
roo DIABETES MELLITUS.

milk, cannot undergo the same mctamorphic changes as glu-
cose in the processes of digestion, and assimilation in health
(nor be converted into it in diabetes); its conversion» into
lactic acid being direct and immediate, not by intermediate
changes, through which the latter pass into this substance.
For this reason milk-sugar, unlike vegetable glucose, is assim-
ilated. It is necessary to notice, however, that milk-sugar,
in the presence of acetic acid and some other vegetable acids,
and of several mineral acids and other substances, was long
ago observed by Simon to be changed into grape-sugar, and
so became liable to alcoholic fermentation, and hence pre-
sumably as injurious to the diabetic as glucose. Hence
milk-sugar may be thus perverted and rendered poisonous
by admixture with other articles in the stomach, whereas
taken quite alone, it may be the best of foods to the hungry
patient. It is not, then, considered to be a fair trial of Dr.
Donkin’s skim-milk treatment, if any other food be allowed to
mix with it in the stomach. It must be made the exclusive
article of diet. The use of lactic acid by Professor Cantani,
Dr. Balfour, Dr. Foster, and Dr. Ogle, is quite” dis-
tinct from the treatment recommended by Dr. Donkin.
They prescribed lactic acid as a remedy intended
to make other foods wholesome; he prescribed skim-
milk as a sole nutriment, which the mixture of
other foods nullifies. As to the quantity demanded, it ap-
pears that a patient can drink as much as a gallon and a
half per diem: but that is an extreme ration; and when the
appetite isso keen, Dr. Donkin advises some of the milk to
be made into curd or “junkets.” But much less than a
gallon and a half will suffice, for much less will supply the
calculated daily wants of the digestive organs. Each pint
of skim-milk contains half its weight of casein in a fluid
state, which, in fact, is liquid bodily tissue. There is 72 per
cent. of water in combination with it, and there is 72 per
cent. of water in the primest beef. Thus, in five pints of
skim-milk a man would get as much nutriment as in 3% lbs.
of beef-steak, which, in an exclusively meat diet, may be
reckoned sufficient even to do a day’s workupon. Dr. Don-
kin has, no doubt, made out a case for at least a temporary
trial of this remedy in all but exceptional instances of dia-
betes. But the treatment must be commenced in the earliest
stages. I have not found it of any use when the disease is
persistently established.

It is desirable to vary the food as much as possible dur-
DIABETES MELLITUS, 101

ing the day, taking the lighter kinds in the later meals.
When soups are taken, they ought to be really good, and
flavored with aromatics or onions, to the exclusion of car-
rots, turnips, and peas. They may be thickened with some
bran finely powdered. Lettuces Dr. Camplin found to agree
well, when eaten sparingly with oil and vinegar, or with a
little salt only, if the vinegar is likely to disagree. Pickles
in small quantities may be permitted to convalescents. If
cocoa agree, it may be taken, prepared from the nibs only.
With regard to drinks: if milk is found to agree, it may be
used as a drink combined with half its bulk of lime-water or
soda-water, or in the form of what is known as “ buttermilk ”’
in Scotland and in Ireland, but which in England is gener-
ally given to pigs, not yet being sufficiently appreciated by
natives south of the Tweed. Dr. Camplin eventually found
it necessary to abstain from all alcoholic drinks; but, where
they are found desirable or necessary, a selection may be
made from those wines and spirits which are freest from
sugars. Of these, clarets may be chemically considered the
best, then Burgundy. The so-called “fruity wines ” must
be entirely interdicted; and of all alcoholic beverages weak
brandy and water is the safest. The amount of brandy
must be always measured, and taken as directed by the
medical attendant. From a teaspoonful to a tablespoonful
in a tumblerful of water is generally sufficient for an ordi-
nary dinner drink; and Dr. Camplin candidly and feelingly
observes, from his own experience, that no diabetic need ex-
pect to recover or continue well who cannot exercise self-
control, and make up his mind to be temperate in all things.
Seeing that under this system of diet the patient is deprived
of the use of ordinary bread, Dr. Camplin devised a form of
bread prepared solely from bran; and the great value of bran
cakes as a substitute for bread in cases of diabetes has now
been established by the experience of so many individuals
that its use ought to be insisted on. The bran used should
be thoroughly washed, so that it may be free from starch as
possible, and finely powdered, so that it may not irritate the
susceptible mucous membrane of the intestines. Such care-
fully-prepared and finely-powdered bran may be obtained
from Mr. Batchley, of 362 Oxford Street, London, near the
Pantheon; also of Mr. Donges, Gower Street,London, North.
But if it is desirable to prepare the powder athome as it is
required, a special mill and sieve for the purpose are necessary,
and may be obtained of Messrs. Evans Brothers, 54 Brick-
102 DIABETES MELLITUS.

lane, Spitalfields, London, E. (Dr. Camplin’s* “ Mono-
graph on Diabetes.”’) ;

Consistently with the experiments of Bernard, “ cod-liver
oil holds out some prospects of a natural plan of treatment
by its use.” Dr. Pavy recommends ground almond powder,
made into biscuits, rusks, and bread, with eggs, as a substi-
tute for ordinary bread. Mr. Hill, 60 Bishopsgate Street,
London, makes such biscuits.

An abstinence from water lessens the formation of sugar;
but it probably accumulates in the body, so that when fluid
is again given, an excessive elimination of sugar occurs
(Ringer, Griesinger); and patients become extremely de-
pressed and ill if water is withheld from them, probably from
the impregnation of the body with sugar (Parkes). Coffee
lessens the sugar, but increases the urea. Rennet, as recom-
mended by Dr. Gray, of Glasgow, at first lessens the sugar
and water; but they afterwards increase again. Warm baths
lessen the amount slightly, When the diabetic symptoms

* The formula for bran cakes is thus given by him:—‘‘ Take a quan-
tity of wheat bran (say a quart). Boil it in two successive waters for a
quarter of an hour, each time straining it through a sieve; wash it well
with cold water on the sieve, until the water runs off perfectly clear.
Squeeze the washed bran in a cloth, as dry as possible, then spread it
thinly on a dish, and place it ina slow oven. When it is perfectly dry
and crisp it is fit for grinding into fine powder. The bran thus prepared
is ground in the mill for the purpose, and must be sifted through a wire
sieve of such fineness as to require the use of a brush to pass it through,
and what remains on the sieve must be reground till it is sufficiently
soft and fine. To prepare a cake, take of this bran powder three or four
ounces, three new-laid eggs, one and a half or two ounces of butter,
and about half a pint of milk. Mix the eggs with a little of the milk,
and warm the butter with the remainder of the milk; stir the whole well
together, adding a little nutmeg and ginger, or any other spice that may
be agreeable. Bake in small tins (patty-pans, which must be well but-
tered), in a rather quick oven, for about half an hour, The cakes when
baked should be a little thicker than a captain’s biscuit. These cakes
may be eaten with meat or cheese for breakfast, dinner, and supper,
and require a free allowance of butter; and the cakes are more pleasant
if placed in the oven a few minutes before being placed on the table.
When economy is an object, when a change is required, or if the stom-
ach cannot bear butter, the cakes may be prepared as follows:—Take of
the prepared bran four ounces, three.eggs, about twelve ounces of milk,
with alittle spice and salt, to be mixed and put into a basin (previously
well buttered). Bake it for about an hour; the loaf may then be cut into
convenient slices and toasted when wanted; or, after slicing, it may be
rebaked, and kept in the form of rusks. Nothing has yet been discov-
ered of equal utility to these bran cakes, combining, as they do, moderate
cost with freedom from starch, and’sufficient pleasantness as an article
of food.”” (Camplin, ‘‘ On Diabetes,” third edition),
DIABETES MELLITUS——DIARRH@GA, 103

subside, congestions, especially of the head, are apt to super-
vene. Such congestion Dr. Camplin found to subside grad-
ually under the use of citrate of ammonia and small doses
of colchicum wine. Warm flannel ought to be worn next
the skin in all cases, and residence in a warm climate will
often be of service as an aid to the means of cure employed.

The great difficulty in the treatment of diabetes is to man-
age the dyspepsia and impaired digestion, and, at the same
time, to diminish and keep in check the formation of sugar.
The first principle consists in varying the alimentation so as
to prevent disgust; the second. is to add fatty aliments in
proper proportion to the alcoholic aliment, the exaggerated
use of the latter acting injuriously on the nervous system;
and the third is to suppress or considerably diminish for
some time the use of feculents.

Diarrhwa.-—Definition—A frequent discharge of loose
or fluid alvine evacuations, without tormina or tenesmus
(Good, Copland), in which the intestinal lesion varies from a
mere condition of irritation, expressed by the increased and
modified secretion (beyond which it does not progress), to
those cases in which there is actual inflammation or other
lesion of mucous membrane, the latter being a higher degree
of the former, the cases passing from one to another by in-
sensible degrees (J. J. Woodward).

The ¢reatment of diarrhcea may be founded on the
following indications: (1.) When the tongueis clean,
the pulse quiet, and all constitutional reaction absent;
(2.) when the tongue is white and coated, the pulse ac-
celerated, some fever present, and the pain or soreness con-
stant and increased by pressure. ‘The stools in either case
may be black, green, white, or mixed with blood indifferently.
When the tongue is clean, if the disease be quite incipient,
one dose of an opiate may be given, combined with a gentle
cathartic. The form may be one grain of opium, combined
with a drachm of compound rhubarb powder, or with three
to five grains of calomel. To remove any offending matter
that may be present, the action of the bowels may be aided

“by castor oil, or a saline cathartic, such as a seidlitz powder
or compound senna mixture. Sometimes it may be advisable
to omit the opium, and to combine antacid remedies with the
laxative, as in the following prescriptions : :

BR. Sode Bicarbonatis Hydrargyri cum creta, aa gr. i,
ad gr. v.; Magnesie Carbonatis, gr. ill, ad gr. vi.; Pulv. Rhei.
gr. v. ad gr. viii.; misce. Or--
104 DIARRHEA.

B. Sod Bicarbonatis; Pulv. Rhei; Pulv Calumbe, a a
gr. iv. ad gr. vi.; misce.

The administration of such a powder may be repeated at
intervals—twice or thrice a day ; and ipecacuanha in small
doses (a quarter or asixth of a grain) may be advantageously
combined with each dose. Other more astringent remedies
may be administered if diarrhcea persists. In many cases a
drachm of syrup of poppies after each stool is sufficient to
arrest it. In severe diarrhoea a scruple to half a drachm of
the compound chalk powder, in some aromatic (peppermint
or cinnamon water,) every four or six hours, may be used
whether blood be or be not in the stools. If the opiate and
aromatics should prove insufficient, it may be necessary to
add to each dose some of the class of pure astringents, as a
drachm of the tincture of kino, or of catechu, or of hzema-
toxydon, or of iron. The following formula (Diarrhcea Mix-
ture) has been found of service :

BR. Conf. Aromat., 3 iij.; Sode Carb., 3iss. (Bicarb.);
Tinct. Opii., 31; ther Chloric, 3 iij.; Ol. Caryoph., m x1;
Mucilag. Acaciz, 31.; Aquz Destil., ad %v.; misce. One
teaspoonful for a dose. This quantity may be given every
two or three hours, or every hour, or every half hour, should
the purging continue.

Absolute rest in the recumbent posture must be maintained,
and warmth applied to the surface of the abdomen. Bland
demulcent food, such as arrow- root, with beef-tea or gruel,
may be taken. ;

There are cases of diarrhoea with a clean tongue, which
will not yield to laxative remedies, nor to opiates, astringents,
or stimulants, either singly or combined, which probably de-
pend on a want of tone in the intestine, associated with de-
composition of intestinal contents and fetid stools. In these
cases five grains of salicine every four or six hours have often
stopped a diarrhcea that appeared fast hurrying the patient
to his grave. Salicylic acid and salicylate of soda have also
been found useful. Tincture of the sesquichloride of iron is
similarly useful in doses of five to ten minutes. In the di-
arrhoea of whitish stools, with frequent calls and sudden de-
sire to evacuate the rectum, when muco-gelatinous matter
like a jelly is passed, no remedy is of so much service as the
extract of nux vomica, to the extent of a fourth to ahalf grain
dose ; or strychnia, to the extent of one-twelfth of a grain,
in a pill twice or thrice a day, with the sulphate of iron and
extract of calumba. Tincture of the pernitrate of iron
DIARRHEA. Tos

(mx. every half hour) may be given with great benefit (W. C.
Maclean). It is in diarrhoea of this kind that ironis of so
much service. The ferri ammonia-phosphas possesses some
desirable properties, especially as to solubility and freedom
from the inky astringent taste of preparations of iron. Its
preparation is given in the following note: [Ferrd Ammo-
nia-P hosphas.—Heat common phosphate of soda to redness.
Take of the pyrophosphate of soda so obtained 31ij. Dis-
solve in one pint of warm water. Then take of protosul-
phate of iron Ziv. Dissolve in twelve ounces of water. Mix
the solutions, collect, wash, and dry the precipitate at a gen-
tle heat over a water-bath. Take of this precipitate 3 j.,
Liq. ammonia P.L., % iss., waterq.s. Dilute the Liq. ammo-
nia with an equal volume of water, and rub up with the phos-
phate of iron in a mortar until the latter is dissolved. Then
dilute to 3 viij. Filter the solution, and evaporate at a heat
not exceeding 120° Fahr., over a water-bath, and proceed as
for the other scale preparations of iron. The dose is one fluid
drachm (W. H. Moss, Dispenser, A. H. C.) In fluid extract of
coto bark (prepared by Ferris & Co., Bristol), we have also a
useful remedy in doses of five to eight minims. Black or
dark stools (meleena) are not so much due to bile (atrabilis of
Abernethy) as that such stools, resembling pitch, are princi-
pally composed of morbid or impaired secretions from the
intestines (Hoffman, Home, Graves). The discharge of the
black matter is followed by a feeling of relief to the system
generally. In cases of true meleena (where the dark color is
due to blood), great debility, and sometimes fainting, may
follow the evacuations. Stimulating and tonic remedies,
such as turpentine, are of ‘benefit (Graves). When diar-
thea is accompanied by a white furred tongue, with pain
and soreness, it is necessary to give opiates, combined with
some mild purgative. Half a drachm to a drachm of Epsom
salts, with a drachm of the syrup of poppies ; or fifteen min-
ims of the tincture of hyoscyamus ; or, in severe cases, with
three to five minims of tincture of opium, every four or six
hours, are remedies on which, as a general principle, we may
very confidently rely. In other cases, rhubarb, castor-oil, or
any other mild purgative, may be substituted for the Epsom
salts. In cases of diarrhoea, accompanied by vomiting, a
drachm of syrup of poppies alone, repeated every half hour,
or every hour, for two or three times, may quiet the stom-
ach, and enable it to bear other remedies. Soda-water, or
the effervescing draught, with a tablespoonful of brandy, with
106 DIPHTHERIA.

or without a few minims of tincture of opium, often remain
on the stomach when everything else is rejected.

‘Most practitioners lay great stress on the color of the
stools, and the necessity of correcting the supposed mor-
bid states of the liver; but the various colors of the stools
are in many instances caused rather by morbid secretions
from the surface of the mucous membrane of the intestines
than by any defective state of the bile in the gall-bladder. In
simple diarrhoea, mercury (which is so often given in a routine
way) in any form is either unnecessary or injurious in the ma-
jority of cases, except as apurgative. It is, however, some-
times necessary, especially in children under four years of age.
One general rule may be acted on—namely, that in the adult,
whatever be the form of the diarrhea, if the stools be dark
at first, and then become light-colored, purgative medicines
are no longer beneficial. In no instance ought they to be
continued longer than is sufficient to remove any irritative
substances accumulated in the alimentary canal. Sulphuric
acid, in doses of the officinal or aromatic diluted drug, of
twenty to thirty drops, with water simply, or combined with
the compound tincture of gentian, has been found a useful
remedy. It may be alternated with the diluted nitro-muri-
atic acid, and prescribed in a similar manner. The dietetic
treatment should be limited to slops, puddings, and white fish
boiled, and the drink‘to weak brandy and water, which acts
locally as an astringent; and generally as a diffusible
stimulus.

Diphtheria. —Definition.—A specific disease commencing
with fever, and producing a membranous exudation in and
upon the mucous membrane (of one or other, or all of
ip covering the tonsils, uvula, and soft palate, the root of the
tongue, the larynx and air passages, the posterior wall of the
pharynx, or the nasa! cavities. The disease is attended with
great prostration of the vital powers; also, by a very early
appearance of albumen in the urine, which may continue for
a very short time only, or may become persistent. In many
cases a remarkable series of nervous phenomena are apt to
supervene, characterized by progressive paralysis, and some-
times by fatal syncope. The disease is contagious, and apt
to be epidemic.

Treatment—There are especially three things it is desira-
ble to bring about, namely:—(1.) Softening or suppuration of
the exudation and its connections—to convert the process
into a catarrhal one; (2.) to thoroughly disinfect the air pas-
DIPHTHERIA, 107

sages; (3.) to overcome the marked asthenia by which all
cases of this disease are marked (Wagenen). To accomplish
the first, vapor of water at a temperature of 120° to 130°
Fahr. should be inhaled continuously for fifteen or twenty
minutes every hour; and where the exudation is considera-
ble and tough a very hot poultice should be applied extern-
ally, or compresses wrung out of hot water and covered with
oil-silk should be used. Under such means the exudation
may break down into a suppurating mass in from twelve to
twenty-four hours; but the deposit may return again, if the
vapor inhalation is omitted too early. Even in those cases
which die, this method of treatment accomplishes euthanasia.
The temperature of the room in which the patient is confined
to bed ought to be kept at 68° Fahr., and its atmosphere
kept moist by the steam from a kettle with a long spout cor-
stantly boiling on the fire, and by large basins placed about
the room, and kept constantly full of hot water. If the pa-
tient can be enveloped in a warm moist atmosphere, so much
the better; and this may be done by making a tent with
blankets over the bed, and, by the aid of a spirit lamp, a tin
kettle of boiling water may be maintained at the boiling
point, and its steam thus made to envelop the patient. The
steam assists very much in dissolving the mucus and in loos-
ening and breaking up the membranous deposit. To accom-
plish the second .indication—namely; disinfection—acetic,
salicylic, or carbolic acid, or sulphurous acid may be used.
Neither is a specific. A wineglass of vinegar to a pint of
water is a good proportion (Sir W. Jenner). The solutions
ought to be made as strong as the patient will bear them;
and should be used with the vapor of water as a spray in a
steam-atomizer, as well as by gargling. The steam antiseptic
spray is the best, as the steam carries the disinfectant to
every part of the diseased surface; while the vapor which
escapes into the room is also a carrier of the antiseptic, as it
is of caloric, when a large room is heated by dripping water
on a hot plate or stone.

Syringing the throat and nares with the perchloride of iron
in solution is also very beneficial. The solution ought to
consist of tincture of perchloride of iron, and of glycerine,
each half a drachm, with two or three drachms of water. A
stronger solution—the strength of the tincture—may be ap-
plied with a large camel’s-hair brush to a patch of exudation,
and the adjacent surface of the mucous membrane; or a pre-
paration, twice the strength of the tincture, may be made by
108 DIPHTHERIA.

mixing equal parts of the liquor ferri perchloride and of
glycerine, and may be used to brush over the patches if the
exudation is very thick. But such an application, as it is
powerfully styptic, should be confined to the surface of the
exudation only. It readily penetrates it, and exerts its bene-
ficial influence on the vessels below (Squire). In short, the
application of this remedy to the whole of the pharynx with
food, or separately as a lotion, to be applied as a gargle, or
a medicine to be swallowed, affords relief.

With regard to topical applications, Sir Wm. Jenner is of
opinion that repeated applications to the throat of caustic
solutions are injurious. He recommends one single but effi-
cient application of a strong solution of nitrate of silver (i.
to 3i. of water), as a remedy which may stay the spread of
the exudative inflammation; but that, on the whole, hydro-
chloric acid and water in equal parts will more frequently
attain the object. It is especially the surface round the ex-
udation, as well as the exudation itself, that should be painted
well over with the solution, the brush being passed over the
surface two or three times in quick succession. ‘Che white
discoloration which results must not be confounded with the
spread of the diphtheritic exudation. The discoloration
from the acid passes away in about thirty-six hours, and that
from the nitrate of silver somewhat quicker. Medicinal car-
bolic acid (as prepared by Calvert, of Manchester) is valu-
able as a gargle, in the proportion of 1 of acid to. 200 parts
of water.

There are considerable differences of opinion regarding
the usefulness of topical applications, and the best means of
applying them. The tincture of the perchloride of iron is
recommended by some to be gently painted over the fauces,
as already directed. The throat should be washed out as
often as possible with permanganate of potash (1 to 300), or
with lime water in a solution of chlorate of potash. The
local application of lime water by frequent gargling or gentle
brushing, with the internal administration of nitrate and car-
bonate of soda, prove speedily curative in the milder cases,
and alleviate distress in the more severe. Ice kept dissolv-
ing in the mouth is often also a great comfort, and its use
should never be omitted where it can be had. Dr. Green-
how remonstrates against the application of the more severe
topical remedies. The pellicle or false membrane ought
never to be torn off. The bowels should be opened freely
by a dose of calomel and jalap; or by calomel and colocynth
DIPHTHERIA, 109

pill, followed in the inflammatory or sthenic forms of the dis-
ease by a saline aperient—e. g., sulphate of magnesia in the
infusion of roses. If feebleness of pulse supervene, if the
redness of the throat assume a dusky hue, if the sense of
general weakness become extreme, wine in large doses fre-
quently repeated is required. Six or eight ounces of port or
sherry during the day for an adult may be given from the
first, with as good a diet as the stomach can digest. During
the course of the disease, much larger quantities of wine and
even brandy may be necessary; but the quantity of stimu-
lants must be regulated by the habits and age of the patients.
A child of three years of age may take with advantage one or
two drachms of brandy every hour—z. ¢., from three to five
ounces of brandy during the twenty-four hours (Sir Wm.
Jenner). So long as there is firmness of pulse the physician
ought to abstain from alcoholic stimulants, and rest con-
tented by giving such saline medicines as exert a slight action
on the skin and on the kidneys, or on both. But a rapid
pulse indicates the necessity of alcoholic stimulants, which
ought to be freely given on the development of the earliest
general symptoms. Under all circumstances efficient daily
action of the bowels must be secured, and the urinary and
intestinal secretions should be examined daily. If blood or
albumen appear in the urine, diuretics are contraindicated.
Mustard poultices, warm linseed-meal poultices, or the warm
wet sheet, as recommended by Dr. Huss in typhoid fever,
may be applied to the loins under these circumstances. The
hot-air bath applied to the body, without removal from the
bed, is also of great service. Diphtheria is most successfully
treated by the administration of mineral acids, especially the
nitric and hydrochloric; also by guaiacum, chlorate of
potash, quinine and iron. Tincture of the perchloride of
iron is now fully recognized as having a beneficial local as
well as general influence on the disease; and it may be ad-
vantageously combined with quinine in the following formula
(Tanner):

RB. Quiniz Sulphatis, gr. ii; Acidi Hydrochlorici diluti,
m x.; Tincture Ferri Perchloridi, m xv.; Infusi Calumbz,
%i.; misce. Fiat haustus, omnibus sextis horis sumendus.

As soon as nourishment can be retained by the stomach
five to ten grains of the perchloride of iron, equivalent to
twenty or forty minims of the tincture, combined with half a
drachm of glycerine and half an ounce of water, should be
given, and repeated every three or four hours (Squire) It
IIo DIPHTHERIA.

should be commenced on the first day of the illness, or as
soon as the nature of. the disease is recognized. Evidence
of its good effects are shown by a diminution of the secre-
tions from the fauces and throat, and improvement in gen-
eral symptoms. Guaiacum is of service in keeping the bowels
open. It ought to be given in the form of the rectified spirit
tincture, to the extent of one drachm combined with two
drachms of glycerine for a dose, as recommended by Dr.
Balmanno Squire. This makes a clear solution, to which no
water must be added.

The third indication—namely, to overcome the marked
asthenia—restoratives are demanded, and feeding is all-im-
portant in the treatment of diphtheria. The night should
never be passed without either nourishment or stimulant be-
ing given; and the quantity of liquid nourishment and of
stimulant given. in the twenty-four hours must be equal
to the estimated requirement of the patient (Squire).
A young child (one to two years) may require a teaspoonful
of brandy every two hours; a child of three years, two tea-
spoonsful, diluted, and given in small portions at a time.
Milk, beef-tea thickened with arrow-root, milk punch, are
most useful alteratives. By so averting death, time is gained
for the general disease to run.its course (Jenner).

Tracheotomy is of little avail in diphtheria, and the sole
object contemplated by an opening in the windpipe is the
‘prevention of death by suffocation. Nevertheless the opera-
tion is indicated in every case where the larynx is blocked up
by membranous or pseudo-membranous formation; when we
can scarcely ever anticipate that the disease will subside in a
few days, and before fatal suffocation occurs. The condi-
tion of the patient is generally improved for the time by the
actual operation, if it 1s not too long deferred, or done in the
death-agony. It is also especially done to gain time; and it
is also indicated whether the impediment to respiration is in
the larynx only, or whether it extends farther down, or
whether secondary changes have already taken place in the
lungs. In the two latter cases the chances of recovery are
generally very much less; but the operation of tracheotomy
does not make the prospects worse for the patient; and it
should be done when the existence of a more than merely
catarrhal affection of the larynx is indicated by great diffi-
culty of breathing, continuing more than two or three days;
or by attacks of suffocation. The operation will not cure
the disease. In this respect it differs greatly from croup;
DROPSY-——DYSENTERY. II!

and it is chiefly in cases of croup, as distinguished from diph-
theria, that tracheotomy is attended with such favorable re-
sults, (See under Croup.) Tracheotomy, if not too long de-
layed, saves many a life in croup.

. In the consecutive paralyses tonics and local galvanism are
the most important remedies, and the bowels should be kept
open by a pill, taken morning and evening, containing from
a quarter to half a grain or a grain of the extract of nux
vomica, with a like quantity of sulphate of iron, combined
with two or three grains of compound rhubarb pill mass.
These may be varied with the administration of pills con-
taining 7, of a grain of strychnia, the strychnia being tritu-
rated with sugar of milk, and made into pills with a sufficient
quantity of extract of gentian. Syrup of the phosphate of
iron in fluid drachm doses may be given twice a day (com-
bined or not with liquor strychnia); and stimulants in the
form of malt liquors, especially stout (if free of cocculus in-
dicus), are beneficial if taken with or after meals, and the
doses of iron may be taken at the same time. The syrup of
the phosphate of iron, quinine, and strychnia I have also
found of great use.

Dropsy, General.—-See Anasarca.
Duchenne’s Disease.— See Paralysis, Bulbar.

Dysentery.— Definition—A febrile disease, accompanied
by tormina, by straining, and by scanty mucus or bloody
stools, which contain little or no fecal matter. The minute
lenticular and tubular glands of the mucous membrane of
the large intestines, with the intertubular connective tissue,
are the chief seats of the local lesion, which sometimes ex-
tends into the small intestine beyond the ileo-cecal valve, as
in cases in which scorbutus is a predisposing cause. Under
some circumstances it is infective.

Treatment—Iit is the obvious duty of the physician to direct
his attention, in the first instance, to the prevention of the
disease. He must enquire especially as to the conditions of
the diet, that it be sufficient’ as to its animal and vegetable
elements, and of good quality. Next, he ought to ensure the
means of detecting the disease early—for time is of the
greatest importance in its.cure. He must remove the patient
from the sphere of action of any of the predisposing or ex-
citing causes, and see that his surroundings are free of all
those circumstances which co-operate in aggravating the dis-
ease, the chief of which are overcrowding, bad ventilation,
I12 DYSENTERY.

bad food, exposure, and intemperance. With regard to med-
icinal agents my friend and colleague, Professor Maclean, has
written me the result of his extensive experience in India and
China:—He is of opinion that the first thing to bear in mind
in the treatment of tropical dysentery is, that the appearance
of strength in the patient, given by the acuteness of the
symptoms, is delusive. Under the use of antiphlogistic
treatment the strength of the patient is apt to fail suddenly;
and this is often the case, even when the treatment has been
more conservative in its character. It was once the custom
in India to deplete freely in this disease, either by a general
bleeding or by the repeated application of leeches; but the
most judicious and successful practitioners in India rarely
bleed now, even in the most asthenic forms of the disease,
and confine the use of leeches within the narrowest limits,
It is certain, too, that mercury is yearly less and less used in
India than it was; and there is much evidence to show that a
corresponding reduction in the mortality of the disease has
been the result. The objections to its use are numerous,—it
entails great suffering on the patient, if pushed to ptyalism,
aggravating his miseries, and too often permanently injuring
his constitution; it has no specific action on the disease, and
its cholagogue effects can be attained by remedies which are
not open to such objections as can be brought against mer-
cury. In sloughing dysentery it is followed by the worst re-
sults; and the observations of clinical observers in India
have shown that individuals under the influence of mercury
are not only not exempt from attacks of the disease, but are
peculiarly prone to be affected by it. This is the case in a
very marked degree in Asiatics (Morehead and Maclean).
Ipecacuanha, in the radix anti-dysenterica, has long been
used in South America in the cure of dysentery,—whence,
indeed, it came. It was much used in India until the mer-
curial notions of James Johnston prevailed. It was again
used by Dr. Twining, of Bengal, by whom it was strongly
recommended, and also by Dr. Mortimer, of Madras. Twin-
ing combined it with blue pill and gentian, and used it chiefly
in small and oft-repeated doses. In South America the prac-
tice has always been to administer an infusion of the bruised
root,— 3 ii. being infused over night in 3 iv. of water, and
given early in the morning. In Peru it is given in doses of
3 ss. to 31. of the powdered root in a little syrup and water.
This practice of giving ipecacuanha in large doses has lately
been revived in India with encouraging success, and Dr.
DYSENTERY. 113

Maclean believes, with the greatest number of cures. It ap-
pears to act on the portal capillaries, and on those of the
mucous membrane of the bowels, and to determine. power-
fully to the skin. It is usually given in doses of half a
drachm ora drachm, either in pills or bolus, or suspended in
mucilage, according to the fancy of the patient. It is advisa-
ble to give an opiate half an hour before, and to withhold all
drink for some hours. Unless there be hepatic complica-
tion, it seldom happens that much vomiting is caused by
these large doses; on the contrary, they are often tolerated
when smaller doses are rejected. The dose should be re-
peated in about six hours. A sufficient interval should be
allowed to intervene between the doses of ipecacuanha, to
admit of the patient being sustained by nourishment adapted .
to the stage of the disease. Dr. Cornish, of the Madras
army, has shown from official documents, that the mortality
from acute dysentery in Southern India under mercurial
treatment was 7.1 per cent. Since the general introduction
of ipecacuanha in full doses it has fallen to 1.3. Dr. Ewart,
of Bengal, has shown that equally good results have follow-
ed the same system in that Presidency. During the forty-
two years, from 1812 to 1853-54, the mortality among Eu-
ropean troops in the Bengal Presidency amounted to 88.2 in
the thousand. But during 1860, when large doses of ipecac-
uanha were administered, the mortality was only 28.87 in the
thousand. Although highly useful in some conditions, it is
not to be regarded as a specific in all forms of the disease.
It is more effectual ih the sporadic and mild acute cases than
in the chronic forms. Its use should be limited to vigorous pa-
tients with acute catarrhal diarrhoea or dysentery; or with
the preliminary catarrhal stage of diphtheritic dysentery
(Woodward). The large dose method of its administration,
which now prevails, is to give as early in the disease as pos-
sible grs. xxv. to xxx. of ipecacuanha in as small a quantity
of fluid as possible. A preliminary dose of opium, may be
of service in enabling the stomach to retain the ipecacuanha.
It can be swallowed in the form of a bolus, by wrapping it in
soluble tissue paper. The patient should then remain per-
fectly still in bed, and abstain from fluid for at least three
hours. If thirst is urgent it may be appeased by sucking
small bits of ice, or taking not more than a teaspoonful of
iced water. In from eight to ten hours, from ro to 15 grains
may be again administered, with the same precautions as be-
fore. The beneficial results are manifested by the tormina
8
114 DYSENTERY.

and tenesmus subsiding, the motions becoming feculent, blood
and slime disappearing; and often, after profuse perspiration,
the patient falls into a tranquil sleep and awakes refreshed.
The ipecacuanha may require to be continued in diminished
doses for several days, with sufficient intervals between each
dose to admit of food being taken; and for several nights
after the stools appear normal, grs. x. to xii. of ipecacuanha
should be still given at bedtime. Astringents in any
shape during the acute stage are not only useless but
dangerous (Maclean, Docker, Waring). Blood-letting has
now been totally superseded and rendered unnecessary by the
use of ipecacuanha. Ergot has beenused in an enema to the
extent of 12 or 15 grains insome bland fluid; or in 6-grain doses
by the stomach, in cases of epidemic dysentery, with the
beneficial result of reducing the quantity of blood in the
stools (Dr. Gros, Practitioner, Nov., 1868). Opium is not
to be regarded as a specific or curative agent, either in acute
or inchronic fluxes. Its use should be restricted to the
fulfillment of two indications, namely:—(r1.) to relieve pain;
(2.) to procure sleep. Chronic opium intoxication is to be
avoided, by suspending its administration, or by alternating
it with other remedies. Hypodermic injections of morphia
give the best anodyne or soporific effects. It is most fre-
quently indicated in cases of, acute gastro-intestinal catarrh.
In alcoholic conditions it may be of advantage to combine
chloroform with the morphia, repeating the dose after an
hour's interval. Dover’s powder,—Puly. ipecacuanha com-
posita, is of service in full doses of grs. x to xv. at bedtime,
followed up by a five-grain pill of the same, taken every
four or six hours for two or three days, or till relief is ob-
tained. In smaller doses, frequently repeated, it may be
combined advantageously with nitrate of silver (Waring).
In mild cases, but where the pains are excruciating and
attended with tenesmus, the warm bath generally gives in-
stantaneous relief in cases following chills, if adopted suffi-
ciently early. Dr. Maclean directs that it be brought to the
bedside, and kept at a high temperature (not under 99° or
100° Fahr.), the patient to remain in it till he feels faint.
He is then to be- carefully and quickly dried, put to bed,
and have grs. xv. to xx. ofipecacuanha. Woodward objects
to the hot bath except in chronic fluxes. Leeches, to the
number of six to twelve, applied round the verge of the anus,
often afford sensible relief to the tormina and tenesmus, by
unloading the portal and hemorrhoidal veins (Waring).
DYSENTERY, 115

In subacute and chronic dysentery, “ no remedy has proved
more useful than nitrate of silver, in doses of ‘half a grain to
one and a half grains daily, reduced to a fine powder, and
conjoined with Dover’s powder in the form of a pill (Dr.
Waring). It has also been extensively used in the form of
enema, as follows:—First throw up into the transverse colon,
by means of a flexible stomach-pump tube, introduced to
the extent of six or seven inches, very cautiously and gently,
enemata of warm water, or milk and water, to the extent of
three, four, or six pints, so as to bring away any fzecal ac-
cumulations. Then follow up this practice by the injection
of two and a half to three pints of distilled water, holding in
solution gr. xv. of nitrate of siver’’ (Hare, Waring).

In chronic cases a combination of sulphate of copper and
of opium is often highly serviceable (J. Brown, Raleigh,
Waring), in the following formula:—

B Cupri Sulph., gr. 4% to %; Pulv. Opii, gr. %. Make
a pill or powder, of which three are to be taken daily.

Five grains of Dover’s powder may be substituted for the
opium.

Solution of the pernitrate of iron is highly commended by
Professor Maclean. It is astringent and tonic in doses of
mx. to mxv. diluted in water. It may also be used as an in-
jection.

Nux vomica, combined with opium and iron, may be of
use (Graves), In malarial dysentery, full doses of quinine
(not less than twenty grains) ought to be given in acute cases
before giving ipecacuanha, and it should be continued till
there is evidence of cinchonism. The two drugs should then
be given in alternate doses till the characteristic good results
of each are produced (Maclean). The bark of the root of
calotropis gigantea (or mudar) has been recently used in
India, and is said to be an excellent substitute for ipecac-
uanha. It is used in doses of a scruple to a drachm, is a re-
liable cholagogue, and sedative to the muscular fibres of the
intestine, rapidly allaying pain, tenesmus, and _ irritation
(Durant, Jud. Med. Journ., May, 1856). On the Continent
the neutral salts and mild purgative medicines are highly
spoken of. Sulphate of soda is to be preferred to sulphate
of magnesia (Mery, J. J. Woodward). It induces a decided
increase in the hepatic secretion, which the Epsom salt fails
to do (Rutherford and Vignall). Phosphate of soda and
Rochelle salts are, for similar reasons, to be preferred to the
Epsom salt, which is the least desirable of saline purgatives
116 DYSENTERY.

in dysentery. Castor-oil is similarly objectionable. It has
no stimulating action on the hepatic secretion. In the treat-
ment of chronic dysentery in the Seaman’s Hospital, London,
the Senior Physician, Dr. C. H. Ralfe, states that having
watched 200 cases, he recorded in 1876 that those who lin-
gered the longest, or at length did well, had little or nothing
to owe to therapeutics, an opinion.concurred in by Dr.
Stephen Ward. He now abstains from action and spccial
treatment, except to meet occasional and urgent symptoms,
and places more reliance on the good effects of rest and diet.
He has, however, systematized the administration of castor-
oil, by giving it on stated days, at least twice a week. It re-
moves retained scybalous fecal matter and irritating dis-
charges, and prevents their accumulation. Some had bismuth
mixture in addition, others had ipecacuanha (12 to 20
grains), in single doses, repeated, if necessary, on second or
third day whenever a relapse or return to the acute form
was threatened. Sixteen out of thirty-eight cases were dis-
charged cured; in nine of whom the duration of the disease
prior to admission had averaged 18 months, and none less
than five months. In painless diarrhoea and in chronic
fluxes bismuth is of use after evacuants. From mercurials
no advantages are to be expected that can counterbalance
the serious objections to their use; but the benefit of the
alterative effects of the remedy may be obtained by minute
doses of corrosive sublimate. In certain cases of- chronic
dysentery Parkes found it most useful commencing with
doses of one eighth to one sixth of a grain in combination
with preparations of cinchona. It increases the hepatic
secretion. Ringer gives the rooth of a grain every hour or
every two hours, alike in acute and chronic dysentery.

Dr. Bryson writes that he has seen all the astringents, both
mineral and vegetable, mercury both internally and exter-
nally, with many other medicines, tried without any benefit;
but there were some means which were useful in relieving
the more urgent and distressing symptoms. Amongst these
he mentions a well-regulated farinaceous diet, opium suppo-
sitories, anodynes, astringent injections, incombination with
opium, cascarilla, resinous astringents, and the application
of leeches to the rectum when tenesmus was distressing, or
over the course of the colon when there was deep-seated
pain. An injection of warm starch (two ounces) with laud-
anum in it, will often give great relief. As much nourish-
ment should be given in a liquid form as the patient can be
DYSPEPSIA. 117

got to take. Milk boiled with flour or arrow-root and _bar-
ley-meal should be taken as often as possible, night and day.
It should be taken cold, even with ice, and in small quantities
at a time; and small pieces of ice not only allay sickness and
nausea, but seem to soothe the irritability of the intestines.
‘Strong beef-tea, or Liebig’s extract of flesh, are most useful.
The value of a change of climate as a curative measure is
forcibly illustrated by Dr. Bryson. He says that the crews
of vessels improve in health almost immediately after quit-
ting the station where dysentery prevailed. Where sewage
is applied to the soil by surface irrigation, it ought to be di-
luted largely with water, and deodorized by carbolic acid.
In the scorbutic form we have a valuable remedy in the
Bael fruit, which contains a large quantity of tannin, with
vegetable mucus, a bitter principle, and a vegetable acid.
It is much used in Bengal; and in the scorbutic form Dr.

Maclean has seen it successful when all other measures have
failed.

_ Dyspepsia.— Definition —Impairment of digestion, aris-
ing without perceptible change of structure or lesion of the
stomach.

Treatment.—Congestion, catarrh, and functional states as-
sociated with what are called dyspeptic symptoms, or “im-
perfect digestion,” are the results of stomach diseases for
which the physician is called most frequently to prescribe.
When there is reason to believe congestion exists, a sparing
and easily digested diet is to be prescribed, with total absti-
nence from fermented drinks: and in cases where catarrhal
inflammation prevails the blandest food must be given in
very small quantities. In severe cases leeches are to be ap-
plied over the region of the stomach, and the patient may
sip iced tea, or suck small pieces of ice, to relieve thirst. In
impaired digestion from any cause, a mode of life tending to
improve nutrition is to be aimed at. The necessity of . strict
attention to diet in all cases of impaired digestion is abso-
lute. If fulness and uneasy sensations are experienced after
dinner, less food should be taken at that meal, and more at
breakfast; the principle being to apportion the amount of
food necessary to sustain the body more evenly over the
waking hours than is commonly done. The great fault in
the dietetic system of this country consists in most people
supporting themselves mainly by dinner. This meal is con-
sequently too large; and the quantity taken at dinner should
118 DYSPEPSIA.

be resolutely diminished till breakfast is appreciated (Leared,
lc. p. 150).

Special symptoms, common to various morbid states, re-
quire special modes of treatment. Excess of acid is best
neutralized by lime-water, magnesia, or alkaline remedies, se-
lected according to the state of the patient’s bowels ; and
the gastric fermentation which is apt to be established may
be checked by brandy and various aromatic spirits. Bicar-
bonate of potash and nitrate of potash, in the proportion of
eight parts of the former to one part of the latter, is useful
in cases of habitual acidity : and all these antacid remedies
should be taken about three or four hours after a meal.
Pills containing from a quarter to half a minim of creasote,
given with each meal, will counteract fetid eructations. It
checks that fermentation in which acetic and carbonic acids
are formed ; while conium and belladonna are the medicines
which better than opium allay general nervous irritability.
In cases of slow digestion, with deficient secretion of the
gastric juice, the rules of treatment are, (t.) To let albu-
minoid food be as liquid as possible. Eggs must be eaten
when cooked short of coagulation of the albumen. (2.) To
let the day’s allowance of food be taken in small quantities
at regular intervals. (3:) That by the administration of al-
kalies the food may pass to the intestines, and be digested there
rather than by the stomach, This latter mode of treatment
by alkalies, reeommended by Chambers, is contrary to that
recommended by Dr. Budd. Both are consistent with phy-
siological facts, and the course to be followed must be de-
termined by the nature of the case. Both gave large doses
of bicarbonate of soda— 3 11. dissolved in a pint of warm wa-
ter—to counteract the excessive acidity, or to promote the
passage of food to the intestines. The amount and kind of
food taken is of importance to be attended to in cases of
slow digestion. If a fair amount of exercise be taken, the
following dietary, slightly modified from that proposed by
Dr, Leared, will be found appropriate in such cases :

BREAKFAST, (8 A. M.)

Mutton Chop, or other Tea, or warm milk and
Bread (stale), . 4 oz. Meat (cooked) free water and sugar, or
from fat and skin, 3 0z. other beverage, } pt.

LUNCHEON, (I P. M.)

No solids, such as Meat
Bread (stale), . 2 oz. or Cheese. Liquid, . . . tpt
DYSPEPSIA. I1g

DINNER, (5 or 6 P. M.)

Bread (stale), . 3 oz ( Meat (cooked) free from ) Liquid, not more than
Potatoes and other fat and skin, . . 4 oz. half a pint.
vegetables, . 4.02.

TEA or SUPPER (not sooner than three hours after dinner.)

Tea, or weak brandy

and water, or sherry

and water, or toast
and water, to the ex-
tent of 4 pint.

No solids, such as Meat

Bread (stale), . son | or Cheese:

The quantity of wine or other fermented liquor, and also of
animal diet, should be thus reduced till the disease subsides
and the urine is healthy. Soups, tea and.coffee, drank, as
they usually are, boiling hot, debilitate the coats of the stom-
ach, tend to produce dyspepsia, and are abandoned by many
persons from their so often exciting cardialgia. The best
bread for the dyspeptic is the unfermented bread, baked by
the process of the late Dr. Dauglish, entirely from wheaten
flour of the best quality. It is known as “aerated bread,”
because carbonic acid gas is substituted for yeast. It is more
easily digested than common household bread. Pastry and
“sweets” must be strictly forbidden. They are “sweet in
the mouth, but bitter in the belly.” Forms of indigestion
marked by excessive acidity and heartburn may be relieved
by bicarbonate of soda, in doses of fifteen grains, combined
with a few grains of nitre, taken two or three times a day.
At the same time, free excretions from the liver and bowels
must be sustained by occasional small doses of blue pill or
podophyllin, combined with extract of colocynth and hen-
bane, while exercise and diet are duly attended to. Weak-
aned digestion from over-fatigue may be restored under the
use of carbonate of ammonia, conjoined with compound tinc-
ture of gentian, or with extract of gentian in the form of a
pill. Extracts of nux vomica or strychnia are also valuable
remedies. Half a grain of extract of nux vomica, half a grain
of sulphate of iron, and four grains of compound colocynth_
pill, form a combination which, taken early in the morning,
or one hour before dinner, generally induces gentle action of
the bowels. (Leared). Compound rhubarb pill may be sub-
stituted in place of the compound colocynth pill, Another
useful ingredient in a dinner pill I find is ipecacuanha, to the
extent of one grain, or half a grain in each, in cases of slow
or torpid digestion. Indigestion from habitual drunkenness,
120 ECLAMPSIA—ECTHYMA,

or where there is great irritability or sensitiveness of the
stomach is best relieved by the pure bitter infusions, such as
gentian, quassia, hops, and calumba, singly, or combined ina
mixture, so that a dose may’ be taken two or three times a day,
an hour before each meal. Grave’s tonic I have found espe-
cially useful. It consists of the tincturés of quassia, calumba,
compound gentian, cinchonia flava, of each an ounce, and
from two to four drachms of the liquor morphie hydrochlor-
atis ; of this mixture a teaspoonful is to be taken one hour be-
fore each meal. Quassia may generally be taken as a cold

. infusion, and is thus prescribed by Niemeyer; “In the
evening pour acupful of cold water over a teaspoonful of
quassia chips; by the next morning a bitter infusion will
have formed—to be taken fasting ;”” or water may be poured
into a bowl made of quassia-wood, sold for this purpose, and
after standing over night in the bowl, the water is to be
taken in the morning. Hop-bitter is most agreeably taken
in the form of the many bitter ales, such as are brewed by
Bass, Allsopps, Ind-Coope, Salt, and the genuine Bavarian
beer, brewed all over Germany. Such ales must be got di-
rect from trustworthy brewers who brew from hops, and
where no injurious substitute is used instead of hops. For
other reasons it is necessary to obtain the ale direct from the
brewery. Once it passes into other hands, there is no guar-
antee that some of the numerous processes for “ stretching,”
and otherwise increasing the quantity, to the disadvantage
of the consumer, will not be practiced. Of the extent of
malt originally prepared by Trommer, as a genuine extract,
containing the soluble constituents of the malt and of the
bitter of the hop, Niemeyer speaks highly in the treatment
of cases of “irritable ingestion,” as having been almost the
only nourishment the patients could take. Small doses of
opium, or of morphia in an ammonia mixture, may De given
‘at bedtime, so as to secure sleep at night, or Grave’s tonic as
above. In prescribing the mineral acids, the following gen-
eral rule ought to be kept in mind, namely, that the influ-
ence of sulphuric acid is astringent, while that of hydrochloric
acid promotes digestion, and of nitric acid secretion (Dr.
Bence Jones).

Eelam psia.— See Convulsions.

Eethyma.—Definition.—An eruption of large round pus-
tules, generally distinct, and seated upon a hard inflamed
base. The pustules are succeeded by dark-colored scabs,
ECZEMA. i 12r

which leave superficial cicatrices behind them, or red stains;
which disappear after a time.

Treatment is chiefly by diluents, simple and emollient
baths, and regulation of diet. Moderate exercise should be
taken, combined with the use of alkaline or salt-water baths.
Mild laxatives are beneficial, and spirits, wine, and beer are
to be refrained from. The food should be as nourishing as
can be digested.. Tonics, such as quinine and iron, are also
indicated. A stimulating lotion, composed of muriatic acid
diluted with water, is of use to brush over the parts and pro-
mote cicatrization. Specific treatment must be adopted
when the disease is associated with syphilis or scabies.

Eezema.—Definition.—An eruption characterized by—
(x.) Infiltration of the skin; (2.) exudation on its surface ;
(3.) the formation of crusts ; (4.) itching.

Treatment of eczema must be constitutional in the first in-
stance; and local applications suited to the nature of the
part affected are to be carefully used. Derangements of the
digestive organs must be especially rectified. If the tongue
is loaded, the appetite bad, the liver torpid, as indicated by
light clay-colored evacuations and costive bowels, small doses
of grey power in combination with quinine are indicated.
Dr. T. M. Anderson suggests the following :—

Kk. Sulphatis Quinie, gr. xii; Pulv. Rhei. gr. xxxvi.;
Hydrarg. c. Creta, gr. xxx.; Sacchari Albi, 3i.; misce, et di-
vide in Pulv. xii.

Two of these powders are to be taken daily by an adult ;
but at any age the dose must be so adjusted that the patient
has at least one full natural evacuation daily. If the patient
is robust, but with the functions of the liver and ‘bowels im-
paired, occasional doses of calomel, alone or in combination
with scammony, will stimulate the torpidity of the digestive
organs ; and at the same time the cutaneous inflammation
will diminish. If the patient is a full feeder, and will not be
persuaded to live more sparingly, one drachm to two drachms
of the sulphate of magnesia may be given twice daily, with a
sixth to half a grain of tartar emetic added to each dose.
The effect of this remedy will be to diminish desire for food,
and at the same time keep the bowels freely open. If the
patient is scrofulous, or debilitated from insufficient food, or
food not nutritive enough, more nourishing food must be °
given, combined with tonics containing iron and cod-liver
oil. Children a few months old, reduced to “skin and
bone,” recover wonderfully under the influence of twenty
122 ECZEMA.

drops of the syrup of the iodide of iron in a teaspoonful of
cod-liver oil repeated three times daily, the dose of the oil
being gradually increased to a tablespoonful (Anderson)
Syrup of the phosphate of iron, or of the phosphates
of iron, quinia, strychnia, should be alternated with
the iodide of iron. The treatment must be steadily:
maintained for at least six weeks or two months. In sever
cases the oil may be rubbed into the skin, in addition to giv-
ing it internally. Cod-liver oil and iron preparations are
almost equally serviceable to eczematous adults. When
there is a difficulty of taking the oil in its pure state, the
emulsion of it will often be found useful; when the appetite
is very deficient, a pure tonic, such as quinine and aromatic
sulphuric acid, may be of service, as in the following :—

&. Sulphatis Quiniz, gr. xvi.; Acid Sulphurici Aromatici,
3iv.; Syrupi Limonum 3 ss.; Infus. Cascarille, ad 3 viii;
misce, et cola per chartam. A table-spoonful to be taken
three times a day half an hour before food.

If the eczematous patients are robust and plethoric, the
local abstraction of blood by leeches or scarification is often
beneficial ; but in general the action of calomel purgation is
sufficient to reduce the inflammatory action, combined with
a regulated abstemious diet of mixed animal and vegetable
foodsimply dressed. Dishes of pastry, pickles, spices, strong
tea, and coffee, are particularly to be avoided ; while the use
of wine, spirits, and malt liquors must be entirely suspended.
If the patient has been in the habit of using stimulants, the
eczema will be more difficult to subdue than if he had been
an abstainer from these fluids. It is sometimes necessary to
prescribe milk diet for a time, all animal food being pro-
scribed.

Of internal medicines, arsenic, sulphur, and the alkalies
are especially useful (Startin, Anderson). Of Fowler’s solu:
tion (the liquor arsenicalis of the Edinburgh Pharmacopceia)
an adult may commence with five minims thrice daily ; and
at the end of a week the dose should be increased by one
drop every second or third day, till the disease begins to
yield, or the medicine to disagree (Anderson), “In order to
secure the virtues of arsenic as an alterative, it will be
necessary to push the medicine to the full development of
the phenomena which first indicate its peculiar action on the
system. Arsenic as a remedy is too often suspended, or alto-
gether abandoned, at the very moment its curative powers
are coming into play. The earliest manifestation of its phy-
ECZEMA, 123

siological action is apt to be looked upon as its poisonous
operation; and the patient declares that the medicine has
disagreed with him. Forthwith the physician shares his
fears; the prescription is changed, and another case is added
to the many in which arsenic is said to have failed after a
fair trial of its efficacy” (Begbie, “ Contributions to Practical
Medicine”, p. 270). Arsenical solutions should be given im-
mediately after food ; and in persons whose digestive organs
are weak, a tonic infusion, such as the infusion of cascarilla
or gentian, is the best vehicle for its administration ; and
a few drops of morphia may sometimes be added, as in the
following :—

R. Solut. Fowleri; Solut. Muriatis Morphiz, aa 3 ii. ;
Syrupi Limonum, %ss.; ‘Tinct. Cocci Cacti, 3ss.; Infus.
Cascarilla,ad 3 xii.; misce. A tablespoonful of this mixture
to be taken thrice daily immediately after food.

The liquor sodz arsenias, in doses of five to ten minims,
is said to cure eczema with less gastric disturbance and with
less irritability of the conjunctiva than the liquor arsenicalis.
As the disease yields, the dose may be diminished; but the
use of the remedy should not be suspended till some time
after the complete removal of the eruption. In the case of
infants at the breast, arsenical solutions may be given to the
mother; and mercury may be combined with the arsenic, as
in Donovan's solution, of which ten minims may be given
thrice daily. Mr. Hunt lays down certain conditions for the
administration of arsenic; and amongst them he forbids its
commencement while signs of active cutaneous inflammation
are present.

The use of the natural mineral waters which contain sul-
phur is the best method of securing the full effects of the al-
terative action of sulphur in chronic cases of eczema where
there is an absence of inflammatory action. These waters
are especially, Harrowgate and Moffat in this country; Aix,
Baréges, St. Sauveur, Cauterets, on the Continent. Alkalies
are most beneficial when the patient has been in the habit of
taking stimulants; and when there is a tendency to acidity
of the stomach, and to the deposit of lithates in the urine, or
to gout, or to rheumatism, aqua potasse may be given, largely
diluted with water, in doses of twenty minims three times
aday. Dr. Anderson recommends sesquicarbonate of am-
monia (now called the carbonate of ammonja in the British
Pharmacopeeia), in doses gradually increasing from ten to
thirty grains. If gout prevails, colchicum ought to be given
124 ECZEMA.

with the other remedies; and in rheumatism the acetate or
bicarbonate of potash in half-drachm doses should be added
to each dose. All these alkaline remedies should be largely
diluted with water. For the relief of pain and procuring
sleep in acute cases, opiates must be administered; and when
they fail tincture of cannibis sativa, in doses of mxxv., has
been found sometimes to procure sleep, or at all events com-
parative ease (Christison). With regard to local treatment,
the first point is to remove all sources of irritation, and es-
pecially the crusts. A’poultice composed of crumbs of bread
and hot almond oil applied to the eruption at night will
usually bring away the crusts in the morning. If they fail
to be detached by this application, they must be again lubri-
cated with fresh almond oil, and forcibly removed when they
are thoroughly softened. If, after the crusts are removed,
the surface is seen to be acutely inflamed, and if there is a
burning heat in place of itching, local sedatives must be ap-
plied. For this purpose Dr. Anderson recommends a cold
potato-starch poultice, a small quantity of powder containing
camphor being sprinkled over the inflamed surface before the
poultice is applied. The camphor powder may be composed
of the following ingredients:—

BR. Camphore, 3ss.; q. s.; Pulv. Oxydi Zinci; Puly.
Amyli,aa 31. This powder must be kept in a stoppered
bottle (Anderson).

Instead of poultices, a mixture of powdered oxide of zinc
and glycerine, in the proportion of half an ounce of the one
to two ounces of the other, will be found to be a soothing
application ; and toit a little camphor may also be added, as,
in the following :—

BR. Camphore, 3i.; Pulv. Oxydi Zinci, 3ii.; Glycerine
et Adipis Benzoati, aa 3iv.; Cochinillini, gr. i.; Spt. Ros-
mar., 31.; vel Ol. Rosar., mii.; misce. This mixture must
be stirred before using it, a thin layer being then rubbed over
the inflamed part twice or thrice daily (Anderson).

Carron oil (liniment aqua calcis) I have found a soothing
remedy. When the disease passes into a chronic stage, as in-
dicated by the disappearance of the burning heat and the
supervention of itching, the local applications must vary with
the condition of the parts. If there be much infiltration of
the tissues, treatment by potash applications is the most ef-
ficient (Hebra, Anderson). The more extensive the disease
the weaker the solution ought to be for application over a
large surface. If the infiltration is slight, common potash
ECZEMA, 125

soap (soft soap, black soap, sapo mollis, sapo viridis), or a
solution of one part of it in two of boiling water, a little oil
of rosemary or citronella being used to conceal the odor, may
be used. A piece of flannel dipped in this liniment should
be rubbed as firmly as possible over the affected parts night
and morning, the solution being allowed to dry upon them.
It should, however, be washed off after each application. If
the patient can bear it, a piece of flannel, saturated with the
solution, may be left in contact with the part all night. An-
other method of treatment is to paint over the eruption night
and morning with a large brush, charged with the aqua po-
tasse of the Edinburgh Pharmacopeeia, its irritant action
being neutralized by means of cold water when the smarting
becomes excessive. A solution of potassa fusa may also be
employed of various strengths. If the case be mild, two
grains to an ounce of water; if more severe, then five, ten,
twenty, thirty, or even more grains to the ounce of water
may be used. But all these stronger solutions must be washed
off very speedily, and they ought not to be employed more
than once daily. Such remedies the physician ought to ap-
ply himself, and not entrust the control of their action to the
patient. As infiltration subsides, the solution ought to be
gradually diluted; and great caution is necessary in using
such local applications upon infants, delicate females, and old
or infirm persons. The affected parts should be bathed re-
peatedly during the day in cold water, during the use of po-
tash applications. The cold douche may be employed where,
it is practicable. If the itching is very intolerable, prussic
acid may be mingled with the potash applications, as in the
following:— ;

BR. Potasse Fuse, gr x.; Acid Hydrocyan. Dil. (Ed. Ph.)
3ss.; Aq. Rosarum, 3ii.; misce. A little of this solution is
to be rubbed firmly over the eruption night and morning, and
at any time when the itching sensation is severe.

If there is a tendency to the formation of fissures, which
are apt to result from the use of potash, cod-liver oil, glycer-
ine, or carron oil should be applied to the parts every night.
Glycerine of aloes is also recommended as a healing agent
by M. Chausit and Dr. Waring. It is prepared by evaporat-
ing four to eight parts of the tincture of aloes, and incorpo-
rating the residuum with thirty parts of glycerine. Tarry ap-
plications are of great value in the local treatment of the de-
clining stages, when infiltration and itching are subdued.
Common tar (pix liquida) or oil of cade (oleum cadini, as
126 ELEPHANTIASIS GRACORUM.

manufactured at Aix-la~Chapelle) should be rubbed firmly
over the eruption by means of a flannel cloth, and allowed to
dry upon it. It should be applied thrice daily, and washed
off with soft soap or petroleum soap. Dr. Anderson recom-
mends that common tar should be combined with one of the
potash solutions—for example, a mixture of equal parts of
common tar, methylated spirit, and soft soap, used as above
directed, will be found useful, or the following preparation,
as less offensive:—

}}. Saponis Mollis, Spt. Rectificati, Olei Cadini, aa 3i.;
Olei Lavandule, %iss.; misce. A little quantity is to be
firmly rubbed over the eruption night and morning; and it
must be washed off before each reapplication.

Of mercurial applications the citrine ointment (Ung.-hyd.
nit.) is the best, or the ointment of the iodide of mercury.
They may be used of their full strength, or diluted with lard,
according to the indications of the case, care being taken
that mercurialism is not induced. When eczema has reached
the dry stage, Mr. Milton regards the dilute ointment of the
nitrate of metcury as the most effectual remedy we possess.
In the itching of pruritus—pruritus scroti and prurigo pudendi
muliebris—especially the prurigo senilis, the dilute ointment
is highly spoken of by Dr. Bowling, United States, and by
Dr. Balmanno Squire in this country, as one of the best rem-
edies for subduing the irritation and itchiness. Dr. Bowling
advises that the parts be first sponged with vinegar or lemon-
juice previous to the application of the ointment; and states
that for fifteen years he has not failed to effect a permanent
cure (Med. Times, June 6, 1868). In using ointments, a
small quantity should be melted on the finger, and rubbed
firmly into the affected part. None should be allowed to lie
undissolved upon the skin; and the part should always be
cleansed with soap and water before reapplication. Epila-
tion should be resorted to in cases of eczema of the hairy
parts of the face. In very mild attacks, or with a view to
prevent the recurrence of the disease, the skin may be washed
occasionally with soft soap and water. Hendrie’s “ Dispen-
sary Petroleum Soap” is recommended by Dr. Anderson, to
whose admirable lectures on ‘‘Eczema,” in the Medical
Times and Gazette for May, June and July, 1863, (since pub-
lished in a separate volume), the reader is referred for more
detailed information. ,

Elephantiasis Grecorum— See Leprosy, True.
EMPHYSEMA—ENCEPHALITIS AND MYELITIS, 127
Emphysema—Scee Lungs, Emphysema of.

Encephalitis and Myelitis.— Definition Inflammation
of the brain and spinal cord substance, with or without im-
plication of the membranes, usually partial.

. Treatment.—1. Encephalitis —So soon as there are any cir-
cumstances which may lead to “head symptoms” after in-
jury, it is well to commence treatment at once with local
antiphlogistics, leeches, and evaporating lotions, such as
muriate of ammonia in solution with vinegar, applied by
tloths, which’ are to be frequently changed. The patient
must be made to observe a rigidly abstemious regimen, and
test with the head elevated above the shoulders. Purgation
ls to be instituted by means of watery evacuants, and the
same general treatment is to be adopted as in meningitis.

2. Myelitis.—In classing ramollissement of the cord with
inflammation, it might appear to infer that the treatment
should be strictly antiphlogistic. It may be laid down asa
general rule, however, that bleeding ought not to be had re-
course to after palsy has occurred. Previous to that symp-
tom it may be admissible; and it may be stated generally,
that so long as the affected muscles are convulsed, rigid, and
irritable, the use of antiphlogistics and counter-irritants may
be indicated; but when the means calculated to subdue ex-
citation have failed to arrest the further progress of the dis-
ease, and paralysis supervenes, stimulants are the only reme-
dies which have the power of restoring to functional activity
those nerve-cells and conducting fibres which are not irre-
trievably destroyed (Meryon). The chances of saving the
patient by other antiphlogistic remedies mainly rest on act-
ing on the alimentary canal so as to produce three or four
motions in the twenty-four hours, and thus create such a de-
rivation as in some degree to relieve the parts. The greater
number of patients that recover are restored by these means.
The particular purgative is not perhaps important; but as
the neutral salts act not only on the intestines, but also on
the bladder, that class of remedies is generally preferred.

With respect to local counter-irritants, as blisters, moxas,
or setons, little favorable can be said, unless they are em-
ployed previous to paralysis, as the tendency to gangrene
renders their application of doubtful utility. When had re-
course to, however, it will be found better to apply them
above the seat of the disease than immediately over it, the
greater vitality of the superior parts giving more assurance
128 ENCEPHALITIS AND MYELITIS.

of the disposition of the wounds to heal. Of all stimulant
remedies, electricity and strychnine are the most potent and
the best. Secale cornutum has been recommended as a
remedy possessing the same power as strychnine (Barbier,
Payen, Meryon). When there is no great pressure beyond
that which simple congestion produces, nor actual disorgan-
ization of the spinal cord, the remedial power of secale
cornutum is said to be very great. It seems especially to
resuscitate the muscular contractility of the rectum and
bladder, the pelvic viscera generally (Guersant, Trousseau,
brown-Sequard, Meryon). The ergot of rye may be given
in the forms and doses as follows:—(1.) Ergot, 5 to 10
grains, infused in boiling water, three times a day; (2.)
Ethereal tincture (not now in the pharmacopeeia), in doses
of from ten to twenty drops, twice or three times a day; (3.)
Extractum ergote liquidum, 15 to 30 minims; (4.) Infusum
ergote, made fresh on each occasion, 1 to 2 ounces; (5.)
Tincture ergote, 15 to 60 minims. It does not relieve the
reflex convulsions, which are sometimes alleviated by
Purssic acid, digitalis, belladonna (Meryon, chlorodyne
or chlor-morphine. [Conflicting statements exist in text-
books on Materia Medica as to the best form of ergot
for internal administration. 1. Ergot contains one-third -
of its original weight of oil, got out by percolation with
ether (Squire). 2. It contains a large quantity of fixed oil,
about 75 per cent. (Garrod). 3, It contains 25 to 28 per
cent. of fixed oil (Stillé and Maish). Ergot preserves its
virtues not much over a year (Stillé and Maish). The active
principle is a body somewhat resembling gelatine, formed
from the gluten of rye ovary, and readily changed by the in-
fluence of chemical agents (Bucheim). A number of non-
crystallizable compounds, possessing more or less activity,
have been isolated from ergot, the most important being
sclerotic acid (to the amount of 4 and 4% per cent.), the
other, scleromucin, to the extent of 2 to 3 per cent. This
multiplicity of uncrystallizable principles may explain why
preparations possessing some activity may be obtained from
very different processes—e. g., Wiggers’ ergotine, obtained in
1830, is soluble in alcohol, but insoluble in water and ether,
and is said to have poisonous properties. Bonjean’s Ergotine
(Germ. pharmacop., as “ Extr. Secalis Cornuti”’)is a con-
centrated aqueous infusion, precipitated by half its weight
of alcohol, and the clear filtrate evaporated. Wenzell (1864)
proved the presence of two alkaloids (ecbolina and ergo-
ENCEPHALITIS AND MYELITIS. 12g

tina). They exist in combination with ergotic acid. These
have been since shown to be identical, and to possess no. de-
cided physiological action (Dragendorff and Blumberg). In
1875 fannet isolated another alkaloid, ergotinina, from the
fixed oil of ergot prepared by ether, by agitating it with
acidulated water. Fresh ergot yields .12 per cent. of ergo-
tinina, which is crystalline, but soon becomes resinous, As
regards the properties of the oil extracted from ergot by
maceration with ether, Stillé and Maish write that “it dis-
plays even greater energy in producing the same symptoms,
and in addition other symptoms (which are specified), than
does ergot itself. The effects continue for several days:’’ but
they add that “ the oil exhibits no influence upon the gravid
uterus, but the residual ergot from which it had been ex-
tracted seems to possess the ecbolic power of the drug unim-
paired’ (The National Dispensatory, p. 545). It does not
appear, therefcre, that we are warranted in rejecting the
ethereal tincture of ergot as an inert preparation, as Mr.
Squire has represented it to be (Compan. to Pharg., 1871).
It may still be the best form of remedy for some cases, al-
though it has become obsolete as 4 pharmaceutical prepar-
ation in our pharmacopeeia; while the residual ergot, pos-
sessing ecbolic powers, may be also useful for othtr pur-
poses. Besides, Mr. Squire states that in the directions for
preparing the extractum ergote liquidum (doubtless a valu-
able and energetic preparation when properly made from
fresh ergot), the ether ordered is not sufficient to extract all
the oil. The quantity, he states, ought to be doubled. So
that this energetic preparation, if prepared as directed in
our British Pharmacopceeia, still contains half the oil left by
the insufficient quantity of ether which is used, so that the
whole of the oil is not now rejected in preparing the ex-
tractum ergote liquidum. <A writer in Medical Times and
Gazette (Oct. 16, 1875), under the signature of “ Eyes
Right,” has described how “ teachers differ” on matters of
fact, and gives the teachings of Squire, Aitken, and Garrod,
on “Ergot” as an example. But from what I have quoted
from the most recent teachings of Stillé and Maish, I do not
find we are justified in excluding the Ethereal tincture of
ergot as an inert preparation. |

After the local pain in the back has been subdued (by the
regular and repeated application of two or three leeches to
the painful part, followed by a large warm poultice over the
whole length of the spine, and a belladonna plaster of equal

9
130 ENDOCARDITIS,

length to follow it, or an occasional blister on each side of
the spine, together with mild, warm purgatives, if necessary).
Dr. Meryon has found no remedy so effectual as strychnia,
in the dose of one-twentieth of a grain, repeated more or
less frequently (twice or three times a day), according to
the evidence of its action It may be combined advantage-
ously with ipecacuanha in cases where the intestinal mucus
seems deficient The absence of pain and of spasmodic
muscular contraction necessitates great caution in deter-
mining the precise moment when the spinal cord is likely to
be benefited by the energetic excitement of strychnia. The
internal administration of this remedy ought, therefore, to be
always preceded by its external use, together with other
stimulants, in the form of embrocations over the spine, when
the stage of excitation has been subdued. In cases with a
history of syphilis, and where there may be some reason to
believe that hardening or induration of the cord or its mem-
branes has taken place, the iodide of potassium may relieve
the early phenomena, and by the aid of setons the progress
of the disease may be held in abeyance, so long as the dis-
charge is maintained from the seton.

When disorganization of the spinal cord has become an ac-
complished fact, the disease is incurable, but yet the exigen-
cies of the patient are not the less pressing on the careful
attention of the physician, and in nothing more so than
in the protection which is called for against bedsores,
which will sometimes occur in spite of the greatest care
(Meryon.

Electricity, after the activity of inflammation has been
subdued, is a therapeutic agent of great value; and the con-
tinuous current of galvanic electricity seems to be just as
efficacious as the induction or intermittent current. But
whether galvanism or electro-magnetism be employed, no
high degree of tension is required for the restoration of mus-
cular power; on the contrary, Dr. Meryon justly believes
that the favorable course of many a case has been retarded
by the employment of strong currents. Dr. Althaus, also, is
in favor of weak currents.

_ Endocarditis.—Dejfinition—An inflammation of the
lining serous membrane of the heart, covering the valves and
lining the chambers of that organ.

Treatment.—No defined line of treatment can be laid
down suitable for all cases; because the circumstances under
ENTERIC FEVER, 131

which endocarditis occurs are extremely varied. What has
been written relative to pericarditis applies equally to endo-
carditis; but the management of cases in which the patients
suffer from valvular lesions and their immediate conse-
quences demands the adoption of various lines of treatment.
Stimulants are generally called for in large quantities; and
digitalis also may be necessary if the action of the heart is
weak and failing. When endocarditis seems lapsing into
the chronic stage, the use of iodide of potassium and liquor
potassz, combined with bitter tonics and abundant nutri-
ment, are to be recommended. Alkalies and carbonate of
ammonia are to be given with free stimulation by alcoholics
in cases of obstruction from blood coagulation in the cavi-
ties of the heart. Cases of malignant, infective, or ulcerative
endocarditis (attended with fever and pyemic symptoms in
which retinal haemorrhages are almost invariable), are to be
treated in the same way as cases of septicemia. They con-
stitute the diphtheritic endocarditis of the Germans, some
septic source poisoning the blood

Enteric Fever.— Definition.—A continued specific fever,
having an incubation-period of about two weeks, with an
eruption on the skin of isolated, elevated, rose-colored spots,
chiefly on the abdomen, appearing generally from the seventh
to the fourteenth day, occurring in crops, each spot continu-
ing visible about three days and vanishing on pressure.
Languor and feebleness are prominent from the first,attended
by headache, abdominal pains, and (early) by spontaneous
diarrhoea; but absolute prostration does not come on till late,
‘the patient rarely taking to bed before the seventh or tenth
day. With the advance of the disease the diarrhoea increases,
the discharges being for the most part liquid, copious, of a
bright yellow color, devoid of mucus, occasionally containing
altered blood. In reaction the discharges are alkaline, and
contain a large proportion of soluble salts with some albumen.
The fever may terminate favorably by a gradual restoration
to health during the fourth week. The average duration of
the illness is about twenty-three days. Death in the majority
of fatal cases occurs towards the end of the third week.
There‘ are special symptoms sometimes associated with the
characteristic lesion of this fever—namely, fulness, reso-
nance, and tenderness of the abdomen; more or less tympa-
nites, with gurgling in the iliac fossz; and increased splenic
dulness. The specific lesions are enlargement of the spleen
and the mesenteric glands, with enlatgement, ulceration, or
132 LNTERIC FEVER.

sloughing of the glands of Peyer and the minute solitary
glands of the small, and sometimes also of the large, intestine.

Treatment and Management of Enteric Fever —The
management of a case of enteric fever resolves itself
into two lines of practice, embracing,—(1.) Preventive mea-
sures. (2.) Therapeutic Treatment.

(1). Preventive Measures, or Measures for Checking the
Spread of Typhoid Fever.--Whatever may be the view theo-
retically adopted regarding either the origin or the propagation
of typhoid fever, it is satisfactory to know that, practically,
medical officers can employ preventive measures which (to use
the words of the late Dr. Lankester) ‘will cover the issues
of both theories.’ If these are universally carried into ef-
fect, it is not too much to expect that this fever might per-
haps soon become extinct. At all events, with the facts be-
sore us, it is unwarrantable to permit the great bulk of what
escapes from the diseased intestine of typhoid fever patients
to be let loose upon society, into the cesspool or sewer, or
on the dung-heaps, in full possession of all their deadly power,
without being first destroyed in the way to be presently re-
commended. ‘The grand fact is clear,” writes Dr. Parkes
“that the occurrence of typhoid fever points unequivocally
to defective removal of excreta, and that it is a disease
altogether and easily preventible.” Typhoid fever ought
therefore soon to disappear from every return of disease,
whethe: in military or in civil life. The measures about to
be specified have been made public mainly through the
writings of Dr. William Budd; and, provided they are
thoroughly and efficiently carried out, it is believed that the
recurrence of typhoid fever may be entirely prevented. To
enable us to judge of the extent of the infection to be des-
troyed, there are two elements to be taken into account,—
First, The amount and duration of the intestinal discharge
in each case; and, Second, The number of cases actually
occurring. With regard to the first, Louis has found
that the average duration of the alvine flux in cases of ty-
phoid fever is fifteen days in mild cases and twenty-six days
in severe cases. With regard to the second point—namely,
the number of cases occurring—the Reports of the Regis-
trar-General show that at least 100,000 to 150,000 cases of
typhoid fever occur annually in England alone. In other
words “every year in England more than 100,000 human
intestines, diseased in the way already described, continue
each, for the space of a fortnight or thereabouts, to discharge
ENTERIC FEVER. 133

upon the ground floods of liquids charged with matters on
which the specific-poison of a communicable disease has set
its most specific mark ” (Budd).

The measures recommended for preventing the spread of
this fever are founded on the power of chemical agents to
destroy absolutely the material which contains or carries the
specific virus of such communicable diseases. Assuming it,
therefore, to be certain that the intestinal discharges in ty-
phoid fever are the media of propagation of the disease, it is
no less certain that, by subjecting the discharges on their
issue from the body to the action of powerful decomposing
chemical agents, they may be entirely destroyed or deprived
of their specfic virus. The following details of procedure
are suggested:—(a) All discharges from the fever patient
should be received on their issue from the body into vessels
containing a concentrated solution of chloride of zinc. (4)
Two ounces of a caustic solution of chloride of zinc should
be put in the night-stool on each occasion before it is used’
by the fever patient. (¢.) All tainted bed or body linen
should, immediately on its removal, be placed in water
strongly impregnated with the same agent. (d.) The water-
closet should be flooded several times a day with a strong solu-
tion of chloride of zinc, or of sulphate of iron or carbolic acid;
and some chloride of lime should be also placed there, to
serve as a source of chlorine in the gaseous form. (¢.) So
long as fever lasts, the water-closet should be used exclu-
sively as a receptacle for the discharges from the sick after
being thus disinfected. (f.) Pieces of rag should be used
for wiping the remains of all discharges from the patient’s
body, and burned immediately after use. The Privy Coun-
cil have now made the principle of this method an integral
part of their “‘ General Memorandum on proceedings advis-
able to be taken in places attacked or threatened by epide-
mic disease.”

(2.) Therapeutic Treatment of Enteric or Typhoid Fever
aims at reducing temperature and subduing vascular excite-'
ment, if these be in excess; restraining and moderating, but
not actually suppressing or altogether checking the diarrhoea;
stimulating and restoring the nervous system; obtaining a
free excretion from the kidneys; and bringing about a gra-
dual elimination of the morbid growth from the intestinal
glands with as little ulceration as possible. To accomplish
the first of these indications the use of digttal’s has been es-
pecially recommended by Wunderlich. He considers that
134 ENTERIC FEVER.

it decidedly mitigates the febrile symptoms which are pres-
ent in severe cases at the time when the ulcers begin to heal,
and which often impede or prevent recovery. He advocates
its use in the severe forms of the fever only, especially at a
time when most danger is to be apprehended from the vio-
lence of the fever in the second week, when the evening
temperature is at its highest (105° to 108° Fahr.), and when
the remissions in the morning are slight; when the pulse is
frequent, 110 to 120 ormore. In mild cases it is superflu-
ous. He finds that in the form of infusion it is easily ab-
sorbed by the intestines of patients suffering from fever;
and, if given in a suitable dose, has most marked effects in
subduing the rate of pulsation, and in reducing animal heat.
Large doses of the infusion should be given without inter-
ruption until the full effect has been obtained,—

An infusion of fifteen or twenty grains of digitalis in eight
or ten ounces of boiling distilled water may be consumed ‘in
twenty-four hours by adult patients.

It acts more rapidly on animal temperature than on the
heart. For the first few days after its use the decrease of
temperature is rather slight, but may afterwards become
considerable; and after the temperature has been much
diminished and again rises, it never attains its former ex-
cessive height. The full effects of the medicine are known
to be brought about if the temperature is reduced 2° or 3°
Fahr. in the evening; and the action of the remedy does not
continue beyond one day after its use has been d‘scontinued.
The diminution of the pulse is slight at first, and
occurs in some cases on the second day after the remedy,
but mostly on the third day, or even later; and on the fourth
or fifth day after the medicine has been commenced, the
rate of pulsation may be diminished by thirty to forty or
fifty beats within from twelve to thirty-six bours. The pulse
may continue to fall even below its normal velocity, and this
reduction of pulsation may last for several weeks in succes-
sion. If the velocity of the pulse should decrease rapidly,
the use of digitalis must be, discontinued at once (“ Arch.
der Heilk., 1862, p. 116). Cold and tepid sponging, or the
cold affusion, are remedies deserving of further trial for
reducing the pulse and temperature. The oppressive head-
ache may be greatly relieved by cold to the head; ard in
all severe cases the hair should be shaved off.

To restrain excessive diarrhcea, lime- water mixed with milk
in equal parts and taken as a drink, is found to be beneficial,
ENTERIC FEVER. 135

agreeable, refreshing, and nourishing. It is clear that the
diarrhoea ought not to be altogether checked. Professor
Gairdner, of Glasgow, is in favor of the French practice of
giving saline laxatives rather than astringents ; also of the
diligent use of enemata to unload the bowels from below,
where anything like abdominal distension has occurred.
These enemata may be simply of warm water, to which a
little aniseed is added; or the asafcetida enema may be
given. Of the propriety of restraining excessive diarrhoea,
there can be no question. Dr. Huss, of Stockholm, is of
opinion that the diarrhcea during the first stage ought not
to be arrested, but abated and mitigated—only if excessive.
If it is suddenly arrested, meteorism is produced ; and pains
in the intestines or vomiting may supervene, with cerebral
symptoms. The febrile phenomena are then increased.
The diarrhoea is too copious or excessive if the evacuations
exceed four or five a day, being of considerable quantity,
and fluid. Such evacuations weaken the patient rapidly,
and should be mitigated by mucilaginous drinks, such as
rice-water, infusion of linseed, decoction of althzea officinalis
or ipecacuanha in small and repeated doses. This latter reme-
dy retards the peristaltic action of the intestines, and lessens
the secretion from-the mucous membrane. The dose must
be regulated so as to avoid vomiting: and the feeling of
nausea which is apt to follow the first dose soon disappears
with continued use.

On the other hand, the highest authorities write: ‘‘ Re-
strain diarrhoea and hemorrhage in typhoid fever, and when
you have fairly locked up the bowels, keep them so. Pa-
tients will go for four or six days, or even longer, without
suffering inconvenience from this state of constipation.”
(Murchison, Todd). The benefits to be derived from the
mineral acids—hydrochloric and sulphuric especially—are
highly spoken of. From fifteen to thirty minims of the dilute
acids may be given every three or four hours; and with
each dose half a grain of quinine, as in the following pre-
scription for an adult:

BR Acid.Sulph. dil., vel Acid. Hydrochlor. dil., m xx. ad.xxx.
Quiniz Sulph. gr. $ ad gr. 1.
Syrup Aurantii, 3 ss.
Aquez Carui, 31.

Fiat haustus, 3a vel 4a hora sumendus.

If there be more than two motions in the twenty-four
1360 ENTERIC FEVER:

hours, with marked prostration, astringents should be had
recourse to (Murchison). A starch enema, containing from
ten to twenty drops of laudanum, should be administered
towards evening, and recourse may also be had to the follow-
ing draught :

BR Acid. Sulph. Aromat., m xxx.

Liq. Opii. Sedativ. (Battley), m iii.
Aq. Menth. Pip. %1.; misce.

Fiat haustus, 4ta vel 6ta quaque hora sumendus.

If the mineral acids are not tolerated by the stomach,
acetate of lead is worthy of trial, in doses of two or three
grains in solution every four or six hours, with or without
an eighth of a grain of morphia (Murchison). Alum dis-
solved in gum, to the amount of twenty-four grains in a day,
which may be increased to one drachm, is best given in the
form of alum whey, prepared by adding one drachm of alum
to a pint of boiling milk, and then straining. Two ounces
may be given after each motion of the bowels (Fouquier,
Murchison). A seidlitz powder may sometimes check
excessive diarrhoea, by altering the secretions, and is espec-
ially beneficial if there be much meteorism (‘Trousseau,
Murchison).

The question, therefore, of checking excessive or encour-
aging moderate diarrhoea, is one which requires the careful
study of each particular case ; and my experience in the
treatment of typhoid fever leads me to recommend rather
the restraining of excessive diarrhcea than either encourag-
ing the action of the bowels or locking them up for days.
The French practice of giving saline laxatives is not a safe
one, and if the action of the bowels is deemed desirable,
enemata will be found sufficient. Nitrate of silver, in doses
of one to three grains, made into a pill, and taken every six
or eight hours, or sulphate of copper, in doses of a quarter
of a grain similarly given, are remedies most useful in tHe
diarrhoea connected with atonic ulcers, after the fourth week
of the disease (Bell, Murchison). If meteorism or tympanites
prevails from the accumulation of air in the colon, it may
sometimes be relieved by the passage of a long flexible tube
by the anus, as far up the colon as it can be madeto go
easily. With regard to stimulation it is not decided how far
alcohol is beneficial. The fever eventually is attendéd with
much exhaustion, and is often protracted, yet typhoid fever
does not seem to bear stimulation so well as typhus. The
tendency to prostration is the only indication for its use ;
ENTERIC FEVER, 137

but stimulation must not be persevered in if the pulse is
quickened by its use, the hectic flush made more manifest,
the tongue made drier, or if delirium supervene. Food and
sustenance are the real preventives of delirium, and the best
stimulants when necessary. With regard to the maintenance
of free action from the kidneys, it is to be observed that so
long as the excretion of urea and uric acid is abundant, no
diuretics are necessary ; but whenever the amount of the
solids falls greatly (which can be known at once with suffi-
cient accuracy by acomparison of the urine passed in twenty-
four hours with the specific gravity), means must be taken
at once to increase, if possible, the urinary elimination. The
warm bath, with repeated small doses of the alkaline car-
bonates, or of the nitrate or bitartrate of potash, will often
effect an increased elimination (Parkes, l. c.)

To accomplish the last indication—namely, to influence
the elimination from the intestinal glands, by direct local
action on the intestinal membrane—Wunderlich and Parkes
especially advocate the use of calomel, if it can be given be-
fore the ninth or tenth day. The late Dr. Anthony Todd
Thomson used to give it; and, from the observation of many
cases under the care of this physician, as well as from his
own experience, Dr. Parkes considers that calomel is a med-
icine to be strongly recommended in typhoid fever. But it
must not be given later than the tenth or eleventh day, and
atno time in large doses. In the great majority of cases
where it can be given during the first week and before the
occurrence of much diafrhoea, the course of the disease is
rendered milder and shorter. Such is now the recorded ex-
perience of Wunderlich, Niemeyer, Parkes, and Wood. One
or two grains twice a day is enough, although Wunderlich
gives one to five grains twice daily ; bu: five grains is con-
sidered by Dr. Parkes to be too large a dose. Dr. Wood of
Philadelphia bears testimony to the benefit to be derived
from mercury about the seventh or ninth day of the fever.
He believes “it tends in some degree to arrest the progress
of the disease in the glands of Peyer, and to promote resolu-
tion of the inflamed patches. He prefers minute doses of
the blue pill mass—a grain every two hours—till the mouth
is slightly affected, associated with small doses of ipecacuan-
ha, when the stomach is not irritable. The beneficial effect
of this combination is shown by the tongue becoming moist,
the skin relaxed, and the symptoms generally being amelior-
ated. Twelve grains of blue pill mass are to be combined
138 ENTERIC FEVER.

with two grains of ipecacuanha powder, and with two grains
of opium powder. The whole is to be divided into twelve
pills, one of which may be taken every hour, or every hour
and a half, or every two hours (Wood, “ Practice of Medi-
cine,” Vol, I. p. 345, 4th edition). Calomel is, however,
contra-indicated if the diarrhoea is excessive, or if there
should be excessive pains in the bowels, with early and vio-
lent meteorism. It is also not proper to be given if the con-
dition of the patient is anzemic, or if there is a decided he-
morrhagic diathesis. It is most useful as a restorative of the
intestinal functions in cases where the tongue is dry and
coated, where thirst is absent, and when the urine is cloudy
and of low specific gravity. If the first dose is vomited, the
administration must be repeated. Calomel has no direct ef-
fect on the pulsation or respiration, nor on the cerebral func-
tions ; but its beneficial influence is wery decidedly appreci-
able by the modifications of temperature which it induces.

No general rules can be laid down to guide the treatment
of the intercurrent phenomena or accidents of the disease.
Combinations of remedies must be adapted to correct the
several functions which may be simultaneously deranged, so
that treatment must be varied according to the functions
mainly implicated or suspended, and to the degree of their
affection. Abdominal pains and meteorism may be relieved
by mustard poultices, or turpentine stupes may be applied,
followed by simple hot water fomentations. After these re-
medies have been used, water compresses over the abdomen
tend to lessen the tension and the gurgling in the intestines,
and to diminish the tenderness on pressure. They counter-
act the inclination to meteorism, and lessen excessive diar-
thoeea. Dr. Huss believes also that the ulcerations in the il-
eum are prevented from spreading, and that perforations of
the intestine have been of much rarer occurrence since he
commenced to use these compresses. The compress, after
being soaked in warm, but not hot water, is well wrung, and
applied so as to cover the whole abdomen ; and it must be
changed two or three times a day, according to its tendency
to dry. The compress is composed of four to eight double
folds of coarse linen, and is to be laid over the whole abdo-
men, and afterwards overlaid with a cover of oiled skin or
india-rubber stuff, to prevent too rapid evaporation. The
compress should fit as closely as possible, and care must be
taken that it be not displaced, otherwise air enters between
the skin and the compress, so that cold, instead of a moist
ENTERIC FEVER, 139

heat, is produced. These compresses may remain untouched
as long as they are moist and warm; and they may be em-
ployed on the chest as well as on the abdomen should capil-
lary catarrh or pneumonia supervene.

Heemorrhage from the bowels, partly fluid and partly in
clots, evacuated with the stools, isa symptom of grave import;
and one urgent aim of treatment is to arrest the bleeding.
Huss found the sugar of lead most serviceable, administered
by the mouth, and also by clysters. By the mouth, two grains
may be given every half-hour, and even every quarter of an
hour; and itis best given dissolved. Twenty-four grains
of crystallized acetate of lead, being dissolved in one drachm
of dilute acetic acid, to which six ounces of distilled water
is added, —a table-spoonful of this solution may be given
every half-hour. At the same time a clyster may be admin-
istered, composed as follows :—Ten to fifteen grains of ace-
tate of lead are to be dissolved in four ounces of distilled
water (warm), to which twenty to thirty drops of tincture of
opium may be added ; and the administration of such a cly-
ster may be repeated in four or six hours if required. Pieces
of ice may also be swallowed now and then; and even
crushed ice may be applied, inclosed in a bladder, over the
abdomen, If bleeding from the nose is not arrested by the
use of vinegar and cold water injected up the nostrils, nor by
the use of cold water compresses applied to the nose, plug-
ging by the posterior nares must be had recourse to. Turpen-
tine is a most valuable remedy in hemorrhages, and in the
stage of ulceration. It was originally recommended by Dr.
Graves, and is highly spoken of by Drs. Huss, Wood, and
Murchison. It may be given in all cases where the tongue
is dry, and when “instead of cleaning graduaily from the
edges and tip, it often parts with its fur quickly, and in large
- flakes—generally, first, from the middle or back part of the
surface, which is smooth and glossy, as if deprived of its pa-
pilla. There is also generally an increase of the tympanites,
and the ulceration of the ileum seems to be attended with
great dryness of the tongue.” Under these circumstances
Dr. Wood gives the oil of turpentine in doses of five to twen-
ty drops every hour, or every two hours. It is best admin-
istered in an emulsion with gum-arabic, loaf sugar, water
(Wood) ; or in anemulsion with the yolk of an egg and honey
or mucilage (Huss). Amelioration of the symptoms may be
observed in twenty-four or forty-eight hours—the tongue
becoming more moist, and covered with a white fur—disten-
T40 ENTERIC FEVER.

sion of the abdomen ccascs to progress, and after a time di-
minishes. The use of the oil should be continued under
these circumstances; but the dose should be gradually di-
minished.

Tonics and stimulants may be absolutely essential on ac-
count of debility attending the advanced stage of the disease,
generally about the third week. When the pulse is slow and
feeble, the skin cool, ‘the tongue and teeth encrusted with
dark sordes, at an advanced period of the fever, then stimu-
lants are obviously necessary. But even when the pulse is
teeble, but yet frequent, and the skin hot, stimulants are even
then known to be of service. It is necesssry to administer
them in every case with great caution, and to watch the
effects constantly and closely. If their use is found to aug-
ment the heat of the skin, or to increase the frequency of the
pulse, or to aggravate the delirium or stupor, it is then nec-
essary to suspend their use. They are known to be doing
good service, however, if they lessen the frequency of the
pulse, and increase its fullness and strength; if the skin be-
comes cool and moist; if the delirium is subdued or moder-
ated, and especially if refreshing sleep be procured. Dr.
Wood recommends the use of wine whey, prepared by add-
ing one quart of good sherry wine to two quarts of boiling
milk, and straining after coagulation. Of this a table-
spoonful or more may be given every hour or every two
hours. If the strength is greatly reduced, it may be neces-
sary to give pure wine or brandy; or even sulphuric or
chloric ether in cases of great prostration. Opium is also a
useful stimulant. It may be given when the pulse is not full
nor strong, and when cerebral symptoms do not exist. In
the later stages it may be given in doses of half a grain, or a
grain, every four, six, or eight hours. It is known to be act-
ing beneficially when it promotes sleep, subdues nervous ex-
citement, and ‘induces gentle perspiration. Carbonate of
ammonia is objectionable, as it may irritate the bowels and
increase the diarrhcea.

The diet is of the utmost importance to be attended to in
cases of typhoid fever from the very commencement of the
disease. It ought then to be both food and drink combined,
in the form of a light nutritious liquid, such as meat fluid,
soup, eggs, and milk. Barley-water, rice-water, toast and
water, thickened more or less with solutions of tapioca, sago,
arrow-root, the juice of sweet fruits, or the very soft pulp of
fruits, or the pure jelly of ripe fruits; but fruit in its crude
ENTERITIS. I4I

state is to be strictly withheld. 1t is necessary, as a rule, to
give food at certain intervals and in certain quantities. A
wine-glassful should -be given at least every two or three
hours, according to the state of digestion and the demands
upon the strength of the patient. It may be that the patient
is unable to swallow, from the dry and shrivelled state of his
tongue. Before offering him food or drink, therefore, the
nurse should put a teaspoonful of lemon juice and water into
his mouth. She must then wait a minute or so, until the cur
upon the tongue and mouth is softened and moist, after
which the patient will often drink or take his food with ease.
The patient ought to have his mouth regularly washed out
with a linen rag, saturated with water, in which a little soda
has been dissolved. Milk in small quantities frequently re-
peated will be found an excellent diet; and animal broths
and jellies may ultimately be given. The extractum carnis,
as prepared by Liebig or Valentine, is a most valuable nutri-
ment for typhoid fever. patients. The best drink is pure
spring water, or soda-water, or barley-water, or water that
has been mixed with oatmeal, but is free from any particles
of oats. ‘The patient generally desires and requires to drink
freely, in order to replace the loss of fluid by perspiration
and diarrhoea; and, in. the advanced stages of the fever, plen-
ty of drink should be given by the nurse. _

The utmost caution is necessary as to diet and aperients
during convalescence; first, as to opening the bowels, castor-
oil or simple enemata ‘are the only means which should be
resorted to; secondly, as to diet, no flesh meat should be al-
lowed till at least seven days after all the febrile phenomena
have passed away, and the food should he as free as possible
of excrementitious matter. Malt liquors should not be taken
before food.

Enteritis.—Definition—Inflammation of the small in-
testines generally, or limited locally.

Treatment,—The treatment of enteritis and intestinal ca-
tarrh, when not arising from a morbid poison, is by leeches
to the abdomen, gentle purgative medicines, combined with
an opiate, fomentations, and purgative or opiated enemata.
After the inflammation has subsided, mild tonics, as the
compound tincture of gentian, with nitro-muriatic acid, may
be substituted, with the prospect of recovering the lost tone
of the parts. When catarrhal diarrhoea exists, if congestion
prevails, connected with the hepatic region, a cathartic dose
T42 ENTERITIS,

of calomel, followed by castor-oil. may be necessary. If the
stools indicate an acid reaction, magnesia may be given with
advantage. When membranous films or shreds of coagul-
able lymph are passed, electro-galvanic applications over the
abdomen and dorsal spinal region, combined with creasote
or tar, in the form of a pill, is worthy of a trial (Simpson.
Cumming, Wood). Next to those remedies are such as de-
termine towards the skin. For this purpose combinations of
Dover’s with James’ Powder, or a solution of tartar emetic
with laudanum, are the most useful medicines, and their
beneficial action may be aided by the use of the warm bath,
and a flannel roller applied with firmness round the abdo-
men (Craigie). Where hyperaemia is excessive, accompanied
by moderate transudation from the intestine, as after exten.
sive burns, accompanied by great pain, cold external appli-
cations are suitable, as well as in the severer forms of ca-
tarrhal enteritis (Niemeyer). The best mode of applying
them is by cloths wrung out of cold water and laid over the
abdomen. In thechronic form, combined with obstruction,
irritating and warm compresses are most suitable Preiss.
nitz’s compress is extensively used for this purpose. A wet
towel in folds, covered with a dry one, is laid over the abdo-
men all night, to be renewed several times daily. The great-
est care ought to be given to the management of the diet.
It ought to be strictly antiphlogistic, consisting of slops and
light puddings. Animal food must be withheld, and only
permitted in the form of soup. The safest diets are those
of arrow-root. sago, tapioca, barley-meal, gruel of oatmeal,
sowens, [“ The husk and some adhering starch separated
from oats in the manufacture of oatmeal are sold in Scot-
land, under the inconsistent name of ‘seeds.’ These, if in-
fused in hot water, and allowed to become sourish in this
state, yield on expression a mucilaginous liquid, which, on
being sufficiently concentrated, forms a firm jelly known by
the name of ‘sowens.’ Not less than a quart of the seeds
are to be rubbed for a considerable time with two quarts of
hot water, after which the mixture is to be allowed to rest
for several days until it becomes sour. It is then strained
through a hair sieve, and the strained fluid left to rest till a
white sediment subsides. The supernatant fluid is to be
poured off, and the sediment washed with cold water; after
which it may be either boiled with fresh water, stirring the
whole time it is boiling, or it may be dried and prepared
when convenient in the same manner as arrow-root. Itmay
EPILEPSY AND HYSTERO-EPILEPSY. 143

be eaten with wine, milk, or lemon-juice and sugar.’’—Pe-
reira, ‘On Food,” p. 326.] barley water, toast water, burnt
oatcake water. This last-named substance, used as a drink,
is said to allay irritation and morbid sensibility of the bowels
(Craigie). When the abdominal pains subside, and stools
become less frequent and the appetite increases, the diet
must be still more scrupulously attended to. Oatmeal por-
ridge boiled to the utmost degree of pulpiness, and not too
consistent, is one of the best of diets, which may be alter-
nated with ground rice alone, or combined with barley flour,
all of which may be eaten with diluted milk from the cow or
with milk undiluted of town-fed cows.

Epilepsy and Hystero-Epilepsy .— Definition.—A com-
plex nervous state, characterized by chronic convulsive at-
tacks not due to organic brain disease, tonic at first, but
which subsequently become clonic, and ultimately impede
the respiratory process. The attack, lasting from an impe’-
ceptible period to two, twenty, or more minutes, is followed
by some exhaustion and sleep. The expression of the epi-
leptic state varies from simple vertigo to the most severe
paroxysm, a momentary suspension of consciousness, a fix-
ity of gaze, a totter of step, and a confusion which appears
and disappears almost instantaneously, which the patient
only can recognize. The cases comprehend—(tr.) Simple
epilepsy, or epilepsy proper, in which there is a paroxysmal
loss of consciousness as the first, or nearly the first phenom-
enon in the paroxysm, and with this loss of consciousness
there is more or less spasm of muscles (including those of
the muscular coats of the arteries). (2.) Epileptiform seiz-
urés, in which there is no evidence of organic brain disease,
but developments of the movements normally represented in
some particular parts of the cerebral cortex. (3.) Hystero-
epilepsy (Hysteria major of Charcot, the Hysteroid of Dr.
W. Roberts, or the Co-ordinated Convulsions of Gowers)
which presents, with loss of consciousness, varied convulsive
momements of more or less co-ordinated spasm, spasmodic
movements of a quasi-purposive character, opisthotonos, em-
prosthotonos, and the like, forming a series from simple hys-
teria to true epilepsy. The co-ordinated spasm may exist
alone, or may be combined with epileptoid phenomena, or
with true epileptic symptoms.

Treatment.—The treatment divides itself into what is to
be done during the paroxysm, and subsequently during the
intervals.
144 EPILEPSY AND HYSTERO*EPILEPSY

When adults are laboring under the paroxysm, little, in
general, can or ought to be done except bringing the patient
into the fresh air, taking off what may be around the neck,
and baring the chest, together with the more imperative duty
of preventing the patient doing himself any injury. Bleed-
ing, so often had recourse to, is rarely found beneficial; ex-
cept, however, as regards females, in cases of suppressed
menstruation. If, however, the paroxysm be greatly pro-
longed, the application of cold to the head, and opening the
temporal artery, where symptoms of excessive cerebral con-
gestion are obvious, may be of some service, as in cases rec-
ognized as plethoric. It is of great importance to shorten
the paroxysm as much as possible. Dr. Sieveking recom-
mends that a trial be made of the galvanic current during
the fit. The conductors should be moistened sponges, so as
to insure the passage of the current to the deeper-seated tis-
sues. The inhalation of ammonia or chloroform, or nitrite
of amyl; or a dose of sal-volatile, or of ether, has been found
useful. The nitrite of amyl not only postpones, but alto-
gether prevents epileptic seizures. “A vinaigrette, or small
stoppered bottle, containing a sponge soaked in nitrite of
amyl, and carried in the pocket, so as to be at hand, will be
found a safeguard to many sufferers from epilepsy. Where-
ever there is time after the initiation of the coma, and before
the development of the proper phenomena of the fit, to
breathe the nitrite of amyl freely, the fit, with its terrible ac-
companiments and disastrous sequel, may in many instances
be not merely postponed, but abolished,’ (Dr. Crichton
Browne, “ West Riding Asylum Reports,” Vol. III., p. 154).

The paroxysm over, the probable exciting cause of the
paroxysm should be investigated, and, if possible, removed;
the state of the bowels should be particularly inquired into
and regulated, and leeches should be applied to the temples
if the headache be severe. In women, also, the catamenia,
if defective or excessive, should be remedied. These few
simple rules are of the first importance, not only as removing
the immediate inconveniences incident to the attack, but also
as a means of prolonging the interval, and perhaps prevent-
ing its future occurrence. We must take into account, and
search out for all causes which may have contributed to the
malady. In assuming the charge of an epileptic, it is neces-
sary to commence first by regulating the external relations
of the patient, his habits, and his bodily health, so that every
suspicious condition of his life to which the origin of the dis-
EPILEPSY AND HYSTERO-EPILEPSY, 145

ease can in any way be ascribed may be corrected (Nie-
meyer). In a few instances the patient, by the adoption of
certain rules, is cured, and the prevailing principles of treat-
ment in epilepsy mainly consist in local derivation, or coun-
ter-irritation directed to subdue cerebral congestion, and in
the use of such tonic remedies as may be indicated by a
careful inquiry into the condition of the individual organs,
and how their several functions are performed. The intens-
ity of the headache suggests more or less active counter-irri-
tation by blisters, dry or wet cupping, ointment of tartrate of
antimony, setons, or even the actual cautery applied under
chloroform to the nape of the neck.

The medicinal remedies that have been employed are va-
lerian, iron, zinc, quinine, musk, opium, asafcetida, the iodide
and bromide of potassium, camphor, and the preparations of
turpentine. The nitrate of silver, once esteemed a specific
in this complaint, has not only failed, but, by occasionally
staining the rete mucosum of a dingy hue, has often perma-
nently disfigured the patient. Of the long catalogue of rem-
edies which has been mentioned, each medicine is perhaps
useful for a few weeks ; but after that period its good effects
are, for the most part, lost, so thatit would appear to act
rather mentally than physically in removing the cause and al-
tering the morbid tendency.

“Whatever remedies or course of treatment you pursue,
do not appear to despond, or use any other language to the
patient than that of hope. Avoid extravagant promises, as
inconsistent with that love of truth which ought to character-
ize every professional man; but unless you have the strongest
evidence against it, do not yourself, nor allow your patient, to
abandon hope” (Dr. Todd, “Clinical Lectures,” Medical
Times, August 12, 1855.

The employment of purgatives is indicated for the re-
moval of waste matter, to act as a derivative from the head,
to expel foreign matters or worms from the intestines, and
generally to regulate the bowels; and the laxatives most
suited to epileptics are rhubarb, compound colocynth pill,
aloes, castor-oil, taraxicum, sulphur in combination with
magnesia or rhubarb; and the Pullna, Hunyadi Janos, Fried-
rischall, or Carlsbad bitter waters. Half a tumblerful or
less, taken in the morning, generally produces a full pulta-
ceous evacuation in two or three hours. The judicious use
of an anthelmintic sometimes frees the patient from the dis-
ease as well as from a tapeworm or other parasite, which not

10
146 EPILEPSY AND HYSTERO-EPILEPSY,

unfrequently may be the eccentric source of the fits. Inde-
pendently of its anthelmintic properties, however, both Drs.
Watson and Sieveking strongly recommend the use of tur-
pentine, It may be given in half-drachm doses every six hours.

If a scar, foreign body, tumor, or neuroma, be found press-
ing ona peripheral nerve, its removal by operation may cure
the epilepsy. Dr. Echeverria has recently given a table of
145 epileptics who were trephined, with the results, which
furnishes irrefragable proofs of the utility of trephining in
epilepsy produced by injury to the cranium (London Med.
Record, May 15, 1879, p. 169).

The preparations of iron and zinc are the most useful ton-
ics; and for the general principles on which iron may be ad-
ministered, the reader is referred to the pages on Anzmia.

Dr. Trousseau believed that belladonna is the least ineffi-
cacious of all the remedies for epilepsy, and from its use he
not only obtained alleviation and improvement in many
cases, but was able to count upon a certain number of cures
(Clinique Medicale, t. il., p. 95). His formula is:

Atropiz Sulphatis, gr. j.; Sp. Vini Gallici, mc. M. One
drop of this solution is to be given every day in the morning,
if the attacks happen in the daytime; or in the evening, if
during the night; the dose to be increased by one drop for
each succeeding month, and to be always taken at the same
period of the day. It should not be pushed beyond the first
toxical indications. If the dose is not well borne, it should
be increased only every second or third or fourth month.
When improvement is apparent, the quantity given in the
last dose should be continued for some time,-and then grad-
ually lessened, and finally stopped, to be, after an interval,
resumed.

A year is scarcely sufficient to test the influence of bella-
donna, and if in the succeeding year some improvement fol-
lows, the treatment is to be maintained for two, three, and
four years (l.c., p. 95). Dr. Trousseau, however, in prac-
tice seems to have adopted a mixed treatment, giving bella-
donna in the morning, with the nitrate of silver, the sulphate
of copper, or the lactate of zinc, in the evening, alternating
these last every ten days. The following are his modes of ad-
ministration:

&. Argenti Nitratis, gr. ij.; Pulv. Acacia, Aque distil.
aaq.s. Div. in pil. x. One every night. Or,

&. Cupri Sulphatis, gr. xx.; Pulv. Sacchari, 3j. Div. in
pil. xx. Two every night. Or,
EPIPLEPSY AND HYSTERO-EPILEPSY. 147

R. Zinci Lactatis, 3j.; Pulv. Sacchari, 3ij. Div. in
pil. xx. One every night. Or, the zinc may be made into
pills with the conserve of roses. /

Within the past ten years the bromide of potassium has
been largely used in epilepsy, and the testimony to its utility
in the disorder is uniform and strong. Dr. C. B. Radcliffe
writes:—“ In the summer of 1858 I began to give this medi-
cine almost promiscuously in cases of epilepsy and epilepti-
form disorder, and from that time to this (864) I have been
continually finding fresh reasons for persevering in the prac-
tice. . . . The conclusion at which I have arrived is,
that bromide of potassium is the only remedy in epilepsy up-
on which most dependence can be placed.” ‘The late Dr.
Bazire, in a note to his translation of Trousseau’s Clinical
Lectures, speaks thus of the experience of the physicians of
the Hospital for the Epileptic and Paralyzed in London,
and of his own, with this remedy:—“ The results obtained
are such as to warrant the conclusion that it is infinitely
superior to all other remedies that have been recommended
against epilepsy. It is certainly far superior to belladonna
in its power of diminishing the frequency and severity of
epileptic attacks and epileptiform seizures in general; nay
more, of warding off the attacks, lengthening the intervals
between them, and, in some cases, of bringing on a cure”
The most recent, and a very high authority, Dr. J. Rus-
sell Reynolds, in his excellent article on Epilepsy (System
of Medicine, Vol. II, 1868), says:—‘‘ Bromidé of potas-
sium is the one medicine which has, so far as I know,
proved of real service in the treatment of epilepsy. In large
-doses it has scarcely ever failed to give much relief. Given
in doses ranging from ten to thirty grains, three times daily,
it has had these effects:—In some cases it has completely
cured the patient, and the cure has been permanent for
years, and is so now. In others it has arrested the attacks,
so that none have occurred for periods varying from a few
months to two or three years; but on the omission of the
medicine the seizures have returned. In such cases the at-
tacks have again ceased on the readministration of the medi-
cine. Ina third series of cases it has diminished the fre-
quency and severity of the seizures, but has not removed
them altogether; the patients, while taking the bromide,
have had one-half or one-third the number of fits to which
they were habituated. Such patients have gone back to the
old frequency of recurrence when the drug has been omitted,
148 EPILEPSY AND HYSTERO-EPILEPSY.

and have again improved when it has been readministered.
In a fourth. but very much smaller number, it has been good
for a time, and then has appeared to cease; and in a fifth,
and yet smaller proportion, it has been apparently with-
out any appreciable effect. . . . It is to be demon-
strated that there is yet something ‘specific’ in the
action of bromide of potassium.” Dr. Voisin, of the
Salpetriere Hospital says, that it does not cure absolutely,
but diminishes the disorder in a marked degree, lessening
and even suppressing the nervous erethisin (Bul. de
Thérapeutique, 1867). Dr. Edward Fox reports fifty-two
cases in which bromide of potassium, in not less than twenty-
grain doses, was found “satisfactory,” and ten cases in
which it wholly failed, in one of which belladonna was more
successful (St. George’s Hospital Reports, Vol. II., 1867).
Dr. Brown Séquard, than whom few have had as large ex-
perience in this disease, began to use the bromide of potas-
sium in large doses towards the end of 1860. He writes:—
“T was soon led to associate the iodide of potassium with
the bromide: and it became almost at once evident that, in
most cases of epilepsy (whether idiopathic, symptomatic, or
sympathetic, but especially in that form, which is much more
common than it is admitted to be, in which that convulsive
affection is allied with or due to, a congestion of the base of
the brain or its meninges), these two remedies did more good
than either of them alone. By the end of 1861, after I-had
ascertained that the bromide of ammonium has a special
therapeutic influence in cases of congestion of the medulla
oblongata, and of the upper parts of the spinal cord, I began
to associate that salt with the bromide and iodide of potas-
sium in the treatment of epilepsy. . . . That mode of
treatment has been submitted to an extensive trial, which
leaves no doubt as regards its superiority. Although cer-
tainly it does not often cure permanently, it usually di-
minishes considerably, the violence and the frequency of the
attacks, and is much more successful than the various modes
of treatment by the best remedies against epilepsy, such as
atropine or belladonna, the sulphate of copper, the nitrate of
silver, strychnine, valerian, zinc, digitalis, or the means of
counter-irritation by applications of ice, moxas, croton oil,
&c., on the spine or head”’ (Lectures on the Diagnosis and
Treatment of Functional Nervous Diseases, 1868, pp. 81,
82). His usual prescription is:—

. -Potassii Iodidi, 3j.; Potassii Bromidi, %j.; Am-
EPILEPSY AND HYSTERO-EPILEPSY. 149

monii Bromidi, 3 ijss.; Potassee Bicarbonatis, Dii.; Infus.
Calumbe, f 3 vj. M.

A teaspoonful before each of the three meals, and,three
teaspoonfuls at bedtime, in a little water.

Dr. Ayer and others have preferred the sodium salt in-
stead of the potassium salt, as it does not seem to have the
same depressing effect on the cardiac muscle in large doses
as the iodide of potassium has. It may be given in from 10
to 30 grains three times a day. Dr. James Ayer’s mode of
prescription is as follows:—

B. Sodii Bromidi, Iodidi Bromidi, Ammonii Bromidi,
aa Ziii., Potassii iodidi, Ammonii iodidi, aa 3 ss., Am-
moniz sesqui-carbonatis, 31; Tincture Calumbe, f 3 iss;
Aque distillata, ad. % vili.; misce.

The full dose of this compound is a drachm and a half be-
fore each meal, and three drachms at bed-time. At the out-
set the patients are informed that regular treatment must go
on for two years, after which the dose must be left to the
patient’s discretion, when, except for averting threatened
attacks, full doses are no longer advisable. As a tonic,
drachm doses of the following mixture may at the same time
be taken after each meal:—

go Strychniz sulphatis, gr. 1; Acidi sulphurici diluti m

; Aq. distillate, f $ iv.; misce.

“The strychnia may be given in smaller doses to begin with.
In all cases the diet must be carefully regulated (Zond. Med.
Record, March 15, 1878, p. 128).

In syphilitic epilepsy, the iodide of potassium is increased
to five or six drachms. Where the attacks begin with violent
laryngismus, the bromide of ammonium is raised to three or
four drachms, and the bromide of potassium diminished
by two drachms. The following rules have been laid down as
to the use of these remedies:— The quantities of these
medicines to be taken daily should be large enough to pro-
duce an evident, though not complete, anzsthesia of the
fauces and upper parts of the pharynx and larynx, this quan-
tity varying, with the patient’s idiosyncrasy, from forty-five to
eighty grains of the bromide of potassium, and twenty-eight
to forty-five grains of the bromide of ammonium, when only
one of these salts is given, and a lesser quantity of each,
but especially of the ammonium, when given together
(Clymer).

These remedies very rarely produce a good effect in epi-
lepsy without causing an acne-like eruption in the face, arms,
150 EPILEPSY AND HYS'TERO-EPILEPSY.

neck and shoulders ; and there seems to be a positive rela-
tion between the intensity of the eruption and their efficacy.
It is important, therefore, when there is no eruption, and also
when it begins to disappear, to increase the dose, unless the
dose given in the twenty-four hours is already so large that any
increase brings on great sleepiness in the daytime, a decided -
lack of will and of mental activity,dulness of the senses, droop-
ing of the head, considerable weakness of the body, and a
somewhat tottering gait. It is never safe for a patient tak-
ing these drugs to be even one day without them, so long as
he has not been quite free from the attacks for at least fifteen
months.

Iron and quinine should be given in epilepsy, unless the
ailment is complicated with anzmia or malarial poisoning,
except, perhaps, in the form of the double salt of the citrate
of iron and strychnine.

A gentle purge every five or six weeks maintains the power
of the bromides (Brown-Séquard, I. c., pp. 84-86).

In night-seizures the bromide of potassium would seem to
have less influence than in day-fits (Duckworth, Williams).

The debilitating effect of the bromides ought to be lessen-
ed by the use of strychnine, arsenic, the oxide of silver,
ammonia, cod liver oil, cold douches or shower-baths, and a
nourishing diet. There is an antagonism between strychnine
and the bromides, and when prescribed together, the dose of
the bromides must be increased.

Dr. E. C. Seguin has also called attention, in the New
York Medical Association, to the evil effects which may fol-
low the abuse or over-use of the various bromides. The
most important of these results are—conditions of-impaired
nutrition, and of nervous atony, which continued for
months or even years ; general debility, with the weak slow
pulse and coldness of the extremities, tendency to stupor,
slight difficulty in speaking, the bromic breath, and acne.
Regarding the method of using the bromide salts in the
treatment of epilepsy and other neuroses, he lays down the
following rules :—(1.) The prolonged use of bromides is
contraindicated by congenital feebleness, but they are all
borne by persons of fairly full habit, and good nervous pow-
er. (2.) The bromides are indicated in cases of abnormally
great irritability of the nervous system in its motor (muscu-
lar and vaso-motor) and ideational tracts ; (3.) These con-
traindications are to be less regarded in the management of
that formidable neurosis, epilepsy. (4.) Epilepsy is to be
EPILEPSY AND HYSTERO*EPILEPSY, « 15t

regarded as the only disease which justifies the deliberate
production of a degree of bromism for its cure.

Dr. Seguin’s method of prescribing the bromides in the
treatment of a case of “idiopathic” epilepsy is the follow-
ing. Two solutions are employed.

BR. Potasii bromidi, %i.; Ammonii bromidi, 3 ss. Aqueze
fontanze, 3 vij.; misce: to be given by the teaspoonful ; and,
B. Sodii bromidi, 3 i.; Ammonii bromidi, 3 ss.; Aque font.,

% vij.; misce: to be given by the teaspoonful.

The quantity administered is to be so divided as to give by
far the largest dose in the evening. The bromide is to be cau-
tiously increased, still keeping the nocturnal dose the largest,
until slight bromism is produced; whichis usually necessary to
be maintained for months, but just as littleis to be given as may
prevent the attack. The precise quantity required must be
studied in eachcase. Children tolerate the bromides, as well
as the iodides, in relatively large doses. It is of importance to
thoroughly dilute the bromides in order to facilitate their ab-
sorption—the dose to be taken in a wineglassful or half a
tumblerful of water. Under no circumstances should the
bromides be discontinued; they may be diminished, but not
stopped entirely ; they should be continued at least three
years after the last attack. The adjunct treatment consists
in the use of measures to prevent the acne to a certain ex-
tent, such as the occasional use of arsenic, sulphur-ointment,
mercurial plaster, alkaline lotions ; to correct the general de-
bility of slight paresis, by the use of strychnia, nux vomica,
oxide of zinc, and quinia: to relieve the dizziness by the in-
halation of nitrite of amyl, by stimulants, and quinia; reg-
ulating the patient’s diet and hygiene, and the use of cream,
cod-liver oil, iron, quinine, phosphorus, strychnia, with nitro-
muriatic acid. In certain cases such medicines as acted more
directly upon the morbid state of the nervous centres were
associated with the bromides, and favorite among these was
belladonna (London Medical Record, June 15, 1877, p. 221).

Picrotoxine has been found to possess anti-convulsive prop-
erties. It was originally recommended by Dr. Crichton
Browne in the treatment of epilepsy, and his experiments
have been recently confirmed by Planat.

Clinical familiarity with epilepsy, and a history of its the-
rapeutics go to show that there are no grounds for belief in
any specific against this affection, and the physician who
promises a cure, or even relief, by mearis of any one remedy in
this disorder, runs the risk of damaging not only himself, but
152 EPILEPSY AND HYSTERO-EPILEPSY.

his art. It cannot, however, be doubted, that, in a certain
number of cases of epilepsy not apparently caused by any
coarse cerebral lesion, the severity and frequency of the
seizures may be greatly abridged, so that the sufferers may
be brought to enjoy often a great degree of immunity and
‘-comfort. The proportion of such cases to the whole num-
ber afflicted is, perhaps, few, but it is still sufficiently numer-
ous to give hope and encouragement to further trial. Such
results, however, can only be surely gained by means which
will increase and develop the vital power generally. It should
be borne in mind that tonic treatment does not alone consist
in the administration of a tonic drug. Whilst many cases of
epilepsy demand the use of tonic medicines to fulfil certain
present indications, they should in no sense be looked on as
acurative, or even remedial, but only as adjuvants. and when
they have done their work should be laid aside. Of this
class of remedies none, perhaps, is more valuable than arse-
nic, given in minute doses. Where there is anemia, iron or
manganese is required. But a general restorative system
must be adopted and persevered in.

The diet of the epileptic should not consist of much meat
{nor much nitrogenized food), nor much of anything. It
ought to be spare diet—simple and unstimulative, and to
the absolute exclusion of alcohol. After a prolonged inves-
tigation on the influence of diet in epilepsy, carried on at
the West Riding Asylum, by Dr. John Merson, he came to
the conclusion that a farinaceous diet is likely to be more
useful in the treatment of epilepsy than a nitrogenous one
(West Riding Lunatic Asylum Reports, Vol. V.,p 1). The
food should contain, as soon as the state of the digestive
organs will permit, a certain portion of fatty and oily con-
stituents, and in most cases cod-liver oil may be given with
advantage. The hypophosphites, as a vehicle for the intro-
duction of phosphorus into the system, would seem to be
of service in improving the general nutrition.

The maintenance of the activity of the cutaneous function
is of the first importance. In the beginning an occasional
vapor or hot-air bath may be taken ; afterwards tepid salt or
fresh-water baths, followed by a general grooming of the
skin. Exercise in the open air, gymnastics, both measured
by the strength of the patient, are to be insisted upon, as
well as such means as will promote the expansion of the
lung tissue. With physical training, mental and moral train-
ing should be combined.
EQUINIA““ERYSIPELAS. 153

Such are the general principles of the rational or restora-
tive treatment of epilepsy, which, it is believed, will give a
larger measure of success than a reliance upon any one of
the innumerable specifics that have had questionable and
temporary repute. If a successful issue is to be had, per-
severance and confidence, both on the part of the physician
and the patient, are chief conditions of success, and this
should be fairly stated at the outset to the sufferer and his
friends.

Ice applied to the cervical spine has caused the severe
paroxysms of hystero-epilepsy to cease (Gowers).

Equinia—See Glanders.

Equinia Mitis.—Defnition.—A pustular eruption, pro-
duced by the contagion of matter from a horse affected with
the grease.

Treatment.—The greatest relief to the constitutional dis-
turbance is obtained by frequent purgation with aloes com-
bined with ammonia, and such moist local applications as
may relieve pain.

Ergotism.—Definition.—A train of morbid phenomena
produced by the slow and cumulative action of a specific
poison ina fungus peculiar to wheat and rye, and which
gives rise to convulsions, gangrene of the extremities, and
death, or to symptoms of ill-health.

Treatment.—Considerable differences of opinion prevail
regarding the treatment of this dietetic disease. The cause,
in the first instance, must be ascertained and removed ; and
to obviate the effects it has already produced, the constitu-
tional treatment must be directed to improve the state of the
blood. Tonics and stimulants are to be administered, after
afree employment of evacuant remedies, to clear out the
alimentary canal completely. The chlorates of potash and
of soda, with antispasmodics, tonics, and narcotics, are
especially indicated. Camphor, musk, ammonia, capsicum,
may be particularly mentioned ; and the strength of the
patient is to be supported by light, nourishing and whole-
some food.

Erysipelas.—- Definition —An acute febrile disease, char-
acterized by a peculiar inflammation of the integument, tend-
ing to spread indefinitely, and even to involve the areolar
tissue beneath the skin. It is accompanied by severe gen-
eral symptoms.

Treatment.—“ Experience has proved that general bleed-
ing has no other effect than to blanch the eruption, without
154 ERYSIPELAS.

notably abridging its duration ;” and from the nature of the
disease blood-letting in any form is not to be thought of.
Rest, saline laxatives, cooling drinks and low diet are the
elements of treatment in mild and simple cases. An emetic
is useful at the commencement; and I have seen, in the
practice of an eminent surgeon (Mr. Syme) that frequent
resolution of an erysipelatous attack has followed an antacid
laxative, such as forty grains of rhubarb to sixty of bicarb-
onate of soda, divided into twelve powders, one to. be taken
every six hours, together with the counter-irritation of a
mustard poultice over the stomach. Laxative and cathartic
remedies are to be selected and apportioned according to the:
violence of the attack and its nature, as tending to the un-
favorable results of the specific inflammation already noticed.
Calomel is a most valuable purgative, as a sedative in febrile
disturbance, especially when followed by castor-oil, or the
common black draught. The indications to the use of cer-
tain remedies, as given in the treatment of scarlet fever, are
equally applicable here. If the febrile state is not subdued,
antimonials are of great service ; and so far as they are diapho-
retic in their action they tend to subdue the vascular ex-
citement. If symptoms of nervous depression ensue, opium,
or opium and ipecacuanha are indicated, also wine and quin-
ine, ammonia and camphor, in asthenic cases with a tendency
te a typhoid state. The tincture of the perchloride of iron,
in doses of ten to thirty minims, three, four, or five times a
day, in water, infusion of quassia, or calumba, is now also a
remedy much in use, and it may be alternated with the syrup
of the phosphate of iron,in doses of a teaspoonful three or
four times a day. In cases where the system is obviously
gouty or rheumatic, and where the joints are affected, col-
chicum with saline diaphoretics are the most efficient reme-
di&l agents. Local applications are potent for good or evil,
and must therefore be used with great caution. The effects
seen on the skin do not constitute the whole disease ; and if
the development of these processes on the cutaneous tissue
is imprudently interfered with, there is imminent danger to
internal organs. To check the advance and prevent the en-
croachment upon new territory, rather than to subdue it, if
already in possession, ought to be the sole aim of local treat-
ment, and to mitigate the local pain and uneasiness. Bland
mucilage, such as that of viscid linseed tea, from which light
muslin cloths have been steeped and spread over the inflamed
surface, sometimes affords relief. Dry flour, or rye-meal,
ERYSIPELAS, 155

frequently dusted from a dredge-box over the erysipelatous
patches, are soothing applications. A thick layer of cotton-
wool dusted with tutty powder is also a soothing application
to the part. A lotion of nitrate of silver painted daily over
the affected parts sometimes gives great relief (one scruple
of the nitrate to an ounce of water, to which ten drops of
dilute nitric acid are added). Dilute nitric acid should, at
the same time, be given internally, if typhoid symptoms pre-
dominate, as in the following formula :

yj: Acid. Nitrici dil, 3i.; Syrup. Zingib., 3ss.; Aquz,
% vss.; misce. A tablespoonful every four hours.

To arrest the spread of the process over sound skin, ni-
trate of silver in very strong solution, or tincture of iodine
have been considered efficient agents. <A line of circumval-
lation is to be painted round the erysipelatous part, so as
completely to enclose it. The nitrate of silver should either
be employed in the solid stick; or as proposed by Higgin-
botham, in solution of eight scruples of the nitrate with
twelve drops of nitric acid in a fluid ounce of water. Dr.
Wood has practised with success and recommends the use of
tincture of iodine. But in this country the boundary line
of nitrate of silver has not been attended with success ; and
our best surgeons are now discontinuing the practice as a
useless source of irritation (Erichsen, Campbell De Morgan).
Sulphite of soda, in solution of ten grains to one ounce of
water, is recommended by Dr. Addinell Hewson, of Phila-
delphia. He has never seen it fail to arrest the progress of
the disease, if it has not advanced to the deeper parts below
the skin. Lint soaked in the solution is to be applied to the
affected part, and over a considerable distance beyond any
visible appearance of redness. The lint is to be covered
with oil-silk, to prevent evaporation. The application of
sulphate of iron as a lotion or ointment tends to shorten the
disease. In lotion, one drachm of the salt to a pint of
water ; in ointment, a scruple to an ounce of lard (Velpeau,
Luke, De Morgan). It has the inconvenience, however, of
soiling linen with which it comes in contact. None of these
lotions should be applied cold, but tepid or warm. Collodion
and iodized collodion are also worthy of commendation.
Long and deep incisions into the inflamed textures are some-
times demanded. This is more especially the case if there
be tension of fibrous tissue, such as the subcutaneous
fasciz ; and erysipelas of the head is frequently greatly
alleviated by repeated innumerable minute punctures, made
I 56 ERYTHEMA-—FEVER, REMITTENT.

by the point of a lancet all over the parts of the face and
scalp which are affected.

Erythema.— Definition. Uniform redness simply, with
puffiness of the skin, distributed in distinct patches of some
size,

Treatment.—Rest, quinine, and iron, after aperients ; car-
bonate of ammonia, after gentle purgation, in doses of 5 to
10 grains three times a day, are the most useful remedies.
Oxide of zinc, in fine powder, dusted over the surface, will
sometimes allay the local irritation.

Favus—See Tinea Favosa,

Febricula.— Definition—A simple fever in which the
expression of the febrile phenomena is of very short dura-
tion, lasting, as a rule, for noi more than twenty-four, thirty-
six, forty-eight, or seventy-two hours, attended with a fre-
quent, full, and often firm pulse, white and coated tongue,
pains in the loins and limbs,. thirst, constipation, a scanty
discharge of high-colored ‘urine, hot and dry skin, sometimes
an eruption of roseola or erythema about the loins or thighs,
coming and disappearing with the fever (Morehead) ; severe
headache, sometimes acute delirium, and flushed face. The
subsidence of the fever is generally associated with copious
perspirations, or herpetic eruptions.

Treatment of Febricula—Such means as emetics, purga--
tives, tepid sponging, diaphoretics, and antiphlogistic regimen
are to be employed. In plethoric individuals, where there is
much headache and flushing of the face, leeches to the tem-
ples may be expedient, but such remedies are not often
necessary (Morehead).

Fever and Ague.—See Ague.

Fever, Break Bone—See Dengue.

Fever » Cerebro-Spinal—See Cerebro - Spinal Menin-
gts.

Fever, Dandy— See Dengue.

Fever, Enteric—See E£uteric Fever.

Fever, Intermittent— See Ague.

Fever, Malignant Purpuric—Scee Cerebro-Spinal Men-
ingitts.

Fever, Puerperal—sSee Puerperal Fever.

Fever, Relapsing—Sce Relapsing Fever.

Fever, Remittent— See Remittent Fever.

 
FEVER, RHEUMATIC—-GASTRITIS. 157

Fever, Rheumatic— See Rheumatism, Acute.
Fever, Typhoid— See Enteric Fever.
Fever, Typhus—Sce Zyphus Fever.

Fever, Yellow—See Yellow Fever.

Gall-Bladder, Inflammation of.— Defixétion.—Inflam-
mation, generally catarrhal, -but occasionally croupous or
diphtheritic, of the mucous membrane of the biliary pas-
sages.

Treatment is similar to that of catarrh of the intestines,
and especially in the use of nitro-muriatic acid internally and
as baths.

Gall-Stones— See Colic, Biliary.

Gastritis.— Definition.-F orms of inflammation tending to
exudations and destruction of parts, cr condensations of tis-
sue, especially about the pyloric opening.

Treatment.—Emetics may be required in cases where the
stomach has been overloaded; and it is certain, from the
gases‘and fluids causing prominence over the stomach, that
it contains decomposing food. One scruple of ipecacuanha,
with one grain of tartrate of antimony, is tne safest and most
efficient emetic. When injurious matters have passed into
the bowels, causing flatulence and colicky pains, mild laxa-
tives may be required, such as rhubarb; or, compound infu-
sion or mixture of senna, or fluid magnesia, in small doses,
may be given every hour or two hours, followed by five or
ten grain doses of bicarbonate of soda. Inchronic or passive
congestion of the stomach, and in chronic gastritis, the ad-
vantage of nitrate of silver has been advocated by the late
Drs. James Johnson and Symonds, and more recently by
many other physicians. Argent. Nitrat., gr. 3, Ex. Hyoscyam.,
gr. ii. to gr. iv., made into a pill, may be continued every
night, the quantity of the nitrate being gradually increased
to two or three grains daily. It may not becontinued, how-
ever, beyond six or eight weeks. Or Argent. nit. Crystal,
gr. ss. to gr. i, Aq. distilat., f 3 ss; may be taken at bedtime—
the stomach being empty——and repeated every night, orevery
second, third, or fourth night, according to the severity of the
gastric symptoms. I have found Seller’smixture of Bismuth of
great advantage;and alkalies combined with morphia. In cases
of acute gastritis, mercurial purgatives by calomel are of ser-
vice. Three to five grains may be given to an adult; followed
by a dose of castor-oil or the compound senna mixture of the
158 GLANDERS—GLOSSITIS.

pharmacopoeia. Where it is not desirable to act so search-
ingly on the small intestines, blue pill with compound colo-
cynth or rhubarb pillin equal parts (@ @ gr. ii.), combined
with one grain of ipecacuanha powder, is a mild and gentle
laxative. Iced water to drink in small quantities, or small
pieces of ice in the mouth, tends to allay thirst, and to ap-
pease pain; and the continuous use of hot water fomenta-
tions over the region of the stomach, as hot as the patient
can bear them, is of great benefit (Brinton).

Glanders.—De/finition.-A specifie catarrhal inflamma-
tion of the nasal mucous membrane, produced by the conta-
gion of matter from a glandered horse, and intercommuni-
cated between men and horses. It is a febrile disease of a
malignant type, characterized by vascular injection of the
nasal mucous membrane, from which an aqueous, viscid,
glutinous, or purulent discharge proceeds. Chancre-like
sores are formed on the mucous surface of the mucous mem-
brane extending to the frontal sinus and neighboring mucous
surfaces. Thelymphatic glands enlarge in the vicinity of
these mucous membranes.

Treatment.—All the remedies hitherto tried in acute glan-
ders have failed. The advent of typhoid symptoms has led
to the administration of quinia, -valerian, serpentaria, am-
monia, and other stimulating medicines. In the more chronic
forms of the disease the recovery of the patient has appeared
to be owing to the excellence of his constitution; during the
natural elimination of the poison, to good ventilation, and to
generous diet, rather than to any effect produced either by
general or local treatment.

Preventive Treatment.—The prophylactic treatment is the
same as that of all other contagious diseases—namely, being
careful to avoid all contact with the morbid poison, espec-
ially when a finger or other part of the hand is abraded; and
if by accident the veterinary surgeon should inoculate him-
self, he ought instantly to destroy the part with potassa fusa.
‘It has been recommended, after the disease has been set up,
to extirpate the enlarged glands; but this practice is as un-
warrantable as hopeless.

German Measles—Sce Measles, German.
Glossitis.— Definitio;;—Inflammation of the tongue.

Treaiment.—Active cathartics are generally of great service,
_ GOITRE, 459

and they are to be given as enemata. Blood must be taken
directly from the tonguc in such cases. Incisions along the
superior surface of the inflamed organ, followed by the action
of the vapor of hot water, may reduce the swelling and re-
lieve congestion. The relief afforded by these measures is
frequently almost instantaneous. Two or three applications
of six leeches at a time to the inflamed parts may produce a
speedy decrease of the tumor (Graves). If suffocation is
imminent tracheotomy or laryngotomy must be performed.
Erythematous inflammation of the tongue with generally
yield to a combination of bismuth in glycerine, such as_bis-
muthi subnitratis, gr. xx,; glycerini, 31,; aque, 3% vi. Of
these make a lotion with which to wash the mouth and
tongue.

Morbid sensibility of the tongue may be soothed by a weak
solution of bromide of potassium, 3 ss. 3i.to 3 vi. of water,
used as a mouth-wash (Symonds.)

Goitre.—Dejinition—An enlargement of the thyroid
gland, by some regarded as specific, and induced by the per-
sistent use of water which has percolated through magnesian
limestone rocks, or strata containing the soluble salts of
lime in salution; or it is regarded as a circulatory disease,
the two-fold blood and nerve supply of the thyroid gland
being favorable to its enlargement under conditions of ex-
cessive and constant muscular exertion.

Treatment.—The: indications are—(1.) To remove from
the district where the disease prevails: (2.) improvement of
the water used as drink; (3.) elimination of the goitrous
poison, or change of constitution. As with the poison of
mercury and of lead, so with goitre, iodide of potassium has
a wonderful effect in subduing the swelling, and probably in
eliminating the poison which produces goitre, whatever that
may be. Iodine has thus acquired the reputation of being
almost a specific against goitre (Coindet, Straub, Gairdner,
Manson, Lugol). In robust subjects it has been advised
that the administration of iodine should be preceded by
general blood-letting, on the principle that the abstraction of
blood favors absorption; but this should not be done unless
the iodine does not seem to be producing any effect; and
whatever may be the preparation of iodine employed, it must
be persevered in for a length of time, and the dose gradually
increased (Dunglison). ‘The best form of administration is
that in which the iodine is mixed with and dissolved by
160 GOITRE.

iodide of potassium. It is then held in solution, and is
sometimes known as Lugol’s solution. It is made by dis-
solving one part of iodine (five grains) with two parts of
iodide of potassium (ten grains), and adding water (to the
extent of one pint). It contains one grain of iodine in four
ounces of the solution. The treatment ought not to com-
mence with a larger dose than one drachm three times a day.
Small unirritating or alterative doses are the most efficient,
and they may be gradually increased when necessary. The
remedy may also be employed externally, in the form of a
liniment or ointment—the unguentum iodum compositum, of
which a small portion may be rubbed upon the swelling night
and morning. In some parts of India the application of an
ointment of the biniodide of mercury has been found effica-
cious. The ointment is prepared by adding finely-
powdered biniodide of mercury to melted lard or mutton
suet or vaseline (in the propo'tion of 15 grs. of biniodide
of mercury to 1 ounce of lard. This ointment is then
applied to the goitre about an hour after sunrise, and is
rubbed in, by means of an ivory spatula, for about ten min-
utes—the patient sitting with his goitre held well up to the
rays of the sun as long as he can bear the exposure. The
ointment may produce a blistering effect, although no vesi-
cles appear on the skin; and in the course of the day it
should be gently rubbed in again, and the patient sent home,
with orders not to touch it with his hands, but to allow the
ointment to be gradually absorbed. A second application is
sometimes necessary in very bad cases. In 1855 no less than
500 Or 600 persons were sometimes treated in a single day ;
and it is estimated that altogether about 60,000 patients have
been so treated ; so that the cases in the district are now far
less numerous than formerly, and the disorder is thus being
extinguished (Mouat, in /udian Annals for April, 1857).
When medical treatment fails, surgeons have attempted to
give relief by one of three operations; but so long as the
disease does not interfere with any of the important func-
tions of the body, nor produce serious discomfort, surgical
interference is not warrantable. These operations are,—(t.)
The introduction of setons through the tissue of the diseased
gland—an operation which has been successful. A thin
double wire is to be passed through the gland, and left there
for a week (Quadri, Tanner, James). (2.) Tying the thyroid
arteries which supply the goitre with blood, and so starving
the tumor, has been attended with varied success (Coates,
GOITRE—GONORRHEAL RHEUMATISM. 161

Brodie, Earle, Wickham). These means having failed (3.)
the gland has been extirpated—an operation which few sur-
geons would now think of undertaking.

Regarding these surgical interferences for the radical cure
of goitre, Sir Thomas Watson observes, that “there is not
one of which the average results have been sufficiently pros-
perous to warrant its repetition, except in cases where life is
put in jeopardy, or made miserable by the swelling; and where
other methods, and particularly the treatment by iodine,
‘have been tried and have failed” (“Principles and Practice
of Physic,” Vol, I, p. 795). He makes, however, an excep-
tion in favor of puncturing any cell or cyst containing fluid,
which sometimes makes up aconsiderable portion of the
tumor. Such cysts may be punctured without much risk,
and with great relief to the patient.

Goitre, Exopthalmic.—DefinitionEnlargement with
vascular turgescence of the thyroid gland, accompanied by
protrusion of the eye-balls, anzemia, and palpitation.

Treatment.—The use of iron and tonics generally are in-
dicated; and the use of digitalis may be indicated in con-
nection with the cardiac symptoms. The indications for
treatment are, to allay the irritability of the stomach by the
use of ice; to give bland, unstimulating, nutritious focd in
small quantities and at short intervals; to producesound and
refreshing sleep by morphia, or any such stimulating sopori-
fic; to administer digitalis; to steady the weak heart and con-
trol its excitement. Iron may improve the state of the
blood; but the hygienic conditions in which the patient lives
are mainly to be rectified (Fletcher). Dr. J. Warburton
Begbie recommended the use of belladonna in combination
with iron (“ Dublin Quarterly Journal of Medical Science,”
Nov., 1865, by Dr. W. Moore).

Gonorrheal Rheumatism.— Definition.—An affection
analogous to acute rheumatism, associated with gonorrhcea.

Treatment—The condition of the digestive organs gener-
ally requires attention and correction. Anodyne fomentation
generally affords relief to the pains of the joints. Dover's
powder is to be given in the acute stage at intervals; and
after the more acute symptoms have been subdued, the
greatest benefit is obtained from blisters, repeated several
times, when effusion within the capsule of the joint -is a
prominent symptom. An elcctuary of guaiacum, sulphur,

11
162 GOUT, ACUTE,

and cream of tartar (in equal proportion) in glycerine I have
found of use. Vapor baths and Turkish baths are both of
great service. The gonorrhcea must be cured as soon as
possible by the usual remedies.

The preparations of iron, iodine, quinine, combined with
ammonia, potass, or soda, in bitter vegetable infusions, ac-
cording to the nature of the urinary symptoms, are the best
tonic remedies, together with fresh air and good diet.
Iodide of potassium ought to be used in the chronic form
of the disease. Pressure over the joint by strips of adhesive
plaster, aided with bandaging from the toes upwards, is often
of great service in subduing the swelling which remains,
after all other symptoms have subsided. Passive motion
must afterwards be used.

Gout, Acute.—Definition.—A specific febrile disorder,
characterized by non-suppurative inflammation, with con-
siderable redness of certain joints,—chiefly of the hands and
feet, and (especially in the first attack) of the great toe; at-
tended by excess of uric acid in the blood, and probably
also of phosphoric acid. The constitutional affection tends
to culminate, at longer or shorter intervals, in a paroxysm,
or “ fit of the gout,” when various joints, textures, or parts
of the body are apt to become affected.

Treatment.—Seeing that the disease is clearly of constitu-
tional origin, its treatment resolves itself into—(1z.) The
selection and administration of those remedies which shall
tend to subdue, control, or eradicate the latent disposition,
constitutional tendency, or gouty diathesis; (2.) The adop-
tion of such means as may be safely used to modify the
severity of or shorten the paroxysms. ‘The paroxysm must
be interfered with cautiously. It is the means which,
nature takes to rid the constitution of the materies morbt,
and which it undoubtedly relieves for a time, if allowed to
runits course. But the removal of the paroxysm, or its
subsidence, does not necessarily remove the constitutional
diathesis. That must be modified by promoting the trans-
formation of the tissues of the body as much as possible in
a healthy way. As to any local treatment during the fit,
Sydenham writes, “If outward applications be required to
ease the pain of the gout, I know of none, though I have
tried abundance both on myself and others, and I have laid
aside the use of topical remedies for many years.” It is
generally admitted that cold is dangerous, while warmth is
GOUT, ACUTE 163

productive of little relief. - In some instances the urate of
soda is deposited in such quantity that the skin ulcerates,
and the salt is discharged in considerable abundance in a
fluid state. It might appear the right practice to apply a
poultice and encourage the discharge, in order that, by its
entire-removal, the.joint might be saved. This, however, is
by some considered dangerous practice, for the discharge is
so debilitating that patients are said to have sunk under this
mode of treatment. It is much safer to wait till the chalk-
stone becomes concrete, and then operate, by the smallest
possible incision, for its removal.’ With respect to the use
of cold water, the practice is as old as Harvey, and subse-
quently it has been adopted and abandoned by many prac-
titioners, Dr. Parry had at one time two patients who at-
tempted to cut short the fit by plunging their feet in cold
water. The relief was instant, but in a few hours both were
dead of apoplexy. The fatal result of this remedy in Sir
Francis Burdett’s case is another instance in point. “A gen-
tleman,” writes Dr. Wood, “ contrary to the advice of his
physician, and anxious for speedy relief, ordered a bucket
of water to be taken into his chamber at bedtime, with the
view of employing it in this way. In the morning he was
found dead in bed.” ;
Antiphlogistics neither alleviate the pain of gouty inflam-
mation nor shorten the attack ; while their untimely use, es-
pecially general and local bleeding and active saline purges,
favors the passage of acute into chronic gout. Rest is ab-
solutely necessary. Warm anodyne lotions or fomentations
may be used, and the part afterwards lightly covered or en-
cased in flannel or fine wool, while the limb is at the same
time kept elevated. The “bootikins’”” of Horace Walpole,
so strongly recommended and given away by him to all his
gouty friends, seem to have been merely a fine bandage of
flannel, applied moist and firmly over the limb, and then a
roller of oiled silk over it, giving moist warmth like a poul-
tice. Writing to Horace Mann, he says,—‘‘ You must put
them on at night, and tie them as tight as you can bear—the
flannel next to your flesh, the oil silk over. In the morning,
before you rise, you must dry your feet with a hot napkin,
and put on a pair of warm stockings freshly aired. Over the
bootikins at night draw a pair of thread stockings” (“ Life
and Letters, Vol. VII., p. 224). Dr. Wood uses a warm
mixture of tincture of camphor with milk, applied by means
of linen compresses, and frequently renewed. Tincture of
164 GOUT, ACUTE.

aconite may be similarly applied (f 3 iss. to f Ziv. of milk).
The hypodermic injection of a fourth to a third of a grain
of muriate or bimeconate of morphia, in any convenient part
of the body, often relieves the local pain, Blisters have been
recommended, and are of most advantage in asthenic chronic
cases, when the inflammation has a tendency to linger in the
articulations, and to cause liquid effusion. In the early fits
of sthenic gout they are unnecessary ; and are contraindi-
cated in advanced gout, when the kidneys have become im-
paired, and also in cases of extreme gouty deposits (Garrod).
As a general rule, however, the less that is done to the local
affection the better. When the pain is very intense, relief
may be given by the application of a solution of atropine,
made by dissolving from two to three grains of the alkaloid
in a weak mixture of spirits and water, and applying it to the
inflamed joint by means of compresses of lint, preventing
evaporation by a covering of oil silk (Garrod).

In the general treatment of gout bleeding is now generally
restricted to two methods, namely—(1z.) By leeches to the
part where the inflammation rises so high, or is so chronic,
as to threaten the patient with the permanent loss of the use
of some joint ; and to cases of metastasis of the disease to
the stomach or other internal organ, when leeches are abso-
lutely necessary ; (2.) By general blood-letting. The fol-
lowing rules are laid down by Dr. Garrod as to the use of
bleeding in. gouty cases :—(1.) Never bleed with the idea of
directly subduing gouty inflammation ; (2) Never bleed in
advanced gout, or when the constitution is much weakened;
(3.) If bleeding be required in order to relieve general or
local plethora, abstract only as much as will effect that ob-
ject, remembering that further depletion tends greatly to ag-
gravate the disease and prolong its duration. Blood-letting
produces a decided sedative action on the heart and other
parts of the circulating system, and it has a most powerful
influence upon the progress of gouty inflammation—an influ-
ence not merely limited to the removal of gout when it at-
tacks the joints, but also of great efficacy in its marked and
irregular forms, in the ophthalmia of gouty habits, in gouty
bronchitis, and in headaches connected with the gouty dia-
thesis (Sir H. Holland, Garrod).

With regard to purgatives, Sydenham, who was as great
an enemy to purging as he was to bleeding, says,—“I am
abundantly convinced, from much experience, that purging,
either with mild or strong cathartics, whether used during
GOUT, ACUTE. 165
t

the fit or in its declension, or in a perfect intermission or
healthy state, .*. . endangers the life of a patient by
hurrying on the disease to the viscera, which were quite safe
before.’ The objection taken by Sydenham to purgatives
was quite valid against those in use in his day, which were
of the most drastic kind; but it may be laid down as a rule
that neutral salts are not ‘only safe but efficient in relieving
gout, though perhaps not to be depended on alone for its
cure. The theory on which they are prescribed is, that the
alkaline base of the neutral salt is absorbed, and combines
with the insoluble urates deposited in the joints, forming a
soluble sub-urate, which can readily be absorbed; and,
again, more alkali being sent to the kidney, that organ is en-
abled to remove more uric acid, in a soluble state, from
the system than under ordinary circumstances. The salts
most in use are the sulphates of magnesia or of soda, and
especially the former ; and half adrachm to a drachm should
bé given every eight, six, or four hours, according to the
state of the bowels and the acuteness of the symptoms. It is
also necessary to afford some relief to the patient from his
excessive suffering. With that view an anodyne should be
added, such as the tincture of hyoscyamus, syrup of poppies,
or some preparation of opium. This method of treatment
relieves the patient and shortens the paroxysm; but when
the relief is complete, it should be abandoned, for sometimes
a paroxysm of gout will return even under its use. Colchi-
cum, or meadow-saffron, was long ago introduced as a spe-
cific in gout, of which the once popular “eau medecinale”

was supposed to be a preparation. Colchium in some cases
seems to be almost specific in its effects, and may be given
as an extract or tincture, or as a wine, combined with some
form or saline draught. Its mode of action is unknown, It
very generally promotes secretion from the skin and kidneys;
but it is useful even when it does not exercise any such
physiological action. The quantity of uric acid and urea in
the urine is said by some to be increased during its use
(Chelius). Dr. Graves makes an opposite statement ; and
Dr. Garrod proves conclusively that colchicum does not in-
crease the amount of uric acid. Dr. Laycock suggests that
it may have a sedative effect on the vital actions going on
in the tissues themselves, and so may arrest the formation of
the gout poison. The wine of the root of colchicum is gen-
erally the form preferred, ten to fifteen or to thirty minims
being given every four, six, or eight hours, and this remedy
166 GOUT, ACUTE.

ought to be continued for some time in reduced doses, after
all symptoms of gout have disappeared (Budd). The bowels
ought to have been freely moved before colchicum is given ;
and a full dose having been given at first, much smaller
doses may be continued, as from ten to twenty minims two
or three times a day, in Seltzer or Vichy water, or in other
alkaline solutions, such as bicarbonate of potash much di-
luted, or combined with iodide of potassium, carefully
watching its effects on the pulse, and never allowing sick-
ness or depression to ensue. It may also be given with car-
bonate of lithia. Scudamore’s mixture of colchicum, mag-
nesia and sulphate of magnesia, is said to be an excellent
purgative in gout when a purgative is required. Although
Dr. Garrod has shown that, purging is not necessary to the
action of colchicum, yet, there are many who believe that
the action of colchicum is promoted by its combination with
laxative remedies. Abernethy was wont to prescribe,—

BR Sodz phosphatis ; Sod sulphatis—aa 3 iv.; Ammo-
niz sesqui Carb., 3ss.; Acid benzoici, gr. xx.; Vin. sem.
Colchici, 3 iss ; Infus.’ Calumbe, ad § viii., of which a sixth
part is to be taken every four or six hours.

Dr. Wood is in the habit of using it in the following for-
mula in a draught :—

B Magnesiz, 3ss.; Magnes. Sulphat., % ss. ; Vin. Col-
chici. rad., m xx. ; Aque Fluv. vel Aq. Acid Carbon., f % iss.

Mercury in the form of “ blue pill,’”’ or in the form of the
“ compound calomel pill” (Pil. Plummeri), followed by the
draught just written, is useful where it is desired to act upon
the intestinal secretions. But mercury in any form must not
be given if the urine contains albumen. If mere constipa-
tion is to be got rid of, rhubarb pill, colocynth and scam-
mony pill, or podophyllin, may be advantageously used.
The iodide of potassium has been much recommended by
Mr. Spencer Wells. Alkaline remedies are of much value
in the treatment of the paroxysms of the joint affection, and
may be prescribed in the form of the bicarbonate, or of the
citrate or acetate of potash. Dr. Garrod prefers the bicar-
bonate, and Dr. Parkes has shown that it increases the elimi-
nation of uric acid and organic solids by the urine (Parkes
on the Urine, p. 298). Much benefit is also derived from
the continuous administration of salines in small doses, re-
peated two or three times a day, in a very dilute form, and
always on an empty or nearly empty stomach, and some lit-
tie while before food (Garrod). If acute gout should have

!
‘GOUT, CHRONIC, 167 |

“ yetroceded,” as it is called, and the stomach or intestinal
canal be inflamed, leeches should be applied to the abdo-
men or epigastrium, followed by a poultice, while the neutral
salts, with the tincture of hyoscyamus, should be given at
least every four or six hours. It is very rare that more act-
ive medicines are necessary.

For further indications regarding the management of gout,
see treatment of the next subject—namely, chronic gout.

Gout, Chronic.— Defuition.—A persistent constitutional
affection, characterized by stiffness and swélling of various
joints, with deposits of urate of soda.

Treatment.—In chronic gout the treatment is the same as
in acute gout; but, as next to hereditary predisposition, a
disproportion between the amount of food and drink taken
and the necessity for it, is a great cause of the disease, means
ought to be taken to regulate the diet and promote healthy
metamorphosis of tissue during intervals of freedom from
gouty paroxysms. The habits of the patient ought to be
regulated by written rules for him to abide by, if he would
be free from gout. The form, the quantity, and the quality
of the food ought to be precisely prescribed. Most gouty
patients eat too much, Vegetables, with soups and meat,
must be allowed only once a day—not oftener. Beer, wine,
and alcoholic fluids generally are injurious, and must be for-
bidden to gouty patients, as they retard the metamorphosis
of tissue. The same is true of tea and coffee. Water, pure
water only, taken in quantities as large as possible, promotes
the metamorphosis of tissue to a greater extent than any
remedies we know of. The drinking of a certain extra quan-
tity of water is essential for the maintenance of health in
gouty patients. It ought to be taken in the early morning—
to the extent of half a pint while dressing in the morning—
and before any solid food is taken. Its use does not lessen
appetite for food—as is the case with beer, wine, spirits, tea,
and coffee. It promotes the flow of fluid by the kidneys,
and increases the excretion of urea. Combined with muscu-
lar exercise, the use of pure water hastens, to the greatest
possible extent, the transformation of tissue ; and combined
with the use of certain mineral waters and baths, a connect-
ing link is established between the dietetic and medicinal
treatment of gout. Whenever an excess of lithic acid or of
lithates is seen in the urine, some alkaline water should be
taken in the morning, instead of plain water; and enough
should be taken to render the urine clear and free from de-
168 GOUT, CHRONIC.

posit. But strong alkaline waters are not to be prescribed
in large quantities, else too great depression and a tendency
to impair the digestive power of the stomach will be the re-
sult. In moderation, the milder alkaline waters taken as a
morning draught are of value. The mineral springs which
exercise the most favorable influence on the gouty constitu-
tion are those of Aix in Savoy, Bath, and Buxton, Ems, Gas-

. tien, Homburg, Karlsbad, Kissengen, Marienbad, Neuenahr,
Pfaffers, Schwalbach, Pyrmont, Spa, Toplitz, Wiesbaden,
Wilbad; and Vichy. Dr. Garrod lays down the following
general rules as a guide to the use of them :—(1.) Their use
should be prohibited when there is much structural disease
in any important organ, especially in the heart or kidneys ;
and even when organic mischief is slight, the greatest caution
in their use is necessary. (2.) They are to be avoided when
an acute attack is either present or threatening. (3.) The
particular mineral water must be selected according to the
nature of the individual case; for the robust, and those of
full habit, the alkaline saline springs should be chosen ; when
torpidity of the bowels predominates, the purgative waters
may be used; when the skin is inactive the sulphur springs
should be used, and when much debility prevails, or an atonic
state exists, then the more simple thermal springs may be
prescribed.

These waters contain either alkaline carbonates, chlorides,
or sulphates. Some are impregnated with sulphurated hy-
drogen, and others contain iron; many, like Wiesbaden,
Karlsbad, and some of the Vichy springs—Wildbad and
Neuenahr—are of an elevated temperature.

The beneficial influence of these natural mineral waters is
especially perceptible in the reduction of plethora by the al-
kaline springs, and in the regulation of the functions of the
bowels and skin. The springs of Vichy are all rich in car-
bonate or bicarbonate of soda—about forty grains to the
pint. Some have a temperature of 101° Fahr. In moderate
doses they cause the urine to become alkaline or neutral;
and used as baths, they have a similar effect. They influ-
ence especially the functions of the liver and the skin, and
are more adapted for the robust and persons of full habit of
body ; but if the system is enfeebled by frequent attacks of
gout, or if there is a tendency to the formation of chalk con-
cretions, the waters of Vichy are not to be recommended.
The waters of Wiesbaden contain a large amount of chloride
of sodium, and are as, high in temperature as 160° Fah.
GOUT, CHRONIC. 10g

They are more highly stimulating and more generally debili-
tating than those of Vichy, and are of service in those cases
where the circulation is slow and the secretions deficient.
The springs of Neuenahr range in temperature from 9o.5° to
104° Fahr., and contain nearly 50 per cent., by volume, of
free carbonic acid, with a considerable quantity of soda salts,
chiefly as carbonates. They stimulate the circulation, aug-
ment the excretions from the kidneys and the skin, increase
the appetite, and diminish stomachal acidity. They are un-
suitable for plethoric habits and where the liver is enlarged ;
but where the constitution is impaired or enfeebled, they are
of great service. The waters of Wildbad, in the Black For-
est, have alsoa high temperature—g2° Fahr.—with much
free carbonic acid, holding salts of soda, and magnesia, and
iron in solution. They are alkaline, and their influence is
similar to the springs of Neuenahr. The waters of Aix are
slightly saline, and of a temperature as high as 135° Fahr.,
containing chloride, carbonate, and sulphide*of sodium, with
free sulphurated hydrogen. ‘They stimulate the liver, kid-
neys, and skin, and are indicated where there may be slug-
gish action of these functions, and where the joints are stiff.
The Karlsbad waters are rich in sulphate of soda, with car-
bonate of soda and common salt. Their temperature is
about 167° Fahr. They are purgative, diuretic, and diapho-
retic, and are beneficial where there is constipation, with con-
gestion of the liver ; and are unsuited for feeble patients.
The waters of Baden-Baden contain common salt combined
with iron, and are also rich in lithia. Toplitz, Gastien, Bux-
ton, and Bath waters are also all somewhat elevated in tem-
perature, and are peculiarly adapted for the treatment of
gout in the infirm, feeble, and old patients. The chalybeate
waters of Spa and Pyrmont are most suitable for anzemic
patients and in the asthenic forms of chronic gout. The salts
of lithia, so abundant in the waters of Baden-Baden, were
originally proposed by Dr. Garrod as a remedy for gout.
They have since been extensively used, and found generally
beneficial. ‘They abound also in the Karlsbad, Aix, Marien-
bad, and some of the Vichy waters. The salts of lithia are
actively diuretic, powerful solvents of uric acid, and generally
they tend to render the urine neutral. Taken for a length
of time in a dilute form, they tend to prevent paroxysms of
gout in chronic cases, and cause soluticn and absorption of
chalky matter. They certainly lessen the deposit of water
and uric acid in the urine; and are of service both in the
170 GOUT, CHRONIC.

acute and chronic forms of gout. The dose is from five to
ten grains of the carbonate of lithia, dissolved in aerated
water, three or four times a day; of the citrate, eight, ten, or
more grains may be given (Garrod, Flint, Clymer). Iodide
of potassium is .a remedy of very great value, especially in
cases where “the pains are increased at night;” but the
bromide of potassium is still more useful. It seems more
highly anodyne and soothing. The iodide of potassium Is
useful in removing the recent thickening in the tissues round
joints ; and of. gouty inflammation, when fluid is effused into
the cavities of joints, and is slow of absorption. Guaiacum
is especially useful in the asthenic gout of old subjects, and
to younger patients also it is beneficial. A combination of
quinine, iron, and arsenic is often of special service, in very
minute doses, in the form of chlorides ; and it is advatageous
to unite small doses of colchicum with the quinine.

The patient generally receives some warning by which he
may try and ward off the gouty seizure. When such warn-
ings are recognized a combination of quinine, colchicum, and
colocynth, taken twice or three times a day, is an excellent
medicine. The pills of Becquerel are also recommended by
Trousseau. They consist of :—

BR. Quiniz Sulphatis, gr. xx.; Ext. Digitalis, gr. ii. ;
Ext. sem. Colchici, gr. x. Divide into ten pills, of which two
or three may be taken daily for three or four days.

Laville’s anti gout liquid and pills are French preparations, .
and are so popularly known and so much esteemed by many
sufferers, who have used them with excellent effect, that they
challenge attention, although they are open to the objection
_of being secret as to their composition, like chlorodyne,
James’ powder, and Warburg’s drops. According to Dr.
Tanner, “from an analysis, the liquid contains the active
principle of colocynth, quinine and thinchonine, with unim-
portant salts of lime. It is used at any period of the attack ;
a teaspoonful being taken in sweetened water or tea, and re-
peated in six hours, if the pain continue and the bowels be
not moved. Twenty-four hours are to elapse before the next
dose, when half the quantity is to be taken two or three times
daily, unless the bowels are irritable. The pills consist of
physalin mixed up with silicate of soda and powdered cham-
zedrys.” One is taken just before a meal, for several weeks.
In the chronic forms of the disorder, where there is no or-
ganic disease of the brain, heart, or lungs, wet-packing, and
the Turkish bath, cautiously and occasionally used, but not
GOUT, CHRONIC. 171

during a paroxysm, under the immediate supervision of the
attending physician, would sometimes seem to be of service,
in lessening stiffness of the joints and restoring or improving
the action of the skin (Clymer.) Trousseau speaks well of the
wet-packing. Hot salt-water baths are also beneficial. The
inhalation of oxygen when followed by clear urine, has also
given great relief, and in some cases cures have resulted.

In atonic gout some light tonic medicine may be given, as
five to ten grains of the citrate of iron. A large number of
chronic cases, however, though the general health is im-
proved by this treatment, are often altogether unrelieved as
to the local symptoms, and are often quite unable to assist
themselves. In these instances the terebinthine remedies ap-
pear to be beneficial, as spruce beer, and Canadian balsam ;
or, one drachm of the oil of turpentine may be taken in an
effervescing draught once or twice a day. Sydenham’s
method of treatment by manna may also be used. He re-
commends, from experience in his own case, large doses of
manna in all cases of what he terms “ bloody urine.” If the
chronic or atonic gout should become retrocedent, and the
stomach and intestinal canal be the seat of the spasmodic
form of the disease, Sydenham strongly recommends that:
laudanum should be given ; but perhaps the following draught
is more efficacious, namely— *

}. Aque Camphore, 3x.; Sp. Aitheris Sulphurici, 31. ;
Sulphatis Magnesize, 3 ss.

It will remove from the stomach any undigested matter
which may remain as an irritating cause. This should be
gee every hour till the patient is relieved; and while it is

eing prepared, hot brandy and water should be freely ad-
ministered, or the spiritus ammoniz aromaticus, in doses of
sixty minims, and hot cloths applied to the abdomen, as well
as hot bottles to the feet.

As indiscriminate feeding appears to have a great influence
in the production of gout, so we expect the regulation of
diet should have great-influence in its removal. During the
fit the diet should consist of slops and light puddings, and
afterwards white fish, till the paroxysm has terminated.
Chronic gout is so distressing that many persons are inclined
to diet themselves with great strictness during the interval.
Sydenham says that a milk diet, or drinking milk as it comes
from the cow, or boiled, without adding anything to it, except
perhaps a piece of bread, once a day, had been much used for
twenty years past in his time, and had done much service to
172 GOUT, CHRONIC,

gouty patients, But on quitting it, and returning to the mild-
est and tenderest diet of other persons, gout has immediately
revived; and he adds, that many cannot bear this regimen.

An entirely water regimen he considers hurtful. The most
digestible meats, such as mutton, well-kept beef and poultry,
with the white kinds of fish, as cod-fish, sole, and whiting,
may be eaten; but salmon, veal, and pork are to be avoided,
as well as cheese, salads, highly seasoned dishes, and rich
sauces, or other “elaborate preparations on the part of the
cook.” The use of alcoholic stimulants requires great cau-
tion. For those who inherit the gouty constitution, total ab-
stinence should be made a rule absolute in youth; and for
all others, unless some obvious necessity arises for their use
and prescription by the physician, when the nature and
quantity of the stimulant must be definitely stated, and meas-
ured out as any other medicine would be. If alcohol inany
form is required, it may be taken as weak brandy, gin, or
whisky and water, or pure dry sherry, like Amontilado or
Manzanilla. Port, Burgundy, and sweet wines must be
avoided; but wines of the Rhine vintages may be taken, if
they do not contain a large percentage of alcohol. The
wine should be of the highest quality, and fully matured and
mellowed. Really good wines are generally used to advan-
tage, and the vegetable extractions of the pure, mature, and
mellowed wines are easy of digestion by the gouty stomach.
The best spirit is whisky, which should also be very old, soft
and mellow, and free from the smoky flavor. All of these
spirits ought to be taken much diluted with water. The pa-
tient should go early to bed, keep the mind free from all dis-
quietude, live with the greatest moderation, clothe himself
warmly, and ride on horseback. When exercise cannot be
taken, friction over the surface of the body is exceedingly
useful. He should be rubbed down with a flesh-brush once
or twice a day, just as a horse is groomed. Turkish baths
taken regularly once a week, or as often as may be indicated
by the medical attendant, are most beneficial. The custom
of going to bed foran hour or two immediately after the bath
—as in Germany—adds greatly to the good obtained from
the bath; the body being covered and completely at rest, the
nervous system is tranquillized, and the skin acts freely. But
much harm may be done by excessive limitation of the sup-
ply of nourishment, as well as by the sudden and complete
abstraction of spirituous fluids that had been used for years;
as well as by other debilitating courses of treatment set about
GRAVES’ DISEASE, 173

too hastily and pursued too vigorously. If the patient is
cachectic, debilitating treatment will make him worse.
“There should be a due admixture of animal and vegetable
food; it is an error to suppose that an animal diet tends more
to the formation of uric acid than a vegetable one. ‘The tor-
toise, feeding on a simple lettuce, excretes a large quantity
of urate of ammonia, far more in proportion to the weight of
the animal than is excreted by the dog exclusively nourished
with meat. Vegetables, as potatoes, greens, and the like,
may be partaken of with advantage; the soluble salts they
contain are of value in keeping up the activity of the secre-
ting organs. The same remarks hold good with regard to
soft fruits when eaten in moderation, as strawberries, grapes,
and oranges; also other fruits when stewed or baked, as ap-
ples and pears; but these latter, as likewise plums, and stone-
fruit in general, should be avoided in a raw state. Extreme
moderation should be exercised when saccharine fruits are
eaten, as sugar is liable in many subjects to lead to the pro-
duction of acidity. The same precaution is necessary in
reference to the addition of sugar to other articles of diet.”
(Dr. Garrod). “Gouty folks should be very moderate in all
their food—not, however, too abstemious, for such patients
are seldom really vigorous, or able to dispense with a nutri-
tious diet. Moderation should be observed, particularly in
respect to the use of stimulants; and each patient must
select for himself, or be advised to take what suits him
best. There is a prevalent opinion that spirits are better
than wines; but this is doubtful. The chief point is, that
whatever stimulant is taken it should be used in the most
strict moderation.” (Sir James Paget).

One other point with regard to the treatment of the patient
during the fit is, that if it be necessary to move him, either
on account of his restlessness or other cause, this should be
done with great care and tenderness by the attendants; for
although the pain may be latent while the parts are quiet,
yet the least shock often causes the most excruciating agony.
The irritable state of mind of the patient during the parox-
ysm has been mentioned; and it is well known that slight
moral causes will often produce a fit, while powerful emo-
tions have sometimes cured one. It is quite essential, theré-
fore, that the minds of gouty patients should be kept as tran-
quil as possible, both for their own sakes as well as for the
comfort of those who minister to their needs.

Graves’ Disease—Sce Goitre, Exophthalmic.
Lia GREEN-SICKNESS-—-H.-EMATEMESIS.

Green-Sickness— See Chiorosis.

Haematemesis.—Definition—A discharge of blood
from the stomach.

Treatment of the acute forms of hamatemesis is similar
in many respects to that of hemoptysis. The great volume
of the arteries of the stomach, and their origin almost im-
mediately from the aorta by means of the cceliac artery, are
reasons which have been alleged for this affection being but
little influenced by general or local bleedings. The vast
amount of blood sometimes lost by haematemesis renders it
necessary to support the patient by acid wines much sooner
and to a much greater extent than in hemoptysis. In
melzena the only chance for the patient is a liberal support
by wine diet and medicines, and by opiates to quiet the
stomach. In cases of hzematemesis from cirrhosis, or other
obstruction to the circulation through the liver, and in the
vicarious heematemesis of women, leeches to the anal region
‘or os uteri, are of service. The action of ice, by swallowing
small pieces from time to time, is very beneficial, covering
at the same time the epigastric region with ice-cold com-
presses, which require to be renewed frequently. Solutions
of dilute or aromatic sulphuric acid, in doses of ten to
twenty minims, or of alum, are of service. Alum may be
given in doses of eight to twelve grains, combined with
Battley’s solution of opium, or with laudanum or sulphuric
acid. In chronic hematemesis, acid. gallici, gr. x.; acid.
sulph. dil.,m x.; aq. distil, f 31, has been recommended by
Dr. Brinton. Solution of pernitrate of iron, in doses of thirty
to forty minims, may be of use. Ergot may also be of service.
Tannin is of service, as one of the best astringents in the form of
a pill (O. Rees)—three to six grains twice or thrice a day.
The patient must maintain absolute rest in bed, and must
not rise to stool. Ipecacuanha in doses to produce nausea
is of service in arresting hemorrhage, and restoring heat to
patients in the collapse of hematemesis (Osborne, Trenor,,
Graves), in doses of one to two grains every fifteen or
. thirty minutes till nausea is felt, when the remedy is to be
discontinued, as vomiting is to be avoided. If stimulants
are required, iced champagne may be given; and when the
vital powers are much depressed; ammon. hydrochlor., 3 iss.;
acid. hydrochlor., f3.ss.; decoct. hordei co., oz. 1, may be
taken every second or third hour (Copland), i in doses of two
or three teaspoonfuls.
HAMATINURIA, PAROXYSMAL—HEADACHE, 175

Hematinuria, Paroxysmal.— De/finition.—A condition
in which the urine contains only the coloring matter of the
blood with albumen, but no blood-corpuscles nor fibrine,
coming on in sudden and irregular paroxysms.

Treatment.—Improvement has taken place under the use
of saccharated carbonate of iron and quinine in full doses.

Hematuria Renalis.—Dejfinition—Hemorrhages in
which blood is mixed with the urine, whether it proceeds
from the kidney, ureter, or bladder.

Treatment.—Tincture of the perchloride of iron is one of
the most useful of remedies, whether in debilitated patients
or in those suffering from Bright’s disease, and whether the
blood comes from the kidneys or bladder. It is best given
in doses of m x. to xx., three or four times daily, in combin-
ation with glycerine; and if there be much cardiac difficulty,
with arterial excitement, it may be combined with digitalis,
as in the following prescription:—

RB. Tinct. ferri perchloridi, m xxx.; Tinct. digitalis, m
xv.; Aq. menth. pip., f 3 iss., repeated every four hours.

Gallic acid, in combination with sulphuric acid, may also
be given ; asalso ipecacuanha, tannin, acetate of lead and
alum, and ergotine, as already referred to under Hzemate-
.Mesis. Quinine and arsenic are remedies indicated in
malarious intermittent cases. Idiopathic hemorrhage often
readily yields to bitartrate of potash, or to the mineral acids.
Dr. Elliotson recommends, as also did John Hunter, the ol.
terebinthine, in doses of m x., m xx., Or M Xxx., every two,
or three, or four hours. Injections of cold water (or water
in which twenty to forty grains of alum have been dissolved)
into the bladder or up the rectum, and also a cold hip-bath,
are useful applications. Dry-cupping over the loins is also
indicated.

Hemorrhage, Cerebral or Spinal— See Apoplexy.

Headache.

Treatment.—(1) Of Sick-headache.—Looking to the true
cause of sick-headache as one which lies deep in the pa-
tient’s idiosyncrasy, and as an affection which is developed
by ahundred different sources of excitement, the advice to
sufferers is to give as much tone as they can to their nerves
by adopting all those methods which experience has shown to
be good, and then avoid, as far as is practicable, all those causes
which are known to excite an attack. Purgation has no good
result. The only remedies which are of any avail are those
176 HEADACHE.

which act on the nervous system, such as hot tea and coffee ;
or, after the stomach is quieter, and the more urgent symp-
toms have passed off, a little wine or ammonia. If the head-
ache take more the form of hemicrania, then other remedies
are occasionally useful, as the local application of the bisul-
_phide of carbon, or galvanism, and internally the bromide of
potassium, This is the only drug which Dr. Wilks has really
seen to be serviceable. Whilst the nausea exists and the
worst symptoms prevail, even this remedy is of no avail. As
regards tea and coffee, which often relieve, it is possible that
these and other stimulants, taken in excess, render the ner-
vous system more susceptible to the attacks. :

In the treatment of the paroxysm nothing is so efficacious
as complete rest in the recumbent posture, with warmth, in
a perfectly quiet and darkened room. A cup of very strong
tea or coffee has also given relief. A comparatively new
drug—guarana—has also been recommended. A full dose
of brandy, or of ammonia, has also sometimes dispelled the
headache ; so has continued sipping of a solution of carbon-
ate of potash or of soda. Pressure upon the carotid artery
of the affected side sometimes also relieves the pain, but for
a time only. Evaporating lotions, belladonna, or aconite
ointment may also ward off or subdue the headache ; but, as
a rule, time is the most efficient element, with warmth to the
feet and to the body, and the induction of sleep.

Adopting the theory of Dr. Latham, what are the indica-
tions for treatment with which it supplies us—(a.) During
the stage of disturbed sensation; (4.) during the stage of
headache ; and, (c) during the intervals between the attacks ?
The following are the results of his experience :— _

(a.) During the Stage of Disturbed Sensation.—It is found
that the longer this stage lasts, the greater will be the head-
ache ; and therefore it is desirable to shorten it as much as
possible. If the condition depend upon deficient supply of
blood to a part, such means must be adopted as shall assist
and increase the flow of blood to the part; and this can be
done in some measure by posture and ‘stimulants. Directly
the glimmering appears, the patient should lie down with the
head as low as possible, and if the glimmering be on the right
or left of the field of vision, he should lie on the opposite
side. Let him take at once one ounce of brandy, either
“neat” or in half a bottle of soda-water. Champagne would
be preferable, being more diffusible ; but its administration
would often involve a little delay. If alcoholic stimulants
HEADACHE, 177

be objected to, or if it be not advisable to recommend them,
then a teasp-onful of sal-volatile in water may be prescribed
instead, Ifthe patient be chilly or his feet cold, the couch
should be drawn before the fire, a hot bottle applied to the
feet, and his body covered over with a warm blanket or eider
down quilt, By these means the heart is enabled to drive
the blood with greater force to the brain, and the duration of
the vibratory movement is thereby materially lessened. Af-
ter it has passed of, tic patient should lie still for a time, so
that the glimmerinz may not return. This injunction will
only be necessary when the headache is slight; if it be severe,
attended with much nausea or vomiting, the patient will be
little disposed or able to leave the recumbent position. If,
instead of the disturbance of vision preceding the headache,
there be a fecling of depression or irritability (fidgets), the
administration of such cerebro-spinal stimulants as henbane,
valerian, assafcetida, spirit of chloroform, or ether, will often
cut short the attack; ten or fifteen drops of the tincture of
henbane, with the same quantity of spirit of chloroform, will
soothe the nervous irritability in the slighter forms, and may
be repeated in three or fourhours, if necessary. If there be
great mental depression, then valerian or assafcetida should
be tried. Stillé says,—‘‘ Nothing is more astonishing in the
operation of remedies than the promptness and certainty
with which a dose of valerian or assafcetida dispels the
gloomy visions of the hypochondriac, calms the hurry and
agitation of nervous excitement, allays commencing spasms,
and diffuses a soothing calm over the whole being of one who
but an hour before was a prey to a thousand morbid sensa-
tions and thick-coming fancies of danger, wrong, or loss.”
Dr. Latham gives the preference to valerian, and prescribes
from half a drachm to a drachm of the ammoniated tincture.
Or it may be combined, as in the following formula, with
bromide of soda; ammoniated tincture of valerian 3 iv. with
3 vi. bromide of sodium, in teaspoonful doses every hour.
The assafcetida may be given in-the form of the spiritus
ammoniz féetidus of the Pharmacopceia, also in half drachm
or drachm doses, As a rule, alcoholic stimulants are not
advisable in this stage of the headache. A small quantity
will cause flushing, heaviness, slight confusion of thought,
&c., without relieving the depression; and though the severe
headache may be averted, alcoholic stimulants do not answer
so well as the remedies previously mentioned.

(6.) During the Stage of [Headache—lf the headache he
178 HEADACHE.

slight and the patient soon able to sit up, there is little to be
done; a cup of coffee or’tea, cheerful conversation, a walk,
drive, or ride, may often help to remove the pain. If, how-
ever, the headache and nausea be severe, then the adminis-
tration of further remedies is called for. The patient should
keep perfectly still and quiet, with the room darkened; for
every sound or sight causes pain, and the slightest movement
is sufficient to produce gastric uneasiness. Sometimes free
evacuation of the contents of the stomach, especially if it
contain undigested food, is followed by relief. Dr. Fother-
gill says,—“ An emetic and some warm water soon wash off
the offending matter, and remove these disorders,” which
may be very well where there is any offending matter to wash
off, but it is not very often that this is the case; the nausea
frequently continues long after the contents of the stomach
have been discharged ; an inverted action of the duodenum
is set up ; the bile appears in the fluids excreted ; the patient
believes that all his troubles are due to “its overflow ;” “it’s.
all liver,” he says, and it is sometimes difficult to persuade
him to the contrary. Generally, then, you should try to re-
lieve and check the vomiting. Iced soda-water, with or
without two or three drops of dilute hydrocyanic acid, or
spirit of chloroform; coldtea; the effervescing citrate ot
potash, with hydrocyanic acid, may often afford marked relief.
The headache may be lessened by applying cloths dipped in
cold water, or evaporating lotions, to the head; if the ex-
tremities be cold and the headache severe, a warm stimulating
foot-bath can be tried so soon as the nausea will allow the
patient to situp. If the attacks occur in the early part of
the day, as soon as the pain has subsided it is generally better
for the patient to sit up, or move about, or take exercise in
the open air. During the attack the appetite is diminished,
the idea even of food provoking disgust. Still, after the
nausea has passed away and the headache has continued a
few hours, a plate of hot soup or some easily digested food
will often have a good effect in equalizing the cerebral circu-
lution. A remedy which may very often be given with ad-
vantage if the headache be severe, is bromide of potassium,
in doses of five, ten, or fifteen grains, to which thirty or forty
minims of sal-volatile may, in some ‘cases, be added with ad-
vantage ; and if the nausea still continue, these may be given
in combination with the effervescing citrate of potash. A
saline purgative at the commencement of an attack is some-
times an effectual remedy ; but, as a rule, the use of purga-
HEADACHE, 179

tives isobjectionable. So far, these measures are only palli-
ative.

(c.) During the Intervals between the Attacks.—First of all,
the exciting cause is to be discovered and removed. Hours
of study or work must be abridged; excessive bodily fatigue,
loss of rest,teverything, in fact, must be avoided which the
sufferers know from individual experience will act as exciting
causes. Where the attacks are associated with excessive
mental work, they should be regarded as danger-signals,
showing necessity for relaxation. The tone of the bodily and
nervous systems must be improved by proper medicinal and
hygienic means; and the chief remedies are steel, strychnine,
phosphorus, and cod-liver oil. The success, however, fol-
lowing these remedies depends a great deal upon the way in
which they are administered. For a day or two after the at-
tack the stomach and bowels may possibly be disordered,
and not in a fit state to tolerate such remedies. This must
first be corrected. The simple vegetable bitters, such as
gentian, with small doses of henbane and some aromatic, may
be of service; and, if necessary, one or two grains of blue
pill, with four or five of compoudd rhubarb pill, may be given
at night. We may then try steel. In anemic cases it may
be advisable to stimulate the action of the heart, as by the
following:—

R. Ammoniz muriatis, % ss., Tinct. actez racemose
aque, aa % iii. Two fluid drachms for a dose after meals
in a wineglass of water.

If there be despondency with depression of spirits, phos-
phorus to the extent of z}y to py of a grain, combined with
nux vomica or carbonate of iron, or both taken with each
meal, will improve the tone of the patient. If the attacks
have been frequent, or if there be any scrofulous tendency,
the iodide of iron may be given in the folowing form:—

}}. Ferri et ammon. citrat., gr. v.; potassii lodidi, gr. ij.5
aque, %j; and, according to circumstances, fifteen to
twenty minims of tincture of henbane or twenty or thirty
minims of aromatic spirit of ammonia may be added.

If the stomach be at all irritable, this medicine may be
given in the effervescing form, adding to each dose twenty
grains of bicarbonate of potash, and directing it to be taken
with a tablespoonful of lemon-juice, or a corresponding
amount of citric acid: the dose to be taken twice a day,
about eleven and four. The effervescing from may soon be
left off, and then to each dose may be added five minims of
180 HEADACHE,

liquor of strychniz (omitting the henbane and sal-volatile,
and continuing the iodide of potassium according as it seems
to be indicated or not). In other cases, the citrate of iron
and ammonia with strychnine may be given at the beginning,
sometimes combined with infusion of calumba. The iron is
indicated by the greater or less anemia of the patient ; but
the strychnine is a very important remedial agent in the
disorder. In small doses it acts as a simple tonic, increasing
the appetite and improving the digestion ; it dilates che ves-
sels, and thus increasing the supply of blood, it augments
the activity of the spinal cord (Harley). It promotes the
capillary circulation, and therefore its use is advisable for
persons troubled with cold hands and feet (Anstie) ; and if
it fulfil these conditions, it is clearly indicated in this dis-
order. Cod-liver oil also often acts very beneficially. “It
has been found by experiment that great exertion and pro-
longed labor can be endured without fatigue when starchy
and fatty foods are alone eaten; . . and there is reason
to think that cod-liver oil is more easily absorbed than other
similar substances’ (Ringer). “It improves the digestive
process, increases the proportion of red corpuscles in the
blood; and invigorates the whole nutritive function”
(Wood) ; and it particularly sustains the energy of the brain
during prolonged mental exertion, A gentleman in the
foremost rank at the bar told Dr. Latham that whenever he
was engaged in a jury-trial which was likely to tax his ener-
gies to a greater degree than usual, the thing which best
sustained him was a good dose of cod-liver oil taken in the
morning before going into court; and others engaged in
mental work have confirmed this view. Besides its
other properties cod-liver oil is a nutrient and tonic in its
action on the cerebro-spinal nervous system. As a remedy
for these nervous headaches, Dr. Latham prescribes it once
a day, beginning with a small teaspoonful immediately
after breakfast, and gradually increasing the quantity toa
tablespoonful, but not beyond, unless in exceptional cases.
The action of the bowels must be regulated, but not by
strong purgatives. Five grains of the Socotrine aloes pill,
given at night, are generally sufficient. Ifthe bowels be
habitually constipated, then no remedy seems to answer so
well as the aloes and iron pill. Five grains given twice a
day, half an hour before meals, will act freely ; and in a few
days the dose will have to be diminished, for its effect is
augmented instead of being lessened by continual adminis-
‘HEADACHE, 181

tration, especially when strychnine is given at the same time.
The natural waters of Friedrichshall or Marienbad may, in
many instances, be of service, given as laxatives.

In 1872 Dr. Samuel Wilks, Physician to Guy’s Hospital,
directed the attention of the profession to guarana as a
remedy for sick-headache, and at the same time asked for the
experience of those who already had some acquaintance with
the drug. His own knowledge of it dated about 1870,
when, after the appearance of a lecture of his upon sick-
headache, he received a letter from Mr. Helmcken, of British
Columbia, inclosing two powders, which he recommended
with much confidenee as able to cure the complaint. “‘ Upon
my first headache after the receipt of Mr. Helmcken’s letter,
I took the powder, but with only doubtful effect. I there-
fore did no more than casually mention the medicine to my
friends, but did not recommend it. A few weeks ago, after
the appearance of a second communication of mine in the
journal upon the same complaint, I received a letter from
Dr. Wood, of Montreal, in which he also recommended
guarana as a remedy for headache, and gave a history of his
own personal sufferings and the relief which he obtained.
He says,—‘ By taking one of these powders and remaining
quiet when I have felt premonitory symptoms by a beginning
of pain always in the right temple (headache on the other
side, or in any other part of the head, I never mind), I have
carried off the attack; and, with the first box, absolutely
put it off for two months—something which had never
occurred in my life before.’ Upon so good an authority, I
determined to try the remedy in a more systematic manner,
and requested my neighbor, Mr. Hooper, the chemist, to
procure me a packet of the powders. These I have recom-
mended to several patients and friends ; and the result is so
encouraging, that I have hastened to suggest their trial to
my professional brethren. One lady speaks most enthusi-
astically of their power, as she has now, on two separate
occasions, had her headache arrested by their use. The
drug has long been known, for mention is made of it in
English and French’ pharmacologies, but appears never to
have come into general use. It consists of the seeds of a
tree growing in Brazil, called Paullinia sorbilis; and these,
according to Johnstone, in his Chemistry of Common Life,
are used as we do cocoa. The seeds are ground into pow-
der, and contain an alkaloid which is said to be identical
with that found in tea and coffee. The medicine is manu-

!
182 HEADACHE.

factured by Grimault & Co., No. 7 Rue de la Feuillade,
Paris” (Wilks, Brit. Med. Journ., April 20, 1872).

The general outcome of experience regarding the treat-
ment of sick-headache seems to be that,—

(1.) Bromide of potassium, Indian hemp, Guarana or
Paullinia powder, are remedies which have afforded relief.
With reference to bromide of potassium, it is so valuable a
medicine in many cases of sick headache that it can scarcely
be superseded by a better remedy. The patient may havea
splitting headache, fatigued and worried after a hard day’s
work. After fifteen or twenty grains of bromide of potas-
sium, he presently goes off to sleep in his easy chair, and
wakes in an hour well (Wilks). It is a medicine which Dr.
Wilks always employs first, having seen such eminent ad-
vantages follow its use. “I have known (he writes) many
patients declare, that the bromide was the first medicine they
had taken in their lives which had the slightest effect in re-
lieving their headache.” As to Cannabis Indica, it seems
best adapted to the interval between the attacks, in doses of
a few drops of the tincture, when headaches are ‘recurrent.
It is best given in ten-minim doses, three times a day, con-
tinued for weeks or months (Wilks, John Murray). As to
guarana powder, it seems most of all useful with females in
arresting headache, so that it must be taken early when the
headache is approaching ; and if headache is not arrested, a
second dose should be taken in fifteen, twenty, or thirty
minutes after the first. If the medicine is of use, the head-
ache will have gone in about an hour. The dose is 15 grains
of the powder ; and as it is somewhat astringent, it might be
combined as an electuary with some laxative, such as the
senna electuary (Hollis).

(2.) Certain classes of cases ought to be distinguished from
each other. There aretwo principal types :—the congestive,
met with in dark or plethoric people, in those with consti-
pated bowels and suppressed secretions, and those addicted
to alcoholic beverages, or leading a monotonous sedentary
life ; and that arising from exhaustion, whether from want
of sleep or want of food, or great bodily or mental fatigue,
strong emotions, &c.—this may be nervous, or asthenic, or
anzemic in many cases, This latter form is very common in
slight, delicate, and tuberculous females, and sometimes in
the male sex. The treatment of these two forms must, of
course, differ widely. An emetic or a purge in the one case
will do what only rest, food, stimulants, and such medicines
HEADACHE, 183

as quinine, iron, opium, hyoscyamus and belladonna may
afford in the other case (Dr. Bathurst Woodman). Rest and
quiet, especially sleep, and abstinence from food, give relief
and cure by a natural process of restoration. Generally, no
relief is obtained till after a night of sound sleep—z. ¢., ‘‘ one
night through the sheets’’---awakening next morning free
from pain, but generally more or less depressed: If depres-
sion continue, phosphorus with nux vomica in the form of
sugar-coated or pearl-coated pills may be given to tne extent
of one-fiftieth of a grain of phosphorus and one-eighth of a
grain of extract of nux vomica three times a day with food.
Such despondency and depression are apt to occur in those
who are over-worked mentally ; or who are harassed by busi-
ness ; or who suffer great mental anxiety. If there be sleep-
lessness, the following pill may be of use:

RB Camphore pulveris, gr. xx. ; Ext. Cannabis Indica,
gr. xii. ; Ext. Hyoscyam., gr. xxiv., misce bene. Divide in
pill xii. signa, one at night, to be repeated in two hours, if
necessary, to procure sleep.

As to local applications, a large sinapism over the stomach,
followed by a warm linseed meal poultice, has sometimes
been of service. If pressure relieves, the head may be bound
round with a handkerchief. When the head throbs and is
hot instinct seems to suggest cold and pressure to the part;
and one of the best external appliances on which we can rely
to procure relief is the wet bandage tied tightly round the
head. The method must be instinctive, for it is universal,
and has been used from all time. Shakespeare is often
quoted to illustrate the morbid states of the body as well as
the passions of the mind, and he also testifies to this ancient
practice. For example, in the scene between Huburt and
Arthur in King John, the latter, when petitioning for the
preservation of his eyes, says :

‘When your head did but ache
I knit my handkerchief about your brows.”

And in Othello we have not only the remedy for headache
given, but the cause. The former was the handkerchief about
which the chief interest of the play centred.

“* Desdemona, Why do you speak so faintly ?
Are you not well?

Othello, I have a pain upon my forehead here.

Desdemona, Faith, that’s with watching : ’twill away again,
Let me but bind it hard, within this hour
It will be well.”
184 HEADACHE.

Sick-headache is not to be cured by gastro-hepatic reme-
dies. It is a purely nervous affection, due to hereditary
predisposition, and excited by causes innumerable which act
on a susceptible nervous system. There is, then, no cure in
the proper sense of the term, for this would imply a change
in the patient’s nature ; and for the attacks themselves, when
severe, the only relief which can be reckoned upon is to be
found in a wet bandage round the head, profound quiet, and,
if possible, sleep (Dr. Bathurst Woodman).

Considerable relief may be obtained from the use of cold
applications, in the form of wet rags, ice in a bladder, or a
little of the ether-spray ; but in not a few cases, after all, the
best treatment during the attack is absolute rest and quiet,
in a dark room, with warmth to feet and body, total absti-
nence, except perhaps from fluids (hot and alkaline) in small
quantities at a time ; to go to bed at once, and refrain from
the use of any remedies.

In a lecture on the therapeutics of headache, delivered at
Bellevue Hospital Medical College, Dr. A. A. Smith sug-
gests certain combinations of remedies which he has found
of service in certain forms of headache: (1.) Malarial
headache, where the pain is most frequently located in the
sub-occipital or frontal regions, or on either side—hemi-
crania, If distinctly periodical, give ten or fifteen grains of
quinine two or three hours before the expected ‘attack. It
may be necessary to push the quinine in divided doses until
cinchonism is produced, and kept up for several days. Then
gradually diminish the dose. If the pain still continues to
recur, resort to arsenic and belladonna, five-drop doses each
of Fowler’s solution and belladonna tincture, after meals, in-
creasing the Fowler’s one drop each day, until cedema arse-
nicalis is produced. This will seldom fail to give relief.

(2.) In Headache dependent on Gout :

B Vini colchici seminum, 3 iij.; Lithii bromidi, % ss. ;
Syr. zingiberis, 3ss.; Aq. cinnamonii, q, s. ad 3 vj.; M.
Sig. 3ss. in a tumbler of Vichy water every four hours.

(3-) Rheumatic Headache is characterized usually by ten-
derness of the scalp, which is increased on pressure or mo-
tion. Use the mild Faradic current on the scalp, and in-
ternally the following :

B Potassii iodidi ; Ammoniz muriatis, aa 3 jss.; Infusi
humuli, %vj.; M. Sig. = ss. four times a day in a wineglass
of water.

In cases which have not yielded to the above treatment,
HEADACHE, 185

bromide of ammonium in twenty-grain doses every two hours
may be effectual.

4.) Ureemic headache is of great importance as a symp-
tom of serious disease. The pain in the head may be the
first evidence that there exists renal disease, and that we
have to deal with uraemic headache. The judicious plan of
treatment in such cases is to call into action one or all of the
three great emunctories of the body, the kidneys, the intes-
tines, and the skin. To make the kidneys act, apply dry
cups over the region of them, and give internally the fol-
lowing :

I Potassz acetatis, 3 vj. ; Infusi digitalis, 3 vj. ; M. Sig.
& ss. every third hour. ‘

The infusion should be made from fresh’ English leaves.
Give this until the kidneys act freely, if you can make them
do it within twenty-four hours. If the kidneys do not act
freely, and the headache be not relieved within twenty-four
hours, give a saline cathartic. A treatment almost domestic,
and often very effectual, is to put an ounce of cream of tar-
tar in a quart of water, and have the patient drink this in
eight or ten hours. It acts both as a diuretic and cathartic.
Do not use hydragogue cathartics unless convulsions be
threatened. Some prefer elimination by theskin, This can
be done by diaphorétics and the hot, moist, or dry air bath.
Diuretics, cathartics, and diaphoretics are only to be used
where there is deficient quantity of urinary secretion. There
are other causes of headache in Bright’s disease which occur
independently of the presence of an abnormal amount of
urea in the blood, and which yet are dependent on the results
of the kidney-disease. These causes may be anemia,
neuralgia, cedema of the brain itself, serous effusion into the
ventricles ; and, in acute Bright’s disease, cerebral conges-
tion. Under the last condition, if the headache be very se-
vere and convulsions threaten, blood may be taken if the
patient’s condition will admit of it, from twelve to twenty
ounces, if necessary to relieve distressing symptoms. The
best way to take it is by means of wet cups over the region
of the kidneys. If the headache be dependent on serous ef-
fusion into the ventricles, or on cerebral cedema, improve the
vitiated condition of the blood, and stimulate the heart and
‘kidneys by. acetate of potash and infusion of digitalis.
There is apt to be general anasarca with this effusion and
cedema.

(5-) The Headache of Acute Alcoholism, or inebriety.
186 HEADACHE

The first indication’ is to remove the alcohol from the intes-
tinal canal. For this, give of rhubarb and magnesia calcined
each a half drachm, and then the following:

B Spiritus ammoniz aromat., 31ij.; Tinctures camph.,
3jss.; Tincture hyoscyami, 3 ijss.; Spiritus lavandule
comp., q.s. ad % ij.; M. Sig. 33. every hour until the head-
ache is relieved, and then give capsicum gr. ij, and quinine
gr. lij. before each meal for several days. If there be sleep-
nessness give R, Sodii bromidi, % ss.; Chloral. hydrat., 3 ijss.;
Syrupi aurantii cort., %ss.; Aque, 3 iijss. M.Sig. 3 ss,at
night; repeat in two hours if necessary to produce sleep.

(6.) Dyspeptic Headache.—lf there be indigestible food. in
the stomach, and it have been there some time, give an
emetic, as mustard and warm water, or sulphate of zinc, gr.
xv. If there is evidence of indigestible food in the aliment-
ary canal beyond the stomach, give gr, xx. of rhubarb and
magnesia each, to remove it from the bowels. If the head-
ache be frontal, and the pain be located immediately over
the eyes, give dilute nitro-muriatic acid in ten-drop doses,
well diluted after meals. If the pain be located about the
roots of the hair, give an alkali before meals, as gr,
xv. of bicarbonate of soda or magnesia. The dyspeptic
headache oftentimes is not confined to these regions, but
spreads over the entire head. In such cases combine an
acid with an alkali, and add to these nux vomica, as in the
following prescription:

RB. Sodz bicarbonatis, 3 ijss.; Acidi nitro-mur. diluti.
31j.; Tinct. nucis vomice, 3 jss.: Syr. aurant. cort., 3 vj.;
Aque, q. s. ad % vj. M. Sig. 3 ss. after meals in a wineglass
of water.

If there be gastric pain, a mild counter-irritant, as a mus-
tard plaster to the epigastrium will often relieve the pain in
the head as well as the pain in the stomach. If flatulence
be a troublesome symptom, give the following:

&. Bismuthi subcarbonatis, 3 ijss.; Tinct. nucis vomice,
3 jss.; Tinct. cardamomi comp.; Spiritus lavandule comp.
aaq.s.ad 3 iv. M. Sig. 3ij. before meals in a wineglass
of water.

If there be constipation, the following pill may be given,
in the morning:

RB. Aloes pulv., 3 ss.; Ext. nucis vomice, gr. v.; Ext.
belladonne, gr. iv.; M. Div. in pilulas, xv.

In some forms of headache associated with stomach in-
digestion, small doses, often repeated, of tincture of nux
HEADACHE, 187

vomica may be effectual. A single drop every fifteen minutes
and continue this two or three hours if necessary. In other
cases, where the headache comes on soon after a meal,
and seems to depend on delayed stomach digestion, large
doses of pepsin are effectual. Give a half drachm of sac-
charated pepsin in a wineglass of sherry wine, three times a
day, and let it be taken during meals.

(7.) Congestive HMeadache—Cerebral congestion as a
cause of headache may be divided into two varieties, active
and passive. These demand almost directly opposite plans of
treatment. In the active variety the patient should be kept
ina darkened room, perfectly quiet, and have cold and evap-
orating lotions applied to the head. A saline cathartic may
be given ; and the following prescription :

ER. Sodii bromidi, Zijss,; Fl. ext. ergot., 3 ijss.; Syr.
zingib., %ss.; Aq.. aurant. flor. q.s.ad Ziv. M. Sig. ss.
every two hours.

If the skin be hot and dry, and the pulse full and rapid,
give two drops of Fleming’s tincture of aconite root every
two hours, until the heart’s action is sensibly diminished.
Sometimes also a hot mustard foot-bath will give relief.
The passive congestive variety demands a different mode of
treatment. It is often found associated with cardiac dis-
ease, and most frequently where there is predominant dila-
tation. Hypertrophy gives rise to the active variety. Im-
prove the condition of the blood by the use of iron, qui-
nine, bitter tonics, alcoholic stimulants, good food, and stim-
ulate the heart’s action by the use of the following:

R. Tinct. digitalis, Ziij., Spirit. amm. aromat., 3 vj.;
Spirit. lavandule comp.; Syr simp., aa q.s.adZiij. M.
Sig. 3 j. every four hours.

(8.) Anamic Headache-—Cerebral anemia: produces a
headache which is often mistaken for the passive cerebral
congestive form. It is associated with general anzmia, ner-
vous exhaustion, and may occur in heart disease, in con-
sequence of enfeebled heart power, such as is met with in
enlargement with dilatation, fatty degeneration, and myo-
carditis. Improve the general condition of the patient, and
stimulate the heart’s action as recommended in the passive
cerebral congestive variety. Nitrite of amyl will relieve the
immediate headache. Let the patient inhale three to five
drops of it on a piece of cotton, placed within one nos-
tril, while the other is held closed. When associated with
nervous exhaustion, employ the following remedies :

’
188 HEART, FATTY—HEART, HYPERTROPHY OF.

R. Strych. sulph.. gi. ss.; Tinct. ferri chloridi, 3 ij.; Gly:
cerine, %ss.; Infusi gentian., q. s. ad3vj M. Sig. 3 ss.
after meals, in a wineglass of water.

Alcoholic stimulants are beneficial in headache dependent
on cerebral anemia. Champagne as a remedy, and not as a
beverage, may be given to those who suffer from nervous
exhaustion, or a tablespoonful of brandy, diluted with
water, after each meal.

(9.) Cerebral Tumors give rise to headache, often severe.
In all such cases, give iodide of potassium ; for it cannot
be safely said that in any given case the tumor does not de-
pend on syphilis, and by administering the remedy, the pa-
tient gets the benefit of the doubt.

There is reason to believe, too, that patients with cerebral
tumors, dependent on other and unknown causes, are bene-
fited by the use of iodide of potassium, If there be
much sleeplessness, use the bromide and chloral mixture
Ergot has also been used. It is usually given in large
doses, beginning with 3i. of the fluid extract three tines
a day, and gradually increasing the dose to half an ounce
(Mew Vork Medical Record and London Medical Record
Sept. 15, 1876.)

Heart, Fatty and other Degenerations of the.—
Definition—A change in the muscular substance of the
heart, which results in elements of the muscular fibers being
replaced by molecular fatty particles. The change tends to
sudden death by rupture of the heart, or by syncope.

Treatment.—Iron in its various forms, quinine, and min-
eral acids, are the medicinal agents suggested by the nature
of this disease. Freedom from anxiety, thorough repose of
mind, entire avoidance of fatigue, gentle but regular exercise
in the open air, careful attention to the state of the skin, with
a generous and nutritious diet at regular intervals, in moder-
ate and equable amount at each meal, are the main hygienic
indications calculated to impart tone to the system, improve
the condition of the blood, and induce a more healthy nu-
trition of the heart (Fuller). A salt-water sponging bath
should be used daily. In cases where digestion is sufficient,
cod-liver oil, cream, and milk may be given with great ad-
vantage (Tanner). The bowels should be so regulated as to
render straining at stool unnecessary.

Heart, Hypertrophy of.—Defnition—An abnormal
growth of the muscular substance of the heart, increasing its
HEART, HYPERTROPHY OF 189

volume by thickening of the cardiac walls; and generally
with dilatation of its cavities.

Treatment.—As the bad symptoms in valvular affections
arise from defective compensation, and as the compensation
depends on the integrity of the heart-muscle, the mainte-
nance of its nutrition is of prime importance. Palliative
treatment is necessarily directed to aid the mechanism by
which the ill-effects of valvular incompetency are to be met.
In affections of the aortic valves, when the heart-muscle is
well nourished, an almost perfect compensation may be main-
tained for years upon a nutritious (albuminous) diet, with
fluids in small quantity—tonics, especially preparations of
iron, being indicated. In the earlier stages a moderate
amount of exercise is beneficial. In mitral affections, the
compensation can never be so complete as to do away with
the tendency to pulmonary complications. While the same
nutritious diet and tonics are indicated to promote the nutri-
tion of the cardiac muscle, exercise must be taken more cau-
tiously; the object being to regulate and moderate the action
of the heart, to control the tendency to local congestion, and
to mitigate or remove the symptoms which result from the
cardiac derangement.

Any bloodletting required ought to be effected by the ap-
plication of a few leeches to the preecordial region, and very
general relief will be obtained by hydragogue purgatives,
aided by dry-cupping, mustard poultices, and turpentine fo-
mentations. When, however, active congestion of the lungs
exists, venesection, cupping, blisters, and sinapisms’ may be
necessary. The distress from simple hypertrophy may, in
the majority of cases, be greatly mitigated by such means as
tend to tranquillize the action of the heart. No known drug
possesses the power of controlling the growth of the heart.
Saline and aloetic purgatives aid the calmative influence of
the local abstraction of blood. Diuretics are useful inde-
pendently of the existence of dropsy. Sedatives of the
heart’s action are indicated throughout, such as hydrocyanic
acid, acetate of lead, digitalis, belladonna, and aconite, in the
form of the alcoholic extract, given in doses of one-eighth of
a grain (Walshe). It is chiefly useful in excessive hypertro-
phy, with hydrocyanic acid and caffeine. In repeating the
doses, the effects must be watched, while they relieve the
painful sensations and disquietude about the heart. If ane-
mia, prevails, animal food should be permitted; and the more
soluble and less astringent preparations of iron should also
Tgo HEART, HYPERTROPHY OF,

be given. Fluids must be taken in small quantities. Like
hypertrophy, dilatation of the heart is not removable by
treatment. To'improve the tone and strengthen the action
of the heart, without exciting its irritability, are the objects
to be aimed at in the management of cardiac hypertrophy
with dilatation. For this purpose the beneficial influence of
digitalis has been ably shown by Dr. J. M. Fothergill, in his
“Hastings Prize Essay” for 1870, published in the British
Medical Journal, commencing July 1, 1871; and also by Dr.
Balthazar Foster in the Aledico-Chirurgical Review for July,
1871. It isan efficient agent in helping to co-ordinate, by
restoring the regularity of the heart’s movements, when
they have become tumultuous and irregular. The mechan-
ism of compensation in each form of valve disease, therefore,
requires to be considered. In hypertrophy digitalis is
only of use when hypertrophy exceeds the limits of com-
pensation. It slows the pulse and regulates the heart-
muscle; but if the heart-muscle is unsound it will not be
of service. As a general rule, the drug is most useful in
mitral affections, and is contraindicated in aortic valve
disease, except in cases in which the hypertrophy has ex-
ceeded the limits of compensation, and become the chief
cause of the symptoms. It slows the pulse and increases
its tension while strengthening and regulating the heart’s
action. The slowing of the pulse increases the period of
ventricular diastole—that is to say, the period during which
regurgitation takes place when the aortic valves are incom-
petent ; consequently, digitalis does harm in this lesion by
augmenting the regurgitation. In mitral obstruction it is
most valuable when the rapid, irregular pulse tells of the
varying quantities on which the ventricle contracts. Some-
times the interval between the ventricular contraction is so
short, and the ventricular charge is so small, that the systolic
wave does not reach the wrist. Under these circumstances
the auricle must have more time to fill the ventricle. This
is what digitalis effects; for by slowing the action of the
heart, the period of time during which the blood from the
distended auricle can flow into the ventricle is increased ;
and as the extra time allows more blood to pass through
the narrowed mitral orifice before the final effort of the
auricle is made, that effort is made on a smaller quantity of
blood, and is consequently more effective ; for the smaller
the quantity of blood which the auricular muscle has to push
before it, the greater will be the velocity given to the cur-
HEART, HYPERTROPHY OF, Igl

rent. The ventricle, through contracting less frequently,
contracts more effectually. Instead of eighty or ninety
‘irregular contractions per minute, we get some sixty steady
equal beats. The pulse grows in force, fullness, and regu-
larity ; the arterial tension rises ; the pulmonary congestion
diminishes ; the kindeys, before inactive, wake up to their
work; and the advancing dropsy subsides (Foster, Med.-
Chir. Rev.. July, 1871). Digitalis is also most useful in mi-
tral regurgitation. In place of a large number of ineffective
contractions, it concentrates the power of the ventricle on a
smaller number of well-directed steady beats, each throwing
a larger charge of blood isto the arteries, and so diminish-
ing, beat by beat, the over-distension of the right heart. It
may be prescribed as an infusion or tincture, and continued
as long as the quantity of urine increases or keeps up to the
maximum which the digitalis produced. Such diuretie effect
is the outward or visible sign of its beneficial action. The
high-colored scanty urine, loaded with urates, is then replaced
by a clear and copious stream, which tells of a steadily-beat-
ing heart and a firmer pulse (Foster). The tincture is the
most convenient form for continuous administration (m v. to
m x., three or four times a day). The freshly-made infusion
acts most rapidly (3ss.to 31. three or four times a day)
along with potash or diuretics, and is conveniently added to
vegetable infusions. Where it is desired to keep up the
action of digitalis for a long time, the powder of the leaves
is the most desirable form. It can then be given in pill,
with the dried sulphate of iron, carminatives, laxatives, or
both, twice a day. Half a grain to a grain of powdered
digitalis, with an equal quantity of sulphate of iron, and a
small portion (4 of a grain) of cayenne pepper, in extract of
gentian or aloes and myrrh pill, is a useful form which
may be continued for months. This pill should be taken
shortly after food. The addition of iron to digitalis is of
great importance. The absorption of digitalis through the
skin, by using poultices of the leaves, or flannel cloths soaked
in the infusion and laid over the skin of the abdomen and
thighs, is often most beneficial where it cannot be given by
the mouth (Christison, Trosseau, Fothergill).

There are some circumstances, however, under which it is
necessary to withhold the administration of digitalis in car-
diac disease—namely (1.) The presence of atheroma (endo-
carditis) to any appreciable extent, and in aortic valve dis-
ease, (2,) Reith, Gull, and Brunton object to its use in
Ig2 HEART, HYPERTROPHY OF.

fatty heart. (3.) Intermittency of pulse is also a contraindie
cation. If that symptom comes on during its use, the fur-
ther administration of digitalis must be suspended, mor-
especially if the pulse becomes thready, and the quantity of
the urine diminished. On the other hand, where intermit-
tency is shown to be the result of the heart’s inability and
distress, the quantity of digitalis must rather be increased
(Fothergill). (4.) The occurrence of persistent vomiting or
noises in the head under its use, suggests that it should be
left off, for a time at least.

The action of the heart is also markedly influenced by
veratrum viride. The dose of the tincture (from five to
twenty minims) should be gradually increased from the
smaller to the greater dose, till some obvious effects are pro-
duced. If the pulse is reduced, or nausea occurs, no increase
of the dose should be made: If vomiting occur, it should
be suspended ; and when resumed, the dose should be dimin-
ished. Veratria may be given in doses of from one-sixteenth
of a grain to half a grain. When the pulse is sufficiently
reduced, the doses should be diminished one half. Mor-
phine or laudanum, with brandy, is an antidote for an over-
dose of veratria, which is an exceedingly powerful remedy
as a cardiac sedative, and requires to be used with
great caution, the patient being constantly watched. Its
depressing effects on the circulation and nervous system are
often very striking—a pulse of 75 or 80 being reduced in
the course of a few hours to 35 or 40 (Record of Pharmacy
and Therapeutics, No. V., p. 35, J. C. Braithwaite). Sleep-
lessness being one of the most distressing symptoms, opium
in some form might be considered advantageous; but “to
give sedatives in such cases would be the refinement of cru-
elty. What keeps the patient awake is not a want of ten-
dency to sleep, but a condition that makes sleep impossible.
Relieve him of his orthopncea, and he would be asleep in ten
seconds, and so dead asleep that it would take a great deal
to rouse him, like a half-asphyxiated child on whom trache-
otomy had just been performed. His great struggle is the
struggle between sleep and life ; with opium thrown into the
scale of sleep, the struggle for life would only be so much
the harder. Only in one way would opium give him ease ;
the narcotic of opium, added to the narcotic of the carbonic
acid already circulating in his veins, might accelerate by
some hours, or even days, the final coma, and make him
sooner sleep the sleep of death. But the euthanasia that is
HEART, HYPERTROPHY OF, 193

purchased by anticipating the natural process of death
comes very near to homicide, and is an alternative that few
would adopt” (Hyde Salter, Brit. Med. Journal, Feb. 8,
1862). Morphia given hypodermically is the best form for
relieving the dyspnoea and sleeplessness of some valvular
affections, especially in mitral valve disease. The dose to
commence with is one-eighth ‘to one-sixth grain of the bi-
meconate of morphia (Dr. Clifford Allbut). But all seda-
tives require the utmost caution in their use.

The groundwork of medicinal remedies consists in the
administration of general tonics in the form of bitters, min-
eral acids,*and preparations of iron. Belladonna may be
employed to tranquillize undue excitement with greater
safety than any other sedative remedy. A plaster of bella-
donna and conium over the heart is of signal service when
pain is usually felt near the apex, associated with palpitation.
Due action of the bowels must be daily obtained, to accom-
plish which the aloetic medicines are the best, aided by the
gentle action of an occasional mercurial aperient.

Careful regulation of the patient’s made of life is above
all things necessary in diseases of the heart. Excitement
of all kinds must be avoided; and the diet should be light,
nutritious, and of moderate quantity; the clothing warm,
and cold should be carefully avoided, especially by those
affected with mitral disease.

When anasarca supervenes, the hydragogue cathartics are
required to insure copious watery discharges from the bow:
els. Electuary of bitartrate of potash, or of gamboge, ela-
terium, podophyllin, and compound jalap powder should be
given on alternate days. Stimulants also may be required,
the most suitable being Holland gin, or whiskey. .

When dropsy appears, diuretics yield most relief. Ace-
tate, nitrate, iodide, and bitartrate ot potass, nitric ether,
compound tincture of iodide, the infusion and spirits of
juniper, or gin, may all be employed i in successive changes,
variously combined. Small doses of blue pill and compound
squill pill at bedtime, will facilitate their action generally ;
and so will cupping over the region of the kidneys, if symp-
toms of congestion of these organs prevail. Hydragogue
cathartics aid the diuretics in subduing the dropsical effu-
sions, such as, elaterium, gamboge, bitartrate of potass, and
compound jalap powder—the two last made into an elec-
tuary.

13
194 HEART, MALFORMATIONS OF—PALPITATION OF.

Heart, Malformations of.—Dejinition. — Deviations
from the normal development of the heart, occurring in the
earlier periods of gestation, and before the termination of
foetal life.

The ¢reatment of malformations which are associated with
cyanosis is mainly preventive of dyspnoea and palpitation,
by the-avoidance of fatigue and mental excitement, the
maintenance of temperature, and especially by a nourishing
diet and warm clothing.

Heart, Palpitation of.—Defnition.—Palpjtation and
. irregularity of the action of the heart, unconnected with or-
ganicmis chief, beyond, in some cases, a notable hypertrophy.

Treatment.—During the paroxysm the patient should lie
flat on his back, bare his neck and chest, and allow the air
to blow freely over him. The best remedies are, camphor
mixture and ther, 3i., with some slight opiate, as the syr
up of poppies, 3j., or tinct. hyoscyami, m xx. These
should be repeated every quarter, or every half hour, or
hour, according to the severity of the attack, till the heart’s
action is soothed. Cold brandy and water may be a substi-
tute for, or adjuvant to, such medicines. If the attack oc-
curs shortly after a meal, some purgative should be given
to clear the stomach and bowels. Bicarbonate of potash
(in 10 to 20 grain doses) is then also an excellent stimulant
as well as antacid and sedative. Leeches to the os uteri in
females, and to the perineum in males, sometimes relieve
palpitation—proceeding in the one case from uterine dis-
turbance, or from varicose veins, hypochondriasis, or hepatic
congestion in either sex. Bromide of potassium and ammo-
niated tincture of valerian are also indicated. Digitalis is
useful under the following conditions :—(a.) When there
are palpitation and acute depression of the heart’s action
from shock (Paralysis of the sympathetic of Romberg),
marked by a small feeble pulse, coldness of skin, cold breath,
diminished temperature, and evidence of the organic system "
of nerves being acutely depressed. The heart’s walls con-
tract ineffectively. It does not respond to the stimulus of
its contents. Combined with other stimulants, the adminis-
tration of digitalis in a case of shock, following parturition,
was followed by the most satisfactory results (Drs. Fother-
gill and Wilks, Med. Times and Gazette, Jan. 16, 1864). In
Dr. Wilks’ case, the patient seemed to be iz articulo mortis
—the face livid, no pulse at the wrist, and a mere fluttering
HEMIPLEGIA, 195

heard over the region of the heart. Brandy and ether had
been given with no result ; and dissolution being imminent,
it was determined to administer digitalis, of which half-
drachm doses of the tincture were given every hour. After
four doses reaction took place, and after seven doses com-
plete recovery occurred. The full veins and condition of
the heart indicated distension and paralysis (Fothergill,
Brit. Med. Journal, July 29, 187%:) (6.) When there is the
irregular action of cardiac asthenia. (c.) When there is pal-
pitation in dilated heart: It is useful to continue the medi-
cines which have been mentioned, but at longer intervals,
for some time. It is important also to counsel the patient
strictly as to diet. It is often found that the palpitation re-
turns after tea or after breakfast, or whenever hot tea or hot
coffee has been drunk. In these cases it is desirable to
avoid all hot slops, and to drink cold water at breakfast, and
indeed at every meal. There are few tonics so beneficial as
the natural tonic of cold water; and persons once accus-
tomed to it feel a return to a modern breakfast a punish-
ment rather than a gratification. Wine should not be taken,
unless largely diluted with water, to be prescribed as required.

Hemiplegia.— Definition —A form of paralysis affecting
one lateral half of the body.

Treatment.—The. object to be aimed at in the early treat-
ment of hemiplegia is to keep down the frequency and force
of the heart’s action. For this purpose strict maintenance
of the horizontal position is necessary ; and when concious-
ness exists, let the mind be kept tranquil by every means.
Remove any local impediment to the easy flow of blood, and
let the head be slightly raised, in a room of equal tempera-
ture. Let the bowels be cleared out, so that no irritation
from them may operate injuriously on the brain. Enemata
ought to be employed ; and castor oil or calomel, with com-
pound jalap powder, may effect an efficient evacuation.
Food should be nutritious and easy of digestion, and not too
abundant.

The gradual removal of blood may be of service by re-
lieving congestion of the right side of the heart, as shown by
engorgement of the veins of the head and neck, and by livid-
ity of surface (Bristowe, Watson). The circumstances under
which its use is inadmissible are thus defined by Dr. Todd:
If the patient be cold and collapsed ; if the heart’s action be
feeble and intermittent ; if there be an anemic state ; if the
196 HEMIPLEGIA.

patient be of advanced age; if their is evidence of exten-
sive disease of the arterial system or of the heart; or, lastly,
if it can be ascertained that already a large amount of
hemorrhage has taken place into the brain ;—these, singly
or conjointly, are reasons why bleeding ought wot to be re-
sorted to. If none of these objections exist, it is to be con-
sidered whether any of the indications noted require to be
fulfilled, and whether they can be fulfilled by a local or gen-
eral blood-letting. Modern investigations show that the
brain is not generally in a hyperemic state; so that it is
chiefly to check or to prevent hemorrhage that bleeding is
to be resorted to in such cases. The sudden or rapid ab-
straction of a moderate quantity of blood, either from the
arm or temple, or by skillful cupping, may check hemor-
rhage, but the quantity taken should be small; and so, like-
wise, the quantity drawn ought to be moderate, if it is de-
sired merely to lessen the frequency and force of the heart’s
action. “Generally, Dr. Todd came to the conclusion that,
in cases of white softening, you are less likely to err by
omitting than by adopting the practice.” The rigidity of
the muscles, which comes on very early and which indicates
an inflammatory process going on round the clot, is to be
combated by urinary and alvine evacuants, and by counter-
irritation. It is not desirable to interfere in the later forms
of muscular rigidity. With regard to the use of expedients
for promoting the restoration of the paralyzed limbs to their
normal condition, Dr. Todd’s experience led him to write
that nothing is of more decided benefit than a regulated
system of exercise—active when the patient is capable of it,
passive when he is not.

Any congestion of the spinal cord apt to supervene on
cerebral hemiplegia must be diminished. The patient should
not lie on his back, but, if possible, flat on his belly, the
arms and legs being encased in flannel, and placed at a lower
level than the spine. A hot douche may also be applied to
the spine, the water falling from a height of at least four or
five feet, through a tube three-quarters of an inch or one
inch in diameter ; and its temperature should be between
98° and 100° Fahr. The application should be continued
two or three minutes, and continued daily for some time.
Dry-cupping over various parts of the spine may also be of
service, and so also may blisters, moxas, and cauteries
(Brown-Séquard).

The most useful internal remedies are those which tend
HEPATITIS. 197

to lessen congestion—namely, belladonna and ergot of rye.
The dose of ergot in powder may be at first three grains
twice a day, and gradually the dose may be increased till it
reaches six grains twice a day. Belladonna may be applied
to the spine in the form of a plaster four inches wide and six
or seven inches long; and if no amelioration of the symp-
toms follows in a few weeks, the extract of belladonna may
be given in doses of a quarter or a third of a grain twice
daily: and if after six or eight weeks of this treatment no
improvement is observed, iodide of potassium, in doses of
five or six grains twice a day, may be given in addition to
the belladonna (Dr. Brown-Séquard). If meningitis is be-
lieved to exist along with chronic myelitis, then the iodide
of potassium should be given from the very commencement,
along with belladonna, or with secale cornutum (Dr. Mer-
yon). It has been given in doses of x. to xvili. grains daily
for two nionths with success, in a case where loss of feeling
over the whole of one side was complete for two years (Bri-
quet). Spermatorrhcea may be relieved by pressure applied
over the region of the prostate (Thomas and Meryon).
Electricity must not be used, even for purposes of diagnosis,
in a recent attack. It may only be used after a long period,
to prevent atrophy of paralyzed limbs, when the application
of galvanic currents and the use of the flesh-brush are recom-
mended. When cedema of the limbs exists, a warm bath to
the part every night is of service. The bowels must be
kept open ; and if anodynes are required, opium should be
avoided, and hyoscyamus, conium, or Indian hemp should
be used instead. Jodide of potassium ought to be taken
before food in the morning, and an hour before dinner, so
as to avoid its presumed decomposition by the gastric juice.

The nutrition of the spinal cord ought to be improved by
the daily use of the cold douche; and sea-bathing may be
of service. If symptoms of irritation do not exist, bella-
donna is not to be given; it is only in cases of congestion
that it may be useful in diminishing paralysis; and the
same rule applies to ergot of rye. Strychnine increases the
amount of blood in the spinal cord. It may be employed
in paralysis only when there is no sign of irritation, and
ought to be avoided when there are signs of congestion or
irritation (Brown-Séquard).

Hepatitis.— Definition Inflammation of the liver.
Treatment.—Tartar emetic, in one-eighth or one-fourth
198 HEPATITIS,

grain doses every two or three hours, is of service in the
acute parenchymatous inflammation, if given sufficiently early
—i.e. within the first three days, when there is much vascular
excitement, a full bounding unyielding pulse, with a dry hot
skin and scanty urine. Tincture of aconite may be similarly
used. General blood-letting is not to be adopted. Local
depletion by leeches over the region of the liver, and also
round the anus, so as more directly to. unload the portal
system, must be at once resorted to in acute cases; followed
by fomentations and large linseed meal poultices, made-as
light and soft as possible, over the hepatic region. Mustard may
be added to them, or lJaudanum may be sprinkled over their
surface. Saline purgation and alkalies, with or without col-
chicum, are also 'to be freely administered. Some cases may
be best treated by ipecacuanha, as in dysentery. In the
early stage of acute primary hepatitis, should there be no
diarrhoea, a mild purgative should be given at the commence-
ment, to be followed by some mild diaphoretic, such as two
drachms of the liquor ammonie acetatis, with five minims of
the tincture of hyoscyamus, every halfhour. Afterthe skin
has been thus made perspirable, the administration of chloride
of ammonium, should be at once commenced in 20 grain
doses twice or thrice daily, carefully noting its effects, after
the manner advocated by Surgeon-Major Dr. William Stew-
art (Madras Monthly Journal of Medical Science, 1872, and
Indian Medical Gazette; Philadelphia Med. Times, April 13,
1878), Dr, Stewart had previously (1870) published a pamph-
let at Rangoon, in which he called the attention of the
profession in India to the chloride of ammonium which has
since obtained a great and well-deserved reputation in India
and other tropical countries for the treatment of hepatic
congestion; and it has been found of great use in this coun-
try as well asin India (Murchison, “Clin. Lectures on Diseases
of the Liver,” 2nd Edition, 1877, pp. 136 and 624). About
fifteen minutes after the first dose a sensation of warmth is
experienced in the epigastrium, which gradually pervades the
abdomen and becomes diffused over the entire cutaneous
surface. The patient may feel “light-headed,” and at times
drowsy, and the acute pain is either removed or limited: to
some fixed point. A free and equable perspiration takes
place over the entire surface in about a quarter of an hour,
and with each dose similar effects will occur. Other pheno-
mena may occur which the patient and physician must be
prepared for—namely,symptoms referable to the liver or relat-
ILERPES, 199

ed parts, and variously described as a “shock,” or succession
of “shocks,” in the hepatic region, “as something giving
way,” a “pricking sensation,” a “ pulling,” “clawing,”
“working” or “ gnawing”’ sensation. Fomentations or bran
poultices are to be applied to the seat of pain. The diet is
to be limited to arrow-root, sago, and barley flower made
with milk, and barley water may be taken freely. Beef-tea
may be added during convalescence. If liver enlargement
continue on cessation of the physiological action of the drug,
with feeling of stiffness, weight, or uneasiness, it may con-
tinue to be given in smaller doses (gr. v. to x.) thrice daily.
The patient must be kept in bed, and in the recumbent posi-
tion. Alcoholic stimulants, fermented drinks, and solid food
must be absolutely forbidden, and the diet restricted to the
farinaceous food already mentioned. Hot turpentine epi-
thems are beneficial. Iodide of potassium, ‘in combination
with taraxacum, is of service in the chronic forms of
hepatitis.

Herpes—Definition.—This lesion is expressed by red
patches on the skin, of irregular form and variable size, upon
each of which there arises a group, cluster, or crop of ex-
tremely minute vesicles, for the most part in acorymbiform
arrangement.

Treatment.—Dry applications, such as enveloping the parts
in cotton wool after sprinkling with oxide of zinc in fine
powder, or with starch, I have always found better than wet
applications. ‘Tincture of aconite and tincture of opium
have been applied to relieve the severe intercostal pain.
The intolerable burning has been relieved by painting over
the vesicated patches with collodion. It tends to preve t
the rupture of the vesicles, andso to prevent ulceration by
promoting healing of the parts under a scab when inflamma-
tion has subsided. An opiate application, such as Dr. Ful-
ler recommends in sciatica, may be of use in some cases of
shingles, namely :—

B.Tinct. opii, Sp. ther. Sulph. co. ;glycerine, aa 3 iii.; Ext.
Belladonna, gr. xx; misce. A strip of flannel soaked in this
should be applied along the course of the deep-seated pain,
and covered with oil-silk, to prevent evaporation (Waring).

The state of the stomach and digestive organs, and diet
generally, should be regulated. Malt liquors should be
avoided; and, if pain is severe, opiate fomentations may be
applied. Herpes preputialis requires no treatment beyond
200 HOOPING COUGH.

careful ablution with tepid water, and the interposition of a
piece of wet lint between the prepuce and the glans penis.
If there is much pain, the lint should be moistened with a
watery solution of opium.

Hooping-Cough.— Definition. An infectious and (some-
times epidemic) specific disease, preceded and accompanied
by fever of variable intensity ; attended in the first instance
by catarrh, and subsequently by paroxysmal fits of con-
vulsive coughing, which occur in numerous, short, rapid,
spasmodic movements of forcible expiration, suddenly fol-
lowed by a prolonged and deep inspiration marked by a
characteristic sound of a loud, sonorous kind, and variously
named the “kink,” “hoop,” or “whoop.” These paroxysms
of expiratory and respiratory convulsive movements alter.
nately recur several times, till the fit ends by a quantity of
mucus being brought up from the lungs, or till the contents
of the stomach are evacuated.

Treatment, On the invasion of the disease, beyond put-
ting the patient on a low or very moderate diet, and attend-
ing to the daily action of the bowels, there is little occasion
for medicine. It will run its course ; and although no drug
has any direct influence over this disease, one of two indica-
tions of treatment may'be followed. The first is to prevent,
if possible, cerebral irritation or convulsions, or any attack of
inflammation, either of the lungs, the stomach, or of the
membranes of the brain. The second indication, after the
period of danger is past, is to prescribe such medicines as
may diminish, mitigate, and control, as far as possible, the
frequency of the paroxysms, co check those secretions which
are in excess, and to excite those which are in defect. These
objects are best obtained by mild sedatives, combined with
gentle purgatives or laxatives. The -hoice of the sedative
has been considered a matter of much importance. The
Continental physicians have bestowed much praise on bella-
donna, others on hemlock, others on henbane, while some
have contented themselves with opium. It must be admit-
ted, however, that none of these narcotics possess any speci-
fic property in controlling this disease, so that the selection
of the particular one must be left to the discretion of the
practitioner. The mildest sedatives, such as hyoscyamus,
or the syrup of poppies, are the safest and best. Should,
however, belladonna be selected (as it seems to be the most
efficient sedative), if the child be under four years of age,
the dose ought-not to exceed one-eighth or one-tenth of a
HOOPING COUGH. 201

grain of the extract, with the same quantity of the powder
of the leaves in a pill, the pill being dissolved in syrup at
the time when it is to be administered (Trousseau). The
dose should be given in the morning; and only once daily,
commencing with one pill, and increasing to two or more.
Or if hyoscyamus is chosen, half a grain to a grain every six
or eight hours ; while, if it be the syrup of poppies, this
medicine should be~- given in such fractional doses of
a drachm as are suited to the age. Powdered belladonna root
has been recently recommended by Vollaut. The dose is
one-fifth of a grain, given at first once, then twice, then four
times a day, and so on until the paroxysms begin to subside,
when it is to be given at much longer intervals. Thus, he
says, the spasmodic period may be positively arrested in
three or four days (Syden. Society Vear-Book, 1862). Cochi-
neal is an anodyne which sometimes affords relief. I have
found it of marked benefit in cases where the child has been
losing flesh from the constant vomiting following the parox-
ysms of cough. The tendency to vomit has always disap-
peared under its persevering use. It is usually prescribed
in the form of a mixture, consisting of cochineal, 10 grains ;
subcarbonate of potash, 20 grains; sugar, 1 oz.; water,
4 02.; rub together and strain (Squire’s Companion to the
Pharmacopeia, p. 62) Of this mixture, a quarter of a tea-
spoonful four times a day is sufficient for a child one year
old; half a teaspoonful for a child of two years old; and a
teaspoonful for a child of four years. Boiled apples in milk
should be given for food. Ari opiate, in the early stage of
the disease, ought not to be administered alone, as it is apt
to check the mucous secretion. Some purgative or laxative
ought, as a general rule in all cases, to be combined with it ;
such as the confectio senne, rhubarb, castor-oil or manna.
The neutral salts, however, sit easiest on the stomach, and
(as the medicine must be continued) they are the most agree-
able to the patient. If at the outset or afterwards the cough
is very suffocative, an emetic is useful. Five to nine grains
of sulphate of copper dissolved in three ounces of distilled
water, and a dessert-spoonful every ten minutes, 1s the most
efficient (Trousseau). Nitric acid, in the following formula,
has been found of service :—

Acid. Nitrici diluti, f 3xii.; Tinct. Cardam, comp.,
f Ziii,; Syrup, f Zitiss.; Aqua, f $i; misce. Of this mix:
ture, one or two small teaspoonfuls may be given every two
hours (Gibb).
202 HOOPING COUGH.

If convulsions should come on suddenly, and without
headache or other symptom of inflammatory action, small
doses of any opiate, and mustard poultices to the feet, may
relieve the patient ; and should convulsions still continue,
an asafcetida injection may be administered. It often hap-
pens that convulsions are combined with a suppression of
the vomiting, and of the usual glairy discharge. In these
cases leeches, followed by a large linseed poultice, should be
applied to the epigastrium. If the unfavorable symptoms
should .advance, and headache or other symptoms show an
affection of the membranes of the brain, leeches should be
applied to the temples and cold to the head. When the
poison excites inflammation of the tissues or substance of
the lungs, bleeding to a limited amount by leeches may be
required ; but the affection is not to be subdued by bleed-
ing, as in simple inflammation. ‘There is in severe hooping-
cough, as in typhus, cholera, and many other affections, an
unknown element which modifies and gives a specific char-
acter to all intercurrent inflammations, If the intestinal
canal be affected, some purgative, combined with calomel,
may be necessary to free the bowels from their contents. If
the stools be white and muciform, and the patient not re-
lieved, an enlarged state of the follicles may be suspected,
and a linseed poultice should cover the abdomen for some
hours, preceded by an enema of syrup of poppies and barley-
water, which should be administered night and morning.

The disease having passed into the third stage, it is desira-
ble to attempt to abridge the duration of the cough, which
oiten extends to a most distressing length ; and for this pur-
pose tonics, antispasmodics, counter-irritants, and other reme-
dies, either externally or internally, have been recommended.
For medicine there is, perhaps, nothing better than a few
drops of ipecacuanha wine combined with a minute propor-
tion of laudanum or belladonna, to be administered every
two, three, or four hours. The more stimulant antispasmod-
ics, as asarcetida, castor, musk, oil of amber, cantharides, and
camphor, are the remedies which have obtained the most
suffrages in the cure of this stage of hooping-cough. The
two first are in most esteem. Asafcetida should be given in
emulsion, in the dose of one or two grains to a child two
years old, repeated three or four times a day, or even as often
as every two or three hours. Cullen preferred cinchona to
asafoetida, and considered it “the most certain means of
curing the disease.” Many other remedies have been men-
HYDROCEPHALUS, ACUTE AND CHRONIC. 203

tioned, as alum, hydrocyanic acid, oxide of zinc, arsenic,
and many preparations of iron. All of these remedies have
been found to a certain extent useful as tonics ; but in esti-
mating the results of remedies, we should be careful not to
mistake temporary recovery for cure ; and the fact of so very
many remedies being highly spoken of suggests doubt as to
the value of either.

When internal remedies have failed to make any impres-
sion, relief may be obtained by means of local treatment, or
by derivatives, as by some liniment or embrocation, as ‘the
liniment of camphor or of ammonia, or with aszfeetida, oil of
amber, oil of turpentine, or the tincture of cantharides. The
general opinion, however, is, that these do little good unless
they contain some opiate, whose absorption they facilitate,
and this may be attended with danger. The application of
strong solution of nitrate of silver to the skin over the larynx
has been much recommended. Foot baths and the warm
bath have also been used, and often with much efficacy. A
change of air is a resource of great value. A change from
the bad air of a town to the purer air of the country is at all
times a great benefit ; it has also been found that a change
from the country to the town is not less beneficial, and that
the patient is benefitted even by the removal to a short dis-
tance from home.

Dietetic and General Treatment.—The patient should not
be allowed animal food from the commencement almost te
the termination of the disease in its acute form. It is desira-
ble also that the temperature of his apartment should be
regulated, and that he should not be exposed to any consid-
erable or sudden change from heat to cold. In mild weath-
er also, if no local symptom forbids, he should be permitte4
to take exercise in the open air. He should likewise, nex.
his skin, wear flannel.

There are no known means of prevention, except an entire
removal from every source of contagion.

Hydrocephalus, Acute—see Meningitis, Tubercular.

Hydrocephalus, Chronic. — Definition. — Effusion of
fluid in the subarachnoid space, or generally distending the
ventricles of the brain, and differing from cerebro-spinal
fluid in containing more albumen (Hoppe) ; occurring chiefly
among children, and when discovered later in life, generally
dating back to childhood. The tissue of the brain in con-
tact with the fluid, especially the commissural parts, is apt to
204 HYDROPERICARDIUM-—HYDROPHOBIA.

be broken down by cedema into a thin white pulp (hydro-
cephalic or white softening).

In hydrorachis the effusion of fluid is within the cavity of
the spinal cord.

Treatment—For chronic cases of hydrocephalus there can
be no relief. In cases of hydrorachis, where a tumor is as-
sociated with spina bifida, iodine injections have been pro-
posed (Velpeau, Debout, Brainard, Gross, Meryon). In op-
erating, the puncture should be very small, by a small flat
curved needle, directed subcutaneously into the sac. A
drain of the fluid may then be allowed to escape through a
canula, and the injection used must be very weak at first, the
object being to excite a slow process of inflammation in the
cyst. One-eighth of a grain of iodine, and a quarter of a
grain of the iodide of potassium in solution, is the quantity
prescribed for injection by Dr. Gross. Dr. Brainard uses a
solution composed of five eighths of a grain of iodine and
half a grain of iodide of potassium to one drachm of water.
The puncture is to be closed with a twisted suture, and coat-
ed over with collodion. Ananodyne should be administered
and the child kept lying on its face. Mr. W. M. Coates, of
Salisbury, has been also successful by a similar method of
treatment. If the life of the child be saved, paraplegia is
still apt to remain, and perhaps involuntary defecation and
micturition (Meryon in Brit. ed. Journal, July 11, 1863,
p- 28; also “‘ Practical and Pathological Researches on the
Various Forms of Paralysis,” p. 25).

Hydropericardium.—Definitzon.—An increase of the
normal liquor pericardii, containing little albumen, and anal-
ogus to the fluid of chronic hydrocephalus.

Treatment must be regarded by the attendant circumstan-
ces of the case, and in accordance with what has been already
written on the subjects of pericarditis and dropsy. Paracen-
tesis may be fequired. :

Hydrophobia.— Definition.—A disease peculiar to ani-
mals of the canine or feline race, the specific poison of which
being implanted by them in man, or in other animals, pro-
duces a similar malady. The salivaor secretion issuing from
the mouth of the diseased or rabid animal contains and so
conveys the poison whicn inoculates rabies, cither through a
wound or through a thin epidermis with abrasion. The period
of incubation of the poison after inoculation varies from tour
to sixteen weeks, or even longer, before the malady becomes
HYDROPHOBIA, 205

developed. The disease is characterized by severe constric-
tion about the throat, spasmodic action of the diaphragm,
and distress at the epigastrium : all of which are aggravated
or brought about by attempts to take fluid, or by the least
breath or current of air on.the surface of the body, which
produces, in the first instance, an effect resembling that pro-
duced upon stepping into a cold bath. Saliva, tenacious and
clammy, issues from the’mouth. Paroxysms of phrensy, or
of uncontrollable impulsive violence (rabidity), supervene.
The duration of the disease varies from three to six or seven
days, the greater number of cases terminating in death on the
second and fourth days from the accession of symptoms.
Death is generally sudden, and unexpected at the moment.

Treatment.—As there are but few authenticated cases of
recovery from hydrophobia, so there are few instances of any
mitigation of the symptoms by the use of medicine. All that
remains is to mention the most leading experiments that have
been made, with the hope that, as they have not been suc-
cessful, they may not be wantonly repeated.

Dr. Hamilton gives twenty-one cases, and adds, “ many
hundreds more are on record,” in which venesection has
been unsuccessful, though frequent and copious. Opium has
been given by Dr. Babington, to the enormous amount of 180
grains of solid opium in eleven hours, without the slightest
narcotic effect, or the slightest mitigation of the symptoms.
Nord has given a drachm of belladonna in twelve hours,
without any benefit. Dr. Atterly gives to achild eight years
old two drachms of calomel by the mouth, and rubbed in two
ounces and ahalf of strong mercurial ointment in a few hours,
with an equal want of success. A case, however, is related
by Ligget, which is said to have been successfully treated by
half-drachm doses of calomel, given to the extent of ptyalism,
induced in three days, after four and a half drachms of
calomel had been taken. The case really appears to be one
ot hydrophobia ; and recovery is said to have been complete
by the twelfth day (Amer. Quar. Journal of Medical Science,
Jan., 1860). Iron, arsenic, nitrate of silver, camphor, musk,
cantharides, turpentine, tobacco, acetate of lead, ammoniacal
solutions of copper, hydrocyanic acid, galvanism, strychnine,
mitrous oxide, chlorine, and guaiacum, have all been given in
equally large doses, but have signally failed. In addition to
these, Ploucquet in his “ Literatura Medica Digesta,” has enu-
merated nearly 150 other medicinal remedies, The failure
of every remedy by the mouth, and the inefficacy of opium,
206 HYDROPHOBIA.

of morphine, and of laurel water, even when injected into the
veins, so convinced Majendie that in hydrophobia the con-
stitution was armed against the action of any medicinal sub-
stance, that on a patient laboring under this disease being
brought to the Hotel Dieu, he determined to rely for all treat-
ment on an injection of warm water into the veins. The
patient, at the time of the operation, is represented as being
absolutely insane, so as to require to be restrained. In this
state, and with a pulse of 150, Majendie injected into his
veins, in the course of two hours and a quarter, two pints of
water, at the temperature of roo°. At the conclusion of this
operation the pulse had fallen to 80, and the patient had re-
covered his senses, so that restraint was no longer necessary.
The sequel, however, renders it doubtful whether this miti-
gation was desirable at the price of the intense suffering which
followed. The poor man lived eight days afterwards, but the
despondency and mental agitation quickly returned, and at
the end of three days the poison (or the state of the blood
induced by it and the warm water) appeared to set up anew
series of actions on the synovial membranes of the wrists,
elbows, and knees, attended with excessive pain, so that ne
was unable to bear the weight of the bed-clothes, and he died
in great torture. The articulations thus affected were found,
on fost-mortem examination, to be greatly inflamed, and
their cavities filled with pus. This case is remarkable as
being the one in which life was prolonged for the greatest
period of time recorded of this disease. The experiment has
since been repeated by Gaspard and others ; but the mitiga-
tion, if any, has been so slight and transient as to give no en-
couragement for repeating it; and, tried on the rabid dog by
Youatt and Mayo, it proved eminently unsuccessful.

The property which some animal poisons have of controlling
and of interrupting the actions of other morbid poisons on
the constitution has caused even animal poisons to be tried
in the cure of thisdiseasc. The rapid and powerfully acting
poison of the viper led to the hope that the bite of that rep-
tile might prove an antidote to the hydrophobic -virus ; but
the experiment, tried in France, Germany and Italy, upon
animals, has been entirely unsuccessful. M. Grindard con-
ceived that the vaccine virus might influence hydrophobia,
and he vaccinated a hydrophobic child in three places, and
afterwards injected five charges of vaccine lymph into the
veins ; but the child died without any marked remission, and
in the usual time. The following draught has been found
HYSTERIA, 207

rather to promote euthanasia than to hold out any prospect of
cure :—

BR Spirit. A&ther. Sulph., Tinct. Opii, aa mxx ; Spirit.
Ammon. Aromat., 3ss.; Chloroform, mxx; Mist. Camph.,
Ziss.; misce. To be given as often as may be considered
safe (Cunningham, Carden).

On the same principle chlorodyne may too be given. The
vapor bath is sometimes useful in moderating spasm,
Having regard to the symptoms generally, and to the morbid
appearances as being in many respects similar to tetanus, the
remedies recommended in that disease might be successful in
some cases of hydrophobia. Sialagogues have recently been
advocated upon theoretical considerations, especially the ex-
tractum jaborandi fluidum, of which one drachm represents
one drachm of the leaves as prepared by Messrs. Gall & Co.
Curare has also been employed, but not with success, mainly
at the suggestion of the late Dr. Francis Gibson of St. Mary’s
Hospital, London. For this purpose, Messrs. Gall & Co.
have prepared an injectio curare (three minims being equal
to one-third of a grain), which it is advised should be injected
at intervals of a quarter of an hour’or more, as soon as indi-
cations of the physiological action begin to diminish.

Preventive Treatment.—The probabilities are, that unless
the operation of excision, or cauterization, be performed
within a few mirutes after the bite of the rabid animal, it is
impossible to save the patient from the fatal disease, which,
according to the susceptibility of his constitution, may
threaten him at any moment. In all probability no prophy-
lactic medicine exists in nature, and the administration of
any potent substance by way of prevention is worse than use-
less ; for, without protecting the patient, it may injure his
constitution. Mild remedies, if they tend to tranquilize his
mind and appease his apprehensions, may be innocently em-
ployed.

The theory which maintains that a zymotic incubation first
takes place in the wound, by which the poison is originally
implanted, suggests the most rational prophylactic—namely,
to destroy entirely by potass fusa the whole cicatrix, where
practicable ; or, by some other surgical means, entirely to
remove it at as early a period as possible, and previous to the
occurrence of symptoms.

Hysteria.—Defnition:—A complex disorder of all the
cerebral functions, of a chronic kind, occurring mainly in
females from the age of puberty upwards, It is probably
208 HYSTERIA.

associated with some morbid state of the emotional or
sensori-motor centres, and presents every variety of altera-
tion, so that the phenomena of hysteria are protean, simulat-
ing or mimicking the phenomena of almost every other dis-
ease, while the most common and characteristic features of
the affection are certain motorial changes of a convulsive
nature, usually of paroxysmal occurrence.

Treatment.—The treatment may be divided into what
should be done during the fit, and into what should be done
afterwards.

When the patient falls into a fit of hysteria, the first thing
to be done is to loosen everything tight about her person,
The window should be opened, and the cold air allowed to
blow over her. She should then be laid in the horizontal
posture on a bed, or on the floor, as a means of rendering
the circulation through the brain more equal, and to enable
* us the more readily to control the convulsive movements of
her body. This being done, many modes of further pro-
ceeding may be followed. Some recommend, in plethoric
cases, that the patient should be bled—a remedy certainly
in many instances manifestly improper, and in all of doubt-
ful efficacy. When the jaw is locked, an enema, consisting
of the yolk of an egg’beat up with two drachms of asafcetida,
with half a pint of water added, may be administered; or,
still better, an enema of turpentine, in which half an ounce
of turpentine is similarly mixed with the yolk of an egg, and
half a pint of water added. These remedies, in some in-
stances, instantly remove the affection, but in other cases
not for some hours. Another remedy is to fill the mouth
with salt. The remedy, however, which supersedes all
others, and is unquestionably the best, is a good drenching
with cold water. ‘I believe there is more virtue in cold
water than in any other single remedy” (Watson). If the
patient lie on the bed, the head should be drawn over its
side, and a large quantity of water poured on it from a con-
siderable height out of a pail, jug, or other large vessel, and
directly over the mouth and nose of the patient, so as to
stop her breathing, and compel her to open her mouth.
This practice is generally introduced into hospitals; and un-
til it was adopted it was not unusual to see three or four
patients in hysteria in the same ward, and at the same time.
Under this practice, however, an hysterical case is rare, the
fit seldom occurs twice in the some person, and the affection

never becomes epidemic.
HYSTERO-EPILEPSY—ICH THYOSIS. 209

After the paroxysm is over, if the patient complains of
continued headache, a few leeches to the temples may be
necessary, especially if the urine be small in quantity and
high colored ; but in all other cases leeches, blistering, or
cupping should be avoided, as tending rather to aggravate
than to control the disease. The next object is to regulate the
bowels by such remedies as may be necessary, and at the
same time to support and tranquillize the patient by stimu-
lants, such as ether or asafcetida, combined with hyoscyamus
in the form of tincture, the syrup of poppies, or small doses
of morphia.

Niemeyer recommends the chloride of sodium and gold as.
a restorative nerve tonic. He prescribes in the form of a
pill, as follows :

}}. Auri. chlorat. natronat, gr. v.; Gum. tragac. Co., 31;
Sacc. Alb.,q.s-; misce. Divide into forty pills, of which one
is to be taken an hour after dinner, and another an hour after
supper. After a time, two are to be taken as a dose at one
time, and increased gradually till eight pills a day are taken;
a cold shower bath twice daily.

The stateof the uterine functions must always be inquired
into. If leucorrhcea be present, or the menstruation be pro-
fuse, the mineral acids, or the bitartrate of potass., will be
found most efficacious, by restoring a more healthy state of
the deranged organs.

The urine is often suppressed for a time after an attack of
hysteria; but unless the bladder be sensibly, and perhaps
painfully distended, no attempt should made to draw the
urine off. Something more should be hazarded to avoid
this necessity, for the catheter once passed, that operation
will require to be performed morning and night, perhaps for
several months. It is important that pity, attention, and
sympathy be withheld.as much as possible from hysterical
patients. The moral and bodily condition deterioates under
such influences. Firmness is essential for successful treat-
ment.

Hystero-Epilepsy— See Lpilepsy.

Icterus—See Jaundice.

Ichthyosis.— Definition —A lesion which involves the
whole tissue of the skin and is characterized by the growth
of thick, dry, imbricated scales 0° a dirty grey color, resting
upon a perfectly uninflamed surface, and never accompanied
by pain, heat, or itching.

14
210- ILEUS—INFLUENZA,

Treatment—Remedial measures are only palliative, con-
sisting mainly of mucilaginous and glycerine lotions, with
vapor baths to mollify the roughness. Potash solutions, or
other preparations of potash, are contra-indicated as local
applications,

Tleus—Sce [ntestines, Obstrurtion of.
Infantile Convulsions—Scee Convulsions, Infantile.

Influenza—Definition—A specific catarrhal inflamma-
tion of the mucous membrane of the air passages, and gen-
erally also of the digestive organs, with severe constitutional
disturbance. The disease is invariable in its essential char-
acteristics, frequently prevailing as an epidemic, attended
with lassitude and prostration to an extreme degree, with
special and early implication of the naso-laryngo-bronchial
mucous membrane, Frequent chills occur, and great sensi-
bility to cold exists over the surface of the skin; the eyes
become injected, and tend to fill with tears, the nostrils dis-
charging an acrid fluid; attended with fixed and intense
pain in the head, mostly frontal over the eyes, sometimes al-
so attended with giddiness. The nights are sleepless, with
delirium or lethargy; cough prevails with yellow expectora-
tion, most troublesome at night, and tending greatly to in-
crease the headache. Fever attends the disorder, some-
times slight and sometimes severe, and of a type varying in
different epidemics and localities. The duration of the fever
is definite, of from four to eight days (Parkes). The sense
of taste is greatly disordered, and there is great anxiety
and depression over the region of the heart.

Treatment.—As a general rule, the great majority of cases
in epidemics of influenza have scarcely required any medical
treatment. In 1782 it was observed that “many, indeed,
were so slightly indisposed as to require little or no medi-
cine; nothing more was wanted to their cure'than to abstain
fortwo or three days from animal food and fermented
liquors, and to use some soft, diluted, tepid drink. A gentle
purgative at the beginning of the disease was useful in mod-
erating the fever; and nature seemed to point out the repe-
tition of it afterwards when there was pain in the stomach
and bowels, and a tendency to diarrhoea.” The same was
observed in 1762. Nothing, likewise, was observed so suc-
cessful in mitigating the cough as to open the bowels, and
afterwards giving a gentle opiate at night. In the year 1837
it was also remarked that, as long as the symptoms were lim:
INFLUENZA, 211

ited to cough, hoarseness, headache, or other pains moderate
in degree, the patients all recovered by putting them ona
low diet, by attending to their bowels, and confining them
for a few days to the house. It was quickly found that the
disease ran a course scarcely influenced by medicine. A
small number, however, required medical aid, either from
the severity of bronchitis, the occurrence of pneumonia, of
angina, or of severe dyspnoea, of the disordered state of the
bowels, or more frequently from the debility induced by the
disorder. Blood-letting, even by leeches, is always hurtful.
It does not relieve the fever, and increases the nervous de-
pression. But when pleurisy, bronchitis, or pneumonia may
supervene, leeches to the chest, or cupping, may relieve
symptoms: A mild purgative dose of calomel (one to three
grains) should be given once at first, followed by a saline
purgative. Dark-colored motions are brought away, the
spirits improve, and the fever abates. But mercury must not
be given beyond an occasional purge. Emetics are also to
be avoided. They increase depression, and are apt to pro-
duce irritability of the stomach difficult to subdue. Hot
fomentations, bran, mustard, or linseed meal poultices to the
chest, or flannel or cotton wool énvelopes, are often of great
comfort and usefulness. During convalescence sulphate of
zinc is a useful tonic when the expectoration is thin and spu-
mous; and alkalies are more useful when it is viscid and
glairy (Peacock). Nitrate of potash, highly diluted and
mixed with lemon juice and sugar, is a most useful drink.
From 60 to 120 grains in twenty-four hours may be taken.
Stimulants are early called for on account of the intense
prostration. Opium must be used with great caution in the
severe pulmonary complications. Its use ought to be put off
till the later stages, otherwise it may increase the tightness
_ of the chest and the dyspnoea. It must not be given till all
danger of lung congestion is past. When the fever and other
immediately alarming symptoms of the influenza had ceased,
there frequently remained a teasing cough, and the conva-
lescents in general complained of languor, want of appetite,
and that their sleep was broken and unrefreshing. For re-
moving these complaints, change of air and riding on horse-
back were most effectual. ‘fo some they were absolutely
necessary; and, in addition to these, mild tonics, or the nat-
ural chalybeate waters drank at the Spas, were of singular
service. In slight cases it was sufficient to limit the patient’
to white fish and puddings; and in the more severe forms, to
212 INSANITY.

slops and light puddings. The night air was universally pre-
judicial. 1t does not appear that any precautionary treat-
ment was of service in preventing the spread of the disease
among the attendants on the sick. ey

Insanity .— Definition.— Disorders of the mind consequent
on brain lesions, or attendant on affections in which the
brain is secondarily or remotely implicated. Feelings, Emo-
tions, Intelligence, or Will of the patients, conjointly or sep-
arately, are exalted, perverted, or impaired. °

The Zreatment of insanity resolves itself into the medical
and the moral management of the case. Medicine indirectly
acts upon the brain as it does upon other organs, so as favor-
ably to influence the course of the disease. It regulates the
different actions and secretions of the viscera of the body,
and thus improves the general health, so that the happiest
results are obtained by the early and judicious use of medi-
cinal agents. Nouniform method of treatment can be taught.
The condition is essentially one of asthenia, feebleness,
anemia, or exhaustion. Local bleeding may be adopted in
some cases with reference to a distant viscus. Leeches to
the vulva and thighs are beneficial in some cases of mania,
monomania, or melancholia’ in adults, when such disorders
of intellect are concurrent with the menstrual period ; and
to the sphincter ani in those cases obviously connected with
suppressed hemorrhoids or hepatic congestion. In somein-
stances leeches may be applied with benefit to the Schneide-
rian membrane, particularly in those cases occurring in early
life, and in persons of plethoric constitution and of sanguine
temperament. Illusions of hearing or of vision, which had
embittered the patient's life, have been removed by leeching
behind the ears or over the superciliary ridges. ‘lhe utility,
in acute mania, of prolonged hot baths was much insisted
upon by the late Dr. Winslow. The patients remain from
eight to fifteen hours in them, at 82° to 86° Fahr., whilst
a current of water at 60° is continually poured over the head.
Various details of what is now known as hydropathic treat-
ment have recently been introduced, with great advantage,
into English asylums, such as the Russian or vapor bath, the
wet sheet, wet pack, and the like. Packing in the wet sheet,
warm baths with cold to the head, will often procure sleep
more certainly than medicine of the sedative or hypnotic class.

Sedatives, or agents which modify directly the condition of
the cerebral tissue, and which procure sleep or rest to the
brain, constitute very valuable remedies, In recent acute
INSANITY 213

Cases they are generally admissible, and are only contra-in-
dicated if constipation keeps up the excitement and sleep-
lessness’ or if local cerebral irritation exists; or if the gen-
eral health and secretions are disordered. In the various
chronic forms of melancholia they are most useful, and in
suicidal insanity. The meconate and hydrochlorate of mor-
phia should be uninterruptedly and perseveringly given, in
gradually increasing doses, until the nervous system is com-
pletely under their influence. The preparation Dr. Millar
has found most useful and the least productive of constitu-
tional disturbance, is a solution of opium in water, acidu-
lated with citric acid (containing about one-sixth of crude
opium) administered every four or six hours, in doses of
from 10 to 20 minims, (equal to 10 grains of crude opium
daily), and continued until the patient feels he can sleep
without it. So also will chlorodyne and chloro-morphine be
of use in some cases, as well as chloral, bromide of potas-
sium, and hyoscyamus. Indian hemp is an extremely useful
sedative, not hitherto appreciated sufficiently for many rea-
sons. (See an excellent paper on its uses by Professor Rus-
sell Reynolds, in Beale’s Archives, Vol. IL, p-154.) It re
lieves pain, is soporific, anodyne, antiepecmodics and while
conducing to sleep, promotes at the same time diaphoresis
and diuresis, without producing headache, vertigo, constipa-
tion, or impairing the appetite. The dose varies from one-
sixth to one-half grain for a child, and from one-third to one
grain and a half for an adult. In cases of mental or emo-
tional disturbance it will be found extremely useful, espe
cially where there is deranged cerebral circulation, with pain
and delirium; in cases of incipient insanity after fever or
sunstroke; and in cases of senile ramollissement. Recently
digitalis, conium, belladonna, have been extensively em-
ployed as calmatives. Endermic medication in insanity offers
numerous advantages; and hypodermic injections, especially
of calmatives and soporifics, have: also recently been em-
ployed. Dr. Reissner’s experience leads him to recommend
morphia, codeia, and narceia, the former being much the
most useful, and the others only to be used in special cases
when morphia fails: Narceia he recommends in those cases
where the injection of the morphia produces unpleasant
symptoms of an uncomfortable kind—not to say of a pois-
onous tendency. Narceia he considers a special remedy in
such cases. Preparations of opium introduced into the sys-
tem by the hypodermic method, are more speedily mani-
214 INSANITY.

fested by the results than when administered by any other
mode. The acetate of morphia is the best form with a min-
imum of acetic acid, in hot distilled water, in the proportion
of five grains of acetate of morphia to one fluid drachm of
water or of glycerine. Qne minim of this represents 7, of a
grain—a safe and useful minimum dose. Two minims (equal
to 4 of a grain), is the best commencing dose for relief of
severe pain, and as a hynoptic in states of nervous irrita-
bility, whether connected with disorder of the intellect or
other diseases. Three minims or 4% of a grain, is an unsafe
dose to commence with; dangerous and even fatal results
have resulted from such a dose. It should not be given till
smaller doses have been tried. Used endermically, the salts
of opium are reckoned to be three times as powerful as when
swallowed (Waring). Hydrate of chloral is of use in subdu-
ing the delirium of mania and sometimes in obtaining sleep,
combined or not with bromide of potassium.

Purgatives may be regularly required. When the bowels
are constipated the form is best determined by the state of
the tongue, and sometimes by the idiosyncrasies or proclivi-
ties of the patient in regard to medicine taking. Supposing
the tongue to be white and coated, the sulphate of magnesia,
or other neutral salt, combined with tincture of hyoscyamus,
in the proportion of 3 j. of the former to mxv. to mxxx. of
the latter, in camphor mixture, is a formula to be recom-
mended ; so also is calomel (five grains) with compound ja-
lap powder (3i.), and a little powdered ginger; and also
watery extract of aloes nightly. If, on the contrary, the
tongue beclean, the cathartic should be given with some
slight bitter, as the infusion of orange peel or of gentian. In
some cases the bowels are not only exceedingly obstinate,
but the patient may be greatly averse to all medicines. In
such cases one or two drops of croton oil placed on the
tongue or introduced in food produces free evacuations.
Mild purgative treatment formed the basis of cure in the
school of Pinel and of Esquirol, usually combined, in cases
of violence, with the application of cold to the head, and of
warmth to the lower parts of the body ; such as piacing the
patient in the warm bath, and giving him the cold douche—
a remedy since more particularly insisted upon, The fur-
ther treatment consists in restoring any other functions that
may be in defect or in excess, as the functions of the uterus
in the female, and of the liver or heart in both sexes, by the
usual remedies applicable for these purposes.
INSANITY. 21g

. When there is anzmia, vegetable tonics, combined with
the preparations of iron, are of great service. At the same
time the patient ought to be supplied with an abundance cf
nutritious and easily digested food. It quiets the noisy, and
lessens the dirty, mischievous, and destructive propensities
of others. Where there is an absolute refusal of solid food,
as in acute mania, it is essential that the liquids (which the
patient for the most part readily takes) should contain as
much nutritive material as possible. Strong soup and broth,
beef-tea mixed with milk and with arrow-root, must be given
often. The best form of food is that in which eggs and
milk largely enter. Two or three eggs beaten up, and mixed
with a half a pint of warm milk, warm ale, or warm porter,
may be given with a sedative every four to six, or eight
hours, and continued daily till excitement abates, or the abil-
ity to take solid food returns. Such stimulant food is well
borne, and absolutely necessary in cases of acute mania. In
melancholia, three to twelve ounces of wine may be neces-
sary in the twenty-four hours; and there is also a tolerance
of opium. Ten minim doses may be given three times a day.
If impulsive tendencies are manifest with despondency, bro-
mide of potassium should be given in thirty to forty grain
doses, with an iron mixture. If the tendency is to atonic
lethargy, large doses of quinine, or small doses of strychnia,
are to be given with the iron. -Easton’s syrup is valuable.
In neuroses of the stomach and gastralgia, arsenic and bis-
muth are both of much service in small doses. Muriate of
ammonia is of special use in those cases in which the de-
pression is intense and paroxysmal in character.

The moral management of disorders of the intellect is by
many supposed to constitute the more efficient mode of cure;
and it must be admitted to be a most important adjunct.
The first important rule is to remove the patient at once from
his family. In slightcases this step is necessary in order that
" he may be induced to exercise such command over himself
as he possesses, and to remove him from influences which
may have been aggravating his morbid state ; such as finding
himself a prisoner, instead of being master in his own house.
In severe cases it is necessary, in order to prevent his doing
mischief either to himself or others. In melancholia no form
of treatment is so efficacious. The great object is to break
up the monopoly of grief and fear which has obtained pos-
session of the mind; andif a new interest can be awakened
or a fresh hope insinuated, this object is in a great part ob-
216 INSANITY.

tained. At the same time solitary brooding and idleness
must not be permitted; and at least cheerful companionship
must be secured. It is important also to seek out and to
treat visceral or constitutional diseases and relieve them—
é. g., gout, syphilis, uterine disorders, climacteric conditions,
and the like. The main featurein the moral management
of the insane in this country is the abolition and absence of
mechanical coercion or restraint. The beneficial action of
this system, generally known as “the non-restraint system,”
is now thoroughly recognized in England and Scotland,
where it has been gradually established in every asylum since
1847-48. But there are certain exceptional phases of insan-
ity, in which some mechanical restraint is the most humane
mode of treatment—the only mode, indeed, of avoicing cer-
tain catastrophes of too common occurrence. In certain
‘conditions of excitement it is proper to place the patients at
once in a darkened room, remote from the noise and the
means of injury to himself or others, so that as few objects
as possible may irritate him, just as a patient with his eyes
affected is kept in adarkened room. The effect of such se-
clusion is generally of a soothing character; and in not a
few cases of periodic maniait is eagerly sought for by the
patients themselves. When a case of melancholia is of se-
vere type from the first, muriate of ammonia and tincture of
opium are the most valuable egents. There is a tolerance of
opium.in simple melancholia. So long as depression lasts
it is taken with benefit to every function. When depression
terminates it may be abandoned at once without inconveni-
ence. As convalescence advances the patient should be in-
duced to undertake some manual labor, or some office in
the asylum or household, which, by amusing his mind, will
invigorate his body, and greatly tend to restore the healthy
working of his brain. There are no more powerful moral
medicines than “occupation,” “recreation,” and ‘‘ educa-
tion.” Occupation should be such that no time is left for
idleness; or for sitting brooding over morbid fancies. The
curative results of well-chosen means of recreation cannot
be over-estimated.. When the circumstances of the patient
admit of it, traveling, which embraces change of air and
change of scene as well as exercise, is oftea highly salutary
in incipient cases; and much has of late been done by the
judicious introduction of music and other amusements into
asylums. Change of scene acts often like a tonic to the de-
pressed and jaded powers; but where there is great restless:
INSOLATION—INTERMITTENT FEVER, ai7y

ness and feverish perturbation, traveling and change of scene
should not be resorted to (Dr. J. Crichton Browne). Con-
certs, balls, conversaziones, evening entertainments, pic-nics,
excursions, fetes champetres, athletic games, pedestrian ex-
cursions, public amusements in towns, and carriage drives,
are all legitimate and well-approved means of maintaining a
constant and varied succession of recreation adapted for. all
classes of the insane. When reason is restored and the af-
fections again fix themselves on their natural objects, and
when the emotions are under control, the patient may be al-
lowed to see his friends, and have his attention directed to
the affairs and interests of his family; but it should be re-
membered that the mind remains weak and enfeebled for
some time after apparent recovery ; and, consequently, the
patient’s restoration to society should be gradual.

An hospital for the insane, or a lunatic asylum, is the
most fit and proper place for a “person of unsound mind.”
But every such asylum ought to be governed by one superin-
tendent, who should be a medical man—an officer of health
to the community over which he presides. He ought to have.
the means of controlling all sanitary arrangements in whole
and in detail—of avoiding over-crowding—of preventing and
destroying effluvia—and of examining the quality of the food,
the water, and the drugs furnished to the establishment.
Chemical and pathological appliances ought therefore to be
at his disposal for his use. The number of patients who
may be thus under the supervision of one medical head in
an asylum ought not to exceed 200 (Esquirol, American
Commissioners in Lunacy). Premature removal from asy-
lum treatment, in opposition to medical advice, is greatly to
be deprecated ; and its baneful results are frequently to be
seen, especially in the sad endings ot cases of suicidal mel-
ancholia. In such cases an acknowledgment should be re-
quired oi the recipient ot the patient, or his friends, that he
is removed notwithstarding the assurance given by the med-
ical superintendent that the patient 1s not recovered, and is
unfit for removal (Dr. Lindsay, Thirty-second report, p. 14).
Such removals not unfrequently induce a change of type
from acute and curable to chronic and incurable mental dis-
ease.

Insolation—Sve Sunstroze.

Iatermittent Fever—Sce Ague.
218 INTESTINES, HEMORRHAGE FROM.

Intestines, Hemorrhage From—Definition.—Loss of
blood from some portion of the mucous membrane of the
alimentary canal below the stomach. It may have its seat
in the small intestines, or in the large, or in both, but prob-
ably never flows from the whole length of the canal.

Treatment—Ergot is a useful remedy. Dr. Macgre-
gor, of Glasgow, records a case of persistent periodical
hemorrhage from the bowels which yielded to ergot when
all other remedies had failed (Glas. Med. Journal, June,
1867). In hemorrhage from the bowels in enteric fever,
the tincture of the perchloride of iron is often useful, and
if associated with much arterial action, it may be com-
bined with digitalis, as in the following formula :

R Tinct. Ferri Perchlorid., m xxx.; Tinct. Digitalis, m
xv.; Aq. Menth. Pip., 3iss., repeated every four hours
(Waring).

In the event of failure, the iron tincture may be used as an
enema, combined with opium, in the foilowmg formuia

BR Liq. Ferri Perchloridi, m xv.; Morphie ‘ydrocl:lor,
gr. %; Aq. Tepid, %iv.; Misce (Dr. John Harley}.

In cases where there is a tendency to syncope from intes-
tinal hemorrhage, oil of turpentine (m x. to m xv.) every half
hour or hour has proved an effectual remedy (Dr. John Har-
ley). The treatment of hemorrhoids consists—(zx.) In fo-
menting them with hot water, with the free use of Castile
soap, when they are in the acute stage of inflammation, and
of a dark red appearance, throbbing, and painfully burning,
as if a red-hot coal had been applied to them. In this condi:
tion dusting with calomel has been found to give relief (Bid-
dle, Atkinson, Practitioner, Vol. XXIII.; 1879, p. 104). (2)
If the pains continue excessive, a {ew leeches may be applied
to the margin of the anus ; and, at the same time, the bitar-
trate of potash, combined with sulphur and guaiacum, in the
proportion of one part sulphur aad of guaiacum to two of
cream of tartar, a teaspoonful being taken three or four times
a day, which ought to keep the bowels gently relaxed. Nu-
merous cases have now been published which confirm the
value of glycerine, in doses of a dessert-spoonful twice a day,
in the treatment of internal and external hemorrhoids (Dr.
David Young, Practitioner, |. c., p. 251). The protruded
bowel ought also to be carefully washed with a sponge and
cold water after defecation, and the use of paper entirely
discarded. To relieve the weight and tension after use of
soap and fomentation, compound gall ointment and bella-
INTESTINES, INFLAMMATION OF—ORBSTRUCTION OF. 219

donna extract, in equal parts, should be freely applied every
three or four hours till the pain subsides. In the chronic
stage, the common pitch ointment is the best application (F.
P, Atkinson, l.c.) Stringent rules ought to be laid down as to
diet, which should be light, and the patient limited to
French and Rhenish wines. Ablution with cold water
should be practiced morning and evening; and some per-
sons are sufficiently sthenic even to bear with advantage
an injection of cold water after each evacuation of the
bowel. In prolapsus ani and hemorrhoids, Professor Cle-
land recommends the use of liquor bismuthi as an enema.
A dessert-spoonful of the liquor is to be mixed with half
a wine-glassful of fluid starch, and, after getting into bed
and returning the bowel to its place, to introduce this enema
and retain it.

Intestines, Inflammation of—See Enteritis.

Intestines, Obstruction of—De/finition—An obstacle’
or impediment which obstructs the passage of contents
through the bowel.

Treatment.—In all cases of intussception, whether oc-
curring in children or adults, the administration of purga-
tive medicines tends to aggravate the lesion and the symp-
toms. Accordingly the rule of practice is absolute—
namely, “to withhold all purgative medicines from the com-
mencement in cases of intussusception.” The bowel being
incarcerated, the stimulus of purgation proceeding from above
downwards is quite unable to undo the incarceration of an
intussusception. A purgative acts injuriously as a stimulus
which cannot be obeyed ; and its obvious tendency is to in-
crease the peristaltic action of the bowels, and therefore to
increase still more the invagination. That such is the case
will be readily understood by a physiological consideration
of the phenomena of intussuception : for although it is not
always easy to account for the first beginning of invagina-
tion, yet physiology enables us to understand how an invagi-
nation once begun, the lesion tends to increase—(1.) From
the peristaltic action of the bowel, gently stimulated and in-
creased by irritation of every kind, so long as tonic irritability
continues. (2.) From the spasmodic action of the part of the
gut above the invagination, preventing spontaneous return.
(3.) From the invagination being thus completed, it continues
permanent, tenesmus occurs, and the violent and repeated
220 INTESTINES, OBSTRUCTION OF.

contractions of the abdominal muscles tend still more to
maintain and increase the lesion. The constant motion and
pressure of parts one upon another in some cases is so great
that the end of the invagination has been known to penetrate
through the walls of the inclosing bowel, so as to appear in
the cavity of the peritoneum. ‘The chief indications are—
(1.) To prevent distension, by reducing, in every possible way,
the quantity of food and drink, restricting the latter to
small but frequent sips (preferably through a long straw or
tube) of cool iced liquids. Food is to be given, as strong
beef-tea, soup, or milk, with equal frequency and caution.
Small doses of alcohol (as brandy with water, or soda-water)
is to be alternated. But if any repugnance exists to food or
drink, or if vomiting is excited by these articles, the amount
given must be reduced. Water, milk, and gruel are to be
given freely in often-repeated enemata. (2.) To assuage
pain and to mitigate excessive peristalsis suggest the same
kind of remedy —namely, opium, which is to be given con-
tinuously and alone in the solid form, preferably as an ex-
tract. The limit of the dose is indicated by the comparative
arrest of pain, the approach of narcotism, and decided con-
traction ot the pupil. Belladonna is only of use as a remedy
to diminish the straining peristalsis. It may be given com-
bined with opium, as two parts of extract of opium to one,
two-thirds, or even one-half part of extract of belladonna in
a pill Enemata are useful as a mechanical aid to removing
obstruction. They may gradually distend the bowel at the
site of obstruction, so as to effect such a change in its posi-
tion and arrangement as may release the impacted portion
The administration of enemata is only safe and efficient if
undertaken by a person of competent skill. The quantity
of fluid must be injected little by little, and must be retained
as long as possible ; and the patient must resolve to tolerate
some pain in reaching the climax of distension at which only
enemata are calculated to relieve obstruction. In cases
where the intussusception is in the large intestine, inflation
of the bowel with air, as originally suggested by Hippocrates
two thousand years ago, in his third book, has of
late years been revived and adopted, first in America, and
subsequently in this country (Gorham, in Guy’s Hospital
Reports, and Med.-Chir. Trans., Vol. IX.) This Hippo-
cratic remedy has undoubtedly been more successful than any
other. Of twenty-eight cases, the details of which were col-
lected by Dr. Osborne, there were only seven recoveries; and
INTESTINES, OBSTRUCTION OF, 221

three ot these were effected by inflation of the colon with air.
Dr. Murphy and Mr. Erichsen have borne strong testimony
to its value in discussion on the subject; and the former
had recourse to the operation on one of his own children
with success (MS. Notes of Dr. Osborne). For its success,
the remedy should be employed at an early period, before
there has been time for adhesion between the contiguous sur-
face of the volvulus. My friend, Dr. David Greig, of Dun-
dee, has had recourse to this method of treatment in numer-
ous instances with perfect success, and has published an ac-
count of his experience in the £din. Monthly Med. Journai
October, 1864. By means of the ordinary elastic enema
tube, fitted to the pipe of a small pair of bellows, he was able
to pass aconsiderable quantity of air into the rectum, con-
tinuing the process till the belly showed signs of considerable
distention, and even till uneasiness prevailed. Its beneficial
action is indicated by relief of the urgent symptoms, such as
straining and vomiting ; and gradually a faecal evacuation is
obtained from the bowels. At the same time warm fomenta-
tions are to be applied to the belly. The use of large ene-
mata, with manipulation, has also been recommended. A
long stomach-tube is to be passed as high up the colon as it
will go, and the anus being firmly compressed round it, warm
water is to be slowly injected, so as to distend the bowel as
much as possible. When the fluid is allowed to come away,
the abdomen should be pressed upon with the hands, so as to
move about the coils of intestine (Tanner). The earlier any
of these remedies are had recourse to, the greater will be the
chances of recovery; and the patient may be put under the
influence of chloroform to facilitate the manipulations.
Gastrotomy, abdominal section, or, as it is now called,
laparotomy, has been successful in many cases, where other
remedies have failed to give relief. Dr. Hilton Fagge and
Mr. Howse have related such a case (Med.-Chir., Trans.,
Vol. LIX., 1876). The operation was advocated by Benja-
min Phillips (see his paper in Med.-Chir. Trans., Vol. XX XI.)
The cases for which it seems suitable are in obstructions
from bands, diverticula, also intussusception, and the like
lesions affecting the small intestine. The objectof the oper-
ation is to divide the cord-like cause of strangulation (Brin-
ton); or to undo an invagination, all of which may be now
easily accomplished under the antiseptic spray. If the
bowels be much distended with air they may be punctured
with a small trocar and canula, Stercoraceous accumula-
222 ISCHURIA RENALIS—-JAUNDICE,

tions must be mechanically removed. Repeated enemata of
warm water, delivered through a long tube, will gradually
permeate and disintegrate the mass ; and when it begins to
break up, continued 3 ii. doses of Epsom salts, with a grain
of quinine, in aromatic sulphuric acid and infusion of gentian
will gradually bring the bowels to a normal state of activity

Ischuria Renalis—See Urine, Suppression of.

Iteh—See Scabies.

Jaundice — Definition.— Certain morbid conditions in
which many of the different tissues and fluids of the body
are dyed yellow, or otherwise discolored, more especially the
conjunctiva and the connective-tissue, from the coloring
matter of the bile.

Treatment.—As a general principle, the larger number of
cases of jaundice from functional disorder (perhaps four out
of five) get well spontaneously, aided by remedies judiciously
selected according to the diagnosis already indicated. The
first indication is to aim at removing.the exciting cause; and
in jaundice due to congestion of the liver, purgatives. seem
to act beneficially in the form of blue pill or Plummer’s pill
with aloes, and nux vomica with rhubarb pill mass. In cases
of acute jaundice—from suppression of the biliary secretion
consequent on a powerful nervous shock or mental perturba-
tion—Dr. Anstie has seen two or three doses of hydrochlor-
ate of ammonia, to the extent of grs. xx. every four hours,
produce a restoration of the biliary secretion. He regards
it as a most powerful restorative of the biliary functions,
Acids and alkalies are alike contra-indicated in cases of
jaundice resulting from active congestion of the liver. Ben,
zoic acid has been recommended ; and Dr. Harley has found
it useful in cases of suppression of bile (by innervation, for
cxample); but in cases of jaundice from obstruction it is
injurious. Podophyllin is also of use in jaundice from sup-
pressed secretion of bile. It ought .to be combined with
hyoscyamus. It is especially useful in the cases of feeble
liver, combined with vegetable tonics, such as gentian and
quinine ; but it ought not to be given in cases of jaundice
from obstruction. The medicine of all others which has
seemed most generally useful is sulphate of magnesia, in half
drachm to drachm doses, combined with fifteen grains of car-
bonate of magnesia, and half a drachm of aromatic spirits of
ammonia, given three times a day an hour before food. The
sulphate of magnesia maintains a free action of the bowels ;-
KELOID-—-LARYNGISMUS STRIDULUS, 223

and the carbonate of magnesia neutralizes any excess of acid
in the stomach or bowels.

Keloid—See Cheloid.
Kidney, Abscess of—Sce Nephritis, Suppurative.

Kidney, Floating—Definition—A floating kidney is a
condition in which the kidney has a mesentery or fold of peri-
toneum attaching it very loosely to the spine, by which it
can be moved about to-the extent of the length of its mesen-
tery. A movable kidney merely slips a little under the
fingers.

Treatment.—Wearing a tolerably tight, elastic abdominal
bandage may completely remove the abnormal condition,
and will at least relieve the dragging and uneasy sensations.
Constriction of the thorax at the lower part by stays or
waistbands must be avoided. Constipation and the conse-
quent straining, as invariably aggravating the mischief, must
be relieved. Treatment generally must be of a tonic nature
(Sawyer, 1. c.)

Laryngismus Stridulus—Defnition—A paroxysmal
spasmodic disease in which the muscles of the glottis are
contracted, the vocal cords tightly stretched and so approx-
imated that the glottis is for a time partially or completely
closed. In the latter case there is arrest of the respiratory
movements and apnoea. In the former case there is stridu-
lous inspiration and dyspneea. The affection depends upon
some morbid excitement of the par vagum and its nerve
centres, direct or reflex, and is usually seen in infants,
especially during the period of first dentition, and in children
before the completion of the second year ; and in the great
majority of cases between the fourth and tenth month. It is
also seen in adults.

Treatment.—T wo important indications have been fulfilled
in carrying out the treatment—viz., the relief of the parox-
ysm, and the removal of the morbid condition, whether local
or general, which gave rise to it.

“The immediate treatment generally falls to the nurse or
mother. The little patient should be raised and placed in a
sitting posture, and then he may be slapped on the back,
cold water may be dashed in the face, and ammonia or
strong acetic acid held to the nose. These measures are
often successful by giving rise to violent expiratory actions ;
but remedies calculated to relieve spasms are equally suc-
224 LARYNGISMUS STRIDULUS.

cessful. The warm bath may be used and emetics given
directly there is a sign of the stridor—when the paroxysm is
on, the child will not drink. A favorite remedy in Germany,
and one that is highly successful, is tickling the fauces with
the finger ora feather until vomiting is produced. Depres-
sing enemeta, such as tobacco, have likewise been recom-
mended, but ‘their use is attended with considerable danger.
The ordinary rules for the treatment of disease apply here;

that is to say, gentle remedies should be used in mild cases,
and those of a more powerful character in dangerous ones.
Putting the lower part of the child’s body ina hot bath and
dashing cold water in its face, is a simple and sometimes suc-
cessful plan. The inhalation of chloroform is a very valua-
ble remedy, but of course, must be used with great care, and
cannot safely be employed by non-professional persons. If
the child appears to be sinking from the apnoea, the trachea
must, of course, be opened, and artificial respiration resorted
to. Indeed this should even be adopted by the practitioner
should he arrive shortly after the apparent extinction of life.
Some practitioners recommend the use of antispasmodic
remedies (whether animal, vegetable, or mineral) between
the fits” (Morell Mackenzic).

Where the exciting cause of the attack can be traced to
dentition, the gums should be lanced ; if the affection should
appear to be due to intestinal derangement, means must be
taken to remove any source of irritation from the alimen-
tary canal, and for this purpose perhaps the best remedy is
a dose of castor-oil. Thymic enlargement should be treated
by the application of leechés (according to the patient’s age
and strength), and afterwards by counter-irritation. As re-
gards the constitutional state predisposing to disease, suitable
treatment will be found detailed in the various articles in
these volumes which treat of scrofula, rickets, hydrocepha-
lus, parasites, and the like. Spasm of the glottis has hither-
to been treated as an infantile disorder, but it sometimes oc-
curs in adults. It is usually met with.in women, and is
commonly regarded as hysterical. In these cases, sedative
Inhalations (which cannot well be used in the treatment of
children) generally give prompt relief.

During the intervals of paroxysm means must be taken
to prevent its recurrence. These mainly consist of atten-
tion to the state of the alimentary canal. A searching
purgative is generally called for to clear out the contents of
the bowels—calomel, jalap, and castor-oil are the most use-
LARYNGITIS, 225

ful agents. Belladonna, to the extent of one-sixth of a
grain thrice daily, combined with bromide of potassium or
of ammonium, may be of use. Sinapisms and liniments
are also of use. The diet ought to be carefully regulated.
Change of air is generally called for, and the tepid and cold
bath must be in daily use.

Laryngitis.— Definition Inflammation of the. lining
membrane of the larynx.

Treatment.—In its early stages a warm, moist, and uniform
temperature, with complete rest of the parts, is of the first
importance. Not only should all use of the voice be inter-
dicted, but the tendency to cough should as much as possi-
ble be arrested by the administration of small doses of mor-
phia, especially in those cases in which paroxysmal cough is
a prominent symptom. Inhalations of hot steam, or steam
impregnated with the volatile principles of benzoin, hops, or
conium, are of the greatest service. Flot poultices and
fomentations may also be ordered. Neither local nor general
blood-letting, blistering, mercury, antimony, nor other low-
ering remedies are to be recommended; after the acute symp-
toms have passed off, astringent solutions may be applied to
the larynx to hasten a cure.

In children, a warm moist temperature, poultices, warm
emulcent drinks, and if there is much dyspncea, emetics of
sulphate of copper or sulphate of zinc, are the most
serviceable methods of treatment. When laryngitis oc-
curs in a subacute form, or shows a tendency to become
chronic, a regular system of inhaling should be prescribed.
Any of the appended forms may be employed; and there
are many others contained in the very useful Pharmacopeeia
of the Hospital for Diseasesof the Throat, published by
Churchill, 1871. For the admistration of the ‘following rem-
edies, the Eclectic Inhaler possesses great advantages; for
whilst the vapor to be inhaled is thoroughly saturated with
the volatile principles employed, and 1s kept at a uniform tem-
perature, the patient is able to inhale without effort. [It can
be obtained of Messrs. Bullock & Reynolds, 3 Hanover
Street, Hanover Square, London; or of Maw, Son, &
Thomson, London.] The inhaler devised by Dr. James
Adams, of Glasgow, is also to be commended.

RB. Creasoti, fl. dr. iij.; Glycerine, fl. dr. ij.; Aquee ad. fl.
oz. iij.; mix. A teaspoonful to be added to a pint of water
at 150° Fahr, and inhaled for five minutes twice or thrice
daily.

15
226 LARYNGITIS.

Fs Pini. Sylvestris, fl. dr. ij.1ij.; Mag. Carb. Lev. gr. aoe
; Aquee ad. fi. oz. iij.; mix., and use as above.
wee addition Oil of Juniper, fi. dr. i, ad. fl. oz. iij.; Oil of
Santal, m xv.; Oil of Myrtle, mxx., are all of service.
It will be found convenient to prescribe light carbonate of
_Magnesia as a medium, in the proportion of one grain to
every two minims of the oil; and the addition of twenty
grains of camphor to any of the above makes the inhala-
tion additionally stimulative. When layrngitis is asso-
ciated with inflammation of the pharynx, lozenges con-
taining guaiacum are very useful in removing the hy-
perezemic condition. Even when the pharynx is not affected,
the experiments of Fournie have proved that lozenges have a
decidedly beneficial effect on diseases of the larynx. It is nec-
essary after an attack of acute laryngitis to cautiona patient
that he is very liable to a recurrence of this affection, and that
heshould therefore be very careful to guard against all prevent-
sible causes of the disease. As laryngitis’is more common to
those engaged in in-door than out-door occupations, and
those living in towns than in the country, Niemeyer recom-
mends out:of-door exercise, with proper precautions, as a
valuable prophylactic measure. Acute laryngitis sometimes
occurs as a complication of erysipelas ; but erysipelatous in-
flammation of the larynx originating in that part is rare.
The local treatment should at first be directed towards ar-
resting the inflammation, by sucking ice, &c.; but when the
morbid process is advanced, the treatment is the same as that
required for ordinary acute laryngitis. The constitutional,
treatment should be that applicable to other forms of erysip-
elas. Tracheotomy, although offering a less favorable chance
than in the simple laryngitis, should be performed if the
symptoms are urgent. Of the other catarrhal forms of
laryngitis may be mentioned those of measles and scarlati-
na. In measles the affection of the larynx may be either a
simple catarrh, or a simple diphtheritic affection. The catar-
thal form may occur before the eruption appears, a day or
two after the rash has come out, or when it is beginning
to decline. Although the inflammation is often severe, it is
seldom sufficient to cause anxiety. The diphtheritic form is
much less common, and “seldom begins until the eruption of
measles is on the decline, or the process of desquamation
has commenced. Its appearance is most frequent from the
third to the sixth day after the appearance of the eruption ;
but it oftener occurs at a later than at an earlier period
LARYNGITIS, 227

(West). The treatment should be the same as that for pri-
mary croup. In scarlatina the laryngitis may be either cede-
matous or croupous: they' are fortunately both rare compli-
cations. The cedematous form may be one of the manifes-
tations of the exanthem, or may be dependent on debility,
or it may be due to the renal affection, which is so common
a sequel of scarlatina. The croupy form is not common,
and seems to have been peculiar to some epidemics. In all
cases of laryngitis associated with scarlatina, there is a great
tendency to the ulcerative process. The treatment required
is of a tonic and nourishing character, with the free use of
_ well-diluted stimulants. Tracheotomy may be necessary when
there is cedema,; but scarification should always be first tried.

In all cases of cedema of the larynx, whatever the cause,
scarification and hot steam inhalations, as recommended
in acute laryngitis, are the most serviceable aids.
When suffocation is: imminent, tracheotomy should be per-
formed.

Applications of mineral astringents to the larynx, either
with the laryngeal brush, or in the form of atomized
inhalations, are of the greatest sérvice; and the “alterna-
tion of topical remedies is often as efficacious in the
cure of chronic laryngitis as it isin the treatment of chronic
inflammation of other mucous passages.” Although Nie-
meyer is of opinion that “induration of the submucous tissue
(of the larynx) is incapable of resolution,” it is the daily ex-
perience that local treatment of chronic thickening of this
region, unless, indeed, it be due to phthisis, is attended with
the very best results. Stimulating inhalations may be used
with great benefit. ‘Amongst the remedies I have found
most efficacious,” writes Dr. Morell-Mackenzie, “are solutions
of perchloride of iron (gr. Go-120 ad. fl. oz. i.), chloride of
zinc (gr. 20-30 ad fl. oz. 1), sulphate of copper (gr. 15 ad fl.
oz. i.), sulphate of zinc (gr. 5 ad. fl. oz. i), alum (gr. 30-60
ad fl. oz. i), chloride of aluminium (gr. 30-60 ad fi. oz. i.).
The perchloride of iron and chloride of zinc are the solutions
I use most largely. Glycerine will also be found a most use-
ful solvent for these agents, as its consistence is better cal-
culated than that of water to keep up prolonged and close
contact between the remedy and the affected membrane. I
seldom employ solutions cf nitrate of silver as applications
to the larynx, for whilst I have not found them more bene-
ficial than other mineral astringents, they are much more
likely to produce spasm and nausea” (Use of the Laryn-
228 LARYNGITIS,

goscope, third edition, page 98). Of atomized solutions,
those of tannin (gr. 5 ad fl. oz. 1.), and perchloride of iron
(gr. 2 ad fl. oz. i,) are most useful. Bergson’s Atomizer,
‘known in this country under the name of Andrew Clark’s
Spray Producer, Dr. Richardson’s Ether Spray Apparatus,
and Dr. James Adam’s Siegle’s Inhaler, are the most con-
venient for administering atomized liquids. Functional rest
is, of course, of great importance in those cases of chronic
laryngitis in which the voice is much affected. If complete
silence cannot be enforced, the patient should be recom-
mended to speak only in a whisper. Relaxation of the
uvula, being a frequent cause of irritation of the larynx, .
should be treated by astringent lozenges of tannin, rhatany,
or kino; and if necessary the elongated part should be cut
off. A warm dry climate is of essential service in obstinate
cases of chronic inflammation of the larynx; as are also
some mineral waters, particularly those of Ems, Ober-Salz-
brunnen, Les Eaux Bonnes, Luchon, Cauterets, Aix-les-
Bains.

Besides the common form above described, there are cer-
tain varieties of chronic laryngitis to which it will be neces-
sary to give a brief consideration. These are—first, those
due to a morbid state of some special tissue of the larynx;
and, secondly, those due to a morbid condition of the general
system, and mainly dependent on constitutional causes. Of
the former, we have glandular laryngitis and phlebectasis
laryngea; of the latter, syphilitic laryngitis and laryngeal
phthisis.

Chronic glandular laryngitis, or chronic inflammation of
the minute racemose glands of the larynx, is generally asso-
ciated with disease of the follicles of the pharynx and tonsils;
but, as the glandulz of the larynx are all of the racemose
character, it is better to use the generic term “ glandular
laryngitis.” It is this disease which has most improperly re-
ceived the name of dysphonia clericorum, or clergymen’s sore
throat. The most common throat affection of the clergy is
not, however, glandular pharyngitis or laryngitis, but merely
chronic inflammation of the pharynx and larynx, with paresis
of the laryngeal muscles. Glandular laryngitis, on the other
hand, is not at all peculiar to those whose profession requires
them to make sustained use of the voice, but generally occurs
in people of feeble constitutional powers.

The symptoms are similar to those of ordinary chronic
laryngitis, but the disease is more intractable. There is a
LARYNX, ABSCESS OF. 229

constant sensation of a foreign body in the throat, and a
corresponding disposition to hawk and clear the throat,
With the laryngoscope, the enlarged orifices of the laryngeal
glands may sometimes be made out. Pathologically; the dis-
ease is essentially one of the secretory system, the normal
secretion of the minute racemose glands, instead of being
clear and transparent, becoming thick, white, and opaque.
By some observers it is thought to be, due to imperfect or
perverted digestion; but it is more probable that the glan-
dulze of the stomach are simultaneously affected.

The treatment is the same as that recommended for simple
chronic laryngitis, except that the use of strong solutions of
nitrate of silver is more often indicated than in that affection.
There is frequently considerable feebleness of the voice, in
which case stimulating inhalations and the application of
electricity are the appropriate measures.

The second variety, that of phlebectasis laryngea, first de-
scribed by Dr. Morell-Mackenzie (Zancet, July 6, 1862),
consists of a venous congestion of the larynx. It is very
uncommon. The symptoms are slight and usually consist
in no more than an uneasy sensation in the larynx, and a
more or less frequent cough. With the laryngoscope, dark
vessels may be seen on various parts of the larynx, particu-
larly on the ventricular bands. The treatment consists in the
destruction of the vessels by the electric cautery, and the
use of vigorous constitutional remedies.

The varieties of syphilitic laryngitis and phthisical laryn-
gitis depend on a special constitutional condition, and will
be treated under Larynx, Ulcer of

Larynx, Abscess of.— Definition —Death of the cartila-
ges, by a molecular or truly carious process, usually preceded
by separation of the perichondrium, and sometimes attended
with circumscribed collections of pus.

Treatment.—The practitioner’s treatment must be directed
to the relief of the pain, the dyspnoea, and the dysphagia.
For the former, subcutaneous injections of morphia should
be administered. The dyspnoea may be such as to render
tracheotomy necessary; and in cases where the dysphagia
is extreme (as nothing can be done to actually dilate the
narrowed cesophagus) the patient must be fed by enemata
or the cesophagus tube. The preferable way, in cases which
will admit of it, is to use an cesophageal tube with a feeding-
bottle attached. By means of an instrument of this kind, in
230 LARYNX, BENIGH GROWTHS IN.

one of the cases referred to, the patient's life was sustained
for more than three months ; and after death there was a
considerable layer of fat covering the body. Of course, great
care must be taken in passing the tube ; but where practicable,
this method of feeding is far more satisfactory i in every re-
spect than the use of enemata per rectum.

Larynx, Benign Growths in.—Definition.—New for-
mations of benign .character, forming projections on the
mucous membrane of the larynx, generally giving rise to
aphonia or dysphonia, often to dyspnoea, and occasionally
to dysphagia.

Treatment.—In cases where the growth is small, does not
appear to increase, and does not give rise to functional de-
rangement, no treatment need be adopted. Where the op-
posite conditions, however, exist, means should at once be
taken to eradicate the growth, or to place the patient out of
danger by performing tracheotomy. Radical treatment may.
be divided into internal, that is, removal or destruction of
the growth through the mouth with the aid of the laryngo-
scope ; or external, by operations through the neck. Inter-
nal treatment may be further subdivided into Mechanical
and Chemical. Mechanical traatment consists in evulsion,
by common laryngeal forceps, tube forceps, ecraseurs, or
guillotines. Added to this, there are a few cases in which
crushing or incision of the base of the growth is effectual.
Chemical treatment consists in the application of various
caustic solutions,—a process seldom satisfactory——and in gal-
vanic cautery. This last method has been very successful
in the hands of some Continental practitioners ; but it can-
not be recommended, on account of the complicated and
unwieldy apparatus required by the practitioner, and of the
great pain often experienced by the patient. External treat-
ment may be divided into thyrotomy, or division of the thy-
roid cartilage, supra-thyroid laryngotomy, or division of the
thyro-hyoid membrane, and infra-thyroid laryngotomy, or re-
moval of the growth through the crico-thyroid membrane,
or by an opening made in the trachea. In addition to these
various surgical procedures, there is the combined method,
in which tracheotomy having been called for, on account of
the urgency of the symptoms, the neoplasm is afterwards re-
moved per vias naturales. All external measures are attended
with less satisfactory results, both as to life and restoration
of function, than those resulting from laryngoscope treat-
ment ; and it should be borne in mind that the more serious
LARYNX, CONTRACTION OF. 231

surgical methods should never be resorted to unless the tu-
mor in the larynx produces symptoms endangering the life
of the patient.

Larynx, Contraction of.— Dejinition.-Narrowing of the
passage of the larynx, the result of various lesions.

The Treatment of narrowing of the larynx resolves itself
sooner or later into tracheotomy. In cases of syphilitic ci-
catricial thickening, iodide of potassium does little good, and
local treatment is of no avail, In chronic tubercular nar-
rowing, treatment is equally futile. In all cases, if the dys-
pnoea is extreme, tracheotomy must be performed at once,
and measures can subsequently be taken for dilating the
contracted passage by any of the mechanical devices which
have been invented for the purpose.

Larynx and Pharynx, Treatment of by Atomized
Fluids.—tThe ¢reatment of diseases of the pharynx and of
the larynx by the use of atomized or spray-producing fluids,
in which medicated vapor and gases are brought to act upon
the parts, has received a great impetus since better appli-
ances have been devised for using such remedial agents. The
aim of such instruments is to atomize or pulverize, or very.
minutely to divide the fluid, by causing it to be thrown as a
fine shower or spray, so as to be inhaled as such by the pa-
tient. Dr. Andrew Clark’s hand-balls, fitted with Bergoon’s
tubes and Maunder’s atomizer, constitute an efficient and
useful arrangement for applying fluids in this way up the
nostrils, to the back of the throat, or over the entrance to
the larynx (Da Costa). Dr. Richardson’s well-known in-
strument for the production of local anaesthesia is also an ex-
cellent atomizer of fluid, and may be used for a similar pur-
pose. :

Where it is desirable to make the topical application di-
rectly upon the diseased part, these are the most simple in-
struments that can be used without loss of time by the phy-
sician; but where inhalation simply of vapor or heated air
variously medicated is all that is required, nothing can be
better than that used by Dr. Fergus, of Glasgow; or an im-
proved apparatus for spray inhalations devised by Dr. James
Adams of Glasgow.

Siegle’s apparatus, and Dr. Morell-Mackenzie’s electric ,
inhaler, and Martindale’s portable inhaler, are all of them
useful and valuable instruments for inhalation of suitable

remedies.
232 LARYNX AND PHARYNX, TREATMENT OF.

On this most useful mode of treatment Dr. Da Costa
makes the following observations. “(1.) Inhalations by
means of atomized fluids are an unquestionable addition to
our therapeutic means; but they are nothing but an addition,
and not a substitute for all other treatment. (2.) In most
acute diseases of the larynx, and still more soin acute disor-
ders of the lungs, their value, save in so far as those of water
may tend to relieve the sense of distress, &c., and aid expec-
toration, is very doubtful; though in some acute affections,
such as in cedema of the glottis and in croup, medicated in-
halations have strong claims to consideration. (3.) In cer-
tain chronic morbid states of the larynx, particularly those
of acatarrhal kind, and in chronic bronchitis, they have
proved of great value. (4.) In the earlier stages of phthisis,
too, they may be of decided advantage; and at any stage
they may be a valuable aid in treating the symptoms of this
malady. (s.) Their influence on such affections as hoop-
ing-cough and asthma is not satisfactorily proved. (6.)
They furnish a decided and unexpected augmentation of our
resources in the treatment of pulmonary hemorrhage. (7.)
They require care in their employment; and in acute affec-
tions we should consider whether, as they have to be used
frequently to be of service, the patient’s strength justifies the
disturbance or the annoyance their frequent use may cause.
(8.) In any case, to be of service, they ought to be carried
on as a treatment with a distinct object, and not intermit-
tingly or spasmodically resorted to.”

Table of doses for Inhalation (Da Costa; (1.) Alum, ro
to 20 grains, to 1 fluid ounce of distilled water. Suitable in
chronic catarrhal states of the pharynx and air-tubes, partic-
ularly in bronchial affections with excessive secretion, when,
as in most inflammatory conditions of the respiratory mucous
membrane, it may be advantageously united with opium. In
a somewhat stronger solution, 30 grains to the ounce, it is
useful in pulmonary hemorrhage. As an astringent, it is
generally more of a sedative, and more suited to conditions
of irritation than tannin (Fieber). (2.) Tannin, 1 to 20
grains.—Useful for the same affections as alum. Employed
in cases of laryngeal ulceration and excrescences, in cedema
of the glottis (Trousseau), and in croup. Here, as well as
in pulmonary hemorrhages, it is used in large doses. In
ordinary cases of laryngeal or bronchial disease, it is well
to commence with a comparatively weak solution—s grains
to 1 fluid ounce of water. If the remedy occasion much heat
LARYNX AND PHARYNX, TREATMENT OF. 233

and dryness, its use should be discontinued. (3.) Iron (per-
chloride of), § to 2 grains.—In earlier stages of phthisis; in
chronic pharyngitis or laryngitis it may be used in a stronger
form-—3 grains to 1 fluid ounce of water. Asa weak. inha-
lation, it is useful in hysterical aphonia. Stronger solutions
—2 to 10 grains to the ounce—are useful in pulmonary
hemorrhage. In ordinary cases in which we wish a non-
astringent salt of iron, the lactate, citrate, or phosphate may
be also used, though they are not, on the whole, as available
as the chloride. (4.) Nitrate of silver, 1 to 10 grains.—Is
useful in ulcerations of pharynx and larynx, and in follicu-
lar pharyngitis. A face-shield is always to be used. 10

rains to the ounce only to be used in cases of ulceration.
5.) Sulphate of zinc, 1 to 6 grains.—In bronchial catarrh
with excessive secretion ; in aphonia connected with chronic
laryngeal catarrh. The Chloride of Zinc (2 to 5 grains) is
also useful inthe same conditions. (6.) Chloride of Sodium,
5 to 20 grains.—Promotes expectoration and diminishes
sputa ; employed in phthisis. (7.) Chlorinated Soda (Liquor
Sodz Chlorinatz), 14 to 1 drachm.—In bronchitis with of-
fensive and copious expectoration ; in phthisis, (8.) Chlor-
ide of Ammonium, ro to 20 grains.—In laryngeal and bron-
chial catarrh, acute as well as chronic, to promote expector-
ation ; also in capillary bronchitis. ‘The dose best borne is
not above ro grains to the ounce. (9.) Opium (watery ex-
tract of), 4 to % a grain.—In irritative coughs, and as an
adjunct to allay irritation. Also for its constitutional ef-
fects. Dose of tincture of opium 3 to 1odrops. Acetate of
morphia, one-twelfth to one-eighth of a grain, has been ad-
ministered ; but large doses require much caution. (ro.)
Conium (fluid extract of), 3 to 8 minims.—Irritative cough;
asthma ; feeling of irritation in larynx. (11.) Hyoscyamus
(fluid extract of), 3 to 10 minims.—Spasmodic cough;
hooping-cough. One-half grain of the extract, gradually
increased ; or the tincture may be employed. (12.) Canna-
bis Indica (tincture of), 5 to 10 minims.—In spasmodic
cough and phthisis. (13.) Iodine, 2 to- 15 minims of the
tincture.—In chronic bronchitis, phthisis, functional aphonia
and hay asthma. (14.) Arsenic (Liq. Arsenicalis). 1 to 20
minims.—Nervous asthma (Trousseau). (z5.) Tar Water, 1
to 2 drachms of officinal solution.—In offensive secretions
from bronchial tubes ; in tuberculosis; as an antiseptic in
gangrene of lungs. (16.) Turpentine, 1 to 2 minims.—In
chronic bronchitis with offensive secretions ; in bronchor-
234 LARYNX, ULCER ,OF THE,

rhoea ; in gangrene of lungs. (17.) Lime Water, used of of-
ficinal strength, or stronger.—In diphtheria ; in membranous
croup. (18.) Water, Distilled.—Cold, in pulmonary heemor-
rhage ; warm water in asthma ; in croup ; and in bronchitis.

For various other modes of applying tropical applications
to the larynx, the student is referred to Dr. Morell-Macken-
zie’s work On the Laryngoscope.

Larynx, Uleer of the.— Definition —Loss of substance
of the larnyx, in rare cases the result of simple inflammation,
caused either by syphilis or phthisis.

(a.) Syphilitic Ulceration.

Treatment.—Secondary laryngeal affections are sometimes
difficult to cure, but after undergoing certain phases of evo-
lution they may disappear spontaneously. If allowed to
run their natural course, condylomata generally disappear at
the end of two or three months, but chronic congestion is
more intractable. Stimulating inhalations, and the local ap-
plication of astringents are sometimes of great service. Ul-
ceration of the larynx (secondary) is seldom so severe as to
require the application of solid nitrate of silver. In tertiary
laryngeal syphilis, large doses of iodide of potassium, in
combination with ammonia, and freely diluted with water,
are of the greatest use ; but local treatment is also of the
first importance. The ‘application of solid nitrate of silver,
or of strong solutions of the same salt (60 gr. ad fl. oz. Hee
or of sulphate of copper (15 gr. ad. fl. oz. i.), is attended
with the most satisfactory results. For applying the solid
nitrate the method of fusing a very small portion of the salt
on to a curved aluminium wire far surpasses, in simplicity
and safety, any other form of laryrigeal porte-caustique.

(b.) Phthisical or so-called Tubercular Ulceration of the
Larynx.

In the treatment of phthisical ulceration, remedies similar
to those recommended for chronic laryngitis may be employed
with advantage. Mineral astringents- havea beneficial effect.
in the early stages, and are useful in relieving the dysphagia
when ulceration of the epiglottis has taken place. Sedatives,
whether in the form of inhalations or as medicines which al-
lay the cough, and so keep the larynx at rest, are also to be
recommended. ‘Treatment, however, is at the best but pal-
liative. Every effort should therefore be made to carry out
preventive measures. Congestion of the larynx in patients
LEAD PALSY. 235

of a phthisical tendency, should be treated with the greatest
promptitude—first, by proper local treatment; secondly, by
complete rest of the voice; thirdly, by a suitable climate—a
warm, dry, and uniform temperature being most to be com-
mended. The constitutional treatment required is similar
to that which will be found described under “ Pulmonary
Phthisis.”

Lead Palsy.— Definition.—A series of morbid phenome-
na induced by the absorption of the salts of lead contained
in solution in drinking-waters, or in various foods and
drinks, or conveyed into the system through the integuments
of those who are in the habit of handling the soluble salts of
lead; or through the pulmonary mucous membrane of those
exposed to the influence of Vapors containing lead.

Treatment.—The objects to be obtained in the treatment
of lead colic are to procure stools, a copious discharge of
urine, and perspiration, with a view of eliminating the poison
from the body. To allay pain is also an urgent necessity.
For these purposes five grains of calomel, fifteen grains of
jalap, and one grain of opium, should be administered as
soon as the patient is seen; and at the end of two hours
about two ounccs of camphor mixture, combined with a
drachm or two drachms of sulphate of magnesia, and twenty
minims of tincture of hyoScyamus may be given, and repeated
every two or every four hours, till the bowels are freely evac-
uated, when relief more or less complete is obtained. The
mixture should be continued at proper intervals for three,
four, or five days, when the patient, though greatly weakened,
has in general recovered. In a few cases, however, the pain
continues, and with considerable severity, after the bowels
have been freely evacuated. The practice in these instances
is to apply a blister to the epigastrium, and to keep the blis-
ter open for afew hours. This additional application will
generally complete the cure. The patient is also relieved if
placed in a warm bath, and at the same time directed to in-
ject repeated enemata of hot water, that stools may be readily
obtained. In the absence of the warm bath, a large linseed
or mustard poultice should be applied over the abdomen.

With respect to the treatment of lead palsy, it has been
believed that sulphur has the power of neutralizing the effects
of lead by forming some innocuous compound with it. It is
not known, however, whether any such compound is really
formed; but lead poisoning in its chronic and constitutional
236 LEAD PALSY.

forms is more successfully treated by sulphur baths than by
any other agent except iodide of potassium, to which they
form a most important adjuvant. The ingredients of these
baths consist of from two to four ounces of’ the sulphuret of
potassium, mixed with from twenty to thirty gallons of wa-
ter. The ergot of rye (secale cornutum) has been said to
produce a considerable increase in the power of the flexor
muscles of the arm in about a fortnight, and the improve-
ment gradually extends to the flexors, till at the end of about
three months the patient has recovered. This may have
been the natural result of elimination of the lead. The ex-
periments of Orfila long agé rendered it probable that lead is
removed from the body by the kidneys; and iodide of po-
tassium promotes the elimination of leadin thisway. It may
be used with advantage combined or not with the citrate of
iron, the use of iron, in some form or other, having been
found of benefit in cases of palsy from lead contamination.
Dr. Parkes has chemically proved that lead can be made to
pass off by the urine by the action of iodide of potassium, in
the same way as mercury is known to be eliminated. The
principle upon which the iodide of potassium acts is that the
lead is in actual union with the affected tissues, being re-
tained among them as an insoluble compound; and the iodide
of potassium, after its absorption into the blood, combines
with the lead, and forms with it a new and soluble salt. The
poison is thus liberated from its union with the injured part,
dissolved out from the damaged fibre, and once more set
afloat in the circulation. Thus the poison and the remedy
are cast out together by the urine (Melsens, William Budd).
It is necessary, however, to notice the dangerous phenomena
which may at first supervene on the administration of iodide
of potassium in cases of lead poisoning; and great caution is
necessary in the employment of this remedy in man for the
first few days. At the moment when the metallic compounds
fixed in the body become dissolved or transformed, the phe-
nomena of acute poisoning may occur, caused by their lib-
eration. So much is this the case, that the treatment may
be supposed to be at first hurtful rather than beneficial. The
patient should have beside him a graduated solution of the
iodidé of potassium; and should begin with a small dose (fif-
teen grains during the twenty-four hours), and afterwards in-
crease or diminish it according to his pains and sensations
(Melsens). Dr. Fagge has also noticed that the administra-
tion of iodide of potassium to a person poisoned by lead, is
LEUCOCYTHAMIA, 237

sometimes followed by the development of a line in the gums
which had previously been absent, and this when the patient
was removed from the influence of lead. :

Galvanism, in the form of Faradization, ought to be used
as a local stimulant to the nerves, with the precaution that its
application is not to be continued too long each time. Ten
or fifteen minutes, at three different periods of the day, or of
every second day, and persevered in for not less than four
weeks, will be found of great service (Todd, Althaus). The
beneficial influence will follow, although, in the commence-
ment of the treatment, even a current of very high tension
does not cause any movement whatever in the paralyzed mus-
cles. In such cases the beneficial influence seems attributa-
ble to the restoration of mobility to the molecules of nerve
and muscle by an induced current, and which is necessary
to enable them to be physiologically active. Severe shocks,
especially in the commencement of the treatment, should
therefore be carefully avoided, as by such the weakened ex-
citability of nerve and muscle may be reduced, in place of
being fostered and developed (Althaus, 1. c., pp. 112 and
11g). It would be rational, however, to defer the applica-
tion of galvanism till the lead has been completely elim-
inated.

Leucocythamia—Definition—A disease sud generis, in
which the number of white corpuscles in the blood is greatly
increased, with a simultaneous diminution of the red. This
state is brought about by chronic exhausting diseases, expos-
ure to.cold and wet, or serious acute affections—such as
typhus fever, :pneumonia, puerperal fever, affections of the
lymphatic glands or of the spleen, and is attended sometimes
by cough or diarrhcea, epistaxis, hemorrhagic effusions,
furunculus or pustulous eruptions.

Treatment.—The most varied remedies have been tried
without checking the increased formation of colorless cor-
pusclés ; but it is suggested that if it is possible to discover
the glandular or splenic affection early, before the alteration
of the blood has made much progress, it is probable that the
disease may be averted. ‘Tonics, nutrients, and stimulants,
are indicated to support the system. The use of the nitro-
muriatic bath ought not to be neglected, and the indications
given under anemia and chlorosis may be followed. Phos-
phorus has been administered with some success by Drs.
Broadbent and Wilson Fox. Sir William Jenner adminis-
tered the drug in capsules containing one-thirtieth of a grain
238 LEPROSY, TRUE,

of phosphorus, two or three times a day for four months,
without appreciable benefit to the patient. The results
generally are unsatisfactory as regards any treatment of these
cases.

Leprosy, True—Defition-—A constitutional, non-con-
tagious, hereditary affection, essentially chronic in its nature,
expressing itself mainly by shining tubercles of different sizes,
of a dusky red or livid color, on the face, the ears (and often
the extremities)—the skin being thickened, wrinkled, rough,
unctuous, divested of hair, and the perspiration highly offen-
sive—in which there is loss of feeling, or other disorder of
innervation, and a tendéncy to ulceration death of the affected
parts. The eyes in extreme cases are fierce and staring, and
the voice is hoarse and nasal.

Treatment.—The only hope of exterminating leprosy lies
in the adoption of hygienic measures tending to improve
the general conditions, physical and moral, of the leprous
poor. Medicinal treatment is of no avail, unless combined
with the regular use of a nutritive unstimulating diet, suita-
ble clothing, protection against the vicissitudes of the weather,
personal cleanliness, and exercise inthe open air. The med-
icines which have been found of most service are tonics and
alteratives, especially preparations of iron and iodine. Mer-
cury is extremely injurious. Arsenic has for centuries been
held in high esteemin India as a remedy in true leprosy. It
is given in the following combination:—105 grains of arsen-
ious acid are triturated with five or six times the quantity of
black pepper. Thus made into a mass, it constitutes the
material of the well-known “ Tanjore pill,”’ of which one the
size of a “tare” is to be taken night and morning (Waring’s
Therapeutics, p 110). The systematic use of baths, simple,
saline, or sulphurated, are decidedly beneficial. Cupping-
glasses or moxas, along the line of the spinal column, has
been of marked advantage in relieving the lesions of inner-
vation whether of increased or diminished sensibility. At
a very early period of the inquiry carried out by the College
of Physicians, the nature of the replies received enabled the
college to assure the Secretary of State for the colonies that
“there was no evidence which, in their opinion, justified any
recourse for the compulsory segregation of lepers.” After
receiving this decided opinion, the Duke of Newcastle forth-
with issued a circular to the Governors of the Colonies, ex-
pressing his opinion, “that any laws affecting the personal
liberty of lepers ought to be repealed; and that, in the mean-
LICHEN—LIVER, ABSCESS OF. 239

time, if they shall not be repealed, any action of the execu-
tive government in enforcement of them, which is merely
authorized and not enjoined by the law, out to cease.” There
appears no more need (or just about the same) for restrict-
ing the liberty of lepers as for restricting the liberty of those
afflicted with gout.

Lichen.— Definition. An eruption commencing as small
red papule, either isolated or confluent. These becoming
excoriated, give vent to a serous fluid in considerable abund-
ance, which ultimately concretes into a crust.

Treatment—Glycerine in the following formula is recom-
mended by Mr. Startin: R. Acid Nit. dil. 3 ssto 3 jj; Bismuth
sub. nit. 38s; Vinct. digital, 333, Glycerini, 34); Aq.
Ros, f 3 vii ss. “To be applied as a lotion frequently to
the affected parts.”

The alkalies internally and externally are of service. Bi-
carbonate of soda, in fifteen grain doses in some bitter infu-
sion, to be increased by eight grains daily till 3j is taken in
the twenty-four hours (Divergie). Alkaline baths and lo-
tions are to be used at the same time—the lotions containing
two or three drachms of the salt to twenty ounces of water.

Liver, Abscess of—Dejinition—Suppurative inflamma-
tion, ending in a circumscribed collection of pus, or in sev-
eral separate abscesses,

Treatment.—The abstraction of blood is most efficiently
accomplished by leeches round the anus. They act more
directly on the portal circulation than over the hepatic re-
gion. When congestion is known to exist, leeches may be
applied with benefit, combined with purgative salines, such
as sulphate of soda or Rochelle salts, and antimony as a dia-
phoretic, to be followed by chloride of ammonium, Hot fo-
mentations applied to the region of the liver are of great
service, and the diet should be as limited as is consistent
simply with the maintenance of life, as long as acute symp-
toms exist. Mercury should not be given, except as an oc-
casional purgative, when the local inflammation is subdued,
and purgatives are only then of use when the intestinal fuinc-
tions are sluggish. It is still a question whether or not an
artificial opening ought to be made, in the absence of fluctu-
ation to justify the operation. “In any cases the opening of a
liver abscess is a critical proceeding; but it should be resorted
to whenever there is a reasonable prospect of getting at the
matter, and when operative proceedings are not so danger-

,
240 LIVER, ABSCESS OF.

ous as to be prohibitory, for it is very desirable to anticipate
spontaneous opening by any of the usual channels, as all are
dangerous. Into the peritoneum, pleura, or pericardium, the
result is of necessity almost always fatal; while even into
the lung, stomach, or bowel, the danger is often great; and
though followed by temporary amelioration, may end in
exhausting disease or purulent contamination of the whole
system” (Sir Joseph Fayrer). Professor Lister’s antisep-
tic method of procedure appears to me the one which
ought to be adopted in opening all hepatic abscesses.

“ When there is reason to believe that matter has formed,
although the physical signs of it may not be clear, attention
should be directed caréfully to the evacuations, especially if
there be diarrhoea, as the abscess may open into the bowel.
This is the probable explanation of recovery in cases where
it has been thought that the abscess had either never really
formed, or that it had undergone absorption. When opening
occurs through the lung or stomach, the symptoms are un-
mistakable. When abscess has-formed, the object is to favor
its evacuation, to support the strength, and to allay irritation.
Much has been written and said about exploring for liver
abscess, and in certain cases, where doubt exists, the pro-
ceeding is justifiable, using a small canula and. aspirator,
when there is enlargement, tenderness on pressure, which
causes nausea and disturbance of the heart’s action, such as
palpitation or sickness, especially if there have been any chills,
Increase of temperature, or sweats.—In the event of matter
being detected at a considerable depth, it may in some cases
be aspirated ; but it may happen that, on account of its
thickness and the presence of flakes of lymph, pus will not
pass through the small canula, and no satisfactory result is
obtained; but if there be any marked probability of its
presence, a large canula may be used and left in after if pus
is found,-the most careful antiseptic precautions being ob-
served in the subsequent dressings. Whenever the matter
lies moderately near the surface, even though a certain
amount of liver-tissue intervene, a free incision is best;
hemorrhage, should it occur, soon ceases, and there is much
better prospect of a free drain afterwards. A large canula
may in some cases be preferable. It would signify little
which were selected, provided antiseptic precautions be
carefully observed, and the exit be free. In the event of
exploration detecting matter deep-seated, but under much
liver substance, the canula is preferable to the knife, used
LIVER, ABSCESS OF, 24

with the aspirator, though great care should be taken not to
exhaust too rapidly, or with too great force, for fear of injur-
ing the liver tissue surrounding the cavity of the abscess and
causing hemorrhage.” (Sir Joseph Fayrer, Zance¢t May 8,
1880, p. 709). ‘‘Cases of doubtful liver-abscesses present
symptoms varying in every degree ; at the one extreme cases
of general cachexia, with irregular slight febrile attacks,
exhibit symptoms as frequently attributable to deranged
stomach, or bowels, or lungs only, as to the liver itself ;
while at the other, slight general enlargement of the organ
would be found associated with that peculiar form of ‘ten-
derness’ in which pressure over the organ produced an
indescribable sensation, inducing either faintness,’ hurried
respiration, palpitation, or nausea with retching, or all of
these at once. In all this large class of cases it was the cus-
tom of Professor W. S. Palmer, of Calcutta, to plunge a long
trocar and canula, of small diameter, into any or all parts of
the liver, through a valvular opening, examining on the spot
the small quantity of extracted matter for pus globules. It
was only in exceptional cases that any signs of pus could be
detected. When it was so detected’the puncture was gener- ~
ally followed by slight inflammatory action at the seat of
puncture, which probably ended in adhesion of the organ to
the parietes, and so facilitated the future opening of the
abscess. When, on the other hand, no pus was found, a
good deal of anxiety was felt in the earlier cases, lest the
puncture should be followed by any evil results. Such
moments of anxiety soon ceased to recur, for it very rarely
happened that the patient did not express himself the next
day as feeling very much relieved ; and in no case did any
bad consequences result from such punctures. The relief
was frequently only temporary, in which case a second, a
third, or a fourth puncture was made at intervals of eight or
ten days. In some, however, one puncture sufficed to cure”
(Lancet, May 8, 1880, p. 709).

To prevent the entrance of pus into the abdominal cavity,
the following method has been recommended by Bégin and
Recamier : tr.) Being decided as to the limits of the abscess,
the patient is (2) laid on his back, with the upper part of the
body bent forward, and the thighs flexed upon the abdomen;
(3.) an incision from two to three inches long is to be made
over the abscess, dividing the skin, the subcutaneous adipose
tissue, the muscles, and the aponeurosis ; (4.) the peritoneum
is then laid open, asin operating for hernia, by slitting it up.

16 ‘
XN

242 LIVER, ABSCESS OF,

on a grooved director to the same extent as the primary in-
cision ; (5.) the wound is then to be dressed with charpie,

and to remain untouched for three days; (6.) at the end of
three days the dressing is to be removed, when the capsule

of the liver will be found to have contracted adhesions to the

margins of the wound so firm that the abscess may be opened

without the danger of pus passing into the abdomen. The

following expedient may indicate whether the liver adheres

to the abdominal parietes or not. When the liver is large,
and the abdominal parietes are thin, it may be made out

“by feeling the edge of the liver, or some prominent part of |
its surface, and marking the place of this with a pin on the

surface of the belly. If the liver be adherent to the abdom-

inal parietes, the line or spot so marked will correspond to

the edge or prominence of the liver in all positions of the

body. If it be not adherent, the liver will slide along the

wall of the belly when the patient draws a deep breath, or

changes his posture—the liver will fall, for example, towards

the left side when he turns from his back over to that side,

and the line or spot will no longer correspond to the edge’
or prominence in question (Budd, of. ci, p. 122).

An interesting case of hepatic abscess is related by Sir
Henry Cooper, of Hull, in the British Medical Journal for
May 23, 1863. He justly takes exception to the method of
Bégin and Recamier, because it may provoke the very danger
it is desirable to avoid. In ali cases in which suppuration
has extended so near the surface as to give the sense of fluc-
tuation, irritation and adhesion of contiguous surfaces have
taken place. The process also interposes a serious delay at .
a critical period. He advocates a direct opening into the
abscess, when there is reasonable ground for believing that
an external outlet for the matter is the direction taken by
the abscess. Peritoneal connections are sure then to have
taken place. Tenderness of the tumor is the most satisfac-
tory indication for the operation, and hardened base of
effused lymph a certain confirmation. Delay exposes the
patient to the risk of rupture of the walls of the abscess by
coughing, sneezing, or the like, and to the laceration of any
adhesions which may have formed; or it allows him to
perish unrelieved from constitutional irritation, and conse-
quent exhaustion. A middle course was devised and carried
out by Dr. Graves, in the Meath Hospital, in a robust man.
External elevation, hardness, and pain, eventually confined
to one spot in the right hypochondrium (after acute inflam-
LIVER, ABSCESS OF, 243

mation of the liver), left to doubt of the formation
of an abscess. Hardness was followed by deep-seated
softness, yet no tendency was shown by the abscess to
point outwards. The swelling remained stationary, and the
integument of natural color; but the general strength
began to fail, and it became an important question
whether the abscess should be opened. It was objected—
(1.) That the external tumor was diffuse ; (2.) that the exact
site of the abscess was uncertain; (3.) that failure to evacu-
ate its contents might prove detrimental. A decision was
therefore given against operation by the surgeons of the
Meath Hospital. Under these circumstances Dr. Graves
remembered that he had seen cases where an incision made
over a deep-seated abscess had failed to give vent to the
matter in the first instance; yet in the course of a few days
the pus found its way to the incision, and burst through it.
He therefore proposed that an incision about four inches
long should be made exactly over the center of the tumor—
that it should be carried through a considerable depth of
muscle, and, if possible, be continued to within about one or
two lines of the peritoneum. This incision was then to be
plugged up from the bottom of the wound with lint, and
thus kept open, in the hope that pus might tend towards the
incision, and finally burst through it. Such an operation
was done. The abdominal muscles were found of consider-
able thickness, and healthy; and although the incision was
very deep, yet the situation of the hepatic abscess was not
felt more distinctly. It now became evident that no pru-
dent surgeon would have persevered in an attempt to open
directly into it. A result was therefore waited for. In two
days the patient sneezed, when purulent matter in very large
quantity burst through the wound. It appeared that the in-
cision had not been made exactly over the abscess, but
rather to one side of it; for the matter did not come from
the bottom, but from the side of the wound; and pressure
on the liver on that side caused matter to flow out in abund-
ance through that part of the wound which communicated
laterally with the abscess. Had the original incision been
continued, it might have failed to open into the abscess
(Dublin Hosp. Report, Vol. IV. p. 40).

After the abscess has opened, strict rest must be enjoined;
and sometimes the cavity is very long in closing up. It
must be kept from putrefactive changes by antiseptic dress-
ings. Convalescence is always tedious; and sometimes
244 LIVER, ABSCESS OF. .

cicatrization is imperfect, continuing to discharge pus for
years (Frerichs). It has been argued, as already indicated
in the experience of Dr. Palmer of Calcutta, that our effort
should be directed to detecting by acupunctute the seat of
an abscess, and evacuating it as soon as possible; and that
this method of exploration or of “prospecting the liver,”
should be commenced as soon as symptoms present them-
selves indicating the possibility of abscess. It has been
argued that because some cases have recovered after such
a method of finding and evacuating an abscess, it is a prac-
tice which should be made the rule, in place of waiting for
some indications that pus has even formed in the liver (Mur-
ray, Cameron), The recommendations to the plan are not
yet based on statistical records, and rest upon the opinions
or impressions of two or three individual men. Certain it
is that the plan recommended is opposed to the well-estab-
lished principles upon which surgical interference rests, and
is opposed to all that is known regarding the pathology
of hepatic abscess, as set forth in the carefully recorded
facts of Waring, Martin, Morehead, Frerichs, Budd, Mac-
lean and Lowe. It is also stated by Dr. Cameron (the latest
exponent of this method of puncture), that in cases of hepa-
tic enlargement, where the trocar has been used more than
once in an unsuccessful search for an abscess, the operation
was followed by the speedy absorption of an enlargement of
the liver, which had resisted all the routine methods of
bringing about its dispersion; and that chis is-a native mode
of dispersing hepatic and even splenic enlargements in India
(Lancet, August 8, 1863, p. 169). Puncturing parts, or acu-
puncture with a very fine needle, is a surgical operation said
to be much in use among the native Chinese and Japanese
hakims. But accurate information regarding the results of
such operations are not on record. It should be remem-
bered, in dealing with large livers or probable hepatic ab-
scess, that an hepatic abscess.always begins from multiple
foci (Rokitansky). We must still look to physicians of large
Indian experience for information on this important subject;
while the antiseptic method of Lister warrants operative in-
terference now which could not have been carried out with
safety before.

The time which elapses after opening an abscess till the
patient’s recovery is generally from one to two months.
When convalescence is established, the functions. of the
liver remain torpid, and its substance often indurated; sub-
LIVER, ACUTE ATROPHY OF. 245

sequently, also, the spleen may be enlarged. In such a
state Sir Ranald Martin recommends the use of nitro-muri-
atic acid baths. They promote the depurative functions of
the liver, kidneys, bowels, and skin.

“The form and manner of preparing and using the acid
bath are as follows:—Take of hydrochloric’ acid, three
parts; nitric acid, two parts; mix the two acids carefully
and slowly, so as to avoid evolution of heat; and having
waited for twenty minutes, add of distilled water five parts,
and mix the whole carefully. For a general bath in which
to immerse the whole body:—Pour into the bath about five
pailfuls of cold water; add two quart bottles, containing
sixty-four fluid ounces of the dilute nitro-muriatic acid, pre-
pared as above, and then sufficient boiling water to raise
the temperature to 96° or 98°. The body is to be quickly
and thoroughly dried with warm towels; and afterwards the
patient must retire to a well-aired and warm bed. The use
of the bath is only to be discontinued when tenderness of
the gums or general malaise.occur; and cuticular irritation
from the acid is to be avoided by diminishing its strength.
Iron and other forms of tonic remedies may also be admin-
istered at the same time, as well as opiates,” (Martin, Oz
Climate, p. 564, et seq).

Liver, Acute Atrophy of.—Defxition—Simple jaun-
dice, which gradually increases, with sensitiveness over the
region of the liver, followed by violent constitutional dis-
--turbance, expressed by pyrexia, headache, delirium, hemor-
thages from various parts, and finally coma. The liver
shrinks to one-half or one-third its normal size. A peculiar
chemical decomposition takes place in the liver, whereby ab-
normal proximate principles are formed, which, being carried
into the blood, may be discovered in various organs of the
body, or, passing out by the kidneys, may be found in the
urine.

Treatment.—English physicians recommend emetics and
purgatives (Corrigan, Griffin, Hanlon). Frerichs recom-
mends that the stronger purgatives should be simply to re-
move congestion, such as senna, aloes, colocvnth ; and the
doses should be such as to secure profuse evacuations.
When atrophy has commenced, no benefit results from med-
icinal treatment. Severe pains indicate the use of leeches,
cupping, and cold cloths, or fomentations, as recommended
under “Enteric Fever.” The occurrence of hemorrhage
indicates the use of mineral acids.
246 LIVER, AMYLOID—LIVER, FATTY.

Liver, Amyloid—See Liver, Lardaceous.

Liver, Cirrhosis of the.—Dejinition.—Interstitial in-
flammation, with increase of the connective tisswe and its
subsequent contraction, leading to other alterations and re-
sults,

Treatment is the possibility of relieving the disorders of
function which threaten life, and so to delay the fatal termin-
ation. Absolute abstinence from spirits is indispensable, and
the diet should consist of mild, simple articles of nourish-
ment, especially easily digested animal food. Coffee, spices,
and articles irritant to the liver must be avoided. Swelling
and tenderness indicate leeches and fomentations. Mild
saline laxatives may be given; and when the tenderness
ceases, the bowels must be kept open by rhubarb and salines.
When nausea or vomiting occurs, hydrocyanic acid, belladon-
na, morphia, or extract of nux vomica, are particularly suit-
able. The gastric and intestinal catarrh require to be sub-
dued by alkaline carbonates. They lessen the viscidity of
the mucous secretion. When pain prevails, cupping or
leeches are indicated over the liver, or leeches to the verge of
the anus. Saline purgatives, such as sulphate of soda or tar-
trate of potash and soda (Rochelle Salts), should also be ad-
ministered, while iced drinks and low diet must be the rule
of life.

What has been said under the subject of simple enlarge--
ment or congestion of the liver may be referred to here as
indicating a line of treatment under the circumstances there
provided for. The saline laxatives are best taken as mineral
waters, especially at Karlsbad or Marienbad. Springs con-
taining small quantities of iron are also of service, such as
Eger, Franzensbrunnen, Kissengen, and Homburg (Nie-
meyer).

Liver, Congestion of—Scee Liver, Simple Enlargement of

Liver, Fatty.—Definition—(1.) Infiltration or deposit
of superfluous fat in the liver-cells, commencing at the cir-
cumference of the lobules, from the blood of the portal vein
capillaries ; (2.) Degeneration of the liver-cells, in which the
nutritive process within the hepatic cells is disturbed, so that
an abnormal increase of the fat naturally contained in the
hepatic cells takes place, which remains there, so that they
become engorged with oil.

Treatment.—Dr. Murchison recommends that large quan-
tities of common salt be eaten with the food, while, if the
LIVER, LARDACEOUS——LIVER, ENLARGEMENT OF, 247

circumstances permit, the alkaline or saline mineral waters of
Carlsbad, Marienbad, Kissengen, Ems, Vichy, Eger, Franz-
ensbrunnen, or Homburg, are to be advised. The diet must
be carefully prescribed, and regulated daily.

Liver, Lardaceous.—Definition.—The existence of a
peculiar homogeneous, translucent, albuminoid material in
the hepatic arteries, cells, and texture of the liver, resembling
an infiltration, but the albuminoid material is not found as
such in the blood.

Treatment.—It is desirable to limit the suppuration of
bones as much as possible by early surgical interference.
Iodine and iron are the remedies indicated by the nature of
the disease and the circumstances under which it occurs;
but nothing is known as to the effects of remedies.

Liver, Inflammation of—sSee Hepatitis.

Liver, Simple Enlargement of.—Defaction.—Simple
enlargement of the liver, from fulness or distention of its
blood-vessels and bile-ducts.

Treatment.—A restricted and judicious diet is of first im-
portance, with abstinence from rich dishes and fermented
liquors. With regard to medicine, Plummer’s pill at bedtime,
followed by Rochelle salts in a seidlitz powder, or Pullna
water, in the morning, or by the usual black draught, or
compound mixture of senna, or by such saline purgatives as
sulphate of soda and bitartrate of potash (which cause a
drain from the portal system of veins), usually give relief. A
purgative dose of calomel, especially combined with com-
pound jalap powder, is of all combinations the most efficient
in diminishing congestion of the liver. After its action the
local weight, the pain, the fulness, and other symptoms sub-
side concurrently, with copious bilious stools. In such cases
it seems to act by irritating the upper part of the small in-
testine, propelling onwards the bile as fast as it flows into
the duodenum, thus preventing its reabsorption (Murchison).
The bilious accumulations thus evacuated constitute the
“Dbilious stools ;”’ but they are not to be regarded as the re-
sult of increased biliary secretion from the liver itself. An
active aperient ought to be prescribed every second or third
day for ten days or a fortnight after the action of the calo-
mel and jalap purgation (Graves). In chronic congestion the
external use of iodine ointment sufficiently diluted is of ser-
vice. Dr. Graves bears testimony to the value of setons over
the hepatic region. Two leeches every second day to the
248 LIVER, SIMPLE ENLARGEMENT OF.

verge of the anus, and repeated from ten to fifteen times,
yield excellent results. Nitro-muriatic acid isa valuable
remedial agent. Podophyllin, in small repeated doses, best
relieves the engorgement and torpor of theliverin those who
have resided long in tropical climates (Gairdner). It may
not act for ten, twelve, or even twenty hours, when the purg-
ing which results is due to the large amount of bile passed
into the bowels. It stimulates the liver to increased secre-
tion. The best mode of administration is to dissolve podo-
phyllin in spirits of wine, in the proportion of one grain to
the ounce, and combine it with essence of ginger, in the pro-
portion of 3 iss. to the ounce. A teaspoonful of this mix-
ture in a wine-glass of water every night, or every second or
third night, secures all the advantages of podophyllin with-
out the disadvantages which result when given in pills (Do-
bell, Brit. Med. Journ., May 24, 1879). Chloride of am-
morium is especially indicated when congestion is the prom-
inent condition. It should be given in doses of grs. v. to xx.
twice or thrice a day after food, combined either with acids
or alkalies, according to the special indications of the case.
The skin must be first induced to become moist and perspir-
able by some diaphoretic. If it is hot and dry, with a tem-
perature of 103° or 104° Fahr., a sixteenth of a grain of tar-
tar emetic should be given every three or four hours till dia-
phoresis occurs (Dr. Wm. Stewart, Philadelphia Med. Times,
April, 1878, also under Hepatitis). When colored deposits
are present in the skin, chlorate of potass should be com-
bined with the chloride of ammonium. Benzoate of soda is
another hepatic stimulant of value (Dr. Dobell). Taraxicum
diminishes abdominal plethora :—

Ext. Tarax., gr. xxxvi.; Ext. Aloes, gr. xii; Ext. Acet.
Colchici ; Pulv. Ipecac. rad. aa., gr. vi; misce. Divide in
pil. xii. Two pills every night.

An electuary, composed of equal parts of sublimed sulphur
and the powdered gum-resin of guaiacum, will be found use-
ful in cases where the congestion of the liver is associated
with hemorrhoids. When dropsy.prevails, doses of the diu-
retic pill of hydrargyrum, squills, and digitalis (a grain and
a half of each ingredient), taken night and morning, are at--
tended with benefit. In bilious congestion copious draughts
of hot water act as an emetic, diluting the bile, and if some
saline purgative be added, the congestion of the liver will be
relieved. If pain prevails over the liver, leeches and fomen-
tations are indicated, with perfect rest in the recumbent posi-
LIVER, WAXY—LOCOMOTOR ATAXY. 249

tion—the diet consisting of arrow-root, sago, milk and water,
barley-water, and afterwards beef-tea when convalescent.

Liver, Waxy—Sce Liver, Lardaceous.

Locomotor Ataxy, Progressive.—Definition.—A pe-
culiar disease of the spinal cord, characterized by unsteady
and disorderly muscular movements (but with muscular
power entire), and more or less progressive loss of the faculty
of co-ordinating power (voluntary and instinctive), There
is sometimes temporary diplopia, with unequal contraction
of the pupils. The course of the disease is slowly progres-
sive ; and the ahatomical lesion is generally a (chronic my-
elitis in the form of) ribbon-like sclerosis of the white pos-
terior columns and horns of the spinal cord, and posterior
roots of the spinal nerves, leading to grey degeneration, some-
times with peripheral structure-change in the cranial nerves,
and chiefly the second, third, and sixth pairs, in cases where
the sight is affected. The disease generally begins in the
lumbar region, and may extend throughout the entire cord,
as far as the upper cervical portion, and even into the me-
dulla oblongata.

Treatment—No benefit is to be got from antiphlogistic
treatment, unless there be marked evidences of inflammatory
irritation. Dry cupping may be of use for the relief of pain.
Derivatives are likewise useless. Thermal baths are also in-
jurious. Cool sponging of the body is of great use; and
cold-water treatment generally, especially the use of the cold
sponge-bath (Erb).

Phosphorus, in the form of phosphates of metals and salts,
of diluted phosphoric acid, as a drink in the daily allowance
of water, of phosphate of soda as an aperient, may be given
with benefit. Strychnine is objectionable. Nitro-muriatic
acid as a tonic, and cod-liver oil as a dietetic agent, may also
be of use. Cannabis Indica and belladonna give the great-
est relief to the pains. Nitrate of silver is recommended by
Wunderlich, in doses gradually increasing to half a grain
daily. Phosphuret of iron is also recommended. Dr. Al-
thaus recommends sulphur baths as adjuvants, relieving pains
and diminishing numbness.

Flannel should be worn next the skin, and chills from cold
and damp carefully avoided, by the use of a chamois leather
or spun silk close-fitting jacket over the flannel, and reaching
from the height of the clavicles as low as the folds of the
nates behind. The diet ought to be of the most nutritious
materials which the patient can digest.
250 LUNGS, CONGESTION OF.

So long as there is active local hyperemia, the use of elec-
tricity is hurtful. Faradization may be of use in restoring,
to some extent, sensibility to the skin, where local cutaneous
anesthesia has prevailed, after which patients seem to walk
better for a time; but when used at all, electricity ought
only to be employed during the pauses in the course of the
disease, and then with great caution, in the form of a con-
stant current, rather than the induced current, or faradiza-
tion. The current should be very weak at first, and the
daily application for not longer than from three to six min-
utes, extended over months. Niemeyer has had no suc-
cess either with nitrate of silver or the constant current of
electricity; but he recommends them to be tried.

Lungs, Congestion of.—Definition—An hyperemia or
over-fulness of blood in the capillaries of the lung, resulting
in the discharge of blood by expectoration (hzmoptysis); or
in an extravasation of blood from capillary rupture into the
air-cells, terminal bronchi and the interstices of elastic tissue
(pulmonary apoplexy).

Treatment.—The medicines most useful in hemoptysis are,
the bitartrate of potash, in doses of a drachm, repeated every
four or six hours, to each dose of which may be added a
quarter to half a grain of opium. The mineral acids, as
the infusion of roses, with diluted sulphuric acid, in doses of
from three to five drops, combined with opium or marphia,
every four or six hours. One to three grain doses of the
acetate of lead, every four or six hours, may be given, with
half a grain of opium to each dose, or combined with dilute
acetic acid and laudanum (A. T. Thompson). The muriate
of soda, in doses of half a drachm to a drachm, is in estima-
tion with some practitioners on the continent.

In atonic hemoptysis, ergot is said to be of service, espe-
cially in the following combination:

R. Ext. Ergote Liq., 3ii; Tinct. Digitalis, 3 ii; Acidi
Gallici, 3i.; Magnes. Sulph., 3 vi; Acid. Sulph. Dil, 3i;
Infus. Rose Acid., ad % viii; misce. A sixth part of this
mixture to be taken every three hours, till haemorrhage
ceases (Dobell, Warring-Curran). Wunderlich also recom-
mends the secale cornutum, in doses of from five to ten
grains, to be pushed until a numb sensation is experi-
enced in the fingers and toes.

The hypodermic injection of ergotine is by far the most
efficacious of styptics in hemoptysis. A grain of (Bon-
LUNGS, CONGESTION OF. 251

jean’s) ergotine should be injected on the back of the
side of the thorax whence the bleeding comes, and re-
peated every two or four hours; and fifteen minims of
tincture of digitalis should be given every three or four
hours, its effect on the pulse being watched (Coghill).

When hemoptysis is connected with amenorrhea, prepara-
tions of iron often succeed when other remedies have failed.
Two grains of the sulphate of iron, with one drachm doses
of the sulphate of magnesia, three times a day, often restore
the menstrual secretion, and cure the hemoptysis. It is in
this form of amenorrhcea that iron is most successful. When
hemoptysis depends on disease of the heart, cupping from
the chest, or moderate bleeding from the arm, combined
with the use of the bitartrate of potash, or the mineral acids,
to which should be added five to ten mimins of the tincture
of digitalis, to give steadiness to the irregular, turbulent, or
rolling action of the heart. Repeated dry-cupping, aided by
the application of ice down the spine, and by the internal
administration of full doses of digitalis—half a drachm of
the tincture, or a grain anda half of the powder (Fuller).
It is chiefly as an adjunct to other means, when hemoptysis
is attended with much vascular excitement, that digitalis is
of service. Full and frequent doses of gallic acid, or lead
and opium, may be given, if the circulation is much acceler-
ated; and of spirits of turpentine, in half-drachm doses, if
the bleeding is unattended with vascular excitement. The
gallic acid is more adapted for chronic cases, and should be
given every hour, in eight or ten grain doses, until the
hemorrhage is subdued, or till a dark-green color in the
sputa indicates its action on the system. Its efficacy ap-
pears to be increased by combination with sulphuric acid,
and-may be conjoined with opium or digitalis.

The following formula is a useful one:—

B Acid. Gallic., gr. xxx.; Acid. Sulph. Dil, 31 Liquor
Opii Sedat., m xxx.; Infus. Ross Co.,f 3 vi; misce. Two
tablespoonfuls for a dose every three or four hours (Dr. L.
Earle).

Absolute bodily and mental, rest must be insisted on
throughout, in cases of pulmonary infarction. Stimulation
must be resorted to in the first instance ; after which the
mineral acids, or super-acid salts, appear to offer the best
hopes of recovery. If the apoplexy be secondary, and de-
pends on disease of the heart, digitalis may tranquillize its
excitement,
252 EMPHYSEMA—LUNG, GANGRENE OF.

Dietetic and General Treatment.—The patient should be
placed in bed, with his head and shoulders raised; the win-
dow should be partly open, so as to keep the room cool. It
has been recommended that the air respired should pass
through a respirator containing ice; and it is common to
place a bowl of ice immediately before the patient, so that
he may suck small portions as often ashe can. A large pad
of spongiopiline, soaked in chloroform, should be laid on the
chest, over the locality of bleeding. ‘The bedclothes should
be light but sufficiently warm. The diet should be slops,
and these slops cold; and if cooled to a low temperature by
ice, so much the better. No red meat, nor beef-tea or stimu-
lants, are to be given; but milk, chicken broth, jelly, and
iced lemonade.

Emphysema.—Dejfinition.—(1) VesicuLaR EMPHYSEMA
Relative increase of air in few or many air-cells of the lungs,
causing a misshapen enlargement of them, by dilatation or
rupture of septa, and the blending of several into one or
many great cysts. It is attended with gradual effacement
of the functional blood-vessels distributed over their walls,
anzmia of the lung in the affected parts, tending to dilata-
tion of the right side of the heart, with anasarca. (2) In-
TERLOBULAR EMPHYSEMA.—Air infiltrating the meshes of
the sub-pleural and interstitial connective tissue of the lungs.

Treatment.—Apart from the management of the bronchial
congestion, on the principles already given under Bronchitis,
little can be done for the special treatment of emphysemal
If bronchial spasm prevail, the spiritus ztheris of the British
Pharmacopeeia may give relief, of which thirty to sixty
minims may be prescribed in camphor water, or in spiritus
ammoniz aromaticus, or in volatile tincture of valerian; or
it may be conbined with stimulant doses (one grain) of
opium; or with twenty minims of the ethereal tincture of
lobelia, belladonna, conium; or the ethereal tincture of In-
dian hemp and hydrocyanic acid may each in turn be found
of service (Fuller). Dry-cupping between the shoulders
often relieves passive pulmonary congestion; and if an at-
tack is imminent, an emetic, or unloading the bowels by a
dose of the compound jalap ’ powder, may prevent its acces-
sion or moderate the paroxysm.

Lung, Gangrene of.—Defnition.—Disintegration and
breaking up of the tissue of the lung. Shreds of lung-tissue
may here and there be distinguished; but the whole mass be-
LUPUS. 253

comes converted into a heap of amorphous granular matter,
of ayellowish-brown or black color, mingled with drops of oil.
The tissue becomes soft and flaccid, in some parts perfectly
liquescent, and generally emits a fetid smell.
Treatment-—The chief reliance is to be placed in all forms
of stimulants, combined with such tonics as bark or quinine
in full and repeated doses. Repeated doses of an ounce of
yeast, as well as the influence of chlorate of potass, are sug-
gested by Dr. Walshe. Ammonia has not been found so
useful as the mineral acids. Inhalation of the vapor of tur-
pentine, poured upon boiling water, exercises a distinctly
remedial power (Skoda). Gargles of Condy’s fluid should
be freely used, and antiseptic inhalation, as described under
“Phthisis.” The mineral acids, especially nitro-muriatic,
combined with quinine, are the main remedies in the chronic
state of this disease.. A generous diet, easily digestible, with
as much malt liquor as can be taken, are also recommended.

Lupus.-—Definition—A spreading inflammation of the
skin or mucous membrane, usually of the face, characterized
by infective cell-growth, tending to destructive ulceration,
but only by accident involving textures deeper than the skin.

Treatment.—The new. formation must be removed or de-
stroyed; but opinions differ as to how this is best effected.
Mr. Jonathan Hutchinson prefers Volkmann’s erasion
method. Cazenave recommends chloride of zinc, arsenical
paste, or the powder of ‘‘Come,” Vienna paste (equal parts
of chalk and quicklime), and other powerful applications of
the like kind. Hebra also recommends cauterization and
employs usually strong nitric acid over the unulcerated, and
nitrate of silver over the ulcerated surface. It is a remark-
able fact in the history of lupus, affirmed by Hebra, that the
lupus disappears during acute febrile diseases, and especially
during typhus. It seems to recur with convalescence. (See
Dr. A. Thomson on Diseases of the Skin, edited by Dr.
Parkes, where numerous interesting cases are detailed, p.

Io.
: te medical treatment has in view the prevention of the
formation of more similar deposits in the substance of the
skin by improving the general health. Cod-liver oil, phos-
phorus, quinine, and bitter vegetable tonics, good food,
bracing air, and the judicious use of stimulants, are all use-
ful in this respect. Iodides and preparations of mercury are
to be avoided; but arsenic may be given with advantage
(Hutchinson). On the other hand, Dr. M’Call Anderson
254 LUPUS,

recommends the use of iodide of starch. [The following is
the formula for its preparation: FB, Iodi, gr. xxiv; amyli, 3 j.
Triturate the iodine with a little water, gradually adding the
starch and continuing the trituration till the compound as-
sumes an uniform blue color, so deep as to approach black.
The iodide should be dried with a heat so gentle as to run
no risk of driving off the iodine, and it ought to be kept in
a well-stoppered bottle. On no account should spirit be
used in its preparation instead of water. The dose is a
heaped-up teaspoonful in a draught of water or water-gruel
thrice daily; but it may be safely increased even up to an
ounce in some cases]. In using it, care must be taken, first,
that the cases are really undoubted cases of lupus erythema-
todes and not lupus vulgaris; and second, that the medicine
is freshly prepared, and in accordance with the directions
above mentioned. Dr. Balmanno Squire has devised an im-
provement upon the treatment of lupus by pricking the skin
at short distances with a pointed instrument, as long since
advacated by Dubini, of Milan, and subsequently by Volk-
mann, of Halle. By means of a many-bladed instrument
which Dr. Balmanno Squire has contrived, and which has
been constructed by Messrs. Weiss, of London, he cuts the
skin into thin strips. The Dubini-Volkmann method
(known as punctiform scarification) has been highly success-
ful. Dr. Squire’s method (termed multiple linear scarifica-
tion) has proved still more successful. It has been tested
and commended in this country by Dr. Walter Smith, of
Dublin, and Mr. Malcolm Morris, of London; while in
Paris, at the Hopital St. Louis, Dr. Vidal and his assistants
treat every Wednesday as many as from forty to fifty patients
by this method. The advantages are the same as those
which attend punctiform scarification—namely, the setting
up of a traumatic inflammation, under which the disease
heals; but the superiority claimed for treatment by closely
and regularly spaced incisions is a more rapid and at the
same time a more complete cure of the disease than can be
effected by means of irregularly distributed punctures. Dr.
Vidal had observed, in sections of the skin thus healed, the
gradual conversion of the lupus cells into fibrous tissue. The
advantages of treatment of the disease by the excitement of
traumatic inflammation as compared with other means of
treatment, are described as being less painful, as causing less
loss of substance, and as leaving less permanent trace of its
performance than the customary methods of local treatment,
MEASLES, 255

namely, the application of caustics or semi-caustics (Brit.
Med. Journ., August 23, 1879, p. 293).

Malignant Purpuric Fever—Sce Cerebro-Spinal Men-
ingitis.

Measles.— Definition.—A purely contagious and infectious
disease, the virus or contagium passing off in the exhalations
of a patient, causing the surrounding air to be contaminated.
The disease is capable of inoculation by the blood and secre-
tions. An eruption occurs in crops of a crimson rash, con-
sisting of slightly elevated minute dots, about the size of
millet-seeds, and having a small papular centre, scarcely per-
ceptible to the touch, and without any sensation of hardness.
Several of these may unite in irregular circular forms, or
crescents, or they may be isolated. The eruption appears on
the thirteenth or fourteenth day after exposure to infection
(Panum, Archiv. Gen. de Med., April, 1851, p. 451, and Ed.
Med. Journal June, 1858, p. 589, quoted by Murchison). It
is preceded by catarrhal symptoms affecting the conjunctiva
and air passages for about four days, accompanied with fever,
which commences with repeated rigors—7. ¢., the real incu-
bation period is about ten days. It lasts six or seven days,
and the whole duration of the disease is completed in from
nine to twelve days. Measles affects the system only once ;
and sometimes prevails as an epidemic.

Treatment.—The constitution during measles is little im-
paired by the short continuance of the fever. The rule, there-
fore, is to interfere as little as possible as long as the disease
is pursuing its normal course, and merely to moderate and
subdue symptoms when they threaten danger, knowing that
the great majority of cases end in recovery without any medi-
cal treatment. The morbilli sine catarrho is usually of such
a mild form as to require no other treatment than a milk diet,
the customary attention to the bowels, and the prevention of
exposure to cold and wet. Measles will not bear exposure of
the surface of the body to cold so well as either scarlatina or
small-pox, on account of the great tendency to bronchial and
pulmonary inflammation. Children must therefore be
watched night and day to prevent them lying uncovered, and
special care must be taken to avoid exposure to cold during
convalescence. An even and moderately moist temperature
must be maintained in the room, steam from a boiling kettle
of water being admitted. The temperature ought to be regu-
lated by the thermometer, and kept at 60° to 65° Fahr. The
256 MEASLES.

room must also be regularly subjected to a current of fresh
air daily, the patient being sufficiently protected at the time.

In the morbilli mitiores the cough, the frequent vomiting,
and the heavy catarrhal symptoms which so generally attend
the primary fever, render medical attendance necessary from
the first moment of the attack. The treatment of these
symptoms, however, and also of the eruptive stage, as long as
the patient continues free from any serious inflammatory af-
fection of the lungs, need not necessarily be active, it being
sufficient to alleviate the cough, allay the vomiting, and check
the catarrh by some of the large class of saline laxatives, lin-
seed tea, or mucilaginous mixtures, to which antimonial or
ipecacuanha wine may be added, if necessary, as a diapho-
retic, and to subdue high vascular action. In making a se-
lection from these, the physician must be principally guided
by the state of the bowels and the condition of the stomach
of the patient. If the bowels be constipated, the milder
salines, as the sulphate of magnesia, are to be preferred.
Often, however, a diet of stewed prunes or fruit will be suffi-
cient. On the contrary, if the patient be purged, and the
vomiting distressing, a neutral mixture or effervescing
draught will be found most beneficial. There are many per-
sons in whom the cough and catarrh are the most urgent
symptoms ; and in such cases, if the stomach be quiet, the
liquor ammoniz acetatis, combined with camphor mixture,
from its more powerful action on the skin, is an excellent ad-
dition. Another remedy, equal or perhaps still more useful,
is ipecacuanha wine. Willan was of opinion that an emetic,
given on the second or third evening, somewhat alleviated the
violence of the catarrhal symptoms, and contributed to pre-.
vent the diarrhoea which usually succeeds measles. An
emetic is especially useful if the disease be threatened with
croup as acomplication: During the eruption he adds, “I
have not observed any considerable effect from antimonials
or other diaphoretics.”” The use of aconite has been found
to moisten the skin; and certainly helps the emergence and
development of the eruption when due, though it seldom re-
duces the temperature before the eruption comes out, but it
reduces the pulse (Phillips). Bathing the feet every evening
seems a beneficial application. Emulsions and mucilages af-
ford but a feeble palliation of the cough and difficulty of
breathing ; but if there is much oppression, with a sense of
tightness, linseed poultice jackets must be applied to the
chest. With respect to opiates, they are not advisable should
MEASLES. 257

bronchitis be extensive, and in’ the early stages especially ;
opium produces an increase of heat and restlessness, without
conciliating sleep. The catarrhal symptoms are frequently
accompanied, even in the very earliest days of the disease,
with much bronchial inflammation, and sometimes with pneu-
monia ; or these affections may occur at any later period,
after the decline of the eruption, from the tenth to the twelfth
day of the attack. For these a stimulant treatment is re-
quired. If pleurisy alone supervenes, mercury is best used
in the form of friction with blue ointment over the chest, a
little croton oil being added to promote its absorption (An-
drew Anderson). In such cases stimulants are called for—
e. g. subacetate of ammonia, chloric ether, wine, or brandy.

During the whole course of measles it is necessary to enjoin
an abstinence from animal food, and to limit the patient to a
low diet and to slops. Liquid food should be given in small
quantities at frequent intervals. The chamber should not
be subject to any sudden change from heat to cold, and the
strictest cleanliness should be observed. With a view to
protect the eyes, the room should be kept dark, so that the
patient may be prevented reading or using his eyes. In large
establishments separation is necessary, to prevent spreading
of the disease, if possible. Should the eruption disappear
(“ striking in of the eruption ”), or be retarded, and untoward
symptoms appear, it is just as unscientific as it is dangerous
to attempt its “restoration.” It is dangerous, because the
rules usually laid down for this emergency may have an inju-
rious effect on the course of the disease. The disappearance
of the eruption is not to be regarded as the cause, but as the
result of a bad form of the disease, and due to the general
collapse of the patient, in which the skin participates. But
this bad form of the disease usually depends on the appear-
ance of some complication, especially pneumonia ; and, if
this fact be not remembered, and the patient be rubbed with
irritating applications, or be placed in a hot bath, with or
without mustard, or wrapped up in wet blankets with decoc-
tion of mustard, “ to bring the eruption out again,” we shall
often do much harm, even if we succeed in our object, because
these procedures do not generally act advantageously on the
pneumonia and other complications, while they increase the
fever” (Niemeyer, Tesxt-book of Practical Medicine), When
convulsions occur in children, it is in all cases necessary, in
the first instance, to determine the most probable source of
the irritation giving rise to the convulsions—z ¢., whether

LZ ‘
258 MEASLES, GERMAN—MENINGITIS,

they depend upon the specific poison of the disease, upon
dentition, or upon intestinal irritation or cerebral disorder.
Hot foot-baths sometimes give relief, as well as sinapisms to
the limbs ; after which, if the convulsions do not subside,
it may be necessary that blood be taken by leeches from the
temples. Diarrhoea should not be checked suddenly, but
kept under control. The patient ought to remain in bed so
long as fever is present, while desquamation is going on, and
the cough is severe ; and he ought to keep his room so long
as catarrh is present. A low state of the general health may
finally result, requiring quinine, iron, or cod-liver oil ; change
of air—especially to the sea-side—and sea-bathing, or cold
bathing in salt water.

Measles, German—Rotheln.— Definition. A specific
eruptive disease, having an incubation period of ten to
fourteen days (Squire), or from two to three weeks (Thomas),
followed by fever, watery discharge from the eyes and nose,
sneezing, and sore throat. The eruption appears on the
third or fourth day, and consists of crimson stigmata, rapidly
running together into patches of an irregular shape, with
obtuse angles, and of sizes varying from a threepenny toa
crown piece, according to the severity of the case. The
eruption continues from six to ten days, and terminates in
desquamation by furfuraceous scales.

Treatment.—The treatment is similar to that of scarlet
fever. The functions of the skin are if possible to be stim-
ulated; and Dr. Paterson found that the aqua acetatis
ammoniz, in the proportion of two ounces to half an ounce
of antimonial wine, and four ounces of water, was a most
useful remedy. The use of colchicum was also had recourse
to with decided benefit.

Meniere’s Disease.—(See Vertigo, auditory).

Meningitis, Cerebral and Spinal.—Defmition.— In-
flammation of the immediate coverings of the brain and
spinal cord, the pia mater, and arachnoid (pia-arachnitis).

Treatment—As a general principle, remedies have little
influence over those forms of the disease which arise during
the progress of any specific or constitutional disease, inde-
pendent of the general treatment indicated for that disease.
When pia-arachnitis arises from mechanical injuries, the
treatment is generally by bleeding. If the first symptoms
are characteristic of inflammation of the meninges of the
brain, and we can only conjecture what it may turn out,
MENINGITIS, CEREBRAL AND SPINAL, 259

leeches behind the ears ought to be applied in the first in-
stance. If this local abstraction of blood proves beneficial,
it may be repeated during subsequent relapses. At the out-
set of the disease laxatives and ice compresses may also be
used (Niemeyer). There is, perhaps, no class of cases in
which the sanative powers of judicious blood-letting become
so apparent as in children in whom the disease has been
observed early and carefully watched. When the inflamma-
tory symptoms are less decided, and the headache slight,
and the disease drags on slowly, a single venesection is ad-
missible. [Dr. Alison relates the following highly illustra-
tive case, confirnied now by the teaching of Niemeyer :—
“A boy, aged eight years, of rather delicate habit, and who
had complained occasionally for some weeks of headache
and disordered bowels, temporarily relieved by laxatives,
calomel, antacids, and a careful regimen, but recurring, and
attended with gradually increasing febrile symptoms, and
shooting pain of head ; impatience both of light and sound ;
pulse gradually rising to 108, distinctly sharp, and beginning
to intermit ; and then nauseaand vomiting, not referable to
any medicine taken, but gradually increasing, until it re-
curred every time that he sat up in bed, for nearly twenty-
four hours ; and a slight but quite perceptible squint show-
ing itself. The full action of laxatives and one application
of leeches, as well as cold to the head, having failed to make
any impression on this course of things, he was bled at the
arm (which in such circumstances and at that age has often
appeared to me distinctly preferable) to twelve ounces, and
the blood was sizy. I donot know what further evidence
we could have had of the existence of such inflammation
within the cranium as would infallibly, if let alone, have gone
on within a few days to delirium, stupor, dilated pupil, slow
pulse, succeeded by very frequent pulse, convulsions, and
death, and have left after it the usual appearances of the
acute hydrocephalus (of Whytt, Cullen and Abercrombie,
now described), dryness of the membranes on the surface of
the brain, distension of the ventricles of the brain with
serum, and some of the marks of inflammatory action either
on the membranes or surface of the brain. Instead of this,
however, I am quite certain that from the time of the bleed-
ing at the arm, this boy never once vomited, that the inter-
mission of the pulse was never again observed, nor did he
again complain of lights or sounds. The pain of the head,
although less violent, continued in the evening of the same
260 MENINGITIS, CEREBRAL AND SPINAL,

day, and twelve leeches were applied within eight hours after
the bleeding ; and from that time he never once complained
of this symptom, nor admitted that he felt it ; and from this
moment he recovered perfectly, and much more rapidly than
he had done from much slighter febrile attacks previously ;
neither has he suffered from that time to this (now thirty
years) any return of serious disease” (Adin. Med. Journal,
p- 777, March, 1856.) In short, all the symptoms vanished
in twenty-four hours, most of them during the flow of blood,
and never recurred—a change, under the circumstances, so
sudden and sanative as is rarely if ever seen after the
use of any other remedy for the same combination of symp-
toms,

wh reference to the sanative influence of general blood-
letting in children for inflammatory diseases, if performed at
the outset, Dr. West observes, that such depletion is as im-
portant a remedy as in the adult ; nor will the most energetic
employment of any other antiphlegistic measure enable us to
dispense with blood-letting. Ina healthy child two years
old, a vein (if easily found) may be opened in the arm, and
four ounces of blood allowed to flow, if faintness be not
earlier produced, without our having any reason to appre-
hend that the plan adopted is too energetic. The immediate .
effect produced is greater than that which follows local de-
pletion, and the quantity.of blood abstracted is less (West,
Diseases of Children).. Bleeding in children and in adults
exercises an influence quite different—because under totally
different circumstances—not yet inquired into ; but certain-
ly blood-letting at ages under adult life is soon repaired
compared to its reparation after that period. Hasse recom-
mends very small doses of morphia (,4¢ of a grain) in the
early stages.

The first thing to be done by way of medicine is to purge
the patient. The purgative is not of great moment, provided
it acts freely. Some prefer two to five grains of gamboge,
others five grains of calomel, with thirty grains of compound
jalap powder. Such doses are to be followed up by a black
draught, or the sulphate of magnesia. So difficult is it to ob-
tain the action of purgatives in this disease, that doses of three
times the strength for adults have been in some instances re-
quired ; but such large doses are never to be given until
the inefficiency of smaller ones has been ascertained (Sir
Thomas Watson’s Lectutes, No. XXVI). The stools are
generally black, or extremely offensive ; and, this state of the
MENINGITIS, CEREBRAL AND SPINAL. 261

bowels corrected, the disease, if sympathetic, often ceases.
If, however, the head be not relieved, some leeches should
be applied to the temples, and the head should be shaved
and surrounded with some cold evaporating lotion, such asa
towel dipped in cold spring water, or in vinegar and water,
or in solution of the muriate of ammonia, with vinegar.

In chronic cases, Foville strongly recommends the cold
douche—pouring cold water over the head from a pitcher
held some distance above it. This remedy must be used
with caution, as it is a powerful depressant, yet producing less
ultimate debility than bleeding. It acts, doubtless, by cool-
ing down the general mass of the blood ; and patients almost
always recover consciousness under its influence. To secure
a lasting result it must be repeated at intervals‘ of a few hours

In children I have certainly seen good results from inunc-
tion with mercurial ointment. (See remarks under the treat-
ment of “Hydrocephalus.”) In advanced life it rarely hap-
pens that the symptoms are so intense as to demand general
blood-letting ; but in vigorous constitutions this measure is
sometimes necessary. The cases which demand it are those
attended by high cerebral excitement and vascular action.
But as a rule local blood-letting is not only infinitely more safe,
but more beneficial, and it can‘be repeated from time to time,
as the nature of the symptoms may indicate; while general
blood-letting can very rarely be resorted to more than once,
and that only at the commencement of the attack. The
beneficial effects of local blood-letting may be greatly aided
by keeping the head well raised, and by the constant appli-
cation of cold water to the scalp; or the occasional use of
bladders filled with crushed ice. The bowels should be
opened as rapidly as possible, unless the patient is feeble,
emaciated, or greatly exhausted, The most active and
searching purge is obtained by calomel and jalap ; or four
or five grains of the compound extract of colocynth should
be given, combined with two or three grains of calomel, in
cases uncomplicated with gout or Bright’s disease, and fol-
lowed in a few hours with a dose of salts and senna. A fair
proportion of nutriment must be given, in the form of milk,

strong beef-tea, sago, tapioca, or arrowroot ; and the patient
should be kept in a quiet, cool, well-aired, and darkened
room, and with cold compresses ‘constantly "applied to the
head. The more active symptoms being subdued, but not
till then, a blister should be placed on the nape of the neck,
The bowels should be kept open regularly, and the strength
262 MENINGITIS, CEREBRAL AND SPINAL.

supported by mild, unstimulating nutriment. When nervous
irritability continues during convalescence, henbane, or mu-
riate of morphia may be given. In the chronic form the
periodical attacks of headdche or of insanity may generally
be relieved by a brisk purge ; and the head should be kept
cool by cloths dipped in vinegar and cold water. If vascular ‘
excitement prevails, leeches may be applied behind the ears.
The bladder must be kept empty of urine by the catheter,
and although wine must be withheld during the active stage of
the disease, it is beneficial when the vital energies begin to
fall (Maclachlan).

The dietetic treatment should be strictly antiphlogistic, the
patient especially avoiding all mental excitement ; and, if not
secluded, he ‘should at least be kept tranquil, not only in
body, but also in mind.

Spinal arachnitis, seldom depending on a morbid poison,
is perhaps in all cases: best treated by bleeding and mild
purgatives. General bleeding is sometimes necessary ; but
local bleeding, either by cupping or leeches, along the verte-
bral column, is most useful, and cannot be omitted with
safety. The medicinal treatment consists in moderate purg-
ing by the neutral salts, as the sulphate of soda or the sul-
phate of magnesia ; for, as these act on the bladder as well
as on the bowels, they are probably the best remedies. But
whatever purgative may be selected, it will be proper to com-
bine it with the tincture of hyoscyamus, or other mild opiate,
to procure the patient any relief from his sufferings. Ergot
of rye (secale cornutum) has been very much used in France;
and Dr. Meryon speaks favorably of its effects, combined
with iodide of potassium, in a case which manifested no
complication of spinal effusion (Medical Times and Gazette,
Aug. 31, 1863). The warm bath is an excellent adjuvant in
the earlier stages of the disease; whilst in the later stages
blisters, setons, moxe, or the ointment of the tartrate of an-
timony, are more beneficial, or at least are deserving of a
trial. The paralyzing effusion may disappear during their
use, combined with the action of diuretics. The external
application of belladonna and chloroform will be found of
essential service in diminishing the violent pain which ac-
companies meningitis of the cord (Meryon). Cold, in the
form of bladders filled with ice, applied along the spinal
cord, may be of service where congestion prevails. Abstin-
ence from all animal diét should be imperiously prescribed
throughout the whole course of the disease.
MENINGITIS, CEREBRO-SPINAL—-TUBERCULAR. 263

Meningitis, Cerebro-S pinal—See Cerebro-Spinal Men-
tngitis.

Meningitis, Tubercular.—Definition—An effusion of
serous fluid between the membranes of the brain, or into its
ventricles, associated with miliary tuberculosis of the men-
inges or at the base.

 

Treatment.—Tuberculous meningitis, in the form of acute
hydrocephalus, can only be successfully combated in the
first or earliest stage.

If the disease be advanced, no efficient treatment has as
yet been determined. The symptoms do not yield to the
lancet like those of simple inflammation. Mercury has been
used to agreat extent, but with little success. In severe cases
mercurial ointment has been rubbed on the back and thighs,
even in very young children, to the extent of half a drachm
to a drachm three or four times in the twenty-four hours.
Calomel also has been rubbed on the gums to the extent of
three or four grains every four or five hours. It has like-
wise been given by the mouth in does of two g-ains every
third or. fourth hour. Mercury given in these large doses
seldom produces salivation in children under three years of
age. But the remedy is not successful, and more generally
produces spinage-like stools, and irritates the alimentary
canal.

On the other hand, Professor Gali of Vienna recom-
mends, after much experience, calomel in quarter or half-
grain doses twice a day; also at the same time inunction of
an eighth or a fourth of an ounce of mild mercurial ointment
into the shaven scalp once in twenty-four hours. The head
is to be kept constantly covered with flannel, to prevent any
check to perspiration. After a lapse of six or eight weeks,
diuretics in the form of acetate of potash, or tincture of
squills, or both, are to be given with the mercury. Counter-
irritation by issues in the neck are also advocated by him to
be kept open for months. Compression of the head by
bandaging, or by well applied strips of adhesive plaster, are
also to be applied over the whole cranium. Puncture of the
skull, if the fluid is arachnoidean, may also prove of service,
—not so if the fluid is ventricular. It is to be done with a
small trocar and canula at the coronal suture, about an inch
and a half from the anterior fontanelle, taking care to avoid
the longitudinal sinus. The fluid must be slowly evacuated,
and compression of the skull carefully maintained for many
264 MERCURIAL POISONING——MILIARIA.

weeks while the fluid is allowed to drain away. The opera-
tion has been successful in very young children.

Hygienic measures ought to be of the first importance in
the rearing of delicate children, so as to prevent if possible
the development of those conditions which lead to effusion
of fluid within the cranium. During the course of the dis-
ease the diet should be slops and light puddings.

In congenital hydrocephalus the unassisted efforts of
nature are incapable of effecting a cure, and it is extremely
problematical if medicine is of any use. When, however, the
case is deemed hopeless, the propriety of evacuating the
water by means of an operation may be entertained. Golis
has given the names of twenty-seven writers who have-ex-
pressed themselves in favor of it, especially if the fluid be
slowly evacuated, and at several repetitions of the operation;
yet he himself, along with seven or eight others, proscribe it
altogether as cruel and useless. But it has been successful;
and when the operation is performed, it seems an axiom that
the fluid should be allowed to escape gradually, for otherwise
extreme faintness and collapse may be expected. In such
cases small doses of ammonia, or a few teaspoonfuls of
brandy and water may revive the little patient. Should re-
action take place, however, at a snbsequent period, a few
leeches and a cold lotion ought to be applied to the head.
It seems also determined that the younger the child the
greater are the chances of success; for if it lives a few years
the sutures of the craniun, though open at the top, are united
by bone towards the base of the skull, and thus presenta
mechanical obstacle to their closure; consequently, the
operation is more apt to fail. If this disease, though exist-
ing at birth, should not develop till later in life, blisters,
mercury, and iodide of potassium to salivation are the
remedies mostly relied on.

Mercurial Poisoning.— Definition.—A series of morbid
phenomena, especially peculiar tremors, with cachectic and
cerebral symptoms, induced by the absorption of mercurial
inhalation of vapors from mercury or its salts, or from the
medicinal administration of the salts of mercury in continu-
ous small doses.

The Zveatment is similar to that already described for
the elimination of lead.

Miliaria.— Definition:—An eruption of innumerable mi-
nute pimples, with white summits, occurring in successive
MORBILLI—MUSCULAR ATROPHY. 265

crops upon the skin of the trunk and extremities, preceded
and accompanied with fever, anxietas, oppression of respi-
ration, copious sweats of a rank, sour, fetid odor, peculiar
to the disease. The base of the pimples and the skin around
are red and irritable.

Treatment of the disease appears to consist in cooling
drinks, purgatives, and antiphlogistics.

Morbilli—See Measles.

Mumps.— Definition.— A specific fever with inflammation
of the parotid and other salivary glands, which is contagious
and sometimes epidemic.

Treatment.—Constant hot fomentations (after leeching in
severe cases) should be applied to the swollen parts. The
maintenance of a constant but gentle action on the bowels,
by saline cathartics, must be attended to. Absolute rest
ought to be enforced, a farinaceous diet enjoined, and no
irritating applications ought to be applied to the swollen
glands. The disease runs a definite course, and is not likely
to terminate unfavorably. /

Muscle, Spasm of.—Definition.—An affection charac-
terized by pathological contractions of muscles, some pain-
ful and some not, but manifested only during the exercise of
certain voluntary or instinctive movements (Duchenne).

Treatment in all these cases must be directed towards the
removal of the probable cause, and improvement of the gen-
eral health (see Scrivener’s Palsy).

Muscular Atrophy, Progressive.—Defnition.—A pe-
culiar wasting of muscles, with atrophy of their substance,
associated with lesions of grey matter in the centre of the
cord—namely, wasting of the ganglionic cells of the anterior
horns, with oleo-granular degeneration, and of the anterior
roots of the nerves of the spinal cord, and attended by
paralysis.

Treatment of wasting palsy ought to be strictly a restora-
tive one , believing that the disease is one of nutritional de-
terioration of the nervous centres. Preparations of wine
and cod-liver oil, with localized faradization, are the most
likely agents to improve the condition of the body (Althaus).
Local means will aid the hygienic—namely, methodical
exercise and douche baths, or cold mineral baths; so also
thermal or sulphur baths, and galvanism. Frictions,
with stimulating liniments (suchas camphor liniment), are
266 MUSCULAR RHEUMATISM.

also favorably spoken of (Duchenne, Gross, Meyer, Roberts).
“Faradization ” ought to be practised at least three times a
week, for from five to ten minutes each, and continued at
least a month before it is given up, if negative results are
only obtained. Every muscle ought to be faradized in a
special manner, according as it has suffered more or less in
its electric contractility and nutrition. The power of the
current ought never to be strong. When the sensibility of
the muscle returns, the intensity of the current may be
diminished. Its application should never be protracted
beyond ten or fifteen minutes at the most—-one minute, on
an average, being allowed to each muscle, or distributed
over several at a time.

If, on the other hand, it turns out, as the searching exami-
nations of Mr. Lockhart Clarke and others would tend to
show, that these forms of progressive paralysis or “‘ wasting
palsy” are always associated with disease of the spinal cord,
the efforts of treatment should, in the first place, be directed
to that part of the cord corresponding to the connections of
the nerves with the site of lesions—the line of treatment to
‘be pursued being determined by the general symptoms.
The application of the constant current of electricity—the
positive electrode being placed in the region of the cervical
sympathetic, and the negative electrode upon the cervical
and upper dorsal regions of the spine—has been followed by
long amelioration, if not by positive cure, in the hands of
Remak and Benedikt (Clymer, in Mew York Medical Jour-
nal, 1866, Vol. III).

Muscular Rheumatism.— Defition.—Pain in the mus-
cular structures, increased by motion.

Treatment.—In muscular rheumatism, the local appliances
which ensure rest and warmth afford most relief. In lum-
.bago nothing is so instantaneously beneficial as strapping the
back from the level of the “seat’’ upwards, in imbricated
layers of straps of adhesive sticking-plaster—emplastrum
roborans—spread upon chamois leather, or the common
warm plaster of the pharmacopceia may be used (Tufnell).
The patient ought to sit with his bare back before a large fire
during the process. Calomel purgation is generally indi-
cated, combined with rhubarb and soda, as the excretions
are generally greatly at fault. The subcutaneous injection
of morphia will generally give temporary relief. Opium may
also be necessary internally ; and a course of bicarbonate of
potash with iodide of potassium may be also indicated.
MYELITIS~-~NEURALGIA. 267

Myelitis—See Encephalitis.

My ocarditis.— Definition. An inflammation of the mus-
cular structure of the heart (extremely rare as an idiopathic
disease), which becomes softened, flabby, and finally degen-
erates In varlous ways.

Treatment under such circumstances cannot be indicated
beyond what has been stated under “Endocarditis;’ but
free stimulation will be called for.

Nephritis, Suppurative.— Definition.“ Inflammation
with suppuration of the substance of the kidney.”

Treatment.—The treatment of acute nephritis must be
according to the usual principles of the treatment of inflam-
mation, by keeping the patient at perfect rest, the applica-
tion of hot fomentations and poultices, preceded or not by
the local abstraction of blood or by dry-cupping. Blisters
in such cases are dangerous, and ought to be avoided. The
neutral salts, with opiates, are admissible in some cases,
especially where calculi or gravel are sources of irritation.
Castor-oil, or other purgative substances which do not act so
immediately on the kidneys, are more useful, such as
compound jalap powder or podophyllin. Should signs of
abscess appear, the pus may be evacuated, as in the case of
liver abscess, and with the same antisceptic precautions.

Nettle-Rash—See Urticaria.

Neuralgia.— Definition —Excruciating pains occurring in
the course of nerves, and in their area of distribution, usually
of a shooting character, which flash with momentary intensity
along the fibres of the affected nerve, occurring in par-
oxysms composed of momentary shocks following one an-
other in rapid succession (Bristowe) ; or returning with re-
newed violence in a part after periods of temporary remis-
sion, due to some unknown morbid state of the nerves of sen-
sation or their centres, a symptom of some local lesion, or
more commonly of a general affection or cachexia.

Treatment.—When the cause of the neuralgia can be dis-
covered, its removal is the obvious procedure to follow.
There can be no question that the disease has often subsided
under the use of various remedies ; but the tendency in neu-
ralgia.to a spontaneous intermission is so great, that it is
doubtful whether in any case medicine can be said to have
cured it. Opiates are unquestionably serviceable in mitigat-
ing the sufferings of the patient, and perhaps in influencing
the disease, but not to the extent generally supposed. Bella-
268 NEURALGIA.

donna, both internally and as a plaster, may sometimes re-
lieve the pain. Stramonium and opium have a similar tem-
porary effect. Chlorodyne is also to be recommended ; and
the tinctures of gelseminum and of guarana.

The remedies of most value are the diffusable stimulants,
such as sal-volatile, hot tea, quinine, chloral, and croton-
chloral, in full doses, and alcohol in small doses, blistering,
the application of ammoniacal fluid to the skin immediately '
over the painful nerves, and the endermic application of
morphia. These remedies act by increasing the supply of
blood to the painful nerve, and, Avo santo, heightening its
vital energy (Anstie, of cit, p. 84). The most speedy way of
obtaining a temporary relief is certainly the application of a
local stimulant, and more especially of some volatile agent,
such as mustard, or, still better, chloroform diluted with seven
parts of some simple liniment, such as belladonna (Anstie).
A rapidly acting blistering fluid is still more effective. But
the more profoundly the general health has been affected,
and especially the greater the degree of anemia, the more
necessary is it to join with the use of stimulants (both local,
such as above mentioned, and general, such as the carbonate
and muriate of ammonia, taken in five and ten grain doses
respectively}, a treatment directed to improving the condition
of the blood by “food tonics,” such as cod-liver oil, arsenic,
or steel, or a combination of some of them, joined with the
use of local stimulation by means of frictions with dilute
chloroform, and the manipulations of the scientific “sham-
pooer” (Anstie, of ciz., p. 87). Dr. Radcliffe reports favor-
ably of the hypophosphite of soda, and believes that the phos-
phorus of this salt acts directly as a food to the nervous tis-
sue. The subcutaneous injection of small doses (% to 4 of
a grain) of morphia in solution will give temporary relief, and
is especially useful to those patients who are obliged to go
through an ordinary day of labor (Anstie, of. cit, p. 87).

When these or other general remedies have proved insuffi-
cient, recourse has been had to local remedies. The most
efficient of these applications is the alkaloid aconitina, rubbed
upon the pained part in the form of an ointment, in the pro-
portion of one or two grains to one drachm of lard. A more
convenient and efficient application is the “anodyne amyl
colloid,” prepared by Messrs. Ferris & Co., of Bristol, from
hydride of amyl, aconitina, veratria, and etheral collodion.
Morphia similarly used, and blisters, have often exercised a
beneficial effect upon the disease. Holding the head over
NEURALGIA, 269.

steam, and the warm bath, are sometimes beneficial in cases
of facial neuralgia. The belladonna plaster is also a favorite
application. When the neuralgia is superficial, compresses
steeped in a solution of atropia have a good effect. For this
remedy Trousseau recommends the following formula :—

B. Atropiz sulphatis, gr. v. ; Aquoe distillates, 3 iii. ; solve.
Renew the compresses several times in the twenty-four hours,
Continue them for at least an hour each time, and cover them
with oilskin, to prevent evaporation. '

When general and local applications are unsuccessful, the
cause may be sought for in a diseased tooth or stump, and in
a very few instances an exostosis of the stump has been dis-
covered, removed, and the disease cured. Sometimes, how-
ever, even when the patient submits to have every tooth in
his head drawn, no relief or benefit may result. The division
of a nerve is sometimes had recourse to ; but even this opera-
tion is very uncertain. Where the causes of neuralgia cannot
be removed, modes of treatment which greatly modify the
change of tissue and the nutrition of parts are often benefi-
cial. Chief among these is the use of electricity; and
Niemeyer gives the results of his experience in the following
propositions =

“1. In treating neuralgia with the induced current, it is
best to employ the metallic electrodes known as the electric
brush. While one electrode, containing a moistened sponge,
is held in one of the patient’s hands, or against any part of
his body, we stroke the brush along the course of the affected
nerve ; if there are any specially painful points, we allow the
brush to remain over them rather longer (electric moxe@).

‘“2, Many cases of neuralgia, which had been previously
treated without benefit by the most varied remedies, were
completely and permanently cured in from twelve to twenty
applications, or even sooner. In other cases no benefit or
cure was effected.”

“3. The first sitting shows whether the neuralgia can be
cured by the induced current. We can only expect a cure
where the pain is decidedly relieved, or entirely disappears,
immediately after the first electrization, even if it should only »
be for a short time. If thistemporary result do not take
place, the continuation of the treatment will also prove inef-
fectual.

“ The application of the induced current as above directed
is very painful. The current employed ought not to be of
greater intensity than the patient can easily bear ; the appli-
270 NEURALGIA,

cations should also be of short duration and frequently re-
peated.. It is only after the patient has actually experienced
benefit that he suffers it with patience.”

Theconstant current is far more effective than the Faradic
in neuralgia. Some cases that have been treated without re-
sult by the Faradic current have been cured by the constant,
but never by the reverse. Niemeyer places both poles along
the affected nerve, and, without attending to the course of
the current, holds the zinc pole on the most painful part and
on those parts where the nerve approaches nearest to the sur-
face, as at the supra or infra-orbital foramen, or at the zygo-
matico-facial foramen, or at the sciatic notch. If it be pos-
sible to get the nerve between the poles, as in the cheek or
nose, he introduces one pole into the mouth or nose to the
point whence the pains radiate, while the other is placed at
the corresponding point on the skin. “ At first the applica-
tion of the constant current is not particularly painful ; but
an unpleasant, burning, piercing pain soon commences, and
gradually increases ; and where the number of electric ele-
ments is large, it may become unbearable.

“The changes induced in the skin at the point of applica-
tion of the constant current, if the electrodes be applied for
a length of time, are far greater than those caused by the in-
duced current. They not only consist in a lively erythema,
a decided swelling of the skin, and an increase of the subja-
cent tissue ; but papules and blebs arise on the skin, particu-
larly at the positive pole. It the action continues long, the
surface of the elevations sloughs off. These changes take
place not only at the point of application, but occur
equally, or at least similarly, in the deeper parts, as is
shown not only by the increase in volume of the sub-
cutaneous tissue and muscles, but also by the following ex-
periments (Erb), which show a great deal about the mode of
action of the constant current in neuralgia and other neu-
roses, as well as in some diseases of the muscles and joints:
If we cross the forearms, placing the volar surfaces in con-
tact, and apply the electrodes to their dorsal surfaces, there
will be reddening not only of the parts to which the elec-
trodes are applied, but of the corresponding points on the
anterior surfaces. Generally, relief immediately follows the
application of the constant current, just as it does that of the
induced current; but occasionally the pain is at first in-
creased, and that should not always induce us to stop the
treatment. There seems to me no doubt that the curative
NEURALGIA, 27%

action of the constant current, in most cases of neuralgia, is
to be explained by the modification of the circulation, endos-
mosis, or change of tissue in the diseased nerve, its neuril-
emma, or the parts around. This ‘catalytic action’ may
result from the chemical disintegration induced through the
nerves, or the attraction of the constituents of the nutrient
fluids toward the pole, or it may occur in some other way”
(Niemeyer).

Narcotics, inthe form of hypodermic injections of solutions
of morphia, are of great value, and it is immaterial whether
the injection is made near the seat of pain, or at a remote
distance from it. “‘ Subcutaneous injections of morphia con-
stitute the only decided and effectual, and truly invaluable,
method of treating neuralgia” (Von Pitha). The hypoder-
mic syringe and the morphia solution are now almost as in-
dispensable acconipaniments of the physician as the stetho-
scope and thermometer. Its use, however, is attended with
similar bad results as the taking of opium in any other form.
The dose must be gradually increased, and the remedy can-
not easily be given up. Ifit is omitted the patient feels dull,
weak, uncomfortable, nervous, and trembles from head to
foot, as after an alcoholic debauch. As a palliative it is
invaluable, to the extent of one-sixth to one-third of a grain
of morphine, injected hypodermically. But in slight cases,
and in sensitive persons, and in the young, very much smaller
doses may relieve the pain—e. g., the twentieth to the twelfth
of a grain. In severe and persistent cases the dose has to
be increased; and it is very desirable not to have recourse to
such hypodermic injections oftener than twice daily. It is
necessary also to employ the remedy with proper caution,
with reference to the patient’s individuality or idiosyncrasy.
The hypodermic treatment with morphia must be commenced
tentatively in small doses. The first dose of a morphia in-
jection for an unknown individual must not be more than
one-twelfth of a grain; and in very sensitive and delicate
women and young people not more than one-twentieth, or
even yet less. If the‘patient is the subject of that peculiar
idiosyncrasy of extreme sensitiveness to opium, symptoms of
poisoning may supervene. Thus, there may be syncope,
spasm of the heart, or an asthmatic paroxysm, the skin being
covered with a cold sweat. Fresh air should at once be ad-
mitted through opened windows, while the patient’s face is
diligently fanned. An assistant should also bathe the face
and temples, as well as the bared chest, with vinegar, and
272 NEURALGIA.

these parts are to be sprinkled at the same time with cold
water. A strong decoction of coffee is to be administered as
an enema, or, when possible, given by the mouth; and, in
extreme cases, artificial respiration must be resorted to. In
most cases these means will succeed, providing that the dose
has not been too large. When the vomiting and disposition
to syncope persist without yielding to the usual measures, a
careful and interrupted inhalation of chloroform may be use-
ful. If there is a constant disposition to nausea and sickness
after the hypodermic use of morphia, it may be counteracted
by adding from a quarter to a third of the tincture of bella-
donna to the morphia solution, then the extract, and, finally,
minute quantities (about one-hundredth of a grain) of the
sulphate of atropia. The extract answers best (Von Pitha).

The injection should be projected into the subcutaneous
tissue, and not into the skin itself; and this may be secured
by pinching up a fold of skin, care being taken not to make
a double perforation in it. Well known or visible vessels or
nerves are to be avoided. The places most eligible for the
injections are—the external parts of the arm and thigh, the
back, and the integument of the abdomen and nates. The
face and neck should be avoided; and the painful regions
ought not to be punctured.

“With respect to the preparation to be employed, it may be
stated that the acetate and hydrochlorate may be used in-
differently. Only in cases in which very large doses are given,
as above a grain, need the acetate be preferred, on account of
its greater solubility. It will form a clear solution in six parts of
water, whereas the hydrochlorate requires twenty parts. Hot
water will dissolve it in ten parts, but, on cooling, half of the
alkaloid is precipitated; so that if a concentrated solution is
wanted, it has to be prepared only just before using it. On
the other hand, the acetate requires great care in keeping it
in a cool place and shielded from the light. The solution
should always consist of morphia and distilled water, without
any addition whatever. The favorite addition of glycerine
has the disadvantage of causing whiterflocculi to be precipi-
tated from the originally clear liquid. Belladonna, however,
may be added, for the reasons already stated, with great ad-
vantage; and although the solution is rendered somewhat
turbid, its efficacy is not diminished. It is very desirable
that similar combinations with different other substances,
and especially other narcotic alkaloids, should be thoroughly
investigated” (Von Pitha).
CESOPHAGITIS. 273

Frictions of the skin with veratrine ointment, in the pro-
portion of gr. iv. to gr. x. of veratrine to 3 i. of lard; or with
aconite ointment, in the proportion of one grain of aconite
to one drachm of lard, have also been used with advantage.
The application of cold water sometimes, but only excep-
tionally, does good, especially if the pain is attended by
heat—applied as a compress, or as a fine douche. Warmth
by means of a hot iron, a stream of warm water, or as a warm
cataplasm, may also afford relief. Richardson’s spray pro-
ducer has also been of use; and also acupuncture as recom-
mended by Teale, especially in the neuralgia of joints persist-
ing after rheumatism or spasm. As internal remedies chloral
and bromide of potassium combined are of great service.

The treatment of sciatica consists in following out, as far
as possible, the removal of the causes and circumstances al-
ready noticed as producing the disease. In the rheumatic
form, the warm baths are most useful, especially the syste-
matic treatment at Neuenahr, Wildbad, Wiesbaden, Teplitz,
and Bath. Iodide of potassium, in large doses, and sulphur,
especially in the form of the Chelsea pensioner, appear to do
most good. Of other specific remedies Niemeyer mentions
the induced, and still more, the constant current of electricity
as rarely failing to do good. Oil of turpentine, as an elect-
uary, is also recommended in the following :—

BR. Ol. Terebinth. 31; Mell. %1., of which a tablespoon-
ful is to be taken twice a day. This is very highly spoken
of by Romberg.

With regard to the treatment of mastodynia or irritable
breast,—a plaster worn on the breast, if composed of anodyne
elements, may soothe the pain and prevent the gland being
touched by the patient, and it as well may give support to
the breast. Cooper recommends the soap plaster with ex-
tract of belladonna, and the following pills :—

B Ext. Conii, Ext. Papaver, aa gr. ii; Ext. Stramonii,
gr. 4% to %, are mentioned by Romberg as useful.

Csophagitis.— Definition. —Inflammation of the textures
of the cesophagus.

Treatment of cesophagitis is by small local bleedings, by
warm cataplasms to the neck, and by moderately acting on
the bowels. In the treatment of the more’ chronic forms -
some sedative is essential. There is always some danger, in
the use of the probang, of rupturing the canal, or of causing
an ulcer. When the case is hopeless, from the small quan-
tity of aliment which reaches the stomach, life may yet be

18
274 OSTEO-ARTHRITIS, CHRONIC,

prolonged by enemata of soups, milk, egg, wine or other
nutritious fluid matters. The question of an artificial
opening into the cesophagus or the stomach may have to be
considered.

Osteo-Arthritis, Chronic.—Defnition—An affection
characterized by pain, stiffness, and deformity of one or
more of the joints, associated with the deposition of new
bone around them. :

Treatment.—Chronic osteo-arthritis must not be treated
either as gout or as rheumatism. Colchicum is considered
by Dr. Garrod to be generally injurious, and so also is alka-
line treatment. The course of management may be shortly
indicated as follows:—Gregory’s powder at bedtime, and
more active aperients at regular intervals, are required as a
necessity. The action of the skin ought to be encouraged
by hot-air baths, the frequent use of the Turkish bath, and
Dover’s powder at bedtime. Warm bathing is generally at-
tended with relief, and recourse should be had to the mineral
springs of high temperature. Schwalbach, Spa, Wildbad, Neu-
enahr, and Tunbridge Wells, are the best. Guaiacum, if borne
by the stomach—combined or not with sulphur, and taken as
an electuary in glycerine—is of great assistance (Garrod), The
free use of dilute phosphoric acid is recommended by Mr.
William Adams. Iodide of potassium is also well spoken of.
Whichever of these remedies may be considered suitable for
any particular case, it ought to be steadily persevered in for
several weeks. Warm clothing and residence in a warm
climate, during the winter months, are necessary elements
for increasing the comfort of the patient. If much emaci-
ation has resulted, cod-liver oil and fats must be prescribed,
combined with the usual tonic remedies—quinine, iron,
strychnia, arsenic, and mineral acids—according to the:
nature of the case. The local remedies must’ be regulated
by the surgeon. Chief of these Dr. Julius Althaus has used -
with advantage that most active stimulant of nutrition—the
continuous galvanic eurrent. It acts as a general tonic to
the system, more especially to the nervous system; and re-
lieves one of the chief complaints, want of sleep, when
hydrate of chloral fails. The best mode of application for
this purpose is to direct the positive pole, armed with a con-
ductor of large surface, to the cervical spine, while the nega-
tive pole, similarly armed, is placed on the pit of the stom-
ach. A gentle current, which even patients of exquisite
PACHY-MENINGITIS—~PALSY, SHAKING. 275

sensibility can well bear, is thus allowed to flow for from
three to five minutes in the direction just described. By
this application, the base of the brain, the spinal cord, and
the cceliac plexus of nerves, are simultaneously brought
under the influence of the current. It also relieves pains,
for which object the constant current must be applied to
the suffering parts, so that the positive pole, armed with a
small electrode, is made to touch the sore points; while the
negative, connected with a large electrode, is placed in the
neighborhood. The current used may in this instance be
somewhat more powerful than where it is employed for
general tonic effects; and if a short application, say of one
or two minutes, be not successful, this may be extended to
four or five minutes. The effect is, in many instances,
almost magical, inasmuch as pain, which has been fixed in
some particular spot for months and years, is, as it were,
charmed away by one or two applications. If such treat-
ment is followed up for a sufficient length of time, even
extensive deformities may be improved (Brit, Med. Jour.,
Sept. 28, 1872).

Pachy-Meningitis. .

Treatment.—Circumscribed suppurations, when recognized,
must be dealt with by the surgeon, under rigid antiseptic pre-
cautions. Evaporating lotions or ice to the head or spine
are also indicated. Free action of the bowels (especially of
the lower bowel by aloetic laxatives) should be maintained.
Circumstances may also indicate iodide of potassium, and
pain is best relieved by large doses of opium or morphia.
The patient ought to be kept perfectly at rest.

Palsy—Sce Scrivener’s Palsy.

Palsy, Shaking.—De/inition.—Involuntary tremors, con-
tinuous and permanent, with lessened muscular power, ag-
itating various members increasingly, allowing no peace; and
while purposed movements may exaggerate the shaking, re-
pose does not cause its disappearance, and sleep alone puts
a temporary stop to the spasmodic agitation of the affected
members. The affection may commence in the hands, arms,
or head, and gradually extend over the whole body.

Treatment-—Fyoscyamine is a palliative merely, while
strychnine, ergot of rye, hyoscyamus and opium, nitrate of
silver, and Calabar bean all aggravate the tremors. The use
of the continued current of a galvanic pile has been attended
with success in the hands of Remak and Russell Reynolds.
276 PARALYSIS, LOCAL,

Paralysis, Local.— Definition.—Paralysis limited to par-
ticular sets or groups of muscles.

Treatment,—Paralysis due to lesions which are destructive
of the nerve are beyond medical aid. In cases suitable for
treatment, and within the first few days, the agents used with
most benefit are,—blood-letting by leechs behind the ear of
the affected side, or over the mastoid region. They ought
to be applied repeatedly, especially if any pain exists on
pressure in that region. Blisters, with dressings to keep them
open, medicated by veratria or strychnia (,/5 to $ of a grain
sulphate of strychnia or of veratria), mixed with five or six
times their weight of pounded sugar. Electrization in the
form of faradization by a Stohrer’s two-celled volta-electric
machine; or in the form of an interrupted galvanic current,
from a continuous current battery (as from a Muirhead’s
battery of fifteen cells), the number of cells being very grad-
ually increased, are agents of much service.

In using faradization each facial muscle should be sepa-
rately influenced, instead of attempting to pass the current
through the facial nerve. The muscles are thus more pow-
erfully influenced, and they are more apt to regain voluntary
contractility at different periods, some muscles before others.
At first the apparatus should be one capable of producing
currents with very rapid intermissions; but when any mus-
cles begin to contract, the intermissions should be few, and
the sittings at long intervals (three times a week, for two or
three minutes only at a time), otherwise contraction of the
muscles is apt to increase and become incurable. The vol-
taic current, from a continuous current battery, induces con-
tractions when the circuit is closed and when it is opened,
and more powerfully at the moment of closure. It 1s said
to restore to palsied muscles the power of contracting under
the influence of faradization. When improvement follows
the use of the voltaic current from a continuous battery, the
number of the cells should be gradually increased as the
muscles get less susceptible to their influence, and then the
battefy may be used oftener. One of the electrodes should
be gently moved along the surface of the muscle, just as the
brush is used in faradization. During the first weeks it
may not be used oftener than once weekly, commencing with
six to ten of Stohrer’s elements,

When contracture of muscles supervenes, they ought to be
stretched or pulled out mechanically. To remedy contrac-
tion of the buccinator, Duchenne recommends the use of a
PARALYSIS, ACUTE SPINAL OF ADULTS. 297

small billiard ball worn for a long time inside the cheek, to
be replaced after atime by a larger one. The late Bazire
gave favorable testimony to the value of this mechanical
aid.

The daily action of the bowels ought to be carefully
regulated, especially by such medicines as keep the colon
in functional activity. Bichloride of mercury (corrosive
sublimate) in small doses, contimued till the gums are
slightly tender, is sometimes of service. In cases where
rheumatism prevails, or periostitic affections, small doses
of iodide of potassium, persevered in for a lengthened
period, are of service, with the frequent use of phosphate
of soda as a daily morning aperient.

Treatment of most of the forms of local paralyses is main-
ly by the continuous voltaic’current to the muscles when the
acute symptoms have passed away, and when no fever or lo-
cal signs of inflammation exist. The use of cutaneous fara-
dization, on a dry surface with a feeble and slowly intermit-
tent current, has. also been strongly recommended by Du-
chenne. Friction, stimulant applications, and blisters are
also of use.

Paralysis, Acute Spinal of Adults.— Definition. —A
sudden feverish attack, with such cerebral phenomena as
deafness, coma, delirium, or general convulsions, soon fol-
lowed by a rapidly developed and complete paralysis, vari-
ously distributed over the trunk and extremities; but gener-
ally in the form of paraplegia. There is entire relaxation of
the paralyzed muscles; an absence of any severe disturbances
of sensation; and there is no paralysis of the sphincters nor
bedsores. The original paralysis is not progressive; but im-
provement gradually takes place as to the restitution of
movement up to a certain point, which is not uniform. In
the end the power of movement in some part is lost forever;
a paralytic and withered limb for life is all that can be hoped
for (Professor W. H. Erb).

Treatment.—The acute myelitis, if detected, first demands
attention. Local abstraction of blood by leeches or cupping
should be had recourse to over the cervical and lumbar en-
largements. The bowels should be freely moved by cathar-
tics, followed by iodide of potassium in appropriate doses.
Rubbing in of mercurial ointment and counter-irritation may
afterwards be employed the whole length of the spine, or
blister, plaster, or painting with the tincture of iodine. Dr.
Althaus has most confidence in the subcutaneous injection
278 PARALYSIS, ACUTE SPINAL OF ADULTS.

of ergotine (Bonjean’s solution in diluted water), one-fourth
grain for achild from one to two years of age, one-third
grain for a child from three to five years, and half a grain
for children from five to ten years, and a grain for patients
upwards of ten years; to be repeated as symptoms indicate,
once or twice a day. When acute symptoms have subsided,
the diseased area within the cord should become the main
object of treatment, by induction of the catalytic action of
the voltaic current. A large electrode, which will cover the
entire diseased area, is to be placed over the lumbar or cer-
vical enlargement, while the other is to be applied to the an-
terior surface of the trunk. First the anode, and then the
cathode, are to act alternately for from one to two minutes
at a time, with a moderately strong current. This treatment
must be continued for a long time, or repeated at intervals
for several years. The faradic current is not to be used at
this period. Such are the recommendations of Erb. They
differ somewhat from the injunctions of Althaus. “It being
most important that the voltaic current should pass through
the anterior cornua, it is better to have one pole on the spine
and the other on the front part of the body, than to place
both electrodes to the spine. If the cervical cord has to be
acted upon, place the positive pole to the nape of the neck,
and the negative to the manubrium sterni. When the lum-
bar enlargement is diseased, the positive pole is put to the
loins, and the negative a little below the umbilicus; while,
when the dorsal cord has to receive the voltaic influence, the
positive pole should be slowly guided along the whole dorsal
spine, the negative being left stationary at the ensiform car-
tilage’”” (Althaus)

If electric contractility remain, much may be hoped for,
so long as nerves and muscles have not altogether degener-
ated. The principles of treatment are the same as have been
advocated in analogous diseases—namely, restorative and
not depressant. The general health must be improved by
the use of baths, with a strong and abundant diet; the use of
cod-liver oil, and prolonged sojourn in mountain air. The
systematic, active, and persistent application of the voltaic
current of electricity is the best means of preserving the func-
tions of the implicated muscles, and of arresting their atro-
phy and degeneration, provided all other hygienic arrange-
ments are maintained which have already been insisted on
as to food, clothing, ventilation, and open air. The cathode
is to be applied over all the paralyzed muscles and nerves;
PARALYSIS AGITANS—PARALYSIS, BULBAR. 279

while the anode is best placed upon the vertebral column at
the height of the main lesion. The strength of the current
should be such as to produce distinct twitchings and lively
redness of the skin. The faradic current may, however, still
be used when the muscles retain their faradic irritability.
The faradic application is to be made with moist electrodes.

Mild purgation may be required; alteratives, especially
small doses of mercury, continued for a long time, have been
of service; and so also have quinine, iodide of potassium,
and iodide of iron.

Friction, kneading, squeezing (massage), and shampooing
ought also to be persevered in. Three or four small circu-
lar wodden balls, about the size of a walnut, shut up ina
box, with holes in its cover, so as to expose one-third of the
surface of the balls on a uniform level, makes a good sham-
pooing apparatus,

Paralysis Agitans—Sce Palsy, Shaking.

Paralysis, Bulbar.—Dejfinition—A chronic and pro-
gressive affection of the bulbar nuclei, in which there is di-
minution and subsequent loss of the motor power of the
tongue, soft palate, and lips, associated with structural
changes in the central nuclei and roots of the motor nerves
which supply the affected muscles. The disease progresses
always more or less rapidly to a fatal termination.

Treatment.—Faradization is of doubtful efficacy at the
commencement, but gives relief at later periods, by tempo-
rarily restoring function to the affected muscles, to the les-
sening of the trouble of deglutition, and by exciting the re-
spiratory acts.

Dr. Dowse relates one case of cure under his care (Brit.
Med, Journal, March 11, 1876, p. 321). The bulbar paraly-
sis came on after a severe epileptic attack. The paralyzed
parts were brought under the influence of galvanism, and in-.
jections of one-sixth of a grain of strychnia, and one-twen-
tieth of a grain of atropia were daily used to the lower ex-
. tremities. At first the induced current from a two-celled
Stohrer’s battery was several times applied to the tongue
without any result ; after this the continuous current from
six cells of Stohrer’s battery was applied, and with the best
results, for the tongue was quickly protruded, and as sharp-
ly retracted. For some days, however, he had no voluntary
power over it; but the use of the daily galvanic stimulus
shortly ensured this, and articulation soon became perfect.
280 PARALYSIS, GENERAL—PARALYSIS OF THE INSANE,

It was for some time almost inaudible, and the letter R. was
the most inarticulate of all the consonants. With this the
power of swallowing soon returned, so that he had complete
co-ordinate voluntary power over those parts supplied by the
bulbar nerves. The last to regain power and sensation were
the lower limbs. The muscular atrophy here was so ex-
treme that nothing but the tibize and integuments appeared
left ; but galvanism, frictions, and injections gave excellent
effects. He also took cod-liver oil, quinine and phosphor-
us. Instead of his being a mute, helpless, and emaciated
creature, he had complete voluntary power over every part
of the body.

When initial pains in the head and neck point to the com-
mencement of myelitic changes, Professor Kussmaul recom-
mends the repeated application of dry-cupping glasses to the
nape of the neck every five days, and in full-blooded strong
persons he would order blood to be abstracted at the first
cupping. Afterwards he would permit the cautious tentative
use of the shower douche, and even the jet douche for strong
persons. Food and drink of a stimulating kind must be
avoided during the first months. As to medicines, nitrate
of silver, administered early, is deserving of most confidence.
He also recommends galvanization. It may be necessary to
administer food through an oesophagus tube, or by nutrient
enemata,

Paralysis, General.—-See Paralysis of the Insane.

Paralysis, Labio-Glosso-Laryngeal.—See Paralysis,
Bulbar.

Paralysis of the Insane.— Definition —An. incessantly
progressive form of general paralysis, in which the cineri-
tious substance of the brain is the seat of cloudy swelling of
its minute elements—the ganglionic brain-cells—with lesion
of minute blood-vessels and increase of connective tissue, as-
sociated with peculiar disorder of the intellect, general fail-
ure of nerve power, muscular debility, frequent blood extra-
vasation (hematoma), convulsions of the nature of apoplexy
and epilepsy combined, and tending to involvement of the
whole brain in degeneration, softening, and atrophy, so that
general and complete paralysis of body and mind results.

Treatment.—Regarding the disease from the commence-
ment as essentially a chronic form of parenchymatous in-
flammation, confined at first to the convexity of the fore-
PARAPLEGIA. 281

half of the hemispheres, and frequently tending to meningitis
more or less complete, Dr. Meyer, (following Jacobs of
Siegberg) has adopted the method of counter-irritation in its
treatment. He keeps open for some months a suppurating
surface. For this purpose the head is to be shaven of hair
over the centre of the fore part of the skull-cap for a space
as large as half the palm of the hand. On the central por-
tion of this shaven space as much tartar-emetic ointment as
will cover a shilling is to be rubbed in efficiently, and. with
some energy, with a linen compress or with the ball of the
thumb. Ona second application caution and gentleness are
necessary, in order that the already loosened epidermis may
not be torn away, for the deprivation of the cuticular layers
causes exquisite pain. Considerable swelling very soon ex-
tends over the frontal region and the face in the course of
three or four days, which may even advance as far as the
back of the head and neck. By this method an eruption of
pustules does not take place ; but a large scab comes off in
one piece by the frequent application of warm poultices, as
soon as the place shows signs of swelling. As soon after the
establishment of this suppurating process as the patient’s
strength will permit, the internal use of iodide of potassium
is commenced, The diet must be digestible and of a highly
nourishing character. The patient is to be sent out as much
as possible for work in the open air, but only in the early
and evening hours in the summer months. Exposure of the
head to the sun or other source of heat is to be avoided.

Paraplegia.— Definition —A form of paralysis affecting
the lower parts of the body, in which both legs, and perhaps
also some of the muscles of the bladder and rectum, are
paralyzed.

Treatment—In cases of reflex paralysis means must be
taken, first-—-To diminish the external or peripheral irritation
which causes the paralysis; second, To improve the nutri-
tion of the spinal cord; third, To prevent the ill effects of
rest on the paralyzed nerves and muscles.

In cases of disease of the urethra or prostate, an injection
of asolution of one grain of the extract of belladonna, in
twenty drops of laudanum, is to be made into the urethra,
and the injection should be retained for half an hour, or even
an hour, after which some emollient decoction should be
used, such as linseed tea, to wash out the passage. Lvery
two or three days this operation should be repeated. If the
bladder be diseased, Dr. Brown-Séquard advises a solution
282 PEMPHIGUS.

of one grain of the extract of belladonna, in twenty drops of
laudanum, to be used as an injection, after complete emis-
sion of urine. Injections of carbolic acid are also of use in
counteracting decomposition of urine and epithelium in the
bladder. If the prostate is enlarged, a suppository ought to
be put at times into the rectum. One of the best supposito-
ries for this purpose is composed.of the following ingredients
namely:—White sugar, white soap, and gum-arabic in pow-
der, of each three grains; opium, in powder, a grain and a
half; or belladonna extract, one grain; or both combined.
These being mixed together, the mass is to be formed into a
conical shape, and being dipped in melted wax, is ready to
be introduced, when required, into the rectum (Simpson).
When the irritation causing reflex paraplegia starts from the
vagina or uterus, a pill of half a grain of the extract of bella-
donna, with a grain of opium, surrounded by a piece of cot-
ton wool, is to be introduced into the vagina, and made to
surround the neck of the womb. By means of a thread it
may be withdrawn so soon as pain ceases or diminishes
(Trousseau, Brown-Séquard). Belladonna ought not to be
used constantly. Opium, combined with strychnia, is of
gseater use in reflex paralysis : and of all remedies, strychnia
is best suited for promoting the second indication, which
points to increasing the nutrition of the spinal cord. The
dose combined with opium must be asmall one—namely one-
fortieth to one-thirtieth of a grain daily; and when used
alone, its dose may be one-twentieth of a grain; and when
employed together with belladonna, its dose must be still
larger. In cases where no congestion or inflammation of
the spinal cord exists, strychnia ought to be persistently em-
ployed ; but its use to be suspended at once whenever it
produces spasms, or even numbness of the feet in getting out
of bed in the morning (Brown-Séquard). Sulphur baths are
also productive of great benefit.

The third indication—namely, to prevent the ill effects of
rest on the paralyzed nerves and muscles—is best met by the
employment of Voltaism and shampooing of the paralyzed
limbs. Two or three applications, of ten minutes each, in a
week, are sufficient ; but of all things it is necessary that the
primary disease (causing by its persistent existence the reflex
paralysis) should be cured or mitigated.

Pemphigus.— Definition —-An eruption of large vesicles,
filled with serous fluid, known as bulle.

Treatment.—Dietetic and tonic, especially by quinine and
PERICARDITIS. 283

the mineral acids. Arsenic is said to be of use in obstinate
cases, improving the general health. Emollient lotions, with
or without opium, are useful local applications; also envel-
oping the parts with india-rubber cloth dressed with sulphur.

Pericarditis— Definition. An inflammation of the fibro-
serous membrane containing the heart, and investing it on
its external aspect.

Treatment.—The results of recorded treatment are unsatis-
factory in the highest, degree. Sir Thomas Watson writes,
that “in a large proportion of the cases, whether they be
treated well or ill, or not treated at all, the patients will seem
to recover.” Although blood-letting and calomel have hith-
erto been regarded as two most efficient agents in accom-
plishing the indications of cure, yet Taylor’s analysis of cases
shows that pericarditis may come on during salivation. The
late Dr. Parkes informed me that he has seen this occur two
or three times. It is, then, very doubtful if calomel ever
does any good in pericarditis, notwithstanding that its use, so
as to affect the gums, is advised by Watson, Graves, Stokes,
and Fuller. Professor W. T. Gairdner, Drs. John Taylor,
of Hudderford (Aled. Times and Gazette, 1849), and J. Risdon
Bennett, of London (Zancet, Dec. 6, 1851), are all unfavor-
able to such a use of mercury. In all the constitutional dis-
eases in which pericarditis occurs as a complication, mercury
is certainly contraindicated. In rheumatism and in Bright’s
disease, which furnish by far the larger number of cases of
pericarditis, mercury is decidedly objectionable ; and it is
now well-known to be productive of most injurious conse-
quences in Bright’s disease. Its use tends to weaken the
heart and the system at large, and thus proves a source of
additional irritation to the cardiac tissue, by undue reaction
on the system.

Venesection is never to be practised. Treatment by bleed-
ing may be carried out by leeches over the precordial region,
or by cupping there in exceptional cases. When the pain is
very marked, where it has strongly the characters of angina,
leeches are to be applied in moderate numbers over the pra-
cordial space. From four to six leeches (W. T. Gairdner),
ten to twenty (Niemeyer), so applied, accordingly to circum-
stances, followed by fomentations, very commonly ‘relieve the
pain, and rapid improvement follows. To judge as to the
repetition of blood-letting, the force of the heart must be ob-
served, as indicated by the pulse at the wrist, by the actual
strength of its impulse, and by the character especially of the
284 PERICARIDITIS.

first sound. If the impulse continues vigorous, and the first
sound is undiminished, blood-letting may be repeated by the
further Zoca/ abstraction of blood by leeches; but if the im-
pulse has manifestly declined in force, while the first sound
is lessened, great caution is required in the further abstrac-
tion of blood. Fomentations, sometimes plain and some-
times medicated with opium, are the-chief local remedies to
be afterwards relied on. In the second stage of the disease,
when liquid effusion distends the pericardium, some reliance
may be put in treatment by a blister of a large size over the
precordia. Diuretics and iodide of potassium are also to be
given. “Stimulants are often imperatively called for. The
weakened heart requires to be supported and invigorated.
This may be effected by the use of wine, and by the use of
opium.” If depletion has been excessive—if signs of mus-
cular weakness supervene—if there be evidence that the
heart, previous to the attack, was in weakened state—if a
tendency to collapse or to a typhoid state manifests itself—
“we must give wine, quite irrespective of the physical con-
ditions of the heart” (Stokes). Niemeyer recommends digita-
lis.as a suitable remedy in cases where the beat of the heart
is very frequent and insufficient, causing cyanotic and dropsi-
cal symptoms. Its effect is then very markedly beneficial.
Opium, in doses of one grain (7 ¢., stimulant doses) every third
hour, seems “ to expend itself solely on the disease,” and its
beneficial effects are seen to result when it does not produce
contraction of the pupil, nor headache, hot skin, furred
tongue, nor constipation (Corrigan, Stokes, Graves, Sibson).
Battley’s solution is perhaps the most useful preparation.
This remedy must be watched closely. There are two more
important circumstances to be attended to—namely, that our
treatment of pericarditis must depend upon the state of the
diseases in which it is first discovered to exist; and it is im-
portant to know that pericarditis from acute rheumatism calls
for a totally different line of treatment from that associated
with Bright’s disease, or diffused inflammation of a low type
(Sibson). In the rheumatic form, colchicum, in the form of
a draught, and the administration of alkaline remedies, are
indicated by the constitutional state. Warmth, especially
moist warmth, and flying blisters are the best agents to pro-
mote absorption. Niemeyer considers that the use of cold
applications; such as ice-bladders, applied over the cardiac
region, is deserving of great reliance; others condemn cold
applications.
PERICARDIUM, ADHERENT—PERITONIT!S, 285

Paracentesis is to be recommended in all those cases in
which the effusion is so great as to cause alarming distress,
orthopnoea, obstruction to the venous circulation, and serious
interference with the heart’s action. In such cases a fine
exploring trocar and canula is to be introduced (not plung-
ed), so as to make a valvular opening below the heart, either
to the left of the xyphoid cartilage, or through the fifth in-
tercostal space, close to its anterior extremity, and the fluid
drawn off by means of a syringe (Sibson, in JMed.-Chir. Re-
view, July, 1854). The result may be merely palliative;
but, as Niemeyer justly remarks, “even to afford the sufferer
opportunity, after the operation, to pass the night in his bed
(perhaps for the first time in a long period), and to enable
him to sleep a little, is a great gain,”

The general principles of safe treatment are summed up
Dr. W. T. Gairdner as follows :—(1.) To make large allow-
ance for the insignificant and spontaneously healing class of
cases revealed more by physical signs than by symptoms,
and to regard them as demanding little active treatment ;
(2.) to consider rheumatic pericarditis in general as a disease
susceptible, to a great extent, of cure under palliative local
remedies and fitting constitutional treatment; (3.) to hold
the general treatment as subordinate to the constitutional
treatment of the disease with which the pericarditis is asso-
ciated.

Pericardium, Adherent.—Defizition.—More or less
adhesion of the opposed surfaces of the pericardium by in-
flammatory exudation (adhesive lymph) becoming organized,
and with more or less complete obliteration of the pericardial
sac.

Treatment must be regulated by the functional difficulties
of the circulation, and by the source to which those difficul-
ties may be traced.

Pericardium, Dropsy of.—Sce Hydropericardium.

Peritonitis.— Definition —An inflammation of the serous
membrane lining ‘the cavity of the abdomen, and covering
the viscera contained in that cavity.

The Zveatment of acute peritonitis must be active in pro-
portion to the amount of pain, the rapidity of the pulse, and
intensity of the inflammatory fever, which is marked by the
peculiar depressing influence of the inflammation of the
heart's action. In mild cases, when the pain is bearable, the
pulse steady and under 100, twenty leeches over the abdo-
285 PERITONITIS,

men, followed by warm fomentations, with the administration
of opium in frequently repeated grain doses, ought to be the
basis of treatment. Leeches applied to the abdomen is the
only method of blood-letting likely to be useful, and a poul-
tice may be required afterwards to encourage the bleeding
in sthenic cases. But where the disease is dueto blood-poi-
soning, constitutional states of ill-health, or to the puerperal
state, blood-letting by leeches is injurious. In the severer
forms the first indication is to relieve pain. The stomach
may be unable to retain food ; and vomiting may be present:
Under such circumstances great benefit may follow the in-
jection per rectum of a pint of strong meat soup slowly
thrown up in three successive portions. After about three
hours’ relief of pain, a fresh new injection of soup is to be
given, when the same relief to pain will follow, the pulse
falling from (say) 124 to 104. Small quantities of broth and
wine may then be borne by the stomach, administered every
two hours (Dr. Anstie), Action of the bowels should be
prevented for several days. Opium should be given in doses
of one to two grains, repeated as often as its effects subside
—generally every two, three, or four hours. Morphia may
be given in repeated doses of a quarter to half a grain. Mor-
phia combined with chloroform, as in the formula for chloro-
morphine’ or chlorodyne, will be found useful in allaying
pain. It is not proven thatcalomel (inducing mercurialism)
has any curative tendency in peritonitis. It has been pre-
scribed traditionally ; but the experience of Dr. Taylor re-
garding mercury in pericarditis, as well as of other physicians
regarding the influence of mercury generally in the cure of
these inflammations, tends to discard it from our methods of
cure in such affections. Nevertheless, in the idiopathic and
latent forms, Mr. Meade has found mercury the best remedy.
In the purely latent forms he prescribes small doses of the
bichloride with some.demulcent. One-twentieth of a grain
three times a day is sufficient. It may be continued for two
or three weeks or more. In the more acute cases he directs
the abdomen to be covered with dilute mercurial ointment
spread thickly upon lint; and he generally finds that the as-
citic fluid begins to be absorbed as soon as the mercury
slightly affects the system. Fomentations and water
compresses are to be diligently employed on the same
principle as described under Enteric Fever. Digitalis, with
other diuretics, may assist the cure. In the more chronic
forms, where the abdomen has become distended, it is some-
PERITONITIS, 287

times desirable to let off the fluid by tapping; after which
remedies act more readily, and generally prevent the return
of the effusion. Diuretics of iodide of potassium, acetate of
potass, and squills, also help to effect the removal of fluid.
The entire abdomen may be covered with cold compresses,
and renewed every ten minutes; but warm cataplasms are
better borne than cold compresses by many patients (Nie-
meyer). In chronic peritonitis I have found iodide of po-
tassium, combined with alkalies, most useful, together with
inunction of the abdomen with the iodine or biniodide of
mercury ointment. Acute peritonitis has been treated by
quinine alone, in large and repeated doses, by M. Beau, at
the Hopital dela Charité. The remedy was given in the pro-
portion of twenty to thirty grains in the twent-four hours.
When the abdomen can bear pressure, a flannelroller should
be firmly applied round the body. Chronic vomiting is a
distressing concomitant to be met by effervescing draughts,
with m j. or m ij. of dilute hydrocyanic acid, or with m iij.
tom v. of tinct. opii.; or one or two drops of creasote in
aromatic water. Diarrhoea is common, hence it is necessary
to combine any laxative remedy with an opiate; and the
bowels may be so irritable as to oblige us to abandon all
opening medicine, and to prescribe astringents, as kino, ca-
techu, or hematoxylon, or the mistura crete composita c.
opio, or the acetate of lead, and even pure opium, to the
amount of two, three, or four grains a day. Under any treat-
ment diarrhoea is dangerous and distressing. The diet in
the acute forms of peritonitis should be of the mildest and
least stimulant kind. During the course of this and several
other diseases of the digestive system, immense distress and
suffering often occur from the accumulation and retention of
gaseous fluid in some portions of the intestinal canal (tym-
panites). Tympanites is best relieved by turpentine enema-
ta; and by the introduction of a rectum tube. When this
symptom reaches such extreme development as to endanger
life, and after the introduction of a rectum tube fails to pro-
cure relief, experience justifies the propriety of making a
puncture into the cavity of the bowel (generally the colon),
through the abdominal parietes, to permit the gas to escape,
and to relieve the tympanites. Life may thus be saved, and
cannot be materially shortened by the operation, if it is per-
formed by a trocar of the very smallest exploring size. The
air gradually and rapidly escapes by the very smallest ori-
fice, which is rather a separation of tissues than a wound,
288 PERTUSSIS—PHARYNGITIS, CHRONIC, ETC.

and soon closes up so completely as to leave no trace behind.
The operation gives the greatest possible relief (See Amert-
can Journal of Med. Science, N.S., XXIV., p. 543; Obstet.
Trans., for 1869, pp. 47, 48, by Dr. J. Braxton Hicks, in
1868 ; Brit. Med. Journal, for Oct. 21, 1871, p. 464, by Mr.
J. Hancocke Wathen). The operation is not the same as
that usually performed on cattle. In them it is generally
the rumen or first stomach that is punctured (M’Bride in
Brit. Med. Journal, Nov. 4, 1871).

Pertussis— See Hooping Cough.

Pharyngitis.— Definition —Inflammation of the textures
of the pharynx. :

Treatment should consist in hot steam inhalations of a
sedative character, poultices externally, and scarification if
cedema takes place. When the uvula is much swollen and
infiltrated with serum, it should be at once removed.

Sub-acute Pharyngitis may occur either as an’ early stage
of the acute form, or as a less serious inflammatory affec-
tion. In this condition it is the mucous membrane alone,
not the areolar tissue, which is inflamed. The symptoms are
less severe than in acute pharyngitis; and ¢rea¢ment consists
in the application of astringent solutions, and the use of
astringent lozenges. The frequent sucking of small pieces
of ice is of great service in reducing the hyperzemic condi-
tion.

Pharyngitis, Chronic or Granular. — 7+catment.—
The patient’s general health must be improved by tonic
measures, but the most important part of the treatment con-
sists in the persevering use of local applications. In the ex-
udative form the spots should be scraped, the secretion emp-
tied, and solid nitrate of silver applied to each diseased
follicle. Lozenges of chlorate of potash and of bitartrate of
potash are useful in stimulating the follicular secretion to a
healthy condition. In hypertrophic pharyngitis the raised
papules must be destroyed one by one. The best applica-
tion for this purpose is a paste consisting of equal parts of
caustic soda and unslaked lime; this is mixed with water, as
required, into a creamy paste, and applied to each papule
~rith a finely-pointed glass or aluminium rod (Dr. Morell-
Mackenzie). The caustic effect of this application is instan-
taneous. The patient therefore should be directed to wash his
mouth with water immediately after the application, so as to
PHARYNX, ABSCESS OF——-PHTHISIS. 289

prevent any other part of the throat being burnt by contact
with the caustic. A combination of ergotine with tincture
of iodine is also efficacious (ergotine, grains xx.; tinct. iod.,
£3i.; glycerine, to make f $i.) To be applied to the phar-
ynx twice a day with a camel-hair brush

In all cases of pharyngeal disease, every form of spice,
pepper, mustard, and piquant food should be strictly pro-
hibited, and all fluids should be taken at a moderate tem-
perature.

Pharynx, Abscess of.—Defixition—Inflammation of
the pharynx, resulting in a limited collection of pus in the
form of an abscess.

Treatment.—lIt is very rarely possible to prevent the form-
ation of pus, and the expedient usually demanded is a speedy
opening of the abscess at its most defending part. Cod-
liver oil and other anti-strumous remedies are also impera-
tively demanded.

Pharynx and Larynx, Atomized Fluids in Treat-
ment of——See Larynx, Pharynx &¢.

Phlegmasia Dolens.—Defixition.—Obstruction of the
veins, radicles, and capillary vessels, with probable implica-
tion of the lymphatics, causing a painful, non-cedematous,
hard brawny swelling of one or miore extremities, attended
with great prostration.

Treatment.—Leeches and blood-letting, as recommended
by Drs. Davie and Lee, are usually inadmissible. Sedatives
and alkaline fomentations, perfect rest, simple diet, and opi-
ates to relieve pain, is the most rational treatment to be fol-
lowed. ‘The fluid in which the fomentation flannels are to
be wrung out is made by adding one pound of bicarbonate
of soda and one ounce of extract of poppies to one gallon of
boiling water. The flannels ought to be changed every
thirty minutes, and applied over the whole limb, and over
the groin and lower part of the abdomen, wherever there is
tenderness. The heat and steam from these are to be re-
tained by means of impermeable cloths.’’ Wine, brandy,
milk, raw eggs, animal food, ammonia, and bark are sure to
be required; and after the acute symptoms have subsided,
there is no remedy so beneficial as efficient bandaging, to-
gether with the preparations of iron, quinine, and tonic veg-

19
290 PHTHISIS.

etable bitters, like calumba, aided by change of residence
(Tanner).

Phthisis.—Definition.—Lesions commencing with in-
duration of a lobe or lobule of the lungs, ending in disinte-
gration of the new material and of the textures involved in
the induration; the formation of caverns, and the accumula-
tion and constant discharge of purulent secrction, with or
without the growth of miliary tubercles.

Treatment.—Looking to the varied pathological conditions
and textural lesions in the lungs comprehended under the
name of phthisis, every case requires special study. In one
case anemia is prominent, and calls for iron, perhaps for
arsenic; in another, continued but small hemoptysis may
call for’ ergot; in another, a racking and frequent cough may
call for special applications and remedies; in another, dys-
pepsia may call for alkalies or acid bitters, or pepsine; in
another, nervous unrest may call for bromides; in another,
laryngeal troubles may call for special local medication;
in another, we have to aim at controlling excessive sweating,
or checking an exhausting diarrhcea (Dr. James Sawyer,
Brit. Med. Journal, 1880, p. 845).

If, unfortunately, a pulmonary catarrh does not abate, or
a pneumonia does not resolve itself within the usual period,
but catarrhal symptoms prevail in the apices, and pyrexia is
persistent, with the severe disturbance of the general health
which has been described, extension of the pneumonic pro-
cess must be prevented by absolute rest in bed, talking being
forbidden, and coughing as much as possible repressed.
Whenever considerable pyrexia exists in the evening, all
duty occupations should be given up, strict rest, equal tem-
perature, the chest to be covered with linseed poultices, fre-
quently repeated, or belladonna liniment, and local bleeding
by leeches, if pleuritic pains exist. No counter-irritation
should be applied to the seat of lesion while pyrexia lasts.
Moderate action of the skin is to be maintained. The body
should be sponged with rectified spirits of wine and hot
water in equal parts (Coghill). White meats only are to be
eaten ; and as much milk. as may be desired. A pint of

‘warm milk from the cow” should be taken as often as
possible.

Should the pyrexia still continue, considerable digitalis,
opium and quinine are the remedies most successful in re-
ducing temperature. Heim’s pill was much employed by
Niemeyer, as it still is in Germany, for this purpose. It con-
PHTHISIS. 291

sists of Pulv. herb. Digitalis, gr. x.; Pulv. rad. Ipecac..! Pulv.
Opii puri. a a, gr. v.; Ext. Gentiani, q. s.; misce et divide in pil.
xx. One pill three times aday. Itis of advantage that quinine
to the extent of gr. xx. be added to this. Each pill will then
contain half a grain of digitalis, one-quarter grain of opium,
one-quarter grain of ipecacuanha, and one grain of quinine;
all of which may be held in form by glycerine or syrup. Dr.
Coghill adopts the following modification: namely, one
quarter of a grain of opium ; half a grain of digitalis powder;
and from one to three grains of quinine, to be given every
three to six hours, watching the effect on the pulse. When
there is great dryness of skin and tongue, half a drachm of
salicine, and two drachms of liquor ammonia acetatis, may
be given instead of the pill. Occasional intercurrent attacks
of pneumonia mark extension of lesions. They are asthenic
in character, and must be treated accordingly; but in all the
sthenic pneumonias or acute bronchitic attacks, no remedy
equals the tincture of aconite. It acts as we read of blood-
letting doing. It should be given at the rate of one minim
every quarter of an hour till the temperature is reduced to
the normal—the thermometer being in use every two hours.
If the temperature drops too suddenly, quinine must be
given in place of aconite.

The general principles of treatment described under
“Scrofula,” are to be adhered to. The use of so-called
“cough-medicines,” antimony, ipecacuanha, and squill
especially, are to be avoided; also the use of mercury, pur-
gatives, and neutral salts. It is unphysiological to administer
narcotics or sedatives when cough is accompanied by expec-
toration. The latter must be expectorated; if retained, it is
injurious. The morbid surface which produces the expecto-
ration must be directly acted on. In the suppurative expec-
toration of bronchitis or pneumonia, and that from a pneu-
monic or tubercular excavation of the lung, the processes
are identical with the suppurative processes in surgical
wounds or ulcers. Dr. Coghill finds that the best mode is
to bathe the suppurative surface in an antiseptic atmosphere
by the inhalation of such materials as creasote, carbolic acid,
and thymol. Warm moist inhalations do not affect the res-
piratory tract beyond the larynx; and are only of value in
affections of that region. When used warm they increase
the sensitiveness to cold. By using the breath only as the
antiseptic medium (inhaling through the mouth and respir-
ing through the nose), we get the whole of the residual air
292 PHTHISIS,

in the lungs saturated with the antiseptic material. This is
the principle of Dr. Coghill’s “ respirator-inhaler,” which
should be ‘used especially after “fits of expectoration,” so
as to act immediately on the surface which has furnished the
matter expectorated. It cannot be used too often; and
should quite supersede “ cough-mixtures.” It is, of course,
only of use in the second and third stages of phthisis and
the suppurative stage of bronchitis; and especially in the
retained fetid expectoration of bronchiectasis. Dr. Cog-
hill’s standard formula (to be modified at discretion) ‘for an
antiseptic solution consists of one drachm of glycerine, one
drachm and a half of creasote, two drachms of carbolic
acid, and one ounce of a saturated solution of thymol: of
which ten to fifteen minims are to be inhaled twice or thrice
a day by the respirator-inhaler. A few drops of chloroform,
or of ether, may be added as a sedative to each dose. In the
first stage of phthisis and other conditions where there is
cough and no expectoration, and in which the cough is inju-
rious by shaking and shattering the tender and infiltrated
lung tissue, the following is an excellent formula:—namely,
Croton-chloral hydrate and codeia, a agr. xij.; Aqua Lauro-
cerasi, glycerine, and Syrup of tolu.aaad. 31j. A dessert-
spoonful, or two teaspoonfuls, may be taken every two hours
when cough is troublesome.

To foster and cherish an appetite for food is another great
aim of treatment. One of the best tonics, if pyrexia does not
exist, is the syrup of iron, quinia, and strychnia. Let it be
given in very small doses at first; followed up by the use of
cod-liver oil, “ of the most agreeable, clearest, sweetest, and
most scentless kind.” The brown oil ought never to be pre-
scribed, except, perhaps, toan Esquimaux. Theoil shouldbe -
given in teaspoonful doses at first. Dr. B. W. Foster, of Bir-
mingham, drew the attention of the Profession to the advan-
tages of ether in promoting the digestion and absorption of
fatty food, and especially of cod-liver oil. A stomach once in-
tolerant of all fat will good-naturedly accept full doses of cod-
liver oil after the use of ether. Sometimes it has been given
separately, before or after the oil; but it is best given com-
bined with the oil—a, mixture now generally known as
“ etherized cod-liver oil.” To every two drachms of the oil
ten, fifteen, or twenty minims of ether are to be added,
according to the wants of the case. The ther purus of
the British Pharmacopceia must be used, so that the oil
may not be rendered muddy, as it will be if the ether
PHTHISIS. 293

contains alcohol or water. The ordinary dose of oil
ought not to exceed two drachms, to which more than
twenty drops of ether may be added, if necessary. The
ether is indicated wherever there is inability to digest
fat, of which it makes an emulsion. It seems to determine,
when introduced into the stomach, a considerable flow of
' pancreatic juice (Claude Bernard; See Brit. Med. Journal,
Nov. 21 and 28, 1868; also, Medical Press and Circular,
1869). Extract of malt (Trousseau) is a remedy of recent
repute. It is a genuine extract, consisting of the soluble
constituents of the malt and of the bitter extractive matter
of the hop. Two or three table-spoonfuls of it are to be
taken daily, diluted in spring water or in warm milk, or in
any other liquid that may be desired. There should be a
careful choice of meats and drinks. Meats rich in osma-
zone and roasted are to be preferred; wines and malt liq-
uors are better than mere alcoholic fluids when alcoholics
are required. Broth made of coarsely brown rye meal,
beef, mutton, or other flesh meat, boiled to make a soup, is
also of service as a diet. Ihave found the following soup
also very serviceable: Take of linseed half an ounce; fine
bran, one ounce; water, one quart. Boil these for two
hours, and strain; then add beef, mutton, or any other meat
that may be fancied, to the amount of one pound, and boil
to a soup, with vegetables, to which celery seed or other fla-
voring may be added. The whole quantity ought to be re-
duced one-third.

Arsenic is an efficient improver of the general nutritive
and assimilative functions. One or two drops of Fowler’s
solution, or #5 of a grain of arsenious acid, should be given
once, twice, or thrice a day, during the meal, continuing it
for months, with occasional intermissions (Clymer). Decided
benefit may follow the use of iodide of potassium, which may
be combined with the ammonio-citrate of iron, or tincture of
the muriate, in a bitter infusion with calumba or cascarilla.
Chloride of calcium has been used for some years by Pro-
fessor James Sawyer, of Birmingham, who writes very highly
of its advantages in combination with cod-liver oil or its
etherized emulsion. He gives 10 grains, dissolved in a
drachm of water and with a drachm of glycerine, in a wine-
glass of milk, twice a day, immediately after meals (Brit.
Med. Journ., June 5, 1880). Dr. Coghill, from his exten-
sive experience at the large hospital at Ventnor, regards the
hypophosphites and lactophosphates alternately as the best
294 PHTHISIS.

general tonics in phthisis. They are in no way specific.
They should not be given if the temperature in the evening
.is above 99.4° Fahr., and, on account of their pyretic char-
acter, should only be given after breakfast and lunch. The
hypophosphite of iron is so powerfully pyretic as only to be
given in extreme anemic phthisis, where the whole daily
thermometric range is low. Its formula consists of Hypo-
phosph. Sodz, Hypophosph. Calcis, a a3i.; Glycerini vel
Syr. Limonis, 3 ij.; Decoct. Cascarilla ad., 3 vj.; of which
a table-spoonful in water may be taken as required, to which
three to five minims of Liq. strychniz is a good addition to
increase appetite. The pharmacopceal syr. of the lactophos-
phates is very good; also the French “Dusart’s.” If an
aperient is wanted it should be given early in the morning.
Its necessity very often in phthisis depends on a sluggish
liver, hence the following is a good formula :—Salicylatis
Sode, 3ij.; Phosph. Sode, 3v.; Sulph. Potass. ad, 3 ij. ;
Puly. Zingib., 3i.; of which a teaspoonful in hot water is to
be taken early inthe morning. If there is an elongated
uvula, the end should be snipped off ; if there is irritation
about the pharynx and upper part of the larynx, it may be
relieved by the inhalation of some of the atomized fluids.

Counter-irritation to the chest-wall is a stereotype method
of cure in local pulmonary congestions. When properly
used in the earlier stages, before there is much loss of
strength, it is undoubtedly beneficial ; but later it is weak-
ening and annoying. Croton-oil liniment is the chief favor-
ite; but a prompt and not too severe application of the fol-
lowing ointment is recommended by Dr. Fuller :

R. Hydrarg. Chlor. Mit., gr. viij; Iodinii, 3 ss. ; -Alco-
hol, f 3iss.; Unguent. Simp., %j. M. Rub in a portion over
the affected lung, morning and evening, until a pustular
eruption comes out

A solution of the nitrate of silver (thirty grains to the
ounce of distilled water) may be painted on the skin beneath
the clavicles every evening until the skin is darkened, and re-
peated after the cuticle peels off. Gentle and continuous
irritation of the skin may be kept up by wearing constantly
on the chest a piece of flannel wet with a weak solution of
iodine in glycerine and water, covering the cloth with oil-
skin, to prevent too rapid evaporation and soiling of the
clothes. The night-sweats, so often annoying and profuse,
diminish under general systemic improvement and restored
cutaneous functions. The best anhydrotic, and almost the
PHTHISIS, 205

only one in use at the hospital at Ventnor, in the Isle of
Wight, is a pill at bedtime, containing #5 of a grain of atro-
pia, which may be combined with digitalis and quinine.
Bathing with vinegar and water, spirits of wine and warm
water, alum and water, are well-known remedies, as well as
gallic and tannic acids, and infusion of common garden sage.
To relieve the diarrhoea Dr. Coghill finds the lead and opium
pill of the British Pharmacopceia the best astringent, with a
milk and arrrow-root diet. A flannel bandage around the
abdomen should be worn. Bismuth, with opium, is also of
use. To control the exhausting attacks which occur in the
more advanced stages, Dr. Frank, at Cannes, suggested the
use of coto bark; and Dr. J. B. Burney Yeo (after an expe-
rience of over three years) has found it to arrest the flux
and relieve intestinal pain and irritation in a short time. A
fluid extract of coto is prepared by Ferris & Co., of Bristol,
the dose of which is from five to eight minims (Zhe Pract-
tioner, 1879, p. 257).

As regards the prevention of phthisis, although Sir Thom-
as Watson states that he does not believe it to be contagious,
he adds :—“ Nevertheless I should, for obvious reasons, dis-
suade the occupation of the same bed, or even of the same
sleeping apartment, by two persons one of whom was known
to labor under pulmonary consumption” (Lectures on the
Practice of Physic). It behooves the physician to warn the
patient’s friends of the dangers incident to long continued
attendance on him, especially if the disease be in an advanced
stage. It would be the height of imprudence for a healthy
person, especially if young and of a scrofulous diathesis, to
sleep in the same bed, or even in the same apartment, with a
consumptive patient ; for although the malady might not be
communicated directly from one to the other, unless possibly
under the condition of some tubercular matter being acci-
dentally introduced into his air-passages or into some other
part of his system, the surroundings and the air would be cal-
culated to predispose him to the disease” (Fuller, On Dis-
eases of the Lungs and Air-passages, p. 431).

It is of importance to know the physical nature of the cli-
mates of the world suitable for the tuberculous patient. (See
Appendix to a third edition of Dr. Walshe’s work on Dis-
eases of the Lungs; the late Sir James Clark’s classic work
On Climate; and Dr. Theodore Willlams’s Lettsomian Lec-
tures in Brit. Med. Journ., 1876). Dr. Williams’s statistics
show the benefit to be derived from life at sea. In cases
296 PITYRIASIS VERSICOLOR.

where destructive lung diseases is suspected, but in which
actual lesion does not exist, a sea voyage to the Cape, or to
Australia, or to New Zealand, round Cape Horm should be
resorted to at once. The prevention of certain forms of pul-
monary phthisis may be looked for in the unrestricted enjoy-
ment of pure out-of-door air. Continuous indoor labor is to
be avoided, and measures taken to prevent bronchial ca-
tarrhs by sufficient warm clothing and the constant use of
flannel next the skin in this country. The effects of hydro-
therapeutic treatment and of muscular exercise at the moun-
tain sanitoria of Switzerland, along with the prescribed use
of wine, fruit, and nutritious diet, are of much importance
to be considered. The purity of the air of mountains con-
sists practically in the absence of all organic particles. The
transparency of the air, which is dependent on its greater dry-
ness, and the more powerful action of light, depending upon
the same cause, aid materially the operation of its purity.
The effect of residence in mountains. on the dimensions of
the chest is also worthy of careful consideration, and has
been studied by M. Armieux, at Bareges, at a height of more
than 3,000 feet. He ascertained that in the case of ninety-
six soldiers sent up to Bareges there was, after four months’
residence, a distinct increase in the measurement of the chest
—a fact which has a very important bearing on cases of
threatened phthisis in the young; and that a mountain cli-
mate is to be considered as favorable to the development of
the thoracic cavity, and consequently as improving the res-
piration. (See also Dr. W. Marcet in Proceedings of R. S.,
Vol. XXVIIL, p. 498). Mountain air may thus be useful in
certain cases and in certain periods of phthisis. It acts by
its purity, by its dryness and ‘transparency, as well as by the
diminution of: atmospheric pressure. These principles have
only, or nearly only, been applied in Switzerland ; but moun-
tain stations for similar cases might very well be selected in
some parts of France. After all, neither barometer nor ther-
mometer, neither hygrometer nor anemometer, can determine
what is the suitable climate for such and such a phthisical
patient. All depends on the nature of his constitution, and
on the way in which the various meteorological conditions
affect him, and on the local lesions in his lung (Drs. J. Mac-
Ll and Gouraud in London Medical Record, July 15,
1876).

Pityriasis Versicolor (sce Zinea Versicolor).
PLAGUE. 297

Plague.—Definition.—A specific malignant fever which
has prevailed at different times and places epidemically, at-
tended with bubo or swellings of the inguinal and other
lyniphatic glands; or occasionally with carbuncles, pustules,
spots, petechiz of various colors, distributed in different
parts of the body; and severe manifestations of implication
of the nervous, sanguineous and bilious systems.

Treatment.—It is to be regretted that recent experience
has not in any degree advanced the successful treatment of
the plague. In the beginning of the epidemic, when the
morbid cause acts with a rapidity so great that some hours
are sufficient to compromise the life of the patient, any
treatment is powerless to arrest the course of the disease,
When, however, the malignancy of the disease abates we
may hope for the recovery of patients (Clot Bey). Looking,
however, to the pathology of the disease, and regarding it as
bearing some resemblance to malignant typhus fever, the
principles of the general treatment of plague ought to be
similar to those laid down in the account of that disease.
We have no sufficient evidence to prove that plague may be
carried beyond those geographical dimits where it is epi-
demic. Quarantine establishments to prevent the trans-
mission of such epidemic diseases are now not only unwar-
rantable, but they are vexatious interruptions to mercantile
enterprise. It is now more than 154 years since any part of
Western Europe has suffered from plague; but till a com-
para'ively’ recent period, more or less of the disease had been
habituate or frequent in the Levant, and though occasions
have been very numerous when arrivals from the Levant in
this country must have been more full of danger than those
now represented, the experiments thus performed on the
public health of England have in no case led.to any injur-
lous result. I am informed by a medical friend who visited
Malta in 1861, that a curious instance of the wavering
nature of opinion regarding the efficacy of quarantine was
afforded during the last Bengazi plague. The Maltese—
the most sensitive people formerly on the subject—abso-
lutely declined to put any quarantine on arrivals from Ben-
gazi, and trade went on as usual, until the Austrians inti-
mated that, unless Malta put Bengazi in quarantine, Trieste
would put Malta in quarantine; and the poor merchants were
obliged to submit. There is little risk of plague being im-
ported now because of the great sanitary improvements
which have taken place; and it is to be hoped that as sani-
298 PLEURISY.

tary measures are developed the barbarism of quarantine will
entirely disappear; except, perhaps, where the intelligence of
the people does not go beyond that of the Russian Governor
of Eupotoria, who requested that the allied armies of France
and England might go into quarantine when they landed in
the Crimea in 1854 ! (Kinglake.)

Pleurisy.— Definition — Inflammation of the serous mem-
brane that lines the cavity and covers the viscera of the
thorax. It is characterized at its outset by febrile chills,
followed by an acute sharp pain in some part of the chest,
frequently called “a stitch in the side.” It is usually con-
fined to one spot about the lateral regions of the thorax.
The acts of respiration are performed rapidly. They are
shallow, irregular, and incomplete. A dry short cough
supervenes, and the pulse is hard and quick. The natural
serous secretion of the pleural sac is arrested in the first in-
stance, but soon becomes increased in quantity and altered
in quality, having a tendency to assume the corpuscular
character. The effusion may rapidly increase, and may ulti-
mately assume a sero-purulent character, the parietes of the
corresponding side of the chest being dilated accordingly.

Treatment.—In acute pleurisy venesection can be dis-
pensed with. It neither cuts short the malady nor prevents
effusion. It may only be adopted in cases of severe dyspncea,
arising from collateral hyperemia, if the compressed part of
the lung is attended with signs of cedema. At the com-
mencement of less severe cases the use of cold compresses,
and of local blood-letting by leeches or cupping, may be re-
peated in the course of a day or two, until relief becomes
permanent ; but the local blood-letting is only to be had re-
course to if the cold compresses do not relieve the pain and
the dyspnoea within two or three hours. Large hot poultices
of linseed with mustard should be always employed when
local pain on inspiration is present of a “catching” or “stab-
bing’ nature. If the pain and dyspnoea are not relieved
within two or three hours, the method originally recom-
mended by Dr. Frederick T. Roberts, in his “ Handbook of
Medicine” (page 508), of mechanically fixing the’ side
affected, so as to prevent its movements as much as possible,
ought to be at once adopted. “Strips of properly adherent
plaster, spread on a firm material, are cut about four inches
wide, and sufficiently long to extend round the side from
mid-spine to mid-sternum, or a little beyond. These are laid
over a variable extent of the chest, according to the severity
PLEURISY. 299

of the case, it being sometimes requisite to include the whole
side—beginning below. The patient is directed to Ex-gire
deeply, and at this time a strip of plaster is fixed at mid-
spine, and drawn tightly round the side in the direction of
the ribs; then another strip is laid over this, but across the
course of the ribs ; the third follows the direction of the first,
overlapping about half its width; the fourth that, of the
second, and so on in alternate directions. A strip may also
be passed over the shoulder, and kept down by another fixed
round the side across its ends.”’ Tartar emetic subdues the
inflammatory tendency. Its use must be abandoned as soon
as the acute symptoms have passed away. Digitalis, rather
than tartar-emetic, may be given in recent cases in the form
of infusion. In the more latent cases one grain of the pow-
der of the leaves may be combined with a grain of quinine.
Blisters are not to be used until the acute stage is past.
When pain has ceased for some days, and absorption of the
fluid proceeds slowly, and the disease promises to become
chronic, a succession of blisters may be of use, applied over
the lateral region of the chest, but not over the seat of pain.
Diuretics ought at the same time to be freely given. The
compound tincture of iodine, in doses of twenty minims
freely diluted, is a valuable medicine at this juncture; and
so also is the liquor iodi of the “ British Pharmacopceia”’ of
1867. After free evacuation of the bowels has been effected,
calomel, to the extent of producing the slightest mercurializa-
tion, is the most beneficial line of treatment, to be adopted
in certain cases only-—namely, in otherwise healthy persons
in whom the pleurisy is not the result of a constitutional dis-
ease. The more rapidly slight mercurialization can be pro-
duced the better. During the first six hours, small doses of
calomel with opium (a grain and a half of the former, com-
bined with a sixth of a grain of the latter, or more, if the
pain continues acute) should be given every half hour, while
mercurial ointment is rubbed into the skin of the affected
side near the axilla every fourth hour (Walshe); or half
grain or grain doses of opium, every three or four hours, in
combination with one or two grains of calomel, and half a
grain of digitalis, may be given, and the whole side may be
covered with a piece of linen spread with mercurial oint-
ment: over this is placed a poultice covered with oiled
silk. The patient must be carefully watched, so that
neither ptyalism nor narcotism is produced. The moment
mercurial action has been established, the further admin-
300 PLEURISY.

administration of the mineral must cease. Opium and digi-
talis are to be continued after the use of calomel has been
suspended ; and with them may be given two grains of
squills or of nitrate of potash, as a diuretic ; or after twelve
or more hours very small quantities of tartar emetic in solu-
tion may be given at night, combined with small doses of
opium and ipecacuanha, to allay general irritation.

In the chronic stage of pleurisy there is a necessity for
generous diet and tonic remedies, such as quinine, in aid of
any diuretics and absorbents which may be employed. If the
patient be kept too low after the stage of active inflammation
has subsided, or be unduly depressed, it will not only be im-
possible to induce absorption, but there will be great danger
of the fluid becoming sero-purulent. When a succession of
blisters has failed in relieving the patient, ioduretted lotions,
or ioduretted ointments, combined with the internal admin.
istration of cinchona with tincture of iodine, iodide of potas-
sium, and small doses of bichloride of mercury, nitre, acetate
of potash, squills, digitalis, and cantharides, have each in
their turn effected the desired object (Fuller). The
fluid has been gradually reabsorbed, and recovery has en-
sued by acombination of iodine remedies, taken internally,
and applied externally—e. g., syrup of the iodide of iron
(3ii.), with simple syrup (%i1.), and a teaspoonful taken
every two hours, in conjunction with the.external application
‘ of a weak solution of iodine (iodine, 3ss.; potass. iodidi,
3ii.; aq. distil, 3 ii.) upon the affected side of the chest
ae Othet formule most useful in such cases are—

1.) A diuretic in the form of a pill, composed of digitalis,
squills, and the mass of pill. hydrargyri, of each a grain and
ahalf. Nitrate of potash (twenty grains), combined with
tincture of the perchloride of iron (fifteen minims), three
times a day, may at the same time be given (Fuller, Cham-
bers). Professor W. T. Gairdner recommends as a diuretic
the cream of tartar electuary, in which the cream of tartar is
mixed in equal proportions with treacle, honey, marmalade,
or syrup of ginger, and in some cases flavored with a few
drops of peppermint oil. The dose is a teaspoonful, re-
peated as often as the stomach will bear it, or as the urgency
of the case demands. Jaborandi, in the form of infusion,
has recently been advocated in the treatment of chronic
pleurisy with serous effusion. (2.) A lotion, to be applied
over the chest by spongeopiline, or by lint covered with oiled
silk, composed of—Bichloride of mercury, gr. iv.; tincture
PLEURISY. 301

of iodine (compound), 3iv. to 3vi.; glycerine, Ziii.; and
distilled water, Zivss. (3.) One or other of the following
ointments may also be rubbed upon the skin, over the side
of the chest—Bichloride of mercury, gr. iv. to vi; iddinc
ointment, Ziv. to 3vi.; lard, or vaseline, Ziv. to. % vi.; or,
bichloride of mercury, gr. iv. to v.;iodine of potassium, 3 ii.;
distilled water sufficient for solution ; and lard, or vaseline,
%1.; Ft. Ung. Feeding the patient upon the driest possible
diet, and withholding water as much as possible, has been
successful in some cases (Schroth).

As a means of relieving the chest in chronic pleurisy and
empyema, the operation of puncturing the chest and letting
out the fluid—an operation to which the name of paracente-
sis has been given—is a useful one; and the practical ques-
tion is as to the time when it should be performed. The con-
dition of the patient’s health and respiration, and the absorp-
tion or non-absorption of the effused fluid, are the aids to a
decision for or against its performance. As long as the
breathing is not seriously embarrassed, and the general health
does not decline, so long are we justified in making full trial
of our remedies. But as soon as extreme shortness and dis-
tress of breathing, or lividity and anxiety of the countenance,
denotes serious interference with the functions of life, delay
is no longer justifiable, and it becomes our duty at once to
give our patient the chance which the operation affords. In
the hands of the American physician, Dr. Bowditch, and
Professor W. T. Gairdner, of Glasgow, and Dr. Budd, of
London, this operation has been the means of saving many
lives. Its effect is to relieve the mind as well as the lungs
of the patient from great oppression. Although before the
operation he may be quite weak, he is often able after it to
get up and walk. Digestion becomes at once improved, and
strength is rapidly regained. The cough, however, is apt to
augment during the first few days ; the pulse retains its quick-
ness; friction-sounds occasionally become developed, and
several months may elapse before the vesicular murmur be-
comes properly re-established in the lung. Generally, the
operation of paracentesis thoracis in simple pleurisy is not to
be performed unless the life of the patient is in jeopardy—
that is, in cases “in which the effusion continues and in-
creases, and the side, instead of shrinking, enlarges ; the
functions of the lung on that side are entirely abolished; nay,
- the use of the remaining lung is greatly interfered with by
the pushing over of the mediastinum ; and the patient is in
302 PLEURISY.

imminent danger of suffocation.” In such cases the oppressed
lung must be relieved by “letting the fluid out ” (Sir Thomas
Watson, Lectures, Fourth Edition, Vol. IL, p. 128). ‘‘ Life
is plainly in jeopardy when the vital functions of the lungs
or of the heart are greatly hindered ; when symptoms pre-
sent themselves of approaching death by apnoea or by syn-
cope. If we discover no cause for those symptoms except
the increasing pressure of liquid pent up in the pleura, ‘we
are warranted in ascribing them to such pressure, and bound
to act upon that persuasion.” Also, if death by asthenia ap-
pears inevitable, the patient losing ground from day to day,
and when all other means of getting rid of the pent up fluid
have failed, the patient should not be denied the chance
which the operation affords. Also, ‘‘ whenever the effused
liquid consists of pus, it should be let out” (1. c., p. 130).
The risks of allowing a localized empyema to remain are
great (Wilks). With the arrangements of Dr. Bowditch’s
syringe we are enabled to remove fluid before the false mem-
brane thickens over the compressed lung, and so makes it
difficult to expand again, The trocar and small canula take
the place of an exploring needle. Therefore, if the lungs are
not bound down by adhesion, or prevented from expanding
by the thickness of the false membrane which covers it,
Bowditch’s syringe and stopcocks enable the fluid, even when
purulent, to be withdrawn without air being admitted. Mr.
Lister’s antiseptic method and precautions as to opening an
abscess ought to be adopted. But when airhas been admit-
ted, and when the fluid within the cavity of the chest has be-
come changed thereby—is purulent and perhaps fetid—the
evacuation, under antiseptic precautions, of the contents by
“drainage”’ seems the most efficient remedy.

In Pneumothorax.—Puncturing the chest walls may give
temporary reliet, by allowing the air to escape; but the op-
eration ought only to be done in cases where the dyspncea is
urgent, and the displacement of the viscera such as demands
that relief which the operation is calculated to give. Other-
wise, the treatment of pneumothorax is best conducted by
small doses of morphia—z. ¢., stimulant doses—frequently
repeated, combined or not with ether or alcohol, with a view
to overcome collapse, relieve dyspnoea, and subdue pain.
When reaction follows collapse, as indicated by heat of skin,
strength and hardness of pulse, soreness and pain of the af-
fected side, local blood-letting by leeches, with saline aperi-
ents, may be used if the strength of the patient warrants such
PNEUMONIA. 303

aline of treatment. Turpentine and poppy fomentations,
followed by blisters, are also indicated if life is sufficiently
prolonged after the primary inflammatory symptoms are sub-
dued. The inhalation of small quantities of chloroform is
useful. In other respects the treatment is similar to that al-
ready stated.

Pneumonia. — Definition. — Inflammation of the lungs,
which, in its acute sthenic form, is often complicated by con-
stitutional or specific diseases. It runs a definite course,
expressed by severe febrile symptoms, which come on sud-
denly, attaining in a few hours a great intensity, but which
may undergo a no less sudden abatement or improvement
between the fifth and tenth day, in proportion to the severity
of the disease and the textures implicated, while the local
productive results of inflammation in the form of the lung-
lesion are yet intense, but which are eventually removed.
The natural course of pneumonia is materially modified by
constitutional or specific diseases, especially if any organ,
such as the kidney, the heart, or the liver, is involved ; or it
may be modified by the secondary contamination of the.
blood by absorption of lung-exudation in the later stages of
the disease, tending to inflammation of the other lung, to
pleurisy, to pericarditis, or to blood-coagula in the cavities
of the heart or great vessels

Treatment.—One of the most discordant topics in the Sci-
ence of Medicine seems still to be with some—the treatment
cf pneumonia. At one time (about fifty years ago) large
bleedings were the rule. But Laennec and Louis were early
convinced that large bleedings were by no means successful,
and that in some cases they were absolutely injurious. The
some difference of opinion was held with respect to large
doses of the tartrate of antimony. At the same time we have
it in our power materially to modify the course and to short-
en the duration of pneumonia by the judicious employment
of blood-letting, leeches, tartar emetic, certain salines, and
opium (Parkes). The correlation of the body-temperature
the number of the pulse, and the respirations per minute,
furnish the best guide as to the course to be pursued in the
treatment of pneumonia. If the pneumonia is not intercur-
rent to some other disease, but happens idiopathically in a
person otherwise healthy ; if the mean body-temperature re-
mains below 104° Fahr., the pulse does not exceed 120 beats
in the minute ; and if the respirations never exceed forty in
304 PNEUMONIA,

the same time, the case must be regarded as a typically fa-
vorable case, which will certainly begin to get well when the
cycle of the pneumonic process is complete—é. ¢., in from
three, four, seven or eight, to twelve days without any special
medicinal treatment ; but with the careful management im-
plied by good nursing, absolute rest in the horizontal posi-
tion, and a strictly antiphlogistic diet. In such cases it is
sufficient to keep the patient in bed, in a well ventilated room,
whose temperature should be kept as near 60° Fahr. as pos-
sible, to relieve thoracic pains by leeches, or fomentations,
linseed and mustard poultices; to relieve thirst by alkaline
or acidulated drinks; and to give frequently repeated small
quantities of nutritious fluid food in the form of milk, milk
and eggs, oatmeal gruel, or even meat soups. The natural
history of an uncomplicated pneumonia shows that it has a
definite cyclical course; that if left to itself in a vigorous pa-
tient, uncomplicated by any other ailment, and if it be of the
typical intensity as here indicated, it almost always ends in
recovery. The expectant mode of treatment of the Vienna
school confirms this view, as the statistics collected by Bal-
four, Magendie, Skoda, Niemeyer, Schmidt, and Legendre
fully prove. In cases of average severity there is a decided
tendency to amelioration of all the symptoms by the eighth
day. The results cbtained by the Homeceopaths have aiso
shown this to be the case. Unless warranted, by certain
special indications, active interference has an unfavorable
effect upon the course of pneumonia (Niemeyer) ; and when
treated by blood-letting, as a rule, it more often terminates
fatally than where no venesection has been practiced (Diett).
Blood-letting is no specific. It does not cut short a pneumo-
nia; and in epidemic pneumonia it is hardly possible to
bleed the patient without rendering him worse. But much
must be left to the discretion of the practitioner. That there
are cases in which the patient can only be saved by general
blood-letting, everybody must admit. The cases of Louis and
of Dr. Alison of Edinburgh establish the propriety of bleed-
ing early, if blood-letting 1s to be used at all. Asa general
tule, the earlier the inflammatory state is detected (if possi-
ble before the third day—Alison) the more likely: will bleed-
ing be followed by well-marked beneficial results, the disease
will be sooner cured, and the convalescence more rapid and
perfect. Blood-letting in pneumonia should only be had re-
course to when the following special indications for it arise :
—(xz.) When the pneumonia attacks a vigorous and hitherto
PNEUMONIA. 305

healthy person, is of recent occurrence (not exceeding fifty
or sixty hours after the rigor), the temperature being at or
exceeding 105° Fahr., and the frequency of the pulse as much
as 120 per minute. The object of such venesection is to re-
duce temperature, lessen the frequency of the pulse, and so
lessen the danger from the violence of the fever. (2.) When
collateral cedema in the portions of the lung unaffected by
pneumonia is causing danger to life, the presence of the
blood is reduced by bleeding, and further transudation
of serum into the air-vesicles is prevented. When the
frequency of respiration is due to the pneumonic pro-
cess alone—not to fever or to pain—and as soon as a se-
rous foamy expectoration appears, together witha respiration
of more than forty or fifty breaths a minute at the com-
mencement of pneumonia; and when the rattles in the chest
do not cease for a time, after the patient has coughed as
well as he can, copious blood-letting is indicated to reduce
the mass of blood, and to moderate collateral pressure. (3).
When there are symptoms of cerebral pressure indicated by
stupor or transient paralysis.

Antimony, in the form of tartar emetic, is another remedy
which has gone through several extremes of administration
in the treatment of pneumonia.. Rasori introduced the prac-
tice of giving it in large doses, and Laennec was so dissatis-
fied with his own results of bleeding that he adopted Rasori’s
method. Few, if any, now believe in the usefulness of such
large doses of antimony; and such a use of tartar emetic has
justly fallen into discredit. When antimony is cautiously
administered as a sedative, or diaphoretic and expectorant,
in doses of the eighth or twelfth of a grain, every two or three
hours, and in doses of a sixth or a quarter of a grain, in the
more sthenic attacks, when the patient is strong and plethoric,
itis a valuable remedy. It may be combined with compound
tincture of camphor, or dilute hydrocyanic acid. It is contra-
indicated in gastric or gastro-enteric irritation. There are
cases where the remedy produces severe depression and
nausea—cases in which the stomach will retain no food, not
even water when given alone. Under such circumstances
the administration of alcohol in stimulant doses often re-
peated is called for, and may require to be combined with
ammonia, chloric ether, and camphor. Alcohol is. especially
indicated by the occurrence of delirium (if vascular excite-
ment does not exist); by a weak, rapid, or dicrotic pulse; by
signs of collapse; by age and general debility of the patient;

20
306 PNEUMONIA.

or in cases of pneumonia secondary to those diseases which
it frequently complicates.

A rational treatment of pneumonia 1s.one which must
secure to each case its own individuality and consideration.
Bleeding, antimony, and blisters may be demanded in one
case ; quinine, opium, and wine iu the next; a third may
require but little interference beyond a well-regulated diet,
moderate stimulants, and absolute rest. It is the proper
combination of remedies, not a single agent or mode of prac-
tice, which must be sought for in its treatment (Lawson).
The so-called “rational” or “restorative” mode of treat-
ment is the one to be adopted in cases of sthenic pneumonia
characterized by heat, above 104° Fahr., dryness of the skin,
a full resistant pulse, over 120, rusty-colored expectoration,
great oppression of the breathing, and to the extent of
beyond forty respirations per minute, blood-letting, had re-
course to at the beginning of the attack, in the stage of con-
gestion before the fastigium of the pyrexia (not later than
forty or fifty hours after the initial rigor), not only affords
immediate relief to the breathing, but removes the extreme
tension of the vascular system, and promotes secretion. The
most suitable time is that during the evening exacerbation
(Huss). These indications for blood-letting should be de-
cidedly marked before it is undertaken ; and the amount of
blood to be lost varies in each case, according to the oppres-
sion of breathing, the type of the disorder, and the constitu-
tion of the patient ; as well as to whether or not there is any
prevalent epidemic tendency associated with the pneumonia.
It is seldom necessary to draw more than from ten to sixteen
ounces ; and eight or ten ounces will usually suffice. After
bleeding, the pain in many instances ceases, expectoration
takes place more easily, and alters in character ; the skin be-
comes moister, and evidence is afforded of the action of
remedies which before proved inoperative (Fuller). But in
many cases it is either unnecessary or inexpedient to let
blood—inexpedient chiefly because of the constitution of the
patient being shattered by excesses, constitutional disease,
anxiety, and mental distress. Under such circumstances, it
impairs the strength, leads to greater impoverishment of
blood, arrests the actions on which the absorption of exuda-
tion-matter depends, and induces a tardy convalescence.
Bleeding ought not to be employed after extensive consoli-
dation of the lung has taken place.

The cases in which tartar emetic, in small doses (one-
PNEUMONIA, 307

eighth of a grain) fails to exercise a curative action are those
in which hepatization proceeds with extreme rapidity; in
which crepitation either does not exist at all, or is of very
short duration, giving place after a few hours to intense
tubular breathing ; and those which are marked by extreme
depression almost from the first. Salines and stimulants with
opium, if necessary, are found to be the most efficient means
of treatment in such cases. Of other proposed remedies, the
following may be noticed, namely:—(r.) Aconite is only to
be given at the very outset, or first stage of pneumonia, from
miil. to mv. of the tincture of B. Ph. every four hours (Wilks);
or from mii. to mili. every three hours at the outset of the
congestive stage (Keith, Hain. Med. Journ., Oct., 1868, p. 905.)
Half a drop to one drop of the tincture in a teaspoonful of
water every ten or fifteen minutes for two hours, and after-
wards to be continued every hour, has been useful in febrile
catarrh and catarrhal croup, and may be useful in some of
the phases of pneumonia, especially to subdue increased
action of the heart and circulation, and to reduce the abnor-
mally high temperature. Care must be taken that the remedy
is not combined with alkalies (Ringer). (2.) Carbonate of
ammonia.—A combination of ammonia and chloroform
(where antimony in small doses is not indicated) may be
taken every three or four hours. Four grains of carbonate
of ammonia, twenty minims of the spirits of chloroform, in
five drachms of camphor water, combine the beneficial
properties of both stimulants (Waters). It is indicated when
the symptoms generally resemble those of delirium tremens,
when the pulse is small and weak and quick, or if delirium is
present. (3.) Digitalis has of late years been employed by
Oppolzer, Traube, Schneider, Niemeyer, and others, as one
of the best agents for the relief of the febrile symptoms. It
lowers the temperature and diminishes the frequency of the
pulse, without exercising so weakening and depressing an
effect upon the system as bleeding. A pulse of 100 to 120
in frequency is an indication for its employment—a less fre-
quent pulse does not require it. It is usual to give it in the
form of infusion, combined with the neutral salts of nitrate
of potass and soda. Digitalis may be advantageously
combined with ergot, in the proportion of four drachms
of the fluid extract of ergot to one drachm of digitalis, with
six grains of the acetate of lead in two ounces of cinnamon
water, of which a tablespoonful is to be given every two
hours till the blood disappears from the. sputa (Wells,
308 PNEUMONIA.

New York Med. Record, Vol. XV., No. 17). (4.) Opium is
of great service. It may relieve the pain of the side, and
diminish the distressing cough. It is also of use in warding
off delirium, combined with stimulants and nourishment. It
ought to be given when there is want of sleep, restlessness,
and staring of the eyes, with slight tremors of the hands. It
may be used hypodermically. (5.) Hydrochlorate of am-
monia is of use in congestion of the lungs, in the advanced
stages of pneumonia, and in the cough of old age. One
drachm is to be combined with one drachm of extract of
liquorice; two drachms of spirit of sulphuric ether, and four
ounces of water, of which a tablespoonful is to be given for
a dose every two or three hours (Waring). Or it may be
given in one or two grain doses every hour or two, mixed
with equal parts of glycerine and water. (6.) Iodide of
potassium, in the advanced stages of pneumonia, appears to
promote the absorption of effusions and indurations. In
severe cases of broncho-pneumonia, combined with tincture
of hyoscyamus and ammonia it may reduce the frequency of
the respiration in a marked degree. (7.) Quinine is of use
chiefly in the advanced stages when the patient is old, the
constitution debilitated, and typhoid symptoms prevail. It
is best given in combination with sulphuric acid, in doses of
five grains every third hour. The pulse ought to become
slower and steadier under its use, and the respiration freer.
It should be given in doses of two grains every two hours, or
in two or three ten grain doses within a few hours, whenever
danger threatens from excessive elevation of the tempera-
ture of the body. (8.) Alkalies—Bicarbonate of potash,
largely diluted in mucilaginous liquids, five grains up to
thirty grains in each dose,—four, six, or even eight doses
being given in the twenty-four hours to the extent of two to
three drachms of the salt per day), alters the character of the
expectoration by the second or, third day of its use. The
viscid sputa become resolved; the fine bubbles become
coarse and large; the red color of the expectoration disap-
pears; its tenacity of adhesion lessens, so that it is brought
up easily, and the cough becomes moist, soft, and expulsive.
Thus the alkali acts as a sedative, allaying the cough and
abating the congestive state on which it depends. The
white pasty fur over the tongue dissolves away in an in-
creased flow of saliva. ‘The urine becomes alkaline, and the
physical signs of pneumonia become resolved. It has also
a marked action as a nerve sedative. A drachm dose in
PNEUMONIA. 309

water produces an agreeable, tingling, numbing sensation, in
the lips, cheeks, and other parts, extending gradually to the
lower limbs. It is especially indicated where the pneumonia
is associated with rheumatism. “Flying blisters,” applied
for four or six hours, so as to redden the skin (not for sup-
puration), is a valuable auxiliary. Suppuration from blister-
ing is to be avoided as exhaustive and prejudicial (Dr. John
Popham, Brit. Med. Journ, Dec. 28, 1867, p. 586). (9.)
Stimulants.—The treatment by repeated alcoholic stimulants
alone is but the opposite extreme of practice to excessive
blood-letting. It has now found its level and appropriate
place as a valuable aid to other remedies, especially in-pa-
tients whose constitutions are depressed under the influence
of life imposed upon them by the “great town system.”
When pneumonia tends to death by exhaustion, as the dis-
ease advances; when exudation has been excessive, the
fever prolonged, or the constitution debilitated before the
attack, such a’state of complete adynamia requires the use
of stimulants, in the form of large doses of camphor, mint,
benzoic acid, alcoholic drinks; and in addition, concen-
trated soups and milk are called for in small quantities,
given often. In old persons, stimulants, with generous diet,
preparations of quinine and iron, are indicated from the very
commencement. Alcoholic stimulants are rarely required in
young persons, or in previously healthy adults.

Some local applications require special notice, namely :—

(1.) Cold Applications —The chest of the patient (the af-
fected side in particular) is to be covered with cloths that
have been dipped in cold water and well wrung out. Com-
presses thus made must be repeated every five minutes.
After afew hours the patients experience a material relief.
The pain, dyspnoea, and frequency of the pulse are reduced,
and the body-temperature may go down an entire degree
(Niemeyer, Smoler). The treatment is not merely palliative,
but tends to shorten the duration of the illness. Few cases
delay to improve beyond the seventh day, many improve
on the fifth, and a very large number as early as the third
day. The remedy is justly held in repute for meningitis and
peritonitis, and hence it may fairly claim to have a similar
good effect in pneumonia.

(2) Linseed Meal Poultices.—On the other hand, heat com-
bined with moisture in this form, made as light and soft as
possible, and sufficiently large as thoroughly to inclose the
affected side, and changed as often as it gets unpleasant, not
310 PODAGRA—PORRIGO FAVOSA,

only affords present relief, but exercises a favorable influence
on the course of the disease. The skin may be at the same
time stimulated by mustard, or terebinthine applications,
added to the poultice.

(3.) Zurpentine—Hot turpentine fomentations may be ap-
plied over the affected side also with advantage.

(4.) In children it is sometimes of importance to be able
to induce cough and expectoration. This can be facilitated
by using a spray of a weak warm solution of carbonate of
soda, to which a little glycerine of carbolic acid is added.
It is a valuable resource in promoting the expulsion of the
plugs of tough mucus which tend to accumulate in the bron-
chial tubes of children with bronchopneumonia (Dr. Burney
Yeo, Brit. Med. Journ., Dec. 7, 1878).

Time is an important element in the cure. As particular
phases in the course of the pneumonic cycle call for special
treatment, so much more successful will the management of
the case be if the indications for interference are understood
and acted upon. The natural course of the disease is to go
on rapidly to a spontaneous favorable termination, by a pro-
cess of resolution through which the solidified lung-tissue
regains its natural and healthy state, independently of rem-
edies. Those remedies that have been specially noticed may
each be of service in safely and surely controlling the circu-
lation when the.indications for treatment are short of requir-
ing the agency of blood-letting. Their effects must be
watched so that they do not lower the vital powers nor dis-
turb the digestive functions. The indications for nourish-
ment, properly adjusted to the circumstances of each case,
and each stage of the case, are of paramount importance
from the first; and the happy issue of a case of pneumonia
depends quite as much upon early and properly feeding the
patient as a case of typhus or enteric fever does. A milk
diet should be given from the commencement, to be followed
by beef-tea and meat-stock soups as the disease advances
and the pulse softens. Stimulants cannot be regarded as the
equivalent of food (Clymer).

Podagra—See Gout.

Pompholox—Sce Pemphigus.

Porrigo Decalvans—See Tinea Decalvans.
Porrigo Favosa—Sce Tinea Favosa.
PSORIASIS. 3it

Psoriasis.—De/inition—An eruption characterized by the
development of irregularly formed patches of a dusky red or
coppery hue, slightly raised above the level of the skin, and
covered with thin, dry, white scales.

Treatment.—Preparations of arsenic are found to be of
great service in this squamous form of eczematous inflamma-
tion. A form of arsenical remedy, known as the Asiatic pill,
is recommended by Cazenave. Its composition is as follows :

R Arsenici Protoxidi, gr.i.; Pip. Nig., gr. xii.; Pulv. Acac.,
gr. ii. Aq. Distill., g. s—Divide in pil. xii. vel. xvi. One
pill to be taken once, twice, or thrice daily after meals.

It is of the greatest importance that the meals and the diet
should be regulated. Small doses of pilule hydrargyri, or
of pilulze calomelanos composita, or hydrargyrac. creta, may
be given at bedtime for a few days, followed each morning
by a drachm of magnesia, given in combination with a tea-
spoonful of lemon juice. The vascular excitement of the
stomach is best subdued by dilute hydrocyanic acid, in the
following formula (A. T. Thomson) :—

B Potasse Carbonatis, 3ss.; Succi Limonis Recentis,
f 3iv.; Acid Hydrocyanici Diluti, miv.; Vini Sem. Colchici,
mxv.; Aque Distillate, f%vi.; misce. Fiat haustus gta.
quaque horz sumendus.

The tone of the stomach is to be restored by small doses
of bicarbonate of potassa, with from twelve to fifteen minims
of the tincture of henbane, in a fluid ounce and a half of the
infusion of cinchona. The eruption and itching disappear
as the mucous membrane of the stomach and bowels return
to a healthy state. The diet should be absolutely free from
stimulants ; and tepid baths, at a temperature of 96° Fahr.,
used every morning for half an hour, are most serviceable.
The bowels should’ be regularly relieved by such mild ingre-
dients as are contained in the following formula for pills :

B Pilule Hydrargyri, gr. vi.; Pulveris Ipecacuanhe, gr.
vi.; Extracti Colocynthidis Comp., gr. xii.; Ext. Hyoscyami,
gr. xvili.; misce. Fiat pilule duodecem. Sum. ij. h. s. quo-
tidie (A. T. Thomson).

Glycerine and emollient lotions are useful local applica-
tions. { have found the itchiness greatly relieved by the
following lotion of bitter almonds, rubbed nights and morn-
ing over the parts affected :

BR Amygdal. Amar. Numero, xx. vel. xxx.; Aquz Rose,
& vii. Contunde et tere simul, dein cola, et adde Hyd. cor-
rosiv. Sublim., gr. xii.; Ammonisze Hydrochloratis, gr. xii.;
312 PUERPERAL CONVULSIONS—-PUERPERATI FEVER.

Spt. Vint Rect., %i.; or, Dilute hydrocyanic acid may be
used to the extent of two drachms to the eight ounces, omit-
ting the corrosive sublimate ; or let borax replace the hydro-
cyanic acid, and omit the spirits of wine.

When the lotion has dried off, oxide of zinc ointment or
glycerine starch ought to be applied to the parts all night.

Puerperal Convulsions—See Convulsions, Puerperal.

Puerperal Fever.—Definition—“ A continued fever,
communicable by contagion, occurring in connection with
childbirth, and often associated with extensive local lesions,
especially of the uterine system.

Treatment.— Having regard to the varied sources whence
puerperal fever may take its origin, prophylactic treatment
ought to be the first consideration; and especially the burn-
ing question as to what ought to be the conduct of the med-
ical practitioner in the face of perils of this kind (Priestley).
Preventive measures are of vital importance, for such
measures have been proven sufficient to arrest the develop-
ment of the disease.

Dr. W. O. Priestley concludes his admirable address as
follows :—

“The method, therefore, to be pursued for guarding lying-
in women from noxious influences, consists of all those
measures which prevent the formation of poisonous materials
in her own system, and which secure her isolation from all
contagion from without. In following out the first indica-
tion, it is necessarv to provide, as much as may be practic-
able, for a woman encountering her confinement in the best
possible condition of health, by impressing upon her the
necessity of obedience to natural laws during her pregnancy.
If complications occur during pregnancy, they must be com-
bated as the circumstances will permit.’ Dr. Barnes has in-
formed us that albuminuria at the end of pregnancy is ex-
tremely apt to go into puerperal fever. On these cases,
therefore, a sedulous watch must be kept, the bowels must
be carefully attended to, and other suitable treatment
adopted. The process of parturition should be conducted
with the view to the genital canal of the woman being ex-
posed as little as may be possible to the effects of irritation,
continued pressure, and laceration. After the birth of the
child, a full and perfect contraction of the uterus should be
secured, by seeing that the organ is not emptied too sud-
denly, and that the hand follows the fundus down from
above as its contents are expelled. Subsequently to de-
PUERPERAL FEVER. 313

livery, the various known methods should be practised
which promote the contraction of the walls of the womb and
the diminution of the uterine cavity; and any clots forming,
should be removed from time to time during the hour after
removal of the placenta. It is superfluous to say that the
placenta should be extracted in its entirety when possible;
and great care should be taken not to leave any detached
portions adherent to the uterine walls. The same precau-
tions should be observed, when practicable, in cases of
abortion. If any considerable laceration of the perineum
have taken place, the edges of the wound should immediately
be united by sutures, not only for the purpose of restoring
the perineum, but also to prevent contamination of the
wound by putrid discharges. In the case of other wounds
in the vagina or cervix uteri, especial care should be taken
to keep them clean by repeated injection, and to leave as
small a raw surface exposed as may be practicable. In all
cases where the lochia are in the least degree offensive, the
vagina should be well injected with Condy’s fluid and water,
or other innocuous disinfectant, twice in twenty-four
hours, or oftener if necessary; and the injection may be
carried into the uterine cavity, if it be much distended, and
there is a suspicion that it harbors foetid contents. The in-
jection of the wound-cavity, however, should be conducted
slowly, carefully, and without force. These uterine injec-
tions were practised long ago by William Harvey, and there
is concurrent testimony in this and other countries of their
marked utility in abating the symptoms, even when puer-
peral fever has apparently set in. Next in importance is to
take care that there is no feecal accumulation in the bowels,
and to recollect that the existence of previous diarrhoea may
be the indication that retained masses are lying in the in-
testines and producing irritation there. It must be within
the experience of many how acute febrile symptoms, ac-
companied, it may be, by delirium or incipient mania, have
passed away with a proper evacuation of the bowels. I may
put it, in short, that, to promote recovery after parturition,
every direct or reflex source of irritation should be removed,
pure air and water ensured, absolute cleanliness observed;
and perfect quietude, mental and physical, should be en-
joined. Nursing the child should also be recommended
when the mother’s condition permits, as puerperal ailments
have been observed more frequent in women who have not
suckled their children. Tosecure the isolation of a lying-in
314 PUERPERAL FEVER.

woman from noxious influences which may be communicated
to her from without may be difficult, and in some cases per-
haps impossible; but as Mr. Callender has informed us how
surgeons have learned to banish, for all practical purposes,
those affections which may be termed septicaemic from surgi-
cal wards of hospitals, so I cannot help thinking that the
accoucheur will in time succeed in preventing the like affec-
tions in puerpéral women, so far, at least, as the hetero-
genetic cases are concerned. We are all agreed as to the
absolute necessity of preventing, directly or indirectly, any
communication between cases of erysipelas and puerperal
patients. We are agreed alsoas to the necessity of the mid-
wifery practitioner avoiding all post-mortem examinations.
His hands should avoid all contact with specific poisons or
septic materials; and if perchance his fingers have touched
anything suspicious, he should at once carefully and
thoroughly disinfect them. The necropsies which seem
most baneful are of those bodies which have recently died of
erysipelas, peritonitis, zymotic disease, or any other inflam-
matory and febrile affections; and in such instances the ac-
coucheur should not even be present in the room when the
dissection is made, as, though he decline to touch, yet his
person and clothes may become infected by the poison.
There may possibly be a doubt whether one who dissects
bodies altered by decomposition or antiseptic injections, as
they are commonly found in the dissecting-room of medical
schools, is so liable to contaminate a puerperal patient as
he who makes a necropsy soon after a death. Semmelweiss,
however, believed that animal matter in a state of putrefac-
tion would cause puerperal fever, and immediately lessened
the mortality, during the fearful epidemic of puerperal fever
which raged in the Vienna hospital in 1846 and 1847, by
obliging all dissecting students to wash their hands in
chlorine or chloride of lime before making vaginal examina-
tions. Impressed by Semmelweiss’s views and opinions, I
endeavored, during my occupancy of the Chair of Obstetric
Medicine at King’s College, to prevent students frequenting
the dissecting-room and post-mortem theatre from attending
midwifery cases, and the result was a very small mortality in
the outdoor maternity charity. This care about absolute
cleanliness of the hands in attending labors should extend
even to occasions when a medical man has had digitally to
examine patients suffering from offensive discharges either
proceeding from the surface or from the interior of the
PUERPERAL FEVER. 315

body. We have heard in this discussion that the*discharges
from cancer may produce fever in a lying-in woman; and
this is probably true of other putrescent discharges. I have
had grave anxiety, extending over some weeks, about a
patient after her delivery; because I had gone straight from
an instrumental case where labor had been so protracted
that febrile symptoms had set in, and the passages had be-
come inflamed, so as to pour out an irritating muco-purulent
discharge. When a medical man has a bad case of puer-
peral fever in his own practice, or is required to see one in
consultation, he should certainly not go direct to another
midwifery patient without first changing his clothes, besides
careful ablution of his hands; and he will be all the safer in
his ministrations if he adopt some of those precautions men-
tioned by Dr. Swayne and others, such as using a Turkish
bath, or the more radical measures for disinfection recom-
mended by Dr. Wynn Williams. [No method, however, has
been pointed out, or even alluded to, in the course of the
discussion by which the septic poison could be got rid of
should it have attached itself in any way to the body or
dress of the .accoucheur or nurse. We have more than one
substance—one in particular—that will not tolerate the
presence of putrid animal matter or septic poison: this drug
is iodine, which, as soon as it is brought in contact with
septic matter, is converted into two harmless substances—
acid and carbon. Let any one who has been in attendance
on any case, whether a parturient female or any other, where
there is any putrid emanation, wash his hands in water into
which he has poured tincture of iodine, and I will answer
for it he has no septic matter under his finger-nails. Again,
if he fancy that his clothes, hair, and skin are saturated with
it, let him go into the water-closet (I mention that as the
smallest room in the house), place a few scales of iodine on
a plate and put a spirit-lamp under it, and he will soon find
himself surrounded by a violet vapor, which will fall upon
him in a shower of minute scales, from which he has only to
protect his eyes. If he then carry with him any of the
puerperal poison, my whole theory of the disease must be*
wrong. One thing I can assert, that in my own practice I
have never had a case of fatal puerperal septiczemia since I
-have used iodine as an antiseptic, now more than twenty
years ago. Iodine is equally efficacious in warding off
septicaimia in other surgical diseases. I have injected solu-
tions of septic poison under the skin of guinea-pigs, and pro-
316 PUERPERAL FEVER.

duced death by septicemia. I have also injected some of
the same solutions, into which I had dropped a few drops of
the tincture of iodine, without producing any ill effects. It
is needless to observe that the prevention and the cure of
this disease go hand in hand together. Should any septic
poison be present in the puerperal woman, wash her out
again and again with solution of iodine until the solution
comes back the same color as it was thrown up. The tem-
perature of the patient will probably be 103° or 104°, and
it will go down in a very short time to 98°. This I have
witnessed since the present discussion began. (Dr. Wynn
Williams.) ]

“Many chemical substances have been recommended to
be added to water for purifying the hands; iodine, chlorine
and its compounds, sulphurous acid, cyanide of potassium,
carbolic acid, and the permanganates. It matters not which
agent is employed, so long as it is used carefully and effici-
ently; and if it be necessary to disinfect clothing, this is
readily done by exposing it in an oven to a high temperature,
for which many -upholsterers have a suitable arrangement.
With all deference to Dr. Matthews Duncan, I have no doubt
that every medical practitioner who earnestly desires to pro-
mote the welfare of his patients and to keep himself blameless,
should at once abstain from attending fresh cases of labor
when one or more of those recently delivered by him have
died with acute febrile symptoms, or are still so ill as to re-
quire his constant visits. When, indeed, there is the remo-
test suspicion that he may convey the poison in his own per-
son, he should not incur the risk of disseminating it. How
long he ought to absent himself from midwifery practice, is
yet a moot point. Dr. Swayne thinks a medical man should
seclude himself for a week only; others think a month
hardly sufficient. The remarkable experience of Dr. Huntly,
of Yarrow-on-Tyne (Brit. Med. Journ. Feb. 27, 1875,
Pp. 27 1), led him to believe that he actually generated poison
in his own body, as the result of some faulty process, which
he communicated to his patients. Taking all the circum-
stances into consideration, I am disposed to recommend a
week’s seclusion after regular attendance has ceased on asin-
gle puerperal fever case. When a series of cases have occurred
in the practice of any one medical man, he should absent
himself from midwifery practice for a month at least. Dur-
ing either the short or long interval of seclusion, the
means for disinfection should be fully carried out.
PUERPERAL FEVER. 317

“Finally, I have to say a word or two asto the propriety of
attending patients suffering from scarlet fever or other zymo-
tic disease, and lying-in-women at the same time. After
what has been said in this debate, I cannot expect the same
accord of opinion as on other parts of the ground I have
gone over; but I would earnestly beg those who have as yet
had so favorable an experience, when attending the two sets
of patients conjointly, to ponder well what has been said by
others on the reverse side of the question. It cannot be
expected that men in general practice, who may be in charge
of a scarlet fever or small-pox patient, shall at once relin-
quish all midwifery practice for the time being, because
zymotic diseases are so prevalent that this would practically
preclude their attending confinements altogether, or make
their attendance on midwifery patients so irregular as to be
unreliable. Nevertheless, in view of the dangers which have
been indicated by various authorities, albeit their experience
may seem to point to different conclusions, they are bound
to exercise vigilance, lest perchance they slip into a pitfall
unsuspected by them. In seeing an ordinary case of illness,
a medical man rarely stays sufficiently long in the sick room
to concentrate any considerable dose of contagium about
him, and the after-exposure to fresh air in passing from
house to house no doubt usefully dissipates any smaller
quantity. I would suggest, however, to those treating in-
fectious cases, and liable at the same time to be summoned
to cases of midwifery, or who may be in attendance on
puerperal women, that they should not stay long in the sick
chamber; not undertake the duties of nurses, as Dr. Duncan
puts it; that they should see puerperal patients before see-
ing infectious cases, and never go from the infectious cases
direct to the lying-in room, without changing clothes and
the most careful ablutions. Some doctors change their
clothes and wash with a disinfectant whenever .they have
seen infectious cases. Whatever either will, or may, con-
duce to the wellbeing of patients, will, I am sure, not be
regarded as either too irksome or troublesome by any mem-
ber of our profession” (Brit. Med. Journ., Jan. 8, 1876).

If scarlet fever can be prevented, the number of puerperal
fever cases would be diminished one-half (Hicks); and
every possible step ought to be taken to remove the preg-
nant female alike from the influence of scarlet fever and
from erysipelas. Dr. Hicks observes, also, “with regard to
the medical attendant, although I have found some fully
318 PUERPERAL FEVER.

aware of the risk of carrying scarlet fever and erysipelas to
the woman in labor, yet I have met with not a few who
either have not taken care, or have not been fully alive to
the danger in which they are placing their patients.” He
considers it well to have three suits of clothes in use when
attending such cases, keeping those out of use before a very
warm fire, or hung out in the open air; the hands to be
frequently washed and the nails short; and a good walk in
the air should be taken before going to any other patient.
Where there are partners, it is advisable for one to attend
contagious cases, and leaving the other to manage the mid-
wifery. With regard to the nurse, the tendency of women’s
dress to retain the fomites of contagion must suggest their
frequent purification by disinfectants, and the use of material
capable of being boiled in the process of washing, and of
otherwise being subjected to the action of disinfectants.
With regard to the prevalance of .the disease in hospitals,
the wards ought to be closed entirely against the admission
of patients, at regular intervals, during which the process of
purification should go on. The ward to be purified should
then be filled with chlorine gas, in a very condensed form,
for forty-eight hours at least; the windows, doors and fire-
places being kept shut. The floors and woodwork should
be covered with chloride of lime, mixed with water, to the
consistence of cream. The woodwork should then be
painted, and the walls and ceilings washed with fresh lime;
the blankets and sheets should also be washed and heated
ina stove to a temperature of 120° to 130° Fahr. The
hospital beds should be stuffed with straw; and as soon as
the case is concluded, the straw ought to be burned, and the
covering of the bed washed and heated like the blankets
and sheets (Collins’s “ Midwifery,” 388). Patients threat-
ened with puerperal fever ought to be isolated.

With regard to medical treatment, pure air, nutriment, and
stimulants are the agents best able to obviate the great
depression which marks the commencement of puerperal
fever. Quinine in large doses has been found useful after
the bowels have been fully evacuated. It ought to be given
till the physiological action of the drug is manifest, from the
deafness and vertigo it produces. A form of quinine is now
made soluble in warm water, which may be injected hypo-
dermically. Opium is of great value. It has been given, to
a large amount in the twenty-four hours, by Drs. Graves,
Stokes, and others, since its great value became known. It
PURPURA. 319

must be given till incipient narcotism is produced; and the best
evidence of its good effects is seen when the respirations become
sensibly diminished from the great frequency they attain in
puerperal fever. If they can be reduced to fourteen or to
twelve, with a pulse below 100, asubsidence of tenderness, and
of tympanitis, the amount of opium may be gradually lessened
and finally discontinued (Clark). Warburg’s tincture (suggested
by Professor W. C. Maclean), has been found successful by
Dr. Playfair in the treatment of puerperal fever.

Purpura.— De fiition.—A disease characterized by purple
spots, patches, or merely points of effused blood, which are
not effaced by pressure. They are usually met with on the
skin alone; but they may appear simultaneously on the
mucous membrane, when they are sometimes accompanied
with more or less hemorrhage.

Treatment.—To treat this disease with success, it 1s neces-
sary to ascertain the circumstances under which it becomes
developed in each particular case. Its treatment may be
comprised in the following measures :—The bowels ought in-
variably, and without exception, to be first thoroughly and
effectually evacuated by means of senna, aloetics, or calomel
and jalap. Oil of turpentine administered in moderate and
repeated doses, has also been recommended. Dr. Hardy, of
Dublin, recommends the tincture of larch bark. He has
long used it as a styptic and carminative tonic; and it is
“one of the most elegant forms of prescribing a terebinthi-
nate’’ (Moore). Fifteen drop doses of the tincture may be
administered every hour or eight or ten drops three times a
day, afterwards increasing the dose according to the age of
the patient and the necessities of the case. In young sub-
jects otherwise robust, when the disease has appeared after
violent exercise or excess, blood may be drawn from the arm,
as practised by Dr. Parry of Bath. Under such circumstan-
ces also the young patient should abstain from animal food
in-every form, and should subsist on boiled rice with whey,
or the light subacid fruits, as grapes, oranges, strawberries.
gooseberries, baked apples, and the like. His drink may con-
sist of tamarind-water, or water acidulated with sulphuric
acid. Under this plan most cases of the disease in the young
will be speedily and readily brought to a favorable termina-
tion. If symptoms of local uneasiness continue after the
urgent phenomena have disappeared, leeches should be ap-
plied in the neighborhood of the part ; and it will be proper
to continue the periodical and regular evacuation of the ali-
320 PYEMIA.—PYROSIS.

mentary canal. When the spots have disappeared and the
hemorrhage has ceased, the constitution recruits rapidly
under the gradual but cautious use of light soups and fresh
fruits and vegetables (Craigie). :

Pyemia.—Definition.—A febrile affection associated with
a morbid state of the system generally, the invasion being
marked by frequently repeated severe rigors alternating with
profuse sweatings, and usually sequent on some inflammatory
and infective condition of wounds, suppurative inflammation
of bone, the puerperal state, or surgical operations, which
results in the formation of secondary lesions in the internal
visceral organs (most frequently in the lungs, the liver, kid-
neys, spleen, and brain), and also in the joints and connec-
tive tissue. Sometimes, but not necessarily, it is associated
with phlebitis or embolism. The blood becomes poisoned,
and contains an excess of white corpuscles and of fibrine.

Treatment.—The aim should be to prevent pyemia by
dressing wounds and injuries by Lister’s antiseptic methods.
Whenever the antiseptic treatment of Lister is properly car-
ried out there is complete absence of pyemia. The indica-
tions are—(1.) To remove all those conditions which favor
the degeneration, metamorphosis, or putrefaction of blood-
clots or tissue in connection with wounds ; (2.) To subdue
the force of the circulating current, so as to prevent excite-
ment during the long and slow metamorphosis of a clot when
it has formed ; (3.) To sustain the strength and allay the
nervous irritability. Wine, brandy, rum, milk, strong animal
soups, and nourishing diet, should be freely given from time
to time, in small quantities. Opium should be given freely.
Exposure of the patients to currents of fresh air—treatment
in the open air, in fact—has been shown by Sir James Paget
to be the most promising of success.

The use of disinfectants, and attention to ventilation, give
support to the belief that the poison is one generated among
cases of accumulated severe wounds and open sores. The
patient ought to be isolated. Condy’s fluid, carbolic acid
wash, and chloralum, are each useful disinfectants. Prepa-
rations of iron are the most suitable tonics.

Pyrosis.— Definition —Paroxysms of pain at the cardiac
or cesophageal region of the stomach, occurring in parox-
ysms which do not cease till the patient vomits up a lmpid
colorless fluid, like water, cold and insipid to the patient’s
taste, but which sometimes gives an acid and sometimes an
alkaline reaction,
PYROSIS. 321

Treatment consists in saline remedies, such as a drachm of
the sulphate of magnesia, with fifteen minims of the tinct.
hyoscyami, three times a day. Many other medicines have
been,recommended, as the tinct. kino, and compound kino
powder, and mixtures of bismuth, especially Seller’s. The
compound tincture of benzoin, to the extent of one fluid
drachm with mucilage, is most efficacious. (Baillie, Symonds).
Sulphurous acid, in doses mxxx, to one fluid drachm, thrice
daily, and shortly before meals, is advocated by Dr. Lawson
(Practitioner, Sept. 1868). It is especially useful where sar-
cine ventriculi are present in the fluid evacuated. The diet

should consist of animal food, and be otherwise nourishing.
Oatmeal and brown bread must be avoided.

Quinsy .—Definition.—Acute inflammation of the tonsils,
which may or may not lead to suppuration.

Treatment must depend entirely on the stage at which the
disease comes under notice. In the early period resolution
may almost invariably be brought about by the administration
of guaiacum, in the form of lozenges. Dr. Mackenzie pre-
scribes a lozenge containing three grains of the extract of
guaiacum mixed with black currant paste, every two or three
hours. But I have found the drug most beneficially pre-
scribed in the following formula:

BR. Magnes. Sulph., 3vi.; solve in aque 5 viii.; adde
Pulv. Guaiaci 3iss.; Pulv. Tragacanth. Co, Dii.; misce
bene. One-sixth part of this mixture may be given every
four hours till the bowels are freely moved.

Minim doses of aconite tincture every hour will maintain
a regular and steady action in subduing the inflammation.
In addition, ice sucked constantly, and iced drinks, are most
grateful to the patient; while, if ice cannot be obtained, cold
thick gruel frequently affords relief. In other gases, how-
ever, greater relief is experienced by holding hot water in
the mouth, and by the inhalation of hot steam, combined
with sedatives—such as benzoin or conium. A mixture of
mucilage or gruel, containing nitrate of potash or borate of
soda, and a small quantity of syrupof poppy, Batley’s solu-
tion of opium, or prussic acid, should be frequently but
slowly swallowed in small quantities, in tea or tablespoonfuls;
the amount of narcotic ingredient being carefully regulated,
so that a definite quantity is consumed in a given time. Ex-
ternally, amustard poultice should be first applied, and af-
terwards linseed poultices. The latter may be constantly re-
peated until the attack subsides; spongiopiline may answer

21
322 RACHITIS—RELAPSING FEVER.

better than the linseed poultices, and is more cleanly. If
suppuration hascommenced before the practitioner sees the
case, great relief will be afforded by puncturing the abscess
with a guarded knife; the incision should always be made
towards the median line. After the abscess has been re-
lieved, the recovery of the patient is usually very rapid; but
the prostration is sometimes considerable, so that nourish-
ment and stimulants are required in abundance. It has
been already remarked that a patient who has once suffered
from quingy is likely tosuffer again; and the question natur-
ally arises as to what preventive treatment should be adopted?
In those cases in which there is any chronic enlargement of
the tonsils, excision should be performed; but in some cases
the glands, though extensively diseased, do not remain en-
larged when the acute inflammation has passed away. Un-
der these circumstances the tonsil may be amputated during
the attack of quinsy. This plan of treatment is commonly
adopted in Germany on its own merits, without any question
as to the recurrence ot the inflammation.

Rachitis—See 2Rickets.

Relapsing Fever.— Definition —A continued fever, hav-
ing a very abrupt invasion and short duration, characterized
by an abrupt relapse occurring after an interval of apparent
health of about a week. ‘There is no eruption on the skin,
nor any specific lesion associated with this fever, which is
marked by rigors, chilliness, severe headache, vomiting, and
often jaundice; a white moist tongue, epigastric tenderness,
confined bowels, enlarged liver and spleen, high-colored
urine, a frequent, full, and often bounding pulse, painsin the
back and limbs, restlessness, and occasionally delirium.
These symptoms abruptly terminate by an exceedingly copious
perspiratién between the fifth and the eighth day; and after
a complete apyretic interval (during which the patient may
be so well as to get up and walk about), an abrupt relapse su-
pervenes on the fourteenth day, counting from the first com-
mencement of the fever. The relapse runs a similar course
to that of the primary paroxysm, and terminates between the
third and the eighth day. In some cases a second, third,
fourth, and even fifth relapse may occur. Death is apt to
happen from sudden syncope, especially after the excessive
perspiration; or from suppression of urine and coma.

Treatment.—All physicians agree that in the primary at-
tack little medicine is required after opening the bowels by
RELAPSING FEVER. 323

castor-oil; or by five grains of the compound colocynth
mass; or by two grains of blue-pill, and three grains of ex-
tract of hyoscyamus given at night, and followed in the
morning by two drachms of the sulphate of magnesia in
compound infusion of roses (Murchison). The symptoms
are not readily under the control of remedies; the vomiting
is often especially persistent. Five grains of calomel, with
one grain of opium, has been found more efficient in subdu-
ing the severity of this symptom than counter-irritation or
effervescing draughts. The violence of the headache in
well-fed, or otherwise healthy patients, is best subdued by
leeches or cupping; andin the poor, weakly and ill-fed, by
blisters to the nape of the neck, or by dry cupping there.
Till the crisis comes, the symptoms may be mitigated, but
not altogether relieved, and cases of ordinary severity are
better left to nature without interference on the part of the
physician. Active purging is to be avoided; and the action
of the kidneys is to be kept up by the frequent use of small
doses of nitre (Ross, Henderson, Cormack, Wardell, Mur-
chiscn). “By keeping up the action of the kidneys from
the first’’ we may “ prevent the occurrence of uremic intoxi-
cation, which is one of the main causes of death in uncom-
plicated cases.”” With this end in view nitre is to be given
as follows:—From one to two drachms of nitre are to be dis-
solved in two pints of barley-water, acidulated with a drachm
of dilute nitric acid, and sweetened with a little syrup.
This quantity is to be used up during the twenty-four hours.
Acetate of potash and nitric ether may be used for the same
purpose; but the nitre has the additional advantage of keep-
ing open the bowels (Murchison). Contamination of the
blood with urinary products is the great danger in cases of
‘relapsing fever; and therefore particular attention must be
paid to the state of the urine, especially towards the period
of the first crisis) When the daily amount is much reduced,
or if entire suppression should ensue, and particularly if
stupor, confusion of thought,or drowsiness should supervene,
the bowels are to be freely moved by compound jalap powder,
or by a turpentine enema. Determination to the skin
should be promoted by the hot-air bath; and saline diuretics
may be given every two or three hours. No means hitherto
discovered will prevent the occurrence of therelapse. The
surface of the body should be frequently sponged over with
cold or tepid water. Stimulants are not usually necessary,
but they may be required in the stage of Janguor or exhaus-
324 REMITTENT FEVER.

tion ensuing on the crisis, or in cases where great debility
has preceded the’ attack. If any anemia exists, or if an
anzmic murmur can be detected, stimulants must be given
early. When jaundice appears, nitro-hydrochloric acid
should be given in combination with nitre, as in the follow-
ing formula:—Twenty minims of hydrochloric acid, with
ten minims of nitric acid, every three hours, each dose
diluted with the drink of nitre and barley-water already pre-
scribed (Murchison).

Remittent Fever. — Definition. Febrile phenomena
of malarious origin, characterized by irregular re-
peated exacerbations and _ remissions being less
distinct in proportion to the intensity of the fever, so
that in malarious yellow fever the exacerbations and
remissions are so connected that the fever resembles a
continued fever. There is great intensity of headache,
the pain darting with a sense of tension across the forehead.
It is accompanied by functional disturbance of the liver, and
frequently by yellowness of the skin, as in malarious yellow
fever, in which, however, the urine is not suppressed, and
continues free from blood and albumen. The malignant
local fevers of warm climates are usually of this class.

Treatment.—With fever so various in its degrees of severi-
ty, it is not possible to do more than indicate the nature of
the treatment which may be followed, as every special case
must be prescribed for and treated by its own special indi-
cations, and with a due regard to the nature of the prevail-
ing epidemic. The best possible hygienic arrangements
should be made, especially to secure efficient ventilation,
with a plentiful supply of fresh air. In every form and va-
variety of the fever one of the most important guides in the
treatment is to be derived from the nature of the prevailing
disease, whether endemic or epidemic, whether sthenic or as-
thenic, and to study each individual case in relation to the
prevailing type. First, the duration of the stage of the fever
must be ascertained—~. ¢., whether it be of some hours’ or of
some days’ duration, and whether, when the practitioner sees
the patient for the first time, the actually existing paroxysm
is at its accession or its decline.

Regarding the method of treatment of remittent fever, my
friend and colleague, Prof. W. A. Maclean, whose extensive
experience in India gives authority to his conclusions, writes
in the following terms :—

“T have been led to take a view of the treatment of mala-
REMITTENT FEYER. 325

rial fevers generally, and remittent fever in particular, differ-
ing from that laid down by many authors. It appears to
me that the so-called antiphlogistic treatment, so much in-
sisted on by many writers, is based on the belief that the
phenomena observed in a case of remittent fever are conse-
quent on a process of inflammation. It is only on such a
belief that antiphlogistie treatment can be justified. During
the exacerbation of a remittent fever there is violent disturb-
ance both of the vascular and nervous systems. Almost
every organ, almost every function suffers,—the gastric in-
intestinal membrane is affected, the liver and spleen suffer,
the ‘brain is involved, for rending headache and delirium
are often present. Is it rational to suppose that an inflam-
matory process can be going on at one and the same time in
all these various organs? Do the appearances observed
post-mortem give any support to such a’ doctrine? If not,
on what principle can spoliative treatment be justified? Is
it not rather the case that this terrible disturbance of so
many organs is due to the presence in the blood of a subtle
poison acting on them all? If so, surely the guiding princi-
ple of the physician in his treatment should be to counter-
act this poison, to neutralize it, or to expel it from the sys-
tem, and so to prevent a recurrence of the exacerbation.
This is the principle on which I have long acted, and I am
satisfied that it is at once a safe and successful one. In qui-
nine we have such an antidote—a therapeutic agent of unri-
valled efficacy, which, if skillfully used, will rarely disap-
point the expectations of the practitioner.

“Tt is always, of course, advisable to have the bowels
thoroughly evacuated ; and if the patient is seen when his
stomach is loaded, it is well to evacuate its contents by an
emetic. In ardent remittents, however, there is generally
little call for this, as obstinate vomiting is almost always a
troublesome symptom, sometimes requiring to be checked.
This done, the period of remission must be watched for, and
the moment it arrives, quinine in a full dose should be given
—not less than fifteen grains in the case of an adult. If the
irritability of stomach be so urgent that the remedy is reject-
ed, while measures must be adopted to allay it—such, for
example, as alkaline remedies in combination with dilute
hydrocyanic acid, turpentine stupes, or even a blister to the
epigastrium—time—precious time—snould not be lost. Qui-
nine should be given by the rectum, in a full and efficient
dose. By mouth or by rectum, or by both, quam in
326 REMITTENT FEVER.

quantity sufficient to induce some of the symptoms of cin-
chonism, should be given before the time of expected exac-
erbation, According to my judgment and experience, it is
bad practice to withhold quinine until an impression has
beén made on the force and frequency of the heart’s action,
from fear of increasing headache, causing congestion of or-
gans, or the like. Animpression on the force and frequency
of the heart’s action is best attained by arresting the parox-
ysm ; and this is done most quickly, simply, and effectively
by the early administration of quinine. I have over and-
over again had patients brought to me from the malarial
quarters of the city of Hyderabad, in whom it was impossi-
ble to distinguish any period of remission—the tongue black
and dry, sordes on the teeth, the skin hot and parched, the
pulse enormously quick, the intelligence feeble or gone—all
- pointing to a system so charged wlth malarial poison as to be
well nigh overwhelmed. In such cases quinine, with concén-
trated beef-tea and brandy, are urgently called for, and should
be administered freely ; and it is astonishing how men, by
such measures, are often snatched from impending death. I
have seen in a few hours consciousness return, a striking re-
duction in temperature, in the frequency of the pulse, with a
remarkable accession of force and volume, follow the treat-
ment indicated above. I do not advise, and never used qui-
nine in the heroic doses advised by some. I have never ex-
ceeded twenty grains; but within such reasonable limits ;
‘have never seen it aggravate-headache. On the contrary, I
believe that in remittent fever—in fact, in all forms of malar-
ial fever with which I am acquainted—I believe quinine to
be a powerful remedy in quieting the tumultuous action of
the circulation disturbed by the presence of this terrestrial
poison. For some years past Warburgh’s tincture has been
much used in the treatment of malarial fevers in Southern
India. It is a secret remedy, and therefore open to the ob-
jections very properly urged against all such remedies. It
is now known that quinine enters largely into this remedy,
the composition of which is published 1 in the Lancet, Vol. IIL,
1875, p. 716. Ihave given this ‘tincture’ a fair trial in
some of the gravest forms of malarial fever, and it has also
been extensively used by some of the most experienced offi-
cers of the Madras army ; and I do not hesitate to say that
I think it a valuable remedy. I have known it arrest at once
some of the severest cases of remittent fever, no exacerbation
appearing after the second dose. It almost invariably acts
REMITTENT FEVER. 327

as a powerful diaphoretic—the most powerful with which I
am acquainted. I have seen patients, under the influence of
this remedy, saturate not only the bed-clothes, but the very
mattress, the patient’s room and his person for days after
giving out a strong odor of the medicine. For this reason it
requires to be used with extreme caution, if at all, in the
adynamic form of the disease.

“In urgent cases I follow the practice of the American
physicians. I donot wait for a remission, but give quinine
at once; and in all I am conservative of the patient’s
strength. JI have seen violent delirium follow free leeching
of the temples, and over and over again seen extreme and
dangerous prostration follow depletive treatment, and that in
cases where the violence of the disturbance indicated power;
but these signs of power in the system are often most delu-
sive, and, if combated by depressing measures, we must be
prepared for sudden signs of oe a Against the system
of treating this fever by saturating the system with mercury,
I enter my strenuous protest. I know nothing more deplora-
ble than the condition of a patient whose constitution, al-
ready depressed by the presence of malaria, is further satu-
rated by another poison which acts as a powerful ally of the
first.”

In the asthenic form of remittent fever, such as that so
well described by the late Dr. Murchison as prevailing in
Burmah, it is necessary to exercise great caution in deple-
tion. All the cases he relates which had been freely bled
exhibited the most aggravated typhoid symptoms, and most
of them died. Even in the instance of young and robust re-
cxuits, low adynamic typhoid symptoms were sure to super-
vene in a short time after blood-letting ; and, even although
it gave temporary relief, it was certain to aggravate, if not to
induce, the subsequent typhoid condition. If the headache
is very severe and the pulse full; if the hair be cut short, or
shaved off the scalp, cold lotions applied to the head, or the
cold douche kept up for ten minutes at a time, gives great
relief, and is the preferable remedy (Murchison). As soon
as possible after the commencement of the paroxysm the
bowels should be cleared out with a purgative of calomel
and compound jalap powder; or by colocynth, antimonial
powder, and calomel. If typhoid symptoms betray them-
selves, stimulants, such as wine and brandy, must be given;
but, as in intermittent fever, “quinine is undoubtedly the
sheet-anchor,” and it is best given, as in the former fever, in

¢
328 “RHEUMATIC FEVER—RHEUMATISM, ACUTE.

one large dose of twenty grains in solution at the very com-
mencement of a remission. Carbo-azotic or picric acid has
been lately introduced as an active remedy in the treatment
of malarious fever. Prepared by Calvert, of Manchester, it
is of a light yellow color ; and in doses of two grains, cau-
tiously repeated, it is to be pushed till the patient gets yel-
low-skinned.

The period of convalescence demands no less careful at-
tention on the part of the medical attendant, especially as to
diet and a timely removal from all malarious influences, by a
sea voyage, or a change of climate. It is to the mismanage-
ment of convalescence, and a too early discharge from hos-
pital principally, that we must refer the numerous and fatal
relapses in the fevers and dysenteries of our seamen and sol-
diers (Martin).

Rheumatic Fever.— See Rheumatism, Acute.

Rheuatism, Acute.*-Definition.—A specific febrile dis-
order, due to a morbid state of the system by constitutional
development, and expressed by inflammation of a peculiar
non-suppurative kind in the fibrous tissues about or surround-
ing the joints, especially in the white fibrous tissues—such,
for instance, as the sheaths of the muscles and muscular
fibres, tendons, aponeurosis, burs, capsular ligaments, per-
iosteum, and pericardium. Many joints may be affected at
the same time or in succession. The various local pheno-
mena of the disease have a tendency to shift from part to
part, the most remote from each other; and the febrile state
is accompanied by profuse acid excretions from the skin, by
the separation, in some cases, of large quantities of uric and
sulphuric acid through the kidneys, and by a highly fibrinous
condition of the blood.

Treatment.—It seldom if ever happens that the cure of
rheumatism can be entrusted to any single remedy. The
constitutional nature of the disease, as already indicated,
points to various methods and combinations of treatment as
most likely to lead to a successful issue. A successful issue
in a case of rheumatism means that the attack should be
passed through without any permanent organic mischief be-
ing left behind. The treatment of rheumatism must pro-
vide, (1.) for the acute attack; (2), for the management of the
system as regards those conditions of the life of the patient
which may have been found to contribute to the constitu-
tional development of the disease.
RHEUMATISM, ACUTE. 329

In the acute attack the patient must be made—(1.)
comfortable, being protected from pain and exposure to
cold air, especially as regards the joints; (2.) to encourage
free excretion from the skin especially, and from the kid-
neys. The general management of the patient is therefore
all important. No linen must touch the skin. A flannel
shirt must be worn next its surface, and the patient must be
put between soft blankets. ‘Bedding in blankets reduces
by a good three-fourths the risk of inflammation of the
heart run by patients in rheumatic fever, diminishes the in-
tensity of the inflammation when it does occur, and dimin-
ishes still further the danger of death by that or any other
lesion; at the same time it does not protract the convales-
cence” (“Chambers’s Lectures, chiefly clinical,” p. 147).
The patient ought to be carefully wrapped up in blankets of
the newest and fluffiest kind that can be got, which are to
be so arranged as to shut off all accidental drafts of air (Dr.
Roberts). On no account are the *bed-clothes to be thrown
off, however warm the surroundings may become; for an
evenly high temperature to the skin, combined with absolute
rest, are of the greatest value in rheumatic fever. These
two conditions are worth all other means of relief put to-
gether (Dr. King Chambers). ‘The bed should be protected
by screens from draughts of air. All the joints, whether
affected or not (ze., the limbs), ought to be enveloped in
cotton wool, a layer of which ought also to be put over the
chest on both sides, with an arrangement for permitting the
region of the heart to be easily got at for its occasional ex-
amination (Dr. Roberts). On the other hand, the following
are the indications which have guided Dr. R. Southey of St.
Bartholomew's Hospital, London, in the treatment of acute
rheumatism :-—

“To relieve local pains; to reduce fever; to diminish the
gravity of the various complications; and to promote early
and complete convalescence. I do not consider that the
materies morbi are eliminated either by sweating or by purg-
ing. A spring bed with a tightly stuffed horse-hair mattress
over it, is that which rests and supports the trunk and
limbs, and relieves the joints most. I am no advocate for,
and have never allowed my patients to be placed between
the blankets instead of the sheets; neither will I permit
flannel bed-shirts to be worn. The object I have in view is
to keep one uniform temperature about them, which the bed
provides for; but not to keep the patient swathed in flannel
330 RHEUMATISM, ACUTE.

reeking and saturated with decomposing perspiration. Asa
matter of fact I observed that a large proportion of hospital
rheumatic patients were persons who habitually wore thick
flannel shirts and under shirts, and did not change them very
often. Cotton shirts and cotton sheetings are better suited
than linen to rheumatic people. My practice has been to
keep my rheumatic cases cool rather than hot. They are
certainly easier in consequence.”

As to medical treatment, venesection, calomel, combined
with purgatives, colchium, and opium, are the remedies
which have been hitherto most generally made use of in the
treatment of acute rheumatism. To the success of each of
these remedies the late Dr. Latham has borne his testimony,
“so far as that, under the use of each,” he writes, “I have
seen patients get well.” No disease has been treated by
such various and opposite methods, so that “acute rheuma-
tism ‘has experienced strange things at the hands of medical
men.” “Had he written in these days Dr. Latham would
have had many other strange things’ to add to his list :—
Alkalies, acids, salines, hot water, cold water, lemon juice,
citric acid, chloral, belladonna, iodide of potassium, ergot,
digitalis, aconite, guaiacum, emetics, sulphur, antimony, per-
chloride of iron, quinine, iodine, plaster of Paris bandages,
galvanism, subcutaneous injection of carbolic acid, blisters,
podophylium, ‘cynara, propylamine, chloro-hydrate of trime-
thylamine, and last, but not least, salicine, salicylic acid, and
salicylate of soda. All these and many more remedies have
Leen used in rheumatic fever; and each has been extolled
as more potent than all the rest (Dr. E. Markham Skerritt,
Brit. Med. Journ., July 28th, 1877, p. 104). But as the dis-
ease, when uncomplicated, tends to terminate sooner or later
in recovery, and may sometimes subside with marvellous
rapidity under every variety of remedy, it is obvious that no
sound inference can be drawn as to the success of any par-
ticular method of treatment, unless such treatment has been
largely adopted in cases of exactly similar severity—as esti-
mated by the correlation of pulse, respiration, and tempera-
ture (measured by thermometer)—and been attended with
tolerably uniform’results. Each and every plan of treatment
which has therefore been hitherto proposed is regarded by
the profession as unsatisfactory. (See account of a discus-
sion upon a paper read by Mr. Dickinson to the Royal
Medico-Chirurgical Society of London, and reported in the
Medical papers of 21st June, 1862). If in one verson’s

s
RHEUMA™ISM, ACUTE. 331

hands any particular remedial course has proved efficient, it
has signally failed in those of another. If at one time a
remedy has proved efficacious, it has been found inert or in-
jurious at another, under different circumstances of age, sex,
constitution, and the like. These facts ought not to appear
strange to those who consider the true nature of the disorder,
and the variety of circumstances under which the physician
may be called upon to minister to his patient’s relief. Bleed-
ing, which in the young, plethoric, and robust, may be neces-
sary to allay excessive vascular action and cause free secre-
tion, may in the weakly induce irritability of the heart, and a
consequent attack of cardiac inflammation. Opium, which
in one person may prove of the greatest service in promoting
free perspiration and in allaying the general irritability of the
system, may in another check: the biliary, “lock up” other
secretions, and thus prevent the elimination of effete or
deleterious matter from. the system. The continued use of
calomel, and constant purgation by it, may be beneficial to
one patient, by removing large quantities of unhealthy secre-
tions, but may unnecessarily exhaust the strength of another,
and tend very greatly to impede recovery. So, in regard to
every remedy which has been proposed: what is useful at
one time may prove useless, or positively injurious, at an-
other. Special attention has also been drawn to the fact by
the mint-water treatment of Sir William Gull and Dr. Sut-
ton, “ that rapid recoveries were often made when the only
treatment was good nursing ;” that symptoms subside wholly
irrespective of treatment between eight and ten days. The
average duration of acute symptoms under treatment was 9.1
days; or from the beginning of the disease 17 days. With
regard to heart complication it is affected early in the dis-
ease—generally within the first week, and if it escaped for
a week it would probably escape altogether. Sir William
Gull and Dr. Sutton thus came to the conclusion that drugs
had little influence in shortening the disease; and many
drugs have had the credit of warding off heart complications
simply because the time for the occurrence of these lesions
had passed before the medicine was given.

To learn how to adapt our present remedies to the exigen-
cies of each particular case is what is now most of all
required. Acute rheumatism is manifestly a highly inflam-
matory disease, but of a peculiar constitutional origin, as has
been fully shown. The blood drawn presents a more copious
layer of “buff” than it does in most other diseases. The
332 RHEUMATISM ACUTE.

proportion of fibrine being greatly increased, we can hardly
feel surprised that bleeding has been largely had recourse
to. But although bleeding has been extensively adopted,
the profession has hitherto been much divided as to the ad-
vantage derived from the practice. A careful analysis of
conflicting evidence leads to the conclusion that general
blood-letting is not to be recommended, and on pathological
grounds it is not justifiable. No advantage is gained as to
time ; but temporary, if any abatement of sufferings follows
its use; lastly, this mode of treatment appears to have caused
in the practice of Bouillaud an unusually large number of
cases of myocarditis—a larger number, indeed, than has been
witnessed by any other person in the profession. A predis-
position to cardiac inflammation is doubtless engendered by
copious and repeated blood-letting: one-half the cases of
acute rheumatism became so complicated after treatment by
bleeding (Dickinson). It undoubtedly increases the irrita-
bility of the heart, and consequently favors the production
of cardiac complication. General blood-letting is only bene-
ficial in first attacks occurring in young, robust, and otheie
wise healthy persons, particularly in those cases which are
marked by unusual severity of their symptoms, or are unac-
companied by free perspiration. It ought at all times to be
cautiously employed and carried to a small extent only—viz.,
from eight’ to twelve ounces, according to the age and
strength of the patient, the object being to favor the action
of other remedies, and to promote free secretion by its use,
rather than to arrest or cut short the disease (Latham, Fuller).
If, therefore, perspiration is free, and remedies are absorbed,
blood-letting is not to be thought of. In mild cases it is
unnecessary; in the delicate, and those of weakly constitu-
tion, it is inadmissible ; and in the well-expressed rheumatic
diathesis, or when the diséase is distinctly ascertained to be
hereditary, it utterly fails in modifying the morbid action,
is ill-borne by the system, and therefore should only be prac-
ticed under the extremely urgent and specific conditions
just mentioned (Willan, Fordyce, Alison, Todd, Watson,
Fuller, Dickinson). If circumstances, therefore, ever war-
rant its employment, it ought necessarily to take the lead of
all other measures, and may be used in the young, plethoric,
and robust, in whom secretion is insufficient, whose pulse is
full and bounding, and whose skin is dry, hot, and burning.
A single bleeding is sufficient to relieve the excessive con-
gestion, on which the want of secretion in a great measure
RHEUMATISM, ACUTE. 333

depends, and which forms an obstacle to the action of those
remedies on which we rely for effecting a cure. Active pur-
gatien is also to be avoided. It is injurious for three reasons:
First, Because it is not necessary to the cure of the patient,
and, like bleeding, tends greatly to reduce his strength and
protrac‘ recovery. Second, Because, from the nature of the
complaint, the patient is quite incapable of moving, and his
sufferings are aggravated, his irritability is increased, and his
heart’s action accelerated, by the repeated shifting of his
position, which is rendered necessary by the calls of nature.
And, Third, Recause it necessarily gives rise to more or less
exposure, which must be prejudicial to a person bathed in
perspiration (Fuller). After having obtained one full dejec-
tion by the following searching combination,which will secure
an abundant flow from the glandular follicles of the intestinal
mucous membrane, the subsequent aim should be to obtain
merely a single free evacuation every morning,

B Calomel. gr. v.; Pulv. Jalap. Co., Dij.-3i.; Pulv.
Zingiberis, gr. iii.-gr. v.; misce—to be taken in a little
milk.

A daily evacuation of the bowels is then to be maintained
by mild salines, such as the potassio-tartrate of soda, sulphate
and carbonate of magnesia, taken as a draught in the morn-
ing; and preceded every second night by a Plummer’s pill
at bedtime, combined or not, according to circumstances,
with a full dose of opium; or, a grain of the watery extract
of Barbadoes aloes may be found sufficient on alternate days.
If the bowels act only once a day, a laxative dose of calomel
and opium may now and again be prescribed, with the view
of modifying the character of the intestinal secretions. Dark-
colored and offensive stools indicate the necessity for the
dose, followed by a draught of infusion of senna, together
with half an ounce of the potassio-tartrate of soda, and twenty
minims of the vinum colchici; and these should be repeated
every evening and morning till healthier evacuations are ob-
tained—~. ¢., till the motions are light-colored, more bilious,
and less offensive. Opium may be given with the greatest
advantage in the early and most painful stage of the disease
occurring in adults, to the extent of six or eight grains of
the powder in twenty-four hours, or two grains of the extract
of opium may be given every night ; to children, half-grain
doses of the powder, or less, according to age, may be given
every three or four hours. The bowels require to be kept
open during its use ; and its influence requires to be closely
334 RHEUMATISM, ACUTE.

watched. If the urine increases in quantity, if the motions
become more healthy in appearance, and the coated tongue
cleaner and less red, the influence of opium is beneficial. It
encourages sweating. Hydrate of chloral is another valuable
soporific and sedative. Colchicum administered alone is a
dangerous agent ; but its virtue as a remedy may be obtained
in small doses in combination with other medicines. It may
be given with small doses of ipecacuanha, alkalies, and opium.
It promotes evacuation by the kidneys. It is only in some
cases, however, that it appears to be of service. It is far less
efficacious in the weak and nervous than in the more robust
and less easily depressed, and of less value in purely fibrous
rheumatism than in cases where the synovial inflamma-
tion predominates. It has proved less advantageous in pro-
portion as the fever has exceeded the articular swelling, and
as the urine has been less highly charged with lithates. The
operation of this remedy must under all circumstances be most
carefully watched: and a daily evacuation from the bowels
must be secured during its use If the lithates disappear
from the urine, if the pulse becomes weak, if faintness, nausea,
or purging supervene, the colchicum must be at once dis-
continued; but till some one of these symptoms occurs, a
grain or a grain and a half of the acetous extract or the
inspissated juice, or from fifteen to twenty grains of the
wine of colchicum, may be safely and with advantage admin-
istered two or three times a day (Dr. Fuller).

Veratria is to be used in small doses The ordinary for-
mula recommended is: :

Veratria and extract of opium, one grain each, to be di-
vided into ten pills, of which two pills are to be given the
first day, three the second, four the third, five the fourth,
and so on, increasing one pill each day, until the condition
of the pulse or the irritation of the mucous membrane com-
pels a diminution.

The beneficial effects of guaiacum are obtained in those
cases which are unaccompanied by perspiration, and in
which the excretory organs are gently excited by the action
of the remedy; but when the patient is perspiring freely, and
when it neither purges nor causes diuresis, very little benefit
is obtained from its use. Combined with bitartrate of po-
tass, sulphur, and rhubarb, it constitutes the chief ingredient
in a celebrated empirical formula, well known to army med-
ical officers under the name of “ Chelsea Pensioner,” which
has obtained a high reputation amongst old soldiers as a
RHEUMATISM, ACUTE. 335

remedy for the “pains,” or chronic rheumatism. In some
large hospitals, both civil and military, this remedy is in
common use in the treatment of old chronic cases. Its com-
position is as follows:

R. Pulv. Guaiaci, 3i.; Pulv. Rhei, 3 ii; Bitart. Potassz;
Sulphur Sublim., aa 3i.; Pulveris Nucis Moschate, 3 ii.:
Mel. vel Glycerina, lbi.; misce bene. Of this compound two
large spoonfuls may be taken night and morning.

Another formula is the following:

. Pulv. Sinapis; Sulph. Sublim. aa 3iii.; Pulv.
Guaiac. Ziss.; Pulv. Rhei, Potas. Nitratis, aa gr. xlv.;
misce bene. Honey, treacle, or glycerine, sufficient to make
the dose into an electuary, is the most convenient form for
use, of which a teaspoonful every alternate evening is use-
ful; or a teaspoonful of the powder may be mixed with
milk, and so taken at bedtime.

But, the general treatment ot the constitutional disease
originally recommended by Brocklesby (1764), and followed
successfully by Macbride (1772), Basham, Fuller, Furnival,
Garrod, and now by many other physicians, is that by alka-
lies and the neutral salts, with colchicum, a little antimony
being sometimes added, with the occasional aid of calomel,
used only as a remedy to promote evacuation from the
glands of the intestinal mucous membrane. Alkalies, and
the neutral salts, may be given in combination with colchi-
cum, full doses of opium, and a little antimony. They aid
disintegration, and increase the elimination of sulphuric acid
by augmenting the alkaline condition of the blood (Parkes).
The alkalies ought to be given largely. Patients lose their
pains under their influence, and proceed rapidly to conva-
lescence. The pulse is generally tranquillized within forty-
eight hours from the commencement of the alkaline treat-
ment; and if in twenty-four hours the pain is lulled and the
local inflammation greatly subdued, the constitution is evi-
dently coming under the influence of the remedy. The du-
ration of rheumatic fever is undoubtedly shortened by alka-
lies:—6 to 7 days, as compared with 9.1 days of mint-water
cure, and the total duration 13 to 14 instead of 17 (Garrod.
The form in which the remedy is to be given is
that of a_ simple saline or nitrate draught, to
which from two to three drachms of the potas-
sio-tartrate of soda may be added, with ten to fifteen minims
of the vinum colchici, from fifteen to twenty minims of the
vinum antimonii, and from ten to fifteen minims of the tinc-
336 RHEUMATISM, ACUTE

ture of opium, or of Battley’s sedative solution, to prevent
the salt running off by the bowels. This draught is to be
repeated for the first twelve or twenty-four hours, at inter-
vals of three or four hours, according to the strength of the
patient and the severity of the attack; and if pain is exces-
sive, a pill containing half a grain to a grain and a half of
opium, or an equivalent dose of Dover’s powder, may be
given once or twice daily. In the use of these remedies,
constipation and narcotism are to be avoided on the one
hand, and diarrhoea to be guarded against on the other
(Fuller). If the saline treatment is to be used alone, then
a solution of nitrate, acetate, and bicarbonate of potash
should be given in such doses that ten or twelve drachms of
the two latter salts together are taken in the twenty-four
hours. Half a drachm of the acetate, with a drachm or a
drachm and a half of the bicarbonate, and ten grains of
nitre, dissolved in an ounce and a half of water and sugar,
or lemonade, or barley water, and given every two hours,
night and day, until the joint affection and pains have be-
gun to yield in severity, are sufficient for this purpose. Or
the following: Nitrate of potash, one drachm; acetate of
potash, three drachms; water or barley water, eight ounces;
—of this mixture one ounce for a dose ought to be'repeated
every two, three, or four hours, according to the urgency of
the symptoms; or from twenty to sixty grains of the bicar-
bonate of soda, or of potash, may be given every three or
four hours in half a bottle of soda or seltzer water; or in an
effervescent citrate of ammonia, or potash draught (Tanner).
This is the treatment which most of all seems efficient in’
warding off the cardiac complications; and Dr. J. J. Furni-
val was the first (after Prout) to direct the attention of the
profession to the use of alkaline remedies (carbonas potass)
in the treatment of Rheumatism, and especially as a pre-
ventive of the cardiac complication (Lancet, 1841, p. 305).
The good effects of such treatment as a preventive of the
cardiac affections have been since fully demonstrated by
Fuller, Garrod, Basham, Goodfellow, and others. Dr. Dick-
inson has given statistics in which the percentage of heart
disease occurring under the alkaline treatment was 2.1 as
against 31.7 under various other remedies. To be effective,
the remedy must be carried out with energy and persever-
ance, till the articular and febrile disturbance are lessened,
and till an alkaline condition of the urine is established as
soon as possible. Liquor potasse in 3ss. doses may also
RHEUMATISM, ACUTE, 337

be given to the extent of Ziii. to 3 vi. in twenty-four
hours (Parkes). Brocklesby is the earliest authority for
the use of large doses of nitre in the treatment of acute
rheumatism. He enjoined, for a diluting drink, water-
gruel boiled smooth, in each quart of which he dissolved
two drachms of nitre, with or without sugar. He often thus
prevailed on soldiers to take ten drachms or more of nitre in
twenty-four hours. Dr. Garrod speaks well of the combina-
tion of quinine with the alkaline treatment after ten years’
trial. It is simply following out the treatment by bark (un-
practical, from the large doses required) recommended by
Fothergill, Morton, and Haygarth. Five to ten grains of
sulphate of quinine are to be given two or three times a day.
The alkaline and saline treatment of rheumatism as the basis
of operation seems the most rational ; for it nas been demon-
strated that in cases of acute rheumatism there is an abso-
lute deficiency of the saline ingredients of the blood; and
while there is also a liability to fibrinous exudation, the ten-
dency of saline remedies is to suspend the separation of fi-
brine (Stevens). The treatment which has saline remedies
for its basis thus contributes to restore the balance of the sa-
line ingredients in the blood, and controls the tendency to
fibrinous deposition. The progress of inflammatory action
being thus retarded, time is gained for other remedies to ef-
fect the diminution of the excess of fibrine present in the
blood, as well as the destruction of the rheumatic element,
whatever that may be. On the other hand, however, the pa-
tient is often left weak and anzmic to a marked degree by
the use of alkalies ; and also, that when heart complications
do come on under alkalies they are more troublesome, the
effusion of pericarditis is often very large in amount, and
there is a greater tendency to carditis. Thusalkalies, while
they shorten the disease, do not always prevent complications,
and they debilitate the patient. Cases treated by alkaline
instead of neutral salt are also slow in convalescence, the
patients being weak and pallid for some time afterwards.
The experience of Dr. Reginald Southey is also against the
alkaline treatment, especially in the relapsing cases. The
alkaline treatment or mint-water is, however, equally well
adapted for the acute continued form; but alkalies, unless
pushed to full and frequent doses, are wholly useless in re-
lieving pain; and in such large doses as half a drachm or a
drachm every two or three hours, they quickly reduce the
strength, and render the patient extremely anemic, “They

a
ce
338 RHEUMATISM, ACUTE.

thus retard convalescence not inconsiderably. (Bartho/o-
mew's Hospital Report).

’ In 1869, Dr. Russell Reynolds reported, in the A7z¢. Med,
Journ., cases of rheumatic fever treated by the tincture of
the perchloride of iron, in doses varying from 15 minints to
a drachm every four hours, with or without 20 to 30 minims
of glycerine, and spirits of chloroform, In Brit, Med. Journ.,

of Oct. 2, 1875, he again gave a summary of results in a
series of sixty-five cases, in which the relief of pain was often
marked and early. In more than half the cases the pain was
gone by the tenth day ; in 22 per cent. all pain had gone by
the fifth day. The pulse sometimes fell from 120 to 40 in
two days; and, in several cases, Dr. Reynolds observed a
remarkable diminution in the frequency of the pulse, at and
after the time at which temperature had become normal,

namely—4o, 30, and even 28; but regular in rhythm and in
force, the patient feeling neither pain nor faintness. The
temperature became normal by the fifth day in 36 percent. ;
and in severe cases before the tenth day in 50 per cent. ; in
moderate and slight cases in 71 per cent. Heart disease was
present in 48.1 per cent.; but no distinction is made between
those cases in which it existed before, and those in which it
came on under treatment. In twenty-three cases treated
with iron in University College Hospital in 1875, the heart
was affected in 30.4 per cent.—a large proportion when com-
pared with those cases of Dr. Dickinson’s treated by alka-
lies, where the percentage was only 2.1. As to duration of
the cases also, the cases treated by iron do not compare fa-
vorably with those treated by alkalies by Dr. Garrod, where
the average duration of the whole number of cases was six
to seven days, Dr. Samuel S$. Dyer of Ringwood has also
given the treatment by the tincture of perchloride of iron an
extended trial, and writes as to the satisfactory nature of the
result (Brit. Med. Journ., May 6, 1876, p. 563). Quinine
has been largely used in France—in large doses—from 15 to
9° grains in the twenty-four hours. The pulse and temper-
ature rapidly fell; the joints were quickly relieved ; and the
heart was seldom ‘implicated, Combined with the alkaline
treatment Dr. Garrod has found quinine more efficacious
than either alone—there being less tendency to relapse ; and
the fever leaves the patient in a much more satisfactory con-
dition. Salicine, salicylic acid, and salicylate of soda have
all been recently and largely used in the treatment of acute
rheumatism ; given in doses of gr. x. to gr, xx. at intervals
RHEUMATISM, ACUTE. 339

of from one to three hours, and in larger doses ot gr. xxx.
every hour. Under all of these remedies the average dura-
tion of the fever has been remarkably shortened—to 4.9 days
under salicine, and 4.4 days under the acid—an advantage
of from one to three days over the results of the alkaline
treatment , and in comparison with the tincture of iron
treatment, in which the temperature became normal in half
the cases in ten days, under salicylic acid it became normal
in half the cases in three days. The duration of rheumatic
fever has, therefore, been shorter under these remedies than
it has been under any other plan of treatment. But there
is no evidence that either of these are specific remedies, for
they do not cut short the disease; nor prevent relapses when
under their influence; nor do they ward off complications.
They seem rather to act by reducing temperature as they do
in other febrile conditions, and they lessen the chance of
complications in the same proportion as they shorten the
disease (Dr. Markham Skerritt). The observations of Fur-
bringer, Reiss, Fischer, Stricker, and others have established
the fact that these remedies possess a remarkable power of
lowering the abnormally high temperatures in febrile dis-
eases. In Dr. Stricker’s experience of the drugs in acute
rheumatism, salicylic acid may be given in hourly doses of
from grains vii. to xv. without injury to the human system ;
and for a longer time to young and vigorous subjects than
to the old and feeble, as toxic symptoms appear sooner in
the latter than in the former. These toxic symptoms are of
various degrees—such as, noises in the ears, difficulty of
hearing, and perspiration, which, when they appear, con-
traindicate the further wse of the remedy.

“In an interesting paper in the Zence¢ of 4th and 11th of
March, by Dr, T. Seclasa: recently of Dundee, on the
treatment of acute rheumatism by salicine, the author relates
seven cases of acute and subacute, and one of chronic rheu-
matism, treated with this remedy, and gives the following
conclusions as the result of his experience :—(r1.) We have
in salicine a valuable remedy in the treatment of acute rheu-
matism. (2.) The more acute the case, the more marked
the benefit produced. (3.) In acute cases, its beneficial ac-
tion is generally apparent within twenty-four, always within
forty-eight, hours of its administration in sufficient dose. (4.)
Given thus at the commencement of the attack, it seems
sometimes {o arrest the course of the malady as effectively
as quinine cures an ague, or ipecacuanha a dysentery. (s.)
340 RHEUMATISM, ACUTE,

The relief of pain is always une ot the earliest effects pro-
duced. (6.) In acute cases, relief of pain and a fall of tem-
perature generally occur simultaneously. (7.) In subacute
cases, the pain is sometimes decidedly relieved before the
temperature begins to fall; this is especially the case when,
as is frequently observed in those of nervous temperament,
the pain is proportionally greater than the abnormal rise of
temperature. (8.) In chronic rheumatism, salicine some-
times does good where other remedies fail ; but it also some-
times fails where others do good. These conclusions, it will
be seen, agree closely with those arrived at by Stricker and
Reiss with regard to salicylic acid. The dose of salicine
used by Dr. Maclagan was from ten to thirty grains every two
three, or four hours ; fifteen grains being an average dose.”
As to salicylate of soda, Dr. R. Southey gives fifteen
grain doses every two hours till sixty grains are taken, and
then continues with fifteen grain doses every four hours, to
keep up the effect of the drug ; and if pericarditis is present
he adds five drops of liq. opil. sedativ. with each dose. His
experience of the perchloride of iron, as recommended by
Dr. R. Reynolds, is not favorable. In the acute continued
cases it has been associated too frequently with hyperpy-
rexia to regard it as altogether free from danger ; and in the
relapsing forms, its administration neither shortened the cases
nor prevented relapses. These relapsing cases of rheuma-
tism may be kept on salicylate of soda very well for the first
seven days; but the opportunity of the spontaneous remis-
sion which then generally takes place, and is indicated by the
thermometer and the patient’s own sensations, should be
seized to shake the periodicity of the complaint. This qui-
nine has the power of doing, given in the proper doses, as in
ague, and at the proper date. Dr. Southey gives two ten-
grain doses at two hours’ interval, between five and seven
p. m., on the evening of the seventh day, and repeats the dose
on the evening of the ninth day again. The natural relapse
is then postponed, and the patient may be permitted better
nourishment, and given a little pepsine and acid with his din-
ner to ensure its better digestion. Should no relapse happen,
again on the fourteenth and sixteenth days full doses of qui-
nine should be given ; but it is not till the thirty-second day
is past that all risk of a relapse is over. During convales-
cence, although the patients are anemic, Dr. Southey does not
recommend iron, as the mineral acids and tincture of nux
vomica promote appetite and digestion far better. Quinine
RHEUMATISM, ACUTE, 341

and iodide of potassium has long been a favorite draught
of his in treating the anzemic relapsing forms. Two grains
of quinine are combined in it with five of iodide of potas-
sium, to be taken every four or six hours after the fourteenth
day (St. Bartholomew’s Hospital Report, Vol. XIV., 1878, p.
22). Hyperpyrexia may occur suddenly and rapidly in acute
“rheumatism, as in other diseases. The temperature may
rapidly rise to a height incompatible with life, with evidence
of profound nervous disturbance ; and usually by the dis-
appearance of pain from the joints. Such hyperpyrexyia
has supervened under all sorts of treatment. The ex-
tremest vigilance on every one entrusted with the care
of the patient must be inculcated; and on the appear-
ance of anything strange in the aspect or demeanor, to
use the thermometer assiduously ; and, if ever it rose to 105°
Fahr., to send at once for the physician (Dr. H. Thomson).
Treatment directed simply to the reduction of temperature
may save the life of the patient. A temperature in rheu-
matic fever above 106.5° Fahr. has hitherto been invariably
fatal ; spontaneous recovery has never been known to occut
when the temperature has passed 106.5° Fahr, ; ‘but death
has occurred before this temperature has been reached—at
105.8° and 106°. Hence the commencement of active treat-
ment by the cold bath ought not to be delayed when such a
temperature has been reached. If left alone, the patient
must die; and the only treatment which has succeeded with
such cases has been the effectual external application of cold,
by the bath, at a temperature of go° or 95° Fahr. in the first
instance ; gradually reduced by the addition of cold water
to 70° Fahr., or even lower in some cases. As far as the bath
is concerned we must take the thermometer for our guide.
“Tt is important to remember that the bath should be pre-
pared and everything got ready before this; for the final
rise of temperature is often very rapid—s.5° in an hour and
a quarter—from 104° to 109.5°, and the patient may die be-
fore the treatment can be applied. There is another practi-
cal point to be borne in mind—that there is almost always a
considerable fall of temperature after the patient is removed
from the bath, so that it is not safe to bring the temperature
down to the normal in the bath. I remember, in the early
days of this treatment, how a ‘friend of mine reduced the
temperature of a rheumatic patient to normal in the bath,
and, to his consternation, found it would not stop there, but
kept going down till it reached 93.2°; there it was fortunately
342 RHEUMATISM, ACUTE,

brought to a stand. The amount of this subsequent fall
varies, but the average may probably be safely taken as 4°.
In accordance with this, I removed the patient from the bath
when the temperature was 102°, and the subsequent fall, oc-
curring in the next ten minutes, was exactly 4°, bringing the
temperature down to 98°” (Dr. Markham Skerritt).

So singularly calming is the bath, even when there is no
great exaltation of the body heat, that it may be administered
as a simple palliative in all exacerbations of delirium and
restlessness, although the heat may have fallen far below its
maximum intensity, even to 102° Fahr.

External topical applications are efficient aids in treatment.
Warm anodyne fomentations are always employed with ad-
vantage ; and of all applications a mixed alkaline and opiate
solution, applied as a fomentation, is the most powerful in
allaying pain. ‘The solution so highly recommended by the
late Dr. Fuller for this purpose, is composed of an ounce of
the carbonate of potash dissolved in a pint of the decoction
of poppies or of rose water, to which six drachms of Bat-
tley’s solution (Liquor sedativus) is added, or common tinc-
ture of opium, which is less expensive and equally efficient
as an external application, but less strong. Chloroform and
belladonna liniment (as recommended by the late Dr. Sibson)
is an excellent pain-relieving local application in either the
acute or relapsing form of the disease. If the hands, elbows,
knees, or feet are the seat of inflammation, gloves or caps
are made of the spongiopiline to fit these parts ; if a greater
extent of surface be involved, a portion of the spongiopiline
is cut large enough to envelop the entire surface. The spongy
surface of this epithem is first moistened freely with water,
and any superabundant fluid squeezed from it, so that the
linen or bed of the patient may not be unnecessarily wetted.
Nitrate of potash, or the salt to be employed, in powder, is
then freely and plentifully sprinkled over the moistened sur-
face, or rubbed in, to secure its solution and the thorough
impregnation of the epithem ; it is then applied to the in-
flamed part, and lightly secured by a roller. Nothing fur-
ther is required than once in about six hours to remoisten
the spongy surface ; fresh addition of nitre is never required,
if sufficient quantity has been used in the first instance. The
salt in powder is hence better than a saturated solution,
which nurses seldom succeed in making (Basham, Med.-Chir.
Trans., Vol. XXXIL, p. 10). Alkaline baths are recom-
mended by Dr. Austin Flint. Two pounds of the bicar-
RHEUMATISM, ACUTE 343

bonate of potass and one pound of the nitrate of potass are
to be dissolved in water, at a temperature of 100° or 99°
Fahr. ; and the patient ought to go into the bath at a tem-
perature of 98° or 98.5° Fahr., and remain for not longer than
ten minutes. <A tepid bath at 98° or 96° Fahr., into-which
the patient can be dipped suspended on a sheet, and lifted
similarly back to bed, comforts them and secures their
cleanliness (Dr. R. Southey). Hot air, or vapor baths, differ-
ent forms of cold bath, the hot blanket pack bath (as ad-
vocated by Dr. T. S. Dow, see in Brit, Med. Journ., 1875,
p- 40), or sponging the skin with cold or tepid water, are
each in turn methods of treatment which have given relief ;
but baths ought neverto be employed if the skin is acting
freely ; only if it is hot, dry, and burning, its action may be
successfully stimulated by means of some of these baths.

In contradistinction to the principle of cure now laid down,
and which has been called the method of neutralization, Dr.
Herbert Davies, Physician to the London Hospital, has re-
cently advocated a method by elimination, originally recom-
mended by Dr. Dechilly, of Vancouleurs, in Ftance, in a
Memoir to the Academy of Medicine, in 1850 (Bul. de
? Acad. de Med., t.xv.), as a safe and rapid mode of combat-
ing rheumatic fever. For this purpose his treatment is ab-
solutely and entirely local, and consists of free blistering
only. Believing that the virus localizes itself for a time in
the inflamed joints, and that the intensity of the local in-
flammation is a measure of the amount of virus collected, he
orders blisters varying in width, but of considerable size,
according to the locality, to be appiled round each limb, and
in close proximity to the parts inflamed. Thus he affords,
through the serous discharge from the blistered surface, a
ready means of exit for the virus. The blisters are to be
applied near to, but not upon every joint inflamed, at the
very height of the inflammatory stage, even when the local
pains are the most severe, and the constitutional disturbance
the greatest. Dr. Dechilly enveloped the whole joint in a
large blister, followed by others, according as joints became
affected. Dr. Jeaffreson, of St. Bartholomew’s, and Dr.
Greenalgh, of the Middlesex Hospital, report favorably as to
the results of Dr. Davies’ method of treatment of acute
articular rheumatism. So also does Dr. Thomas B. Peacock,
of St. Thomas’ Hospital (Brit. Med. Journ., Jan. 18, 1873).
It has been.tried in France also, and reported on favorably
by Dr. Laséque, of the Necker Hospital in Paris (Arch. Gén,

a
344 RHEUMATISM, ACUTE.

de Med., Nov., 1865). The success of the plan is said to de-
pend entirely upon the blisters being applied and allowed to
remain until they have thoroughly acted. Linseed-meal
poultices subsequently applied will be found ‘highly service-
able in promoting a sufficient flow of serum. ‘The blisters
should be put entirely round the affected limb; and when
the knees are the joints which suffer, the blisters should be
cut at least three inches wide. If this method of treatment
be adopted, no medicine ought to be given beyond an occa-'
sional purge, and no advantage results from combining the
alkaline or neutralization system of treatment with that by

- blisters, or the method by local elimination. If the two
methods are combined, the period of convalescence is pro-
tracted. In some few cases, however, Dr. Peacock 1s of
opinion that constitutional treatment ought to be freely used
in combination with the blistering. In other cases it is of
advantage to combine the blister treatment with such tonics
as quinine and iron. In the practice of Dr. R. Southey, of
St. Bartholomew’s, London, painting the affected parts in the
acute con‘fnued form with a mixture of equal parts of liniment
of iodine and tincture of iodine has appeared to procure all
the benefit advocated by Dr. Davies for his blister treatment.
That the poison is. really thrown out by the blister method
of treatment is deduced as well from the rapid and perma-
nent relief resulting from the local treatment as from the
neutral and even alkaline condition of the urine, which is a
usual and early result of the treatment, as well as a rapid
diminution in the force and frequency of the pulse (London
Hospital Clinical Reports).

The diet of the patient, in acute rheumatism, should be
strictly limited to slops, such as arrow-root, beef-tea (Liebig’s
Extract of Flesh), milk and lime-water, or milk made warm,
to which a little carbonate of soda, nitrate of potash, or bi-
carbonate of potash is added; light puddings, to which
sherry or brandy may be added, if depression exist ; and
even in many chronic cases it is desirable to limit the diet to
puddings and white fish. To obviate the great drain upon
the system, it is necessary, however, that the rheumatic pa-
tient be better fed than in cases of idiopathic inflammation.
Beef-tea and jellies may be given, and strong coffee might
also be administered frequently, on the same principle that
it has been given in typhus fever by Dr. Parkes, following up
the indications obtained from the physiological action of
that beverage as expounded by Lehmann,
RHEUMATIC ARTHRITIS—RICKETS, 348

The nature and treatment of the local complication, such
as pericarditis, will be considered separately ; but in addi-
tion to the alkaline remedies, which have an undoubted influ-
ence in shortening the duration of the illness, the bedding in
blankets, is a most important measure for preventing the
cardiac affection, especially in cold weather and in cold
climates.

Rheumatie Arthritis—Scee Osteo-Arthritis, Chronic.

Rheumatism, Chronic. — Defnition.—Chronic pain,
stiffness, and swelling of various joints.

The Treatment of chronic rheumatism does not differ in its
general details from that of acute rheumatism. Decoction
of cinchona, preparations of guaiacum, with alkalies and col-
chicum, are the best remedies after the action of such search-
ing evacuants as calomel and jalap have removed morbid
accumulations, and improved intestinal secretions. The va-
rious forms of the so-called ‘Chelsea Pensioner,” compris-
ing guaiacum and sulphur, the composition of which is given
under “ Rheumatism, Acute,” are of great service. Iodide
of potassium is also of great benefit in the arthritic forms of
chronic rheumatism, combined or not with preparations of
aconite and colchicum. Warmth of flannel and the warmth
of bed, with free perspiration, generally tends to mitigate and
shorted the severity of the paroxysms of chronic rheumatism.

Rheumatism, Gonorrheal—See Gonorrheal Rheuma-
tism.

Rheumatism, Muscular—See Muscular Rheumatism,

Rickets.—Definition—A constitutional disease of early
childhood, characterized by a cachexia which precedes for
several weeks or months a peculiar lesion of the osseous sys-
tem, manifested by curvature of the shafts of the long bones
and enlargement of their cancellous extremities. The growth
of the bones is characterized by irregularity, by non-solidifi-
tion of their growing layers, and by the progressive forma-
tion of medullary cavities in the old bone, thus rendering
the body laminz thin and brittle (Virchow). Some of the
solid visceral organs also exhibit peculiar lesions, such as in
the spleen and liver, where there is generally lardaceous dis-
ease.

Treatment.—Ventilation of the room in which the child
lives is of first importance. Milk diluted with lime-water
(about a fourth part), and a teaspoonful of cream added, is
the best of food, or the Swiss preserved milk. Sugar ought
346 RING WORM-~SC ABIES,

not to be added to the milk. Liebig’s Food for Children,
or Valentin’s flesh juice, “ Maltine,” Parrish’s Chemical
Food, and Trommer’s Extract of Malt, are all valuable
agents in the dietary. About once a week a dose of rhu-
barb, soda, and calumba, in equal parts, should be given,
rollowed next day by a teaspoonful or more of castor-oil.
Prepared chalk and soda may also be given twice or thrice
a day, with or without rhubarb and calumba (see under
treatment of Scrofula). When the febrile disturbance is
‘subdued, the child should live as much as possible in the
‘open air. Vinum ferri ought then to be given in the follow-
ing formula? R. Vin. ferri f3i.3ii.; quinie sulph., gr. i,
acid sulph. dil. mi.-ii. This form is especially useful when
the skin is flabby, covered with perspiration, and anemia
well marked. Or small doses of the syrup of the phosphates,
‘of iron, quinine, and strychnia, or syrup of the phosphate of
iron and lime, may be given along with the food, or just be-
fore meals. Cod-liver oil is of essential service; but the
‘stools ought to be examined daily; and if any of the oi!
ipasses by stool its dose ought to be diminished, or its ad-
ministration suspended for a time. (Sir William Jenner,
The Medical Times of 1860, Vol. I).

Ringworm—Sce Zinea Tonsurans.
Rotheln—See Measles, German.
Rubeola—See Measles.

Saturnism—See Lead Palsy.

Scabies.— Definition.—Lesions consisting of an eruption
‘of distinct slightly acuminated papules or vesicles, accom-
panied with constant itching, due to the irritation caused by
the burrowing underneath the epidermis of a female Acarus
(“Sarcoptes scabei’’), for the purpose of depositing her
eggs.

Treatment.—Such applications are to be made to the skin
that, while tending to kill the Acari, they will not increase
the irritation of the dermis; and if the Acari are thus de-
stroyed, the eruptions willin general subside in due course,
If much irritation of the skin prevails, warm baths are to be
‘prescribed, and opium may be given internally. In healthy
adults the whole body of tHe patient ought first of all to be
thoroughly scrubbed over with good black (soft) soap, and
the process continued for at least half an hour. The patient
SCABIES. 347

should then get into a warm bath, in which he should re-
main for another half hour. Having thus washed and dried
himself thoroughly, he is to rub himself over with the fol-
lowing ointment:

i. Subcarbonatis Potasse, 3.1; Sulphuris, 3 ii; Axun-
giz, % xi; misce.

Next morning a warm bath is to be taken to clean the
surface of the body from the remains of the anointing of the
previous night. The cure ought now to be complete, so far
as the destruction of the Acari is concerned (Hardy, Hel-
merich, Anderson). The genuine pomade of Helmerich is
one-third stronger than that which has been just quoted
from Dr. Anderson. The potash in the black soap and oint-
ment acts as a solvent of the epidermis, and thus allows the
sulphur to come into more immediate contact with the
Acarus. A warm bath and plenty of hot water ablution
completes the cleansing process. The treatment may, how-
ever, be inapplicable to children, females, and men with
delicate skins or constitutional affections of the skin. In
them, although the principle of treatment is the same, the
process of cure must be more slowly conducted by less pow-
erfully irritant substances. The patient having cleansed
himself thoroughly in a warm bath, with ordinary vellow
soap, the following lotion may be applied:

&. Calcis, %ss; Sulphuris, 31; Aqua, % viii. These
ingredients are to be boiled and stirred constantly till a
homogeneous mixture is produced, which is to be strained
through a sieve.

These ingredients ought to produce a quantity more than
sufficient for one person, and should be rubbed into the
skin, not too roughly, every night for several evenings. The
cases of scabies in the Belgian army are treated by this lotion °
(Velminskz, Anderson). When the person affected is pre-
disposed to exematous eruptions, the following application
is recommended:

R. Sulphuris, Olei Fagi, a a 3 vi.; Saponis Viridis, Axun-
giz, a albj.; Crete, 3iv.; misce.

This ointment should be well rubbed in, after the skin has
been prepared for it by the use of the warm bath and cleans-
ing the body with common yellow soap. The potash in the
black soap of the ointment acts as already stated, the chalk
tends to remove the epidermis mechanically, the tar coun-
teracts the tendency to eczema, and the sulphur destroys the
Acari. The ointment ought to be left on overnight
348 SCARLET FEVER.

(if the skin is not too irritable), and should be washed off in
the morning (Wilkinson, Hebra, Anderson). Specific print-
ed directions should be given to each patient; and cards are
useful for this purpose, similar to those in use in the Dis-
pensary for Skin Diseases in Glasgow. ‘The following are
the directions printed on each card, which is given to each
patient along with the quantity of ointment required:

“rst. Scrub the whole of your body (except the head) as
firmly as possible, without hurting yourself, with black soap
and water.

“end. Sit in a hot bath for twenty minutes, or if you can-
not get a bath, wash yourself with hot water thoroughly.

“ard. Rub some of the ointment firmly into the skin of
the whole body (except the head) for twenty minutes. Let
the ointment remain on the body all night.

“Repeat these processes every night for three nights, and
then return to the dispensary.

“Besides, put all your washing clothes into boiling water,
and iron all your other clothes thoroughly with a hot iron.”

The ordinary compound sulphur ointment of the pharma-
copeeia is also an efficient remedy. The cure being com-
plete so far as the person is concerned, care must be taken
to destroy the Acarus and its eggs which may be amongst
the clothes of the patient. For this purpose they should be
exposed to hot air at the temperature of at least 150° Fahr.,
or boiled in water, or exposed to the action of sulphur by
steaming them amongst sulphur vapors. If such methods’
are systematically carried out, itch cases ought never to oc-
cupy hospital beds, either in civil or in military life.

Scarlet Fever.—Dejinition—A specific febrile disease,
the product of of a specific contagion, which is reproduced
during the progress of the affection. “The duration of the
incubation stage may be only a few hours; in a large pro-
portion of cases it probably does not exceed forty-eight
hours, and very rarely exceeds seven days (Murchison). On
the second day of the illness, or sometimes later, a scarlet
efflorescence appears on the fauces and pharynx, and on the
neck and face, which spreads over the whole body, and
commonly terminates in desquamation from the fifth to the
seventh day. The fever is accompanied with an affection
of the kidneys, with albuminuria, often with severe disease
of the throat, or lymphatic glands of the neck, and is some-
times followed by dropsy and other lesions. The disease
SCARLET FEVER. 349

Tuns a definite course, and, as a rule, occurs only once dur-
ing life.

Treaimeni.—Scarlet fever being accompanied by appar-
ently inflammatory symptoms, the practice of bleeding has
prevailed on the first breaking out of the disease in all coun-
tries, and with the most disastrous results (Willan) ; so that
Morton speaks of witnessing 300 deaths from scarlatina in a
week. This practice prevailed down to the time of Huxham,
who abandoned it, and introduced a treatment by bark.
Thus an entirely opposite system of treatment has been
gradually introduced, and the records of medicine enable us
to state the results of these opposite modes :— “‘ Of cases
treated at the Foundling Hospital by bleeding in 1786, and
of cases treated at the London Fever Hospital in 1829, in
the same manner, one in six died after bleeding, while only
one in twenty-two died after a directly opposite mode of
treatment. The conclusion was inevitable, that the chances
of recovery are diminished by the practice of bleeding,
nearly in the ratio of four to one, as compared with the
chances of recovery supposing the patient not to have been
bled.

It should be laid down as a maxim, that in cases of scar-
let fever medical advice ought always to be had:srecourse to
as early as possible ; for the worst cases we meet with are
those in which the disease has, from its apparently mild
character, been left to itself. In the mildest form of the dis-
ease it is sufficient to confine the patient to the house ; to en-
join strictly a milk diet ; to regulate the bowels ; and, above
all things, to avoid the nimia diligentia medicorum. Any
active interference with the normal course of the disease is
to be avoided. The sick room ought to be kept at a uni-
form temperature, and not exceed 60° to 65° Fahr. The
patient must not be overladen with bedclothes ; and the skin
ought to be sponged over twice daily with tepid water, dif-
ferent parts being exposed in succession, and carefully dried
with soft cloths. The water should be used without soap,
but with an abundance of Condy’s fluid in it. As much
fresh air as possible should be admitted to the room. The
best drink is water, pure and cold; while soups of meat,
Liebig’s extract of meat, stewed fruit, and milk, ought to
form the staple diet. Constipation is to be overcome by en-
emata of tepid water and salt, avoiding purgation by medi-
cine, In the simpler cases of scarlet fever such manage-
ment is sufficient,
350 SCARLET FEVER.

In the cases commencing with much sickness and general
disturbance, a gentle emetic at the outset is believed to
modify the future course of the disease. Ipecacuanha, with or
without tartar emetic, is the best form for administration ;
and half an ounce of castor oil ought to be given after the
action of the emetic has ceased. Looking to the morbid
condition of the blood, and to the tendency which exists to
the deposition of fibrine in the right cavities of the heart,
small doses of carbonate of ammonia (three to seven grains),
administered every hour, or every three hours, as soon as the
symptoms are decided, have been recommended (Peart,
Witt, Richardson). Or, the liquor ammonie acetatis may be
used with an excess of ammonia, to the amount of from
three to five drops of liquor ammoniz added to two fluid
drachms of the former in a liberal quantity of distilied water
(Richardson). It is important to administer these medicines
in small and frequently repeated doses ; and, if possible, let
the remedy be taken as a drink; and as such chlorate of
potash may be used freely.

The treatment of the milder forms of the fever, when the
tonsils are considerably enlarged, is, first, to tranquillize the
stomach and allay its perverted action when vomiting exists,
either by small doses of the sulphate of magnesia, or by ef-
fervescing salines—medicines which, according to the state
of the bowels, may be given every four or every six hours.
The gum resin of guaiacum is of great service in subduing
the cynanche tonsillaris, and may be prescribed in the fol-
lowing formula :—

BRB. Magnes. Sulp., 3vi.; solve in Aqua, 3 viii.; adde
Puly. Guaiaci, 3iss.; Pulv. g. Tragacanth. co., Dij.; msce
bene. One-sixth part of this mixture may be given every
four hours, till the bowels are freely moved.

As soon as this object is effected, and itis ascertained that
the tonsils are still greatly enlarged and swollen, it may be
necessary to relieve them, if no adynamic symptoms exist, by
the application of six to twelve leeches about the angles of
the jaw; and the bleeding may be further encouraged by the
application of a poultice. The trifling loss of blood thus
sustained does not impair the general strength of the patient,
if it is done sufficiently early, while it greatly reduces the
swelling of the tonsils, and may prevent them becoming per-
manently enlarged. Another advantage is gained by the ap-
plication of leeches to the throat—namely, that they relieve
the affection of the head symptoms. If the tonsils are thus
SCARLET FEVER. 351

relieved, the fever ought to be permitted to run its course
uninfluenced by medicine, beyond the occasional administra-
tion of the saline draught and ice, or the inhalation of steam.
Such remedies should be persevered in till the disappearance
of the eruption, and till the healthy granulations of the throat,
and the decline of the fever, give evidence of a state of con-
valescence, At this point some mild tonic medicine is de-
sirable. With children under ten years of age, however, it is
better to trust to the soothing effects of warm poultices round
the throat, and inhalation of steam, than weaken the child by
loss of blood.

The severe forms of the disease, characterized by the less
swollen state of the tonsils, and by their being more livid and
gorged with blood ; by ulceration being deep and spreading ;
by the slough being fouler than in the milder varieties ; and
by the greater tendency of the inflamed parts to run into
mortification—the necessity of adopting a more stimulating
plan of treatment, and one more calculated to support the
powers of the constitution, is manifest, and experience has
shown its good results. Nourishment in the form of soups,
meat extracts, or milk, must be given in small quantities fre-
quently repeated, in proportion to the prostration of the pa-
tient. The administration of wine, and of the “‘ extractum
carnis Liebigit,” should theretore be the basis of the treat-
ment of such cases. The quantity of wine for an adult may
be from four to six ounces in twenty-four hours, and for a
child about half that quantity or less. The wine should be
taken in small quantities, mixed with two-thirds water ; or it
may be given with sago, atrow-root, jellies, or other demul-
cent food. The earlier the wine is given in the disease the
better, whether delirium does or does not exist ; regardless,
also, as to“vhether the tongue is moist and white, or brown
and dry; and it should be continued till the patient is con-
valescent. Liebig’s extract of flesh may be given like beef-
tea, as a drink. While pursuing this plan, itis necessary that
the patient’s bowels should be attended. In cases more
severe, brandy may be required, or carbonate of ammonia in
liquor cinchonz ; and iron in some form should be given in
frequently repeated small doses, either with the nourishment
or with the medicines already mentioned ; or it may be com-
bined with quinine and aromatic sulphuric acid.

If an emetic is first given it may be proper, before adopt-
ing any special continuous mode of treatment, to follow its
action by a dose of calomel as a purgative, and this especially
352 SCARLET FEVER.

with robust children, to be followed in six or seven hours by
castor-oil or magnesia ; and the bowels are ever afterwards to
be kept open by remedies suited to the state of the patient
and the nature of the disease. The following are the princi-
pal indications which must guide the treatment :—If there is
much excitement of the system, in an otherwise strong, well-
grown subject, depleting cathartics are to be given ; if nausea
and vomiting prevail, a seidlitz powder is of service; if the
discharges from the rectum are acrid and acid, with acidity
of the stomach, magnesia is preferable * if there is abdominal
pain, castor-oil with opium (Wood).

Again, when the synovial membranes inflame, and the
joints become enlarged and swollen, all stimuli should be
withdrawn, and a moderate action of the bowels should be
kept up by means of the sulphate of magnesia, with camphor
mixture, or with carbonate of ammonia, or quinine in infu-
sions of chiretta or of gentian; and if pain be severe, some
sedative should be added, as the tincture of hyoscyamus in a
dose of fifteen minims.

The more formidable affection in scarlet fever is dropsy,
sometimes with effusion into the pleure. Bleeding by leeches
over the region of the kidneys is then of service, in cases
which will tolerate this remedy, especially if cedema appears
in the tace, and is accompanied by headache,—from two to
four ounces in the child, and from four to eight ounces in
the adult may be taken. The good results of cupping (even
of dry cupping) are also very remarkable; and of continu-
ously hot poultices over the lumbar region, with or without
the addition of digitalis. By these means renal conges-
tion is relieved, and the urine becomes more copious
and less albuminous. Hot air or vapor baths, to ex-
cite cutaneous action, may be also of service, comBined with
diluent drinks. Diaphoretic doses of antimony, and moder-
ate but not severe purging, may be had recourse to, if ana-
sarca makes progress. ‘The compound powder of jalap, or
the bitartrate of potash alone in drachm doses, three times a
day, are then most useful, especially as an electuary, in which
the cream of tartar is mixed with nearly an equal quantity of
honey, treacle, or marmalade, or syrup of ginger, and flavored
if necessary, with a few drops of peppermintoil. Squillsand
digitalis are also of special service as diuretics till the urine
resumes its natural appearance. In young children (of five
years of age and under) digitalis in scarlatinal dropsy is al-
most always beneficial, given in combination with perchloride
SCARLET FEVER. 353

of iron. It is followed by a steady increase in the quantity
of urine, with a corresponding subsidence of effusion. Five
minims of the tincture of the perchloride of iron, with a
drachm and a half of the infusion of digitalis in anis or cara-
way water, may be given three times a day, and continued
without intermission for fourteen days. Children bear such
doses, and larger ones, of digitalis remarkably well; and the
infusion in preference to the tincture, with iron and a nutri-
tious diet (Cheadle, Brit. Med. Journ., November 23, 1872).
The muriated tincture has the best reputation. The iodide
of potassium in small doses is also useful; and with this lat-
ter remedy the syrup of the iodide of iron may be combined,
if it is desirable to continue the chalybeate ; or syrup of the
phosphate of iron, combined with glycerine in drachm doses
of the combination.

Gargles are unnecessary for children, for they cannot gar-
gle; but they are of the greatest service, especially the de-
odorizing gargles or washes, when the patient can be taught
to use them. A weak solution of chloride of lime, or of
chlorine water, or of Condy’s fluid, or permanganate of
potash, is well adapted for such a purpose. The following
is recommended as a most efiectual gargle:

Solution of peroxide of hydrogen (eae ten volumes
of oxygen), six ounces; tincture of myrrh, an ounce; rose
water, five ounces (Richardson). :

This gargle may be used at pleasure; it is refreshing to
the patient, and removes the offensive secretions. With
young children, who are unable to use a gargle, the throat
may be washed out, by holding the little patient with the face
downwards, and then pumping the solution over the surface
of the fauces through a bit of gum catheter from a double-
acting india-rubber bag (Richardson, Clinical Essays, p.
110). As an invariable routine practice, Dr. W. T. Gaird-
ner strongly recommends that “ thesteam of hot water should
be inhaled from the beginning to the end of the fever, as
long at least as the throat is sore.” In slight affections it is
sufficient to employ infusion of linseed in water, acidulated
-with nitro-muriatic acid, weak solutions of alum, nitre, or
commoh salt. When membranous diphtheritic patches are
observed on the fauces, andthe color of the mucous mem-
brane is of a dark-red, capsicum infusion, or powdered red
pepper, is an excellent application (Wood); and in children
who cannot gargle, it may be applied with a hair pencil. So-
lutions of zinc, or nitrate of silver, are also of service, Ul-

23
354 SCARLET FEVER.

cerations may be touched dauy with a solution of nitrate of
silver (one drachm to two ounces of water), applied by means
of a hair pencil or a sponge probang; whilea weaker solu-
tion (grains v. to x. to two ounces of water) is at the same
time injected through the nostrils when there is discharge,
and it gives great relief. Turpentine and glycerine in equal
parts brushed over 'the ulcerated throat is also a valuable ap-
plication, and the sulphurous acid spray may be of service.
In swelling of parotid and submaxillary glands, ice in bags
of oil silk fastened round the neck and angle of the jaw, with
lumps of ice in the mouth, diminish engorgement, and tend
to avert suffocation. These details are given because the
physician must decide, upon the merits of the individual case,
the nature of the treatment he will adopt. It must be re-
membered that cases of scarlet fever, if left to themselves,
with rest and careful nursing, will generally get well unless
the epidemic constitution is a malignant type. The mere
intensity of the fever is no ground for active interference by
way of treatment, if the pulse is full and of good strength.
Much is to be trusted to the shortness of the fever, remem-
bering that there is no disease in which the patient is more
apt to be delirious, and in which the temperature may reach
a, high degree, with less danger, than in scarlet fever, (W. T.
Gairdner, Clinical Medicine.) On the other hand, it
must also be remembered that any continuous and excessive
increase of the temperature of the body may be followed by
the occurrence of adynamia and threatened paralysis of the
heart from excessive prostration, and that such cases sud-
denly and urgently demand such therapeutic interference as
may tend to reduce temperature and maintain the strength.
Treatment by. the cold water douche or affusion, as orig-
inally advocated by Drs, Jackson and Currie, is now again
recommended in the treatment of malignant scarlet fever,
where the cerebral symptoms are early and severe. Nie-
meyer and others bear testimony to its having a most markedly
beneficial effect. The patient may be placed in an empty
tub, and have the cold water poured over him, or his naked
body may be wrapped‘ in wet sheets, to be renewed and re-
applied at intervals of ten to fifteen minutes, the patient be-
ing put to bed in the interval. If either of these measures
fail, then such powerful stimulants as carbonate of ammonia,
camphor, or alcohol, may be had recourse to, administered
by enemata if need be, combined with milk or beef-tea, or
gruel.
SCARLET FEVER, 355

Preventive Treatment—Mere fumigation will not, it should
be remembered, destroy the miasmata in the sick-room; and,
consequently, the doctrines ‘of separation, of ventilation, and
of cleanliness, are as imperative in this disease as in small-
pox. The isolation of healthy persons from those affected
with the disease, and from those who have intercourse with
such patients, is essential, and is the only rule that promises
any good results, The following rules (drawn up from the
experience of Drs. Ballard and Budd) ought to be carried
out in every house where conveniences can be obtained; such
conveniences ought to exist in every hospital, and in the
houses of the poor they ought to be carried out as far as
practicable (1.) Remove from the sick apartment all su-
perfluous woolen or textile matters, such as carpets, curtains,
and anything of that nature, which are known to be reten-
tive of disease-germs. (2.) Measures of disinfection should
be used as early and as thoroughly as possible. Carbolic
acid in solution, or as carbolate of lime, is especially useful
to sprinkle on the floor, and with which all parts of the room
may be washed prior to cleansing and lime-whiting; and all
articles to be washed ought to be soaked first in a solution
of carbolic acid. (3.) A basin charged with chloride or car-
bolate of lime, or some other convenient disinfectant, is to be
kept constantly on the bed for the patient to spit into, which
must be emptied and replaced at regular intervals. (4.) A
large vessel (a tub) containing water impregnated with Con-
dy’s fluid, or carbolic acid solution, should always stand in
the room (or near by) for the immediate reception of all bed
and body linen on its removal from the person or contact
of the patient. (s5.) In place of using pocket-handkerchiefs,
use small pieces of rag for wiping the mouth and nose, so
that each piece, after being used, may be at once burned.
(6.) Two basins, one containing Condy’s fluid or carbolic
acid solution, and another containing plain soft water with
carbolic soap, and a good supply of towels, must always be
ready and convenient, so that the hands of nurses may be at
once washed, first with soap and water, and then in Condy’s
fluid water without soap after they may have been soiled by
specific excreta. The dresses of nurses and attendants
should be of linen, or smooth washable material. (7.)
Glasses, cups, and other vessels used by or about the patient,
are to be scrupulously cleaned before being used by others.
(8.) The discharges from the bowels and kidneysare to be re-
ceived, on their very issue from the body, into vessels charged
356 SCARLET FEVER

with disinfectants. (9.) To prevent the minute particles of
desquamation from flying off as impalpable powder, their
power for evil must be destroyed in situ, by anointing the
surface of the body (the scalp included) twice a day with
olive oil. It may be slightly impregnated with camphor,
which Dr. Budd considers sufficient, or carbolic acid. The
process relieves the itching of the skin, and is very soothing
to the patient.. So soon as efflorescence is observed on the
skin of the neck and arms (as early sometimes as the fourth
day), which marks the first liberation of the germ-carriers of
the specific disease-poison, the employment of the oil is to
begin, and ought to be continued until the patient is well
enough to take ,a warm bath, in which the whole person
(scalp included) is well scrubbed, carbolic acid soap (Cal-
vert’s or Macdougall’s) being abundantly used during the
process. These baths are to be repeated every second day,
until four have been taken, when, asfar as the skin is con-
cerned, the disinfection may be regarded as complete, al-
though a further quarantine of a week may be advisable.
(10.) The chamber in which the sick person has been con-
fined must now be thoroughly washed out, using freely car-
bolic acid and soft or black soap (which may now be got
ee for the purpose) (Brit. Med. Journ., 1869, Jan. 9,
. 23).
If a patient be from the outset thus isolated from all who
are susceptible of contagion,—if everything proceeding from
him is drenched with chemical disinfectants before it leaves
the sick-room,—if the exhalations from the skin, and
the peeling skin itself, are mechanically imprisoned by
inunction with oil until they can be removed by a warm
bath,—and if all clothing, bedding, and furniture are
disinfected at the close of the illness, a case of scarlet
fever ought to remain barren of results. But to carry
out such a process thoroughly requires the command of
space, of money, and of attendance; and requires also wis-
dom and self-denial on the part of relatives and friends. If
it were possible to begin to-morrow, and to carry it out in
every case, scarlet fever would have ceased to exist in the
country at the end of two months, and it is possible, or even
probable, that it would never return. ‘“ When, however, we
look abroad at the actual condition of the people among
whom the disease works its ravages, we see at once that, with
regard to very many of them, and especially with regard to
the poor in towns, isolation and disinfection are no more
SCARLET FEVER. 357

than idle words, In the class above the very poor, among
small tradespeople, small employers, and the like, where the
adoption of proper measures, although difficult, would not
be impossible, it is rare to find the intelligence and .the ac-
tive conscientiousness that would induce them to bear re-
straints, to take trouble, and to incur loss, for the sake of
preventing injury to their neighbors. Even among the
wealthy and educated, disinfection and isolation are but im-
perfectly carried out. Such people like to do as they please.
and resent dictation from medical men. If the cases are
severe, mental anxiety and distress break down the barriers
of precaution. If they are trivial, strict precaution would
too often be thought fussy and unnecessary. Medical men
cannot in such cases enforce what is right. They can only
recommend it; and they recommend it subject to the remem-
brance that their business is to heal the sick, not to quarrel
with the healthy. It is a curious weakness of human nature,
that many otherwise rational creatures are angry at the sug-
gestion that their loved ones can be sources of danger to all
around them, or that their house is properly shunned by
the neighbors; and beyond this there is the belief, not alto-
gether unfounded, that it is useless to isolate and disinfect
in a single case, where there isno reason to believe that a
similar course will be generally adopted. In the case of
schools and public institutions, it might be well to prevent
dispersion by positive enactment. But in other instances, if
the principle were once asserted and acted upon, that an in-
fectious disease must be registered, as a matter of. public
concern, public opinion would do the rest. Such provisions
as we have suggested are, perhaps, as much as could be at
present carried into effect; and their influence, both sanitary
and educational, would be of incalculable value.”

There are also beginning to arise some sceptical misgiv-
ings regarding our present hygienic views and practice with
regard to scarlet fever. “ One failure starts a doubt in a be-
liever’s mind; a second confirms it; a series of failures makes
one look out for a better creed. Are we doing any good
with our present preventive means? If they could be uni-
versally enforced, as they have been in isolated families with
disciplined minds, they would succeed; but when this is at-
tempted with large thickly packed communities, can they be,
or have they ever been, successfully enforced? By the imper-
fect execution of them through the length and breadth of the
land, do we increase or lessen the mortality from disease ?”
358 SCARLET FEVER.

These questions were put by Dr. Davies, of Bristol, who,
writing of an epidemic of scarlet fever there in 1875, con-
tinues as follows :—“I feel certain that we increase the anx-
iety of the domestic and social troubles of the public by
our preventive measures; and J feel doubtful of the answer
to the former question. Take, for example, an imaginary
but typical case in private practice. There is a family
named X., in easy circumstances. They have five children
—three boys and two girls. There is an epidemic, of a very
mild type, of scarlet fever in the locality. Hundreds have
had the disease; but there has been no death. The season
is July; the weather rainy, the atmosphere moist. The
youngest boy, aged 4,,contracts the disease in the prevalent
mild type. The other four children, by the advice of their
medical attendant, are sent to a distance, and escape the in-
fection. The sick child recovers. Two years elapse. The
eldest son goes to Eton, Rugby, Marlborough, or some other
public school. An epidemic of a severe type has just broken
out where he'is ; he contracts the disease. The parents are
telegraphed for to see their son, supposed to be dying.
They travel to and fro three hundred miles. The patient
ultimately recovers, and escapes only by the skin of his teeth.
The school is temporarily broken up. The convalescent is
sent to a fashionable watering-place before he is properly
disinfected, and there he spreads the disease. The second
son has escaped, through being kept at a distance from his
brother. He has, in the course of time, taken his degree at
college; has been admitted as a barrister; has, after a long
struggle, made his position; has been married. He passes
through Paris on his honeymoon. The weather is cold, the
wind easterly. In Paris an epidemic of scarlet fever pre-
vails. He contracts the disease and dies in a strange land;
and leaves his young bride a widow among strangers. In
time, the eldest girl is married to arich man. She is in due
time confined of her first-born. The bells are ringing, and
all goes on merrily as a ‘marriage bell.’ A fortnight after-
wards, that house is desolate. In that house are now only
a bereaved husband and motherless infant; the subtle seeds
of this mysterious disease have been inadvertently introduced
to the puerperal patient in the nurse’s shawl, or on the sleeve
of the doctor’s coat. I will not follow this case further; but
ask, in all seriousness, would not life and suffering have been
saved if all the family had been allowed to pass through the
disease when it first appeared among them in a mild type,
SCARLATINA—~SCURVY, 359

when they were all children? I wish it to be thoroughly un- |
derstood that, as a health-officer, I have never had the moral
courage to discard my former profession of faith, and to un-
dertake the responsibility of giving practical effect to my
doubts. I have never used disinfectants so extensively as
during the present epidemic, and yet our failure is complete,
The doubts I have expressed do not in any way extend to
typhus and enteric fevers, small-pox, and Asiatic cholera, It
is a fact beyond contradiction that occasionally this tiger of
pathology seems to stalk abroad, having left both claws and
teeth at home. Could we not play with him then? Inocu-
lation from mild cases of variola previous to the discovery of
vaccination proved of immense benefit. We can import
scarlet fever. We can choose our type and season of the
year. Is there a milder exanthem of an allied species that
can prevent or modify this disease? Rotheln is nearly
allied, is very infectious, but harmless. Does it modify
scarlet fever, or is it modified by it? I have for some time
looked upon it with affection, but am afraid to theorize on
the subject. Can any one throw light on this unexplored
field? Observation convinces me that there is some un-
known condition which gives immunity to some persons from
scarlet fever: what is this condition? An analogous condi-
tion was known in the Vale of Berkeley regarding small-pox
before the days of Jenner, and might have remained un-
known to the outer world had not that great man unearthed
it. Who will be the Jenner of scarlet fever?’ A somewhat
similar argument is used by Thomas in his article on scar-
latina in Ziemssen’s “ Cyclopedia,” Vol. II., p. 300.

Different prophylactic medicines have been recommended;
amongst which belladonna has had the greatest number of
advocates; but its value has diminished greatly, as the
weight of testimony is against its possessing any prophylactic
virtues (Wood). Even when continued fora week, it affords
no protection against scarlet fever (Niemeyer).

Scarlatina—See Scarlet Fever.
Scorbutus—See Scurvy.

Scurvy .—De/finition—A morbid state characterized by
sponginess of the gums and the occurrence of livid patches
under the skin, of considerable extent, which are usually
harder to the touch than the surroundin¢e tissue. Analtered
state of the albumen of the blood is associated with this con-
dition, and the phenomena are brought about by a deficient
360 SCURVY.

supply of the organic vegetable acids, or of the salts of fresh
vegetables. It is ushered in by debility, lassitude, lowness
of spirits, attended by fetor of the breath, and the gums
swell by irritation, till they overhang the teeth in palmated
excrescences. The livid subcutaneous patches and spots
appear upon the skin of considerable extent, especially on
the lower extremities and among the roots of the hair. Spon-
taneous hemorrhages may take place from the mucous ca-
nals; contractions of the muscles and tendons of the limbs
occur, with pains, and sometimes superficial ulcerations.
Treatment.—The disease, “so fatal when left to itself, is
cured with the greatest facility. Symptoms apparently the
most grave and serious vanish as if by magic, and without
leaving behind them any serious injury to the constitution.
The sanious discharge from scorbutic sores has been known
to change color, and to become healthy in a few hours
after the commencement of treatment. In pure cases of
scurvy the blood, and the blood only, is at fault,” (Parkes)
“Lemon juice,” writes Dr. Watson, “is really a specific
against scurvy, whether it be employed as a preventive or as
aremedy. It supplies something to the blood which is essen-
tial to its healthy properties.” ‘The potato seems to be no
less efficacious as a remedy and preventive (Budd), and all
the antiscorbutic remedies are most efficient in the form of
juice—from raw and uncooked fruit. The reader will find
a most interesting account of the efficacy of potatoes and of
onions in Dana’s Zwo Years before the Mast—a book well
worth reading. The antiscorbutic principle, whatever it may
be, is in greatest amount in unripe fruits; it lessens gradu-
ally as they ripen; and if the juice be obtained, the princi-
ple disappears, or is decomposed and rendered - inefficient,
when fermentation occurs. When lime-juice becomes musty,
a mucilaginous principle is developed at the expense of the
citric and malic acids; and the percentage of citric acid
gradually decreases (Sir William Burnett, Parkes). Good
lemon juice seems to be more effectual, however, than pure
citric acid; probably from its containing malic and tartaric
acids besides citric, and from the citric acid being in the
form most casily absorbed and decomposed by the digestive
organs of man. The Materia Medica gives numerous anal-
ogous examples of the superior efficacy of a medicine in its
natural combinations (Parkes). ‘his is all we can vet say,
however, regarding the actions of either of these means of cure,
notwithstanding the researches of the chemists of the pres-
SCURVY. 361

ent day. Moreover, it is sufficient; and with such remedies at
command, the prevalency of scurvy in merchant vessels, or in
any navy, ought nottoexist. ‘‘ The one thing wanted in order
that scurvy should be entirely banished from the mercantile
marine is proper provision for the dietary of the crew,—such
provision as is enforced in emigrant ships, where each per-
son’s weekly allowance must have in it at least 8 oz. of pre-
served potatoes, and 3 oz. of other preserve:1 vegetables (car-
rots, onions, turnips, celery, and mint), besides pickles and 3
oz. of lime-juice; where, also, there is considerable variety
of bread stuff; and where, on two days in the week, pre-
served (not salted) meats must be given. With such a diet-
ary as this, the details of which might be varied, provided
its principle were adhered to, the occurrence of scurvy would
be impossible. And even with dietaries inferior to that just
described, scurvy would not occur as it does, if but the pro-
visions of the ‘ Merchant Shipping Act’ (17 and 18 Vic., c.
104) were obeyed,—that whenever a crew shall have been
consuming salt provisions for ten days, lime juice or lemon
juice and sugar shall be served out at the rate of half an
ounce each per day; and if, during the voyage, the opportu-
nities which offer themselves were fairly used for getting new
supplies of fresh animal and vegetable food; but owners dis-
obey the law, and captains neglect opportunities to counter-
‘act the results of this disobedience. Owners, notwithstand-
ing the law, will send forth their ships on long voyages with-
out any provision of lime-juice, or with lime-juice insufficient
in quantity, or with lime-juice of which the quality is bad;
and captains, with half their crews more or less disabled, are
known to run past St. Helena or the Western Isles, when a
few hours’ delay would obtain sufficient provisions to repair
the mischief occasioned by first neglect” (Simon and
Barnes's Sixth Report on Public Health, 1864, p. 20). It is
perhaps hardly fair to attribute the improved health of the
navy entirely to the introduction of a daily allowance of
lemon juice, considering that the quantity of the diet was
greatly increased, and its quality greatly improved, contem-
poraneously with this addition. It is gratifying, however, to
see how largely these combined measures have improved the
health of the navy, and rewarded the cares of those who su-
perintend it. During the nine years preceding these changes
the sick seamen sent to the hospitals were 1 in 3.9, while in
the nine succeeding years the proportion was only 1 in 8.4;
so that not only has scurvy almost disappeared from ships
362 SCURVY.

of war and naval hospitals, but the efficiency of the navy has
actually been increased threefold.

Dr. Parkes advises that the following measures be adopted
in time of war, or in prolouged sojourn on board ship, or at
stations where fresh vegetables are scarce: “(1.) The supply
of fresh vegetables by all means in our power. Even unripe
fruits are better than none, and we must risk a little diar-
rheea for the sake of their antiscorbutic properties. In time
of war every vegetable should be used which it is safe to use,
and when made into soups all are tolerably pleasant to eat.
(2.) The supply of dried vegetables, especially potatoes, cab-
bages, and cauliflowers; turnips, parsnips, &c., are perhaps
less useful; dried peas and beans are useless. As a matter
of precaution these dried vegetables should be issued early
in the campaign, but should never supersede the fresh vege-
tables. (3.) Good lemon juice should be issued daily (1 oz.)
and it should be seen that the men take it. (4.) Vine-
gar (4 oz. tor oz. daily) should be issued with the rations,
and used in the cooking. (5.) Citrates, tartrates, lactates,
and malates of potash, should be issued in bulk, and used as
drinks, or added to the food. The easiest mode of issuing
these salts would be to have packets containing enough for
one mess of twelve men, and to instruct the men how im-
portant it is to place them in the soups or stews. Possibly
they might be mixed with the salt, and issued merely as salt”
(“ Prac. Hygiene,” 2nd Ed.,'1866, p. 466).

Our recent Arctic expedition, in 1876, is of interest for
two reasons: (1.) As regards a peculiar theory as to the ac-
tion of lime-juice which the commander of that expedition
entertained and acted upon, based as it was upon a ground-
less and absurd hypothesis, that by doubling the dose of
lime-juice for a month he believed he could, so to speak,
“saturate” his men with it before they started on an im-
portant sledging expedition, so that they might be able todo
without it on these journeys. Lime-juice is simply ararticle
of diet; and is no more “ cumulative” in its action than any
other aliment which goes to nourish the body. Its nutritive
influence continues for so long and no longer than the time
when it is continued and assimilated as an article of diet.
The assumption of the theory was entirely gratuitous and
unfounded; and to have acted upon it against competent
medical opinion was unjustifiable. (2.) Another theory was
entertained to palliate the omission of lime-juice from the
sledging rations. namely:—that lime-juice when exposed to
SCURVY. 363

an extreme degree of cold deteriorates and ceases to have
any antiscorbutic properties.

“This theory was not only disproved by the evidence of
the medical officers on other sledging expeditions, but was
effectually answered by the fact that the whole expedition
was virtually saved from the most fearful mortality from
scurvy by the opportune discovery of a depot of lime-juice
left five years before by the “ Polaris’’ expedition, lying in
a cask on the ice exposed to the extremity of cold alterna-
ting with heat. It had also been much weather-beaten, and
on its surface mixed with snow; but it nevertheless proved
to be in no respect deteriorated in. its antiscorbutic powers,
and served to keep off the last extremities of disease from
the sledging parties to whose relief it was sent:in time. It
appears, indeed, to us, and it will appear, we think, to any
one who reads the whole narrative, that, but for the timely
discovery of this depot of the “ Polaris” lime-juice, and its
utilization for the sledging parties, there is good reason to
fear that so large a proportion of the crews would have been
destroyed by scurvy, that it is doubtful whether the whole
expedition would not have been lost from the want of suff-
cient power to bring the ships out of the ice. However this
may be, the frozen lime-juice rendered the most essential
services, and the theory that freezing destroys its virtues is
most effectually disposed of ” (Brit. Med. Journal, March
10, 1877).

In fact there is nothing in the history of our latest Arctic
expedition of 1876, which does not point to the cause of the
outbreak of scurvy as similar to all those which history has
already recorded; and which will again produce the disease
if the teachings of history are similarly neglected and set
aside.

The great body of evidence taken by the committee ap-
pointed to inquire into the causes of the outbreak of scurvy
in the Arctic expedition fully shows that “the outbreak was
due essentially to the omission—or, rather, to the refusal—
of Captain Nares to send lime-juice with the sledge parties.
It was shown that the provisions of the ships were ample in
quantity and excellent in quality; and, further, the commit-
tee having had before them the preliminary memorandum
by Sir Alexander Armstrong, the Director-General of the
Medical Department of the Navy, strongly and explicitly re-
quiring the issue of a daily ration of lime-juice, and having
heard Sir George Nares’ explanation of the reasons which
364 SCRIVENER’S PALSY,

induced him to act in defiance of that memorandum, decided
that in doing so he made himself responsible for the out-
break of scurvy which occurred, and that he had no suffi-
cient reason for not carrying out the rules laid down in the
memorandum.”

“Tt is a satisfaction to find that throughout the whole of
this inquiry the Medical Department of the Navy comes out
with the utmost possible credit. Nothing could be more
clear, more explicit, more absolutely prophetic than the
memorandum which was furnished to Sir George Nares by
the Admiralty from Sir Alexander Armstrong, on the im-
measurable importance of supplying the men with a daily
ration of lime-juice. The whole of his direction for the
maintenance of the health of the men are indeed most able,
practical, and judicious: and, had they been strictly followed
out, the results would have been very different. The con-
duct of all the medical officers of the expedition appears to
have been such as to merit and to receive the warmest ap-
probation of their superiors from first to last, and they show-
ed a devotion to duty which is entirely comparable with that
displayed by the officers and men of this gallant expedition
generally. They can seek for no higher praise, and it is on
all hands conceded that they merit no less. One moral of
this inquiry, which is salient on the face of it, and which we
can hardly be expected to abstain from pointing, is, that
combatant officers will do well always to respect the func-
tions of the medical officers, and to attribute just weight to
medical recommendations. In framing false medical theo-
ries, ar.d in assuming the responsibility of refusing to act
upon his medical instructions, Sir George Nares brought a
great disaster upon this expedition; and he assumed the full
responsibility of it” (Brit. Aled. Journal, March 10, 1877.)

Scrivener’s Palsy.—Definctvox.—Morbid excitement of
the motor fibres of the nerves of the muscles of the fingers
and thumb holding the pen, resulting in cramps, so as com-
pletely to prevent writing, and thus the condition becomes
equivalent to a local palsy or paralysis.

Treatment.—Complete.rest from the usual mechanical use
.of the hand must be insisted on. Nourishing food, with a
milk diet in abundance, or cod-liver-oil, are essential. In
one case division of the muscle in which the cramp seemed
first to commence had a good effect (Stromeyer). In four-
teen days after subcutaneous section of the long flexor of the
thumb, the patient was again able to write. Dieffenbach
SCROFULA. 365

often repeated a similar operation, but without success.
These may be regarded as very radical surgical methods of
securing absolute rest to the wearied muscles. Mr. Solly, in
his lately published surgical experiences, described several
cases of this peculiar affection, in which tonic treatment,
with rest from writing, was attended with good results.
Niemeyer has been successful with the galvanic current.
He applied the current to the muscles of the thumb and
index finger. Exercise of the affected muscles materially
tends to increase the disease.

As to medicines, when the disease has not gone beyond
the sensation of heat and cramps in the ball of the thumb, I
have seen good results from the syrup of the phosphates of
iron, quinine, and strychnia; and generally those remedies
noticed under the subject,of anzemia may be prescribed.
Mechanical appliances, such as contrivances which fill up,
as by a ball, the palm of the hand on which the fingers rest
in writing, have been of service; and there are also appli-
ances by which writing may be accomplished without the aid
of the fingers, and which therefore may be of service in
securing rest to them.

Scrofula.—Definition.—A constitutional disease, result-
ing in the deposit of a soft unorganized matter of a white or
pale-yellow color, firm, resembling curd or soft new cheese,
but less tough, sometimes granular and friable, and consist-
ing of a large proportion of albuminous matter. It is often
found mixed with purulent-like fluid, or occurring in round-
ed masses of different degrees of firmness, and varying in
bulk from that of a millet-seed toa hen’s egg or larger;
sometimes contained within natural canals and cavities of
the body, and sometimes inclosed in cysts, or cccasionally
diffused as if by infiltration through the texture of a part.
To the rounded masses the name of tubercle has been given;
and the substance itself has been named scrofulous or tuber-
culous matter. Scrofula also expresses itself in specific
forms of inflammation or ulceration. It manifests a remark-
able tendency to certain specific forms of nutritive disorder,
which are strikingly wasting in their effects upon the body,
namely:—(a.) Scrofula with tubercle; (b.) scrofula without
tubercle; and (c.) certain local scrofulous affections, such
as eruptions of a peculiar kind, many cutaneous ulcers, cer-
tain enlargements of the joints, tubercular meningitis, hydro-
cephalus, scrofulous ophthalmia, tubercular pericarditis,
scrofulous diseases of glands, phthisis pulmonalis or pul
360 SCROFULA.

monary consumption, acute miliary tuberculosis, tabes
mesenterica, and tubercular peritonitis.

Treatment.—(a.) Preventive—There is perhaps no subject
in the whole range of medical science which the student
ought to study more carefully than the cachexia, or special
form of ill health associated with the occurrence of tubercle
and scrofulous affections as here described. As a practi-
tioner he will find that he becomes often painfully concerned
in the deepest interests of families and society, through the
threatened or actual ravages of scrofulous diseases. The
extensive prevalence of the scrofulous cachexia—the great
and almost inevitable mortality of the scrofulous diseases
themselves when completely developed, stamp the morbid
state associated with them as a topic which, at the outset of
the student’s career, ought to ‘engage a large share of his
study. Most assuredly the physician will have to turn his
knowledge of the pathology of scrofula to account in every
phase of his professional life. When he fully appreciates
what experience has adequately demonstrated, that the
scrofulous cachexia springs from causes over which the pub-
lic (rather than the medical profession) have control, he
must be at once impressed with the belief and encouraged
with the hope, that when he acquires the confidence of fam-
ilies in the practice of his profession he may exercise a pow-
erful influence for good in teaching how much the public
may control the'ravages of scrofula and consumption by
prudent marriages,. by sanitary attention to offspring, and
by the necessity of free ventilation and of fresh air in dwell-
ings. ‘There are several circumstances which show the great
influence of public sanitary measures in contralling the
development of scrofula, when these measures are scientific-
ally directed to the preservation of general health, especially
where men are associated together in great communities—an
influence much greater than the best directed efforts of the
medical profession can establish through their materia med-
ica. It is by the mode of life as citizens of the world, in
the social relations of husbands and wives, parents and child-
ren; in the public relation of masters and workmen, that the
extent and ravages of consumption and scrofula are to be
controlled. It is by a strict attention to the rearing of off-
spring, and in the subsequent regulation of food, clothing,
cleanliness, and occupation; in the choice of a profession,
and by many other circumstances which have an obvious
influence (perhaps at first sight inappreciable) on the main-
SCROFULA. 367

tenance of the general health, that our hopes of success as
practitioners of medicine must rest in the prevention of that
bad habit of body which develops and propagates the scrofu-
lous diseases in civilized society.

(6.) General Treatment.—The general treatment now in
most reputeis founded on the ‘doctrines — (1.) That
scrofulous local lesions will heal of themselves if the
nutrition of the system can be maintained and the con-
tinuous growth of tubercle arrested; (2.) that the periods
of frequent temporary arrest of all the general and local
symptoms of disease ought to be diligently taken ad-
vantage of to improve and preserve health by hygienic
means (3.) that the efforts of the practitioner should be
directed to the digestive rather than to the pulmonary sys-
tem; (4.) that the kind of morbid nutrition in the body
generally, and altered morphological change in the tissues
of the orgar. where the deposit takes place, appear to be
chiefly due to excess of albuminous and deficiency of fatty
elements in the chyle. The treatment, therefore, to be pur-
sued must be essentially reparative of the waste of tissue
generally; corrective of what has been unfit in the indivi-
dual diet and mode of life; and, lastly, supplementary of
the elements of nutrition which have been deficient. During
the past thirty years in Germany, and twenty-three years in
this country, the treatment of scrofulous affections has gradu-
ally but steadily become more and more firmly based on those
pathological doctrines which the late Dr. J. H. Bennett, of
Edinburgh, was mainly instrumental in first elucidating, and
in earnestly recommending to the notice of the profession
generally in this country. The view here taken regarding
the nature of scrofula leads to the belief that—(z.) The
biood is impoverished through the preliminary dyspepsia
which precedes the growth of crude tubercle; (2.) that in
pulmonary phthisis the growth of crude tubercle results in a
consolidation primarily in the air vesicles; (3.) that the
successive formation and softening of these crude tubercles
lead to ulcerations of the pulmonary and other tissues—to
the infective processes which set up the growth of true
miliary tubercle—and, promotes wasting of the body gener-
ally.

It nas been now fully shown, especially by the observa-
tions of Dr. Bennett, in the first instance, confirmed by the
extensive experience of the physicians at the Brompton Hos-
pital for Consumption, in London, that such treatment as is
368 SCROFULA.

directed to remove the malassimilation of food frequently
checks the tendency to the repeated occurrence of tubercles,
while those which previously existed remain harmless ; that
general symptoms and physical signs may disappear com-
pletely ; and that even extensive excavations in the pulmon-
ary tissue may heal up and cicatrize. According to the tes-
timony of Dr. Wood, of Pennsylvania, the fatal results have
not. only been postponed, but the death-rate from phthisis
has diminished in the principal cities of the United States
since such principles of treatment have been adopted. The
indications of general treatment are therefore:—(1.) To im-
prove the faulty nutrition, which is the cause of the scrofu-
lous cachexia, and of the exudations assuming the characters
of tubercle; (2.) To subdue the fever which attends the
growth and changes going on in the tubercle-nodules, and to
favor the absorption either of the entire exudation, or of
such portions of it, that what remains may undergo such
changes as are consistent with its future harmless existence
in the organs or other parts where it may have grown; (3.)
To prevent the recurrence of fresh exudation by careful at-
tention to hygienic regulations, especially during the inter-
vals of apparent return to health.

To fulfil the first of these indications it is of all things
important that fatty matter be assimilated in large quanti-
ties, and it appears that such is most readily absorbed and
assimilated when in the fluid condition. The substance of
all others found most beneficial has been cod-liver oil. At
the Brompton Hospital more than 600 gallons of this oil are
used annually. ‘There, on a great scale, its merits have been
tested and compared with the effect of treatment conducted
on general principles, and irrespective of its use. The result
has been to confirm, in the estimation of the medical profes-
sion, the great value of the remedy in the treatment of
phthisis, when appropriately administered, and combined
with the use of such other measures as any special circum-
stances in the individual patient may require (Thomson).
The general opinion of the profession with regard to cod-
liver oil may be summed up in the statement originally made
by Dr. Bennett,—namely, that “it rapidly restores the ex-
hausted powers of the patient, improves the nutritive func-
tions generally, and stops or diminishes the emaciation. The
night perspirations subside, the cough is quieted, and the ex-
pectoration is diminished after the oil has been used for a
few weeks. A very constant and well-marked favorable
SCROFULA. 369

change under its use is to be noticed in the diminution of
the pulse, which gradually but steadily has been observed to
come down at the rate of five or six beats weekly ; and dur-
ing the same period the weight of the body has been known
steadily to increase at the rate of half a pound to a pound.
In females it is a significant and highly favorable symptom
when the catamenia return after the oil has been used for
some time. The usual dose adopted by the late Dr. Thomp-
son, at the Brompton Hospital, is one or two teaspoonfuls
twice a day at first, and gradually increasing the quantity to
half an ounce three times a day. Dr. Bennett recommends
somewhat larger doses—namely, for an adult, a tablespoon-
ful three times a day, which may often be increased to four
or even six with advantage. When the stomach is irritable,
however, a tea or a dessert-spoonful is enough to commence
with. It appears from the observations of Dr. Thompson
that no additional advantage is obtained by pushing the oil
beyond the limits of the doses adopted by him at the Bromp-
ton Hospital, from the fact that where its use has most obvi-
ously increased the weight of the body, to the extent in one
instance of a pound per week for twenty-one weeks, only
three pints had been taken during that time. The kind of
oil used, as far as coarseness or fineness is concerned, seems
not to affect the beneficial result in any material degree.
Some patients even prefer the coarse to the fine oil. The
experience of some is, moreover, favorablé to combining the
oil with liquor potasse as an emulsion ; and as it appears
that undue acidity prevails as well in the stomach as in the
intestinal canal, the addition of the alkali ought, on theoreti-
cal grounds, to be advantageous. It seems also that, when
cod-liver oil was first used as a medicine, more than fifty
years ago, in the treatment of rheumatism, it was then ordi-
narily combined with an alkali. It may be taken, however,
unmixed, or it may be floated on milk, or nitro-muriatic acid
mixtures, or on lemonade, soda-water, lemon juice, or ora
saline draught during effervescence, when such combinations
are suited to the patient. Creosote has been recommended
to be added, as it is said to render the stomach more tolerant
of the remedy. The following formula, quoted from Dr.
Thompson’s “Clinical Lectures on Pulmonary Consumption,”
yields a palatable mixture, which ought to be combined as
an emulsion:—

“ An ounce and.a half of cod-liver oil, four drops of creo-
sote, two drachms of compound tragacanth powder, and four

24
370 SCROFULA,

ounces and a half of aniseed water. Of this mixture an
ounce may be taken thrice daily.”

Besides cod-liver oil, other animal fats and oils, where they
can be taken and assimilated, are sure to be followed with
benefit. Hence milk rich in fatty matter, such as asses’
milk, and milk drawn from the cows at a short interval after
the greater part of their milk has been withdrawn, and which
is known in Scotland as “afterings,” are found to be fol-
lowed by improvement where they are persevered in and are
assimilated. So also has it been with cream and butter. Dr.
Bennett instances the partial success occasionally of caviare,
bacon, pork, mutton chops, and the marrow of the bones of
oxen; while Dr.-Thompson instances the good effects he has
obtained from the use of oil obtained from the foot of the
young heifer (neat’s-foot oil). The administration of any of
these remedies is quite consistent with doctrines now taught
regarding the pathology of scrofula, and it is useful to know
their individual value, in order that in particular cases one may
fall back upon their use where a change may be desirable.

It has been considered that some of the good effects of
cod-liver oil may be due to the biliary elements with which it
has been incorporated. ‘This view is not supported by the
experiment of adding ox-gall to other animal oils not derived
from livers, as no beneficial results have been observed to
follow. But as the active principle of the gastric juice has
been now successfully isolated by chemistry, and has been
successfully used to aid the digestion of food in the stomach,
might not some principle be obtained from the liver which
might aid the assimilation of fatty substances when mixed
with the intestinal juices ?

In fulfilment of the second indication mentioned the
propriety of abstracting blood has been much discussed.
It has been already seen that febrile symptoms of a very
severe kind sometimes attend the exudation and consolida-

on of crude tubercle. It is also a more or less frequent ~
clinical observation that pneumonia, bronchitis, and pleuritis,
in acute or chronic forms, are intercurrent attendants on the
deposit and future changes of tubercles in the lungs.
“Hence,” as Dr. Bennett justly observes, “there are all
kinds of intermediate changes between the simple and tuber-
cular exudations constantly going on in the progress of a
case of pulmonary tuberculosis. The phenomena of phthisis,
pneumonia, pleurisy, and bronchitis, in their acute or chronic
forms, may appear together, and be inextricably mingled, or
SCROFULA 371

they may succeed each other at intervals.” Thus, scrofulo-
sis, both as a constitutiona] and as a local disease, is scarcely
ever free from exacerbations, the various local and con-
stitutional states acting and re-acting on each other. While,
therefore, on the one hand, the system requires an increas-
ed and well-directed supply of nutritive materials, on the
other hand, there are constitutional states of excitement, de-
pending on local irritation, which require to be subdued, and
which may even demand antiphlogistic treatment. What-
ever theoretical view may be taken as to how the exudation
may most readily be absorbed, all physicians are now at one
as to the propriety of preserving the general strength, of effect-
ing elimination of effete material, and of meeting antiphlogis-
tic indications rather by diaphoretics, diuretics, emetics, and
purgatives, than by abstracting any considerable amount of
blood, either at once or at repeated intervals. In fact it is
now observed that the administration of appropriate diet,
and abstinence from lowering remedies, with cod-liver oil,
while they correct theegeneral nutrition, may be so regulated
as to subdue the constitutional irritation by a perseverance
in their use for a period of not less than four or six weeks.

In fulfilling the third indication,the real power of the science
of medicine may be demonstrated. It is by well-directed
hygienic measures, successfully and efficiently carried out,
that the real strength of the physician may be put forth to
prevent the recurrence of fresh exudation; and his hygienic
exertions towards the patient are to be redoubled during the
temporary intervals of apparent return to health. It is now
almost an axiomatic truth, that of all things which deterio-
rate the constitution on the one hand, and influence pulmon-
ary congestion on the other, none are so detrimental as im-
pure and deficient air, together with frequent variations of
temperature, and changes from sudden heat to chilling cold.
These latter vicissitudes may be considered characteristic of
the physical climate of Great Britain and Ireland. “The
conditions of preventive treatment which have seemed most
useful are nutritious food and proportionate great exercise
in the free and open air. So important has this last con-
dition proved to be, that it would appear that even consider-
able exposure to the weather is better than keeping phthisi-
cal patients in close rooms, provided there be ro bronchitis
or tendency to pneumonia or pleurisy”” (Parkes, p. 445).
Tonic treatment consists essentially in the adoption of those
means which promote or stimulate the healthy nutrition of
374 SCROFULAs

the body. Its elements exist in fresh air, abundant exercise,
sufficient repose, and judicious diet. A hygienic code appli-
cable to the tuberculous cachexia has been recently laid
down by Dr. B. W. Richardson, in the second volume of the
Santiary Review, and very recently in a special work On the
Hygienic Treatment of Pulmonary Consuraption. It is de-
rived from these elements of tonic treatment; and as it puts
well-known truths, too little appreciated, in a formal and more
important aspect than is wont, its precepts are here quoted.

I. A supply of pure and fresh air for respiration tn constant-
ly required by the tuberculous patient.—As it is known that if
one per cent. of carbonic acid exist in a room, the air is un-
fit for a healthy person, it is therefore much more so for a
consumptive one. The temperature of a room ought to be
equally maintained at from 55° to 56° Fahr., ventilation and
heating being effected by open fireplaces. A single room
ought not to perform the two offices of a bed-room and a
sitting-room. The sleeping-room ought not to afford less
than 1,000 feet of space; and if larger, so much the more
healthful will it be. In connection with these statements,
while it is objected, for obvious reasons, with much justice, to
the treatment of tuberculous patients in special hospitals,there
is much on the other hand that might be improved in all our
hospitals, with reference to the arrangement of the patients,
to secure to them fresher air than they generally obtain.
“Constant though imperceptible movement of the air is the
point to be attended to ’—7. ¢., thorough ventilation. All
who are able to be out of bed ought to have their meals in a
common room, which is not used for any other purpose, and
is apart from the wards or dormitories.

Il. Active excercise in the open air is imperatively demanded
by the tuberculous patient.—In the words of Dr. Jack-
son, “He must be made to feel that the risk is in staying in
the house, and not in going out of it.” But the skin must
be perfectly protected; and while a chill, or inclement wea-
ther, is to be avoided, the patient must go out in all seasons,
without being too fastidious about the weather, walking ex-
ercise being persvered in as much as possible. ‘ The best
climates for phthisis are perhaps not necessarily the
equable ones, but those which permit the greatest number of
hours to be passed out of the house” (Parkes). Next to
diet, exercise in the open air is, of all things, the most im-
portant: it should be carried as far as the vigor of the pa-
tient will permit. It should not be done rashly, but boldly;
SCROFULA. 373

and, if possible, the patient ought to have faith in it; for
without this he is not likely to pursue it so far as he can,
and then he will not derive from it all the benefit which it
can afford (Jackson). It is very important to remember, in
regard to training animals and young persons, that they have
much more extent and range of lung than are required in
the quiet everyday pursuits of life. Less lung is used when
the young person or other animal lies down or sleeps, or is
depressed; and, on the contrary, walking, running, wrestling,
the force of the passions, each or all of them bring the
greatest amount of lung into action or use. In short, the
amount of lung in use is an ever-varying quantity; and just
as much lung may come to be used as a habit as the listless-
ness or vigor of the individual moment requires. There is
every range, every variety, till the top of the wind, the to

of the speed (the full vital capacity) is attained (Sibson)
Practically, therefore, the more fully the lungs are judiciously
used, the more is their capacity nursed; and, conversely,
the less they are used and expanded, the more useless they
are likely to become, if not absolutely diseased. Under a
judicious system of training, an undeveloped man, even al-
though he may be feeble, narrow-chested, and sickly, may
yet. become active, full-chested, and healthy. We have
numerous examples of this among the boys in our training
ships for seamen. The over-fed, short-winded pugilist,
rower, or cricketer, may in a few weeks be changed, by
training alone, to the firm-fleshed, clear-skinned, long-winded
winner of the boxing fight, the foot race, or the rowing
match. It is this want of use that probably renders the
apices of the lungs more liable to the growth of tubercle in
them than in any other part of their substance. It is a por-
tion of the lungs which has less play or expansion than any
other portion, and is apt to be bound down by the sur-
rounding parts. The apices are, therefore, the parts most
likely to remain in a quiescent state of non-expansion,
especially when acts of respiration are inadequately per-
formed, either owing to the constrained position of the body
in certain trades, or from habitual stooping of the body from
listlescness of habit or want of vigor in the system. This
quiescent state of the air-cells is favorable to the growth of
tubercle; and thus the apices of the lungs are the most com-
mon seat of tuberculous growths (Reviewer in Medical Mirror,
Vol. L., p. 638). The effects of want of exercise and of im-
pure air are thus most potent agencies in causing phthisis.
374 SCROFULA.

“The much greater prevalence of phthisis in most of the
European armies (French, Prussian, Russian, Belgian, and
English) can scarcely be accounted for in any other way than
by supposing the vitiated atmosphere of the barrack-room to
be in fault.” In all the places where phthisis has
prevailed, in the most varied stations of the army,
in the most beautiful climates, the only common condition
was the vitiated atmosphere which our barrack system every-
where produced; “and, as if to clench the argument, there
has been of late years a most decided decline in phthisical
cases in these stations, while the only circumstance which
has notably changed in the time has been the condition of
the air” (Parkes, p. 91). Indeed, the air is rendered so
so impure by respiration, that while an atmosphere so vitiated
has a most injurious effect upon the health, contamination
of the air has been so great, where lung diseases abound, as
to give rise to the idea that phthisis appeared to be propagated
by contagion (Bryson, Parkes). It is therefore within the
power of the authorities of the Army and Navy so to direct
the physical training of young persons, that the apparently
sickly and the short-winded may in time be developed into
the wiry and active young man, long in wind, sound in body,
and lithe of limb—a result which, however, can only be at-
tained by judicious feeding, careful exercise throughout the
development of the body, and by the gradual nursing of the
breathing powers. The opposite of this is seen in the break-
ing down of recruits at a very early period of service in the
army—within the third year—a result likely to be greatly
obviated by the gymnasia introduced by Government for the
physical training of recruits before and after they are in-
structed in drill, by better and more abundant food, and im-
proved barracks. The Austrian runners also furnish instances
of breaking down by over-exertion in running at ages un-
suited for their strength. They seldom live above three or
four years, and gradually die of consumption (Remains of
Mrs. Trench, p. 72). In all physical training the condition
of the heart must be considered not less than the lungs, see-
ing that its movements respond to the movements of the
chest and the lungs. ‘They are members of one great system;
and in nursing one we nurse the other; for by giving tone
and health to one we must give tone and strength to the other
(Sibson). If, on the contrary, the development and gradual
training of the lungs are not successful, the lesions which be-
come developed are of a peculiar character, and are apt to
SCROFULA. 375

be thought very lightly of; because, in the first instance, they
are so little capable of appreciation by a single observation;
and, secondly, because the lesions are insidious, and take
some time before they reach a stage to be apparent.

TI. Zt zs important to secure for the patient a uniform,
sheltered, temperate, and mild climate to live in, witha tem-
perature about 60° andarange of not more than 10° or 15°;
where also the soil is dry, and the drinking-water pure and not
hard.—The classic work of reference on this topic is that by
the late Sir James Clark. If it is possible to give a practical
abstract of his extensive and valuable experience, it may be
done somewhat as follows:—(1.) After the functions of the
digestive organs and skin have been re-established in im-
proved action, the patient who labors under a tuberculous
cachexia may derive benefit by a residence in a mild or tem-
perate climate (such as has been defined), conforming to all
the hygienic and medicinal treatment -already mentioned.
(2.) When symptoms, however slight, indicate that tubercul-
ous deposit has located itself in the lung, removal to a mild
climate, especially if effected by a sea voyage, under favor-
able circumstances, may still be useful as a means of im-
proving general health, of lessening the chance of intercur-
rent inflammatory affections of the pulmonary organs, and
even of arresting the further progress of the disease. The
nausea, squeamishness, or even sickness, which with some
are always more or less associated with a sea voyage, are
beneficial to cases of incipient tuberculosis. The effects of
such nausea tend to increase the natural secretion and
elimination from the pulmonary mucous membrane; so that
minute portions of tubercular exudation, commencing to
consolidate in the air-vesicles, are effectually, gradually, and
gently passed out with the motion of the pulmonary mucus
in the expectoration. The sensation of nausea tends to sub-
due any local vascular irritation; and the unceasing motion
of a sailing vessel tends to keep upa constant exercise which
is advantageous to the patient. (3.) When extensive tuber-
culous disease exists in the lungs, little benefit is to be ex-
pected from a change of climate; and a long journey will
most certainly increase the sufferings of the patient, and
hurry on a fatal termination. (4) There are cases, however,
of chronic consumption which may derive benefit from resi-
dence in a mild climate,—namely, cases in which the deposit
is limited to a small portion of the lungs, and little systemic
irritation prevails or in cases in which the disease has ceased
376 SCROFULA.

to extend to the lungs, but where a long time is required to
complete repair. -

IV. Zhe dress of the scrofulsus patient ought to be of such a
kind as to equalize and retain the temperature of the body.—
Under this topic waterproof coats, boots, and shoes are to be
condemned. Flannel ought invariably to be worn next the
skin in all seasons; and in winter a chamois leather vest may
be required over the flannel.

V. The hours of rest should extend from sunset to sunrise.

VI. Indoor or sedentary occupation must be suspended ; but
outdoor employment in the fresh air, even in the midst of snow,
has been and may be advantageous.

VII. Cleanliness of body is a special point to be attended to in
the hygienic treatment of tuberculosis.

VIII. Marriage of consumptive females, for the sake of ar-
vesting the disease by pregnancy, ts morally wrong and physically
mischievous.

IX. The medicinal treatment must be adapted to the site of
the local scrofulous deposits and the general nature of the par-
uicular case.—Iron and iodine in various forms are the most
useful remedies; but medicine is utterly powerless and use-
less unless the hygienic means now insisted upon are carried
out to the utmost.

(c.) Medicinal Treatment-—When medicine is required to
move the bowels, as it often is, nothing serves so well as pow-
ders of rhubarb, soda, and calumba, taken three times daily,
or morning and evening only, or an hour before food. Mer-
cury in any form is not borne by scrofulous patients. Lime-
water to the extent of half an ounce taken with milk, three
or four times a day, is of marked benefit in those cases of
long standing where gland after gland becomes the seat of
abscess and ulcer (Shapter). The muriate of barytes, next
to iodine, exerts the most decided influence over scrofula.
It increases the appetite and the secretions (Adair, Crawford,
Phillips). The whole class of tonic remedies are of essential
service; such as, small doses of quinine with conium; iron in
all its most digestible forms (see under anzemia). The em-
ployment of acids is often also called for, especially if ‘per-
spirations become excessive. A useful formula consists of:

Acid Hydrocyan. dil. 31., glycerine % ii; acid nitric. dil.

3 1i., Infus quassiz ad 3 xitiss—a tablespoonful for a dose.

But of all remedies iodine and its compounds are the most
valuable in scrofula. The following formula is that which
Dr. Shapter has found most useful:
SMALL-POX. ; 377

R.. Iodine gr. x.; potasse hydriodatis gr. xx., aque § ii.
From 8 to 12 minims are to be dropped into a glass of water
and taken three or four times a day by an adult.

It improves appetite and the complexion; subdues the
general symptoms, and promotes absorption of the scrofu-
lous glandular swelling. Iodism or iodic saturation must,
however, be very carefully guarded against.

Small-pox.—Definition—Small-pox ‘in man is the pro-
duct of a specific and palpable morbid poison, which is re-
produced and multiplied during the course of the malady.
It is contained in the contents of the pustules, and in the cu-
taneous and pulmonary excreta of small-pox patients. After
a definite period of incubation (of about seven to nine days,
in cases of inoculated, and from.ten to thirteen days by ordi-
nary infection) a remitted fever is established, and followed
by an eruption.on the skin on the third day of the fever af-
ter forty-eight hours’ illness, and sometimes on the mucous
surfaces. The eruption on the skin passes through the stages
of papule, vesicle, pustule, scab, and leaves marks or cica-
trices on its site. The disease runs a definite course, and,
as a rule, exhausts the susceptibility of the constitution to
another attack.

Treatment.—Since the first accounts by the Arabian phy-
sicians of the ravages of small-pox in Mecca, the history of
this disease may be considered in three great eras, each of
which is characterized by remarkable epochs, and a fourth
may be said to be running its course now. The first of these
eras is marked by a commencing epoch of improvement in
the treatment of small-pox. In few diseases has medical
opinion undergone a more obviously beneficial change, and
to Sydenham is due the merit of this revolution in medical
practice. The epoch of the second era is marked by the
discovery of the singular and ‘beneficial phenomenon. that
the virulence of the poison of small-pox was greatly mitigated
by introducing or engrafting the disease into the system,
through the cutaneous tissue, thereby causing the transfer-
ence of the disease from one person to another, by inocula-
tion. To Lady Mary Wortley Montague is due the merit
of having introduced the practice of inoculation into this
country in 1722—a deed which must be considered as one
of great heroism, when measured by the knowledge possessed
by the physicians of those days. The third great era in the
history of small-pox is marked by the epoch of that remark-
able discovery which has rendered the name of Jenner im-
378 SMALL-POX

mortal—namely, the modifying and protecting influence of
vaccination. He found that a certain disease in the cow,
known as the cow pox, could be transferred to the human
subject by inoculation ; and that, having been so transferred,
it modified, to a considerable extent at least, the course of
the disease, if it did not altogether prevent in the human sub-
ject the occurrence of small-pox in its natural state. A
fourth era may be said to have commenced in this country
almost imperceptibly. It may be described as marked by an
epoch of transition, in which doubt and scepticism have
arisen as to the efficacy of vaccination ; tending to propagate
an erroneous popular belief ; and consequently, leading to
the ineffective adoption of means which practically have
been proved to be sanative in the highest degree. In other
countries, on the contrary, and especially in Central Europe,
this present period is marked by implicit faith in the virtues
of vaccination, and the successful legal enforcement of this
sanative measure. The most plausible objections to vaccina-
tion must now give way before the one great fact that, dur-
ing the last century, one-tenth of the population died of
small-pox, while another tenth were disfigured for life by the
disease ; and that since the introduction of vaccination, the
general mortality from all diseases is less, and that of small-
pox is reduced to a minimum.

An account of the treatment of small-pox resolves itself,
therefore, into a consideration of two topics, namely,—(z.)
The usual therapeutic, curative, or sanative treatment of the
disease ; (2.) The sanitary treatment—vz. ¢., the means of
protecting individuals from the small-pox ; or of modifying
the influence of the malady by inoculation or by vaccination.
Of these in their order,—-

I. Therapeutic, Curative, or Sanative Treatment of Smalt-
Pox.—The main object, in the first instance, is to prevent,
if possible, a copious eruption ; for the severity and danger
of the disorder may be measured, in some degree, by this.
The vulgar belief, that “better out than in,” does not apply
in the case of small- -pox. The great object is to reserve the
strength of the patient ; and the attentions of an experienced
nurse are demanded. A third indication is to watch for and
deal vigorously with intercurrent inflammatory action, which
is apt to be set up. It has hitherto been the belief and ot-
thodox teaching, that the disease is not under the influence
of any specific or antidote ; that there is no remedy which
will cut short the disease ; that it must run its course ; and
SMALL*POX, 379

that it is the business of the physician to assuage the unto-
ward symptoms and avert the dangerous accidents which
may arise, by all the most approvéd methods of treatment,
in accordance with the science of medicine of the present
day. That there are grounds for modifying this belief and
dogmatic teaching, the following statements will show :—
The chief physician of Iceland, Dr. J. Hjaltenin, believes
that it may be stamped out by the action of sulphur-
ous acid gas; and relates how, in its malignant
form, it was so treated, and stamped out of that
island without a single person of the inhabitants
becoming infected. The disease was imported into Iceland
by French fishing vessels coming into the harbor of Rey-
kjavik, to ask for medical aid; having on board men sick of
small-pox. Vaccination and revaccination were immediately
instituted; and government at once erected a quarantine
hospital, to which the cases were taken from the ships. The
epidemic showed a high degree of malignancy; and Dr.
Hajaltelin, being a firm believer in the power of disinfect-
ants and antiseptic remedies, resolved to try such remedies,
one after another; the only question being whether
to use those compounds which. acted by oxygenizing or by
disoxygenizing. He ultimately decided to use the disoxygen-
ating antiseptics, as being the most safe; and fixed upon
sulphurous acid as less irritant for the respiratory organs
than chlorine. He used it externally by fumigation, by
burning refined sulphur in the sick rooms, and internally by
giving sulphurous acid mixed with pure water—the usual
dose being 31, mixed with one ounce of water, and repeated
every third hour. The patients at first disliked the fumiga-
tion, from the strong and pungent odor of the sulphur; but
they soon felt its good effects and desired to have more.
These good effects were,—the heat of the eruptive fever
diminished, and the vesicles dried very quickly, leaving the
skin covered with thin brown scales, which soon fell off.
Out of 22 patients so treated he only lost one, who came to
the hospital moribund, and who died thirty-nine hours after
arrival, Seven had confluent small-pox; and of these three
were in the suppurative stage. Others were cases of discrete
small-pox having the eruption of vesicles abundant. He
thus sums up the good effects of the disinfectant method of
treatment by sulphurous acid externally and internally:—
(1.) It mitigated the primary and secondary fever; lowering
“the temperature, and thirst was diminished, even when fever
380 SMALL-POX.

ran high. (2.) The general symptoms were also lessened in
severity, such as the headache, backache, and pains in the
joints. (3.) He believed the sulphurous acid and vapors
had a destructive influence on the small-pox virus. Its de-
structive effects on parasite life are undoubted (Brit. Med.
Journal, Nov. 4. 1871, p. 519).

Treatment by Vaccination.—There are also some grounds
for believing that vaccination and the hypodermic injection
of vaccine lymph “may curb the small-pox,” even when
performed.at a period subsequent to the reception of the
variolous poison: and the observations and practice of Mr.
R. C, Furley, detailed in the British Medical Journal for
June 8, 1872, show that vaccination will modify small-pox
after the eruption has appeared. An impression prevailed
that it was dangerous to be vaccinated while small-pox was
prevalent; and also that it was of no use to vaccinate so
long as the former vaccination mark was quite distinct.
Both these ideas are opposed to facts. On the contrary,
Mr. Furley’s cases show that vaccination, and the injection
of vaccine lymph, especially if done about the second or
third day of the disease, possess valuable curative powers, so
that a disease which promises to be most severe is curbed or
modified. Mr. Furley uses a hollow needle for injection, the
bore of the tube of which is large enough to admit a vaccine
tube, from which the lymph is forced directly into the circu-
lation. He injects hypodermically in both arms.

Dietetic and General Treatment.—In the first instance, the
course to be pursued is for the physician to act on the de-
fensive, and simply protect his patient from certain injurious
influences to which he may be exposed,—such as, heating
drinks to force out the eruption, which are apt to be given
by ignorant and officious friends. Throughout the whole
course of the disease, the diet should be strictly limited to
slops, sago, arrow-root, and ripe fruits, with cold water or
lemonade for drinks, with or without ice. The chamber in
which the patient lies should be cool, not above 60° Fahr.,
and freely ventilated. The bed-clothes should be light, the
body-linen daily changed; and, when the disease is long, the
patient’s back should be often examined to prevent slough-
ing. The scalp, likewise, should be examined, and, if full of
pustules, the hair should be cut off, to prevent its matting.
If the disease be recognized early, however, it is proper to
shave the scalp, because the irritation which attends the
suppuration of the pustules is thereby diminished, and cold
SMALL-POX. 381

may be more efficiently applied to the head, if necessary.
In the early stage of the primary fever, in severe cases more
especially, it is necessary to have the bowels well opened in
the first instance, and to keep them regularly moved daily by
saline medicine, or an enema of three parts water to one of
vinegar. A cathartic pill, composed of the following in-
gredients, will be found to be efficient in most cases, especi-
ally if aided by a Seidlitz power, given six or eight hours
after the pill; namely,—Two grains of calomel, one grain of
the compound extract of colocynth, one grain of gamboge,
and one grain and a lialf of scammony, made consistent with
a little aromatic oil The bowels must be daily attended to,
and castor-oil, or rhubarb, or magnesia, may sometimes be
required. Saline diaphoretics, in the form of James’s powder;
of the aqua acetatis ammoniz, to which a grain or two grains
of tartar emetic has been added, so as to have } or 5 of a
grain in every tablespoonful of the mixture, is an efficient
and cooling diaphoretic. Spirit of nitric ether, or the nitrate
of potass, may be added if required. The surface of the
body, over the hands, face, and feet, ought to be sponged
several times a day with tepid water mixed with Condy’s
fluid, or with sulphurous acid, with a view to relieve the
intolerable itching; but caution is necessary to prevent ex-
posure to cold. Cold-cream, or a liniment of olive oil,
glycerine, and lime-water, or of Carron oil (linimentum aqua
calcis), smeared from time to time over the itching surface,
by means of a camel-hair pencil, may be found to afford re-
lief; and chlorine lotions are highly spoken of by Eisenmann,
With regard to the occurrence of convulsions in children, it
is not found that opiates, as recommended by Sydenham and
Cullen, are expedient. When the children are robust, or
previously in good health, local bleedings, by means of one
or two leeches to the temples, are more beneficial. Delirium,
violent screaming, intolerance of light or sound, heat of
head, all of which indicate a tendency to meningeal conges-
tion, still more clearly warrant the application of leeches.
With regard to the propriety of bleeding (general) in adults,
it is now well ascertained that it will neither eradicate the
fever nor diminish the amount of the eruption; moreover,
experience has now amply shown that loss of blood is badly
borne in all infectious diseases. The persistent application
of cold to the head, and repeated affusion of the body with
cold water, is to be preferred, in cases where there is much
cerebral excitement. When delirium, with restlessness,
382 SMALL-POX.

wakefulness, and a frequent pulse, is continuous, an opiate,
or the free use of alcoholic stimulants, are indicated; and
opium is most advantageously given combined with tartar
emetic. A draught, composed of thirty minims of the solu-
tion of muriate of morphia, with half a grain of tartar emetic,
will be found beneficial in such conditions, especially when
given at bed-time. If the temperature rise higher, large doses
of quinine, 3 to 5 grains, every three or four hours, are to be
given. Cooling drinks, with or without ice, of lemon-juice,
tamarinds, neutral effervescing powders, are always agreeable
to the patient, who ought, for the sake of coolness, to be
very lightly clothed. After the eruption has fully appeared,
this is all which in ordinary cases requires to be done, and
if, towards the tenth or eleventh day, there is much restless-
ness or sleeplessness, an opiate may be given.

In the complications which sometimes ensue, such as in-
flammation of the throat and base of the tongue, opiates are
found to be injurious. The general treatment must be by
cathartic or purgative clysters, if swallowing is difficult. In
the other inflammations, however, opiates are of the greatest
service, provided the symptoms be not those of cerebral op-
pression or bronchitis. In bronchitis, nauseating doses of
antimony every hour sometimes procure relief; and if relief
does not follow in the course of thirty to thirty- -six hours,
stimulant doses of mistura ammoniac with squills ought to be
given every second hour to promote free expectoration.

In the advanced stage of the secondary fever the strength
of the system requires maintenance and support; because
the abundant suppuration and extensive cutaneous irritation
combine to exhaust the strength, as shown by the weakened
pulse, the dark and dry tongue, blueness, paleness, or cold-
ness of the extremities. Tonics, stimulants, and generally
nutritious diet, are now called for. Quinine, mineral acids,
malt liquors, especially the light bitter ales, light porter, wine,
and even brandy, may be demanded. The diet should con-
sist of milk, strong animal broths, eggs, raw or lightly boiled,
according to the discretion of the physician, and regulated by
the digestive powers of the patient.

The development of a severe eruption on the conjunctiva
is to be especially guarded against, by the assiduous employ-
ment of cold water applications, or by compresses moistened
with a weak solution of corrosive sublimate (one grain to six
ounces of water, with or without the addition of muriate of
ammonia (Niemeyer),
SMALL-POX. 383

To prevent the face from being seamed, scarred, or
“pitted” by the suppuration of the pustules, has taxed the
ingenuity of physiologists and physicians. It has been stated
that the influence of the atmospheric air is essential to the
development of ths pustules, and, accordingly, anything
which would effectually exclude this influence would prevent
the occurrence of ascar. But it is evident that the chance
of scars can only be diminished by those means which are
calculated to allay the general violence of the disease. When
the eruption is severe, it is almost impossible to prevent the
formation of “ pits,” because the depression results from the
expulsion of a small slough; and the more mild the suppura-
tive inflammation can be rendered, so in proportion will the
chance of sloughing, and therefore “pitting” be dimin-
ished.

The local means which have been adopted to prevent
“pitting” may be shortly stated as follow:—(1.) To open
each individual pustule after suppuration has commenced.
(2.) To cauterize the pustules with nitrate of silver. (3.) To
employ both methods—that is, to open each of the pustules
when it becomes vesicular, and introduce a strong solution of
nitrate of silver into the cavity of the vesicle. At the end of
a week scales fall off, and no pit is left. Or, lastly, to paint
the face with a solution of nitrate of silver, in the proportion
of one drachm of the nitrate to the ounce of water. (4.) The
application of a mercurial plaster, with the view of producing
resolution of the papule. The preparation in use for the
purpose at the Children’s Hospital in Paris consists of twenty-
five parts of mercurial ointment, ten parts of yellow wax, six
parts of black pitch. With this plaster the face is to be cov-
ered, and so to remain for several days, (3-) Sulphur oint-
ment, applied several times a day. (6.) Calamine mixed with
olive oil, to form a coherent crust (Bennett). (7.) Tincture
of iodine, painted over with abrush. (8.) Saturated solution
of gutta percha in chloroform (Drs. Graves and Wallace).
(9.) To smear the face over with common olive oil. (r10.)
Skoda prefers compresses moistened with solution of corro-
sive sublimate (two to four grains in six ounces of water) to
mercurial plaster, which induces too much elevation of tem-
perature. (11.) Hebra recommends cold water compresses
only.

All of these applications have been for the most part, ap-
plied to the face, the hands, and the arms only

The severity and the mortality of small-pox have led many
384 SMALL-POX.,

to think of means by which the disease might be completely
extirpated. This leads to the consideration of—

Il. Lhe Prophylactic, Sanitary, or Preventive Treatment of
smatl-pox.—Morc than half a century azo it was generally
taught, among English physicians, that small-pox attacked
the same individual only once in the course of life, and that
its double occurrence in the same person was either very rare
or next toimpossible. The observations of Drs. Willan, John
Thomson, Mr. Cross, Dr. Barnes, Dr. Craigie, and others
since the time of these eminent physicians, lead to the follow-
ing general conclusions :—(1.) Small-pox, though in general
attacking the same individual only once during the course of
life, may, however, affect him a second, and even a third
time. (2.) This happens much more commonly when. the
first attack has been one of mild distinct small-pox, than
when it has been severe ; and if the first attack has been one
of confluent small-pox, it is rare for the same individual to
have a second attack. (3.) It is established by numerous ob-
servations, that an attack of any one of the varieties which
have been named spurious small-pox, or abortive small-pox,
or chicken-pox, by no means secures the same individual from
an attack of confluent small-pox at asubsequent period. (4.)
Small-pox produced by inoculation does uot necessarily se-
cure the individual against an attack of small-pox induced in
the natural way. (5.) Every previous attack, however, of
small-pox, whether natural or inoculated, exercises some
modification on that whichsucceeds. This modification may
be various in degree, from very slight and almost impercepti-
ble to very conspicuous and remarkable. In this modifica-
tion the symptoms of eruptive fever may be mild and of
short duration ; and the eruption may consist of vesicles or
hard pustules, which disappear without suppuration. (6.)
The most powerful modifying agent on the course of
small-pox is the action of the cow-pox on _ the
constitution, or the disease produced by the appli-
cation of vaccine lymph to the exposed skin. The specific
disease so induced, in a large portion of cases, not only ren-
ders the individual less likely to be affected by the variolous
effluvia, but, if he is affected, changes very much the charac-
ters of the disease which may supervene. Though the fever
which precedes the eruption in cases of this class be similar
in form and equal in degree to that by which the inoculated
small-pox is attended, the eruption is either papuliform or
tuberculated, without much surrounding inflammation. A
SMALL-POX. 385

similar eruption is produced when vaccine and variolous mat-
terare inoculated at the same time in the same individual;
or when a person who is exposed to the variolous contagion
has been inoculated with vaccine lymph early enough to mit-
igate, but not wholly to supersede, the eruption of small-pox.
In such circumstances the vaccine lymph and variolous mat-
ter restrain and counteract the operation of each other on
the system and on theskin. To these eruptions of modified
small-pox the general name of varioloid eruptions has been
applied. (7.) Cow-pox destroys the susceptibility to inocu-
lated small-pox almost entirely; but the susceptibility to the
natural disease, or that by inhalation, it does not entirely ex-
tinguish. This susceptibility, however, it diminishes in a
much greater degree, and much more effectually, than in-
oculated small-pox does. (8.) The susceptibility to second
attacks of small-pox,* and attacks of small-pox after vaccina-
tion, is principally favored by the existence of an epidemic
constitution of the atmosphere, and by the circumstance of
early life, or the age below ten years. If no epidemic influ-
ence exists, the occurrence of second attacks of the disease
may not be observed for a long series of years. But if, on
the other hand, the atmosphere should possess or acquire an
epidemic or variolous constitution, then neither the circum-
stance of a previous attack of small-pox, nor vaccination,
can insure many of those under ten years of age, and not a
’ few between that and thirty, from attacks of small-pox.

The preventive management of small-pox consists: (1.)
In the artificial production of the disease by inoculation, or
artificial variolation. (2.) In the modifying and protective
influence of vaccination.

Inoculation consists in the application of small-pox matter
or virus.to the surface of the corium, exposed by a puncture
or scratch. The result is a local inflammation similar to
small-pox, attended with an eruption and a fever, generally
milder in form than small-pox acquired by breathing an at-
mosphere contaminated with the specific poison of the dis-
ease. The poison thus passes through the mucous mem-
brane to infect the blood; and hence thisis called the “nat-
ural way” of contracting small-pox. For obvious reasons,
the operation of inoculating the poison of small-pox has been

 

* The average number of second attacks of small-pox seems to be one
percent. (R. Acad. of Med., Marseilles, 1828 ; and B, and F. Med,-

Chir. Review, Jan., 1848, p. 74).
25
386 SORE THROAT, CLERGYMAN’S—ST. VITUS’ DANCE,

rendered illegal in this country, and the practice of vaccina-
tion has been attempted to be enforced by law.

Sore Throat, Clergyman’s—Sce Pharyngitis, Chronic.

Sore Throat, Sloughing.—~ Definition. — Idiopathic
ulceration of an acute form, attacking the tonsils and rapidly
running into sloughing of the fauces.

Treatment.—In all cases of sloughing sore throat a stimu-
lating and tonic treatment must be pursued. Tincture of
the perchloride of iron, quinine, and chlorate of potash, are
the most suitable internal remedies. Disinfecting gargles of
carbolic acid or permanganate of potash are not. only agree-
able to the patient, but very useful in checking the offensive
discharges.

Spasm of Muscle—Sve Muscle, Spasm of.

Spleen, Inflammation of—Sce Splenitis.

Splenitis.—Definition.—A primary acute inflammation
of the substance of the spleen.

Treatment.—Bleeding in splenitis will not effect a cure,
while mercury is most pernicious. A spleen mixture, not-
dissimilar to that recommended by Celsus, is most in vogue
in India. The best, according to Mr. Twining, consists of
the following:

BR. Pulv. Jalap.; Pulv. Rhei.; Pulv. Calumba; Pulv. Zin-
gib; Potass. Supertart., a a 3 j.; Ferri Sulphat., ‘Dss.; Tinct.
Senne 3ss.; Aquz Menthe Pip., Zixss. Of this mixture
an ounce or an ounce aad a half is to be taken twice a day,
or such quantity as may produce three or four stools in the
twenty-four hours.

The iodide of potassium and the bromide of potash have
been more recently recommended. The dose of the bro-
mide of potash is gr. v. to x. ter die, combined wlth camphor
mixture. The marked influence of ‘the biniodide of mercury,
in the form of an ointment rubbed into the skin over the
surface of a goitre, in reducing its enlargement, has been al-
ready noticed. It has been similarly used in cases of en-
larged spleen ; and the invalid soldiers who suffer from
enlarged spleens invariably apply for some to take away with
them when they are discharged from Netley Hospital.

Spinal Cord, Inflammation and Suppuration of—
See Encephalitis.

St. Vitus’ Dance—See Chorea.
STOMACH, CHRONIC ULCER OF. 387

Stomach, Chronic Ulcer of.— Definition —Inflamma-
tion of the stomach, ending by loss of substance in the form
of an ulcer.

TLreatment.—Chronic ulcers are to be treated by rest to
the stomach, and by dietetic rather than by medicinal means.
The patient must eat in small quantities, especially of milk
compounded with arrow-root, macaroni, semolina, sago,
tapioca, biscuit powcer, barley meal, Indian meal, or oat:
meal-gruel. Iced milk, combined with one-quarter to one-
third of lime-water, is particularly recommended, two or
three tablespoonfuls of which are to be taken at short in-
tervals; so that about two quarts of milk may be thus used
during the day; rendering regular and more bulky meals un-
necessary. The lime-water tends to prevent coagulation,
and the milk more readily passes unaltered into the intes-
tines, to be digested by them rather than by the stomach.
The most complete rest possible ought to be given by stop-
ping the supply of all nutriment by. the mouth, and support-
ing the patient for several days by nutritive enemata. Per-
fect quiet in the recumbent posture must be observed, the
lips and tongue being moistened from time to time by a
little water. The patient may thus be kept for eight or nine
days, or even longer, on nutrient enemata alone, when the
pain, the irritability of stomach and of the system will cease.
The substances most useful for enemata are milk, strong un-
salted beef-tea, raw eggs beaten up in milk, occasionally a
little brandy, and (generally in two enemata daily) ten or
twenty minims of tincture of opium. The enemata should
be as small as possible, from two to six ounces only ata
time. The interval to the stomach thus gained of complete
rest is of the greatest importance towards success in the
treatment of gastric ulcer; and, combined with the restricted
diet described, will usually effect a cure in three weeks (Dr.
Balthazar W. Foster, of Birmingham, rit. Med. Journal,
June 3d, 1865). Next to dieting, blood-letting by two or
three leeches, applied to the region of the stomach about
twice a week, affords obvious benefit. Blistering applied to
the spine may relieve the dorsal pain. Small lumps of ice
may be swallowed if the stomach is irritable; and astringent
remedies, especially the salts of metals, such as a combina-
tion of iron and alum, are of use; and gallic acid, nitric acid,
and bitter barks may be administered. Constipation is to
be counteracted by enemata. When hemorrhage occurs,
small bits of ice may be swallowed, and rest maintained in
388 STOMATITIS.

the horizontal posture. Astringent medicines are to be ad-
ministered, such as oil of turpentine, acetate of lead and
opium, alum and tannic acid. Oil of turpentine should be
given in doses varying from ten to twenty minims in cold
water, and repeated more or less frequently according to the
urgency of the symptoms. Ergot may also be employed.
When hemorrhage is copious, a mixture containing ten
minims of diluted sulphuric acid and five grains of gallic
acid in water, taken every two or three hours, is the best
remedy (Dr. B. Foster). Vomiting may be relieved by dilute
hydrocyanic acid (five minims), combined with bicarbonate
of soda (twenty or thirty grains) in solution, repeated every
two or three hours. The subnitrate of bismuth, in doses of
ten to twenty grains, every six or eight hours, alone or com-
bined with five to ten grains of compound powder of kino,
has a remarkable effect in relieving pain, vomiting, and
diarrhoea (Brinton). Seller’s bismuth mixture is also an
efficient remedy.

Stomatitis.— Definition.—Inflammation of the mouth.

Treatment.—The mouth should be frequently washed with
emollient fluids, such as linseed infusion, diluted glycerine
and biborate of soda, or honey mixed with biborate of soda.
The following lotion may be painted over the lips and
mucous membrane of the mouth and tongue, namely:—
Sodz Biboratis, fl. dr j.; Glycerini, fl. oz. ii; Aqua Rose, fl.
oz. iv.; misce (Tanner). Creasote, vinegar, carbolic acid,
glycerine, and alcohol are also recommended as local appli-
cations. The late Dr. Symonds, of Bristol, recommended
combinations of turpentine, with glycerine and alcohol;
equal parts of turpentine and glycerine, applied with a soft
brush two or three times a day, being, in his opinion, a
curative application, whether the lining of the mouth be red
and puffed, or pale and cedematous, or studded with super-
ficial ulcers, or opaque yellow accumulation of secretion or
epithelium. He also recommended that follicular ulcers on
the inside of the lips and cheeks and tip of the tongue should
be treated by sulphate of copper applied once or twice a day
(Brit. Med. Journal, March 13th, 1868). In severe cases,
where the breath becomes fetid, with the submaxillary glands
large and swollen, the lips and gums tumid, the face flushed
and swollen, and the fever intense, chlorate of potash must
be freely given internally, to the extent of five grains every
four or six hours. Besides these remedies, the solution of
the pernitrate of iron, internally, has a beneficial effect upon
STOMATITIS, GANGRENOUS—SUNSTROKE. 389

the sores, prescribed in the following formula:—Lig. Ferri.
Pernitratis, gtt. xl; Syrup. Aurant, fl. oz. ss.; Aque, fl. oz vss.;
misce. A fourth part may be given to a child three or four
years of age four times a day (Dunglison). In cases where
parasitic vegetable productions abound (parasitic thrush),
the application of a solution of sulphite of soda (fl. dr. i. to
fl. oz. i. of water) removes the deposit in twenty-four hours
(Jenner), The secretions of the mouth being acid, the salt
is decomposed, and sulphurous acid is set free, which de-
stroys the parasite. A change of air is often absolutely
necessary to restore the patient to health; and arsenic and
jodine, combined with good diet, are useful restorative
agents in repairing the faulty nutrition of the child.

Stomatitis, Gangrenous—Scee Cancrum Oris.

Struma—See Scrofula.

Sunstroke.— Definition An affection of the nervous
system associated with vertigo and sometimes with head-
ache, or the gradual accession of ‘listlessness and torpidity,
with a desire to lie down (Longmore, Barclay). These fe-
brile phenomena may culminate in more or less sudden in-
sensibility, without the powcr of sense or motion, the breath-
ing rapid, and getting more and more noisy as death ap-
proaches. Convulsions of the extremities when in a com-
plete state of coma, in which the patient gradually dies. The
approach of death is indicated by the failure of the heart’s
action, the fluttering of the pulse, the irregularity of the res-
Piration; and the fatal event may supervene within five min-
utes to a few hours after the disease has become fully ex-
pressed. Death is either by syncope, apnoea, or by a com-
bination of the two. In cases which recover, various seque-
le are apt to supervene, such as forms of paralysis, more or
less complete, choreic movements, melancholia, and other
forms of disorder of the intellect.

Treatment.—Keeping in view the nature of this disease,
and the various modes in which death may approach, the
line of treatment may be indicated as follows:

With regard to the class of cases in which death tends to
occur suddenly from syncope, there is little. opportunity af-
forded for treatment; but the measures indicated are,—re-
moval to a cooler place, if possible, as from the engine-room
or stoker’s place on board steamships to the open deck; the
cold douche, but not too prolonged; keep the surface wet
and exposed to a current of air, or assiduously fanned: ex-
390 SUNSTROKE.

clude light as fa1 as possible; remove 6r loosen tight and
oppressive clothing; the immediate employment of stimu-
lants, external and internal, by the rectum as well as by the
mouth, and ammonia to the nostrils. Depletory measures
of any kind are not to be thought of. In the less rapidly
decisive cases prompt treatment is of the greatest use, while
delay is fraught with the greatest danger. The patient must
be immediately stripped of his outer clothing; and, being
placed in a semi-recumbent position, the cold: douche is to
be applied, from a height of three or four feet, over his head
and along his spine and chest, his extremities being at the
same time sponged over with cold water. Relaxation of the
pupil is the first symptom that shows the good effect of the
treatment, which may require to be repeated several times,
on account of returning insensibility; but if there is any evi-
dence of failure of the pulse, this treatment must be discon-
tinued, and the application of cold to the head is then all
that can be borne. Stimulants administered by the rectum
are recommended by Dr. Levick, to counteract the tendency
to prostration. In some cases in India rousing by flagella-
tion with the sweeper’s broom was had recourse to with good
effect by Sir Joseph Fayrer. The hair is to be cut short as
soon as possible, and a blister applied to the nape of the
neck, the surface having previously been well sponged over
with the acetum lytte. When the first violence of the attack
is subdued, increasing confidence in the ultimate result may
be indulged in so soon as vesication takes place; and in
cases where insensibility recurs, after an interval of ten or
twelve hours, it may be removed by the application of a
second blister to the vertex; which may even be again re-
peated, there being no doubt as to the good effect it pro-
duces. Sir Joseph Fayrer, on the other hand, expresses a
want of faith in their efficacy. A blister may also some-
times be applied along the spine in the worst cases. Stimula-
tion by the use of the electro-galvanic current, with the
moist sponges applied along the sides of the neck, chest,
epigastrium, ought also to be employed. Sinapisms ought
generally to be applied to the extremities, and to the chest
or sides. :

As soon as possible after the employment of the douche,
a strong purgative enema ought to be given, those of a stim-
ulant nature being preferred. But as the enema may have
to be repeated several times before any effect is produced
on the bowels, it may be advisable to let the first enema be
SUNSTROKE. 391

of asimple purgative character, and afterwards let it be fol-
lowed up by turpentine enemata.

If cerebral congestion is indicated by the state of the eyes
already described, a few leeches to the temples may relieve
the congestion (Longmore, Barclay); but the prevailing
opinion among medical officers of experience in the treat-
ment of this disease is against the employment of blood-let-
ting by venesection, even in severe cases, In all the cases
which have been recorded in which it has been employed, it
seems to have been generally hurtful, and to have hastened
the fatal termination. In cases when it has seemed at first
to give relief and to mitigate the symptoms, the improvement
has been only transient, and followed by relapse into a more
dangerous and fatal condition. But no absolute rule can be
laid down in regard to abstraction of blood. There are
cases in which it may be necessary, in order to avert suffo-
cation; but they are the exception, and it is possible there
may be more danger to life in the laboring and distended
heart and the embarrassed iungs, than in the loss of a few
ounces of blood; which, if it would have tided the patient
over the danger, as it sometimes might do, would be the
lesser evil, and as such should be chosen. Each case must
be treated on its own merits (Sir Joseph Fayrer).

In cases where the breathing is much oppressed, and the
bronchial tubes loaded with mucus, the patient should be
turned occasionally over on his face and side. In the con-
vulsive form of the disease, where the greatest irritability of
the nervous system prevails, the douche is found to be inad-
missible, from the agony which it occasions. In such cases
Dr. Barclay has seen great benefit from the inhalation of
chloroform. After a few inspirations the convulsions for the
most part ceased, and sleep was very easily induced; but in
one or two instances, after a considerable interval of con-
sciousness, febrilc symptoms increased in severity, coma
supervened (probably effusion having occurred within the
cranium), which was followed by death. But the cases in
which chloroform can be used are comparatively few; and
very great care is necessary in its employment, so that the
inhalation may be suspended at once, as soon as any effect
is produced upon the pulse.

In the most severe forms of the disease the principle of
management is to reduce as quickly as possible the blood.
heat, and that before tissue changes have begun. As the
hyperpyrexia is due not only to the direct operation of heat
392 SUNSTROKE.

on the nerve centres, blood, and tissues, but to the fever
set up by vaso-motor disturbance, those remedies are
indicated which have been already mentioned as useful
for the reduction of temperature. The unduly heated blood
is a poison for the cardiac and vaso-motor centres tend-
to cause death, either by syncope or asphyxia. This
is best effected in sunstroke by rubbing the body over with
ice, as large. as can be handled, as recommended by Dr.
Levick, and as has been proved to be successful by Baumler
and Dr. Woodman at the London Hospital. Tepid body
baths, with cold affusion to the head and back of the neck,
or general cold affusion, may be employed; also, injections
of iced water. Keeping pieces of ice in the axilla until there
is returning consciousness, which may not be for several
hours, and, therefore, great caution is required in such use °
of ice, so as not to induce gangrene of the skin, or continued
depression, as indicated by a thermometer in the mouth,
axilla, or rectum.

The sequela of sunstroke are generally, persistent head-
ache, fixed or shifting pain in the back, choreic movements
of the forearm and hand, convulsive disorders, mental weak-
ness. These symptoms are suggestive of hematoma of the
dura mater, as a probable lesion in such cases, and indicate
rest, attention to the functions of the skin, and change of
air, and removal front a hot to a cold climate. All stimu-
lants and all excesses of diet, or errors in diet, are to be spe-
cially guarded against. When the pain is fixed and severe,
long-continued counter-irritation at the nape of the neck,
and a course of iodide of potassium, may bénefit the patient;
but many cases are quite unrelieved by treatment, as the
records of the invaliding hospital at Netley show every year
(Dr. Maclean).

Measures for the Prevention of Sunstroke. —(z.) If a march
is to be undertaken during hot weather in India, all weak
and sickly men should be weeded out and left behind. (2z.)
The costume should be suitable for the early morning hours
before sunrise, as well as for the scorching period which fol-
lows, when the men are for the most part in their tents. It
should consist of materials of slow conducting power, of a
color by which heat is not readily absorbed, and its fitting
should be as loose and light as possible. A flannel shirt
should be worn, to prevent exposure to sudden chills, and a
ilamnel belt round the loins may be worn with advantage,
except in the hottest weather. The shirt-collar should either
SUNSTROKE, 393

be open, or made so wide as to prevent all risk of its press-
ing injuriously on the veins of the neck: Above all, some
form of knapsack should be devised other than that hitherto
in use. The authorities, strongly urged by the late Dr.
Parkes, have adopted a valise equipment, which is a great
improvement on the older knapsack, and Surgeon-Major W.
S. Oliver has devised another, which has also been favorably
reported upon. Both of‘them do away with the use of cross-
belts, so injurious to the functions of the organs within the
chest. The march ought not to commence too early in the
morning. The troops should be on the new ground about
an hour after sunrise, and the pace should never exceed
three and a half milesan hour. There should be a halt for
seven or eight minutes every hour, or oftener, if the men are
exhausted; and a longer halthalf way, when each man should
have a cup of coffee and a biscuit, They ought also to have
their ration before starting in the morning. An ample sup-
ply of water should be provided for themen by “‘ bheesties”
attached to each company, and always compelled to march
with it. No man should be allowed to fall out without be-
ing accompanied by a non-commissioned officer, who should
bring him to a medical officer at once if sick, and if not, he
should bring him up to the column at the halt. Allmen so fall-
ing out should be brought up to hospital tents for examination
immediately on the arrival of the regiment in camp. Themen
should carry nothing on the march but their rifles and am-
munition—the quantity of the latter being kept as small ‘as
is consistent with safety. They should be allowed to march
“easy” and loosely clad, more particularly in passing
through jungles or ravines. No halt should ever take place
on such ground when better may be had within a moderate
distance. When the sun is up, halts should be so timed that
shelter may be obtained by open topes. Camps should be
formed on as high and open ground as possible. The sites
for camps in India marked out by the “ official” pillars, are
generally the most objectionable that could have been select-
ed (Barclay, Indian Sanitary Commissioners, and others).
As much space should be allowed between the tents as the
ground will admit of. Tents should be pitched as speedily
as possible, camels and elephants being provided for their
transport—carts never. “ Kus-kus” matsshould be kept
constantly wet.

Troops in the field during the continuance of the hot
winds in India should have the best description of tents that:
394. SUPRA-RENAL CAPSULE DISEASE—SYPHILIS,

can be got for hospital purposes, and be provided with the
best known means for keeping them cool. An abundant
supply of water in camp is of the utmost importance, care
being taken that the bags containing it are in good repair,
hung up within easy reach of the men, and kept always filled
with water. Sentries should be under cover during the
heat of the day; and the men should be instructed, when-
ever they go out in the extreme heat of the sun, to puta
wetted towel or thick handkerchief over the head, under
the cap, and around the back of the neck and face. The
men should be encouraged to take exercise during the
cool of the evening; or, at all events, to leave their tents, so
as to permit of their thorough ventilation; and wherever it
is practicable, bathing should not be omitted. Rations of
spirits ought to be discontinued inIndia. It may be a ques-
tion as to what should be substitutedinstead; but all author-
ities are agreed that the system of “spirit rations” tends to
convert young soldiers into drunkards. The sleeplessness,
which sometimes isa premonitory symptom, of the disease,
may be relieved by chloral hydrate combined with bromide
of potassium, followed by a purge.

Supra-Renal Capsule Disease—See Addison’s Disease.

Syphilis.—Dejinition.—The result of a specific living
poison ; or, of “‘asomething ” of an uncertain nature, but ca-
pable of self-multiplication, which breeds in the blood and
tissues, which is introduced into the system solely by con-
tagion, inoculation, or implantation on some part of the body
of a healthy person,—v. ¢., a not yet syphilitic person, gener-
ally through an abrasion or sore consequent on sexual inter-
course with an infected person (acquired syphilis), or by in-
heritance (congenital syphilis). Three weeks or a month
after contagion and absorption of the poison, a peculiar se-
ries of phenomena begin to show themselves, which mark
the general infection of the system, namely,—First, a distinct
specific fever is followed by or attends the development of ;
Second, the principal anatomical signs of general infection,
which consist of—(@.) induration lepers round the spot
where the virus has been implanted ; (4.) induration of the
lymphatic system of glands; (¢.) the development of a cu-
taneous and mucous exanthem ; (¢.) the formation of nodes
or gummatous nodular tumors in the connective tissue gen-
erally, and especially in that of the true skin, bones, mucous
SYPHILIS, 395

membranes and solid visceral organs, ¢. g., liver, brain, lunes
and heart (visceral syphilis) ; (e.) a cachectic condition of the
system which follows and accompanies the phenomena of in-
fection ; and (/.) indurations which may remain in the form
of hardened fibrous tissue in various parts of the body for an
indefinite period of time. The whole course of the disease
is characterized by slow, but progressive development, often
marked by periods of recrudescence.

Treatment. —(a.) Preventive-—There are certain facts
which must be kept in view in the consideration of prophy-
laxis. (1.) The disease spreads principally by sexual inter-
course ; (2.) prostitution is the source whence the syphilitic
virus is ever freshly drawn, and the experience of thousands
of years has shown prostitution, alike in the ancient and the
modern world, to be an unavoidable evil, the suppression of
which is impossible ; (3.) with the intimate relations existing
at the present day between all parts of the world, and the
unbounded intercourse between different places at home and
abroad, which has been developed in recent times, syphilis is
constantly being transported from one place to another. In
the interest of public health it is the duty of the State not
only to limit prostitution, but to exercise a supervision
over it.

Keeping these facts in view, there are other facts which
suggest the direction in which preventive methods for re-
pressing the extent of syphilis ought to be persistently car-
ried out, namely :—(1.) Official supervision over prostitution
has had the most favorable influence in diminishing syphilis.
This is shown in many ways :—(a.) Everywhere it is found
that secret, unwatched prostitution is far more active in the
spread of syphilis than prostitution which is under control ;
(2.) In 1866, the second Contagious Diseases Act was
passed, after long and careful consideration, and is the one
now in force. In the Army Medical Department Report for
1875, it appears that during three years immediately preced-
ing the operation of those Acts, the average annual ratio of
cases of primary and secondary forms of disease was 104.4
per 1,000, whereas in 1875 it did not exceed 45.8, and in the
period from 1870 to 1878, the average rate of prevalence of
the disease fell to 44 per 1,000 men; and further, it appears
that the ratio of primary disease was 53.4 in 1866, but in
1875 it had declined to 33.5. (c.) Through the courtesy of
Sir W. M. Muir, K.C.B., the Director-General of the Army
Medical Department, I am able to give the results for 1878.
396 SYPHILIS,

At fourteen stations under the Act, the average annual
strength of the troops was 53,813, among whom admissions
for primary venereal sores averaged 4o per 1,000, and 78 per
1,000 for gonorrhoéa. On the other hand, at fourteen other sta-
tions not under the Act, the average strength of the troops
being 45,316, the ratio of admissions among them was 86 per
1,000 for primary venereal sores, and 121 for gonorrhoea.
Thus, at the stations not under the act, the average rate of
admission for both forms of disease was 103.5 per 1,000, as
against 59 at the stations under the Act. At these fourteen
stations under the Act, the highest rates of admission for
primary sores were 53 and 54 respectively per 1,000, at
Aldershot and the Curragh ; whereas at the fourteen stations
not under the Act the rates of admission for these diseases
ranged upwards to 140 in Warley, 154 in Dublin, 205 in
Manchester, and 250in London. So with regard to gonor-
rhoea, the highest rate among the fourteen stations under
the Act was 110 at Winchester per 1,000; whereas, at the
fourteen stations not under the Act it ranged upwards
to 151 in London, 161 in Warley, 163 in Sheffield, and 177
in Manchester, per 1,000. (¢.) In unprotected [The
term unprotected district is meant to include the principal
cities of the United Kingdom where women can practice
prostitution in any public thoroughfare, at any hour of the
day or night, without hinderance, and inveigle men to their
homes ; and this, too, under the very eyes of the authorities,
who are powerless to interfere unless the solicitation be to
the annoyance of any passenger or householder, who must
in that case accompany the police to the station to charge
the woman with the offence, which is rarely or never done.
Should the authorities have credible evidence that the woman
so conducting herself is suffering from a contagious disease,
which she may communicate to others having relation with
her, they cannot in any way interfere to prevent it. This
woman, when unable any longer (in conseqnence of the se-
verity of her disease) to follow her miserable calling, has no
other resource (prostitution failing),to procure her a livelihood
than to fall back on the foul wards of a workhouse (Acton).]
cities like London, Manchester, Dublin, Sheffield, Preston,
the severity of the cases is greater than in the protected
[A protected district is one where a woman, instead of con-
tinuing wholly or in part to gain an honest livelihood, walks
the streets, soliciting different men, and consequently comes
under cognizance of the police as being a common prosti-
SYPHILIS. 397

tute. The British Legislature has determined that in cer-
tain garrison towns such a woman, after being repeatedly
warned, and still persisting in a life of prostitution, shall
submit to a medical examination, on the ground that, should
she be diseased, she would communicate a contagious com-
plaint to those having relation with her. It is further enact-
ed that if the woman be found diseased, she shall be at once
sent to hospital, and not allowed to leave till she is, in the
opinion of the surgeon, perfectly cured. Ifthen desirous of
abandoning her evil courses, the girl is relieved from further
surveillance, and will be sent to her friends at the Govern-
ment’s expense. If, on the other hand,a common woman,
on being discharged from hospital, and released altogether
from the operation of the Acts, returns to a protected dis-
trict, and is again found by the police acting as a public
prostitute, she must again be registered. In every case the
authorities wish-it to be clearly understood that they do not
sanction or authorize prostitution ; they only watch over it
from their anxiety to prevent its worst evils, and to ameliorate
the condition of the women, and check disease (Acton).]
places, where the great majority (after the Acts have been
“in operation for a year or two) suffer from very mild forms
of the disease. In 1870 a Royal Commission was appointed
to consider the questions raised in the House of Commons
ona motion fora repeal of the Act. The report of this
Royal Commission speaks most decidedly upon the effects
of the Acts in the reduction of the worst forms of disease
among the lower classes of prostitutes, and acknowledges
that they have both directly and indirectly promoted the ob-
jects sought to be attained by those Acts. ‘“ They have
purged the towns and encampments to which they have been
applied of miserable creatures, who were masses of rottenness
and vehicles of disease ;’’ and it was agreed that, for the pub-
lic good, particular districts which are from any cause pecu-
liarly liable to contagious disease should be subjected to
special sanitary legislation. (e) In passing these Acts also,
Parliament pronounced the strongest protest against the
right of an individual suffering from a loathsome disease
knowingly to communicate it to another; hence, in the in-
terest of all, the State has the right to limit the personal lib-
erty of such persons as may be considered dangerous to the
common welfare, and to use force, if necessary, to obtain an
examination as to the condition of their health. Regular,
frequent, and thorough examinations are absolutely neces-
398 SYPHILIS.

sary. [It seems useless to argue with the opponents of these
Acts, who, while loudly denouncing them as immoral be-
cause they render vice easier and safer to men, yet wish for
the establishment by Government of voluntary lock hospi-
tals and lock wards, which, if they proved equally efficient,
must obviously be attended by the same result; who, while
stating that the Acts render vice easy and safe, declare al-
most in the same breath that they are hygienically a failure,
and that wherever they have been in operation disease has
increased instead of diminished : who, while charging them
with all sorts of pernicious and degrading influences, yet
deny them any credit for the collateral benefits which they
have been shown to have produced ; who denounce them as
unwarrantably interfering with individual liberty, on account
of their compulsory clauses, and yet would not object to the
compulsory detention of women in hospital until cured, pro-
vided they were left to apply voluntarily for admission. How,
they further ask, if the present system is an infringement of
personal liberty, is that principle less infringed if the compul-
sion is removed from one end of the procedure but retained
at the other? Surely if compulsion is unjustifiable, it should
be abolished altogether ; but if it is to be retained at all, it
should be retained in the form which has been found most
effectual ; and the evidence of those most competent to judge '
shows that the early detection of disease in public women by
periodical examination is essential to the efficiency of the
system. Even the Royal Commission were constrained to
say, “ We are satisfied from the evidence that the frequent
examination of women is the most efficacious means of con-
trolling the disease.” It is not less important in the interest
of the unfortunate women themselves, who obtain the im-
mense advantage that their disease is discovered and treated
at the earliest possible period, so that while they are pre-
vented communicating it to others, they are themselves saved
from all the serious and painful consequences of neglect.
(Brit. Med. Journ., July 22, 1876)]. (f.) The beneficial effect
of these Acts on the civil population cannot be ignored.
During the five years 1870-74 the annual death-rate from
syphilis (including congenital syphilis) in the eleven districts or
stations where the Acts were then in operation, was 21 per
cent. lower than it was during the five years 1861-65 before
the Acts came into operation in 1866 ; whereas in the rest
of England and Wales the death-rate from this disease was
20 per cent. higher in the second than in the earlier period.
SPPHILIS. 399

(g.) Up to the present time, it has been everywhere found
that just that class of prostitutes who are the most apt to
spread syphilis will not subject themselves to treatment ex-
cept under compulsion. All prostitutes found to be syphili-
tic should be kept in hospital till they are cured. (4:) It
may also be fairly urged and acted upon, that entire classes
of men who notoriously contribute largely to the spread of
syphilis, as, for instance, soldiers and sailors, should be sub-
ject to periodical examinations ; and that sailors especially
shouid be inspected before leaving a port, and again before
entering another, and that if found infected they should be
placed in quarantine. The workmen in some of the glass-
works in the neighborhood of Lyons have of their own ac-
cord demanded such examinations, to do away with the pos-
sibility of infection from the tubes used by them in blowin
glass, which are passed from mouth to mouth (Baumler). (5
Not only ought the Contagious Diseases Act to be main-
tained and extended to the whole of this country, but the
time has come when, as Dr. Baumler observes, it is the duty
of all civilized states to combine and adopt some common
course of action against these diseases. There is need of
universal prophylactic regulations being more and more wide-
ly recognized.

A great responsibility rests upon those who oppose the
working of such Acts—so fully proven to be preventive of
disease, and in every respect beneficial. ‘‘In the eyes of
every physician, and indeed in the eyes of most Continental
writers who have adverted to the subject, no other feature
of English life appears so infamous as the fact that an epi-
demic which is one of the most dreadful now existing among
mankind, which communicates itself from the guilty hus-
band to the innocent wife, and even transmits its taint to
the offspring, and which the experience of other nations con-
clusively proves may be vastly diminished, should be suffered
to rage unchecked because the legislature refuses to take of-
ficial cognizance of its existence, or proper sanitary measures
for its repression.” (Iuecky, History of Europ. Morals, Vol.
II., p. 301).

(2.) The facts relative to the Pathology of syphilis which
have been stated in the text, show that Prophylaxis ought
to take cognizance of the vehicles by which healthy persons
are apt to be inadvertently infected—(z) From the use of
such drinking vessels, plates, spoons, towels, &c., used by
those suffering from secondary forms of syphilis; (4.) con-
400 SYPHILIS.

tamination from surgical instruments which have been, em-
ployed upon the syphilitic; (c.) the selection of healthy
children from whom other children are to be vaccinated—
only those children known to be healthy, and whose parents
are known to the physician, should be used as the sources of
vaccine matter; (¢.) the choice of wet nurses for healthy
children ought also to be carefully selected, so as to exclude
those who may show the least suspicion of having had sy-
philis; (¢.) on the other hand, it jis necessary to prevent
children with hereditary syphilis being given to healthy wet
nurses; (/.) the guardians of syphilitic children ought to
be warned of the danger of their infecting healthy children
through kissing them, and also by the use of the eating and
drinking utensils of such infected children (Baumler).

(3.) Individual Prophylaxis—From what has been written,
it must appear clear that the only chance of preventing in-
fection, alike on the part of the male and the female, is per-
sonal cleanliness after sexual intercourse. Much of the good
that has resulted from inspection of females to the females
themselves, as in Paris, Brussels, and other places, has been,
I believe, mainly attributable to the greater attention to per-
sonal cleanliness which such inspections have brought about.
Numerous lotions have also been used; and if a man will
have sexual intercourse with a strange woman, let him wash
immediately: after the act, taking care to cleanse thoroughly
the folds of the prepuce, especially near the freenum, and in
the sulcus of the corona glandis. If a woman will have sex-
ual intercourse with a strange man, let her use a syringe with
hot water, to wash out the vaginal passage, taking care to
cleanse thoroughly the folds of the mucous membrane at the
orifice of the canal and of the labia pudenda, The real pre-
ventive remedy after exposure to infection is the most an-
cient, the most simple, and the most efficient—Wash, and be
clean. ,

(4.) Syphilization—By this name an operation is meant
which has forits object the eradication of syphilis from the
system by repeated inoculations of the syphilitic virus itself,
Dr. Boeck, of Christiana, is the most persistent advocate of
this mode of dealing with syphilitic cases as a remedy against
constitutional affections. And it was at one time seriously
‘ proposed to introduce syphilization as a prophylactic, from
its analogy to the inoculation of the virus of variola (Auzias
Turenne). The method is entirely unjustifiable.

(4.) Therapeutic treatment.—As in the case of other sper
SYPHILIS. 401

ific diseases that are implanted by inoculation, the effect of
the virus begins at once at the point of inoculation, and may
not be destroyed as to its contaminating powers by any
agency we know of. Experience shows that we must not
conclude that, even by an early destruction of the sore, the
occurrence of constitutional infection will be prevented ;
and the application of caustics to abraded surfaces after their
exposure to contagion is quite useless to prevent infection.
The poison is observed in a very short time—within a few
hours (Berkeley Hill). Still, however, in some cases positive

‘results have been obtained which encourage attempts to
arrest the local progress of the sores with escharotics, if they
are applied at an early period, and before contamination of
the system is evinced by indurations. Ricord and Sigmund
have found that sores destroyed by the more powerful caus-
tics, within from three to five days, have not been foltowed
by syphilitic symptoms. But these may have been cases of
soft chancre, which would not infect. The only efficient
caustics for this purpose are—(1.) The strong nitric acid ;
or, (2.) The potassa cum calce (most conveniently used in
the form of small sticks). Nitrate of silver is useless, from
its limited action and deficiency of penetration.

If the sore threatens to slough, the parts should be wiped
dry, and fusing nitric acid applied, and afterwards a lotion
of the potassio-tartrate of iron, while the same drug is given
internally: Chloride of zinc paste (Fell’s) is a useful eschar-
otic to excite a healthy action round the periphery of a sore.
If great pain attends the local progress of the chancre, mor-
phia in liquor ammonia acetatis is highly beneficial. ‘“ Black
wash” of the strength of 8 grains of calomel to the fluid
ounce of lime ,water, or weaker, as 5 or even 3 grains to the
ounce, is of use in the treatment of large ulcerating indura-
tions. The experience of 300 years has shown that mercury

‘is a remedy which acts as a direct antagonist to the virus of
syphilis ; and no unprejudiced person can deny that its ac-
tion upon syphilis is quite evident, especially upon the cuta-
neous manifestations of the disease.. Mercury, administered
during a primary sore, seems to be one of those agents which
are able to break the regular order of the manifestation of
symptoms, as it does to several other diseases; although it
may not seem to possess any certain prophylactic power.
[There are remarkable variations in opinion as to the influ-
ence of mercury in curing syphilis. At one time discussion
ran high regarding its use; and, of course, extreme state.
26
402 SYPHILIS,

ments were made on both sides, while the facts adduced
never warranted the extreme conclusions. Consequently, at:
one time mercury has been regarded as capable of absolutely
preventing the constitutional affection; at another time it.
has been accused of giving to the syphilitic virus the impulse:
which sets up its worst results. It is now quite certain, how-
ever, that mercury administered continuously to the extent
of salivation, or approaching it, exerts a poisonous influence,
and produces constitutional effects of a very dangerous kind)
(Graves) ; and Hunter himself says “new diseases arise from
mercury alone ;” while it cannot be doubted that in cases in
which mercury has been freely given, we are never certain
that secondary symptoms may not supervene. Barensprung,
of Berlin, during his most extensive experience, came to the
conclusion that syphilis not only can be cured without mer-
cury, but, under its use, he believed the disease is often ren-
dered latent for months and years, and its complete cure de-
layed. Starvation and Zitmann’s weaker decoction were the
means he employed for cure (Az, de Berlin Charité, ix., t,
1860; Syden. Society Year-Book, 1861). Hermann came to
similar conclusions, from his experience in the syphilitic
wards of the Vienna Infirmary. The experience of Diday
is not less decided. He states that mercury cannot now be
said to cure syphilis radically, so as to render all relapse im-
possible. He does not, however, as is the case with the
others, practically withhold mercury in every case. If the
primary lesion becomes an indurated, woody chancre, mercury
is given. If the chancre is a doubtful one, he recommends
waiting till some of the early constitutional phenomena ren-
der the nature of the case evident, and indicate the probable
gravity of the syphilis with which he has to deal. He em-
ploys iodine, iron, and quinine, on the appearance of slight
relapses, with a tonic and supporting regimen, He recom-
mends iodides, to combat the chloro-anzmia, and to relieve
the pain of tertiary ulcerations,

Numerous examples may be seen in museums, which are
placed there to show that the poisonous effects of mercury
produce worse lesions than those of syphilis; and, when
combined with the syphilitic virus in a strumous person, the
worst lesions of all. In the extreme of syphilitic infection,
it ought never to be forgotten that a specific chlorosis results
from syphilis, amounting to anemia; and that mercury will
bring about a similar anemia, But while numerous instances
are quoted by authors of the poisonous effects of mercury
SYPHILIS. 493

inducing lesions similar to those of syphilis, the investiga-
tions of Kussmaul, Professor of Medicine at Erlangen, show
that mercurial poison produces no single affection or symp-
tom that is identical with, or not easily distinguishable from,
those of syphilis. His experience’ was among the manufac-
turers of mirrors using mercury in the town of Furth; and
he shows that mercury has but one influence over syphilis—
that is, the power of controlling many of its symptoms.
Both kinds of treatment (ntercurial and non-mercurial)
have been extensively tried since 1816, and formal experi-
ments have been organized on the subject, namely,—First,
In 1822, in Sweden, by Royal command, when reports were
annually furnished from civil and military hospitals as to
trials of the two methods ; Second, Dr. Fricke experimented
in the Hamburg General Hospital, and published his results
in 1828; Third, In 1833 the French Council of Health pub-
lished a report on the subject. Long before any of these
reports -were initiated, however, the surgeons of the British
Army had the boldness to declare themselves against the
system of treatment with mercury, as it was then carried out,
and, running into the opposite extreme, introduced measures
of non-mercurial treatment altogether. This change was
mainly due—(1.) To Mr. Fergusson, who practised it during
the Peninsular Wars (Med.-Chir. Trans., Vol. IV.) ; (2.) To
Mr. Rose, of the Coldstream Guards, at the same time, but
independently of Mr. Fergusson ; (3.) To Dr. John Thom-
son, the first Professor of Military Surgery ; who, by lec-
tures in the University and College of Surgeons in Edin-
burgh, and by his published writings, was mainly influential
in convincing Scotch medical men of the evil effects of mer-
cuey in venereal diseases. The inquiry, begun in 1816 by
these military surgeons, requires to be re-investigated with
all the present advanced knowledge of the nature of the di-
sease which we now possess, and with a better prospect of
detecting the fallacies which surround the investigations. Un-
der the simple treatment of those eminent men, there can be
no doubt that mixed cases of soft, as well as of indurated
chancres, and specific or syphilitic sores, were allowed spon-
taneously, as it were, to develop their distinctive ‘characters.
No confidence can now be placed in the results thus pub-
lished, as derived from clinical observation, because the cure
of soft, suppurating, and mixed sores, gonorrhoea, vegeta-
tions, suppurating bubos, are all indiscriminately given as
evidence of the cure of syphilis. Moreover, cases cannot
404 SYPHILIS.

be accepted as cured at the time they are simply discharged
from present treatment, because they may seem to be pro-
gressing to a favorable termination, but not absolutely cured,
as is the case with the records of Fricke’s experiments.

The great benefit obtained by the experiments, observa-
tions and discussions regarding mercury in syphilis, carried
on during the first quarter of the present century, as Dr.
Berkeley Hill justly observes, has been to show—(1.) That
all venereal ulcers can be healed without mercury ; (2.) That
this drug is not the cause of the relapses so frequent in syph-
ilis; and, (3.) That very much less mercury is required to
control syphilis than had been previously supposed neces-
sary. Some interesting cases of syphilis cured without the
use of mercury are related by Surgeon-Major Dr. Peter Boi-
leau, in the Brit. Med. Journ., for July. 1879. |

The present position of opinion with regard to mercury in
the cure of venereal sores seems to be this, namely,—That
it is a very valuable and essential remedy in cases of syphilis,
but not in cases of soft chancre ; and the difficulty is to ex-
press always the nature of the cases for which it is most
suitable. Even those who believe most fully in its virtues
acknowledge that in primary affections, as when given in the
treatment of the local sore, its administration will not always
prevent the occurrence of constitutional symptoms; never-
theless the value of mercury in the cure of the induration of
the true infecting chancre is now fully recognized. The
local lesion, if it appears after the usual prolonged period of
incubation, is as much a manifestation that the constitution
is already affected as is the developed vesicle of variola
vaccina a manifestation that the constitution is affected with
variolous poison. Looking, also, to the nature of the virus
of syphilis, the excision of the primary lump or sore—the
specific induration—as practiced by Dr. Veale, assistant to
the Professor of Medicine in the Army Medical School at
Netley (Zdinburgh Monthly Journal, July; 1864), and by
Dr. Humphrey, of Cambridge, (British Medical Journal,
August 13, 1864), is a’ justifiable operation; for the original
sore, when it has become a “lump” (as in its state of
“ woody-like” induration), is an undoubted maintainer of
infection and of contamination of the system. If, therefore,
it can be easily and completely insulated, as when on the
prepuce, the cure of the constitutional symptoms may be
facilitated and shortened. There are also certain forms of
secondary syphilis for which the administration of mercury
SYPHILIS, 405

is unsuitable. These are the pustular eruptions, or ecthy-
matous states in rupia and in syphilitic anemia, For the
cure of other secondary symptoms mercury is certainly of
service. If given to the extent to which I have. limited its
use in the text, I believe that secondary symptoms disappear
more rapidly under its regulated use than by any other plan
of treatment. All our treatment of syphilis rests on that evi-
dence which must always guide the hand of the physician,
namely, —practical experience. That has certainly taught
us that the mercurialism of John Hunter’s time was an error;
and that its regulated administration in cases of syphilis is
undoubtedly beneficial, and especially during the evolution
of the specific symptoms of infection. Dr. Jeffrey Marston,
late of the Royal Artillery, has given an admirable summary
(British Medical Journal of Feb. 21, 1863) of the means and
indications of treatment by mercury which he has found
most useful. His experience shows that the system ought to
be affected as slowly as possible; and there ought to be a re-
mission of the remedy for a time as soon as that effect has
been attained. As soon as the symptoms for which the
mercury was given have disappeared, steel and other mineral
tonic remedies ought to be given; and in three cases where
the general health seemed to have suffered, podophyllin in
small doses (one-sixth of a grain), with extract of belladonna,
was given with marked benefit. If the system is too early
brought under the influence of mercury, and the symptoms
are not benefited, chlorate of potash in compound tincture
of cinchona may be given with advantage; and in strumous
subjects the bichloride of mercury, dissolved in ether and
added to cod-liver oil, is found to be most useful. Some of
the most intractable forms of syphilitic squama are best
treated by a combination of liquor arsenicalis, solution of
bichloride of mercury in very small doses, and tincture of
sesquichloride of iron; while the use of soap in ablution
ought to be avoided (Startin). In the administration of
mercury for the cure of syphilis, salivation, or anything ap-
proaching to that condition, should never be induced. Ten-
derness of the gums should be the utmost physiological
effect, very gradually and gently brought about. As soon as
the evolution of consitutional symptoms has commenced,
such as the specific induration of the sore or glands, cutan-
eous, scaly, tubercular, condylomatous affection, or iritis,
the sooner mercurial treatment (to the extent indicated) is
commenced the greater will be the benefit. The good
406 SYPHILIS.

effects of mercury are known by the following results :—
“ Given early, it promotes the dispersion of the induration
at the point of contagion or inoculation, and the enlarge-
ment of the glands; it delays and lessens the severity of the
cutaneous eruptions, and of all the symptoms which accom-
pany the early skin eruptions” (Berkeley Hill). When in-
duration is apparent, mercury ought to be’ at once adminis-
tered; and all the useful effects of the remedy are generally
obtained when the slightest possible sign of its influence is
betrayed by the gums and breath. The most convenient
form of administration is either a pill or fluid solution of
corrosive sublimate (perchloride). ‘The dose should always
be small, and combined so as not to irritate the bowels.
Grey powder or blue pill may be compounded in the follow-
ing forms, namely :—Two grains of grey powder with two
grains of compound ipecacuanha powder, made into a pill
with glycerine, two of which are to be taken daily; or two or
three grains of blue pill combined with a quarter of a grain
of opium powder, with sufficient glycerine to make a pill, and
taken every night at bedtime. Either of these forms is suffi-
cient for women and young men. In adult men, three grains
of blue pill or grey powder twice or thrice a day; or one
grain of calomel every night and morning, with a third of a
grain of opium, are most suitable. When the mercury is
obviously producing its physiological results, it may be
omitted for a day, and then again carried on in smaller or
less often repeated doses. Dr. Berkeley Hill recommends that
the perchloride of mercury be mixed with iodide of potass, so
that a freshly formed biniodide of mercury is kept suspended
in a solution of iodide of potass, in the following formula :—

% Perchloride of Mercury, gr. 3; Iodide of Potass., grs.
96; Compound Tincture of Bark, 4 ounces; Sesquicarbonate
of Ammonia, grs. 60. Water sufficient to make up 8 ounces.

The dose of this compound ought to be two teaspoonfuls,
half an hour before meals, three times a day. Two-thirds of
a grain of perchloride of mercury maybe taken daily; but
except in such a solution as the above its action is uncertain.
In Germany, Zitmann’s decoction is much used. It is of
two kinds—the stronger and the weaker. The former is
compounded as follows :—

BR, Rad. Sarsaparille, 3 xii; Aque, Tbxxiv.; Coque per
horas duas et adde Aluminis, % iss.; Hydrarg. Chloridi, mitis
(calomel), 3ss.; Antimonii Oxy. sulphureti, 3i.; misce.
Coque ad §, et adde Fol. Senne, % iii; Rad. Glycyrrhize,
SYPHILIS. 407

%iss.; Sem. Anisi, 3 ss. Infunde per horam et cola. The
dose of this decoction is half a pint to a pint morning and
evening.

The weaker decoction is compounded as follows :—~

Capiat residuum decocti fortioris et adde Radicis Sarsa-
parille, 3 ii; Aqua, lbxxiv.; Coque per horas duas et adde
Cort. Canellz, Cort. Limonem, Sem. Cardamomi, a a 3 iii.
Infunde per horam et cola. The dose of this decoction is
one pint at intervals during the day. ~

Another mode of preparing it with somewhat different
‘proportions of ingredients is given by Dr. Berkeley Hill, as
:follows :—

B. Sarsaparilla, % xii.; Water, three gallons. Macerate
‘twenty-four hours, and put ina linen bag; White Sugar,
3vi.; Alum, 3 vi.; Calomel, 3 iv.; prepared Cinnabar, 3i.

Hang the linen bag in the liquor and boil down, while add-
‘ing four gallons more water, till the liquor is reduced to
‘two gallons ; remove the bag. and add to the decoction the
following ingredients, namely :—Anise Seeds, 3iv.; Fennel
Seeds, 3iv.; Senna Leaves, %13%4; Liquorice Root, & iss.
Press and strain. ,

About half a pint to a pint is the daily quantity to be con-
sumed of the compound. While the amount of mercury it
‘contains is rarely enough to produce any unpleasant effects,
it is enough to control the disease. A weaker decoction of
the woods is free from mercury, but is of no value beyond a
diet drink.

Iodide of potassium, in doses adjusted to the individual
ase, appears to act with rapid benefit in some of the syphil-
itic diseases of the interior of the cranium giving rise to ex-
treme pain. Its administration often causes intense suffer-
ing in patients who have been treated previously by mercuti-
als. Two distinct effects are produced :—First, the com-
pounds of mercury fixed in the body are rendered soluble
and active ; and secondly a form is given to them which al-
lows of their elimination, with more or less rapidity, in a state
of combination with one of the elements of the iodide; and
thus the patient is subjected anew to a mercurial treatment
by the compounds of mercury already present in his body
(Melsens, in Brit. and For. Med.-Chir. Review, 1853). The
dose of iodide of potassium should at first be small, not more
than fifteen grains in the twenty-four hours—increasing the
dose if the patient bears it well (Melsens, Guillot). Its ac-
408 SYPHILIS.

tion is aided by a blister over some portion of the shaven
scalp, and by having the blistered surface dressed with mer-
curial ointment ; and generally, it may be said that local
treatment gives very valuable aid. For example, cutaneous
or mucous raised papules remaining persistent, an ointment
composed of oxide of zinc, calomel, and simple cerate, has-
tens their absorption. Eruptions of lichen, acne, and herpes
are similarly benefitted by the application of oxide of zinc
lotion or ointment ; and if prurigo and urticaria be also pres-
ent, diacetate of lead lotion willexpedite the cure. Vesiculo-
crustacecus spots will cease to reappear if the affected parts are
painted for a few days with a solution of nitrate of silver (gr.
x.-xx. fo 3 i), and oxide of zinc lotion applied afterwards.

In the more advanced stages of the suppurative affec-
tions, the use of pyogenic counter-irritants ought not
to be neglected, such as tartar-emetic ointment. They
tend to keep up just so much of a discharge as may be
consistent with the strength of the patient ; and are worthy
of a trial.

In the dry forms of syphilitic cutaneous diseases, and in
chronic eczema of the extremities, tar ointment,or an alcoholic
solution of tar, is an excellent application; and the disap-
pearance of indolent glandular swellings is greatly aided by
the use.of strong solutions of iodine. Superficial forms of
ulceration attending the pustules of ecthyma are benefitted
by the use of solutions of nitrate of silver or sulphate of cop-
per, and generally by caustics and local stimulants. If a
sloughing condition threaten ulcerating sores, lotions of the
potassio-tartrate of iron will generally improve their aspect.
In psoriasis palmaris, and similarly fissured conditions of the
skin, glycerine lotions are most useful. But all these local
remedies, it must be remembered, are only aids to the con-
stitutional treatment, whether by mercury or iodide of potas-
sium, or simply by a well-regulated hygiene. The patient,
during the whole of the treatment, should be warmly clad—
should be fed upon a good but plain diet—should take plenty
of exercise in the open air in fine weather—should use occa-
sionally (once or twice a week)—warm baths—and avoid
stimulants, unless specially indicated and prescribed. Dur-
ing the febrile stage and the exanthem stage he ought to be
confined to his bed.

The administration of mercury, to affect the system rap-
idly, is best effected through the agency of the mercurial
vapor bath. It is a mode of administration not liable to af-
SYPHILIS. 409

fect the digestion, and it permits other remedies to be given
by the mouth at the same time, if they be considered neces-
sary. It is also mild, slow, and equable in its action. The
mercurial vapor bath is to be managed in either of the fol-
lowing ways. The first method is best adapted for the prac-
tice of a large institution ; the method recommended by Mr.
Lee is better suited for private practice :—

“The patient is seated on a chair, and covered with an
oil-cloth lined with flannel, which is supported by a proper
framework. Under the chair are placed a copper bath, con-
taining water, and a metallic plate, on which is placed from
one to three drachms of the bisulphuret of mercury, or the
same quantity of the grey oxide, or the binoxide of this met-
al. From five to thirty grains of the iodide of mercury may
be employed, or a scruple of the iodide, with a drachm and
a half of the bisulphuret. Under the bath and plate spirit-
lamps are lighted. The patient is thus exposed to the influ-
ence of three agents,—heated air, steam, and the vapor of
mercury., At the end of five to ten minutes perspiration
commences, which becomes excessive in ten or fifteen min-
utes longer. The lamps are now to be extinguished ; and
when the patient has become moderately cool, he is to be
rubbed dry. He should then drink a cup of warm decoction
of guaiacum or sarsaparilla, and repose for a short time”’
(Langston Parker).

Mr. Henry Lee’s mode of proceeding is more simple :—
“A special and convenient apparatus is used (made by Sav-
igny & Co.), which consists of a kind of tin case, containing
a spirit-lamp. In the centre, over the flame, is a small tin
plate, upon which from fifteen to thirty grains of calomel is
placed, while around this is a sort of saucer, filled with boil-
ing water. The lamp having been lighted, the apparatus is
placed under a common cane-bottomed chair, upon which
the patient sits. He is then enveloped, chair and all, in one
or more double blankets, and so he remains well covered up,
for about twenty minutes, when the water and mercury will
be found to have disappeared.”

With regard to sarsaparilla as a remedy, Sigmund, Syme,
and many other acute observers, have come to the conclusion
after long and careful trials of the best sarsaparilla, that it
does not, fer se, exercise the slightest perceptible influence
on the course and termination of syphilitic diseases. It is
usually given in combination with some mercurial prepara-
tion, as in the decoction of Zitmann.
410 TABES DORSALIS--TETANUS,

As to the original local sore of syphilis, it may be dressed
simply with lint soaked in warm or cold water, and renewed
every three or four hours. The indurated glands, if they
are painful, may be tomented, and the horizontal posture
maintained. Moderate exercise. may be taken if all local
irritation is subdued ; and then slightly stimulating lotions
may be used to the sore, such as sulphate of zinc, in the pro-
portion of one or two grains to the ounce; or the liquor
plumbi diacet. dil. of the pharmacopeeia ; or the black or yel-
low wash if the surface is indolent.

Tabes Dorsalis.—(See Locomotor Ataxv, brogressive).

Tetanus — Definition.—Involuntary, persistent, intense,
and painful contractions, cramps or spasms, of more or less
extensive groups of voluntary muscles ; so that the whole of
the body may seem to be affected, the spasm yielding and
becoming intermittent in some groups of muscles, while at
the same time it exists in others, or the continuous tonic
spasms are characterized by paroxysmal aggravation of
extreme intensity.

Treatment.—So long as the phenomena are peripheral and
reflex, the removal of the offending part may arrest the dis-
ease ; but when it has become central, it is probably always
fatal. There are thus two forms of tetanus which demand
recognition for treatment as early as possible. Baron
Larrey affirms that this disease, if left to nature, is
quickly fatal. Sir James Macgrigor says that all the most
powerful remedies were fully tried in the Peninsular War,
and that little or no dependence could be placed on any of
them. There is great tolerance of all kinds of sedatives and
narcotics.

Much good, however, is gained by attempting to restore
the secretions to a healthy state; also by supporting the
patient with food and drink, and by endeavoring to tranquil-
lize the high irritation under which he is laboring. The
medicines to be employed are moderate doses of purgative
medicines, with tinct. opii m xxv., or its equivalent, ro grains.
of Dover’s powder, given every three or four hours; and
these conjoined with moderate quantities of wine, sago, mixed
with strong beef-tea or soup, or other nutritious diet. Musk,
also, in ten-grain doses, has been given wit! some advantage.
Some authors lay much stress on a local treatment in trau-: .
matic tetanus. Baron Larrey, as the result of his great ex--
TETANUS, 4ll

perience, says: “When it is caused by the wound, we should
not hesitate to operate on the first symptom of tetanus, and
thus, as far as possible, remove the causes of irritation.” If
tetanus follows amputation, he recommends the stump to be
sprinkled with powdered cantharides ; and in cases where a
nerve has been included in the ligature, that the ligature be
removed either by section or by actual cautery. In the
British army, however, all these proceedings have been
adopted, and with very little success. Amputation has been
frequently performed without any mitigation of the symptoms.
The wound has also been excised, submitted to actual cau-
tery, been blistered, and dressed with every kind of ointment;
but the disease has run its course, cither uninfluenced, or its
fatal termination has been accelerated. Hennen has even
seen the wound heal «ind the jatient die on the same day.
Nothing, in fact, is so unsatisfactory as the results yet ob-
tained from either the general or local treatment of this fatal
affection. Larrey has often attempted, from the difficulty of
swallowing fluids that sometimes attends tetanus, to pass an
elastic tube ; but in all cases he says he met with acontracted
state of the cesophagus i~possible to overcome, while the
attempt was constantly followed by the immediate occurrence
of the severest spasmodic attacks.

“Tf, however,” as Mr. Poland observes, “we can help our
patient on one day after another, we gain much. Constant
watching and constant attention are required by night as
well as by day, and unflinching perseverance on the part of
the sufferer to aid all efforts made in his behalf, besides the
avoidance of all causes of excitement, and more especially
drafts of cold air or winds, taking care to preserve a uniform
temperature as much as possible.’”’ No hope of recovery
may be indulged in unless the spasmodic seizures continue
to diminish in length and frequence, distinct relaxation of
the contracted muscles occurring during those intervals of
diminished spasm; and unless the patient becomes able to
take food, recovery in the fortunate cases takes place with
extreme slowness. It is not till after the lapse of weeks
that the muscles entirely lose their spasmodic tension.
Russian vapor baths are well spoken of by Hasse and
Niemeyer. .

Too free use, alike of narcotics and of anaesthetics, must
be guarded against. They are valuable aids in maintaining
the existence of the patient from paroxysm to paroxysm.
Aconite has been used in large and repeated doses by De

¢
412 TETANUS,

Morgan, Smith, Sedgwick, Woakes, and Wunderlich. It
ought to be used hypodermically, and there appears to be a
great tolerance of the remedy. Cannabis sativa or Indian
hemp, is a remedy of real value, if it can be got genuine and
fresh. Three grains of the extract, or thirty drops of the
tincture, may be given every half hour or hour till narcotism
is attained. Cold should at the same time be applied to the
spine (Muller, O’Shaughnessy, Chuckerbutty).

The more or less obstinate constipation of the bowels
which characterizes this disease, and which is accompanied
by a feetid state of the dejections, ought to be overcome by
(1.) turpentine enemata, and (2.) calomel and jalap purga-
tives. This is most important.

A case of traumatic tetanus under the care of my friend,
Dr. John Liston Paul, Surgeon-Major of H. M. Indian
service, is reported in the Madras Monthly Journal of Med-
teal Science for July, 1872, which recovered under the per-
sistent use of belladonna tincture, carefully observing the
effects of the drug upon’the system.. The bowels were first
freely acted upon by calomel, gr. v., and compound jalap
powder, gr. xx.; and immediately on the action of the bowels
commencing, ten minims of the tincture of belladonna were
given in half an ounce of water. In an hour five minims
more were given ; and every hour afterwards an increase of
three minims was added to the previous dose, till twenty
minims were given at one dose. The administration of
belladonna was commenced at 10:30 A. M., and by 4:30 P.M.
a dose of twenty minims was thus gradually reached. This
dose was continued in half an ounce of water every hour till
10 P. M., after which it was given every second hour till the
following day, when no relief to the rigidity or paroxysms
being obtained, this dose was increased to twenty-five minims
every hour. This treatment was persevered in, with the aid
also of chloral hydrate occasionally, as well as ice applied to
head and spine, and movement of the bowels by active pur-
gatives of jalap and croton oil. At three intervals the bella-
donna had to be suspended, on account of its poisonous
physiological action being obvious in the delirium, thirst,
and other symptoms. The patient was under active treat-
ment with belladonna for fifteen days ; the amount of tinc-
ture taken in that time being ten ounces four drachms and
thirty minims.

* Yandell states that chloroform up to this time has yielded
the largest percentage of cures in acute tetanus (Braz, Oct.,
TETANUS. 413

1878). He is of opinion that the true test of a remedy for
tetanus is its influence on the history of the disease in the
following respects : (@.) Does it cure cases in which the dis-
ease occurred prior to the ninth day after the injury? (d.)
Does it fail in cases whose duration exceeds fourteen days ?
Tried by these tests he asserts that no agent has yet estab-
lished its claims as a true remedy for tetanus. But among
the numerous medicines used in the treatment of tetanus
chloral is one of the latest, and appears to possess many
advantages. Bauer, in his article on tetanus in Von Ziem-
sen’s Cyclopedia, states that other remedies are practically
and properly being more and more supplanted by chloral-
hydrate. This is superior to every other means, even the
inhalation of chloroform ; and the control of the spasm will
be attained most satisfactorily by the combination of chloral
with bromide of potassium. Billroth also records success in
cases of tetanus from the. use of chloral.

Dr. J. R. Beck has collected (84. Louis Medical and Surgical
Journal, June, 1872) thirty-six cases of traumatic tetanus
treated essentially by chloral in which a recovery took place
in twenty-one instances. Dr. H. C. Wood has tabulated
(Treatise on Therapeutics, pp. 292, 293) eighteen additional
cases resulting in nine recoveries and nine deaths. In the
Practitioner for November, 1872, Dr. Macnamara, of Calcut-
ta, gives his experience in tetanus among the natives, and
says that he treats them by giving forty grains of chloral at
bedtime, and by providing proper diet of a nourishing kind.
In severe cases, an additional thirty-grain dose is given at
midday. Out of twenty successive cases seventeen. recov-
ered. Though these cases were probably idiopathic in many
instances, the testimony is nevertheless valuable. Within
the past few years the medical journals have been constantly
reporting cases of recovery from tetanus under the use of
chioral, but isolated cases have their value diminished, be-
cause the fatal cases are not so likely to appear in print.
Nevertheless, the fact remains that many cases of traumatic
tetanus have recovered while such treatment has been em-
ployed. The drug has been introduced into the system by
various channels; M. Oré has treated cases of tetanus,
though unsuccessfully, intravenous injections of hydrate of
chloral (Practitioner, August, 1877); while success has fol-
lowed its administration hypodermically in acute traumatic:
tetanus( American Journ. of Med. Sciences, April,1877, p.5 54);
and it is stated that a case recovered where chloral, in con-
414 TETANUS,

junction with bromide of potassium, was given by enema
(Hospital Gazette, New Vork, April, 1877, p. 15, from Lon-
don Lancet). Dr. Agelastos, of Bucharest, believes that he
prevents the occurrence of lock-jaw in traumatic cases by
the timely employ of chloral (ew York Med. Journ., April,
1877, p. 436). Verneuil says that chloral allays the muscular
contractions, and especially those of the respiratory appa-
ratus, which in the last stages of the disease cause asphyxia;
and that it changes the acute into the chronic form of the
disease. He gives instances of cure where the patients took
1oo grains and 245 daily without any bad symptoms. The
first of these tetanic patients recovered after thirty days,
having been given 3 vj. of chloral during that space of time
(Mew Vork Med. Journ., 1876, p. 97). While in charge, as
Resident Surgeon, of Dr.’R. J. Levis’s ward in the Pennsyl-
vania Hospital, Dr. Roberts had the care of four cases of
traumatic tetanus, all of which were treated with hydrate of
chloral; of this number three recovered, and one died out
of nineteen cases.

The evidence appears, indeed, to be very strong in support
of the efficacy of chloral hydrate in the treatment of tetanus;
and if one thing stands more prominently out in the history
of medicine during recent years, it is the influence for good
which is being exercised and becoming more easily controll-
ed by the judicious use of those very powerful remedies.
Dr. Van Somerer. of Madras also records successful cases
from the use of chloral hydrate, and recommends a more
heroic administration of the drug (Aladras Monthly Journal,
May 1872).

Woorara or Curare is reported to have cured thirteen out
of thirty-three cases (Demme, Busch). Appropriately given
it effectually controls the spasms, and thereby spares exhaus-
tion from them. ‘The hypodermic injection of a solution of
curare deserves extensive trial, commencing with such small
doses as 4 to 4 of a grain, gradually increasing from 4 to 14
grains. A solution of one to two grains in 100’ drops of
water should be made fresh, and 10 drops of this solution in-
jected asa dose. The action lasts about four or five hours,
ns upon this fact its repetition must be regulated (Dem-
me).

The Calabar bean seems next or equal in importance as a
remedy in tetanus. In 1874 an analysis of published cases
showed that out of 64 cases of traumatic tetanus treated by
this medicine, 33 recovered. Since then this unusual pro-
TETANUS, 415

portion of cures of a disease which was before nearly always
fatal, has been considerably increased. When the treatment
has failed, the failure has been mainly attributable to an
inefficient use of the remedy. The minimum dose of the
extract of physostigma which should first be administered,
is one-third of a grain. It should be repeated every quarter
,of an hour, untilits specific operation is developed, and the
spasms are completely overcome. This effect should be
steadily maintained, and then reproduced as often as the
spasms recur, It is usually necessary to increase the dose in
order to maintain its original impression (Stille and Maisch,
The National Dispensatory, p. 1080), In the New York
Medical Record of July 6, 1878, Dr. Burke reports two cases
which occurred under his care in New York. One was seen
onthe tenth day after injury to the foot from treading on a
rusty nail. Drop doses of fluid extract of physostigma, of a
strength of 60 grains to the drachm, were first ordered,
together with castor-oil, as the breath was foul. On the
following day the dose of Calabar bean was increased to a
drop every half hour combined with 31. of whiskey to coun-
teract the depressing effects of the Calabar bean. Finally,
the dose was gradually raised till mxiii. of the fluid extract
of Calabar bean were administered every half hour; whilst
as muchas two pints of whiskey were given daily. The
other ingesta were always fluid, consisting of milk, eggs, and
beef-tea. As good effects were produced the quantity of the
extract was gradually reduced, and finally, in about six
weeks, entirely discontinued, good care and nourishment
completing the cure. In a second case the dose was gradu-
ally raised till mxv. of the fluid, extract were given every
hour, whiskey, at the same time, being always administered.
The full physiological action of the drug was also obtainable
by injecting hypodermically mxxii. to mxxxiii. of the alcoho-
lic extract of the Calabar bean every hour, 3 iv. of whiskey
were also given by hypodermic injection, and about an ounce
by the mouth. ‘The patient steadily improved under a treat.
ment in which the alcoholic extract was injected hypodermi-
cally in doses ranging from mx. to mxxv. every hour. He
was ultimately discharged cured. One grain of the extract
of Calabar bean may be given by the stomach; or one-third
of a grain, mixed with x. or xv. minims of water,and neutra-
lized by Carbonate of soda, by subcutaneous injection, re-
eated in two hours, and increasing the dose gradually.
Sir Joseph Fayrer records two cases of traumatic tetanus
416 TETANUS.

treated and cured by opium smoking and internal adminis-
tration of chloroform and hemp. Both patients were Hindoos.
The average quantity of opium-goolic smoked daily by one
patient was 84 grains. Thechloroform and hemp were given
as in the foilowing prescription:—

RB Chloroform; mx ; Extract of Indian nemp, gr i.; Mucil-
age, 3i; Camphor Mixt. 71. Misce. To be repeated every
six hours.

Surgeon-General Gordon, during the siege of Paris,
reports that M. Demarquay saved several patients’ lives who
had manifested early symptoms in the form of trismus by
means of very hot air-baths followed up by the hypodermic
injection of morphine. In the fully developed cases these
remedies were not successful. The inhalation of the nitrite
of amyl has been recommended by Dr. W. S. Forbes of Phil-
adelphia, in quantities of three to five drops.

A case of tetanus having occurred, the bowels should first
be relieved by a large enema with turpentine, after which
perfect quietness in a darkened room, free from noise or cur-
rents of air, must be insisted upon, as the best means of pre-
venting the fits of spasms. The use of the ice-bag along the
spine as recommended by Todd, has afforded relief by allay-
ing spinal irritation; but its action is very depressing, By
far the largest mass of testimony has accumulated in favor
of supporting the strength of the patient by the frequent ad-
ministration of nutritious foods, tonics, stimulants, and opi-
ates, the latter of which must be given in the most liberal
and persevering manner. These remedies (nutrient aad
medicinal) must be administered both by the mouth, by the
rectum, and by the hypodermic method (Hamilton). Stimu-
lants and abundant nourishment appear to give more pros-
pects of success in the treatment of tetanus than any other
means; and with the use of chloroform, chloral, and Calabar
bean to lessen the spasms, perfect rest, quietness, and free-
dom from currents of air,the sufferer may be able to withstand
the exhaustion, and live through the acute period of the
disease.

Systematic feeding of patients with liquid and strengthen-
ing food, at short intervals, has been employed with very
good results in the hospital of the University at Pennyslvania.
The food must be given at intervals of every two -or three
hours; and should consist mainly of milk, with a small quan-
tity of alcohol. Solid food is to be avoided. Medicinally,
the patient must be brought well under the influence of the
TETANUS. 414

Bromide of Potassium, by an initial dose of two drachms to
half an ounce, to be followed by half a drachm to a drachm
every three or four hours. Thirty grains of chloral are to
be given with some opium at bedtime. Chloral also is to be
used when necessary in the daytime. Nitrite of amyl and
’ chloroform should not be used continuously, but should be
resorted to from time to time to stop violent spasms. If
bromism should be produced, chloral and opium should be
relied on; or, cannabis indica may be substituted for the
bromides. Where there is much cerebral congestion a blister
may be put on the nape of the neck (Philadelphia Medical
Times, Oct. 13, 1877, and London Medical Record, Dec. 15,
1877, p- 500).

Nerve-stretching has been recently advocated as a remedy
in tetanus. It is an operation first introduced and recom-
mended by Nussbaum for the cure of neuralgia and other
painful and spasmodic nervous affections. Within the last
few years it has been tried in this country in the treatment
of tetanus, by Milner, Verneuil, Callender, Eben Watson, and
by Mr. Henry Morris in the Middlesex Hospital, London,
and by Surgeon-Major J. J. L. Ratton, in Madras Medical
College, with varying success. M. Verneuil’s case occurred
after a crush of the hand. Traction was made on the median
nerve at the elbow, and on the ulnar near the wrist. The
man completely recovered, but no particulars are given as to
the duration of the case, or as to its being acute or chronic.
Two cases reported by Dr. Eben Watson both died. The
patient operated upon and reported by Mr. Henry Morris al-
so died. The case differed from the others in its very great
severity and acuteness; and he did not think that the pro-
gress of the case had been in the least retarded or mitigated
by the nerve-stretching. On the contrary, the course of the
symptoms seemed to become more severe and more rapid;
and he could not help expressing his conviction that nerve-
stretching in tetanus would not prove a favorable mode of
treatment. It seemed to be unscientific in principle; and so
far as experience went, most unsatisfactory in practice. The
idea was to destroy the conductivity of the nerve-trunk, so
as to cut the spinal cord off from its comfnunication with the
peripheral nerves at the seat of injury. In doing this a very
severe shock or irritation was likely to be excited by the
nerve-stretching itself; so that the condition of the cord, be
it what it may, whether a material change, a state of excite-
ment from irritation, or a “bad habit” induced by a “de-
418 TETANUS.

praved current,” seemed more likely to be aggravated than
mitigated by a new and great disturbance of the same nerve
channel at a spot much nearer to the spinalcentre. But the
operation is still sub judice (Brit. Med. Journ., June 21,
1879).

On the other hand Surgeon-Major Ratton writes hopefully
of the operation, aided by the administration of chloral.
The case he relates is that of a strong Hindoo woman thirty
years of age,in whom symptoms of lockjaw appeared after
having taken a cold bath on the third and last day of a
menstrual period; and in whom there were also deep syphilitic
ulcers over the left ankle, some with sinuses and tense
cicatricial bands. He regarded the case as one of traumatic
tetanus, the symptoms ‘of which rapidly developed into an
explosion of acute tetanic violence, which he believes would
have killed the patient but for the nerve-stretching; and
which, at the same time, would not have saved the patient
but for the chloral. The sciatic nerve was stretched with
“the force required’ to lift a three-pound weight” for the
space of two minutes, and afterwards jerked once or twice
with about double that force before being replaced. Nota
single spasm recurred for 18 hours after the operation, when
slight spasms reappeared; and if at this time chloral had not
been pressed, the spasms would have gathered strength.
This is the fifth time Surgeon-Major Ratton has stretched
the sciatic nerve for traumatic tetanus, and each time the
operation has suppressed spasm for many hours; and if dur-
ing these valuable hours of rest, chloral is properly plied, he
believes the chances are that spasm will not return. He has
given chloral very freely, so as to maintain narcotism for
ten days. During the three critical days of the case of the
Hindoo woman, on and after the operation day, she had 300
grains of chloral daily. In such cases there is a great toler-
ance of chloral. In this particular case he purposely re-
frained from operating until the symptoms of tetanus were
alarming, for he desired to test the value of nerve-stretching
in acute cases only, for subacute cases often get well of
themselves, while acute cases never do. He doubts if any
treatment will avail to cure acute tetanus unless age (say
about thirty years, or prime of life) and stamina of constitu-
tion are with the physician. In this case the duration of the
disease was twenty-three days. It is only the strong who
can hope to battle through the exhausting effects of tonic
and clonic tetanic spasms prolonged for days, generally with
TINEA DECALVANS—TINEA FAVOSA, 419

insufficient nourishment, often for days at a time able to take
nourishment by rectal alimentation only; yet considering the
well-merited reputation of tetanus as a fatal disease, surely
it is a solid gain that even a few cases may, under certain
circumstances, be saved by the resources of modern medi-
cine (Brain, Part VII., Oct., 1879, p. 483).

Tinea Decalvans.— Definition —A fungous disease caus-
ing the formation of rounded or oval patches of baldness,
sometimes solitary, more generally multiple. It affects the
hairy scalp principally; but the beard, the: genital organs,
and hairy portions of the skin may also suffer.

Treatment consists—(1.) In preventing the spread of the
disease circumferentially. All the hairs within a quarter of
an inch of the circumference of the patch ought to be care-
fully extracted. The head should be washed daily with soft
or black soap. All the downy hairs within the patch must
be similarly removed till healthy hairs begin to grow; and
some of the parasiticide lotions or ointments must be in-
dustriously used. (2.) Stimulants, or even blisters, must be
applied to the surface of the bald patch after the fungus has
been destroyed. A mixture of equal parts of collodium
and of ether cantharidalis (collodium vesicans) is the most
useful stimulant. The following lotions may be found ad-
vantageous alternately with the collodium stimulant
namely :—

%. Liquor Ammonie, 3 iss; Ol. Olive, 3 ii; Ol. Macidis,
3 ss.;Spiritus Rosmarini, 3 iv-; Aq. Rose, 3 ii; misce bene.
To be used night and morning, applied over the bald
patches.

Mr. Startin recommends a lotion nearly similar, namely:—

. Spt. Ammon. co., £3i; Glycerine, f3ss.; Tinct.
Cantharidis, f3i. to f 3ii.; Aq. Rosmar., 3 viii.

Mr. Erasmus Wilson recommends the following:—

R. Ol. Amygdal.; Liq. Ammoniz, aa 31.; Spt. Rosmarini;
Aq. Mellis, aa Zii.; misce. To use as a lotion.

Of course, none of these agents have any good result if
there are no bulbs or roots of hair left whose growth can be
stimulated by such application; but when hair falls off, or
breaks away after debilitating illness, or from dryness of the
scalp, they are often useful.

Tinea Favosa.— Definition.—A fungous parasitic disease,
composed of cup-shaped scabs, sometimes distinct and
separate, at other times indistinct or confluent. The fungi
(Achorion Schonleinii Puccinia favi) are capable of being

 
420 TINEA FAVOSA,

'

implanted by transference from one person to another. The
hairy scalp is its most common site, but the disease may be
developed on the face, neck, or limbs.

Treatment.—The treatment of the various forms of favus
is now very strictly determined. Some practitioners, how-
ever, still rely entirely on a constitutional treatment, such as
small doses of rhubarb and soda, small doses of mercury,
some preparation of iron; or on vegetable tonics, as the in-
fusion of cascarilla or compound infusion of gentian. With
such treatment, if the health improves, it is believed the
fungus will spontaneously disappear. Others, again, as
entirely rely on a local treatment, attempting to exterminate
the disease by cauterization, or by applying some favorite
ointment. As in the last described disease, the crypto-
gamous parasite must be destroyed, and its germs eradicated.
The best method to accomplish this is, in the first instance,
to shave the head and apply a poultice till all the scabs, or
very nearly so, are removed; and this being affected, the
whole hairy scalp, or site of the favus fungus, should be
anointed with some of the following applications:—The tar
ointment (ungt. picis liquid) has hitherto been the ortho-
dox application. This ointment should be washed off night
and morning with soft soap and water, and be as often re-
applied. The head should be shaved twice or thrice a week,
and where there are other children, the affected child should
be isolated as much as possible, to prevent the disease
from spreading. This: form of porrigo, in the early
stages, will sometimes yield by washing the part with the
oleum terebinthinz night and morning, and cutting the hair
close. Two parts of carbolic acid to three parts of glycerine
and water used twice a day, with the daily use of carbolic
acid soap, have been also found of service.

But favus is more often rebellious to every mode of treat-
ment. It has been known to yield to fomentations, or to
bread poultices. The application of the lunar caustic round
the patches, about a line from their outer margin, is another
favorite method of treatment. In the later periods of the
disease, Dr. Willis recommends—

A solution of sulphate of copper, in the proportion of
seven grains to ten ounces of water; or of the nitrate of
silver in the same’ proportions. The mild ointment of the
nitrate of mercury, a salve of the black sulphuret of the
same metal (sulphuretum hydrargyi nigr., 3j. ad. 3 ij.,
adipis %j); the unguentum picis, an ungent of the cocculus
TINEA TONSURANS., 42T

Indicus (3j. to 3ij., adipis %j.,) may be tried one after
the other; and in different instances each may have the
merit of the cure,

The most effectual remedy is unquestionably the eradica-
tion of the affected hairs, and the use of such parasiticidés
as have been already mentioned under the different forms
of Tinea. Dr. Anderson finds that when favus affects the
head, all treatment is absolutely useless except epilation.
The other methods are merely palliative, the disease re-
appearing whenever the treatment is stopped. Treatment
with olive oil is very useful in many cases before proceeding
to epilation. After the hair is cut short, and the favus
crusts removed with poultices, the parts affected should be
smeared thoroughly night and morning with fresh almond
oil; and once or twice a week the head should be washed
thoroughly with soft soap and warm water. After a few
weeks of this treatment the hair becomes less friable, and
epilation is much more easily and efficiently performed, and
does not cause so much local irritation. The hairs are to be
removed singly with the forceps, not pulled out along with
all the healthy growth in their neighborhood, as used for-
merly to be done by the barbarous application of the pitch-
cap. When favus occurs on surfaces not particularly coy-
ered with hair it yields at once to the application of a solu-
tion of sulphate of copper, or of the nitrate of silver in
water, or to the solution of sulphuric acid, as recommended
by Sir William Jenner. The treatment of favus recom-
mended by Robin and Bazin is epilation, and the applica-
tian of the corrosive sublimate solution, or of acetate of
copper ointment (1 part to soo lard), to kill the plant still
remaining adherent to the hair follicle

Tinea Tonsurans.—Definition.—An affection implicat-
ing the hairs of the skin, scalp, or chin, and usually assum-
inga circular form. The hair becomes dry and brittle, hav-
ing a tendency to crack or break across. Itching accompa-
nies the primary eruption, which is generally at first erythe-
matous, with slight swelling, and a parasitic fungus ultimately
appears (Achorion Lebertii—Trichophyton tonsurans), which
had been developing between the epidermis and the true
skin. The fungus has a pure white color and powdery as-
pect. It covers the epidermis between the hairs, and forms
around them a complete white sheath. Inflammation of the
hair follicles and of the surrounding tissues occurs; and when
422 TINEA TONSURANS.

pus forms, the fungus is destroyed at the expense of obliter-
ation of the roots of the hair, when perfect baldness ensues
(Bazin, Anderson).

The Zvreatment of ringworm has been long one of the most
difficult points in dermatology. Its principles, however, are
now well understood, and few cases resist the proper meas-
ures. Theessential point is to apply tothe roots of the hairs
a preparation which may destroy the fungus; if this can be
done, the disease is cured. It is first of all necessary to re-
move the hair. This isin part generally accomplished be-
fore the case comes under treatment, by the course of the
disease; if it has not been sufficiently done, “ epilation” can
be accomplished by a chemical agent, or by extraction with
pincers. The forceps most suitable for this little operation
are those about three inches long, having a weak spring, so
that the hand may not be fatigued in using them. They
should be made so that the two extremities come together
very exactly, and dé not slide the one upon the other. Each
extremity should be a couple of lines broad, so that a fascic-
ulus of hair may be caught up at one time when required;
and should be furnished on the inside with very fine, but at
the same time blunt, transverse denticulations, so that they
may not cut across the brittle hairs. M. Bazin recommends
an ointment composed of lime and carbonate of soda, of each
one part, and thirty parts of lard, as an agent to remove the
hair. The oil of cade, however; appears to be the best de-
pilatory known, and with this mode of treatment epilation
with the pincers may be combined. If the hairs are pulled
out in the proper direction, there is very little pain, especially
after the sensibility of the skin has been blunted by the use
of the oil of cade. The removal of the hairs permits a “‘par-
asiticide” solution to be applied to the hair follicles, within
which are the prolific spores of thefungus. For this purpose
M. Bazin recommends either a solution of bichloride of mer-
cury (1 part to 250 of water), or an ointment of the acetate
of.copper (1 part to 500 of lard), about two grains to an
ounce of water; and a little alcohol or muriate of ammonia
should be used to facilitate the solution of the mineral. The
oil of cade should be mixed with glycerine in the proportion
of half a drachm to a drachm of the oil to an ounce of gly-
cerine. Kuchenmeister’s experience shows that the alco-
holic solutions act most powerfully. Dr. Parkes used, with
excellent effect, a solution of the pernitrate of mercury, about
one part to thirty or forty of water. This is, however, a very
TINEA TONSURANS, 423

powerful remedy, and is to be cautiously used, as it easily
blisters the scalp; also, an ointment composed of sulphate of
copper (one part), alum (three parts), and lard (twenty to
thirty parts, according to the age of the j:atient). Probably
a better and safer parasiticide than any of these is sulphurous
acid (Sir William Jenner). Diluted with equal parts of gly-
cerine, or with two or three parts of water, it is to be applied
on a piece of lint to the affected part, and covered with oil-
silk to prevent evaporation (AZed. Times, Aug. 20, 1853).
The following formula for sulphur may also be used:

BR. Sulphur, %iv.; Hydrarg. Ammon.-chloridi, Hydrarg.
Sulphuret,aa 3ii; Ol. Olive, %i.; Adipis, % iv.; Creasoti,
mv. It must be well rubbed into the patches of tinea.

Or, a lotion of one, ounce of hyposulphite of soda in twelve
ounces of water (Dr. Tilbury Fox). The internal use of cod-
liver oil at the same time that sulphurous applications are used,
has also been recommended (J. H. Bennett). My friend,
Staff-Surgeon Dr. Davidson, has found the following method
of treatment to succeed, namely: to apply tincture of iodine
to the affected parts twice a day for fourteen days, and after-
wards ointment of the bichloride of mercury (Corros. subli-
mat). After the third or fourth application of the iodine,
the disease ceases to spread, and the hair (which may have
been thinning rapidly) ceases to fall off. A kind of crust is
formed by the application of the iodine, which scales off in
the form of a scurf when the ointment is applied. Soft soap
(black soap) applied to the patches of disease at bedtime,
and washed off in the morning, fitsthe parts for the better
reception of other local remedies. Washing the head 1 efore
medical treatment is begun, sometimes tends to spread the
disease to parts of the head which had been sound before.
Goa powder, called also Bahia powder and Araroba powder,
first introduced to European medical practice by Sir Joseph
Fayrer, has also become a remedy, made into an ointment
composed of 20 grains of the powder, ro drops of acetic
acid or common vinegar, and an ounce of benzoin ointment.
It is applied by means of a hair pencil (Dr. Da Silva Lima).
Its active principle, chrysophanic acid, has the objectionable
property of staining; but it forms an efficient ointment in the
treatment of some forms of ringworm, to to 60 grains to an
ounce of lard being melted together in an oil-bath.

The iodide of arsenic in doses of one-tenth of a grain,
gradua.ly increased to one-fourth of a grain for an adult; one-
fifteenth of a grain for a child six years old; and from one-
424 TINA VERSICOLOR—TONGUE, ULCER OF.

eighteenth to one-twentieth for younger children, improves
the general health (Neligan, on Diseases of the Scalp).

Tinea Versicolor.—Definition.—A fungous affection of
the skin, characterized by one or more broad irregularly-
shaped patches of a yellow or yellowdsh-brown color, occur-
ring most frequently on the front of the neck, breast, abdo-
men, and groins, having a predilection for those parts of the
body covered by clothing. The patches do not generally
rise above the surface of the skin; and there is usually some
degree of itching.

Treatment.—Local applications constitute the principal
part of the treatment. A solution of the bichloride of mer-
cury, in the proportion of two grains to an ounce of water,
applied over the affected parts once or twice daily, is gener-
ally effectual in destroying the progress of the fungus. Mer-
curial or sulphur baths have a similar effect, either singly or
combined, care being taken to avoid salivation. The use of
black soap night and morning is recommended by Dr. An-
derson, or the use of the following mixture:—

&. Bichloridi. Hydrarg., Di.; Alcoholis, %ss.; Saponis
Viridis, et Aquz distillate, aa %iiss.; Ol. Lavandule, Di.;
misce. To be used night-and morning in the same way as
the black soap; but if the gums get tender, its use must be
suspended.

Great attention must be paid to cleanliness, The patient
should change his flannel clothing very often, and should not
sleep in the same flannels that are worn during the day.

Tongue, Inflammation of—Sce Glossitis.

Tongue, Uleer of the.—Defnitio »—Inflammation, sim-
ple or specific, terminating in ulcers.

The ¢reatment of syphilitic ulcerations of the tongue varies
according to the severity and form of the affection. In the
secondary varieties the local application of solutions of
chloride of zinc, with washes of chlorate or permanganate of
potash, are frequently sufficient; but sometimes the applica-
tion of solid nitrate of silver is desirable. In the tertiary
forms of syphilitic ulceration, solid nitrate of silver must be ap-
plied daily, and large doses of iodide of potassium frequently
administered. In mercurial ulcers, constitutional treatment
of a tonic character, disinfectant gargles, and generous diet
are indicated. It may here be mentioned that in all cases
of diseases of the tongue, all irritants, as spices and pepper,
TONSILS, ENLARGED—TYPHLITIS. 425

as well as smoking, sucking of lozenges, or any other measure
calculated to increase the flow of saliva, must be strictly pro-
hibited.

Tonsils, Enlarged.—Definition—Hypertrophy of the
tonsil, generally with induration.

Treatment.—Although enlarged tonsils may be the result
of constitutional derangement, they in themselves also inter-
fere with the proper development and health of the body.
Thus, they constantly obstruct the free passage of air into
the chest, and thus interfere with the due development of
the chest and the proper oxygenation.of the blood; they give
tise to an unhealthy secretion in the mouth; they sometimes
interfere with sleep; and, in the case of adults, they subject
the patient to repeated attacks of quinsy, with its associated
conditions of difficult deglutition and pain.

‘The importance of removing the diseased and redundant
portions of the affected gland will be at once evident.
Tonics, sea-bathing, and other constitutional means, do not
appear to exercise any beneficial effect in either diminishing
or arresting the growth of tonsils predisposed to hypertrophy;
nor are the applications of caustics of the slightest value,
unless they are so strong as to destroy a large portion of the
gland. It is better, therefore, to excise the enlarged tonsil
im all cases when the respiration is affccted, or where there
is disease of the follicles predisposing to frequent attacks of
inflammation and suppuration. ‘The best method of removal
is with a guillotine or wire écraseur. Dr. Mackenzie has
lately invented a double guillotine, by which, in one opera-
tion, both tonsils are removed. This is a great desideratum
in the case of children; as, after one tonsil has been re-
moved, the practitioner has great difficulty in inducing his
little patient to allow a second similar operation. Hzmor-
rnage seldom happens after removal of the tonsils; should it
occur, ice will generally check it; and if this does not answer,
afew half teaspoonfuls of a fluid containing tannic and gallic
acids in suspension, slowly sipped, will be certain to stop all
bleeding.

Tremor, Mercurialis—See Mercurial Poisoning
Typhlitis.—Definition—Inflammation of the cecum,

which may lead to ulceration of its mucous membrane, and
not unfrequently of the entire wall of the bowel.

Treatment.—A full dose of castor-oil (%ss. to Zi.) is in-
426 TYPHOID FEVER—TYPHUS FEVER.

dicated if vomiting does not exist. Drastic purgation is not
‘to be thought of. The use of enemas through long rectum
tubes are the most efficient means of relief, which may throw
up four or five pints of liquid in a continuous stream, so as
to soften, crumble down, and set in motion the fecal collec-
tions. Salt, castor-oil, or turpentine, or milk oughi to be
added to the,fluid injected (Niemeyer). Any effusion left
may be resolved by the use of iodide of potassium. Leeches
may be required if pain on pressure continues in the iliac
region.
Typhoid Fever—Sce Enteric Fever.

Typhus Fever.—Definition.—A continued specific fever,
having a duration of from ten to twenty-one days, usually
fourteen, characterized by an eruption on the skin, of a gen-
eral dusky mottled rubeoloid rash, appearing between the
fourth and seventh days, at first slightly elevated ; disappear-
ing on pressure, but, after the second day, persistent, and re-
maining so for eleven or twelve days; and often becoming
converted into true petechiz. Languor and weariness are
prominent from the first, gradually passing into sluggishness
of intellect, with confusion of thought, followed at the end
of the first week by delirium, stupidity, oblivion, and com-
plete prostration. In still more severe cases, somnolence,
stupor, and sometimes coma, with tremors, subsultus, and
contracted pupils supervene, when prostration becomes pro-
found. The disease may terminate favorably from the thir-
teenth to the seventeenth day. If it proves fatal, itis gen-
erally between the twelfth and the seventeenth day, leaving
no specific lesion in any part of the body, beyond hyperzemia
and blood changes, softening and disintegration of the heart
and voluntary muscles, hypostatic congestion of the lungs,
atrophy of the brain, and cedema of the sub-arachnoid and
pia mater. Typhus fever is eminently contagious, and oc-
curs in strongly-marked epidemics (Murchison).

General Indications for Treatment.—They may be summed
up as a combination of measures to reduce excessive heat, to
insure proper excretion, and to act on the semi-paralyzed
nerves; and, ‘‘every remedial agent which shall be found to
promote the elimination of urea, without increasing the de-
structive metamorphosis of tissue, will deserve a trial in ty-
phus ” (Murchison, p. 268). To reduce heat and to regu-
late elimination are but secondary indications in the
treatment of typhus fever, compared with the influence which
TYPHUS FEVER. 427

must be exercised over the nervous system; and one of the
greatest objects of therapeutics at the present day is to find
substances which will act on the nerves and the blood, and
restore them in some way to their normal action.

Special Imdications for Treatment.—Our objects in the
treatment of typhus fever should be,—(z.) To neutralize the
poison and to correct the morbid state of the blood; (2.)
To promote elimination of the poison and the products of
the destructive metamorphosis of tissue; (3.) To reduce
the temperature ; (4.) To sustain the vital powers, and to
obviate the tendency to death; (5.) To relieve the distress-
ing symptoms ; and, (6.) To avert and subdue local com-
plicatious (Murchison, p. 265).

1. In the belief that the morbid condition of the blood in
typhus fever may be due tothe presence of ammonia in some
as yet unknown combination, the use of mineral acids has
been recommended by many physicians. Murchison con-
siders their beneficial effects in. typhus as undoubted, and in
this opinion he is confirmed by the experience of Huss of
Stockholm, Haller of Vienna, of Mackenzie, Chambess, and
Richardson, in this country. Huss recommended dilute
phosphoric acid in doses of twenty-five to forty drops every
second hour, believing that the phosphorus exerts a special
influence on the central organs of the nervous system. But
in the advanced stage, and especially if sweating, numerous
petechiz, or ecchymoses be present, he has recourse to di-
lute sulphuric acid in doses of fifteen to twenty drops every
hour or every second hour. Dilute hydrochloric acid is pre-
ferred by Drs. Murchison, Richardson, Mackenzie, and
Chambers. It may be given to the extent of half a drachm
of the dilute acid, mixed with a like quantity of the tincture
of syrup of orange every three hours. Dr. A. P. Stewart
has used with advantage the tinctura perchforidi ferri, in
doses of thirty minims every three hours. Dr. Murchison
recommends nitro-muriatic acid. He prescribes twenty min-
ims of hydrochloric acid with ten minims of nitric acid every
three hours each dose being diluted with the patient’s drink,
such as barley water sweetened with syrup of ginger and fla-
vored with lemon peel. But if the “typhoid state” is
developed in a marked manner, dilute sulphuric acid,
in doses of fifteen to twenty minims every three hours,
in combination with ether, and small doses of quinine,
are to be had recourse to, asin either of the following

formule :—
428 TYPHUS FEYER

R. Acid. Hydrochlor. dil., mxx.; Acid. Nit. dil. mx. ;
Spt. Asther. Nit., mlx. ; Liquor. Cinchone, mxxx.; Decoc.
Scopar. comp., 3%i.; misce. A draught so composed may
be administered every third hour.

Or, B. Quiniz Sulph., gr. 4; Acid. Sulph. dil., mxx. ad
mxxx, ; . ther. Salphe mxy, ad mxxx. Syrup, Aurant.,
mlx, ; "Decoc. Scopar. comp.. 31. - misce. A draught so
composed may be administered every third or fourth hour.

When the acids are cautiously administered in smaller
doses, in conjunction with a few minims of solution of muri-
ate of morphia (if the bowels be irritable), sweetened with
syrup of orange peel and diluted with water, the draught is
generally relished, and the tongue from being dry, and hard,
and brown, becomes moist and clean (Perry).

2. Perhaps the best general inethod to insure proper ex-
cretion is to supply the system with abundance of diluents
containing alkaline salts, which are not given in the food,
and to maintain the action of the kidneys, the bowels, and
the skin. Plenty of pure drinking water tends to increase
the flow of urine, and so helps to wash away the products
of metamorphosis. Chloride of sodium, the alkaline salts of
potash, and probably also those of soda, tend to aid the for-
mation of urea, and its elimination. Dr. Murchison has
been in the habit of ordering large quantities of salt to be
mixed with the patient’s beef-tea. In most cases it was great-
ly relished, and apparently beneficial.

Purgatives tend to insure a proper excretion, probably by
removing from the blood some of the abnormal products
formed in fever. The great relief which sometimes follows
their use, as well as the fall of temperature, seems to show
this. Where there is retention of urea, they aid its elimina-
tion, because we know that urea passes off sometimes by the
mucous membrane of the stomach and bowels. The patient
should be allowed to drink freely of. water; and five grains
of the nitrate of potash, or a small dose of the tincture of
digitalis (miv. to mx.), may be given with each dose of the
nitro-muriatic acid already mentioned. Dr. Murchison re-
commends nitre whey, prepared by boiling 3ii. of nitre in
a pint of milk, and straining; or a drink prepared by dis-
solving 3i.to 3ii. of the bitartrate of potash in a pint of
boiling water, flavored with lemon peel and sugar ; but if the
patient be very prostrate, orif the bowels be relaxed, 15
minims of the spirit of nitrous ether is to be substituted for
the nitrate of potash
TYPHUS FEVER. 429

Tea and coffee have been recommended in the stupor of
typhus ; and it is probable that their good effects are due to
their power of eliminating the urea already formed in the
blood (Dr. Parkes). The coffee may be given as an extract,
or as a strong infusion of the powdered berry made in the
ordinary way. Tea has been recommended as an infusion
of the green tea leaf. As beverages or common drinks in
fever, both tea and coffee have been found to relieve the
headache, the pulse becoming fuller and stronger under
their use. Bocker, L. Lehmann, and Hammond, all agree
in showing that in health they greatly lesson the urea
(Parkes On the Urine, p. 76). To restrain excessive metamor-
phosis it has been proposed to administer coca—the dried
leaves of the erythroxylon coca—which, when indulged in
by ahealthy person, prevents for a time the feeling of fa-
tigue, and diminishes the amount of urea (éo de ?) excreted,
Hence its possible value as a therapeutic agent (M’Bean,
Brit. Med. Journ., March 10, 1877, p. 291). A drachm toa
drachm anda half of the tincture is to be given in water
every four hours ; or an infusion of the leaves may be taken
when thirsty. :

The action of the bowels is to be maintained by emetics
and laxatives. In the first instance, if the patient is seen
early—i. ¢., before the sixth day—an emetic of ipecacuanha
(one scruple), and of antimony (one grain), or of carbonate
of ammonia (two scruples), in place of the antimony, is to be
administered. If the bowels remain confined after the emetic
a mild laxative of rhubarb and calomel, or of castor-oil, is to
be given; and failing these, or in place of them, a simple
enema is to be administered (Murchison, p.. 277, 2nd Ed.).
The advantages of emetics are, that they relieve the patient
to some extent by mitigating or removing headache and gen-
eral pains. They also reduce the temperature, abate thirst,
and quiet gastric disturbance. Emetics, however, are con-
tra-indicated if the patients are unusually weak, or if the dis-
ease has advanced beyond the first week. Laxatives and
enemata, however, ought to be repeated daily, if required, so
as to secure a motion of the bowels once a day. In this re-
spect the treatment is different from the treatment which
ought to obtain in enteric fever. Excrementitious matters
in the intestines must be removed by gentle aperients. The
dark offensive matters accumulated in the intestinal canal in
typhus fever may have a secondary deleterious effect on the
system if they are allowed to remain. Purging, however, is
430 TYPHUS FEVER.

to be avoided, and fresh-made compound rhubarb pill mass,
which tends to stimulate the peristaltic action of the intes-
tines, is as good a medicine as can be given, followed, if nec-
essary, or alternated, by a small dose of castor-oil, or, by a
simple enema.

Diaphoresis is not. to be encouraged beyond the insensible
transpiration of the skin, to remove which the wholesome
detergent of tepid water sponging is most beneficial. It
ought to be used twice or three titnes daily, and quantities
of Condy’s fluid or of muriatic acid (3i. ad Oj.) may be
mixed with the tepid. water (Murchison), The measure
is a good one in a hygienic point of view; and it con-
tributes—

3. To reduce temperature, the external application of cold
water, as was once practised to an extreme degree by Currie
(and originally recommended by Dr. Robert Jackson), has
been again recently advocated. In health such an applica-
tion as that of cold water has a great effect in reducing tem-
perature, and tends to increase metamorphosis of tissue
(Lehmann, Sanderson).

4. The vital powers are to be sustained by food in the
first instance. For this purpose, nourishment ought to be
given often, and at stated intervals —at least once every three
or four hours after the fourth day of the fever. Even if the
patient is asleep, or seems to be so, he must be roused at
these stated intervals (not oftener) to take his food or his
stimulants. But if, towards the period of the crisis, the pa-
tient appears to be in a sound sleep, he ought not to be dis-
turbed. The indications for treatment just described apply
to the earlier stages of the fever, up till about the fourteenth
day. Beef tea, broths, meat juice, bread pudding, arrow
root, jellies, milk, eggs, and alcoholic fluids, are the foods on
which the typhus fever patient must be sustained. Alcohol
in small quantities, as well as tea, coffee, lemonade, soda-
water, water poured from standing over oatmeal, and taken
cold or after boiling and then cooling, and other fluids, have
a directly stimulant action on the nervous system and on the
organs of circulation ; at the same time, alcoholic drinks di-
minish the metamorphosis of the tissue elements. Few reme-
dies, however, require more discrimination in their use ; and
the following guides for their administration are compiled
from the careful’ observations of Dr. Murchison (p. 288,
2nd Ed.) :—(1.) Patients under twenty years of age do best
without alcohol; but most patients over forty are benefited
TYPHUS FEVER, 431

by alcohol from the commencement of the second week of
the illness, or earlier ; while persons of intemperate habits
require alcohol earlier, and in greater quantity than others.
(2.) In individual cases the indications for alcoholic stimu-
lants are mainly derived from the state of the organs of cir-
culation ; and the profession is indebted to Dr. Stokes (1839)
for pointing out the importance of cardiac and radial pulses
as guides for the use of alcohol in fever. The indications
are,—(a.) Extreme softness and compressibility of the pulse.
An undulating, irregular, intermitting, or imperceptible pulse
more imperatively demands stimulants than a merely rapid
pulse. So also an abnormally slow pulse—c. ¢., 40 to 60—
is a stronger indication for stimulation than a quick pulse.
(o.) When the cardiac impulse becomes ‘weak, and when the
first sound is impaired or absent, a liberal allowance of stim-
ulants is demanded;, and in every case where there are
doubts as to the propriety of giving stimulants, the heart
must be examined with the hand and with the stethoscope,
because the state of the pulse alone is not sufficient to judge
from. The impulse may be found to diminish progressively
from the fifth or sixth day to the termination of the disease ;
and for several days prior to death or recovery it may be en-
tirely absent. The systolic sound of the heart becomes daily
more feeble, and ultimately may be quite inaudible, leaving
the second sound clear and distinct; and before the first
sound is altogether lost, it may become so short that it is dif-
ficult to distinguish it from the second sound. If the action
of the heart be rapid, its sounds may thus come to resemble
closely those of the fetus in utero. A violently excited heart
all through the disease, with cold surface, cold breath, and
feeble pulse, demands wine from the first ; but even with its
judicious use the prognosis in such cases is extremely doubt-
ful (Stokes, Graves, Murchison), Other indications for
stimulants may be stated as follows :—(c.) If by raising the
patient to his semi-erect position a tendency to syncope is
induced, or great prostration is manifest, with diminished
strength and volume of the pulse, then stimulation must be
commenced. (3.) The darker and more copious the erup-
tion, the more is the necessity for stimulants, especially
if petechiz are numerous. (4.) Profuse perspiration,
with no improvement: in the general symptoms, requires an
increased supply of stimulants; but a burning dry skin is in
icself an indication against alcohol. Coldness of the ex-
tremities is an indication for alcohol, especially when at the
432 TYPHUS FEVER.

same time the temperature of the trunk is considerably ele-
vated. (s5.) Stupor, low delirium, subsultus, involuntary
evacuations,—symptoms generally of the typhoid state, are
indications for the liberal administration of alcohol ; but the
propriety of giving stimulants in delirium depends on the
state of the pulse. If, on the trial of stimulants, the patient
becomes tranquil, they do good, and may be continued ; if
the reverse, their use must be suspended. (6.) A dry brown
tongue is an indication for wine or brandy ; and if it becomes
clean and moist at the edges under the use of either, such
stimulation is beneficial. (7.) Complications, as a rule, in-
crease the necessity for stimulation ; and large quantities of
stimulants are called fer if pyzemia, erysipelas, bronchitis,
pulmonary hypostasis, pneumonia, inflammatory swellings,
bed sores, or local gangrene shonld supervene. (8.) Alco-
hol, as a rule, is contra-indicated if there be severe darting
or throbbing headache, or acute noisy delirium, especially
when these symptoms co-exist with great heat and dryness
of the skin, flushing of the face, suffusion of the eyes, and
little or no impairment of the cardiac and radial pulse. When
alcohol is given under such circumstances, it should be re-
stricted to the intervals of the paroxysms of delirium. (9.)
Scanty urine of low specific gravity, containing little urea or
much albumen, and suppression of urine, are in themselves
indications against the use of alcohol.

The effects of alcoholic stimulation require to be most
carefully watched throughout the whole period of their ad-
ministration. Four ounces of wine in the twenty-four hours
is enough to begin with ; for if the blood be overloaded with
the products of alcoholic ingestion, further alcoholic stimu-
lation will lead to increased contamination, and it is rare that
more than eight ounces of brandy in twenty-four hours are
necessary. ‘There are differences in the demand for stimuli
in the typhus of different countries, and in the fever of differ-
ent epidemics. Dr. Wood tells us that in America cases re-
quiring wine or brandy are extremely rare. Dr. Stokes says
that the typhus in Ireland demands large quantities of wine.
In Scotland, also, wine is the great mainstay in the treatment
of typhus fever, requiring often to be administered largely.
Port, sherry, marsala, madeira, brandy, gin or whiskey, pos-
sess no peculiar advantages apart from the alcohol contained
in each, Spirits contain 50 to 60 per cent. of alcohol, sherry
and port from 17 to 24 per cent., and malt liquors from 6 to
8 percent. Two fluid ounces of spirit will thus be equal to
TYPHUS FEVER, 433

five or six of wine, and spirits ought to be given diluted ; and
if the prostration is great, and when the skin is cold and
covered with perspiration, the best stimulant is brandy or
whiskey punch, given as hot agit can be taken, in small quan-
tities at a time, frequently repeated. In urgent cases stimu-
lants ought to be given every hour ; and, as a rule, a larger
quantity will be required during the night and early morning
than in the daytime, for it is usually towards morning that
temperatufe tends to get low, and the vital powers are at
their lowest ebb (Murchison). At the same time it must
ever be remembered, as Sir William Jenner justly observes,
that “in no disease is the advantage of refraining from med-
dling more clearly displayed than in typhus fever ; and in no
disease is the prompt use of powerful remedies more clearly
indicated. It is in determining when to act and when
to do nothing, that the skill of the physician as a curer of
disease, in the case of fever is shown. Interfere by deple-
tion or stimulation when nothing should be done, and the
patient is lost, who, if it had not been, for you, would have
been safe. Refrain from depletion or withhold stimulants
when the one or the other is required, and the patient sinks
into that grave from which judicious treatment might have
saved him.”

A large, well-ventilated apartment, fresh air, a cool, but
not a cold atmosphere, quiet, abstinence from solids, and a
free supply of water, milk and water, coffee, weak broth,
beef tea, according to the discretion of the physician, are
the conditions and remedies on which a large majority of
cases will recover. But the patient must be constantly and
carefully watched. There is no disease where the attentions
of a well instructed nurse are more demanded ; and there is
no class of patients in hospitals so apt to be neglected by
the attendants, especially as to the regular administration of
the remedies prescribed. It is not uncommon to find that
the wine allotted for the day has been administered at a
draught, when it ought to have been given in small quanti-
ties at regular intervals, with care and watchfulness. How
often do we see almost hopeless cases recover under the careful
nursing of an intelligent person, regulated by the dictates of
common sense and conscientious solicitude, guided by the
judicious directions of a physician who knows well the na-
ture of the disease with which he has to deal! The nurse
ought to note down the hours at which food or medicine has
been given, or any remarkable change in the symptoms. She

28
434 TYPHUS FEVER.

might also, if she were instructed, take observations with the
thermometer, for the information of the physician at each
visit. Dr. Murchison recommends that, in urgent cases,
food and alcoholic stimulants must be persisted in as long as
the patient is able to swallow; and even when he can no
longer swallow, the case is not to be given up; for he has
seen cases where life appeared to be saved by frequent ene-
mata of beef-tea and brandy after the patient had ceased to
take anything by the mouth,

Of special symptons which call for relief, the most urgent
is generally headache. If headache should persist after de-
lirlum sets in, with a rapid pulse (¢. g., 120), attended with
nausea, some saline, effervescing mixture, with four drops of
dilute hydrocyanic acid, may be given every six hours. In
the persistence of headache, dry cupping, such as has been
recommended by Dr. Sieveking, might furnish an aid to
guide the treatment, by determining whether it may not de-
pend upon repletion or upon emptiness of the cranial ves-
sels. When applied to the nape of the neck, dry cupping
may afford relief, if r€pletion has to do with the continuance
of headache. Under such circumstances the face is gener-
ally flushed, the conjunctive red, and the skin dry and hot.
If the dry cupping does not relieve such symptoms, the hair
must be shaved off the head, and the scalp covered with
crushed ice inclosed in a bullock’s bladder, or recourse may
be had to cold affusion. The application of cold water is
best effected by bringing the patient’s head over a basin at
the edge of the bed, and having a vessel arranged so that the
cold water (at 40° or 50° Fahr.) may drip continu-
ously from a height of two or three feet upon the
head (Murchison). A skein of worsted arranged in the
water, with the ends overhanging the basin will main-
tain a constant flow of water from the basin, which may
be directed to fall upon the scalp. Dr. Murchison recom-
mends that in young subjects two or four leeches may be
applied to the temples; and in aged or infirm persons warm
fomentations to the head are advisable (Graves and Murchi-
son); a double fold of lint moistened in warm water and
vinegar, is to be laid over the scalp, covered with oiled silk,
and the application renewed every three hours. But if
anzmia is the cause of the headache, as may be suspected
from the state of the vascular system, then stimulants are
called for. Four to six ounces of wine may be given in
divided doses during the day and night of twenty-four
TYPHUS FEVER. 435

hours. If the pulse continues to get weaker, the wine must
be increased. It must be borne in mind that the headache
of typhus naturally abates about the eighth day; but it is
sometimes rendered worse by sleeplessness; and if the reme-
dies for headache do not relieve it, nor tend to induce sleep,
then opiates may be given, combined with antimony, if the
skin be dry and hot and the pulse of good strength. Dr.
Murchison thinks that the employment of opium in typhus
is more dreaded than it ought tobe. The dose of opium
should be given about g Pp. m., followed in two hours by half
the dose if the patient does not sleep. The form of the
opiate and dose may be ten to twenty minims of Battley’s
solution, or fifteen minims of the solution of the bimeconate
of morphia, or five grains of the opium pill or compound
soap pill of the British Pharmacopceia. Dr. Murchison
teaches us to distinguish two forms of delirium as a guide to
the administration of opium, combined with antimony in the
one form, and with ethereal stimulants in the other. When
the condition of the patient approaches more to that of
delirium ferox, the cardiac and radial pulses being of good
strength, after trying the cold affusion, and remedies already
mentioned, then opium combined with antimony ought to be
given without delay, as in the following prescription:

R. Liq. Opii. Sedat. (Battley’s) m Ix; Antim. Tart., gr. if
ad gr. ii.; Aqua Camph. 3 vi; misce A large spoonful o.
this mixture is to be given every hour until sleep is induced.

On the other hand, if the delirium approaches in its char-
acter that of delirium tremens, the radial pulse is usually
quick and feeble, the cardiac impulse diminished, and the
first sound of the heart. more or less inaudible, then the
opium must be combined with alcoholic or other stimulants,
the amount being regulated by the state of the pulse and
heart. Dr. Murchison suggests the following prescription:

RB. Liq. Op. Sed. (Battley’s)3ss.; Spt. A‘theris, m 1x.;
Aque Camph., ad 3 iil.; misce. Commence by giving two
tablespoonfuls of this mixture, and repeat it every hour till
sleep is obtained. : ;

Or opium to the amount of half a grain may be combinea
with three grains of camphor in a pill, and such a pill may be
repeated, if necessary, every two hours.

Cascs recuiring such treatment ought to be seen at least
threc or four times daily. If dyspnceea is urgent, and lividity
of the face betoken pulmonary lesion, defective arterializa-
tion of the blood and venous congestion‘of the brain, opium
436 TYPHUS FEVER.

in any form must be withheld; and it must likewise be dis-
continued if any tendency to stupor supervene, or if there be
any marked contraction of the pupil—e. ¢., “the pin-hole
pupil” of Dr. Graves. This physician proposed the use of
belladonna in such cases, and he, as well as Dr. Benjamin
Bell and Dr. Murchison, bear their united testimony to its
usefulness. Dr. Craves prescribed it as follows: ‘

&. Ext. Belladonne, gr. i.; Ext. Hyoscyami, gr. vi.; Pil.
Hydrar., gr. xxx.; misce. This mass being divided into six
pills; one may be given every three hours,

Dr. J. Harley recommends 15 to 20 minims of the tinc-
ture every four hours; or to inject hypodermically from yy
to js of a grain of sulphate of atropia. But digitalis is the
remedy on which Dr. Murchison places most reliance.
From 15 to 20 minims of the tincture; or from 6 drachms
to 3 ounces of the infusion may be given in the twenty-four
hours (1. c., p. 284). Musk and camphor are stimulants of
very great value, which have fallen into unmerited neglect.
Camphor may be given in emulsion in doses of five grains
every two hours; or in the form of an enema in doses of a
scruple. Huss and Graves also bear testimony to the good
effects of these remedies. In a case of complete sleepless-
ness Dr. Graves gave the following combination of these
medicines with the best results:

R. Antim, Tart., gr. ss.; Pulv. Moschi, gr. x.; Camphor,
gr. v.; Tinct. Opii, mx; Aque dil.,%i misce. A similar
draught may be given every two hours; and after the third
dose the patient will generally fall into a quiet sleep.

The hydrate of chloral has been found to be preferable, in
certain circumstances, to opium in typhus fever. As a seda-
tive and hypnotic, it is successful in every form of cerebral
excitement; but it seems to have a more immediate and per-
manent curative action on cases of acute delirium at the
acmé of typhus, than in the delirium tremens of the second
and third weeks, when the blood is loaded with the products
of the fever. It is also of use where there is bronchitis and
congestion of the lungs,-when opium may not be given.
With regard to the dose, 40 grains is found to be a poisonous
dose in typhus, producing depression and irregularity of the
heart’s action. All the benefits without the dangers may be
obtained with 20 grain doses for adults; 2 grains for chil-
dren of one to two-years; 3 grains for three years; and 10
grains for children from nine to fourteen years. Itis to be
URINE, SUPPRESSION OF. 437

given in an ounce of water, sweetened with half an ounce of
syrup (Dr. J. B. Russell).

When there is danger of stupor passing into profound
coma, the best effects may result from a small cupful of a
strong infusion of coffee, given every three or four hours,
employing at the same time such measures as have a deriva-
tive action on the kidneys—e. g., dry cupping; mustard
poultices to the loins; wet compresses of thickly folded flan-
nel, wrung out of hot water, passed round the loins, and cov-
ered with a piecegf water-proof cloth, retained in its place
by a bandage or towel. These remedial agents are all the
more necessary if the urine contain either blood or albu-
men. At the same time free evacuation from the bowels
should be secured by a purgative, or by a turpentine enema.
If the lethargic state supervenes early, and before there is
great exhaustion, the douche has been found to be of great
service as a stimulant, provided there be considerable eleva-
tion of temperature, and little irritability of the nervous sys-
tem (Todd, Armitage, Murchison).

The region of the bladder should be examined by the
physician at least two or three times daily, by manipulation
and percussion, and if there be the slightest doubt as to its
containing urine, the catheter must be introduced.

Urine, Suppression of.—Definition—A complete or
partial suspension of the functions of the kidney, by which
the quantity of urine is greatly in defect, or its secretion en-
tirely suppressed.

Treatment.—When suppression does not depend on any
morbid condition of the blood, and is primary, the patient
should be placed in a warm bath, and be purged by substan-
ces that act on the kidney, as the neutral salts. Indeed, if
the case be slight, purging by any cathartic is sufficient. If
this method should not succeed, m x. to xxx. of the tinct.
cantharides should be tried every four or six hours, accord-
ing to the urgency of the case. Many physicians prefer a
tonic treatment, as the camphor mixture and ether, or the
tinct. ferri muriatis m xxv. to]. Belladonna is a useful remedy
and so also is digitalis applied as a fomentation of the fresh
leaves over the abdomen; or an ounce of the tincture may
be added to a warm linseed poultice, or the dried leaves may
be made into a poultice, to which half an ounce of the tinc-
ture may be added. It is chiefly in cases in which the pulse
is rapid that digitalis is suitable ; and the urine will not begin
to flow till the digitalis has reduced the action of the heart
438 URTICARIA—UVULA, ELONGATED.

(J. D. Brown, in Medical Times, January 25, 1868). In the
suppression of urine attending cholera, Dr. E. Goodeve rec:
ommends the following :—

RB. Tinct. Digitalis, mv. tom x.3 Spr. Aéther. nit., m
xxx. ; Liq. Ammon. Acet., mlx.; Aq. £3i.; misce. Such
a draught may be taken every three or four hours. (Rey-
nold’s System of Medicine, Vol. I., p. 183.)

The treatment of symptomatic anuria resolves itself entirely
into that treatment which will remove the primary disease.

Urticaria.—De/finition.—An eruption of little solid elastic
eminences, roundish or oblong, pale in the centre, and red at
the circumference. These are commonly called “ wheals,”
similar to the results from the strokes of a lash.

Treatment Emetics and purgatives in the first instance ;
afterwards the correction of faulty digestion. The surface
of the eruption may be dusted over with flour; or the fol-
lowing lotion may be used :—

R. Carbonatis Ammonie, 31.; Plumb. Acetatis, 311. ;
Aque Rosarum, viii. ;

In the chronic form, especially associated with uterine irri-
tation Or ovarian tumors, I have found bromide of potassium
of much benefit. It ought to be given in a full dose of ten
grains twice daily, which is to be doubled at bedtime. Qui-
nine is also useful, combined with rhubarb and carbonate of
ammonia,

Ri. Sulphatis quiniz, gr. xii.; Solve in Glycerine, m il. ;
Pulv. Rhei., gr. xxiv.; Carb. Ammon., gr. xviii; misce et
divide in pil. xii—Signa, “‘ One three times a day.”

Uvula, Elongated.— Defixition.—Relaxation or paralysis
of the uvula, which becomes so elongated that its top may
touch or rest upon the surface of the tongue.

The Zreatment of elongated uvula must depend on the de-
gree of relaxation present, and the previous duration of the
affection. Slight and recent cases often get well by the per-
severing use of astringents. Gargles, containing tannin,
rhatany, or perchloride of iron, lozenges, and local applica-
tions, may all be used with advantage; and, indeed, it is
found convenient to brace up the mucous membrane by em-
ploying these different methods at the same time. When
the uvula has been considerably relaxed for some months the
elongated portion should be snipped off. While hardly any
slight affection of the throat produces such serious symptoms
as elongation of the uvula, there is no slight operation that
VARICELLA—VERTIGO, AUDITORY. 439

gives such complete and permanent relief as its removal.
Should any hemorrhage follow the operation, treatment simi-
lar to that recommended after excision of the tonsil must be
adopted.

Varicella—See Chichen Pox.
Variola—Sce Small-Pox.

Vertigo, Auditory.—Definition—A condition charac-
terised by sudden attacks of vertigo, paroxysmal in their oc-
currence, depending on a morbid state of the organ of hear-
ing, and especially with lesions of the semicircular canals.

Treatment.—Of practical importance in the treatment of
labyrinthine vertigo, and at the same time in illustration of
its pathology, it is to be remembered that the tympanum is
supplied with arterial blood from the carotid, and its veins
discharge into the jugular; that the labyrinth is supplied by
the vertebral, and its veins discharge into the superior pe-
trorsal sinus; that the vertebral artery derives many of its
vaso-motor nerves from the inferior cervical ganglion; and
that these nerves communicate witli the brachial plexus.
The same ganglion furnishes the inferior cardiac nerve—the
principal inhibitory nerve of the heart. Besides these con-
nections a fasciculus is given off from the pneumogastric,
near the recurrent laryngeal, to the lower cervical ganglion.
We have, therefore, in this ganglion an organ connecting the
upper extremities, heart and upper portion of the digestive
tract, with the labyrinthine circulation. From any irritation
there may consequently arise a diminished inhibition, which
will relax the walls of the vertebral artery, and so cause
pressure on the endolymph with consequent vertigo (Woakes,
Chicago Med. Jour. and Exam., Nov. 1878).

Hence such vertigo does not necessarily imply previous
disease of the ear. Gunshot wounds of the upper extremi-
ties are often followed by dizziness (Weir Mitchell). Qui-
nine, in large doses, and tobacco diminish vascular tonus;
while bromine, the bromides, and especially hydrobromic
acid, stimulate vascular innervation. Hence the antagon-
istic effect of the latter on the tinnitus aurium caused by the
former (quoted by Mr. D’Arcy Power, London Medical Re-
cord, April 15, 1879, p. 152).

The treatment of labyrinthine vertigo, the result of de-
structive lesions, can be but palliative; but auditory-nerve
vertigo, due to irritative lesion, may be more or less relieved.
Absolute rest is the first essential. The direct treatment of
440 WHOOPING-COUGH.

labyrinthine affections is a subject for the special aural sur-
geon; and it is obvious that when symptoms point to the
existence of any disease or irritation in the accesuible parts
of the éar, special treatment should’ be directed to those
morbid states. When there is evidence of an irritative pro-
cess, blistering behind the ear sometimes affords very mark-
ed relief to the vertigo. Occasionally there may be evidence
of a constitutional condition on which the aural disturbance
is dependent. In some cases there may be reason to believe
that a gouty change in the membranous labyrinth is the
cause of the morbid action (Hinton, Gowers). Marked re-
lief is afforded under these circumstances by colchicum and
potash. In rare cases the vertigo may depend on a syphi-
litic inflammation of the labyrinth. Such a case has been
described by Moos of Heidelberg. One of the most severe
forms of paroxysmal vertigo which Dr. Gowers has seen was
in a child, with almost complete déafness and every sign of
inherited syphilis. In all syphilitic cases the specific treat-
ment for syphilis is, of course, required.

It has been remarked that certain drugs have a marked
influence on the organ or nerve of hearing. The effect of
quinine induced Charcot: to employ it, in full doses, in a
case of auditory-nerve vertigo, with some beneficial result.
Dr. Gowers has tried it; but he has not found that any
marked effect was produced on the vertigo. The influence
of salicylate of soda upon the equilibrium suggested its use
in this disease. It does not remove the giddiness; but in
some cases it lessens its intensity, in doses of from five to
ten grains three times a day. The most unremitting care
in diet and regimen is necessary. Antacids have been found
useful in subduing stomachal disturbance, and so arresting
an actual attack, and carbonate of bismuth has been of use.
The bromides of potassium and of ammonium have been the
most beneficial of all medicines in subduing the paroxysms;
and the good effects of bromide of potassium are increased
by belladonna, and also by its combination with bark. Other
sedatives alone, such as opium, Indian hemp, gelseminum,
and hyoscyamus, are, in the experience of Dr. Gowers, with-
out ‘effect. The affection is a very obstinate one; but when
the several factors in the individual cases are sought out and
corrected, a considerable amount of relief may be afforded
(Dr. W. R. Gowers).

Whooping-Cough—Sec Hooping Cough.
WRITERS CRAMP—YELLOW FEVER, 441

Writer’s Cramp—( See Scrivener's Palsey.)

Yellow Fever--Dejinition.—A specific fever of a malignant
and continuous type; occurring, as a rule, only once during
life, and propagated by contagion. It is attended by yellow-
ness of the conjunctive and skin, delirium, suppression of
urine, interstitial haemorrhages and hemorrhages from the
stomach, mouth, nares, and rectum (black vomit, black
stools), aslow and, at times, an intermittent pulse. It is
limited to very definite geographical limits, never having been
known to propagate beyond 48° north Latitude, nor without a
temperature of 72° Fahr. at least. It has been imported
into Lisbon, into S. Nazaire (in the department of the Lower
Loire), into Plymouth and Southampton, where the import-
ed cases have run their course and proved fatal, but the dis-
ease did not extend to others. It has also been imported
and become epidemic as far south as Monte Video. It has
occurred as high as 4,000 feet above the sea-level (Newcastle,
in Jamaica). But, as a rule, it is endemic in low districts on
the sea coast, and rarely occurs over an elevation of 2,500
feet above the level of the sea.

Treatment.—An early attention to first symptoms among
the susceptible is of the greatest value in saving hnman life.
The diagnosis of cases in which the attack has been said to
have been “aborted’’ by remedies may be questioned, and
such a belief is opposed to the doctrines of sound pathology.
Moreover, the “heroic ” doses of calomel which were given
in such cases, combined with quinine, cannot be too strongly
discountenanced, for “‘ they were first recommended on the
strength of a crazy hypothesis ” alone. ‘The practice is said
to have frequently proved successful in Jamaica; but ac-
cording to Dr. Davy, it was not attended with beneficial re-
sults at Barbadoes, and the American physicians at New
Orleans have not found it to answer their expectations in
stopping the fever. The large and frequently repeated doses
of quinine were often also highly injurious (Lawson). This
discrepancy may, in some measure, be explained
by what has been stated at the outset in explaining the path-
ology of this peculiar fever. Itis in cases where the fever is
of the periodic, paroxysmal, or paludal form, and not
the continuous or true yellow fever, that quinine
may be of use, if the system can be brought under its influence.
The ill effects of quinine in specific yellow fever consist in
its checking secretion and deranging the circulation within
442 YELLOW FEVER.

the head. It is an object to keep the bowels freely open,
and to get the skin to act freely. The main object of the
physician should be to moderate excessive action in any
organ, and to endeavor to bring about as complete a crisis
as possible about the fifth day, which seems to be the natural
period of resolution of the disease. For this purpose noth-
ing is of more importance than to re-establish the secreting
function of the colon, and to obtain foeculent evacuations—
not mere bilious discharges, but proper dark-brown foeculent
stools (Lawson). Gentle excitement of an extensive portion
of the lining membrane of the colon, with frequent copious
enemata of a pint anda half of warm water, in which a table-
spoonful of common salt has been dissolved, and to which
has been added a tablespoonful of olive-oil, or more stimulat-
ing enemata, such as of turpentine, deserve a full and careful
trial. All the depurative functions must be kept in activity.
Turpentine is recommended by Dr. Copland, by Dr. Archi-
bald Smith, and Mr. Laird of H.M.S. “ Medea ’’—one drachm
doses by the mouth, or half-ounce doses as a lavement,
several times daily, using it also as an epithem on the abdo-
men. ‘“‘When the mucous surfaces,” writes Dr. Blair, “as
indicated by the tongue, were denuded of epithelium, the
use of gum water was decidedly beneficial. lt lubricated,
defended, and soothed the raw surfaces. The strength was
generaily three drachms of the purest powdered gum arabic,
dissolved in six ounces of cold water, and a tablespoonful of
this given every one or two hours. The patient at last gets
tired of it; but for thirty-six or forty-eight hours of the most
critical period of the disease it is used without dissatisfaction,
and then can be substituted by, or alternated with, smoothly
and thin made arrow-root. When the heat of surface was
ardent a wet sheet or blanket was used for the reduction of
temperature by evaporation, with frequently very good effect
(and if ice could be obtained, its internal use is well worthy
of a.trial). But in the later stages of the disease, when the
skin was cool or cold, the patient seemed to have an instinc-
tive craving for its reapplication, and frequently asked to be
put into it. There would appear to be two causes for this
feeling. We find it to exist in cases in which black vomit
has been copious, and the associating thirst distressing; also
in cases where there has been no black vomit of any conse-
quence, and the breath is highly ammoniacal. In the former
class of cages the stomach ceases to be an absorbing viscus
in anything like the proportion of its secretions and transu-
YELLOW FEVER. 443

dations. The skin is therefore employed in reducing the
crisis of the blood by the absorption of water, as shipwrecked
mariners are said to quench their thirst. But not only does
the skin afford an inlet for the imbibition of diluting fluids,
but the softening of the cuticle would seem to afford an ad-
ditional outlet for the noxious elements of the circulation;
and it is probably in this direction we must in” future look
for auxiliary means of relieving the blood of its poisonous,
metamorphosed, and effete constituents, the onus of which is
now thrown on such vital organs as the stomach and lungs.
At one time the heat of the surface was so ardent and persist-
ent that the wet sheet failed to reduce it effectually. The
most distressing symptom in yellow fever, both to the patient
and the medical attendant, is irritability of the stomach; it
is so constantly present, and so often uncontrollable, that
the knowledge of every available means of checking it is of
the utmost importance. The food during the course of
yellow fever should be of the blandest description—chicken
tea, arrow-root, sago, and barley-water constituting the chief
articles; and these should be taken in minute quantities at a
time when the stomach is at all irritable. This rule applies
to drinks of all kinds. The patient is greedy for a large
draught of fluids; but by sucking them through a glass tube,
or a straw, or a hollow reed of small bore, or by the tea or
tablespoonful, they are much more likely to be retained. A
cold infusion of oatmeal was found an agreeable drink for
Scotch seamen, of which they did not seem to tire. A dis-
like of sweets was observed among the patients; and when
lemonade was asked for, the usual quantity of sugar was ob-
jected to, probably from its rendering the liquid too dense
for ready absorption by the stomach, and therefore less
quenching. Tea was found so uniformly to disagree with
the patients, and cause vomiting, particularly in the ad-
vanced. stages, that at length it had to be expunged from the
yellow fever dietary. Dilute alcoholic drinks were given
freely, and with good effect, When brandy céuld be ob-
tained pure (tolerably free from acidity and fusel oil), and
was well diluted with water, that spirit answered every indi-
cation. Sometimes the effervescing wines were relished and
retained, but they are very liable to the objections of con-
taining foreign matters and the products of mismanaged
fermentation (Blair). For or five minims of chloroform pre-
pares the stomach for the reception and retention of food,
by lessening its irritability; and the dose should be repeated
444 YELLOW FEVER.

a short time before food is again taken, as the effect of the
chloroform is transitory (J. D. Macdonald). On the same
principle the cdministration of chlorodyne may be advocated,
the composition of which is given by Mr. Squire in his “ Com-
panion to the Pharmacopeceia.”” Lime-water has been also
found to have a most beneficial effect in allaying vomiting,
and thus enabling the patient to partake of food; and the
essence of beef is well adapted for such’ cases, or beef-tea
and arrow-root in equal quantities mixed. ,

During the course of the disease, auxiliary treatment may
be required to meet contingent'symptoms. This is embraced
chiefly in the use of sinapisms and stimulating liniments.
Tenderness over the liver may be benefited by them. Dr.
Blair writes that when the primary reaction was violent, and
the face turgid, and the head symptoms severe, arteriotomy
was performed with benefit. In a few such cases, and when
the patient was young, strong, and full-blooded, and where
the dynamic congestions were so violent that the vessels
yic ded to the turgescence and impulse, and blood-corpuscles
without tube-casts, or even but a haze of albumen, was pres-
ent in the urine, a vein in the arm was opened, and free
bleeding relieved thc tension of the vascular system. In
such cases convalescence was slow and unsatisfactory, but
the immediate results were beneficial. The severe pain in
the loins, which is a constant symptom in yellow fever, is gen-
erally associated with renal congestion; and sinapisms or
stimulating liniments afford great relief to the lumbar pain
(Macdonald). With regard to the administration of opium
in any form the rule is, not to give it when there is suppres-
sion, or tendency to suppression, of urine. Restlessncss aud
sleeplessness are best met by chlorodyne, remembering that
the effect of yellow fever on the system is to make it sensitive
to narcotics. The congestion of the kidneys about the fourth
or fifth day requires watching, so as to diminish the chances
of suppression, by reducing congestion and preventing the
closure of yriniferous tubes by accumulated epithelium.
For this purpose Dr. Lawson recommends cupping, either
dry or with the abstraction of blood, and the use of frictions,
with stimulating liniments over the loins. These, with arm
baths or hot-air baths, deserve a full trial; and small doscs
of acetate of ammonia, with potash or soda, or their salts in
common use, with diaphoretics (so as to act gently on both
kidneys and skin), may prove beneficial.
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