g
 
 G. W. HARVEY. M. D. 
 
 Physician & Surgeon, 
 
 SALT LAKE CITY, UTAH.
 
 O. W. HARVr 
 
 p] 
 
 {JNEW 
 
 pf j 
 
 Eclectic Medical Practice ./ 
 
 DESIGNED FOR 
 
 Students and Practitioners 
 
 ? 
 
 H. T. 
 
 WEBSTER, M. D. 
 
 Professor of the Principles and Practice of Medicine in California Medical College ; 
 Author of Dynamical Therapeutics. 
 
 VOLUME I. 
 
 Webster Medical Publishing Co. 
 
 1018 Washington Street 
 
 Oakland, California
 
 JJOO 
 
 in? 
 
 Copyright 1899 
 BY H. T. WEBSTER
 
 O. W. HARVEY, M. D. 
 
 Physician &Sim 
 
 
 PREFACE. 
 
 THE author is not aware that an urgent demand has existed 
 for the publication of this book. Indeed, it was not prepared with 
 the impression that the profession was in urgent need of it, or 
 that it would prove a remarkable innovation in the medical world. 
 Medical men will come and go and the world will move on, after 
 these pages have passed into forge tfulness; and time will chroni- 
 cle a newer practice doubtless a better one when the years have 
 marked the inevitable progress of events. 
 
 The students of the California Medical College, to whom the 
 author has been something of an authority on practice for the past 
 sixteen years, have frequently importuned him to publish a work 
 which would embody the substance of his lectures, that a text- 
 book for ready reference might be had. To satisfy this demand 
 the present volume was begun several year* ago. Other duties, 
 however, have delayed the work, and the prospects of its completion 
 at an early date were so poor that at the request of several mem- 
 bers of the Class of '99 a first volume has been published, the 
 second to follow within the coming two years. 
 
 Special pains have been taken in the preparation of the text to 
 dwell on the description of disease, that there may be no need 
 of frequent reference to allopathic works for points on etiology, 
 pathology, symptoms, diagnosis and prognosis. At the same time, 
 it has been the author's aim to render the book as complete as pos- 
 sible on that which has been the peculiar merit of Eclectic works on 
 practice in the past, treatment. 
 
 Attempt has been made, throughout the work, to give every 
 writer from whom points have been drawn his just due, especi- 
 ally when anything appropriated appeared to be original in its 
 conception. As appropriate credit has thus been given, it would
 
 PREFACE. 
 
 only be superfluous to reiterate here what the text will plaiuly 
 show. 
 
 Credence has been given the teachings of bacteriology, on the 
 ground that it offers the only reasonable theory for the spread 
 of infections diseases that has ever yet been advanced. Though 
 there are those who scout its doctrines, unfortunately for their 
 skepticism they are unable to offer another as good an explanation 
 of the spread of contagium. Without its teachings we would be as 
 gadly at sea as before. Undoubtedly, many of the theories of bac- 
 teriologists are sound, though there may be much to learn; and 
 there may be some things taught which will have to be unlearned at 
 a later day. Until a better explanation of the etiology of infectious 
 diseases has been offered, however, I shall follow its lead, to a mod- 
 erate extent, at least.
 
 G. V7. HARVEY. M. D. 
 
 Physicians 
 
 TABLE OF CONTENTS. 
 
 SECTION I. 
 GENERAL REMARKS ON FEVER AND INFLAMMATION. 
 
 PAGE 
 
 I. Fever 1 
 
 II. Inflammation 17 
 
 Hypertrophy 36 
 
 Atrophy 37 
 
 III. Degenerations 41 
 
 IA r . Bacteriology 60 
 
 SECTION II. 
 SPECIFIC INFECTIOUS DISEASES. 
 
 I. Typhoid Fever 69 
 
 II. Typhus Fever 90 
 
 III. Relapsing Fever 97 
 
 IV. Cerebro-spinal Fever 101 
 
 V. Small-pox , 108 
 
 VI. Vaccination 120 
 
 VII. Chicken-pox 123 
 
 VIII. Scarlet Fever 128 
 
 IX. Measles 141 
 
 X. Rubella 150 
 
 XI. Mumps 153 
 
 XII. Whooping-cough 156 
 
 XIII. Epidemic Influenza Itil 
 
 XIV. Dengue Fever 165 
 
 XV. Diphtheria 167 
 
 XVI. Erysipelas 187 
 
 XVII. Septicaemia and Pyaemia 193 
 
 XVIII. Asiatic Cholera 200 
 
 XIX. Yellow Fever 208 
 
 XX. Malarial Fever 216 
 
 Intermittent Fever --'2 
 
 Remittent Fever 22(> 
 
 Pernicious Malarial Fever :M"> 
 
 Typho-malarial Fever -4:\ 
 
 Chronic Malarial Fever ' 2.~> 1 
 
 XXI. Anthrax 258 
 
 XXII. Hydrophobia 260 
 
 XXIII. Tetanus...
 
 vi CONTENTS. 
 
 PAGE 
 
 XXIV. Acute General Tuberculosis 268 
 
 X X V . sy philis 273 
 
 XXVI. Leprosy 286 
 
 XXVII. Glanders 
 XXVIII. Airtinoraycosis 
 
 XXIX. Infectious Diseases of Doubtful Nature '2W 
 
 Simple Continued Fever -' : 
 
 Weil's Disease -''"> 
 
 Milk Sickness '2\>~ 
 
 Malta Fever r "2w 
 
 Miliary Fever '2'.*> 
 
 Mountain Fever 300 
 
 SECTION III. 
 CONSTITUTIONAL DISEASES. 
 
 I. Rheumatism 301 
 
 Acute Articular Rheumatism 303 
 
 Subacute Articular Rheumatism 306 
 
 Chronic Articular Rheumatism 307 
 
 Muscular Rheumatism 309 
 
 II. Pseudo-rheumatic Affections 311 
 
 Arthritis Deformans 311 
 
 Gonorrhopal Rheumatism 315 
 
 III. Gout 316 
 
 IV. Lithaemia 323 
 
 V. Diabetes Mellitus v .... .".26 
 
 VI. Diabetes Insipidus 331 
 
 VII. Rickets 333 
 
 VIII. Scurvy 338 
 
 Infantile Scurvy 341 
 
 IX. Purpura 342 
 
 Purpura Hemorrhagiru 343 
 
 X. Scrofula 344 
 
 XI. Haemophilia 346 
 
 SECTION IV. 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 I. Diseases of the Mouth 348 
 
 Herpes Lahialis 348 
 
 Simple Stomatitis 348 
 
 Aphthous Stomatitis 349 
 
 Foetid Stomatitis 350 
 
 Mercurial Stomatitis '{."] 
 
 Eczema of the Tongue '''>- 
 
 Parasitic Stomatitis :>~>'2 
 
 Gangrenous Stomatitis 353 
 
 Pyorrhoea Alveolaris 354 
 
 II. Diseases of the Salivary Glands . 356 
 
 Hyperseeretion of the Salivary Glands 356 
 
 Arrest of the Sah' vary Secretion 357 
 
 Inflammation of the Sah' vary Glands 358 
 
 III. Diseases of the Pharynx 358 
 
 Acute Pharyngitis 358
 
 CONTENTS. vii 
 
 PAGE 
 
 III. Diseases of the Pharynx, Continued :{;> 
 
 Phlegmonous Pharyngitis 360 
 
 Gangrenous Pharyngitis , 360 
 
 Chronic Pharyngitis 362 
 
 Ulceration of the Pharynx 364 
 
 Ludwig's Angina 364 
 
 IV. Diseases of the Tonsils 364 
 
 Follicular Tonsilitis 364 
 
 Peritonsillar Abscess 366 
 
 Chronic Tonsillitis 368 
 
 V. Diseases of the (Esophagus 371 
 
 (Esophagitis 371 
 
 Obstruction of the (Esophagus 373 
 
 Functional Disease of the (Esophagus 374 
 
 VI. Diseases of the Stomach 376 
 
 Acute Gastritis 376 
 
 Phlegmonous Gastritis 378 
 
 Parasitic Gastritis 379 
 
 Chronic Gastritis 379 
 
 Dilatation of the Stomach 390 
 
 Peptic Ulcer 392 
 
 Cancer of the Stomach 398 
 
 Non-malignant Tumors of the Stomach 403 
 
 Haematemesis 404 
 
 Functional Gastric Dyspepsia 406 
 
 Hypersecretion and Hyperacidity 408 
 
 Gastralgia 409 
 
 Peristaltic Unrest 411 
 
 Rumination 411 
 
 VII. Diseases of the Intestines 411 
 
 Morning Diarrhoea 411 
 
 Acute Intestinal Catarrh 412 
 
 Chronic Intestinal Catarrh 415 
 
 Phlegmonous Enteritis 418 
 
 Pseudo-membranous Enteritis 418 
 
 Mucous Colitis 419 
 
 Ulcerative Enteritis 420 
 
 Dysentery 4l!f> 
 
 Cholera Morbus 431 
 
 Cancer of the Intestine 433 
 
 Intestinal Obstruction 437 
 
 Intestinal Hemorrhage 441 
 
 Typhlitis 443 
 
 Appendicitis 444 
 
 Proctitis 449 
 
 Periproctitis 450 
 
 Hemorrhoids 451 
 
 Amyloid Degeneration of the Bowels 455 
 
 Diarrhoea 456 
 
 Constipation 458 
 
 Intestinal Colic 461 
 
 Estival Infantile Enteritis 464 
 
 VIII. Diseases of the Mesentery 470 
 
 Miscellaneous Affections 470 
 
 IX. Diseases of the Liver 471 
 
 Jaundice .' 471 
 
 Infantile Jaundice. . . 474
 
 CONTENTS. 
 
 PAGE 
 
 IX. Diseases of the Liver, Continued 471 
 
 Malignant Jaundice 476 
 
 Abnormalities of the Hepatic Circulation 478 
 
 Interstitial Hepatitis 480 
 
 Abscess of the Liver 486 
 
 New Growths in the Liver 490 
 
 Fatty Liven. 493 
 
 Amyloid Liver 495 
 
 Tuberculosis of the Liver 496 
 
 X. Diseases of the Bile Passages 497 
 
 Catarrhal Inflammation of the Biliary Passages 497 
 
 Gall-stones 498 
 
 XI. Diseases of the Pancreas 508 
 
 Hemorrhage 503 
 
 Acute Pancreatitis 504 
 
 Chronic Pancreatitis 505 
 
 Fatty and Waxy Degeneration 506 
 
 Cancer of the Pancreas 507 
 
 Calculi and Cysts 507 
 
 XII. Diseases of the Peritonaeum 508 
 
 Acute General Peritonitis 508 
 
 Peritonitis in Infants " 1 - 
 
 Localized Peritonitis 512 
 
 Chronic Peritonitis 513 
 
 New Growths in the Peritonaeum 515 
 
 Ascites . . . . 516
 
 NEW ECLECTIC MEDICAL PRACTICE. 
 
 VOLUME I. 
 
 SEGTIOI2 I, 
 
 GENEEAL EEMAEKS ON FEVEE AND INFLAMMATION. 
 
 I. FEVERS. 
 
 Synonyms. Febris; Pjr; Pyretus; Pyrexia. 
 
 Definition, A pathological condition characterized by eleva- 
 tion of temperature, acceleration of pulse, disturbance of circulation, 
 arrest of secretion and excretion to a certain extent, disturbance of 
 innervation, and loss of flesh. 
 
 General Classification, Fevers have been divided into two 
 general classes. In one the exciting cause is a zymosis, which pro- 
 vokes a primary constitutional disturbance (idiopathic), while in the 
 other class the febrile action is secondary to a localized inflamma- 
 tion. But modern writers have discarded this classification, it being 
 apparent from comparatively recent discoveries in bacteriology that 
 the difference in many cases is more apparent than real. The mod- 
 ern classification would be into Infectious Fevers and Non-infectious 
 Fevers, both classes including certain forms of idiopathic and symp- 
 tomatic fever of the old classification. In the present work no 
 attempt at strict classification will be made, as the subject is yet in 
 an unsettled state, and infectious fevers will therefore be classed 
 with acute infectious diseases. 
 
 The Detection of Fever, The diagnostic symptom of fever 
 is an elevation of the temperature of the body above the normal 
 range (98. 5 C F., approximately). All other indications of fever, such 
 as acceleration of pulse, disturbance of circulation, arrest of secretion 
 and excretion to a certain extent, etc., may be present, and yet
 
 2 INTRODUCTION. 
 
 without a disturbance of the temperature there will be no fever. 
 However, in exceptional cases at particular periods it may be 
 below instead of above the normal rate. The temperature-changes 
 are detected by the use of the clinical thermometer. 
 
 Thermometry. The ordinary thermometer consists of a glass 
 tube marked with the degrees, and terminating at the lower extrem- 
 ity in a bulb which contains the bulk of the mercury, a portion of 
 this rising into the tube and being further raised as warmth is 
 applied to the bulb. A detached portion of mercury ( the register ) 
 is separated from the main column and remains stationary after 
 
 CLINICAL THERMOMETER. ( O. L, J.) 
 
 cooling, marking the highest point reached during each trial. This 
 should be shaken down below 95 each time before using the instru- 
 ment. Before and after using, the thermometer should be sterilized, 
 especially in case of infectious diseases. In testing the tempera- 
 ture the bulb may be placed in the mouth, axilla, or rectum, as may 
 be most convenient or seem most appropriate. In females the vagina 
 may be resorted to instead. In order to insure full expansion of 
 the mercury the bulb should remain in position for fully five min- 
 utes, care being taken to exclude the air by closing the lips when 
 the bulb is under the tongue, or holding the arm snugly to the side 
 when it is in the axilla. Delirious and comatose patients cannot 
 be relied upon to retain the bulb in the mouth, and the axilla should 
 then be resorted to. Packs or other dressings about the chest may 
 then render it preferable to introduce the instrument into the rec- 
 tum. Where the thermometer is a bugaboo to timorous children 
 the rectum should be chosen. The temperature of the rectum is 
 about one degree higher than that of the axilla. 
 
 Stages of Fever. It has been a time-honored custom to name 
 the three stages of fever the "cold,"the "hot," and the "sweating" stage, 
 respectively. These names have been abandoned by modern author^. 
 however, as the sensation of chilliness is not always noticeable 
 during the first stage, and the thermometer may demonstrate a 
 marked rise of temperature even while the subject is experiencing 
 the chilliness. Better terms, then, are: (1) the stage of invasion ; (2) 
 stage of acine, fastigium, or stadium; and (3) stage of defervescence, 
 or decline. The stage of invasion in malarial fevers and others 
 occurring in markedly malarious regions is usually signalized by 
 a marked chill, or rigor. Outside of such influence, the chilly stage
 
 FEVER. 3 
 
 of typhoid fever, scarlatina, measles, etc., may or may not be notice- 
 able. During the stage of invasion the temperature is rising. Dur- 
 ing the stage of acme, fastigium, or stadium, it inclines to touch, 
 repeatedly, the highest point; and during the stage of defervescence 
 or decline, it is falling, either rapidly or by gradations, toward the 
 normal point. 
 
 Termination of Fever. Fever may terminate (1) by crisis, 
 and (2) by lysis. Crisis is characterized by rapid and permanent 
 decline of temperature; a decline of four or five degrees occurring in 
 twenty-four hours, with sudden establishment of all the secretions 
 and excretions, with disappearance of nervous symptoms and other 
 discomfort. Lysis is attended by a gradual fall of temperature or 
 by remitting gradations, the morbid symptoms subsiding gradually, 
 the stage occupying several days or a week. 
 
 Febrile Remissions. Prior to the general use of the fever- 
 thermometer among physicians fevers were divided into two gen- 
 eral classes, a division which the thermometer has shown to be 
 faulty. The malarial fevers were classed as periodic; and enteric, 
 typhus fever, and the exanthemata, were classed as continued. But 
 the thermometer demonstrates that all fevers manifest a diurnal 
 variation of temperature, the minimum being reached about 6 A. l., 
 and the maximum about 6 p. M. Therefore, no fever is continued, in 
 the sense suggested. However, certain forms are so nearly continu- 
 ous in the maximum range that they are classed as Continued Fevers, 
 though the arrangement is different from the old one. Typhus fever, 
 scarlatiua, and sometimes typhoid, in which the variation between 
 the maximum and minimum temperature is only 1 to 1.5, may be 
 included in this division. In another division there are marked 
 diurnal remissions, but the minimum never reaches the normal point 
 during the fastigium, and only at or near the end of the decline. 
 These are properly Remittent Fevers. Examples of this type are 
 typhoid (usually), malarial remittent, and hectic. In still another 
 class the temperature falls to normal or below that point, during the 
 diurnal decline. Such are classed as Intermittent Fevers. The prin- 
 cipal intermittent fevers are malarial intermittent, relapsing, hectic 
 (occasionally, though usually remittent), and Charcot's intermittent 
 (gall-stone fever). It will be observed that this classification can- 
 not be very permanent, as severe cases of typhoid may hardly show 
 diurnal variation of temperature at all, while mild cases, or those 
 complicated with malaria, usually manifest marked remissions and 
 exacerbations. 
 
 Causes of Fever. The presence of microorganisms or their 
 alkaloids (toxines) in the blood; local inflammations acting as
 
 4 INTRODUCTION. 
 
 exciting causes; the products of fatty metabolism; and paralysis of 
 the heat center. 
 
 Parasitic Origin of Fevers. The past few years have thrown 
 much new light upon the origin of infectious fevers. The micro- 
 scope has opened a naw era in the etiological phase of these dis- 
 eases, and rendered obsolete doctrines respecting causation formerly 
 promulgated. It is not impossible that changes may yet occur in 
 views which are now almost universally accepted, but it hardly 
 seems that so many observers can be mistakan as to the identity of 
 the germs which are believed to be the exciting factors in several of 
 the different forms of this class of diseases. If it be granted that 
 the new doctrine is established in a single instance it cannot be 
 doubted that all diseases of the same class contagious and infec- 
 tious fevers will finally be traced to similar causes, and their spe- 
 cific germs pointed out and described. 
 
 It is pretty certain that infectious fevers depend for their origin 
 and spread upon the propagation and transmission of specific micro- 
 Organisms which are conveyed from sick to well, either directly or 
 through fomites -which serve to preserve and convey them, each dis- 
 ease depending upon its own particular germ, and never originating 
 spontaneously. Some microorganisms have special indigenous 
 habitats where they exist perpetually, to be widely disseminated 
 under favoring influences, afterward dying out, except in their favor- 
 ite haunts. Such is the character of cholera, which is indigenous to 
 East India; yellow fever, indigenous to the Antilles; and typhus 
 fever, indigenous to Northern Europe. Others, when they invade 
 new territory, remain there permanently, on account of the power 
 of the germs to resist external influences, hibernating at times and 
 possibly gaining strength from filth and putrefaction. Examples of 
 such are diphtheria and typhoid fever. 
 
 Infection, then, may be said to be the development, within the 
 blood, from a transmitted germ or microorganism, of a colony of the 
 same species, the excretions and secretions of which give rise to 
 poisonous ptomaines (toxines), resulting in general sepsis of the 
 fluids of the body, and consequent destructive action upon the blood 
 and tissues. All organisms, during their activity, produce more or 
 less waste or excrementitious material, which, in the case of the 
 infectious microbe, constitutes the poisonous element. The virulence 
 of the poison depends upon the individuality of the microorganism, 
 and this accounts for the comparative severity of some infectious 
 diseases and the mildness of others ; while the condition of the sys- 
 tem in different individuals, or their power of resistance to disease, 
 may account for mild and severe cases in the same home at the
 
 FEVER. 6 
 
 same time. A comparative severity and mildness of different epi- 
 demics is also observable, depending largely probably upon hygienic 
 surroundings and atmospheric influences. 
 
 The human system may be infected with either vegetable para- 
 sites or microorganisms (bacteria), or minute animal organisms 
 (hsematozoa). Many of the bacteria are self-limiting in the human 
 system, perishing either from lack of nourishing pabulum, from poi- 
 soning by their own toxines, by phagocytosis, or in some way not 
 yet suggested, thus leaving the individual completely or partially 
 protected from subsequent attacks. The hsematozoa of Laveran, 
 which are supposed to be the microorganisms of malaria, do not 
 produce the severe septic effects caused by some of the bacteria, 
 are not self-limiting, and if the disease they cause be arrested there 
 is left a predisposition to a return of the malarial manifestation. 
 It is possible that when the blood is once infected with malaria the 
 principle may remain, in a more or less active state, perpetually. 
 
 The study of the microorganisms of disease belongs to bacteriol- 
 ogy, and no more reference will be made to it in these pages than is 
 necessary to discuss the practice of medicine intelligently. Really, 
 Eclectics realized the importance of correcting septic processes, and 
 had adapted specific agents to their correction, long before they 
 were known to be caused by microorganisms ; and we can do but lit- 
 tle better, if any, in treatment now. But we have gained an impor- 
 tant advantage in preventive medicine, and can now treat the subject 
 with an intelligence and positiveness not possible with previous lack 
 of information. 
 
 Symptoms of Fever. Elevation of temperature, arrest of 
 secretion and excretion, acceleration of the pulse and respiration, 
 disturbance of the nervous system, coated tongue, traces of albu- 
 men in the urine, deposit of urates, loss of flesh and strength. 
 
 The temperature varies much in its maximum height in different 
 cases, and in its average maximum height in different forms. Some 
 fevers are characterized by an unusally high maximum temperature, 
 and the moderate rate is the exception. Such are typhoid fever, 
 scarlatina, typhus and relapsing fevers. Others are fevers of low 
 maximum temperature, as a rule, such as rubella, cerebro-spinal 
 fever, and measles. Some protracted fevers which terminate by 
 slow lysis are marked near the close by subnormal temperature, the 
 thermometer registering below 97.5 F. during the morning remis- 
 sions. The subnormal temperature is rather common to the conva- 
 lescent period of typhoid fever and pneumonia ; also in collapse from 
 shock, hemorrhage, heart failure; or perforation of visceral walls, 
 as of the bowel in typhoid fever, the lung in phthisis, or the stomach
 
 6 INTRODUCTION. 
 
 in round ulcer. The temperature may be subnormal in certain chronic 
 diseases, such as diabetes, cancer, and chronic cardiac, cerebral, 
 and spinal affections. The temperature of cholera is remarkably sub- 
 normal, it frequently remaining at 90 85 for several days. 
 
 The temperature of some fevers follows a pretty constant course, 
 in the majority of cases; thus, the temperature of typhoid fever 
 runs a typical course usually, and so does that of typhus, relapsing, 
 malarial, and other fevers. Others are notoriously irregular in this 
 respect cerebro-spinal fever and diphtheria, for example. Complica- 
 tions are marked by sudden changes of temperature, thus: The ad- 
 vent of nephritis or inflammation of other important organ in scar- 
 latina, diphtheria, etc., is announced by a rapid rise of temperature; 
 intestinal hemorrhage in typhoid fever is characterized by abrupt 
 decline of temperature; etc. In all severe cases of protracted fever, 
 frequent use of the thermometer will enable the practitioner to 
 detect complications much earlier than he otherwise would, and 
 will prepare him for proper therapeutic adaptation at an early stage, 
 when his change of treatment may be of benefit. 
 
 Wunderlich has made the following classification of the tempera- 
 ture of fever, which is worthy of record : 
 
 1. Subfebrile ; temperature 99.5 100.4. 
 
 2. Slightly febrile; temperature 100.4 101.3. 
 
 3. Moderately febrile; temperature 101.3 103.1. 
 
 4. Decidedly febrile ; temperature 103.1 104. 
 
 5. Highly febrile; temperature 103.1 in the morning and above 
 104.9 in the evening. 
 
 6. Hyperpyretic ; above 106. 
 
 A moderately elevated temperature without remission is more to 
 be feared than one that is much higher in its maximum but which 
 declines markedly each twenty-four hours. 
 
 The pulse is increased in frequency in most fevers, though dur- 
 ing the stage of calm in yellow fever it becomes remarkably slow, 
 being reduced to forty or fifty per minute; and in malignant forms 
 of malarial fever it may be abnormally slow. The pulse is easily 
 disturbed by slight causes in early childhood, and is then not of much 
 importance as a symptom, either in diagnosis or prognosis. The 
 quality of the pulse is as important as its frequency ; the small 
 pulse of debility, the strong pulse of sthenia, the full, hard pulse 
 of obstruction, the full, bounding pulse of sthenia with arterial relax- 
 ation, the oppressed pulse of capillary congestion, the sharp, wiry 
 pulse of nervous irritation, the feeble, fluttering pulse of impending 
 dissolution or cardiac debility, each carries its suggestion to the 
 observant practitioner.
 
 FEVER. 7 
 
 Disturbance of the nervous system may vary from slight restless- 
 ness to extremely violent delirium, in which it may be necessary to 
 employ force to prevent the patient from getting out of bed. Two 
 kinds or qualities of nervous disturbance are observable in different 
 cases ; viz., that of active irritability, and that of oppression or drows- 
 iness. In one there is irritation, and in the other there is intoxica- 
 tion, from the disturbing toxine. The active symptoms are most 
 liable to appear early in the course of a fever, and the second later on, 
 though either may be marked from the beginning, while in other 
 cases the nervous symptoms may not be at all prominent at any time. 
 
 The tongue furnishes important symptoms in many cases of fever 
 regarding diagnosis, prognosis, and treatment. The tongue of scarla- 
 tina is peculiar and almost diagnostic, that of gastric irritation un- 
 mistakable, and other morbid conditions are just as certainly shown 
 by the tongue. We are enabled to select many remedies with tolera- 
 ble certainty, and thus meet varying conditions of disease with a read- 
 iness not otherwise possible. Special notice will be given this sub- 
 ject under the head of treatment 
 
 Tissue Changes Resulting from Fever. High and long- 
 continued fever results in considerable change in the quality of the 
 tissues, the amount of fever bearing an important relation to the ex- 
 tent of morbid change. After high and prolonged fever the different 
 organs are more or less swollen, opaque, and friable. Evidence of 
 recent circulatory disturbance is furnished by the injected vessels 
 and general oedema. Microscopic appearances indicate marked 
 alteration of histological elements; the cellular elements are increased 
 in size and their protoplasm has become granular, obscuring the 
 nucleus. The granular condition is due to the presence of albumen 
 and fatty particles. The tissue-changes occur most markedly in 
 pyaemia, erysipelas, typhus, typhoid, and other infectious fevers, and 
 in acute rheumatism. Alterations may be so extreme as to amount 
 to necrotic changes, such as those in the tissues of the liver in yel- 
 low fever, though this is probably due largely to the specific char- 
 acter of the disease. The organs in which pyrexial changes are 
 most observable are the liver, the heart, the kidneys, the muscles, 
 and the lungs. 
 
 General Treatment of Fever. Rest in bed is the first 
 essential, and the earlier the patient gives up exertion and affords 
 every assistance possible in this way the better are his chances of 
 an early recovery. In many cases the early symptoms are so urgent 
 that the patient succumbs at once and goes to bed; but in other 
 cases, such as typhoid fever for example, the onset may be so insid- 
 ious that he may remain about and on his feet until his recuperative
 
 8 INTRODUCTION. 
 
 energies are too nearly exhausted to assist him through the trying 
 ordeal which follows. But physical rest is not the only essential 
 here. Where there is the least tendency to nervous irritability, the 
 room should be darkened and all noise strictly prohibited. Talking 
 must not be allowed in the sick room ; even whispering must be pro- 
 hibited. 
 
 Ventilation is also highly important in the treatment of fevers, 
 especially those of an infectious character. The emanations from sub- 
 jects affected with diphtheria, typhoid, typhus, or yellow fever, in an 
 unveutilated room, are always additional elements of danger. It 
 has been observed in epidemics of both typhus and yellow fever 
 that patients who have been carried out of hospital wards in an 
 apparently hopeless condition into the open air have revived, and 
 in some cases gone on to complete recovery; and it is a favorite prac- 
 tice with those of extensive experience with these diseases to treat 
 them in tents or open barracks. But neglect of ventilation must not 
 be permitted in any infectious disease, though in such an instance as 
 measles cold air is not allowable, on account of its irritating influ- 
 ence upon the sensitive respiratory membrane. The temperature 
 of a fever apartment should ordinarily be about 60 F., though no 
 rule can be laid down to supplant the discretion of the physician in 
 individual cases. In each case the temperature should be maintained 
 at about the same degree of warmth throughout the disease. 
 
 The diet in fevers should, as a rule, be liquid or semi- solid. In 
 most fevers morbid changes occur in the mucosa of the alimentary 
 canal which incapacitate this tract for the performance of its usual 
 functions. As a liquid diet is more easily digested and assimilated, 
 it must consequently be the appropriate form for use. In case 
 of typhoid fever the use of solid food is absolutely dangerous, haz- 
 arding perforation of the weakened intestinal wall; while in diphthe- 
 ria and scarlatina a liquid diet is more readily swallowed. Doubt- 
 less, the natural efforts required for the digestion of solid food dis- 
 turb the heat center indirectly, and so occasion more or less rise in 
 temperature. Therefore, in all protracted fevers especially, a liquid 
 diet is the only admissible form of food for use. But it is riot aloue 
 requisite that the diet shall be liquid. Quality must be considered. 
 It was once believed that beef tea was all the food necessary for a 
 fever patient, but it is now generally conceded that one would starve 
 in time if fed upon nothing but this article. It has been asserted, 
 with good reason, that it contains no more nourishment than urine. 
 Kepresenting, as it does, the products of a destructive metabolism, 
 it hardly seezns capable of even exerting the stimulant influence 
 attributed to it Nourishment is an important qualification of liquid
 
 FEVER. 9 
 
 foods, and we find this varying in amount in different kinds. Milk 
 is a leading article in this line, bub its use is attended by the objec- 
 tion that the curd which forms after it becomes acidulated in the 
 stomach may become a firm and resisting mass, difficult to dispose 
 of. This objection, however, may be obviated by adding from one 
 to two ounces of lime-water to each pint of milk before using. In 
 these days prepared foods have done away with many of the problems 
 of old in the feeding of fevers. Among those to be especially com- 
 mended are malted milk, lactated food, and Mellin's food. I have 
 fed many cases of typhoid fever on Mellin's food throughout, with 
 most excellent satisfaction. Vegetable broths, soups, and gruels are 
 excellent alternates when the animal foods become objectionable; 
 and some of them are very nourishing, such for instance as rice 
 water, bean soup, and oat and cornmeal gruels, though these should 
 be carefully strained when used in enteric fever. Food should be 
 given often and in small quantities during the active stages of pro- 
 tracted fevers, the same regularity and promptitude being observed 
 as in the administration of medicine. 
 
 In most cases of fever the fauces are dry and thirst is an urgent 
 symptom. There is no objection to the free use of water in such 
 cases, unless there be gastric irritability with rejection of fluids as 
 soon as swallowed; in which case the stomach must be given complete 
 rest and proper medication for a time, while the thirst is palliated 
 by packing the epigastric region with a folded towel which has been 
 wrung out of cold water, or by using a rectal injection of cold water, to 
 be retained. Liquid diet answers well here, sustaining as well as 
 relieving thirst, and whey, barley-water, toast-water, koumiss, lem- 
 onade sweetened with maltine or grape-sugar, tamarind-water, and 
 many other articles may be selected to satisfy the taste, or to 
 conform to other requirements. Bits of ice may be held in the mouth 
 and allowed to dissolve, but this must not be carried too far, for 
 fear of embarrassing recuperative processes by chilling the stomach. 
 
 In all protracted fevers the danger of permitting the patient to 
 remain continually in one position should not be overlooked. 
 Hypostatic congestion of the lungs is almost certain to follow where 
 a person is allowed to lie upon the back or in any other fixed position 
 for a long time, and fatal sequelae are very liable to follow getting 
 up, from the pulmonary complication. Bed sores are always a men- 
 ace, and liability to them is much increased when pressure is made 
 constantly upon one part for protracted periods. It is the duty of 
 the physician to know these facts, and to instruct attendants to turn 
 the patient every three or four hours, so that he may lie a portion of 
 the time on each side and a portion of the time on the back.
 
 10 INTRODUCTION. 
 
 The medicinal treatment of fevers will vary considerably in differ- 
 ent varieties, and also in different cases of the same character. In 
 brief, there can be no fixed course to pursue, but each case must be 
 individualized, and treated as a separate proposition. It may 
 seem from this statement that the subject must be a very com- 
 plicated one, then, but this is not so, for a proper understand- 
 ing of the principles involved reduces the problem to a few simple 
 propositions. 
 
 While remote causes of fever have been noticed, it is to be remem- 
 bered that toxines generated by the presence of parasites or other 
 impurities are the immediate elements to be considered. Though 
 the foreign element may have been provocative of the condition, 
 nature has apparently provided the means for its final elimination, 
 if, in the meantime, the zymotic action has not been so extensive 
 as to destroy the life of the patient. It appears to many that 
 efforts of therapeutists toward the destruction of disease-producing 
 germs after they have entered the circulation will always prove 
 futile, as many germs are capable of resisting the action of drugs 
 powerful enough to destroy human life when swallowed. In the 
 rational treatment of fevers, then, we will limit ourselves to the man- 
 agement of the poisonous ptomaines generated, and their effects. 
 
 One of the great dangers in fever lies in the high temperature 
 which attends many cases. This interferes with secretion and excre- 
 tion, and encourages degeneration of tissue, wasting, and loss of 
 strength, as well as favoring fatal changes in such delicate and sen- 
 sitive organs as the brain, lungs, and other vital parts. We will 
 strive, then, from the commencement of treatment to lower the maxi- 
 mum temperature toward the normal point by every safe and rational 
 means. The popular plan for the accomplishment of this purpose 
 among the most successful class of practitioners is the use of the 
 special sedatives, in minute and frequently repeated doses. 
 The recognised special sedatives are: aconite, belladonna, gelsemium, 
 jaborandi, veratrum, and rims tox. Though powerful depressants in 
 large doses, these remedies exert a remarkably calmative effect upon 
 the circulation in many cases of fever, without depressing, when 
 administered in minute doses, and repeated as often as every hour, 
 day after day. Not only are the force and rapidity of the circulation 
 and frequency of the heart's action diminished, but nervous ere- 
 thism is calmed, and secretion promoted. Each one manifests 
 decided peculiarities which adapt it to special cases or conditions. 
 These conditions are suggested by the character of the pulse usu- 
 ally, though other symptoms may assist in the selection of the cor- 
 rect agent. The following hints are submitted:
 
 FEVER. 11 
 
 Aconite is the remedy for the ordinary fever of debility in mid- 
 dle life, in children^ and elderly adults. The characteristic pulse is 
 small and rapid, but distinct and regular (not wiry). It is applica- 
 ble to infectious as well as non-infectious fevers, while it assists in 
 controlling local inflammation, especially that of mucous mem- 
 branes. It is calming to conditions of nervous excitability, though 
 not as useful as rhus tox. where this symptom is marked. It pro- 
 motes normal secretion, especially from the skin and mucous mem- 
 branes; and though it quiets excitement of the circulatory organs, it 
 doubtless improves their normal energy at the same time. In using, 
 for an adult, add five or eight drops of Lloyd's or Worden's aco- 
 nite to four ounces of water, and administer a teaspoonful every 
 hour. 
 
 Belladonna furnishes us with two peculiarities of action, depend- 
 ing upon the method of administration. When half a drachm or a 
 drachm of the third decimal dilution is added to four ounces of water, 
 and a teaspoonful given every hour, it is applicable to debilitated 
 conditions marked by furious delirium. In this case the eyes are 
 wild, the face is flushed bright red, the mind abnormally active and 
 aggressive, while the pulse is small, feeble, and oppressed, and the 
 patient markedly prostrated. In the other case we obtain its effects 
 from more material doses. Adding five or ten drops of the specific 
 medicine or a green plant tincture to four ounces of water we have 
 a remedy for febrile conditions attended by feeble capillary circula- 
 tion, suggested by coldness of the extremities, feeble, oppressed 
 pulse, inelastic tissues, dullness or drowsiness, sensation of swim- 
 ming in the head, dilatation of the pupil, muttering delirium, etc. 
 
 Gelsemium is the remedy for febrile conditions in sthenic sub- 
 jects, at least those in which prostration is not a marked feature. 
 It controls vascular excitement, promotes secretion, relaxes spasm, 
 and alleviates pain. The typical indications for it are a full bound- 
 ing pulse, flushed countenance, bright eyes, and contracted pupils. 
 The delirium of gelsemium is of active character. In using for its 
 sedative effect, from twenty to thirty drops of a saturated tincture 
 of the fresh root should be added to four ounces of water, and a 
 teaspoonful of this administered every hour. 
 
 Jaborandi is another sedative for sthenic conditions. It controls 
 vascular and cardiac excitement, promotes secretion, especially from 
 the skin, and alleviates muscular pain. Its cooling influence upon 
 the skin imparts a grateful sensation to the fever patient, and modi- 
 fies the exalted temperature shortly after its use is begun. In or- 
 der that the agent may be reliable it must be prepared from the 
 fresh crude article; the ordinary fluid extracts of the market being
 
 12 INTRODUCTION. 
 
 comparatively worthless for sedative purposes. "When using, add 
 from one to three fluidrachms to four ounces of water, and give a 
 teaspoonfnl every hour. Full, strong, hard pulse, with dry skin and 
 severe muscular pain is a special indication for its use. 
 
 Veratrum is also a remedy for sthenic febrile conditions. It 
 sedates vascular excitement of the general circulation, lowers an 
 Exalted temperature, and promotes general secretion. It fills much 
 the ,same place as jaboraudi, though it is not as satisfactory. Its 
 special indication is a full hard pulse, with elevation of tempera- 
 ture. It is contraindicated where gastric irritation is present lu 
 using, add fifteen or twenty drops of a reliable drug to four ounces 
 of water, and give a teaspoonful every hour. 
 
 Ferric PJios. is Schiissler's remedy for fever, and it often proves 
 reliable, its searching effects sometimes becoming appreciable after 
 the special sedatives have failed. It is especially adapted to the 
 treatment of symptomatic fevers before plastic exudation begins in 
 the inflamed part. In using, add three grains of the 3x trituration 
 to four ounces of water, and give a teaspoonful every hour. 
 
 Potassium Chloride is the remedy for symptomatic fever after 
 plastic exudation has begun, as it promotes rapid removal of the 
 exudate by absorption, thus preventing obstructive organization 
 and destructive changes. In using, add five grains of the 3x tritu- 
 ration to four ounces of water, and order a teaspoonful every hour. 
 
 Adjuvants may often be employed with advantage to aid the 
 influence of the special sedatives. Prominent among these are the 
 vapor bath, cold, tepid and hot packs and baths, and various enemata. 
 
 But though the special sedatives answer an excellent purpose in 
 the treatment of non-infectious and malarial fevers, as well as in 
 some other mild infectious fevers, such as roseola, measles, mumps, 
 and chicken-pox, there are others where there are such rapid 
 destructive and septic changes in the blootfe and tissues, that they are 
 almost or wholly inefficient. In typhoid fever, typhus fever, yellow 
 fever and diphtheria, where general necrotic changes are pronounced, 
 1 ittle satisfactory use can be made of them. We must then depend 
 upon the antiseptic sedatives remedies which combine antiseptic, 
 antinecrotic and stimulating properties with those of a special sed- 
 ative. Prominent in this class are echinacea, lachesis, baptisia, and 
 salicylate of ammonium. 
 
 Echinacea is not only an arterial sedative, not quite as markedly 
 so as the special sedatives, probably, but it controls necrotic tenden- 
 cies in the blood and tissues, both when used locally and when taken 
 internally. It seems to be an organizer, improving the vitality of the 
 circulating fluids and tissues, fortifying them against septic and
 
 FEVER, 13 
 
 necrotic changes. In all febrile conditions where septic states tend- 
 ing to necrosis of tissue arc common, as well as where they are actu- 
 ally present, it commands the loading place as a remedy. The 
 pathology of the disease in question will afford the indications for 
 it breaking down of the blood corpuscles with destruction of the 
 fibrin element, and granular degeneration of the fixed cells, with lo- 
 calized necrosis of the soft tissues. This we find, to great or less 
 extent, in all severe infectious diseases. The average dose for an 
 adult is ten drops of a saturated tincture of the recent plant, or its 
 equivalent, repeated every hour. 
 
 Lacliesis comes nearest echinacea in its power over necrotic condi- 
 tions occurring in febrile diseases. It improves the power of the 
 heart when this organ is laboring tinder the depressing influence of 
 toxines, and stimulates the organs supplied by the pneumogastric 
 nerve generally. It is especially indicated in infectious diseases 
 attended by feeble, tremulous heart induced by toxic causes. In fevers 
 of low form, where there is marked prostration with phagedenic tend- 
 encies of the tissues, as in malignant scarlatina, diphtheria, hemor- 
 rhagic variola, etc., it is perhaps our best recourse, especially where 
 cardiac failure portends. The 6x trituration may be administered in 
 two-grain doses every two or three hours in such cases. 
 
 Baptisia is recommended in a class of cases similar to those in which 
 echinacea is so efficacious. It acts as a sedative and stimulant in 
 typhoid conditions, and controls to some extent necrotic tendencies; 
 sloughing of tissue in the intestine in typhoid fever, the throat in 
 scarlatina and diphtheria, etc., responding to its action. Duskiness of 
 tissue, prune -juice discharges and low muttering delirium indicate 
 it. We once thought that we possessed the acme of treatment in such 
 conditions when provided with this remedy, but there is little doubt 
 that echinacea far excels it in any case where it is adapted. From 
 two to ten drops of the saturated tincture of the fresh root or its 
 equivalent, may be administered every hour or two in cases requir- 
 ing it 
 
 Scdicylate of ammonium is an antiseptic sedative of rare virtue where 
 a persistently high temperature renders a case of infectious fever 
 especially serious. When other remedies fail in such cases we may 
 safely depend upon this agent to reduce the temperature, and it is 
 an antiseptic of excellent service at the same time. Full directions 
 for preparing, dose, etc., can be found in "Dynamical Therapeutics." 
 
 Another class of remedies, which I shall here term correctives, 
 fulfills important indications in fever on many occasions. The action 
 of these remedies is chemico-vital in nature perhaps, the result 
 tending toward the correction of excessive acidity or alkalinity.
 
 14 INTRODUCTION. 
 
 They can hardly be considered as antiseptics, but they correct condi- 
 tions which materially interfere with the proper action of remedies 
 generally. Three important remedies of this class are sulphite of 
 sodium, sulphurous N acid, and hydrochloric acid. 
 
 Sulphite of sodium is a corrective where there is a heavily loaded 
 tongue, presenting a pasty-white appearance, with pallid mucous mem- 
 braue. This indicates excessive alkalinity of the system, and a salt 
 of sodium is the natural corrective. Before we can reasonably expect 
 other remedies to produce their ordinary effects this must be corrected. 
 A few days of sulphite of sodium will accomplish this, and all other 
 aggravated symptoms will be correspondingly modified. The sulphite 
 may be administered in one- or two-grain doses every three or four 
 hours during the day, until the morbid condition of the tongue calling 
 for it has disappeared, which will usually be within three or four 
 days. It is advisable to administer the remedy in capsules, where 
 swallowing is readily accomplished. 
 
 Sulphurous acid is a corrective where the tongue is coated brown, 
 with dark sordes on the teeth and lips, or even without these accom- 
 paniments. Under this coating the mucous membrane is darker red 
 than is natural, it usually being uncovered at the sides and tip. Low 
 forms of fever often present us with this condition, and sulphurous 
 acid is then an appropriate remedy. Twenty drops of the acid, well 
 diluted in water, may be given every three or four hours. 
 
 Hydrochloric acid is the corrective where the tongue is red, slick, 
 and shining, presenting a beefsteak appearance. Probably there is 
 a lack of acid in the system in these cases, as acids seem to help lag- 
 ging cases immediately where the indication is marked. Fifteen or 
 twenty drops of dilute hydrochloric acid, in syrup, may be adminis- 
 tered in such cases every four hours, to prepare the way for other 
 remedies. 
 
 The subject of antiperiodics demands a little space. There are 
 certain fevers characterized by marked periodicity which seems to be 
 the leading feature of the attack, and which must be interrupted 
 before much progress can be made toward a cure. There are those who 
 even argue that the cure is completed when the periodicity is inter- 
 rupted ; but this is a mistaken idea, for the physician who expects to 
 cure malarial attacks with quinine or other antiperiodics will find him- 
 self disappointed in a majority of the cases treated. Quinine and 
 other antiperiodics notably quinine interrupt periodicity, but do 
 not remove the materies morbi from the system, and the periodical 
 manifestation returns after a cycle, or multiple of cycle, of seven days. 
 
 While antiperiodics, then, are important remedies to interrupt 
 marked periodicity where the cause arises from malarial influence,
 
 FEVER. 15 
 
 curative effects can not be expected from them usually, and rational 
 means applied to the morbid conditions existing must follow their use 
 if permanent benefit is to be insured. Quinine is the ideal antiperiodic, 
 and the one which is usually employed. But, unfortunately, it is not 
 always a remedy which can be administered without objectionable 
 results. When administered to certain patients it produces ringing in 
 the ears, nervous irritability, and even delirium, aggravating already- 
 existing evils instead of benefiting them. The proper time for the 
 administration of quinia is during the intermission or remission of per- 
 iodical diseases, and the system should be prepared for its use by the 
 previous administration of such remedies as render the tongue moist 
 and cleaning, the pulse soft and open, and place the nervous system 
 in a condition of tolerance. This can frequently be accomplished by 
 the use of the special sedatives, selected as already suggested. Qui- 
 nine is of little use in the treatment of infectious fevers caused by 
 bacteria. It seems to disturb the patient and aggravate the symptoms, 
 in the majority of cases. Its principal place is in the treatment of 
 malarial couditions, and here we only rely upon it to interrupt the 
 periodicity. 
 
 There are other antiperiodics which sometimes excel quinine in 
 certain respects, and are worthy of notice in this place : 
 
 Arseniatc of quinia, 3x trituration, is not usually as active as qui- 
 nine, but it is sometimes more efficacious, and is less unpleasant for 
 children and sensitive adults. It is better adapted for steady admin- 
 istration in chronic cases, as it does not leave behind the objection- 
 able effects of quinine upon prolonged use. 
 
 AUtonia should also be recollected where stubborn cases of perio- 
 dicity are met, for it will repay careful study aud trial. It is recom- 
 mended in malarial cachexia where the tongue is coated and the urine 
 loaded with phosphates. It seems more permanent in its effects 
 than quinine, though slower in action. 
 
 Faradism, the "tonic treatment" being employed, is not to be 
 forgotten in the treatment of chronic periodicity. When assisted by 
 cabinet vapor baths it is almost invincible. 
 
 The use of stimulating tonics during convalescence should have 
 gone out of fashion long ago. Such drugs as strychnia, nux vomica, 
 calisaya, quinia, etc., tend to derange digestion, set the nervous sys- 
 tem on edge, aud thus oppose recuperative processes. Such agents 
 may be of some service in preventing the return of malarial attacks, 
 but are usually objectionable during convalescence from other infec- 
 tious fevers. 
 
 Undue muscular exertion should be avoided during convalescence, 
 the patient being prohibited from rising from bed before the weak-
 
 16 INTRODUCTION. 
 
 ened condition of the heart-muscle and degenerated tissues gener- 
 ally has been corrected. The food should be selected with care 
 during this time, and adapted to the particular condition which may 
 have been brought about by the morbid action preceding. After 
 typhoid fever and certain other diseases the alimentary mucous 
 membrane is in a debilitated condition for several weeks, and the 
 return to ordinary diet should be gradual, the food being selected 
 with due regard to this fact After all cases of protracted infectious 
 disease the digestive apparatus is weakened, and recuperates slowly, 
 and there is great danger in the early use of crude aud indigestible 
 food soon after convalescence. Diphtheria is an affection in which 
 collapse and death have followed injudicious feeding early after con- 
 valescence ; and this danger arises in every case of severe infectious 
 disease. 
 
 The abuse of opiates in favors in past years has been a matter of 
 common record. Even our old Eclectics cannot plead innocence in 
 this direction, as their favorite remedy for febrile conditions was for- 
 merly the diaphoretic powder, containing enough opium to disturb 
 the nervous system unpleasantly, in many instances. There are 
 few febrile conditions where opium or its alkaloids can be used suc- 
 cessfully Doubtless, in many cases, life has been sacrificed by the 
 stupid administration of this drug. The practice of old, with its 
 crudities, could recognize but one remedy for restlessness and pain, 
 and that was some form of opium ; and as such symptoms were com- 
 mon, it entered largely into the ordinary treatment of fevers. It 
 excites the brain and nervous centers generally, arrests secretion 
 and paralyzes function, with resulting debility after the narcotic 
 effect has passed off Delirium, increase of pyrexia, dryness of the 
 tongue and skin, with diminished urinary excretion, follow its use, 
 while enough of the drug to cause slumber in the wakeful and rest- 
 less fever-subject is liable to produce profound prostration. Its 
 occasional use may be allowable, but its objectionable features as 
 a drug for common use should be fully realized. Unfortunately, 
 it has been superseded, to some extent, by a class of drugs the 
 coal-tar products which may leave behind extreme prostration and 
 cardiac debility, from which recovery is slow and difficult. Our 
 materia medica contains numerous safe resources for the relief of 
 such symptoms as those for which these drugs are prescribed in 
 fevers, as every diligent and observing practitioner must know. 
 Opium may be administered cautiously where the skin is not dry, 
 where the pulse is soft and open (not hard or wiry), where the 
 tongue is moist and normal in shape (not dry and contracted, nor 
 reddened and pointed at the tip), and where the nervous system is
 
 INFLAMMATION. 17 
 
 not markedly disturbed. Of course there are extreme cases where 
 all indications may be disregarded and lethal doses of opiates admin- 
 istered, these being hopeless, and attended by excruciating pain. 
 
 Muscular pain, where opiates were once employed so extensively, 
 and where the coal-tar derivatives are now administered too fre- 
 quently, is a common symptom of many fevers. When rheumatoid in 
 character, as it often seems, it may usually be alleviated by the use 
 of organic remedies which leave no ill-effect behind. Among these 
 may be mentioned rhamnus californica, especially valuable where 
 a laxative effect is desirable; cimicifuga; caulophyllum ; bryonia, 
 when the pain is principally about the thorax. Salicylic acid from 
 wintergreen, and salicylate of sodium may be of service. And some- 
 times phenacetin one of the least objectionable of "" the coal-tar 
 products will be found to answer the best purpose. However, it 
 should be recollected that the muscular pains which attend cerebro- 
 spinal fever and some other affections depend upon localized irrita- 
 tion of nervous structure, which must be removed before muscular 
 pain can be controlled with these remedies. Here, the local nervous 
 lesion will demand first attention. 
 
 Cathartics, which were once supposed to exert an important influ- 
 ence in the treatment af fevers, are used but little by modern 
 practitioners. The idea that febrile excitement can be materially 
 lessened by their action now receives little credence. There is no 
 doubt that such drugs disturb and irritate the intestinal mucosa, in- 
 terfering with digestion and assimilation; and when it is recollected 
 that the alimentary canal is not an excretory apparatus, and 
 that there is a tendency toward structural degeneration here in 
 most fevers, the common use of cathartics in their treatment seems 
 extremely irrational. 
 
 H. INFLAMMATION. 
 
 Synonyms. Phleginone; Phlogosis; Phlegmasia; eta 
 Definition. A localized disturbance of cellular and vascular 
 function, of destructive tendency, characterized by hypersemia, exuda- 
 tion of blood- and tissue-elements, and migration of leucocytes, 
 attended by pain, heat, redness, swelling and impairment of function 
 in the part affected. 
 
 Etiology. The causes of inflammation are local irritants, which 
 may be divided into two general classes, viz., simple and infectious. 
 Simple causes are those which are non-infectious. They comprise 
 mechanical injuries ; chemical effects, such as the action of caustics ; 
 extreme congestion due to sudden arrest of secretion; etc. Infec- 
 tious causes comprise numerous varieties of microorganisms, some
 
 18 INTRODUCTION. 
 
 of which have been separated, cultivated and studied, and some of 
 which exist at present only in imagination. At least, their presence 
 has not yet been satisfactorily demonstrated. However, there are 
 extremists who assert that all true inflammatory action depends 
 upon the presence of microorganisms in the affected tissues. 
 
 Infective inflammation may probably arise either from the direct 
 action of the microbes upon the tissues, from the irritation of their 
 toxines, or, as is usually the case doubtless, from a combination of 
 these influences. 
 
 Pathology. The pathology of inflammation is so complicated 
 that a separate study of some of its essential features will be most 
 likely to convey a clear conception of the nature of the disease. We 
 will therefor* consider in the beginning the principal histological 
 elements concerned. 
 
 HISTOLOGICAL ELEMENTS INVOLVED. 
 
 Blood-vessels. The principal vascular changes of inflammation 
 occur in the capillaries, though the minute veins participate. 
 Through the walls of these vessels the blood-elements make thier 
 escape, and through them the exudate largely enters the circulation 
 after the inflammatory action has subsided. The walls of the capil- 
 laries consist of a single layer of nucleated endothelial cells, united 
 by an interstitial cement -substance. Inflammatory action disinte- 
 grates the interstitial substance at various points, and openings (sto- 
 mata) are left between the edges of the cells, through which the 
 inflammatory exudation makes its escape. Mechanical and chemical 
 influences doubtless conspire to bring about this con- 
 dition. The engorgement of the vessels gives rise to 
 distension and intravascular pressure, and the large 
 volume of blood in the part increases the heat, this 
 combination of forces soon resulting in defective 
 points in the cement-substance, where stomata after- 
 wards appear. 
 
 MA< ; - There seems to be an excitement in even the most 
 minute blood-vessels which suggests a nervous stimulus. The arteri- 
 oles pulsate tumultuously, and the entire inflamed part is filled with 
 a throbbing sensation, probably due to vascular excitement and nerv- 
 ous erethism. The developmental and nutritional properties of 
 these organs are also evidently disturbed, as evidenced by the fact 
 that vascular tufts may be developed during inflammation in such 
 non-vascular structures as the cornea; and new capillary loops are 
 occasionally put forth exuberantly in other tissues. 
 
 Tluc, Blood-corpuscles. Three kinds of blood-corpuscles exist, and 
 all are concerned in inflammatory action. These are (1) the white
 
 INFLAMMATION. 19 
 
 corpuscles, (2) the red corpuscles, and (3) the blood-plaques or third 
 corpuscles. The accompanying diagram is suggestive of the rela- 
 tionship which these sustain to the circulation. The globular bod- 
 ies near the wall of the vessel are white cor- 
 puscles, the oblong figures accompanying them 
 suggest the third corpuscles, though these are 
 not readily visible in circulating blood, and 
 
 the dark central baud of disks the red corpuscles. The white cor- 
 puscles, being of lower specific gravity than the red, are crowded 
 out of the center of the current, and move along the periphery. 
 
 The white corpuscles take the most active part in the process of 
 inflammation. They possess the power of spontaneous motion, and 
 leave the capillaries and veins at an early period, migrating by amoe- 
 boid motion through the connective tissue, there being adapted to 
 a variety of functions. Leucocytes are continually undergoing 
 change of form, their locomotion being due to 
 this property. Infolding processes enable them 
 to take up floating particles and inclose them in 
 their substance. How these foreign particles are 
 afterward disposed of does not seem very clear. 
 Possibly pathogenic microbes are aimlessly dis 
 
 FOBMS OF A SINGLE LEUCO- > r J 
 
 M E OT!S SEKVED WITHIN TEN tributed through the tissues and blood-vessels, 
 other debris being scattered along iu much the promiscuous manner 
 in which it is taken up. Doubtless the leucocytes exert a solvent 
 or digestive influence upon certain substances incorporated. Leuco- 
 cytes should not be confounded with embryonal connective-tissue cells, 
 which are at first detached, possess the power of amoeboid motion, 
 and resemble them very closely morphologically, but differ, from 
 the fact that they may become fixed tissue-cells at a later period, 
 and assist in the repair of damaged structure, or play a very mis- 
 chievous part in interstitial inflammation. 
 
 A leucocyte consists of a hyaline mass contained in the meshes of 
 a reticulum of protoplasmic fibers and containing a nucleus. The 
 nucleus and reticulum constitute important parts of the structure, 
 and are broken up during degeneration into a pus-corpuscle. 
 
 The destination of a migrating leucocyte during inflammation is 
 uncertain. If the inflammatory action be slight and terminate in 
 resolution, it usually assists in clearing up the affected area and then 
 returns to the circulation, either directly, through a stoma, or by way 
 of the lymphatics. Where the inflammatory action is more severe and 
 there is considerable destruction of tissue, its substance may con- 
 tribute to the growth of embryonal tissue-cells (after deliquescence). 
 In another instance it may be converted into a pus-corpuscle.
 
 20 INTRODUCTION. 
 
 The red corpuscles are too well known to require description. 
 Possessing no power of spontaneous motion, their passage through 
 the walls of the blood-vessels is wholly a passive process, due to a 
 damaged condition of the vascular walls and engorgement of the 
 vessels. The number of red corpuscles outsidn the blood-vessels in 
 an inflamed area will suggest a relative amount of disturbance of this 
 character. Being intimately connected with the production of ani- 
 mal heat, it is more than probable that the abnormal elevation of 
 temperature observed in inflamed areas is due to the increased 
 number of red corpuscles present. The same observation applies to 
 the redness observed in an inflamed part, increased quantity of arte- 
 rial blood imparting the heightened color. Being incapable of 
 amoeboid motion, the red corpuscles are not such common carriers 
 of pathogenic germs as white corpuscles, and as they do not return 
 to the general circulation after diapedesis, they probably exert little 
 influence in the spread of infection. After the inflammation has sub- 
 sided they become broken up, and the detritus is absorbed. 
 
 The third corpuscles are small colorless spheres or granules, 
 twenty times as numerous as the red corpuscles. They probably 
 represent the fibrin-element of the blood ; and it is likely that they 
 exude from the vessels during inflammation and constitute the prin- 
 cipal bulk of the fibrin found in inflamed tissues. 
 
 Fixed-tissue Cells. The fixed-tissue cells participate in the 
 histological changes of inflammation. Where the inflammatory 
 action is severe, death of a community of these cells may occur in 
 the center of the affected area, a mass of necrosed tissue marking 
 the site. This is observed upon a small scale in a common boil 
 (furunculus), and upon a larger, in phlegmonous inflammation. The 
 direct cause of this necrotic influence is not yet satisfactorily settled. 
 Radical believers in the doctrine that all clinical inflammation is 
 microbic in origin, ascribe the condition to either the direct 
 action of microorganisms, or to powerful toxines generated by them, 
 except where starvation of the cells occurs from strangulation of 
 their blood-supply. But, as it is generally admitted that chemico- 
 vital influences are largely concerned in the destruction of the 
 interstitial cement in the capillaries whereby these vessels become 
 permeable by the blood, it might not be unreasonable to ascribe 
 destruction of fixed-tissue cells to a similar influence, occasionally, at 
 least. In chronic inflammation, instead of destruction of fixed- 
 tissue cells, as in acute inflammation, there is proliferation of these 
 elements, these furnishing the bulk of the inflammatory product, 
 instead of exudation. This process, though not immediately destruc- 
 tive, may give rise to extremely serious results, by impairing the
 
 INFLAMMATION. 21 
 
 functions of such vital organs as the liver and lungs. In intersti- 
 tial hepatitis (cirrhosis) and interstitial pneumonia, proliferation of 
 connective-tissue cells is almost invariably attended, sooner or later, 
 by fatal results. 
 
 Exudation. The exudation which occurs in inflammation con- 
 sists of solid and liquid parts. The solid parts are represented by 
 the blood-corpuscles, which have already been considered. The 
 liquid part, which consists of blood-plasma, is termed the inflamma- 
 tory translation. 
 
 This accompanies the corpuscles in their passage through the 
 openings in the vessels caused by the damage to the vascular walls, 
 its escape being due to the vis a tergo and the porosity of the vas- 
 cular structures. The swelling which attends acute inflammation is 
 largely due to the inflammatory transudation, the amount in the 
 affected tissues determining the extent of the tumefaction. The 
 oedema which attends certain inflammatory conditions is the result 
 of excessive transudation. This is likely to occur when parts 
 freely supplied with connective tissue are involved, such as the deep 
 muscular tissues, the lungs, the eyelids, scrotum, etc. Where the 
 parts are firm and there is little connective tissue, there is but small 
 amount of inflammatory transudation. After inflammation subsides, 
 the transudation is removed by absorption unless suppuration occur, 
 in which case it becomes the pus-serum. 
 
 Where deep-seated inflammation occurs, the exudation is poured 
 out into the cellullar tissue and lymph spaces, where the various 
 changes already described are carried on. This may be interstitial, or 
 parenchymaious inflammation. When acute, the exudation is increased 
 by the addition of liquid elements from the tissue-cells. In suppura- 
 tive inflammation, either a part or the whole of the exudation 
 is transformed into pus. The blood-corpuscles, as well as many of 
 the fixed-tissue cells, become pus-corpuscles. Hemorrhagic inflam- 
 mation is characterized by the presence of an excessive number of 
 .red corpuscles in the exudation. In most cases of inflammation 
 a few red corpuscles escape from the blood-vessels, but in this 
 instance enough are poured out to constitute actual hemorrhage, 
 the exudation presenting a reddened appearance suggestive of the 
 condition. Such cases are attended either by serious local or general 
 lesions. A very high grade of inflammatory action may prove suf- 
 ficiently destructive to the blood-vessels to bring about this result 
 Depravity of tissue from previous disease, or serious obstruction to 
 the general circulation, as in valvular disease of the heart, chronic 
 nephritis, hepatic cirrhosis, etc., dispose to such condition, as well 
 as syphilitic and erysipelatous complications. 
 
 Usually, in inflammation of serous membranes, the exudation is
 
 22 INTRODUCTION 
 
 poured out upon the surface, and the leucocytes and third corpuscles 
 are here destroyed, the combination of the fibrin ferment, debris from 
 the leucocytes, and blood-plasma forming fibrin, constituting a thick 
 layer of coagulable material, which becomes firmly welded to the 
 serous surface by means of capillary blood-vessels and granulations, 
 these sprouting up and growing into it. This forms a nidus or hot-bed 
 for the proliferation of connective-tissue cells, and as the endothe- 
 lium participates actively in the inflammatory changes, perforations 
 occur, through which embryonal connective-tissue cells wander, to 
 undergo rapid multiplication and organization, until the exudation 
 is entirely removed and replaced by connective tissue. If opposing 
 surfaces such as the reflections of the pleura or peritoneum are 
 involved, entire serous sacs may thus be obliterated, a growth of new 
 connective tissue completely bridging the chasm. If, on the other 
 hand, the endothelial cells remain intact, no embryonal connective- 
 tissue cells are liberated, and the exudation is absorbed, leaving the 
 serous surface free. If a serous inflammation be severe enough to 
 result in suppuration, the leucocytes and embryonal cells become 
 converted into pus-corpuscles, and collections of pus, such as empy- 
 ema, pyocardium, and purulent peritonitis, result. Where the trans- 
 udation is largely in excess of the corpuscular elements of the exuda- 
 tion, the inflammation runs a sub-acute course, and results in the 
 accumulation of a considerable quantity of serous fluid in the cavity. 
 
 When mucous membranes are involved, the mucous follicles secrete 
 profusely in most instances, flushing away the exudation which 
 is thrown out upon the surface, and constituting catarrhal inflamma- 
 tion. At a later stage, the leucocytes and embryonal cells become 
 converted into pus-corpuscles, and these mix with the mucus to 
 form a muco-purulcnt discharge. In croupous inflammation, the fibrin- 
 element predominates, and a coagulum which resists the flushing 
 influence of the catarrhal discharge is formed, and this coagulum 
 becomes more or less firmly attached to the mucous-epithelium, the 
 cells of which undergo a process of necrosis. Thus is formed, 
 the pseudo- or false-membrane. When the necrosis of the mucous 
 membrane is only slight, the secretion of the mucous follicles 
 beneath the exudation may suffice to lift it away; in more severe 
 cases, as in diphtheria, for example, the entire mucous membrane 
 is involved in the necrosis, and the separation involves a slower pro- 
 cess of sloughing. 
 
 In catarrhal inflammation of mucous membranes, thickening may 
 occur from inflammatory induration of the submucous tissue follow- 
 ing organization of the exudation. The large amount of fibrous 
 material thus developed causes contraction, which, in tubular organs, 
 may amount to permanent stricture.
 
 INFLAMMATION. 
 
 23 
 
 PHENOMENAL HISTOLOGICAL CHANGES OCCURRING DUBING INFLAMMATION. 
 
 When iuflammation occurs in thin, transparent, vascular struc- 
 tures, such as the web of a frog's foot, tongue, mesentery, bladder, 
 etc., and the part is properly placed under a microscope of the 
 requisite power, some of the histological phenomena presented may 
 be seen and studied. After the part has been properly placed and 
 secured, iuflammation is excited by the action of some irritant, usu- 
 ally a caustic, like the point of a red-hot needle, croton oil, nitrate 
 of silver, or some similar irritant to animal tissues, and an excita- 
 tion in the minute bloodvessels in an area surrounding this point is 
 soon observable. 
 
 If the normal condition of the blood-vessels is carefully noted 
 before the irritant is applied, a striking change will be apparent 
 after the inflammatory action has become fully developed. In the 
 __ normal condition, the red cor- 
 puscles remain in the center of 
 
 the vessel, the surrounding space 
 
 being occupied by clear plasma, 
 
 in which an occasional leucocyte 
 
 is seen, moving leisurely along 
 
 the vascular wall. The minute 
 
 capillaries contain few if any red 
 
 corpuscles, and the stream in all 
 
 the vessels moves along evenly 
 NORMAL CIRCULATION, and steadily, as attested by the 
 behavior of the corpuscles. The first change in S 
 the vessels is that of contraction, probably a reflex action due to 
 the stimulating influence of the local irritation. Soon, however, the 
 vessels become dilated, and it is seen that the corpuscles are hurry- 
 ing along with increased momentum. The red corpuscles increase 
 in number rapidly, encroaching upon the space normally occupied 
 by plasma and leucocytes. At first, the corpuscles hurry through 
 the part as well as toward it, there being a largely increased amount 
 of blood in motion toward, passing through, and moving away from 
 the affected area (active hyperaemia). But after a time a slowing of 
 the current becomes noticeable. The leucocytes now become promi- 
 nent factors. Large numbers of them leave the axial current and 
 join the slower procession along the walls of the small veins and cap- 
 illaries, showing more and more of a tendency meanwhile to adhere 
 and remain fixed to the inner suri'ace of the vessel. Though the 
 current may sweep them away again and again, they manifest a per- 
 sistent tendency to return and adhere to the vascular wall. Finally, 
 the entire inner wall of the small veins becomes paved with them,
 
 24 INTRODUCTION. 
 
 and they seem piled upon one another in heaps, obstructing the 
 lumen of the vessels in some places, causing complete arrest of the 
 current (stasis). Careful inspection will now enable the observer 
 to discover the fact that many of the leucocytes are passing, by amoe- 
 boid movement, through the attenuated and damaged walls of the 
 veins and capillaries. Some may be found just beginning the transit 
 by sending a narrow prolongation through, while the bulk of the 
 corpuscle is still within the vessel. Others may be found well on 
 the way, a portion of each lying outside the vessel and a por- 
 tion within it, the part engaged in the vascular wall being marked by a 
 pronounced constriction, while others will be found wholly outside 
 the vessels in the connective tissue. 
 
 To summarize, then, microscopical observation of a transparent 
 membrane with inflammatory engorgement, will enable one to detect 
 increased rapidity of the blood-current with subsequent retardation, 
 dilatation and increased tortuosity of the minute vessels, migration 
 of leucocytes (see illustration), diapedesis of red corpuscles, altera- 
 tion of fixedtissue-cells, etc. 
 
 The changes in the circulation of the inflamed area vary in pro- 
 portion to the position occupied in relation to the central point of 
 irritation. At a considerable distance from the place of injury the 
 circulation may still be normal. Nearer, the blood-vessels are 
 dilated and the stream moves more slowly; still nearer is a zone in 
 which there has been free emigration of leucocytes; and, when we 
 reach the immediate neighborhood of the point of injury, the blood no 
 longer flows through the vessels but remains stagnant, complete 
 stasis having resulted. The meshes of the surrounding tissues are 
 swollen, being distended by coagulable lymph, and the connective- 
 tissue fibers are enlarged and softened. The epithelial cells of 
 affected organs are swollen, their protoplasm is granular and more 
 opaque, and fatty granules are frequently contained in them. Pro- 
 liferation of new tissue gives rise to amoeboid embryonal cells, 
 which mingle with the leucocytes and red corpuscles that have 
 exuded from the vessels. In many cases of inflammation, microbes 
 play an important part, and are found in the leucocytes and red 
 corpuscles, as well as in the plasma. 
 
 Cornea and Cartilage contain no blood-vessels, and, consequently, 
 the vascular changes which are noted in other tissues are not observ- 
 able, though in the case of inflammation of the cornea it will be 
 noticed that vascular loops may spring from the sclerotic vessels 
 and invade the plasma-channels, this being the result of inflamma- 
 tory stimulation. 
 
 One of the first microscopical phenomena of corneal inflammation
 
 INFLAMMATION 25 
 
 is the appearance of migrating leucocytes in the plasma-channels, 
 which are found in great numbers, packing the passages and moving 
 toward the point of irritation. Simultaneously, the fluid contents of 
 the spaces are increased in quantity, the spaces being distended 
 and the cornea swollen, the tissue-cells becoming softened and 
 opaque. The infiltration results from fluid supplied partly by adja- 
 cent blood-vessels, and partly from the tissue-cells of the affected 
 structure. Vascular loops spring up from the sclerotic vessels at the 
 periphery, and follow the leucocytes along the plasma-channels. 
 Sometimes these become so prominent as to constitute what is known 
 as pannus. 
 
 Cartilage possesses no circulating channels in its structure, its 
 circulation being carried on by cellular diffusion, solely. Conse- 
 quently, active inflammatory action does not occur, chondritis being 
 a chronic process. The principal changes which occur early, there- 
 fore, can only be noticed as changes in the cartilage cells, which 
 undergo enlargement, softening, and degeneration. After long-con- 
 tinued inflammation of cartilage, however, new vessels may grow 
 over the affected surface, and even penetrate the substance of the car- 
 tilage and grow in the direction of the inflammatory focus, similarly 
 to the vascular phenomenon presented in paunus. 
 
 Phagocytosis is a term applied by Metschnikoff to a destructive 
 process supposed, by him, to be exerted upon microbes by leucocytes 
 and certain fixed tissue-cells, such 
 as mucous corpuscles, connective- 
 tissue cells, endothelia of blood- 
 
 , , -.-IT ii i i UNSUCCESSFUL PHAGO- 
 
 vessels, alveolar epithelium 01 the lungs, and certain CYTOSIS. 
 cells of bone, marrow, lymphatic glands, the spleen, etc. The process 
 is accomplished by amoeboid action, the cell folding or closing the 
 microbe within its substance, and afterward destroying it by some 
 process, probably digestive in character. Cells which are supposed 
 to accomplish this action are termed phagocytes. Sometimes the 
 microbes multiply in the cells in such numbers that the phagocytes 
 are destroyed instead, and fatal results, general or local, follow. 
 Against the testimony of Metschnikoff, who asserts that he has wit- 
 nessed the operation of phagocytosis, we have the statements of 
 other eminent pathologists that cells do not possess the power of 
 destroving microbes which inhabit their substance. As there seem 
 to be very positive statements upon both sides of this proposition, 
 it is evident that the question requires future time for its complete 
 solution. 
 
 Chronic inflammation is attended by much less vascular excitement 
 than the acute form. Consequently, migration of leucocytes is lim-
 
 26 INTRODUCTION. 
 
 ited, if occurring at all, and the inflammatory transudation is derived 
 chiefly from the fixed tissue-cells, young cells here playing an active 
 role. New tissue is developed, which, if it be not removed during 
 the reparative stage, constitutes a permanent hyperplasia. Hyper- 
 plasia of connective tissue figures prominently in the morbid auat- 
 o.ny of interstitial inflammation of the liver, lungs, brain and spinal 
 c >rd, choking out functional cellular structures iu these organs, and 
 strangulating, by slow process of contraction, the circulation of blood, 
 upon which their functional activity depends. 
 
 Another result of chronic inflammation is the development of 
 granulation-tissue, which is composed largely of embryonal cells, cor- 
 responding to the type of tissue in which or from which they grow, 
 modified by disease-influences, such as the presence of microbes. 
 The gummata of syphilis may be cited as an illustration of this class 
 of growths. 
 
 TERMINATIONS OF INFLAMMATION. 
 
 The inflammatory process may be arrested at almost any step in 
 its course, and the termination of the morbid action be consequently 
 modified by the stage of arrest. If the irritation is not severe and 
 the morbid action ceases before there has been destruction of tissue 
 and purulency, the exudation is absorbed and the tissues are left in 
 a normal condition, resolution having taken place. Long-continued 
 inflammation, however, results in the death of the tissue-cells near 
 the point of most concentrated excitement, and as there is liable to 
 be a lodgment of many leucocytes here, we may have necrosis of tis- 
 sue with purulent degeneration of the surrounding parts, constituting 
 what is termed suppuration. 
 
 Pus consists of two parts : (1 ) Corpuscular elements derived from 
 leucocytes and embryonal tissue-cells, which have undergone de- 
 structive changes; and (2) pus-serum, a fluid derived from the in- 
 flammatory trausudation. The formation of pus depends, in infec- 
 tious inflammation, upon the direct action of microorganisms upon 
 the leucocytes and embryonal cells (unsuccessful phagocytosis), or 
 upon the destructive action of the toxines generated by them upon 
 these bodies. Pus, however, may arise from other causes, as certain 
 chemicals injected into the tissues will cause similar changes. Severe 
 inflammatory action from any cause may prove destructive to the 
 elements which afterward degenerate into pus. 
 
 When purulent destruction occurs upon an open surface, and is 
 gradual (and attended by molecular disintegration), the pus escapes 
 freely, and constitutes idceration. When a considerable portion of 
 tissue is simultaneously involved in necrotic change, it is removed 
 in a mass, and is termed a slough. If pus accumulates in the tissues, 
 an absciss is the result. The disposal of the pus in such a case will
 
 INFLAMMATION. 27 
 
 depend upon circumstances. If it be small in amount, and the sur- 
 rounding tissues are in an excellent condition of health, the rather 
 uncommon result of absorption may occur, the corpuscular elements 
 being first liquefied. However, the pus is commonly evacuated by a 
 burrowing process, the surface being reached through the least- 
 resisting tissues, in a direction suggested by the force of gravity, 
 in many instances. 
 
 Occasionally, pus may be inspissated, and retained in the tissues, 
 the process being technically termed caseation. It suggests degener- 
 ative changes later on. 
 
 In chronic inflammation, the inflammatory action is not severe 
 enough to destroy the tissue-cells, and they are stimulated sufficiently 
 to undergo multiplication and rapid reproduction (proliferation). 
 Connective tissue is especially prone to active proliferation of cells 
 when chronically inflamed, and when the stroma of organs like the 
 liver, kidneys, lungs, etc., becomes thus involved, the inherent con- 
 traction which follows the development of this tissue in the interior 
 of an organ gives rise to obliteration of circulating vessels and paren- 
 chyma-cells, until the functions of the part may be completely 
 destroyed, the organ becoming hardened, and presenting the condi- 
 tion known as cirrhosis. 
 
 The destruction of tissue following necrosis of cellular elements 
 is usually replaced by proliferation of connective-tissue cells, which 
 organize and fill up the vacancy. When this occurs upon the surface, a 
 kind of epithelial covering not exactly like the original one covers 
 in the new growth. New growths of connective tissue also fill up 
 pus-cavities in the deeper structures, more or less contraction mark- 
 ing each point afterward The new growth is termed a cicatrix. 
 
 Symptoms. In mild cases of acute inflammation, the local man- 
 ifestations are the only observable symptoms ; and these vary much, 
 according to the part or tissue involved. However, in all acute 
 inflammations there is a group of symptoms, more or less well- 
 marked, not easily overlooked. These are, increased local heat, red- 
 ness, swelling, pain, and impairment of function. In chronic inflam- 
 mation, the disease may be so insidious in its progress that vital 
 organs are fatally impaired before the patient is conscious that he is 
 seriously ill. 
 
 In acute infectious inflammation, as well as in other cases involv- 
 ing important organs extensively, constitutional disturbances, which are 
 usually well marked, accompany the local symptoms, and the local 
 irritation is proportionally severe. The onset is liable to be marked 
 by chilliness, if not by an actual rigor. Reaction is attended 
 by pronounced febrile symptoms, such as elevation of the tempera-
 
 28 INTRODUCTION. 
 
 ture of the general circulation, arrest of secretion and excretion to a 
 certain extent, restlessness, etc. If the inflammatory action con- 
 tinues for several days with unmitigated severity, hectic fever and 
 colliquative sweats begin to appear. A chill, occurring after inflam- 
 matory action has been established for several days, suggests com- 
 mencing suppuration in some important organ. 
 
 One of the first prominent symptoms of inflammation is increased 
 local redness, this being due to the active hypersemia which occurs 
 in the beginning. Though this may not always be a prominent fea- 
 ture, close inspection of vascular tissue will usually detect engorge- 
 ment at the point where the active disturbance is progressing. 
 Later, after the active stage has passed and the vessels become 
 packed with corpuscles which move through the vessels but slowly 
 if at all, the bright redness of the active stage gives way to a darker 
 red, or purple hue. 
 
 The increased amount of blood in the part gives rise to dilatation 
 of blood-vessels, general swelling, and augmented local heat. The 
 elevation of local temperature is readily demonstrated when a ther- 
 mometer is applied to the surface of the affected part and its tem- 
 perature compared with that of other portions of the surface not 
 affected. The local elevation has no direct reference to the general 
 elevation, which is due to systemic infection and its influence upon 
 the heat centers. The local elevation of temperature sustains a 
 direct relation to the amount of blood in the part. 
 
 The inflammatory exudation is an element to be added to the 
 local hypersBmia in the causation of the tumefaction. Fluids are 
 poured out from the damaged vessels to distend the para-vascular 
 tissues, and to these are to be added the transudation from the 
 fixed tissue-cells, as well as the corpuscular elements which have 
 escaped from the blood-vessels. Inflammatory transudation differs 
 from the transudation of simple oedema, in that the inflammatory 
 transudation contains albuminous elements, while these are absent 
 from dropsical effusion. 
 
 Pain is a result of the swelling, which causes pressure upon the 
 extremities of sensory nerves. However, the amount of pain is not 
 proportionate to the amount of swelling, the resistance of the struc- 
 ture involved determining the amount of pressure and consequent 
 compression of nervous structure. Loose tissues may be swollen 
 remarkably and yet not be very painful, while inflammation of firmer 
 parts may give rise to excruciating pain, and not present much of a 
 swollen appearance. The resistance offered to the inflammatory exu- 
 dation determines the amount of pain, to a great extent. The pain 
 of acute inflammation is usually throbbing in character, this being 
 due to increased pulsation of all the minute arteries, as well as to
 
 INFLAMMATION. 29 
 
 the exalted sensibility of the nerves of the affected part. Accom- 
 panying the throbbing sensation may be paroxysms of darting or 
 burning pain. 
 
 All the symptoms of inflammation may be fully developed within 
 twenty-four hours after commencement, though usually a longer 
 time is consumed in its full development, and the symptoms may be 
 progressive for several days, in severe infectious cases. The extent 
 to which a part may become involved will depend upon the viru- 
 lence of the existing cause, partly, and partly upon the receptivity 
 of the tissues to its action. 
 
 Tenderness on pressure is a very important symptom of inflam- 
 matory action. Sensitiveness is a condition which is almost always 
 present, even if the part be painless when undisturbed. In some 
 cases the pain is reflex, the irritation being manifested in a part dis- 
 tant from the real point of morbid action. In morbus coxarius, for 
 example, the inflammation is in the hip joint, while the pain is in the 
 knee. Pressure upon the trochanter in such a direction as to crowd 
 the head of the femur into the acetabulum will elicit tenderness, 
 while no ordinary amount of pressure about the knee will cause dis- 
 comfort. In some cases of proctitis, the pain will be in the hip, 
 along the sciatic nerve or in some other remote part, while pressure 
 about these regions will fail to elicit tenderness, and the actual seat 
 of the disease is only demonstrable after careful examination of the 
 rectum. The pain of eudometritis may be persistently manifested 
 in the ovarian region, but tenderness will not be discovered until 
 the uterine cervix is disturbed. 
 
 In some cases, impairment or perversion of function may be the 
 only prominent symptom of inflammatory action. The almost com- 
 plete arrest of the urinary discharge in acute Bright's disease may 
 be the first noticeable symptom. The gravity of a case may not 
 depend so much upon the comparative amount of tissue destroyed, 
 as upon the character of the function impaired. For example, the 
 tissue-destruction involved in a fatal case of pneumonia might not 
 be of such serious consequence were it not for the arrest of the 
 important oxygenating functions of the parts involved. And arrest 
 of this function will give rise to the leading symptoms of the case, 
 such, for instance, as hurried respiration, dyspnoea, cyanosis, cough, 
 expectoration, etc. 
 
 It thus becomes apparent that any attempt to describe the diver- 
 sified symptoms of inflammation within the limited scope of a siugle 
 article, must be rambling and unsatisfactory. Indeed, much of the 
 space in the following pages will be occupied in the consideration of 
 the symptoms of various inflammatory conditions.
 
 30 INTRODUCTION. 
 
 Treatment. The diversified conditions liable to be met in a 
 variety of cases of inflammation, render it inexpedient to attempt to 
 cover the ground occupied by the proper treatment of individual 
 forms in this place. This will be the task to be fulfilled in the pages 
 which follow. However, there are certain well-established principles 
 to be observed in all instances, and a consideration of these will 
 assist the practitioner very much in individualizing his cases. 
 
 There is much to be considered in a proper regiminal treatment, 
 in discussing the general management of inflammation. Provisions 
 against irritation of an already inflamed part are as important as cur- 
 ative means, and these often amount to as much if not more than 
 medicinal treatment. Kest to an inflamed part means much when its 
 activity augments inflammatory action, as is often the case. 
 
 Rest being important in treating inflammation of any part, the 
 questions arise, What does it constitute, and how shall it be attained? 
 These the physician of practical turn will nearly always be able to 
 solve by the application of common-sense principles to individual 
 cases. It is axiomatic that neither excessive functional activity 
 nor abnormal irritation of an organ or part should be allowed to 
 continue longer than salutary measures will suffice to repress it. 
 
 To illustrate, imagine a case of recto-colitis, in which the evacua- 
 tions are frequent, and attended by severe tormina and tenesmus. 
 Suppose now that the patient be allowed to rise and sit upon a stool 
 at every period of evacuation, thereby adding to the irritation by 
 change of position and by voluntary straining. In such a case 
 which is no uncommon illustration of the management pursued by 
 many the therapeutist may find his best prescriptions at fault 
 many times, and will occasionally find his patient growing worse 
 instead of better, until he has enjoined quiet in the recumbent pos- 
 ture with the use of a bed-pan during evacuation, and instructed the 
 patient to exercise the will-power to postpone the attempts at evac- 
 uation as long as possible, in order that straining and other causes 
 of hypersemia thus entailed may occur only at prolonged intervals. 
 Prompt response to the properly selected remedies will then follow, 
 and the benefit of rest to the affected part will become so prominent 
 that no one can doubt its presence. Take, again, a case of irritation of 
 the respiratory mucous membrane arising from measles. Suppose, 
 now, the patient be allowed to remain during the course of the dis- 
 ease in an apartment where the temperature is below the freezing 
 point, the cold air acting as a local excitant to the irritated surface. 
 The best remedies we may select here cannot equal, in beneficial 
 results, the adoption of means to bring the temperature up to 65 
 or 70 F. and maintain it there, during the continuance of the bron-
 
 INFLAMMATION. 31 
 
 chial irritation. Indeed, neglect of this measure may result fatally 
 in cases which would terminate favorably under proper surround- 
 ings without any medication at all, pulmonary inflammation being 
 excited by the irritation set up from the excessive cough, arising 
 from exposure of the pulmonary membrane to the chilly atmosphere. 
 Suppose a case of chronic laryngitis, due to the titillating influ- 
 ence of an elongated uvula. Could it be reasonably expected that 
 medicine would cure the i.isease while the cause of irritation was 
 remaining? Certainly not. And the physician who possessed such 
 an exalted opinion of remedies as to expect it, would be blind to 
 the true philosophy of therapeutics. 
 
 The rest which irritated and inflamed organs receive from opi- 
 ates is seductive, and usually of little permanent good, while the 
 effect of the drug is often harmful to the general condition of the 
 patient, impairing his recuperative energies. However, this favorite 
 method, long perpetuated by the dominant school, is not to be 
 abandoned completely, though its omission should be the rule 
 rather than the exception. 
 
 Position may exert an important influence upon the results of 
 inflammatory action, when this operates upon the circulation of the 
 affected part. Hypostatic pressure is influenced by gravity, even 
 within the body; and flexure of certain parts may compress impor- 
 tant blood-vessels to impede the circulation, when the force of gravity 
 is not at fault. Destructive and fatal pneumonia may arise during 
 typhoid fever, from allowing the patient to remain constantly upon 
 the back for weeks at a time, the fatal effects of hypostatic pressure 
 upon debilitated tissues being here demonstrated. Chronic metritis 
 may be due to flexion of the uterine cervix impeding the circulation 
 of blood through the uterine vessels. 
 
 Undoubtedly, inflammatory conditions of the intestinal walls are 
 often aggravatad by the local effect of improper food. Fatal cases of 
 typhoid fever may owe their unfortunate termination to such influ- 
 ences; and dysentery, which, under proper management, would ter- 
 minate favorably in brief time, may be prolonged until permanent 
 chronic disease is the result, because proper attention has not been 
 given to the fact that a local hyperaemia exists in the intestinal 
 mucous membrane, which renders careless and indiscriminate feeding 
 highly improper and detrimental. 
 
 These few illustrations will suggest the proper course to the dis- 
 criminating practitioner. Give therapeutics their proper place, and 
 do not expect them to accomplish impossibilities. 
 
 It is evident, then, that many more details are to be considered in 
 the management of inflammation generally, than those which concern
 
 32 INTRODUCTION. 
 
 the administration of remedies; for, though these are highly impor- 
 tant, neglect of a proper regimen may neutralize the best-directed 
 therapeutic efforts, and subject the most reliable remedies to 
 condemnation. 
 
 In the therapeutic management of inflammation, we must be 
 guided by the stage which has been reached in pathological develop- 
 ment, the relief of irritation and conservation of the vitality of the 
 part affected being the principal objects sought. "We will leave the 
 destruction of pathological microbes concerned to the bacterio- 
 logical enthusiast and neophyte, and concern ourselves, in this direc- 
 tion, with neutralizing the ptomaines generated, and reenforcing 
 physiological processes, so far as possible. 
 
 Let us first consider the treatment of active hypercemia; for, in 
 the proportion that this can be controlled, in a corresponding ratio 
 will the integrity of the tissues involved be preserved. Two classes 
 of remedies are to be considered here, namely, (1) general vas- 
 cular sedatives, and (2) local vascular sedatives. 
 
 The general vascular sedatives have already been considered, 
 under treatment of fevers. They include the special-sedative class 
 of Scudder, and the antiseptic sedatives. These are to be employed 
 to control the symptomatic fever, usually, though they should not 
 be considered mere appendices of this character, as inflammations 
 in which constitutional symptoms are not prominent are manifestly 
 modified by them. Indeed, the hypersemic conditions of inflammation 
 may be successfully treated without other means, except properly 
 selected local applications. As the appropriate method of employ- 
 ing these remedies, as well as their adaptation, has already been dis- 
 cussed, the reader is referred to preceding pages (10, 11, 12, 13, 
 14), and to Dynamical Therapeutics, for further suggestions. 
 
 However, we can improve upon this treatment by adding a class 
 of remedies local vascular sedatives which sedate special 
 localized vascular areas. For example, while we may treat pneumonia 
 with tolerable satisfaction by the use of aconite, gelsemium, jab- 
 orandi, and other general vascular sedatives, we will derive better 
 satisfaction by combining with the properly selected " general seda- 
 tive, a remedy from the group which sedates the vascular area sup- 
 plied with blood by the bronchial arteries; such, for example, as 
 asclepias, bryonia, ipecac, lobelia (?), etc. So with acute pharyngi- 
 tis. The general sedatives may control the local vascular excite- 
 ment, and the results be very satisfactory to those accustomed to 
 older and less direct methods; but more rapid and satisfactory 
 results follow when phytolacca, cistus canadensis, or some other 
 agent which specifically influences the vascular area supplying the
 
 INFLAMMATION. 33 
 
 pharynx is added for its sedative effect. The local sedative usu- 
 ally acts with greater therapeutic power upon the special part 
 than the general sedative, but the combination acts best to cover 
 both general and local disturbances of active hypersemia. If we 
 make a careful study of dynamical therapeutics, we will find that 
 many different parts and organs possess their specific vascular seda- 
 tives, which exert an important influence in controlling hypersemic 
 conditions. 
 
 By the use of such agents we may be enabled to so control the 
 active hyperaamia of the affected part as to quiet the inflammatory 
 action before the later stage, such as migration of leucocytes, inflam- 
 matory engorgement, stasis, alteration of fixed tissue-cells, etc., has 
 made much progress. Consequently, there is little exudation to be 
 absorbed, and the blood-vessels and fixed tissue-cells are saved from 
 damage, while necrotic processes are averted, recovery then being 
 rapid and complete. It matters little how severe an inflammation may 
 be, faithful adherence to such principles is sure to provide against 
 the worst results, which might ensue without their observance. 
 
 When the para-vascular tissues become involved, the disease has 
 progressed beyond the reach of vascular therapeutics. However, as 
 para-vascular disturbances may go on simultaneously with hypersemia, 
 it is not in order to abandon our sedatives upon the adoption of a 
 new line of treatment. These should be continued, and alternated 
 with additional measures, as long as active hyperaemia persists. 
 
 The period of commencing inflammatory exudation announces 
 the time for a new step in the treatment of all severe cases of inflam- 
 mation. Wherever the formation of pus would be disastrous, as 
 in inflammation of any internal organ, where its exit might be 
 attended by serious consequences, it is highly important that this 
 purulent degeneration be forestalled and prevented, if possible, as 
 it often is. In many cases of pelvic cellulitis, typhlitis, hepatitis, 
 pneumonia, etc., where purulent accumulation might otherwise occur, 
 potassium chloride, 3x trituration, properly employed, will assist 
 the normal processes to remove and dispose of inflammatory exuda- 
 tion so safely as to leave no bad results behind, and convert por- 
 tentous cases into that favorable form where resolution disposes of 
 serious sequlae. It is remarkable how soon pain, hectic fever, and 
 tenderness will vanish before this remedy, in a large majority of cases. 
 True, weeks may be required to bring about the desired results in 
 some cases, and the remedy may fail, as all others will ; but it is one 
 of the most precious boons of modern therapeutics, after all. Add 
 five grains of the 3x trituration to half a glass of water, and give a 
 teaspoon ful every hour.
 
 34 INTRODUCTION. 
 
 A step further, and we find that purulency cannot be controlled. 
 We now need a remedy which will hasten the change rapidly, that as 
 small a portion of tissue as possible may be sacrificed ; and we will 
 resort to calcium sulphide, for this purpose. When there is a tend- 
 ency to persistency of suppurative action, this remedy will often 
 assist promptly in bringing the degenerative change to an end, as, 
 for instance, where there has been purulent pneumonia, and the pus 
 cavity continues to suppurate after evacuation, preventing the 
 maturity of embryonal^ tissue-cells, and the repair of the part. 
 
 Then we have more extreme cases, where a sloughing tendency 
 is announced by purple tissues, with darkened center, or perhaps 
 actual necrosis of the focus of inflammatory action, with manifest 
 progression of the necrotic change, where none of the remedies already 
 named will be of much if any account. It is here that we will expect 
 to derive the wonderful influence of echinacea, employing it both 
 internally and locally, saturating the system with it, and stimulating 
 local areas by its direct action. Nothing like this remedy was ever 
 known in medicine before its time, and the physician who neglects to 
 avail himself of it is sacrificing the vital interests of his patient 
 where marked uecrotic tendencies are developing. From ten to 
 Wenty drops of a saturated tincture of the fresh plant may be given 
 every hour, and a dilution of one part of the same to three or four 
 of water should be applied locally at frequent intervals. Another 
 remedy of this character is baptisia, a traditional agent for such con- 
 ditions, and one which deserves much praise, though it does not 
 compare with echinacea in efficacy. 
 
 Then we have a class of inflammations where the skin and its 
 reflections are involved in erythematous or erysipelatous irritation, 
 the condition being marked by tendency to rapid spreading, and 
 severe burning pain. Here we get the best effects from echinacea inter- 
 nally, though it may be assisted by aconite, jaborandi, or some other 
 appropriate special sedative, and its local influence, which is most 
 effective, may be assisted by applications of plumbi acetatis, citric acid, 
 etc., in solution. Where such conditions become chronic, the grand 
 constitutional influence of berberis aquifolium, should not be forgotten. 
 
 The symptomatic fever which attends inflammation will call for the 
 medication already directed under the general treatment of fevers 
 The sedatives, both arterial and antiseptic, should be properly adapted 
 when called for; and the element periodicity should be recognized and 
 properly met, if success is to be expected to follow treatment 
 
 The local treatment of inflammation has undergone quite a rev- 
 olution since the days of bacteriology. Hot poultices, once the 
 favorite resort of the practitioner, have been relegated to the past, their
 
 INFLAMMATION. 35 
 
 use being opposed to antiseptic precautions, it being believed that they 
 furnish a nidus for the development of pathogenic germs. Cold, 
 applied over the affected surface, is less conducive to suppuration, 
 and water may be used to saturate appropriate packs for this pur- 
 pose. The temperature of the water employed should depend upon 
 the patient, one of delicate nervous organization not being well 
 adapted to resist the shock of very cold applications. Tepid water 
 would suit such individuals best, and impart all the beneficial influ- 
 ence to be derived. In pneumonia, especially in children, cold- or 
 tepid-water packs should rank among the best means of treatment 
 during the stage of active hyperaemia; and such remark applies to 
 acute inflammatory action in almost any other organ. Where super- 
 ficial surfaces are involved, some appropriate medicine may be added 
 to the water, which will serve both as a therapeutic agent and vehi- 
 cle to carry the medicine. For instance, superficial inflammation 
 of the skin may require the local influence of diluted carbolic acid, 
 echinacea, citric acid, or some other cooling, soothiug, or cleansing 
 agent. 
 
 The diet of inflammation should be nutritious, but not stimulating. 
 The old idea that inflammation should be starved out, was a much 
 mistaken one, and has long since given way to more sensible views. 
 The waste of tissue and expenditure of heat involved calls for nour- 
 ishment to make good the loss, and demands that the patient be 
 properly fed. 
 
 In active inflammatory states of severe character, a diet of milk 
 may be all that is desirable, this being diluted one-half with w^ter 
 or Vichy. A better diet here will be found to consist of malted 
 milk, though the patient soon tires of this form of food. From 311 
 to seven ounces of milk may be administered every two hours. 
 Where the alimentary canal is involved, the diet must be selected 
 with reference to existing conditions, care being observed to avoid 
 everything liable, from its indigestibility or mechanical influence, 
 to irritate the sensitive mucous membrane. Malted milk or beef- 
 peptonoids will here be found excellent, preference being given to 
 malted milk. Gruels, prepared from arrowroot or oatmeal, some- 
 times break the monotony of a continuous milk diet, and serve an 
 excellent purpose as nutritives. Bicewater is very nourishing, and 
 serves at the same time as a cooling drink in inflammatory diseases. 
 The cream from cream-codfish is excellent, and unobjectionable dur- 
 ing the later stages, after inflammation has somewhat subsided. At 
 this time the yolks of eggs which have been boiled an hour, will be 
 found nourishing and unirritating. Eggnog though alcoholic stim- 
 ulants are rarely demanded may now be administered sparingly.
 
 36 INTRODUCTION. 
 
 When acids are indicated by the tongue and craved by the patient, 
 they are excellent in the form of acidulated driuks, such as lemonade, 
 acid phosphate, etc. Later on, a light diet of toast, poached eggs on 
 toast, custard, rice, etc., may be indulged in. Tea and coffee should 
 be used sparingly, if at all. 
 
 HYPEKTEOPHT. 
 
 HYPERTROPHY is enlargement of an organ or part from increase 
 in the size or number of its numerical elements. Simple increase 
 in bulk, however, may occur without constituting hypertrophy, as 
 proliferation of cells of new growth or of connective tissue may 
 occur to increase bulk, without adding to the function-elements. 
 Various degenerations may also increase the size of a part, which 
 could not then be considered as hypertrophiecl. 
 
 In order that a muscle may be hypertroplded, there must be an 
 increase in the size or in the number of the muscle-cells. In hyper- 
 trophy of the thyroid gland, there must be an increase in the number 
 or size of the normal cellular elements of the part; therefore, some 
 cases of goitre are true hypertrophies, while others are due to degen- 
 eration or hyperplasia. In true hypertrophy the enlargement must 
 be due to increase in the normal cells of the part. 
 
 Normal hypertrophy frequently occurs, as, for example, when 
 there is an increase in the elements of the uterine structure and of 
 the mammary glands during the developments of gestation. The 
 hypertrophy of the muscles of the calf in the ballet-dancer, of those 
 of the forearm in the blacksmith, etc., is of a similar nature, though 
 in every instance it must be considered as compensatory a develop- 
 ment in keeping with the requirements of the case. An example of 
 compensatory hypertrophy is afforded by the hypertrophy of the 
 heart when obstruction of the orifices demands the exhibition of 
 greater power to propel the blood through them in a given space 
 of time. 
 
 Irritation, which invites undue afflux of blood to a part, may result 
 in hypertrophy. The enlargement of the cheeks and nose in acne 
 rosacea probably depends upon this principle. In inflammation, the 
 surrounding area is stimulated to greater than normal activity, and 
 hyper-growth of normal tissue may result, as enlargement of bone 
 in periostitis. The process by which hypertrophy develops from the 
 normal elements of a part is one of cell growth, of which there 
 are two kinds, namely, direct and indirect Indirect cell develop- 
 ment is technically termed karyokinesis. Recent advances in biol- 
 ogy have improved our knowledge of the minute structure and 
 developmental history of cell growth in this particular.
 
 ATROPHY. 
 
 37 
 
 Modern knowledge of cell structure differs materially from the 
 conception entertained by older writers, such as Schwaun, Remak, 
 and Virchow, who held that a structureless mass of protoplasm con- 
 taining a homogeneous nucleus was the essential feature. Some writ- 
 ers even contended that a nucleus was not necessaary, a simple mass 
 of protoplasm representing, in certain instances, an individual cell. 
 For the purpose of karyokiuesis, however, a much more complicated 
 structure is essential, and more complete researches into the minute 
 structure of the histological formation of cells have demonstrated 
 that a nucleus with internal organization is an important essential 
 of this process. 
 
 SUCCESSIVE STEPS IN KAHYOKINESIB. 
 
 The nucleus contains a reticulum of minute fibers, the meshes of 
 which are filled with a homogeneous substance. From the fact that 
 the fibers may be stained with certain coloring matters they have 
 been termed chromatin threads, while the homogeneous substance it 
 contains, resisting colors, is termed achromatic. The cell contents 
 outside the nucleus also contain fibers, irregularly distributed 
 through its substance. When the cell is in a quiescent condition 
 the chromatin threads are very slight; but when karyokinesis 
 begins, they become swollen, and converted into a skein of convo- 
 luted fibers. This afterward assumes the shape of a star, the 
 wall of the nucleus meanwhile disappeariDg. Then follows the 
 equatorial stage, in which the chromatin fibers divide into two 
 groups and cluster about the poles of the nucleus, a clear space 
 bring left along the equatorial line. Then the cell wall contracts 
 in this region and a separation of the two parts follows, the chrom- 
 atin threads in each cell subsiding into the former condition of 
 quiescence, and becoming surrounded by a limiting membrane. 
 
 ATROPHY. 
 
 ATROPHY is a diminution in the size of an organ or part, due to 
 loss of substance in its histological elements, or decrease in the 
 number of such parts. 
 
 Where the decrease is only that of size of elemental parts, the 
 condition is termed simple atrophy: where there is loss in the number
 
 38 INTRODUCTION. 
 
 of such elements, it is termed numerical atrophy. As numerical atro- 
 phy must be the result of previous diminution in size in the elements 
 which have disappeared, it is evident that simple atrophy must 
 precede and accompany numerical atrophy, the two often being asso- 
 ciated, though simple atrophy may occur alone. It must be patent 
 that numerical atrophy is of the more serious character, as, when 
 the histological elements of a part are destroyed the condition will 
 be permanent, unless new cells are created something not likely to 
 occur while in simple atrophy, under favorable circumstances, the 
 elements may be restored to their former condition. 
 
 A familiar example of simple atrophy is loss of the subcutaneous 
 adipose tissue which attends general emaciation. The adipose tis- 
 sue here consists of connective-tissue cells filled with fat. When 
 the fat is absorbed, the cells diminish in size, the general bulk of 
 the body thus becoming wasted. In a similar manner the fat may 
 be removed from the connective-tissue throughout the body, and 
 portions of the contents of cells of other structures, thus resulting in 
 diminution of bulk. The cells of glandular organs may thus be 
 involved, suoli parts as the liver, kidneys, mammary glands, spleen 
 testicles, lymphatic glands, and other organs becoming wasted in 
 size in this manner. The primitive fasciculi of muscles may also be 
 thus affected, this being common in the heart and voluntary mus- 
 cles, during wasting diseases. When restitution occurs, there must 
 be an increase in the nutritive activity of these parts, and supply of 
 more nutritive material. 
 
 In numerical atrophy, the loss of substance and lack of nutritive 
 supply results in molecular disintegration of the elementary cells, this 
 usually occurring in circumscribed areas, and only a granular debris 
 finally remains, to mark the focus of atrophic action. This differs 
 from necrosis, in that the substance is absorbed and carried away 
 gradually in atrophy, while in necrosis there is such rapid death 
 of the part that its substance remains as a foreign body, subject to 
 immediate expulsion, the granular debris of atrophy still remaining 
 a part of the living tissue, though its bulk be lessened and its func- 
 tion destroyed. 
 
 Atrophy may be general or partial. In general atrophy, all the 
 organs and tissues, to a greater or less extent, are involved in loss 
 of substance, while partial atrophy is limited to separate parts. 
 General atrophy is usually simple, only the size of histological ele- 
 ments being involved, while partial atrophy is often numerical, cer- 
 tain histological elements being completely destroyed. 
 
 A better conception of the different forms and conditions of atro- 
 phy may be had by considering the causes of general and partial
 
 ATEOPHY. 39 
 
 atrophy. These may be summed up under three general heads: (1) 
 Deficient supply of nutritive material; (2) excessive waste; and (3) 
 impaired nutritive activity, 
 
 Any condition of affairs which interferes with the supply of 
 sufficient nourishment is soon followed by wasting of the entire body. 
 Starvation, insufficent food supply, soon manifests itself by emaciation 
 and general atrophy of all the tissues of the body, the adipose tissues 
 first wasting, the firmer structures being involved later. Conditions 
 of the system which operate to interfere with the appropriation of 
 food bring about the same result, as, for instance, obstruction to the 
 passage of food into the stomach or intestines, such as stricture, or 
 interference with the absorption of the food after digestion, as 
 disease of the mesenteric glands, liver, etc. Any condition which 
 prevents proper nutritive pabulum from reaching the blood in a 
 digested condition will cause general atrophy. 
 
 Excessive waste of normal tissue-elements also results in general 
 atrophy. We observe this in continuous hemorrhages, in diabetes, 
 albuminuria, prolonged and profuse suppuration, and in the destruc- 
 tion of tissue which attends febrile disease. 
 
 Impaired nutritive activity is the usual cause of the atrophy of old 
 age senile atrophy. As age advances the plastic power of the 
 tissues diminishes; and they are unable to appropriate nutritive 
 material vigorously; and there is also enfeebled circulation. The 
 result is a general wasting of the tissues, slow but permanent. 
 
 These causes are usually combined in the bringing about of 
 emaciation. For example, in the marasmus of phthisis there is 
 excessive waste from the colliquative sweats and profuse expectora- 
 tion, the digestive organs are so involved that little food is con- 
 sumed, while the assimilative powers are impaired. And so with 
 almost every other condition of general atrophy except starvation 
 from lack of food. Disturbance of one organ or function begets dis- 
 turbances of others, and a chain of circumstances results from the 
 combination, all of which tend toward loss of tissue general 
 atrophy. 
 
 The causes of partial atrophy are: (1) Imperfect supply of blood; 
 (2) diminished functional activity; (3) increased functional activity; (4) 
 the action of certain drugs; (5) nervous influence; and (6) inflammation. 
 
 Imperfect supply of blood is usually the result of pressure upon 
 the arteries concerned in carrying nutritive material and distributing 
 it to the affected part. This may arise at a distance from the atro- 
 phied organ or area, from pressure to a main trunk from the growth 
 of a tumor or contraction of cicatricial tissue, or it may be due to 
 the proliferation of connective- tissue elements of the stroma of an
 
 40 INTRODUCTION. 
 
 organ with subsequent contraction, resulting in strangulation of the 
 normal circulation. Direct pressure upon a part which is not yield- 
 ing may result similarly, as when an aneurism, or even an arterial 
 trunk, presses against the surface of a bone, causing indentation and 
 atrophy of its tissue in that particular place. The pressure of 
 hydrocephalus within the cranium causes thinning of the cranial 
 bones ; that of retained secretion in the bladder from urethral obstruc- 
 tion, atrophy of the kidney, etc. 
 
 Diminished functional activity is a common cause of atrophy. Dis- 
 use of the muscles of locomotion is soon followed by atrophy of 
 these parts. Let a person remain in bed for a few weeks, even when 
 in fair bodily health, and the muscles of the lower extremities 
 become very much lessened in size. The disuse of foetal organs 
 which follows the changed conditions of birth results in rapid and 
 complete destruction of the functional capacity of the ductus arteri- 
 osus, the umbilical arteries and veins, and the Wolffian bodies. The 
 involution of the uterus after parturition, and the wasting of the 
 lower jaw after loss of the teeth, are other examples of physiological 
 atrophy from disuse. 
 
 Groups of paralyzed muscles soon atrophy, though in some cases 
 this may not be due to loss of function alone, trophic influences 
 being brought more or less to bear; for there are evidently certain 
 nervous filaments which connect nutritional centers in the spinal 
 cord with every part of the body. 
 
 After establishment of an artificial anus, the rectum becomes 
 atrophied, often dwindling away to a mere fibre-cellular cord. Sec- 
 tion of nerve trunks is followed by atrophy of the distal extremity, 
 and atrophy of the optic nerve follows enucleation of the eye or 
 destruction of its function-elements. 
 
 Increased functional activity is occasionally, though rarely, a cause 
 of atrophy. Some glandular structures, especially that of the tes- 
 ticle, dwindles away as a result of excessive activity. 
 
 Certain drugs cause atrophy of particular organs. Iodine causes 
 more or less wasting of the lymphatic glandular system; bromine, 
 'of the testicles; and fucus vesiculosus and the juice of phytolacca 
 berries are said to produce atrophy of adipose tissue. 
 
 The atrophy which results from inflammation is usually due to 
 the organization of new fibrous tissue in the stroma of organs, the 
 contraction of which compresses the circulation and thus cuts off or 
 impedes blood supply to such an extent as to deprive the affected 
 parts of normal nourishment. Dwindling away of the elements of 
 an affected organ therefore results, and, when this is a vital organ, 
 like the liver or kidney, fatal results follow.
 
 DEGENERATIONS. 41 
 
 There is often the association of fatty degeneration with atrophy, 
 the same condition interference with normal supply of nutrition 
 operating to bring about both these results at once. During senility 
 both conditions are often associated, atrophy and fatty degeneration 
 occurring together as results of limited blood supply to the affected 
 part. Brown atrophy of the heart is an instance of the association 
 of these conditions. It consists of gradual atrophy of the muscular 
 fibers, attended by the formation of brownish yellow or blackish 
 pigment. The fibers are often at the same time the seat of fatty 
 degeneration. Association of atrophy and fatty degeneration are 
 not uncommon in pulmonary tuberculosis, pernicious anaemia, and 
 other wasting diseases. 
 
 It is not probable that all cases of atrophy may be benefited by 
 treatment; indeed, comparatively few of them can be improved. Cor- 
 rection of the conditions which lead to them is the first thing to be 
 thought of, though this is not always possible. In some cases 
 the condition may be modified, at least, by the judicious use of elec- 
 tricity and massage, these measures encouraging the circulatory and 
 nutritional activities. The action of certain drugs improves the 
 plastic power of atrophied parts, though the subject requires a fur- 
 ther investigation. For example, sabal serrulata influences the 
 mamary glands and testes in this manner, increasing their size and 
 functional power. Bryonia exerts a similar influence upon the retina 
 and optic nerve. Collinsonia thus influences the rectum, and rham- 
 nus calif ornica the muscles. 
 
 111. DEGENERATIONS. 
 
 THE degenerations differ from atrophy, in that there is altera- 
 tion in the quality of the cells of an affected part which not only 
 impairs but destroys their functional capacity. Complete annihila- 
 tion of a part may thus result, its character being histologically as 
 well as functionally altered. 
 
 Two kinds of degeneration occur, which are described as (1) met- 
 amorphoses, and ( 2 ) infiltrations. 
 
 The metamorphoses are the result of a direct change in the albu- 
 minoid constituents of the cells of a part, by which they are con- 
 verted into a new material. This is attended by a complete destruc- 
 tion of the intercellular substance, which softens and loses its 
 normal characteristics, the entire normal structure of the part being 
 annihilated. 
 
 The infiltrations are characterized by the infiltration of new ele- 
 ments into the cells of a part, which displace the normal elements to
 
 42 
 
 INTRODUCTION. 
 
 CLOUDY SWELLING. 
 
 a certain extent, but which does not destroy them nor interfere com- 
 pletely with their functions. The intercellular substance is not usu- 
 ally destroyed, and the affected part may retain a modified portion of 
 its structural and functional individuality. 
 
 PARENCHYMATOUS DEGENERATION. 
 
 THE common name for this form of degeneration is "cloudy 
 swelling," though it is otherwise known as albuminous, serous, and 
 granular degeneration. Ifc consists of a swell- 
 ing of the anatomical elements of portions of 
 the body, accompanied by granulation of the 
 cell-contents, and disappearance of the nuclei. 
 The granules resemble fat-granules in appear- 
 ance, but differ from them by being soluble in 
 acetic acid, and insoluble in alcohol or ether. 
 The parenchyma-cells of important organs, 
 such as the liver, kidneys, heart, etc., are 
 especially prone to such a condition, the organs 
 becoming swollen, pale, and friable. Cells 
 which undergo this degeneration are not necessarily destroyed, a 
 gradual return of their integrity following favorable constitutional 
 conditions. 
 
 This form of degeneration attends many severe acute diseases, 
 the infectious fevers being especiafly prone to it. All soft tissues 
 participate, though the abdominal and thoracic organs and kidneys 
 suffer most. It may follow poisoning from arsenic, phosphorus, or 
 the mineral acids. 
 
 Cloudy swelling occurs especially in epithelial elements. The 
 accompanying illustration represents progressive stages of degenera- 
 tion of this character in the epithelial cells of the urinary tubules, in 
 acute tubal nephritis. 
 
 FATTY INFILTRATION. 
 
 Fatty infiltration consists of infiltration of fat into cells in such 
 a manner as to displace the nucleus and crowd aside other elements 
 without destroying their functions. The fat accumulates within 
 the affected cells as distinct globules, displac- 
 ing the nucleus and protoplasm, though after 
 it is removed by absorption the cell remains in 
 a normal condition. Fatty infiltration occurs 
 as a normal process, due to the presence of 
 more fatty material in the body than is required 
 FATTY INFILTBATIOH. ^ or physiological purposes, the excess then 
 being stored in the connective tissue for future use. The favorite
 
 DEGENERATIONS. 43 
 
 points for fatty infiltration are adjacent to the radicles of the nutri- 
 ent vessels. 
 
 In fatty infiltration the fat is derived from the oleaginous, saccha- 
 rine, and nitrogenous principles of the food, instead of from the 
 affected tissues themselves, as in fatty metamorphosis. 
 
 Abnormal fatty infiltration occurs in obesity and emaciation. 
 In the one instance, there is more fat in the body than the natural 
 oxidizing powers are capable of destroying; and, in the other, the 
 oxidizing processes are so interfered with that the fat, in even a 
 small amount of food, is incompletely oxidized, accumulation of fat 
 in the cells resulting. Thus, in chronic phthisis, we may find that 
 fatty infiltration is often present. 
 
 The accompanying illustration represents the gradual infiltration 
 of a cell with fat, with displacement of the normal cell-contents. 
 
 FATTY DEGENERATION. 
 
 FATTY degeneration, or fatty metamorphosis, differs from fatty 
 infiltration in that there is an alteration of the normal cell-contents 
 instead of infiltration of fat, the normal cell-elements thus being 
 destroyed, the albuminous constituents of the tis- 
 sues themselves being converted into fat. 
 
 Thus the cell furnishes the fat for its own sub- 
 stance, minute granules or globules of fat making 
 their appearance in the cell, the entire protoplasm 
 finally becoming converted into fat-granules. 
 
 States which interfere with the proper quality of 
 
 FATTY DEGENERATION . , , , , .. -j?ii 
 
 OP THE HEABT. the blood, so that the tissues are imperfectly nour- 
 
 ished, as in pulmonary tuberculosis, protracted anaemia, and other 
 wasting diseases, tend to general fatty degeneration, certain tissues, 
 such as the heart, liver, kidneys, walls of arteries, and voluntary 
 muscles, being especially prone to fatty deposits. 
 
 The metamorphosis of fatty degeneration begins in the proto- 
 plasm of the cells, outside the nucleus though this is soon involved 
 and broken up as transformation of minute particles of the albumin- 
 oid substance into fat-granules. These multiply, and the destruc- 
 tive change invades the nucleus, transforming its substance into 
 fatty granules and obliterating its limiting membrane. As fatty 
 granulation progresses in the cell, its entire contents become fatty, 
 the change involving the cell wall and intercellular substance. 
 Neighboring cells becoming involved and the intercellular structure 
 becoming disorganized, the fatty remains of numerous cells may coa- 
 lesce to form fatty masses, which exist at the expense of the nor- 
 mal tissue invaded.
 
 44 INTRODUCTION. 
 
 The accompanying cut represents a section of the cardiac muscle 
 which has undergone fatty degeneration. The striaB are seen broken 
 up in places, their substance having been converted into fatty gran- 
 ules, which are distributed more or less profusely throughout the 
 structure. 
 
 Parts which are insufficiently supplied with blood on account of 
 pressure upon nutrient arteries are prone to this form of degenera- 
 tion, the coronary arteries being partially occluded by atheromatous 
 products when fatty degeneration of the cardiac muscle occurs. 
 
 Separation of nerves results in fatty degeneration of the distal 
 extremities. Organs which have become atrophied from disuse are 
 prone to fatty degeneration, as a result of diminished blood-supply 
 and imperfect oxidation. The tissues of old persons are liable to 
 such changes, due to impoverishment of blood-supply, the metamor- 
 phosis occurring in the cartilages, cornea (arcus senilis) and lens 
 (cataract), and in the brain (cerebral softening). 
 
 MUCOID AND COLLOID DEGENERATION. 
 
 THESE forms of degeneration resemble each other so much that 
 they are very liable to be confounded, though there is a material 
 difference in the nature of the two. Mucoid degeneration is more 
 liable to affect the intercellular substance, while colloid degeneration 
 is more liable to affect the cellular elements. Colloid material differs 
 from mucin, the product of mucoid degeneration, chemically, in con- 
 taining sulphur, and in not being precipitated by acetic acid. 
 
 Mucoid Degeneration. This process has its normal type in the 
 secretion of mucus by the mucous follicles, the epithelial cells here 
 being converted into mucin and cast off, forming a transparent gelat- 
 inous substance, familiar to every observer. Mucoid tissue consti- 
 tutes the earliest form of every foetal structure, a higher development 
 being taken on later, though the mucoid material persists in the 
 vitreous humor of the eye throughout life, and is familiar to the 
 obstetrician in the structure of the umbilical cord. 
 
 Other structures than the mucous membrane may develop this 
 substance (mucin) under abnormal conditions. Connective tissue, 
 cartilage, bone, marrow, adipose tissue, and sarcoma (a new growth), 
 may undergo abnormal mucoid softening. This is liable to occur 
 simultaneously in considerable patches, the basement membrane 
 becoming involved, the fibrous structure contained in it being con- 
 verted into homogeneous material. The tissue-cells may then persist, 
 undergo fatty degeneration, or partake of the mucoid change. 
 
 Mucoid degeneration most frequently occurs in cartilage, espe- 
 cially the intervertebral and costal cartilages of old people. Con-
 
 DEGENERATIONS. 45 
 
 siderable cavities of cyst-like accumulations of mucin may be found 
 here as the result of such change. The myxomata or inucoid tumors 
 consist of this material. The causes of this form of degeneration 
 are unknown. 
 
 Colloid Degeneration. This differs from mucoid degeneration in 
 the fact that the cells are the parts especially involved. The albu- 
 minoid material in the cells becomes converted into colloid, this 
 first appearing as minute lumps in the interior of the cell, which 
 gradually increase in size, crowding the nucleus aside, and finally 
 representing the entire cell structure. This constitutes a colloid 
 mass, which swells up and bursts the cell wall, to coalesce with con- 
 tents of neighboring cells which have undergone a similar change. 
 This coalescence results in the formation of cysts or accumulations 
 of greater or less size, of a gelatinous, shining, transparent material, 
 resembling cooked sago in appearance, though of a yellowish color and 
 tolerably firm consistence. 
 
 Colloid changes occur most frequently in enlargement of the thy- 
 roid and lymphatic glands, in the choroid plexus, and especially in 
 the new growths. 
 
 AMYLOID DEGENERATION. 
 
 THIS term, with our present knowledge, is evidently a misnomer, 
 though when Yirchow applied it he supposed, from the resemblance 
 of the chemical reaction between this substance and iodine to that 
 between iodine and starch and cellulose and iodine, that it belonged 
 chemically to the starchy group, and named it "amyloid" (like 
 starch). But later investigators have demonstrated that the sub- 
 stance of amyloid degeneration is a nitrogenous formation, an albu- 
 minoid, and not in any way related to starch. 
 
 Its reaction with certain matters, however, is remarkable. When 
 a solution of iodine is added to it, it becomes colored mahogany 
 brown, the surrounding unaffected tissue appearing pale yellow. 
 Iodine and sulphuric acid impart a blue color to it, and methyl-blue 
 and gentian a bright red or pink color. 
 
 To the naked eye, the morbid deposit appears semi-translucent, 
 waxy, or lardaceous resembling the fatty portion of fried bacon. 
 When it invades internal organs extensively, they become swollen, 
 resistant to pressure, increased in weight, their capsules being tense, 
 dry, and pale. When it invades the spleen, the cut or broken surface 
 resembles boiled sago, and the condition has been commonly termed 
 "sago spleen." The liver, kidneys, lymphatic glands, serous mem- 
 branes, mucous membrane of the alimentary canal, blood-vessels, and 
 connective tissue, are all liable to the invasion of this degeneration. 
 
 It accompanies depraved states of the blood due to prolonged
 
 46 INTRODUCTION. 
 
 disease, such as tubereulosis, leukicmia, suppuratiou of bone, chronic 
 dysentery, etc., though it is absent in cancer. It occasionally follows 
 iuflainmmtory action. It is very liable to develop during senility, 
 without other apparent provoking cause. 
 
 The character of the deposit is not yet well determined. The 
 consensus of opinion seems to be in favor of the belief that the 
 deposit is fibrin which becomes separated from the blood by meta- 
 morphosis or infiltration. Color is added 
 to this theory by the fact that the disease 
 nearly always begins about the capillaries 
 and minute arteries, the deposit appearing 
 in the peri-endothelial fibrous tissue coating 
 the outer side of the endothelial wall. If 
 this occur in internal organs in which the 
 parenchyma-cells lie within capillary plex- 
 uses, the organ-cells may remain unaffected 
 SECTION OF AMYLOID KIDXEY. while the capillaries are extensively 
 
 a, Norina capillary loop. invrVIvArl Tf tlii nppnr in tlift livpr flip 
 
 b. Amyloid capillary loop. IBTOITBO. 11 U11S OCCUT in fBf liver, 1 
 
 d, Hy r aun l effica 8 u t m liver cells may remain unchanged between 
 ZSSuSSfSSS: the masses of amyloid material which are 
 
 e, Loosened fatty epithelium. a e p OS ited about the capillary plexuses 
 surrounding them. So with the kidney; the amyloid deposit is 
 massed about the capillaries of the glomeruli and other minute ves- 
 sels, while other histological elements remain unchanged; though in 
 some instances the connective tissue of a part, such as the spleen 
 and lymphatic glands, may suffer most. 
 
 Fatty changes are liable to attend amyloid degeneration, this 
 being due to obstruction and compression of the blood-vessels. 
 
 Certain concretions called amyloid bodies appearing normally in 
 the brain, prostate gland, and vesiculse seminales, afford the same 
 color reactions with iodine, and iodine and sulphuric acid. They 
 bear no relation to this form of degeneration, and are probably a 
 normal accompaniment of advancing years. 
 
 CALCAREOUS DEGENERATION. 
 
 THIS is an infiltration, not a metamorphosis. It consists of the 
 infiltration of normally soft tissues with calcareous and magnesian 
 salts, rendering them brittle, chalky, and to the touch, gritty. It 
 occurs as a normal process when calcareous elements are deposited 
 in cartilage preparatory to the formation of bone, but here the infil- 
 tration is succeeded by organization of the calcareous material into 
 cells and bone tissue, while in degeneration, the calcareous material 
 remains as an infiltration, destroying the elasticity of the part and 
 impeding the function of the cells invaded.
 
 DEGENERATIONS. 47 
 
 Both cellular and intercellullar elements may be infiltrated, 
 though the first portion to be involved usually is the intercellular 
 structure. Calcareous degeneration may be a final termination of 
 fatty degeneration, and a very favorable one when vital organs, 
 as the lungs, are involved, as, when this change has occurred, it 
 becomes a permanent one, further degeneration and breaking down 
 being arrested. In such cases the calcareous infiltration may be 
 regarded as the lesser of two inevitable evils and welcome as a favor- 
 able termination of destructive action. 
 
 When the arteries become involved, much more serious conse- 
 quences are liable to follow, as obstruction to these organs from 
 inelasticity aud narrowing of their lumen is certain to follow, with 
 consequent destruction of parts supplied with blood through them. 
 Atheromatous changes in the arteries are liable to be followed by 
 this state, especially about the aorta and the arteries of the extrem- 
 ities, the middle coat, and finally the entire structure, becoming 
 calcified. Senile gangrene is thus a common result of this condition. 
 
 Calcareous degeneration may occur under two different circum- 
 stances or influences. In the one there appears to be a perversion 
 of the plastic forces, by which the normal calcareous elements of 
 bone are deposited in an aberrant manner, or else there is an excess 
 of calcareous material in the blood, many organs being simultane- 
 ously involved, such as the kidneys, lungs, stomach, intestines, dura 
 mater, and liver. This may occur in osteomalacia, where there is an 
 insufficient amount of lime in the bones to render theia normally 
 firm. In the other condition there has been previous disease of the 
 parts infiltrated, the degeneration being a passive process due to the 
 inactivity of the function-elements of affected parts. This form is 
 that usually occurring in sei.ile subjects. 
 
 The infiltration usually consists of carbonates an 1 phosphates of 
 calcium, with a, small quantity of the magnesium salts. When treated 
 with dilute mineral acids, there is bubbling of gases at first, and final 
 dissolution of the calcareous material, the part regaining its elasticity. 
 
 PIGMENTATION. 
 
 INFILTRATION of the tissues with haemoglobin causes more or less 
 marked staining, which has been classed among the degenerations 
 under the name of "pigmentary degeneration," when the haemoglo- 
 bin becomes converted into hsematoidin, and is permanently fixed. 
 Many cases of extravasation of blood are followed by a tempo- 
 rary staining of the tissues, but the coloring material is in a con- 
 dition to be absorbed, and is soon taken up and carried away. But 
 the haemoglobin remains, in other cases, and becomes converted
 
 48 INTRODUCTION. 
 
 into a granular or crystalline substance, hsematoidin, which remains 
 permanently fixed, staining the tissues. 
 
 Pigmentation, of itself, is not a serious condition ; and when it 
 affects the skin, it is a sign that some local or constitutional dis- 
 turbance has been at work to bring about destruction of the red 
 blood-corpuscles and liberation of their coloring material. Certain 
 cachectic states are especially prone to be followed by permanent pig- 
 mentation of some of the tissues. Chronic malaria is ofle of these, 
 and the fairest complexion is liable to be permanently browned in 
 spots and sallowed, after a prolonged attack of this disease. 
 
 The tissues of the liver, kidneys, stomach, and other internal 
 organs may be thus infiltrated after chronic atrophic local affections 
 of these parts, the organs assuming a darkened color, and thus 
 remaining during the remainder of life, though such diseases are 
 usually fatal, not because the pigmentation is a serious matter, but 
 because the causes which brought it about have also conspired to 
 effect serious degenerative changes in vital organs. 
 
 The coloring material observed in lung-tissue is not usually of 
 this character, as here minute particles of carbon are inhaled from 
 the atmosphere and taken up by the cells of the mucous membrane 
 lining the respiratory passages, and there permanently fixed. This 
 has been termed a normal staining by some, and it would seem that 
 this is proper, seeing that it is universally present in healthy lungs. 
 However, without combustion of wood or coal these particles would 
 not be present in the air, and the lungs would probably be free from 
 the coloring matter. Sometimes this coloring is accompanied by 
 true pigmentation, the result of inflammatory extravasation and other 
 agencies, tending to fixation of haBmatoidin in the pulmonary tissues. 
 Staining of the tissues observed in subjects who have taken nitrate 
 of silver for a long time is due to the deposit of particles of silver, 
 and not to true pigmentation. 
 
 NECROSIS. 
 
 NECROSIS is the term applied to local death of animal tissues. 
 This may occur from a variety of causes, and under a wide diversity 
 of conditions. Whether it affects a single cell, group of cells, or an 
 entire organ, complete suspension of nutrition aud function follows, 
 and the necrosed tissue begins a process of permanent dissolution 
 aud disorganization. 
 
 If the amount of necrosed tissue be small, and recuperative 
 processes active, the disintegration may be molecular, the dead mate- 
 rial being gradually absorbed and its place supplied by normal 
 structure. When somewhat more extensive nd the destruction 
 more rapid, the breaking down may result in excavations, which are
 
 DEGENERATIONS. 49 
 
 afterward filled with fibrous or cicatricial tissue. When an exten- 
 sive area of external soft tissue is involved, an obvious mass of dark- 
 ened tissue stained by infiltration with liberated haemoglobin 
 appears, and is finally separated in a mass, ihe necrosed i ortion 
 constituting a splmcelus, or shugh, the condition being commonly 
 known as ' mortification." If a mass of bone-tissue be involved 
 instead, the separated portion is termed A sequestrum. Other masses 
 seated deeply in certain tissues may be converted into cheesy- 
 appeariug bodies and become encapsulated, the condition being 
 defined as caseation; or it may become infilt-ated with calcareous 
 material, calcification. When caseation or calcification occurs, the 
 condition may be considered one of more or less pronounced 
 permanency, though destructive changes may occur later. 
 
 Again, the dead tissue may be absorbed, leaving a cavity which 
 becomes walled about with fibrous tissue, affording a space into 
 which fluids infiltrate, the arrangement constituting a cyst. This is 
 most liable to occur when areas of necrosis are located in the brain. 
 
 A peculiar form of necrosis is that which is termed hyaline or 
 coagulation necrosis. This consists of the infiltration of necrosed 
 masses with lymph, in which the third corpuscle has become lique- 
 fied, fibrlnogen being developed, which ultimately welds the mass 
 firmly together, a further change converting the necrosed area into 
 hyaline material. This occurs in diphtheria, waxy degeneration of 
 muscles, typhoid, typhus, relapsing fevers, tubercle, etc. 
 
 Colliquative necrosis is allied to the coagulative form, though it 
 occurs in non-inflammatory conditions, in which the presence of scant 
 amount of fibrinogen precludes coagulation, the affected part under- 
 going disintegration and liquefaction, instead of becoming coagu- 
 lated. The brain contains little coagulable material, and colliqua- 
 tive necrosis is liable to occur here as a result of deficient supply of 
 nutrition. Softening of the walls of the heart may also be due to 
 colliquative necrosis when previous fatty degeneration has destroyed 
 the muscular structure to great extent, necrosis finally being due to 
 continued diminishing of the supply of blood resulting from increas- 
 ing obstruction of the coronary arteries. 
 
 The causes of necrosis may be divided into two classes : ( 1 ) Local 
 injuries, and ( 2 ) arrest of nutrition. 
 
 Local injuries may be due to mechanical or chemical causes; to 
 inflammatory action ; to long-continued febrile action inducing extreme 
 cloudy degeneration in internal structures ; to the poisonous influence 
 of microbes, as in erysipelas, diphtheria, hospital gangrene, etc. 
 
 Arrest of nutrition is due to obstruction of the circulation from 
 various causes, such as strangulation; gradual occlusion of arteries
 
 50 INTRODUCTION 
 
 from senile changes; pressure from new growths; embolism, ami 
 thrombosis. 
 
 Dry gangrene is usually the result of necrosis in parts exposed 
 to the air where the supplying arteries are occluded. The arterial 
 obstruction may be the result of frost-bite, of a gradual filling of the 
 lumen from senile changes in the arterial walls, such as calcification, 
 atheroma, or of embolic infarction. The affected part becomes dark 
 and leathery, then hard, black, and brittle. The anatomical elements, 
 seen under the microscope, appear shrunken and withered. 
 
 Moist gangrene or sphacelus is mortification followed by putre- 
 faction, and development of gases in the affected part. This change 
 is due to the action of certain bacteria in the fluids of the gangrenous 
 structure, which gain access either through the air or circulation. 
 Increase of swelling, external blistering, offensive odors, oozing of 
 putrefactive fluids, and disintegration of soft parts thus affectod, 
 follow at an early period. When bone becomes necrosed, the process 
 of disintegration is more gradual. 
 
 TUBERCULOSIS. 
 
 TUBERCULOSIS is a condition characterized by the formation of 
 nodules or tubercles within various tissues of the body, formed by 
 an aggregation of cells, due to proliferation of surrounding tissue- 
 elements, resulting from chronic inflammation caused by the pres- 
 ence of the tubercle bacilli. They are new growths, of low vitality. 
 Tubercles arise from small cells which originate from a meso- 
 blastic membrane developed from connective tissue, or from the 
 endotheliuin of blood-vessels or lymphatics. A focus of irritation 
 
 is set up by the action of the bacilli upon 
 . the tissues, and proliferation and aggrega- 
 * tion of these elements result. Leucocytes 
 congregate about this focus, and granula- 
 tion tissue is developed. Usually one or 
 more epitheliod or lymphoid cells take 
 on a hyper-plastic growth, and, fed by 
 broken-up leucocytes, develop into giant 
 
 MIUABY TDBEBCIJC. cells, with homogeneous structure, numer- 
 
 a, Giant ceii. ous nuclei, and branching processes. 
 
 b, Nuclei of giant cell. ... - , .,, ,. ., ,, 
 
 c, Epuheiioid ceiu. About these are grouped epithelioid cells 
 
 d, Lymphoid eel !. .,. T>-J- J.-L L \ 1 
 
 and leucocytes. Binding the tubercle in 
 
 a mass is usually a fibrous reticulum, composed of the remains of 
 normal connective tissue which has been distended and attenuated 
 by the proliferated cells, and the branching processes of giant cells. 
 In the meshes of this reticulum are the epithelioid and lymphoid 
 cells, and leucocytes. An elementary tubercle is microscopic in size,
 
 DEGENERATIONS. 51 
 
 but numbers of these become aggregated into larger masses, visible 
 to the naked eye. The tubercle formation is non-vascular, and when 
 vessels are found in them they are the remains of preexisting capil- 
 laries, around which the nodulated growth has developed. Bacilli 
 are distributed throughout these growths, being most numerous 
 about the central portion, where breaking down of structure begins. 
 They are also found within the giant cells. 
 
 Tubercles are unstable structures, and they soon undergo fatty 
 degeneration in the center from lack of nourishment, their non- 
 vascular character precluding possibility of blood supply to interior 
 parts. Consequently, the central part undergoes caseation, and, as 
 softening proceeds, an abscess-cavity is formed in the center, and sev- 
 eral miliary tubercles uniting, these cavities coalesce, forming con- 
 siderable of an opening, the walls of which are studded with bacilli. 
 Destruction of surrounding tissues results, and as this is progressive, 
 destruction of the entire organ invaded follows, as well as of other 
 parts to which the bacilli are distributed by the circulation. General 
 destruction and dissolution of the entire organism must therefore 
 finally result. 
 
 Another change which tubercles may undergo is that of fibrous 
 degeneration, the common ending of proliferation of connective-tissue 
 cells during chronic inflammation. Here the tissues which surround 
 the tubercle take on fibrous inflammation, and the newly-developed 
 fibrous tissue contracts and converts the growths into a fibrous 
 nodule. 
 
 Tuberculosis is characterized by the subsequent invasion of vari- 
 ous organs or the entire system, after the process has once begun. 
 The bacilli enter the lymphatics, usually making halts here for a 
 time, but they finally reach the blood through the thoracic duct, and 
 are distributed throughout the entire system. In some cases they 
 spread along membranes or through structures, invading new parts 
 by continuity. 
 
 Tuberculization of tissue seldom occurs without complication. 
 Many other morbid products are observable in tissues affected by 
 tuberculosis, beside the typical tubercle structure. The general con- 
 stitutional depravity results in feeble digestive power and nutrition, 
 tending to atrophy of all the tissues, especially the muscles. The 
 atrophy may end in degenerative change, and fatty metamorphosis 
 and infiltration be one of the consequences. Inflammatory changes 
 may develop pigmentary degeneration, hyaline necrosis, and cloudy 
 swelling of epithelial elements. Tuberculous material may become 
 fatty, calcareous, or fibrous. Hyperplasia of connective tissue may 
 invade extensive areas.
 
 52 
 
 INTRODUCTION. 
 
 Rapid loss of flesh and strength, involving all the functions, veg- 
 etative as well as volitional, acceleration of the pulse to a hundred 
 beats per minute or near there, persistent elevation of the tempera- 
 ture of the body two or three degrees, hectic fever with colliquative 
 sweats, and prominent evidence of local irritation corresponding to 
 the part principally affected, are the leading clinical features of the 
 condition. 
 
 The tubercle bacilli are vegetable microorganisms about one-third 
 the diameter of a red blood-corpuscle in length, and about one-sixth 
 
 as broad as long. They exist 
 in both an active and passive 
 condition, rapid multiplication 
 characterizing their active state, 
 while it is not unlikely that 
 they may remain passive in the 
 system for a long time, when 
 conditions unfavorable to their 
 increase are present, without 
 producing any disturbance of 
 health. Indeed, it seems as 
 though it would be almost 
 
 GAC vfrwpof impossible for any one to escape 
 
 ' 
 contamination ironi them under 
 
 such favoring circumstances as those which have formerly existed. 
 When they are active, they present a beaded appearance, indicating 
 the formation of spores, and rapid multiplication. They possess no 
 power of spontaneous motion. They differ from most other bacteria 
 in resisting the bleaching influence of strong mineral acids, after 
 being colored. 
 
 Various modes of infection are known to exist. Hereditary or con- 
 genital tuberculosis occasionally occurs, though the disease is rarely 
 thus transmitted. In such cases, the bacilli or their spores pass 
 from the maternal circulation, or are transmitted by the male parent. 
 It is probable that both avenues afford passage to the bacilli occa- 
 sionally, as they are often found in the blood, and have been found 
 in the testes. 
 
 Acquired tuberculosis may result from ( 1 ) inhalation ; ( 2 ) inocula- 
 tion; and (3) from ingestion of tuberculous food. 
 
 Inhalation of the bacilli is the usual mode of transmission, as the 
 large proportion of pulmonary tuberculous disease attests. The 
 facts that so many tuberculous subjects are able to be about until a 
 short time before death, and that they have been encouraged to 
 remain in the open air during pleasant weather, expectorating upon
 
 DEGENERATIONS. 53 
 
 the ground, where the sputum dries and becomes powdered dust, and 
 the bacilli retaining their vitality for a long time, to be wafted here 
 there in the atmosphere and inhaled by chance passers-by, account 
 for the readiness with which this disease becomes spread about. 
 Cloisters, prisons, and asylums are especially liable to become thus 
 infected, dust deposited upon furniture, ceilings, and casements, 
 being likely to become contaminated, long use of such quarters by a 
 variety of persons being almost certain to result in the dissemination 
 of tubercle bacilli by some one. Such places then become perma- 
 nant hotbeds of infection, unless especial effort is made to thoroughly 
 disinfect them, and afterwards confine tuberculous cases to special 
 quarters. Private houses where the disease has prevailed are sub- 
 ject to the same danger. 
 
 It is patent that careful and rigorous measures to collect and 
 thoroughly destroy the sputum of tuberculous 'patients will be the 
 most successful method of arresting the ravages of the disease. 
 
 Inoculation is another common method of transmission. This 
 may be developed through the act of kissing, from the use of con- 
 taminated surgical instruments, the hypodermic syringe, dental for- 
 ceps, etc. Butchers may be inoculated from the flesh or skin of 
 bovines, for the disease is common among horned domestic cattle. 
 Handling contaminated meat is also liable to result in inoculation 
 before cooking, though long-continued heat destroys the bacilli. 
 Medical students and practitioners are liable to inoculation during 
 dissection and autopsies of tuberculous persons, as well as from 
 operations upon such subjects. It is asserted that the disease has 
 been disseminated among Jewish children from the practice of suck- 
 ing the fresh wound of the prepuce by tuberculous operators. 
 
 Infection from food often occurs. One of the most widespread 
 causes of infection is the use of cows' milk in feeding infants. It is 
 conceded that a large percentage of cattle are tuberculous. Much of 
 the condensed milk, as well as that furnished by dairymen, is therefore 
 subject to suspicion of tuberculous infection. Acute miliary tubercu- 
 losis, a disease very common among children, is in all probability 
 the result of such a diet, the alimentary canal offering a ready place 
 for the introduction and dissemination of the bacilli. A diet of 
 raw meat, such as German sausage and raw beef, is also inimical to 
 safety on this score. Danger lurks in every piece of raw beef as an 
 article of food, though a person may make occasional use of it for a 
 lifetime and escape infection. 
 
 The treatment of tuberculosis has proven almost a complete failure 
 from time immemorial. And recent times, despite the remarkable 
 advances which have been made in the knowledge of its etiology,
 
 64 INTRODUCTION. 
 
 have afforded us little improvement npon treatment. In spite of 
 the splendid achievements of Koch, in the discovery of the tubercle 
 bacilli, his tuberculin inoculations have signally failed to offer any 
 hope of beneficial results. And it is probable that other researches 
 in this direction will prove as fruitless. 
 
 The majority of successful innovations in medicine have sprung 
 from humble sources. Savants have proven failures, when the suc- 
 cessful treatment of stubborn diseases has occupied their attention. 
 Usually their reasoning has been too crude for the intricate pro- 
 cesses of life and correspondence with physiological principles. 
 Attempt to cure tuberculosis by directing the means toward the 
 extermination of the bacilli in the body, will probably always prove 
 a failure. Changes of climate, whereby the normal forces are 
 encouraged, and affected organs placed under more favorable circum- 
 stances, are probably the best measures adopted by the profession 
 at the present time, though I believe there exist more positive 
 measures, which will cure a large majority of cases of pulmonary 
 consumption, after such an advance has been made that numerous 
 pulmonary hemorrhages have occurred, if faithfully employed. In 
 order to prepare the reader for a proper conception of these means, 
 I will transcribe the account of 
 
 THE DUKE OP WURTEMBERG's REMARKABLE CURE BY JOHANNES SCHROTH, 
 
 as translated from the German by Dr. Wiliiam Weber, an alum- 
 nus of the California Medical College, and former patient and pupil 
 of Schroth. Though not literal in every particular, the following 
 contains the gist of this translation : 
 
 "It is incredible how few people there are who think for them- 
 selves, and how often the seemingly most original and independent 
 persons are found, upon close investigation, to be on y the slaves of 
 the thoughts and opinions of others. Enough . . . the sluices 
 of prevalent opinion were opened against the method of Schroth, 
 and only the great importance of its new and unheard-of ideas 
 could prevent the same from being consigned to oblivion. At that 
 time cases were reported, such, for instance, as that of the Duke of 
 Wurteinberg, which, from the importance of the person involved, 
 commanded attention. I shall here give some details of that cure, 
 which will furnish some of the characteristics of Schroth, as well as 
 a better understanding of his mode of treatment 
 
 "Duke William of Wurtemberg, Captain of the Koyal Imperial 
 Austrian Regiment of the Line, No. 45, in storming a redoubt of the 
 enemy at the battle near Novara (Italy), on March 12th, 1849, at 
 about noon-time, was wounded one inch below the patella,by a shot 
 fired at close range a pointed bullet. This injured the tendons
 
 DEGENERATIONS. 65 
 
 and ligaments of the knee-joint, perforated and splintered the tibia, 
 separated the muscles of the calf, and severed several arteries, com- 
 ing out on the posterior surface of the leg. 
 
 "The Duke, wounded in this manner, lay on the battle field for 
 some time, and later was removed to a field-hospital, and the follow- 
 ing day, to Mortara, near the conquered redoubt. The loss of blood 
 was considerable, but the weakness caused thereby rendered him 
 less sensitive to pain. Nevertheless, at the hospital, the Duke was 
 bled twice. 
 
 " On March 28th, he was transported to Pavia, and suffered great 
 pain during the trip. Suppuration had set in, which spread over 
 the whole calf. Compressing bandages sometimes increased the 
 pain to the point of syncope. Pyrexia set in, and, in the opinion of 
 his attending physician, his life was in imminent jeopardy. 
 
 " On account of the malarious climate, the Duke was removed to 
 Mailand, and was here taken charge of by the Surgeon in Chief of 
 the Royal Imperial Lombard Gendarmerie Regiment, the latter part 
 of April. On May 7th, a long incision was made in the calf to arrest 
 the progress of fistulse in that region, and a progressive improve- 
 ment seemed to follow, for a short time. About the middle of June 
 the patient left his bed for the first time, but could make no use of 
 his leg. Warm baths were administered to him every other day, 
 and he attempted to walk on crutches, and occasionally rode about 
 in a carriage, toward evening. 
 
 "Evidently, however, there was little improvement for the follow- 
 ing six weeks, for the pain increased, and the Duke left Mailand the 
 first of August en route for Baden Springs, near Vienna, for the pur- 
 pose of trying the effect of these waters for relief. His condition 
 was now so extreme that convulsions occasionally occurred. Though 
 this trip was signalized by excruciating suffering, he improved some- 
 what at Baden for the first fortnight, but after the effects of the 
 change passed away, his strength again began to fail, and the inflam- 
 mation and pain in the diseased leg continued to increase with added 
 suffering. Up to this time the patient had never been able to stand 
 on his diseased leg. As in Italy, prominent surgeons at Vienna 
 advised him to submit to amputation, but this was obstinately 
 opposed by the Duke. 
 
 "His condition becoming continually worse, he went to Karlsruhe, 
 in Prussian Upper Silesia (the place of his birth), arriving there 
 September 22d, very much exhausted. An eminent surgeon was 
 now summoned from Berlin, who proposed to remove the head of 
 the tibia; but as the Duke was very low, and as the surgeon could 
 not positively promise a satisfactory result, the proposal was rejected.
 
 56 INTRODUCTION. 
 
 "At this desperate stage of affairs, at the advice of his former 
 teacher, Dr. Merten, and against the wishes of his family, the Prince 
 decided to go and consult the naturalist physician, Johannes Schroth, 
 ut Lindewiese, near Grafenberg, whose reputation for wonderful 
 success in the treatment of similar troubles had long been noised 
 abroad. On November 12th, he therefore lelt for Lindeweise, arriv- 
 ing in an exhausted condition on the following 14th. 
 
 "When Schroth investigated the case, he was appalled by the 
 appearance of the diseased leg. The knee was swollen to half more 
 than its normal size, and the swelling was hardened by hyperplastic 
 deposits in the inflamed structures and about the fistulous open- 
 ings. The part was extremely sensitive and painful, and the least 
 motion of the joint was impossible. The bone was enlarged, and 
 almost the entire tibia was found honeycombed. Tiie probe would 
 break through the decomposed and softened bone at almost every 
 point along its shaft and about the tuberosities, with the most gentle 
 pressure. At a depth of about three inches from the surface, in the 
 neighborhood of the old wound, were splinters of bone, and from 
 here fetid ichor was constantly discharged. From above the knee 
 down into the calf, enlarged and painful lymphatic glands (the size 
 of a pigeon's egg) were found. Continuing with the examination 
 Schroth found the liver and spleen enlarged : a condition he ascribed 
 to laguna fever, from which the patient had suffered while in Venice. 
 
 "The difficulty was, not only to cure the local affection, but to 
 invigorate, if possible, the broken-down constitution. To do this 
 Schroth thought it necessary that an excretion of morbid matter 
 from the system should take place, and formation of new and healthy 
 blood be induced. It was his idea that only under such circum- 
 stances could the diseased organs be regenerated to normal condi- 
 tions. The physician present, educated in the principles of the 
 scientific schools, could not believe in a regular treatment without 
 remedies, and remonstrated with Schroth, advising him not to inter- 
 fere with such a desperate case, for fear that the apparently unhappy 
 final result would militate against him. But Schroth asked of the 
 Duke three days for consideration, and then said, with full convic- 
 tion, to the well-meaning physician: 'The Duke will be cured. I 
 am sure of success.' 
 
 "The discoverer of this mode of treatment, to make such a cure 
 possible, first found it necessary to build up the entire constitution. 
 Otherwise a continuous curative reaction would have been impossi- 
 ble. About the middle of November, Schroth commenced the treat- 
 ment, and from this time until December 30th, the Duke ate and 
 drank every day. Nights, he was wrapped in a peculiar abdominal
 
 DEGENERATIONS. 57 
 
 pack, invented by Schroth. The diseased leg was gently rubbed 
 mornings and evenings, with the moistened hand, as long as possible 
 on account of pain excited, then soft linen, in the form of straps, 
 was wetted in cold water and wrapped about it fourteen or sixteen 
 thicknesses, and allowed to remain twelve hours, by which time the 
 dressing had become dry. The Prince himself thus reports the his- 
 tory of the treatment : 
 
 "'My diet was extremely simple. In the forenoon I ate nothing, 
 as I did not like the stale bread. At noon I got a piece of dry 
 boiled beef, and occasionally, some dry rice or potatoes with the 
 same in the afternoon, at about four o'clock, and was permitted to 
 drink some wine, to which, however, I could not accustom myself, 
 in spite of being very thirsty. Not until after a fortnight I began 
 to get accustomed to get along without water. The suqcess of this 
 treatment, which was just as simple as ingenious, was surprising in 
 the highest degree. On the second day the already cicatricial por- 
 tions of the wound opened again, and a great deal of pus was dis- 
 charged; the existing severe pain diminished, I got easy, and the 
 fever disappeared. At the same time my appetite improved, and at 
 the fair at Lindeweise, which was just then celebrated, I ate as much 
 as anyone. On this occasion I tested Old Schroth's ingenuity. To 
 my great satisfaction he allowed me to eat some beef soup, which 
 he had strictly forbidden in case of wounds. On the very same 
 evening, when the bandage was removed, we noticed a very bad swell- 
 ing about the kuee, just as he had predicted, and Schroth explained 
 to me the effect of beef soup on wounds, as long as the stomach can- 
 not digest normally. In order to have the case tested further, he 
 encouraged me to drink some cold beer, on the next afternoon. I 
 drank about two glasses, and when he bandaged the wound about 
 three hours afterwards, it showed a gray-colored, morbid pus, on 
 the lower part of the wound, and on the upper, watery matter was dis- 
 charged. The borders of the wound were also very red and painful. 
 This was a clear proof that my digestion was very poor, and that all 
 fluids went directly to the wound. A general consumption would 
 have been the inevitable consequence of persisting in such a course.' 
 
 " On December 2d, the patient could step on the wounded leg 
 for the first time since Novara, and walk several times up and down 
 his room. The limb showed more strength, but there was yet pain 
 in the knee and articulations of the foot. At last, the fever left 
 entirely. 
 
 "When the healing process commenced, the regular treatment was 
 begun. He was now wrapped in large packs, but his system was so 
 much exhausted that Schroth allowed him to continue his previous
 
 58 INTRODUCTION. 
 
 diet. Not nntil the middle of January was his strength built up suf- 
 ficiently to enable him to undergo the main or regular treatment, 
 and the patient himself says the following about it: 
 
 "'The more thirsty I was, the more pus was discharged from the 
 wound. This was a dark, tenacious liquid, mixed with blood, and 
 of a very bad odor. The more pus discharged, the stronger and more 
 movable became the leg. When, after about three weeks, my tongue 
 got clean, and the discharged liquid became lighter in color, Schroth 
 allowed ree to enter the so-called after-cure. In a few days the 
 suppuration ceased, and in a few days more the wounds closed up 
 entirely. During the main cure I had lost a great deal of flesh, but 
 now, when I was filling up again, my leg got very strong, and it took 
 only a short time to overcome the limping and be again in full 
 strength and health. At the end of January I made my appearance at 
 Grafenberg, to show the followers of Priesnitz' hydropathic cure 
 the great and wonderful results of S^hroth's mode of treatment. On 
 March 1st I considered myself as being in normal health, and am 
 under obligation to Father Schroth for this extraordinary cure in the 
 short space of sixteen weeks.' 
 
 "The Duke, in grateful acknowledgment, published the following 
 article, in No. 43 of the journal Oesterreichischer Sctdatenfreund, Vienna, 
 April 23d, 1850: 
 
 " ' To MY COMRADES IN THE ARMY : The undersigned considers it his 
 duty to direct the attention of his wounded comrades to a new mode 
 of treatment, which effects a surer cure than all modes of treatment 
 practiced by physicians. The farmer, Johannes Schroth, at Neider- 
 limlewiese, near Freiwaldau, in Austrian Silesia, for many ye;irs has 
 treated fresh and old wounds by a new and extraordinary method, 
 and at all times attains a most successful result, but the same is 
 very little known. 
 
 " 'A great many call his cure "the stale bread cure," and ridicule 
 the same, because they think he cures wounds with stale bread; but 
 this is not the case. The principle of Schroth's cure is not to allow 
 much fluid to go to the wounds, and he effects it by a strict, dry diet. 
 He forbids his patients the drinking of water entirely, and orders 
 mainly stale bread and wine for nourishment. At the same time he 
 applies local packs, which may remain a longer or shorter time, 
 depending upon circumstances. It cannot be said that the cure is 
 easy, but it is neither very hard, and not a great sacrifice for a sure 
 recovery of health. 
 
 "'I will cite some cases, beginning with my own. A pointed ball 
 had pierced my shin directly below the knee. I had been in bed for
 
 DEGENERATIONS. 69 
 
 nine months, and there was no hope of a recovery ; but Schroth cured 
 me in four months. The pensioned Colonel of Tschebury had been 
 suffering since 1809, from the consequences of several wounds. Dur- 
 ing 1849 he use I the cure and got cured from all his old troubles. 
 An old wound of course needs a longer time to get well than a new 
 one, but in the latter case the success was extraordinarily rapid and 
 brilliant. 
 
 "'Two cases more which occurred under my own observation will 
 finish my account of cures. A farmer's girl had her arm fractured 
 and the joint splintered. By the use of packs and a peculiar diet, 
 Schroth cured this case in such a manner that she could afterward 
 use her arm as well as ever. An old, strong farmer cut his shin-bone 
 with an ax, almost through, and several tendons were severed. After 
 three weeks' treatment he was able to use his leg ap;ain. 
 
 "'I shall be very glad at any time to give my comrades of the 
 army details of this treatment, which saved me, and, I hope, will do 
 a great deal more for others. 
 
 WILLIAM, Duke of Wurtemberg. 
 
 "'Vienna, August. 1850.'" 
 
 It is upon such principles as these that Dr. Weber depends for 
 the cure of pulmonary and other forms of tuberculosis ; and that he 
 cures, I have reason to know. Withdrawal of water from the system 
 increases the proportion of red corpuscles and other solid constitu- 
 ents and improves the reparative power of the circulating fluids. 
 Withdrawal of fluids also seems to cause rapid destruction of 
 abnormal tissues of feeble vitality, and they melt away and are dis- 
 charged. Tubercles break down and are cast off under the new con- 
 ditions, while the formation of grauulation-tissue and other steps of 
 tubercle growth are arrested, and the evacuated cavities are cicatrized. 
 
 There are many unpleasant features connected with the manage- 
 ment of this mode of treatment of such cases, the principal causes of 
 contention being the prejudices of both popular and professional 
 sentiment and education. The idea of limiting the diet of a con- 
 sumptive patient, in the light of our present education, seems atro- 
 cious; yet we might recollect that those who are most freely fed may 
 die sooner than those who are not so well favored (?). Plenty of 
 ordinary food and drink seem to furnish the very pabulum required 
 for the rapid development of the bacilli and production of tubercle 
 deposit. 
 
 Wine alleviates the thirst somewhat, but not altogether; but here 
 it is a medicine. It hardens the tissues, and fortifies them against 
 the inroads of the bacilli Possibly these are starved out for lack of 
 water, as vegetable organisms require this for their proper growth, 
 and animal tissues possessing the best absorbing power, probably
 
 60 INTRODUCTION 
 
 and animal tissues possessing the best absorbing power, probably 
 rob them of the limited supply furnished by a dry diet But these 
 are theories, though the facts remain. 
 
 The patient becomes fearfully emaciated at first, and had better 
 not be seen by his friends, as they will not now be likely to add 
 encouragement to his resolution to persevere. As 75 per cent of 
 the body is water, withdrawal of a large proportion of the amount 
 ordinarily consumed must bring about a remarkable shrinkage in bulk. 
 The patient soon becomes fearfully weak and emaciated, the expec- 
 toration increases in amount, and symptoms are at first most threat- 
 ening. But after a few weeks the amount of material expectorated 
 begins to grow markedly less in amount, and finally ceases altogether, 
 though treatment must be faithfully continued until the cough and 
 expectoration have ceased entirely. Then, even upon the limited 
 diet, the patient gradually regains digestive power and strength. 
 
 IV. BACTERIOLOGY. 
 
 BACTERIOLOGY is the science of bacteria. Bacteria, microorgan- 
 isms, or microbes, are minute vegetable organisms representing the 
 lower forms of vegetable life and related to the algae botanically, which 
 naturally maintain a parasitic existence in human and animal fluids 
 and tissues, but many of which may be cultivated artificially outside 
 these situations. As vegetable organisms, they are peculiar on 
 account of the absence of chlorophyl in their composition, and in 
 their mode of reproduction by fission, and the formation of spores. 
 They normally exist in communities of many different kinds, and 
 possess the power of rapid multiplication, under proper circumstances. 
 This fact confused positive knowledge of their relation to disease 
 until bacteriological research separated them by cultivation into pure 
 cultures, enabling inocultion tests as to the specific character of 
 many distinct forms, to be made upon animals. 
 
 When developed, a bacterium represents a cell, consisting of an 
 enveloping membrane containing protoplasm. The membrane is usu- 
 ally very firm and adherent, is separated from the protoplasm with 
 difficulty, and is also resistant to external influences. 
 
 TECHNOLOGY. 
 
 A knowledge of the peculiar characteristics of individual bacteria 
 comes from ability to isolate them by cultivation. A portion of dis- 
 eased structure may contain numerous colonies of bacteria in con- 
 fused admixture, these differing materially in their properties and 
 significance. One variety may be innocuous, another may exist there 
 accidentally, while still others may sustain a direct causal relation 
 to the pathological condition.
 
 BACTERIOLOGY. 61 
 
 Nutrient media are necessary for the cultivation of bacteria out- 
 side of animal tissues; and of these two classes are employed, viz., 
 natural and artificial. 
 
 Natural media are those which are employed in their natural state, 
 such as pleuritic fluid, the fluid of hydrocele, blood-serum, potato 
 and other vegetables, eggs, etc. 
 
 Artificial media are prepared substances, such as bouillon, gela- 
 tine, agar, and certain saline mixtures, such as Pasteur's, Cohn's, 
 and other preparations classed as mineral media. 
 
 Some bacteria thrive best on one material, and others on another. 
 
 A variety of media are therefore necessary, in order to meet the 
 demands of different occasions. 
 
 Sterilization of everything connected with the manipulation of 
 bacteria is necessary in the successful propagation of pure cultures. 
 Great dexterity is also requisite upon the part of the manipulator, 
 in order that successful results may be arrived at. A sterilized 
 chamber for the prosecution of bacteriological experiments is essen- 
 tial, and ovens for the sterilization of everything connected with the 
 work must be at hand, as a few seconds' exposure to the air may 
 contaminate a pure culture, and thus destroy accuracy. On this 
 account the most expert operator may fail to propagate successfully. 
 
 A knowledge of microscopy is also essential, and the operator must 
 understand mounting specimens and adjusting them upon the stage, 
 so as to bring them into proper light and focus. 
 
 Staining of specimens is also an important matter, and this com- 
 prehends considerable skill and experience. 
 
 The technique of obtaining a pure culture from a mixture of a vari- 
 ety of germs may be briefly summarized as follows: 
 
 Sterilized media are inoculated with a sterilized platinum needle 
 from the pathological specimen to be investigated, in successive 
 series, upon the principle of dilution observed in preparing drug- 
 attenuations. For example, after one inoculation has been made the 
 second is carried on from this, the third from the second, and so on. 
 Usually the third inoculation so reduces the number of bacteria that 
 they may be singled out by spreading the medium in a thin layer 
 upon a sterilized plate, each one then breeding a separate colony. 
 Each of these may now be transferred to a separate culture-mediuhi, 
 and if it contain only the one kind of microbes, upon growing, 
 it constitutes a pure culture. 
 
 Guinea-pigs, mice, and other lower animals may be inoculated 
 from these cultures, and the effects observed. Some may prove 
 wholly inocuous, others producing variable symptoms. When one 
 of the cultures constantly proves toxic, its effects are more carefully
 
 62 INTRODUCTION. 
 
 observed, and in this manner the specific causes of various infectious 
 diseases are determined. However, there is not always a certainty 
 as to the specific microbe of a disease, as bacteriologists are frequently 
 compelled to abandon positions which have been taken with much 
 positiveness. The toxines generated by bacteria seem to vary in 
 their poisonous influence in different individuals, depending perhaps 
 upon constitutional susceptibility or temporary predisposition, owing 
 to constitutional depravity, and confusion arises, where it might seem 
 that like causes ought always to be followed by like results. To 
 illustrate the meaning here it may be remarked that the Klebs- 
 LofHer bacillus, which was but recently regarded as the specific 
 microorganism of diphtheria declared so by both investigators after 
 careful and painstaking investigation seems innocuous in some 
 instances, and has been found in the buccal and nasal cavities of 
 perfectly healthy persons. With all the positiveness of bacterial 
 research, then, there seems to be much uncertainty, after all. 
 
 A large majority of bacterial forms grow freely in gelatine and 
 agar, though some, such as the tubercle bacillus, gonococcus, and 
 others, require special media. Others, such, for example, as the 
 spirochsBte of Obermaier, cannot be cultivated in any known medium. 
 
 STAINING AND PREPARING. 
 
 THE peculiar resistant qualities of bacteria enable them to retain 
 coloring material when surrounding tissues or media yield to bleach- 
 ing influences. Aniline colors are chiefly employed for staining, 
 these being retained by the microbes, while they are removed from 
 surrounding parts by bleaching, with different processes. Thus the 
 bacteria are left highly colored, while the field in which they lie is 
 approximately achromatic, rendering them prominent to vision under 
 proper magnifying power. Basic dyes possess special value for pen- 
 etrating the nuclei of cells and bacteria, and when such colored 
 specimens are heated in acetic acid the nuclei are dissolved, diffusing 
 the coloring material through the protoplasm generally, rendering 
 the complete organism distinct. The basic dyes most in use are 
 methyl blue, methyl violet, gentian violet, dahlia, basic fuchsine, 
 Bismarck brown, etc. Some bacteria cannot be penetrated with 
 simple solutions of basic dyes, and more complex preparations are 
 required. 
 
 L&filer's sdution may be resorted to here. A compound of 30 
 parts of a concentrated alcoholic solution of methyl blue, and 100 
 parts of a 1-1000 solution of caustic potash in water is first used. 
 After the preparations remain in this for a few minutes, they should 
 be treated with a \% solution of acetic acid, then washed with abso- 
 lute alcohol, and cleared with cedar oil.
 
 BACTEKIOLOGY. 63 
 
 Gram's method is a favorite one with bacteriologists. In this, 
 the specimens must be put to macerate in absolute alcohol, before 
 the staining process. After removal from this, the prepared cover- 
 glasses are allowed to float, prepared side down, upon a mixture 
 composed of water solution of aniline oil 100 parts, to saturated 
 solution of gentian violet 5 parts, for a few minutes. From here 
 they are transferred to an iodo-iodide of potash solution, and allowed 
 to remain for one minute, when they are washed with absolute alco- 
 hol from one to three minutes, until they become free from color to 
 the naked eye. They are then cleaned up in oil of cloves, and 
 mounted in Canada balsam or glycerine-jelly. 
 
 This method stains the bacillus tuberculosis; bacillus anthracis; 
 bacillus leprae; diplococcus pneumoniae; pneumococcus Friedlander; 
 streptococcus erysipelatis; actinomyces; and all pyogenic bacteria. 
 
 It does not stain the bacillus of glanders (bacillus mallei); 
 bacillus typhosus (bacillus of Eberth); diplococcus intercellularis 
 meniugitis; gonococcus; spirillum choleras asiaticaa (comma bacil- 
 lus); or spirochaete Obermaieri (relapsing fever). 
 
 Of these, Loffler's solution stains gonococcus, diplococcus inter- 
 cellularis, and bacillus typhosus. Water solutions of dyes stain 
 bacillus mallei, spirillum choleraa, and spirochsete Obermaieri, these 
 being afterward brought out with 1% solution of acetic acid. 
 
 Preparations may be double-stained, so that the field and bacteria 
 present contrast colors, the bacteria presenting a deep blue tint, 
 while the ground or field is carmine, a strong and attractive contrast 
 thus being made, and the bacteria being brought out more clearly. 
 
 The tubercle bacillus is so important that special attention to its 
 staining will be proper. In common with the bacillus of leprosy it 
 differs from other bacteria in resisting the bleaching power of strong 
 mineral acids. Cover-glass preparations of sputum, blood, tubercle, 
 pus, etc., containing this microbe should be first treated with a 
 solution composed of 100 parts of aniline water, 11 parts of an alco- 
 holic solution of fuchsine, methylene blue, or methyl violet, and 10 
 parts of absolute alcohol (Erlich's solution). At ordinary tempera- 
 tures the specimens should be allowed to remain in this for twenty- 
 four hours. If the solution containing the specimens is heated, 
 a few minutes will suffice, this being termed the "rapid process." 
 The cover-glass preparations should now be removed and passed over 
 a gas-jet three or four times, until steam begins to rise. After this 
 they should be washed in a solution consisting of nitric acid one 
 -part, to water two or three parts. After nearly decolorized, wash in 
 plenty of water or alcohol. Sections should be treated with alcohol, 
 cleared with oil of cloves, and preserved in balsam.
 
 r,4 INTRODUCTION. 
 
 But this process will also develop the bacillus of leprosy, aiid 
 the following method will be useful to distinguish between these twc 
 forms of bacteria. Fill a watch-glass with water, and add from four 
 to six drops of a saturated alcoholic solution of fuchsine. In this 
 place the cover-glass preparation for six or eight minutes, and after- 
 ward treat with 1-10% nitric acid for twenty seconds, afterward 
 washing in distilled water and treating with aqueous solution of 
 methylene blue. After this clear with oil of cloves. This removes 
 coloring from the tubercle bacilli, leaving only the bacilli of leprosy. 
 If nothing can now be seen, the microbes before observed were evi- 
 dently those of tuberculosis. If sections are to be treated, allow them 
 to remain in Erlich's solution for two or three minutes, after which 
 pass through the nitric acid solution for half a minute, then stain 
 with water solution of methyl blue. Only the bacilli will be stained 
 by this process. 
 
 BIOLOGY. 
 
 EARLY investigators in the domain of bacteria inclined toward 
 the belief that they all sprung from a common source, and that the 
 different forms represented various stages of development, or the 
 influences of varying environment. But, while one species may be 
 represented by different forms during development, the mature form 
 of an individual species does not vary, and its individual char- 
 acteristics and properties are always the same, under the same 
 circumstances. 
 
 ** 
 
 *ttv q \^ 
 
 Ua tt ' V^ 
 
 FOBMS OF BACTERIA. 
 
 Experiments in propagation have demonstrated that more than 
 thirty generations of pus-microbes and other kinds may be cultivated 
 without change of form or property. They are as distinctly sep- 
 arate species at the end of this time as in the beginning. 
 
 Three distinct forms of pathogenic bacteria have been discovered 
 and described, namely, (1) the ball or berry (coccus), (2) the rod 
 (bacillus), and (3) the corkscrew (spirillum or spirochcete). 
 
 In some instances there may be a near approach in the resem- 
 blance between two individuals belonging to different classes. For
 
 BACTERIOLOGY. 65 
 
 instance, an oblong coccus may resemble a short bacillus, a double 
 coccus a short bacillus with club-shaped ends, etc. 
 
 When cocci are arranged in pairs, they are called diplococci. 
 When in fours, and in the form of a square, rnicrococcus tetragones. 
 When in the form of a cube, sarcina. When arranged in the shape of 
 a bunch of grapes, staphylococci. When they are arranged in chains, 
 streptococci. An irregular bunch, held together in a mass by a vis- 
 cid fluid, is termed a zooglcea. 
 
 W T heu circumstances are favorable to their development, the 
 reproduction of bacteria occurs with great rapidity. In some forms 
 multiplication is brought about by fission or splitting of the bacte- 
 rium into halves. In others, the multiplication results from the 
 development of spores, similar to the seed formation of flowering 
 plants. The cocci multiply by fission. A cell elongates and becomes 
 constricted in the middle. As the constricting process continues, 
 the bacterium separates into two equal parts, each of which soon 
 attains the size of the parent cell. If the cells remain in contact and 
 multiplication continues longitudinally, a chain or streptococcus is 
 formed. Rod bacteria which multiply by fission separate in the mid- 
 dle and each half grows to the size of the parent, when separation 
 occurs in each half, as in the parent cell. Bacilli usually multiply 
 from spores. When these develop in a bacillus, darkened spots 
 first appear at equidistant points, which soon (within twenty hours) 
 develop into pearly, opaque segments. These then part, and each 
 develops into a separate bacterium. Spores are usually more resist- 
 ing to destructive influence than bacteria, though a heat of 212 F. 
 destroys them. 
 
 The nutrition of bacteria demands oxygen, nitrogen, carbon, 
 water, and a limited amount of mineral salts. Water is indispensa- 
 ble to their growth, and prolonged desiccation is fatal to many, though 
 others may exist for a long time in a dormant state when desiccated, 
 to renew activity when moisture is supplied. Oxygen is indispensa- 
 ble, though some grow in open air, while others cannot be cultivated 
 except in media in which they can grow beneath the surface. Bacte- 
 ria which grow only in the open air are termed aerobii; those which 
 only grow away from the opeu air, anaerobii; others, which can 
 grow in either situation, are termed anaerobii by election. Bacteria 
 obtain their carbon and nitrogen principally from the media in 
 which they grow. Their growth brings about certain changes in the 
 media which determine their character, in certain directions. For 
 example, certain kinds decompose their media and produce color 
 (chromogenic bacteria). Others give rise to ferments (zymogenio 
 bacteria ). Still others, and the important class to physicians, origi-
 
 66 INTRODUCTION. 
 
 nate various toxic conditions (pathogenic or disease-producing 
 bacteria). 
 
 Many bacteria possess the power of spontaneous motion, from 
 conditions of their nutrition. The motion may be directly due to 
 cilia, with which some forms are supplied, or, in other cases, to 
 contraction of the protoplasm In other instances both these agen- 
 cies may be concerned. 
 
 Certain conditions or provisions are essential n determinin : the 
 identity of pathogenic bacteria. Thev must be found in the bodies of 
 animals or human subjects suffering with or dead from disease. 
 They should be cultivated from such sources, when possible, and a 
 pure culture of them should produce the same disease when inocu- 
 lated into animals. Such animals, when diseased, should contain in 
 their blood and tissues the identical bacteria found in the tissues or 
 fluids of the affected individual in the beginning. 
 
 Bacteria cause disease in different ways. Some kinds (pyogenic 
 bacteria) attack the leucocytes and embryonal cells and convert them 
 into pus-corpuscles. Others produce hyperplasia and the develop- 
 ment of new growth, as in the generation of tubercle. Still others 
 generate toxines, which produce constitutional diseases, such as the 
 infectious fevers. 
 
 Some infectious diseases have not yet been demonstrated to be 
 the results of specific germs, these probably existing, but having thus 
 far escaped the scrutiny of bacteriologists. Germs have been dis- 
 covered and declared the causes of disease, and afterward demon- 
 strated to be harmless saprophytes. The field of bacteriology is yet 
 full of speculation aud uncertainties. Much remains to be cleared 
 up, and doubtless much has been accepted as true which later 
 research will determine as unfounded. 
 
 A few bacteria have been pretty well located and described. 
 Others are yet subjects of speculation, investigation, and debate. 
 Those which are generally accepted as specific causes of disease will 
 be briefly described in the following order : 
 
 PATHOGENIC COCCI. 
 
 Diplococcus Intercellularis Meningitis. This is found in the exuda- 
 tion of cerebro-spinal meningitis. The cocci occur in pairs, united. 
 
 Diplococcus Pneumonice Lanceolatus. Occurs in the exudation of 
 croupous pneumonia. Cocci united in twos. Under cultivation, 
 loses its capsule. 
 
 Gonococcus. Occurs in gonorrhceal pus. The cocci occur in twos, 
 similar to the arrangement of coffee-grains. 
 
 Staphylococcus Pyogencs Aureus. Foundin yellow pus. The cells 
 are grouped in bunches, and are of a yellow gold color.
 
 BACTERIOLOGY. 67 
 
 Stapliylococcus Pyogenes Albus. Found in pus, similar to preced- 
 ing, except that the color of the cultures is white instead of yellow. 
 
 Stapliylococcus Pyogenes Citrus. Also found in pus. Kesembles 
 other pus-microbes, except that the cultures are lemon-colored. 
 
 Streptococcus Pyogenes. Occurs in the pus of phlegmons, in the 
 shape of chains of cocci. 
 
 Streptococcus Erys'ipelatis. Found in the lymph-spaces of erysip- 
 elatous parts. It is probably identical with streptococcus pyog- 
 enes, though found under different circumstances. 
 
 PATHOGENIC BACILLI. 
 
 Bacillus Anthracis. The bacillus of anthrax, found in the lymph 
 and blood of animals suffering from splenic fever. It occurs in 
 single rods or long chains, when cultivated. 
 
 Bacillus (Edematis Malignce. The bacillus of malignant oedema. 
 Found in human subjects and animals suffering with this disease. 
 Grows under gelatine (anaerobic), giving rise to gas bubbles. 
 
 Bacillus Leprce. The microbe of leprosy, found in leprous 
 tubercle. It resembles the bacillus of tuberculosis. Grows in 
 blood-serum. 
 
 Bacillus MaUeL A short, slender rod, resembling the bacillus of 
 tubercle, found in the secretions and tissues of subjects suffering 
 with glanders. Grows on blood-serum and potato. 
 
 Bacillus Pneumonia. Short rod. single or in chains, found in the 
 exudation of croupous pneumonia. It is covered with a capsule in 
 pneumonia, but the capsule is absent in cultures. It grows on 
 gelatine. 
 
 Bacillus Bhinosclerma. Found in the tubercles of rhinosclerma. 
 Resembles the diplococcus pneumonise in form and cultures. 
 
 Bacillus of Syphilis. A short rod found in the lesions of syphilis. 
 It has not been cultivated. 
 
 BaciUus Typhosus. The bacillus of typhoid fever. A short rod 
 with rounded ends, found in the evacuations, and also in the 
 mesenteric glands and spleen of subjects affected with the disease. 
 
 PATHOGENIC 8PIBILLI. 
 
 Spirillum Choleras Asiaticce. Curved rods, resembling a comma in 
 shape, sometimes curved in the shape of a letter S, and sometims of 
 corkscrew form. Found in the evacuations of cholera Grows in 
 gelatine. 
 
 Spirochcete Obermaieri. The spirillum of relapsing fever. It has 
 never been cultivated, but has been inoculated, and has reproduced 
 the disease in healthy animals and men.
 
 68 INTRODUCTION. 
 
 PATHOGENIC PUNQL 
 
 Actinomyces. The fungus ound in the tumors of actinomycosis. 
 A club-shaped fuugus, which grows in the form of radii. Has teen 
 cultivated on agar, and grows in small grayi>h dots. 
 
 Achorion Schdnleinii. The fuugus found in patches of favus. 
 When cultivated upon agar, it grows in patches presenting the 
 characteristic color of this aff ction. 
 
 But the science of bacteriology does not include all the micro- 
 organisms of disease. Bacteria are vegetable organisms, while there 
 are numerous instances in which disease is caused by the presence of 
 animalcules in the body. The plasmodium of malaria is an example 
 of this kind, and the filaria sanguinis hominis another, these crea- 
 tures existing in the blood, while the trichina spiralis, echinococcus, 
 germ of the tapeworm, etc., are embedded in the solid tissues. 
 Due notice will be given these parasites under the diseases in which 
 they occur.
 
 SECTION II, 
 
 SPECIFIC INFECTIOUS DISEASES. 
 
 I. TYPHOID FEVER. 
 
 Synonyms. Enteric Fever; Typhus Abdominalis. 
 
 Definition. An acute infectious disease excited by a specific 
 bacillus, and marked by inflammation of Peyer's glands ; clinically 
 characterized by fever of gradual development, headache, delirium, 
 stupor, abdominal distention, diarrhcea, splenic engorgement, and an 
 abdominal rash. 
 
 Historical Note. Prior to 1813, typhoid fever was not dis- 
 tinguished from other forms of protracted pyrexial disease. In 
 1813, Paul Bretonneau, of Tours, described "dothienenterite" as a 
 distinct disease, and contemporary writers described "entero-mesen- 
 teric fever." The views of Bretonneau were disseminated by his 
 pupils, especially by Trousseau and Velpeau, until the profession of 
 Paris accepted them. In 1829, Louis' work was published, contain- 
 ing a description of typhoid fever for the first time under that name 
 in a recognized text-book. The students of Louis included members 
 of various foreign nations, among whom were Americans, Gerhard, of 
 Philadelphia, soon publishing, in the American Journal of Medical 
 Sciences, the first full and accurate account of the disease ever writ- 
 ten in any language. James Jackson, Jr., of Boston, another pupil of 
 Louis, returned from Paris in 1833, and soon proved, in his father's 
 hospital wards, the identity of the then so-called typhus fever of this 
 country with typhoid. His death occurred soon afterwards, but in 
 1838 and 1839, James Jackson, Sr., and Enoch Hale prepared mem- 
 oirs which were published by the Massachusetts General Hospital, 
 fully describing the difference between typhus and typhoid fever, 
 their views being generally accepted by American physicians, though 
 it was several years before the mass of the profession in Europe 
 admitted the distinction between these two forms of febrile disease. 
 It was not until 1850 that all points of dispute were finally settled. 
 
 Etiologj^. It is now generally conceded that typhoid fever is 
 the result of an infection of the system of the affected individual 
 with a specific germ (the bacillus of Eberth). This is found most 
 constantly in the intestinal discharges of the sufferer, and, as it 
 retains its vitality for a long time, it may finally drift into wells, res- 
 ervoirs, or springs, thus contaminating drinking water, the infection 
 entering by way of the alimentary canal. Even without previous
 
 70 SPECIFIC INFECTIOUS DISEASES. 
 
 history of typhoid infection, the use of potable water from wells or 
 springs located in the neighborhood of privies, sewers, or barn-yards 
 is hazardous, as fecal material seems to possess the property of pre- 
 serving the typhoid bacillus for years, if it be not a medium for the 
 germ from some unknown source outside the human body. After 
 the historical flood which occurred in Western Pennsylvania, in 
 1889, a widespread epidemic of typhoid fever occurre 1 in the rural 
 districts, where it had formerly been unknown for a long time, 
 and the disease was traced to infected wells in most instm 
 where it seemed probable, from their location, that they had received 
 washings from n ighboring privies. But the recent fecal material 
 of typhoid-fever patieii s is less virulent, though doubtless it is fre- 
 quently a source of contamination among nurs3S and those who wash 
 the clothing. In large towns and cities, where milk is distributed 
 from common supplies and transported from rural districts where 
 contaminated water has been used to rinse the cans, without scald- 
 ing, and to increase the bulk of the article, the cause of epidemics 
 of this disease is readily accounted for, provided the water supply 
 of the hydrants has not been defiled. Doubtless the bacilli may 
 sometimes enter the circulation through the lungs, in the condition 
 of a dry powder, floating in the atmosphere. 
 
 Certain predisposing causes are believed to operate in encour- 
 aging the spread ot epidemics, such, for example, as the autumn 
 season, early life, etc. The greater prevalence of typhoid fever in 
 the autumn is probably due to the fact that greater liability to con- 
 tamination from drinking water and floating germs in the atmosphere 
 then prevails. After a protracted drought, the ground water is low, 
 and springs and other water sources drain contaminated foci closely, 
 thus being more likely to be charged with the specific poison. The 
 same atmospheric condition may result in the presence of floating 
 germs in the air, which may fall into drinking water, or enter the 
 system through the organs of respiration. Youth and early adult 
 life is the period of greatest susceptibility, the majority of cases 
 occurring between the ages of fifteen and twenty-five. It is pro- 
 gressively infrequent alter thirty-five, though it may occur at any 
 period, the foetus becoming infected through the maternal circula- 
 tion during late months of pregnancy. Not all who are exposed to 
 the contagion suffer from it, as all are not susceptible, and some 
 who are affected do not suffer severely, perambulating cases being 
 frequently observed. It occurs both epidemically and endemically, 
 being endemic in most large cities, in which case there is great dif- 
 ficulty in tracing the infection to its source. 
 
 One attack usually confers immunity against subsequent exposure.
 
 TYPHOID FEVEK. 
 
 71 
 
 The bacillus of typhoid fever is a short, thick, motile bacterium 
 with rounded ends, in one and sometimes both of which an opaque 
 glistening spot is observed, supposed by some to represent a spore, 
 it being noticed most frequently in cultures. These bacilli may be 
 preserved for an indefinite time in water, and here they probably 
 slowly multiply. A heat of 140 F. destroys, though extreme cold 
 does not injure them, congealment in ice producing no apparent inju- 
 rious effect. They multiply rapidly in milk, and cultures grow in 
 various other culture-media, the growth being invisible on potato. 
 Repeated trials of inoculation upon animals have failed to produce 
 the disease, though this has been explained by the hypothesis that 
 animals are not susceptible. 
 
 Pathology. It is highly probable that the constitutional dis- 
 turbances arise from toxines generated by the bacilli. Brieger has 
 described a typhotoxine, and Frankel a toxalbumin, though knowl- 
 edge of these poisons is not yet very complete. The intestinal 
 lesions are probably due to the conjoined local influence of the 
 bacilli and their toxines. To these influences may be added septic 
 elements absorbed from the local inflammatory and necrotic areas. 
 
 The characteristic anatomical lesions of typhoid fever are found 
 in the alimentary canal, though it is important to recollect that 
 the granular degeneration (cloudy swelling) of tissue, common to all 
 protracted fevers, is marked in this disease, involving the muscular 
 structure of the heart, this suggesting great caution during convales- 
 cence, lest the patient overtax his strength. According to Ziegler, 
 the morbid changes in typhoid appear chiefly in the lower part 
 of the ileum and the upper part of the colon ; they are seldom met 
 with much higher or lower in the intestine. The changes consist 
 essentially of a necrotic inflammatory infiltration of the follicular 
 structures and the parts around them, accompanied by a catarrhal 
 inflammation of the rest of the mucous membrane.
 
 72 SPECIFIC INFECTIOUS DISEASES. 
 
 "In the first few days of the attack the mucous membrane of the 
 lower part of the ileum and its agminated glands of Peyer's patches 
 are intensely congested and uniformly swollen. Soon the swelling 
 of the patches becomes more marked, raised and winding ridges not 
 unlike the cerebral convolutions in miniature appearing on their 
 surface. The swelling extends more or less quickly over the whole 
 of each patch, so that it has iu general the look of a bed or 
 garden plot projecting above the general surface. When the swell- 
 ing is at its height, the ridges are generally leveled up, as it were, 
 and are no more distinguishable. The surface of the patch is then 
 smooth, or pitted minute depressions correspond to the sites of the 
 individual follicles. The solitary follicles form rounded nodules by 
 virtue of the same process. 
 
 "When this stage (of swelling) is complete, the patches and fol- 
 licles, which at first were bright red in color, become pale and 
 creamy white. 
 
 "The swelling of the patches and follicles is chiefly due to the 
 extreme cellular infiltration of the mucosa and submucosa. 
 
 "The number of swollen patches varies much. Often but a 
 small number or even a single one is markedly affected ; while in 
 other cases the affection extends upwards to the jejunum or down- 
 wards to the anus. 
 
 TYPHOID ULCERS IN THE 
 CICATRICES THi -RESULT OTTYHOIO 
 
 "In the second week of the disease, partial disintegration and 
 necrosis of the swollen patches usually sets in. The disintegration 
 attacks the whole of the central part of the patch, or two or more 
 parts of it simultaneously. The surface quickly assumes a frayed or
 
 TYPHOID FEVER. 73 
 
 ragged appearance, and becomes yellow or brown from the action of 
 the bile. Gradually the disintegrated tissue or slough becomes 
 loosened at its base and edges from the surviving structures, and 
 ID a few days is cast off. After the separation of the sloughs, an 
 erosiou or typhoid ulcer is left, the floor of which generally looks 
 smooth and clean. The borders of the ulcer at this stage are still 
 swollen and infiltrated. 
 
 "The ulcers usually remain coextensive with or very slightly 
 overpass the area of the infiltrated patches and follicles ; they rarely 
 invade the tissues beyond. Cases however occur in which, especi- 
 ally around the ileo-caecal valve, extensive tracts of mucous mem- 
 brane are attacked and disintegrated by the advance of the ulcerative 
 process. In the vertical direction it seldom goes beyond the mucosa 
 and sub mucosa. It is only when the infiltration of the muscular 
 coat has been extreme that they too break down and ulcerate. In 
 exceptionally severe inflammation the serous coat also may be 
 attacked, but never to the same extent as the overlying layers; per- 
 foration and fatal peritonitis may occur in such a case. 
 
 "The processes of absorption and repair begin at various stages 
 of the disease. If no necrosis takes place, the swelling of the 
 patches goes down as the infiltrated material is absorbed; the patches 
 thereupon become less stiffly turgid, and once more hyperaemic. 
 Bed corpuscles escape from the damaged vessels, and the tissue takes 
 on a red or blood-stained tint which presently turns to a slaty 
 gray. The infiltrated borders of the ulcers become reduced and 
 softened, and hypersernic by the same steps. Often enough consid- 
 able hemorrhage ensues, leading not only to hemorrhagic infiltration 
 of the tissue but to actual escape of blood into the intestinal canal. 
 As the healing process goes on, the softened and overhanging bor- 
 ders of the ulcer become adherent to the floor; the latter is gradu- 
 ally covered over with delicate granulations, and soon receives an 
 investment of epithelial cells." 
 
 Fortunately, the site of a typhoid ulcer heals without contrac- 
 tion, and intestinal stricture does not follow the extensive ulceration 
 that so frequently attends ordinary suppurative processes. A 
 smooth, shallow depression remains for a long time, presenting a 
 slaty-gray color, and devoid of glands and follicles. 
 
 The meseuteric glands are more or less involved, those whose 
 absorbents correspond to the portions of the intestine principally 
 affected showing the most important changes. They become enlarged 
 at the outset, and after the tenth or fourteenth day begin to softeu, 
 their contents becoming friable at first, and later degenerating into 
 a pus-like fluid, mixed with sloughs. Finally, the glands become
 
 74 SPECIFIC INFECTIOUS DISEASES. 
 
 tough, contracted and shriveled. Daring the period of softening 
 they may burst iuto the peritoneum. 
 
 The spleen becomes congested aud softened, its cells undergoing 
 granular degeneration. The liver partakes of similar characteris- 
 tics, and the gall-bladder may be the seat of catarrhal or diphthe- 
 ritic inflammation. During the late stage of the disease the bile may 
 be watery in consistence, colorless, and acid in reaction. Peritonitis 
 may occur from extension of the intestinal irritation; from intestinal 
 perforation; from rupture of mesenteric glands, or spleen; or from 
 perforation of an ulcer in the gall-bladder. The kidneys may 
 become congested, and the tubules choked up with detached epi- 
 thelium, owing to granular degeneration of the cellular elements. 
 The congestion may also extend to the mucous coat of the blad- 
 der. Pulmonary congestion is almost always found among the 
 post-mortem evidences of the disease. The blood is tlark and fluid, 
 and the white corpuscles are increased in number. Disintegration 
 of the red corpuscles is also noticeable at times. No particular 
 changes are observable in the nervous system, though there may be 
 an excess of serum in connection with the brain and its membranes. 
 
 Symptoms. INCUBATION. This lasts from two to three week-. 
 During this time there are no peculiar symptoms, and in many 
 cases the patient does not suspect that anything is wrong. In 
 other cases there may be a feeling of prostration with headache, 
 vague pains, loss of appetite, and sleeplessness. 
 
 INVASION. The onset of typhoid fever is often so gradual and 
 insidious that the actual time of beginning is not appreciable to the 
 patient Indeed, in some cases he may not be indisposed enough to 
 give up business and go to bed before the fifth or sixth day. There 
 is not the marked chill which ushers in many forms of fever, and 
 though there may be chilly sensations in the start, these do not 
 usually amount to a pronounced rigor. Headache is a more constant 
 and urgent symptom, the pain usually invading the frontal region at 
 first, though as time passes it finally becomes more general. Attend- 
 ing this there are giddiness, roaring noises in the ears, lassitude, 
 fugitive pains, restlessness and insomnia, loss of appetite, furred 
 tongue, nausea, epistaiis, and usually diarrhoea, with abdominal pain. 
 Attention to the state of the temperature, during this time, will dis- 
 close the fact, usually, that it is gradually rising, each succeeding 
 day marking an advance upon the preceding one of less than a degree, 
 and each morning showing a remission of about one degree below 
 that of the previous evening. This gradual accession continues for 
 six or eight days, by which time the maxtnium is reached, and the 
 increased pulse-rate and arrest of secretion having been keeping in
 
 TYPHOID FEVER. 75 
 
 touch with the rise in temperature, a high grade of pyrexia has 
 finally been established. 
 
 The pulse is now (beginning of second week) running from 100 
 to 110 per minute in the evening, with slightly lessened rate in the 
 morning during the remission, the temperature ranging as high as 
 105-109 F. The skin is hot, dry, and husky, and there is marked 
 restlessness, the patient complaining bitterly of headache, or else 
 being delirious (delirium first appearing during the night to pass off 
 during the following day, but soon becoming continuous), with noc- 
 turnal aggravation; the tongue has taken on evidence of encroach- 
 ing depravity of the blood, being coated white with reddened tip 
 and edges or loaded with foul accumulations, while there may be 
 nausea and vomiting, even during the first week. 
 
 The fastigium is now reached, and we find the patient loses flesh 
 and strength rapidly. The pulse becomes dicrotic and feeble, as 
 the heart loses power; the tongue becomes shriveled, dry, and brown. 
 Active delirium exists, which passes into a condition of low, muttering 
 semi-coma in the third week. Now occur stupor, subsultus, tremors, 
 involuntary evacuations, and other evidences of profound exhaustion 
 and prostration. Sordes collect upon the sides of the mouth and 
 teeth in sufficient quantity to form crusts, and become more abun- 
 dant as the disease progresses. The countenance presents a pale, 
 leaden appearance, with a hectic flush in the center; the face lacks 
 expression, the patient sleeping with the mouth open, and tending 
 to slide downward, toward the foot of the bed. 
 
 The morning remissions become lengthened during the third 
 week, and as these increase in length and the maximum temperature 
 diminishes, the morning decline finally reaches the normal during 
 the fourth loeelc, the pulse gradually becoming stronger and less fre- 
 quent, the cerebral symptoms disappearing, and delirium giving way 
 to restful slumber, the tongue becoming cleaned and moistened, and 
 the skin relaxed and softened. During the waking periods the 
 patient now (fifth week) complains only of prostration and hunger, 
 his appetite and weakened mental condition conspiring to render 
 him peevish and exacting, in matters pertaining to a proper diet. 
 
 As early as the first week by the sixth day there will be found 
 pain and tenderness in the right iliac fossa. Slight pressure elicits 
 pain now, attended with gurgling, and the sensitiveness becomes 
 more marked as the disease progresses. Examinations of this char- 
 acter should be made with the palm of the hand, and the pressure 
 be gentle. By the beginning of the second week tympanites begins 
 to appear, the abdomen gradually becoming distended and drum- 
 like. This usually becomes extreme as the disease advances, being
 
 76 SPECIFIC INFECTIOUS DISEASES. 
 
 due to a collection of gas in the large intestine. The tympanites is 
 an indication of serious pathological change in the alimentary canal, 
 and so lon^ as it continues it is patent evidence that the patient is 
 in a precarious condition. 
 
 A common though not constant symptom of typhoid fever is 
 diarrhoea. This may be present during the first week, but may not 
 appear until the third, though it is liable to be most prominent dur- 
 ing the second. The evacuations are peculiar, being of a greenish- 
 yellow color, aud being described as "pea-soup discharges." 
 Sometimes they are dark in color, resembling coffee-grounds. They 
 are alkaline in reaction, and upon standing deposit a granular sedi- 
 ment, the upper portion being watery in character. In mild typhoids, 
 as well as in some severe ones, diarrhoaa may be absent. 
 
 Intestinal hemorrhage is said to occur once in about every 
 twenty cases. It is the result of sloughing of an artery in the intes- 
 tinal wall, and is a very dangerous complication. The hemorrhage 
 may occur without any external evidence of the discharge, rapid fall 
 of temperature and great prostration attending. In other cases, the 
 blood flows in large quantity from the boweL Slight hemorrhages 
 from the mucous membrane of the bowel may occur early in the 
 disease, but they are of trivial consequence, as they consist merely 
 of capillary oozing, similar to that of the early epistaxis. Arterial 
 hemorrhage rarely occurs earlier than the latter part of the second 
 week, and is more likely to occur during the third. If the intesti- 
 nal structures be fortified during the preceding time, there is dimin- 
 ished risk that this accident will occur. The treatment from the 
 beginning should look toward a favoring of the integrity of the 
 intestinal structures. 
 
 Between the seventh and twelfth days the characteristic eruption 
 appears. It is found most abundant upon the abdomen and chest, 
 but may be isolated over other parts of the body. It appears in 
 minute, round, rose-colored spots, slightly elevated above the general 
 surface, disappearing upon pressure, but returning immediately after- 
 ward. Each spot remains visible for three days, but successive 
 crops may appear during a period of ten or twelve days. In some 
 cases they are so faintly marked that great care may be necessary in 
 order to <letect them. They possess little significance therapeutic- 
 ally, but are considered a diagnostic symptom of true typhoid fever, 
 by many. They are, however, sometimes absent. 
 
 During the first two weeks, the urine is scanty and dark colored, 
 and shows a high specific gravity; after the second week the quantity 
 is increased, and during convalescence it becomes pale and abundant, 
 and its specific gravity is lowered. It is asserted that upon an aver-
 
 TYPHOID FEVER. 77 
 
 age the amount of urine voided during typhoid fever is greater than 
 the normal amount during the same length of time ; but this is prob- 
 ably due to the fact that the diet is largely liquid now. thus provid- 
 ing for a greater amount of fluids in the body. Albumin is occasion- 
 ally found in the urine of typhoid patients, though not in many 
 instances. 
 
 The nervous symptoms of typhoid fever are prominent through- 
 out its course, in most instances. The mental symptoms during the 
 early part of the disease are often those of apathy, the patient being 
 torpid, careless, and unimpressible, answering questions slowly, and 
 giving little heed to his surroundings. In other cases, however, 
 extreme restlessness may be manifested in the start, the patient 
 changing his position frequently, tossing about almost constantly, and 
 failing to find rest anywhere. Active delirium often sets in with 
 the establishment of the fastigium, it sometimes being necessary to 
 employ force to prevent the patient from doing himself or his attend- 
 ants harm. At other times, though this condition is liable to come 
 on later, there is more of a subdued delirium, characterized by 
 dreamy aberrations attended by incoherent mutterings typhoma- 
 nia. This condition is pretty well established by the latter part of 
 the third week or fore part of the fourth. Gradually, in favorable 
 cases, this passes into a somnolent condition, and the fever runs its 
 last few days and terminates with the patient sleeping most of the 
 time. 
 
 The special senses are often involved. Impairment of hearing is 
 a common symptom, it being necessary to speak above the ordinary 
 tone to elicit an answer. Vision is also impaired, for a time, in many 
 cases. Paralysis of the sphincters is a prominent symptom in some 
 instances, the evacuations passing involuntarily, and necessitating 
 the use of diapers to protect the bedding, while in other cases reten- 
 tion of urine from loss of vesical power may demand the regular use 
 of the catheter. 
 
 TEMPERATURE. The temperature of typhoid fever the typical 
 temperature shows a gradual rise of a little less than a degree per 
 day above the maximum of the preceding one, with a morning remis- 
 sion of one degree for the first week or about eight days. Dur- 
 ing the second waek the maximum of each day remains about the 
 same as that marked on the eighth day, with a morning remission of 
 near one degree. During the third week the remissions become more 
 marked, though the maximum still remains at about the same height. 
 During the fourth week the remissions become still more marked, 
 while the maximum declines day by day, until the normal line is 
 reached during the decline, actual intermissions finally occurring.
 
 78 SPECIFIC INFECTIOUS DISEASES. 
 
 During the last two or three days of decline, the periods corre- 
 sponding to the morning remissions may be marked by slight sub- 
 normal temperature, and this may continue into convalescence. 
 
 Usually the temperature begins to rise about the middle of the 
 day on the first day of the fever, and the exacerbation continues 
 until six or eight o'clock in the evening, when it remains stationary 
 until about midnight; then it begins to decline and continues to do so 
 uutil six or eight o'clock the following morning, when the minimum 
 of the remission is reached for that day; the temperature now 
 remains about at this point until the middle of the day, when it 
 again begins to rise, and remains elevated until midnight, as before, 
 when it again begins to decline, continuing to do so until six or 
 eight o'clock in the morning, when it remains about stationary until 
 the following noontime, when it again rises as before. This rotation 
 of rise and decline the temperature rising a degree higher than the 
 maximum of the preceding day and falling about a degree each 
 intermission thus continues for the first week. 
 
 While such is the usual course of the disease, marked variations 
 may occur as the result of complications, and these variations may 
 often be considered as the most positive index of such complica- 
 tions. Treatment may modify the temperature very much, and some 
 drugs, as antifebrin, possess the power of lowering the temperature 
 rapidly, though not always safely. Belapses are not uncommon in 
 typhoid fever, and are marked by gradual rise of temperature. 
 Intestinal hemorrhage, when profuse, is usually marked by a sudden 
 fall of temperature, to the extent of two or three degrees. When 
 this fall occurs during the second or third week, and is accompanied 
 by marked prostration, it is pretty good evidence that an artery has 
 been opened in some intestinal ulcer, and that profuse hemorrhage 
 has occurred, even though no blood has been voided in the 
 dejections. Perforation of the bowel is soon followed by a rapid 
 decline of temperature, which is succeeded by abrupt and extreme 
 elevation, and collapse. 
 
 Occasionally, the stage of invasion is abruptly announced by a 
 sharp chill, which is followed by a high temperature without the 
 gradual rise, the case opening at once into tLe fastigium. When 
 malarial complication exists, the temperature may resemble that of 
 intermittent fever until the abdominal lesions develop, there being 
 a daily chill, followed by fever and sweating, for the first week. 
 
 Cases in which the temperature declines to normal at the close 
 of the second week are spoken of as "aborted typhoids," the early 
 convalescence being due to the fact that the intestinal lesions sub- 
 side without going on to ulceration.
 
 1YPHOID FEVER 
 
 79 
 
 A} 
 
 ts 
 M 
 
 J 
 
 
 
 
 
 
 N 
 
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 N 
 
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 80 SPECIFIC INFECTIOUS DISEASES. 
 
 Relapses and recrudescences are not to be overlooked. Relapse s 
 are due to reinfection of the intestine from sloughs which have been 
 cast off from above, in cases which have not received proper medica- 
 tion during the first attack. They are not common, but are said to 
 occur in from 3 to 18 per cent of all cases, though exceedingly rare 
 in Eclectic practice. If they occur during the fastigium, there is 
 merely a prolongation of the stage of active fever. Most frequently 
 they occur from five to eight days after the termination of the pri- 
 mary attack, though this period may be prolonged to twenty-five 
 days. When they thus occur, the temperature curve is repeated, 
 though it is very much shortened, the stage of invasion ending in 
 from three to five day.-, and the other stages accordingly, ten to four- 
 teen days being occupied in this second course. Recrudescences are 
 temporary rises of temperature occurring during convalescence, 
 from dietary indiscretions or overexertion. These occur suddenly, 
 and, in favorable cases, terminate in from one to five days. 
 
 During convalescence, the temperature may remain persistently 
 elevated two or three degrees for several weeks, this being due to 
 unhealed ulcers in the intestine, which only recover by slow stages. 
 
 Diagnosis. The regular and gradual rise in temperature and 
 morning remission during the first week, the abdominal tenderness 
 and intestinal irritation, the rash, and the infectious character of the 
 disease, will be sufficient to warrant the diagnosis. It might be sup- 
 posed that as this disease is dependent upon the presence of the 
 typhoid bacillus in the alimentary canal, a microscopical examination 
 of the dejections would readily settle the question in any doubtful 
 case. But it seems that there are many difficulties in the way of 
 detecting these bacteria here, and that it is only in a small propor- 
 tion of the cases that they can positively be identified. Dr. Adolph 
 Gehrmann, an authority upon bacteriolgy, remarks (Fort Wayne 
 Medical Magazine}: 
 
 "Reported demonstrations of the isolation of typhoid bacillus 
 from the evacuations of patients are not numerous. Pfeiffer, Kar- 
 linski, Fraeukel and Simons have so reported. In the case of the 
 last-named experimenters, out of eleven separate attempts by means 
 of direct cultivation by Koch's plate method, success was attained in 
 but three instances. The diagnosis here was made \>y obtaining 
 cultures of typhoid bacillus by selecting colonies on the plate cul- 
 tures peculiar to that organism. A method of this kind is most diffi- 
 cult, as only the smallest quantity of discharges can be taken, and the 
 dilution must be extreme, in order to separate them widely enough 
 to obtain isolated colonies. Where bacteria of all kinds are in such 
 great numbers, there must first be some quick means of separating
 
 TYPHOID FEVER. 81 
 
 the organism in question from all others, and lastly some means of 
 establishing its identity. The separation of typhoid bacillus from 
 the majority of its associated bacteria is not a matter of great diffi- 
 culty, but its final identification has proven a most serious obstacle. 
 Typhoid bacillus is not a distinctive species. Its similarity to bacil- 
 lus coli communis is so close that the proposed distinctive features 
 have been overthrown, one after another. Apparently there is a 
 group of bacteria haviug typhoid bacillus at one extreme and bacil- 
 lus coli at the other, while between them is a gradually changing 
 series of va.rieties. Much more time has been devoted to the study 
 of these peculiarities and to the presence of the group in water sup- 
 plies, than to the relation of these bacteria to the intestinal canal. 
 This variability of typhoid bacillus has always occasioned the great- 
 est difficulty in studying the biology of the organism itself, or in 
 investigating the cause and nature of the disease." 
 
 Prognosis. Though a disease cf grave aspect, the mortality, 
 under proper treatment, ought not to be great. In ordinary epidem- 
 ics, 5 or 6 per cent ought to be a large death rate, where modern 
 Eclectic methods of treatment are pursued. There is a marked 
 difference in the severity of different epidemics, the abdominal symp- 
 toms being exceptionally severe in some, while in others the cerebral 
 symptoms are aggravated. Hospital reports usually show a larger 
 percentage of deaths than commonly occur in the private practice of 
 Eclectic physicians, and the custom of recommending such patients 
 to the care of hospitals is not to be commended. During a recent 
 epidemic of typhoid fever in this city (Oakland), the mortality in 
 Fabiola Hospital (Homeopathic) was remarkably great, though not 
 many deaths occurred in private practice, and these almost entirely 
 under old school treatment. 
 
 Hyperpyrexia, aggravated delirium, hemorrhage, and peritonitis, 
 are unfavorable symptoms, and should lead to a guarded prognosis. 
 
 Treatment. The treatment of typhoid fever may be divided 
 into preventive and restorative. At the commencement of an epidemic, 
 the conscientious physician will make early inquiry into the origin 
 of the disease, and &ee that as few persons as possible are exposed to 
 the infection. In rural districts, the water supply is usually the 
 source of contamination, the disease having previously been com- 
 municated to some well or spring from which the family or families 
 affected are using, all who drink the water receiving the germs into 
 their systems. In cities, such water may be used to dilute the milk 
 distributed before it is conveyed from the country, or in washing the 
 cans in which it is transported, and the disease thus be distributed. 
 In such cases, the health officer who does his duty will see that the
 
 82 SPECIFIC INFECTIOUS DISEASES. 
 
 supply of milk containing the germs of the disease is ferreted out, 
 and shut off by strict quarantine. Wells or springs suspected or 
 known to be contaminated, should be avoided, and where there is 
 positive evidence that such a place has been vitiated, it should be 
 filled up and a new one dug. Wells or springs in the neighborhood 
 of privies, barn-yards or sewers, should be looked upon with suspi- 
 cion, and the water avoided. 
 
 As the specific poison exists in the evacuations of typhoid 
 patients, great care is demanded during the course of the disease 
 that these be so treated that there will be no possibility of contami- 
 nation resulting from them. A porcelain bedpan should receive the 
 discharges, and before use this should be charged with half a pint 
 of saturated solution of sulphate of iron or copper. A more conven- 
 ient plan, considering the preservation of the bed, is to sprinkle the 
 bottom of the vessel over with dry powdered sulphate of copper, 
 while immediately after the evacuation crude muriatic acid or a 
 strong solution of copperas is added. It should now be allowed 
 to stand a sufficient length of time for the chemicals to react thor- 
 oughly upon the morbid material. The disposal of the contents of 
 the pan is an important consideration. When possible to do so, it 
 should be emptied into a trench and immediately covered, new 
 trenches being du^ frequently. Care should be observed to see that 
 the fecal material is not emptied upon the surface of the ground, nor 
 deposited near the well or spring from which drinking water is 
 obtained. If it becomes necessary to empty the evacuations into a 
 closet-trap, this should be frequently scalded with boiling water, 
 and none should be emptied here until thoroughly disinfected. 
 
 Care should be taken regarding the disposal of cloths, wearing 
 apparel, and bedding, which may be soiled by the discharges, that no 
 contamination is conveyed to the non-infected. Cloths of no particu- 
 lar value may be burned, and other fabrics should be immediately 
 washed, being thoroughly boiled during the process of cleansing. 
 A very good plan would be to immerse the clothing in a 11000 
 solution of bichloride of mercury before any attempt at cleansing 
 was made, the immersion to be continued an hour. Nurses should 
 be careful about communicating the infection with their hands. 
 
 The rooms occupied by typhoid fever patients should be free 
 from opportunity for the breeding of fomites. Carpets and tapestry 
 would be best dispensed with, as well as all furniture, except such 
 as is needed for patient and nurse. There should be a free sup-, 
 ply of pure air, though the temperature should not be far below 
 60 P. The room should be kept quiet, and all causes of disturbance 
 to the patient avoided.
 
 TYPHOID FEVEli. 83 
 
 In order to avoid any chance of injury to the bowel, the diet 
 should be liquid in character, rice water and malted mil 1 ^ or Mellin's 
 food constituting the principal part, all solid food being dispensed 
 with; and fruits should not be allowed under any consideration. 
 The food should be given at regular intervals, as promptly and regu- 
 larly as medicine, and in small quantities, repeated as often as every 
 two or three hours. 
 
 Owing to the marked debility of the tissues brought about during 
 this disease, and the tendency to hypostatic congestion resulting, the 
 patient should not be allowed to remain for any considerable length 
 of time in one position. As he is liable to soon become helpless 
 and unconscious, the nurse should be instructed to turn him from 
 side to side and from side to back frequently, especially during the 
 day, and this precaution should be so observed that he shall not 
 remain in one position more than four hours at a time, unless intes- 
 tinal hemorrhage or other complication render it inadvisable to dis- 
 turb him. In all manipulation, the delicate condition of the bowels 
 should be recollected, that injury be not added to that inflicted by 
 the pathological changes which are going on. 
 
 Good nursing shows a better record of mortality in the manage- 
 ment of this disease than that of old. and harsh methods of treat- 
 ment. Cathartics should be carefully avoided. Opiates and mercu- 
 rials are dangerous in the extreme. Quinine and other bitter tonics, 
 as well as stimulants, should only come in late in the course of the 
 disease or during convalescence, if at alL 
 
 What are the rational therapeutic indications in the treatment of 
 this affection? Where do we find the most marked evidence of mor- 
 bid action? Evidently, the severity of the affection is manifested 
 upon the intestinal structures, and the case becomes grave in pro- 
 portion as the pathological changes here are marked. It is true 
 that there may be a cerebral complication in isolated cases which 
 will render the prognosis serious where the abdominal symptoms 
 are not severe, but this is hardly the rule, and is a rare exception. 
 If we will direct the excellent means at our command to the relief 
 of intestinal irritation, and to the fortifying of this part against 
 pathological changes from the very beginning, we shall not find 
 many cases to present very grave features. 
 
 There are two remedies which I think we may employ for this pur- 
 pose with a great amount of confidence, viz., baptisia and echinacea. 
 It is not necessary that we discriminate particularly as to "specific 
 indications" in differentiating between the use of these agents here. 
 Bolh possess a relation of a restorative character to sloughing mucous 
 membranes, and a restorative character where necrotic conditions
 
 84 SPECIFIC INFECTIOUS DISEASES. 
 
 are present or threatened, anil both are recognized as valuable anti- 
 septics. Echinacea is a remedy of especially valuable properties where 
 a sedative, antiseptic, restorative, and vital stimulant ar^ required 
 in the one agent, and its excellent effects where meningeal irrita- 
 tion is present is an additional recommendation. I believe that 
 most cases of typhoid fever may be safely trusted to the action of 
 this remedy alone. 
 
 As there will probably be a demand for other treatment, we will 
 not obstruct the opportunity for further medication by alternating 
 these-, but will administer them in combination. To half a tumbler 
 of water add a drachm of baptisia and two or three drachms of ech- 
 inacea, and order a teaspoonful every two hours. We will let this 
 combination be the basic remedy, and will continue it until conva- 
 lescence has been announced by a normal temperature. It would 
 not usually be a pleasant combination, as to taste, but the typhoid 
 patient will make no objection to it, as his sense of taste has prob- 
 ably been abolished, for the time. 
 
 With this treatment directed toward the prominent pathological 
 lesion, we will hold our reserves in readiness for such complications 
 as may arise. 
 
 HYPERPYREXIA, A prominent and serious symptom of many 
 cases of typhoid fever is an excessively high temperature. Kapid 
 destruction of tissue must result in such cases, and danger to tissues 
 naturally jeopardized, such as the intestinal walls and brain, is very 
 much increased. When the maximum temperature is above 106 F. 
 during the stadium, the condition may be considered hyperpyretic. 
 There are various opinions among physicians of our faith respecting 
 the proper treatment of this condition. Professor Seudder taught, and 
 he has many followers who agree with him, that the febrile feature 
 of typhoid fever is successfully met by the use of the special seda- 
 tives aconite, veratrum, and gelsemiuin. The argument is that 
 these remedies, properly adapted, administered in minute doses, 
 and frequently repeated, control and strengthen the action of the 
 heart and bloodvessels, lessen excitement, and promote secretion, 
 thus lowering the maximum of the temperature throughout the 
 course of the fever. I have been a believer in this doctrine myself, 
 and I am satisfied that the plan, if not overdone, is followed, in a 
 large percentage of the cases, with successful results. Where this 
 plan is to be pursued, the proper remedy should be selected upon 
 certain well-knowu principles (see author's "Principles of Medicine"), 
 and administered in minute doses at frequent intervals throughout 
 the course of the disease. 
 
 However, while I am a firm believer in the special sedative treat-
 
 TYPHOID FEVER. 85 
 
 ment of fevers generally, my recent experience has led me to believe 
 that little real benefit foUows the practice in tlie management of 
 this form Typhoid fever is a mild form of septicaemia, and seems 
 unimpressibls ly such means, when compared with results in other 
 forms. The thermometer will not manifest any decided impression 
 from this plan of treatment in the majority of cases. Still, there is 
 no gainsaying the fact that these remedies may improve the patient's 
 chances, by soothing nervous excitement and promoting rest short- 
 ening the period of active delirium. 
 
 What I consider a more pronounced antipyretic in such cases as 
 are here under consideration (hyperpyretic), is the salicylate of 
 ammonium. The formula is as follows, though the salt may now be 
 obtained, prepared, in the drug market: 
 
 R Salicylic acid, jii ; carbonate of ammonium, jiii; aquse menth. 
 piper., ffiv. M. Dose, a teaspoonful. 
 
 This may be administered every two hours, in alternation with the 
 combination of baptisia and echinacea, until the temperature has 
 fallen below that of hyperpyrexia. Indeed, this remedy may be 
 continued throughout the course of the disease with gratifying 
 effect, in many instances. 
 
 Another excellent means in hyperpyrexia, and one which may be 
 used in conjunction with this or employed ind pendently, is the cold 
 abdominal pack. This may envelop the entire form, but one large 
 enough to reach from th^ axillae to the thighs will usually afford bet- 
 ter satisfaction. The bed is protected w^h an oilclo h or rubber 
 blanket, and half a sheet is wrung out of cold water and wrapped 
 about the body as already suggested, to be renewed every two hours, 
 until no longer needed. A good substitute for this application is a 
 large clyster of cold water, though here the patient must aid in 
 retaining it, a condition requiring possession of the mental faculties, 
 and one not always available. In making use of rectal injections 
 here, the weakened condition of the bowel must "be borne in mind, 
 and the application of much force carefully avoided. 
 
 The administration of large doses of quinine for the purpose of 
 lowering the temperature in these cases has been strongly advocated 
 by certain old school authors, and some reputable writers of our 
 own school have indorsed the doctrine. My experience has been 
 that such medication usually aggravates cerebral symptoms, and 
 does not markedly lower the temperature. However, circumstances 
 alter cases, and it may be possible that certain epidemics or certain 
 localities m;iy present us with cases where such treatment woulJ. be 
 strictly the proper thing. However, I would enjoin caution in this 
 method until the fact was proven clinically in at least one case of an
 
 86 SPECIFIC INFECTIOUS DISEASES. 
 
 epidemic, before beginning the indiscriminate use of quinine as an 
 antipyretic in typhoid. As a general rule, the proposition is bad. 
 
 There nre those who extol acetanilide as an excellent remedy for 
 this purpose. It is asserted that an immediate fall of temperature 
 follows the administration of from three to five grains, and that a 
 period of two or three days ensues before the temperature rises to 
 H point demanding a repetition of the close. But it is to be remera- 
 b:red that this remedy is markedly depressing, and upon theory, 
 not a desirable agent to administer in such a condition of prostra- 
 tion as is found in this disease. It would be fair to expect a large 
 mortality to attend such treatment, even though we be assured that 
 such is not the case. I would be inclined to regard this remedy 
 with grave suspicion, however, until fully convinced by observation 
 of some one el-e's practice that the vaunted benefits can positively 
 be derived with safety. 
 
 DELIRIUM. The delirium of typhoid fever is sometimes appall- 
 ing. The patient may be so furious as to seemingly force the respon- 
 sibility upon the physician of attempting to control the ravings with 
 drugs. As this goes on day after day, attendants or friends may 
 urgently ask th&t strong drugs be used to promote slumber. In 
 such cases the physician must preserve the greatest moderation as 
 to the character of his medication, seeing that active narcotics are 
 strictly avoided, as there could hardly be a more dangerous place 
 for their exhibition. It may be true that attendants become worn 
 out in their efforts to prevent the patient from leaving his bed, and 
 it may seem that the efforts of the patient himself may end in fatal 
 exhaustion, but there is much less danger of this than of the effects 
 of opiates. Minute doses of aconite and rhus tox. may afford some 
 benefit, or small doses of belladonna, 3x dilution. Possibly, though 
 not probably, small doses of bromides may benefit. Passiflora is not 
 of much use as a calmative during febrile action. Sulfonal may ben- 
 efit some, but is not likely to. Cold cloths to the head, anil some- 
 times ice-bags, may afford good results. The general condition and 
 benefit of the patient should, however, always be held paramount to 
 that of special means for the relief of what is but one of the phases 
 which this fever almost always presents. In due time the active 
 delirium gives way to that dreamy wandering consequent upon the 
 exhausting effects of the first onset, and the better the management 
 has been up to this time the better the patient's chances will be to 
 survive the further ordeal. Sometimes, where there are presented 
 quite vividly the indications for gelsemium flushed face, bright 
 eyes with contracted pupils, full, bounding j>uls>, etc., the zealous 
 Eclectic (or specific inedicationist) may be tempted to push this
 
 TYPHOID FEVER. 87 
 
 drug beyoud safe bounds, and cause debility of the circulation, from 
 which the patient may rally with difficulty. It is well to remember 
 that recovery from this fever is a sort of evolution, through which 
 the proper treatment consists in safely guiding the case to a success- 
 ful issue by fostering the processes of life so far as possible, and 
 avoiding all measures which might interfere with the best perform- 
 ance of these functions. 
 
 The beneficial effects of tepid baths in such cases should nofc be 
 forgotten. The restlessness and furor of the stage of active delirium 
 should be met with frequent sponging, and the nurse should possess 
 the requisite knowledge to prompt persistent resort to this measure. 
 Sponge baths should be applied several times a day, and it will soon be 
 noticed that the patient rests better, for a time, after this application. 
 
 GASTRIC COMPLICATIONS. The stomach is frequently disturbed by 
 morbid conditions which interfere with the action of remedies. 
 Gastric irritation may le present, marked by nausea, rejection of 
 food and medicine, and restlessness; the tongue will be pointed, 
 and reddened afc the tip. Here we will usually be able to correct 
 the condition with small doses of aconitj and rhus tox., and it may 
 seem best to dispense with all other treatment for a day or two, 
 until the stomach has become well settled. Add ten or fifteen drops 
 of rhus tox. and five drops of aconite to half a glass (four ounces) 
 of water, and order a teaspoonful every hour. This may possibly 
 fail after a fair tria 1 , but is hardly likely to; however, two grains of 
 subnitrate of bismuth every two hours may then be tried, and, in 
 event of failure with this, minute doses of ipecac or peach bark 
 infusion. 
 
 Another gastric complication which is very common in the 
 course of typhoid, is excessive acidity of the stomach. This is 
 marked by the broad, flabby tongue, evenly and thickly coated with 
 a pasty white coating. As sepsis is more or less marked there will 
 be an element of color in this coating, it often being described as 
 "dirty." Sodium sulphite is here the corrective, and this agent 
 should be administer d in one- or two-grain capsules, every two or 
 four hours until the tongue cleans or presents a different aspect. 
 It is important to correct such a condition in order that other rem- 
 edies may be readily appropriated. 
 
 SPECIAL SEPTIC CONDITIONS. While typhoid fever is of itself 
 a markedly septic disease, and while the use of echinacea and bap- 
 tisia has been advised throughout, partly for their antiseptic influ- 
 ence, there are special conditions liable to arise which may demand 
 other remedies of this class, though not likely to be marked if these 
 remedies are c mtinu >d from the beginning. Sulphurous acid is an
 
 88 SPECIFIC INFECTIOUS DISEASES. 
 
 agent which is sometimes urgently demanded in the treatment of 
 this disease. The condition which requires it is indicated by brown 
 coating on the tongue and sordes on the lips and teeth; here sulphu- 
 rous acid should be given in twenty- or thirty-drop doses, well diluted, 
 every two or three hours. The beefsteak tongue clean, dark-red, 
 slick may appear toward time of convalescence, and will demand 
 the use of mild acids, such as acid drinks or dilute muriatic acid. 
 Of the latter, ten to twenty drops may be given every four hours, 
 until the characteristic condition of the tongue has given way to a 
 natural appearance. 
 
 DIARRHCEA. This symptom is a very common one in typhoid, and 
 one which it might seem necessary to control. However, it is to be 
 recollected that it is but a result of the catarrhal inflammation of 
 the mucous membrane of the lower bowel, and the rational manage- 
 ment will consist in the use of means which will control the intesti- 
 nal irritation, to which we have already directed echinacea and 
 baptisia. There would be no logic in attempting to control this 
 difficulty with astringents; and it would only be a return to the crude 
 practice of obsolete medicine. Salol has been highly recommended 
 in certain quarters, on account of its antiseptic influence in intestinal 
 sepsis. But the advocates of this remedy are those who are not 
 acquainted with Eclectic remedies, such as echinacea and baptisia. 
 
 Aside from the use of proper antiseptics and correctives from 
 the beginning, the diarrhoea may properly be allowed to take its 
 course, as general treatment will serve a better purpose than local 
 measures. If any particular remedy were to be recommended, it 
 would be a decoction of erigeron canadense plant, a remedy that is 
 readily obtainable in the autumn season. This cannot do any harm, 
 and may be drunk freely. 
 
 TYMPANITES. Extreme distension of the abdomen may seem to 
 demand special attention. With the improved treatment I have 
 called attention to, there will be but few cases where it will be prom- 
 inent; however, an occasional case may demand attention. An old 
 and useless (as it seems to me) practice consists of the application 
 of turpentine stupes to the abdomen. The room and surroundings 
 are thus filled with the disgusting fumes of turpentine, that every- 
 body in the vicinity may recognize the fact that som -thing is being 
 done. This may afford some satisfaction, but the utility of the 
 measure is doubtful. Rectal injections of clysters containing asafcet- 
 ida also have their advocates, and it is possible that there may be 
 more benefit derived from them. Intestinal antiseptics, adminis- 
 tered internally, as salol or naphthol, are more to be commended. 
 
 INTESTINAL HEMORRHAGE. The slight hemorrhages of capillary
 
 TYPHOID FEVER. 89 
 
 origin, and which occur early in the course of the disease, require 
 no treatment; but after the second week intestinal changes may 
 have occurred, which will render hemorrhage liable to escape from 
 the arteries which supply the intestinal walls, and which will demand 
 prompt arrest, when this is possible. It does not seem that there 
 will be much danger of hemorrhage when the treatment here sug- 
 gested is faithfully followed throughout the early part of the 
 disease, though it is true that some epidemics are attended by more 
 severe intestinal lesion than others, and that the condition of the 
 patient prior to the attack may predispose him to deep necrotic 
 changes here ; but I have found little reason to expect intestinal 
 hemorrhage of serious nature, in my experience. 
 
 A patient with intestinal hemorrhage should be kept strictly 
 quiet, and should have decoction of erigeron canadense administered, 
 two.-ounce doses every half hour, until the active hemorrhage is 
 arrested. If oozing continues, the remedy may be repeated at longer 
 intervals, until the discharge is entirely arrested. It has been 
 advised to apply ice-bags to the abdomen and administer hypoder- 
 mic injections of ergo tine. A pill containing acetate of lead, gr. ii, 
 and extract of opium, gr. x, administered every four hours, has been 
 known to succeed where there was persistent oozing. 
 
 The collapse which follows intestinal hemorrhage may require 
 hypodermic injections of strychnia, these being employed in fifteenth 
 or thirtieth of a grain doses, and repeated every two hours until 
 reaction takes place. 
 
 CONSTIPATION. In a few cases constipation may be present, and 
 pressure may be brought to bear to induce th^ physician to admin- 
 ister a cathartic. It would be bad practice, however, to administer 
 opening medicines to any one affected with enteric fever. It would 
 be better to allow the bowels to remain ten days without an evacua- 
 tion than to commit the error of administering a cathartic. True, 
 theie might be some urgent symptom requiring a violation of 
 tliis rul , but the danger of allowing ample time for nature to 
 regulate this condition is not usually comparable with that of forcing 
 an evacuation with cathartics. Mellin's food is an excellent article 
 of diet where constipation is present, though the condition will 
 hardly arise unless pure milk is employed as food, which should not 
 b;; allowed in any case. 
 
 Convalescence is a critical period in the management of typhoid 
 fever, as the patient is prone to indulge in exercise and diet which 
 may prove fatal iu their results. Fatal peritonitis may follow the 
 early ingestion of solid food, and the patient should be solemnly 
 warned of the danger incurred by too early indulgence in such
 
 90 SPECIFIC INFECTIOUS DISEASES. 
 
 matters. During this period the diet should be restricted to milk, 
 cream, gruels, jellies, and animal broths. Ice-cream, in moderate 
 quantities, may be permitted, but solid food, such as meats, vege- 
 tables, and fruits, should be strictly forbidden. 
 
 As healing of the intestinal ulcers is not completed until two or 
 three weeks of convalescence have passed, the patient should 
 remain in the recumbent position, part of the time at least, and 
 avoid all exercise, except walking about the sick-room, during thai 
 time. The use of solid food should be begun with very small quan- 
 tities at a time. 
 
 SUPPLEMENTAL THERAPEUTICS. A few other means employed in 
 the treatment of this disease, are worthy of mention. 
 
 Intestinal Antisepsis. Modern old school authorities regard this 
 with great favor, some asserting that through it the course of the 
 disease may be aborted. The principal remedies used are salol, 
 beta-naphthol, salicylate of bismuth, creosote, iodide of potassium, 
 and some other antiseptic agents. 
 
 Further suggestions on the treatment of this disease may be 
 found in "Dynamical Therapeutics." 
 
 n. TYPHUS FEVER. 
 
 Synonyms. Ship Fever; Jail Fever; Irish Ague. 
 
 Definition. This is an acute, contagious disease, characterized 
 by sudden and marked prostration; abrupt invasion of fever, with 
 rapid rise of temperature ; a peculiar rash ; marked nervous symptoms; 
 and a termination by crisis, about fourteen days from commencement. 
 
 Etiology. The poison of this disease has not yet been identi- 
 fied, but it is probably similar to that of other infectious diseases, 
 viz., a microscopic germ, capable of producing the disease by rapid 
 multiplication and the generation of ptomaines in a healthy per- 
 son, after entering the system, upon exposure to the infection. 
 Near approach to one affected is usually a requisite to infection, and 
 the carrying of the disease in clothing, as in small-pox, is of very 
 rare occurrence. It rarely travels from house to house, and is usu- 
 ally communicated to those in constant attendance, instead of to 
 occasional visitors, nurses and house-physicians being much more 
 likely to contract the disease than the visiting physician. Loomis, 
 in his work, "Practical Medicine," relates that during an epidemic of 
 typhus fever which prevailed in New York, from 1861 to 1864, 
 of those who attended to washing and packing away the clothing 
 of patients brought into the hospital, after it had been removed 
 in the reception room, all, even to an individual, escaped the disease,
 
 TYPHUS FEVER. 91 
 
 while every one whose duty it was to assist in carrying them from 
 the reception room to the wards, took the fever. 
 
 It would seem, then, that near approach to those affected is 
 essential to the contagion, and that this is modified much in open air, 
 our author stating that less than two and a half feet measure the 
 average limit of infective distance from an affected person, under 
 such circumstances. 
 
 While Loomis states that the disease seems not readily prop- 
 agated by fomites alone, most authorities assert that it can be so 
 conveyed. The hospital experience referred to in former para- 
 graphs, however, appears to throw much doubt on the statement. 
 
 Only the great seaports afford cases of this kind on the American 
 continent, and these are usually brought there by vessels entering 
 from foreign parts. Europe seems to be the geographical center of 
 origin, the disease being common in Russia, England, and Ireland. 
 
 The disease is most liable to occur among those who are occupy- 
 ing crowded quarters, such as old tenement-houses, jails, and other 
 illy ventilated public places. Owing to improved sanitary condi- 
 tions, typhus fever occurs but rarely, in modern times. 
 
 A single attack affords an individual immunity against subse- 
 quent ones. 
 
 Pathology. The pathological lesions of the tissues and blood 
 found in typhus fever resemble those of typhoid, in many particulars. 
 The blood in typhus is found darker in color than normal, and when 
 abstracted during life it is seen to have lost its normal property of 
 coagulation; and, if a clot forms, it is brittle and pultaceous, the 
 mass seeming to be devoid of fibrin elements. The red corpuscles 
 are increased in number at first, but they diminish as the disease 
 progresses; there is also a change in the salts, the blood rapidly 
 undergoing ammoniacal decomposition when drawn from the body. 
 Before standing, the blood contains urea and ammonia in excess. 
 Microscopic examination shows many of the corpuscles degenerated, 
 broken up, their edges irregular and serrated. The coloring matter 
 thus set free stains the lining of the bloodvessels, heart, and other 
 tissues. 
 
 Enlargement and friability of the heart, lungs, Uver, and kidneys 
 are not so marked usually as in typhoid, though the tendency to 
 cloudy swelling and granular degeneration of the voluntary muscles, 
 heart, kidneys, and other internal organs, is present. Pultaceous 
 clots are often found ra the cavities of the heart, or adhering to the 
 walls of the larger bloodvessels. Splenization and hypostatic con- 
 gestion of the lungs, as well as pulmonary oedema, are common results 
 of this disease.
 
 92 SPECIFIC INFECTIOUS DISEASES. 
 
 The brain differs much from that of typhoid fever in its post- 
 mortem appearance. The vessels are here more or less congested, 
 and the sinuses and large vessels are often engorged with blood, 
 while the brain of the typhoid fever patient presents an aueemic 
 appearance. Sometimes and this may ba characteristic of certain 
 epidemrcs of typhus there maybe more or less extensive exudation 
 of serum into the meshes of the pia mater, instead of marked con- 
 gestion. Sometimes this effusion is turbid, suggesting meningitis 
 as a complication. In these cases the arachnoid will be dotted over 
 with yellow or yellowish-white spots, and its glistening appearance 
 will be lost. 
 
 The abdominal lesions of typhus are not characteristic, and this 
 will serve to distinguish it from typhoid, should any confusion exist. 
 There may be congestion of the intestinal glands, with tendency to 
 ulceration, but such a condition prevails more or less in scarlatina 
 and measles, and is not distinctive of typhus. The marked and dis- 
 tinctive ulceration which characterizes typhoid is not present in 
 typhus fever. 
 
 Glandular enlargements constitute a prominent feature of the 
 pathology of typhus fever. The superficial cervical glands, and the 
 parotid and sublingual, are often so much swollen as to interfere 
 with deglutition. This marked swelling may sometimes apparently 
 be the immediate cause of death. 
 
 The inguinal glands are also often swollen, so much as to retard 
 the venous circulation from the lower extremities, and cause exten- 
 sive swelling of these parts. Sometimes the irritation extends to the 
 veins, and a condition resembling phlegmasia dolens results. Again, 
 the cellular tissues may be involved and suppuration occur, resulting 
 in large abscesses. 
 
 The special senses are not so markedly involved as in typhoid, 
 and the digestive organs are not much disturbed, in the majority of 
 cases, vomiting and diarrhoea being of comparatively rare occurrence. 
 
 Symptoms. INCUBATION. This may last from a few hours to 
 two weeks. During this time there may be ill-defined sensations of 
 discomfort, with dull headache, loss of appetite, fugitive pains, and 
 other premonitory symptoms; but such indications are usually 
 absent, the onset being unannounced. 
 
 INVASION. The sta^e of invasion is abrupt. Premonitory symp- 
 toms, such as malaise, headache, insomnia with restlessness at 
 night, nausea, anorexia, etc., may mark a few days of the latter portion 
 of the period < f incubation, but often the first symptom is a decided 
 chill, \\hich is short, sharp, and sudden; this is followed by fever, 
 with rapid rise of temperature. Sometimes the chill is not marked, 
 and only slight chilly sensations announce the onset. Following
 
 TYPHUS FEVER 93 
 
 the chill is a marked headache, which steadily increases in severity. 
 It involves the frontal region, and soon becomes intense. Severe 
 pains in the back and limbs attend, and as febrile symptoms, with a 
 rapidly rising temperature, come on, a sense of extreme prostration 
 overpowers the patient. Loomis relates that at one time, while he 
 was making his visits in a typhus fever ward, his house physician, 
 who had contracted the disease, staggered and fell at his side while 
 accompanying him, and died on the eighth day. Though loss of 
 muscular power is not usually so sudden, the patient will be com- 
 pelled to take his bed witiiin twenty-four hours, and the attending 
 prostration is more marked early than in any other febrile disease. 
 Soon, in the majority of cases, the patient becomes so weak as to be 
 unable to turn in bed, and lies helpless on his back Paralysis of 
 the sphincters soon attends, with involuntary evacuation of urine and 
 feces. Dysphagia, partial aphonia, and inability to protrude the 
 tongue, are often present. Muscular tremors, subsultus tendinum, 
 picking at the bedclothes, hiccough, strabismus, and opisthotonos, 
 may occur in desperate oases. 
 
 The fever may run a typical course, the stadium being reached in 
 many cases as early as the third day. However, this stage may 
 not be attained unt.l two or three days later. The regularity with 
 which typhoid fever advances during the first week is not observed 
 in this form, and a record of the temperature during the first few 
 days would not be much assistance in diagnosis. 
 
 TEMPERATURE. Though chilly symptoms may persist for two or 
 three days, the temperature rises rapidly, and within the first twenty- 
 four hours may reach 105 or 106 D F. In other cases, two or three 
 days may be occupied in the development of the fastigium. The 
 morning and evening variations are most marked at midnight, but 
 these are not regular as in typhoid, there hardly being a regular 
 periodicity, and the crisis occurs without any increase in the length 
 or degree of the diurnal variation. Sometimes, on the day pre- 
 ceding the crisis, the temperature rises three or four degrees higher 
 thau before. The temperature usually ranges the highest during 
 the second week. 
 
 The headache of typhus is a notable feature, appearing early, and 
 steadily increasing in severity for the first week. Associated with 
 this is dullness and confusion of intellect, sometimes vomiting. It 
 is said that the headache of typhus is much more constant and 
 severe thau that of any other fever. 
 
 The pulse is rapid and full in the beginning, but it soon becomes 
 feeble, soft, and compressible, and increased in frequency. In 
 unfavorable cases, when a fatal termination is nearing, it becomes
 
 94 
 
 SPECIFIC INFECTIOUS DISEASES. 
 
 dicrotic, irregular, and intermitting. The tongue is swollen at first, 
 ami covered with a white coating, but in a few days it becomes 
 brown, and, later, black, dry, and fissured. In severe cases, the 
 tongue is shrunken, and rolled in a ball, at the back of the mouth. 
 
 The countenance presents a peculiar appearance, the face being 
 darkly flushed, and the expression dull and weary, the cheeks often 
 being of mahogany color. The sleep is restless and disturbed, and, 
 when the patient is awake, his mind does not seem clear, even in 
 the early part of the disease. 
 
 Delirium of pronounced character comes on about the eighth 
 day, though it may be present much earlier, and the headache, which 
 has been such an unpleasant feature, now subsides. It is more 
 marked at night, at first, usually passing off in the morning, to 
 return at night; but it soon becomes continuous, varying, in different 
 
 DAY 
 
 or 
 
 DttEASC 
 
 /or' 
 
 106 
 
 1CS 
 1C4" 
 
 100 
 
 99 
 
 98 
 
 S 
 
 Iff 11 
 
 V 
 
 12 13 14 15 till 
 
 TEMPEKATCBE IN A CASE OF TYPHCB FEVEB. 
 
 patients, from a low muttering, to the most active and noisy kind. 
 Loomis asserts that acute delirium is most apt to be present when 
 the patient is intelligent and highly cultured, and that of muttering 
 character in aged persons, or those of little culture. Stupor or som- 
 nolence follows the period of delirium, the patient lying in a condi- 
 tion of coma vigil, for hours before death. Favorable cases are 
 more apt to be marked by somnolence, prior to the period of crisis. 
 The rash of typhus fever appears from the fifth to the eighth 
 day of the disease, usually on the fifth. It consists at first of dirty 
 pink spots, which appear on the abdomen and gradually extend 
 over the body, showing everywhere except on the face and palms 
 of the hands. These spots vary in size, from mere points to three
 
 TYPHUS FEVER. 95 
 
 or four lines in diameter, are slightly elevated, and disappear on 
 firm pressure. In a day or two the eruption becomes much darker, 
 of purplish, mulberry color, the elevation subsides, and the spots 
 remain uader pressure. 
 
 Diagnosis. It is not difficult to distinguish typhus from other 
 diseases which it may sometimes resemble, if it be recollected that 
 it is a contagious disease, confined to its immediate surroundings. 
 While it may resemble typhoid fever in some of its characteristics, 
 it must be remembered that the invasion of typhoid is very gradual 
 usually, while this is sudden in its onset. The abdominal symptoms 
 of typhoid are also characteristic, while tympanites and tenderness 
 on pressure are absent in typhus, and diarrhoea is hardly ever 
 present. The rash, on the fifth day, is entirely different in appear- 
 ance from that of typhoid, which appears later. 
 
 The duration of typhus fever is also a distinctive feature, the 
 disease terminating by the fourteenth day, while few ca^-es of typhoid, 
 aud no severe ones, terminate within three weeks. Cerebro-spinal 
 fever resembles typhus in some cases, but the rash is different in 
 character and the temperature is lower, hardly ever rising over 102 
 or 103 F., and the disease runs a much more protracted course, in 
 most cases. Where there is meningeal inflammation in typhus, 
 there are many symptoms in common with this disease, such as the 
 intense headache, delirium, rigidity of the muscles, etc. Only those 
 practicing in seaport towns need take the trouble to exclude typhus 
 from a doubtful diagnosis, as the disease seldom or never penetrates 
 to the interior, in this country. 
 
 Prognosis. This is, without doubt, a dangerous disease, and 
 one which is liable to result fatally, with the best of treatment. 
 Unfortunately, Eclectic methods have never been thoroughly tiied, 
 so that no estimate from such a standpoint can be made. Those 
 conversant with the disease and the results of treatment, vary in 
 estimating the deaths from one in five to one in sixteen of the cases 
 affected, in different epidemics. The mortality seems to vary at 
 different times, some epidemics being much more severe than others. 
 The surroundings of the patient certainly exert much influence upon 
 the disease, pure air and other favorable influences encouraging a 
 successful issue. When the patient is debilitated in the start, has 
 been addicted to alcoholism, or is the subject of gouty diathesis, 
 his chances of recovery are diminished. Overcrowding or bad ven- 
 tilation are opposed to favorable results. Complications are often 
 the causa of death, such as cerebral or pulmonary congestion, and 
 some one of these complications may be a peculiar feature of each 
 epidemic; and as this is marked, so the mortality is liable to be
 
 96 SPECIFIC INFECTIOUS DISEASES. 
 
 increased. The prognosis is less grave, when the disease occurs in 
 childhood. 
 
 Treatment. Evidently, from what old school authorities assert, 
 there is little to be expected from treatment; that is, from the action 
 of medicines. Loomis asserts that fresh air is the only thing which 
 will neutralize the poison of this disease. He advises placing the 
 patient in a tent or open pavilion so that the air can circulate freely 
 around him, covering him with blankets, if the air be chilly. He 
 asserts that he has seen patients apparently overwhelmed by the 
 fever poison, so much as to be in a state of coma with high tempera- 
 ture, and apparently rapidly succumbing to the disease brought 
 from crowded tenement houses and placed in tents, begin to rally 
 within four or five hours, and go on to speedy recovery. This 
 author places more stress upon such plan of treatment than upon 
 any drugs that may be employed. The same writer deprecates the use 
 of alcohol as a stimulant, averring that, though it may seem to bene- 
 fit at first, it is liable to finally arrest secretion, prevent the elimina- 
 tion of urea, and disturb nutrition, thus lessening the chances of 
 recovery. He indorses the employment of opiates to induce sleep, 
 asserting that the protracted insomnia is of itse If sufficient to cause 
 a fatal termination. To reduce the temperature, he recommends cold 
 baths and quinine as antipyretics during the last week, and urges 
 the importance of proper feeding, stating that the patient must be 
 required, and even compelled, to take nourishment, advising the plan, 
 should he refuse to take it without, of pouring liquids down through 
 a rubber tube passed into the stomach, by way of the nose, 
 when the patient clinches his teeth and refuses to receive it. Milk, 
 malted milk, Horlick's food, etc., will answer the purpose, and some 
 should be given regularly and at frequent intervals, as iu the treat- 
 ment of typhoid fever. During convalescence, care should be taken 
 that tho patient be not exposed to sudden changes of temperature so 
 as to take cold, or permitted to overexert himself (as this might 
 result in coagulation of blood in the veins) until after the blood has 
 been restored to a normal condition. Moderate exercise in the open 
 air is commendable. Convalescence is usually rapid. 
 
 I am of the opinion that this disease could be much modified by 
 the action of echinacea. I have treated a few cases that I diag- 
 nosed as typhus fever at the time, which I am now convinced were 
 cases of cerebro-spinal fever; but from the close resemblance, and 
 the excellent action of echinacea in these cases, I would expect good 
 results from it in fyphuoj and salicylate of ammonium ought to 
 reduce the temperature and lessen the tendency to blood depravation. 
 
 Should the opportunity arise, I hope that some of our Eclectic
 
 KELAPSING FEVER. 97 
 
 physicians will test these remedies in this disease and report results 
 to our medical journals. Doubtless, the antipyretic influence of jab- 
 orandi and other vascular sedatives, cold packs, baths, etc., will 
 ameliorate the severity of the symptoms, lower the maximum tem- 
 perature, and assist in preserving vital structures against destruc- 
 tive action. 
 
 III. RELAPSING FEVER. 
 
 Synonyms. Spirillum Fever; Famine Fever; Hungerpest. 
 Definition. An acute, contagious febrile disease, characterized 
 by two paroxysms of high fever of from five to seven days each, 
 with an intermission between, of from three to five days' duration. 
 Etiology. When relapsing fever occurs in this country, it is 
 the result of importation from Europe. This is of rare occurrence, 
 so much so that the disease has not been deemed worthy of mention 
 by all American authorities on practice. The disease occurred as 
 an epidemic in New York City, in 1872-3, and in Philadelphia, in 
 1844. In both instances, it was brought from Europe by emigrants. 
 It is highly contagious, and within a few years past bacteriologists 
 have asserted that the producing factor is a parasitic organism the 
 spirittum Obermaieri. It has been called "famine fever," but those 
 who are well fed are as susceptible to the contagion as others. Bad 
 water and food, overcrowding, and vitiated air, predispose to epi- 
 demics. The disease is not likely to be carried on clothing, and is 
 seldom communicated except by direct transmission. 
 
 The spirillum of relapsing fever (spirochaete of Obermaier) is a 
 narrow spiral filament, which measures from three to six times the 
 
 diameter of a red corpuscle in length, and 
 is readily seen moving about among the 
 blood-disks during the paroxysms the only 
 periods in which they are visible. Shortly 
 before the crisis and during the intermission 
 they are not found, though small, glistening 
 bodies, supposed to be spores, are then 
 detectable. During the paroxysms, inocu- 
 or *<-A^ "^ion of a healthy person with the blood of 
 '"' an affected subject will propagate the dis- 
 ease. It is also communicable to monkeys, in the same way. 
 
 Pathology. There are no lesions characteristic of this disease 
 alone, the parenchymatous changes due to febrile action appearing 
 here in proportion to the severity of the disease, as elsewhere. 
 The liver and spleen are enlarged, the spleen frequently being the
 
 1)8 SPECIFIC INFECTIOUS DISEASES. 
 
 seat of infarctions. The cortical substance of the kidneys is con- 
 gested, and the bulk of the organs thus increased, while granular 
 infiltration of the uriniferous tubules, similar to that noticed in 
 other fevers, may be noticed. In some cases, extravasations of 
 blood are found distributed throughout the organ. Extravations of 
 blood may also be found upon the mucous membranes, especially 
 of the intestines, stomach, and bronchial tubes. The blood coagulates 
 imperfectly, as in typhus fever, though coagula in the blood-vessels 
 are rare. 
 
 Symptoms. INCUBATION. This period may be short, lasting 
 only a few hours in some cases, though it is usually of six or eight 
 days' duration. During this time there are not often any symptoms 
 to suggest the coming onset. 
 
 INVASION. This is usually abrupt, a pronounced chill announcing 
 the commencement of the attack. This is attended by frontal head- 
 ache of excruciating character, severe pains in the muscles of the 
 limbs and back, nausea, and vomiting. The temperature rises rap- 
 idly, usually reaching its highest point within twenty-four hours after 
 the initiation of the disease. It may rise as high as 104 or 106, 
 and, in some cases, as high as 109 F. 
 
 The pulse increases in frequency very rapidly, and this disease 
 is remarkable for the rapidity which the pulse reaches 140, 150, or 
 160 beats per minute within the first twenty-four hours. It is small 
 and compressible, usually, sometimes dicrotic. 
 
 Delirium is not a common symptom, the patient generally retain- 
 ing control of his mental faculties throughout, though sleepless- 
 ness is a common condition, on account of the severity of the 
 muscular pains. The pains may affect the joints particularly, and 
 may become the most unpleasant part of the disease. 
 
 As the liver and spleen become involved by the second day 
 weight and uneasiness in the upper portion of the abdomen, espe- 
 cially in the hypochondrium, will be noticed, while enlargement and 
 tenderness of both liver and spleen will be found upon palpation. 
 Jaundice develops in many cases, and this may be accompanied by 
 vomiting and diarrhoea. 
 
 Marked prostration, irregularities of the pupils, soreness and 
 stiffness of the muscles of the eyes, etc , are other features. By the 
 sixth or seventh day the febrile symptoms have become aggravated 
 to their fullest extent; the pulse Is 150 or 160 per minute, the 
 tongue is dry and brown, the muscular pains are excruciating, and 
 emaciation has begun to be marked, while the prostration is extreme, 
 it seeming that a fatal issue must be near at hand. Now, a sudden 
 remission occurs, profuse perspiration breaks out on the surface,
 
 RELAPSING FEVER. 
 
 99 
 
 secretion becomes established from the kidneys, the headache and 
 pains subside, sometimes a critical diarrhoea occurs, and the pulse 
 rapidly falls to 80 or 90 beats per minute, while the temperature 
 becomes normal within twelve hours from the first appearance of 
 subsidence. Then, barring a sense of weakness, the patient feels 
 perfectly well. His appetite begins to return, he gets out of bed, 
 and appears to be rapidly convalescing. His pulse will now be found 
 to be slower than normal, and his temperature normal, or near there. 
 But this period of comfort is of short duration. In a few days (three 
 or four, sometimes a week) the attack is repeated, with more sever- 
 ity than before. 
 
 DAY 
 
 OF 
 
 D/SfASf 
 
 1 
 
 tor' 
 
 toe' 
 
 JOS 
 
 104' 
 103' 
 
 7 7 
 
 10 
 
 93 
 
 TEMPERATURE IN A CASE OF RELAPSING FEVER. 
 
 The headache, the arthritic and muscular pains, the high tempera- 
 ture, and the rapid pulse, are again ushered in with great rapidity, 
 sometimes with and sometimes without a chill, and the hepatic and 
 splenic congestion again occurs. This continues from two days to a 
 week, when a second crisis occurs, similar to the former one, and 
 within twenty-four hours from commencement the pulse and tem- 
 perature have reached normal, and the unpleasant symptoms have 
 again subsided. This time, usually, the convalescence is real, and 
 the patient goes on to complete recovery, though in some cases three 
 or four relapses may occur. 
 
 Some of the complications of relapsing fever are pneumonia, col- 
 lapse, ophthalmia, diarrhoaa, and dysentery. 
 
 Diagnosis. After the disease has been established, the diag-
 
 100 SPECIFIC INFECTIOUS DISEASES. 
 
 nosis is not difficult, its contagious character, the distinct intermis- 
 sion after several days of fever, the severe headache, and the ar- 
 thritic pains, will afford a correct picture of the disease. Dengue 
 fever, though it resembles this disease in many particulars, is char- 
 acterized by an eruption, which appears during the second parox- 
 ysm, and the remission does not amount to an intermission, as in 
 relapsing fever. In typhus, the headache is almost invariably suc- 
 ceeded by delirium by the beginning of the second week, while delir- 
 ium is not common in this disease. The intermission occurring by 
 or before the end of the first week will also settle the question of 
 typhus. The slow invasion of typhoid fever will distinguish it from 
 relapsing fever, in which the invasion is accomplished within twenty- 
 four hours after the onset. Abdominal symptoms are also a marked 
 feature of typhoid, while they are not present here. The history of 
 the case will suggest, to the American practitioner, a foreign origin 
 for the disease. Cerebro-spinal fever is marked by severe head- 
 ache and muscular pain, but the temperature is usually low, as com- 
 pared with that of relapsing fever, and is very irregular if high one 
 day it is liable to be low another, and is not to be relied upon to fol- 
 low any regular course. 
 
 Prognosis. The prognosis in relapsing fever is very favorable, 
 notwithstanding the severe ordeal through which the patient passes. 
 Though a disease attended by much suffering, it does not seem as 
 inimical to life as some diseases of apparently milder character. 
 Loomis estimates that only about three per cent of all the cases 
 treated in the hospitals of New York, during the epidemic referred to 
 in this article, died. Syncope and other complications, such as 
 bronchitis, pneumonia, diarrhoea, dysentery, and ursemia from renal 
 congestion, supply the greatest mortality. Aged and feeble persons 
 may die from collapse during the crisis, though this is not likely to 
 occur. 
 
 Treatment. The Eclectic portion of the profession has had 
 no opportunity to test the value of their methods of treatment in 
 this disease. It is asserted by those who have had extensive expe- 
 rience with it that quinine is of no service in its management. It is 
 also asserted that aconite, arsenic, and veratrum have been tried as 
 antipyretics, without avail. Cold baths have been resorted to with 
 as little profit. It is asserted that opiates have relieved the severe 
 pain, and given better satisfaction than other methods of treatment. 
 Free ventilation should be given the rooms of patients under treat- 
 ment with this disease, without doubt 
 
 It seems that jaborandi or salicylate of ammonium ought to lessen 
 the maximum temperature of this disease, and, at the same time,
 
 CEREBRO-SPINAL FEVER. 101 
 
 assist in controlling the severe headache and pain. A decoction of 
 rhamnus californica ought also to assist in relieving the intensity of 
 the pain, if not in banishing it altogether. 
 
 Complications should be treated as they arise, according to mod- 
 ern Eclectic methods. A liquid diet should be employed throughout 
 the disease, and hygienic methods of management strictly observed. 
 
 Of course we will not lose sight of the proper precautions neces- 
 sary to counteract any tendency to blood depravation which may be 
 manifested by the condition of the tongue. The proper correctives 
 are well known to all modern graduates of our schools, and need not 
 be mentioned here. During convalescence, cactus graudiflorus, 
 cereus bonplandii, or digitalis may be administered for the tendency 
 to heart failure ; and this may be necessary, during the first remission. 
 
 IV. CEREBRO-SPINAL FEVER. 
 
 Synonyms. Cerebro- spinal Meningitis; Spotted Fever ; Pete- 
 chial Fever; Malignant Purpuric Fever. 
 
 Definition. An acute, infectious disease, characterized by 
 inflammation of the oerebro-spinal meninges; excruciating pain in 
 the head, back, and limbs; irregular fever; and often by convulsions 
 or opisthotonos, and a petechial rash. 
 
 Historical Note. This disease was first identified in Geneva, 
 in the early part of the present century. Soon afterward (1806) it 
 appeared in Massachusetts, and has since visited almost every part 
 of the United States and Canadas. 
 
 Etiology. The exciting cause of this fever is yet a question. 
 It may occur epidemically or sporadically, but is most liable to occur 
 as an epidemic. All ages are subject to it, but young persons and 
 children are most liable to attacks. Bad hygienic surroundings are 
 predisposing causes, overcrowding, bad ventilation, insufficient or 
 unwholesome food, dampness, etc., being supposed adjuncts. 
 
 Recent investigations have resulted in the conclusion that the 
 exudate invariably contains a lance-shaped coccus, identical with 
 the diplococcus of pneumonia, and the constant presence of this 
 bacterium suggests it as the exciting cause. 
 
 It is not considered contagious, either directly or through fomites, 
 though crowding of communities together, as in garrisons and bar- 
 racks, seems to predispose to outbreaks. 
 
 Pathology. The pathology of this disease indicates two forms 
 of cerebro-spinal meningitis. The first to be mentioned is the 
 sporadic form, where the anatomical lesions are confined to evidences 
 of simple inflammation of the meniuges of the brain and spinal
 
 102 SPECIFIC INFECTIOUS DISEASES. 
 
 cord, the second or epidemic form being characterized by evidences 
 of grave visceral and sanguineous changee, akin to those of typhus, 
 typhoid, and other putrid fevers. The brain is always found more 
 or less involved, the dura mater being tense and shining, and the 
 surface, especially at the convexity and base, studded with punctate 
 points of extravasation. Hypersemia of the pla mater is also a 
 constant condition, the vessels usually being injected, and the sur- 
 face roughened, this condition involving both the brain and spinal 
 cord. The sinuses of the dura mater may contain much softly 
 coagulated blood, especially in the epidemic form of the disease, and 
 extensive exudation of sero-fibrinous or sero-purulent fluid is found 
 over both the convexity and base of the brain. In the latter situa- 
 tion, the cranial nerves are often imbedded in this substance. The 
 amount and color of this exudation vary, it sometimes presenting a 
 whitish, soft appearance, and being in small quantity, while again it is 
 abundant, and yellowish or greenish in appearance, suggesting puru- 
 lency. This condition may involve the posterior surface of the cord, 
 a purulent fluid being found under the arachnoid. The blood is 
 dark and tarry in appearance in the epidemic form, the fibrin dimin- 
 ished, the white corpuscles increased, the fluid rapidly decomposing 
 when exposed to the air. The muscles are dark colored, and the 
 tissues generally have undergone granular degeneration. There is 
 often congestion of the lungs, liver, and spleen, the parts being 
 enlarged and increased in friability. The skin is frequently the 
 seat of an eruption, of petechial spots, though there is no regular 
 time for its appearance. After death, purple or purpuric spots 
 appear, especially along the region of the spine ; and these are often 
 present during life, in certain epidemics. 
 
 Symptoms. The symptoms of this disease are of wide diver- 
 sity of character, though there are a few such as severe headache 
 and pain in the back and extremities which are invariable. The 
 pain is notably severe in the upper portion of the spine, the head 
 being thrown backward to relieve the tension on the ligamenturn 
 nuchsB early in the onset, the suffering here being described as 
 excruciating. The length of the period of incubation is not known. 
 
 INVASION. In some cases the invasion of the disease is abrupt, 
 the patient being seized with a chill and loss of consciousness, while 
 coma, convulsions, and death, may follow within a few hours. But 
 these are the extreme cases in the epidemic form. When the disease 
 is sporadic, the symptoms are more gradual in their advance, and 
 the chill is not so apt to be pronounced, though the patient may com- 
 plain of chilly symptoms for several days. The reaction is slight, 
 the temperature not rising much above normal. The headache and
 
 CEREBRO-SPINAL FEVER, 103 
 
 pain along the spine however will be marked, the patient will be 
 restless and sleepless, and there will be loss of flesh aud emaciation, 
 as the case progresses. Often the pupils will be found of unequal 
 size, while the features present a fixed or staring expression. The 
 vase-motor supply to the face will be involved early, and irregular 
 control of the blood-vessels will give rise to variability in the appear- 
 ance of the face,, it being brightly flushed or presenting a hectio 
 appearance at times, and within a few minutes afterward showing 
 a ghastly pallor, especially after the patient has become prostrated 
 and debilitated. This irregularity in the circulation of the face is a 
 notable feature, in the protracted form of this disease. 
 
 In two or three days, sometimes later, delirium comes on. This 
 varies widely in character, sometimes being wild and violent, and at 
 other times mild and muttering. In the slow form this may not 
 appear, however, until several days later. Sometimes it is of a 
 maudlin character, resembling the vagaries of a drunken person, and 
 in women, it may resemble hysteria. I recollect a case treated a few 
 years ago, in which the patient, a married woman of about thirty, 
 resisted my attempts to inspect her tongue during the first visit, 
 cried peevishly when disturbed, and acted so childishly that I sup- 
 posed her husband, toward whom she manifested the same disposi- 
 tion, had crossed her in some way, and that she was working off a fit 
 of sulks, though he assured me that this was not the case. Within 
 twenty-four hours, however, there were retraction of the head, irregu- 
 larity of the pupils, opisthotonos, and tonic spasms of the extremi- 
 ties, with coma. Hemiplegia, followed by death, resulted within 
 ten days from the time I was first called. In this case the tempera- 
 ture was normal most of the time, and never above 102 F., the 
 extremities being cold continually. 
 
 In other cases the delirium is of the most restless character, and 
 the patient will make violent efforts to leave the bed, requiring an 
 attendant at his side constantly. In one case, that of a little boy, 
 the patient struggled to get out of bed, shrieked, at times, and tore 
 the Lair out of his head, before his mother (who took great pride 
 in his curls) could be induced to cut it short. "With the majority 
 of infants there is constant restlessness and insomnia, there seem- 
 ing to be intense and persistent suffering (as there undoubtedly is), 
 and this is evidently aggravated by moving or lifting the patient. 
 Hypercesthesia of the ekin and muscles is so marked that the least 
 touch or pressure often elicits complaint, and when a child retains 
 its consciousness, it will cry in anticipation, when preparations are 
 being made to move it. 
 
 There are many grades of symptoms in this disease, the spasmodic
 
 104 SPECIFIC INFECTIOUS DISEASES. 
 
 action of the muscles coming on early in some cases, and not appear- 
 ing for several weeks, in others. Some observers have divided the 
 cases into the slow and rapid forms. I once witnessed an epidemic 
 where children were the ones principally affected (the disease follow- 
 ing measles), in which a little patient would roll its head, fret, aud 
 moan, without intermission, five or six weeks, waste away, and finally 
 die in a state of marasmus, apparently suffering intense pain at the 
 base of the brain, one hand keeping a constant motion backward and 
 forward about the mastoid process for days and nights at a time, 
 the suffering being much increased whenever the child was lifted or 
 moved. During this epidemic, some rapid cases developed, and 
 patients died in convulsions and coma within a few hours after the 
 onset. The disease was ushered in usually like a remittent fever 
 (sometimes with symptoms of cholera infantum), but the means com- 
 monly employed to interrupt the paroxysms in that disease produced 
 only temporary effect in these cases, relapses soon following. 
 
 The rapid form of the disease usually prevails during an 
 epidemic, if at all, while sporadic cases are usually of the slow form. 
 On account of the typhoid symptoms which attend, many physicians 
 have been in the habit of confounding it with typhoid fever ; but there 
 is no analogy between that disease and this. There are no abdominal 
 symptoms, and there is not the regularity about the temperature, as 
 in typhoid. 
 
 In sporadic cases occurring in this country, there is not a very 
 marked change in the appearance of the tongue, except during the 
 late period of severe cases, it then becoming pinched, dry, and brown. 
 Usually, there is a remarkable absence of disturbance of the alimen- 
 tary canal. The tongue is not much altered in appearance, there is 
 no gastric irritability, and the bowels are not disturbed; though 
 there may be slight constipation, but not more than might result 
 from protracted recumbance in a state of health. Sometimes, how- 
 ever, dysenteric symptoms are present, especially if the disease occurs 
 during the heated season. In one instance occurring in my experi- 
 ence, an epidemic was characterized by the appearance of muco- 
 enteritis among children, this afterward becoming complicated with 
 cerebro-spinal symptoms, which soon became prominent. 
 
 The pulse may be only slightly accelerated, or it may be very 
 rapid. Like the temperature, it is liable to marked variation in a 
 brief period, the pathological changes likely to occur in the neigh- 
 borhood of the vaso-motor and pneumogastric centers suggesting 
 the probability of such a state of affairs. As to quality, the pulse 
 is small and wiry, in the majority of cases, but becomes dicrotio, late 
 in the course of the disease.
 
 CEEEBKO-SPINAL FEVER. 105 
 
 The temperature is variable, but there is usually a tendency 
 toward a low range. It is hardly ever above 103 F., and is more 
 apt to range below than above this limit. In many casaa, the extrem- 
 ities are cool throughout the course of the disease, and the tempera- 
 ture of internal parts not much above normal. However, in excep- 
 tional cases a very high temperature range may be registered early, 
 and usually, shortly prior to a fatal termination, there is marked ele- 
 vation, even though there has not been much fever before. A record 
 of the temperature in one case is no suggestion as to that of another; 
 the pathological changes occurring so near the heat center seem to 
 disarrange all calculations tallying with experience gained in certain 
 other fevers. 
 
 The eruption is usually limited to the face, neck, and lips, though 
 it may appear on the trunk and limbs. Vesicles resembling fever- 
 blisters appear on the lips, and may be limited to this region. 
 In other cases, the eruption may resemble that of typhus fever. 
 Ecchymoses may appear on the body, especially about the hips and 
 dorsal region where decubitus has caused pressure, and these are 
 particularly noticeable after death. There is no regular time for the 
 eruption to appear, and no stated length of time for it to remain, it 
 being present throughout the course of the disease in some cases, 
 and only for a single day in others, while in still others there may 
 be all grades between these limits. Epidemics have occurred in 
 which the ecchymoses were so prominent that the disease was termed 
 "spotted fever." 
 
 The senses are markedly affected in this disease. There are 
 photophobia, perversion or loss of taste, and deafness. The patient 
 may stare at one when he is spoken to, or seem to, but make no 
 reply, for the reason that he does not hear what is said; and 
 he may not recognize the presence of any one, when apparently 
 looking squarely at his interlocutor. 
 
 The respiratory tract is often affected, there being sighing inspira- 
 tion, in some cases, and in others irritation, amounting to bronchitis 
 or pneumonia. Many other complications may arise. 
 
 Diagnosis. This disease is readily diagnosed from typhoid 
 fever by the irregular temperature and absence of abdominal symp- 
 toms. It resembles typhus in many of its phases that is, many 
 cases do but its non-coutagiousness and history will prevent mistake 
 in this direction. In malarious districts it may at first be mistaken 
 for malarial fever, but its persistence, the early development of 
 delirium, opisthotonos, and other nervous phenomena, and refusal to 
 yield to anti-malarial treatment, will soon settle the question. It 
 may be confounded with acute rheumatism occasionally, but the
 
 106 SPECIFIC INFECTIOUS DISEASES. 
 
 absence of acid sweats, of swelling of the joints, aud the presence of 
 rigidity of the muscles, and cerebral symptoms, will soon exclude 
 this disease. 
 
 The greatest difficulty will be in differentiating between spo- 
 radic cases of this disease and tuberculous meningitis, where there 
 is absence of tuberculous material in other situations, although 
 retraction of the muscles of the neck, and spasms of the muscles of 
 the extremities, are not nearly so marked in the tuberculous form. 
 
 Prognosis. This is always grave, whether the disease occur 
 epidemically or sporadically. It is a disease subject to sudden and 
 repeated relapses, and the mildest cases are liable to finally termi- 
 nate fatally. Pathological changes occur so near the vital spot, 
 the medulla oblongata, that unexpected extension of inflammatory 
 action may ensue at any time, and fatally involve vital function. 
 Children and elderly people are the most unfavorable subjects. 
 
 The epidemic form usually lasts about fourteen days, if death 
 does not occur earlier, but an intermittent form may be subject to 
 several apparent relapses, and continue for six or eight weeks. 
 
 Serious sequelae are liable to follow recovery, especially among 
 children, such as deafness, blindness, and impaired mental power 
 amounting sometimes to idiocy. Paralysis of the lower extremities 
 may result, with slow recovery, several years being consumed. 
 
 Treatment. The most approved hygienic treatment should be 
 adopted in the management of epidemics of this disease. All 
 disease-producing causes should be removed, such as bad air and 
 improper food and water, and the patient should be placed in a 
 dark, cool, well-ventilated room, away from all noise or cause of dis- 
 turbance. The food should be liquid in character, such as milk, 
 malted milk or lactated food, and this should be administered regu- 
 larly, and at frequent intervals, throughout the course of the disease. 
 To quench the thirst, cold water may be given freely. Attention 
 must be paid to the evacuations, and catheterizatiou resorted to if 
 there be retention of urine. Enemata may occasionally be required 
 to evacuate the bowels. 
 
 There is little to be expected from ordinary medication in the 
 treatment of this disease. Remedies which ordinarily relieve mus- 
 cular paiu produce no alleviation here, as the pain is the result of 
 pressure (;n the roots of the sensory nerves, and ordinary anal- 
 gesics are as good as thrown away when administered. As much 
 may be said of the special-sedative plan of treatment. The point of 
 irritation is so nea? the vaso-motor center that therapeutic action 
 here is overpowered by the pathological condition, and aconite, 
 veratrum, gelsemium and jaborandi are usually powerless to control
 
 CEREBKO-SPINAL FEVER. 107 
 
 febrile action. Indeed, there is usually little call for tins class of 
 agents. 
 
 The employment of cold baths and packs, ice-bags to the head, 
 and other depressing local agencies, seems incompatible with good 
 judgment, when we stop to consider that we are dealing with a dis- 
 ease in which there is little reactive tendency, and, almost invaria- 
 bly, a low temperature. The treatment ought to be gently stimu- 
 lating, and supporting throughout not depressing in the least. 
 
 Opiates should not be administered, as they arrest secretion, 
 debilitate, and lessen chances of recovery. It is better to restrain 
 the patient by force when necessary, using precaution not to annoy 
 or irritate him unreasonably, until a curative agent can have time 
 to act; and, from the nature of the case, this will be but slowly. 
 
 The inflammatory action in this disease is not that of simple 
 character, but is probably akin to an erysipelatous condition, where 
 not only sedatives, but remedies which correct an underlying blood- 
 dyscrasia, are demanded. On this theory, I have administered jabo- 
 randi with some benefit, but have afterward found it usually unre- 
 liable. Later, I began the use of echinacea, and now believe that 
 I have found the best remedy extant for this disease. I cannot 
 promise that it will cure every case, for I have lost patients with 
 it who have had the remedy from the very beginning, and so have 
 some of my professional friends. But it is, after all, the only rem- 
 edy I have ever seen administered in this disease, with the excep- 
 tions of jaborandi and rhus tox., which has ever seemed to be of the 
 least benefit. Some cases will recover if left to good nursing, and 
 under these circumstances claims may be made in favor of any plan 
 of treatment; but as some epidemics are light, a low mortality rate 
 would not impress my mind favorably toward ordinary methods of 
 medication. 
 
 But if echinacea be administered faithfully throughout most 
 cases, and cathartics and opiates be avoided as well as sedative 
 medication the mortality will be found to be very small, except in 
 epidemics of the most violent character. Of course this compre- 
 hends the best nursing that can be had. Appropriate food, good 
 management, proper bathing though not too much of this are 
 required ; and other sick-room needs must be attended to. Ten or 
 fifteen drops of* a good preparation should be administered every 
 hour to an adult, the dose for children being regulated to correspond. 
 Let this be continued throughout the disease. 
 
 Bhus tox., in minute doses, may relieve the restlessness, to a lim- 
 ited extent, and it also relieves thirst and controls nausea. "Where 
 frequent convulsions occur in infantile cases, it is the best remedy
 
 108 SPECIFIC INFECTIOUS DISEASES. 
 
 we have to combine with echinacea, as a cerebral calmative, and anti- 
 spasmodic. Where there is marked elevation of temperature with 
 sthenia, jaborandi will answer better in controlling the convulsive 
 action and restlessness. The usual doses will be proper here fif- 
 teen or twenty drops of rhus to four ounces of water, dose (for an 
 adult), a teaspoonful every hour. Two fluidrachms of specific jab- 
 orandi to four ounces of water, dose, a teaspoonful every hour. 
 
 Convalescence is usually slow, and care should be observed during 
 this period to prevent the patient from taking much exercise or 
 being seriously disturbed mentally, for fear of relapse. One of the 
 best safeguards against such an occurrence is the steady use of ech- 
 inacea throughout, in the usual doses, repeated three or four times 
 daily. 
 
 V. SMALL-POX. 
 
 Synonyms. Variola. German, Pocken; Blatter. 
 
 Definition. A contagious, eruptive fever, characterized by a 
 peculiar eruption, which is first papular, then vesicular, and then 
 pustular, the disease being further characterized by a secondary 
 fever, which follows the decline of the primary pyrexia upon the 
 development of the eruption, the remission continuing until the begin- 
 ning of maturation. 
 
 Etiology. The poison of small-pox is extremely tenacious, no 
 other eruptive fever being capable of retaining its infedling proper- 
 ties in fomites so long. It has made trips across the Atlantic from 
 Europe, and onward across the American Continent, in trunks of 
 clothing, to be afterward liberated, to infect such as were susceptible, 
 who were exposed to its influence. In such cases, the fomites will be 
 found to contain particles of the eruption, in which the virus exists. 
 The contagiousness of such material has been known to remain for 
 years, Goss, for instance, stating that he knows of a case where the 
 disease was communicated to persons while cleaning out a cellar 
 under a house in which patients had been sick with small-pox two 
 years before. It can only be produced by its own contagion, and is 
 only communicable to persons who are not protected from it, such 
 protection consisting in the influence of a previous attack, and, to a 
 considerable extent, in vaccination. A vigorous condition of the 
 system undoubtedly fortifies against it to some extent, it not being 
 so highly contagious as measles. The infectious principle exists in 
 the virus of the pustules, as it may be inoculated from this source, 
 and it may also be conveyed by the breath, as well as by exhalations 
 from the body. In this day, the disease does not seem to be as con- 
 tagious as it must have been in olden time, as frequent exposures 
 occur without the communication of the contagion. As the period of
 
 SMALL-POX. 109 
 
 maturation of the vesicle is asserted to be the most infectious stage, 
 the time of exposure doubtless explains why so many are exposed 
 who escape the contagion i. e., the disease does not become highly 
 contagious until the vesicle becomes maturated. Yaccination is 
 also believed to have exerted a generally protective influence upon 
 the whole community, as it was formerly a virulent and rapidly fatal 
 disease, sweeping pestilence and desolation far and wide. It is 
 asserted that during the century preceding vaccination, fifty mil- 
 lions of people died of small-pox in Europe. It is also asserted that 
 the disease is now dying out, and that it only possesses historic 
 interest, as it hardly occurs as an epidemic except in uncivilized 
 lands where the population is unprotected by vaccination. Colored 
 races are especially susceptible to the disease, whether it occur in 
 their native land or where they have been transported. In the West 
 Indies, where it was conveyed from Europe by the Spaniards, in 1507, 
 it exterminated whole races of natives ; and in Mexico, where it was 
 carried by the Spanish troops, three and a half millions of people 
 died from its effecta It is asserted that wherever the whites and 
 Indians have lived in the same neighborhood since the introduction 
 of vaccination, the Indians have perished in large numbers, while the 
 whites have suffered comparatively slight effects. One attack usu- 
 ally confers immunity, though this is not invariable. The disease 
 occurs most frequently in cold seasons, a suggestion that lack of 
 ventilation predisposes to its effects. Nursing infants enjoy some 
 immunity, but liability grows intense at the end of the first year 
 and continues up to forty, wfren it becomes less marked. 
 
 The specific cause is probably a microorganism, though this has 
 not been identified as yet, after many attempts have been made to 
 discover it. It is believed that when found it will be discovered in 
 the pustule. It is probable, however, that the breath and emana- 
 tions from the body contain it as well. 
 
 Pathology. The most characteristic pathological change occurs 
 in the skin, and attends the development of the eruption. This 
 begins with the formation of hardened nodules in the cutis vera, 
 occasioned by swelling and proliferation of groups of cells, each 
 nodule being destined to become a vesicle. This cellular change 
 extends throughout the skin and involves the rete mucosum, and a 
 hard, elevated nodule is soon developed. A process of vacuolation, 
 occasioned by necrobiotic changes in the interior cells, soon sets in 
 in this nodule, some deliquescing to form a set of loculated cavities 
 filled with fluid surrounding a common center of structure which 
 remains firm, holding the center down. These cavities are filled 
 with a serous fluid containing red blooJ-corpuscles and leucocytes.
 
 110 
 
 SPECIFIC INFECTIOUS DISEASES. 
 
 As proliferation of cells and accumulation of fluids continue, the 
 tense border around rises, leaving a central, or umbilicated depression. 
 Some assert that the center is held down by a sebaceous gland or 
 hair follicle, while others aver that the depression is occasioned by 
 the remains of undissolved fibrous tissue in the nodule. However 
 this may be, the condition imparts a characteristic appearance to 
 the eruption for some time after fluid has appeared in the vesicle, 
 none other of the exanthematous fevers presenting such an appear- 
 ance during eruption. It is seen that each vesicle is a compound 
 one, consisting of a multilocular aggregation of fluid-cavities around 
 a common center, separated by delicate partitions, and if one of 
 these be pricked and evacuated, the others remain filled, unless 
 too much violence has been employed. The fluid filling these vesi- 
 TOCK or SMALL-POX c les is at first clear, but it soon 
 
 becomes opaque, and purulency 
 rapidly ensues, the vesicle being 
 converted into a yellow pustule, 
 the structure holding down the 
 center now becoming softened 
 and giving way, allowing the 
 umbilicated depression to rise 
 and present, as the apex of a 
 cone-shaped eminence. An are- 
 ola of hypersemic tissue now 
 surrounds the base of each pus- 
 tule, and when they are closely 
 set, the entire surface of the skin is reddened and congested. A 
 drying up of the pustules is followed by the formation of scales, 
 which dry most rapidly in the center, thus contracting and becom- 
 ing depressed, here constituting a second umbilicated stage. 
 
 The crusts consist of dried pus-cells and epithelial detritus. 
 After a time these are thrown off by the ordinary exfoliative process. 
 The suppurative action invades the true skin more or less deeply, 
 sometimes perforating it, and invading the subcutaneous structures. 
 Sloughing of the openings follows, leaving cavities which heal by cic- 
 atrization, cup-like depressions resulting; and a permanent pitting 
 of the skin is the final effect, when the cutis vera is deeply involved. 
 The mucous membrane of the upper air passages, mouth, fauces, and 
 oesophagus undergo modified changes of this character, and the 
 organs involved are hyperaemic, inflamed, and more or less ulcerated. 
 The tissue-changes common to protracted pyrexia are more or 
 less marked in nearly all the organs. In fatal cases, the blood is 
 dark and lacking in fibrin ; there are clots in the right ventricle of
 
 SMALL-POX. Ill 
 
 the heart; hemorrhagic extravasations are scattered about beneath 
 the mucous and serous membranes; the heart, lungs, liver, spleen, 
 and other internal organs are softened, and either pale, flabby and 
 swollen, or congested. The mucous membranes are congested, sof- 
 tened, ulcerated, their epithelium partially separated and covere 1 
 with a tenacious mucus, with here and there evidences of pustula- 
 tion, in small round spots covered with a false membrane or present- 
 ing signs of superficial ulceration. Peyer's patches are sometimes 
 congested, and the pleural cavity may be filled with serous fluid. 
 
 Symptoms. The symptoms of this disease vary so widely in 
 different cases that it will be best to give a general outline first, 
 and particularize afterward. 
 
 TKe period of incubation varies ordinarily from seven to twelve 
 days, though in exceptional cases it may continue as long as three 
 weeks. During this time it is unusual for the subject to complain of 
 unpleasant symptoms. 
 
 The onset of small-pox, even in mild cases, is usually abrupt and 
 severe. There is a marked chill, often nausea and vomiting, fever, 
 headache, and excruciating pain in the loins, this sometimes amounting 
 to a condition of temporary paraplegia. In children, there may be 
 convulsions at the start, with intervening coma. The febrile action 
 is usually high, the temperature reaching 103 or 104 F. in a few 
 hours, and ranging as high as 105 or 106, by the time the eruption 
 is out. However, the temperature is often much lower, and it may 
 not reach more than 102.5 elevation during the invasion stage. 
 The tongue is usually coated with a white covering, this often being 
 of a dirty, pasty character ; the pulse is accelerated and the skin is 
 moist, perspiration usually being present throughout the stage o 
 invasion. Soreness of the throat will now be complained of, the 
 voice being hoarse and husky, and the patient will complain of 
 pain in the pharynx and difficulty of swallowing. The headache, 
 which is severe in the beginning, gradually increases until the erup- 
 tion appears, when it subsides along with the fever, backache, and 
 other unpleasant features of the invasion stage. The stage of inva- 
 sion lasts about three days, and during this time the patient becomes 
 considerably prostrated, often being unable to rise from bed; and he 
 may be extremely restless, and sometimes delirious. During this 
 stage, the menses appear, in the majority of women affected, whether 
 it be at the proper time or not. 
 
 The stage of eruption begins when minute red points make their 
 appearance along the edge of the hair on the forehead, on the chin, 
 and other parts of the face. This may be preceded by a rosolous 
 rash, which appears during the invasion, upon the inner aspect of the
 
 112 
 
 SPECIFIC INFECTIOUS DISEASES. 
 
 arms and thighs. The eruption appears on the scalp first and 
 spreads to the face, then appears on the wrists, arms, chest, neck, 
 and other parts of the body, coming out lastly on the lower extremi- 
 ties about twelve hours after its appearance on the face. The pap- 
 ules show a disposition to arrange themselves in groups of threes 
 and fives, scattered more or less thickly over the surface, being most 
 abundant on the face. By the second day, the finger pressed upon 
 them receives the sensation as though a shot were buried in the 
 skin, the nodule at first being firm and resisting. This gradually 
 rises on the surface. Soon the nodule is observed to have become 
 umbilicated, and to contain a watery fluid. The fever, headache, 
 backache, and all other unpleasant symptoms, except the burning 
 and itching of the skin, now subside, and the temperature approaches, 
 though it does not reach the normal standard, and it remains down 
 until the stage of maturation has begun. Vesicles may now be seen 
 in the nares, mouth, and pharynx. 
 
 The stage of suppuration begins about the eighth day of the erup- 
 tion, or the tenth or eleventh day of the disease. The fluid in the 
 vesicles becomes turbid from the admixture of pus corpuscles on the 
 sixth day, and by the eighth the stage of suppuration is fully 
 established. A marked ring of tumefaction now surrounds the base 
 
 STAGE OF SUPPURATION IN CONFLUENT SMALL- POX. 
 
 of each pnstule, the tissues being reddened, oedematous, and swol- 
 len; where the pustules are thickly set, the entire surface swells 
 remarkably ; this is especially liable to be the case with the face 
 and extremities, where the eruption is most apt to be confluent. 
 The eyes are obliterated, to all appearance, the cheeks and nose are 
 frightfully deformed, while the entire face is covered by a hideous 
 mask of ripened pustules, and the hands and feet are swollen into 
 balls. A characteristic and sickish odor now emanates from the 
 patient, rendering him obnoxious to the sense of smell, and fright- 
 ful itching urges him to tear and scratch the affected surface, which 
 oozes quantities of purulent material. The throat is swollen and
 
 SMALL-POX. 
 
 113 
 
 painful, and sometimes deglutition is impossible. About the eighth 
 or ninth day of the eruption the pustule is fully formed, and the 
 stage of suppuration is completed. This stage is usually ushered in 
 by a chill, and the temperature rises, sometimes higher than during 
 the stage of invasion, though manifesting a distinctly remittent char- 
 acter, rising in the evening, and declining in the morning. A corre- 
 sponding increase in the pulse-rate attends, high fever with delirium 
 frequently being present. Sometimes there are typhoid symptoms; 
 the tongue is heavily loaded with a pasty, white coating, or is brown 
 and dry; the patient is restless and delirious, lies in a state of coma, 
 or mutters incoherently ; the pulse is feeble and fluttering, or quick 
 and tremulous ; there is diarrhoea with involuntary evacuation, and 
 general prostration of all the vital forces. By the eleventh or twelfth 
 day of the illness, desiccation begins, and the fever and inflamma- 
 tion subside. 
 
 The stage of desiccation is occupied in the drying up and casting 
 off of the pustules in the form of crusts. This process begins on the 
 scalp and face, where the eruption first appears, and follows the 
 course of the outbreak. The redness, tenderness, and oedema of the 
 skin now begin to subside, and the purulent material becomes black- 
 ened and hardened at the apices of the pustules, forming crusts, 
 
 which become puckered, contracted, 
 and depressed in the center. Grad- 
 ually, the skin assumes its normal 
 color and appearance between the 
 pustules, and the scabs loosen and 
 separate, each leaving a reddish- 
 brown stain with a sunken center, 
 which remains reddened for five or 
 six weeks and then disappears, or 
 remains permanent as a whitened 
 scar. With the fall of the crusts, 
 the appetite and ability to sleep 
 return, and the patient begins to 
 regain health and strength. 
 
 Authorities on practice usually 
 describe small-pox under three 
 forms, viz., (1) variola vera, (2) vari- 
 ola hemorrhagica, and (3) varioloid. 
 
 STAGE OF DESICCATION IN VABIOLA CONFLUKNS. Ya,riolob VCTd is divided into two 
 
 divisions, depending upon the amount and extent of the eruption, 
 namely, discrete and confluent. 
 
 9
 
 114 
 
 SPECIFIC INFECTIOUS DISEASES. 
 
 The discrete variety is characterized by a scattered eruption, even 
 on the face and hands, where it is most marked. Though the symp- 
 toms of the stage of invasion may be severe, the eruption is not 
 attended by severe suffering, and the secondary fever is much modi- 
 tied, as compared with the confluent form, the normal temperature 
 being reached several days earlier, and there being little liability of 
 disfigurement from pitting. 
 
 Confluent small-pox. This is a much more severe form of the dis- 
 ease than the discrete variety. The initiatory stage is shorter than 
 that of the discrete form, and the symptoms are more violent, the 
 temperature rising as high as 107 or 108 R, the pulse being 
 
 DAY 
 
 OF 
 
 DISEASE 
 
 1 
 
 2 
 
 J 
 
 4 
 
 cT 
 
 
 
 V 
 
 3 
 
 9 
 
 10 
 
 11 
 
 12. 
 
 U 
 
 U 
 
 IS 
 
 16 
 
 1J 
 
 if 
 
 101 
 
 106 
 
 1CS" 
 1C4 
 1CJ 
 1C 
 101 
 100* 
 39 
 '3S C 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 A 
 
 A 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 A 
 
 
 
 
 
 
 A 
 
 
 
 
 
 
 
 
 
 
 ( 
 
 
 
 
 
 
 
 
 A; 
 
 
 
 
 
 
 
 
 
 
 
 
 9 
 
 
 
 
 
 / I A 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 r 
 
 V/" 
 
 or 
 
 v\ 
 
 x\ 
 
 
 
 
 
 
 
 
 
 
 / 
 
 ^^ 
 
 j 
 
 
 
 
 
 fcn 
 
 A 
 
 
 
 
 
 
 
 
 
 r 
 
 
 
 
 
 
 
 
 
 v^ 
 
 ^ 
 
 .^ 
 
 
 
 E 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 V 
 
 s^ 
 
 ^^^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 STAGE OF 
 INVASION 
 
 3TAGEOF 
 PAPULES 
 
 STAGE OF 
 VESICLES 
 
 -STAGE OF 
 PUSTULES 
 
 STAGE OF 
 CHU3T3 
 
 ^TAGE Or 
 DESICCATION 
 
 TEMPERATUBB IN A CASE OF SMALL-POX. 
 
 correspondingly increased in frequency. The patient may be seized 
 with convulsions, or enter rapidly into delirium or coma, from the 
 very start. Children, especially, are apt to be seized with violent 
 and repeated convulsions. The tongue is loaded with a dirty-white 
 fur, or there is obstinate gastric irritation with persistent vomiting. 
 The eruption appears by the second day, and the red points are 
 closely set, the entire surface being covered early with a reddened tint, 
 interspersed with numerous deep-red points. The throat symptoms 
 are marked and distressing, the patient suffering in the early stage 
 with severe pain in the pharynx, and difficult deglutition, as well as 
 laryngeal irritation, attended by hoarseness and cough. These 
 symptoms are much aggravated during succeeding stages, oedema of 
 the glottis, or extensive sloughing of the tissues of the throat, prob- 
 ably succeeding. The eruption forms large bullre, with flattened sur-
 
 SMALL-POX. 115 
 
 faces on the face, covering it as a complete mask; and confluent 
 patches may appear on portions of the body, though the confluent 
 eruption is chiefly on the face. The countenance is so swollen as to 
 be unrecognizable, and the suffering is intense, if the patient be con- 
 scious. After desiccation, if the patient survive, large, contracting 
 cicatrices mark different portions of the face, the eyes are liable to 
 be destroyed from severe keratitis, and other scarring results. Few 
 recover from malignant attacks of this form. Reaction is not 
 marked in the suppurative stage of this form, the reactive powers 
 being too nearly exhausted; and the temperature may even be sub- 
 normal. The pustules may contain blood instead of pus, though 
 this does not comprehend the hemorrhagic form of the disease. 
 
 The hemorrhagic form of small-pox is characterized not only by 
 the exudation of blood into the pustules, but there are extravasation 
 of blood within the skin and hemorrhages from various mucous sur- 
 faces. H^re the symptoms of malignancy manifest themselves from 
 the very start, and the patient is liable to die from exhaustion or 
 septic poisoning, before the completion of the stage of eruption. 
 
 Varioloid is an imperfect form of the disease, in which the stages 
 are all but faintly marked, and in which the eruption is not fully 
 completed. The disease runs a mild course, and the patient recovers 
 without pitting, and without much discomfort. It occurs in persons 
 who are not very susceptible to the disease, or who have been pro- 
 tected by vaccination. That it is genuine small-pox, so far as the 
 infectious principle is concerned, however, is attested by the facts 
 that an attack affords immunity from visitations of small-pox, and 
 that a susceptibl : and unprotected person may contract variola in 
 severe form from one affected with it Many of the cases of small- 
 pox that are met in modern time are nothing more than varioloid, the 
 almost universal resort to vaccination having partially, at least, pro- 
 tected nearly every one from its olden-time ravages. 
 
 Complications. The severe complications which formerly attended 
 this disease are not so common in these days, probably because the 
 treatment has become more rational, as well as the affection less 
 severe. Probably the most numerous of these occur in hospitals, 
 where many patients are congregated. Severe cases, however, are 
 liable to be complicated with destructive inflammation of many dif- 
 ferent parts and organs. 
 
 Pulmonary complications are probably the most serious and fre- 
 quent. (Edema of the glottis and asphyxia, unless tracheotomy be 
 performed, frequently occurs in severe cases. Severe bronchitis, 
 with extension of the inflammation to the small tubes, is likely to 
 occur in children. Pneumonia not unfrequently occurs, and effusion
 
 116 SPECIFIC INFECTIOUS DISEASES. 
 
 into the pleura! sac from involvement of the pleura, is then apt to 
 follow. A sequel to severe pulmonary inflammation may be peri- 
 cardial inflammation, resulting in hydrops pericardii or fatty degen- 
 eration of the walls of the heart 
 
 Cellular abscess involving the cutaneous tissues may result from 
 the extension of boils through the skin, in scrofulous children. lu 
 such cases extensive gangrene may attend the suppurative action. 
 
 Sloughing of delicate parts, such as the scrotum and labia, may 
 occur in children, especially those of scrofulous tendency, and deep- 
 seated abscesses may be attended by phagedenic ulceration, upon 
 their discharge. 
 
 Inflammation of the conjunctiva, with severe ulceration of the 
 cornea, often with destruction and evacuation of the humors, was 
 once quite a common complication. 
 
 Otitis, with destruction of the structures of the internal ear and 
 extensive ulceration of the osseous portion, is among the possibil- 
 ities of severe cases of this disease. 
 
 Suppuration of the joints; destruction of the hair follicles, rendering 
 the patient permanently bald; bed-sores; meningitis; and paralysis, 
 may be looked for in very bad cases. 
 
 Diagnosis. The history of the case may throw some light 
 upon it, where a diagnosis is called for early in the disease. Is the 
 patient an immigrant, recently from some public route of travel, or 
 has he been exposed to the influence of fomites of such character? 
 Or, is there any account of suspicious eruptive fever in the neighbor- 
 hood? The fact that the patient has been vaccinated does not mili- 
 tate very much, as its protection may have passed away. The onset 
 of variola is sudden, abrupt. The temperature rises rapidly, the 
 pain in the loins is excruciating, and the tongue is coated white, and 
 not of the strawberry character of the scarlatina tongue. The erup- 
 tion is also much more "shotty" in feel than measles, and it is more 
 macularin appearance than scarlatina; not so punctate. The catar- 
 rhal symptoms are not so marked early in measles, and the erup- 
 tion does not spare the nose or region of the mouth, as does scarla- 
 tina. When the vesicles are developed, there can be no mistake. 
 
 Prognosis. In these times, the prognosis of small-pox is much 
 more favorable than formerly. If treatment be at all modern, few 
 cases take on the severer form, and the pitting and other sequelae 
 are slight Unfortunately, most cases are left to the care of the 
 health officer, who is usually of the kind which employs the most 
 unsuccessful therapeutic measures; but still the mortality is usually 
 low after all, owing to the modified form in which the disease 
 generally appears.
 
 SMALL-POX. 117 
 
 When the confluent form is present, the prognosis is much more 
 grave; and hemorrhagic variola is exceedingly fatal, very few recov- 
 ering. There are so many complications of serious nature attending 
 coufluent small-pox, that death from exhaustion is liable to occur 
 during the third week, after the infectious disease has run its 
 course. 
 
 Age and sex determine something in regard to mortality; infants 
 and old persons are bad subjects, and likely to die if the disease is 
 severe. Women do not endure the disease as well as men, probably 
 owing to the almost inevitable menstrual disturbance. A severe 
 invasion is not always indicative of a confluent eruption and serious 
 after-effects, as the eruption may be slight, and the remaining por- 
 tion of the case mild. 
 
 Hemorrhages occurring from several of the mucous surfaces 
 different organs may be considered indicative of serious results; 
 or early extravasation of blood into the vesicles, or into the skin. 
 
 Pregnancy is an unfavorable condition for a patient with small- 
 pox. (Edema of the glottis is a complication that offers poor hopes 
 of recovery, as tracheotomy is imperatively demanded, and this 
 becomes a serious operation under such circumstances. 
 
 Treatment. The prophylactic treatment will consist of vac- 
 cination, immediately after exposure, or as soon as possible. If 
 this should fail to arrest the disease, it promises to at least lessen 
 its severity. The diet should be regulated during the stage of incu- 
 bation, so that all greasy and stimulating food may be avoided, light, 
 farinaceous foods and fruit only, being allowed. Plenty of pure air 
 is important in this disease, and it should be seen that rooms occu- 
 pied by small-pox patients are well supplied with this essential to 
 successful treatment. Loomis asserts that the most satisfactory 
 treatment employed in small-pox epidemics with which he was con- 
 nected, was administered in barracks, where there were snow-drifts 
 on the floor of the wards occupied by the patients. Pent-up air is 
 quite likely to develop bad cases out of those which might otherwise 
 be light, and must be avoided. 
 
 The medicinal treatment will consist in following out the simplest 
 indications. The morbid changes which occur in the skin, develop 
 the serious aspects of all bad cases, and if these can be modified or 
 controlled, a mild course is assured. Remedies which lessen the 
 initial hypersemia will modify the later action and ameliorate symp- 
 toms, if they do not shorten the disease. 
 
 Eclectics will resort to the special sedatives early, even before 
 the true character of the disease is fully developed ; and this method 
 is the philosophical plan, as it will control, to a certain extent, the
 
 118 SPECIFIC INFECTIOUS DISEASES. 
 
 cutaneous hyperaBmia. The whole class of remedies of this group- 
 aconite, veratrum, gelsemium, jaborandi may be applicable, in 
 treating several cases. But wherever there is not gastric irrita- 
 tion to contraindicate it, jaborandi will be the preferable one, on 
 account of the directly sedative influence it possesses on the skin. 
 Two or three drachms of the specific medicine, or some other relia- 
 ble preparation, should be added to half a glass of water, and a t'-.-i- 
 spoonful should be administered every hour, as soon as the initial 
 fever begins. This will be an excellent prescription to follow until 
 the fever subsides, as its cooling, soothing influence upon the skin, 
 through the systemic circulation, will be highly appreciated by 
 the patient. 
 
 But the frequent occurrence of nausea and vomiting will pre- 
 clude such treatment in many cases, and something more adapted 
 to gastric irritability will be demanded. Here we may expect tie 
 best results from rhus tox. and aconite, in the usual proportions, 
 five or six drops of aconite and fifteen or twenty of rhus to four 
 ounces of water, dose, a teaspoonful, for an adult, every hour. 
 
 The sodium sulphite tongue excessive acidity with sepsis, as 
 indicated by the dirty pasty coating should not be disregarded 
 in the treatment. The nearer we can bring the condition of the 
 patient to a standard of health in a general way, the less severe will 
 be the later stages of the disease. The brown coating on the tongue 
 suggesting sulphurous acid may occasionally be present, and the 
 suggestion should be heedei. As an intercurrent remedy, to fortify 
 the blood against septic changes, and also fortify the tissues against 
 suppuration and sloughing, we certainly cannot do better than 
 administer echinacea. Ten drops of echinacea should be given 
 every second hour throughout the course of the disease, as it will 
 be almost certain to modify the tendency to pitting, as well as pro- 
 vide against septic changes liable to attend the extensive accumula- 
 tion of purulent material upon the cutaneous surface. 
 
 In no other form of eruptive fever is the use of baths, to cleanse 
 and soften the skin, so important as here. From the very beginning, 
 the surface should be sponged frequently, with warm water and unir- 
 ritating soap, such, for instance, as Loyd's Asepsin Soap, or some 
 mild and cleansing preparation of the kind. A bath of this charac- 
 ter should be administered several times a day by sponging the sur- 
 face, and after the eruption it should be continued, with the free 
 use of some emollient application, to prevent the skin from harden- 
 ing and imprisoning the pus, during the stage of suppuration. 
 
 Pitting of the face is to be avoided, if possible, and to provide 
 against this the skin over the part should be kept especially moist,
 
 SMALL-POX. 119 
 
 and the air and light should be excluded. For this purpose a mask 
 should be worn, this being fashioned from a piece of muslin, of 
 appropriate shape, with openings for the mouth, nose, and eyes. 
 This should be wetted every hour, in a dilution of an ounce each of 
 specific echinacea and glycerine, in six ounces of water. Each time 
 the mask is removed for saturation, the face should be well sponged 
 with tepid water rendered slightly alkaline with mild soap. Or, 
 the following solution may serve better to control the itching: 
 # Resorcin ji, glycerine fss, water f vi, M. Apply with soft sponge, 
 every hour. 
 
 Muscular pain, during the initiatory and eruptive stages, may 
 demand special attention. Jaborandi is a verv applicable remedy, 
 and, as it has been recommended for the initial fever, it will meet 
 this indication as well. However, sometimes we may find it an 
 assistance to resort to cimicifuga or phenacetin. Rhamnus cah 
 may be found to answer well here, though where there is any ten- 
 dency to diarrhoea it would be better to depend upon some other 
 remedy. The backache may also be much relieved by the 'applica- 
 tion of hot cloths to the part, though the treatment for muscular 
 pain will probably prove sufficient. 
 
 Complications must be met with appropriate treatment. (Edema 
 of the glottis will demand prompt tracheotomy. Pneumonia should 
 be treated by packing the chest with cloths wrung out of tepid water, 
 in addition to proper internal agents, though echinacea will be as 
 appropriate as any remedy iu fiis case. Boils and abscesses should 
 be opened early, and well cleansed with diluted tincture, or specifics 
 echinacea. Mouth and throat complications will be pretty well 
 provided for by the general treatment. 
 
 There may be times when a stimulant may be demanded to pre- 
 vent fatal collapse, though where echinacea is used properly through- 
 out the course of the disease alcoholic stimulants will be rather 
 inefficient, provided it should fail to sustain the vitality. However, 
 should signs of sinking occur, the judicious exhibition of brandy or 
 whisky is regarded as good treatment in some quarters, and cer- 
 tainly cannot be objected to in desperate cases. However, alcoholic 
 stimulants, usually, should be tabooed, as their stimulating effects are 
 calculated to aggravate inflammatory action and its later result, 
 suppuration. 
 
 During the stage of desiccation, daily baths of warm water will 
 assist in softening the crusts and render the skin more soft and pli- 
 able. After each bath the skin should be well oiled, the inunction 
 assisting in the process of desiccation, and also acting as a protection 
 to the weakened cutaneous surface, guarding against chilling of the
 
 120 SPECIFIC INFECTIOUS DISEASES. 
 
 cutaneous capillaries. The diet should be mild and unstimulating, 
 but nourishing and assimilable. 
 
 SUPPLEMENTAL THERAPEUTCIS. Some think highly of inaugurating 
 the treatment with a thorough alcoholic vapor bath. This is doubt- 
 less excellent to relieve the lumbar pain, while it may assist internal 
 agents in modifying the entire course of the disease. A thorough 
 emetic may be employed with good results in malignant cases marked 
 by drowsiness with tendency to coma, and cold extremities with fee- 
 ble pulse. Some practitioners believe in small-pox specifics. Two 
 %gents prominently recommended by their respective admirers are 
 timicifuga and sarracenia purpurea pitcher plant. In the use of 
 either of these a decoction is preferred, the dose being a tablespoon- 
 ful, repeated every three or four hours. 
 
 VI. VACCINATION. 
 
 Definition. The introduction of cow-pox into the human sys- 
 tem, as a protection against small-pox. 
 
 History. In 1776, Dr. Edward Jenner observed that in some 
 of the northern counties of England, employe's of the dairies there 
 who suffered from a certain form of ulcer upon their hands appar- 
 ently contracted from cows while milking, possessed immunity from 
 small-pox. Like many other medical discoveries, however, this fact 
 was known to the people a long time before Jenner noticed it, and 
 his attention was probably first called to it through this medium. 
 History has it that a Holsteiu schoolmaster vaccinated three pupils 
 in 1771, and in 1774 an English farmer vaccinated his wife, because 
 of his belief in the power of bovine virus to prevent small-pox, as 
 seen in his dairy-maids. 
 
 Jenner maile his first vaccination on a man in 1796, and published 
 his belief in the doctrine first in 1798. Waterhouse, of Boston, 
 introduced the practice into this country in the following year, and 
 in 1800, it was introduced into France. For the first six years after 
 the announcement of his discovery, Jenner was subjected to the most 
 outrageous villification and abuse imaginable by his countrymen, all 
 over Great Britain. He was attacked by the leading physicians and 
 sujgeons, reviled and denounced from the pulpit by the clergy, 
 and scoffed at, as the "crack-brained doctor," by the common people. 
 Placards, containing caricatures of Jenner, were posted throughout 
 the principal streets of London and other large cities and towns of 
 Great Britain, and he was treated to many other indignities. Within 
 six years, however, there was a revolution of sentiment, Jenuer, by 
 this time, having compelled the profession, by his success, to aJopt
 
 VACCINATION. 121 
 
 his views; and soon afterward, vaccination became generally prac- 
 ticed for the prevention of small-pox. 
 
 But the opposition did not altogether cease here. In spite of 
 the fact that almost the whole world was convinced, when small-pox 
 was ravaging Europe and there was so favorable au opportunity to 
 observe the contrast between those protected and those unprotected, 
 a small minority maintained their opposition; and there exists to-day, 
 in England, and to a limited extent in America, a class of people 
 calling themselves anti-vaccinationists. They assert that they do 
 not object to the vaccination of others, but they cry oat against com- 
 pulsory laws demanding it upon themselves. They claim the privi- 
 lege of being let alone, and being allowed to face small-pox without 
 the protection of kme-pox. They dwell upon tales of horrible 
 diseases transmitted by vaccination, such as syphilis, scrofula, skin 
 diseases, etc., and of erysipelas and other serious conditions being 
 transmitted or developed, through the operation. In twenty-six 
 years, I have never seen anything worse than a few mild cases of 
 erysipelas, though there doubtless are exceptional instances where 
 vaccination may result very injuriously. Accidents may sometimes 
 occur in the simplest affairs of life. I once knew a man to die 
 through having a corn cauterized with sulphuric acid ; but this need 
 not forever taboo the practice of attempting to destroy corns. The 
 kind of freedom desired by the anti-vaccinatonists would be like 
 that which permitted a man to burn down his own house whether it 
 joined that of a neighbor or not; welfare of the neighbor's house, in 
 his opinion, seemingly, ought to hold no comparison to his own 
 personal freedom. The proper kind of liberty is that which confers 
 the greatest good upon the greatest number. However, no doubt 
 the anti-vaccinationists have been beneficial to mankind. Their 
 outcry has been conducive to greater caution in the preparation and 
 introduction of material for use in vaccination, in order that bad 
 results may be avoided. Non-humanized virus is now largely used, 
 it being obtained by inoculating healthy calves, the management 
 of vaccine farms being followed as a special business. The material 
 is usually furnished to physicians through the drug trade. 
 
 However, non-humanized virus soon loses its specific contagium, 
 and, if the material is not of recent origin, it is very liable to fail to 
 produce the desired effect. Even when fresh, it is estimated that it 
 will prove successful in only about 70 per cent of the cases treated. 
 According to my own observation, 50 per cent would be a better esti- 
 mate. Where several children are vaccinated at the same time in a 
 certain family, and the operation proves successful in ono, it cannot 
 be improper to vaccinate the others of the same family from this
 
 122 
 
 SPECIFIC INFECTIOUS DISEASES. 
 
 vesicle, provided it has developed a normal course; for humanized 
 virus is much more reliable than auimal. If symptoms of ery- 
 sipelas or severe inflammation should develop daring its course, 
 there would be good reason for avoiding this virus, and it would 
 not be likely to contain the element of cow-pox infection. It would 
 be a better plan, however, not to vacciuatu those of another family, 
 as, if there should be any objectionable taint in the first, it might be 
 conveyed to others, in this manner. 
 
 Vaccine virus is now usually supplied to the market in the shape 
 of "points," these being thin slips of pointed bone, the tips of which 
 have been dipped into the contents of a Lovine cow-pox vesicle, and 
 dried, for the market. 
 
 Vaccination consists in moistening the tip or point of one of these 
 in pure water, ana with it, scratching the cuticle away from over an 
 area of about a fourth of an inch in diameter on the arm, above the 
 insertion of the deltoid muscle. The scratching should be done so 
 
 that one series of scratches will cross that of another, and it should 
 be continued until slight capillary hemorrhage appears upon the 
 abraded surface. When this occurs, the point should be again 
 moistened, and both sides of the portion covered with virus should be 
 carefully and sedulously rubbed upon the abraded surface, until the 
 material has been thoroughly incorporated with the oozing fluid, and 
 forced into the ruptured capillaries. The operation of vaccination' 
 from the arm of one subject to that of another, is very simple. A 
 needle may be thrust inlo the ripened vesicle, and afterward pushed 
 into the skin of the one to be vaccinated. To render the infection 
 more certain, the operation may be repeated, the point being intro- 
 duced a second time into the first puncture made in the arm of the 
 person to receive vaccination. 
 
 If the vaccination passes through the following stages, it may be 
 considered as having' exerted a protective influence upon the subject: 
 Upon the third day after the vaccination, there will be developed 
 upon the site of the operation a small red point or papular elevation, 
 which becomes a bluish-white vesicle, and upon the fifth day there 
 will be developed around this a yellow margin. This vesicle increases 
 slowly in size up to the eighth day, when it is seen to be umbili- 
 cated. A reddish areola now appears, developing around it, this
 
 CHICKEN-POX. 123 
 
 showing faintly on the seventh day, and being very distinct by the 
 ninth. This areola continues to increase in size, spreading around 
 the vesicle for three or four days more, until, by the eleventh or 
 twelfth day it may be one or two inches in width from the vesicle, in 
 all directions, and the redness be marked. The arm will now be 
 swollen and elevated about the vesicle, the neighboring axillary 
 glands will be hardened and enlarged, and the arm and axillary 
 region somewhat tender and painful The pustule ruptures on the 
 twelfth or thirteenth day, and by the fifteenth the crust is found to 
 have assumed a brown color, which deepens until the seventeenth or 
 eighteenth. This falls off spontaneously on the twentieth or twenty- 
 fifth day, leaving a purplish-red scar, which gradually turns white. 
 Meantime, after the rupture of the vesicle, the reddened areola grad- 
 ually fades away, and the swelling and tenderness subside, until "by 
 the time of the fall of the crust the soreness and inflammation 
 have completely disappeared. 
 
 If, instead of the vesicle on the eighth day a pustule be formed, 
 a disturbance of the regular development of a vaccine vesicle is 
 announced, and the vaccination cannot be considered as protective. 
 The intervention of erysipelas is very liable to destroy the specific 
 character of the vesicle, and interfere with the protective effect of 
 the operation. 
 
 Yaccination should be resorted to during the first year of life, 
 and again every seventh year until puberty; it should then be 
 repeated again, as the protection gradually dies out. After this, and 
 before as well, vaccination should be repaated upon the advent of 
 every case of small-pox into the neighborhood. 
 
 VH. CHICKEN-POX. 
 
 Synonym. Varicella. 
 
 Definition. A mild, acute, infectious, eruptive disease, chiefly 
 affecting children, characterized by a vesicular rash involving the 
 superficial layers of the epidermis, attended by slight febrile dis- 
 turbance, no important sequelae, and favorable prognosis. 
 
 Etiology. This is a disease of infancy and childhood, in a 
 large majority of cases, though it may occur during adolescence, and 
 even in adult life, in rare cases. However, such a large majority of 
 cases occur during and before the first two or three years of age, 
 that the physician seldom sees it in later life, especially after the 
 sixth year. It is said that infants under six months of age enjoy a 
 certain amount of immunity. It does not occur in marked epidemics, 
 as some of the other eruptive fevers, but is liable to appear in large 
 cities at all seasons of the year and at all times, its appearance seem-
 
 124 SPECIFIC INFECTIOUS DISEASES. 
 
 ing to be sporadic in character, in some cases. The disease is con- 
 tagious, the respired air being the medium of contagion, probably, 
 though it is asserted that it may be conveyed by a third person. 
 Though efforts have been made to isolate the microorganism of this 
 contagion, they have so far been f utile. For a long time there was 
 much confusion as to the identity of this disease, many believing it 
 to be a modified form of small-pox, identical with the irregular cases 
 of varioloid which occur after partial protection by vaccination. 
 But the fact that such cases may originate small-pox in the unpro- 
 tected, while varicella never produces such a result, establishes the 
 identity of this disease as a distinct affection. 
 
 Pathology. The only distinguishable morbid condition aris- 
 ing from this disease is that occasioned by the cutaneous eruption. 
 This consists of numerous minute red spots, varying from twenty- 
 five to two hundred, which soon become small vesicles containing a 
 clear, watery, alkaline fluid. These rest on a hypersemic base, though 
 in many cases the areola is absent. There seems to be a division of 
 opinion, as to the internal structure of these vesicles, some main- 
 taining that they consist of a single cavity, while others assert that 
 they are divided into compartments by delicate partitions. From 
 other testimony, it seems that some consist of single compartments, 
 and others may be divided. As the superficial layers of the skin 
 only are involved, the structure is so delicate that the vesicles do not 
 bear much investigation without rupturing. They arise from an 
 exudation underneath the superficial layers of the epidermis, lift- 
 ing them from the rete malpighii, this layer not being involved. 
 The eruption may, and often does, involve the mucous membrane of 
 the mouth and throat; and even the alimentary canal may suffer. 
 Sometimes, however, the deeper layers are involved, and even the 
 true skin may become ulcerated, and pitting result. However, this 
 is more likely to be the effect of scratching. 
 
 Symptoms. The period of incubation usually occupies from 
 ten to fifteen days. The invasion stage of varicella is more generally 
 absent than observable. Generally the first symptom noticeable 
 will be the rash, and this will appear while the child is playing 
 about, and making no complaint. The physician is then summoned, 
 because the mother becomes alarmed, and desires a diagnosis made 
 of the condition. Again, the rash may be attended by a slight fever- 
 ishness, which occasions peevishness and irritability. The temper- 
 ature may be found at 101 or 102 " F., though rarely higher, and 
 not often as high as 102. Still, there may be some complication in 
 other cases, which will occasion considerably more elevation of tem- 
 perature, such, for instance, as malarial fever. I have seen this
 
 CHICKEN-POX. 125 
 
 disease complicated in this way and attended by a regular remittent 
 fever, with morning remissions and afternoon exacerbations, the 
 temperature reaching 103 and more. In such cases the eruption 
 may be the source of considerable discomfort from the itching 
 occasioned, when the fever is at its height. Sometimes the eruption 
 in the mouth becomes a marked source of irritation, much smarting 
 and burning being occasioned when the patient partakes of food. 
 
 The eruption appears at first as small, red, slightly-elevated spots, 
 resembling the rose-rash of typhoid fever in appearance, which come 
 out first on the upper part of the back and chest, and spread rapidly 
 over the body, face, scalp, and extremities. The face, especially the 
 forehead and temples, furnishes the most characteristic and abun- 
 dant eruption. There is great variability as to the abundance of the 
 eruption, some cases furnishing only a few scattered vesicles, while 
 others cover the entire cutaneous surface thickly. A few hours after 
 the maculae or hypersemic spots appear, a small vesicle can be 
 observed in the center of each macula, and this quickly enlarges to 
 its full size. When developed fully, the vesicles are ovoid or round 
 in form, and vary in size from that of a pin-head to that of a small 
 pea. They are thinly covered, being quite superficial, incased only 
 by the outer layers of the epidermis, and the covering is on 
 the stretch, while there may be a slight zone of redness about 
 the base. These are so shiny and glistening in many cases as to 
 resemble drops of water on the skin. They are sometimes congre- 
 gated into small groups, resembling zoster. The fluid in these 
 vesicles is clear as water at first, and invariably of an alkaline reac- 
 tion. As the vesicles mature, they may become cloudy and yellowish 
 from the presence of a few pus-cells, but they never become purulent. 
 Fresh crops of maculae succeed each other by a few hours two or 
 three times, so that the vesicles may be observed in all stages of 
 progress over a limited area, though those which appear first are 
 the most perfectly formed, many of the later masculse never pass- 
 ing beyond the vesicular stage, but fading away soon after their 
 appearance. Others form small and imperfect vesicles, but these do 
 not arrive at maturity. By the second or third day the eruption 
 begins to decline, the vesicles becoming wrinkled and flaccid, from 
 partial absorption of their contents. Others grow tense and burst, 
 and still others are ruptured by the patient, while scratching. As 
 they dry up, they form thin, brownish crus.ts. In a few days, the 
 crusts fall off or are scratched off, leaving reddish patches of skin at 
 their sites, which gradually assume the normal tint. In some cases 
 ulceration of the skin occurs, and permanent, pitted scars remain. 
 
 If the mouth and throat are examined during the stage of erup-
 
 126 SPECIFIC INFECTIOUS DISEASES. 
 
 tion vesicles may be found here, they being most numerous on the 
 palate, hard and soft. Thesa soon rupture, leaving small ulcers, 
 which sometimes become quite irritable. Sometimes the cervical 
 glands are slightly enlarged and tender. The prepuce and vagina 
 may become the seat of vesicles, and when this is the case, painful 
 urination, and smarting following the act, are complained of. A 
 severe diarrhoea occurring during this stage would suggest the pres- 
 ence of the eruption upon the intestinal mucous membrane. 
 
 English authors describe a form of varicella which they term 
 varicella gangrenosa, and which is characterized by the appearance of 
 gangrene in the vesicles, these spreading and manifesting a tendency 
 to sloughing, instead of drying up, as in ordinary chicken-pox. The 
 gangrenous vesicles are the seat of deep ulcers, which penetrate the 
 skin and attack subcutaneous structures. It is said to be very fatal, 
 pyaemia and exhaustion resulting, in many cases. It seems that the 
 disease is not confined to puuy, illy-nourished children, but may 
 attack the robust aud well-conditioned. Epidemic influences and 
 unsanitary surroundings may be responsible for it. It has never 
 been reported in the United States, to my knowledge. 
 
 Diagnosis. The diagnosis of varicella would not be such an 
 important matter, were it not for the fact that varioloid and this 
 disease are frequently confounded; and such a mistake might place 
 the practitioner in au awkward dilemma, provided he diagnosed a case 
 of varioloid as varicella, and caused the exposure of a neighborhood 
 to liability of small-pox. And it is a matter of history that for quite 
 a long time varicella was not recognized as a separate disease at all, 
 but was considered as a variation of varioloid. Care should be 
 exercised, then, in doubtful cases, that the physician does not jeop- 
 ardize his reputation by a blunder in this direction. The imper- 
 fectly formed vesicles of varioloid may resemble those of chicken- 
 pox, and confusion arise, unless some other important particulars of 
 development be taken into consideration. It will be remembered 
 that the eruption of varicella appears at first upon the upper part of 
 the body, and spreads from there to the face, while variola, like 
 small-pox, appears first on the forehead and face. The invasion stage 
 of varioloid is also more marked than that of chicken-pox, there 
 often being vomiting, backache, headache, and considerable elevation 
 of temperature ( two or three days before the appearance of the erup- 
 tion), while in varicella, if any period of invasion be noticed at all, 
 it will not continue more than a day before the appearance of the erup- 
 tion. The age of the person attacked also will enable one to arrive at a 
 pretty positive conclusion, for though varioloid might attack very small 
 children, varicella is a disease that would hardly be expected at all,
 
 CHICKEN-POX. 127 
 
 to attack adults. An eruption, then, of the character of that of 
 chicken-pox found upon an adult would suggest varioloid, though 
 it would not be positive proof. The maculae of varicella are soft, 
 and are seen to be merely hypersemic spots in the skin when the 
 surface is put upon the stretch, while the papules which first appear 
 iu varioloid are more deeply imbedded, and impart a shotty feel to 
 the finger when pressure is made upon them. Also, they develop 
 slowly, the papular stage continuing three or four days. It has 
 been asserted that certain syphilitic eruptions resemble varicella; 
 but the multiform character of syphilitic eruptions, their chrouic 
 course, and the absence of pronounced fever, ought to distinguish 
 this disease from varicella, to the most superficial observer. 
 
 Prognosis. Varicella is the most benign of all the exanthema- 
 tous fevers. It is so mild that little need of medication arises in 
 the majority of cases, though unpleasant symptoms may appear, call- 
 ing for treatment. I have never seen a case which occasioned me 
 the least anxiety, and would consider that one must have been 
 very badly treated indeed, if it did not progress favorably from the 
 beginning. A few permanent cicatrices may remain upon the face, 
 as the result of violence during the stage of eruption, but these will 
 not be so numerous as to constitute disfigurement, and they will 
 occur in but few cases. 
 
 Treatment. The treatment of varicella will not be a matter 
 that will be of much moment to the physician, many times, as his 
 services will usually be required more for diagnostic purposes than 
 for treatment. If a febrile condition is found to be present, with 
 restlessness and irritability, a combination of aconite and rhus tox., 
 in water, in appropriately minute quantity to act as a gentle sedative 
 without disturbing the circulation, will be found serviceable. Where 
 the vesicles have appeared in the mouth, and cause unpleasant smart- 
 ing upon the taking of food or drinks, minute doses of phytolacca 
 and aconite will be useful. For a child two or three years of 
 age, two or three drops of Lloyd's aconite and ten or fifteen drops of 
 phytolacca added to four ounces of water, will furnish enough medi- 
 cine, when a teaspoonful is administered every two hours. Where 
 there is marked periodicity in the fever, one or two grains of arseni- 
 afe of ijuinia, 3x trituration, may be given every four hours, until 
 the periodicity ceases, which will be in two or three days. Itching 
 of the skin may be quieted with alkaline baths, or the application of 
 the following mixture : R Resorcin one drachm, alcohol one ounce, 
 glycerine half an ounce, and water ten ounces. Mix, and apply with 
 a soft sponge, or linen cloth. Lar^e vesicles upon the face should be 
 emptied early, the openings being well sponged, to anticipate pitting,
 
 128 SPECIFIC INFECTIOUS DISEASES. 
 
 and prevent itching, and scratching which might result in scarring. 
 During the course of the disease, an even temperature should be 
 maintained in the room occupied, and the patient protected from 
 draughts of cold air. Physic should be tabooed, as well as the use 
 of stimulating food. 
 
 VHI. SCARLET FEVER. 
 
 Synonyms. Scarlatina; Scarlet Bash. 
 
 Definition. An acute, contagious disease, characterized by 
 inflammation of the skin and mucous membranes, accompanied bv 
 an eruption of bright-red color (from which the disease takes its 
 name), a high temperature, a tendency to destructive inflammation 
 of the throat, and an unusual predisposition to nephritis and des- 
 quamation of the cuticle. 
 
 Etiology. The cause of scarlet fever is a specific infection 
 presumably a microorganism, though it has never been isolated. 
 It may be communicated directly, from one affected, or through a 
 third person. The epidermis seems to carry and preserve the poi- 
 son for months and even years, and the disease is most commonly 
 disseminated by desquamated particles, which find lodgment in 
 clothing, carpets, upholstery, etc. Mail-packages, accidentally con- 
 taining it, may convey the disease for long distances, and travelers 
 may carry it in their baggage, from continent to continent. Another 
 medium of transmission is hair, in which particles may become 
 lodged, and transmitted from place to place. Loomis asserts that 
 an instance occurred under his observation in which the disease was 
 carried by a dog, from the children of one family to those of another, 
 the animal, having been around the infected children for several 
 days, afterward making a single visit to a neighbor's house. The 
 breath of affected persons undoubtedly contains the infective prin- 
 ciple, this probably being usually the medium of direct transmission. 
 
 The danger to infection of fomites is proportionate to the length 
 of time they are exposed to the contagium. A member of a family 
 where the disease was prevailing, or the nurse, would be more lia- 
 ble to convey it in clothing than the physician, who would only 
 make brief calls. It is rarely the case that the disease is trans- 
 ported by a medical attendant. 
 
 Another medium of conveyance is food, especially milk, the dairy- 
 man being capable of communicating the disease to many families, 
 should it occur in his own household. Furthermore, it is believed, 
 by some, that cattle may be affected from it. It is inoculable. 
 
 A single attack of scarlatina is usually protective against subse- 
 quent exposure. The accounts we frequently hear, of several attacks 
 of scarlatina in a single individual, should be receieved with much
 
 SCARLET FEVER 129 
 
 allowance, as it is common among physicians to render a grossly 
 incorrect diagnosis between this disease and rubella. Many phy- 
 sicians diagnose rubella, habitually, as scarlatina, there being con- 
 siderable resemblance in the general picture; and we often hear of 
 scarlet fever in the neighborhood when there has been none about, 
 but simply slight cases of rubella. This accounts for the assertion 
 that a child has had the disease and is protected, when it is really 
 as susceptible as ever to scarlatina, and falls a victim, on exposure. 
 
 It is essentially a disease of childhood, though adults may be 
 affected. Adults, however, usually escape with a mild attack. 
 
 Pathology. The general tissue-changes of fever are well marked 
 in this disease, and hardly require special mention. There are the 
 granular degeneration, the loss of fibrin in the blood, the conges- 
 tion of the braiu, spleen, liver, and other internal organs, and other 
 changes due to a protracted pyrexia, which we find, more or less, in 
 all febrile diseases. The skin and throat bear the principal brunt of 
 the disease, and the results are manifested in the anatomical changes 
 which occur. Often the kidneys become involved, and the alterations 
 which attend and follow acute nephritis are manifested in these 
 organs. 
 
 Sequelce result in destructive inflammation of the middle ear, 
 inflammation and suppuration of the glands and cellular tissue of 
 the neck, keratitis, inflammation of the serous membranes, etc. 
 
 The eruption may fairly be regarded as the distinguishing lesion. 
 The skin becomes excessively hyperaemic, congested, and cedematous, 
 the fingers being swollen and stiff, this being attended by serous 
 exudation into the rete Malpighii. Bapid cell proliferation in the 
 underlying layers of the epidermis results, and when the hypersemia 
 subsides the epidermis is cast off, the exfoliation being due to the 
 excessive production of newly-formed epidermis beneath. During 
 the period of hyperaemia, extravasations may occur in the skin. 
 
 The mucous membrane of the mouth and throat becomes congested, 
 extravasated, and cedematous. An abundant secretion of catarrhal 
 material is usually poured out, forming a tenacious coating upon 
 the surface of the tonsils and fauces, though the parts may be dry 
 and glazed, instead. The color is bright red at first, but in several 
 cases the parts become strangulated and sloughy, with dark and livid 
 color. Follicular sloughing, or a more general breaking down, may 
 invade the tonsils and adjacent parts. The subcutaneous tissues .may 
 be involved in suppurative action, giving rise to retro-pharyngeal 
 abscess, and the connective tissues and cervical lymphatics may be 
 invaded, extensive slouching abscesses resulting, with destruction 
 of arterial twigs, followed by dangerous hemorrhage. The parotid 
 
 10
 
 130 SPECIFIC INFECTIOUS DISEASES. 
 
 and sublingnal glands may be affected, severe inflammatroy action 
 attending. 
 
 The kidney presents the characters of acute B right's disease. 
 The entire organ is congested, extravasations occurring here and 
 there. The glomeruli are altered, and the convoluted tubes are 
 sometimes found to be the seat of croupous inflammation, this 
 involving the entire length of the tubuli uriniferi. All the, charac- 
 teristics of severe acute nephritis may be observable. 
 
 Symptoms. The period of incubation varies from a few hours 
 to a week, the time usually being six days. It is difficult to describe 
 the symptoms of this disease understaudingly in few words, as there 
 is a great diversity of conditions, depending upon the severity of 
 the disease, the character of the epidemic, the parts rucst violently 
 affected, and other states which modify or aggravate the character 
 of the attack, in some particular or manner. I will here describe the 
 symptoms of an average case, and afterward endeavor to discrimi- 
 nate between some of the most marked classes of cases. The dis- 
 ease may be divided for description into three stages, naturally 
 marked by their peculiar symptoms, viz., a stage of invasion, a 
 stage of eruption, and a stage of desquamation. 
 
 The invasion stage begins abruptly. A chill is followed by high 
 fever, though the temperature rises progressively through this stage 
 until the rash appears. The chill is usually marked, sometimes 
 amounting to a rigor, and in small children it may be attended by 
 convulsions or coma. Rapidity of pulse is characteristic of this dis- 
 ease as an eruptive fever, 130 to 140 beats per minute not being an 
 unfrequent rate. Vomiting is almost a constant symptom, the ejec- 
 tion beiug forcible and projectile in character, and the gastric irri- 
 tation difficult to control. Burning and prtcJding sensations in the 
 skin and throat, with stiffness of the muscles of the neck, are 
 early symptoms, and the skin imparts the sensation of pungent heat 
 to the hand of the observer. Headache is marked, being aggravated 
 by the vomiting, and restlessness and delirium may occur, even dur- 
 ing the pyrexia of this stage. In one or two days, usually in about 
 thirty-six hours, the rash appears, and the stage of invasion comes 
 to an end. 
 
 The eruption stage usually begins with the temperature at 103 or 
 104, but this soon rises to 105 F., or more. The vomiting, pungent 
 heat of the skin, throat mischief, and nervous symptoms, soon 
 become aggravated; the patient vomits more frequently, is very 
 restless, and often the delirium increases. The rash first appears 
 on the neck, breast, and back, rapidly spreading over the entire sur- 
 face except an area about the mouth, where it seldom appears thus
 
 SCARLET FEVEK. 131 
 
 constituting a rather distinctive feature of the disease, the lips 
 being pallid, the contrast with reddened cheeks thus being quite 
 striking. The eruption first appears as scarlet points (uot elevated 
 above the surface) which gradually spread until they coalesce, the bor- 
 ders being of lighter color than the center. They then coalesce, form- 
 ing au even pinkish or scarlet ground, dotted with minute bright red 
 points. The rash may or may not be confluent, it often appearing 
 in isolated patches, instead of being evenly spread over the surface, 
 it then being found on the chest, abdomen, neck, cheeks, and inner 
 aspect of the arms and thighs. It disappears on pressure, and after 
 the fourth day a letter may be traced upon the surface, to remain 
 until all its outline is completed, before fading out. This is a char- 
 acteristic peculiar to scarlatina, rashes similar in appearance hardly 
 leaving so permanent a line. The color of the rash may vary, it 
 being scarlet in some cases, in others pinkish, and in still others of 
 a dusky or purplish hue. The last characteristic marks grave cases, 
 and the danger is in proportion to the depth of the purplish tint of 
 the eruption. Miliaria often appear about the neck and chest, and 
 the papillsB become prominent in some cases (cutis anserina), while 
 petechise mark the points of minute extravasations. By the third 
 or fourth day the eruption has reached its full development, and it 
 begins to fade by the fifth. The skin is now found to be cedematous, 
 the hands and fingers manifesting the effusion most markedly, the 
 fingers being swollen and clumsy from the subcutaneous oedema, 
 By the tenth day the eruption has usually disappeared. 
 
 During the eruptive stage the general symptoms of the invasion 
 stage are all aggravated. Intense thirst is present. The vomiting 
 often disappears after the first day, though it may continue in an 
 aggravated form, especially if the disease has thus far been clum- 
 sily treated. The tongue,, which in the start was covered with a white 
 coating, except at the tip and edges, which were reddened, now cleans 
 and presents a deep red appearance, with elevated papillae resem- 
 bling a ripened strawberry in its aspect. It is moist in moderate 
 cases, but in more severe ones it, as well as the mouth and throat, 
 becomes dry and parched, tlie mucous membrane presenting a glazed 
 appearance. Later, the tongue may become brown and cracked. 
 The throat now becomes decidedly hypersemic, the soft palate, 
 uvula, pillars of the fauces, and often the posterior surface of the 
 pharynx, presenting a bright red appearance, the parts being swol- 
 len and cedematous. The oedema may be so marked that the uvula 
 and tonsils meet, closing the fauces. "When moist, there is a tena- 
 cious secretion exudate from the follicles of the tonsils adhering 
 about the openings of the follicles, or spread over the inflamed
 
 132 
 
 SPECIFIC INFECTIOUS DISEASES. 
 
 mucous membrane. In some cases the secretion is absent, the 
 mucous membrane being dry, and the exudation retained, forming 
 abscesses in the follicles. Sometimes retro-pharyngeal abscesses 
 may result from the inflammatory action. Ulceration follows the 
 eruptive stage in severe cases usually, though in very bad ones it 
 may occur earlier, follicular ulceration being the least extensive form, 
 though larger areas may be invaded. The patient complains of 
 severe pain upon swallowing, the voice is nasal in character, the 
 neck is stiffened and swollen, the cervical glands are knotted, hard, 
 and tender, and extensive inflammation of the connective tissue may 
 portend deep and dangerous abscesses in the cervical region. 
 
 The temperature of the erup- 
 tion stage usually rises until the 
 rash is fully developed, when it 
 gradually falls, a crisis generally 
 occurring when it begins to fade, 
 the temperature falling to nor- 
 mal. A slight rise in tempera- 
 ture after this is not unexpected, 
 the cutaneous changes occasion- 
 ing more or less symptomatic 
 fever, an elevation of a degree 
 and a half or two degrees con- 
 tinuing until the eruption has' 
 faded and desquamation has 
 well begun. 
 
 The pulse continues rapid, as 
 long as pyrexial action exists, 
 rapidity being a characteristic, the rate often reaching as high as 
 160 per minute during the fastigium. 
 
 Secretion from the skin and kidneys is arrested, the urine being 
 scanty and highly colored, and usually containing excess of bile pig- 
 ment, and a sediment of lithates, or free uric acid. 
 
 The desquamative sfage begins a few days after the rash has dis- 
 appeared, though there is no regularity about the beginning of this 
 period. Sometimes it begins before the rash has entirely faded, and 
 again it may be weeks before desquamation will be noticed. The 
 more intense the eruption the earlier desquamation usually begins, 
 for the pronounced changes in the epidermis tend to a prompt cast- 
 ing off of the superficial layer. In milder cases, the casting-off pro- 
 cess is liable to be postponed for a long time even four or five 
 weeks. Prior to the peeling process, the epithelium presents a dry, 
 wrinkled appearance, after which it begins to break away in fine, 
 
 DAY 
 Of 2 
 DISEASE 
 
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 4 
 
 
 
 6 
 
 7 
 
 8 
 
 9 
 
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 101" 
 
 100 
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 TEMPERATURE CURVE IN SCARLET FKVEII.
 
 SCARLET FEVER. 133 
 
 bran-like scales. Over the neck, breast, and other parts where the 
 skin is delicate, it separates in this way; but where it is thick, as 
 iu the palms, and on the soles, the epidermis may come away in 
 large patches, even the entire surface of the palm being cast off in a 
 single patch, in some instances. The period of desquamation com- 
 moiily la^ts ten days or two weeks, but it may continue for a much 
 longer time in some instances, relapses of dssquamation seeming to 
 sometimes occur, the scaliness lingering about the fingers and toes. 
 It is asserted, by good authority, that the infection lingers until the 
 last scale of epidermis has been cast off. During this period, the 
 pulse is abnormally slow, falling to 65 per minute in many instances, 
 and the temperature is depressed to subnormal The skin now lacks 
 its normal covering and protection, and the patient is easily affected 
 by a cool temperature, or sudden changes of air. 
 
 The great variation in the symptoms of this disease, has led to 
 its division by authors, for description, into three varieties, viz., 
 scarlatina simplex, scarlatina anginosa, and scarlatina maligna. These 
 forms are apt to occur epidemically, the simple form sometimes 
 marking every case, while the more severe anginosa form may pre- 
 vail in another. Occasionally, the malignant form appears as a 
 scourge, attended by frightful fatality. 
 
 In scarlatina simplex, the symptoms are all of a mild character. 
 The chill is slight and the reaction mild, the temperature not reach- 
 ing more than 102 or 103 F., the eruption coming out in patches 
 (with little oedema of the skin) of bright scarlet or pink color. 
 The soreness of the throat is not severe and passes off early, the 
 fever declining in a day or two, convalescence thus being soon estab- 
 lished. Desquamation is slight, when compared with that of the 
 other forms. Though this variety is treacherous, the prognosis is 
 usually favorable. Still, each case demands careful management. 
 
 Scarlatina anginosa appears in more severe form. The chill is 
 marked, the febrile reaction is high, and there is vomiting and head- 
 ache upon the appearance of the eruption, which becomes confluent. 
 The throat symptoms are quite severe, though not extremely 
 destructive, and the temperature reaches 105 to 106, the patient 
 frequently being delirious an 1 restless, or suffering with thirst, head- 
 ache, ami other marked discomfort. Late in the course of this form, 
 ulceration of the tissues of the throat may occur, but it does not 
 seem of that active kind which attacks the throat in malignant scar- 
 latina as early as the fifth or sixth day. In this form the eruption 
 does not fade entirely before the tenth or twelfth day, and all the 
 stages are more protracted than in the first variety. Sometimes a 
 persistently high temperature may attend this form, depending upon
 
 134 SPECIFIC INFECTIOUS DISEASES. 
 
 nephritis and other complications, which are rare in scarlatina sim- 
 plex. Desquamation is a marked feature of this form, the entire 
 palm of the hand or sole of the foot sometimes peeling away in 
 a single patch, 
 
 Scarlatina maligna, like the other forms, usually occurs in epi- 
 demics. It is markedly fatal, from twenty to fifty per cent of the 
 cases terminating fatally, in different epidemics. Two varieties of 
 scarlatina maligna may be described, the nervous and the sloughing. 
 In the nervous variety the cerebro-spinal system seems profoundly 
 involved from the very beginning, the patient passing into the m;>st 
 violent symptoms at once. The chill may not be remarkable, but 
 the vomiting is extreme from the commencement, often attended by 
 purging. The temperature rises to 107 or 108 R, early, convulsions, 
 violent delirium, or coma, quickly following. The onset of the dis- 
 ease seems overwhelming, and a condition of collapse is liable to 
 be reached by the fifth, or sixth day, the eruption perhaps never 
 appearing. By this time, the breathing is rapid and shallow, the 
 pulse fluttering, the countenance haggard, and the skin clammy, as 
 the patient lies in a state of coma. Dissolution rapidly follows. In 
 another form, the throat mischief is excessively developed by the 
 fifth or sixth day, the fauces becoming remarkably swollen and ten- 
 der, and deglutition very difficult and painful. The throat is found 
 deep red or dark purple in color, and dotted with patches of ashy- 
 gray exudation with blackened edges. The lymphatic glands at the 
 angles of the jaw and the connective tissues around them are swol- 
 len and inflamed, marking the sites of subsequent sloughing. The 
 face is livid and haggard; the pulse is quick, feeble, and fluttering; 
 sordes appear upon the teeth and lips; the tongue is dry, brown, 
 and cracked; the breath is offensive and putrid; an ichorous dis- 
 charge exudes from the nostrils, and soon rapid and wide destruc- 
 tion of tissue occurs, involving the soft parts about the fauces, and 
 even perforating the skin from the inside. (Edema of the glottis 
 may now occasion suffocation, hemorrhage from destruction of 
 important vessels may exanguinate the patient, or pyaemia may 
 slowly sap the vital forces. Such cases are almost certain to termi- 
 nate fatally. 
 
 Scarlatina is a treacherous disease, and the mildest case, there- 
 fore, is often fraught with danger. There are always liable to arise 
 complications, which may bring about a fatal termination. In some 
 apparently mild epidemics, where the scarlatinal attacks seem only 
 that of the simple form, nephritis will follow or attend the desquam- 
 ative process, and anasarca aud albumiuuria prove fatal. Or inflam- 
 mation of the middle ear may arise during the course of an appar-
 
 SCAELET FEVER. 135 
 
 ently mild attack of the disease, and terminate in symptoms of 
 meningitis. Other serious complications, such as typhoid symptoms, 
 may arise, where, in the beginning, and even as late as the termina- 
 tion of the eruptive stage, the disease is apparently of the mildest 
 character. I will briefly consider a few of the more common com- 
 plications and sequelae of this affection. 
 
 Complications and Sequelae. Probably the most frequent 
 complication is that which arises from kidney mischief. The first 
 symptom which will attract attention here usually, will be anasarca. 
 The child may appear to be doing well and convalescing properly, 
 when suddenly it is observed that a marked dropsical condition has 
 arisen. This is during or immediately following the desquamative 
 period. The disposition of many is to ascribe this to sudden chill- 
 ing of the surface when the skin is poorly protected by epidermis; 
 and this may have a bearing, but it seems that certain epidemics are 
 attended by a predisposition to such a complication. As such cases 
 have been almost unknown in my practice, I am disposed to ascribe 
 them to too heroic treatment in the beginning; to the use of too 
 active diaphoretics or diuretics more especially diuretics which set 
 up an irritation which the natural tendency of the disease carries 
 forward to an actual nephritis. In all cases of scarlatina, it is best 
 to avoid unnecessary stimulation of the kidneys; and it is difficult 
 for me to understand why they should be stimulated at alL Consti- 
 tutional symptoms, such as headache, vomiting, restlessness, and a 
 return of pyrexia, the temperature rising two or three degrees, but 
 the pulse becoming markedly slow and full, now attend. The urine 
 will be found to contain albumen and casts, as well as blood-corpus- 
 cles. Sometimes hematuria will be present In two or three days, 
 in favorable cases, the fullness of the tissues will gradually subside, 
 the swelling of the hands, feet, abdomen, and tissues generally, will 
 become less marked, the patient will brighten up from the depres- 
 sion resulting from this condition, the appetite will improve, the 
 urine clear up, and recovery go on uninterruptedly. In unfavora- 
 ble cases, the pulse becomes more feeble but increased in rapidity, 
 the anasarca increases, the patient passes into a condition of coma 
 or convulsions, and death terminates the case. 
 
 Inflammation of the serous membranes is another sequel of scarla- 
 tina. Among these, the part most liable to be involved is the endo- 
 cardium, and fatal endocarditis is liable to be the final result. 
 Pleuritis, peritonitis, syuovitis, sometimes going on to suppurative 
 arthritis, but more commonly to the joint symptoms of inflamma- 
 tory rheumatism, are sequelae of this disease. 
 
 A very serious complication is diphtheria, which occasionally
 
 136 SPECIFIC INFECTIOUS DISEASES. 
 
 occurs, and is very liable to prove fatal. Unlike the complications 
 already named, which are apt to appear late in the course of the 
 disease, this affection may arise at any time, though it usually 
 occurs during the period of desquamation. The symptoms do not 
 differ from those of the uncomplicated disease, except that char- 
 acteristic exudation and marked depression are noticeable. A fatal 
 course is almost invariably run when this complication arises, the 
 already debilitated condition of the patient offering feeble founda- 
 tion for successful treatment. 
 
 Among other complications which occasionally attend may be 
 named eye affections, such as keratitis, retinitis, and complete loss 
 of vision. Also anemia, spinal disease, paralysis of single nerves, 
 deafness, chorea, epilepsy, valvular disease, and chronic albuminuria. 
 
 Diagnosis. The diagnosis of scarlatina ought not to be diffi- 
 cult, yet there is often confusion and mistake in identifying it. 
 There ca-i be little excuse for confounding it with measles, for in 
 that disease the catarrhal symptoms are so prominent, in the major- 
 iry of cases, that they cannot be mistaken, while they are absent in 
 scarlatina, especially in the beginning. The eruption of measles 
 appears first on the face, while that of scarlatina shows first on the 
 neck and breast. The fever of scarlatina persists after the appear- 
 ance of the eruption, while in measles, it falls. The catarrhal fea- 
 tures of measles, however, constitute such a distinctive character 
 that there is hardly a possibility of confounding it with scarlatina. 
 
 Confluent small-pox may at first resemble scarlatina, so far as the 
 eruption is concerned, though the "shotty" feel of the papules will 
 here be an aid in diagnosis, and the first vesicle will settle the 
 question. 
 
 Rubella (roseola) 'is the disease which is most commonly mis- 
 taken for scarlatina, and many physicians seem not to know that 
 such a disease as rubella exists, their diagnosis of all such cases 
 being that of scarlatina. There is a great deal of resemblance 
 between rubella and mild cases of scarlatina (scarlatina simplex), 
 though it would be almost impossible for an epidemic of mild scar- 
 latina to occur without the occasional cropping out of some of the 
 sequelae, such as anasarca, otitis, etc., while these are almost never 
 known in rubella. The constitutional symptoms of rubella are also 
 out of proportion to those of scarlatina, when the comparative sever- 
 ity of the throat symptoms are considered. In roseola, also, there 
 is much less permanency of the white line left when the finger is 
 drawn over the skiu, than in scarlatina. The period of desquama- 
 tion in roseola is not marked, and only a slightly branny scaling 
 occurs, and seldom ever the large patches which are cast off from
 
 SCARLET FEVER. 137 
 
 the palms and soles in scarlatina, though such a result sometimes 
 happens. 
 
 Cases of malignant scarlatina may occur in which there is no 
 eruption before death, but the presence of a prevailing epidemic will 
 readily point out the character of the disease. It is not probable 
 that there will be any confusion in the diagnosis between diphtheria 
 and this disease, the ashen-gray exudation and marked prostration 
 of diphtheria, without the heat of the skin which marks scarlatina, 
 serving to point out the difference. 
 
 Prognosis. Scarlatina is a treacherous disease, and the prog- 
 nosis should always be guarded. After a few cases have been seen 
 throughout their course, and the epidemic has been shown to be 
 mild, of course a guardedly favorable prognosis may be rendered, 
 where an epidemic of scarlatina simplex is prevailing, and where the 
 throat affection is slight and constitutional symptoms are mild, the 
 eruption appearing within forty-eight hours from the commence- 
 ment. The more abrupt the onset, such as vomiting, delirium, etc., 
 the darker the eruption, and the more severe the throat symptoms at 
 an early stage of the disease, the more doubtful the prognosis. Age 
 exercises considerable influence, infants and children up to the age 
 of five years being the most unfavorable subjects. Beyond this age, 
 up to adult life, the prognosis is better. Adults affected with car- 
 diac or renal disease, and pregnant women, are unfavorable subjects. 
 An epidemic may develop some peculiarity, such as malignancy, ana- 
 sarca, etc., the knowledge of which will have an important bearing 
 upon the prognosis during that season. 
 
 Treatment. Prophylaxis. As this is a highly contagious dis- 
 ease, it is important that patients affected with it, as well as those 
 who have been exposed, should be strictly secluded from those not 
 infected. Scarlet-fever patients should be confined to the sick room 
 until desquamation has completely ceased; and as long a time as 
 three weeks should be allowed for this, after the period of desquama- 
 tion has begun. Unnecessary furniture should be removed from the 
 room, thus leaving as little material to act as fomites as possible. 
 The clothing aud secretions of the patient should be thoroughly 
 disinfected, as in typhoid fever, and during the period of desquama- 
 tion, measures should be taken to prevent the dissemination of par- 
 ticles of dry cuticle. These will consist in the use of warm sponge 
 baths and fatty inunction, or the use of olive oil upon the skin after 
 sponging. Nurses and others much about the sick room should not 
 have intercourse with those who have not been exposed, until after 
 the period of desquamation has passed, and their clothing should be 
 carefully disinfected before being worn in public. The apartment
 
 138 SPECIFIC INFECTIOUS DISEASES. 
 
 occupied should be disinfected and aired, with the windows open for 
 several weeks prior to further occupancy. The funerals of those dying 
 with this disease should be private, that danger of spreading the 
 infection in this way may be avoided. 
 
 Medicines have been recommended to prevent the development of 
 the disease after exposure, or to lessen its severity. Belladonna 
 has long been recommended as one of these, but there is much dis- 
 agreement as to its virtue. I think it exerts little if any formida- 
 ble influence in genuine scarlatina. Arsenic has been recommended 
 by some who deny the virtues of belladonna. It should be admin- 
 istered in minute doses of Fowler's solution in such case, and its 
 use should be begun as long as possible beforehand. Echinacea 
 promises more, to ward off the severe forms of the disease, than all 
 other remedies ; for, though it may not be considered prophylactic 
 in the strict sense of the word, it fortifies the blood against sepsis, 
 the tissues against phagedena, and the cerebro-spinal centers against 
 acute morbid changes. In malignant scarlatina, all susceptible per- 
 sons who have been exposed should take three or four doses of this 
 medicine per day, one drop for each year of age being a good rule 
 to follow in dosage. 
 
 The medicinal treatment of scarlatina cannot be reduced to a 
 routine practice. So many varying conditions confront us in every 
 epidemic, that individualization of cases in treatment will be the 
 only successful plan to pursue. However, a few suggestions may 
 aid the practitioner to meet the various conditions which arise. 
 The principal requisite is a knowledge of the proper application of 
 dynamical therapeutics. 
 
 In the treatment of scarlatina simplex little is required, except the 
 use of aconite and phytolacca, in small doses, frequently repeated, to 
 control the fever and throat irritation, thus guarding against sequelae 
 and complications, as the disease progresses. During exfoliation 
 and convalescence, the patient should wear flannels next the skin, 
 and the surface should be anointed with lard twice a week, to pro- 
 tect the denuded surface against sudden chilling, thus acting as a 
 safeguard against nephritis and other complications. Bathing must 
 be avoided for several weeks. The diet should be light and assim- 
 ilable, a liquid diet taxing the throat the least Halted milk here 
 serves a valuable purpose. The dose of aconite will vary from one 
 to five drops in four ounces of water; dose, a teaspoonful every hour, 
 amount depending upon the age. If an active agent like Lloyd's 
 aconite be used, care must be observed that the dose be not so large 
 as to embarrass the vital processes. Convalescence is a protracted 
 period in recovery from scarlatina, and too much care cannot be
 
 SCARLET FEVER. 139 
 
 taken now, as it is the most critical time of scarlatina simplex, and 
 a critical period in all other forms of the disease as well. 
 
 The treatment of scarlatina anginosa will demand the employment 
 of a wider range of remedies. The febrile action here is so high, and 
 the cutaneous irritation so marked, that aconite does not supply the 
 demand for a prouounced sedative. Where there is not the urgent 
 gastric symptoms, manifested by nausea and vomiting, the most 
 acceptable sedative is jaborandi, -which lowers the temperature, 
 imparts a cooling influence to the cutaneous surface, and controls 
 the irritation of the fauces, to considerable extent. Sometimes, 
 however indeed often we shall be obliged to dispense with this 
 agent, on account of the nausea and vomiting, and depend upon aco- 
 nite and rhus tax. Where jaborandi is admissible, I add from one to 
 two drachms of the specific medicine to four ounces of water, and 
 give a teaspoonful every hour, until the eruption is well out, and 
 until the fever has begun to decline. Where the gastric irritation is 
 marked, nothing will do better, usually, than a combination of minute 
 doses of aconite and rhus, though sometimes a resort to bismuth, 
 peach-lark frfusion, ipecac, etc., will answer better. However, a very 
 certain indication for rhus tox. is the "strawberry tongue," and here 
 we almost universally have it. The throat symptoms are always 
 severe here, and will occupy considerable of our attention. Our 
 sedatives will assist some in relieving the tumefaction and pain, but 
 we must prescribe something still more positive. Phytolacca and ech- 
 inacea, in combination, will here be found to serve an excellent pur- 
 pose. Half a drachm of specific phytolacca and two drachms of 
 specific echinacea in four ounces of water, for a child five years of 
 age, will not be too strong. Of this we may administer a teaspoon- 
 ful every half hour, in severe cases, until relief follows. Often, 
 much benefit may be obtained by using a spray of echinacea, one 
 part to four of water. Where there is dryness, with much burning 
 and pain, it affords considerable relief. Sometimes a better remedy, 
 used as a spray, is a drachm of essence of peppermint to an ounce 
 of water to which has been added ten drops of carbolic acid. To 
 assist the action of the sedative and other treatment in quieting 
 irritation and restlessness, lowering the temperature, etc., the fre- 
 quent application of warm alkaline baths is advisable. Cold water is 
 not so good in scarlet fever, for, while it affords temporary relief, 
 there is some doubt about the advisability of applying cold water 
 where the skin has been subjected to so much debilitating influ- 
 ence. Local applications to the throat may or may not amount to 
 much. One thing is certain, however, they afford comfort to patient 
 and friends, in that something is being done in this direction, and
 
 140 SPECIFIC INFECTIOUS DISEASES. 
 
 should not be omitted. The throat may be swathed with cloths 
 wruug out of vinegar and water, or a solution of hydrochlorate of 
 ammonium, half an ounce of the salt to a pint of water. Fatty 
 inunction over the surface of the body is an important measure after 
 the stage of desquamation has begun, as it lessens the liability to 
 serious complications, and fortifies the skin against sudden chilling. 
 Where there is extension of the inflammation alon^ the eustachian 
 tube to the middle ear, pulsntilla and piper methysticum are valuable 
 agents to prescribe ten or twenty drops of pulsatilla and ten or 
 fifteen drops of piper methysticum to four ounces of water; dose, a 
 teaspoouful every three hours. In persistently elevated temperature, 
 where the ordinary sedative treatment fails, the talicylate of ammo- 
 nium will be found an excellent resort, where the stomach will retain 
 it During convalescence, a subnormal temperature is a common 
 condition, and will call for echinacea, arseniate of quinia 3x, nitro- 
 glycerine, or sometimes, small doses of sulphate of quinia. 
 
 The malignant form of scarlatina presents us with the class of 
 cases pronouncedly demanding echinacea, when the nervous phenom- 
 ena are marked. Where vomiting is persistent, and the medicine 
 cannot be retained in the stomach, an effort should be made to 
 derive its effects by hypodermic means. Subcutaneous injections of 
 the drug may be made, and its effects obtained, even though the 
 stomach will not retain it. Where the tongue is heavily coated 
 from the beginning, a thorough emetic will prepare the way for 
 other treatment and interrupt the force of the disease, in a great 
 measure. Sometimes the hypodermic use of Aulde's nuclein may be 
 of service here. The phagedenic form will be much modified by free 
 doses of echinacea, administered during an early stage, and contin- 
 ued throughout the course of the disease. Comatose conditions may 
 be benefited with small closes of belladonna, though baptisia or ech- 
 inacea should constitute a large part of the internal treatment in 
 this ease. Wbere extensive sloughing occurs, nothiug will do better 
 as a local application than echinacea, one part to three of water, 
 applied frequently. Burrowing ulcers may be syringed with it, the 
 throat may be gargled with it, and cloths saturated with it may be 
 kept bound over the external surface. 
 
 Anasarca will suggest the use of apocyuum, convaUaria majalis, or 
 digitalis. Febrile conditions will here be met appropriately with 
 jaborandi. Sometimes an active hyilrogogue cathartic will assist in 
 reducing the swelling, and diverting renal irritation. Vapor baths 
 are applicable to this condition, and alone will often succeed 
 in removing the morbid accumulation and relieving the renal 
 obstruction.
 
 MEASLES. 141 
 
 Many other sequelae may arise which will require attention long 
 after the termination of the disease proper, and they therefore do 
 not come under this department. 
 
 IX. MEASLES. 
 
 Synonyms. Bubeola; Morbilli. 
 
 Definition. An acute, contagious disease, characterized by an 
 eruption which appears on the fourth day, preceded and accompa- 
 nied by marked catarrhal symptoms notably affecting the bronchial 
 tubes, and a fever of moderate height. 
 
 Etiology. Measles is a highly contagious disease, and it is not 
 probable that it ever arises spontaneously. The breath is supposed 
 to contain the elements of infection, at least the catarrhal elements 
 from the mucous membrane seem to contain the infectious princi- 
 ple in the most concentrated form, though it has been proven that 
 the blood contains the element of the disease, as its inoculation 
 imparts the infection from the sick to the well. The infection seems 
 to be volatile, as a brief exposure of infected fomites to the air renders 
 them innocuous. Experiments upon measles patients for the object 
 of proving that the breath contains the elements of infection, made 
 by causing affected persons to breathe through glass tubes coated on 
 the inner surface with glycerine, resulted in the discovery, micro- 
 scopically, of bacteria, which develop to a certain point in their 
 career, in a proper medium, aucl then disappear. They have also 
 been found in the blood, in the true skin, in sweat glands, and in the 
 lymph spaces. They occur in a variety of shapes: ovoid, spherical, 
 rod-shaped, spindle-shaped, etc. The infection begins with the com- 
 mencement of catarrhal symptoms, and continues until some time 
 after the rash has faded. A single attack usually confers immunity, 
 though two or more attacks occasionally occur in the same person. 
 It is largely a disease of children, because it is so intensely conta- 
 gious that children are not liable to escape it, but adults are fully 
 as susceptible as children if not protected by a former attack, and 
 it is much more severe in its effects when attacking adults than chil- 
 dren. Endemic in populous centers, it becomes epidemic at intervals. 
 
 Pathology. Autopsies of cases resulting fatally furnish evi- 
 dence that some complication and not the disease itself, strictly, has 
 been the occasion of the fatal issue. The common febrile changes 
 in the blood, such as loss of fibrin, lack of coagulability, and dark 
 color, with hypostatic congestion of the lungs, hyperaemia of the 
 mucous membranes, liver, and other internal organs, wifh extrav- 
 asation into their structures, are present. The skin affords evi- 
 dence of active alteration, in swelling of the corium, as well as of the
 
 142 SPECIFIC INFECTIOUS DISEASES. 
 
 rete Malpighii, from active cell proliferation, this extending along 
 the hair and sweat-gland ducts into the glands. The bacteria 
 already described as existing iu the breath are found in the liver, 
 the external layer of the cutis vera, in the sweat glands, in the lungs, 
 and other parts. In most severe cases of measles, capillary bron- 
 chitis is a common attendant or complication, and catarrhal pneu- 
 monia is commonly associated with it. The severity of measles 
 depends much upon epidemic influences, a cerebro-spinal complica- 
 tion sometimes prevailing, rendering an epidemic extremely fatal. 
 Gastro-intestinal hyperaemia may sometimes be marked, giving rise 
 to gastric and enteric symptoms. Hypersemia of the conjunctiva is 
 a common condition, and in adults who are severely affected this 
 may involve the Meibomian glands and even the lymphatics associ- 
 ated with them, terminating in lymphangitis and suppuration, as 
 well as suppuration of the Meibomian glands, to be followed by 
 chronic irritation of these structures, with frequent recurrence of 
 swelling and suppuration of the edges of the eyelid, as long-perpet- 
 uated sequelae. 
 
 The eruption is papular in character, the papules first appearing 
 on the face. They gradually extend to all parts of the body, 
 appearing last upon the back of the hands. The papules constitute 
 the red patches, and are the result of inflammation of the seba- 
 ceous follicles, each representing the center of a reddened semiluuar 
 patch. In the center of each patch, in many places, will be found a 
 central hair. The papules may be felt better by the finger than 
 seen, in many cases. If there has been profuse sweating, the epi- 
 dermis may be raised into small vesicles, or if the inflammation has 
 been very active, there may be extravasations of blood into the skin. 
 Sometimes there is coalescence of the patches in places, especially 
 about the face, and oedematous spots result. 
 
 Symptoms. The average period of incubation is estimated by 
 reputable authors as about eight days, though frequently a much 
 longer time elapses after exposure before the disease develops. 
 Some authors give two weeks as the average time. From eight days 
 to two weeks may, then, be regarded as a fair estimate. During this 
 time, the disease remains latent, the subject experiencing no knowl- 
 edge of its presence. 
 
 The first noticeable feature of an onset of measles in a child will 
 probably be announced by the appearance of catarrhal symptoms. 
 The patient is observed to be troubled with "snuffles," cough, prob- 
 ably, watery eyes, with photophobia, and he is peevish and fretful, 
 complaining of headache and chilliness. A marked chill is not com- 
 mon, though for a little time now the thermometer may register a
 
 MEASLES. 
 
 143 
 
 subnormal temperature. The cough is peculiarly harsh and rasping, 
 \vithout moisture. The headache is confined largely to the frontal 
 sinuses, and is dull, aching, and constant. Sometimes the onset is 
 more abrupt, convulsions ushering in the initial symptoms, or the 
 fever being high from the start. At all events, febrile symptoms will 
 bocome established within twenty-four hours, secretion being arrested, 
 the skin becoming hot and dry, the urine scanty and high colored, 
 there being loss of appetite, thirst, and restlessness. 
 
 The temperature is not usually excessively high in measles, nor is 
 the pulse so rapid as in scarlatina. The temperature ranges from 
 
 100 to 104 F., slight diurnal 
 
 DAY 
 
 OF- 
 
 DISEASE 
 
 /0T 
 10* ' 
 101' 
 100' 
 
 39 
 98' 
 SI 
 
 1 
 
 S 
 
 4 
 
 3 
 
 9 W 
 
 TEMPERATURE CUKVE IN MEASLES. 
 
 remissions occurring with grad- 
 ual rise, until the eruption has 
 reached its height, when it 
 abruptly falls, the temperature 
 reaching normal within thirty- 
 six or forty-eight hours. The 
 pulse may run from 100 to 120, 
 and in young children it may 
 run as high as 160, but is not 
 much altered in character, except 
 as regards frequency. 
 
 Before the eruption appears, 
 an examination of the throat will 
 enable one to detect dark red 
 spots on the soft palate and 
 fauces, which later become dif- 
 fused over the surface, marking the approach of the cutaneous erup- 
 tion. The cutaneous eruption appears at the end of the third or 
 the beginning of the fourth day, exceptionally as late as the fifth. 
 It first appears as small spots of raspberry-red color, on the fore- 
 head and sides of the face, spreading to the neck, cheeks, breast, 
 and down the body, usually covering the entire surface lastly invad- 
 ing the back of the hands in about four days from its first appear- 
 ance on the forehead. The spots rapidly coalesce into irregular 
 crescentic patches, with intervening spaces of unaffected tissue. 
 About the face these patches often become oedematous. 
 
 During the progress of the eruption, the fever becomes aggra- 
 vated, and the cough is more deep, harsh, and rasping, often being 
 almost continuous. The headache is now severe, the respirations 
 hurried, and wheezing in many instances, and there is marked dread 
 of light, the eyes being sensitive and suffused. There is itching
 
 144 SPECIFIC INFECTIOUS DISEASES. 
 
 and burning of the skin, epistaxis is common, and there is enlarge- 
 ment of the superficial lymphatic glands. When the eruption is 
 fully developed, the finger drawn over the surface will leave a white 
 line, which, however, rapidly disappears. The eruption recedes pro- 
 gressively in the course that it pursued while making its appearance, 
 beginning first with the parts where it appeared first and following 
 the line of its development. The marked redness gradually disap- 
 pears, the redness assuming a yellowish tinge and gradually fading 
 out, until the last sign is a slight staining of the surface. 
 
 The desquamative stage bears little resemblance to that of scar- 
 latina. Instead of being scaly or branny, the cuticular elements fall 
 off in the form of fine powder, often being unappreciable to the 
 observer, and it is unattended by fever or other constitutional dis- 
 turbance, the temperature being normal and convalescence established. 
 
 Atypical Course. The regular course of measles may be 
 interrupted by omission of some prominent stag6| or marked vari- 
 ation may occur, signally altering the character of the disease. 
 Sometimes the catarrhal symptoms are absent and the eruption 
 appears without any warning. Such cases are styled morbilli sine 
 catarrho. Other cases occur in which the eruption is absent, or at 
 least very scanty. In these cases the catarrhal symptoms are 
 marked, and there can be no mistaken diagnosis, as the disease will 
 be prevailing with regular symptoms in other patients. Cases 
 occurring without the eruption are referred to as morbilli sine exan- 
 themate. So-called black measles occurs in different forms, all pre- 
 senting evidence of more or less malignancy, and being due to the 
 occurrence of the disease among bad hygienic surroundings. In one 
 form there will be about the same initiatory symptoms, but the tem- 
 perature will be very high, ranging from 106 to 107. Restlessness 
 and delirium may now be marked, the tongue will become dry, and 
 the eruption will appear dark from the very beginning, important 
 changes in the blood being so indicated. This may be due partly to 
 epidemic influences, such cases being likely to occur frequently dur- 
 ing certain epidemics, while they may not be seen at all during 
 others. In this case also the temperature runs a remarkably high 
 course. In still another class of cases the eruption appears in 
 petechial black spots scattered over the surface, due to a hemor- 
 rhagic condition of the patient. In connection with thjs symptom, 
 hemorrhages from the mouth, nose, stomach, intestinal tract, and 
 kidneys, is liable to occur. These are considered very grave forms 
 of the disease. 
 
 Complications and Sequelae. Congestion of the branchial 
 mucous membrane is one of the conditions of this disease, but it
 
 MEASLES. 145 
 
 may become so aggravated as to constitute a complication. The 
 sonorous rales beard ordinarily over the chest are common to the 
 usual case of mea.sles; but when capillary bronchitis arises, the con- 
 dition may be considered a complication, as it is by far the most 
 serious element of the disease. There are now small crackling and 
 subcrepitant sounds over the affected area, with absence of the nor- 
 mal respiratory murmur. When lobular pneumonia is present, the 
 symptoms are much the same as these, except that there is dullness 
 on percussion over the affected portion. There is now marked 
 increase in the rise of temperature, the pulse is increased in fre- 
 quency, the respiration is hurried and difficult, and the countenance 
 is cyanotic in appearance. 
 
 The conjunctival congestion may also constitute a complication, 
 this sometimes becoming prominent, purulepcy, with a high grade of 
 inflammatory action attending. Ulceration of the cornea sometimes 
 occurs, followed by rapid destruction of vision. 
 
 Stomatitis sometimes occurs as a complication, the mouth being 
 swollen, hot, and dry, and often extensively ulcerated, though this is 
 most apt to be the case where the patient has been mercurialized. 
 Here the fauces and pharynx may be involved, and the trouble may 
 expose the glottis, causing oedema and suffocation. Sometimes it, as 
 well as the other complications, may be peculiar to some certain epi- 
 demic, being present in almost every case, to greater or less extent. 
 
 Extension of the inflammation of the pharynx into the eusta- 
 chian tubes, and from there into the middle ear may occur, giving rise 
 to suppuration and perforation of the tympanum, and even suppu- 
 ration in the mastoid cells, to be followed by a long train of unpleas- 
 ant and serious symptoms. 
 
 Cerebro-spinal meningitis occasionally occurs as a complication of 
 an epidemic of measles, the disease presenting many of the symp- 
 toms of cerebro- spinal fever. When this occurs, the disease becomes 
 protracted and stubborn. The rash may fade out, the bronchial 
 symptoms persist, and continue until the patient is worn out and 
 exhausted. Or, convulsions may set in and terminate the case 
 speedily. 
 
 Diagnosis. With the dry, harsh cough and other catarrhal 
 symptoms of measles combined with the eruption, the disease can 
 hardly be mistaken for any other of the exanthemata. In no other 
 affection is the persistent cough so noticeable. If, however, it 
 should happen that a severe pulmonary complication should attend 
 rubella or scarlatina, the watery eyes and nasal symptoms would 
 hardly be counterfeited. In children, the eruption of typhus fever 
 might resemble that of measles, but in typhus the rash does not
 
 146 SPECIFIC INFECTIOUS DISEASES. 
 
 appear on the face, while here is the first place it appears in mea- 
 sles. Nor is the eruption accompanied by catarrhal symptoms in 
 typhus, while the delirium of that disease is absent in measles, 
 unless it be the typhoid form. Then, the history of the case will 
 go far toward settling any matter of dispute of this nature. The 
 absence of severe cough and other catarrhal symptoms will be a 
 diagnostic point where there might be a mistaken identity between 
 this disease and rubella. Early enlargement of the posterior cer- 
 vical gjands in rubella would assist in the discrimination, as well as 
 the marked congestion of the fauces, which is not very prominent in 
 measles, even though the exanthem is early spread over the soft 
 palate. 
 
 It is hardly possible to confound measles and scarlatina, as the 
 catarrhal symptoms are so much more marked in the former, while 
 the inflammation of the fauces in the latter disease is of a pro- 
 nounced character. 
 
 Prognosis. The prognosis of this disease will vary much, 
 according to the circumstances attending. When the patient is 
 placed under favorable circumstances for good nursing and this is 
 supplied, hardly any uncomplicated case ought to terminate fatally. 
 A warm room, where the air can be kept at an even aud somewhat 
 elevated temperature, is essential to a favorable recovery from the 
 bronchial irritation. The poor, then, who are badly housed, and 
 whose houses are but indifferently warmed, and those who are una- 
 voidably exposed to cold air, such as soldiers, are not favorable sub- 
 jects during winter weather, as serious pulmonary complications are 
 almost certain to arise, which render the prognosis unfavorable. 
 The age of the patient also exerts an important influence upon the 
 question of prognosis, children recovering with much less liability 
 to serious complication than adults. Black measles, either the hem- 
 orrhagic, ulcerative, or typhoid form, presents us with grave diffi- 
 culties, and the prognosis should be extremely guarded. Measles 
 occurring during pregnancy is liable to prove fatal to the foetus, 
 absorption being the probable result, though the mother may not 
 suffer severe effects. Marked disturbance of the menstrual function 
 is liable to follow a severe attack of measles in the adult female. It 
 has been said that when a pregnant woman passes through an attack 
 of measles without aborting, the child is as well protected against 
 future attacks as though affected after birth. Capillary bronchitis, 
 pneumonia, croupous laryngitis, diphtheria, and cerebro-spitial men- 
 ingitis, are all serious complications, and the presence of either of 
 them might be considered as reason for a guarded prognosis. 
 
 Treatment. The preventive treatment consists of strict quar-
 
 MEASLES. 147 
 
 antine against the disease, confining those who are affected to sepa- 
 rate quarters, and isolating the nurses and attendants. Excretions, 
 and all clothing worn by the patient and nurses, should be thoroughly 
 disinfected, as in typhoid fever, and the quarantine should continue 
 until the period of desquamatiou has ended. It is hardly desirable 
 to quarantine all epidemics of measles, as children suffer less from 
 the disease than adults, except during infantile age, and, as the con- 
 tagion almost always exhausts every community of unprotected sub- 
 jects, an escape during childhood only destines the adult to a more 
 severe attack during maturity. However, as some epidemics are 
 attended by malignant symptoms in almost every case, avoidance of 
 the disease is always commendable at such times. 
 
 The medicinal treatment of uncomplicated measles is simple, 
 though the practitioner should be on the alert for complications, 
 that their severity may be modified early. To control the conges- 
 tion of the mucous membrane to some extent, control the cough and 
 encourage early departure of the cough and coryza, the use of small 
 doses of jdborandi and asdepias, in combination, serves an excellent 
 purpose. Add a drachm of each to half a glass of water, and give a tea- 
 spoonful every hour. This will modify the cough, assuage the fever, 
 quiet restlessness, and impart a sensation of coolness and comfort 
 to the skin, as well as lessen the severity of all the congestive 
 symptoms. Alkaline baths to the skin are grateful, though they 
 should be warm. The room should be darkened so as to prevent 
 the bright light from irritating the eyes, and when these organs are 
 much irritated, cold compresses are of service to assist in prevent- 
 ing later complications and sequelae of this character. The temper- 
 ature of the room should be warm and equable throughout the 
 course of the disease, as cool air is aggravating to the cough. 
 
 Sometimes the patient will object very much to jaborandi, as 
 well as asclepias, and something less objectionable may be required. 
 Aconite and rhus tox. afford satisfaction in the majority of cases, 
 and this combination is especially to be recommended where there 
 is marked restlessness, with a tendency to delirium at night. Add 
 five drops or less (according to the age of the child) of aconite, and 
 ten or fifteen of rhus (or less in very young children) to half a glass 
 of water, and give a teaspoonful every hour. This is essentially the 
 prescription where there is gastro-intestinal irritation, with nausea, 
 vomiting, or diarrhoea. 
 
 The cough sometimes proves a stubborn symptom, and demands 
 especial attention. One of the most successful remedies for the 
 cough of measles is drosera, which may be administered by adding 
 ten or twenty drops to four ounces of water, and giving a teaspoon-
 
 148 SPECIFIC INFECTIOUS DISEASES. 
 
 ful every hour. Sometimes this will fail to afford satisfaction, and 
 we will need to resort to sticta, sanguinaria, or ipecac. Echinacea 
 will sometimes cut short a cough of this character after more 
 approved drugs have failed. When the cough arises from catarrh of 
 the smaller tubes capillary bronchitis, evidenced by stuffy, sull'u- 
 cative cough, purple, cyanotic countenance, and dyspnoea tartar 
 emetic, 2x or 3x (3x for children), will be the proper remedy. Two 
 or three grains may be administered at a dose, repeated every two 
 hours until the special symptoms demanding the remedy disappear. 
 Where chronic catarrhal symptoms persist, three grains of calcarea 
 carb., every three or four hours, may be administered to complete 
 the cure. 
 
 Malignant measles demands remedies to correct depraved states 
 of the blood, in the majority of instances. Specific indications will 
 often point out the proper agent to correct the basic lesion and place 
 the system in such a condition that the ordinary remedies are suc- 
 cessful in these cases. Where there is excessive acidity of the stom- 
 ach, as manifested by the broad, flabby tongue, with pasty white 
 coating, sulphite of sodium will be the proper corrective. It may 
 be given in from one- to three-grain doses every two or three hours, 
 until the marked indications are removed. The brown coating on 
 the tongue will suggest sulphurous acid, and this should be given a 
 leading place in the treatment, until the marked indication for the 
 remedy has vanished. Ten or twenty drops of a reliable prepara- 
 tion, well diluted with water, should be administered at a dose, every 
 three or four hours. During the course of the disease, the clean, 
 slick, dark-red tongue (beefsteak tongue) may be developed, calling 
 for appropriate doses of hydrochloric acid. In many of these con- 
 ditions the patient will be very sick, some peculiar unpleasant fea- 
 ture or symptom being more than ordinarily prominent. Typhoid 
 symptoms are almost certain to be present, a strong tendency to 
 delirium or coma attending, and the temperature running high in 
 comparison with that of ordinary cases. Where there is a ten- 
 dency to coma, with cold extremities, the sedative in these cases 
 may be replaced with minute doses of belladonna, two drops of the 
 specific medicine to four ounces of water, combined with minute 
 doses of aconie; dose, a teaspoonful every hour. In the majority 
 of these cases, however, echinacea will answer a better purpose, its 
 corrective influence on the depraved condition of the blood being 
 better, while it is as positive a remedy to improve the capillary cir- 
 culation as belladonna. In the petechial form, as well as that 
 attended by ulceration f the mouth, echinacea will be found an 
 excellent resort to correct the depravity of the blood and prevent
 
 MEASLES. 149 
 
 phagedenic processes. Oar older therapeutists would have pro- 
 posed baptisia here, but this was before the profession was 
 acquainted with the remarkable properties of echinacea. 
 
 In epidemics where cerebro-spinal disturbances are marked, we 
 will find echinacea our best resort, it being the best remedy we pos- 
 sess for cerebro-spiual fever, or for its complications. A drop for 
 e;ich year of age up to fifteen will be as satisfactory a plan of dos- 
 age as any other, for this remedy. It may be repeated every two 
 hours, in urgent cases. 
 
 A markedly high temperature may sometimes attend, and some- 
 times we find this present where the extremities are cold and the 
 circulation in the superficial capillaries feeble. Where the remedies 
 already suggested fail to produce a sedative effect, I would suggest 
 the use of salicylate of ammonium, in appropriate doses. 
 
 Convulsions occurring during the onset of this disease will not 
 require special treatment, aconite and rhus, as directed for ordinary 
 sedative purposes, being the proper remedies here. If called dur- 
 ing the convulsive action, the physician may direct the child to be 
 put in a warm bath, or wrapped in a flannel blanket wrung out of 
 warm water. As soon as the action of the sedative is established, 
 the signs of convulsions disappear. 
 
 Warm alkaline baths are sometimes of service where the erup- 
 tion is attended by severe burning and itching, and in black measles 
 where there is feeble capillary circulation, or where there has been 
 a retrocession of the rash, as well as where the rash is tardy in 
 making its appearance and the patient seems to be suffering on that 
 account, a sponge bath of aqua ammonia diluted in water (an ounce 
 to a quart of water) will often assist. 
 
 Where pulmonary symptoms are pronounced, a pack of cloths 
 wrung out of tepid water, applied to the chest, will be found an excel- 
 lent auxiliary to the properly selected remedy, frequently affording 
 speedy relief to urgent symptoms, such as dyspnoea, cough, etc. 
 
 The diet during measles should be mild and unstimulating in 
 character, but nutritious. Plain milk, lime water being added for 
 young children, or what is better, malted milk, will furnish all the 
 nourishment needed during the active period of the disease. Later, 
 during the desquamative stage, solid food may be taken, moderately 
 at first. Cold water may be allowed freely during all stages of this 
 disease, as well as during all fevers, provided there is no gastric 
 irritation present, to contraindicate its frequent use. Ice water, 
 however, is too cold. 
 
 During the stage of desquamatiou and immediately afterward, 
 the skin is poorly protected against draughts of air and sudden
 
 150 SPECIFIC INFECTIOUS DISEASES. 
 
 changes, and should be well clothed, as there is almost as ranch 
 danger to the pulmonary organs as to the kidneys during the 
 late stage of scarlatina. Inunction of the skin with lard or olive 
 oil is a commendable measure where there is the least possibility 
 that the patient may become chilled. During winter, spring, and 
 autumn, in the Eastern States, this measure is an important one. 
 Flannels should be worn invariably, for several weeks after 
 convalescence, 
 
 X. RUBELLA. 
 
 Synonyms. Rotheln; German Measles: Epidemic Roseola. 
 
 Definition. A specific, mildly contagious, eruptive disease, 
 resembling measles many times in its eruption at others scarlatina, 
 and resembling scarlatina in the accompaniment of sore throat, but 
 lacking the cough and other catarrhal symptoms that characterize 
 measles, and the high temperature and sequel that usually attend 
 scarlatina. 
 
 Etiology. Rubella occurs epidemically, and is feebly conta- 
 gious. The contagious character of the disease, however, is not so 
 marked as that of scarlatina and measles, several instances coming 
 under my observation where one in a family of children has been 
 affected while the others escaped, and there were many other iso- 
 lated cases in the same neighborhood; though usually the majority 
 of children in families are affected, when it is once introduced. 
 It seems that the intensity of the contagious principle differs dur- 
 ing different epidemics, the disease sometimes manifesting marked 
 contagiousness, and again seeming to be but slightly contagious, if 
 at all. This is probably the reason why there is such a difference 
 of opinion among medical authors on the subject, some claiming 
 that it is eminently contagious, while others of fully as much relia- 
 bility aver that it is not contagious at all. In some epidemics, chil- 
 dren are the only subjects affected, while in others, adults are com- 
 monly attacked. In such cases, adults suffer fully as much, if not 
 more, than children. It is asserted that a single attack affords pro- 
 tection from subsequent ones of the same disease, though it is cer- 
 tain that it affords no immunity from measles or scarlatina. 
 
 Pathology. The most marked pathological changes occur in 
 the skin, throat, and cervical glands, though these are not of radical 
 character. The skin-changes consist of irregular hypersemic blotches, 
 which vary in size from a pin's head to a fourth of an inch in diam- 
 eter. They are slightly elevated, but disappear under pressure, and 
 do not impart the hardened feel to the touch that is observed in the 
 early stage of measles, indicating less plastic exudation, and less
 
 RUBELLA. 151 
 
 inflammatory action. The eruption appears upon all parts of the 
 body, and the patches are round not crescentric, like those of mea- 
 sles. There is no exudation of serous or lymphoid material into the 
 rete Malpighii as in scarlatina, nor inflammation of the sebaceous 
 follicles, as in measles. The throat is congested, sometimes markedly 
 so, and the cervical lymphatics, especially the posterior cervical, 
 are swollen and tender, even early in the course of the disease. 
 Slight powdery desquamation from the skin occurs, but seldom in 
 the form of flakes, as occurs in scarlatina. The important conges- 
 tion of internal organs that marks the more severe forms of erup- 
 tive fevers, is not present to any considerable extent in this. 
 
 Symptoms. The stage of incubation is said to be about two 
 weeks in length. 
 
 The stage of invasion is hardly noticeable in many cases, though 
 there may be a distinct chill, and even convulsions, during the 
 attack. The eruption occurs within twenty-four hours after the inva- 
 sion, though many cases manifest no unpleasant symptoms until the 
 appearance of the eruption, the child being at play when it is first 
 noticed. It appears first on the face, and spreads over the entire 
 body within two or three days, disappearing within twelve or twenty- 
 four hours after its appearance, a progressive subsidence following 
 the march of its appearance. The rash varies in color from the 
 scarlet appearance of that of scarlatina to the raspberry color of 
 measles. Often it is but faintly marked, though the more pro- 
 nounced the rash the more severe the other symptoms. The rash 
 is often distinctly separated into little spots or patches, though 
 again it may be evenly spread, as in scarlet rash. Desquamation 
 occurs as a powdery exfoliation, the superficial parts of the epider- 
 mis only being involved, serious disturbance of the cuticle of the 
 palms and soles not being noticeable, as in scarlatina. The pulse is 
 increased in frequency, being, in some cases, small and wiry. The 
 temperature is slightly elevated, one or two degrees being the average, 
 though in severe cas?s it may reach 103 F. 
 
 The throat symptoms are sometimes apparently quite severe, the 
 tumefaction and difficulty of swallowing being marked and trouble- 
 some, though the irritation is superficial, as manifested by absence 
 of sloughing or destructive action later. Sometimes the follicles of 
 the tonsils are involved, and white patches of exudative material 
 appear about their orifices. The redness, however, does not spread 
 over the palate, as in scarlatina. The muscles of the neck are often 
 stiff and painful, and the muscles of the body generally are sore, the 
 patient complaining of a bruised feeling. Muscular rheumatism may 
 attend severe cases. The cervical lymphatics will be found swollen
 
 152 SPECIFIC INFEC1IOUS DISEASES. 
 
 and tender early in the course of many cases, especially the occip- 
 ital lymphatics. Most cases are so mild that the patient considers 
 it a hardship to remain in bed, and, if allowed, he will be up and 
 around before the appearance of the eruption. 
 
 The tongue is coated with a thin white coating, early, through 
 which dark red points appear, and later the organ may appear slick 
 and dark red in color. The organ is usually pointed and reddened 
 at the tip, though there is rarely nausea or vomiting. 
 
 Complications and *equclce are almost unknown in this disease, and 
 although these are mentioned by authors as occasionally occurring 
 (anasarca, for instance), it seems that such can only be the case 
 where a very bad plan of treatment has been pursued. 
 
 Diagnosis. Probably there is no other disease known in which 
 physicians make so many blunders in diagnosis as in this. The 
 blunder, however, is usually on the safe side for their credit as 
 they commonly diagnose it as scarlatina. The great number of 
 cases of scarlatina which occur around us with no mortality would 
 be surprising, were it not for the fact that the physicians who man- 
 age them are the most arrant blunderers in therapeutics possible, 
 in most instances, and really sometimes find it difficult to pull a sim- 
 ple case of rubella through successfully. About as positive a diag- 
 nostic point as can be scored then is that if no mortality or sequelae 
 attend we are having an epidemic of rubella. Mark the low temper- 
 ature, the absence of violent gastro-intestinal symptoms, of delirium, 
 and destructive action in the throat, which attends scarlatina. Mark 
 also the absence of pronounced catarrhal symptoms, the absence of 
 the rough, deep cough, which announces measles to the whole house- 
 hold. Mark, also, the brief stay of the rash, and the small amount 
 of pyrexia during its presence, and you will find enough distinctive 
 features to determine a case of rubella. 
 
 Prognosis. Without the most absurd and irrational treatment, 
 and the worst nursing imaginable, and without some unexpected and 
 unwarrantable complication, the prognosis is always favorable. 
 
 Treatment. A combination of aconite, rhus tox., and plnjtolacca, 
 from one to five drops of aconite, fifteen to twenty of rhus, and ten 
 to thirty of phytolacca, in four ounces of water, dose, a teaspoon ful 
 every hour, will represent the proper routine prescription, this cov- 
 ering the usual indications. There may be cases in which muscular 
 pain will be prominent, demanding the judicious use of a"cfanilide, 
 cimicifvga, or rhamnus californica. Itching and burning of the skin 
 may suggest the local use of the resorcin lotion recomm ndcd for a 
 similar purpose under the treatment of chicken-pox. Finally, fatty 
 inunction, during desquarnation, is to be commended.
 
 MUMPS. 153 
 
 XI. MUMPS. 
 
 Synonyms. Epidemic Parotitis; Specific Parotitis. 
 
 Definition. Mumps is an acute, contagious inflammation of 
 one or both parotid glands, attended with fever, and usually result- 
 ing in resolution, with a tendency to metastasis to the testes in the 
 male, and to the ovaries or mammary glands in the female. 
 
 Non-specific or metastatic parotitis may occur as a secondary 
 symptom in certain infective diseases, such as typhoid fever, Dyae- 
 mia, diphtheria, measles, etc., and usually terminates in abscess. 
 In the idiopathic variety, this, as a rule, does not occur. 
 
 Stephen Paget has collected a large number of cases in which 
 injury or disease of the abdominal or pelvic organs, unattended by 
 septic processes, was followed by an idiopathic, non-specific parotitis. 
 
 Etiology. Mumps, like the eruptive fevers, is propagated by 
 contagium, and, like them, one visitation usually confers immunity 
 from subsequent attacks. However, a person having "single mumps" 
 is liable to a later invasion of the other gland. 
 
 Pasteur claimed to have discovered the "bacillus parotidis," but 
 attempts at the inoculation of animals with it have failed, and the 
 nature of the virus is therefore still an open question. 
 
 Mumps rarely occurs sporadically. On the coasts of France, 
 Holland, England, and some localities in this country, it is said to 
 be epidemic. Isolated cases are occasionally met with, but it usu- 
 ally occurs iu the epidemic form. Mumps is a disease of childhood, 
 the period when the system is most liable to its invasion being 
 between the second year and puberty. Persons who have escaped 
 parotitis iu childhood areliot necessarily exempt from its influence; 
 in fact, during some epidemics, adults are chiefly affected. Females 
 are not so liable to contract the disease as males. The immunity of 
 infants is attributed to the slight development of the parotids, and 
 the narrowness of Steno's duct. The humidity of the atmosphere 
 undoubtedly assists in the propagation of this disease, the autumn 
 and spring months being the period when it is most frequently met. 
 
 Pathology. The catarrhal inflammation commences primarily 
 in the ducts, and spreads rapidly to the glandular structure. There 
 is at first an intense hypersemia, resulting in serous exudation and 
 tumefaction. The acini are oedematous, anil there is inflammatory, 
 serous, and cellular infiltration of inter-alveolar fibrous structure, 
 the surrounding connective tissue and adjacent parts being more or 
 less involved. The inflammation terminates by resolution, fibrous 
 induration, or suppuration, usually the first. Occasionally, paroti- 
 tis results in atrophy of the gland.
 
 154 SPECIFIC INFECTIOUS DISEASES. 
 
 Symptoms. The period of incubation lasts from one to three 
 weeks, during which there is little premonitory disturbance, though 
 the swelling of the parotids is often preceded by proclromata, 
 the patient complaining of anorexia, nausea, pains in the head 
 and back, and constipation. There is a chili (or chilly sensations), 
 followed by fever, quick pulse, scanty urine, and a dry skin. The 
 patient complains of stiffness and tension in the parotids, and tume- 
 faction, usually beginning on the left side. The usual phenomena 
 of inflammation heat, pain, tenderness, and swelling are present 
 The pain, while unpleasant, cannot be termed severe. It is increased 
 by swallowing, speaking, or pressure. The swelling extends in all 
 directions, and we have a general cetlema of the affected side. The 
 lower jaw is greatly restricted in movement, and mastication and 
 enunciation are difficult, and, at times, impossible. Salivation is an 
 occasional symptom. When stomatitis and ptyalism develop, there 
 is considerable fetor. Occasionally, the submaxillary and sublin- 
 gual glands participate in the inflammation, and cases have been 
 reported where the parotids were unaffected, the swelling being 
 confined to the smaller salivary glands. The lymphatic glands in 
 the immediate vicinity are usually swollen. 
 
 In general, the fever is not very high ; in fact, some cases run an 
 apyrexial course, the main discomfort arising from the tension over 
 the parotids, and the immobility of the lower jaw. 
 
 In from three to four days the disease has fully developed. About 
 the seventh or eighth day resolution and subsidence of the swelling 
 begin, or, as is often the case, the other gland becomes involved. 
 While the above is the usual course, some cases present serious fea- 
 tures, there being hyperpyrexia, intense pain, delirium, and great 
 vital impairment. 
 
 Complications and Sequelae. Where there has been high 
 fever and marked nervous symptoms, delirium and even maniacal 
 attacks are noted, or, in severe cases, meningitis, hemiplegia, and 
 coma. Cerebral congestion may result from pressure on the jugular 
 vein. Visual affections are more infrequent, amblyopia being the 
 most serious. Acute albuminuria, gastro-intestinal disturbances, 
 and arthritis, have been noted. Impairment of hearing, persisting, 
 in some cases, is an occasional unpleasant sequela. 
 
 The most frequent complication, however, is orchitis. The testic- 
 ular inflammation develops oftenest after the subsidence of the 
 swelling in the parotid, and is largely dependent upon the character 
 of the epidemic though too early exercise on the feet may be pro- 
 vocative of it under other circumstances, though usually the severity 
 of the original disease has little to do with this condition. Bilateral
 
 MUMPS. 155 
 
 orchitis is rare, although at times the second testicle is in turn 
 attacked. It is seldom noticed before puberty. In an epidemic 
 where 495 soldiers were attacked with mumps, Granier found 115 
 cases of orchitis. The inflammation does not run any regular 
 course, although it seldom extends over a week. 
 
 In the female, ovaritis occasionally develops, and, infrequently, 
 mastitis or vulvo-vaginitis. 
 
 Suppuration of the parotid seldom occurs. Where pus forms, 
 there is marked constitutional disturbance, and the pain is severe, 
 as the glaud is provided with a strong capsule and the surrounding 
 fascia is deep and firm. As a rule, the pus opens into the auditory 
 meatus, but it may pass along the sheath of the carotid to the skull, 
 burrow its way behind the pharynx into the maxillary joint, or down- 
 ward into the thorax. It is, therefore, a serious complication. 
 
 Treatment. Mumps is a self-limiting disease, and, in the major- 
 ity of cases, there is not much call for medicine. Externally, a 
 layer of cotton wadding covered with oil silk is sufficient, although 
 some prefer inunctions of oil or a hot or cold compress. When the 
 pain is severe, a lead and opium lotion gives considerable relief. 
 Phytdacca is extolled by some. For the fever, aconite is indicated: 
 $ Specific aconite gtt. v, specific phytolacca jss, aqua q. s. f iv. M. S., 
 3! every hour or two. At the beginning, there is frequently a defi- 
 ciency of saliva, and specific jaborandi (-511 jiii) can be added. 
 
 Plyalism is sometimes present during the later stages, and calls 
 for belladonna, or the fractional dose of jaborandi or iris. 
 
 - It is seldom that there will be a call for any sedative except 
 aconite, but occasionally there will be an irritation of the nervous 
 system and determination of blood to the brain, calling for the exhibi- 
 tion of gelsemium (jss fiv), or the sharp stroke of the pulse and 
 nervous erethism, with or without the tongue symptoms, which 
 would indicate rhus tox. (gtt. x to xx fiv). 
 
 Abscess is a rare complication and must be met? promptly by sur- 
 gical treatment, in order to prevent the danger consequent on the 
 burrowing of pus. Most cases are likely to break in the ear if not 
 interfered with, but the lance should nevertheless be used early. 
 Sometimes it is necessary to make a careful dissection, where tlie 
 pus is deep. Where we suspect a possible breaking down of the 
 glandular structure, calcium sulphide is to be given in small doses with 
 a reasonable expectation of its aborting the abscess. 
 
 Orchitis is treated by rest and support of the testes. Strapping 
 is not often called for. The following lotion is about as good as 
 anything to apply locally : R Plumbi acet. 31, tinct. opii ?i, tinct 
 aconite fss, aqua q. s. fvi. M. S., Lotion.
 
 156 SPECIFIC INFECTIOUS DISEASES. 
 
 In other cases, a lotion consisting of equal parts of echinacea, 
 phytolacca, and belladonn i (green plant tincture or specific medi- 
 cine ), will serve a better purpose. This may be kept applied con- 
 stantly, with moistened cloths. Inter. lally, we administer phylo- 
 licca or pulsa'illa, with our sedative. 
 
 XII. WHOOPING 
 
 Synonyms. Pertussis; Tussis Convulsiva. 
 
 Definition. An acute, infectious disease, characterized by the 
 gradual development of a spasmodic cough of peculiar character, 
 signalized by a series of explosive expiratory efforts followed by a 
 long-diawn inspiration attended by a peculiar crowing sound, the 
 "whoop," the cough being preceded by symptoms of a common 
 cold, and followed by a period of gradual subsidence. 
 
 Historical Note. Whooping-cough was described by the 
 ancient Greeks as bex theroides. Old writers mentioned it as tussis 
 convuhiva. Cnllen wrote of it under the name whooping-cough, and 
 described it clearly. Considerable discussion was engaged in during 
 past years as to the character of the disease, some claiming that it 
 arose from irritation of the pneumogastric nerve, and others that it 
 was caused by enlargement of the tracheo-bronchial glands. Lin- 
 naeus foreshadowed the modern microorganism-theory of the etiology 
 of the disease when he ascribed it to an insect. Later, Poulet, Let- 
 zerich, and Binns suggested the fungoid nature of pertussis. 
 
 Etiology. The present knowledge of other infectious diseases 
 renders it most probable that this depends upon a specific micro- 
 organism, which operates upon some portion of the respiratory 
 mucous membrane. This has not yet been demonstrated to the sat- 
 isfaction of microscopists, however, though several announcements in 
 the affirmative have been made. Thus, in 1867, Poulet found in the 
 sputa of pertussic patients minute bodies which he termed infusoria, 
 and Letzerich pro luced the disease hi animals by inoculating the 
 trachea with the sputa of affected human subjects, while he asserted 
 that he found a fungus in the secretions of the respiratory passages. 
 Buhl, Oertel, and Hiiter also found them. The contagium is given 
 off in the breath and sputa of affected individuals, and probably in 
 emanations of the body as well, as the disease undoubtedly perme- 
 ates the blood. Children are mo.->t liable to the d.sease, and it usu- 
 ally occurs epidemically, though it may appear endemically. Adults 
 occasionally suffer from it. The mortality among the children of 
 colored races is stated by some authors to be twice as great as that 
 among the white population. Clothing and rooms may be infected 
 so as to convey the disease, in the absence of an affected subject,
 
 WHOOPING-COUGH. 157 
 
 though doubtless the common means of infection is by direct conta- 
 gion. The most common period of life subject to it is that before 
 the third year, though it sometimes occurs during extreme old age. 
 Where the seasons are marked, spring and autumn seem to favor its 
 appearance, and it is supposed in some quarters to be influenced by 
 measles, it often appearing quickly alter an epidemic of that disease. 
 One attack usually protects from a second. The infection is believed 
 to persist for five or six weeks after the "whooping" period has 
 passed off, the patient being capable of communicating it during 
 that time. 
 
 Pathology. The most marked changes are found about the 
 respiratory organs. There is catarrh of the air passages hyperse- 
 cretion of the mucous membrane of the glottis, larynx, trachea, 
 bronchi and their ramifications with congestion and hyperplasia. 
 Emphysema is a common condition, as well as pulmonary collapse 
 in fatal cases. Capillary bronchitis and pneumonia frequently 
 occur, leaving their traces in the post-mortem appearances. There 
 is intestinal irritation, evidenced by petechial extravasations upon 
 the gastric mucous membrane and wall of the small intestine; and 
 the liver and spleen may be enlarged and fatty. Hemorrhage into 
 the subdural space sometimes occurs, and more frequently there are 
 points of extravasation in the brain and spinal cord. There is often 
 an ulcer under the tongue, by the frsenum linguae, in severe cases, 
 due to forcible protrusion of the tongue against the lower incisors 
 during the paroxysms of coughing. The bronchial and tracheal 
 glands are usually enlarged. 
 
 Symptoms. After an incubation of from seven to ten days, three 
 stages develop, viz., the catarrhal, paroxysmal, and stage of decline. 
 
 The catarrhal stage resembles a common cold in its characteris- 
 tics, there being snuffling of the nose as in coryza, cough, slight 
 feverishness, peevishness, and restlessness at night. The physician 
 may now be requested to administer a remedy for the "cold," and 
 upon doing so lie will find that the prescription fails, and he may be 
 applied to for a more successful treatment a second time before it 
 will occur to him that there must be something more than a common 
 cold that will resist well-proven remedies for such a simple com- 
 plaint. The cough is dry at first, but sooner or later becomes moist, 
 the secretion being a tenacious, viscid, transparent mucus. Parox- 
 ysmal symptoms gradually appear, aud the cough increases in sever- 
 ity, the secretion being more abundant, the respirations shallow, and 
 the pulse rapid. The duration of this stage varies from three days 
 to three weeks, though it usually lasts about ten days. 
 
 The spasmodic stage is announced by a paroxysm terminating in
 
 158 SPECIFIC INFECTIOUS DISEASES. 
 
 a pronounced whoop, which settles the question of the nature of the 
 disease, and at the same time ushers in a period of severe suffering 
 for the patient, unless the affection be modified by appropriate treat- 
 ment. The paroxysms of coughing soon become peculiar and dis- 
 tressing. A whistling inspiration, followed by a succession of short, 
 sharp, expiratroy explosions, announces the paroxysm, the expiratory 
 explosions continuing without inspiration until the patient grows 
 cyanotic and exhausted, and seems to have lost the power to fill the 
 lungs or stand upon the feet, the parent or nurse finding it neces- 
 sary to support the child, which is completely relaxed and helpless 
 in the throes of the paroxysm. The face presents marked evidence 
 of increasing venous stasis, becoming more and more cyanotic, while 
 the eyes bulge out, the lips and cheeks become swollen, the jugulars 
 standing out like blue cords, and the face and limbs being covered 
 with perspiration. The glottis, which is now in a condition of spas- 
 modic closure, finally opens partially, to permit the patient to draw 
 a long, laborious inspiration, which enters the glottis with a sharp, 
 crowing sound the whoop. Vomiting is now liable to occur, the 
 gagging serving to dislodge accumulated mucus. The child is much 
 prostrated during the paroxysm, and the lower sphincters may be so 
 relaxed that involuntary evacuations occur. If the patient is deli- 
 cate, it may now fall into an exhausted sleep, or, as in most cases, it 
 may soon recover and go about its play; but it is terrified after a 
 time by the approach of another paroxysm (which furnishes some- 
 thing of a premonition), and may run to its mother or nurse to cling 
 to her for protection and aid. From six to forty or more of these 
 paroxysms may occur in twenty-four hours. 
 
 During the paroxysm, the thorax is dull on percussion during 
 expiration, owing to the contraction of the muscles, and remarkably 
 resonant on inspiration, the respiratory murmur being almost indis- 
 tinct on inspiration on account of the small amount of air admitted 
 through the chink at the time. Between the paroxysms, the respir- 
 atory sounds are numerous and variable. There may be sonorous, 
 sibilant, and moist and dry crepitant sounds in the same patient, 
 predominance depending upon the amount and character of pulmo- 
 nary complication that may have arisen. Bronchitis is often a com- 
 plication, and where the small tubes are affected, they are liable to 
 become blocked (capillary bronchitis) and occasion cyanotic symp- 
 toms and prostration, very much complicating the case. 
 
 During the violence of the paroxysms, numerous accidents are 
 liable to occur; the pulmonary alveoli may become ruptured and 
 permit of inflation of the cellular tissues of the lung with air 
 (emphysema), which may occasion serious results by permanently
 
 WHOOPING-COUGH. 159 
 
 infiltrating the part and interfering with normal function. Kupture 
 of cerebral vessels with apoplexy may occur, or excessive strain 
 to the abdominal mnscles may result in hernia or prolapsus ani. 
 
 Vomiting after the paroxysms is a common symptom, and this 
 may amount to gastric irritability, with habitual vomiting of food, 
 tending to inanition and marasmus. In most cases, however, the 
 vomiting is confined to efforts to expel the tenaci >us mucus which 
 accumulates in the throat during the paroxysms, and which is 
 removed with the greatest difficulty, the assistance of the nurse's 
 finger often being required to dislodge it. 
 
 Conjunctiva!, cutaneous, and pulmonary extravasations often occur 
 during the paroxysms, the eyes becoming bloodshot, and the face 
 presenting purple blotches of extravasated blood, as a result of the 
 violent strain daring the act of coughing. 
 
 The nervous system is in a condition of hyperaesthesia in many 
 cases, the patient being excessively peevish and irritable; cerebral 
 congestion, convulsions, and even permanent insanity have arisen 
 during the course of the disease. 
 
 After five or six weeks from the beginning, the paroxysms com- 
 mence to decline in severity; the whoop gradually ceases, and the 
 case starts on the road to recovery, though sometimes the paroxysmal 
 stage becomes chronic, and persists for a year or more. In other 
 instances, whenever the patient may contract a cold, the paroxysms 
 return with considerable severity until after the cold has been dis- 
 sipated. In about nine weeks from the commencement, in ordinary 
 cases, the paroxysms and cough have ceased permanently. 
 
 Complications and Sequelae. The sequelae of pertussis 
 occupy a prominent place in its history. The persistent vomiting may 
 give rise to gastro-intestinal irritation, followed by marasmus of per- 
 sistent character, attended by muco-enteritis, from which the patient 
 may rally with the greatest difficulty, and only under the most 
 approved plans of treatment. 
 
 Phthisis, if latent in the system, or if the child be exposed to 
 contamination, often runs a rapid course after an attack of whoop- 
 iug-cough; acute general tuberculosis may develop also. Emphy- 
 sema and pneumo-thorax, as well as broncho-pneumonia, are complica- 
 tions and sequelae to be expected, on account of the severe strain 
 upon the lungs. 
 
 Treatment. The treatment of pertussis is not usually applied 
 with very much philosophy. Empirical prescribing is commonly 
 resorted to, and this is the best that we can seem to do with our 
 present state of knowledge. Though pathologists may agree that 
 the irritant is a microorganism, its exact location has not yet been
 
 160 SPECIFIC INFECTIOUS DISEASES. 
 
 decided, and if it had, its destruction might involve the use of rem- 
 edies which would necessarily destroy the pulmonary tissues. If 
 ptomaines are generated, there has been little accomplished toward 
 their correction in the treatment thus far employed. Indeed, old 
 school authorities content themselves (and blight the enthusiasm of 
 their followers) by declaring that there is little that can be done 
 for the disease except to meet complications as they arise. A few 
 cases seem to defy treatment, it is true, but others, and the majority, 
 can be so modified that the course of the disease can be shortened, 
 and little danger or trouble arise from it. 
 
 Agents which exert the best influence are adapted to the relief of 
 convulsive tendencies arising from irritation of the pneumogastric 
 nerve, and these are equally adapted to spasmodic cough, whether 
 from pertussis or other provocation. 
 
 Of the best of these is drosera. It will control a large share of 
 the cases of whooping-cough, and soon banish the whoop though I 
 have used it where its influence was entirely wanting. When this 
 proves to be the case, the best we can do is to try another remedy. 
 Add from ten to twenty drops of a reliable article of the tincture 
 (homeopathic, or specific medicine) to half a tumbler of water, and 
 give a teaspoonful every two or three hours, in severe cases. If the 
 cough has become pretty well established, it may require a week to 
 bring about the desired effect. If, by the end of this time, there 
 is no noticeable improvement in the cough, it will be rational to 
 abandon this remedy and try another. 
 
 A remedy which has proven excellent, and which I have found 
 prompt in relieving the severity of the cough, is magnesium phos., 3x 
 trituration. One or two grains of this may be administered every 
 two hours during the day until relief follows, the number of doses 
 then being lessened. 
 
 Where inflammation of the small bronchial tubes, with catarrhal 
 secretion (capillary bronchitis), arises, tartar emetic 3x trituratiou, 
 alone or alternated with calcarea phos., 3x, will be found excellent, 
 calcarea phos. being especially demanded where the child is anaemic, 
 and tending toward a condition of marasmus. 
 
 Quinine inunction, or the internal use of arseniate of quinia, 3x, 
 may be demanded, where the disease prevails in malarious districts; 
 and sometimes polymnia uvedalia or grindelia squarrosa will be 
 proper remedies, on account of splenic hypertrophy and consequent 
 congestion of the portal circulation. Where a condition of maras- 
 mus is well developed (the child having been attacked with convul- 
 sions and having entered upon a critical state), the tonic treatment 
 with faradism, repeate.l every second day for several weeks, will 
 materially assist in tiding the patient through.
 
 EPIDEMIC INFLUENZA. 161 
 
 Cool-tar products have been highly extolled as remedies for the 
 convulsive cough. I Lave known coal-miners to carry their children 
 into the mines to remain all day, for the purpose of arresting this 
 disease, after medicines have failed; and it is asserted that this 
 is almost certain to succeed. Antipyrin is said to be remarkably 
 efficacious in many cases, iii doses of from one to three grains. Phe- 
 nacetin possesses a similar reputation, though it is not as reliable as 
 antipyrin. Acetanilid is less objectionable than antipyrin. 
 
 Castanea vesca has proven a satisfactory remedy, and should not 
 be forgotten where stubborn cases are encountered. Ten drops of a 
 tincture of the green leaves should be administered every three or 
 four hours. 
 
 Bromoform, in three-drop doses (administered in a swallow of 
 water), repeated three times daily, is reported as nearly a specific. 
 
 Inhalations sometimes prove beneficial, and should be resorted to 
 in such cases as seem to defy other measures. The following may 
 prove of service: R Essence of peppermint gtt. x-xx, carbolic acid 
 gtt. iii-v, distilled water fi. M. Allow the patient to inhale from 
 a spray apparatus, every hour. Or, a one per cent solution of resor- 
 cin may be used instead. 
 
 Children recovering from whooping-cough should be warmly 
 clothed to prevent them from taking cold, and, where recovery seems 
 unduly protracted, a change of climate should be advised whenever 
 practicable. 
 
 XIII. EPIDEMIC INFLUENZA. 
 
 Synonyms. Epidemic Catarrh; Catarrhal Fever; Contagious 
 Catarrh ; French, La Grippe ; German, Blitz Catarrh. 
 
 Definition. Influenza is an acute, infectious, epidemic disease, 
 characterized by fever, great prostration, severe pain in the head, 
 back, and limbs, marked nervous phenomena, and catarrh of the 
 respiratory and gastro-intestinal tract. The catarrh may be limited, 
 or affect all the mucous membranes to the same extent. 
 
 Historical Note. The name is not descriptive of the disease, 
 although, as indicating its epidemic character, it is not inapt The 
 influence (influenza) of the stars was supposed to be causative and, 
 in the absence of pathological knowledge, the rapid spread of the 
 disease from continent to continent was not unnaturally ascribed to 
 stellar influence. 
 
 La grippe has prevailed, at intervals, for several centuries, being 
 first described in 1323. Many of the epidemics are historical, such 
 as those occurring in 1831, 1847, and the late epidemic of 1889-90. 
 
 At times, influenza has extended over almost the entire globe. 
 
 12
 
 162 SPECIFIC INFECTIOUS DISEASES. 
 
 It has traversed the whole of Europe in the space of forty days, 
 the rapidity with which it travels being one of its remarkable char- 
 acteristics, this probably suggesting the German name "lightning." 
 It has figured in the expression of national dislike and jealousy, as 
 the French call it the "Italian fever;" the Italians term it the "Ger- 
 man disease ;" the Germans repudiate this by alluding to it as the 
 "Russian pest;" while the Muscovite passes it along as the "Chinese 
 catarrh." However, the majority of epidemics have originated in 
 Russia. 
 
 Etiology. Of the causative germs of influenza, we as yet 
 know nothing. Meteorological conditions have but little influence 
 in its production, and, although the epidemics usually occur in the 
 winter months, they do not differ in character from those appearing 
 in the spring and autumn. Damp, cold, and foggy weather, which 
 would be a prolific cause of colds, would help to disseminate it by 
 rendering the system more liable to invasion, just as local conditions 
 tending to produce diarrhoea and dysentery would favor the spread 
 of Asiatic cholera. 
 
 It usually lasts about six weeks, and is severe in proportion to 
 the extent of its prevalency. No class or age is exempt, although 
 children often escape its influence, probably on account of their not 
 being so liable to exposure. 
 
 Some of our later investigators do not believe the disease depend- 
 ent on bacteria, but ascribe it to an organism of a different character. 
 The discovery of the plasmodium of Laveran may have pioneered 
 the way for the discovery of the peculiar microorganism responsible 
 for the production of the disease. One attack does not confer immu- 
 nity, and repeated seizures are common. 
 
 Pathology. There are no special or characteristic pathological 
 phenomena, the various lesions depending on the different structures 
 involved. If there are marked gastro-intestinal symptoms, the 
 mucous membrane of the stomach and bowels will be found con- 
 gested. Except in the rarer cases where there is but little catarrhal 
 inflammation of the respiratory tract, we will find it more or less 
 pathologically changed. The lungs are usually distended and pro- 
 truded, instead of collapsing, when the thorax is opened. The 
 smaller bronchi are much injected, the mucous membrane, here and 
 in the larger bronchi, being inflamed and covered with mucus. A 
 softening and swelling of the bronchial glands is also noted. When 
 pericarditis has been a complication, we have the usual anatomical 
 changes. 
 
 Symptoms. La grippe manifests itself in all degrees of inten- 
 sity, its clinical features depending on the structures principally
 
 EPIDEMIC INFLUENZA. 163 
 
 involved, and the complications that ensue. The disease usually 
 begins without prodromes. There is an initiatory chill, followed by 
 fever of a remittent type, ranging from 101 to 102 JF. The pulse 
 is not as rapid as one would expect from the fever present, although, 
 in serious cases, it may run up to 120 per minute. The urine is 
 scanty and high colored. With the fever, there are splitting head- 
 ache, and pains in the eyes and frontal sinuses. The joints and mus- 
 cles, especially of the back and lower limbs, are racked with pain, of 
 a character almost as excruciating as that noticed in dengue and vari- 
 ola. A prostration, far in excess of that to be expected from the 
 symptoms, is manifested early, pathognomonic of la grippe. Pro- 
 fuse sweating is usual, throughout the course of the disease. The 
 catarrhal symptoms begin in the upper passages, and there are pres- 
 ent coryza, hoarseness, soreness in the pharynx and trachea, and a 
 distressing cough, at first dry, but soon changing its character, as 
 the secretion is increased. As the disease advances, the sputum 
 becomes copious and muco-purulent. There is a constriction of the 
 chest, with difficult breathing, prsecordial oppression, and feeble 
 cardiac action, in elderly subjects. The involvement of the gastro- 
 intestinal mucous membrane is evinced by nausea and vomiting. 
 The tongue is coated, and usually moist. There is constipation, 
 which frequently gives place to diarrhoea. In epidemics where the 
 digestive symptoms are marked, dysentery is not uncommon. There 
 may be tenderness over the liver, and a jaundiced condition. 
 
 The complications met with are pharyngitis, laryngitis, oedema 
 aud congestion of the lungs, pneumonia, bronchitis, pleurisy, and 
 subacute gastritis. More rarely we have congestion of the liver, 
 parotitis, pericarditis, and various cutaneous disorders. Pneumonia 
 is the most serious complication. Copeland states that in the epi- 
 demic of 1831, of the patients at Hotel Dieu, over 20 per cent had 
 lobular pneumonia. 
 
 Ocular disturbances are among the sequelae, soreness of the ocu- 
 lar muscles, photophobia, and retinal congestion being most com- 
 mon. Loss of vision may occur from the effects of this disease, 
 through retinal hemorrhage. 
 
 Diagnosis. Some of the cases are liable to be mistaken for 
 "bad cold," but the sudden onset, great prostration, and catarrhal 
 features are usually sufficient to demonstrate a case of influenza. 
 After an epidemic is well under way, no mistake should be possible. 
 
 Prognosis. The prognosis is good in the adult where the con- 
 stitution is not greatly impaired; but the mortality is sometimes 
 quite high among children and the aged. Organic diseases, such as 
 parenchymatous or intestinal nephritis, emphysema, fatty heart, or
 
 164 SPECIFIC INFECTIOUS DISEASES. 
 
 pulmonary troubles, render the prognosis more or less doubtful 
 The disease is serious according to the severity of the complications. 
 
 Treatment. If we are called early enough, an attempt should 
 be made to abort the disease. If we fail in our object, we can, in a 
 great many cases, modify some of the symptoms, and the patient is 
 no worse off for the attempt. 
 
 Diaphoresis should be induced by the alcoholic vapor bath, or 
 such remedies as serpentaria (jss ji, p. r. n.), jaborandi (gtt. xx 388, 
 p. r. n.), or the diaphoretic or Dover's powders (gr. v-x, p. r. n.). A 
 hot pediluvium should preface the treatment, and the patient should 
 be well covered and hot drinks used, to assist the diaphoretic action 
 of the drugs. Old school physicians attempt to abort the disease 
 with large doses of quinine. 
 
 Where there is no great depression, and in the lighter attacks, 
 phenacetin will be a valuable remedy; but in serious cases, all depress- 
 ing remedies should be avoided. Phenacetin modifies the fever and 
 relieves muscular pain better than slower acting remedies. It is 
 well to add arseniate of quinia 3x to it in most cases. Three grains 
 of the former to two of the latter every three hours, will be the 
 usual dose. Our sedatives can be given alternately with the phenac- 
 etin. Aconite (gtt. 1-6 th), veratrum (gtt. i), or gdsemium (gtt. i-ii), will 
 be indicated for the febrile condition, the former being preferred 
 where there is much gastro-intestinal disturbance. Jaborandi (gtt. ii-v) 
 may be added, where the skin is dry. For the muscular pain, macro- 
 tys (gtt. ss) or arnica (gtt. l-10th) are prescribed, but the phenacetin, 
 jaborandi, and sinapisms (the latter moved from place to place as 
 required), will give better satisfaction. 
 
 Milk should be the principal diet for the first few days, until the 
 gastric irritability passes away. For this condition, rhus tox. (gtt. 
 l-3d) can be added to the sedative. It will also help to relieve the 
 coryza and frontal pain. A pack or sinapism over the epigastrium 
 usually gives considerable relief. 
 
 In the treatment of the respiratory symptoms, we are guided by 
 the nature and extent of the lesion. Where the cough is rasping 
 and explosive, the trachea and its bifurcations being principally 
 affected, bryonia (gtt. l-3d) will usually give relief. Inula helenium 
 has been used successfully in past epidemics. Its effects are limited 
 to the bronchi, and by adding to it asdepias, we have a powerful 
 combination. They may be given, aa, gtt. v, in syrup and water, 
 every two hours, or oftener, if required. 
 
 In acute cough, with dryness and ticlding, rhus tox. (gtt. l-3d) 
 may be prescribed. It influences both the circulation and the nerve 
 supply, and overcomes that teasing and tickling which is so annoy-
 
 DENGUE FEVER. 165 
 
 ing. Sticta (i*tt. ss-i) is a remedy that is not serviceable in ordinary 
 coughs, but frequently does good work in influenza. We do not use 
 it where there is abundant secretion, but where there is dryness and 
 wheezing, the cough being rasping and persistent. 
 
 Stannum 6x will meet that not uncommon condition where there 
 is a sense of exhaustion while speaking, with a tired sensation of the 
 larynx. 
 
 Inhalations of find, benzoin co. (jss-^i in aqua buL Oi) are grate- 
 ful to the patient, and help to relieve the catarrhal condition. 
 
 At night, the cough can be controlled with tinct. serpentaria co. 
 and glycerine, aa, 388, in hot, sweetened water. 
 
 Complications are to be met as they appear, the main object 
 being to avoid depressants, and keep up the strength of the patient. 
 
 XIV. DENGUE FEVEE. 
 
 Synonyms. Dengue; African Fever; Dandy Fever. When 
 this disease first appeared in the British West India Islands, it was 
 called the dandy fever, from the stiffness and constraint which it 
 gave the limbs and body. The Spaniards of the neighboring islands 
 mistook the term for their word, dengue (pronounced deng'ga), denot- 
 ing prudery, which also might be considered as denoting stiffness. 
 Thus the origin of the name. It is also termed "break-bone fever." 
 
 Definition. A specific, infectious disease, peculiar to warm 
 countries, characterized by paroxysms of fever, attended by severe 
 muscular and periosteal pains, with anomalous eruptions. 
 
 Etiology. That this affection depends upon a specific conta- 
 gium, seems proven by the fact that it has been transported in 
 clothing and other fomites from distant parts, on the occasion of 
 more than one epidemic. Its first appearance in this country dates 
 from the landing of a cargo of slaves from Africa. It occurs epi- 
 demically and sporadically, and attacks all classes of people, from 
 infant to aged, rich and poor, in common. While most liable to 
 break out in southern latitudes, it has prevailed in more northerly 
 sections, an epidemic having occurred, according to Loomis, in Phil- 
 adelphia, in 1780. An extended epidemic occurred in the West 
 Indies, in 1827, and one in our Southern States, in 1880. There is 
 some dispute among observers as to whether the disease is conta- 
 gious or not, and as to whether one attack provides immunity 
 against others. 
 
 Dr. McLoughlin, of Texas, has discovered a microbe, which he 
 presumes to be the active causative agent The organism is a form 
 of streptococcus. Whether it prove to be the genuine cause of 
 the disease may yet be considered questionable.
 
 166 SPECIFIC INFECTIOUS DISEASES. 
 
 Pathology. The pathology of dengue seems to resemble that 
 of malarial fever in many respects, and it was once believed to be a 
 modified form of that affection. Arthritic changes, similar to those 
 of rheumatism, are observed in some cases, though, as few ever 
 prove fatal, little is known about the morbid anatomy. 
 
 Symptoms. A period of about four days' incubation is followed 
 by an abrupt onset, usually initiated by a chill, though in children 
 convulsions may be the first indication of its presence. The temper- 
 ature now rises rapidly, reaching, in some cases, as high as 107 or 
 108 F., the pulse running at from 120 to 140 beats per minute. 
 
 There is severe frontal headac/ie (with photophobia, lachrymatiou, 
 and flushing of countenance ), pain in the back, limbs, and joints, 
 with or without nausea and vomiting. After about twelve hours, the 
 pains in the limbs, back, and joints become very much aggravated, 
 lancinating pains shooting from the lumbar region down the course 
 of the sciatic nerve, and along other large trunks. The lymphatic 
 glands take on inflammatory action early in the course of the disease, 
 the swelling and tenderness beginning in the inguinal glands, and 
 soon afterward appearing in the axillae and neck, these parts now 
 being exceedingly sensitive and painful. The epididymes are also 
 involved in a similar state, becoming swollen, sensitive, and painful. 
 The muscles and soft tissues become tender to the touch, all the 
 joints (both large and small) being reddened and swollen. The 
 fever continues unabated for from one to five days, when it termi- 
 nates in crisis. In many cases, a transitory, erythematous rash now 
 appears, beginning on the palms of the hands and neck, and spread- 
 ing over the entire body. This is liable to appear about the fifth 
 or sixth day. 
 
 The decline of the fever, however, is deceptive. It is really 
 only a remission, which lasts from two to five days, when a second 
 paroxysm of fever occurs, attended by all the previous muscular and 
 arthritic pains, headache, etc. But this paroxysm is less severe 
 than the first, and a termination by crisis ensues in two or three 
 days, and permanent convalescence now follows. 
 
 The disease is very prostrating in its tendencies, and convales- 
 cence is slow, from mental and physical debility. Colliquative 
 sweats, diarrhoea, and epistaxis often occur during the remission. 
 
 Diagnosis. Dengue may be confounded with remittent fever, 
 as it usually occurs in malarious regions; but the persistency and 
 severity of the muscular pains, and the glandular enlargement, with 
 the cutaneous eruption, will be distinguishing features. The fever 
 preceding the arthritic pains, and the erythematous rash, will dis- 
 tinguish it from inflammatory rheumatism, which it resembles; and,
 
 DIPHTHEKIA. 167 
 
 if this be not sufficient, the glandular enlargements will be further 
 distinguishing features. In its course, it resembles relapsing fever, 
 but it differs from this in the fact that it is a disease of the interior, 
 while relapsing fever is a disease of sea-ports, and lacks the marked 
 swelling of the joints and lymphatics, as well as the eruption, which 
 characterize dengue. 
 
 Prognosis. Though an apparently alarmingly severe disease, 
 the prognosis is almost always favorable, only those of extreme old 
 age, or very young infants, succumbing. 
 
 Treatment. The treatment will be directed toward a modifi- 
 cation of the severe febrile disturbance and its accompanying unpleas- 
 antness. A remedy especially adapted to the picture presented by 
 the symptoms is jdborandi. This should be given in small doses 
 (two or three drachms to four ounces of water; dose, a teaspoonful 
 every hour), repeated sufficiently often to moisten the skin, control 
 the pulse, and lower the temperature, when the severe pain will be 
 mitigated. Pliytolacca may be added for the lymphatic inflammation, 
 the jaborandi being combined, as, for instance, It Specific jaborandi 
 3111, specific phytolacca ji, water fiv. M., order a teaspoonful every 
 hour. When delirium is marked, gdsemium or rhus fox., selected with 
 regard to special indications, may be added to the treatment already 
 prescribed, or employed separately. 
 
 Whenever practicable, a vapor bath or two, repetition being made 
 available of a few hours after the preceding one, ought to do much 
 toward relieving the force of the onset, and conducting the case 
 through a mild course. The alcoholic vapor bath may do here, 
 though the cabinet vapor bath is preferable, when at hand. 
 
 Attempts should be made to modify the severity of the pains 
 with macrotys, rhamnus californica, or phenacetin. Opiates may seem 
 to be demanded, but they should be avoided in all ordinary cases. 
 In malarious districts, the judicious use of quinine may sometimes 
 prove beneficial, especially if periodicity be marked. 
 
 Careful nursing should signalize the period of convalescence, 
 until the patient has regained his wonted vigor. 
 
 XV. DIPHTHERIA. 
 
 Synonyms. Angina Maligna; Angina Suffocata. German, 
 Braune Pruna (glowing coal). Spanish, Garrotillo. 
 
 Definition. An acute, infectious disease, characterized by the 
 exudation of a membrane upon a recently irritated surface usually 
 the tonsils and adjacent parts the membrane containing the Klebs- 
 Loffler bacillus, the disease being attended by blood-poisoning from 
 ptomaines generated, resulting in profound prostration and anaemia,
 
 168 SPECIFIC INFECTIOUS DISEASES. 
 
 with liability to extensive pbagedena of the parts locally affected, or 
 to paralysis of various organs and muscles, as well as pulmonary 
 complication. 
 
 Historical Note. Diphtheria is a disease which has been 
 known from the days of antiquity. Asolepiades, who lived one hun- 
 dred years before Christ, performed laryngotomy for the relief of 
 obstructed respiration, and it is therefore probable that he treated 
 membranous croup and diphtheria. Aretseus, a Greek physician, who 
 lived at the beginning of the Christian era, described mild and 
 severe cases of diphtheria clearly, and Galen, who lived in the fol- 
 lowing century, wrote vividly of a fatal disease characterized by the 
 coughing, hawking, and spitting of a membrane. Coelius Aurelianus, 
 and Aetius, the latter of whom lived in the fifth century, described 
 it also, in unmistakable terms. No literature upon the subject 
 exists to show that it prevailed during the Dark Ages, but this must 
 be ascribed to the dearth of written records made during that time. 
 It is evident that it occurred in severe epidemics in the sixteenth 
 century, and from then to the present day an unbroken chain of tes- 
 timony exists to show that it has remained as one of the most fatal 
 scourges of human life. It has seemed to travel from the east west- 
 ward, the disease probably having been brought to this country by 
 Europeans. It it believed that the first cases occurred near Boston, 
 about the middle of the sixteenth century (1638 to 1663). The mod- 
 ern name "diphtheria" was first applied by Pierre Bretonneau, of 
 Tours, France. 
 
 Etiology. The disease is endemic to most large cities, pre- 
 vailing epidemically at certain periods. It is not confined to cities, 
 however, it sometimes occurring in rural districts, with great viru- 
 lence. It is contagious, the infection probably being communicated 
 through the membrane, both moist and dried particles being infec- 
 tious, the virus possessing a remarkable tenacity of life. Modern 
 microscopical investigators have been inclined to the opinion formed 
 by Klebs in 1883, and indorsed more recently by Loffler, that the 
 active principle of diphtheria is a germ, found in the diphtheritic 
 membrane, which is described by bacteriologists under the name 
 "Klebs-Lofiler bacillus." 
 
 This is a non-motile bacillus, about the third of the diameter of a 
 red blood-corpuscle in length, and about two and a half times as 
 long as broad. It is rounded at each end, and somewhat enlarged, 
 having a dumb-bell appearance. It contains no spores that are vis- 
 ible. It stains with alkaline methylene blue, and thrives in blood- 
 serum, bouillon, milk, and on raw potato. It is very ten.acious of 
 life, having been known to retain its vitality for five months, when
 
 DIPHTHERIA. 169 
 
 the membrane was wrapped in a dry cloth; and when stained, it 
 resists the bleaching power of acids. The ptomaine generated by 
 this bacillus, as w<pll as other septic processes arising from changes 
 occurring under the diphtheritic membrane, probably give rise to 
 the grave symptoms whiok often attend. 
 
 The most recent observations tend to throw mnch doubt upon 
 the identity of the Klebs-Loffler bacillus as the specific causal germ 
 of diphtheria. In numerous instances, a similar microbe has been 
 found in various situations in the buccal and nasal cavities, tonsil- 
 lar crypts, etc. in healthy individuals, apparently the same kind; 
 thus affording strong evidence of its non-malignant character, and 
 necessitating further inquiry before the question is fully settled. 
 
 Sewer-gas has been supposed to be an active factor in the cau- 
 sation of the disease, but knowledge of the fact that the virus 
 possesses great tenacity of life, and that it has been common prac- 
 tice to empty cuspidors containing sputa of diphtheritic patients 
 into the drains, will account for contamination arising from sew- 
 ers, whenever traps are faulty. The fact that houses where the 
 disease has been, remain points of infection for so long, is easily 
 explained by the knowledge that the virus retains its vitality for 
 a long time when dried, and that it may become a portion of the 
 dust which may finally settle upon the walls, to be afterward dis- 
 tributed by a commotion in the atmosphere, and become implanted 
 
 upon a receptive surface, such as the sensi- 
 tive throat of a child. Lack of caution in 
 the disposal of carpets and bedding which 
 have been about a diphtheritic patient, may 
 incline to the same result 
 
 Direct contamination, from one diphthe- 
 ritic P atient to another, is also frequent. 
 In mild cases, children are often about among their companions with 
 diphtheritic throats, and the coutagium may carry death to a sus- 
 ceptible person when the one communicating it may not be very 
 severely affected. Although it is a disease which is not very widely 
 diffused by one affected (a few feet of distance affording safety), the 
 indiscriminate use of drinking utensils among children of a commu- 
 nity or school, and especially among those of a single family, affords 
 ready means for the spread of the disease. The fresh membrane, 
 when implanted upon the mucous membrane of an unaffected per- 
 son, seems often to possess particular virulence; and physicans and 
 nurses frequently lose their lives by the communication of the dis- 
 ease from children, while attempts are being made to treat an affected 
 throat, the gagging, coughing, and " spluttering" of a fractious
 
 170 SPECIFIC INFECTIOUS DISEASES. 
 
 patient serving to project a particle of membrane with sufficient vio- 
 lence to implant it upon some receptive mucous surface of the 
 operator. 
 
 Animals are supposed, by good authority, to be a medium of com- 
 munication of the disease. It is certain that mammals and fowls are 
 often affected with rapidly fatal diseases, manifested principally by 
 membranous exudation in the throat. I have seen many cases of 
 the kind among chickens in California, and it is said to be a 
 common disease among other domestic fowls. Calves and cats are 
 subject to membranous throat diseases, though it is claimed in cer- 
 tain quarters that these are not communicable to the human family. 
 But it has been observed, in several instances, that severe outbreaks 
 of diphtheria have been preceded by such a disease among fowls, 
 when no case of the trouble had been observed for a long time 
 before. The rapid flight of pigeons their wide circle of haunts 
 would therefore suggest a cause for the distribution of the disease 
 to great distances in rural communities. Dr. M. W. Taylor (London) 
 observed a case in 1888, in which a young man, from no other appar- 
 ent possible cause, was taken violently ill with diphtheria four days 
 after cleaning out a pigeon-loft ; and he came to the final conclusion 
 that the disease must have resulted from infection from sick pigeons. 
 In 1884, upon the island of Skiathos, off the coast of Greece, diph- 
 theria appeared, where it had not been known for a period of at 
 least thirty years before, under the following circumstances : During 
 that year a dozen turkeys were introduced to the island, two of them 
 being sick when they were taken there. Seven out of the dozen soon 
 died with the disease, which was evidently contagious; three recov- 
 ered, and two were sick at the time of the inquiry. In two of the 
 fowls, a pseudo-membrane was found upon the laryngeal mucous 
 membrane, and in one that recovered there was paralysis of the feet. 
 During the time of the sickness of these fowls, diphtheria arose 
 among the inmates of the house adjoining the inclosura in which the 
 turkeys were confined, the prevailing wind being favorable to waft 
 the emanations in that direction, and an epidemic of the disease 
 occurred, lasting five months, one hundred and twenty cases occur- 
 ring in a population of four thousand, with thirty-six deaths. Many 
 other instances are on record, conclusively proving that diphthe- 
 ria may be communicated to the human family through the medium 
 of fowls. 
 
 Diphtheria is essentially a disease of children, and though older 
 persons may be affected, the gravity of the case usually depends 
 upon the age of the patient; the younger the child, the greater the 
 danger, other things being equal. It is asserted that new-born chil-
 
 DIPHTHERIA. 171 
 
 dren possess a certain immunity, but this is probably due to the 
 fact that they are not so liable to come in contact with drinking- 
 cups, spoons, and other utensils apt to be used in common by other 
 members of the family, and are protected largely from probabilities 
 of outside contamination. However, new-born children are fre- 
 quently attacked, especially in hospitals, and usually with fatal 
 result, the throat difficulty being attended or preceded by phlegmo- 
 nous inflammation of the umbilicus. 
 
 While adults usually resist the disease in ordinary epidemics and 
 recover, aggravated epidemics occur where it is fatal to nearly all 
 with whom it may come in contact. Another circumstance where it 
 is singularly fatal is that where the fresh virus is implanted upon a 
 mucous surface, as often occurs to physicians while manipulating 
 the throats of children for diagnostic or therapeutic purposes. A 
 prominent physician of Oakland died within a few days, a few years 
 ago, from an accidentof this kind occurring while performing trache- 
 otomy upon a desperate case in a child. Such cases are not at all 
 uncommon. 
 
 Pathology. The disease manifests itself in a variety of ways. 
 A more or less extensive destruction of tissue attends the location 
 of the membrane, this usually being the fauces, though other parts, 
 as the nares, eustachian tubes, middle ear, larynx, trachea, lungs, 
 mouth, oesophagus, or stomach, may occasionally be the seat of the 
 exudation. Occasionally the eyes may be the point of destructive 
 inflammation, either from extension of the disease through the nasal 
 duct, or as the result of direct contamination. In hospital practice, 
 it has been found that diphtheria is liable to locate itself upon the 
 raw surface left after the operation of circumcision, with resulting 
 destructive inflammatory action. 
 
 The exudation varies much in extent, sometimes covering but a 
 small surface, and at others involving large areas, covering the entire 
 fauces, uvula, and pharynx, and extending throughout the nares, or 
 perhaps into the larynx and trachea. Dr. J. Lewis Smith records a 
 case (Keating's Cyclopaedia) in which a cast from a considerable 
 section of the lower bowel was voided by an adult patient, under his 
 observation. The thickness varies from the eighth of an inch to as 
 much as a third of an inch, in some cases. 
 
 The cause of the most severe and dangerous symptoms is the 
 systemic poisoning arising from the ptomaine generated by the spe- 
 cific bacillus, though septic ferments also arise from pent-up necrotic 
 fluids confined under the membrane, in the majority of cases, with- 
 out doubt, which complicate and add to the constitutional gravity 
 of the disease. In some cases extensive sloughing of tissue results
 
 172 SPECIFIC INFECTIOUS DISEASES. 
 
 at the point of location of the membrane, but this would not be seri- 
 ous in character, were it not for the systemic effects of the poison. 
 In fact, the local symptoms cannot be considered a criterion of the 
 seriousness of the case, as some which exhibit but slight local dis- 
 turbance may result fatally in a short time, from heart failure. 
 
 The diphtheritic poison in the membrane induces a necrosis of 
 the cells with which it comes in contact, and a blackened line is 
 found about the borders aud under the surface of the exudation in a 
 few days after its appearance. The superficial cells and leucocytes 
 are first attacked, then the deeper structures, a coagulative process 
 or "hyaliue transformation" of the dead structures succeeding, which 
 results in the formation of the leathery (sometimes pultaceous) mem- 
 brane. Foci of necrosi^ proceed inward from the surface, and 
 become localized in various internal organs, such as the bronchial 
 and mesenteric glands. 
 
 When completed, the membrane is found to consist of a delicate 
 interlacing network of fibrin, containing epithelial cells more or less 
 altered, leucocytes, nuclei, mucus, and amorphous matter, as well as 
 the Klebs-Loffler bacillus, streptococci, and staphylococci. In a 
 few days after its formation, decomposition begins. During the 
 active stage of the disease, the membrane reappears with remark- 
 able rapidity upon forcible removal, a few hours sufficing to replace 
 it entire, as firm and extensive as ever. When the membrane is 
 removed, a raw, bleeding surface is left. 
 
 The kidneys and lungs are notably the seat of pathological dis- 
 turbances in diphtheria. Albuminuria is a frequent complication, 
 and though this may arise from feeble action of the heart, obstructed 
 respiration, or fever, the direct action of the diphtheritic poison upon 
 the structures of the kidneys, is most apt to be the cause of the 
 renal complication. We then have parenchymatous inflammation of 
 greater or less degree, followed by hemorrhagic infarcts, glomeru- 
 litis, disseminated inflammatory action, with cell infiltration and dis- 
 integration. The epithelial cells lining the tubuli uriniferi become 
 broken down and separated, forming casts. In the lungs there are 
 evidence of pulmonary apoplexy, disseminated extravasations, capil- 
 lary bronchitis, and infiltration of the alveoli. 
 
 Capillary hemorrhage and fatty degeneration of the cells may 
 occur in the liver. The spleen may be swollen, so as to distend its 
 capsule to the utmost, the pulp protruding upon rupture or slicing of 
 its covering. There is softening of the pulp, with extravasations of 
 blood into its substance and hyaline degeneration of its vessels, in 
 protracted and severe cases. Extravasation of blood occurs in the 
 heart, under the pericardial and endocardial surfaces, with degenera-
 
 DIPHTHElilA. 173 
 
 tion of the muscle-nuclei. The lymphatic glands of the carvical and 
 submaxillary regions are swollen, and contain evidence of histolog- 
 ical change. There are hypersemia of the cells, hemorrhagic points 
 in the periglandular tissue, and distribution of necrobiotic foci in 
 various places. Hyaline degeneration is also observable at various 
 points in the glandular tissue. The bronchial glands present evidence 
 of similar changes. 
 
 The blood is darker than normal, and there seems to be a defi- 
 ciency in the amount of fibrin, coagulation being imperfect. There is 
 a notable increase in the number of white corpuscles, wi$i evidence 
 of debris of broken-down red corpuscles, as seen under the micro- 
 scope. Extravasation of blood occurs in the brain and its menlnges, 
 as well as in the lungs, spleen, and kidneys. 
 
 Nature. The nature of diphtheria is peculiar in many respects. 
 It may be primary or secondary, usually occurring as a primary dis- 
 ease, but infrequently appearing as a secondary affection in scarla- 
 tina, and occasionally in typhoid fever, small-pox, measles, and 
 whooping-cough. When it appears in these diseases, a marked 
 aggregation of symptoms is observable, and the membrane will be 
 found upon the surface of some point of irritation the fauces in 
 scarlatina, probably the larynx in pertussis. The complication is 
 a grave one, usually proving fatal. 
 
 When occurring in patients in whom there already exists a local 
 inflammation, the membrane usually appears upon the irritated sur- 
 face. In scarlatina, where the fauces are the seat of irritation, the 
 membrane is found upon its appearance. In coryza preceding a 
 diphtheritic attack, the membrane is likely to be located upon the 
 Schneiderian membrane. If conjunctival irritation precede it, the 
 eye is liable to be the point of location. Eye hospitals have been 
 notoriously the place of resort of diphtheritic conjunctivitis. Cir- 
 cumcision of the prepuce among children in hospitals has been so 
 frequently followed by the location of diphtheria in the part after- 
 ward, that it has been considered advisable to substitute the opera- 
 tion of stretching the prepuce instead of incising it, for the purpose 
 of avoiding this danger. When a blister is applied to the surface of 
 the body in a severe case of diphtheria, the abraded surface is soon 
 covered with membrane exudate. 
 
 A point to which much discussion has been given is, Is diphthe- 
 ria primarily local or constitutional? A considerable number main- 
 tain that the membrane forms first, and that the ptomaines are 
 afterward absorbed, rendering the disease constitutional after the 
 membrane has been located for a time. Bnt it is observed that the 
 membrane speedily returns upon its removal during the active stage
 
 174 SPECIFIC INFECTIOUS DISEASES. 
 
 of the disease, and it would seem from this fact that it is an effect, 
 rather than cause, of the constitutional state. The long incubative 
 period usual to ordinary cases also suggests constitutional contam- 
 ination prior to the appearance of the membrane. In some cases, 
 the constitutional symptoms are marked before the membrane 
 appears. The system succumbs rapidly in severe cases before the 
 poison from the membrane could apparently have time to act, were 
 the constitutional symptoms deferred to the time for absorption 
 from the membrane to cause them. Albuminuria and nephritis are 
 often present on the first day in severe attacks, and it would hardly 
 seem that such remarkably rapid results could follow the first appear- 
 ance of the membrane. 
 
 Symptoms. The stage of incubation varies from two to twelve 
 days. Where the disease is communicated by inoculation, it appears 
 usually within two or three days after the introduction of the virus ; 
 where it originates in the ordinary manner, it varies from seven to 
 twelve days. It is observable that when the stage of incubation is 
 short the disease is severe, while in those cases in which this is pro- 
 tracted, it is mild. 
 
 The constitutional symptoms usually appear simultaneously with 
 the advent of the membrane. Sometimes these are altogether absent, 
 and the local symptoms are all that exist to indicate the presence 
 of the disease. There are few cases which do not exhibit more or 
 less constitutional symptoms early in the course of the affection. 
 The ordinary febrile invasion often marks the beginning of the dis- 
 ease, such as chilliness, followed by fever of considerable height, the 
 temperature rising to 105 or thereabout, during the invasion stage. 
 Sometimes, in young children, the disease is ushered in with vomit- 
 ing or convulsions. Where the febrile condition is ushered in with 
 a chill, the temperature usually runs a higher course than when the 
 disease comes on insidiously. In the former case, the temperature 
 is liable to reach 105 F. numerous times during the course of the 
 disease, while in the latter case, a temperature of 103 F. is seldom 
 reached. 
 
 There is no correspondence between the local and constitutional 
 symptoms. In some cases the fever may be very slight and the 
 membrane spread quickly from the start, with rapidly fatal results, 
 while in others the fever may ran high, and the local manifestation 
 Xe limited to a small patch of membrane upon one of the tonsils. 
 The temperature, if high, is liable to fall, after the first two or three 
 days of the disease, to near normal, and the membrane may spread 
 rapidly, while there is little or no pyrexial excitement. Later, 
 however, there is almost certain to be a rise in the temperature,
 
 DIPHTHERIA. 176 
 
 probably due to a systemic infection, different from that of the pure 
 diphtheritic virus, doubtless from purulency developed about the 
 location of the membrane, or from some local inflammatory action, 
 such as nephritis, tonsillitis, or pharyngitis. 
 
 But however near normal the temperature may be in marked 
 cases, the pulse indicates profound constitutional disturbance, either 
 by irregularity, or pronounced acceleration with feebleness, or by 
 both. In many cases the pulse will be feeble, small, and rapid 
 throughout the disease, sometimes, in young children, running as 
 high as 170 per minute. In other cases it may be rapid in the start, 
 but fall 40 or 60, within a day or two. In still ether cases, it may 
 be intermittent or remittant throughout the course of the disease, 
 suggesting grave results from the beginning. 
 
 The tongue hardly ever presents evidence of morbid condition of 
 the stomach or circulating fluids, as in some other infectious dis- 
 eases. It is usually moist and slightly furred, but commonly pre- 
 sents no marked indication for remedies as suggested by specific 
 tongue indications in certain other cases. 
 
 The urine will often be markedly scanty early in the disease, and 
 if it be tested for albumen, it will be found loaded with this sub- 
 stance ; though renal complication is not universally present. 
 
 Local Symptoms. Within twenty-four hours after the beginning 
 of the disease, where it affects the fauces or neighboring parts, there 
 will probably be found some enlargement, tenderness, and redness 
 of the tonsils ; and inspection of the fauces at this time will detect 
 the diphtheritic exudate, beginning to form over the anterior surface 
 of these organs, first appearing as a small patch of ashen-gray mem- 
 brane probably, but spreading rapidly, and often extending to the 
 uvula and posterior wall of the pharynx. At first it may be difficult 
 to distinguish this from the exudate of follicular tonsillitis, as this 
 may run together from two or more lacunae in some cases, and form 
 patches of considerable size. However, this may be removed with- 
 out much difficulty, while that of diphtheria is firmly attached; after 
 the membrane has spread upon the uvula, there can be no confusion 
 in this direction, as the exudation of tonsillitis is not found except 
 upon the tonsillar surface. The tonsils and fauces soon become con- 
 gested and oedematous, and the cervical lymphatics enlarged and 
 painful, the neck being swollen and stiffened. In a few days, the 
 membrane becomes necrotic, exhaling an offensive odor and coming 
 off in shreds of dark gray or black masses of decomposing material, 
 this occurring, in many cases, at the end of a week. The time of the 
 detaching of the membrane varies, however, and it may remain two 
 weeks or more before falling off. The surface covered by it is raw 
 and bleeding, after its removal.
 
 176 SPECIFIC INFECTIOUS DISEASES. 
 
 The odor of diphtheria, when the case is a severe one and there 
 are marked putrefactive tendencies, is characteristic, and offensive 
 in the extreme, resembling that of the recent excrement of chickens 
 most markedly, though exaggerated and more offensive still. 
 
 There are two varieties of diphtheria, as regards the exudation, 
 one in which there is a tendency to rapid development of membrane 
 without much putrefactive change, and another where there is a tend- 
 ency from the start to necrotic changes in the membrane, and break- 
 ing down of tissue, accompanied by offensive odor of the exhalations, 
 without so much disposition to rapid advance. In the first case, the 
 danger seems to be principally that of asphyxia, from blocking of 
 the respiratory passages, while in the other it lies more in the 
 extreme exhaustion which soon results. 
 
 Nasal diphtheria is sometimes insidious at first, the membrane 
 forming out of sight in the nasal cavities, all the general symptoms 
 of the disease appearing without the local evidence of the cause of 
 the trouble. It usually extends to the pharynx after a time, the 
 membrane appearing on the posterior pharyngeal wall, or on the pil- 
 lars of the fauces, or tonsils. It may extend along the eustachian tubes 
 and give rise to inflammation and destruction of the middle ear, 
 with perforation of the membrane. As the exudation spreads along 
 the nasal mucous membrane, the nostrils become obstructed, the 
 patient breathing through the mouth, and speaking in a "throaty," 
 muffled tone. A sanious coryza soon develops, which is excoriating 
 to the lip, and, as the disease progresses, epistaxis frequently occurs. 
 Where the membrane invades the eustachian tubes, there is tinnitus 
 aurium and sticking pains in the ear, aggravated by swallowing, with 
 more or less permanent loss of hearing. 
 
 When the oesophagus is invaded, there is dysphagia, with regurgi- 
 tation of fluids and frequent vomiting, the vomited matter containing, 
 as the disease progresses, portions of membrane. Later, portions of 
 the membrane may appear in the stools. 
 
 Sometimes the vagina, rectum, or labia are invaded, and there 
 may be pain, tenderness, swelling, and redness over the inguinal 
 glands. 
 
 Pharyngeal diphtheria may extend to the larynx and trachea, or 
 laryngeal diphtheria may be developed independently, when the 
 membrane begins in the nares. It is most apt to occur in young chil- 
 dren; the younger the child, the more liability to this form of the 
 disease. A croupy cough soon becomes prominent, respiration 
 being rough, and the voice raspy and indistinct, soon falling to a 
 whisper. The dyspnoea is marked, the auxiliary muscles of respira- 
 tion being taxed, paroxysmal attacks of difficult breathing occurring
 
 DIPHTHERIA. 177 
 
 at frequent intervals. The supra- and infra-scapular spaces sink 
 during inspiration, cyanosis becomes marked, and stupor or extreme 
 restlessness becomes pronounced, as dissolution approaches. Death 
 by suffocation finally results. Pulmonary changes are evidenced by 
 areas of dullness and absence of the respiratory murmur, with sub- 
 mucous, subcrepitant, crepitant, and sibilant rales intermingled. 
 The epiglottis, vocal cords, and interior of the larynx become com- 
 pletely covered with exudation, which, in many cases, extends far 
 down the trachea. 
 
 PARALYSIS. This is a distinctive feature of diphtheria, appear- 
 ing to greater or less extent iii almost every severe case, doubtless 
 being the cause of death in many instances of heart failure. Care- 
 ful investigation of the nervous system has been made, to deter- 
 mine what the pathological lesions, if any, were, and it has been 
 claimed by some authors that degenerative changes in the nervous 
 structures account for the condition. Charcot and Vulpian, in 1862, 
 detected granular degeneration of the nerves of the soft palate. 
 Oertel, in 1871, found extravasations in the substance of the brain, 
 spinal cord, and spinal nerves; in one case where death had occurred 
 from diphtheritic paralysis. Buhl found a similar condition, and, 
 in addition, determined that the nerves were thickened at their roots, 
 and that their sheaths were filled with lymphoid cells and nuclei. 
 However, this does not prove that diphtheritic paralysis is occa- 
 sioned by such changes in those who recover, and from whom 
 the paralysis spontaneously disappears in a few months. The 
 fact of speedy spontaneous recovery militates against the proposi- 
 tion that structural changes necessarily operate in producing them. 
 It seems apparent that the paralysis may be the result of the 
 depressing action of the diphtheria ptomaine on the functional activ- 
 ity of the nerve centers. The most common point of paralytic exhi- 
 bition, except the heart, perhaps, is the group of muscles about the 
 fauces and pharynx. Difficulty of articulation and swallowing are 
 here the prominent symptoms, the uvula hanging down and the epi- 
 glottis losing its reflex action, attempts at deglutition being attended 
 by the regurgitation of fluids through the nose, solids causing much 
 struggling and difficulty, when attempts are made at swallowing. 
 Paralysis of the laryugeal muscles, with aphonia, usually attends 
 this condition. These symptoms come on late in the course of the 
 disease, when the membrane is disappearing, or a week or ten days 
 afterward. The paralysis of the epiglottis may endanger the lungs, 
 through liability of portions of food to pass into the larynx, and, as 
 sensation as well as motion is gone, reflex coughing is not thus 
 excited. Expectoration is impeded, and the pharynx may be blocked
 
 178 SPECIFIC INFECTIOUS DISEASES. 
 
 with tenacious mucus, which the patient lacks the power to remove. 
 As the pharyngeal paralysis disappears, other muscles of the 
 body may become involved, the lower extremities being most liable 
 to suffer. There is no regularity of the symptoms, however, a hand 
 or arm, a foot or leg, the muscles of the neck, the orbicular muscles 
 or the lower sphincters, all being liable to paralysis. Cardiac paral- 
 ysis is also liable to occur during convalescence, and sudden collapse 
 may take place upon too sudden exertion, many days after the 
 patient seems out of danger. 
 
 However, paralysis of this kind usually subsides spontaneously, 
 time and care being about all that are necessary for complete recov- 
 ery of sensation and motion in the affected part. 
 
 The bowels seem to escape serious disturbance in this disease, 
 unless, as happens in rare cases, the membrane locates upon some 
 portion of the intestinal mucous membrane. Usually there is no 
 disturbance in their functions a favorable condition for recupera- 
 tion after the debilitating disease has spent its force, surely. 
 
 Diagnosis. The diagnosis of diphtheria is not always a simple 
 matter. Pseudo-membranous exudations often occur upon the laryn- 
 geal mucous membrane which are not diphtheritic; for though they 
 may cause death in a short time by asphyxiating the patient, they 
 do not infect the system with the profound constitutional poisoning 
 of that disease, nor do they present other clinical symptoms of diph- 
 theria, such as the peculiar stench, contagiousness, and paralytic 
 sequelffi, when recovery results. Also, bacteriologists are somewhat 
 confused as regards the evidence afforded by the Klebs-Loffler bacil- 
 lus, as it is asserted that there are cases of angina attended by an 
 exudation which contains a bacillus identical, morphologically, and 
 in its behavior on culture, with this germ, which does not communi- 
 cate diphtheria when inoculated. 
 
 Clinical characteristics are the best criterion by which to deter- 
 mine the identity of the disease, in general practice. The extreme 
 prostration, the markedly feeble and rapid pulse from the start, the 
 putrid odor, in conjunction with the characteristic leathery mem- 
 brane, can hardly be mistaken for any other disease, even if it should 
 be attended by angina with a pseudo-membrane. In large cities, 
 where diphtheria has become established ( and this is the case with 
 almost any city possessing a sewerage system), the chances are all in 
 favor of any angina attended by the formation of a leathery mem- 
 brane in the throat being diphtheria. The exceptions are certainly 
 rare, and are only worthy of notice to complete the requirements of 
 a text-book on practice. Pseudo-membranous croup lacks the pros- 
 tration that marks true diphtheria, is not attended by the rapid, fee-
 
 DIPHTHERIA. 179 
 
 ble pulse, and is free from the stench that characterizes disintegra- 
 tion of the diphtheritic membrane. 
 
 Prognosis. The prognosis of diphtheria is always doubtful 
 when the poison is sufficiently intense to markedly disturb the vital 
 functions. Even though the membrane may not be extensive, the 
 constitutional effects may result seriously, as there are so many ave- 
 nues open to a fatal result. If the prostration be not marked at first, 
 there is always a possibility that the kidneys may become involved 
 so seriously as to destroy the patient. Then, if this danger be past, 
 there is still danger that heart failure may suddenly terminate the 
 case. It being a treacherous and uncertain disease, care must be 
 observed nob to pronounce too favorably, in any event. 
 
 It is to be remembered, however, that there is great difference in 
 the character of different epidemics, and that a prognosis may 
 depend considerably upon the epidemic influence at hand. Mild 
 epidemics are attended by small mortality, and the treatment that 
 seems to make little impression in severe cases may suffice at such 
 times. 
 
 The age of the patient, also, will exert an important bearing upon 
 the prognosis, the younger the subject the greater the danger of lar- 
 yngeal complication, probably one of the most serious conditions 
 liable to attend. 
 
 The period of the disease determines to a certain extent the char- 
 acter of the danger. During the first six or seven days laryngeal 
 complication, or septicaemia, is most liable to appear. The voice 
 should now be watched, to determine whether it becomes husky or 
 croupy. A throaty voice, with snuffling breathing, will suggest nasal 
 complication, another portentous sign, as such cases seldom recover. 
 Bapid prostration, with lividity of countenance, delirium, or tendency 
 to drowsiness, especially if the pulse be irregular and the tempera- 
 ture elevated, will suggest septicaemia. After the first six or seven 
 days, inflammatory complications, if these exist (such as nephritis or 
 tonsillitis), have become fully developed, and the danger may now be 
 in this direction. Or, at this time, sudden death by syncope is lia- 
 ble to result from heart-clot, or abrupt arrest of cardiac action from 
 other causes. After the second week, nervous symptoms, especially 
 paralysis, may be expected, though if the patient has reached this 
 period, the prognosis may be considered more favorable, as the par- 
 alytic symptoms are not liable to prove fatal unless the heart 
 becomes involved. 
 
 Treatment. The patient should be isolated, and a strict quar- 
 antine established between the sick-room and all outsiders, except 
 the nurses and physician. Carpets and superfluous fomites, such as
 
 180 SPECIFIC INFECTIOUS DISEASES. 
 
 rugs, lace curtains, and extra bedding, should be removed. Dis- 
 charges from the mouth, throat, or other parts liable to contain diph- 
 theritic matter, should be disinfected with a strong solution of 
 corrosive sublimate before being emptied, and then should be buried 
 in a trench dug for the purpose; or, when possible, it should be 
 received from the patient on cloths, these to be immediately burned. 
 A basin of weak carbolic-acid solution should be near the bed for 
 washing the sponges, etc., used about the patient, and, instead of 
 pocket handkerciefs, cloths, which may be immediately burned, should 
 be employed. Care should be observed to keep all feeding-cups, 
 glasses, and spoons separate, and these should be cleansed in an 
 antiseptic solution before being allowed to leave the room, to be 
 washed. Linen, over a piece of waterproof made into a bib, to pin 
 over the nightdress of the patient, will serve as a protection against 
 the irritation of the neck and throat 'from the acrid discharges which 
 are liable to excoriate the skin, if coming in contact with it. 
 
 At the termination of the case the room and its contents should 
 be thoroughly fumigated by burning sulphur, the air in the room 
 being moist at the time, or else the walls and floor should be dili- 
 gently scoured with a strong solution of corrosive sublimate, and the 
 bedding and other clothing well boiled in a carbolic solution. 
 
 When possible, experienced nurses should be in charge of every 
 case of diphtheria, as intelligent precautions against the spread of 
 the disease are as important as attention to the patient in hand; and 
 the life of the patient may depend largely upon proper care at such 
 times, especially after the operation of tracheotomy, prompt feed- 
 ing and other details now being especially important. 
 
 Physician and nurse should be careful about keeping the mouth 
 closed while standing over the patient, and in treating the throat or 
 making examinations it is wise to wear a mask or silk handkerchief 
 over the mouth and nose, as a safeguard against accidental infec- 
 tion. The hands of the attendant should be cleansed frequently, in 
 disinfectants, those of the physician especially before leaving the 
 room after examining the patient, and those of the nurse especially 
 before taking meals. 
 
 It is an excellent plan to see that the room is constantly perme- 
 ated with steam from an antiseptic and aromatic solution. The fol- 
 lowing prescription is highly recommended by Dr. J. Lewis Smith, 
 and I have used it with considerable satisfaction : ^ Carbolic acid 
 and oil of eucalyptus, aa, fi; spirits of turpentine, fviii. This should 
 be mixed, and a tablespoonful of it mixed with a quart of water 
 for use, in a shallow vessel, which is kept constantly simmering upon 
 a gas or keroseue stove. This tends to soften the exudation and
 
 DIPHTHEKIA. 181 
 
 encourage secretion of the mucous membranes, thus assisting in 
 throwing it off. 
 
 Ventilation must not be neglected, as it is especially important 
 here, on account of rapid vitiation of the air from putrescent odors 
 and emanations. 
 
 It should be remembered that syncope and sudden death are not 
 uncommon in this disease, and that the upright position is inclined 
 to promote such an accident. The recumbent posture is the safe one 
 for the patieut until convalescence is well established. I have known 
 of several cases where dangerous syncope resulted from incautious 
 getting up before the disease was fully under control, and even dur- 
 ing early convalescence. 
 
 The medicinal treatment of diphtheria is still very unsatisfactory 
 in its results. It is true that many mild cases seem to do well on 
 aconite and phytolacca, but these would probably recover if left alone 
 therapeutically, and carefully nursed. Doubtless phytolacca relieves 
 the congestion about the fauces to a certain extent, and is therefore 
 of some use this being its specific province; and it will be called 
 for where there is considerable tonsillitis. But when we encoun- 
 ter severe cases, we are frittering valuable time away, when we 
 depend upon it, in the least, as a remedy for diphtheria, as its effects 
 can be but illusory. The " special sedatives" are also subject to 
 objections, as they can exert little or no control over the course of 
 the disease, and though pyrexial action be present, it is not so det- 
 rimental as the after-effects of any remedy which can act as a 
 cardiac depressant in minute doses, where there is so much inev- 
 itable prostration. Aconite, veratrum, gelsemium, and jaborandi 
 should be tabooed here, as there is no rational room for their 
 exhibition. If a sedative remedy is to be employed especially for 
 its sedative effects, there can be no objection to ferric phos. 3x, which 
 is very reliable for the general purposes of a sedative, and cannot 
 produce bad results. The markedly anaemic condition would rather 
 favor the theory of its application. 
 
 We seldom find the antiseptic propositions, manifested by the 
 tongue, which are found in some other acute infectious diseases. 
 The gastro-iutestinal canal does not seem to become sufficiently dis- 
 turbed to develop marked tongue symptoms, and when the disease 
 is ushered in by vomiting, it is usually caused by an effect upon the 
 nervous centers produced by the diphtheritic poison, rather than by 
 morbid accumulations or local irritability. I have never yet seen a 
 case where the sulphate of sodium, rhus tox., sulphurous acid, 
 hydrochloric acid, or any other specifically tongue-indicated anti- 
 septic was pronouncedly called for. Where this was the case, I
 
 182 SPECIFIC INFECTIOUS DISEASES. 
 
 should administer the proper one with faith that some good might 
 be accomplished. Chlorate of potassium has seen its day, as the 
 common complication of nephritis is well recognized, and also the 
 fact that this drug is very liable to produce a similar condition 
 without other causes. It is so detrimental as to be considered dan- 
 gerous, by modern therapeutists. The disease is necrotic in its tend- 
 encies, and should not be furthered in its effects by strong chemicals 
 which are liable to favor destruction of red blood-corpuscles and 
 fibrin, as well as firmer structures. 
 
 Probably we at present possess but two or three ideal remedies 
 for diphtheria; and, unfortunately, they are not always successful. 
 However, echinacea combines nearly all the properties desirable for 
 the fulfilling of the most important indications in the treatment of 
 this disease, as an internal agent. It is a sedative, while it stimu- 
 lates the vital forces at the same time. It is eminently antiseptic 
 and anti-necrotic. Furthermore, it is undisputably harmless in its 
 effects. There can be no danger in saturating the system with it, 
 and this should be done throughout the disease, unless there be 
 some prominent call for another remedy, the action of which might 
 be embarrassed by it. In all cases where septic and necrotic tenden- 
 cies are prominently marked, ten or fifteen drops of specific medi- 
 cine, or green-plant tincture, every hour, to a child eight years of 
 age, will be demanded. Where it is desirable to obtain the effect of 
 some other remedy, this should be employed as an intercurrent, 
 throughout the treatment. 
 
 Another remedy, which is better adapted to many cases, on 
 account of its superior action in cardiac failure, is lachesis, an agent 
 which has made many cures of severe diphtheria. My attention was 
 called to it many years ago, under the following circumstances: 
 A severe epidemic broke out in a neighboring township, while I 
 was practicing in the country, and proved to be remarkably malig- 
 nant in character, being fatal in almost every case affected; and it 
 did not cease until entire households were eradicated, adults and 
 children in common, though it was confined to a small neighborhood. 
 Several families employed old-school physicians, but at last the dis- 
 ease entered a family of homeopathic proclivities, and a young homeo- 
 path, who had recently located in the neighborhood, was called. 
 There were several members in this family, but all recovered except 
 one, which was considered a remarkable circumstance, as the disease 
 completely swept away several families which had been treated by 
 allopaths. In conversation with the homeopath afterward, I learned 
 that he had depended almost entirely on lachesis, in the treatment 
 of his cases.
 
 DIPHTHERIA. 183 
 
 The remedy is so well adapted to this disease that I will reprint, 
 from Hughes' Manual of Pharmacodynamics, an extract bearing on 
 its action, both in this disease and others attended by local gangrene 
 and systemic infection : 
 
 "Malignaut local inflammation, with secondary blood infection 
 and nervous prostration, have proved preeminently the sphere of 
 lachesis. A typical instance is traumatic gangrene. Of this dis- 
 ease Dr. D. M. Dake has published three cases, which are so decisive 
 as to overcome even Dr. Hempel's skepticism as to the virtue of the 
 remedy. They are given at length in the second edition of his 
 Materia Medica ; and in the fourth volume of the American Homoeo- 
 pathic Review Dr. Searle, of Brooklyn, has recorded two others. To 
 these I would add the testimony of Dr. Franklin, who, as army 
 surgeon in the late civil war in America, had abundant opportunity 
 of seeing the disease. 'I have used this remedy,' he writes in his 
 Science and Art of Surgery, 'in a number of cases of gangrene follow- 
 ing wounds, and have never been disappointed in its results. In a 
 case of comminuted leg fracture, terminating in gangrene and threat- 
 ening speedy destruction of the limb, the gangrene was quickly 
 checked by the internal and external use of lachesis, the inflamma- 
 tion subsiding, and the healing process moving on to a complete cure. 
 In another case of compound dislocation of the ankle-joint, with frac- 
 ture of malleolus externus, followed by gangrene, lachesis effected a 
 speedy cure, the patient making a good recovery under the surgical 
 treatment employed. I cannot recommend too highly the use of 
 this agent for gangrene, and am confident that the observations of 
 all who have employed or may employ it will bear me out in the 
 assertion that it is eminently curative of gangrenous affections.' 
 
 "It is affections of this kind, moreover, which form the bulk of 
 the paper of Dr. Carroll Dunham, to which I have referred. He 
 begins with a case of septicaemia occurring in his own person, as the 
 result of a wound incurred during the post-mortem examination of a 
 case of puerperal peritonitis. Both the local and general symptoms 
 were severe, but they rapidly yielded to lachesis 12, three times a 
 day. Next he relates an epidemic of malignant pustule, in which he 
 treated eight cases with lachesis alone. 'It relieved the pain within 
 a few hours after the first dose was given, and the patients all 
 recovered very speedily.' Then he speaks of three cases of phlebitis 
 supervening upon ulcers (probably syphilitic) of the lower extrem- 
 ities. There was great and sudden prostration of strength, low mut- 
 tering delirium, and general typhoid symptoms, indicating pyaemio 
 infection. The effect of lachesis was all that could be desired, the 
 patient rallying promptly, and all symptoms of phlebitis speedily
 
 184 SPECIFIC INFECTIOUS DISEASES. 
 
 disappearing. Last, he narrates one case, and refers to others, of 
 carbuncle, in which the constitutional symptoms denoted very great 
 prostration, not preceded or attended by the nervous and vascular 
 erethism which is sometimes observed in similar cases. The absence 
 of this condition, he thinks, in all these disorders, the indication for 
 luchesis as against arsenicum, when the asthenia is not so complete 
 as to call for carbo vegetabilis. 
 
 "Dr. Dunham finally refers to the usefulness of lachesis in cer- 
 tain cases of diphtheria. In these the tumefaction of the throat was 
 slight, and the redness of the mucous membrane hardly noticeable, 
 the diphtheritic deposits consisting merely of two or three patches 
 hardly larger than a pin's head. But the prostration of strength 
 was quite alarming; the pulse became, in a very short time, slow, 
 feeble, and compressed; a cold, clammy sweat frequently covered 
 the forehead and extremities; the breath was foetid; the appetite 
 entirely destroyed. 'In such cases,' he writes, 'in all in which the 
 constitutional symptoms thus predominated over the local, lachesis 
 produced prompt and lasting improvement, so much so that very 
 rarely was any other remedy given subsequently.' To the same 
 effect is the testimony of Dr. Tietze, of Philadelphia, in the fourth 
 volume of the United States Medical and Surgical Journal. He men- 
 tions a purple, livid color of the affected parts, with dull, dry 
 appearance and little swelling, also pain out of all proportion to the 
 amount of inflammation, as local characteristics of the remedy. He 
 places it third to belladonna and apis in throat affections, in the 
 descent from sthenic to asthenic conditions. Dr. E. M. Hale also 
 contributes to the American Journal of Homoeopathic Materia Medica 
 three similar cases of diphtheria in children, which made a rapid 
 recovery under lachesis, while the rest of the family (altogether 
 eight in number) under old-school treatment succumbed to the 
 disease." 
 
 In using this remedy, I prescribe two or three grains of the 6x 
 trituration, to be repeated every two hours. 
 
 But there is a form of diphtheria in which the tendency to early 
 putrefaction and necrosis is not so marked as that of rapid spread 
 of the membrane. We hore have the danger of blocking of the lar- 
 ynx with exudate to encounter, especially in young children; and 
 neither echinacea nor lachesis seems to possess the property of con- 
 trolling plastic exudation. Potassium chlor. 3x comes nearer ful- 
 filling this requirement than any other remedy we know of, and 
 Schuessler has been very enthusiastic over its action as a specific for 
 diphtheria, on this account It certainly is of considerable service 
 in this particular class of cases, as I know from experience, and here
 
 DIPHTHEEIA. 185 
 
 we will administer echinacea or lachesis every three or four hours, 
 and give potassium chlor., adding ten grains of the 3x to half a glass 
 of water; dose, a teaspoonful every hour. 
 
 There are many other remedies which have been advocated for 
 the internal treatment of diphtheria, such as sulpho-carbolate of sodium, 
 benzoale of sodium, pilocarpine, turpentine, eucMorine, tincture chloride 
 of iron, etc. The numerous remedies recommended by different 
 authors are suggestive of the fact that few of them possess the 
 required virtues, when desperate cases are encountered. However, 
 a careful study of these is recommended, lest something useful be 
 neglected. 
 
 The use of alcoholic stimulants throughout the disease is an old 
 practice, but some adhere to it at the present day. Mild cases will 
 recover under such treatment, doubtless, as they will recover sponta- 
 neously ; but as alcohol does not cure anything else, it is difficult to 
 believe that it will cure severe cases of diphtheria. Happily, it is not 
 so fashionable a remedy as formerly, and one can now omit it from 
 his treatment without losing caste among his allopathic neighbors. 
 
 The local treatment of the membrane is an important matter, at 
 least is so considered, as this is liable to be the nidus of septic accu- 
 mulation, and the source of septicaemia infection, quite independently 
 of the original diphtheritic virus. To abridge the extent of this for- 
 mation, lessen its thickness, and render it as little septic as possible, 
 seem, then, important considerations. These are to be accomplished 
 by the use of solvent antiseptics, such as lime-water, pepsin, trypsin, pap- 
 yotin, and peroxide of hydrogen, as well as many others not here men- 
 tioned. The douche may be used to irrigate the nasal cavities in nasal 
 diphtheria, though too much of this is liable to bring on inflamma- 
 tion of the middle ear. 
 
 Swabbing of the throat has fallen into disrepute in many quar- 
 ters, as the struggles of the patient in resisting the operation, for 
 which many children entertain a great horror, are liable to result in 
 blind and forcible efforts, which irritate the tender and partially dis- 
 organized structures, inviting the deposition of more membrane, and 
 aggravate what inflammation may already be present. Atomization 
 of fluids with a spray apparatus is the best method of application, 
 the remedies being employed in solution. 
 
 The following combination affords good satisfaction, the throat 
 being sprayed with it frequently : R Glycerine gtt. xx, carbolic acid 
 gtt. xv, aqua f i, essence of peppermint jiss. Misce. Or, R Oil of 
 eucalyptus f ii, beuzoate of sodium 31, bichromate of sodium ^ii, glyc- 
 erine f ii, lime-water Oi. Misce. These may be used both for nasal 
 and pharyngeal exudation.
 
 186 SPECIFIC INFECTIOUS DISEASES. 
 
 Where the laryngeal exudation becomes so abundant as to impede 
 the respiration, and is evidently advancing, tracheotomy or intuba- 
 tion should be resorted to early, before the patient has become so 
 exhausted as to render the effort useless. 
 
 Inflammatory conditions must be met by proper special reme- 
 dies. Tonsillitis may demand phytolacca; inflammation of the mid- 
 dle ear, piper methysticum or pulsatilla; nephritis, rhus aromatica 
 or vesicaria commuuis. 
 
 The paralysis may be benefited somewhat by the proper applica- 
 tion of galvanism and the internal use of nerve stimulants, but time 
 usually relieves such conditions nearly as rapidly as treatment, and 
 if patient and friends are assured that a favorable outcome may be 
 expected, this symptom will not cause much trouble. 
 
 The food, during the disease and during convalescence, should be 
 of the most nutritious character, and, at the same time, of a kind to 
 be easily swallowed and digested. Meat juice, malted milk, beef 
 peptonoids, and plain, fresh milk may all be resorted to, as is most 
 convenient and acceptable. Food should be given in small quantity, 
 often, as it is to be remembered we are dealing with a rapidly pros- 
 trating affection. Cathartics should be avoided, as they embarrass 
 digestion, and derange the functions of the alimentary canal. 
 
 Time has favored belief in the antitoxine treatment, in desperate 
 cases. There is no doubt that the injection of the substance into 
 the circulation is fraught with considerable danger, for numerous 
 cases are on record where it has been employed for prophylaxis, 
 in which sudden death was the result. But, again, it has been fol- 
 lowed by favorable changes, where death seemed imminent, and it 
 seems indisputable that in its proper place'it is sometimes surpris- 
 ingly efficacious. The proper plan, it seems to me, is to hold it in 
 reserve for cases which defy other therapeutic measures, aud, when 
 these arise, to employ it in combination with them. From corre- 
 spondence with several of our best physicians, as well as from read- 
 ing our current medical literature, I am convinced that we cannot 
 afford to ignore it as a means of salvation, in occasional cases. 
 
 Saveral reliable brands of horse-serum are in the market, each 
 package being accompanied by full directions. Where death has 
 seemed imminent in a few hours, numerous cases of malignant diph- 
 theria have convalesced within twenty-four hours after the hypo- 
 dermic use of this agent; the temperature speedily falls, the mem- 
 brane rapidly disappears, the symptoms of prostration pass away, 
 and, though an erythematous rash, with cutaneous irritation, may 
 attend, convalescence soon follows. However, it should only be 
 employed in those cases which offer little other hope.
 
 ERYSIPELAS. 187 
 
 XVI. EEYSIPELAS. 
 
 Synonyms. St. Anthony's Fire ; Bose. 
 
 Definition. An acute, contagious disease, excited by the strep- 
 tococcus erysipelatis, characterized by a peculiar inflammation of 
 the skin and subcutaneous tissue, attended by an irregular fever and 
 tendency to rapid spread, with speedy resolution and liability to 
 relapse. 
 
 Etiology. The cause of this is undoubtedly local infection 
 from a specific germ, which gains entrance to the tissues through 
 some abrasion of the cutaneous or mucous surface. The disease 
 was formerly divided into traumatic and idiopathic erysipelas, from 
 the fact that it develops occasionally in wounds, and seems to some- 
 times develop upon a cutaneous surface where no abrasion of the 
 skin has been made; but closer inspection will always show that 
 there has been an opening in the integument, through which the 
 germ has entered. The division, therefore, is manifestly illogical. 
 The abrasion may amount to only a slight excoriation, such as a 
 mosquito bite, a small pustule, an intertrigo, or some minute point 
 that escapes notice until the erysipelatous manifestation is developed. 
 A common place for the appearance of the disease is the face, and 
 the first point of localization may be out of sight, upon the mucous 
 membrane of the nose, mouth, eyelid, or ear, it spreading from there 
 upon the skin, through one of the natural orifices. Or, it may arise 
 at the genitals or anus, intertrigo, eczema, chafing, a pustule, an ulcer, 
 or some other break in the skin, admitting the infection. Erysipelas 
 may arise in the pharynx and traverse the eustachian tube to the 
 middle ear, pass through the tympanum and appear on the face; or it 
 may arise in the nose, and passing through the nasal duct, appear in 
 the eye, to spread from there to the face; or it may pass from the nos- 
 tril to the face, or from the pharynx through the mouth, and the dis- 
 ease seem idiopathic, when some abrasion, not observable, has 
 allowed the streptococci to enter the tissues. Erysipelas is pecul- 
 iarly severe and fatal in new-born children, though after six months 
 of age it is not more severe, probably, than in adults. Puerperal 
 women are also more than ordinarily susceptible to the infection. 
 Vaccination provides a ready point for the entrance of the infection, 
 and erysipelas is not an uncommon sequela of that operation. That 
 the disease can be communicated from one to another, has been 
 proven by the vaccination of several persons from one who shortly 
 afterward developed it, all the others soon developing the disease 
 also. This is one of the principal objections to the employment of 
 humanized virus in vaccination. Some persons seem predisposed to 
 yearly attacks of erysipelas, the disease returning about the same
 
 188 SPECIFIC INFECTIOUS DISEASES. 
 
 period, for years in succession. The face is usually the point of 
 attack here, rhinitis, eczema, acne, or some other abrasion of the 
 skin affording it entrance. Erysipelas usually occurs sporadically, 
 though epidemics occasionally develop. 
 
 It has been a disputed 
 question whether the germ of 
 erysipelas is a separate and 
 distinct organism, similar to 
 but not identical with the 
 pus-streptococcus. Koch and 
 others, after careful investi- 
 gation, have decided that it 
 is identical with the s'repto- 
 
 - | 
 
 .%.(** curt*.) COGC.US pyogenes, while others, 
 probably fully as reliable, 
 
 declare that though the similarity is great, there is a distinction. 
 From a clinical standpoint, the latter view seems the correct one. 
 
 Pathology. An early infiltration of the skin and subcutaneous 
 connective tissue is the first marked pathological alteration, though 
 careful inspection will now find the streptococci occupying the lym- 
 phatics, where they are at first confined, whence they soon afterward 
 invade the adjacent connective tissue. The skin becomes cedema- 
 tous and sharply raised over the affected area, the part being at 
 first bright-red, tense, and shining, though afterward becoming livid 
 or brown, the epidermis now being thrown off in scales or flakes. 
 The infiltration is serous or fibrinous in character, and contains an 
 abundant supply of cells (leucocytes), which surrouud the vessels. 
 The streptococci, which first appear in the lymphatics, soon invade 
 the connective tissue of the skin, and, sparingly, the subcutaneous 
 tissues, in chaplets or coherent masses, which constitute colonies, 
 and around which necrotic changes, more or less marked, occur. The 
 amount of exudation and necrotic change determines the severity 
 and characteristics of the case. Where the exudation is moderate 
 in amount, there is not very extensive destruction of tissue, scaling 
 and flaking of the epidermis, with a more or less permanently estab- 
 lished debility of the skin being left behind, manifested by a deep- 
 ening of the color of the affected part, which may persist for some 
 time after convalescence. Where the exudation is more abundant, 
 blebs and vesicles rise on the surface, due to necrotic changes in the 
 cells of the rete Malpighii, at numerous adjacent points, with subse- 
 quent deliquescence of the partitions, and liquefaction of the con- 
 tents. This constitutes erysipelas vesiculosuin or bullosum. Some- 
 times pus accumulates instead, constituting erysipelas pustulosttm. 

 
 EKYSIPELAS. 189 
 
 These dry up into scabs, becoming erysipelas crustosum, and if necro- 
 sis occur about them, we have erysipelas gangrenosum, the necrosis 
 varying in extent markedly, in various cases. The mucous membrane 
 of the respiratory tract may partake of the general characteristics of 
 the cutaneous affection, the tissues of the lungs becoming infiltrated 
 and occupied by streptococci, with the resultant changes. The 
 pathological condition will differ from croupous pneumonia, from the 
 fact that there is no plastic exudation into the alveoli, as in that dis- 
 ease. In severe and prolonged cases, the tissues generally undergo 
 the general changes common to prolonged pyrexia. There is paren- 
 chymatous degeneration of tne muscles, intestines, liver, spleen, kid- 
 neys, etc., though these changes are not pathognomonic of the ery- 
 sipelatous disease. 
 
 Symptoms. From three to seven days' incubation occur after 
 the entrance of the streptococci, before the disease becomes fully 
 developed. 
 
 Like some other infectious diseases, the actual attack is preceded 
 by more or less marked prodromal symptoms, such as drowsiness, 
 irritability, malaise, muscular pains, etc. The disease proper often 
 begins with a chill, more or less marked, though in young children, 
 convulsions or vomiting may replace it. A rise of temperature fol- 
 lows, the thermometer soon marking as high as 105 F. While 
 irregular, the temperature is liable to remit slightly in the morning, 
 with an evening exacerbation, though this rule may be reversed. It 
 may not rise above 103 in mild cases, and it may reach 106 and 
 higher, in severe ones, the temperature depending much on the extent 
 of the local disease. As long as the local inflammation continues to 
 advance, the fever continues high, though the advance usually ceases 
 by the third or fourth day. About the fifth or sixth day it may fall 
 rapidly to normal, though this cannot be depended upon. With 
 rise of temperature, the pulse becomes correspondingly increased in 
 rapidity, ranging, in adults, from 100 to 120 per minute. 
 
 The local manifestation is almost always a coincidence ; an elevated, 
 reddened point of localization is observed, which spreads rapidly, 
 showing an abrupt elevation at its borders, and in which there are 
 sensations of tension, burning, itching, tingling, and darting pains. 
 The redness disappears upon pressure, leaving a pit in the cedema- 
 tous tissue, but returns rapidly upon its removal, the part being 
 sensitive to touch. Where the subcutaneous tissue is abundant, as 
 about the eyes, the swelling is a remarkable feature of the disease, 
 the eyes soon being swollen shut, their presence almost obliterated, 
 and the countenance disfigured. During the active progress of the 
 disease, while the fever remains high, it is accompanied, in many
 
 190 SPECIFIC INFECTIOUS DISEASES. 
 
 cases, by severe constitutional symptoms, such as loss of appetite, 
 nausea, vomiting, intense headache, thirst, and even delirium. The 
 tongue becomes dry and brown, and is usually covered with a thick 
 coating, which may be pasty-white. The urineia scanty, high colored, 
 and often albuminous, and the botoels are constipated. Where the 
 face and scalp are extensively affected, the patient may be delirious 
 or comatose. Where the mucous membranes join the skin near the 
 point of attack, they are frequently involved. When recovery termi- 
 nates the case, the swelling gradually subsides, the redness disap- 
 pears, the temperature declines, secretion becomes reestablished, 
 and the appetite returns. Where death ensues, the patient usually 
 dies with a high temperature. 
 
 The disease manifests a marked predilection for the face and 
 scalp, it being estimated that nearly seventy per cent of the cases 
 encountered are located here. Where the scalp is deeply involved, 
 a permanent, or at least a long-continued, alopoecia may result over 
 the most severely affected surface. 
 
 In the new-born, the disease usually commences about the navel 
 or the genitals. Imperfect healing of the navel may leave an open- 
 ing for the entrance of the miroorganisms, and chafing about the pri- 
 vates, so common in very young children, is attended by excoriations, 
 offering abrasions favorable for the ingress of the disease. The dis- 
 ease arises insidiously in these cases usually, only a slight blush 
 indicating its presence, for three or four days. Finally, a high fever 
 develops, and the local manifestation becomes observable. The skin 
 is soon enormously distended and glistening, subcutaneous abscesses 
 develop in many cases, and gangrene soon follows. The inflamma- 
 tion iray extend along the umbilical vein, and paritonitis, with puru- 
 lent infiltration, result. The child is extremely restless, cries con- 
 stantly, refuses nourishment, finally becomes comatose, and dies in 
 this condition, or in convulsions. 
 
 The disease is an acute one, and runs its course in from ten to 
 fourteen days, usually, though it may leave serious sequelae, which 
 may persist for a long time. Among these are abscesses of the skin, 
 gangrene, bronchitis, and pneumonia. Where the throat is severely 
 involved, oedema of the glottis may arise. Cardiac affections, such 
 as endocarditis and pericarditis, may ensue. Inflammation of the 
 meninges sometimes results, and death may be caused by this affec- 
 tion, the disease extending through some of the foramina, where the 
 head and face are involved. Eye affections, such as keratitis, pan- 
 ophthalmitis, and amaurosis, are of occasional occurrence. 
 
 Diagnosis. The diagnosis of erysipelas is not difficult. The 
 intense redness and swelling, localized, and usually known to arise
 
 ERYSIPELAS. 191 
 
 from a wound or break in the integument, the intense swelling, with 
 abrupt border of the tumefaction, this being accompanied with high 
 fever and other marked constitutional symptoms, can hardly be mis- 
 taken for any other disease. Rims poisoning might present some of 
 the local symptoms of erysipelas, but the severe constitutional symp- 
 toms would be absent. Other cutaneous affections would be subject 
 to the same exception. Where there was any question in the clini- 
 cal aspect, a microscopical examination might detect the characteris- 
 tic streptococcus. 
 
 Prognosis. The character of the surroundings will suggest 
 much, as to the probable outcome of a case. In traumatic ery- 
 sipelas, occurring in crowded hospital wards, the condition is always 
 a serious one. Where the case is sporadic, and sanitary conditions 
 are favorable, with a patient of constitutional vigor, the prognosis is 
 not unfavorable. When the disease occurs in new-born children or 
 puerperal women, a guarded prognosis is safest for the reputation 
 of the attending physician. 
 
 Treatment. A better knowledge of the etiology and pathology 
 of erysipelas has not advanced the treatment of the disease, to any 
 great extent. The best treatment we possess is an empirical one, 
 though the general principles of dynamical therapeutics apply here, 
 as elsewhere. The treatment may be divided into constitutional and 
 local, the aim being to neutralize the ptomaines generated and the 
 inflammatory action as much as possible, it not being probable that 
 treatment directed to the destruction of the streptococci will amount 
 to anything more than an aggravation. 
 
 It is well in the beginning of treatment to inspect the tongue 
 carefully, to see if there be any prominent indication of blood-sepsis. 
 One of two remedies will be indicated here, provided there is any 
 call for remedies of this character. We may have the sulphite of 
 sodium indication, suggested by the broad, flabby tongue, with pallid 
 mucous membrane, covered with the pasty- white coating; and we 
 may have the sulphurous acid tongue, indicated by the dark-red mucous 
 membrane with brown coating, this being usually dry. Sometimes 
 there is no prominent tongue indication, and the treatment is much 
 simplified. For the sodium tongue, we will administer capsules con- 
 taining sodium sulphite, 1 gr., every three hours. For the sulphu- 
 rous acid tongue, twenty drops of this drug, well diluted, at about 
 the same intervals. 
 
 Having seen to it that provision is made for sepsis as indicated 
 by the tongue, we will devote ourselves to other treatment, nearly if 
 not quite as important. The nature of erysipelas is to destroy con- 
 nective tissue by necrosis. If we can mitigate this tendency, we shall
 
 192 SPECIFIC INFECTIOUS DISEASES. 
 
 be able to modify the extent of the destructive action, lessen the 
 spread of the disease, and protect the tissues from very severe inflam- 
 matory and degenerative changes, as well as ameliorate, considerably, 
 the severity of the general symptoms. Our best remedy for necrosis 
 of soft tissues is echinacea; and it should constitute a portion of the 
 treatment of every case, being administered steadily throughout the 
 entire course of the disease. It is not incompatible with any other 
 remedy we may need, and can be administered in combination (in 
 alternation, or in conjunction) with any other treatment. Ten or fif- 
 teen drops may be advantageously administered, to an adult, every 
 hour during the height of the disease, and four or five times a day 
 during convalescence, to guard against relapse. 
 
 A high temperature would suggest the combination of jdborandi 
 with echinacea, three or four drops of the specific medicine every 
 hour tending to reduce the temperature as well as the local inflam- 
 mation, through its sedative action. Any one who has experienced 
 the gratefully cooling influence upon the skin in his own person dur- 
 ing fever or inflammatory action, can appreciate the benefit liable to 
 be derived from this remedy in such a condition as erysipelas. 
 
 E/ius tox. is especially useful as a sedative where the tissues of 
 the face are involved, as it seems to possess a specific influence upon 
 this part, and exerts its influence for the better speedily and effec- 
 tively. I employ it in combination with aconite, using five or eight 
 drops of specific aconite to fifteen or twenty of rhus, in half a glass 
 of water, giving a teaspoonful every hour. Where the tongue is red- 
 dened at the tip and edges, and pointed, tremulous on protrusion, or 
 where the patient is particularly restless, or nauseated, it is espe- 
 cially commendable. 
 
 Markedly necrotic conditions might suggest the use of baptisia, 
 though it would be difficult to imagine a case where baptisia would 
 succeed if echinacea had failed to arrest the tendency to gangrene. 
 LacJiesis should be borne in mind where phagedenic tendencies are 
 pronounced, two or three grains of the 6x or lOx, every two hours. 
 
 Periodicity might be present in a malarious region, and demand 
 the use of an antiperiodic. In such a case, the antiperiodio would 
 constitute an important part of the treatment, and it should be used 
 appropriately, the exacerbation being anticipated with proper doses 
 of yuinia sulphas for several days, until the periodicity has been 
 interrupted. In treating children and delicate persons, the 3x trit- 
 uration of arseniate of quinia may be found more acceptable to the 
 stomach, less disagreeable to the nerves, and fully as effective, given 
 in two- or three-grain doses, four or five times daily. 
 
 Local applications should figure extensively, in the treatment of
 
 SEPTICAEMIA AND PYAEMIA. 193 
 
 erysipelas. Echinacea is one of the best of these, its antagonism to 
 necrosis of tissue being as well marked locally as constitutionally. 
 Cloths saturated in a twenty-five per cent dilution of a saturated 
 tincture or the specific medicine, in water, should be laid upon the 
 affected area, and renewed every hour. Acetate of lead is an applica- 
 tion which is soothing and cooling, and was once a favorite local rem- 
 edy with me. A saturated solution, in water, may be applied on sat- 
 urated cloths, frequently repeated. Another excellent agent is citric 
 acid, used in saturated aqueous solution, as above directed. Another 
 remedy, which many laud very enthusiastically, is the spirit of Min- 
 dererus. This is probably the best use this old formula can be made 
 of, as its local influence in erysipelas is sometimes remarkably fine. 
 
 Cathartics can exert no beneficial effect in the treatment of this 
 disease, and should be avoided, as their use is unscientific and 
 uncalled for. Enemata may be employed where evacuation of the 
 bowels is an urgent matter, though the small amount of food con- 
 sumed will obviate necessity that the bowels move every day. 
 
 Complications should be met by rational measures. Abscesses 
 should be opened early, and cleansed with dilute peroxide of hydro- 
 gen, diluted echinacea, or weak solutions of carbolic acid and glycer- 
 ine, in water. Ophthalmic complications will call for the local appli- 
 cation of diluted echinacea, a weak solution of citric acid or sugar of 
 lead. Cardiac complications may demand calcium fluoride, cactus 
 grandiflorus, or convallaria. 
 
 The diet should be nutritious but not stimulating, fatty meats 
 and high seasoning being forbidden. Milk, plain and malted, fari- 
 naceous foods, digestible fruits and vegetables, and eggs, well cooked 
 or rare, will constitute an appropriate regimen. 
 
 XVIL SEPTIOEMIA AND PYJEMIA. 
 
 SEPTIOJSMIA and pysemia are often confounded. Some medical 
 writers have even failed to distinguish between them, but have 
 regarded the two conditions as identical. However, there is at least 
 one distinguishing feature, and that is that pyaemia is marked by the 
 diffusion of abscesses through various parts of the body, as the result 
 of lodgment of ernboli distributed from a primary abscess, while 
 septicaemia is a general poisoning of the fluids, without foci of sup- 
 puration. Each will be considered separately. 
 
 SEPTICAEMIA. 
 
 Definition. A general febrile disease, without foci of suppu- 
 ration, caused by the absorption of septic bacteria and their pto- 
 maines usually bacteria of suppuration. 
 
 14
 
 194 SPECIFIC INFECTIOUS DISEASES. 
 
 Etiology. Septicaemia may result either from the absorption 
 of toxines from without the circulation (septic intoxication), or from 
 the generation of toxines in the circulation, through the multiplica- 
 tion of septic bacteria within the blood-vessels (septic infection). In 
 either case, absorption of septic material or bacteria must first take 
 place from some nidus of putrefaction in intimate association with 
 the circulation, such as ft pent-up wound, a retained placenta under- 
 going decomposition, typhoid ulcers, old tubercular cavities, etc., 
 from which free access of air is excluded. Cavities open to the air 
 hardly ever become the origin of septicaemia. 
 
 Symptoms. There is great variation in the severity of the 
 symptoms of different cases of septicaemia, depending upon the 
 amount and intensity of the septic material giving rise to them. 
 Some cases may be so mild as to be almost overlooked, while others 
 are so profound as to result fatally, within one or two days after the 
 onset. 
 
 Senn, in his Principles of Surgery, segregates cases of septicaemia 
 into three general classes: namely, (1) fermentative fever, (2) sap- 
 rsemia, and (3) progressive septicaemia. 
 
 Fermentative fever (resorption fever) is the simplest form of 
 wound complications, the absorption of mildly septic fluids being 
 similar in results to those of transfusion, or the injection of pepsin 
 into the blood. It may follow slight injury or operation, especially 
 operations where superficial necrosis in wounds attends the action 
 of solutions used in dressings; or it may result from extravasation 
 of blood. Soon after the development of the provoking cause 
 within a few hours a mild fever (without a chill) arises, the tem- 
 perature rapidly running up to 103 or 104 F., where it may remain 
 for twenty-four or seventy-two hours, when it subsides spontaneously, 
 no severe constitutional symptoms appearing at any time. 
 
 Saprcemia is a form of septic intoxication due to putrefactive 
 changes occurring in dead material. Ptomaines are thus formed, 
 various microorganisms being concerned at divers times, such as 
 pyogenic bacteria, and various forms of the proteus group. As these 
 microbes multiply and grow, toxines are developed, which are 
 absorbed into the circulation, and produce the condition just named. 
 SapraBmia, then, is the toxaemia resulting from the introduction of 
 ptomaines into the blood from a putrefactive localized focus. Soon 
 after the absorption of such material, constitutional symptoms 
 develop; a slight chill is followed by marked reaction, the tempera- 
 ture rising to 103 or 104 F., with rapid pulse, headache, perhaps 
 nausea and vomiting, and great prostration. Typhoid symptoms 
 rapidly follow, there being restlessness and delirium, with reddened,
 
 SEPTICAEMIA AND PY.2EMIA. 195 
 
 pointed tongue, which later becomes dry and contracted, or presents 
 a glazed appearance. Three factors are necessary to produce this 
 condition: namely, dead tissue, putrefactive infection of this mate- 
 rial with septic microorganisms, and time for the ptomaines to be 
 absorbed. A focus of putrefaction may be due to lacerated or bruised 
 tissues, blood-clots in wounds, to retained secundines, etc. 
 
 Progressive septicaemia is due to more than absorption from a 
 localized focus of putrefaction. In addition to ptomaines absorbed, 
 microorganisms within the blood continue to generate toxinos. The 
 microbes most common in this form of septicaemia are the pyogenic 
 bacteria. 
 
 The symptoms of progressive septicaemia are developed soon after 
 the absorption of the septic material; seldom later than the third 
 day, and often within twenty-four hours. They resemble those of 
 sapraBmia, only they are more profound. There is an initiatory chill, 
 followed by a temperature of 103 or 104F., with varying intermis- 
 sions. The pulse is weak and wiry from the start, evidencing great 
 prostration, and it soon becomes soft and compressible. Inflamma- 
 tory action may proceed rapidly along the lymphatics, from the focua 
 of putrefaction to vital organs. The patient inclines to drowsiness 
 and stupor, early, though he may be aroused by violent vomiting 
 alternated with diarrhoea. The face presents a yellowish pallor, and 
 assumes a vacant expression ; the pupils are often dilated, and the 
 tongue is dry, and red at the edges, with a brown dorsum. Such 
 cases are liable to prove fatal within from two to four days. 
 
 Diagnosis. The difference between the symptoms of this dis- 
 ease and pyaemia is sufficiently characteristic to enable the practi- 
 tioner to readily differentiate. In septicaemia there is not the pro- 
 nounced chill at the initiation that marks pyaemia, which is ushered 
 in by a pronouuced rigor. In pyaemia the chills recur, and are as 
 prominent as an ague, in some cases, while in septicaemia there is 
 but the one chilly period, and that is at the onset, and it usually 
 amounts to only slight shivering, or mild rigors. In septicaemia the 
 temperature rises rapidly to 105 or 107 F., while in pyaemia it 
 gradually rises to 102 or 104. The skin, in pyaemia, presents & 
 peculiar leaden yellow hue, while in septicaemia there is not this 
 peculiar discoloration. Pyaemia develops gradually, while septicae- 
 mia is a disease of rapid onset. The history of the case will usu- 
 ally assist in determining between septicaemia and typhus or typhoid 
 fever, should there be any question in this direction. 
 
 Prognosis. The prognosis will depend upon the amount of 
 septic material absorbed in the beginning, and upon the facility with 
 which the putrefactive focus can be evacuated, and rendered aseptic.
 
 196 SPECIFIC INFECTIOUS DISEASES. 
 
 Where the symptoms are mild in the beginning and it is possible to 
 evacuate the offending material, as by cleansing the uterus, when it 
 contains putrefactive placental remains, with proper curettage, there 
 is good ground for a favorable prognosis. But, when the onset is 
 violent, the patient being immediately seized with urgent vomiting 
 and purging, delirium speedily following, there is but little pros- 
 pect that recovery will follow. Collapse and dissolution are liable 
 to soon attend such a condition. 
 
 Treatment. The treatment of severe cases of septicaemia will 
 be more of a surgical than therapeutic nature. Septic cavities 
 should be drained and cleansed with antiseptic solutions as thor- 
 oughly as possible, at an early date. If the uterus contain putrefac- 
 tive material, it should be evacuated by proper curettage and flushed 
 frequently, with warm antiseptic solutions, until constitutional symp- 
 toms have passed away. In puerperal peritonitis, where the perito- 
 neal sac contains septic material, the only probable chance for the 
 life of the patient is a thorough cleansing of the cavity with anti- 
 septics, through an abdominal incision. All putrefactive cavities 
 should be repeatedly flushed, until dead material has been completely 
 removed. Therapeutic measures may accomplish some good. Tongue 
 indications should be carefully observed, and any prominently indi- 
 cated dynamical antiseptic administered, as soon as called for. Sul- 
 phite of sodium or sulphurous acid may be required, though baptisia 
 or echinacea may often serve a good purpose. Professor Scudder's 
 favorite remedy for septicaemia due to putrefying placental material, 
 when there was fetor about the patient, was minute doses of potas- 
 sium chlorate. To counteract the prostration, heart stimulants, such 
 as nitro-g^cerine or strychnia (hypodermically), may be demanded to 
 tide the patient over. Restlessness and delirium, with pyrexia, may 
 call for aconite and rhus tox., gelsemium, OTjaborandi. 
 
 Lachesis, in 2-grain doses of the 6x trituration, repeated every 
 two hours, is an excellent internal remedy to correct the septic con- 
 dition of the blood. 
 
 Prophylaxis consists in observing proper antiseptic precautions 
 in the management of wounds, abortions, and obstetrical cases. 
 
 PY2EMLL 
 
 Synonym. Pyothremia. 
 
 Definition. A general infectious febrile disease, resulting from 
 the entrance of emboli infected with the microbes of suppuration 
 into the circulation, characterized by the formation of metastatio 
 abscesses in various parts. 
 
 Etiology. The cause of pyaemia was once believed to be the
 
 SEPTIC^MIA AND PYAEMIA. 197 
 
 absorption of pus into the circulation from primary suppurating sur- 
 faces. Later, Virchow called attention to the part played in the 
 genesis of the metastatic abscesses by thrombi and emboli, and later 
 investigators now declare that these emboli must be charged with 
 pyogenic microbes (infected), in order that infarctions shall degen- 
 er.ite into embolic abscesses. The results of lodgment of non-infec- 
 tious material (emboli) are simply mechanical infarctions but when 
 a thrombus contains pyogenic bacteria, the leucocytes and embryonic 
 cells degenerate into pus-corpuscles, and a focus of suppuration 
 results. When pus-organisms induce coagulation necrosis in the 
 smaller vessels about suppurating wounds, producing thrombi and 
 purulent phlebitis, small fragments of the thrombi (emboli) are car- 
 ried by the circulation to different parts, where they find lodgment, 
 the pus microbes there forming colonies, and setting up suppuration. 
 
 Pathology. The distribution of metastatic abscesses depends 
 upon the location of the primary distributing focus on its relation 
 to the special portion of the circulation involved. 
 
 In external wounds and osteo-myelitis, as well as in acute cuta- 
 neous phlegmon, the embolic abscesses are most liable to develop 
 wedge-shaped infarcts in the lungs ; though the emboli may pass 
 through these organs, and become lodged in the liver or kidneys. 
 
 "When the primary suppurative foci are in the first capillary dis- 
 tribution of the portal circulation, as in the intestines in typhoid 
 fever, the metastatic abscesses appear in the substance of the liver, 
 with or without pyelo-phlebitis. 
 
 Ulcerative endocarditis may result in showers of small metastatic 
 abscesses which invade the lungs when the right endocardium is 
 involved, and the spleen, kidneys, intestines, and skin, when the 
 suppurative action is in the left heart (the arterial pyaemia of 
 Wilks). 
 
 So-called idiopathic pyaemia occurs, in which the primary lesion 
 is not apparent, but in which numerous abscesses are scattered 
 about, in various parts. 
 
 The blood, in pyaemia, tends to spontaneous coagulation in the 
 vessels, wherever there is slowing of the current. Colonies of 
 micrococci are found in various places in the blood, and on the walls 
 of the vessels. 
 
 Pyrexial changes are observed in the internal organs and other 
 soft tissues, similar to the granular degeneration marking other 
 febrile diseases. The spleen is swollen, and exhibits parenchyma- 
 tousdegeneration. 
 
 Pygemic inflammation of the serous membranes is often present, 
 the pleura, peritoneum, and pericardium, being involved. The pleura
 
 198 SPECIFIC INFECTIOUS DISEASES. 
 
 is especially susceptible, the plenral cavity sometimes filling rap- 
 idly with purulent material Snppurative arthritis may occur, and 
 lymphangitis is liable to arise in the neighborhood of metastatic 
 abscesses. 
 
 Symptoms. Chitta are important symptoms of pyaemia, these 
 occurring at the commencement of the disease, six or seven days 
 after the infection which gives rise to it has begun. The chills 
 may recur regularly or irregularly. When they recur with regular- 
 ity, the condition is liable to be mistaken for malaria. The more 
 frequent the chilis, the more numerous the metastatic abscesses, 
 the chilliness usually heralding the origin of a new point of infec- 
 tion, and attending the commencement of suppurative action. 
 
 The fever which attends varies in character, though it is usually 
 intermittent or remittent. When intermittent, the temperature may 
 rise to 104 during the acme, continue there a few hours, then sub- 
 side, with sweating, to normal In some cases there may be several 
 chills during twenty-four hours, with paroxysms of fever between, 
 each chill being preceded by a remission, or the temperature fall- 
 ing to or below normal. 
 
 Gastric symptoms are not usually so marked as in septicaemia, 
 nausea and vomiting seldom occurring; and delirium is rarely pres- 
 ent, unless the brain be the seat of metastatic abscesses, the men- 
 tal condition continuing sound throughout. The pulse soon becomes 
 feeble and rapid, and the skin assumes an icteric tint, due, suppos- 
 ably, to the destruction of red corpuscles and consequent staining of 
 the skin with hematoidin. 
 
 The local as well as the general symptoms vary in proportion to 
 the number and location of the abscesses. Where many emboli are 
 diffused throughout the body, they are usually small, and the local 
 symptoms are obscured largely by the severe and rapidly fatal gen- 
 eral disturbance, the disease terminating with typhoid symptoms 
 and death, in from one to three weeks. In those cases where the 
 emboli are fewer, a more chronic course follows, and the active con- 
 stitutional symptoms are less severe. Such cases are more chronic, 
 and the locations of the abscesses are indicated by pain, and varying 
 functional disturbances. 
 
 When the lungs are involved, dyspnoea will be a constant symp- 
 tom, its extent being determined by the number and size of the 
 abscesses. Large abscesses located near the pleura will give rise to 
 pleural inflammation, signalized by lancinating pains and dry crep- 
 itus, or friction sounds, upon auscultation. Over the region of 
 the infarct may be heard crepitant rales and bronchial respira- 
 tion, and percussion will now discover dullness. If the abscesses
 
 SEPTICAEMIA AND PT^MIA. 199 
 
 be located near the heart, the pericardium may be involved, and 
 cardiac symptoms supervene. 
 
 Embolic abscesses in the kidneys will be determined by the pres- 
 ence of albumin and pus in the urine. Arthritic abscesses will be 
 easily recognized by the redness, swelling, and pain. Other loca- 
 tions may be involved where the symptoms are obscure; large 
 abscesses may develop internally, so insidiously without pain as 
 to reach immense proportions before they are recognized. In other 
 cases, the subcutaneous connective tissue may be involved, with the 
 symptoms of ordinary abscess. 
 
 Chronic cases may linger along for months, before a final fatal ter- 
 mination, the patient gradually losing flesh from the constant hectic, 
 until death from exhaustion results, or extensive amyloid degen- 
 eration of vital organs interferes with processes necessary to the 
 maintenance of life. 
 
 Diagnosis. The history of the case will usually assist in 
 determining the condition of affairs, unless there be idiopathic 
 pyaemia present where no local focus of infection is known. If mala- 
 ria be confounded with it, quinine may be employed for diagnostic 
 purposes, it being remembered that while this drug will interrupt 
 the chills of malaria, it exerts no pronounced influence over those of 
 pyaemia. Remembering the points of distribution of emboli, we 
 will hardly be liable to confound this disease with acute atrophy 
 of the liver, acute rheumatism, or typhus, or typhoid fever. 
 
 Prognosis. The prognosis is always unfavorable. However, 
 patients of powerful recuperative energies, who are not severely 
 affected where the abscesses are few and far between sometimes 
 recover. 
 
 Treatment. It is doubtful that there are anti-suppurative rem- 
 edies sufficiently potent to arrest the action of the pyogenic microbes 
 after they have once entered the circulation as extensively as in 
 pyaemia. It may be worth while to attempt this with echinacea, in 
 acute cases, and with calcium sulphide or berberis aquifolium in more 
 chronic ones; but the outlook will not be very promising. How- 
 ever, there is nothing like faith and perseverance, and these remedies 
 judiciously administered can do no harm, at least. The anti-suppu- 
 rative action of potassium choride 3x should also be recollected here. 
 
 Abscesses, when accessible, should be treated antiseptically, and 
 stimulants and nutritives should be regularly administered, to sus- 
 tain the patient as much as possible. 
 
 Allopathic authorities advise the free use of alcoholic stimulants, 
 it being their belief that life may thus be prolonged, in some cases, 
 until the disease subsides.
 
 200 SPECIFIC INFECTIOUS DISEASES. 
 
 XVIII. ASIATIC CHOLERA. 
 
 Synonyms. Epidemic Cholera; Spasmodic Cholera; Malig- 
 nant Cholera. 
 
 Definition. Epidemic cholera is an acute, specific, infectious 
 disease, endemic in some parts of India, but carried, in epidemic 
 form, to other localities. It manifests itself either by choleraic diar- 
 rhoea, having no distinct characteristic; cholerine, which differs but 
 little clinically from cholera-morbus ; and pronounced cholera, char- 
 acterized by copious "rice water" purging, persistent vomiting, severe 
 muscular cramps, marked prostration, emaciation, and collapse, 
 rapidly followed by dissolution, or recovery. The dejections of the 
 several varieties contain the distinctive cholera bacillus. 
 
 Historical Note. Asiatic cholera has prevailed in India for 
 centuries, but until the great epidemic of 1817, very little was heard 
 of it outside of the medical reports of the East India Company. 
 The statement of some authorities that cholera originated at Jessore 
 in 1817 is erroneous, as there were ten extensive epidemics on the 
 Indian peninsula from 1503 to 1817. 
 
 The great cholera epidemic of 1817 first attracted general atten- 
 tion, from the extent of territory traversed and the appalling loss of 
 life that followed. Within an area of 195,935 square miles, almost 
 every town and hamlet suffered from its ravages. Europe had thus 
 far escaped ; but the epidemic of 1827 did not stop at the bounda- 
 ries of India, but, advancing through Afghanistan and Persia, it 
 moved on to Russia, and by 1832 it had devastated the whole of 
 continental Europe, aoid had spread to America. In 1840, during 
 the Opium War, the English troops carried the disease from India 
 to China. From the extreme east of Asia it now began its west- 
 ward march, and traversing the length of the continent, entered Rus- 
 sia, in 1846. Here, after decimating the Empire, it continued its 
 progress westward, over Europe. As in 1832, it again crossed the 
 Atlantic, but this time did not cease its progress until it reached the 
 Pacific Ocean, having traversed the habitable globe in the space of 
 eight years. In 1851-63, cholera again reached Europe over the old 
 route, via Russia, and passed with emigrants to this country, where it 
 prevailed widely, though not so extensively as in the former epidemic. 
 
 The outbreak of 1865 chose a new route. Beginning in the 
 Bombay Presidency, it traveled to Mecca, where 30,000 died of the 
 disease. Leaving the Holy City, it passed to Alexandria, via Suez, 
 crossed the Mediterranean to Europe, and reached New York in 1866. 
 
 The last visitation in this country occurred in 1873, the disease, 
 as before, entering Europe through Russia, and being brought here 
 by European emigrants.
 
 ASIATIC CHOLERA. 201 
 
 The Egyptian epidemic occurred in 1883, and was, as before, 
 directly traceable to pilgrims. A stringent quarantine prevented its 
 passing to Europe. 
 
 The last European epidemic occurred in 1892. It originated in 
 the Punjab, and was rapidly disseminated over India. The great 
 Twelfth Year pilgrimage, with its million pilgrims, was broken up, 
 and flying devotees carried the plague in all directions. It reached 
 Europe inside of six months. America warded it off by a rigid 
 quarantine, and, although New York harbor was full of infected ves- 
 sels, only two cases occurred on the mainland. 
 
 Etiology. The etiology of cholera has been a prolific cause of 
 controversy, and, although the doctrine of Koch is adopted by the 
 majority of the profession, there is a respectable minority who reject 
 (or only partially accept) his ideas. Numerous theories have been 
 advanced, but the subject is too extensive to permit of their being 
 discussed here. 
 
 Koch, in 1884, advanced the idea that the disease was due to a 
 specific microbe, the comma bacillus, which gained entrance to the 
 alimentary canal by contaminated food and water. The bacteria are 
 
 shorter but more bulky than the tubercle 
 bacilli, and slightly curved; hence the 
 name comma bacillus. Some are joined, 
 and form an S, and, again, they frequently 
 grow in spirals. Koch himself inclined to 
 the opinion that they were a transition 
 form between bacilli and spirilli, if not 
 
 . 11* mi. j n 
 
 genuine spirilli. They are found in the 
 dejections, and in the structure of the intestine. Barely, they are 
 noticed in the vomitus, but in that case regurgitation through the 
 pylorus is supposed to account for their appearance. They can be 
 cultivated in various media, but drying destroys their vitality. In 
 this they differ from many other bacteria, notably the bacillus 
 tuberculosis. 
 
 Cholera is endemic in certain localities on the Indian peninsula, 
 and within this district the disease is always in existence. Here, 
 peculiar climatic and topographical conditions, an overcrowded pop- 
 ulation, and the utter disregard of sanitary measures among the 
 natives, furnish an opportunity for the development of microorgan- 
 isms, scarcely to be equaled elsewhere. There have been no epi- 
 demics which cannot be traced back to the Bombay Presidency. The 
 disease always proceeds along the routes of travel and commerce, 
 without regard to climate. Trading caravans, invading armies, and 
 pilgrim hordes, have disseminated the disease, time and again.
 
 202 SPECIFIC INFECTIOUS DISEASES. 
 
 Cholera is not contagious ; or, like typhoid fever, only exceptionally 
 so, and physicians and nurses handle patients with impunity. 
 
 The bacilli may gain admission to the system directly, as from 
 food and water infected from fecal discharges, or they may multiply 
 outside of the body, and, contaminating the water supply, reach the 
 system indirectly. As the disease is propagated from the stools, 
 bad sanitary conditions furnish the opportunity for its spread. 
 Milk, and vegetables washed in water containing the bacilli, are often 
 sources of infection. Soiled garments and bed linen are responsible 
 for a great many cases of cholera. This has been noticed frequently 
 in the cases of washer- women. In the East, the custom of wearing the 
 clothing of the dead is common. It is, however, through a vitiated 
 water supply that cholera is principally propagated, and it is thus 
 enabled to disseminate itself through a community with astonishing 
 rapidity. The disease does not prevail extensively in high altitudes. 
 Hot, sultry weather is favorable to its development, and epidemics 
 are more common in summer and autumn. However, it may be 
 stated that one of the worst Russian epidemics occurred during an 
 exceptionally severe winter. No age is exempt, and the poorly fed, 
 debilitated, and intemperate are especially prone to be attacked. 
 
 It is an eastern proverb that fear kills more than cholera, but it 
 is doubtful if the emotions have as much to do with rendering the 
 body susceptible to the disease as some writers imagine. Author- 
 ities differ as to oue attack conferring immunity against a second. If 
 this is the case, the duration of the period is short 
 
 Pathology. The post-mortem appearances vary considerably, 
 depending on the stage of the disease in which death resulted. The 
 temperature frequently rises after death, and the body cools slowly. 
 Rigor mortis begins early, and the rigidity is marked, the limbs 
 often being distorted. Post-mortem movements are a peculiar fea- 
 ture, sometimes changing the position of the body. These move- 
 ments have often given rise to reports of persons being buried alive. 
 
 Decomposition is late in making its appearance. The integu- 
 ment has a leaden pallor, and is mottled and wrinkled. The blood is 
 thick, tarry, and slightly coagulable, darker in color, and slightly 
 acid. There is marked dryness of the tissues. The peritoneum is 
 dry, and covered with a viscid substance. The stomach presents no 
 characteristic appearance. The small intestines usually contain a 
 turbid, whey-like fluid and the cholera bacillus. The epithelial 
 denudation is probably post mortem. The mucous membrane is 
 swollen, and usually pale. The solitary and Brunner's glands, and 
 Peyer's patches, are swollen and prominent, the latter congested, and 
 occasionally ulcerated. The large intestine is frequently collapsed,
 
 ASIATIC CHOLEKA. 203 
 
 and the solitary and agminated glands swollen. Cases have occurred 
 where the colon appeared normal. 
 
 Symptoms. The period of incubation varies from two to five 
 days, but in exceptional cases only a few hours elapse before the 
 disease manifests itself. 
 
 The symptoms vary greatly in severity in different cases, as is 
 characteristic of infectious diseases generally. The degree of inten- 
 sity does not necessarily depend on the number of bacilli that gain 
 entrance to the body, although this should usually be the case. Pre- 
 disposition and physical conditions have undoubtedly a great influ- 
 ence in determining the severity of the disease. Although the vari- 
 eties merge into one another, there are three recognized types 
 that are present during an epidemic, and it will be conducive to an 
 understanding of the disease to describe them separately. 
 
 Choleric diarrhoea cannot be differentiated from ordinary diarrhoea, 
 except by bacteriological investigation. A patient may have what 
 he considers a simple diarrhoea and unwittingly communicate the 
 disease to others, without ever knowing that he has had Asiatic 
 cholera. All diarrhoeas should therefore be looked upon with sus- 
 picion, during an epidemic of cholera. As a rule, the flux occurs sud- 
 denly, and the discharges are copious and thin. They range from 
 three to five during the twenty-four hours. Sometimes they are 
 more frequent, and then are not bile-stained. Colic and griping are 
 not usual. There is a coated tongue, slight nausea, headache, and 
 occasionally slight cramps in the legs. The duration of the attack 
 is from several days to two weeks, often tending to relapse, or merg- 
 ing into the more serious forms. The Koch bacilli are present, and 
 can be demonstrated. 
 
 In cholerine, there is vomiting as well as purging, diarrhoea not 
 necessarily preceding the former. An attack resembles cholera 
 morbus very closely. The stools are larger and more frequent than 
 in choleraic diarrhoea, and soon become serous, resembling the rice- 
 water discharges of pronounced cholera. They contain the cholera 
 bacillus. Emesis soon follows the diarrhoea, and after the contents 
 of the stomach are expelled, the vomitus becomes watery and taste- 
 less. There may be considerable thirst. There is pain in the epi- 
 gastrium, and abdominal discomfort, but griping is not necessarily 
 present. Cramping of the muscles of the legs is usually noted. The 
 patient complains of being faint and dizzy. The urine becomes 
 scanty, and, if the purging persists, may become suppressed. Albu- 
 men is not unlikely to be present, in severe cases. The skin is cold, 
 the voice becomes hoarse, and the features have an anxious expression. 
 
 Some cases take on a typhoid condition, with a slight febrile rise,
 
 204 SPECIFIC INFECTIOUS DISEASES. 
 
 resulting in a slow recovery. In others, the symptoms are severe, 
 and collapse comes early in the disease. Others, again, develop 
 pronounced cholera, with all its characteristic symptoms. 
 
 Recovery from cholerine is the rule, though relapses are frequent, 
 and convalescence slow. 
 
 Pronounced Cholera. Here, we recognize three different stages: 
 the prodromal stage, the stage of attack, and the stage of reaction. 
 
 The prodromal stage varies greatly in different cases, and is some- 
 times not apparent, the disease beginning with its more severe man- 
 ifestations. The period of incubation varies from twelve hours to 
 several days, and there is malaise, more or less depression, head- 
 ache, restlessness, slight digestive derangement, and a feeling of 
 discomfort, followed, as a rule, by symptoms similar in character to 
 those described under the head of choleraic diarrhoea. Occasionally 
 there is no flux during this stage. 
 
 The diarrhoea, if it has preceded the period of attack, becomes 
 more severe, and assumes the rice-water appearance, so characteristic 
 of this disease. The number of evacuations increases from four or 
 five to twenty, or, in some cases, sixty a day. There is little or no 
 pain in evacuating the bowel, the act being performed without much 
 effort, the discharges coming away in a stream. Emesis sets in 
 early, and, after the contents of the stomach are evacuated, the vom- 
 itus becomes whey-like, resembling the discharges from the boweU 
 The vomiting is projectile, and not attended with nausea. It is fre- 
 quently attended with a distressing singultus. This excessive loss 
 of fluid produces a drying of the tissues, and the blood becomes 
 diminished in quantity, and thickened. The secretions are arrested, 
 but the sweat glands increase in activity, and the patient is covered 
 with a clammy perspiration. The cramps in the muscles, especially 
 those in the legs, are extremely painful, but outside of this there is 
 little complaint 
 
 The patient himself often expresses surprise at the little discom- 
 fort attending the excessive discharges. Sensation is probably 
 blunted. As the disease progresses, the patient emaciates rapidly, 
 the skin is cold and dusky, the lips blue, features pinched, and eyes 
 sunken. The hands are wrinkled, like those of a washer-woman, the 
 breathing is short and hurried, increasing to thirty, sometimes forty, 
 respirations per minute. The pulse is small and rapid, at times dis- 
 appearing from the wrist. Although the patient's temperature is 
 subnormal (at times 80 R), he complains of heat, and resists efforts 
 made to increase the warmth of the body. He is apathetic, and lies 
 motionless and indifferent, although conscious. This condition lasts 
 from three to forty-eight hours, resulting in death, or reaction.
 
 ASIATIC CHOLERA. 205 
 
 Stage of Reaction. After passing through the distressing symp- 
 toms of the algid stacje, the patient may gradually rally. The tem- 
 perature rises, the pulse and respiration improve, the cramps cease, 
 the stools become infrequent and more fecal, vomiting ceases, the 
 urine is secreted, but is at first scanty, high colored, and albuminous. 
 Convalescence is slow, and relapses common. 
 
 COMPLICATIONS. Cholera typhoid is a common complication at 
 this stage, anl often carries off the patient already weakened and 
 debilitated by disease. 
 
 Urcemia is a serious complication, and frequently fatal. After 
 reaction, the urine still remains suppressed or scanty, and very albu- 
 minous. The patient is drowsy, face flashed, pulse slow, and bow- 
 els constipated. There is headache, at times delirium. A spinach- 
 like material is vomited. There are convulsions, coma, and death. 
 
 Cutaneous eruptions frequently make their appearance in the sec- 
 ond week of the attack, during convalescence. All the varieties of 
 the acute exanthamata have been noticed. They appear in a varia- 
 ble percentage of cases, during different epidemics. As low as 1%, 
 and as high as 46% of cases have been noticed. It is regarded as a 
 favorable sign, and is usually followed by an improvement in the 
 patient's condition. 
 
 Diphtheritic inflammation of the mucous membrane is a frequent 
 cause of death, the upper air-passages suffering most frequently. 
 
 Pleuritis and pneumonia are occasional complications. Suppura- 
 tive parotitis is less frequent, but usually results fatally, from pyaemia. 
 
 Diagnosis. The epidemic character of the disease, and its 
 great mortality, should prevent error in diagnosis, although, at the 
 beginning of an epidemic, isolated cases may not be recognized. 
 
 Cholera morbus is the only disease with which it can be con- 
 founded. We have here vomiting, rice-water discharges, and col- 
 lapse, as stated under the head of cholerine, the presence or absence 
 of the characteristic bacilli often being the only means of diagnosis 
 between that variety of Asiatic cholera and cholera morbus. 
 
 Poisoning by arsenic or antimony differs greatly in its clinical 
 features. The vomiting is painful, and preceded by burning in 
 the stomach and oesophagus. The diarrhoea is not of the rice-water 
 variety, but mucous- and blood-stained. The poison is easily detected 
 by analyzing the vomitus or dejections. 
 
 Prognosis. The prognosis is very unfavorable, as the average 
 mortality is 50%. Epidemics vary in severity, and the death rate 
 ranges between 20% and 80%. The disease is particularly fatal 
 among the aged, young children, and the intemperate. Where chol- 
 era develops rapidly, the prognosis is grave, a gradual increase being
 
 206 SPECIFIC INFECTIOUS DISEASES. 
 
 considered a favorable sign. The mortality is always greater dur- 
 ing the early history of an epidemic, the virulence of the disease 
 seeming to be mitigated during the succeeding months. If the dis- 
 ease does not find favorable conditions for its further development, 
 its intensity is gradually exhausted. The death rate is increased as 
 the equator is approached. 
 
 Treatment. PROPHYLAXIS. In a disease where one man may 
 disseminate the seeds of an epidemic, preventive measures stand 
 first. Hygienic conditions, both private and public, have an impor- 
 tant bearing on the spread of cholera. Cess-pools and privy vaults 
 should be disinfected, and all standing and stagnant water should be 
 drained, if possible. Filth should not be allowed to accumulate. 
 The water supply should receive attention; where there is a possibil- 
 ity of infection, the water should be boiled. Quarantine regulations 
 should be enforced. Of the value of a rigid quarantine, we have had 
 a striking example in the cholera epidemic of 1892, when, at New 
 York, the disease was prevented from gaining an entrance into this 
 country. Cholera stools should be disinfected and buried. Cloth- 
 ing that has been in the sick-room should be thoroughly disinfected, 
 especially when soiled by the patient Everything that can possi- 
 bly spread the disease should be cleansed or destroyed. 
 
 The medical treatment of choleraic diarrhcea will be similar to that 
 of ordinary serous diarrhoea. The compound tincture of cajeput 
 (American Dispensatory) may be administered in fifteen- or twenty- 
 drop doses, repeated every fifteen or twenty minutes. Instead of 
 this, or in combination with it, a decoction of the fresh erigeron can- 
 adense plant may be taken freely, the patient being made to drink a 
 wine-glassful every fifteen or twenty minutes, until its action in 
 arresting the evacuations becomes manifest. Or, instead, one may 
 employ three grain doses of arsenite of copper 6x, repeated every 
 half hour, until two or three doses have been taken, then every hour, 
 until relief follows. 
 
 In cholerine, the first important step will be to arrest the vomit- 
 ing. This we will probably be able to do with minute doses of aco- 
 nite and rhus tox., as follows: B Specific aconite gtt. v-vii, rhus tox. 
 gtt x-xv, aqua fiv. M., and order a teaspoonful every fifteen min- 
 utes, until the vomiting ceases. As the emesis becomes arrested, the 
 intestinal evacuations will usually cease. Where need of stimulants 
 is apparent, we may derive better results from the compound tinc- 
 ture of cajeput, used as already advised. 
 
 In pronounced cholera such remedies must be aided by the appli- 
 cation of brisk cutaneous stimulants, by means of sinapisms, capsicum 
 liniment, or friction with dry capsicum aided by dry heat. The
 
 ASIATIC CHOLERA. 207 
 
 hvpodermic injection of a third of a grain of muriate of pilocarpine 
 will assist in equalizing the circulation and modifying the severity 
 or the symptoms where there is much elevation of temperature; and 
 where algid symptoms are prominent, the thirtieth of a grain of 
 strychnia may be employed, the dose to be repeated at the discre- 
 tion of the practitioner. To relieve the urgent thirst, the combina- 
 tion of aconite and rhus tox. will be found excellent, and as a drink, 
 a cold decoction of erigeron canadense will be best. 
 
 The patient must invariably remain in the recumbent position, and 
 on no account rise to stool, or for any other purpose. The effort 
 and change of position are almost certain to bring on aggravation of 
 the intestinal disturbance, and repetition may render an otherwise 
 favorable case fatal. 
 
 Occasionally, acids or alkalies may be specifically indicated. 
 
 The diet is an important consideration, both from a prophylactic 
 and curative standpoint. As cholera is a zymotic disease, the germs 
 may be lurking in any raw food or drink that may be taken, and 
 strict sterilization of everything taken should be observed, and no 
 raw food or drink of any kind allowed. It should be a standard 
 rule to boil everything, and food should not be served in dishes 
 whicli have not been washed in boiling water. Sterilized water 
 should be used in the preparation of medicines, and for drinking, and 
 rinsing the mouth. As cholera germs do not thrive in acid media, 
 acid beverages may be drunk freely, if they do not seem to aggravate 
 the g istro-intestinal disturbance. As a prophylactic, sour lemonade, 
 further acidulated with a few drops of sulphuric acid, has been 
 highly recommended. Vinegar, lime juice, and other sour drinks 
 may be employed lor the same purpose. 
 
 As alkaline fermentation in the stomach favors infection, only 
 plain food should be eaten during the prevalence of an epidemic, 
 pastries and fried dishes being avoided. 
 
 Lastly, during a cholera epidemic, it is best to avoid everything 
 likely to ordinarily produce diarrhoea. During the active period of 
 the disease, there is little use of attempting to administer nourish- 
 ment to the patient, as the diarrhoea and intestinal evacuations are 
 thereby only increased. Now, hypodermic injections of warm salt 
 water (a teaspoonful to a pint of boiled water) should be freely 
 made, into the thighs and abdomen, to replace the drain upon the 
 blood caused by the serous diarrhoea. 
 
 When vomiting ceases, and the symptoms of collapse abate, small 
 quantities of fluid nourishment may be gradually and cautiously 
 administered. A teaspoonful or two of pancreatinised milk, koumiss, 
 beef tea, or fresh beef juice, may at first be given. If this be
 
 208 
 
 SPECIFIC INFECTIOUS DISEASES. 
 
 retained, a little more may be administered after a brief interval, 
 the quantities being gradually increased. Horlick's milk may now 
 be given in small quantities. As the stomach remains feeble and 
 sensitive for a long time, the amount and quality of the food must 
 be gradually advanced to milk, egg albumen in brandy, or cham- 
 pagne, and other nourishing fluid food, before solid food is allowed. 
 
 XIX. YELLOW FEVER. 
 
 Synonyms. Febris Flava; Typhus Icterodes; Black Vomit; 
 Yellow Jack. Spanish, Vomito Nigro. 
 
 Definition. An infectious, contagious disease, characterized 
 by sudden invasion, and fastigium of from two to seven days' dura- 
 tion, with termination by lysis, the fall of temperature being attended 
 by a remarkable slowing of the pulse, this decline being followed by 
 a second rise in temperature, attended by phenomenal icterus, hema- 
 temesis, albuminuria, suppression of urine, and rapid and profound 
 prostration. 
 
 Etiology. This disease seems to be indigenous to the eastern 
 sea-coast of tropical America, especially the West Indies, where it 
 prevails endemically throughout the seasons, and occasionally spreads 
 as an epidemic, during periods of remarkable territorial receptivity, 
 along lines of travel, into the temperate zones. It is a disease of hot 
 climate, filth, moisture, and a low altitude, the seaports of the trop- 
 ical regions being its principal places of resort, though at the pres- 
 ent time railroads offer ready means of transportation into the inte- 
 rior, during severe epidemics. 
 
 The principle of infection is believed to be a microorganism, 
 though all attempts to isolate it have thus far proven futile. Accord- 
 ing to Dr. John Guiteras (Keat- 
 ing's Cyclopaedia) the disease is 
 mild in children in its native 
 haunts the West Indies being 
 often unrecognized by diagnosti- 
 cians, and as common as measles 
 is among children in our own com- 
 munity, nearly all adults in these 
 communities being protected by a 
 previous attack during childhood. 
 Colored races seem especially 
 prone to mild attacks of it while 
 young, and are therefore protected 
 from a second attack in later life, 
 rendering it a notorious fact that colored races enjoy a marked immu-
 
 YELLOW FEVER. 209 
 
 nity. Whether colored people born and bred in the North enjoy 
 any more immunity than white persons, may be a matter of question. 
 Like measles, it seems that an attack in adult life is much more 
 severe than in childhood, and when adults who do not enjoy the 
 advantage of protection come in contact with it, it is remarkably vir- 
 ulent and fatal. It is said that Creoles are less liable to the disease 
 than whites, negroes less than Creoles, and Indians of tropical regions 
 least of all. That yellow fever is not a malarious disease is abun- 
 dantly proven by the fact that malarial fever is never contracted upon 
 the high seas, it being distinctively telluric in origin, while yellow 
 fever may be spread on shipboard, provided fomites have been taken 
 on in port, and decimate the whole crew, as well as contaminate 
 those from other vessels who may chance to go on board, for any 
 protracted time. 
 
 It is asserted by some that yellow fever is not directly conta- 
 gious from one person to another, but that it is conveyed by fomites, 
 the contagium seeming to accumulate infective power as it is nurtured 
 by confinement and other favoring causes, such as decomposition, 
 warmth, and moisture. It is certain that plenty of fresh air is abont 
 as reliable a preventive of the disease (save strict quarantine) as 
 any that has been tried, and it would therefore seem that the infec- 
 tion gains virulency after leaving a subject, through such causes. 
 Severe epidemics in temperate regions <are usually checked by the 
 first frosts, and a pronounced "freeze" stamps it out at once. 
 
 Occasionally the disease invades places far north of its native 
 habitat, a severe epidemic having occurred in Philadelphia, in 1793, 
 four thousand, out of eleven thousand persons attacked, perishing. 
 It first appeared in the United States in Boston, in 1693, and has 
 since appeared occasionally at other points, sometimes in severe epi- 
 demics, up to the present time. It has been conveyed as far north 
 as Portsmouth, New Hampshire. Occasionally the infection is win- 
 tered over, and appears the following season with unabated severity, 
 as occurred at Memphis in 1879, when it hibernated. During late 
 epidemics, there has been a tendency for the disease to follow lines 
 of railway into the interior from southern seaports, severe and fatal 
 cases occurring far inland. 
 
 Pathology. The anatomical changes of yellow fever are found 
 in all parts of the body, though the most marked disorganization 
 occurs in the liver. This organ is found to be markedly yellow in 
 appearance (resembling box-wood in color). Disorganization of the 
 parenchyma has occurred, necrotic masses being found in and 
 between the cells, with fatty degeneration, resulting in the disten- 
 sion of these bodies with oil. In other cases, the degeneration is
 
 210 
 
 SPECIFIC INFECTIOUS DISEASES. 
 
 granular, the nuclei of the hepatic cells being obscured or entirely 
 destroyed. The organ breaks down on firm pressure, and on section 
 the tissues are found drier than normal, less blood than usual being 
 in the vessels. 
 
 The skin is markedly yellow, the color varying from dark orange 
 to a bright golden yellow, and petechise, eruptions, pustules, ecchy- 
 moses, and extravasations are liable to be found upon the surface. 
 The mucous membranes may also present a yellowish tinge. The adi- 
 pose tissue, too, is deeply stained an icteric hue. 
 
 Important changes are found to have taken place in the blood, to 
 these the marked yellowness of the tissues being due. The red cor- 
 puscles are broken down in many instances, or they are serrated and 
 shriveled. The broken-up contents are altered, and the hematin is 
 
 converted into bile pigment, this staining the tissues the character- 
 istic yellow. Ammoniacal decomposition sets in soon after the with- 
 drawal of the blood from the body, due to alteration in its saline 
 constituents, and it is found that there is partial loss of coagulating 
 quality, the fibrin-factors having apparently lost their function. 
 
 There is active catarrh of the mucous membrane of the upper 
 portion of the alimentary canal, with ecchymosis and varicosis of the 
 superficial veins, the extravasations being largely due to the forcible 
 vomiting of the disease. The urinary tract also affords evidence of 
 similar changes, the kidneys being the seat of parenchymatous 
 inflammation, with fatty degeneration and breaking down of tissue. 
 Infarctions are found in the lungs, pulmonary apoplexy sometimes
 
 YELLOW FEVER. 211 
 
 occurring. Pleural ecchymosis, with effusion of bloody serum into 
 the pleural sac, is also one of the occasional occurrences. 
 
 The musdes are darker than normal, their dark color contrasting 
 markedly with the yellow color of the skin and adipose tissues. 
 Marked granular degeneration is found to have taken place in the 
 histological elements, this probably being due rather to some spe- 
 cific poison (ptomaine) generated during the disease than to simple 
 pyresial changes, as the temperature in yellow fever is not high 
 enough, nor sufficiently prolonged, to account for the very decided 
 morbid alterations. 
 
 The heart is soft, friable, and flabby, and the muscle is found to 
 have undergone more or less granular degeneration. The cavities 
 contain considerable broken-down, fluid blood, with occasional clots. 
 Guite"ras remarks that he has always fouiid the left heart contracted. 
 Neither the endocardium nor pericardium bear evidence of inflam- 
 matory action. 
 
 The spleen is not prominently altered, though it may be slightly 
 congested, softer, more friable than natural, and of darker color. 
 
 Slight changes may be noticed in the brain and spinal cord. These 
 may consist of hypersemia (not marked), punctate extravasations in 
 the meninges, and occasionally, effusions in the lumbar and sacral 
 regions. 
 
 Symptoms. The stage of incubation lasts from a few days to a 
 week. It may, in exceptional cases, extend to fourteen days, but 
 they are rare where the period after exposure extends beyond a 
 week. In cases where but a short time elapses after exposure, the 
 disease usually proves very virulent. 
 
 There is a marked difference between the course of a mild attack 
 of yellow fever and a severe one. In the mild attack, the severest 
 symptoms arise during the initial fever, the remission being followed 
 by but slight febrile symptoms, and often these are absent. In all 
 probability the secondary fever is the result of the poisoning of the 
 system by the ptomaines generated during the first attack, by the 
 germs of infection which excited the primary fever. 
 
 The invasion is usually sudden, consisting of a marked chill, 
 speedily followed by fever, attended by severe pains in the head, back, 
 and limbs, the pain being notably severe in the back and legs; and 
 there is nausea and vomiting. The temperature rises rapidly at 
 first, though yellow fever is not ordinarily a disease of very great 
 pyrexia. The pulse becomes full, strong, and rapid at first, though 
 it soon weakens, the skin being dry (sometimes moist) and hot, and 
 secretion arrested generally. The eyes early present a peculiar shin- 
 ing appearance, being markedly suffused, and this, with the bronzed
 
 212 
 
 SPECIFIC INFECTIOUS DISEASES. 
 
 or yellowed color of the countenance, and staring look, impart to the 
 visage a remarkably sodden and dejected aspect The tongue is 
 covered with a thick white fur from the outset, except at the tip and 
 edges, which are red and bare. The bowels are usually constipated, 
 though hemorrhagic diarrhoea may be present. The mind is usually 
 clear to the last, though delirium may set in in the late stage, the 
 patient being wild and restless, and determined to get out of bed. 
 By the third or fourth day of the disease, the temperature will have 
 reached its height, the thermometer registering hardly ever more 
 than 104 to 105 F., though it may rise as high as 110. When the 
 
 fourth day has been reached, 
 the temperature declines rap- 
 idly, running down to near 
 the normal line, marking a 
 distinct remission, which may 
 last for two or three hours, 
 or two or three days. This 
 constitutes the period of 
 calm, the patient being free 
 from suffering, except that of 
 marked prostration, after 
 which a second rise in tem- 
 perature begins. This usu- 
 ally begins without a chill, 
 and rises more gradually than 
 during the invasion. The 
 temperature may now again 
 reach 104 or 105, where it remains a day or two, to fall again, con- 
 tinuing to do so, in favorable cases, until the normal point is reached. 
 The pulse of yellow fever, after the first few days, is said to be 
 peculiar, a sensation being imparted to the finger as though there 
 were gas in the arteries, the name "gaseous pulse" being applied to 
 it. It is now markedly compressible. It hardly ranges above 110 
 per minute, during the fever, and, in mild cases, it may not be more 
 than four or five beats above the normal rate. During the remis- 
 sion, or stage of calm, it falls remarkably, lowering to a thirty or 
 forty rate per minute. 
 
 About the third day the icterus begins to appear, being observ- 
 able at first in the sclera, and rapidly spreading over the body. The 
 color is deep, like that of pyaemia, almost bronzed in appearance. It 
 is due to staining of the skin from the pigment formed from the ele- 
 ments of broken-down blood, which are deposited in the tissues, 
 and. not from hepatic secretions. The perspiration now stains the 
 
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 4 
 
 
 
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 7 
 
 
 
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 11 
 
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 104 
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 1CJ 
 
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 99 
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 TEMPERATUBE CURVE IN YELLOW FKVEB.
 
 YELLOW FEVEK. 213 
 
 linen yellow, and a cadaveric odor emanates from the body. When 
 the third stage is reached, the color becomes a mahogany hue. 
 
 The vomiting is a marked feature of the disease, it beginning 
 immediately after the chill, and persisting during both febrile stages. 
 It may be severe or not, in many mild cases being restricted to the 
 rejection of food, as soon as taken. In other cases, the contents of 
 the stomach are ejected first, then a yellowish-green material, of 
 alkaline reaction, is projected, the alkalinity being due to ammoniacal 
 decomposition of the blood. If the case is severe and ominous, there 
 is soon hemorrhage into the stomach, and black contents are ejected, 
 constituting the characteristic "black vomit" of this disease. If, 
 instead of this, yellowish-green, alkaline material continue to be 
 ejected, the symptoms may be considered more favorable. 
 
 The urine is scanty early in the disease, and, as the morbid 
 changes progress in the kidneys, traces of albumin may be found. 
 It is acid in reaction at first, but as ammoniacal decomposition sets 
 in, it becomes alkaline, and colored with bile-pigment, which becomes 
 more abundant as the disease progresses. If not present before, 
 the bile pigment makes its appearance during the stage of remission, 
 and soon fatty casts, leucin, and ty rosin will appear in the secretion. 
 A strong urinous odor now pervades the entire body. Compkte sup- 
 pression of urine will appear in fatal cases, and this symptom may 
 be regarded as an almost certain percursor of a fatal issue, it being 
 asserted by good authority that, though cases with black vomit may 
 recover, those with suppression of urine are almost certain not to. 
 
 Diagnosis. In severe cases occurring during an epidemic, 
 there can hardly be any danger of mistake in diagnosis. The severe 
 attack with vomiting, the peculiar suffused and staring expression of 
 the eye, the marked icterus, coming on the third day, the early 
 decline of the fever in the first stage, with the remarkable slowing of 
 the pulse, and its peculiar compressibility (gaseous pulse), the 
 black vomit, the mahogany color in the last stage, are not all found 
 in other forms of infectious fevers. The history of the case will fur- 
 nish sufficient testimony in the early part of most attacks to enable 
 the physician to be on his guard against a careless diagnosis. Dr. 
 Guiteras asserts that endemic cases occurring among children are 
 not so easily recognized. Many of the distinctive symptoms are not 
 prominent here, and it may be mistaken for ephemeral fever due to 
 heat, unless considerable care is observed. 
 
 Prognosis. Some epidemics are extremely fatal, others not so 
 markedly so. The epidemic influence (territorial receptivity) will 
 determine, to great extent, the amount of mortality to be expected. 
 One fact is always to be recollected, viz., the disease is ever to be
 
 214 SPECIFIC INFECTIOUS DISEASES. 
 
 dreaded when wandering from its indigenous haunts, or when affect- 
 ing adults who have not been protected by a former attack, especially 
 the unacclimated. Where the yellowish-green vomit continues 
 throughout the disease, the case may ordinarily be considered a 
 favorable one, and when this is replaced by the black vomit, it is 
 always grave, though recovery may ensue. Marked scantiness of 
 the urine is an unfavorable symptom, and when this secretion 
 becomes suppressed, there can be scarcely any hope of a favorable 
 termination. A gradual subsidence of the vomiting, and diminution 
 of the amount of albumin in the urine, may be considered as favor- 
 able signs. Convalescence is remarkably slow in this disease, six 
 months being required to thoroughly recuperate from it. 
 
 Treatment. Prophylaxis is first to be considered, and this can 
 best be assured by strict quarantine. Not only all individuals who 
 have been exposed or who may be affected, as well as all articles of 
 clothing that have been about the disease, should be strictly excluded 
 from contact with those who have not been infected, but everything 
 surrounding the disease should be strictly avoided by the well who 
 do not possess immunity. Pure, cool air, in elevated regions, is also 
 a good prophylactic, as it will be remembered that the disease is one 
 of filth, warmth, and decomposition. Camping out is practiced much 
 upon these principles in yellow fever regions, when the disease pre- 
 vails as an epidemic. Even here, however, a strict quarantine 
 should be practiced. 
 
 The experience of Eclectic practitioners with this disease seems 
 to have been very limited. Goss states that the treatment should 
 consist largely of the use of antiseptics, and recommends baptisia as 
 a leading remedy. Aconite for the fever, belladonna, when meningeal 
 irritation is indicated, minute doses of arsenic for the vomiting, and 
 camphor, during the stage of collapse, are the other principal reme- 
 dies suggested by this author. 
 
 The disease is evidently one where necrotic changes are at the 
 foundation of the serious mischief which results. The breaking 
 down of the blood, the destructive changes in the liver and kidneys, 
 the black vomit, these are all due to a necrotic tendency, and sug- 
 gest the most reliable remedy obtainable to arrest it. If we can 
 find a remedy which possesses sedative properties combined with 
 those of an antiseptic, anti-necrotic, and stimulant, we shall have the 
 very remedy required. It will be recollected that the second stage 
 of this disease is attended by a very slow and feeble pulse, and there 
 is therefore a decided objection to any sedative which does not pos- 
 sess, at the same time, stimulating properties. I think that we pos- 
 sess one remedy which is well adapted, in its properties, to the com-
 
 YELLOW FEVER 215 
 
 bination of requirements suggested by the pathology of this disease, 
 and this is echinacea. I do not write from any experimental knowl- 
 edge of the disease, for I have never seen a case ; but I observe that 
 those who have written from experience seem to be sadly at sea, 
 concerning its medication, and believe this remedy alone would 
 accomplish more than most of the routine treatment usually 
 prescribed. 
 
 Baptisia also exerts an influence of this kind, though it is slow 
 in action, when compared with echinacea. The two remedies might 
 probably be used together with profit, the combination being admin- 
 istered perseveringly, throughout the treatment. 
 
 Two remedies, exerting a similar influence, and highly prized by 
 the homeopaths, are lachesis and crotalus hor. Crotalus hor. is espe- 
 cially indicated where a strong hemorrhagic tendency is suggested 
 by ecchymoses, extravasations, and black vomit. Dr. Holcombe, 
 of New Orleans (as well as others), has used it in such cases with 
 excellent success. The 6x of lachesis, and the 3x of crotalus hor. 
 may be employed, both being obtainable at almost any homeopathic 
 pharmacy. 
 
 The condition of the tongue early in the disease, as well as the 
 vomiting, would suggest rhus fox., and this might be combined with 
 minute doses of aconite. Where the vomiting prevents the retention 
 of remedies per stomach, hypodermic injections of specific echinacea 
 would be philosophical treatment, and it could do no harm, at least. 
 
 Scudder recommends the use of an emetic where the tongue is 
 heavily coated, and this might be advisable if there were not too much 
 gastric irritation in the beginning. In this disease, however, the 
 morbid condition lies far beyond the reach of remedies which exert 
 a local influence upon the stomach. The blood-corpuscles first, and 
 later, the tissues of important vital organs, become necrotic, and unless 
 we can find a remedy which will neutralize this tendency early, 
 treatment can be of but little avail, in severe cases. 
 
 The hypodermic use of pilocarpine (l-3d grain) may be resorted 
 to where pyrexial action is dangerously high, and strychnia (l-30th 
 t>rain) may be administered in the same manner, when a power- 
 ful stimulant is required. 
 
 There may be malarial complication, demanding treatment for 
 this phase of the disease, but yellow fever is not a malarial disease 
 of itself, as it arises and prevails where no malaria is present. How- 
 ever, arseniate of quinia 3x, or sulphate of quinia, may be required 
 during convalescence. 
 
 Cathartics should be avoided, the bowels being evacuated with 
 enemata, when this is necessary.
 
 216 SPECIFIC INFECTIOUS DISEASES. 
 
 The diet should be in digestible and nutritious form. This will 
 comprehend the use of such articles as milk, animal broths, pan- 
 oreatinized milk, Horlick's malted milk, etc. No solid food should 
 be taken for several weeks after convalescence has begun, and fruits 
 and vegetables should be avoided during this time. 
 
 -'XX. MALARIAL FEVER. 
 
 Synonyms. Marsh Fever; Swamp Fever; Paludal Fever. 
 
 Definition. A specific, non-contagious disease, caused by the 
 hematazoa of Laverau, and characterized by periodical paroxysms 
 of fever, tendency to enlargement of the spleen, with general conges- 
 tion of the portal system, and progressive anaemia. 
 
 Etiology. From almost time immemorial, the origin of mala- 
 rial fever has been ascribed to the presence of decaying vegetation; 
 and moisture and warmth being necessary to vegetable decay, and 
 such surroundings being the localities where malarial fevers are most 
 prevalent, the natural inference has been that such influence was 
 responsible for the condition of the system which gave rise to them. 
 It was thus widely believed that gaseous emanations, arising from 
 such material, constituted the materies niorbi. 
 
 But the microscope has enlightened us upon this subject, and it 
 is now known that the blood of a person suffering from malaria inva- 
 riably contains some form of a species of hematozoa (the plasmodium 
 of Laverau) a living creature, which undergoes various processes of 
 development in the blood, through which the red corpuscles are 
 destroyed and ansemic conditions brought about, the various phe- 
 nomena of fever attending, as the results of the presence of this 
 parasite. 
 
 Knowledge of other parasitic animal forms which maintain an 
 existence in the blood, assists us in drawing philosophical deduc- 
 tions as to the cause of a disease, upon the nature of which medical 
 men have differed for centuries. 
 
 The life history of the filaria is interesting, in illustrating the 
 instrumentality of intermediate influences sometimes concerned in 
 the transmission of infectious diseases, and it is also suggestive of 
 the manner in which the plasmodium malarias which belongs to the 
 same family may be transmitted. 
 
 The filaria nocturna, which inhabits the human circulation, in 
 hot countries, is taken up by the mosquito (from the human circula- 
 tion), during its blood-sucking process, and afterward, when the 
 insect flies away to the water and dies, after gorging itself, is released 
 from the decaying body into the water, to be afterward taken, with
 
 MATERIAL FEVER. 217 
 
 drinking water, into the human stomach alive, and able to enter the 
 circulation of the new host, there to undergo reproduction. Such 
 being the facts with regard to one species of hematozoa, there is 
 great probability that a similar method of transmission with another 
 may be possible. 
 
 There are some facts that give such a proposition color, as 
 regards the plasmodium malarias. Among them may be mentioned 
 that out of many families residing in malarious neighborhoods, it 
 is known that most of those escape malaria, during its prevalence, 
 who confine themselves strictly to boiled water, for potable purposes. 
 Another is, that altitudes and latitudes where the mosquito does 
 not exist are largely free from malaria, while such regions as favor 
 its existence most are the ones where malaria prevails most 
 extensively. 
 
 The author finds the foregoing views, penned several years ago 
 (1895, not published, but presented to his class in the winter of 
 1895-96), have been put forward by Dr. Manson, March 14, 1896, 
 as published in the British Medical Journal. It is certainly a very 
 rational view of the matter. 
 
 At Dr. Manson's request, Surgeon-Major Boss performed several 
 experiments to test this theory. 
 
 Upon placing a person who was affected by malaria, and in 
 whose blood the plasmodium was demonstrable, under a net with 
 mosquitoes, raised from the eggs, and confined, so they could not 
 obtain food elsewhere, and allowing them to suck his blood, the 
 mosquitoes being afterward killed and their stomachs examined 
 the result was that the hematozoa of malaria were found there in 
 plentiful numbers, undigested and alive, and nearly all of them pro-' 
 ceeded to develop rapidly into mature forms. Some of these mos- 
 quitoes were allowed to deposit their eggs in water, where they died, 
 and this water was afterward drank by a native. Within eleven 
 days afterward, the native developed fever, and his blood was found 
 to contain organisms. The second time, however, the experiment 
 proved without result We must regard this, then, as only a theory, 
 to be substantiated or disproven in the future. Against it, we have 
 the positive assertions of reliable physicians that malaria has been 
 known by them to prevail extensively in mountainous regions, where 
 the mosquito was never (or hardly ever) seen. 
 
 The plasmodium malarice (hematozoon of Laveran) appears in the 
 blood in a variety of forms, these probably representing different 
 stages of development, though it is likely that there are several 
 varieties of malaria-producing organisms belonging to one family 
 but of different species. Their development is as follows:
 
 218 
 
 SPECIFIC INFECTIOUS DISEASES. 
 
 7<V7VMco*USct/<.AH f osien 
 ' 
 
 The spore, floating in the blood, attaches itself to a reel corpuscle, 
 and finally penetrates it, to absorb, in this situation, nourishment from 
 the corpuscle, and grow to mature form, pigment granules, due to 
 the hemaglobiu absorbed from the blood-corpuscle, accumulating 
 iu its center. Segmentation of the nematozoon now succeeds, and 
 the spores are set free ( by the destruction of the red corpuscle ), to 
 attack other corpuscles in their turn. Crescentric bodies form, repre- 
 senting one phase of these parasites, and it is believed by some that 
 
 MALARIA, they are inter- 
 
 changeable into 
 sphere s t h e 
 developed 
 plasmodium or 
 / / } hematozoon. 
 ' / X Some believe 
 that the cres- 
 cents are associated chiefly with irregular forms of malarial fever, 
 and malarial cachexia. Flagella, or lash-like processes, develop from 
 hematozoa which are fully matured. 
 
 Golgi, who leads the Italian school of bacteriologists, believes 
 that the different Jorms of malarial fever depend upon different varie- 
 ties of hematozoa; that the tertian form depends upon a variety that 
 completes its development in forty-eight hours, the quartan upon 
 one which develops within seventy-two hours, etc. Other types are 
 supposed to be due to the maturity of two or more generations of 
 the same variety occurring at different periods ; as, for instance, quo- 
 tidian ague representing the maturity of two generations of the ter- 
 tian variety alternately. Probably, also, there may be a mixture of 
 varieties to still more complicate matters, and embarrass regularity 
 of paroxysms. 
 
 Differentiation may be made between the tertian and quartan 
 varieties during the stage of sporulation. Then, the spores are found 
 to be more numerous in the tertian variety than in the quartan, while 
 in the latter they are larger. 
 
 Maliynant forms of malarial fever are also to be differentiated 
 from others by the microorganisms. Not only are the hematozoa 
 smaller, but the spores are also smaller, and less numerous, while 
 the corpuscles shrivel, when attacked. 
 
 It is believed that at the time of maturation of the parasite and 
 the liberation of spores, a toxine is set free, which originates the 
 paroxysm, the variety of parasites present (or certain combinations 
 of varieties) determining whether the paroxysm be quotidian, ter- 
 tian, quartan, etc. When a patient removes from malarious sur- 
 roundings, the persistency of the disease depends upon the presence
 
 MALARIAL FEVER. 219 
 
 of the ehraatozoa in the blood, certain forms probably being more 
 permanent than others. 
 
 CONDITIONS WHICH PREDISPOSE TO ATTACKS OF MALARIA. Tempera- 
 ture exerts an important influence. An average temperature of 58 is 
 necessary for its development, and it does not prevail epidemically 
 short of an average temperature of 60 F. Moisture is another essen- 
 tial, and the regions where it is most prevalent are those about 
 marshy districts, where, during the heated season, the water becomes 
 low and stagnant. Salt water is not malarious, but marshes of salt 
 and fresh water combined as where rivers empty into salt marshes 
 are liable to be very much so. Neio soil, freshly exposed to the 
 atmosphere, as when prairies have been turned up by the plow, or 
 extensive excavations are being carried on during the building of 
 railroads, canals, etc., is very liable to provoke epidemics of the dis- 
 ease. Regions where there is a non-porous sub-soil, are usually 
 malarious, as the wells are shallow, and the drinking water comes 
 from near the surface. Vegetable decomposition has been supposed 
 to figure extensively in the propagation of malaria, but it is highly 
 probable that the presence of a large amount of such material may 
 be coincident with other conditions upon which the infection actu- 
 ally depends. Extensive irrigation with fresh water under warm 
 sunshine, continued day after day, or often enough to keep the 
 ground moist, is almost certain to be attended by the appearance of 
 malarious diseases in the neighborhood. The infection may be 
 wafted by the wind for several miles, when conditions are favorable. 
 The following incident suggests what might be expected under sim- 
 ilar circumstances: The crew of a ship which anchored within four 
 and a half miles of a malarious shore, and remained there for several 
 days, were finally attacked by malaria, six days after the wind had 
 blown off the shore for a short time. None of the crew were ailing 
 when the anchorage was made, and all were well until now. As 
 malaria is a disease of the land, never originating on the high seas, 
 the evidence that the disease arose in this instance through the 
 agency of the wind, seems conclusive. Night air is almost cer- 
 tain to provoke aggravation of ordinary malarious infection, upon 
 repeated exposure to it. 
 
 CONDITIONS WHICH OPPOSE MALARIOUS INFECTION. Latitude north 
 of 63 north, and south of 57 south, is usually exempt from mala- 
 ria, though this does not apply to the Pacific Coast, where the Japan 
 current causes a much higher average temperature, far north, along 
 the coast, than usually exists outside of its influence. Altitude is 
 another bar to its invasion, an elevation of 1,000 feet being usually 
 exempt from its influence, though mountainous regions, where stag-
 
 220 SPECIFIC INFECTIOUS DISEASES. 
 
 nant water is evaporating, under the average temperature essential 
 to its development, may not be free from it. It has been proven 
 that the use of boiled loaler for potable purposes will exempt a large 
 majority of those confining themselves to it during malarial epidem- 
 ics, though it is doubtless true that the infection may be inhaled, as 
 well as taken with water. Drainage is an important factor in the 
 removal of malarious elements from a neighborhood. Many parts of 
 the United States which were once markedly malarious, are now tol- 
 erably free from such influence, since the surface has been provided 
 with proper drainage to prevent the stagnation of water upon or 
 near the surface. Freezing arrests the activity of malaria germs, 
 though it may not arrest their action when once within the system. 
 However, malarious diseases begin to subside as soon as the autum- 
 nal frosts appear, and, though periodicity may be an element in win- 
 ter diseases, among those who have been previously affected, no 
 pronounced malarious attacks occur in new subjects until the follow- 
 ing spring. Large cities, where the ground is thickly set with 
 buildings, and the streets are covered with pavements, are usually 
 exempt from malaria. But, where the city is largely one of residences, 
 and much irrigation of lawns goes on during the summer months, 
 as in California, during the dry season, malaria prevails extensively. 
 In Oakland, California, where there are so many large lawns under 
 irrigation, the summer months are marked by malarious disturbances, 
 though few outbreaks of ague are known, probably on account 
 of the modifying influence of the sea-breeze, wafted through the 
 Golden Gate. Marine air neutralizes the propagation of malarial 
 germs considerably. A long-continued sea voyage is nearly a cer- 
 tain cure for malaria, if other means prove futile. 
 
 General Pathology. The morbid conditions which occur in 
 malaria, arise largely from the destructive action of the parasites 
 upon the red blood-corpuscles; for, though there may be a high 
 fever during the paroxysms, the tissue-changes usually due to pyrex- 
 ial action are not so marked as in more continued fevers, on account 
 of the periods of recuperation afforded here by the intermissions or 
 remissions. However, in pernicious malarial fevers, the extreme 
 hyperpyrexia may lead to early fatal results. 
 
 From the development and destructive action of the spores 
 within the corpuscles, we have a large amount of pigment material 
 (hemoglobin) liberated, which becomes distributed through the 
 serum and tissues, and permanently deposited in many of the solid 
 structures. Even in mild malarial attacks, permanent pigmentation 
 of spots in the skin is common, due to the deposit of hematoidin in 
 the rete mucosum; and internal parts are found, upon post-mortem
 
 MALARIAL FEVER. 221 
 
 examination, to afford evidence of a similar abnormal staining. 
 Thus the spleen, liver, kidneys, peritoneum, brain, and other parts 
 may be found to contain deposits of this pigmentary material, derived 
 from the coloring normally held in the red corpuscles, but liberated 
 by the destructive action of the hematozoa. The white corpuscles 
 also become loaded with this material, and are doubtless instrumen- 
 tal in distributing it to various solid structures. The extent of pig- 
 mentation varies with the duration and severity of the disease; acute 
 attacks, when not frequently repeated, may not leave much evidence 
 of this character, while in chronic malarial poisoning (malarial 
 cachexia) the staining may be a marked feature. 
 
 The destruction of red corpuscles may be followed by two classes 
 of results. In one class, we find disturbance of the spleen and its 
 associate viscera, and in the other those which attend upon impov- 
 erishment of the blood from removal of red corpuscles anaemia and 
 hydrsemia. 
 
 The spleen, being intimately associated with the birth of red blood- 
 corpuscles and the destruction of old ones, seems remarkably dis- 
 turbed by the abnormal destruction which goes on through the action 
 of the malarial parasite. Simple hyperaemia probably attends at 
 first, especially during the paroxysms, and now there is little 
 structural chauge, the temporary distention probably only serving to 
 relax and debilitate the tissues of the organ, as autopsies, after 
 death from pernicious malarial fever, demonstrate the spleen to be 
 swollen, soft, and pulpy. But a long-continued and oft-repeated 
 influence of this character is followed by structural changes, due, 
 apparently, to chronic inflammation, as there is abundant evidence 
 of hyperplasia from extensive proliferation of connective-tissue cells. 
 There is enormous enlargement of the organ, and its tissues are firm 
 and resisting. When cut, the capsule is found thickened, and the 
 internal structure is fibrous, and resisting to the knife. Rich pig- 
 mentary deposits are found scattered through its substance, and, 
 where the changes have gone far forward, points of melanotic deposit, 
 or amyloid degeneration, may be found distributed throughout the 
 organ. The liver, and other organs connected with the portal cir- 
 culation, partake, to more or less extent, of these changes. 
 
 The loss of red corpuscles entails a condition of hydraemia (the 
 serum being tinged a more or less pronounced chocolate color), and 
 general impoverishment of the blood and tissues. The tissues are 
 pallid and feeble, the circulation being impaired, respiration being 
 hurried upon exertion, and palpitation of the heart arising from 
 slight effort. In advanced malarial cachexia, oedema is a common 
 condition of the tissues, and effusion into the serous cavities is com-
 
 222 SPECIFIC INFECTIOUS DISEASES. 
 
 monly found after death. The poverty of the blood conduces to 
 various degenerative changes, amyloid degeneration of different organs 
 occurring in extreme cases of malarial cachexia. When death occurs, 
 it is usually either from exhaustion, or hemorrhage. 
 
 In pernicious malarial fever, the ravages of the hematozoa are 
 particularly noticeable, under microscopical examination. The red 
 corpuscles exhibit the presence of the parasite in all stages of devel- 
 opment, with the corpuscles in every stage of destruction. The arte- 
 rioles and capillaries of the brain are crowded, in some places, with 
 parasites, debris of broken-down corpuscles, and pigmented leuco- 
 cytes. 
 
 The following forms of malarial fever are usually described: 
 
 INTEBMTTTENT FEVEB. 
 
 Synonyms. Fever and Ague; Chills and Fever; Ague. 
 
 Definition. A form of malarial fever, marked by separate par- 
 oxysms, each consisting of a chill followed by fever terminating in a 
 sweating stage, with a distinct intermission (return to normal tem- 
 perature ) before the following paroxysm. 
 
 Etiology. Intermittent fever is one of the phases of malarial 
 disease, and is a common form resulting from malarial infection. 
 Whatever tends to depress the physical or mental powers, lessens 
 the ability of the individual to resist the invasion of the infection, 
 and delicate and debilitated persons are usually first to be affected, 
 when a community is invaded by the morbid influence. Intemper- 
 ance, exposure to the night air, overwork, exposure to chilling 
 draughts of air and other vicissitudes, are among the predisposing 
 causes. 
 
 Pathology. The lesions of this disease are not very marked, 
 and are confined almost entirely to congestion of the internal organs. 
 The spleen and liver are nearly always enlarged to a greater or less 
 degree, but this enlargement is the result of simple hyperamia, 
 instead of structural change. These only appear after the parox- 
 ysms have been often repeated after the malarial poison had been 
 influencing the system for a long time. Other internal organs, nota- 
 bly the kidneys and mucous membrane of the intestines, are involved 
 in the hyperaemic condition, though not to so great an extent as the 
 liver and spleen. 
 
 The blood changes are not so marked as in typhoid, typhus, and 
 some other forms of infectious fever. It clots imperfectly, however, 
 and is abnormally dark in color. Diminution of the fibrin-elements 
 and red corpuscles occurs when the disease continues long, and dur-
 
 MALARIAL FEVER: INTERMITTENT FORM. 223 
 
 ing a paroxysm there is a notable increase in the number of white 
 corpuscles. 
 
 Symptoms. These will depend upon the type which the dis- 
 ease assumes. In the quotidian type, a chill occurs every twenty- 
 four hours, in the tertian type every forty-eight hours, in the quar- 
 tan type every seventy-two hours. Many cases tend to recur every 
 seven days, and this tendency should be borne in mind during treat- 
 ment, that provision be made for it. These types may occur in 
 double form, two paroxysms occurring daily in double quotidian, 
 one every day in double tertian, but at a different hour on every 
 alternate day, the paroxysms also differing in character, being 
 marked by severe chill and light fever one day and light chill and 
 severe fever another, or varying in some other particular. 
 
 The paroxysms are marked by three stages : a cold stage or chill ; 
 a hot stage, or the stage of fastigium; and a stage of decline, or the 
 sweating stage. 
 
 The cold stage is characterized by a pronounced rigor; the 
 subject shakes, from head to foot. Cold sensations first creep along 
 the spine, but later pervade the entire body. The finger-tips and 
 nose become blue, the skin shriveled, and covered with prominent 
 papillae (cutis anserina); the face becomes pale, the eyes sunken and 
 anxious, and the voice faint and husky. The sufferer becomes weak 
 ;ind tremulous, and, as the chill continues, he shakes and shivers 
 convulsively, and his teeth chatter. The respirations are now short 
 and sighing; the surface of the body is cold to the touch; micturition 
 is frequent, the urine being pale and limpid. After half an hour 
 or more these symptoms gradually subside ; the patient no longer 
 complains of being chilly, and becomes more comfortable. 
 
 But he soon realizes that a sense of warmth is rapidly pervading 
 his body, and finds that the warmth is more than that of comfort; 
 the skin becomes dry and hot, the face flushed, the eyes suffused and 
 bright; the pulse bounds, the carotids throb; the tongue is dry, and 
 there is intense thirst, and often vomiting. These symptoms con- 
 tinue to increase in severity until the patient is extremely restless 
 and uncomfortable, the paroxysms often being attended by excruci- 
 ating muscular pain, this frequently involving the pericranial mus- 
 cles. During a quotidian ague, the hot stage may continue for eight 
 or ten hours, and that of a quartan four or six, though in any case 
 it may terminate in oue or two hours. 
 
 There is hardly any state where the febrile symptoms are more 
 marked for a short time than in this disease. Though the teir\pera- 
 ture may rise to 104 F. during the chill, it may reach 107 during 
 the hot stage. There is marked arrest of secretion, the urine is
 
 224 
 
 SPECIFIC INFECTIOUS DISEASES. 
 
 scanty almost suppressed and high colored. The skin and mouth 
 are dry, there is intense thirst, the breath is hot, and the bowels 
 are constipated. Severe headache and restlessness often mark this 
 period. In children, convulsions and coma are not rare. 
 
 As the sweating stage approaches, a moisture appears on the fore- 
 head, and soon covers the entire surface of the body. Restlessness 
 
 and discomfort rapidly abate. The 
 temperature falls speedily, pain and 
 headache subside, a free perspiration 
 bathes the surface, the urine flows 
 copiously, thirst disappears, and the 
 patient seems as well as common. 
 An interval now occurs, correspond- 
 ing to the type of the fever, after 
 which another paroxysm is ushered 
 in with a chill, and a repetition of 
 the symptoms of the three stages is 
 again gone through. 
 
 Badly treated, and neglected 
 cases of this disease continue to 
 present a recurrence of the parox- 
 ysms, and, after a time, the regular- 
 ity of the disease may become dis- 
 turbed, the attacks occurring 
 erratically, the general health of the 
 subject becoming much deranged, 
 the stomach becoming foul, the tongue coated with a pasty wliito 
 coating, the liver and spleen becoming enlarged, and a complication 
 of jaundice and anaemia being strikingly manifested. Such cases 
 constitute chronic intermittents (malarial cachexia), and demand 
 careful and discriminating treatment, even for the arrest of the par- 
 oxysms, as ordinary remedies are quite likely to fail in controlling 
 them. 
 
 Diagnosis. The diagnosis of intermittent fever is very simple. 
 We distinguish it from remittent fever by the fact that there is a 
 complete intermission between the paroxysms, the following attack 
 being ushered in with a chill, while there is not a complete inter- 
 mission in remittent fever, there being but the initiatory chill, usu- 
 ally, and only a near approach to normal temperature between the 
 exacerbations of fever which follow. There is hardly a chance that 
 intermittent fever will be confounded with pyaemia, as in this dis- 
 ease the chills occur irregularly, and the history of the cases will 
 disclose a different class of etiological factors, in each instance. 
 
 NTERMITTENT.
 
 MALARIAL FEVER : INTERMITTENT FORM. 
 
 225 
 
 Treatment. That class of practitioners who regard quinine 
 and arsenic as specifics for ague, are usually unsuccessful in its man- 
 agament. Whittaker asserts that the hematozoa disappear from 
 the blood after the administration of quinia, and assumes that the 
 specific for the disease is this drug= Depend upon it, they who fol- 
 fow such teaching will leave but sorry results behind, and their 
 patients will finally be obliged to remove from the country or employ 
 other physicians. If they arrest the paroxysms of an ague, which 
 they will, in many cases, there will usually be relapse after relapse, 
 until malarial cachexia will finally be established. Quinia hardly 
 ever cures ague, though it is our best antiperiodic the best agent 
 to interrupt the paroxysms. Arsenic is more permanent in its action, 
 but it should not be depended upon alone to perfect a cure in as 
 stubborn a disease as intermittent fever. 
 
 JCL 
 
 \ 
 
 QUOTIDIAN INTEBMITTEN-T. 
 
 QUABXAX lyTERMTTTEXT. 
 
 Probably it will be best to consider the treatment of the stages 
 separately. The management of the cold stage may do much to deter- 
 mine the severity of the remaining portion of the paroxysm. If a 
 patient be placed in an alcoholic vapor bath or a steam bath at the 
 beginning of the chill, the paroxvsm may often be almost entirely 
 aborted, the chill quickly passing off, and the hot stage being com- 
 pletely averted. The use of a hot pack, the patient being wrapped 
 in a blanket wrung out of hot water, hot irons or hot ears of corn 
 being placed around him to assist in maintaining the warmth, if nec- 
 
 16
 
 226 SPECIFIC INFECTIOUS DISEASES. 
 
 essary, will answer the same purpose, as will any other external 
 appliance which will determine a rapid flow of blood to the surface. 
 In this way, the severe congestion of the internal organs, sure to 
 attend the ordinary course of the disease, is prevented, and the reac- 
 tion necessarily following, is averted. Those who desire to succeed 
 in such cases can instruct fhe nurse in the administration of this 
 treatment, and when the physician arrives, his task will be simpli- 
 fied. When the physician is at hand, he may find considerable sat- 
 isfaction in the use of nitrite of amyl, by inhalation, in this stage, 
 from three to five drops being thus administered. 
 
 During the hot stage, the administration of the special sedatives, 
 properly selected and adapted, is to be commended. Gelsemium is 
 an excellent agent, as it controls the determination to the brain so 
 commonly attending, and lessens the height of the fever, by promot- 
 ing secretion from the skin, lungs, and kidneys. Jaborandi is also 
 excellent, though it should not be administered in too large doses. 
 Two or three drops of gelsemium or ten of jaborandi may be admin- 
 istered every hour during this stage, in ordinary cases. But gastric 
 irritation may be present, and neither of these remedies will then be 
 appropriate. Here a combination of aconite and rhus tox. will be 
 demanded, as the sedative action is admirable, while the gastric irri- 
 tability is nicely controlled by this prescription. Add fifteen or 
 twenty drops of rhus and five or ten of aconite to four ounces of 
 water, and give a teaspoonful every half-hour. Such measures will 
 shorten the length of the hot stage, thus hastening the advent of the 
 stage of decline, and will, moreover, prepare the way for the ready 
 appropriation of the antiperiodic, which it will be necessary to 
 administer during the intermission. f 
 
 The sweating stage brings its own relief, and demands no especial 
 treatment, though the patient should guard against chilling, while 
 relaxed. 
 
 An important measure now is to interrupt the periodicity of the 
 disease and prevent, if possible, a recurrence of the paroxysm. If 
 the hot stage has lasted eight or ten hours, we are pretty sure that 
 there will be a chiU on the following day at about the same hour as 
 on that of the first attack, and we will prepare to meet it by fortify- 
 ing the nervous system with a powerful and appropriate stimulant. 
 Our first choice will be the sulphate of quinia, though we prefer not to 
 produce too profound cinchonism, since this is liable to leave 
 unpleasant, if not permanent, effects behind, such as tinnitus aurium, 
 deafness, etc. Our sedative has prepared the patient for this remedy, 
 however, so that the small dose will suffice. We will begin seven 
 or eight hours before the time of the expected chill, and administer
 
 MALARIAL FEVER: INTERMITTENT FORM. 227 
 
 three three-grain doses of quinia sulphas, in capsules, one every 
 two hours. This will give us an advantage over the single dose, 
 should the ague prove "anticipating," and should it prove "defer- 
 ring" the plan will hardly be less effective than the administration 
 of the single dose. If everything is in good condition for the recep- 
 tion of the quinine, we may expect that the chill will not occur. 
 For fear that we may have a tertian, instead of a quotidian, it may 
 now be well to continue the sedative in minute doses for the next 
 day, and repeat the quinine as on the day previous. If, instead of 
 complete success the first day of treatment, we are disappointed in 
 finding the chill to reappear on the second or third, in spite of the 
 antiperiodic, we will repeat it the following time, when success will 
 be almost certain to be the result. 
 
 It is good practice to continue the use of the sedative through- 
 out the period of treatment. By this means, the system is prepared 
 for the kindly acceptance and effective action of the antiperiodic, a 
 cure being speedy and certain. In order that quinine may be 
 received kindly by the stomach, and readily absorbed, and its action 
 be unattended by unpleasant nervous symptoms, the skin and 
 tongue should be moist, and the pulse should be open and soft. 
 This condition is to be brought about by the action of properly 
 selected sedatives. Gelsemium, being anti-malarial in its properties, 
 as well as sedative, is an ideal sedative in malaria, unless clearly 
 contraiudicated by the oppressed, feeble pulse and cold extremities. 
 In this case we will use belladonna instead. Use these remedies as 
 follows : R Green plant tincture or specific medicine gelsemium gtt. 
 xx, water fiv. M. Dose, a teaspoonful every hour. B Specific 
 medicine belladonna gtt. iii v, water fiv. M. Dose, a teaspoonful 
 every hour. Aconite combines well with both remedies, and assists 
 their action. Ten drops of Lloyd's aconite may be added to either 
 prescription, for an adult. 
 
 Having arrested the paroxysms, the next measure is to place the 
 system in such condition that there will not be a return of the chills 
 and fever within a few days afterward. In order to fortify the nerv- 
 ous system against probability of this recurrence, I think highly of 
 the third decimal trituration of arseniate of quinia. This should con- 
 stitute a regular medicine for a month, two or three grains being given 
 thrice daily, before meals. The activity of the portal circulation 
 should be looked after, as the congestion resulting here from the 
 agu^ has most assuredly left a sluggish capillary action, and impaired 
 function. The following prescription will be of service here, to be 
 administered after meals, three times daily: B Polymnia fi, chio- 
 nanthus vir. fi M. Ten to fifteen drops, in water. Keep a watch
 
 228 SPECIFIC INFECTIOUS DISEASES. 
 
 on the seventh, fourteenth, twenty-first, and twenty-eighth days. 
 On these days administer a three-grain capsule of quinine with the 
 arseniate of quinia, before each meal. After the twenty-eighth day 
 the disease may be considered cured, provided there has been no 
 paroxysm in the meantime. If there has, there should be a period 
 of complete immunity assured, for four weeks after the last paroxysm. 
 
 MASKED INTERMITTENTS. Periodical manifestations often occur in 
 malarious districts, which evidently result from malarious influence, 
 and require a similar treatment to that employed in intermittent 
 fever; at least the periodical phase of such cases demands the treat- 
 ment applied to the periodicity of intermitteuts. Beyond this we 
 need to apply the special treatment required by the characteristics 
 of each particular case. 
 
 Undoubtedly, the etiological factor here is identical with that of 
 intermittent fever, the disease manifesting more of a local predilection. 
 
 Supraorbital pain, of intensely painful character, appearing in 
 the forepart of the day and continuing until evening, to pass off and 
 reappear on the following day, at about the same hour, and to recur 
 day after day, is a common manifestation of this kind. Occipital 
 pain is another form of neuralgia which appears periodically, and 
 may be due to malaria. Severe abdominal colic, appearing at some 
 time in the day or night, continuing for several hours and then sub- 
 siding, to return the following day or upon the second day, is another 
 form of masked ague. Periodical sciatica, intercostal or frontal pain, 
 tic douloureux, periodical attacks of croup, asthma, diarrhoea, dysen- 
 tery, hematuria, torticollis, etc., have been observed as periodical 
 manifestations of malarious infection, and relieved mainly by the 
 employment of antiperiodics. 
 
 Many times malarious influence complicates other diseases and 
 renders them stubborn to treatment, until the malarial element has 
 been recognized and met. This assertion applies to almost every 
 form of acute disease, and it should be suspected wherever marked 
 periodicity is manifested persistently. Here an antiperiodic should 
 be exhibited at an early period in the treatment. 
 
 Periodical muscular pain will demand quinine and cimicifuga. 
 Periodical tic douloureux will demand quinine and piper methysti- 
 cum. Periodical pain in the middle ear will demand quinine and 
 pulsatilla. Periodical dysentery will demand quinine and ipecac. 
 Periodical croup will demand quinine and aconite, etc. In each 
 case, the antiperiodic should anticipate the paroxysmal attack in the 
 same manner as in the treatment of that of intermittent fever. In 
 case a chronic condition of the kind becomes established, the treat- 
 ment applicable to chronic intermittents will be applicable here.
 
 MALARIAL FEVER: REMITTENT FORM. 229 
 
 REMITTENT FEVER. 
 
 Synonyms. Bilious Eemittent Fever; Jungle Fever. 
 
 Definition. A form of malarial fever in which the temperature 
 remits, but does not intermit, and the exacerbations are diurnal in 
 character, invariably. 
 
 Etiology. This form of malarial fever is most liable to occur 
 in marshy districts,, the malarial poisoning being intense in quality, 
 or else the patient manifesting a marked susceptibility. It is 
 undoubtedly due to the same character of poison as the infection 
 of intermittent fever, one form frequently merging into the other, 
 when neglected or badly treated. Remittent fever is believed to be 
 a manifestation of a more severe grade of malarial infection than 
 intermittent fever, and in severe cases it is not uncommon for a 
 remittent fever to become an intermittent, during convalescence. 
 The severity of this disease is determined largely by climate, that 
 which occurs in temperate regions being mild and tractable when 
 compared with that which occurs in the tropics. 
 
 Pathology. The pathology of remittent fever is almost iden- 
 tical with that of intermittent, the difference being that of degree 
 instead of kind. The cause being the same, we could hardly expect 
 much difference, though the more continuous febrile action would 
 naturally result in greater tendency to pathological changes. Dimi- 
 nution of red globules and loss of fibrin in the blood is common to 
 both forms. Free pigment-granules, however, are more abundant 
 in remittent fever than in intermittent They are seldom present in 
 intermittent, except in the pernicious forms, while they are almost 
 constantly present in all forms of remittent. This pigment is due to 
 particles of hemaglobin, liberated from the corpuscles and floating 
 free in the plasma, it being transformed into granular or crystalline 
 hematoidin. 
 
 The spleen is enlarged, but not so markedly as in intermittents, 
 suggesting that the splenic congestion may be more the result of the 
 cold than of the hot stage. Pigmentation is here a marked feature 
 of the pathological condition, and the congested tissues are dark 
 and friable in advanced stages of severe cases. The liver presents a 
 peculiar appearance, though there is not remarkable congestion; the 
 peculiarity is the color, the organ presenting a bronzed hue, through- 
 out its substance, the "bronzed liver" being regarded as character- 
 istic of this disease. However, it is occasionally, though rarely, 
 met with in intermittent and pernicious fever. 
 
 Changes occur in the mucous membrane of the alimentary canal. 
 The mucous membrane of the stomach and small intestines is con- 
 gested and softened, and the glandular structures are enlarged.
 
 230 
 
 SPECIFIC INFECTIOUS DISEASES. 
 
 There may be ulceration in places, though not of the character of 
 that of typhoid fever. 
 
 Symptoms. There is usually an intimation of the approach of 
 this disease manifested by a sense of oppression in the epigastrium, 
 with headache and general malaise, for two or three days before the 
 chill occurs. The tongue often accumulates a pasty-white coating, 
 and the appetite disappears, during this time. Though marked, the 
 chiR is not as protracted as that of intermittent fever, and there is 
 not the tremulousness and shaking, chattering of the teeth, etc., 
 which occurs in ague ; and the sensation of coldness is general in its 
 inception, not coming on by creeping along the spine in the begin- 
 ning, as in intermittents. Symptoms of nausea may be manifest 
 even during the chill, but if not, they are apt to appear soon after 
 the hot stage begins. Thirst is almost always an urgent symptom. 
 
 Jlf. 
 
 tc 
 
 - 
 
 REMITTENT FEVER. 
 
 The temperature may advance two or three degrees during the 
 chill, but it rises rapidly after the hot stage begins, and within ten 
 or twelve hours after its inception the thermometer may mark 105 or 
 106 R The skin becomes dry and hot, the pulse increases in fre- 
 quency, ranging from 100 to 120 per minute, being full and bounding 
 in individuals of fair reactive power. The face is flushed, the eyes 
 suffused, the conjunctiva congested, and the patient is restless and 
 uneasy. Muscular pain is now a common symptom, there being ach- 
 ing in the back and limbs, in many cases, or severe hemicrania; in 
 many cases there is full, throbbing headache. As the headache con- 
 tinues, the gastric symptoms are apt to become aggravated, the nau- 
 sea and vomiting being one of the most unpleasant features of the 
 case, though this symptom is not invariably present. Epigastric 
 pain is a very distressing symptom, in many of the cases in which
 
 MALARIAL FEVER: REMITTENT FORM. 231 
 
 vomiting is present, and this is aggravated instead of relieved by 
 vomiting. The material ejected by vomiting becomes greenish as 
 soon as the contents of the stomach have been evacuated, this "bil- 
 ious" material having given the name "bilious fever" to the disease, 
 in many quarters. Constipation of the bowels is a common symp- 
 tom; though, if it be not arrested by treatment, diarrhoea sets in 
 later. 
 
 After ten or twelve hours, a slight perspiration appears on the 
 forehead and gradually extends over the body, while many of the 
 unpleasant symptoms disappear. The gastric symptoms now become 
 ameliorated, the restlessness and headache subside, the temperature 
 falls several degrees, and the patient experiences a number of hours 
 of comparative comfort surcease from the sufferings of the hot 
 stage. But the hot stage does not entirely disappear. The ther- 
 mometer will indicate a temperature above normal during the most 
 comfortable period, and, on the following day, the fever will return, 
 and all the discomforts and suffering of the preceding day will be 
 repeated, with aggravation of many of the most important ones, 
 unless proper treatment has been promptly begun. The increase of 
 fever, with the attending symptoms, is termed the exacerbation; the 
 decline of the fever and attendant symptoms, the remission. 
 
 It will be noticed, however, that the decline of the fever the 
 interval between the exacerbations is not followed by a chill before 
 the following rise of temperature occurs. There is a regular rising 
 and falling of the fever, day after day, with but the one chill that 
 which initiated the attack. This fact will distil guish the disease 
 from ague. 
 
 Not all cases of this fever are so severe as the symptoms here 
 given might indicate. Often the symptoms are much more mild, and 
 the disease occurs without the manifestation of severe gastric dis- 
 turbance. Again, proper treatment, begun early, will often mask the 
 full development of the case. Sometimes the febrile symptoms are 
 not marked, the temperature of the exacerbation not reaching more 
 than 103, the corresponding symptoms being much modified. Here, 
 however, there will likely be considerable nervous prostration, with 
 gastric irritability, attended by nausea, insomnia, anorexia, irritable 
 stomach, indicated by pointed tongue, with reddened tip and edges, 
 small, wiry pulse, and idiosyncrasy against the kindly reception of 
 quinine as an antiperiodic. Such patients are usually delicately 
 organized, and require an entirely different course of treatment from 
 that which is applicable to the more sthenic cases. 
 
 Diagnosis. The diagnosis of malarial remittent fever is not 
 difficult, though it would be if the temperature curve were to be
 
 232 SPECIFIC INFECTIOUS DISEASES. 
 
 depended upon alone unless a microscopical examination of the 
 blood were made to detect the plasmodium malarise. The remis- 
 sions are not only shown by the thermometer, but there is a clinical 
 picture of relief afforded during the remission, not observable in 
 remittents of non-malarious origin. After the use of sedatives for a 
 short time, the reception of quinine is kindly and its action effective, 
 while this is not the case in other remittents. The vomiting and 
 bilious symptoms are present in yellow fever, but here there is but 
 the one paroxysm, and its contagious character is soon developed. 
 The single chill in the beginning will differentiate it from intermit- 
 tent fever, which is characterized by a succession of rigors. 
 
 Prognosis. Simple remittent fever, of malarial origin, is not a 
 grave disease, under proper treatment. It hardly ever proves fatal, 
 though often prolonged and aggravated by improper management. 
 Ordinary cases ought to be convalescent within four or six days. 
 
 Treatment. Simple cases of remittent fever, in temperata 
 regions, are usually readily arrested within the first week. Quinine 
 is the remedy which arrests the paroxysms, it only being necessary 
 to prepare the patient for its ready appropriation. With secretion 
 arrested, absorption by the stomach is impaired, and a stimulant to 
 the nervous centers, like quinia, when absorbed, acts as an irritant, 
 instead of promoting normal functional action. The administration 
 of the antiperiodic, then, without first preparing the patient for it, 
 produces unpleasant effects, and does not yield as good results as 
 when the way is properly paved for its use. A properly selected 
 sedative, then, is the first desideratum, and this should be adminis- 
 tered in small doses, frequently repeated, throughout the course of 
 the disease. It is hardly necessary to enter into details as to the 
 proper sedative to be selected. Gelsemium will be recollected as the 
 ideal sedative where there is the full, bounding pulse, with bright eyes, 
 contracted pupils, flushed face, etc. Jaborandi will, however, often 
 afford better satisfaction in these cases. The specific medicine will 
 hardly fail to accomplish good work here. 
 
 The gastric complication which attends many cases will, how- 
 ever, modify this selection, the condition demanding a remedy which 
 will serve the double purpose of a general, as well as gastric, seda- 
 tive. Aconite is here the leading remedy as a sedative, while rhus 
 tox. combines well with it, as it is one of the most reliable gastric 
 sedatives we possess, the same property belonging, in not a little 
 degree, to aconite. 
 
 The size of the dose to be employed in these cases is an impor- 
 tant consideration. Too much of a sedative action would ba likely 
 to embarrass instead of assisting the cure, and too little would only
 
 MALARIAL FEVER: REMITTENT FORM. 233 
 
 be temporizing. The ability of the stomach to tolerate the medicine 
 should also be considered. Two drachms of specific jaborandi (or 
 some other reliable preparation) should be added to four ounces of 
 water, and a teaspoonful ordered every hour. Where gelsemium_is 
 employed, the dose may vary from one-half drop to two drops, 
 repeated every hour. In using the aconite and rhus combined, from 
 five to ten drops of aconite and fifteen or twenty drops of rhus in 
 four ounces of water, will meet the requirements, the dose being a 
 teaspoonful every hour, as with the other remedies named. 
 
 Muscular pains should not be neglected, as they are common com- 
 plications (or conditions) of this disease. Often we may be able to 
 combine cimicifuga or rhamnus californica with the sedative mixture, 
 and arrest this at an early period of treatment. Where it is stub- 
 born, a decoction of rhamnus should be given separately, in full 
 doses, until a laxative effect is produced; or, in the absence of the 
 bark, a good fluid preparation may be administered in fifteen- or 
 twenty-drop doses, until the same object is attained. In many cases 
 I have been well pleased with the action of a combination of phenace- 
 tin and arseniate of quinia. I employ it in capsules, each containing 
 three grains of phenacetin and two of arseniate of quiuia, the capsule 
 being administered every three hours, until the object, the relief of 
 the myalgia, has been accomplished. However, the remedies for 
 pain should not interfere with the steady use of the appropriate 
 sedative. 
 
 During the remission is the proper time for the administration 
 of the antiperiodic. This will ordinarily be quinine, and it will usu- 
 ally act promptly and effectively, as well as kindly, in interrupting 
 the exacerbations and subduing the disease, when the tongue is moist 
 and cleaning, and the pulse full and soft. We need not wait for 
 decided evidence of this condition after the sedative has been admin- 
 istered for twenty-four hours, for this will almost certainly insure 
 the kindly appropriation of the quinine. Three grains of this rem- 
 edy, in capsule, may be administered as soon as the remission 
 beccmea well marked, and repeated every hour until three doses 
 have been taken, or until a marked rise in temperature is manifested. 
 The exacerbation now being again initiated, the antiperiodic should 
 be withdrawn until the next remission, when it should be repeated 
 as before. While the antiperiodic is being administered, the seda- 
 tive may be continued, as well as during the exacerbations, through- 
 out the course of the disease. 
 
 There are certain septic conditions which may interfere with the 
 kindly appropriation of the antiperiodic, at least with its curative 
 effect, and these should not be forgotten, as they are rather common
 
 234 SPECIFIC INFECTIOUS DISEASES. 
 
 in remittent fever. The most important condition of this character, 
 as it is the common one, is that marked by the pasty white coating 
 on the tongue, suggesting excessive acidity of the gastro-intestinal 
 canal. Such a condition will demand the administration of sulphite 
 of sodium, which may be given in capsules, from half a grain to a 
 grain at a time, repeated every three hours, until the toDgue has 
 begun to clean. This must be a cardinal feature of the treatment 
 when the indication for it is well marked, if success is to be expected. 
 The proper action of all other medicine will depend upon this meas- 
 ure. Sometimes an emetic will be demanded as an initiatory meas- 
 ure of the treatment. Here the tongue will be heavily loaded at the 
 base, there will be gaseous eructations, and other evidences of chy- 
 lopoietic torpor. In order to insure proper results here, the patient 
 should have a thorough emetic, and it may be necessary to repeat it 
 on the following day. A yellow-coated tongue suggests a cathartic. 
 The treatment of the nervous form of remittent fever requires the 
 use of aconite and rhus tox. as a sedative. The gastric irritability, 
 indicated by the pointed tongue, with reddened tip and edges, 
 demands this treatment, and the nervous irritability, restlessness, 
 nocturnal delirium (which occasionally attends), and small, rapid 
 pulse, all suggest this sedative. As the remissions are not marked, 
 and as quinine does not seem to act well in interrupting the fever, 
 it is well to avoid it as a remedy here entirely, and depend upon 
 arseniate of quinia, 3x trituration, as this is acceptable, easily toler- 
 ated, and very effective, though not as rapid in its influence as qui- 
 nine, in appropriate cases. The sedative being administered in the 
 doses already suggested, three grains of arseniate of quinia may be 
 administered every four hours, until the disease is arrested. Some- 
 times a typhoid condition seems to approach; the patient becomes 
 somnolent, semi-delirious, and prostrated, and echinacea may prove 
 the best sedative. The combination of cdstonia with the arseniate of 
 quinia is often a good measure, the combination being that of two 
 or three grains of alstonia with the same quantity of arseniate of 
 quinia 3x, in capsule. 
 
 During the height of the exacerbation, sponging of the surface, 
 at occasional intervals, will be advisable, and cold cloths on the 
 forehead, or sponging the head and fanning, will assist in relieving 
 the unpleasant head-symptoms. The diet should be light, liquid 
 food being preferable, and it is needless to urge much upon the 
 patient, as the probability of an early termination of the disease will 
 render it important that the stomach should not be burdened with 
 food during the height of the disease. Rice-water, milk, toast, and 
 other light articles, may be taken during the remissions.
 
 MALARIAL FEVER: PERNICIOUS FORMS. 235 
 
 PERNICIOUS MALABIAL FEVER. 
 
 Synonyms. Congestive Fever; Tropical Typhoid Fever; Per- 
 nicious Fever. 
 
 Definition. A malarial disease, characterized by severe ana- 
 tomical lesions, and attended by rapid prostration and death, unless 
 promptly treated during its early stages. A malignant form of mala- 
 rial disease. 
 
 Etiology. The cause of this disease is identical with that of 
 other forms of malarial fever, the malignant character being due to 
 a predisposing condition of the system, to an average high tempera- 
 ture, or to epidemic influences. It prevails quite extensively where 
 the average temperature reaches for a time 65, but it may occasion- 
 ally be observed in more temperate regions, though not with such 
 marked fatality. I have seen several well marked cases of the com- 
 atose variety of this disease in Ohio, and one case of the delirious 
 form in Missouri, though all were promptly amenable to treatment 
 but one, a comatose case, in which treatment was rejected early. 
 
 Pathology. The morbid lesions of pernicious malarial fever 
 are less marked in autopsies than those of malarial cachexia. In 
 the blood the abundant destruction of red corpuscles is notable, as 
 well as the large amount of black pigment derived from them, found 
 particularly in the visceral capillaries. A crenated condition of the 
 red corpuscles may be found upon microscopical examination, and 
 the relative number of white corpuscles is large, this being due, not 
 to any marked increase in number, but to the rapid destruction of 
 the red corpuscles which has occurred. The spZeen-changes, common 
 to acute malarial affections, are also present. The organ is swollen, 
 soft, and almost black in color, the fluid contained being dark and 
 watery. The kidneys are hypersemic and pigmented, and the heart 
 is pale and flabby. The lungs are congested, the lower lobes being 
 especially engorged. The nervous system is more or less involved, 
 the brain being hyperaenic, the ventricles filled with serum, and the 
 cerebral capillaries blocked with debris of broken-down corpuscles, 
 hematozoa, and pigment 
 
 Symptoms. Pernicious fever may assume a variety of types, 
 and it may appear in the beginning as an intermittent or remittent 
 form of fever. It may begin as an ordinary intermittent and assume 
 the character of pernicious fever after one or two paroxysms; or it 
 may begin as an ordinary remittent and continue so for several days 
 before the pernicious symptoms are manifested. In other cases, a 
 premonitory chill initiates the symptoms, which immediately appear 
 as those of one of the varieties of pernicious fever.
 
 23G 
 
 SPECIFIC INFECTIOUS DISEASES. 
 
 Several varieties of this fever have been described, the disease 
 seeming to manifest itself in a different manner in different localities, 
 or in different seasons. It has been asserted that epidemic influ- 
 ences operate at different times to determine the prevalence of par- 
 ticular varieties. 'Though the pathological lesions are but slightly 
 varied in different cases, the symptoms are of a marked diversity of 
 character. Seven prominent varieties may be mentioned, viz., the 
 comatose, the delirious, the gastro-enteric, the icteric, the algid, 
 the hemorrhagic, and the colliquative. 
 
 The symptoms of the comatose variety are marked almost from 
 the beginning. An ordinary attack of intermittent or remittent 
 fever may ensue, but the hot stage is attended by a comatose condi- 
 tion, from which it is almost impossible to arouse the patient. He 
 lies in a state of stupor and unconsciousness, upon his back, his face 
 upturned, flushed, eyes congested, pupils dilated, pulse slow and 
 labored, respiration slow, deep and stertorous. The temperature now 
 
 ranges from 105 to 107 F., in the 
 axilla. There is loss of power of 
 the sphincters, involuntary evacua- 
 tion from the bladder occurring, or, 
 instead, the urine may be retained, 
 and the bowels move involuntarily. 
 The patient passes deeper and 
 deeper under this influence, the com- 
 atose state becoming more marked 
 for ten or twelve hours, when a 
 moisture may appear upon the fore- 
 head, a perspiration break out over 
 the entire surface, and the patient 
 awake, perspiring profusely. An 
 intermission or remission now fol- 
 lows, when a more severe attack 
 is attended by all the symptoms of 
 the former comatose condition, in an 
 aggravated form, aud the patient 
 
 PEBNICIOU* MALABIAL FKVEB: maV t>aSS into a fatal stupor. Or, 
 
 COMATOSE VARIETY. J r ... 
 
 he may pass into a condition of apparent death, remain in that state 
 for hours. But almost invariably fatal results follow, the prognosis 
 becoming more unfavorable with each succeeding exacerbation. 
 
 In the delirious form, after the patient passes into the hot stage, 
 active delirium sets in, the patient raving and tossing, and finally, as 
 the delirious stage advances, attempting to get out of bed, and resist- 
 ing opposition by struggling furiously. This may last for hours, the
 
 MALARIAL FEVER: PERNICIOUS FORMS. 
 
 237 
 
 patient screaming wildly and endeavoring to escape from the room. 
 The face is flushed, the eyes congested, the pulse full and bounding. 
 The temperature may be very high, often reaching 107 or 108 F., 
 in the axilla. This may go on for hours, the hot stage finally termi- 
 nating in a short remission, or the patient sinking into a condition 
 of fatal coma. If a remission occurs, another stage of delirium soon 
 follows, and a fatal termination is almost certain to result. 
 
 In the gastro-enteric variety, the prominent feature of the hot 
 stage is violent vomiting and purging. The efforts are attended by 
 great prostration, by cramps in the extremities, weight and burning 
 in the stomach, and intense thirst. The symptoms are similar to 
 those of Asiatic cholera, except that the evacuations are not the 
 rice-water discharges of that disease, they usually being blood-stained 
 in appearance, or like the washings of raw meat. Sometimes, how- 
 ever, the evacuations resemble those of cholera. Authors describe 
 a peculiar respiration attending this disease, it being a double sigh- 
 ing inspiration, followed by a double sighing expiration. Collapse 
 and death are likely to follow the first attack. 
 
 The algid variety is what is commonly known as "congestive 
 
 chill." The surface of the body 
 becomes of marble coldness after 
 the initiatory chill is past and 
 the hot stage of an intermittent 
 or the exacerbation of a remit- 
 tent has begun. The surface of 
 the body begins to grow cold, and 
 finally only the surface of the 
 abdomen is warm to the touch, 
 while the patient complains of 
 gastric heat and thirst. The rec- 
 tal temperature may run as high 
 as 104 or 105 F., or in some 
 cases, even higher. The skin 
 becomes clammy, the pulse slow 
 and faltering, the axillary tem- 
 perature falls as low as 88 or 
 lower, the extremities are like 
 marble in coldness, the tongue is 
 cold, white, and clammy, the 
 breath is chilly, and the voice 
 becomes feeble and indistinct. 
 Sometimes there is coma in this form, and sometimes delirium. 
 Usually the patient is conscious, however, and does not realize much 
 
 PEBJTICIOUS MALARIAL FEVEB: 
 ALGID VARIETY.
 
 238 SPECIFIC INFECTIOUS DISEASES. 
 
 discomfort, except that of exhaustion and great internal heat. The 
 common termination of this condition is death, the disease going 
 rapidly forward to a fatal termination. 
 
 The remarkable symptom in the icteric variety is the yellow tinge 
 of the skin, marking a profoundly jaundiced condition. The disease 
 begins with a severe chill, which is protracted, and during which a 
 remarkable yellowness of the skin develops. This jaundice involves the 
 conjunctiva and entire skin, and gradually deepens, until the surface 
 is markedly greenish-yellow. Vomiting usually sets in at an early 
 period, and this is attended by a bilious diarrhoea. Severe headache, 
 pain and fullness in the spleen and over the kidneys, numbness in 
 the limbs, and great restlessness, attend. The urine is scanty and 
 dark-colored, so much so as to constitute the condition termed "mel- 
 anuria." The pulse is small and frequent, and respiration labored. 
 As the hot stage arrives, the pulse becomes full, rapid, and bounding, 
 the skin very dry and hot, the temperature high (106 or 107), the 
 headache bursting, and the thirst intense. Within three or four 
 hours, this stage is liable to terminate fatally. If the skin becomes 
 moist, a sweating stage comes on, and a remission becomes estab- 
 lished. But each succeeding paroxysm becomes more and more 
 severe, unless the disease is arrested by treatment, until a fatal ter- 
 mination ensues. This form occurs eudemically in certain local- 
 ities, prevailing whenever any form of pernicious fever appears there. 
 
 The hemorrhagic variety is characterized by hemorrhage from the 
 kidneys. The fever may be intermittent, remittent, or continuous in 
 character. The subjects are usually victims of profound mercurial- 
 ism, of chronic malarial cachexia, or chronic alcoholism. It occurs 
 in tropical regions, and is attended by symptoms of jaundice, it being 
 a combination of the icteric and hemorrhagio states. It is com- 
 mon in the swampy regions of the Southern States, Alabama, 
 Mississippi, Arkansas, and Louisiana being the theater of its action, 
 where low marshy regions along the rivers furnish the requisite con- 
 ditions for its development Hemorrhage from the kidneys may 
 occur in almost any region and attend malarial disease, but in many 
 cases it is not of the malignant character that is comprehended by 
 the hematuria of pernicious hemorrhagic fever. This disease resem- 
 bles yellow fever in many of its characteristics, but it does not occur 
 epidemically, and there is more splenic enlargement. 
 
 Blooa appears in the urine sometimes during the cold stage, but 
 more profuse hemorrhage is apt to occur during the period of febrile 
 action. The urine is dark, acid, and albuminous, and contains tube- 
 casts and blood-corpuscles, there being a copious sediment deposited 
 upon standing. Where a marked remission occuis, the hemorrhage
 
 MALARIAL FEVER : PERNICIOUS FORMS. 239 
 
 may cease for the time being, but it returns upon the onset of the 
 following paroxysm or exacerbation. Icterus, vomiting, severe head- 
 ache, aud pain in the back and loins, attend. The respiration is 
 sighing and oppressed, the decubitus is dorsal, the tongue is first 
 broad and moist, and covered with a pasty white coating, but later, 
 after icteric symptoms have developed, the coating becomes yellow. 
 In fatal cases, it turns dry and brown, or becomes covered with black 
 sordes. The pulse is full and oppressed. The bowels are often 
 constipated in the beginning, but a watery diarrhoea appears later, 
 the dejections beinsj yellow, green, or black. The temperature 
 runs from 106 to 108 during the hot stage, and this continues for 
 several days, the decline being attended by a period of profound 
 adynamia, which lasts for several days. This disease is very apt to 
 terminate fatally. 
 
 In the colliquative variety, a prostrating sweat follows the hot 
 stage, and continues during the intermission. The pulse is feeble 
 and oppressed, the respiration is sighing and labored, and the suc- 
 ceeding exacerbation begins with the patient very much prostrated 
 and exhausted. After two or three such periods, he sinks and dies 
 of exhaustion. In other cases, severe hemateinesis or hematuria 
 may occur during the sweating stage, and rapid prostration follow, 
 often with fatal results. 
 
 Diagnosis. There is little probability of confounding this dis- 
 ease with anything but yellow fever, and this might be the case in 
 the icteric form, if it were not recollected that yellow fever occurs 
 epidemically, and that it is contagious, which is not the case with 
 icteric pernicious fever. The gradual rise in temperature and insid- 
 ious invasion of the acme stage, with the abdominal symptoms, 
 would usually distinguish typhoid fever. When gastro-intestinal 
 symptoms are present in pernicious fever, they are violent in char- 
 acter, resembling those of cholera or yellow fever. The absence of 
 an epidemic will exclude danger of confounding it with either of 
 these diseases. 
 
 Treatment. The violence of the attack in pernicious fever will 
 usually interfere with the selection of remedies on the lines usu,.Uy 
 suggested in specific medication. However, prominent indications 
 in this direction should not be disregarded, as some prominently 
 indicated remedy, such as sodium sulphite, might be the turning pivot 
 upon which the life of a patient would depend. The simple admin- 
 istration of quinine, as advised by some authors, is certainly not all 
 that can be advised, though it is admittedly an important item of the 
 treatment; 
 
 The comatose variety should be treated by a hot bath, which may
 
 240 SPECIFIC INFECTIOUS DISEASES. 
 
 be administered by packing the patient with flannels wrung out of 
 hot water, while fall doses of jaborandi are swallowed until per- 
 spiration has been established. If the patient cannot be aroused 
 sufficiently to be induced to swallow the drug, one-fourth grain of 
 pilocarpin may be administered hypodermically, and repeated in an 
 hour, if a decided action is not manifested by that time. As soon as 
 the action of the drug is manifest by the indication of perspiration, 
 twenty or thirty grains of quinine, either the bisnlphate or sulphate, 
 shon .d be administered hypodermically, and the injection should be 
 repeated every two hours until the patient has passed under the 
 influence of the drug, and is out of immediate danger. As soon as 
 the attack is arrested, means should be taken to remove such spe- 
 cific conditions as are prominently manifested by the individuality 
 of the case. Portal congestion, a condition almost certain to be 
 present, should be met with pdymnia or carduus marianvs; gastric 
 conditions should be corrected, and, as there will be likely to be 
 acidity with sepsis, sulphite of sodium will meet the indication, '-tongue 
 loaded with pasty-white coating." Other specific indications should 
 be met, as far as possible. Gastric irritation may be treated with 
 aconite and rhus tax. If practicable, the patient should be removed 
 from the intensely malarious district into the most salubrious neigh- 
 borhood possible, until time has been allowed for recuperation. 
 
 In the treatment of the delirious variety the hot pack is especially 
 applicable, and here also the hypodermic use of pilocarpin will be the 
 most prompt and effectual method of bringing the circulation under 
 the influence of a sedative and equalizer, and preparing the way for 
 the appropriation of quinine. Whatever form or variety of pernicious 
 fever we may encounter, there is an overpowering accumulation of 
 the provoking element in the circulation, which oppresses the vaso- 
 motor centers, and causes congestion of internal organs. To equal- 
 ize the circulation then is the first requirement, and nothing will do 
 this so readily and promptly, considering the facility of administra- 
 tion, as pilocarpin. A flannel blanket wrung out of hot water and 
 wrapped around the patient as hot as can be borne without scald- 
 ing, answers the double purpose of confining a struggling patient, 
 and of equalizing the circulation and lowering the temperature. 
 Under the influence of these measures, t he patient will soon become 
 calm, and fall into a sleep, from which he will awake apparently 
 almost recovered. However, the antiperiodic must be promptly 
 administered, as a second paroxysm is liable to appear, in worse 
 form than the first 
 
 In the icteric form, the addition of p&ymnia uvedalia is an impor- 
 tant aid to treatment, and here the dose must be large, fifteen or
 
 MALAEIAL FEVER: PERNICIOUS FORMS. 241 
 
 twenty drops of the specific medicine every hour or half hour not 
 being too much. There is no objection to combining chionantJius 
 with it, though the action of this drug is too slow for the speedy 
 effect here desired. 
 
 There is no objection to the employment of the same treatment 
 in the colliquative form of this disease, for, though there may be pro- 
 fuse sweating, there is want of proper circulation an oppression of 
 the nervous centers which regulate the circulatory system and pil- 
 ocarpin will afford good results here, establishing more of a salutary 
 condition in the sudoriparous glands, and preparing the way for the 
 kindly action of the antiperiodic. 
 
 It must be recollected that many cases of this kind are attended 
 by persistent vomiting, of a character which is very difficult to 
 speedily control; therefore, hypodermic medication offers the most 
 rational means for the administration of remedies, as we are assured 
 that it will be retained until its effects have been produced. Any 
 one of the special sedatives may be employed hypodermically, aco- 
 nite, belladonna, veratrum, or gelsemium acting as effectively that 
 way as per mouth, though aconite and belladonna, if not veratrum, 
 better be omitted, since the large dose of such powerful remedies is 
 never advisable, and the large dose must be administered here in 
 order to get speedy results. 
 
 It will be observed that little discrimination is made as to the 
 treatment of different varieties, and such is not necessary. For, 
 though the symptoms may vary widely, there is such a sameness in 
 etiological and pathological respects that it would be folly to waste 
 valuable and often vital moments treating accidental symptoms. 
 These may all be hunted up and prescribed for after the patient's 
 life has been saved from immediate jeopardy, and we have a case 
 of malarial cachexia to treat. 
 
 HYPODERMIC INJECTION OF QUININE IN MALARIAL FEVER. On this 
 subject I will quote an article by H. Martyn Scudder, M. D., pub- 
 lished in the Medical Record in 1885 : 
 
 "About a year after my arrival in India I was placed in charge 
 of a general hospital and dispensary, situated about seven miles 
 from Madras, in a town which, with its suburbs, contained a popu- 
 lation of over thirty thousand inhabitants. In the year 1876 I was 
 induced, by several articles published in the British and Indian 
 medical journals, to try extensively the treatment of intermittent 
 and remittent fevers by the hypodermic injection of sulphate of qui- 
 nine. As over nine thousand patients were annually treated in this 
 hospital and dispensary, I was enabled to try this treatment on a 
 large settle. 
 
 IT
 
 242 SPECIFIC INFECTIOUS DISEASES. 
 
 "At first I employed a solution made with ordinary sulphate of 
 quinine and dilute hydrochloric acid, and I was astonished at the 
 wonderful result produced by these hypodermic injections. Cases 
 that had been taking twenty arid thirty grains per diem by the mouth 
 without any apparent effect, were cured at once by the injection of 
 from eight to twelve grains. In the first 100 cases, subjected to 
 this treatment, I had 5 cases of abscess following the injections. 
 Not being satisfied with this result, I determined to try a solution 
 of the quinisB sulph. solubil. (an English preparation very similar to 
 our bisulphate), prepared with a little tartaric acid. I found this a 
 great success I might almost say a perfect success. I have used 
 this injection in over two thousand cases without any bad effects, 
 with the exception of one case of small abscess. Even in this case 
 I am inclined to think there would have been no abscess if the 
 patient's arm had been firmly held, and if the operator had not been 
 interrupted by the violent movements of the chilL 
 
 "During the last three years of my residence in India I was set- 
 tled on the Neilgherry Hills, where I had a good opportunity of car- 
 rying on this mode of treatment by hypodermic injection, and of 
 ascertaining that it was as efficacious with Englishmen as it had 
 proved to be with the natives. Near the tops of these Neilgherry 
 Hills, at an elevation of about six thousand and eleven thousand 
 feet above the level of the sea, are situated the two large sanitaria 
 of South India, with an English population of from five thousand to 
 ten thousand, according to the season of the year. The climate of 
 these hills at this elevation being cool and healthy, Europeans are 
 able to live there in comfort and bring up their families. A great 
 number of English gentlemen are residents upon these hills, being 
 engaged in the cultivation of coffee, tea, cinchona, or 'planting,' 
 as it is termed. To work their large and valuable estates great 
 numbers of native laborers are employed. These plantations are 
 situated on the slopes of the hills, at an average elevation of three 
 thousand five hundred feet, and therefore below what is called "fever 
 range" that is, the hilly or mountain tracts of South India are gen- 
 erally infested with malaria until you reach an elevation of over 
 five thousand feet. At certain times of the year it is unsafe to sleep 
 even for a single night on these estates. The native laborers are 
 obliged, however, to live down there, and are therefore constantly 
 prostrated with fever. I have frequently been called to visit one of 
 these estates, and in a single morning would often have to adminis- 
 ter hypodermic injections of quinine to over fifty of these native 
 laborers. In addition to constantly and regularly employing hypo- 
 dermic injections of quinine in the treatment of malarial fevers, I
 
 MALARIAL FEVER: TYPHO-MALARIAIj FORM. 243 
 
 administered quinine in this way in puerperal septicaemia, where I 
 found it had a very beneficial effect. 
 
 "A considerable number of cases of puerperal septicaemia oc- 
 curred in the lying-in ward of the General Hospital and Dispensary 
 already alluded to. The native doctors and midwives have no real 
 knowledge of anatomy and physiology, and they often employ most 
 violent means to hasten difficult labors. It is therefore not at all 
 surprising that many cases of septicaemia and peritonitis result 
 
 "I have already mentioned that the solution generally used was 
 composed of quiniae sulph. solubil., tartaric acid, and distilled water, 
 the strength of the solution varying from fourteen per cent, to twenty 
 per cent. With adults I usually injected two syringefuls (that is, 
 from five to eight decigrammes) into the upper and outer part of 
 the arm, or in the back of the shoulder, pushing the needle well 
 down into the subcutaneous tissues and even into the muscle. The 
 pain produced was always trifling and of short duration. Some- 
 times a little redness and very slight swelling occurred, but soon 
 disappeared. I once administered to an English army officer, taken 
 suddenly with a congestive chill, eight syringefuls of a sixteen per 
 cent solution in twelve hours, with the very best of results, except 
 that he was somewhat deaf for a day or two. Of course I do not 
 mean to assert that this treatment by hypodermic injection always 
 drove the malarial poison entirely out of the system, or effected a 
 permanent cure ; but one or two injections nearly broke up the fever, 
 and effected a cure at the time, so that a patient would have no 
 return of the fever, unless he exposed himself anew by visiting a 
 locality where malarial fever was rife, or allowed his general health 
 to run down. I had two patients wealthy English gentlemen who 
 were accustomed to come every few months and get me to give them 
 a hypodermic injection of quinine as a prophylactic measure when 
 they were about to visit a notoriously feverish locality. During the 
 eighteen months that I have been practicing here in Chicago, I have 
 made the use of hypodermic injections of quinine several times, with 
 perfect success. In conclusion, to show what perfect confidence I 
 have in this mode of treatment, I have only to mention that I have 
 had quinine injected into my own arm on two occasions." 
 
 TYPHO-MALAEIAL FEVEB. 
 
 Synonyms. Continued Malarial Fever; Bemitto-Typhus Fever. 
 
 Definition. A term applied to forms of malarial fever present- 
 ing features of a continued type, such as nervous prostration, 
 absence of appreciable relief during remissions, tongue indications
 
 244 SPECIFIC INFECTIOUS DISEASES. 
 
 foreign to those of pure malarial iever, and pronounced aggravation 
 from the influence of quinine. 
 
 Nature. The term " typho-nialarial fever" has been something 
 of an omnibus, under which quite a variety of conditions have been 
 grouped, the only specific characteristic common to all being the 
 manifestation of malaria as exhibited by marked periodicity in th<> 
 beginning. Some authors discard the term altogether, on the ground 
 that true typho-malarial fever is a complication of typhoid fever with 
 malaria, and that there is no excuse for classifying a new disease. 
 If this were true, it might be wise to adopt such a course; but every- 
 body who has had much experience in malarious regions knows that 
 oases of fever frequently occur here which are different from pure 
 malarial fever, in their tendency to run a continued course (BO far 
 as the unpleasantness of their symptoms is concerned), with typhoid 
 symptoms, in spite of antiperiodics and other treatment which will 
 arrest ordinary malarial attacks, and which are not true enteric fever, 
 as there is nothing in their history to indicate a possibility of such . 
 infection, and abdominal symptoms are the exception rather than 
 the rule ; and then this is an accidental complication, instead of an 
 important feature of the disease. 
 
 Other diseases than typhoid fever may be complicated with mala- 
 ria, such, for instance, as dysentery and pneumonia, and when these 
 diseases occur as an epidemic where malarious conditions are pre- 
 vailing, we may have typho-malarial dysentery or typho-malarial 
 pneumonia; but this kind of a complication is not the condition for 
 which the name is here intended. 
 
 The name had its origin about the time of the last American war, 
 when the soldiers of the north were stricken on the banks of the 
 Chickahominy with a severe and fatal disease, the symptoms doubt- 
 less being due partly to the paludal influence of the surrounding 
 swamps, and partly to such anti-hygienic influences as the deposi- 
 tion of much fecal material upon the surface, to contaminate neigh- 
 boring springs and other sources of supply of drinking water, with 
 the typhoid fever bacillus. Doubtless this was a combination of 
 malaria and true typhoid fever, a condition which it is not the inten- 
 tion to discuss here. I have appropriated the name for an entirely 
 different disease. 
 
 The object of this article is to discuss a malarial fever in which 
 there are typhoid symptoms, without combination of specific typhoid 
 fever conditions a condition often, but not always, characterized by 
 marked periodicity, occurring in malarious districts, but in which 
 the measures which arrest ordinary malarial fevers prove futile, and 
 in which the patient passes through various stages of septic fever,
 
 MALARIAL FEVER: TYPHO-MALAKIAL FORM. 246 
 
 as indicated by the tongue-changes and accompanying symptoms, 
 the disease running, in spite of treatment, from fourteen to twenty- 
 one days. 
 
 The following notes on the parasite of malaria, by TJ. S. N. Sur- 
 geon Craig, suggest the reason for the disappearance or occasional 
 absence of marked periodicity, as well as throwing light upon the 
 etiology of malarial diseases in general : 
 
 "It is during the apyrexial period that the organisms grow, pro- 
 ducing few or no symptoms. It is only when the stage of segmenta- 
 tion is approached that the temperature begins to rise, and reaches 
 the acme about the time that segmentation has been completed; 
 then declining to normal, the paroxysm lasting an indefinite period, 
 depending on the potency and quantity of the toxine evolved. 
 
 "In the ordinary tertian, and double tertians, the quartans and 
 their combinations, the length of the paroxysm averages from about 
 six to ten hours. 
 
 "In the sestivo-autumnal, or the remittents, as they are com- 
 monly called, the duration of the paroxysm is much longer, averag- 
 ing from eighteen to twenty-two hours, or even as long as thirty-six 
 hours in some cases; thus, it is the overlapping of these paroxysms 
 which gives the irregularly continuous fever; that is, the toxin pro- 
 duced by one set of organisms does not become eliminated before 
 the adveut of a fresh quantity of toxin by the succeeding set of 
 organisms. 
 
 "In the pernicious and congestive forms of these fevers, the toxin 
 is in such a virulent form that sometimes one paroxysm is sufficient 
 to cause the death of the patient. 
 
 "It is not the high temperature which kills in all cases, for we find 
 that in some c ises the temperature becomes subnormal, 96 F. or 
 less, and remains so, the patient dying in a condition of coma, just 
 as in the hyperpyrexial case." 
 
 Etiology. As will be inferred from the foregoing, the etiology 
 is somewhat obscure. Undoubtedly the plasmodium raalariae figures 
 as one of the exciting causes, but there must be an additional factor, 
 or else it would not be so markedly different from pure malarial 
 fever in its clinical characteristics. 
 
 This is evidently not the specific bacillus of true typhoid fever, for 
 the disease cannot be traced to fecal material, nor does it propagate 
 its kind in the manner peculiar to that disease. Indeed, it is doubt- 
 ful that it is contagious, or even infectious, except so far as the mala- 
 rial element is concerned. 
 
 It is probable that the condition depends upon a peculiar state 
 of the system, brought about by various anti-hygienic causes, such
 
 246 SPECIFIC INFECTIOUS DISEASES. 
 
 as depressing influences from mental worry, overwork with anxiety, 
 retained secretions, improper diet, or vitiated air, in combination 
 with the ordinary causes of malaria. 
 
 Loomis asserts that sewer gases seem to be the elements which 
 have predisposed to it, in cases which have come under his notice. 
 
 Symptoms. It is difficult to describe the symptoms of this 
 disease, as different cases vary so much. Some peculiarities may be 
 mentioned, however, which are applicable to many of them. They 
 run from fourteen to twenty-one days, in spite of treatment While 
 an ordinary case of malarial fever, whether intermittent or remittent, 
 can be arrested within the first week, such treatment usually fails 
 to arrest this variety, and it persists in running through its course. 
 Most cases also present marked malarial symptoms in the beginning, 
 in the manifestation of chills and other periodicity, and later grow 
 out of this into a more continued type, as the nervous system 
 becomes more and more involved. 
 
 While some observers state that intestinal complication is a com- 
 mon condition, my experience has been that there is little disturb- 
 ance of the bowels, though in a large class of cases gastric irrita- 
 tion is common. In those cases manifesting intestinal irritation, the 
 season of the year and the character of food eaten prior to the attack 
 are liable to play provoking parts. 
 
 Two prominent classes of cases are found, and I shall divide all 
 cases into these two classes, though occasionally a case will be 
 encountered which cannot be included in either one. We will call 
 them the septic class and the nervous class. 
 
 In the septic class the attack is usually abrupt and severe. There 
 is a marked and prolonged chill, and this may be repeated every 
 day for three or four days, resembling the paroxysms of an inter- 
 mittent fever; or, instead, there may be but the one chill, and the 
 remissions and exacerbations of a remittent fever may mark the 
 onset Instead of the marked relief that attends the intermissions 
 or remissions of an ordinary malarial fever, however, the patient 
 suffers continually, and is not inclined to get out of bed, marked 
 prostration manifesting itself from the start. During the exacerba- 
 tions, the temperature ranges from 103 to 105 F., the pulse is full 
 and strong, hard or bounding, and there is severe muscular pain in 
 various parts of the body, usually involving the lumbar and pericra- 
 nial muscles ; and these pains persist, though not so severely, during 
 the periods of remission. 
 
 The totigite is coated heavily, with a white or pasty- white coat- 
 ing, the organ is broad and flabby, and there is a putrefactive odor 
 about the breath.
 
 MALAEIAL FEVEE : TYPHO-MALARIAL FORM. 
 
 247 
 
 In three or four days, whether antiperiodics have been used or 
 not, it becomes evident that the patient is growing weaker, and that 
 there is no progress toward recovery. He has no desire to get out 
 of bed, though restless and uneasy, and there may be delirium at 
 night. The chills have now passed away, and there is less appear- 
 ance of a remission in the morning than at first, though the ther- 
 mometer may indicate fully as much decline of temperature. There 
 are now loathing of food, thirst, severe muscular pain, and marked 
 restlessness. The tongue begins to take on a brownish tinge by the 
 end of the first week, and in two or three days more the coating 
 may flake off, leaving the mucous membrane bare, dark red, and 
 slick the characteristic beefsteak tongue. Or, the coating may 
 become dry and brown, and gradually wear off by attrition, the beef- 
 steak characteristic not appearing. 
 
 Meantime, as the disease progresses, the patient becomes less 
 restless, the night delirium passes off, and a condition of apathy or 
 drowsiness comes on, the patient finally becoming somnolent, and 
 falling into a profound slumber during the morning remissions ; and 
 
 A 
 
 TEMPERATUBE CURVE IN TYPHO-MALABIAL FEVER (FATAL CASE) 
 
 soon prolonged sleep comes on, the skin becomes moist, the urine 
 throws down a copious sediment, and convalescence is established 
 between the fourteenth and twenty-first day. 
 
 In the nervous class, the onset is not so abrupt nor severe, 
 fever comes on more insidiously, though even here the periodi. 
 of malaria is manifested. The pulse is small and rapid, compr< 
 sible, or wiry. Prostration is evident early, and is more marked than 
 in the septic class, though the patient does not seem to suffer
 
 248 SPECIFIC INFECTIOUS DISEASES. 
 
 severely. The tongue, instead of being large and broad, is narrow 
 and contracted, tremulous on protrusion, and often pointed, and red- 
 dened at the tip and edges, in which case there is constant nausea 
 and loathing of food, and sometimes vomiting upon the taking of 
 even fluids, with provoking thirst. The tongue becomes dry and 
 brown early, in many cases, though it may remain moist throughout. 
 A thin white coatiug may be present along the center of the organ, 
 but it soon becomes clean and slick, or the coating becomes shriv- 
 eled and brown. 
 
 Restlessness is a marked feature of this condition, and the patient 
 is delirious at night, sometimes actively so, and the condition is 
 very much aggravated by quinine or opiates. 
 
 The skin is dry and harsh, the secretions generally are arrested, 
 the urine being scanty and high colored, and, when becoming more 
 profuse at the end of the fever, it throws down a copious sediment. 
 
 Another form of the nervous variety is the comatose form. In 
 this, the subject becomes comatose within a day or two after the 
 attack begins, there being complete prostration of all the voluntary 
 forces. There are mouth-breathing, brown tongue, dilatation of the 
 pupils, involuntary evacuation of urine, and, in some cases, apparent 
 paralysis of the extremities, though motion returns in a few days, 
 when favorable symptoms succeed. The temperature, in this form, is 
 not remittent to any marked degree, the curve resembling that of 
 typhus fever. Within a few days, in favorable cases, the remissions 
 become more marked, and the patient rouses from his lethargy, and 
 passes through conditions already described. 
 
 Typho-malarial fever, occurring during the heated term, may 
 take on intestinal irritation, and develop diarrhoea or dysentery; or, 
 if bunglingly treated with cathartics in the start, it may develop 
 such symptoms at any time; but when properly managed, the bow- 
 els are not usually seriously disturbed, without the operation of some 
 special provoking cause. 
 
 Diagnosis. The absence of the severe abdominal complica- 
 tions of typhoid fever, and the isolated character of the attacks, will 
 exclude this disease from the diagnosis. The delirium is not so 
 severe nor so obstinate to treat as that of typhus, and the former 
 history of the case will usually enable the practitioner to discrimi- 
 nate between them. Cerebro-spinal fever often takes on similar 
 symptoms, but the severe muscular pains of cerebro-spinal fever, the 
 retraction of the head, and the irregular course of the fever, will 
 usually declare the character of that disease. It will hardly ever 
 be confounded with pernicious malarial fever, for the reason that 
 that disease usually occurs in southernlat itudes, while this is a 
 disease of temperate regions.
 
 MALAEIAL FEVER: TYPHO-MALARIAL FORM. 249 
 
 Prognosis. There are very few fatalities attending this dis- 
 ease, when proper therapeutic means are employed from the begin- 
 ning. Though a disease of grave aspect in the early part of its 
 course, rational treatment will almost invariably bring the patient 
 safely through. 
 
 Treatment. One rule should be observed in the treatment of 
 this disease, and that is, to refrain from attempting to break it up, 
 as though it were a case of ordinary malarial fever. Heroic doses 
 of quinine should be left out of the treatment altogether. 
 
 In the septic variety, where the tongue is heavily loaded at the 
 base, an emetic, administered early, may lessen the severity of the 
 conditions which follow, and also prepare the system for the better 
 reception of other remedies. 
 
 The broad, flabby tongue will call for one-grain doses of sulphite 
 of sodium, administered every two or three hours, until the peculiar 
 coating has begun to disappear. The septic condition should thus 
 be followed with the appropriate remedy indicated by the tongue, 
 throughout the disease. As the tongue cleans and shows the beef- 
 steak color and general appearance, muriatic acid will be the proper 
 corrective. If, instead of the beefsteak tongue, the coating becomes 
 browu, with tendency to the deposit of sordes on the teeth and lips, 
 sulphurous acid will be more proper. 
 
 Where muriatic (hydrochloric) acid is required, we will prescribe 
 as follows: R Dilute muriatic acid fi, simple syrup or water fiii. M., 
 and order a teaspoonful every three or four hours. Sulphurous acid 
 may be administered in twenty-drop doses, well diluted, every two 
 or three hours, when called for by the brown coating of the tongue. 
 
 The proper antiseptic should be accompanied by the proper sed- 
 ative. With the full, strong pulse, we will find jaborandi an excel- 
 lent remedy, though if there is active determination of blood to the 
 brain, as indicated by the bright eyes, contracted pupils, and full, 
 bounding pulse, gelsemium may be combined with it or alternated 
 advantageously. ^ Jaborandi jiii, water fiv. M., and order a tea- 
 spoonful every hour. Or, R Gelsemium gtt xx, water f iv. M., and 
 order a teaspoonful every hour. 
 
 The sedative mixture should be administered assiduously until 
 the temperature falls and signs of convalescence appear. Usually, 
 as the disease progresses, the sthenic character of the pulse gives 
 way to a condition of lessened force in the impulse, and the sedative 
 may properly be changed to small doses of aconite and rlius tox. 
 For example, R Lloyd's aconite gtt. v-x, rhus tox. gtt. x-xv., water 
 ziv. M., and order a teaspoonful eveiy hour. Where there is drow- 
 siness, coldness of the extremities, dilated pupils, doughy condition
 
 250 SPECIFIC INFECTIOUS DISEASES. 
 
 of the tissues, soft, compressible pulse, and other indications of 
 feeble capillary circulation, # Belladonna (specific nn-dicine or 
 homeopathic tincture) gtt. vi, water |iv. M., and order a teaspoon- 
 ful every hour. 
 
 If there be intestinal irritation, with diarrhoaa, a better antiseptic 
 than the sulphate of sodium, sulphurous acid, or muriatic acid, will 
 be echinacea or baptisia. However, if there be the marked tongue 
 indication for any one of these remedies, it should have the 
 preference. 
 
 The nervous type, bearing evidence of gastrio irritation by the 
 elongated tongue, with restlessness, will call for aconite and rhus tox., 
 early. R Specific aconite gtt. v, specific rhus tox. gtt. x, water fiv. 
 M., and order a teaspoonful every hour. This will constitute the 
 treatment for several days, until all evidence of gastric irritation has 
 passed away. As the beefsteak tongue appearance comes on, the 
 preparation of muriatic acid already described may be made use of, 
 in connection with the sedative mixture of aconite and rhus tox., 
 which must be continued as long as the thermometer indicates the 
 presence of febrile action. Sometimes the tongue will suggest sul- 
 phurous acid instead of muriatic, and sometimes echinacea or bap- 
 tisia will be more effective, the indications for these remedies not 
 being so marked, but the typhoid condition suggesting some agent 
 of antiseptic character. 
 
 The treatment already suggested will apply to the comatose vari- 
 ety, belladonna, aconite and rhus tox. being most applicable. Ech- 
 inacea will be an especially excellent antiseptic here, though where 
 there are prominent indications for others, it should not be used to 
 their exclusion. 
 
 Quinine should be omitted until convalescence sets in, and then 
 be administered in small doses, if at all. Better remedies here 
 are arseniate of quinia 3x, or tea- or fifteen-drop doses of a reliable 
 fluid preparation of grindelia squarrosa. 
 
 Daring the height of the fever, the surface should be sponged 
 with alkaline tepid water each day, as it contributes to the rest and 
 comfort of the patient, as well as assisting the natural efforts to 
 throw off the fever. 
 
 The diet should be similar to that of typhoid fever, liquid in 
 character, though solid food may be resumed within a much shorter 
 time. Milk, malted milk, gruels, etc., avoiding fruits, may consti- 
 tute the food for the term of fever, the patient being fed regularly, 
 as a supporting regimen now seems important, to encourage ready 
 recuperation.
 
 MALARIAL FEVER : CHRONIC FORM. 261 
 
 CHBONIG MALARIAL FEVER. 
 
 Synonym. Malarial Cachexia. 
 
 Definition. A chronic malarial manifestation, characterized by 
 anaemia, sallow, waxy pallor of the skin, and splenic enlargement, 
 with attendant indigestion, debility, languor, and other malarial 
 manifestations. 
 
 Etiology. This condition may arise from repeated attacks of 
 acute malarial disease, or it may come on gradually, as the result of 
 long-continued latent malarial poisoning. 
 
 Pathology. The morbid results of this condition differ from 
 those of malarial fever principally in extent. The spleen seems to 
 be the part which suffers the most anatomical change. It is very 
 much enlarged, sometimes filling nearly the entire abdominal cavity, 
 and often being ten or twelve times its normal size, tough, firm, and 
 resistant. The capsule is thickened and uneven, and there may be 
 adhesions to adjacent structures. There is marked pigmentation 
 throughout the entire organ, and hyperplasia or degenerative changes 
 have left their evidences in the structures. The liver and kidneys 
 are similarly altered, though not so prominently so as the spleen. 
 The blood-changes are not so marked as in the various forms of 
 malarial fever, but its impoverished condition is manifested by ten- 
 dency to dropsical effusions into the cellular tissues and serous cav- 
 ities. Fibrinous coagula are sometimes found in the arteries, and 
 cavities of the heart The plasmodium of Laveran, it is asserted, 
 is found in the blood, the crescentric form being the most common. 
 
 Symptoms. Malarial cachexia furnishes us with a great vari- 
 ety of symptoms, but there is such a sameness in the pathological 
 conditions resulting in different cases, that a rational treatment is 
 suggested as applying to the class of cases, and this need not vary 
 so widely in individuals as might at first be supposed. The sub- 
 jective symptoms are legion. Sometimes they are those of a chronic 
 intermittent, with rather erratic manifestation of the paroxysms, 
 these being attended by unusual symptoms of prominence, such as 
 a neuralgic manifestation, periodical tic douloureux, sciatica, pleu- 
 roclynia and sometimes by extreme gastric or intestinal disturbance, 
 hemicrania, etc. In other cases, the ague type will not be manifest 
 at all, and it may be difficult to detect any .evidence of periodicity in 
 the case, unless some acute aggravation arises. 
 
 In all cases, there is prominent evidence of disturbance of the 
 assimilative and reconstructive processes. The complexion presents 
 us with a sallow, waxy pallor, characteristic and striking; the patient 
 is debilitated and enervated; palpitation of the heart attends and 
 follows slight exertion; digestion is feeble; the bowels are usually
 
 252 SPECIFIC INFECTIOUS DISEASES. 
 
 constipated; the skin is dry and harsh; the tissues flabby and illy 
 nourished; the tongue broad, flabby, and covered with a pasty white 
 coating. 
 
 There will be found upon inspection, a fullness of the abdomen 
 over the epigastric and hypochondriac regions, the lungs being 
 crowded upward, and respiration being stuffy and difficult. Some- 
 times there are decidedly asthmatic symptoms as a result of the pres- 
 sure from splenic and hepatic engorgement. Hepatic engorgement 
 is so common that icteric symptoms are often more or less manifest, 
 in many cases. 
 
 Perversion of the sensibility of the cutaneous nerves is a symp- 
 tom which is not uncommon. I have seen a few cases where the 
 entire scalp seemed cold to the patient, though not to the touch of 
 the observer, and remained so for months until restored by elec- 
 tricity and vapor baths. In other cases, there may be tingling and 
 numbness in some portion of the cutaneous surface, notably that 
 upon the outside of the thighs. Whether this is alone the result of 
 malaria or of the abuse of quinine and calomel is not quite clear to 
 my mind, but it usually occurs in those who have been subject to 
 old orthodox allopathic treatment for a considerable length of time. 
 
 A certain class of symptoms is always present: more or less ver- 
 tigo, tinnitus aurium, anorexia, nausea, and difficult digestion. The 
 patient wakes in the morning with a foul metallic taste, dizziness, 
 sense of confusion in the head, and general soreness and stiffness. 
 Myalgic pains, with stiffness of the muscles, are common in this con- 
 dition, and there is frequently a sense of weariness, constantly pres- 
 ent, with nocturnal wakefulness. 
 
 Catarrhal symptoms are not uncommon, these manifesting them- 
 selves in a catarrhal bronchitis, or in the form of muco-enteritis. 
 Hemorrhages, such as epistaxis, hematuria, menorrhagin, and even 
 hemoptysis, may originate as a symptom of malarial infection. Stub- 
 born menorrhagia, occurring in malarious districts, may sometimes 
 be cured with means directed to the relief of malaria, when appar- 
 ently more rational measures fail 
 
 Diagnosis. The existence of malarial surroundings, and the 
 fact that the patient has been exposed to their influence for a long 
 time, connected with the fact that there is anaemia, without any 
 other known cause, will suggest malarial cachexia. Enlargement of 
 the spleen will add testimony to this supposition. Exclusion of seri- 
 ous renal affections will be made by urinary analysis, and careful 
 palpation will serve to exclude hepatic cirrhosis. Periodical man- 
 ifestations will add to the testimony of malarial origin. Microscop- 
 ical examination by competent observers will probably detect the
 
 MALARIAL FEVER: CHRONIC FORM. 253 
 
 hematozoa of Laveran; however, few practitioners will need to go 
 thus far in order to render a correct diagnosis, even provided they 
 possess the necessary apparatus. Another condition liable to be 
 confounded with malarial cachexia is leukaemia, in which there are 
 enlargement of the spleen and anaemia. Here, however, there is great 
 increase in the proportion of white blood-globules, and treatment 
 for malarial cachexia produces no effect. As leucocythsemia is usu- 
 ally a fatal disease, and treatment for malarial cachexia could not 
 damage the patient, a mistake of this kind would not be serious, at 
 any rate. 
 
 Prognosis. The prognosis will depend largely on the care and 
 attention paid to the management of the case. "When possible 
 to remove the patient from malarious surroundings to a higher 
 and more healthy neighborhood for a few months, a much more 
 speedy recovery will probably follow. Advanced stages which have 
 gone on to structural changes in the spleen with amyloid or 
 melanotic degeneration and effusion into the serous cavities, are 
 unpromising. A large majority of the cases, however, may be con- 
 sidered favorable, under the treatment here suggested. 
 
 Treatment. There seem to be rational propositions afforded, 
 by the symptoms and pathology of this disease, for a direct and suc- 
 cessful treatment. However, each case of disease will always be an 
 individual one, and no routine treatment need be expected to 
 invariably succeed. But one condition is always present here, viz., 
 splenic congestion. It would almost seem that the cachexia really 
 hinged upon this condition, the congestion being the precursor of 
 the anaemic state. What little knowledge of the functions of the 
 spleen we possess would naturally lend color to this proposition. If 
 the splenic congestion could be averted in the start, it is probable 
 that the cachexia would never result, the other complications follow- 
 ing as sequelae of obstruction to important circulatory channels and 
 necessary blood-making functions. 
 
 The proposition resolves itself then into the treatment of a case 
 of chronic (but ordinarily curable) splenic congestion, with attendant 
 incidental complications. Fortunately, the Eclectic materia medica 
 contains a goodly list of remedies which are potent in curing 
 splenic congestion. Carduus marianus, ceanothvs, grinddia sqnarrosa, 
 and polymnia uvedcdia, all possess particular merit in this direction, 
 and, equipped with them, we are prepared to attack the disease at 
 its very foundation. The leading proposition throughout, then, will 
 be to promote normal splenic function, and preserve a free portal 
 circulation by the aid of one or all of these remedies. This accom- 
 plished, the remaining part of the task will not be difficult There
 
 254 SPECIFIC INFECTIOUS DISEASES. 
 
 is such a similarity in the action of these remedies that it will not 
 be easy to always discriminate and select the one best adapted to 
 au individual case. However, there are some leading points which 
 it may be well to consider. In many cases the combination of two 
 or more of them may afford better satisfaction than the use of a sin- 
 gle one. 
 
 Carduus marianus is adapted to the treatment of rather recent 
 cases, in which there is a mental complication bordering on hypo- 
 chondriasis ; the patient is low spirited, and inclined to melancholy. 
 Where this is a prominent characteristic of the disease, no question- 
 ing will be necessary to bring the symptom out; it will be manifest 
 upon all occasions. Here, carduus is the remedy for first choice 
 Obscure pains in the pectoral region or other part of the thorax, as 
 under the left scapula, would also suggest carduus. 
 
 A prominent indication for ceanothus is pain in the spleen. With 
 marked splenic enlargement attended by much pain, it should have 
 the preference over others of its class, as a rule, though there is no 
 objection to rotation of the others where this fails. However, we 
 are here prescribing something that is very direct, and there is little 
 probability of failure if a proper diagnosis has been made. 
 
 Painless enlargement of the spleen may be taken as an indication 
 for the use of polymnia. And here it is well to make avail of the 
 external, as well as the internal, use of the drug. The polymnia 
 ointment here comes into use, it being applied over the enlarged 
 organ, and rubbed in with plenty of friction. Dyspeptic complica- 
 tion of marked character is another indication for polymnia, such as 
 burning in the stomach after eating, or fullness and distension with 
 gases, attended by difficult, sighing respiration. This comes very 
 near the condition characterized as "prsecordial oppression," a symp- 
 tom also suggesting polymnia in this disease, though not excluding 
 the others, should this fail. 
 
 Grindelia squarrosa has not been tried as thoroughly as the three 
 already canvassed. There may be obscure cases, not very well 
 marked, where this will do better than any other remedy. It has 
 relieved splenic pain and dyspeptic symptoms of long standing for 
 me very satisfactorily in several cases, and I should expect much 
 from it in any case of splenic enlargement in maltrrial cachexia. It 
 needs more study to fix a place for it. As we do not object to a 
 reasonable amount of combination, two, three, or all these remedies 
 may be combined occasionally, though usually I would not expect as 
 prompt results as where a proper selection had been made of one or 
 two of them. 
 
 A natural sequence of splenic congestion is hepatic disturbance,
 
 MALARIAL FEVER: CHRONIC FORM. 255 
 
 of greater or less severity. Sometimes this amounts to congestion 
 of the liver, announced by enlargement, with tenderness on pressure. 
 In other cases, there may only be functional inactivity. In either 
 case icteric symptoms are likely to be more or less manifest. Con- 
 gestive hepatic disturbance will suggest the use of chelidonium, in 
 combination with the appropriate spleen remedy; hepatic torpor 
 without congestion will properly be met with chionanthus. Cheli- 
 donium should not be given in more than two- or three-drop doses, 
 repeated four times daily; chionanthus may be given in ten-drop 
 doses, at about the same intervals. A good method would be to com- 
 bine the spleen and liver remedies in the same dose. 
 
 Often the stomach will be found to give rise to the most promi- 
 nent symptoms. "We have the torpid stomach, where the tongue is 
 heavily coated at ihe base, and where there seems to be a morbid 
 accumulation in the viscus, as suggested by eructation of gases, diffi- 
 cult digestion, etc. When this condition is present it will be found 
 a persistent one, and its removal will become an important matter. 
 The treatment here is the administration of emetics, repeated once or 
 twice a week, until the eructations have ceased, and the tongue has 
 assumed a normal condiiion. I usually employ powdered ipecac, giv- 
 ing from three to five grains, stirred in half a cup of hot water, 
 repeating every ten minutes, until free emesis follows. It is well to 
 order an extra teacupful of hot water between the doses. In other 
 cases, the tongue will be broad and flabby, and evenly coated with a 
 dirty, pasty white coating. This is also a persistent symptom, and 
 must be removed, in order that the patient may make rapid prog- 
 ress. "We expect to correct this with sulphite of sodium', dose, a 
 grain, in capsule, four timas daily, continued until the coating has 
 disappeared. Gastric irritation is another symptom that sometimes 
 demands attention, though it is not common in malarial cachexia. 
 It is recognized by the pointed tongue, with reddened tip and edges, 
 accompanied by vomiting, and disgust for food. "We remedy this by 
 using, for several days, a mixture of five or eight drops of aconite 
 with twenty drops of rhus tox., in four ounces of water; dose, a tea- 
 spoonful every one or two hours. Meantime, our spleen remedies 
 should be steadily administered, whatever other treatment may be 
 indicated. 
 
 Normal activity of the general circulation is an important consid- 
 eration, whatever the condition may be. Even splenic congestion 
 may be reached by a method which will provide for a vigorous cut;t 
 neous capillary circulation. The vapor bath, either the alcoholic, or, 
 what is preferable, the steam cabinet bath, is an admirable remedy 
 in chronic malarial poisoning. It very materially assists, and is even
 
 256 SPECIFIC INFECTIOUS DISEASES. 
 
 capable of curing most cases, unaided by other means. When prac- 
 ticable where the means are at hand a steam cabinet bath may 
 be taken every other day for a fortnight, and afterward twice a week, 
 until recovery has been fully established. This does not interfere 
 with other treatment and is a powerful adjuvant, to say the least of it. 
 The gastric, hepatic, and splenic symptoms yield to it speedily, and 
 digestion and assimilation are speedily restored to a normal condition. 
 The baths may be much aided by using, in conjunction with them, 
 the tonic faradic treatment described in Dynamical Therapeutics. 
 
 Some authors advise the removal of the patient to a non-mala- 
 rious district. This is good advice, but, unfortunately, a large per- 
 centage of these patients are not financially able to incur the expense 
 of such a change. We must be able to do better than choose one of 
 these alternatives sending them away, or leaving them at home 
 to die. 
 
 We do not want much quinine in the treatment of these cases. 
 We will find, if we make the trial, that they have worn quinine out 
 that this drug aggravates instead of ameliorating. If there is 
 periodicity and quinine is administered for its interruption, no 
 impression will be made, usually. It is not impossible that malarial 
 cachexia may really be largely chronic quinine poisoning. At least 
 that drug bears the reputation of producing portal congestion, and 
 in this case such a condition is just what we are endeavoring to get 
 rid of. Alstonia and arseniate of quinia, in alternation, are more effec- 
 tive here, and less objectionable. As a steady tonic here, when I 
 desire to employ an anti-malarial agent-, I prescribe the following 
 capsule: R Alstonia constricta gr. iii, arseniate of quinia, 3x trit, 
 gr. ii M., and fill one capsule. Duplicate No. 30. S, One after 
 each meal. 
 
 Since the foregoing was written, I have given especial attention 
 to grindelia squarrosa, as a general curative agent in chronic malarial 
 cachexia. A careful review of Prof. Bundy's writings, and an inves- 
 tigation of some of his arguments as to unreliability of preparations 
 of this agent often found in the market, with subsequent extended 
 use of a tincture prepared by myself from the recent plant, have con- 
 vinced me that this is the best remedy we possess for the cure of 
 malarial cachexia. I will premise quotation of what Prof. Bundy 
 has written upon the subject, by asserting it as my b -lief, that he 
 has not overestimated the value of this remedy, and that when a 
 reliable preparation one true to name is employed, it will seldom 
 prove disappointing. Following is the quotation with reference 
 to the subject, from Prof. Bundy's pen: 
 
 "The continuance of chronic intermittents is most frequently the
 
 MALARIAL FEVER: CHRONIC FORM. 257 
 
 result of splenic hypertrophy. The hypertrophy is a secondary 
 matter at first, but when well established it becomes the perpetuat- 
 ing cause. This, I am satisfied, is a fact, and so long as the hyper- 
 trophy exists, so long will the paroxysms continue to return. Qui- 
 nine, arsenic, picrate of ammonium, etc., are given separately and 
 combined in every conceivable manner, yet the paroxysms appear 
 every eighth, fifteenth, or twenty-second day for months, until the 
 patient becomes bloodless and reduced to a mere skeleton, the abdo- 
 men distended by an enlarged spleen, and from dropsical effusion. 
 
 "What is necessary in this case is to remove the splenic hyper- 
 trophy, which is positively the perpetuating cause, in combination 
 with malarial influences, if the patient lives in a malarious district. 
 ' There is a balm in Gilead,' and when the profession has frittered 
 away time enough in 'tinkering' with routine and hackneyed treat- 
 ment in unsuccessful attempts to cure chronic intermittents, it may 
 see fit to resort to this remedy, and learn how to succeed in curing 
 them. 
 
 "The drug is grindelia squarrosa. I have cured over seventy 
 cases in the past four years, and I have yet to see the case it will 
 not cure if properly given. That it may sometimes fail is entirely 
 possible, as almost any remedy is liable to sometimes disappoint; 
 but failure in my hands in curing chronic ague has never occurred 
 with this remedy. 
 
 "My last case is that of a child 18 months old. The spleen was 
 four times the natural size, and this condition had existed seven 
 months when I commenced treatment. I gave R Fluid extract of 
 grindelia squarrosa (P., D. & Co.'s) ^iii, syr. acacia and aqua dest. aa, 
 fii. Sig., a teaspoonful four times daily. $ Tinct. ferri. chlor. ?i, 
 simple syrup fiii. M. Sig., one teaspoonful four times daily. One 
 prescription was given before and the other after meals. From 
 three to ten weeks of this treatment may be necessary." 
 
 Bundy believed that there was a great deal of fluid extract of 
 grindelia squarrosa in the drug market which was not true to name, 
 but which was, instead, fluid extract of grindelia robusta. For the 
 two varieties resemble each other very much, and are liable to be 
 confounded by inexperienced herb-gatherers. This may explain the 
 failures which often attend the use of this remedy in the treatment 
 of chronic malaria. From extended personal experience with a tinc- 
 ture prepared by myself from the recent herb gathered near Colusa, 
 by a medical gentleman who knew Bundy while there, I am con- 
 vinced that the fluid extract of Parke, Davis & Co., labeled grindelia 
 squarrosa, is true to name, and I am doubtful about the identity of 
 every other preparation I have found in the market.
 
 258 
 
 SPECIFIC INFECTIOUS DISEASES. 
 
 XXI. ANTHRAX. 
 
 Synonyms. Malignant Pustule; Splenic Fever; Malignant 
 (Edema; "Wool-sorter's Disease. 
 
 Definition. An acute, infectious disease, caused by the bacil- 
 lus anthracis, characterized by destructive inflammation at the seat 
 of inoculation, and severe constitutional symptoms of grave charac- 
 ter, arising therefrom. 
 
 Etiology. The bacillus anthracis, the active principle of this 
 disease, was the first specific microbe of disease detected and 
 
 described. It is from two to 
 three times the diameter of 
 a red blood-corpuscle in 
 
 v^: ;y^gg^s=- j^'rz- length, the rods often being 
 &"CT ''' v :'/', f E^X^J**^ ML united. It multiplies by fis- 
 
 - fc^55V * ^5^ /j^^^xjgj 
 
 *\^**^^'&*?*^ si D> anc * S rows ver J rapidly 
 ^\V.'fVa>^* on cu lture medium, the 
 
 spores possessing remark- 
 able vitality, though the 
 bacilli are easily destroyed. 
 It is introduced into animal 
 tissues by inoculation from the bites or stings of insects, into the 
 stomach with the food, and into the lungs through inspired air. 
 
 It is a malady principally infecting cattle and sheep, though those 
 of the human family who are about and .exposed to infected animals 
 and animal products, are most liable to become diseased. Thus, 
 butchers, tanaers, wool-sorters, herdsmen, etc., are more liable to 
 acquire the disease than ordinary individuals. 
 
 It is more common in certain parts of Europe and Asia than in 
 this country, though it is not uncommon in South American cattle 
 districts. 
 
 When a region becomes infected, the bacillus seems to be perpet- 
 uated for a long time. Pasteur believed that the bacilli might be 
 brought from the buried carcass of an infected animal to the surface 
 by earth-worms, and there prove a source of infection to new indi- 
 viduals. Others doubt the soundness of these views, though they 
 admit the persistency of the infection, in regions once contaminated. 
 
 It will be described under the following heads : 
 
 EXTERNAL ANTHRAX. 
 
 MALIGNANT PUSTULE. In this form of anthrax, the inoculation 
 usually occurs upon an exposed part, such as the face, hands, arms, or 
 neck, arid is probably due to the bites or stings of insects. The 
 first announcement of the disease is a small papule, though its
 
 ANTHKAX. 259 
 
 appearance may be heralded a few hours by burning and itching in 
 the vicinity. The papule enlarges rapidly, until a vesicle appears 
 upon its summit and a hardened areola surrounds its base. Within 
 thirty-six hours a brown slough appears in the center, denoting the 
 point of inoculation. Numerous vesicles now appear, surrounding 
 the vicinity of this point, and resembling the numerous openings of 
 a carbuncle. The local inflammation spreads rapidly, extreme indu- 
 ration and swelling speedily appearing, and the lymphatics convey 
 the irritation to neighboring glands, which become swollen, indu- 
 rated, and painful. Constitutional symptoms soon appear, a rapid 
 rise of temperature and other febrile phenomena being afterward 
 followed by subnormal temperature, coma, and death. In favorable 
 cases, the constitutional symptoms are not SO severe, and the local 
 symptoms are marked by sloughing at the point of irritation, with 
 gradual healing of the cavity. 
 
 MALIGNANT (EDEMA. This occurs in parts containing a large 
 amount of connective tissue, and which are liable to puffy swelling 
 under other circumstances, such as the eyelid, head, hand, arm, and 
 other parts. There is here an absence of the papule and vesicle, 
 
 and, when sloughing occurs, a large sur- 
 face is involved. The oedema spreads 
 rapidly, involving large areas, and the 
 constitutional symptoms are almost 
 always extreme, and usually lead to a 
 
 or 
 OQOB M A, 
 
 The character of the lesion its prog- 
 ress and the severe constitutional symptoms which attend, in addi- 
 tion to the occupation of the patient, will usually afford a clear diag- 
 nosis, in either malignant pustule or malignant oedema. Microscop- 
 ical examination of the fluid of the affected part will disclose the 
 presence of the anthrax bacilli. 
 
 INTERNAL ANTHEAX. 
 
 MYCOSIS INTESTINALIS. This form arises from the reception of 
 the parasite into the stomach with the food, when the flesh of dis- 
 eased animals is eaten, or the milk of affected cows is drunk. The 
 symptoms are ushered in with a chill, and attended by severe gastro- 
 intestinal disturbance, such as vomiting, diarrhoea, burning pain in 
 the stomach and intestines, dyspnoea, cyanosis, and extreme restless- 
 ness, followed by coma or convulsions. This form of the disease 
 usually attacks several persons simultaneously those who have 
 eaten, at the same time, of the flesh of an animal affected with 
 anthrax.
 
 260 SPECIFIC INFECTIOUS DISEASES. 
 
 WOOL-SORTER'S DISEASE. This disease arises among the employes 
 of large wool- or hair-sorting establishments, the microbe being 
 inhaled during the handling of the diseased material. The hair and 
 wool imported into Europe from South America and Russia seem to 
 be most commonly infected. The dust arising during the handling 
 of these products seems to contain the bacillus anthracis, at least 
 the microbe gains entrance to the interior of the body during the 
 commotion, either by way of the stomach or lungs, and serious 
 symptoms follow. The patient is attacked with a chill, followed by 
 fever, attended by racking pains in the limbs and back, short, rapid 
 breathing, with severe pains in the chest, and usually signs of bron- 
 chitis. Gastric symptoms often supervene, vomiting and purging 
 attending, and rapid prostration follows. Sometimes there is delir- 
 ium during the advanced stage of the disease, and sometimes coma. 
 
 The diagnosis in such cases is difficult, and can only be inferred 
 from the occupation of the sufferer and the violent symptoms, until 
 investigated from a bacteriological standpoint. 
 
 Treatment. The treatment thus far followed has not yielded 
 a great amount of satisfaction. It is advised to destroy the pustule 
 by tlie use of actual cautery or caustic potash, and sprinkle pow- 
 dered bichloride of mercury over the surface. Subcutaneous injec- 
 tions of carbolic acid about the pustule, to prevent the spread of the 
 bacilli, are also advised. It seems to me that such treatment can- 
 not but make a bad matter worse, and aggravate the whole affair. 
 Probably echinacea will be a better remedy, both internally and 
 locally, the system being saturated with it. Lachesis and crolalus hor. 
 would be applicable, also. It is a fact that heroic treatment often 
 aggravates diseases which it is intended to relieve, and this is likely 
 to be one of the instances. 
 
 XXn. HYDROPHOBIA. 
 
 Synonyms. Rabies; Lyssa. 
 
 Definition. Hydrophobia in man is an acute, specific, conta- 
 gious, almost invariably fatal disease, due to an unknown microorgan- 
 ism, and transmitted by some animal, by inoculation. After a period 
 of incubation, there are violent spasms of the muscles of deglutition 
 and respiration; later, general convulsions, great prostration, and 
 finally ascending paralysis, and death. 
 
 Etiology. The disease is principally noticed in dogs (90%), 
 although it has occurred in cats, wolves, foxes, badgers, martens, 
 hyaenas, jackals, polecats, horses, asses, mules, oxen, and sheep. 
 
 The disease is common in Russia, less so in England and France, 
 and rare in Germany and America.
 
 HYDKOPHOBIA. 261 
 
 It is produced by the bites of animals suffering from rabies, or by 
 accidental inoculation of wounds with their saliva or blood, the lat- 
 ter occurring occasionally iu autopsies of infected animals. The 
 virus may be swallowed, or may come in contact with the unbroken 
 skin, without developing the disease. It retains its vitality some 
 time after the death of the animaL Communication from man to 
 man is defied. The consensus of opinion seems to be against the 
 spontaneous origin of rabies among animals. 
 
 All persons bitten by rabid animals do not contract the disease, 
 the percentage of cases being about 12 to 14 The saliva is often 
 prevented from gaining entrance to the wound by the clothing. In 
 other cases, cauterizing the bite destroys the virus. Efforts to dis- 
 cover the microbe which produces the disease, have thus far failed. 
 
 Pathology. There are no well-defined pathological changes. 
 Rigor mortis is marked, and decomposition sets in early. The blood 
 is thin, and darker than usual. The blood-vessels are more or less 
 congested, excepting those of the heart, spleen, and liver, which 
 are normal, as a rule. The pharynx and fauces are much congested, 
 the same condition being observed in the mucous membrane of the 
 alimentary and respiratory tracts. The brain and spinal cord, with 
 their membranes, are hyperaemic, and considerable oedema is present 
 Scattered throughout the whole central nervous system, but more 
 noticeable in the base of the brain and spinal cord, there are patches 
 of inflammatory deposit. 
 
 Symptoms. The stage of incubation is much longer than in 
 most of the infectious diseases, and usually lasts from two to six 
 weeks; rarely, it is protracted to a year or more. The wound heals, 
 if sufficient time elapses, and the patient's health is about as usual. 
 The length of this stage is influenced by the age of the individual, 
 children manifesting symptoms of rabies sooner than adults. 
 
 From one to three days before the serious symptoms develop, 
 the patient has more or less constitutional disturbance. There is 
 headache, anorexia, insomnia, a feeling of dread and apprehension, 
 and a general hyperaesthesia. The countenance has a look of anxiety, 
 and the pupils are dilated. There may be pain in the region of the 
 wound, with more or less tenderness aud congestion, with occasional 
 suppuration. Frequently, all local symptoms are absent. "We now 
 notice more or less respiratory oppression. There is difficulty in 
 enunciation aud deglutition, caused by muscular spasm, and a sensa- 
 tion of choking about the pharynx. Water is refused, on account of 
 the painful spasmodic condition excited in the throat. There is an 
 abundant secretion of viscid saliva, which cannot be swallowed, and 
 is constantly expectorated.
 
 262 SPECIFIC INFECTIOUS DISEASES. 
 
 Respiratory or pharyngeal phenomena may be the first indication 
 of tin approaching attack, other premonitory symptoms being absent. 
 
 The spasmodic condition at length begms to assume a serious 
 phase, and the patient is excited, not only by attempts to swallow, 
 but the sight of water, or a mere suggestion of drinking, producing a 
 convulsion. General hyperaBsthesia develops to such a degree that 
 loud sounds, an unexpected touch, currents of air, bright lights, or 
 the contact of the bedclothing, is sufficient to initiate a spasm. 
 These seizures last from one- to three-quarters of an hour, and leave 
 the sufferer exhausted. In the intervals, his mind is clear, but he is 
 tortured by apprehension of returning attacks, and anticipations of 
 his terrible sufferings. The convulsive action that was first confined 
 to the respiratory organs, soon becomes general, with periods of hal- 
 lucination and mania, due to excitement and partial asphyxiation. 
 The mouth and fauces are dry, and there is a constant hawking of 
 adhesive mucus and saliva, which are expectorated indiscriminately 
 over the bed and attendants. The pulse, which was at first normal, 
 grows weak and rapid, and the temperature rises, raging from 101 to 
 103 F. This stage of the disease lasts from one to three days, and 
 death may occur from exhaustion or asphyxia. 
 
 Occasionally there are no convulsions, the patient complaining 
 principally of dyspnoea. Some few are enabled to swallow through- 
 out the disease, although considerable pain accompanies deglutition. 
 There is now a gradual transition to the third stage, the stage of 
 paralysis, which lasts from three to eighteen hours. The prostration 
 grows more marked, and there is a diminution of convulsive action. 
 Respiration is much easier, and the spasmodic condition of the laryn- 
 geal muscles is diminished, so that liquids can be swallowed. Rap- 
 idly ascending paralysis commences, and respiratory and cardiac fail- 
 ure closes the scene. 
 
 Diagnosis. After hydrophobia has fully developed, there is no 
 possibility of a mistake in diagnosis. The only diseases that may 
 simulate it are lyssophobia (hydrophobia imaginary), tetanus, and 
 cases of epilepsy or hysteria, where the organs of deglutition are 
 affected. In rabies, the muscles of mastication are not affected, the 
 convulsions are not tonic, and the apnoea is due to spasms of the lar- 
 yngeal muscles and not to those of the chest Hysterical persons 
 sometimes develop symptoms that simulate hydrophobia. They 
 imagine they have the disease, and have paroxysms, in which they 
 refuse to drink, grasp the throat, and manifest more or less violence 
 iu their excitement. There is no elevation of temperature, and the 
 hallucination lasts longer than true rabies. Probably in these cases 
 hypnotic suggestion could be successfully used.
 
 HYDROPHOBIA. 263 
 
 Treatment. The disease once established, death is almost 
 inevitable, and we can only use such methods as will modify the 
 severity of the dying struggle. 
 
 Prophylaxis, therefore, assumes great importance, and all suspi- 
 cious cases should receive prompt attention. The physician is not 
 called, as a rule, until some time after the injury, and the destruction 
 of the lacerated flesh should not be delayed. If chloride of zinc, 
 caustic potash, or concentrated carbolic acid are at hand, the wound 
 should be cauterized, after being carefully washed. If there is likely 
 to be any delay in procuring the cauterizing agent, the flesh that has 
 coma in contact with the teeth should be excised, the knife cutting 
 wide of the wound. It is advisable to apply a cup, and favor hem- 
 orrhage. The actual cautery, while severe, is efficient. The wound 
 should be kept open for at least a month. If there is any doubt 
 about the dog having hydrophobia, it should be kept penned up a 
 sufficient time to develop the disease. When the animal is not mad, 
 the patient may thus be saved weeks of useless apprehension and 
 mental suffering. 
 
 The discovery of preventive inoculation, by Pasteur, created quite 
 a furor, and institutions for the treatment of rabies have been 
 founded in various parts of the Old World. Pasteur found that the 
 virus increased in potency when a number of rabbits were success- 
 ively inoculated, so that when this more virulent product was used, 
 only seven days elapsed before the symptoms of hydrophobia devel- 
 oped, whereas fifteen were required in the primary inoculation. The 
 virus is taken from the spinal cord of the rabbit, and it was discov- 
 ered that it gradually decreased in intensity when the cords were 
 preserved in dry air. A dog was now inoculated with virus twelve 
 or fifteen days old, and the process was repeated with stronger solu- 
 tions, until it was found that he had acquired immunity from the 
 disease, and that the most potent virus had no effect upon him. In 
 his treatment of patients, Pasteur used virus of greater intensity 
 011 successive days, and claimed to be able to abort the disease when 
 the patient was seen early enough. Much doubt exists, however, 
 with regard to the efficacy of Pasteur's methods. 
 
 In former times, the unfortunate who developed rabies was 
 smothered between two mattresses; and, although the practice seems 
 barbarous, it was undoubtedly humane. 
 
 All treatment fails to check the course of the disease, so our 
 attention is directed toward alleviating the suffering of the patient. 
 Ha should be removed, by his attendants, to a dark room. Chloro- 
 form anaesthesia, an I narcosis by hypodermic injection of morphine, 
 are carried to extreme length, all milder agents being discarded as
 
 264 SPECIFIC INFECTIOUS DISEASES. 
 
 useless. Cocaine, applied to the throat, will diminish the hyperses- 
 thesia, and permit of liquids being taken. Death occurs in from two 
 to ten days. lu rare cases, patients may survive for three weeks. 
 Curare, amyl nitrite, and nitro-glycerine, recommended in the article 
 on tetanus, may be tried, but reported cures are open to suspicion. 
 
 Professor Goss asserts that echinacea exerts a prophylactic influ- 
 ence, when administered steadily after the period of inoculation, in 
 fifteen- or twenty-drop doses, repeated four or five times daily. 
 
 Cures have been reported from the inhalation of oxygen gas, after 
 the spasmodic symptoms have appeared. 
 
 XXIII. TETANUS. 
 
 Synonyms. Lock-jaw ; Trismus. 
 
 Definition. Tetanus is an acute or chronic infectious disease, 
 characterized by a progressive tonic spasm of the voluntary muscles, 
 with paroxysmal exacerbations, resulting, as a rule, in death. It 
 may occur in epidemic form among the wounded, in times of war, or 
 in children, in lying-in hospitals. 
 
 Pathology. Where pathological lesions are present, they are 
 secondary, and dependent on the excessive muscular spasm, the pri- 
 mary disturbance being reflex and functional. Occasionally the 
 nerves supplying the affected parts show inflammatory changes. 
 The spinal cord and medulla are at times hypersermic, and there may 
 be effusions and more or less extravasation. 
 
 Etiology. Tetanus is due to the bacillus tetani, which gains an 
 entrance into the body through a traumatism. The old division of 
 the disease into traumatic and idiopathic tetanus 
 is questioned by modern authorities, and all 
 cases are believed to be due to an injury of some 
 character. 
 
 The baviUus tetani is short and straight, with 
 an enlargement at one end, due to sporulation. 
 Several ptomaines are derived from it, and it is 
 believed that the irritation of the nervous sys- 
 tem is mainly due to their presence, as but few of the bacilli are to 
 be seen in the body. The spores are to be found in manure, garden 
 soil, decomposing liquids, masonry, and the dust of streets. It is 
 anaerobic. 
 
 Tetanus may follow injuries of most any kind, such as wounds, 
 burns, fractures, or dislocations. It has occurred after abortion, and 
 normal labor. Surgical operations, such as the ligation of piles, 
 amputations, castration, or even the passage of uterine sounds, have
 
 TETANls 265 
 
 been followed by lock-jaw. In infants, the bacilli gain an entrance 
 through the navel. 
 
 A rare case has been reported, where the disease was due to an 
 accumulation of bird-shot in the appendix vermiformis. Where teta- 
 nus follows a simple fracture or dislocation, the disease is supposed 
 to be due to internal infection. Telluric conditions are believed to 
 have much to do with the development of tetanus. It is more fre- 
 quently met with in hot climates. It has been frequently noticed 
 that, after battles, sudden changes of temperature have been fol- 
 lowed by the development of many cases of this disease among the 
 wounded. While no age or sex is exempt, adult males furnish the 
 greater number of cases. 
 
 Symptoms. The stage of incubation is variable in length, but 
 it generally lasts about a week. 
 
 The patient first notices a stiffness in the neck and lower jaw, 
 and ia apt to attribute it to a cold. As the symptoms become more 
 noticable, there is difficulty in mastication and deglutition, and these 
 acts are attended witli more or less pain. The lower jaw becomes 
 fixed, as the depressors are unable to overcome the spastic contrac- 
 tion of the temporal and masseter muscles. The face becomes dis- 
 torted, the muscles of expression contracting, and producing the 
 characteristic risus sardonicus. The spasmodic condition gradually 
 involves the other groups of muscles, the wrists and fingers being 
 the only parts of the body not sharing in the general and gradually 
 increasing contraction. The trunk becomes rigid, and, on movement 
 of the diaphragm, a severe pain passes from the ensiform cartilage 
 through the body, accompanied by a distressing dyspnoea. The 
 lower extremities are in most cases in a line with the body, the head 
 is drawn back and fixed, and the arms either parallel with the truuk 
 or drawn across the chest. The abdomen is is hard and broad. In 
 general, the powerful muscles of the back and limbs bind the body 
 i;i the form of a bow, and, during exacerbation, the patient rests upon 
 the occiput and heels. This position is termed "opisthotonos." 
 More rarely the spiue is bent forward and the head comes in con- 
 t.-ict with the knees, a condition of "emprosthotouos." Still more 
 uncommon is "pleurosthotonos," the muscles of one side of the body 
 giving a lateral curvature to the spinal column. The muscular 
 spasm is continuous, but there are paroxysmal exaggerations, so 
 severe as to, in some cases, project the patient from bed. These 
 convulsive seizures have been known to fracture a bone or rupture 
 a muscle. They are excited by attempt at muscular action, or are 
 spontaneous. Soon, however, sudden noises or any disturbance will 
 produce them, and the patient lies in constant fear of another seizure.
 
 266 SPECIFIC INFECTIOUS DISEASES. 
 
 During the interval when the cramping pain ceases, there is sore- 
 ness and aching in the muscles. The bowels are almost always 
 constipated. Frequently, contraction of the sphincter muscle of the 
 bladder causes retention of urine. Here priapism will often be 
 noticed. The body is wet with a profuse perspiration. The mind 
 remains unclouded, and the patient retains his faculties to the List. 
 As the result of the excessive muscular contraction, the pulse and 
 temperature are more or less affected. Frequently, just before 
 death, the temperature rises as high as 114 F. As food cannot be 
 taken, and rest is impossible, exhaustion begins early, the patient 
 lasting only two or three days. Respiration is greatly embarrassed 
 during the spasms, and death often occurs from apncea. 
 
 CHRONIC TETANUS: TETANUS MITIS. In chronic tetanus there is 
 a much longer period of incubation. Barely, an acute attack may 
 assume a chronic type, and, if so, there is a possibility of recovery. 
 In tetanus mitis, the muscular involvement is extensive, but there 
 are intervals when there is a partial cessation of the spasm. In 
 favorable cases, these, growing longer, permit of the patient's obtain- 
 ing some rest. Some few of these cases recover. A mild form of 
 tetanus, where the muscles of the neck and face are alone involved, 
 is termed "trismus." 
 
 Diagnosis. From cerebral or cerebro-spinal inflammation, by 
 there being no coma or delirium, and the absence of fever during the 
 intervals of the attacks. 
 
 In strychnia poisoning, consciousness is lost, the muscles of the 
 neck, head, and jaw are not primarily affected, there is retinal hyper- 
 sesthesia, and objects look green. The vomitus, when analyzed, will 
 give the strychnia reaction. Hj r steria or epilepsy may slightly 
 resemble tetanus, but only during its earlier stages. In its milder 
 forms, it has been mistaken for rheumatic inflammation of the jaws. 
 
 Prognosis. The prognosis is grave, especially in wounds 
 received in battle. Chronic cases occasionally recover. After the 
 fifth day, there is a fighting chance, and when the patient passes the 
 twelfth day, the prognosis is quite hopeful. The disease is invaria- 
 bly fatal in the very young, where the period of incubation is short, 
 and when rigidity begins early. 
 
 Treatment. PROPHYLAXIS. All suspicious injuries should be 
 disinfected. Where the wound has become foul, or when it has been 
 produced by some dirty object, especial care should be taken to ren- 
 der it aseptic. Foreign bodies should be sought for if there is a 
 possibility of their having found lodgment in the tissues. In epi- 
 demics, all cases should be isolated. 
 
 MANAGEMENT. As in rabies, the patient should be placed in a
 
 TETANUS. 267 
 
 darkened room, and kept absolutely quiet. All noises, and everything 
 of a disquieting nature, should be prevented. Chloroform is admin- 
 istered by inhalation, frequently. Chloral by rectum, and morphine 
 subcutaneously, are administered in large doses, milder acting drugs 
 being useless. Potassium bromide, ji every three hours, is highly rec- 
 ommended. It may be combined with the chloral. The rigidity of 
 the muscles may be partially overcome by deep hypodermic injec- 
 tions of atropine. Amyl nitrite and ghnoin, theoretically, should help 
 to relieve the spasm, and have been used more or less successfully, in 
 tetanus. As we desire to disturb the patient as little as possible, 
 remedies that may be administered by inhalation, subcutaneously, or 
 by rectum, are of prime importance. Curare, being a motor paral- 
 yzer, is indicated, and may be pushed to its full physiological influ- 
 ence. Of the crude drug, we may administer from gr. l-20th to l-5th. 
 Curarine may be used hypodermically, in doses of from l-200th to 
 1-lOOth of a grain. 
 
 A valuable remedy, and one which may be obtained almost any- 
 where, is tobacco. The officinal infusion (31 Oi) may be given by 
 enema, fiv being the maximum dose. In administering, we regulate 
 the dose and time of repetition by the effects produced. It should 
 be used cautiously. It is absorbed very rapidly by the stomach, 
 the alkaloid being given in minute doses. If desirable to adminis- 
 ter hypodermically, the following formula may be used: B Nico- 
 tine gr. ss., aqua dest. jii. M. Sig. l-24th gr. 
 
 Hale asserts that passiflora incarnata is a cure. It is probably 
 not superior to gelseinium and scutellaria, which, while of benefit 
 in trismus, fails in tetanus. Where there is retention of urine, the 
 catheter should be used. Highly nutritious foods should be given, 
 either through a stomach tube or by enemata. Success has been 
 reported with injections of the tetanus anti-toxin of Tizzoni and 
 Cattaui. 
 
 But we cannot expect to cure tetanus with specifics in many 
 instances. When the period of incubation is long-continued, as fre- 
 quently occurs, we will find that the general system has taken on a 
 septic condition, which must be corrected before anti-spasmodics will 
 afford much satisfaction. Each individual case will require careful 
 analysis, and where the best anti-spasmodic may fail, the properly 
 directed antiseptic treatment may promise much. I have in recollec- 
 tion a severe case of trismus, which occurred years ago, that seemed 
 to be rapidly passing into a hopeless stage, in the hands of an allo- 
 pathic physician, which rapidly improved, and nearly recovered 
 within a week, when alcoholic vapor baths were administered every 
 twenty-four hours, and their action aided by the internal administra-
 
 268 
 
 SPECIFIC INFECTIOUS DISEASES. 
 
 tion of sulphite of sodium and baptisia, the former drug being promi- 
 nently indicated by the pasty-white coating ou the tongue. 
 
 In malarial regions, periodicity may be a marked feature of the 
 disease, the spasms becoming violent during the exacerbations, and 
 almost, or quite, disappearing during the remissions. Here we must 
 exhibit quinine, in antiperiodic doses, promptly, if we are to expect 
 benefit from other treatment 
 
 The physlo-medicalists expect the steam bath to accomplish much 
 toward a cure, and this, aided by such relaxauts as lobelia, scutettaria, 
 gelsemium, etc., constitutes a very effective means of treatment, these 
 practitioners being very successful here. 
 
 Aplopafypus laricifolius, if the fresh plant can be obtained, is an 
 excellent remedy, though whether much can be done with a tincture 
 without a fomentation of the plant to the affected part, remains to be 
 proven by experience. From experience with it in veterinary prac- 
 tice, upon my own carriage horse, I am not favorably impressed 
 with it. 
 
 XXIV. ACUTE GENERAL TUBERCULOSIS. 
 
 Synonyms. Acute Miliary Tuberculosis; Typhoid Tubercu- 
 losis. 
 
 Definition. An acute, infectious disease, most common to the 
 period of puberty, characterized by the rapid dissemination of tuber- 
 cles throughout the entire body by auto-infection, the tubercles 
 being iisually concentrated in some vulnerable portion, such as the 
 lungs, the mesenteric glands, or the meninges, with almost invariably 
 rapid and fatal termination. 
 
 Etiology. An understanding of the etiology of this disease 
 necessitates a study of that of tuberculosis in general, as acute gen- 
 eral tuberculosis is but a variety of a disease which manifests itself 
 in various phases. For many years the study of tubercle has been 
 attended by much obscurity and dissatisfaction. The doctrine was 
 long adhered to that tubercular deposit was a result of inflammatory 
 action, it being due to some peculiar predisposition of the system 
 to a dyscrasia. This idea has, in recent years, been well proven a 
 fallacy, and the individuality of the disease its tangible identity 
 pointed out. Tubercle is now believed, by modern pathologists, to 
 arise from the destructive action of the tubercle bacillus, a parasitic 
 microorganism, the discovery of which was announced by Koch, in 
 1882. 
 
 The tubercle bacittus is a slender rod, which is about one-third the 
 diameter of a red blood-corpuscle in length, and about five times as 
 long as broad. It may be straight or slightly curved, as seen under
 
 ACUTE GENERAL TUBERCULOSIS. 
 
 269 
 
 the microscope, uniform in appearance throughout, except that cer- 
 tain individuals exhibit from 
 four to six highly refractive 
 spherical spaces along the body, 
 regular intervals, which are 
 supposed to represent spores. 
 These seem to be particularly 
 numerous when tubercular dis- 
 ease is developing rapidly, 
 while in cases which are quies- 
 cent, or retrograding, the spores 
 are absent. The bacilli mani- 
 fest a remarkable resistance to 
 destructive agencies, and retain 
 
 r*f -"** * ** their vitality almost indefinitely, 
 
 even resisting the bleaching 
 action of acids, when once stained in the bacteriological laboratory. 
 Bacilli may supposedly be expectorated in tuberculous material, 
 and become a part of the common dust, by desiccation and exposure, 
 to afterward enter the lungs of uncontaminated individuals through 
 inspiration, during a disturbance in the atmosphere, and produce 
 fatal infection, provided the subjects are susceptible. 
 
 It is not difficult to explain many of the seeming inconsistencies 
 of the theory of the bacillus-origin of tuberculosis. It has long been 
 a recognized theory that the disease, or predisposition to it, is hered- 
 itary. This doctrine need not be greatly disturbed by the new 
 pathology. Some individuals seem remarkably susceptible to the 
 disease, while others seem proof against it, and this receptivity tends 
 to run in families, though not so confined, by any means. A con- 
 sumptive wife may infect her husband, while perishing from the dis- 
 ease, and vice versa, the activity of the disease-agency remaining 
 dormant in the second individual for years, to afterward develop an 
 activity fatal to that individual, and, possibly, to others intimately 
 associated. People thrown much together are liable to communicate 
 it to one another. Houses in which consumptive families have 
 resided, seem to retain the infection for years, and those of the most 
 perfect physique may develop the disease from occupying them 
 afterward, thoiigh they may remain the hosts of the bacilli for years 
 before active disease becomes manifest. Public institutions, especi- 
 ally penitentiaries, where close confinement is the rule, seem to breed 
 the infection. It is a notorious fact that tuberculosis is very com- 
 mon in these institutions, and that the most robust and hardy con-
 
 270 SPECIFIC INFECTIOUS DISEASES. 
 
 atitutions succumb to it after a few years* confinement, where it has 
 been breeding for a long time. The disease has even been conveyed 
 from a consumptive mother, through the placenta, to the child in 
 utero. 
 
 Diet is not an uncommon source of contamination. The tuber- 
 cle bacillus thrives in other animals than man, especially in boviiies. 
 Cow's milk may therefore be contaminated from within, and may 
 become a prolific source of the disease. The custom which has pre- 
 vailed within the past years so largely of raising children on con- 
 densed milk, has doubtless much to do with the presence of miliary 
 tuberculosis at the period of adolescence, the activities which ure 
 then aroused in the orgauism assisting in the rapid distribution of 
 the bacilli and their speedy destructive action. Doubtless there are 
 some who resist the infection when exposed, and escape altogether, 
 while others may become hosts of the parasites and resist them suf- 
 ficiently to reach adult life, before some predisposing accident places 
 the coustitution in a sufficiently depraved condition for the bacilli to 
 accomplish their ravagea 
 
 Pathology. In acute miliary tuberculosis, the bacilli may be 
 distributed from any center where they first become lodged, through 
 the lymphatics, veins, and even the arteries, becoming disseminated 
 through all the tissues of the body, except, perhaps, those of the 
 salivary glands and pancreas (though it is now asserted that the 
 last-named organ is not exempt). 
 
 The lungs are most frequently and largely involved, then the 
 liver, intestines, kidneys, spleen, pia mater, peritoneum, pleura, dura 
 mater, and brain. Deposits are more rarely and sparsely distributed 
 in the thyroid gland, suprarenal bodies, female genitals, striped mus- 
 cles, and stomach. 
 
 When the lungs are infiltrated, the condition is easily recognized 
 by the eye upon autopsy. The organs are filled with little gray 
 transparent nodules of varying size, some being so small as to be 
 hardly noticeable, while others are of the size of a pin's head, or a 
 millet seed. If a portion of the lung be taken between the finger 
 and thumb, it imparts a hardened, shotty sensation, and, if the lung 
 be sliced, lumpy elevations, corresponding with these bodies, may be 
 observed upon the freshened surface. They are usually transparent, 
 though some of them may have an opaque center, suggesting the 
 commencement of gaseous changes. Inflammatory changes are also 
 more or less marked in the lung tissues, such as oedema, catarrh of 
 the mucous membrane, plastic exudation, etc. The pleura may be 
 involved, and found to be the seat of more or less tubercular deposit, 
 as well as of former inflammatory action. Sometimes the tuberculi-
 
 ACUTE GENERAL TUBERCULOSIS. 271 
 
 t 
 
 zation is confined to a portion (as a single lobe) of the lung. The 
 liver and spleen present similar appearances when notably affected, 
 the tubercles being quite evenly distributed through the organs, and 
 showing a slight tendency to coalesce. 
 
 Tubercles show a strong tendency to caseation, in most instances, 
 but this disease runs its course so rapidly that little change in this 
 direction occurs. In all fresh tubercles, bacilli are found upon 
 microscopic examination, but the sputum does not contain these 
 microorganisms in this affection, as they do not break down before 
 death. When the tubercle has gone on to necrosis and caseation, 
 they are not so abundant, only the spores remaining in the cheesy 
 detritus. 
 
 Symptoms. A prominent symptom is fever, usually ushered 
 in with a chill, or a succession of chills. The fever is irregular, the 
 temperature running from 102 to 104, the skin being hot and pun- 
 gent, sometimes dry, and sometimes bathed in a sticky perspiration, 
 the pulse being remarkably feeble and rapid, the tongue pointed, and 
 reddened at the tip and edges, or dry, brown, and fissured, the urine 
 scanty and high colored and the bowels constipated, unless there is 
 intestinal irritation. 
 
 Soon there is a hectic flush on the cheek, the skin becomes trans- 
 parent, with prominent, superficial veins; rapid emaciation follows, 
 with extreme prostration. Cutaneous eruptions, such as sudamina, 
 roseolous rash on the chest and abdomen, and herpes labialis, are 
 not infrequent accompaniments. 
 
 A remarkable feature of most cases is the pulmonary irritation, 
 manifested by dry, hacking cough, with succeeding expectoration, 
 muco-purulent, at first, and, later, sanguinous in character. With 
 these symptoms are remarkable increase in the number of respira- 
 tions (50 or 60 to the minute) with dyspnoea, and cyanotic expres- 
 sion of countenance. Sibilant and subcrepitant rales now abound, 
 and areas of dullness, with bronchial breathing, are found later on. 
 
 When the meninges are principally affected, there is intense 
 headache, photophobia, extreme restlessness, delirium, facial palsies, 
 stupor, convulsions, coma, and Cheyene-Stokes breathing. Tuber- 
 cles may occur upon the retina, with attending visual defects. 
 
 When the intestine and peritoneum are the principal points of 
 deposit of the tubercles, there are pain, tenderness, abdominal full- 
 ness, diarrhoea, and, often, gastric irritability. 
 
 The disease may last five or six weeks, though it usually termi- 
 nates fatally in from two to four. Death most frequently results 
 from pulmonary oedema and asphyxia, or cerebral amemia and col- 
 lapse, though when the meninges are largely involved, convulsions, 
 paralysis, or coma, may terminate the scene.
 
 272 SPECIFIC INFECTIOUS DISEASES. 
 
 Diagnosis. The irregular fever, the marked local symptoms, 
 usually of pulmouary origin, the absence of epistaxis (a common 
 symptom in the early part of typhoid fever) and markedly rapid res- 
 piration, with cyanotic symptoms, will distinguish this disease from 
 typhoid fever, which it resembles somewhat, in its superficial aspects. 
 It also resembles cerebro-spinal fever when the tubercles involve 
 the meninges and brain, in some respects, though it runs a more rapid 
 course than the slow form of that disease, and is not attended by 
 the tonic spasms which mark the active form. 
 
 Prognosis. The prognosis is almost invariably fatal. All that 
 can be expected of treatment is to palliate the most unpleasant 
 symptoms, and render the last hours of the patient as endurable as 
 possible. 
 
 Treatment. This must be unsatisfactory, at best There must 
 necessarily be a steady progress from bad to worse, and the treat- 
 ment which may succeed in palliating to-day, will naturally lose its 
 effect to-morrow, seeing that the disease is steadily progressing 
 toward a fatal termination, and that the structural changes are con- 
 tinually more and more aggravated. However, we may lessen the 
 severity of some of the unpleasant symptoms, and do this in the 
 beginning without the use of opiates to any great extent, though 
 toward the close of the disease opiates are about all that will afford 
 any relief from the cough and other unpleasant symptoms. 
 
 Gastric irritation will be a common cause of complaint, nausea 
 and disgust for food, being a common feature. To relieve this, as 
 well as to control the fever and restlessness, a combination of aco- 
 nite and rhus tox. will be found excellent. Add five drops of aconite 
 ( Lloyd's or Worden's ) and ten or fifteen drops of a saturated tinc- 
 ture of fresh rhus tox. leaves to half a glass of water, and give a tea- 
 spoonful every hour. This excellent prescription will render good 
 service for a long time, and even throughout the disease, lessening 
 the fever, quietiug nervous erythism, and alleviating pulmonary irri- 
 tation, to considerable extent 
 
 The lungs will usually demand something positively soothing, to 
 lessen the tendency to continual hacking cough. It is best to avoid 
 morphine internally here as long as possible, and the following pre- 
 scription, used in the form of a spray, by inhalation, will serve a good 
 purpose, for a time, at least. & Essence of peppermint ji, aqua ?i, 
 morphia sul. gr. i, glycerine 31, carbolic acid gtt. xv. Mix, and use 
 as often as required, three or four inhalations of the vapor being 
 taken at a time. 
 
 Sometimes antifebrin will be excellent, to lessen the fever and 
 soothe the pulmonary irritation, and there can be no objection to its
 
 ACUTE GENERAL TUBERCULOSIS. 273 
 
 use here, as there can be no danger of after-effects, seeing that the 
 case is hopeless at any rate. When these measures fail, the internal 
 administration of morphine may be begun, to quiet unpleasant symp- 
 toms. Codeine is often preferable to morphine in alleviating cough 
 and other unpleasant features, as it interferes less with the secre- 
 tions, and is less irritating to the nervous system. It may be admin- 
 istered in syrup, in doses of from l-4th grain to 2 grains. 
 
 To assist in alleviating the pungent heat of the surface and pro- 
 moting rest, as well as to restrain the colliquative sweats which are 
 liable to be present, a cool solution of citric acid, ji to the pint of 
 water, may be used to sponge the surface, once or twice a day. 
 
 Stimulants, such as quinine, or whisky, should be avoided, as 
 they can but increase the discomfort of the patient. Only sufficient 
 food to supply the demands of hunger should be given, and plenty 
 of cold water (as this will usually be craved) may be allowed, though 
 iced water, when taken too freely, is liable to provoke abdominal 
 pain. 
 
 During the last few days, it may be necessary to administer opi- 
 ates freely, to control the cough and lessen the restlessness. Abdom- 
 inal pain may demand colocynth, dioscorea, or nux, and diarrhoea may 
 call for bismuth and morphine, in appropriate doses. 
 
 XXV. SYPHILIS. 
 
 Synonyms. Pox; Lues Venerea. 
 
 Definition. A specific, contagious disease, of venereal origin, 
 of slow development and chronic course, which may be congenital 
 or acquired, manifesting itself, when inoculated, by a series of path- 
 ological changes, which usually occur in regular order, as follows : 
 First, a special tissue-change at the point of introduction, occurring 
 from twenty-one to twenty-five days after inoculation (primary syph- 
 ilis) ; second, constitutional symptoms, which develop within two or 
 three months afterward, characterized by fever, cutaneous eruptions, 
 irritation and ulceration of the mucous membranes, especially that 
 of the pharynx (secondary syphilis); and third, granulomatous 
 growths, which develop three, four, or five years afterward, affecting 
 the muscles, bones, and skin (tertiary syphilis). 
 
 Historical Note. Though doubtless a disease of greater antiq- 
 mty, general attention was not called to syphilis as a peculiar and 
 formidable disease, until the year 1494, when it occurred as an epi- 
 demic, among the troops of the French king, Charles VIII, who was 
 then besieging Naples. From here, it seemed to spread all over 
 Europe, and contemporary medical writers of various nations styled
 
 274 SPECIFIC INFECTIOUS DISEASES. 
 
 it, according to caprice and prejudice, the "French disease;" the 
 "Neapolitan disease;" the "Spanish disease;" the "German disease," 
 etc. As this outbreak was contemporary with the return of Colum- 
 bus' sailors from the voyage of American discovery, a popular belief 
 arose that the malady had been transmited from the American 
 Indians. It soon became apparent that the disease originated from 
 sexual intercourse, and that crowded quarters, promiscuous and 
 excessive indulgence, and indifference to slight venereal abrasions, 
 promoted the spread of the affection in virulent form ; and it is not 
 unlikely that these circumstances favored its rapid spread and 
 alarming prevalence, in Charles' army. 
 
 For nearly three centuries afterward, the profession universally 
 confounded all forms of venereal disease with syphilis, and consid- 
 ered them of common origin. In 1767, Balfour declared that gon- 
 orrhoea was a separate disease, distinct from other forms of venereal 
 disorder, and a local affection. These views were combated by the 
 profession generally, however, and it was nearly thirty years later 
 (1793) before another writer of distinction (Benjamin Bell) espoused 
 this doctrine. Still the profession stood aloof from such views, and 
 it finally remained for Eicord, thirty-eight years later (1831), to 
 reiterate them, and convert the profession generally to their accept- 
 ance. Bicord, however, left chancroid and syphilis confounded, and 
 it has only been within the past twenty years that the true distinc- 
 tions, which enable us to classify the latter affection, have been fully 
 established. 
 
 Etiology. Doubtless syphilis is due to the presence of a spe- 
 cific germ, which causes all the pathological manifestations where 
 mercury does not aggravate its action. Several observers, notably 
 Lustgarten, have observed bacilli in the secretions and morbid prod- 
 ucts of syphilitics, resembling the smegma bacillus, which they 
 believe to be the active principle of the disease. Lustgarten always 
 found them inclosed in round cells, probably the micrococci of other 
 observers. Farther study, however, seems necessary to firmly 
 establish the identity of the microorganism of syphilis. 
 
 While contagious through inoculation among human beings, many 
 assert that the disease is not communicable to the lower animals, 
 others claiming that apes and monkeys are susceptible. One attack 
 affords immunity from subsequent ones generally, and a mother who 
 has borne a syphilitic infant seems protected from it, even though 
 she may not manifest any evidence of having been affected as a 
 result, the suckling and handling of syphilitic offspring producing no 
 ill effect, while other wet nurses are readily contaminated. 
 
 Acquired syphilis is the result of inoculation with the blood or
 
 SYPHILIS. 275 
 
 morbid discharges of a person who has been comparatively recently 
 syphilized. The longer the disease remains in the system, the less 
 liability of contamination remains, as a general rule, though it may 
 be communicated many years after the primary symptoms have dis- 
 appeared, and healthy children may be begotten by parents recently 
 syphilized. In from three to five years, however, the liability is 
 almost entirely removed. 
 
 While inoculation is usually the result of impure sexual inter- 
 course, there are many other avenues through which accidental 
 infection may take place. The barber may transmit it with hig 
 combs, brushes, or razors; the dentist, with his lances or forceps; 
 the physician, with his hypodermic syringe or thermometer; the sur- 
 geon, with his scalpel or other instrument; the gynaecologist, with 
 his speculums, sounds, forceps, etc., and parturient women may 
 infect the fingers and hands of midwives. Community drinking 
 cups may become contaminated; kissing may communicate it; bes- 
 tial practices often result in the communication of the disease to the 
 lips and tongue, and, probably, insects and other pests, such as fleas, 
 mosquitoes, etc., may convey it from one person to another. 
 Humanized vaccine virus is quite an efficient means for the convey- 
 ance of syphilis, and, as the disease has thus been frequently spread 
 by it, little use is made of humanized virus, though it is much more 
 successful in transmitting kine-pox than virus from the bovine. 
 
 Hereditary transmission may be referred to either or both parents. 
 Usually, a syphilitic husband or wife will infect the other parent 
 before conception takes place, and it will be difficult to decide 
 whether the child is syphilized through the sperm, or through the 
 ovum. However, the male parent may impart the disease to the 
 ovum without contaminating the mother, and the child be born 
 syphilitic, while the only apparent influence exerted upon the mother 
 may be that of rendering her immune against infection. Or, the 
 mother may become infected, and the child may or may not be con- 
 taminated through the placenta. 
 
 General Pathology. The primary sore (chancre) of syphilis 
 is surrounded by a diffused infiltration of the connective tissue with 
 small round epithelioid and giant cells, among which are found the 
 bacilli of Lustgarten. Thickening of the intima of the small arter- 
 ies, and alterations in the nerve-fibers distributed to the part, also 
 occur. Hyperplasia and induration of the neighboring lymph-glands 
 are associated with this condition. When the chancre is mixed 
 with the virus of chancroid, rapid breaking down of these tissues 
 occurs, the edges of the ulcer thus formed becoming raised and 
 indurated, as the time for primary development arrives.
 
 276 SPECIFIC INFECTIOUS DISEASES. 
 
 The lesions of secondary syphilis are many and diversified. There 
 are ulceration of the fauces and irritation of the laryngeal mucous 
 membrane (especially when mercury has been administered to excess), 
 eruptions of various kinds on the skin, condylomata about the gen- 
 itals, iritis and other eye affections, etc., these being attended, dur- 
 ing the first two or three months, by protracted fever. 
 
 Tertiary syphilis is marked by syphilomata (gummata), which 
 develop in the bones, periosteum (nodes), skin, muscles, lungs, 
 liver, kidneys, brain, heart, testes, and adrenals. They differ in 
 size, varying from very minute bodies, almost microscopic, to large, 
 solid tumors, an inch or more in diameter, these being hard and 
 resisting, except when they are located in the skin or mucous 
 membranes; when breaking down, rapid ulceration may attend. 
 Histologically, they consist of granulomatous tissue, resembling 
 tubercle, a cross-section affording a grayish- white, homogeneous 
 appearance, consisting of a periphery of translucent, fibrous tissue, 
 with a firm, caseous center. Dense, sclerotic tissue may envelop 
 clusters of three or more of these bodies. As few blood-vessels are 
 supplied to these bodies, there is a constant tendency to breaking 
 down of the central portion, by coagulation necrosis and the forma- 
 tion of fibro-caseous material, while progressive fibrous growth 
 occurs at the periphery. Absorption of the caseous material may 
 ultimately result, a fibrous scar remaining. 
 
 ACQUIRED SYPHILIS. 
 
 Pathology and Symptoms. The .period of incubation varies 
 from two to six weeks, though it usually lasts about four. Dur- 
 ing this time there are no symptoms, unless there be the complica- 
 tion of gonorrhoea or soft chancre, these diseases then taking their 
 accustomed course, until the syphilitic infiltration begins at the 
 point of inoculation. 
 
 INVASION. The primary sore of acquired syphilis usually begins 
 as a small pimple (papule), appearing upon an indurated base, about 
 the fourth week after inoculation. This may slowly increase in size, 
 for from two to four weeks, and then mildly ulcerate, over a small 
 surface in the center. Or, the papule may begin to ulcerate at once, 
 and assume the character of an indolent ulcer. In complicated 
 cases, the primary sore is painless and insignificant, and causes lit- 
 tle trouble, unless aggravated by heroic treatment, compressed 
 beneath the prepuce, or irritated by chafing. Unless it be mixed 
 with the virus of chancroid, it slowly passes through a protracted 
 stage of mild ulceration for several weeks, without spreading, and 
 then disappears, leaving, at its site, an indurated and reddened spot.
 
 SYPHILIS. 277 
 
 In from eight to fourteen days after the appearance of the pri- 
 mary sore, painless enlargement of the lymphatic glands begins, those 
 traversed by lymphatics arising from the affected spot being first 
 involved, the enlargement and induration gradually extending to the 
 entire lymphatic system. The enlargement is not accompanied by 
 active inflammatory symptoms, and suppuration never occurs, unless 
 the syphilitic infection is complicated with secondary pus infection, 
 an accident not liable to attend uncomplicated syphilis. When the 
 genital organs are primarily affected, the glandular enlargement 
 appears first in the inguinal region, in a week or two more the 
 axillary glands become involved, and, in a week or two more, the 
 cervical and occipital. These are now perceptible to the touch, 
 enlarged, and hardened. Should the inoculation be made in a fin- 
 ger or hand, the lymphatic enlargement might be expected to appear 
 first in the axilla of the corresponding side, in such instances the 
 glands nearest the infected spot being first affected. Sometimes the 
 lymphatics themselves are enlarged, feeling, under the finger, like 
 hardened cords. 
 
 Secondary symptoms develop, from the sixth to the twelfth week 
 after the appearance of the primary sore. These vary in constancy 
 of order, though fever is often an early symptom. When this occurs, 
 the temperature is not usually high, it varying from 101 to 103 F., 
 though it occasionally reaches 104 or 105. This is attended by 
 headache, loss of appetite, muscular pain, insomnia, emaciation, and 
 anaemia. 
 
 Pharyngitis is quite certain to come on early, and is especially 
 severe if the patient has been recently mercurialized, the inflamma- 
 tion then extending to the mouth, and becoming ulcerative in char- 
 acter, both in the mouth and throat. The irritation is also liable to 
 extend to the larynx, laryngeal cough and aphonia attending. Some- 
 times the ulceration is deep and extensive, rendering deglutition 
 painful, and giving rise to much other local unpleasantness. Often 
 the stomatitis involves the lips, stubborn, indurated fissures remain- 
 ing here for months. Aggravated symptoms of this character are 
 almost always due to the action of mercury, and seldom if ever 
 appear, if this drug is avoided from the start. 
 
 About the eighth week, a macular eruption appears upon the 
 abdomen, and spreads to other regions. It appears on the chest 
 during the ninth week, on the shoulders the tenth, on the arms dur- 
 ing the eleventh, on the forearms the twelfth, and on the hands, dur- 
 ing the thirteenth. It is symmetrical, appearing on both halves of 
 the body simultaneously, and is of a copper color. Papules appear 
 about a month later. A row of these may be situated along the
 
 SPECIFIC INFECTIOUS DISEASES 
 
 margin of the forehead, constituting the Corona Veneris. Pustul>-* 
 may now appear, these being rarely seen however before the fourth 
 month. They may be small and hard, feeling "shotty" under pres- 
 sure, like the eruption of small-pox, or large, like the eruption of 
 impetigo. They may ulcerate, and become covered by rupial crusts. 
 Still later, a squamous eruption may appear, resembling psoriasis, and 
 often termed "syphilitic psoriasis." This form appears most com- 
 monly on the palms of the hands, and soles of the feet. 
 
 It will thus be observed that the eruption of syphilis is poly- 
 morphous, none of the forms being distinctive of this particular dis- 
 ease, though the polymorphous character is peculiar to the develo} - 
 ment of syphilis. When the eruption invades mucous membranes, 
 mucous patches, warts, and condylomata result. 
 
 Syphilitic eruptions are not usually painful, or sensitive. They 
 are slow of development, and resisting to the influence of treatment, 
 months being occupied in producing an impression on them with 
 internal remedies, or local applications. 
 
 ALopcscia and iritis frequently occur, as symptoms of the second- 
 ary stage, especially in badly treated cases. 
 
 Tertiary syphilis, it is believed by many, is the result of mercuri- 
 alization, rather than of the disease alone. The condition could not 
 be brought about by mercury alone, and it is doubtful that the dis- 
 ease would reach such a stage without the pernicious influence of 
 that drug. Eclectic physicians, of long-continued and wide experi- 
 ence in venereal diseases, aver that tertiary syphilis never follows, 
 where mercurials are avoided and the patient has been properly 
 treated from the start, with vegetable antisyphilitics. 
 
 The syphilides of this stage are unsymmetrical, and tend to exca- 
 vate the tissues deeply. Bound, deep ulcers occur upon the skin 
 and mucous membranes. Sometimes the ulcerations upon the skin 
 are tubercular and serpiginous, and these are always stubborn and 
 chronic in character. Periosteal nodes appear along the shins, ami 
 these are accompanied by severe nocturnal (osteocopic) pains. Gum- 
 mata, which undergo various degenerative changes at a later period, 
 may develop in the skin, subcutaneous structures, or internal organs. 
 When gummata develop in the viscera, they are liable to undergo 
 fibrous transformation, with subsequent puckering and deformity, 
 thus giving rise to serious obstruction of the function of the part. 
 
 The brain and cord, lungs, liver, digestive tract, circulatory sys- 
 tem, kidneys and testes are all liable to the deposition of syphilitic 
 gummata. 
 
 Gummata in the brain and cord form tumors, varying in size from 
 that of a pea, to that of a Avalnut. They seem to develop from the
 
 SYPHILIS. 279 
 
 meuinges, and are nearly always attached to the dura mater or pia 
 mater. They may occur singly or in masses, and are most frequently 
 developed in the cerebrum. They undergo a variety of changes, 
 such as caseous, fibrous, or cystic degeneration. They do not occur 
 as frequently in the cord as in the brain, though gummatous tumors 
 have been fouud in all regions of this structure. 
 
 The presence of gummata in the brain and cord gives rise, in the 
 early period of their presence, to meningitis, arteritis, and localized 
 foci of sclerosis. Later, as the arteries become occluded, or local areas 
 become debilitated by the meningeal inflammation, softening of the 
 cerebral structures occurs. Or, cerebral hemorrhage may occur 
 as a result of syphilitic arteritis, the weakened vessels giving way. 
 
 Tertiary lesions of this character usually coine on years after the 
 first appearance of the disease, though occasionally they appear 
 within a few months. Psychical disturbances develop early in such 
 cases, and the careful observer soon becomes convinced of structural 
 cerebral disease. Delirium, either abrupt or preceded by headache, 
 giddiness, etc., may appear, or there may be a gradual lapse into a 
 condition of drowsiness and coma, while in other cases paretic 
 dementia is the leading symptom. Convulsions may supervene, epi- 
 leptic seizures sometimes alternating. Sometimes cerebral syphilis 
 displays the symptoms of tumor of the brain. There is inflamma- 
 tion of the optic nerve, with headache, vomiting, convulsions, etc. 
 Sometimes the early symptoms may be abrupt, resembling results 
 of thrombosis or embolism, hemiplegia being the first indication of 
 cerebral disturbance. In other cases, there may be loss of normal 
 power of muscular coordination, the gait being staggering and 
 unsteady, like that of a drunken person. When spinal syphilis 
 occurs, the gummata are attached to the meninges, and imbedded in 
 the substance of the cord. Meningeal inflammation may be provoked 
 by their presence, and this may result in convulsions, or other reflex 
 action. Sclerosis may develop from fibroid changes, locomotor 
 ataxia being the result, or the various symptoms of compression of 
 the cord may arise, from the presence of the morbid growth. 
 
 Syphilis of the lungs is common in the new-born subject of hered- 
 itary syphilis, and in acquired syphilis it occasionally occurs, com- 
 ing on here after the second year. Gummata, varying in size from 
 that of a pea to that of a marble, become deposited throughout the 
 hepatic tissues. When these are numerous, the fibrous changes 
 which occur cause such marked contraction that the organ becomes 
 very much distorted and disfigured, so much so as to sometimes 
 resemble a bunch of grapes. However, sometimes the gummata 
 soften and liquefy instead of undergoing fibrous chauge, the diseased
 
 280 SPECIFIC INFECTIOUS DISEASES. 
 
 organ becoming, where the morbid deposits have been numerous, 
 soft and fluctuating. In some cases, Glisson's capsule may become 
 thickened through the syphilitic influence, perihepatitis and increase 
 of connective tissue giving rise to contraction ;md deformity. In 
 many cases, the symptoms are those of hepatic cirrhosis. There are 
 digestive disturbances, icteric symptoms, slightly marked, emaciation, 
 and ascites. If the ascitic fluid be evacuated, and careful palpation 
 be made over the right hypochondriac region, the marked irritability 
 of the organ will be detected. In other cases, extensive amyloid 
 degeneration of the liver may follow the deposition of the gummata, 
 this involving the spleen and intestinal mucosa also, and there will 
 be anaemia, albuminuria, and anasarca, or ascites. 
 
 In syphilis of the digestive tract, there may be syphilitic deposit in 
 the oesophagus, stomach, small intestine, csBcum, or rectum. When 
 gummata are deposited in the oesophagus, stricture is the result 
 Syphilitic ulceration of the stomach and intestines, as well as of the 
 oesophagus, is rarely met. The common location of intestinal syph- 
 ilis is the rectum, gummata being deposited in the submucosa, above 
 the internal sphincter, the changes which follow giving rise to nar- 
 rowing of the opening, and permanent stricture. These changes are 
 gradual in their enchroachment, sometimes occupying years for the 
 complete development of the rectal stricture. 
 
 Syphilis of the circulatory system may involve the heart or the 
 arteries. A warty endocarditis occasionally occurs in syphilitic sub- 
 jects, and gummata may develop upon the valves, giving rise to 
 various secondary changes, such as fibrous or sclerotic. The myo- 
 cardium may be the seat of gummatous growths also, these caus- 
 ing inflammatory action, and even rupture of the heart-wall. 
 
 The arteries may be occluded through a syphilitic arterio-sclerosis, 
 or so weakened that aneurisms result. In obliterating eudarter- 
 itis, there is proliferation of the subendothelial tissue, the hyper- 
 plasia occurring within the elastic tunics, and enchreaching upon the 
 lumen, until the vessel is closed. This condition is not peculiar to 
 syphilis, however, and not diagnostic of this disease, unless there 
 are gummata in other parts, or there is a confirmatory history of 
 syphilis. When nodular gummata develop in the adventitia, how- 
 ever, there can be no mistake. Globular tumors of varying size 
 appear, especially upon the cerebral arteries, giving rise to inflam- 
 matory action in the surrounding tissues. 
 
 The kidneys are occasionally the seat of gummata, though these 
 are not usually numerous. Cicatrices are found upon post-mortem 
 examination, though there are no clinical symptoms which lead to 
 their detection during life. Possibly in future time the further per-
 
 SYPHILIS. 281 
 
 fection of skiagraphy will enable the practitioner to determine their 
 existence before death. 
 
 The testicles are frequently the seat of gummatous deposits, the 
 growths occurring in indurated masses, in the substance of the organ, 
 and not in the epididymis, as in tubercle. The gland becomes 
 enlarged, but the swelling is painless, and does not tend to degener- 
 ative change. Syphilitic orchitis may arise independently of gummata, 
 a fibroid degeneration, with increase of interstitial elements and 
 gradual contraction of the organ, ensuing. This is a slow and pain- 
 less process, involving one side particularly, it being recollected that 
 tertiary lesions are not symmetrical, as in the case of secondary 
 lesions. 
 
 CONGENITAL SYPHILIS. 
 
 Pathology and Symptoms. Congenital syphilis presents us 
 with all the pathological conditions found in acquired syphilis, except 
 that the primary lesions do not develop. If the disease appear while 
 the child is yet in utero, it may be still-born (or survive a few 
 months), with all the symptoms of bad cases of secondary and ter- 
 tiary syphilis, combined. In still-born children, and even in those 
 born alive, large areas of, and even an entire lung, may be affected 
 with loldte pneumonia of the fcettis, a condition in which the affected 
 part is consolidated, firm, heavy, and airless, presenting, upon section, 
 a grayish- white appearance (white hepatization of Yirchow); and 
 miliary gummata are scattered through the structure. The alveolar 
 walls are here thickened and infiltrated, and the cells are filled with 
 desquamated and swollen epithelium. 
 
 Diffused syphilitic infiltration of the liver is often present. Though 
 the organ preserves its form, it is large, hard, and unyielding to 
 pressure. It is yellowish in appearance, resembling the color of 
 sole-leather, and when cut, foci of infiltration are observable upon 
 microscopical examination (miliary gummata) and connective tissue 
 is found greatly increased in amount. Jaundice is frequently pres- 
 ent, the icterus persisting until a fatal issue follows. 
 
 When the disease exists at birth, the child presents a wasted, 
 wrinkled appearance, the abdomen is abnormally large, and there are 
 cutaneous lesions, especially around the wrists and ankles (bullae), 
 and upon the hands and feet (pemphigus neonatorum). Snuffles ;ire 
 common with syphilitic babies, and fissures in the corners of the 
 mouth aud herpetic eruptions behind the ears, are nearly as common. 
 Ulceration of the lips is often present. The bones are liable to be 
 diseased, separation of the epiphyses usually being present in such 
 cases. 
 
 A syphilitic child maybe born healthy, and thrive, for a few weeks
 
 282 SPECIFIC INFECTIOUS DISEASES. 
 
 before the syphilitic manifestations appear. Between the fourth 
 and eighth weeks, however, irritation in the nasal passages becomes 
 manifest, and persists, in spite of ordinary treatment for congestion 
 of the Schneiderian mucous membrane. There are snuffles and 
 mouth breathing, these being so urgent that the child may be una- 
 ble to nurse. This syphilitic rhinitis becomes progressive, and a 
 catarrhal discharge is soon established, varying from a sero- 
 pus to blood. Ulceration, followed by necrosis of the nasal bones, 
 may take place, unsightly depressions at the root of the nose often 
 resulting. Continuing along the eustachian tube, the middle ear 
 may be involved, destruction of important parts here terminating in 
 permanent deafness. Simultaneously with the development of the 
 suufflas, or soon after, cutaneous eruptions appear, first about the nates, 
 in the form of irregular brown patches, or as eczematous or erythem- 
 atous rashes. Sometimes papular syphilides appear here in the 
 beginning. The mouth is involved early, the lips and tongue pre- 
 senting ulcers and fissures, the child soon communicating the dis- 
 ease to the nipple of the wet-nurse, unless artificially nourished. 
 The disease, in the form of infantile syphilis, is very infectious, not 
 only the wet-nurse but other members of the household becom- 
 ing contaminated, possibly through kissing, or the common use of 
 towels or other toilet articles. The cuticular appendages, such as 
 the hair and nails, are usually affected, the hair and eyebrows fall- 
 out, and onychia developing. Laryugeal irritation becomes mani- 
 fest in many cases, the voice being harsh and high pitched, the cry 
 of the syphilitic child being thus peculiar. The glands are not gen- 
 erally enlarged, as in acquired syphilis, though where cutaneous 
 lesions are severe and deep-seated, neighboring lymphatics may 
 become affected. The liver and spleen are usually enlarged, and hem- 
 orrhages are not uncommon, these issuing from the gums and umbili- 
 cus, or into the subcutaneous tissue, forming hemorrhagic patches 
 beneath the skin. 
 
 Syphilitic children usually perish before the period of infancy 
 has passed, though they may survive, and continife to live through a 
 protracted period of stunted growth. Childish peculiarities persist 
 into years of adolescence. A syphilitic patient at twenty-one may 
 not appear more than ten or twelve years old. If the child seems to 
 have recovered during infancy, the disease is likely to reappear at 
 puberty. Then he may present a wizened, wasted appearance, and 
 a prematurely old look. The skin is sallow, and there are cranial 
 peculiarities, which mark the presence of the disease. The peculiar 
 appearance of such a patient is designated as "infantilism." The 
 forehead projects, the frontal eminences are prominent, and the era-
 
 SYPHILIS. 283 
 
 nium is asymmetrical. The Hutchinson teeth are present, these 
 being characterized by a notched condition of the cutting edge of 
 the middle incisors, which are peg-shaped narrower at the extrem- 
 ities than at the gums. The bridge of the nose is sunken, and the tip 
 is turned up (pug-nose). About the period of puberty, eye aud ear 
 affections are liable to develop. Of eye affections, keratitis and iri- 
 tis are most common. The keratitis is interstitial, the cornea pre- 
 senting a steamy appearance, sometimes one and sometimes both 
 being affected. After a time, the cloudiness may clear up, though 
 spots or specks of opacity may remain permanently. While a vari- 
 ety of ear affections may be due to syphilis, a peculiar kind may 
 develop about puberty, in which deafness comes on rapidly and 
 remains permanently, in spite of treatment, and in which there are 
 no obvious local lesions, the pathological changes probably affecting 
 the labyrinth. The bones tnay be involved, both early and late. 
 Some of the marked cases of chronic gummatous periostitis may be 
 mistaken for rickets. 
 
 Synovitis, enlargement of the spleen, and gummatous deposits in 
 the liver, kidneys, and brain, may all occur as late manifestations of 
 hereditary syphilis, as well as of the early stages. 
 
 General Diagnosis. Syphilis may exist in obscure form, and 
 be the underlying factor in the obstinacy of many cases which 
 would otherwise improve rapidly under medication. A proper treat- 
 ment, as well as prognosis, depends, then, upon the ability of the 
 practitioner to recognize and provide for them. There is a disposi- 
 tion on the part of many patients to conceal the fact, when they have 
 been affected by acquired syphilis, and the physician must be pre- 
 pared for this, and draw his conclusions accordingly. As few are 
 acquainted with all the symptoms liable to follow, however, careful 
 questioning will enable the physician to come very near the truth, 
 however well the patient may attempt to guard it. The history of 
 throat and skin lesions, loss of hair, emaciation, etc., occurring as 
 associated symptoms, are very good evidence, when attending condi- 
 tions already suggest the disease. In primary syphilis, the patient 
 may contract gonorrhoea coincidentally, and the chancre be concealed 
 within the urethra, along the fossa navicularis; but the presence of 
 enlargement and induration in the inguinal region, and the develop- 
 ment of mucous and cutaneous lesions later, with fever and loss of 
 strength, will convey intelligence of the specific character of the dis- 
 ease. In advanced cases, nodes on the shins or other parts of the 
 skeleton, old scars, and more or less thickening of the lymphatic 
 glands, especially in the inguinal and occipital regions, are confirm- 
 atory of a suspicion of the presence of syphilis. In congenital syph-
 
 284 SPECIFIC INFECTIOUS DISEASES. 
 
 ills, there is little danger of mistaking the disease. The early 
 appearance of snuffles, in conjunction with cutaneous and mucous 
 lesions, can hardly be mistaken for any other affection. The pecu- 
 liar developments at puberty, already described, will be confirmatory 
 testimony, as the case progresses. 
 
 Prognosis. In these days, the old virulence of syphilis seems 
 to have become nearly exhausted. With rational treatment, few 
 cases of acquired syphilis will result seriously, or even develop very 
 unpleasant secondary symptoms, while tertiary manifestations may 
 generally be entirely avoided. Unfortunately, many cases of this 
 disease fall into the hands of old school physicians, who adhere to 
 the stupidly pernicious practice of administering mercury during the 
 early stages. The result is, that the following lesions are more 
 severe, and much more difficult to control. We can promise much 
 more to a patient who has avoided mercury throughout, than one 
 who has been subjected to the action of that drug for several weeks' 
 time in the start. It is possible that mercury may suppress the 
 cutaneous lesions somewhat at first, but if these are allowed to 
 come out, while the use of proper vegetable antisyphilitics is made, 
 they will usually disappear permanently, within a brief period. Mer- 
 cury invariably aggravates the mucous lesions about the mouth and 
 throat, these becoming increased and prolonged, as mercurial treat- 
 ment is persisted in. 
 
 Congenital syphilis is less amenble to treatment than the acquired 
 form, though it is possible that early treatment, through the mater- 
 nal circulation, might avert many of its evils. 
 
 Treatment. Preventive treatment is always to be considered. 
 A syphilitic patient should be warned to avoid the common use of 
 toilet articles, drinking cups, pipes, etc., with uncontaminated per- 
 sons. A syphilitic child should be reared on the bottle, unless its 
 own mother nurse it, and precautions should be observed as to 
 the use of towels, combs, drinking-cups, etc., and other children, as 
 well as adults, should avoid kissing and fondling it. The person who 
 attends to washing its clothing should see that there are no abra- 
 sions on her hands, through which the virus may find entrance to the 
 circulation. With an intelligent idea of the nature of the disease, 
 suggestions as to proper care to guard against infection will natu- 
 rally arise, in the inind of every thinking person. 
 
 The medicinal treatment of acquired syphilis is simple, and, at the 
 same time, effective. B.erberis aquifolium is as near a specific for 
 syphilis as we can hope for, in any case. But, as syphilis is a dis- 
 ease of slow development and chronic course, we must not expect a 
 few weeks' treatment to eradicate it. Many patients improve so rap
 
 SYPHILIS. 285 
 
 idly upon it that they finally, in a few weeks, consider themselves 
 cured, and then abandon treatment, to their ultimate sorrow; but 
 when continued for months and years, nothing could be more satis- 
 factory than the results thus obtained. Syphilitics, in the wasting 
 stage of the disease, improve in appetite and flesh under this rem- 
 edy, debility disappears, and former vigor is soon restored. Peri- 
 osteal pains subside under its influence, and gummata are averted, 
 though it possesses no power to discuss them, when once formed. 
 But the ulceration which follows their breaking up in the skin and 
 mucous membranes becomes less stubborn, and usually heals within 
 reasonable time. It removes the cutaneous eruptions of secondary 
 syphilis in a few weeks, and assists in healing the patches in the 
 mouth aud throat. 
 
 Corydalis formosa is a remedy which rivals berberis aquifolium. 
 To avert gummatous periostitis and prevent the formation of nodes, 
 it is probably without a rival. It combines well with berberis, and 
 I am in the habit of prescribing as follows, in most cases of syphilis, 
 for constitutional purposes : B Fluid extract berberis aquifolium fi, 
 specific corydalis fss, alcohol fii, aqua, ad. q. s., Oi. Sig., Take a 
 tablespoonful four times daily. This combination will answer every 
 purpose, where syphilitic cases have not previously been subjected 
 to the baneful effects of mercury. "When this drug has been used, 
 however, tertiary lesions may be stubborn, and demand the employ- 
 ment of iodide of potassium, to hasten the liquefaction of syphilides, 
 when breaking down begins in the skin and mucous membranes. 
 This may then be given in tolerably large doses (gr. x) for a few 
 weeks, to be temporarily discontinued, until the patient has time to 
 recuperate from the resulting debility, upon berberis. It is well, in 
 such cases, to alternate the berberis with the potassio iodide, as well 
 as follow with its temporary administration. 
 
 Stubborn cutaneous eruptions, following upon the administration 
 of mercurials, may sometimes yield to large doses (gtt. x) of Dono- 
 van's solution, repeated three or four times a day. It may be sug- 
 gested that this combination contains mercury, an objection which 
 can hardly be raised to its use when the system has already been 
 thoroughly poisoned with the drug. Sometimes stubborn cutaneous 
 lesions, such as palmar psoriasis, can be cured by the persistent local 
 use of Webster's compound sulphur ointment : Ify Lanolin Ib. i, ol. tar 
 f i, sp. m. veratrum ? i ; thicken with powd. sulphur. This should be 
 applied morning and evening, for a year, constantly. 
 
 The primary sore of syphilis needs little attention, unless it be 
 developed where it is subjected to pressure or chafing. Twenty 
 drops of nitric acid, diluted in four ounces of water, constitute a
 
 286 SPECIFIC INFECTIOUS DISEASES. 
 
 cleansing wash, which tends to heal the abrasion and prevent the 
 growth of condylomata. It should be applied four or five times 
 daily. When the chancre is concealed beneath a constricted prepuce 
 (phymosis), aggravation is liable to result, and an irritable, ragged 
 ulcer may arise from the pressure. In such a case, the prepuce 
 should be slit freely, so that all compression may be avoided; the 
 lotion of dilute nitric acid will now suffice to readily heal the 
 abrasion. 
 
 Echinacea has been presented, by modern Eclectic physicians, as 
 a remedy for syphilis. My experience has been confined to its use 
 where stubborn pharyngeal ulcers have manifested an irritable, sensi- 
 tive condition. Here, echinacea, both locally and constitutionally, 
 produces satisfactory results. Sometimes the local use of galvan- 
 ism is useful to assist in healing painful and stubborn pharyugeal 
 and palatal ulcers, two or three milliamperes being applied to the 
 spot with the negative pole, and repeated every other day. 
 
 As constitutional remedies for this disease, additional to what 
 have already been mentioned, may be named chaidmoogra oil, which 
 may be administered in ethereal solution, or in capsules. 
 
 StiUingia sylvatica, in the form of a green plant tincture, combined 
 with iodide of potassium, is especially recommended in tertiary 
 syphilis. Cfdoride of gold, in tertiary syphilis of the bones, in second 
 decimal trituration, is worthy of trial. 
 
 Professors Goss, of Georgia, and J. W. Hamilton, of California, 
 are enthusiastic admirers of echinacea, administered in from thirty- 
 to sixty-drop doses of a saturated tincture of the fresh root. 
 
 XXVL LEPROSY. 
 
 Synonyms. Lepra; Elephantisis Grsecorum; Leontiasis. 
 
 Definition. A chronic infectious disease, caused by the bacil- 
 lus leprse, characterized by tuberculous growths in the skin and 
 mucous membranes, and areas of ansesthesia and destructive ulcera- 
 tion, corresponding to the distribution of nerves which become 
 affected by the development of the bacilli in their structures. 
 
 Etiology. Leprosy is a disease of the earliest antiquity 
 known to the earliest writers. It prevails along the shores of the 
 Mediterranean sea extensively, though since the middle ages it once 
 nearly disappeared from Europe, except in Norway and the Orient. 
 On the Pacific Coast, the disease is occasionally found among Cau- 
 casians, and the Chinese are frequently affected. The Sandwich 
 Islands are notoriously affected, there being over a thousand lepers 
 at the settlement of Molokai. At Tracadie, N. S., is a lazaretto, in
 
 LEPROSY. 287 
 
 which are confined about a score of lepers, the disease having been 
 introduced by emigrants from Normandy, during the latter part 
 of the seventeenth century. The number of persons affected is dimin- 
 ishing, the settlement having formerly contained over forty mem- 
 bers. It is most liable to spread in hot climates, the West Indies, 
 the Gulf States, and Mexico, being homes of quite a large number 
 of lepers. All ages and all classes may be affected. 
 
 The exact method of transmission is not positively known, 
 though it is generally believed that th.e disease may be propagated 
 by sexual congress. It certainly is not very contagious, unless there 
 be special exposure, for healthy persons may be about lepers for 
 years, and remain uncontaminated. Osier states that not one of the 
 Sisters of Charity, who for forty years have nursed the lepers of Tra- 
 cadie, have contracted the disease. It is believed to be hereditary. 
 
 Dr. Morrell Mackenzie, in an article written a short time before 
 his death, declared that leprosy is alarmingly on the increase, all 
 over the world. He asserted that in Spain and Portugal, as well as 
 in other parts of Southern Europe, the disease is rapidly gaining 
 ground, the fact being due, according to his belief, to the lax pro- 
 visions of the proper authorities for isolating those affected. He 
 was a firm believer iii the contagiousness of the affection, and 
 deplored the custom of so mauy of regarding it as non-contagious, 
 since such belief led to lack of proper isolation of those affected. 
 Jonathan Hutchinson and others ascribe the complaint to diet, 
 Hutchinson believing that a fish diet tends to its production. A 
 large contingent scout such a proposition, however, asserting that 
 there are many facts in history which contradict such a statement. 
 
 The bacillus leprce resembles the bacillus tuberculosis in many 
 respects, though, as has already been pointed out (in the Introduc- 
 tion), there is a distinction. It can be found in the tuberculous 
 structure of leprosy, in large numbers, though it does not propagate 
 in inoculation tests upon animals, thus differing decidedly, in one 
 respect, from the bacillus tuberculosis. 
 
 Pathology. Like tubercle, the tuberculous growths of leprosy 
 are due to granulomatous infiltration, from the irritating influence of 
 the bacilli upon the embryonal cells of connective tissue.' The 
 growth involves the skin later, and grows outward, tuberous projec- 
 tions forming over circumscribed areas, between which are ulcera- 
 tion or cicatrization. These give rise to disfiguration of the surface, 
 und, when the face is involved, remarkable distortion of the features 
 may result. Sometimes deep ulceration may further disfigure the 
 part, amputation of the fingers and toes thus occasionally resulting. 
 When the bacilli develop in the substance of the nerve-fibers, there
 
 288 SPECIFIC INFECTIOUS DISEASES. 
 
 is more or less destruction of their functions, and peripheral neuri- 
 tis results, with localized areas of anaesthesia, and trophic changes 
 in the skin. The bacilli are found in great numbers iimong and 
 within the cells of the tuberculous growths, and among and within 
 the affected nerve-fibers. 
 
 Symptoms. Two clinical forms are described, viz., tubercular 
 leprosy, aud anaesthetic leprosy : 
 
 The first appearance of tubercular leprosy may be that of sharply 
 defined spots upon the skin, resembling erythema or psoriasis. Sen- 
 sibility may here be exalted, at first, and, after a time, the spots may 
 become pigmented. Anaesthesia gradually develops, and there is 
 either a gradual outgrowth of tuberculous nodules over the surface, 
 or the spots gradually fade out, becoming perfectly white (lepra 
 alba). The mucous membranes become involved gradually, the voice 
 growing hoarse and husky, and finally being entirely lost, from 
 involvement of the laryngeal mucous membrane; and death may 
 result from laryngeal complications, giving rise, later, to pneumonia, 
 of chronic form. The eyebrows and eyelashes, as well as the other 
 hairs of the face, fall out; tuberculous growths may form upon the 
 conjunctivas, resulting in blindness from leprous keratitis, and the 
 face may become frightfully thickened and distorted, from the cuta- 
 neous tubercular outgrowths. The most common locations of the 
 growths are the face, breast, scrotum, and penis. 
 
 Anaesthetic leprosy differs materially in its characteristics from the 
 tuberculous form, though due to the same cause. Here the disease 
 is largely confined to nerve-trunks, while its outward manifestations 
 are exhibited upon the surface, in peripheral results of disturbed or 
 arrested sensory or trophic functions. The earliest symptoms are 
 pains in the limbs, and areas of hypercesthesia, anaesthesia, or numbness, 
 upon the surface. Maculae or pigment-spots may appear upon the 
 trunk and extremities, here to persist for a time and afterward dis- 
 appear, leaving localized areas of anaesthesia. Bullae upon the sur- 
 face may denote trophic disturbances, these appearing, in some cases, 
 quite early. Enlargement and nodulation of superficial nerve-trunks 
 may be felt, after the disease has progressed for a time, and the 
 trophic disturbances become more and more marked, as the disease 
 progresses. Pemphigus-like bullaa form and break, leaving deep and 
 destructive ulcers; contractures and necroses of the fingers and toes, 
 and other destructive changes, follow. The changes are persistent 
 and gradual. 
 
 Diagnosis. The macular spots, with hyperaasthesia and sub- 
 sequent anaesthesia, will suggest the character of the disease early. 
 Later, the development of tuberculous growths on the face and other
 
 GLANDEKS. 289 
 
 parts, with attending symptoms, could hardly be mistaken; and the 
 manifestations of anaesthetic leprosy are about as positive. 
 
 Prognosis. As there has not yet been discovereda cure for lep- 
 rosy, and the tendency is continually, though slowly, toward a worse 
 condition, the prognosis, as to a cure, must necessarily be unfavor- 
 able, though life may not be materially shortened by the disease. 
 
 Treatment. The treatment of leprosy is not liable to bring 
 laurels to the attending practitioner. There are no remedies which 
 produce striking results, and we cannot expect to do more than lessen 
 the rapidity of its progress. Lepers hardly continue treatment long 
 enough to give any remedy a fair trial, and few are appreciably bene- 
 fited with drugs. Chaulmoogra oil and gurjun oil have been recom- 
 mended. Berberis aquifolium should be thought of favorably. In 
 any case, treatment should be persisted in for a long time many 
 months if improvement is to be expected. 
 
 The protection of the uncontaminated public is more important 
 than the cure of a few individual cases. Lepers should be isolated 
 and confined, so that the disease may not spread. This is a matter 
 in which law-makers in all civilized countries should act together, 
 that proper lazarrettos may be instituted, where such subjects can 
 l>e provided for, and restricted from intercourse with the world at 
 large. 
 
 XXVII. GLANDERS. 
 
 Synonym. Farcy. 
 
 Definition. A specific, infectious disease of horses, communi- 
 cable to man, characterized by the formation of nodules of granuloma- 
 tous tissue, occurring chiefly in the nares (glanders) and beneath the 
 skin (farcy). 
 
 Etiology. The cause of this disease is a short, non-motile 
 bacillus, resembling the tubercle bacillus, which enters the body 
 through an abraded surface, either of the skin or the nasal mucous 
 membrane, the disease usually being contracted from affected horses, 
 though it may be communicated from man to man, washer-women 
 having been inoculated from the clothing of those affected. 
 
 Pathology. The disease consists in the formation of granu- 
 lomatous tumors, of low vitality, which tend to early breaking down. 
 They are composed of epithelioid and lymphoid cells, among which are 
 found the bacilli the irritating elements which provoke the morbid 
 growth. These nodules manifest a tendency to undergo rapid 
 destructive changes, which result in ulceratioii of the mucous mem- 
 brane and deeper structures of the nose, in glanders, and in abscesses 
 beneath the skin, in farcy. Internal organs sometimes become 
 
 30
 
 290 SPECIFIC INFECTIOUS 'DISEASES. 
 
 involved, and the characteristic nodules are then found in their 
 structure. 
 
 Symptoms. This disease may occur in either the acute or 
 chronic form, both these occurring in the nasal and subcutaneous 
 varieties. 
 
 When the nose is involved, an acute attack is inaugurated by gen- 
 eral febrile disturbance, with redness, swelling, and lymphangitis at 
 the point of inoculation, nodules soon forming about the vicinity, 
 which break down a few days later, melting away in a profuse, muco- 
 purulent discharge. The cervical lymphatics soon become swollen, 
 hardened, and painful. Associated with these symptoms is a cuta- 
 neous eruption, first papular, then pustular, which appears on the 
 face and about the joints, resembling, in general appearance, the 
 eruption of variola. Severe constitutional symptoms attend the local 
 manifestations. There are fever, rapid prostration, and typhoid 
 symptoms, the disease terminating fatally in from eight to ten days. 
 When the chronic form occurs, the symptoms are at first those of a 
 severe coryza. There is ulceration of the nasal mucous membrane, 
 with laryngeal irritation and ulceration, which may linger for 
 months, recovery finally taking place in some cases, though a fatal 
 termination usually follows. 
 
 When the skin is involved in acute farcy, there is severe phleg- 
 monous inflammation at the point of inoculation, with rapidly 
 spreading swelling, the lymphatics becoming involved, and nodules 
 (farcy buds) forming along thoir course. These soon reach a stage 
 of suppuration, and abscesses form in the vicinity. Pain and swelling 
 occur about the joints, though the eruption observed in the nasal 
 form is rarely met. Severe constitutional symptoms, similar to 
 those of septicaemia, rapidly develop, and a fatal termination is 
 almost inevitable, within twelve or fifteen days. Chronic farcy is 
 more gradual in its inception, and it is characterized by the presence 
 of localized tumors, usually in the extremities. These break down 
 into abscesses and form deep ulcers, without much constitutional dis- 
 turbance. In chronic farcy, the lymphatics are not usually involved, 
 and the disease may continue for months or years, recovery occa- 
 sionally resulting finally, though pyaemia and death follow more 
 frequently. Sometimes acute glanders may result from auto-inocu- 
 lation. 
 
 Diagnosis. The diagnosis will not be difficult, the severity of 
 nasal glanders distinguishing it from all other forms of nasal trouble, 
 unless the chronic form occur. Here, it may be necessary to submit 
 some of the discharge to a bacteriologist, for culture and other 
 inspection. The history of the case, the "farcy buds," and early sub-
 
 ACTINOMYCOSIS. 291 
 
 cutaneous abscesses of acute farcy, can hardly be mistaken for any 
 other disease, especially when the history of the case will usually 
 afford evidence of exposure to infection from a diseased horse, at a 
 recent date. 
 
 Prognosis. The prospects of recovery from acute glanders or 
 farcy are exceedingly doubtful, and the prognosis must be almost 
 invariably unfavorable. Recovery from chronic glanders and farcy 
 sometimes occurs, and there may be some hope offered, though even 
 here there is little prospect of a favorable termination. It is said, 
 however, that the noted French veterinary surgeon, Bouley, recov- 
 ered from an attack of chronic farcy. 
 
 Treatment. Prophylaxis is the important part of treatment, 
 because restorative treatment is not attended by very promising 
 results. If the point of inoculation can be discovered early, it is 
 advised to excise, or destroy it with caustics. Farcy buds should be 
 opened early, and thoroughly drained, with local antisepsis. Inter- 
 nally, we may derive pome benefit from the persistent use of echina- 
 cea or berberis aquifolium, preference being given to echinacea in 
 acute cases, and to berberis aquifolium in chronic ones. In acute 
 attacks, either of nasal glanders or farcy, little Mope can be offered, 
 though this need not deter us from trying the best Eclectic remedies 
 in our possession. 
 
 XXVin. ACTINOMYCOSIS. 
 
 Synonyms. Big-jaw; Lumpy-jaw. 
 
 Definition. A specific infectious disease of cattle, pigs, horses, 
 and other animals, communicable to man, caused by the ray fungus 
 (actinomyces). 
 
 Etiology. The actinomyces is a fungus, consisting of micro- 
 scopic threads, radiating from a common center, bearing, on their ends, 
 bulbous or club-like terminations. Infection prob- 
 ably occurs from feeding, as the tissues about the 
 jaws are usually affected first, though the disease 
 may originate in the intestines, lungs, brain, or 
 skin. It is believed that barley or rye may con- 
 tain the fungus, and be a source of the disease 
 among cattle, if not men. Doubtless diseased flesh 
 also conveys it to man. It is asserted that the 
 . fungus may gain entrance through abrasions in the 
 skin and mucous membranes, and through cavities in decayed teeth. 
 
 The disease is rare. 
 
 Pathology. The pathological change consists in a convei 
 of mature connective tissue into a granulomatous mass, composed of
 
 292 SPECIFIC INFECTIOUS DISEASES. 
 
 ronnd and epithelioid cells, with occasional giant cells, the growth, 
 in its early condition, resembling that of ordinary tubercle. After 
 a time, however, there begins a rapid growth of the tumors, owing 
 to active proliferation of the connective tissue in the neighborhood, 
 the morbid condition then much resembling sarcoma, in its general 
 appearance. Suppuration begins later, and the pus contains yellow 
 particles, visible to the naked eye. The growth now becomes bur- 
 rowed with fistulous sinuses and scattering abscesses. Chronic 
 inflammation of the surrounding tissues attends, though the lym- 
 phatics do not become involved. The later course of the disease 
 resembles that of a malignant tumor. 
 
 Symptoms. These vary, to correspond with the location of the 
 morbid growth. If the fact is primarily affected, an irregular, nod- 
 ulated swelling will involve the cheeks, jaws, temples, tongue, or 
 some contiguous part, with slow and painless enlargement, at first, 
 though it will take on a rapid growth later. When suppuration 
 begins, and irregular fever attends, the condition resembles that of 
 chronic pyaemia. Septic symptoms may be prominent, and the 
 symptoms may simulate those of typhoid fever. When the lungs 
 are involved, cough will be a prominent feature, and the disease 
 will run a course similar to that of some cases of pulmonary tuber- 
 culosis, or fcetid bronchitis. When the skin is involved, nodular 
 excrescences appear upon the surface, which ultimately ulcerate, and 
 pass through a protracted period of suppuration, the ulcers stub- 
 bornly remaining for years, thus bearing a resemblance to tuberculo- 
 sis of the skin. When the brain is the part affected, symptoms of 
 cerebral tumor are manifest Epileptic symptoms, unsteadiness of 
 gait, and mental disturbance, in the beginning, with delirium and 
 coma, later on, are liable to appear. When the intestines are involved, 
 gastro-intestinal disturbance will be prominent. 
 
 The disease may involve parts distant from the face, secondarily, 
 there then being a complication of the disturbance about the face 
 with the various visceral troubles. 
 
 Diagnosis. The presence of the actinomyces in the pus will 
 be the distinctive diagnostic feature, though when the location of the 
 affection is in its usual part, about the face, the general picture and 
 peculiar course will be highly suggestive. The yellow particles in 
 the pus, often visible to the naked eye, demonstrated, upon micro- 
 scopical examination, to be actinomyces, will settle the question. 
 
 Prognosis. Wherever the disease is located, there is always 
 liability of secondary infection. Its course is likely to resemble, 
 clinically, that of sarcoma, and it almost invariably goes on to a fatal 
 termination. However, when the disease is restricted to the skin,
 
 INFECTIOUS DISEASES OF DOUBTFUL NATURE. 293 
 
 or is located so superficially as to permit of surgical interference 
 without involving vital parts, recovery may follow early treatment. 
 Treatment. The treatment is principally surgical If the dis- 
 ease be located where it can be exposed, the surgeon's knife should 
 be called into service, to eradicate every vestige of the morbid 
 growth. When the case progresses to suppuration, the treatment 
 pursued in pysemia is all that can be offered. 
 
 XXIX. INFECTIOUS DISEASES OP DOUBTFUL NATURE. 
 
 SIMPLE CONTINUED FEVER. 
 
 Synonyms. Febricula; Synocha; Synochoid. 
 Definition. An infectious fever, usually of short duration and 
 favorable prognosis. 
 
 Description and Etiology. In non-malarious districts, dur- 
 ing the absence of epidemics or endemics, febrile affections occur, 
 which arise from colds, retained secretions, errors in diet, excessive 
 mental or physical effort, exposures to the sun, or other accidental 
 cause, outside of any known specific infection, which may be classed 
 under this name. There is no regular or stated course of continu- 
 ance, in this class of fevers, the gravity of the cause, the constitu- 
 tional resistance of the patient, or the treatment, determining the 
 period of duration. In some cases, the fever will terminate in a 
 day or two, while in others, it may continue for from ten days to 
 three weeks. 
 
 Sometimes the system is in such a predisposing condition that 
 the fever assumes quite a serious aspect, and takes on a high grade 
 of temperature and pulse-rate, the maximum temperature reaching 
 as high as 106 for several days, and the pulse running at a rapid 
 rate, full and bounding. Such patients possess powerful reactive 
 constitutions, and the course of the fever is actively inflammatory in 
 its characteristics, tending to inflammation of the lungs or brain, if 
 it does not terminate within the first week. This character of feb- 
 rile manifestation has been described as a separate form, under the 
 name, "synochal fever." After this time, typhoid symptoms grad- 
 ually appear, and delirium and blood depravation, as manifested Ly 
 the condition of the tongue, develop. Or, typhoid symptoms may 
 appear early in the course of the disease, within the first two or 
 three days, and the temperature may run a course much like that of 
 typhoid fever, during the fastigium, the prostration, nervous symp- 
 toms, and blood depravation simulating that disease very much, 
 though the fever may terminate within two weeks, usually, under
 
 294 SPECIFIC INFECTIOUS DISEASES. 
 
 rational treatment. This form has been described by some writers 
 under the term, "synochoid," or "common continued fever." 
 
 Symptoms. The disease usually begins with an abrupt rise 
 in temperature, the stage of invasion only occupying the first day, 
 or a few hours. The temperature may rise as high as 102, 103, 
 104, 105, or 106, during the evening, but, if the fever lasts over 
 the second day, there is a morning remission of one or two degrees, 
 each day. Where the temperature is very high, the form known as 
 synocha may develop, and the disease run for a week, the pulse being 
 full and bounding, respiration hurried, and the patient restless and 
 wakeful. There is headache during this stage, the eyes are bright, 
 the urine is scanty, and perspiration is arrested, the skin being 
 hot and dry, the bowels constipated, and the appetite absent. 
 The patient is usually more restless and uncomfortable during the 
 after part of the day and early part of the night, morning hours 
 being attended by subsidence of the more aggravated symptoms. 
 Continuing in this way for five or six days, favorable cases terminate 
 suddenly, by rapid lysis, or crisis ; secretion becomes established, the 
 urine flows freely, the skin becomes moist and cool, the pulse normal, 
 and respiration easy and natural, the headache subsides, and the 
 appetite returns. 
 
 If the fever does not abate at this time, and, also, if there has 
 been considerable of a period of incubation, the symptoms from the 
 start may assume a typhoid character. This constitutes the form 
 known as synochoid, or common continued fever. When so from the 
 beginning, there is usually a marked chill, following several days of 
 depression. Though not so severe as an ague, the patient will com- 
 plain of coldness of the extremities, and of chilly sensations, creep- 
 ing over the body. These are soon alternated with flushes of heat, 
 until febrile action is well established. Now we begin to note the 
 typhoid symptoms. The tongue is soon coated; the coating may be 
 pasty white or it may be yellowish, or there may be a tendency to 
 an irritable condition of the stomach, as indicated by the elongated 
 tongue, with reddened tip and edges. Whatever the condition of 
 the tongue in the commencement, it is liable, in the later stages, to 
 be either clean and slick, with dark red mucous membrane, or the 
 coating to become brown and dirty. In bad cases, there may be 
 sordes on the teeth and lips. The pulse is now small and feeble, 
 and the patient is liable to develop considerable disturbance of the 
 cerebral centers, as manifested by dreamy delirium, or coma-vigil. 
 While this condition resembles that of typhoid fever, in many 
 respects, there is usually absence of diarrhoea, tympanites, and other 
 abdominal symptoms characteristic of true typhoid. Pulmonary
 
 INFECTIOUS DISEASES OF DOUBTFUL NATURE. 295 
 
 complication often attends protracted cases of this fever, and, occa- 
 sionally, serious cerebral congestion. 
 
 Diagnosis. The su'dden onset and early decline of the fever, 
 without complication, will enable one to readily diagnose the simpler 
 cases. Where typhoid symptoms appear, and the disease becomes 
 protracted, there will be an absence of the serious abdominal symp- 
 toms that characterize true typhoid. The rash of typhoid fever will 
 also assist in clearing up a doubtful diagnosis. It should be recol- 
 lected that typhoid fever occurs as an epidemic or endemic, and that 
 sporadic cases can seldom be supposed to exist, while the opposite 
 is true of this form. Where it is necessary to render a diagnosis in 
 obscure or doubtful cases, microscopical inspection of the supply of 
 drinking water and milk, and the evacuations, may assist in clearing 
 up the obscurity. 
 
 Prognosis. There is little danger of a fatal termination, even 
 in the most aggravated form, if judicious management be observed. 
 Though the synochoid form may present some aggravated features, 
 proper treatment if ill usually correct them in good season, and a 
 favorable termination in all cases, except those of great debility or 
 extreme age, ensues. 
 
 Treatment. Abbreviated cases of febricula require little treat- 
 ment, more than that which will render the patient less uncomfort- 
 able. Small doses of aconite and gelsemium may be employed to 
 lessen the height of the fever, and a full dose of bromo-seltzer may be 
 administered, if there is severe headache. Cooling lotions may be 
 applied to the head, and mildly acid drinks administered, until the 
 attack passes off. 
 
 The synochal form will demand the use of jdborandi, as follows : 
 9 Sp. m. jaborandi ^iii, water fiv. M., and give a teaspoonful every 
 hour, until the fever declines. When the pulse is bounding, with 
 other gelsemium indications, that agent may be preferred. An alkaline 
 sponge bath, administered every day, or a cold abdominal wet pack, 
 will assist in reducing the fever, with safety to the patient. 
 
 The synochoid form may be treated as a case of typhoid fever. 
 Sometimes the indication for some special antiseptic will be pro- 
 nounced, and the important part of the treatment will consist in sup- 
 plying this demand. For more definite instruction here the reader 
 is referred to the general treatment of fevers, in the Introduction. 
 
 WEIL'S DISEASE. 
 
 Synonyms. Acute Infectious Jaundice; Bilious Typhoid of 
 Griesinge"r. 
 
 Definition. An infectious disease, characterized by marked
 
 296 SPECIFIC INFECTIOUS DISEASES. 
 
 jaundice, high fever, severe pains in the extremities and back, and 
 albuminuria, with termination, in from ten to twelve days, by lysis. 
 
 Etiology. The exciting factor of this disease is unknown. It 
 is most liable to occur in hot weather, among males between twenty 
 and forty years of age, and is especially liable to affect butchers, 
 these facts suggesting that exposure to putrefactive exhalations from 
 animal and vegetable decomposition may exert a causal influence. 
 Mild epidemics may occur. 
 
 Pathology. Little is known of the morbid anatomy of this 
 disease, as it seldom proves fatal. The symptoms suggest obstruct- 
 ive jaundice and renal irritation. There is evidently splenic 
 engorgement, detected by palpation during the course of the disease. 
 The kidneys are congested, with acute parenchymatous degeneration 
 of the histological elements. 
 
 Symptoms. The onset is abrupt, there being a chill or suc- 
 cession of rigors followed by high fever, the temperature .rapidly 
 rising to 104 or 105, and the pulse to 100 or 110 per minute. The 
 fever is remittent, and remains high for about the first week, when 
 it declines by lysis, terminating about the tenth or twelfth day. The 
 jaundice appears early, often on the second day, the icteric hue 
 being deep yellow, in the skin and conjunctive, the tongue being 
 loaded with a yellowish fur. There is nausea, disgust for food, and 
 sometimes vomiting, in the beginning, and a diarrhoea of clay-colored 
 stools is liable to appear later. Severe headache, thirst, backache, 
 and pains in the extremities mark the exacerbations, while the 
 remissions are attended by little amelioration. Bile, along with 
 albumin, is present in the urine. As the disease progresses, it 
 becomes less active, and the patient is finally prostrated, and may 
 manifest more or less marked typhoid symptoms. 
 
 In about one-fourth of the cases, a relapse occurs six or seven 
 days after the return to normal, the temperature again rising, as in 
 relapsing fever. The relapse is mild, however, and only lasts five 
 or six days. Convalescence is slow and tedious, sometimes occupy- 
 ing two or three months. 
 
 Diagnosis. The symptoms of jaundice occur too early for that 
 which sometimes arises in relapsing fever, and the history of the 
 case will usually distinguish between this disease and that. In 
 typhus fever the jaundice also occurs later, while the rash of that 
 disease, about the sixth or seventh day, is characteristic. The his- 
 tory of the case, and the markedly epidemic character of typhus, will 
 assist in distinguishing it. 
 
 Prognosis. This is almost universally favorable, few cases 
 resulting fatally.
 
 INFECTIOUS DISEASES OF DOUBTFUL NATURE. 297 
 
 Treatment. The treatment will be adapted to each particular 
 case. To Control the fever and assist in eliminating the morbid 
 elements from the system, the properly selected sedative should be 
 administered every hour, during the first week, at least. Where 
 there is nausea with indications of gastric irritability, aconite and 
 r h us should be given: R Green plant tincture of rhus tox. gtt xv, 
 Lloyd's aconite gtt. v vii, water fiv. M., and order a teaspoonful 
 every hour. Or, where there is less tendency to nausea, more pro- 
 nounced sedatives may be employed. R Specific jaborandi jii-iii, 
 water fiv. M., and order a teaspoonful every hour. Determination 
 of blood to the brain will call for gdsemium, and capillary congestion 
 for belladonna. In connection with the sedative, or alternated with 
 it, the following should be administered every two hours, in tea- 
 spoonful doses : # Sp. m. polymnia ji, sp. m. chionanthus jss, sp. m. 
 chelidonium ji, water fiv. If the tongue is .heavily loaded with a 
 dirty, yellowjsh- white coating, sulphite of sodium should be given, in 
 one-grain doses, every three or four hours, until the coating has disap- 
 peared. A bland and nutritious diet should be allowed during con- 
 valescence, and some appropriate bitter tonic should stimulate the 
 recuperative functions, attention being especially paid to the 
 demands of a malarious district 
 
 MILK SICKNESS. 
 
 Definition. A disease supposed to be communicated to man 
 from eating the flesh or drinking the milk of cattle affected by 
 what is commonly known as "trembles." 
 
 Etiology. This disease formerly prevailed among the early 
 settlers of the states bordering on the western slope of the Alleghany 
 Mountains. Cattle and sheep were subject to a peculiar nervous 
 affection called trembles, characterized by refusal of food, injec- 
 tion of the eyes, and staggering gait, with trembling of the muscles, 
 and, finally, death in convulsions. The cause of this disease has been 
 supposed to be some form of plant-food taken with the wild herbage, 
 the disease having gradually disappeared, as clearing up of the for- 
 ests, and cultivated fields, have been the order. In some sections of 
 North Carolina, it still prevails. When milchers are affected, it 
 is said that they may not manifest the disease unless overdriven, 
 the poison lurking in the milk and proving fatal to those con- 
 suming it. Sheep, as well as domestic cattle, may be affected, their 
 flesh, as well as that of beeves, proving poisonous when eaten. It 
 is said that an ounce of butter or cheese from an affected cow, or 
 four ounces of beef, raw or cooked, three times daily, will prove
 
 298 SPECIFIC INFECTIOUS DISEASES. 
 
 fatal to a dog, within six days. Nothing definite is known respect- 
 ing the specific principle of the disease. 
 
 Pathology. Little has been recorded of the pathology of this 
 affection, as few scientific investigations by autopsies have been 
 made. Doubtless the principal lesions will be found in the ali- 
 mentary canal and cerebro-spinal centers. 
 
 Symptoms. The symptoms of the disease in man are charac- 
 terized by two or three days of prodromes, such as restlessness and 
 gastric discomfort, followed by acute pain in the stomach, with nau- 
 sea and vomiting, thirst, and fever, which rapidly passes into 
 typhoid symptoms, the tongue becoming swollen and tremulous, the 
 breath foetid, the bowels constipated, and the urinary secretion more 
 or less diminished. There is great restlessness and irritability at 
 first, but this may give way to coma and convulsions. Death may 
 occur in three or four days, or the disease may run three or four 
 weeks. 
 
 Diagnosis. The rapid onset of the disease, with the violent 
 gastro-intestinal irritation and nervous symptoms, will suggest its 
 presence, in sections where it is likely to prevail. 
 
 Prognosis. The disease has fortunately become rare, as it is 
 nearly always fatal in its results. The profound poisoning seems to 
 defy the best treatment that has yet been tried. 
 
 Treatment. Opiates should be avoided, and remedies admin- 
 istered to control the vomiting. Bismuth, and aconite and rhus tox, 
 may be tried, for this purpose. When the vomiting has been 
 arrested, echinacea should be administered freely. Passiftora and 
 lackesis may also be thought of. 
 
 MALTA FEVER. 
 
 Synonyms. Mediterranean Fever; Neapolitan Fever; Bock 
 Fever. 
 
 Definition. A febrile disease, which prevails at the Island of 
 Malta, Naples, and other points about the Mediterranean Sea, char- 
 acterized by an initiatory attack of mild febrile action of about a 
 week's length, followed by a remission of two or three days, with 
 a prolonged relapse of increased severity and persistent duration, 
 during which gastro-intestinal, pulmonary, cardiac, and arthritic 
 disturbances are liable to develop. 
 
 Etiology. The nature of this disease is yet in dispute, it being 
 generally denied that it is due to malaria. Some have asserted that 
 it is typho-malarial fever, there being marked febrile exacerbations 
 and remissions; but it does not yield to quinine, and does not behave 
 like ordinary malarial fever. An examination of the blood will fully
 
 INFECTIOUS DISEASES OF DOUBTFUL NATURE. 299 
 
 settle the question. Some have contended that it is typhoid fever, 
 but there is absence of the characteristic lesions of that disease. 
 Rheumatic symptoms are sometimes present, and, catarrhal manifes- 
 tations being prominent, it may be due to atmospheric influences. 
 Sewer-gas has been suggested as a possible causal factor, though it 
 is doubtful if any one has yet named the proper one. 
 
 Pathology. There is irritation of the gastro-intestinal and pul- 
 monary mucous membranes, with enlargement and congestion of the 
 spleen, endocarditis, and effusion into the joints and other serous 
 cavities. 
 
 Symptoms. In the commencement, the symptoms may resem- 
 ble those of mild quotidian ague, though usually the invasion is more 
 insidious, and the patient may be unable to name the day upon which 
 his illness began. Anorexia, lassitude, drowsiness, and slight head- 
 ache are the first symptoms here, and these gradually advance, until 
 there is nausea, vomiting, and diarrhoea, a few days later. Febrile 
 symptoms alternated with chilliness now appear, and the severity 
 of the symptoms increases day by day. Severe frontal headache has 
 developed by this time, and the patient is sleepless, restless, nau- 
 seated and thirsty, constantly. In about a week, in mild cases, these 
 symptoms abate, and the patient supposes himself convalescent, and 
 goes about his duties. In two or three days however the old symp- 
 toms return, with increased severity. The nausea and vomiting are 
 more aggravated, and there is active diarrhoea, this sometimes 
 amounting to dysentery, with severe tenesmus and the evacuation of 
 muco-sanguineous stools. Again, there may be symptoms of pneumo- 
 nia, with cough and rusty sputum. In other cases, the prominent 
 symptom may be that of excruciating pain in the back or one of the 
 extremities, which is so severe as to prevent motion. There is steady 
 loss of flesh, anaemia comes on with loss of hair, enlargement of the 
 spleen and liver, and the patient slowly drags through a protracted 
 convalescence, with extreme debility. The febrile symptoms are 
 marked by periodicity, with evening exacerbations and morning 
 remissions. 
 
 Treatment. The treatment should be in accordance with the 
 suggestions in the general treatment of fevers given in the Introduc- 
 tion. Hygienic precautions should be especially observed. 
 
 MIUABY FEVER. 
 
 THIS disease, which is otherwise termed "sweating sickness," 
 prevailed in various parts of Europe and England during the fifteenth 
 and sixteenth centuries, but it has been confined, during later times, 
 to certain districts in France and Italy. When it occurs, large
 
 300 SPECIFIC INFECTIOUS DISEASES. 
 
 numbers of persons are attacked at once, the disease spreading rap- 
 idly, like influenza. The disease is characterized by fever, profuse 
 perspiration, and an erythematous eruption surmounted by a crop 
 of miliary vesicles. Severe cases are attended by determination of 
 blood to the brain and active delirium at first, with prostration and 
 coma later on. Death sometimes occurs in a few hours, the outset 
 of epidemics often being attended by a high death-rate. 
 
 MOUNTAIN FEVEB. 
 
 A SEVERE form of fever prevails in elevated regions of the Rocky 
 Mountains, to which this term is applied. Two varieties are 
 described, one a continued, and the other a periodical form, either 
 intermittent or remittent In the continued form, the character- 
 istic lesions of true typhoid fever are found, and in the period- 
 ical type the early manifestations are those of malaria, with later 
 development of the typhoid element It is asserted that the severe 
 form of mountain fever is more liable to prove fatal than typhoid 
 fever in lower altitudes; that treatment is less effective in such ele- 
 vated regions than nearer sea level, delirium, stupor, and extreme 
 destruction of tissue in the intestines rapidly advancing to a fatal 
 issue. Dr. Hayes, formerly of Denver, Colorado, several years ago 
 reported success in the treatment of this fever with echinacecu
 
 SEQTION III, 
 
 CONSTITUTIONAL DISEASES. 
 
 I. RHEUMATISM. 
 
 Definition. A constitutional disease, characterized by pain 
 and tenderness in the locomotor apparatus, including the joints and 
 muscles, with tendency to endocarditis and acid sweats. 
 
 Etiology. Considerable confusion exists regarding the etiology 
 of rheumatism. The latest theory is that it is due to the presence 
 of microorganisms in the blood, and some authors class it as a spe- 
 cific infectious disease. But, while various microbes have been found 
 in the blood of rheumatic persons, there does not seem to be any 
 one that is constantly present. Defective dissimilation has been 
 ascribed as the cause by Prout and his * followers, upon the ground 
 that lactic acid or one of its compounds results from the faulty 
 appropriation of the food, and that this irritates the various tissues 
 of the locomotor apparatus. However, clinical and therapeutical 
 experience has proven this theory to be wrong, as acids instead of 
 alkalies sometimes prove curative, and, in the majority of cases, sim- 
 ple vegetable agents prove more curative than either acids or alka- 
 lies. Many regard the disease as a catarrhal condition, the causes 
 which produce colds with irritation of the pulmonary or other 
 mucous membranes being directed to the locomotor apparatus 
 instead, and provoking the various unpleasant effects observed here. 
 Such disturbances may be trophic in character, from impressions 
 reflected from the central nervous system; or, they possibly originate 
 morbid secretions, such as lactic acid, through influences exerted 
 upon the sympathetic. One fact is established, and that is, that the 
 disease prevails to the greatest extent in temperate, humid sections, 
 where sudden changes of temperature from warm to cold are com- 
 mon where exactly the conditions prevail which predispose to 
 catarrhal affections. While rheumatism is more common in Eng- 
 land and Canada than in the United States, it grows less common 
 here as advance is made toward the equator, and, in such dry and 
 elevated regions as Arizona, severe cases are almost unknown. It is 
 quite common along the sea coast of central California, but much less 
 so in the more arid regions of the southern interior. 
 
 There seem to be certain predisposing causes, such as debility 
 from over-work, bad food, and other unsanitary conditions, tending 
 to bring it on upon slight provocation. Malarial attacks are liable
 
 302 CONSTITUTIONAL DISEASE& 
 
 to be complicated with rheumatism, and rheumatism may follow an 
 attack of malaria and prove very stubborn, the malarial anaemia 
 becoming much aggravated by the rheumatic condition. 
 
 The cla^s of persons affected oftenest is that which comprises the 
 robust and middle-aged male population, which is exposed most to 
 vicissitudes of weather. Still, every age and condition may suf- 
 fer from it, though the disease is rare among very young chil- 
 dren. Laborers, sailors, drivers, bakers, iron-workers, and others 
 liable to sudden chilling of the surface when over-heated, or to wet- 
 ting in the cold rain, are those most commonly subject to acute rheu- 
 matism. Heredity is believed to exert a certain influence, it being 
 observed that the members of certain families are especially prone 
 to rheumatic attacks, this probably being due to hereditary suscep- 
 tibility. The disease presents itself in various forms, and the follow- 
 ing varieties will be considered separately : 
 
 ACUTE ABTICULAR RHEUMATISM. 
 
 Synonyms. Acute Rheumatism; Inflammatory Rheumatism; 
 Rheumatic Fever. 
 
 Definition. An acute, non-contagious fever, characterized by 
 severe inflammation and swelling of one or more of the joints, with 
 puffiuess and tenderness, and tendency to metastasis. 
 
 Etiology. This has already been sufficiently discussed under 
 the general head. Inflammatory rheumatism usually occurs during 
 the spring and winter months, when dampness and sudden changes 
 prevail. 
 
 Pathology. The changes which occur are not especially char- 
 acteristic of this disease, more than of any other inflammatory con- 
 dition. In many cases where there has been remarkable enlarge- 
 ment of the joints and excruciating pain, no structural change can be 
 detected after death. In other cases, there are hypersemia and 
 enlargement of the synovial membranes and ligaments, with turbid- 
 ity of the synovial fluid, which contains leucocytes and third corpus- 
 cles. If the heart be involved, the ordinary conditions of carditis 
 are found, and other inflammatory complications present the usual 
 appearances of inflammation of this part There is an unusual 
 amount of fibrin in the blood. Suppuration of affected parts is rare, 
 unless there be secondary complications, such as pleurisy, pericar- 
 ditis, or periostitis. One attack predisposes to subsequent ones. 
 
 Symptoms. There may be anorexia, dyspepsia, malaise, and 
 wandering pains, for two or three days prior to the actual onset, 
 though these are often absent, the attack then being abrupt. A chill 
 or, more commonly, chilly sensations announce the commencement of
 
 RHEUMATISM. 303 
 
 the attack. The temperature now rises quickly, the thermometer 
 indicating an elevatioii of from 103 to 104 F., within twenty-four 
 hours; the tongue is coated, there are headache and often pain and 
 soreness in the throat. The pulse is full and soft, and running at 
 100 per minute. The skin is often, though not always, moist and 
 frequently covered with a sour sweat. The urine is scanty, and, on 
 standing, it deposits urates abundantly. Miliaria often appear upon 
 the surface, and sometimes a pronounced roseolous eruption is pres- 
 ent. Simultaneously with the onset of the fever, changes in one or 
 more of the joints appear. There may be swelling and puffiness at 
 first, without redness or pain, but pain soon becomes excruciating, 
 and the swollen part is reddened and exceedingly tender to the touch, 
 the weight of the bedclothes being oppressive. THe large joints 
 are most apt to be involved, such as the knee, ankle, shoulder, wrist, 
 and elbow, though the fingers and toes may be implicated. Some- 
 times nearly all the joints of the body may be involved, even the 
 vertebral articulations, the sterno-clavicular joint, the synchondroses 
 of the ribs and symphysis pubis, and the sacro-iliac synchondrosis 
 also. The joints of the ary tsenoid cartilages have been thus affected. 
 
 A marked feature is a tendency to subsidence of the inflamma- 
 tion in one joint, with simultaneous appearance of swelling, pain, 
 and redness in another (metastasis). 
 
 Anaemia rapidly develops as the disease continues, and the acid 
 sweats become neutral or alkaline. Endocarditis is liable to develop, 
 an apex bruit being now detectable. 
 
 The fever declines by gradual lysis in favorable cases, though 
 the disease may continue for weeks when badly managed, permanent 
 stiffness and deformity of the joints remaining as a result of inflam- 
 matory deposits about their structures. 
 
 In malarial districts, a marked periodicity may become manifest, 
 the pain being paroxysmal, or marked exacerbation may occur every 
 day, or every second day. 
 
 There is usually little mental disturbance, the patient being con- 
 scious and rational, and thus capable of appreciating his sufferings 
 intensely, unless free use is made of opiates, in which event delir- 
 ium may be present. Sometimes internal organs other than the 
 heart are involved, the bladder sometimes being severely affected, 
 producing dysuria, with severe tenesmus, or complete ischuria 
 requiring catheterization. 
 
 Diagnosis. The severe joint-symptoms, with tendency to 
 metastasis, will distinguish this disease from others. Pyaemia, where 
 the joints are affected, may resemble it at first, but suppurative 
 synovitis follows in pyaemia, and not in acute articular rheum a-
 
 304 CONSTITUTIONAL DISEASES. 
 
 tism. Arthritis, not rheumatic in character, remains persistently in 
 one joint, while metastasis occurs in rheumatism, more than one 
 joint is apt to be involved, and cardiac symptoms may develop. 
 
 Prognosis. Properly treated, few cases of rheumatism ought 
 to result fatally, and perfect use of the joints ought to follow recov- 
 ery. The principal danger is in cardiac complication, and this can 
 usually be controlled promptly by Eclectic methods. The disease 
 usually lasts three or four days in one joint, and it may con- 
 tinue three or four weeks, in obstinate cases, though it will usually 
 subside much earlier. Ulcerative endocarditis sometimes remains 
 after an attack of rheumatism, and fatal results follow at a more or 
 less early date. Endarteritis, pleurisy, pneumonia and other pul- 
 monary affections, meningitis, and peritonitis may follow as sequelae. 
 Chorea also occasionally develops, while subacute or chronic rheu- 
 matism may remain after the acute attack has passed off. 
 
 Treatment. We possess a number of effective remedies for 
 inflammatory rheumatism, and only need to adapt them correctly to 
 be speedily successful, in the majority of cases. The alcoholic vapor 
 bath, or what is better when it can be obtained, the cabinet vapor 
 bath, is excellent and will often succeed alone in effecting a perfect 
 cure in two or three days' time. The application should be thorough 
 enough each time to promote profuse perspiration, and should be 
 repeated every day, and aided, when practicable, by the tonic faradic 
 treatment. To assist this, or as an independent measure, two full 
 doses of specific/o&orandi will be found excellent, from twenty to thirty 
 drops being given two hours apart, the following prescription being 
 administered every hour afterward until recovery, unless it becomes 
 necessary to abandon it in two or three days for other means : # Sp. 
 m. jaborandi $iii, water fiv. M. Dose, a teaspoonfuL 
 
 If there be any special indication of blood depravation this 
 should be met in the meantime, in order that special treatment may 
 not be embarrassed. Sometimes there is excessive acidity of the 
 stomach with septic complication, indicated by the creamy, or dirty- 
 white coating on the tongue, and salts of sodium may be demanded. 
 Here we may derive benefit from the salicylate of sodium, using a 
 three-grain capsule every three or four hours. Usually, however, 
 the sulphite of sodium will correct the septic condition better, though 
 it is not so specifically adapted to the rheumatic condition. Occa- 
 sionally, there may be lack of acids, indicated by the dark red 
 mucous membrane and slick tongue, calling for twenty-drop doses 
 of dilute muriatic acid, to be repeated every four hours until the spe- 
 cific condition has been corrected. 
 
 When such measures fail to effect a speedy impression, the best
 
 RHEUMATISM. 305 
 
 remedy to rely upon is rhamnus californica, wine-glassful doses of a 
 strong decoction of the bark, or twenty- or thirty-drop doses of the 
 extract being administered every three or four hours until free 
 catharsis is established, and afterward continued in small doses, just 
 short of catharsis. This remedy will seldom fail to bring about sat- 
 isfactory results in a few days. A combination which has afforded 
 me good results in past time is: R Sp. m. cimicifuga jii, wine 
 of colchicum seed f ss, spts. nit. dul. fi, simple elixir, ad. fiv. S. 
 Take a teaspoonful every three hours. Phenacetin sometimes brings 
 relief, and is worthy of trial in stubborn cases. A capsule consist- 
 ing of phenacetin gr. iii, caulophyllin gr. l-10th, and arseniate of 
 quinia 3x gr. ii, is my favorite form for administration, one being 
 the dose, to be repeated every two hours until profuse perspiration 
 follows. 
 
 The general propositions which apply to the treatment of fevers 
 may be applied in the treatment of rheumatism. The irritable stom- 
 ach will cull for aconite and rhus tooc.; periodicity for antiperiodio 
 doses of quinine, etc. 
 
 Opiates should generally be avoided, as their action is calculated 
 to prolong the disease and increase the liability to serious cardiac 
 complication. 
 
 Blisters should be employed sparingly, if at all. Sometimes, 
 when severe cardiac complication seems to threaten vital action, a 
 large fly-blister, applied to the left pectoral region, may produce a 
 desirable derivative effect. 
 
 Local applications to the inflamed joints may sometimes be of 
 satisfactory service, and, as the sufferer will usually demand them, 
 they must not be forgotten. Diluted chloroform is probably the 
 best application, an ounce to four of alcohol being used to moisten 
 wrappings of cotton, which should be covered with flannel band- 
 ages wrung as dry as possible from hot water. A favorife applica- 
 tion with old school physicians, though not very effective, is turpen- 
 tine, applied freely, the parts being afterward enveloped in raw 
 cotton. Various anodyne liniments have their respective advocates. 
 
 The diet should be carefully regulated, meat and stimulants being 
 strictly prohibited during the febrile stage. A milk or bread-and- 
 milk diet is sufficient during this time, enough being allowed to 
 satisfy the demands of the appetite; or, if there be anorexia, milk 
 should be administered in small quantities every two or three hours. 
 When milk cannot be taken (and many spleen against it), soups and 
 broths may be allowed instead. Oyster soup, clam broth, oat- 
 meal gruel, etc., are appropriate substitutes. Such drinks as vichy 
 or seltzer may be taken, though plain w.iter is proper, or, where 
 21
 
 306 CONSTITUTIONAL DISEASES. 
 
 craved by the patient, lemonade, dilate celery phosphate, barley 
 water, or rice water may be drunk freely. It is well to avoid sac- 
 charine food, both during the disease and during convalescence, the 
 diet of convalescence being restricted, at first, to rice, arrowroot, oat- 
 meal, corn meal, unsweetened puddings, soup, wine jelly, blanc-mange, 
 and malted foods. The return to animal diet should be gradual, and 
 only after the fever has subsided for at least a week. Then the 
 yolks of eggs, boiled an hour (one each day), fish, sparingly at first, 
 oysters, and the white meat of broiled or roasted chicken may be 
 taken, along with cooked celery, spinach, asparagus, etc. Baked 
 apples, or pears, without sugar, may be allowed, but sugar and alco- 
 hol should be avoided for weeks, as they are liable to provoke a 
 relapse. 
 
 SUBACUTB ARTICULAR KHEUMATISM. 
 
 This form of rheumatic disease may follow an attack of acute 
 rheumatism, or it may occur in an individual who has formerly suf- 
 fered an acute attack and afterward been exposed to some exciting 
 cause of the trouble. The pathology is similar to that of the acute 
 form, except that the joint affection leaves no trace of disorganiza- 
 tion, though there are similar blood changes. There is not the mor- 
 bid tendency to metastasis that characterizes acute rheumatism, and 
 the joints do not become reddened and swollen, nor are they painful, 
 unless moved or strained. Only one or two joints may be involved. 
 Anaemia is a manifest symptom, and cardiac complications are liable 
 to occur. The disease may come on gradually, in some cases, with- 
 out a previous history of acute rheumatism. There is little or no 
 fever. The condition may persist for from six or seven weeks to 
 three or four months. 
 
 The treatment consists in the steady use of rhamnus californica, 
 and the daily application of thorough massage about the affected 
 joint or joints. The rhamnus californica should be prepared by boil- 
 ing a drachm of the recent bark for twenty minutes over a slow fire 
 (after it has been infused in a pint of cold water), from one to two 
 tablespoonfuls being administered four or five times daily. Where 
 but one joint is affected the patient may be able to apply the mas- 
 sage himself, and then he should knead the affected part vigorously 
 and thoroughly, several times each day. This will be found very 
 effective. 
 
 The diet should be unstimulatiug, milk being preferable. Per- 
 sons subject to rheumatism should wear fiannel underclothing 
 throughout the year.
 
 KHEUMATISM. 307 
 
 CHRONIC ARTICULAR BHEUMATISM. 
 
 Synonym. Chronic Rheumatism. 
 
 Definition. A chronic, articular disease of advanced life, char- 
 acterized by thickening of the capsules and ligaments of the joints, 
 without marked deformity, the disease being aggravated by damp- 
 ness and atmospheric changes. 
 
 Etiology. This is a disease which comes on after middle life, 
 either insidiously or as a sequela of former attacks of acute or sub- 
 acute rheumatism. Damp localities predispose to it, such as dark 
 and damp dwellings, sleeping in ground-floor apartments, or over 
 damp cellars, etc. It is aggravated during the winter and spring, 
 and the joints are rendered stiff and lame from prolonged rest, 
 motion and exercise tending to relieve them for a time. It is most 
 common among those of laborious occupation. Such persons are 
 usually good "weather prophets," as they are susceptible to atmos- 
 pheric changes, and are usually influenced in advance of the advent 
 of a marked change of weather. Sometimes only one large joint 
 may be affected, though several are usually involved at the same 
 time. 
 
 Pathology. In some cases there is no structural change, the 
 syuovial structures being injected, but not much altered other- 
 wise, there not being much effusion. Usually, in long-standing 
 cases, the fibrous tissue around the joints, the fibrous envelope of 
 the nerves, the fascise, the peritoneum, and the aponeurotic sheaths 
 of the muscles are all involved in chronic inflammation. There is 
 thickening as well as increased vascularity of the synovial mem- 
 branes, the fringe-like processes are enlarged, and the synovial fluid 
 is turbid. Sometimes there are erosions of the articular surfaces. 
 Deformities may arise from the formation of constricting bands of 
 fibrous material about the diseased joints, and the deformity 
 may be more prominent from atrophy of the surrounding mus- 
 cles, through local disease or from reflected trophic influences. 
 Cardiaccomplications are seldom present 
 
 Symptoms. The symptoms come on gradually, slight soreness 
 and stiffness of the affected joints being first noticed during damp 
 and cloudy weather, or on the day following some severely laborious 
 occupation. This is more noticeable upon rising in the morn- 
 ing, and it gradually disappears as the affected part becomes 
 accustomed to action. The affection becomes more troublesome 
 during sudden changes, and in the cold and damp months of 
 winter aud spring. The joints gradually become more impeded 
 in their range of motion, finally being painful when at rest 
 There is usually slight tenderness upon pressure, but the joints are
 
 301 CONSTITUTIONAL DISEASES. 
 
 only slightly swollen and not reddened, unless there be extreme 
 aggravation. Suffering is usually increased at night and ameliorated 
 by exercise in the morning. Stiffness, soreness, and impairment of 
 the joints slowly increase with advancing age, though there is never 
 marked deformity nor serious loss of motion. The large joints are 
 usually involved, though the finger-joints may be affected in those 
 who use the hands severely, such as washerwomen. 
 
 Diagnosis. This affection should not be confounded with 
 arthritis deformans, for here there is marked deformity of the joints, 
 almost complete loss of motion, and gradual progress from one joint 
 to another, with never any improvement, while weather changes exert 
 no influence upon it. There is also pronounced deformity in gout, 
 and the small joints are the parts affected. 
 
 Prognosis. While not inimical to longevity, the prognosis, as 
 to a cure, is not favorable, unless the patient be removed to a new 
 and healthful climate. However, when proper treatment is begun 
 early and persevered in, the severity of the disease may be much 
 modified. After structural changes have gone on in the joints, palli- 
 ation of the most distressing symptoms is the best that we can hope 
 for - without radical change of climate. 
 
 Treatment. Early in the disease, massage and electricity will 
 be of good service. Both faradism and galvanism are useful, strong 
 currents of each being passed through the affected part or parts, 
 alternated at every sitting (every two or three days). 
 
 Rhatnnus calif ornica is now of some use, and it should be persisted 
 in for months, alone, or combined with grindelia squarrosa if the 
 neighborhood be malarious. The patient should dress the year 
 round in warm flannels, to prevent chilling of the joints from draughts 
 and dampness, and avoid a catting, so far as possible, requiring much 
 outlay of muscular effort. The diet should be nutritious, but red 
 meat should be generally avoided, the patient being instructed to 
 depend upon fish, eggs and fowl, avoiding sweets and alcoholic 
 drinks, the basis of his diet consisting of farinaceous food, with a 
 few fresh vegetables. 
 
 Aggravations should be met appropriately. Periodical aggrava- 
 tions will call for proper antimalarial treatment. Active inflamma- 
 tory aggravation of a particular joint may be benefited by blistering 
 the part. Chloroform liniment may relieve the pain at night. In 
 other cases, warm or cold applications afford more relief. 
 
 Patients of competent means should be advised to spend their 
 winters in a warm climate, southern Europe, southern California, or 
 Arizona offering prospects of greater comfort than ordinary climates. 
 There are certain thermal springs that afford much benefit to these
 
 RHEUMATISM. 309 
 
 patients, such, for instance, as the Hot Springs of Arizona or Vir- 
 ginia, Byron Springs, near San Francisco, or those of Banff, in the 
 Rocky Mountains, etc. 
 
 MUSOULAB RHEUMATISM. 
 
 Synonym. Myalgia. 
 
 Definition. A painful disease of the muscles and their fasciae, 
 as well as of the periosteum, arising from constitutional influences. 
 
 Etiology. Sudden chilling after exertion, overstrain of the mus- 
 cles, protracted exposure to dampness, and malaria are among the 
 exciting causes. It is most commonly met with in those who apply 
 themselves to severe bodily exertion, and is apt to follow draughts 
 of air, wetting from chilling rains, etc. Rheumatic or gouty per- 
 sons are most subject to attacks, and they may be seized during 
 changeable weather, without undue exposure. 
 
 Pathology. Investigations into the pathology of this disease 
 have thrown little light upon the subject. The muscles undergo few 
 if any anatomical changes, and such changes are not constant. Occa- 
 sionally there may be evidence of inflammation of the sheaths of the 
 muscles, or scanty serous exudation into their substance, and, at other 
 times, signs of degeneration of the muscular fibers. Sometimes 
 thickening or degeneration of the neurilemma of the nerves supply- 
 ing the part may be observed. 
 
 Symptoms. Many attacks of muscular rheumatism occur sud- 
 denly. " Crick-in-the-back " is an illustration of this, the person, 
 in apparently the best of health, being suddenly seized with an excru- 
 ciating pain in the lumbar region, so severe as to give rise to intense 
 suffering upon the least attempt at motion. Severe attacks of pleu- 
 rodynia also occur, in which the body is drawn toward the affected 
 side, and breathing is accompanied by intens'e, lancinating pains. 
 lu malarial regions, muscular rheumatism is very apt to be periodi- 
 cal, the attacks occurring in re'gular exacerbations, every day or 
 every second day, with remissions or complete intermissions between. 
 Sack attacks may pass off in a few days, or may turn into a chronic 
 form, the pain becoming permanently located in some muscle or 
 group of muscles and causing almost constant discomfort. Some- 
 times the muscular structures of the internal organs, such as the 
 stomach, intestines, bladder, oesophagus, etc., may be involved, the 
 functions of these parts then being impaired, while a painful state 
 of the part exists simultaneously. The disease is almost purely 
 local, little febrile or other systemic disturbance being present. 
 
 Localization of the pain in various regions has given origin to a 
 number of special names for this affection, such as lumbago (lumbar
 
 310 CONSTITUTIONAL DISEASES. 
 
 rheumatism), torticollis (stiff neck), and pleurodynia or rheumatism 
 of the intercostal or other muscles of the chest, those of one side 
 usually being involved. Sometimes the abdominal muscles are dis- 
 tinctly involved, giving rise to severe cramping pains in this region. 
 
 Diagnosis. The characteristic symptoms of muscular rheuma- 
 tism will usually distinguish it, metastasis being a symptom not com- 
 mon to any other painful disease of the muscles. The periosteal 
 pains of syphilis will be distinguished by the fact that changes of 
 weather do not affect them appreciably, and the accompanying symp- 
 toms of syphilis will afford additional light on the subject. Lumbago 
 might be mistaken for renal colic, but it is to be remembered that 
 lumbar pain in lumbago renders motion painful and difficult, while 
 in renal colic the patient moves about in all positions during the 
 paroxysm, and the pain darts along the ureter of the affected side, 
 the corresponding testicle often being retracted, while the urine is 
 scanty and probably bloody. In spinal pain, pressure upon the spin- 
 ous processes causes increased suffering while lateral pressure is 
 not painful, the opposite being the case in lumbago. Pleurodynia is 
 often diagnosed as pleurisy. It should be remembered that pleurisy 
 is attended by fever and cough with friction sounds on ausculation, 
 while in intercostal rheumatism the principal symptoms are pain 
 and dyspnoea, while motion of the affected muscles aggravates. 
 Abdominal rheumatism may be mistaken for peritonitis, but the 
 absence of fever and the severe constitutional symptoms attending 
 this disease will clear up any obscurity. Trichinosis is attended by 
 pains which resemble those of muscular rheumatism, but here there 
 is oedema of the feet, and the history of the case, usually occurring 
 in several individuals simultaneously, with microscopical examina- 
 tion, will settle any question of this character. 
 
 Prognosis. There is no danger of a fatal termination of this 
 disease, though it is quite liable to return upon slight provocation. 
 An acute attack may be relieved in a few hours, though when neg- 
 lected it may become chronic and prove very troublesome. 
 
 Treatment. To relieve an attack of muscular rheumatism, the 
 alcoholic or steam vapor bath answers an admirable purpose. Some- 
 times an extremely severe case may be advantageously relieved, in 
 the start, with a l-4th grain dose of morphine, either hypodermically 
 or per mouth, though the use of opiates is, as a rule, to be avoided, 
 as they seem to finally fix the disease in the system and render it 
 more stubborn. The vapor bath may be assisted by two or three 
 wine-glassful doses of a hot decoction of cimici/uga root, taken every 
 twenty minutes or half-hour. 
 
 Periodicity should be expected in malarious regions, and a return
 
 PSEUDO-RHEUMATIC AFFECTIONS. 311 
 
 of the attack be anticipated within one or two days, appropriate 
 doses of quinine or arseniate of quinia being administered. 
 
 As a specific remedy, cimicifuga, in tablespoonful doses of a cold 
 decoction, may be continued for several days, every three or four 
 hours, or, where desirable to employ smaller doses, the specific 
 medicine or a saturated tincture of the root may be used, by adding 
 half a drachm to four ounces of water. A combination of aconite 
 and cimicifuga (Scudder) answers well, the prescrfption being as 
 follows: $ Lloyd's aconite gtt. v-vii, green plant tincture cimici- 
 fuga gtt. xx, water fiv. M., and order a teaspoonful every hour. 
 
 Where cimicifuga fails, where the tongue is coated yellow, or 
 where there is habitual constipation, rhamnus californica may be 
 used, a decoction (ji to the pint of water), in double-tablespoonful 
 doses, being preferred to any alcoholic preparation. The dose 
 should be reduced if too free action on the bowels follows. 
 
 When the pain becomes localized and remains stubbornly, 
 the following prescription, continued for a fortnight, will often 
 result in a cure: $ Phenacetin gr. iii, caulophyllin gr. l-10th, 
 arseniate of quinia 3x gr. ii. M., ft. capsule 110. 1. Duplicate no. 60. 
 Sig., Take one every four hours. The prolonged use of this capsule 
 may result in profuse and and prolonged perspiration, the subse- 
 quent use of two-grain doses of picrotoxin 3x, four times daily, being 
 required to control it. Massage is of much assistance in chronic 
 cases, the muscles gaining tone and energy under its influence, and 
 being thus enabled to better resist disease agencies. 
 
 In chronic cases, we will rely upon this agent in connection with 
 the prolonged use of rhamnus calif ornica or manaca f occasional alter- 
 nation of these remedies being advisable. Manaca may be adminis- 
 tered in from two- to five-drop doses (fl. ext.) four or five times daily. 
 
 In malarious districts, much advantage will attend the continued 
 use of fluid extract grindelia squarrosa (P. D. & Co.), in ten- or fif- 
 teen-drop doses, three or four times a day, in connection with the 
 antirheumatic. 
 
 The diet should be similar to that recommended under the treat- 
 ment of articular rheumatism. 
 
 II. PSEUDO-RHEUMATIC AFFECTIONS. 
 
 ARTHRITIS DEFORMANS. 
 
 Synonyms. Rheumatoid Arthritis; Rheumatic Gout. 
 
 Definition. A progressive, destructive disease of the joints, 
 characterized by inflammation and degeneration of the cartilages 
 and synovial membranes, with the development of bony growths
 
 312 CONSTITUTIONAL DISEASES. 
 
 upon the articular surfaces, and thickening of the ligaments and 
 other soft parts, rendering the joints immobile and deformed. 
 
 Etiology. Though formerly believed to be closely related to 
 both rheumatism and gout, there is a rapidly growing belief, among 
 pathologists, that no connection exists with either, in the causes or 
 nature of this affection. The pathology differs essentially from both 
 that of rheumatism and gout, there being no blood changes as in 
 rheumatism, and no urate of soda deposits as in gout. The symp- 
 toms, iu the start, may so closely resemble those of chronic articu- 
 lar rheumatism as to render the distinction difficult, but this is prob- 
 ably a matter of diagnostic obscurity rather than of similarity of 
 nature. It is asserted that several facts tend to confirm a nervo- 
 trophic theory. Of these may be mentioned the similarity of the 
 affection to joint diseases due to affections of the cord, as in locomo- 
 tor ataxia; the apparent origin of the disease from shocks, mental 
 worry, etc.; the tendency to symmetrical distribution of the lesions, 
 and changes in the muscles, skin, and nails, evidently due, in great 
 measure, to trophic influences. It is asserted that damp dwellings 
 and insufficient and improper food predispose to it, though it seems 
 to be an assumption rather than an established fact. Heredity may 
 exert some influence, though the disease is so rare that a family 
 record over a protracted period must be necessary to arrive at defi- 
 nite conclusions. It is more common in females than in males, and 
 the small joints are most liable to be involved in this sex, males 
 being more subject to involvement of the large articulations. The 
 elderly, the middle-aged, and the young may be affected, though the 
 period between twenty and thirty is the age most susceptible. 
 
 Pathology. The articular cartilages and synovial membranes 
 suffer the earliest and most marked changes, though the ligaments 
 and muscles undergo prominent alterations later on. The artic- 
 ular cartilages become softened and villous in the center, where the 
 greatest pressure is exerted, and gradually wear away, until the extrem- 
 ities of the bones are exposed, these then becoming eburnated. and 
 constituting the articular surfaces. The circumferences of the car- 
 tilages remain and undergo irregular nodulated proliferation, ossifi- 
 cation setting in later, the bony nodosities (osteophytes) serving to 
 lock the motion> of the joints. Meantime, the fringes of the synovial 
 membranes become increased in number and hypertrophied, from 
 augmented vascularity, and later undergo fibrous degeneration, the 
 whole membrane thus becoming thickened and hardened. New bone 
 may also spring up from the periosteum, and the joint gradually 
 becomes locked with bony growths, and firmly bound with thickened 
 bands, the ligaments, as well as the synovial membranes . becoming
 
 PSEUDO-KHEUMATIC AFFECTIONS. 
 
 313 
 
 hardened and thickened, until the joint is finally almost immovable. 
 The muscles atrophy at length, and both hypertrophy and atrophy 
 occur about the expanded extremities of the bones, varying deform- 
 ities thus arising. The nerves about the joint may participate, a 
 chronic neuritis becoming established. 
 
 Symptoms. This disease may be divided into two general 
 forms, viz., acute and chronic. The acute form may be divided into 
 two varieties, the nodosities of Heberden, and the general progress- 
 ive form. 
 
 The nodosities of Heberden are usually confined to the fingers, the 
 disease becoming arrested after involving these parts. The tubercles 
 at the sides of the dorsal surfaces of the second phalanges become 
 slowly enlarged, slightly reddened, and the affected joints are easily 
 hurt by accidental knocks, though not usually 
 painful. The cartilages may become soft, and 
 the extremities of the bones bared later. The 
 joints gradually become more and-more stiffened 
 and disfigured, until all use of the affected part is 
 lost, the patient meantime enjoying good health 
 otherwise. This form is most common among 
 'women. 
 
 The general progressive form may come on 
 suddenly, with acute symptoms, or it may 
 develop by a chronic course. Acute attacks 
 simulate subacute articular rheumatism, though 
 it will be observed that there is absence of 
 blood changes, acid sweats, and cardiac com- 
 plication. There is swelling, pain, and sore- 
 ness of the joints, the synovial capsule and 
 bursse being especially involved, redness usu- 
 ally being noticed, and the local symptoms are 
 accompanied by moderate febrile disturbance. Periods of recupera- 
 tion and exacerbation may attend this form, the acute symptoms 
 subsiding after a few weeks or months, and an approach toward 
 recovery apparently following, to be succeeded by relapses or exac- 
 erbations until the disease has progressed so far as to hopelessly 
 cripple the subject. Anaemia, followed by slight hectic, may ensue 
 upon the subsidence of the fever, the disease thus insidiously 
 advancing, the patient never entirely recovering complete use of the 
 joints 
 
 Children, or women between twenty and thirty years of age, who 
 have become debilitated by child-bearing or from excessive lactation 
 may be affected, the puerperal period being an apt time for the acute 
 onset. It may also occur about the menopause. 
 
 ARTHRITIS DBFORMANS.
 
 314 CONSTITUTIONAL DISEASES. 
 
 The chronic form of progressive arthritis deformans comes on 
 insidiously. Slight pain, tenderness, and swelling may involve a 
 single joint at first, apparent recovery shortly ensuing, perhaps, 
 but recurrences continuS to follow, one after another, until perma- 
 nent deformity and impairment of function become settled. Other 
 joints have become involved before this time, sometimes all the large 
 ones being implicated, though often not more than one or two may 
 be affected. These gradually become rigid and motionless, and mus- 
 cles atrophy from disuse and degenerative changes, contraction of 
 the flexors gradually drawing the thighs upon the abdomen and the 
 legs on the thighs, while the arms are drawn to the sides, with the 
 forearms flexed upon them and the articulations locked, the patient 
 remaining in a recumbent posture, unable to move about or use his 
 extremities, except, possibly, the hands, which may have escaped. 
 
 Diagnosis. There is more deformity and less severe pain when 
 the joints are at rest than in acute or chronic rheumatism, and 
 immobility progresses more rapidly than in either of those affec- 
 tions. In gout, the smaller joints are almost exclusively affected, 
 while in this disease all joints are equally liable, and the attacks are 
 not erratic, as in gout. 
 
 Prognosis. There is little prospect of recovery, after the dis- 
 ease has progressed far enough to render the joints immobile, though 
 if treatment be begun early it may be considerably modified. 
 
 Treatment. We know so little about remedies which influence 
 trophic impulses that we cannot prescribe with any certainty on these 
 lines. However, we are acquainted with a few remedies which seem 
 to exert an influence over the nutrition of the joints, and it is possi- 
 ble that some if not all of them act through the trophic centers. It 
 is certain to my mind that minute doses of silica 3x, continued 
 through a long period (a year or more), exerts a decided influence 
 upon arthritic conditions of the finger-joints (Heberden's nodosities). 
 With this as a pointer, we may make a systemtized study of such 
 other agents as have been known to favorably influence joint affec- 
 tions of various character, and, as the chronicity of these cases will 
 afford a good opportunity to test them well, they may be used in 
 rotation, giving each one an extended trial, unless, perchance, the 
 successful one should be found early in the day. We will find, upon 
 referring to Dynamical Therapeutics, that calcium floride, stillingia, 
 berberis aquifolium, corydalis, and several other remedies are service- 
 able in arresting the development of nodes, while cistus canadensis, 
 kdum pafustre, and puLsatilla possess the reputation of influencing 
 various structures about the joints. A careful study of these reme- 
 dies in this connection will afford some satisfaction to the investi-
 
 PSEUDO-RHEUMATIC AFFECTIONS. ,. 315 
 
 gating physician, and may prove of lasting benefit to the patient. 
 Massage is an excellent measure, and it should be put in practice 
 early and persisted in for years, especial attention being paid to the 
 spinal column, joints, and muscles. Cold compresses are serviceable 
 to relieve pain in the joints, and should be applied at night espe- 
 cially (provided they are comforting to the patient), that rest may con- 
 tribute toward recovery. Motion of the joints should be avoided, 
 except passive motion during massage to prevent contraction of the 
 muscles. Electricity affords little if any benefit. Depleting agents, 
 such as iodide of potassium and the salicylates, should be avoided. 
 
 The diet should be generous, nourishing, and stimulating the 
 very opposite to that of rheumatism. Where the digestion is good, 
 beefsteak, roast beef, mutton, and fowl, fish, eggs, and milk may be 
 taken liberally. Also fats, such as butter, cream, suet pudding, olive 
 oil, and other oleaginous articles. Malt liquors are not objection- 
 able here, and porter, ale, or stout may be used, to stimulate diges- 
 tion, and assist in nourishing the patient. 
 
 Where the patient is financially qualified, the hot springs of Vir- 
 ginia, Arkansas, or Banff may be recommended before the disease 
 has advanced beyond reasonable prospects of benefit. 
 
 GONOBEHCEAL RHEUMATISM. 
 
 Definition. A septic synovitis or arthritis, due to infection 
 from gonorrhoeal virus. 
 
 Etiology. It is now generally believed that ptomaines gener- 
 ated within and absorbed from the urethra give rise to the mild or 
 non-suppurating form, while the more severe or suppurating cases 
 arise from the infection of the system with pus-organisms. It occurs 
 more frequently in men than in women, possibly because the genital 
 passage affords greater opportunity for the burrowing of the gonor- 
 rhoeal virus. Relapses are common and progress slow, under the 
 most favorable conditions. 
 
 Pathology. There is synovitis, with dryness of the synovial 
 membrane, a crackling sound attending motion of the joint. In 
 severe cases, there is destruction of the cartilages, and permanent 
 thickening of the synovial membrane. 
 
 Symptoms. The symptoms vary considerably, the disease 
 sometimes running an acute and rapid course, and at others assum- 
 ing a chronic condition, which may last for years. In some cases, 
 the symptoms will be limited to arthritic pains, which linger about 
 the joints for a long time, there being total absence of redness, swell- 
 ing, or tenderness. Sometimes the joints are intensely painful, red-
 
 316 CONSTITUTIONAL DISEASES. 
 
 dened, and swollen, the condition resembling inflammatory rheuma- 
 tism, but being of more persistent and less active character. In 
 another case, a single joint may be involved, with extreme swelling 
 aud oedema and a probability of suppuration, though resolution may 
 follow. Chronic hydrarthrosis may be one of the conditions, while 
 iu other cases the burste of the patellae, olecranon, and tendo Achil- 
 lis may be the parts principally affected. 
 
 One peculiarity about the disease is its tendency to involve artic- 
 ulations seldom affected by articular rheumatism, such, for instance, 
 as the sterno-clavicular, sacro-iliac, iutervertebral, and temporo- 
 111 axillary. Fain is a prominent feature. 
 
 Diagnosis. The history of the case will be sufficient aid in 
 diagnosing this disease from other affections of the joints. 
 
 Prognosis. Not favorable to a speedy termination, though it 
 may not shorten life. 
 
 Treatment. Herberts aquifolium, cistus canadensis, and echinacea 
 should be tried persistently. Cabinet vapor baths afford some relief. 
 It is asserted that free incision of badly affected joints with subse- 
 quent irrigation, affords the best results, fixation of the joints to 
 prevent motion alleviates much pain. 
 
 IU. GOUT. 
 
 Synonyms. Podagra. 
 
 Definition. A disorder arising from disturbances of the assim- 
 ilative functions, characterized by attacks of acute inflammation of 
 the small joints, with the gradual deposition of urate of soda in the 
 articular cartilages and other parts of the joints, with erratic consti- 
 tutional disturbances. 
 
 Etiology. Sixty per cent of all cases of gout are hereditary, 
 showing a constitutional predisposition. Inability to properly 
 assimilate nitrogenous material results in an excess of urates in the 
 system, these becoming deposited in the cartilages and other tissues, 
 and exciting inflammatory action. 
 
 Gout is a disease of middle life, few suffering from it while young, 
 unless there be an exceptionally strong hereditary tendency. The 
 gouty person is diseased from inability to oxidize nitrogenous food; 
 excess of this, faulty digestion, and sedentery habits which tend to 
 lack of oxygen inthe system being provoking factors. Workers in 
 lead are especially prone to gout. 
 
 The idea that all gouty persons are gourmands is a mistaken one 
 An individual may be an apparently moderate consumer of nitroge- 
 nous food and yet be gouty, because he peculiarly lacks the consti-
 
 GOUT. 
 
 317 
 
 tutional ability to safely dispose of nitrogenous food, either through 
 sedentary habit, hereditary weakness, or character of vocation. Not 
 all subjects of gout are wealthy and high-lived. The disease occurs 
 among the poorer classes who consume much malt liquor, in connec- 
 tion with poor food and bad hygienic surroundings. 
 
 Pathology. The blood of gouty persons shows an excess of 
 uric acid. If five or six drops of acetic acid be added to ^iii of blood- 
 serum from a gouty person in a watch-glass, and a thread be 
 immersed here a few hours, it will be found to be incrusted with 
 crystals of uric acid. The same results occur, however, when serum 
 from the blood of a leukaemic or chlorotic individual is employed. 
 In gout, the uric acid combines with sodium, and becomes deposited 
 as urate of soda in the tissues of the articulations, especially of the 
 lower extremities. 
 
 mm 
 
 .?..ir.v/, .v-*,-,: : ..>>-. 
 
 GOUTY CABTILAGE. 
 
 PAPILLA OF GOUTY KXDSEY. 
 
 These deposits may become extensive in chronic gout and form 
 concretions of chalky material (tophi or chalk-stones), which, in 
 extreme cases, may even cause ulcerations through the skin, and 
 appear externally. These concretions, in greater or less quantity, 
 accumulate in the articular cartilages and cause necrotic areas, the 
 part furthest from the circulation being probably most affected. 
 The cartilage in the first joint of the great toe is liable to be involved 
 in the beginning, but the knees, ankles, and small joints of the hands 
 become affected in succession. The cartilages are first involved, 
 then the nbro-cartilages and ligaments may be infiltrated; the syn- 
 ovial fluid may also contain crystals of urate of soda. Immobility of 
 the joints results in long-standing cases, as exostoses, occurring 
 upon the margins of the articular surfaces, serve to lock those already 
 stiffened by concretions deposited in the fibro-cartilages and liga- 
 ments. Chronic gout is often signalized by the appearance of yel- 
 low nodules in the cartilage of the ear, at the margin of the helix, 
 composed of gouty concretions. These may also accumulate in the 
 cartilage of the eyelid, nose, and larynx. The deposit is interstitial,
 
 318 CONSTITUTIONAL DISEASES. 
 
 though it may appear to be upon the surface of the cartilage, subse- 
 quent coagulation necrosis affecting its release. 
 
 The kidneys and arteries suffer most severely, after the joints. 
 Both cortical and medullary portions of the kidney may be infiltra- 
 ted with crystals of urate of soda, but the papillae are most promi- 
 nently affected, striae of whitish deposit appearing here, both in the 
 intertubular tissue and within the tubules. These occur in intersti- 
 tial nephritis, and their presence cannot be considered pathogno- 
 monic of gout unless there be the articular disturbance to confirm it. 
 Arterio-sclerosis commonly occurs in chronic gout, it being asserted 
 that concretions of urate of soda are found on the cardiac valves, the 
 left ventricle being* hypertrophied. 
 
 Symptoms. Gout may be divided into regular and irregular 
 forms. In regular gout the manifestations occur about the joints, 
 principally, while in irregular gout there are no arthritic manifesta- 
 tions, internal organs being the points of uratic deposit. In a few 
 acute cases there is retrocedent or suppressed gout, the disappearance 
 of the arthritis being attended by serious disturbance of internal 
 organs, such as severe gastro-intestinal symptoms (vomiting, purg- 
 ing, abdominal pain, and prostration), cardiac manifestations, such 
 as dyspnoea, irregular action of the heart, or angina, and sometimes 
 cerebral complications, such as delirium and coma, or apoplexy. 
 
 In acute gout there may be premonitory symptoms, such as 
 fugitive pains in the small joints of the hands and feet, insomnia, indi- 
 gestion, and irritability of temper, for several days prior to the 
 onset If the urine be examined now it will be found to contain 
 urates and traces of albumin or sugar. Asthmatic attacks may also 
 occur during this time. At length, between the hours of one and 
 four o'clock A. M., the subject is suddenly seized with an excruci- 
 ating pain in the metatarso-phalangeal articulation of the great toe 
 of one foot (usually the right), and this persists for hours, the pain 
 being throbbing, tensive, or burning. The part swells rapidly, and 
 soon appears as though suppuration were impending. It is hot, tense, 
 and shiny, and extremely sensitive, the pain becoming agonizing, as 
 though the part were squeezed in a vise. The pain subsides in the 
 mo'rning, though the part remains swollen throughout the day, and 
 about the same hour on the following night there is a recurrence, 
 this state of affairs continuing for six or eight days, the severity of 
 fche symptoms gradually wearing away. During the paroxysms there 
 is considerable constitutional disturbance, the temperature rising to 
 102 or 103 F. Desquamation of the skin follows the subsidence of 
 the swelling. Within from three months to a year another attack 
 occurs, and now the disease is liable to manifest a tendency to reach
 
 GOUT. 
 
 319 
 
 further out and involve new territory. If one joint only was affected 
 at first, the corresponding joint on the opposite foot may now be 
 affected also, and another time one or more additional joints may be 
 involved. The recurrences incline to become more and more fre- 
 quent after each repetition, and, finally, a constant inflammatory con- 
 dition, constituting chronic gout, becomes established. During all 
 these attacks suppuration of a joint never occurs. 
 
 All goufc is, strictly speaking, chronic gout, but the term is usually 
 applied to those cases where the paroxysms coalesce and the joints 
 have become permanently involved. Concretions of chalky material 
 have now formed around the articulations, and there is such crip- 
 pling as to interfere with locomotion and prehension. The joints 
 
 become noticeably distorted enlarged and 
 nodulated and immovable, the skin cover- 
 ing them being congested, and the super- 
 ficial veins dilated. Tophi may perforate 
 the surface here later, and be discharged as 
 a yellowish-white substance, or remain, 
 causing chronic ulceration. 
 
 The general health now appreciably 
 deteriorates, the "gouty diathesis" being 
 established. The skin is pale and sallow, 
 and the patient presents a general appear- 
 ance of invalidism. There are muscular 
 cramps, dyspeptic symptoms, cardiac dis- 
 turbances with occasional prsecordial pains, 
 irrritability and restlessness, nocturnal 
 wakefulness, tic douloureux, urinary diffi- 
 culties with albuminous deposits, gouty 
 Daily heat and redness of the nose is a common 
 
 GOUTY HAND. 
 
 abscesses, etc. 
 symptom. 
 
 Irregular gout presents itself in numerous forms. Retrocedent 
 gout, which occurs in acute attacks, is included under this term. 
 Numerous individuals who belong to gouty families may never man- 
 ifest articular disease, and yet be subject to gouty affections uratic 
 deposits in structures other than those of the joints and these mav 
 be either acute or chronic. 
 
 Nervous affections are common results of irregular gout. Head- 
 ache, vertigo, delirium and acute mania may result from retrocedent 
 gout. More chronic conditions arise from gradually acquired uratic 
 deposits in internal organs. Epileptic seizures, neuritis, with neu- 
 ralgia, formication and numbness, startings of the limbs, cramps, 
 meningitis, or apoplexv may be due to the influence of gouty deposits
 
 320 CONSTITUTIONAL DISEASES. 
 
 in various portions of the nervous system, though the apoplexy 
 will usually be due to involvement of the cerebral arteries. Gouty 
 implication of the sheath of the sciatic nerve may give rise to an 
 obstinate form of sciatica, which may extend upward and involve the 
 spinal cord. 
 
 Vascular disorders may arise from gouty deposits in various parts 
 of the circulatory organs. There is no special cardiac inflammation 
 arising from gout, as in rheumatism, but cardiac disturbances from 
 gouty encroachment are not uncommon, patches of deposit may 
 occur upon the pericardium. Valvular enlargement and obstruction, 
 with subsequent hypertrophy and fatty degeneration of the heart- 
 muscle, may arise from uratic deposits in their structure. Atheroma- 
 tous conditions of the arteries, or arterio-capillary fibrosis with 
 thickening of the muscular coat of the small arteries may be set up. 
 Various unpleasant symptoms may thus arise, such as erratic cardiac 
 pains, and sometimes angina pectoris, palpitation at times, or slow, 
 feeble, and irregular or intermittent pulse, sensations of constriction 
 about the cardiac region, with dyspnoea, anxiety, and sense of 
 impending dissolution. 
 
 Digestive disorders are common symptoms of irregular gout. 
 There may be erratic pains in the epigastric region with difficult 
 digestion, or occasional attacks of gastritis, with cramps and vomit- 
 ing, accompanied, perhaps, with intestinal colic and diarrhoea. 
 Hepatic colic may arise, or fatty degeneration of the liver. Dys- 
 phagia is not an unfrequent symptom. 
 
 Urinary difficulties are among the complications of irregular gout. 
 There may be renal colic with calculous formations, both renal and 
 vesical, with chronic vesical and urethral irritation, and, sometimes, 
 oxaluria. 
 
 Pulmonary affections may be gouty in character, and due to uratic 
 deposits in these organs. Asthma, dry bronchitis, and emphysema, 
 are the common ailments, pneumonia never arising as a sequela of 
 gout. 
 
 Cutaneous affections, arising in persons of hereditery tendency to 
 gout, may be very stubborn and intractable, and be ascribed to a 
 gouty diathesis. Eczema, erythema, acne, urticuria, psoriasis, pru- 
 rigo, both local and general, as well as destructive inflammation of 
 the iris, with loss of sight, may be ascribed to gouty influences. 
 
 Diagnosis. The only disease liable to be mistaken for gout is 
 rheumatism. It will be remembered that gout is comparatively rare 
 in this country, while rheumatism is quite common. The onset of 
 gout is also peculiar, only one joint being involved in the beginning 
 (two at most), and that usually the metatarso-phalangeal articula-
 
 GOUT. 321 
 
 tion of the great toe. The time of attack between midnight and 
 morning is also peculiar. Subjects of gout are either hereditarily 
 predisposed, or thfey have been addicted to high living or malt 
 liquors and are accustomed to sedentary habits, while subjects of 
 rheumatism have been accustomed to hardships and exposure. 
 Acute articular rheumatism affects young persons and is usually 
 attended by high fever, while gout hardly ever comes on before 
 thirty-five and is attended by mild febrile symptoms. Tophi never 
 form iu rheumatism and are common in gout, and the microscope 
 will detect crystals of uric acid in the blood of gouty persons but 
 not irf those with rheumatism. The joint affection of pyaemia will 
 hardly be mistaken for that of gout, as the previous history will 
 not permit of any confusion of this kind. 
 
 Prognosis. Gout is not a rapidly fatal disease, and its sub- 
 jects may live to old age, though serious visceral complications are 
 liable to eventually terminate fatally. Recovery is rare, unless the 
 subject abandons a sedentary life and high living. Albuminous 
 urine, with absence of uric acid in the secretions, is ominous, espe- 
 cially if the subject be cachectic and the joints are greatly crippled. 
 
 Treatment. A gouty subject should forever abandon an in-door 
 and sedentary life, and forswear alcoholic liquors and saccharine 
 substances. An out-door life, with moderate exercise, should be 
 adopted, and he should eat to live, not live to eat. A high and dry 
 location is the best place of residence, and a climate permitting of 
 plenty of out-door life the year round is preferable, as this conduces 
 to the inhalation of a generous amount of oxygen. High, well ven- 
 tilated rooms, without draughts, should be occupied at night, and 
 early retiring should be an established custom. Young persons 
 hereditarily disposed to gout should be encouraged to take plenty 
 of exercise, though actual subjects of the disease should avoid active 
 exertion. 
 
 The diet is an important consideration. Sugar should be strictly 
 avoided, and fruits containing much saccharine material should also 
 be dispensed with; for, though not a nitrogenous material, the pres- 
 ence of sugar during the digestion of nitrogenous food tends to the 
 formation of uric acid. Sweet wines and malt liquors, for similar 
 reasons, come under this objection. Dilute old claret and whisky, 
 or dry sherry are the least objectionable, though total abstinence is 
 best, unless there is some urgent need for alcohol something not 
 liable to often occur. Much starchy food is also objectionable, as 
 the starch is converted into sugar during digestion. 
 
 The diet of a gouty person should consist principally of fresh 
 green vegetables, with a few fruits which do not contain much
 
 322 CONSTITUTIONAL DISEASES. 
 
 sugar used sparingly. As this entails a certain objectionable bulki- 
 ness to the amount of food required, however, a small portion of 
 lean beef or mutton may be allowed each day, though this should 
 never be cooked but once never warmed over. Pickled meats 
 should never be used, as they are especially objectionable, and so also 
 are all forms of pickled fish. Certain kinds of fresh fish are allow- 
 able, such as those which are tender when boiled or broiled (the 
 form to be taken in ), but those of firm flesh and containing consid- 
 erable fat, like the salmon, mackerel, halibut, and codfish should be 
 avoided. The best fisli for the gouty are the bluefish, whitefish, 
 bass, and shad, which may be taken occasionally, as a change of food. 
 Oysters and clams are allowable, but shrimps, lobsters, and crabs 
 should be prohibited, their use on salads being especially pernicious. 
 Eggs are generally prohibited. Milk disagrees with many, and is 
 believed to be injurious to old persons afflicted with gout. Veal, 
 pork, bacon, ham, and game are not allowable. A few vegetables 
 are prohibited on account of the fact that they contain oxalic acid, 
 which produces oxaluria. These are sorrel, radishes, asparagus, 
 and rhubarb. Some debar tomatoes and spinach, on the same 
 grounds. Beets, being sugar-producing vegetables, are forbidden, 
 and also those which possess the objection that they occasion flatu- 
 lence, such as cabbage, green corn, matured peas, beans, onions, 
 and corn. Oil should be omitted from salads, as all fats embarrass 
 the digestion of nitrogenous food. All food cooked in fat must be 
 avoided, though butter may be allowed sparingly. Farinaceous food, 
 stale bread, rice, sago, tapioca, oatmeal, and cracked wheat may be 
 allowed, but pastry, hot rolls, warm bread, hominy, and griddle cakes 
 should be avoided. All preserves and confectionery are to be for- 
 bidden; also fruits which contain a large amount of sugar, as grapes, 
 figs, banannas, and prunes. Strawberries are also objectionable, 
 because they contain much acid. Fruits, served for the gouty, 
 should be taken without the addition of sugar. Apples and pears, 
 when well-ripened (fresh, baked, or stewed), may be allowed. 
 Oranges and lemons may be partaken of sparingly. Nuts, pickles, 
 vinegar, spices, strong condiments, salted foods, truffles, and mush- 
 rooms are to be prohibited. 
 
 Fluids are essential, and water may be taken freely, as plenty of 
 diluent tends to flush the tissues and wash away gouty material. 
 All fluids, however, should be taken between meals. Weak tea and 
 coffee may be taken without sugar, though they are better omitted 
 entirely, not because they aggavate gouty conditions, but because 
 there are other objections. Alcoholic drinks have already been men- 
 tioned. Saline and mineral waters are excellent for gouty subjects,
 
 LITELEMIA. 323 
 
 and two or three courses at certain mineral springs every year are 
 to be com mended. Some of the leading waters of this country are 
 at the springs of Saratoga, New York; St. Clair, in Michigan; St. 
 Catherine, in Ontario; the hot springs of Arkansas, Virginia, and 
 California (Paso Robles), and various others. The Carlsbad Springs 
 in Bohemia are a favorite resort for Europeans, and many Americans. 
 
 The medical treatment of gout consists in the use of cdchicum and 
 guaiacuni during acute attacks, and lithium as an alternate, or remedy 
 for the intermediate periods. Five grains of the citrate of lithium 
 may be taken at a dose, three or four times daily, dissolved in a 
 glassful of potash water. During an acute attack, the affected foot 
 should be elevated and from twenty to thirty drops of wine of col- 
 chicnm administered every three hours, until its purgative action 
 becomes manifest, when the dose should be diminished to one-fourth 
 the size, or less. This may be alternated or combined with the cit- 
 rate of lithium, as already directed. A flannel or cotton batting 
 wrapping should be kept around the affected joint, and this may be 
 moistened with chloroform liniment, to be repeated, if relief attends 
 its action. Sometimes a hypodermic injection of morphine, near the 
 joint, is useful to relieve the severe suffering. Chronic gout will 
 require the judicious selection of proper tonics, the influence of sil- 
 ica upon the nutrition of cartilage being remembered. 
 
 Dr. Lional S. Beale believes that other alkalis than lithia are 
 sometimes more efficacious. He believes in their rotation, as the 
 single agent seems to finally lose much of its effect when continued 
 for a protracted period. He thus employs various carbonates, such 
 as carbonate of lithia, potash, soda, and ammonia. Vapor baths 
 will assist in the treatment of chronic cases, by promoting activity 
 of the skin. 
 
 During acute gout considerable benefit may be derived from jab- 
 orandi and other properly selected sedatives, administered often, in 
 small doses, though as much benefit must not be expected as in 
 rheumatism. 
 
 IV. LITHJEMIA. 
 
 Definition. A condition in which there is an excess of uric 
 acid in the blood, characterized by disturbances in the retrograde 
 changes of the body, with excess of lithic acid in the urine, the renal 
 secretion being increased. 
 
 Etiology. This disease is a functional one (there being no 
 uratic deposits in the system), the tendency to such a condition 
 depending largely upon inheritance. It afflicts those who have never 
 indulged in excessive eating or drinking, a primary weakness of the
 
 324 CONSTITUTIONAL DISEASES. 
 
 digestive and assimilative powers seeming to be at the fonndation 
 of the trouble. In other cases, excesses in eating or drinking, or 
 protracted sedentary habits may be reasons for its acquirement. 
 Indulgences in the consumption of meat, stimulants, or narcotics, 
 sexual excesses, or prolonged mental or nervous strain may either 
 develop such a state, or aggravate and render prominent latent 
 lithaemic tendencies already inherited. Lack of power to digest 
 nitrogenous material results in the formation of uric acid in the 
 blood. The condition is sometimes associated with rectal disease, 
 especially papillae and pockets, and it seems as though this condi- 
 tion might be a frequent causal factor. 
 
 Anything that interferes wito. a free supply of arterial blood to 
 the superficial capillaries will naturally tend to bring about lithse- 
 mia. Obstruction may be one cause, and perverted or inadequate 
 peristaltic action of the alimentary canal another. Splenic or 
 hepatic engorgement tends to interfere with the free flow of blood 
 through the casliac axis, and therefore interferes with a vigorous 
 abdominal circulation. Malarial cachexia commonly predisposes to 
 this condition, and lithaemia may arise as a result. The second con- 
 dition, torpid peristaltic action, may arise from chronic constipation, 
 the frequent cause of this condition being rectal disease, with 
 sphincteral spasm. That oxygen in the intestinal capillaries aids in 
 the elimination of uric acid in the blood has been proven experi- 
 mentally, by the rectal use of oxygen gas in lithaemia. 
 
 Pathology. Arterial changes are the most common and seri- 
 ous pathological changes which occur. While there is no evidence 
 of uratic deposits in the tissues, arterio-sclerosis from fibroid degen- 
 eration frequently occurs. Many disturbances similar to those aris- 
 ing from irregular gout also arise, such as gastro-intestinal irritation, 
 asthma, cardiac disturbance, neuralgia, and headache. 
 
 Symptoms. Acute and chronic indigestion are the leading fea- 
 tures of this disease. Acid eructations, flatulency, and constipation 
 are usually present, though the bowels may move regularly or there 
 may be diarrhoea alternated with constipation. Though there may 
 be no coating on the tongue, the breath, as well as the exhalations 
 and perspiration, is usually offensive. 
 
 The skin and its appendages manifest evidences of perverted 
 nutrition. The skin is dry and scaly, and there are often cutaneous 
 eruptions, eczematous in character. The hair and nails are dry and 
 brittle. Temporary palpitation of the heart is a common symptom, 
 this being functional in character, usually, and is often aggravated 
 or brought on by eating. Slight jaundice may be present, and care- 
 ful palpation may detect hepatic congestion. Nervous symptoms,
 
 LITH^MIA. 326 
 
 such as headache, giddiness, insomnia, with oppression of breathing 
 at night, requiring an upright position, melancholy and despondency 
 with erratic irritability and anxiety, are prominent features, due 
 rather to digestive disturbance than to the presence of lithic acid. 
 The urine is usually high-colored, and deposits a sediment upon 
 standing until cool. This may consist of uric acid, urea, phosphates, 
 and oxalate of lime. Examination of the heart may detect arte- 
 rial tension, and such a condition may persist years without apparent 
 serious results, though finally gout, arterio-sclerosis, or contracted 
 kidney will become fully developed. 
 
 Diagnosis. The persistent and distressing gastric disturbance 
 following eating, and the almost constant presence of an excess of 
 uric acid and phosphates in the urine, will distinguish this condition. 
 
 Prognosis. "Where treatment is begun early, and intelligently 
 pursued, there is little doubt of success, provided the patient will 
 assist by adhering to a proper diet. 
 
 Treatment. Attention should be paid to the habits of the 
 patient as regards exercise, diet, and the general condition of the 
 alimentary canal. Careful examination should be made to deter- 
 mine, if possible, a local cause for the flatulency and indigestion. 
 Hypertrophy of the spleen will demand the use of carduus marianus, 
 poiymnia, ceanothus, or, if there be pronounced malarial complication, 
 grinddia squarrosa. Hepatic congestion will suggest chelidonium, nux 
 vomica, or nitro-hydrochloric acid. To relieve the excess of uric acid 
 in the blood, the citrate or carbonate of lithia should be taken in three- 
 or four-grain doses, dissolved in water, three times daily. Pipera- 
 zin is another remedy for this condition, and a very reliable one. 
 Three or four grains may be taken at a dose, four times daily. 
 
 Cabinet vapor baths, aided by the tonic faradic treatment, exert a 
 highly beneficial influence here, promoting cutaneous secretion and 
 invigorating the organs of digestion and circulation, as well as 
 relieving insomnia and painful conditions. The patient should 
 remain in the bath from fifteen to thirty minutes, and it should be 
 repeated two or three times each week. It will assist other meas- 
 ures very much, and should not be omitted. 
 
 Careful inspection of the condition of the rectum should be made, 
 and any evidence of disease here be corrected. Rectal pockets and 
 papillae should be incised, and hemorrhoids, ulcers, and other dis- 
 ease properly treated, the sphincter ani, meantime, being well 
 stretched. 
 
 The diet should consist largely of milk and vegetable food, butch- 
 ers' meat being an aggravating cause of the difficulty. Fruits are 
 not objectionable, and may be partaken of freely. Only once a day
 
 326 CONSTITUTIONAL DISEASES. 
 
 should any form of meat be included in the dietary, and this should 
 then be used sparingly. Quantity should also be considered, and 
 the amount of food consumed limited to the actual needs of the body. 
 
 In order to promote free peristaltic action and a vigorous abdom- 
 inal circulation, a copious clyster of strong salt water should be used 
 every morning, soon after breakfast, and repeated, if a free evacua- 
 tion does not follow the first injection; and upon retiring at night 
 and rising in the morning, the whole abdominal surface, especially 
 that over the epigastric region, should be vigorously slapped with 
 the open hands. This may seem a hardship at first, but it will 
 finally become a source of pleasure. 
 
 Mineral waters are beneficial, and plenty of pure water is always 
 proper. Alcoholic beverages are not admissible, and tea and coffee 
 should be substituted by a single cup of weak cocoa at breakfast, 
 milk or water being taken at other times. 
 
 V. DIABETES MELLITTTS. 
 
 Synonyms. Glycosuria; Glucosuria; Glyeoheemia; Mellituria. 
 
 Definition. A constitutional disorder arising from malassimi- 
 lation, characterized by the presence of sugar in the urine. 
 
 Etiology. It has been discovered that an area exists in the 
 medulla oblongata (on the floor of the fourth ventricle) which pre- 
 sides over the glycogenic functions, and that if this part be irritated, 
 either experimentally or accidentally, sugar soon afterward appears 
 in the urine. Concussion of the brain, cerebral hemorrhage, softeu- 
 ing of the brain, or other cerebral disease, such as cirrhosis or 
 pressure from tumor, may give rise to glycosuria. Any cause of irri- 
 tation of the glycogenic center, even mental stress, such as severe 
 mental strain, grief, or sudden shock from fright or surprise, may 
 result in this disease. Alcoholism, pregnancy, indigestion, and the 
 immoderate use of sugar and new wine have been ascribed as causes. 
 
 Pathology. Sugar is found in the blood, and in the secretions 
 and excretions of all organs, though most abundantly in the urine. 
 The amount may equal nine or ten parts in a thousand of the blood, 
 and here are also found glycogen, acetone, and kreatin, the propor- 
 tion of fat also being greater than normal. 
 
 Nearly all the vital organs manifest evidences of degenerative 
 changt. as the disease progresses. The liver is hypersemic, with 
 .ireas of fatty degeneration, and the lungs show points of catarrhal 
 pneumonia with gangrenous tendencies, tuberculous deposits, or 
 patches of pleuritic inflammation. The spleen is enlarged, congested, 
 anil hardened. The kidneys are hypersemic, and bear evidence of
 
 DIABETES MELLITUS. 327 
 
 parenchymatous inflammation. The heart is pale, soft, and flabby, 
 and the muscles generally are pale and dry. The brain is variously 
 altered, sometimes being cirrhotic, at others softened, and tumors 
 may be present about the fourth ventricle, suggesting a probable 
 cause of the disease. Wandering parasites (cysticerci) may burrow 
 in the region of the diabetic area and cause the irritation essential 
 to the disease. The pancreas is often notably altered, atrophy and 
 fibroid degeneration being the condition. Emaciation is a marked 
 feature in autopsies, and the skin is usually the seat of various 
 degenerative changes, such as boils, carbuncles, and gangrene. 
 
 Symptoms. Two forms occur, the acute and the chronic. 
 The acute form commonly attacks young persons or those below 
 middle age, while chronic diabetes is most usually observed in 
 those of advanced life. Acute cases are rapid in their course, termi- 
 nating fatally within a few weeks, while chronic diabetes may linger 
 for years. 
 
 In any event, the onset is usually insidious. The subject may be 
 impressed that he is losing strength and flesh, that there is 
 unnatural thirst, and that he is obliged to rise frequently to urinate, 
 during the night. Sexual desire soon becomes abolished, and intol- 
 erable itching of the genitals or other parts, with unnatural dryness 
 of the skin and mucous membranes, is present. Arrest of the menses 
 occurs in women, often with troublesome pruritus pudendi, as well 
 as itching of the cutaneous surface. 
 
 Thirst is a prominent and distressing symptom, and a large 
 amount of water is consumed, the greatest quantity being demanded 
 an hour or two after meals. Digestion is often good in chronic 
 cases, and the appetite may be ravenous. 
 
 The tongue is dry, red, and glazed, or, in some chronic cases, 
 covered with a dry brown coating ; the throat is dry, and the saliva 
 scanty and viscid, or absent. The gums are pale and retracted, and 
 bleed easily, and the teeth soon become carious. The breath and 
 exhalations from the body generally are marked by a sweetish odor. 
 In acute cases there may be nausea and vomiting, with dyspeptic 
 symptoms, and intense headache followed by delirium and coma may 
 occur. 
 
 The special senses may be involved, especially that of sight, soft 
 cataract or amblyopia sometimes developing. The temperature, 
 pulse-rate, and respiration are usually below normal. Mental symp- 
 toms are prominent in most cases of diabetes. The patient is irri- 
 table, peevish, restless, and melancholic, with periods of dullness 
 and apathy. 
 
 THE URINE. The urine is a subject of considerable importance
 
 328 CONSTITUTIONAL DISEASES. 
 
 in this disease, as it is the principal element to be considered in 
 diagnosis. Occasionally there is not marked increase in quantity, 
 but usually the amount voided is enormously large, amounting, in 
 mild o ises, to from six or eight pints, to as high as fifty in extreme 
 cases, within twenty-four hours. The specific gravity is high, rang- 
 ing from 1.026 to 1.045. The urine is pale and clear, almost as lim- 
 pid as water, and possesses a sweetish odor and taste, and an acid 
 reaction. Tests for sugar detect a varying quantity (from one to 
 ten per cent) of sugar present. Ten or twenty ounces, and even as 
 much as one or two pounds, may be excreted in twenty-four hours. 
 
 Various tests, to determine the presence of sugar in suspected 
 urine, have been recommended. A few of the most important ones 
 are appended: 
 
 Trommer's Test. Add a few drops of a dilute solution of sulphate 
 of copper to a drachm of urine in a test-tube, and then an equal 
 balk of liquor potassse. Boil, and if sugar be present, a yellow or 
 orange red precipitate occurs. 
 
 Filing's Test. Add a drachm of Fehling's solution to a test-tube 
 and boil. If the solution remain clear, add a few drops of the 
 suspected urine, and boil again. If there be sugar present, the yel- 
 low suboxide of copper is precipitated. 
 
 Fermentation Test Add a particle of yeast to a test-tube full of 
 urine, and invert the tube so it will stand in the same liquid, in an 
 open vessel. If there be sugar present, fermentation will go on with 
 the formation of carbon dioxide, which accumulates in the upper 
 portion of the tube and gradually expels the urine. 
 
 Bismuth Test. To half a drachm of the suspected urine add an 
 equal bulk of solution of potassa and a pinch of subnitrate of bis- 
 muth, and boil for one or two minutes. If sugar be present, black, 
 metallic bismuth deposits. 
 
 COMPLICATIONS. Various complications arise as results of the 
 continued presence of the saccharine material in the blood: 
 
 Cutaneous affections, such as eczema, boils, and carbuncles, and 
 sometimes gangrene, are apt to arise. Pruritus may attend any of 
 these, or arise independently. The frequent calls to urinate and the 
 local irritation caused by the affected urine give rise to severe ery- 
 thematous inflammation about the genitals in some cases, especially 
 in women, and balanitis is not uncommon in men. In other cases 
 there may be only troublesome itching. 
 
 The urinary tract generally, may be involved. Cystitis or nephri- 
 tis may be present, and albuminuria may develop in connection with 
 arterio-sclerosis. 
 
 Pulmonary complications are frequent, pneumonia or pulmonary
 
 DIABETES MELLITUS. 329 
 
 gangrene arising, the pleura sometimes participating. Tuberculous 
 complication often occurs in the bronchi or lung parenchyma, in 
 which the tubercle bacilli are present, demonstrating true tuber- 
 culosis. 
 
 A wide range of nervous symptoms attend this disease. Diabetic 
 coma is a frequent complication among young subjects. It may 
 sometimes be the first symptom to be noticed, and it terminates 
 many cases suddenly. Headache, delirium, and dyspnoea, with sub- 
 sequent cyanosis, rapidly failing pulse, exhaustion-, and coma, with 
 death in four or five days, are the usual symptoms. Sometimes sud- 
 den exhaustion and coma come on after severe exertion, the patient 
 succumbing in a few hours. In other cases, the patient may be sud- 
 denly attacked with severe headache and intoxication, without pre- 
 vious dyspnoea or exertion, and rapidly sink into unconsciousness 
 and fatal stupor. 
 
 Disturbances of motion and sensation arise in various instances. 
 Periplieral neuritis, characterized by numbness, tingling, or neuralgic 
 pains darting through the lower extremities, sometimes occurs, 
 attended by loss of muscular power, with absence of knee-jerk, power 
 in the extension of the feet, and even loss of strength in the arms 
 and legs. k 
 
 Diagnosis. The loss of flesh and strength, with thirst and 
 marked increase in the amount of urine voided, will suggest the dis- 
 ease, and urinary analysis will settle the question. 
 
 Prognosis. Mild cases of glycosuria may recover under treat- 
 ment, and chronic cases may be modified, for years, but there can be 
 little hope held out in acute attacks. 
 
 Treatment. Though modification of the diet cannot be 
 expected to exert a curative influence, it doubtless lessens the sever- 
 ity of the disease, and thus aids in its successful management. Mbn- 
 tal strain is aggravating in its influence, and the patient should 
 be removed from all causes of -worry or mental effort, and be allowed 
 to live a quiet and even life, in a mild climate, where winter and sum- 
 mer nearly meet. As the capillary circulation is usually poor, the 
 underclothing should be of flannel or silk, and the skin should be 
 kept moist and open by a daily cabinet vapor bath (unless the patient 
 be too much exhausted) and by daily falty inunction with massage. 
 
 The diet should consist of easily digested meats, fish, poultry, 
 and game without reserve, except liver, crabs, lobsters, and oysters; 
 liquids, except those containing sugar, such as beer, sweet wines, and 
 sweet aerated drinks; and vegetables, except potatoes, turnips, para- 
 nips, squashes, vegetable marrow, asparagus, corn, beets, and arti- 
 chokes. Fruits should be prohibited, except lemons, oranges, and
 
 330 CONSTITUTIONAL DISEASES. 
 
 currants. The bread should be restricted to gluten and bran bread, 
 and almond and cocoanut biscuits. All wheat and rye bread should 
 be avoided, while such farinaceous foods as rice, hominy, tapioca, 
 semolina, sago, arrowroot, and vermicella are not permissible. It is 
 said that gluten flour obtained in this country contains too great a 
 proportion of starch that that from Paris and London contains a 
 much smaller amount of this element, and is to be preferred. As 
 the breads especially prepared for diabetics are all unpalatable, and 
 soon become distasteful to the patient, it may be better to allow a 
 restricted quantity (a few ounces) of ordinary bread daily, though 
 this should then be well toasted, to disorganize the sugar and 
 dextrin. 
 
 The milk diet advised by Donkin and at one time popular in dia- 
 betes has failed to prove generally satisfactory, though some cases 
 improve on it. 
 
 As a substitute for sugar, saccharin and glycerine may be 
 employed. 
 
 The medical treatment of diabetes is not yet very successful, 
 though we have improved upon older methods. Syzygium, when a 
 recent preparation can be obtained, removes the sugar from the urine 
 in many instances. Unfortunately, there is no guarantee of the char- 
 acter of an article obtained, and it has often been so long in the mar- 
 ket as to have lost its therapeutic value. Three or four grains of 
 the powdered seeds, in capsules, constitute a dose, to be repeated 
 three or four times daily. In the use of any remedy in this disease, 
 perseverence is a necessary virtue. Nitrate of uranium controls pro- 
 fuse urinary discharge, and thus modifies many unpleasant features. 
 Where there is much pain and restlessness, the following capsule 
 may answer a good purpose : # Phenacetin gr. ii, nitrate of uranium 
 3i trit., gr. iii. M. This may be given every two or three hours. 
 
 Rhus aromatica and lycopus virginicus have both, according to 
 written reports, accomplished cures -of diabetes. Whether these 
 were cases of genuine glycosuria or merely diabetes iusipidus, where 
 agents controlling an excessive hydruria are expected to succeed, 
 still remains to be satisfactorily proven. There is no reason either 
 of these remedies should fail. Lycopus is invigorating to the diges- 
 tion, promotes normal activity of the heart and arteries, and allays 
 gastric and enteric I irritability, thus seeming well adapted to some 
 of the conditions of this disease, while it controls relaxation of the 
 renal capillaries, thus being commendable for trial, at least. It has 
 the reputation of having cured many cases of diabetes mellitus. 
 It should be given in ten-drop doses of the specific medicine, every 
 three or four hours. Professor I. J. M. Goss, in his Practice of
 
 DIABETES INSIPIDUS. 331 
 
 Medicine, describes the case of an old man (74 or 75 years of age) 
 whose urine showed a specific gravity of 1.045 and upon evapora- 
 tion yielded a considerable quantity of what was apparently saccha- 
 rine material, in which rhus aromatica effected a complete cure 
 within three months. Lycopus and uranium were used the first 
 month of treatment, with only the result of lessening the volume of 
 water passed. The following month he was put upon 30-drop doses 
 of rhus aromatica three times daily, and, at its expiration, there was 
 a noticeable diminution in the amount of urine voided, and its 
 specific gravity was 1.032. The same treatment was continued for 
 another month, the patient meantime gaming flesh and strength 
 rapidly, and, after the third month he reported himself well, and so* 
 continued. It is to be regretted that a chemical analysis was not 
 made at the beginning and ending of treatment in this instance, 
 that more positive statements might have been made. 
 
 Opium possesses the reputation of limiting the progress of the 
 disease, codeia being the form generally preferred, as it is less 
 constipating. The drug may be begun in small doses half a grain 
 three times daily anil gradually increased, as the patient becomes 
 tolerant, to six or eight grains in twenty-four hours. 
 
 Dr. J. Q-. Pierce has employed bromide of potassium in the treat- 
 ment of cases where the disease was brought on by injury, such as 
 falls resulting in concussion, with promising results. In one of 
 his cases, that of a young girl, it was brought on by extreme grief at 
 the death of her mother, and here a complete cure resulted. 
 
 During coma little can be done, though inhalations of oxygen 
 and intravenous injections of a three-per-cent solution of bicarbon- 
 ate of sodium have been recommended and employed, but not with 
 very satisfactory results. 
 
 VI. DIABETES INSIPIDUS. 
 
 Synonyms. Polyuria; Polydipsia. 
 
 Definition. A constitutional disease, characterized by extreme 
 thirst and the excretion of a large amount of colorless urine of low 
 specific gravity, containing neither sugar nor albumin. 
 
 Etiology. The etiology of this disease is obscure, but many 
 circumstances point to a nervous origin. For instance, it is apt to 
 follow blows on the head, or injuries to th'e occipital region of the 
 skull. Bernard discovered a spot in the floor of the fourth ventricle 
 in animals, the puncture of which was followed by this condition. 
 It occurs most commonly in young persons, and heredity seems to 
 exert an influence. Excesses in drinking, both of ice-water and
 
 332 CONSTITUTIONAL DISEASES. 
 
 alcoholic liquor, have been followed by it. It sometimes appears dur- 
 ing the course of such visceral lesions as hepatic cirrhosis and 
 abdominal tumors, some impression being made here upon the renal 
 nerves, in all probability. Cerebral tumors have caused it, and sun- 
 stroke, apoplexy, and other brain lesions have been followed by it. 
 Males are more subject to it than females, probably because they 
 are more liable to causes of violence which predispose to it. 
 
 Pathology. Various degenerative changes have been found in 
 the central and sympathetic ganglia. Anatomical lesions of the 
 kidneys and bladder sometimes occur, the bladder being hypertro- 
 phied, and the pelves of the kidneys, and ureters dilated. Chronic 
 pulmonary complications may arise, with fatal termination by 
 tuberculosis. 
 
 Symptoms. The principal symptoms in the beginning are 
 inordinate flow of urine, and thirst. The urine is limpid, colorless, 
 of low specific gravity, and shows no reaction with agents employed 
 for testing for sugar. The disease may come on insidiously or sud- 
 denly, the amount of urine voided finally reaching from thirty to 
 sixty pints per day. The specific gravity varies from 1.003 to 1.008. 
 The reaction is faintly acid, there is a greenish, opalescent color, and 
 uric acid, urea, and kreatin are present in larger than normal quan- 
 tities. As the flow of urine increases, the thirst becomes propor- 
 tionately pronounced, and the amount of liquids consumed bears a 
 direct relation to the quantity of urine voided. 
 
 As the disease progresses the skin becomes dry and harsh, the 
 nails brittle, and the temperature subnormal. The general condition 
 of the patient varies considerably in different cases. Sometimes the 
 excessive thirst and profuse urinary flow are about all the symptoms 
 noticed, the subject maintaining tolerably good health otherwise. 
 In other cases digestive derangements, with loss of appetite and 
 gastro-intestinal disturbance with prostration and emaciation, grad- 
 ually advance. Sometimes vomiting and rapid emaciation attend, 
 followed by cough, hectic, and fully developed phthisis. Salivation is 
 an occasional symptom, and it may persist throughout. 
 
 Diagnosis. Polyuria may arise in other diseases besides 
 diabetes. Hysterical persons sometimes void large quantities of 
 urine in a short time, but the polyuria is of short duration, at erratic 
 intervals. In diabetes insipidus the profuse discharge is constant, 
 and observation of a patient for a month will settle the question as 
 to the diabetic nature of the disease. Absence of sugar will dis- 
 tinguish it from diabetes mellitus. 
 
 Prognosis. The disease may continue for years, without 
 seriously undermining the health. Spontaneous recovery some-
 
 RICKETS. 333 
 
 timea occurs during the course of acute diseases, and death, when a 
 fatal issue attends, is usually the result of intercurrent affections. 
 Spontaneous recovery is rare. 
 
 Treatment. Whenever the cause can be ascertained, it should 
 be removed. The skjn should be warmly clothed in flannels, and a 
 warm and equable climate should be chosen for residence. 
 
 The medical treatment will consist of those agents which tend to 
 constringe the renal capillaries, either by direct action, or through 
 the vaso motor nerves. Bhus aromatica, tycopus, nitrate of uranium, 
 faborandi, and other agents^ have been used with varying success, to 
 control the excessive nrinary flow. As the disease is probably nerv- 
 ous in origin and probably often reflex, the difficulty of directing 
 the specific agent to the point of irritation is apparent; and, even if 
 the trouble arise from lesiona about the medulla, we are at a loss to 
 prescribe a remedy which will maintain a steady and permanent con- 
 trol over it. Olycerole of gallic acid, in half-teaspoonful doses, some- 
 times acts beneficially in restricting the excessive discharge of urine. 
 A solution of twenty grains of quinine in an ounce of tincture of 
 muriate of iron, dose, ten drops every three hours, sometimes serves 
 a good purpose. Phosphoric acid bears an excellent reputation, and 
 is reported to have accomplished numerous cures. Scitta maritima, 
 in fractional-drop doses, sometimes exerts an excellent influence. 
 Full doses of valerian, ergot, antipyrine, and various other drugs, 
 have their advocates. 
 
 An active state of the skin is advantageous, and this may be 
 brought about by the use of the cabinet vapor bath, repeated two 
 or three times weekly. The galvanic current, one pole at the nape of 
 the neck and the other at the loins may be tried, but its efficacy 
 is doubtful, even though it is highly recommended. 
 
 VII. RICKETS. 
 
 Synonyms. Rhachitis; Rachitis. 
 
 Historical Note. The term rickets is supposed to be either 
 from the Saxon word "rick," a hump, or from a Dorsetshire verb 
 "rucket," to breathe laboriously. The disease was first described 
 bv English writers, and the first case noticed appeared in Dorset- 
 shire. Therefore many writers retain the original term, "rickets," to 
 designate the disease. Those of more classical turn prefer the term, 
 "rhachitis," which is derived from a Greek word signifying spine. 
 
 Definition. A constitutional disease affecting children, char- 
 acterized by disturbance of normal processes of ossification, attended 
 by enlargement of the epiphyses, with softening of the bones and 
 resulting deformity.
 
 334 CONSTITUTIONAL DISEASES. 
 
 Etiology. Three periods of life are especially liable to this 
 disease, viz., the foetal period, the infantile period, and that of ado- 
 lescence, malnutrition being responsible. It is said that large num- 
 bers of still-born children are found, upon careful investigation, to 
 be rickety. The usual period for the development of the disease is 
 between the sixth month and the third year. Both sexes are equally 
 susceptible, statistics showing about an equal number to be affected. 
 Heredity plays an important part, though constitutional weakness is 
 all that can be claimed in this respect. Protracted lactation and 
 repeated pregnancies lower the vitality of mothers, the younger 
 children of large families being more 'prone to rickets than the older 
 ones, excessive and prolonged lactation resulting, doubtless, in deteri- 
 oration of the mother's milk. As European families are much 
 larger, as a rule, these facts may suggest a reason for the greater 
 prevalence of the affection in Europe than in America, where it is 
 comparatively rare except among children of European immigrants, 
 and negroes. Poor ventilation, dampness, and want of sunlight are- 
 believed to predispose to it, especially when infants are weaned 
 early and fed upon farinaceous diet, starchy food tending to the 
 formation of lactic acid. The disease is more prevalent in large 
 cities than in rural districts or small towns. 
 
 As to the actual condition which is responsible for the improper 
 bony development, there are numerous theories, all taking for 
 granted that there is a lack of phosphate of lime to supply the devel- 
 oping bones with the proper amount of earthy material somewhere. 
 The lactic-acid theory assumes that there is an excess of lactic 
 acid generated in the alimentary canal by imperfectly digested 
 starchy material, and that this removes the lime destined for the 
 bones from the blood in the form of soluble salts, and irritates the 
 bones at the same time. Others have asserted that insufficiency of 
 earthy salts in the food gives rise to it, but this is disputed, as rick- 
 ets may occur under the best of conditions of this kind. Lack of 
 fats and proteids in the diet of rhachitic children has been supposed 
 to be responsible for it. Syphilis, malaria, bronchitis, and other 
 conditions have been held responsible for the development of rickets, 
 but it must still be admitted that there is some obscure element at 
 work in most cases which cannot be accounted for, and that the spe- 
 cific cause is yet to be determined. The rickets of adolescence is 
 probably a result of an infantile attack which has been barely warded 
 off, or not fully recovered from, bu 1 ; which has remained in a latent 
 state throughout childhood, and developed through the important 
 systemic changes then occurring.
 
 RICKETS. 333 
 
 Pathology. During the active stage the most marked patho- 
 logical changes occur at the points of junction between the epiphyses 
 and shafts of the long bones. The cartilage which separates these 
 parts is normally thin (about two millimeters in thickness), but in 
 rickets it becomes expanded into a thick, reddish-gray, translucent 
 cushion, while the adjacent bony structure is enlarged and softened. 
 The vascular layer which underlies the periosteum is softened, pulpy, 
 and thickened, the periosteum itself being thickened and swollen, 
 and its attachment to the bone more than ordinarily tenacious ; and 
 a pale-red, pulpy fluid infiltrates the epiphyses, periosteum, and 
 bones. The bones of the skull, the ribs, and the wrists are 
 most frequently involved, the proportion of inorganic material being 
 very much decreased, it being supposed that lack of phosphate of 
 lime in the system results in the absorption of that element from 
 bones already ossified to supply growing bones in the developing 
 child. The bones become soft and yielding, bodily weight and mus- 
 cular action tending to twist them out of their normal shape. The 
 liver and spleen take on various pathological changes. The spleen 
 becomes engorged and enlarged, and the liver is sometimes affected 
 with fatty infiltration. The lymphatic glands are occasionally 
 enlarged. 
 
 When the process of ossification begins to be reestablished, the 
 bone is laid down so rapidly that layers of new formation appear on 
 the surface, causing, in many cases, increased deformity. 
 
 Symptoms. Rickets is usualty the outcome of a protracted 
 period of ill health, in which there are no obviously specific symp- 
 toms. The child will be noticed to be pale, restless at night, with a 
 disposition to kick the bedclothing off, and there is usually a 
 marked tendency to relaxed sweats, especially about the head. It 
 gradually grows pot-bellied, the tissues becoming flabby and inelastic, 
 and most cases manifest a general tenderness about the body, the 
 child crying out with pain when handled. This symptom may be 
 so marked that the gentlest effort at moving the patient may pro- 
 voke intense pain, as manifested by shrieks from the sufferer. The 
 "paralysis of rickets" may now become developed, the child losing 
 the ability to walk, if it has already learned to do so, and it may lose 
 the use of the arms as well. However, there is no real nervous 
 lesion in such a case, the inability to use the parts depending upon 
 muscular weakness and tenderness of the bones and periosteum 
 instead of lack of nervous impulse. This condition is termed "Par- 
 rot's disease," and precedes the marked changes in the bones, and 
 therefore is liable to be confounded with latent meningeal or spinal 
 trouble.
 
 336 CONSTITUTIONAL DISEASES. 
 
 Sometimes there is the complication of bronchitis with these 
 indications, and this may give rise to elevation of temperature and 
 other febrile symptoms. In other cases the chronic disease may 
 develop without intercurrent complication, and little active constitu- 
 tional disturbance be manifested. Thus, acute and chronic rickets 
 have been described, though there is essentially no difference 
 between them, except as the incidental complication may determine 
 the condition. 
 
 After a somewhat protracted period the osseous changes begin to 
 appear. Tlie ribs and the wrists manifest the earliest and most 
 marked changes. The points of junction between the ribs and cos- 
 tal cartilages protrude as a "rosary" of bead-like enlargements, 
 readily felt upon palpation, and the wrists assume characteristic 
 shapes, enlargement of the lower extremeties of the radius and ulna 
 imparting a noticeable bulging to the parts. The typical head of 
 rickets is now gradually developed. The forehead becomes high, 
 square, and prow-shaped, with decided prominence of the frontal 
 eminences; the parietal eminences may also be prominent, and 
 the skull is elongated. The intellectual powers are not necessarily 
 retarded by rickets, the brain usually developing, and expanding its 
 functions as though there was no disease present, though there may 
 be exceptions to the rule, and dementia, idiocy, or imbecility be the 
 condition. The face of a rhachitic child is large above and diminu- 
 tive below, as the jaws are usually small and the lower one retracted, 
 giving the chin a retreating appearance. This affords an intelligent 
 expression to the countenance, the child impressing the observer 
 as an individual of precocity, though marks of ill health are por- 
 trayed by the enlarged and superficial veins of the scalp and fore- 
 head, and open anterior fontanelle. The sutures of the skull close 
 more slowly than usually, and a gutter may be left along their course, 
 following ossification. Dentition is also delayed, the first tooth 
 appearing about the ninth month, and the last deciduous tooth about 
 the third year. When developed, the teeth may present the charac- 
 teristic appearance described as " Hutchinson's teeth." 
 
 Thinning or wasting of the tables of the skull may occur, until 
 portions of its surface become so attenuated as to yield to gentle 
 pressure, imparting the sensation to the finger of the crackling of 
 parchment This is termed "cranio-tabes." It is not often observed 
 in this country. 
 
 Hypersemia of the brain and meninges is liable to attend, and 
 hydrocephalus is extremely apt to follow such a condition. 
 
 Deformities of the chest are very liable to attend rickets, and 
 sometimes a condition of this character is all that may be found to
 
 HICKETS. 337 
 
 attest the presence of the disease, or its results. As the framework of 
 the thorax becomes softened, the muscles and atmospheric pressure 
 tend to bend the bones out of shape, the most yielding point being 
 at the costo-sternal juuction. Sometimes the thorax is flattened lat- 
 erally, the sternum being projected forward, constituting "pigeon 
 breast," or pectus carinatum. At other times the deformity may be 
 unilateral, one side yielding more than the other, or one side 
 being depressed and the other bulging. The diaphragm exerts a 
 tension on the ribs which is sometimes marked in rickets, a line of 
 depression, corresponding to the points of its attachment, encircling 
 the thorax. In some cases the results of the distended abdomen 
 may remain after the bones have become hardened and the abdomen 
 has flattened, the lower ribs remaining rolled outward and upward, 
 maintaining a peculiar deformity. 
 
 Spinal curvature is common in this disease, three forms being 
 described, viz., kyphosis (backward curvature), scoliosis (lateral 
 curvature), and lordosis (forward curvature). 
 
 Softening of the long bones may result in bowing of the forearm, 
 bow-legs, knock-knees, etc. The sacrum may yield to the pressure 
 from above and throw the direction of the pelvic axis backward, the 
 condition imparting a squatting posture to the person when standing. 
 Almost every deformity imaginable may arise in this disease, from 
 distortion of the bones. 
 
 Diagnosis. The disease should be suspected when a child 
 becomes pallid, with doughy, flabby tissues, and tendency to profuse 
 perspiration about the head habitually, especially at night. Such 
 symptoms are sufficient for therapeutic diagnosis at least, and they 
 sound a warning which should not be unheeded, for now is the time 
 to administer the treatment to forestall serious osseous changes. 
 After these have begun a short time, there can be no mistaking the 
 condition, the deformities and general symptoms combining to make 
 the picture complete. 
 
 Prognosis. Permanent dwarfing, added with various deform- 
 ities, follows the subsidence of the disease. Many of the lesser 
 deformities, such as enlargement of the epiphyses, diminish with 
 growth, though spinal curvature, pigeon breast, and rhachitic skull 
 mark the results of the disease throughout life. During its course, 
 various complications tend to fatal results, the principal of these 
 being bronchitis, broncho-pneumonia, diarrhoea, hydrocephalus, and 
 amyloid degeneration of internal organs. Proper treatment, begun 
 early, usually benefits in a short time. 
 
 Treatment. The most important consideration in treatment 
 is attention to hygienic methods. If the child be nursing, and the 
 
 23
 
 338 CONSTITUTIONAL DISEASES. 
 
 mother seem to be in indifferent health, it must be removed from 
 the mother's breast and a healthy wet-nurse substituted. Or, if 
 this be impossible, it should be put upon properly prepared cow's 
 milk, the various infant foods containing too much sugar and dextrine 
 for such children. If the cow's milk be sweetened, sugar of milk 
 and not cane-sugar should be used. The child should be kept in 
 the open air much of the time, as oxygen and sunlight are impor- 
 tant aids in treatment. 
 
 One of the most efficacious medicines is calcarea carh, 3x tritu- 
 ration, administered in two- or three-grain doses, four times daily. 
 This is especially indicated when there are nocturnal head-sweats, 
 and it should be prescribed immediately upon the appearance of 
 this symptom, as it may prove prophylactic against further develop- 
 ment of the disease. 
 
 Silica 3x is another remedy indicated in sweating about the 
 head, and it exerts an excellent influence over reparation of bony and 
 cartilaginous structures. It may be alternated with calcarea carb. 
 or employed alone, with good results. 
 
 Schuessler's tissue remedy is worthy of trial in rickets, as it 
 often proves efficacious. Calcium phosphate will usually act better in 
 minute doses in this disease than in the large ones often advised, 
 and the 3x trit uration, in two- or three-grain doses, three or four times 
 daily, is worthy of confidence. 
 
 Phosphoric acid, in minute doses, phosphorus, and cod-liver oil 
 are other remedies which have been highly recommended. 
 
 The tonic faradic treatment will be found to assist the action of 
 medicines very much in the management of this disease. It may be 
 repeated two or three times a week. 
 
 vm. SCURVY. 
 
 Synonym. Scorbutus. 
 
 Definition. A chronic constitutional disease, due to deficiency 
 of fresh vegetable and animal diet, characterized by anaemia, pros- 
 tration, sponginess of the gums, and tendency to hemorrhage. 
 
 Etiology. Scurvy, in times past, was preeminently a disease of 
 the sea, the crews of slow sailing vessels, who had exhausted their 
 vegetable food and lived on salt pork and biscuits for a long period 
 of time, being the ones principally affected. In these times, when fa- 
 cilities for preserving vegetables in hermetically sealed cans for an 
 indefinite period has become perfected, the disease is comparatively 
 rare. Armies, in time of war, are sometimes obliged to subsist on 
 salt meat and hardtack for a protracted period without fresh food,
 
 SCURVY. 339 
 
 and the men are then liable to contract scurvy. During recent times, 
 the miners of Alaska have been the most common sufferers, depriva- 
 tion of fresh vegetables and other ingredients supplied by them be- 
 ing very common to that country during the winter months. Several 
 cases of the kind have been at the Maclean Hospital within the past 
 two years, all Alaskan miners recently landed from the north. 
 
 Considerable difference of opinion exists as to the identity of the 
 specific causal factor. Some follow Garrod and believe that absence 
 of the potassic salts is answerable for the pathological developments, 
 while others believe that the condition arises from the lack of mal- 
 ates, citrates and lactates, from which the carbonates, which render 
 the blood alkaline, are derived. At any rate, a gradually diminishing 
 alkalinity of the blood attends, and there seem to be good grounds 
 for logical reasoning from cause to effect in this connection. 
 
 Physical influences, outside of that of diet, and mental states un- 
 doubtedly exert a certain effect in the production of the disease. 
 Homesickness, especially when attended by other depressinginfluences 
 seems to lessen the resisting power of the system; epidemics of the 
 disease on convict ships in olden times, and in prisons, where the 
 diet would hardly warrant it, go far toward establishing the proposi- 
 tion that mental influence of a depressing nature is an important 
 causal factor. 
 
 All ages are liable to it, though elderly persons are most suscep- 
 tible. Starvation alone seems not to dispose to it, as scurvy has 
 never followed the most prolonged fast; only those who eat food lack- 
 ing the proper elements being attacked. 
 
 Pathology. There is decreased alkalinity of the blood, which 
 is dark, fluid, and does not coagulate readily. Deficiency of the pot- 
 ash salts has been demonstrated. The capillaries present evidences 
 of alteration of the endothelial cells and are choked, in places, with 
 red corpuscles. Ecchymosis is common, the skin and subcutaneous 
 tissue, the muscles, the joints, the subperiosteal tissue, the mucous 
 and serous membranes and the internal organs all being more or less 
 involved. Hemorrhages occur in the internal organs, especially in 
 the kidneys and bladder. The gums are especially involved, being 
 swollen, spongy and hemorrhagic, and often ulcerated, even so that 
 the teeth become loosened or fall out. Parenchymatous changes 
 occur in the spleen, liver, kidneys, and heart. The spleen may be 
 markedly enlarged and swollen. 
 
 Symptoms. The disease advances insidiously. Gradual loss 
 of flesh, with prostration and pallor, attract first attention. Spongi- 
 ness of the gums may now be noticed, these parts being swollen, ten- 
 der, hemorrhagic, and fungous in appearance. Loosening of the 
 teeth commonly occurs, though the affection of the gums is not always
 
 340 CONSTITUTIONAL DISEASES. 
 
 present. The tongue is swollen and livid, ecchymosis may appear in 
 the mucous membrane of the mouth, and the breath is foetid and of- 
 fensive. Sometimes the salivary glands are swollen. Ecchymoses 
 may now be observed about various parts of the cutaneous surface ; 
 these are first seen about the legs, then on the trunk and arms, especi- 
 ally about the hair-follicles. These may be minute, purple spots, or 
 may be larger, and may cause cutaneous swelling. The face appears 
 bruised and swollen, presenting a livid appearance. The skin is dry, 
 rough and generally of a muddy pallor, though it may be sallow and 
 leaden in hue, and slight blows or bruises are followed by extensive 
 extravasations. 
 
 Severe darting pains affect the limbs, especially about the calves 
 and popliteal spaces, and node-like swellings, from deeply seated ec- 
 chymoses, often appear on the shins. 
 
 The circulation is feeble, the pulse small and slow, except when 
 there is excitement, and there is palpitation of the heart, with anaemic 
 murmurs, and dyspnoea upon slight exertion. Where the disease is 
 advanced, syncope may follow even moderate exertion. Sleeplessness, 
 disordered vision, and other nervous disturbances are common. 
 
 The bowels are constipated, and the urine scanty, often albumin- 
 ous, and there is diminution of the normal ingredients, except phos- 
 phoric acid and the potash salts. 
 
 Diagnosis. The history of the case and a careful inspection of 
 the gums will distinguish between scurvy of these parts and mercurial 
 poisoning. In purpura there are not the marked lesions of the gums 
 that usually attend scurvy, and they occur in isolated cases, while 
 scurvy is liable to appear in epidemics. Purpura also resists the 
 restorative influence of lime-juice, while this agent readily relieves 
 scurvy. 
 
 Prognosis. If the conditions which give rise to the disease are 
 removed, and it is not far advanced, the prognosis is good. Death 
 results in from ten to fifteen per cent of cases, gradual heart-failure, 
 meningeal hemorrhage, extravasation into serous cavities, intestinal 
 inflammation, and other intercurrent conditions usually carrying the 
 patient off. When complicated with syphilis or chronic alcoholism, 
 the prognosis is less favorable. 
 
 Treatment. When fresh vegetables are not to be had during 
 long intervals, scurvy is to be feared, and, if possible, prophylaxis 
 should be observed. Hall and Kane asserted that the eating of raw 
 meat acted as a preventative of scurvy during their Arctic experience, 
 while cooked meat would not. Raw potatoes have been used for the 
 same purpose by the miners of Alaska, and with good effect, accord- 
 ing to reliable reports. The daily consumption of a small amount of 
 lime- or lemon-juice serves the best purpose, probably, though limes
 
 INFANTILE SCURVY. 341 
 
 and lemons are not always to be had. Other antiscorbutics are mus- 
 tard, radishes, cabbage and water-cress. 
 
 When a patient is seriously sick with scurvy, he should have per- 
 fect rest, as the great debility of the heart and other vital organs for- 
 bids that he should exert himself in the least He should remain in 
 bed, and take three or four ounces of lime-juice or lemon-juice, well 
 diluted in water, every day. On account of the tenderness of the 
 gums, the food should be liquid in form, and should consist of beef 
 tea, meat soups, broths, soups thickened with vegetables, milk, and 
 eggs. Return to solid food should be gradual, and the use of lemon- 
 or lime-juice should be continued for a prolonged period during 
 convalescence. 
 
 The medicinal treatment should consist of a fifteen-drop dose of 
 a reliable preparation of berberis aquifolium, administered in a little 
 water, and repeated four or five times daily. 
 
 INFANTILE SCURVY (BARLOW'S DISEASE). 
 
 IMPERFECT adaptation of food may give rise to scurvy in children, 
 as well as in adults. It is frequently the case that iuiants and young 
 children are deprived of fresh vegetables and their immediate deriva- 
 tives until a scrobutic condition is engendered. An infant at its 
 mother's breast, or fed upon fresh cow's milk, though not taking 
 vegetables, derives, from this source, constituents immediately elab- 
 orated from them, and the nourishment is properly adapted to the de- 
 mands of nature. But when artificial foods are employed, or the 
 child is fed upon condensed milk (which has been cooked), and no 
 fresh milk or other fresh food is employed, scorbutic conditions are 
 liable to arise, in the midst of plenty. 
 
 The symptoms resemble those of scurvy in adults, though, as the 
 disease will not occur as an epidemic, the physician may overlook 
 the true state of affairs. The skin presents a muddy pallor, the gums 
 are spongy, and a purpuric rash appears on the lower extremities, and 
 later bruise-like ecchymoses will be noticed upon various parts of the 
 cutaneous surface. Officious practitioners "may attempt to cure such 
 cases by lancing the gums, with the mistaken idea that they are 
 swollen from efforts at dentition, and provoke fatal hemorrhage. In 
 one case of this kind which came under my observation, the child 
 continued to bleed from the incision for two weeks, and finally died 
 apparently from loss of blood. There is probably pain and tender- 
 ness in the calves and other parts of the lower extremities, as the 
 child cries wh u they are moved or put upon the stretch. Obscure 
 swellings occur upon various parts of the lower extremities, due, 
 probably, to extravasations under the periosteum; and these are usu-
 
 342 CONSTITUTIONAL DISEASES. 
 
 ally symmetrical appear upon both extremities consecutively, in 
 about the same location. The limbs are drawn up at first, but later 
 become relaxed and lie immobile and flaccid, as though paralyzed, 
 with the toes turned outward. 
 
 The anaemia is profound, and the patient is extremely prostrated 
 and asthenia The eyelids are puffy, one or the other or both are 
 ecchymosed, and protosis or falling of the eyeballs may occur, con- 
 secutively, due, doubtless, to ecchymoses in the orbits. There may 
 be slight elevation of temperature, but the pulse is feeble and irregu- 
 lar. The general aspect of the child will be suggestive of rickets, 
 though the symptoms will be much more accute than in that disease. 
 
 Treatment. Fresh milk should at once be substituted for arti- 
 ficial foods. If the infant is very young the best substitute for pre- 
 pared foods will be a wet nurse. However, it is not always possible 
 to obtain such a substitute, and fresh cow's milk, properly diluted, 
 and sweetened with milk sugar, will be in order. It has been noticed 
 that raw meat has been found a preventative of scurvy, while cooked 
 meat is not ; and so it seems to be with cooked milk and condensed 
 milk possesses the objection of having been cooked. 
 
 Further than this the treatment will be similar to that for adults 
 affected with the same disease Lemon- or lime-juice, well diluted, 
 should be used sparingly, and meat-juice or gravy, with seived pota- 
 to, potato-soup, and other digestible forms of vegetable diet, com- 
 mensurate with the age and condition of the child, should be allowed. 
 
 IX. PTTRPURA. 
 
 Purpura is a disease liable to attend a variety of pathological 
 conditions. Strictly speaking, it is the term applied to extravasa- 
 tions into the skin from systemic causes apart from those of scurvy. 
 Symptomatic purpura may arise as a concomitant of some other dis- 
 ease, or from the action of drugs or poisons. It may arise from ma- 
 lignant endocarditis, pyaemia, septicaemia, typhus fever, measles or 
 small-pox. The rashes which attend the exanthemata are examples 
 of purpuric eruptions. Again, it may be toxic, and due to poisoning 
 from venomous reptiles; the action of certain drugs, such as bromide 
 of potassium, iodide of potassium, copaiba, quinine, and some others. 
 A not uncommon form of symptomatic purpura is that which arises as 
 a complication of arthritic disease, and this may, to all intents and pur- 
 poses, be a severe attack of inflammatory rheumatism attended by a 
 purpuric rash, covering the legs, and even the body and arms. In other 
 instances, the rheumatic symptoms may not be so marked, and may 
 amount only to muscular pains. A form of rheumatic purpura, de- 
 scribed as peliosis rheumatica, or Schonlein's disease, where the pur- 
 puric symptoms are extreme, amounting to oedema of the skin, with
 
 PURPURA. 343 
 
 various eruptive characters, such as wheals, vesicles, etc., complicated 
 with multiple arthritis, sore throat, and elevation of temperature, to 
 101 102 R, sometimes occurs. 
 
 Cachetic purpura may arise during the progress of cancer, tuber- 
 culosis, Hodgkin's disease, albuminuria, or during senility. 
 
 Neurotic purpura may appear during the course of certain nervous 
 affections attended by organic changes in a given area of nerve sup- 
 ply. Locomotor ataxia, acute myelitis, and severe neuralgias are 
 instances where such purpuric conditions have arisen. 
 
 Mechanical purpura may attend venous stasis of any form, and 
 may occur after severe vomiting, paroxysms of whooping cough, or 
 seizures of epilepsy. In these cases the purpuric spots will be most 
 likely to appear in the face. 
 
 Henock's purpura usually occurs in children, and is another vari- 
 ety of symptomatic purpura. Various portions of the body may be 
 affected, and the disease may continue for years, with occasional out- 
 breaks between periods of freedom. The lesions may occur in the 
 skin, in the intestinal mucous membrane, in the joints or in the kid- 
 neys. The cutaneous symptoms may consist of erythematous erup- 
 tions, instead of simple purpura. The intestinal lesions may be 
 manifested by crises of pain, vomiting and diarrhoea; the kidney dis- 
 turbances by attacks of hemorrhagic nephritis, the arthritic compli- 
 cations by pain and swelling in the joints. 
 
 PURPURA HEMOBRHAGICA. 
 
 TRUE purpura is recognized by pronounced purpuric spots or ec- 
 chymoses, with hemorrhages from the mucous membranes. It is 
 otherwise known as morbus maculosus Werlhofi, and is attended by 
 changes in the blood-vessels, or in the blood itself, probably both 
 combined, and extravasations into the connective-tissue spaces of the 
 rete mucosum, and into the mucous membranes. The serum soon 
 absorbs from the skin, leaving the red corpuscles, which may either 
 undergo gradual absorption or degenerate, leaving a permanent pig- 
 mentation. The extravasated blood in the mucous membranes is 
 liable to escape, and hemorrhages from the mouth, nose and other 
 mucous surfaces may attend. Extravasations into the serous mem- 
 branes sometimes, though rarely, occur, and the peritonoeum, peri- 
 cardium, pleurae and pia mater may be the seat of purpuric spots. 
 The muscles, bones, periosteum, conjunctiva and retina occasionally 
 suffer from purpuric extravasations. 
 
 Symptoms. Malaise and digestive derangements may precede 
 the onset of the disease for several days or weeks. The eruption 
 appears suddenly, coming out on the extremities and trunk first and
 
 344 CONSTITUTIONAL DISEASES. 
 
 usually stopping there, though the head and face may also be affected. 
 Bleeding from mucous surfaces may now set in, and profound anae- 
 mia may rapidly develop from epistaxis, hromateinesis, or haemopty- 
 sis. Loss of blood may result fatally, or cerebral hemorrhage may 
 carry the patient off. Sometimes the disease assumes marked malig- 
 nancy, and terminates fatally within twenty-four hours, with large 
 purpuric extravasations in the skin. Cutaneous hemorrhages and 
 extreme prostration are the leading symptoms, bleeding from the 
 mucous membranes being absent or death occurring before it begins. 
 This is termed purpurafulrninans. Recovery is gradual, the purpuric 
 spots disappearing, in favorable cases, in ten days or two weeks. 
 
 The diagnosis is to be made between this disease and scurvy, and 
 will readily be made in adults, who have been necessarily deprived 
 of fresh vegetables; though in children more care is required. In 
 scurvy swelling and ulceration of the gums is a prominent symptom, 
 while it is liable to be absent in purpura. It will hardly be con- 
 founded with malignant forms of eruptive fevers, where epidemic ten- 
 dencies and a high temperature are readily recognized. 
 
 Treatment. Symptomatic purpura should be managed accord- 
 ing to the special condition giving rise to it The exanthemata should 
 be recognized and properly treated ; and rheumatic purpura will yield 
 to treatment for ordinary rheumatism. A study of conditions, and 
 proper treatment for special demands, must be the duty of the attend- 
 ing practitioner. In the treatment of purpura hemorrhagica such 
 remedies as berberis aqui/olium, cistus canadensis, arctium lappa, 
 corydalis, etc., should be thought of. Where hemorrhages are severe 
 and threatening, erlgeron canadensis, may be of service. In malignant 
 forms, such agents as echinacea, lacJiesis, or baptisia, may be of avail. 
 Sometimes ten drops of tincture of muriate of iron every three or 
 four hours answer a temporary purpose, though ferruginous prepara- 
 tions are not usually to be depended upon. Ordinary hemostatics 
 may fail utterly to control purpuric hemorrhage, though it may be 
 well to try them. 
 
 X. SCROFULA. 
 
 Definition. Scrofula is a term applied to many different condi- 
 tions of the system, depending upon a peculiar diathesis now believed 
 to be tuberculous. On this account most medical authors ignore the 
 term, and consider scrofula as a form of tuberculosis. 
 
 Etiology. The scrofulous diathesis is usually inherited, and 
 may be due to syphilitic, intemperate or phthisical progenitors. The 
 children of parents closely related by blood are liable to inherit a 
 scrofulous tendency; and it may be acquired during early life, through 
 the influences of bad air, food and other antihygienic surroundings.
 
 SCKOFULA. 345 
 
 Symptoms. If scrofula and tuberculosis are not identical, they 
 are so closely related as to be interchangeable. However, subjects 
 may survive scrofulous inflammation and live a lifetime afterward, 
 where tuberculosis in ordinary form would soon prove fatal. Extreme 
 ckronicity, with tendency to caseous degeneration, are its leading feat- 
 ures. It is principally a disease of children, and is manifested by 
 transparency of the skin, blue veins, lustrous eyes, precocity of 
 intellect and nervous irritability. Scrofulous subjects are either 
 markedly of the encephalic temperament, or else are of the lymphatic 
 type, in which case they have large heads, coarse features and thick, 
 flabby skins, with overproduction of fat about the nose and upper lip. 
 Glandular enlargements are early characteristics of scrofulous chil- 
 dren, though prior to these developments cutaneous inflammations, 
 of chronic character, are liable to appear, especially about the corners 
 of the mouth, upon the edges of the eyelids or in the ears. Tonsillar 
 enlargements are common, and catarrhal affections are difficult to cure 
 and tend to return upon slight provocation. Pharyngeal, laryngeal 
 and bronchial catarrh are induced by slight causes, and in little girls 
 vaginal leucorrhoea and troublesome vulvitis are not uncommon. 
 Slight injury to the joints is liable to result in suppurative inflam- 
 mation of destructive character, and caries of the joints, with tuber- 
 culous deposits, often develops without the aid of traumatism. 
 
 Diagnosis. There is little possibility of mistaking scrofulous 
 inflammation for any other disease. The diathesis bears its evidence 
 with it, and the chronicity of the affection aids in determining its 
 character. Scrofulous deposits contain tubercle bacilli, and these 
 are also found in inflamed scrofulous glands. 
 
 Prognosis. Scrofulous children often pass through childhood 
 to adult life and live to a fair old age, though crippling from joint 
 affections is not rare. Tuberculous intestinal disease, acute hydro- 
 cephalus, croup and pulmonary diseases are very liable to arise in 
 such children. 
 
 Treatment. Prophylaxis is to be considered. Blood relations 
 should avoid marriage among themselves ; broken down, phthisical 
 and syphilitic persons should not marry at all. 
 
 A plain, nutritious diet, with plenty of open-air exercise in sun- 
 shine, should be encouraged. Cutaneous eruptions should be met 
 with calcium sulphide, calcarea phos. and berberis aquifolium orstillhi'jia 
 sylvatica. Affections of the joints are best met by radical surgical 
 measures. Affections of the lymphatic glands yield best to calcium 
 sulph. or calcium fluoride, though such vegetable remedies as coryalis, 
 phytolaccca, stillingla, berberis aquifolium and other reputed alteratives 
 are not to be neglected here.
 
 346 CONSTITUTIONAL DISEASES. 
 
 XL HEMOPHILIA. 
 
 Definition. A constitutional fault, of hereditary character, con- 
 sisting of a tendency to uncontrollable bleeding upon slight provo- 
 cation, and even spontaneously in many instances. 
 
 Etiology. Haemophilia is a systemic fault which, in the major- 
 ity of instances, is transmitted from mother to son. The daughters 
 of such a mother are not liable to be bleeders, but the male children 
 they bear will probably be subject to haemophilia. Thus the weak- 
 ness is handed down to the male portion of the family, while the ten- 
 dency to transmit the weakness is entailed upon the female portion. 
 While the sons are bleeders, their children seem to be exempt, the 
 disease being transmitted through the female alone. This rule has 
 its exceptions, and there is undoubtedly occasionally a female subject 
 who proves to be a bleeder. Therefore, it has been estimated on good 
 authority that about one in thirteen of the subjects of haemophilia 
 is of the female sex. There are exceptions to the rule that haemo- 
 philia is hereditary, as it is occasionally acquired ; though just the 
 essentials to its origin from healthy stock is not known. 
 
 Pathology. There are no peculiarities of structure about the 
 blood-vessels of subjects of haemophilia usually, though in some in- 
 stances anatomical changes have been found in the capillaries. Un- 
 usual thinness is the only peculiarity liable to then attract attention. 
 Probably lack of tonicity is more at fault than tenuity of structure, 
 as proper tone about the stomata in the minute vessels would be im- 
 portant in the control of capillary hemorrhage. Hemorrhages have 
 been found in and about the joints, and inflammation of the syovial 
 surfaces. Possibly the morbid state may depend upon some peculiar 
 fluidity of the blood, rather than upon fault of the bloodvessels. 
 
 Symptoms. Uncontrollable bleeding from trivial causes is the 
 leading feature of the disease. A slight scratch, blow or cut, the 
 extraction of a tooth, or even epistaxis, may result in prolonged and 
 alarming hemorrhage, which persistently resists all ordinary means 
 of relief. 
 
 Sometimes the bleeding is traumatic and sometimes spontaneous. 
 Traumatic bleeding may be interstitial, and may consist of petechiae 
 and ecchymoses, as well as bleeding into the joints. Spontaneous 
 bleeding may occur from the nose, mouth, stomach, bowels, urethra 
 and other internal organs, as well as from the skin, at various points, 
 such as the navel, vulva, scrotum, eyelids, ears, finger tips, etc. 
 
 The bleeding is a capillary oozing, but it may be so profuse as to 
 occasion rapid dripping of blood from the part and cause speedy 
 prostration. Continuing on, day after day, it soon becomes alarm- 
 ing, and may finally result in fatal syncope. When the bleeding is
 
 HEMOPHILIA. 347 
 
 into the joints, there is pain and swelling not unlike the symptoms of 
 rheumatism, especially if it is accompanied by elevation of tempera- 
 ture and accelerated pulse. 
 
 Diagnosis. Where a knowledge of the family history can be 
 had, the diagnosis will be much simplified. Prolonged bleeding from 
 trivial causes will hardly occur, except in purpura, and the symptoms 
 of this disease are not likely to be mistaken. 
 
 Prognosis. When hsemophilic manifestations appear very early 
 in life, the outlook is less favorable than when they are deferred 
 until adult life. More than fifty per cent of boys who become bleed- 
 ers very young, in a given number of cases, die before the seventh 
 year. It is believed that the longer a bleeder survives the greater 
 chance he has of outgrowing the tendency. In female patients sub- 
 ject to haemophilia the menstrual and parturient functions are fraught 
 with more than ordinary danger. 
 
 Treatment. Exciting causes should be avoided as much as 
 possible. Boys who belong to haemophilia families should avoid ac- 
 tive habits, so that danger from traumatism may be lessened. The 
 avocations of such persons should be selected with this object in 
 view. One of the very worst cases of this kind I ever treated was 
 that of a carpenter, who scratched the back of his hand slightly with 
 a saw. I had previously, several years before, treated him for dan- 
 gerous bleeding following the extraction of a tooth. Tooth-extraction 
 and all minor surgical operations should be avoided in such patients, 
 as far as possible. 
 
 When bleeding has begun, absolute rest should be required, and 
 oil of erigeron should be administered, in ten-drop doses, repeated 
 every hour or half-hour. If this fails, small doses of carbo. veg. may 
 be tried. Blius aromatica is a good remedy, though the oil of eriger- 
 on has proven the best remedy for me. Ergot, gallic acid, tannin and 
 a score or less of other commonly known haemostatics might be sug- 
 gested, to be tried in their turn, as there is no known specific. Sub- 
 sulphate of iron, locally, is the best aid to internal measures. A low 
 diet is to be commended.
 
 SBOTIOI2 IV, 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 I. DISEASES OF THE MOUTH. 
 
 HERPES LABIALIS. 
 
 THIS affection is quite a common one, and seldom requires atten- 
 tion, as it is self-limiting, in the majority of cases. It often appears 
 with a cold, and a common name for the condition is "cold-sores." 
 Herpes labialis often appears during the course of cerebro-spinal 
 fever, as well as in the course of other fevers, and requires no special 
 attention. When it becomes chronic, or persists for a longer time 
 than usual, phytolacca may be used internally, while a dilution of 
 grindelia robusta is applied locally. R S.m. or normal tinct. phyto- 
 lacca, gtt. x-xx, aqua ad. fiv. Dose, a teaspoonful every two hours. 
 R Saturated tinct. grindelia robusta 3!, aqua ad ?i. Apply every 
 three or four hours. In long-standing cases, berberis aquifolium may 
 act better internally than phytolacca. 
 
 SIMPLE STOMATITIS. 
 
 THIS is the commonest form of inflammation of the mouth, and all 
 ages are subject to it. It usually results from the action of irritants, 
 such as hot or highly-seasoned food, strong drinks or tobacco. In 
 children, dentition or gastro-intestinal irritation may account for it. 
 It often arises during the acute specific fevers. 
 
 There is redness and dryness of the mucous membrane at first, 
 involving a greater or less portion of the oral mucous membrane, with 
 excess of secretion later on. Burning of the surface attends, with 
 smarting upon attempts at mastication. Sometimes the tongue is 
 swollen and furred. There may be slight elevation of the tempera- 
 ture, especially in children, although constitutional symptoms are not 
 marked. 
 
 The treatment will consist of a weak dilution of glycozone, ji to 
 boiled water fii, or 31 of grindelia robusta to water fiv, used as a 
 wash. A solution of chlorate of potassium ji to water fiv often an- 
 swers well. Internally, R Phytolacca jss, aqua ad fiv. Dose, a 
 teaspoonful every hour. The local applications will usually be 
 sufficient.
 
 DISEASES OF THE MOUTH. 349 
 
 APHTHOUS STOMATITIS. 
 
 Synynoms. Follicular Stomatitis; Croupous Stomatitis. 
 
 Definition. An ulcerative form of stomatitis involving the mu- 
 cous follicles of the oral mucous membrane. 
 
 Etiology. Aphthae may attend any inflammatory disease of the 
 tongue or mouth, though age and hygienic surroundings may exert 
 an influence. It most commonly occurs among children, and may 
 even appear as an epidemic. It frequently attends the acute infec- 
 tious diseases, one of the worst epidemics I ever saw being a compli- 
 cation of chicken-pox. It is quite common among children as a spo- 
 radic and idiopathic affection, and may be caused from indigestible 
 food remaining in the mouth, unripe fruit, candy, etc. Cachetic con- 
 ditions and bad hygienic surroundings may be blameable for its ap- 
 pearance. Some women are troubled with aphthous ulcers at each 
 menstrual period, and pregnant and nursing women are sometimes 
 affected by a stubborn form. 
 
 Pathology. Semi-transparent vesicular elevations appear on 
 the mucous surfaces of the cheeks, gums, and tongue and around each 
 of these is a reddened base; these constitute what are termed "aph- 
 thae." Sometimes they are very numerous, studding the mucous 
 membrane thickly, and at other times they are few and scattering. 
 As these rupture they leave irregular ulcers, which heal slowly. If 
 several coalesce they form a single, large, irregular ulcer, which may 
 be tardy about healing. Sometimes there may be deeper sloughing, 
 and the submucous tissues are excavated. 
 
 Symptoms. When occurring in nursing infants, the first sign 
 will probably be a refusal to take the nipple ; and if the child at- 
 tempts to nurse it will quit often and cry peevishly, because of the 
 pain excited. With older persons mastication is painful and diffi- 
 cult, and the taking of fruits or anything sour excites excruciating 
 pain ; and the same is true of hot food or drink. Slight febrile ex- 
 citement may be present, the submaxillary glands may be hardened 
 and swollen, and ptyalism may be more or less of a factor. Children 
 are liable to suffer from a diarrhoea, as a complication. 
 
 Treatment. The practice of treating these ulcers by the appli- 
 sion of caustics, or even by local washes, is usually unsatisfactory, 
 though a weak dilution of liydrozone sometimes assists, when used as 
 a wash. The specific treatment consists of the use of phytolacca, 
 which selectively influences the oral mucous membrane with repara- 
 tive effect. As there is usually more or less febrile complication, the 
 addition of aconite to the prescription is advisable. K Specific 
 phytolacca gtt. x-xxx, specific aconite gtt. i-vi, aqua ad. fiv. Admin- 
 ister a teaspoonful every hour. Where ptyalism is a prominent and
 
 350 DISEASES OF THE DIGESTIVE ORGANS. 
 
 persistent feature and there is marked disposition for the vesicles to 
 coalesce and form large, ragged ulcers, jaborandi is an important rem- 
 edy. Ten or fifteen drops of the specific medicine (or any other re- 
 liable form) should be added to the prescription just offered. Nurs- 
 ing sore mouth is very stubborn, and will seldom yield to such treat- 
 ment. Attenuations of lachesis have had the best influence here of 
 any remedy I have used. 
 
 F(ETID STOMATITIS. 
 
 Synonyms. Ulcerative Stomatitis; Putrid Sore Mouth. 
 
 Definition. An ulcerative form of stomatitis, which occurs in 
 crowded communities, like jails, camps, etc., where surroundings are 
 detrimental to health. It may arise from the use of a community 
 drinking cup or similar cause; and a predisposition to it is encour- 
 aged by unwholesome food, bad ventilation, carious teeth or those 
 upon which there is an accumulation of tartar. Bacteriologists be- 
 lieve that the specific etiological factor consists of a microbe ; and 
 the belief has been entertained, in some quarters, that the disease is 
 identical with the foot-and-mouth disease which infects cattle and 
 that it is conveyed in the milk. Other theories have been advanced, 
 but no positive knowledge exists as to the real specific causal factor. 
 It sometimes occurs sporadically. 
 
 Symptoms. The ulcerative process begins at the margins of 
 the gums and spreads along over two or more aveoli. The gums and 
 surrounding mucous membrane become swollen and spongy, bleed 
 easily, and ragged ulcers form along the gingival margin, with ten- 
 dency to rapid increase in size. The breath is foul, the tongue is 
 coated. There is severe aching and throbbing pain in the mouth, 
 which is intensified and becomes burning and stinging upon -taking 
 food. There is ptyalism, usually profuse, and the submaxillary 
 glands are swollen and tender. Constitutional symptoms develop; 
 there are dryness of the skin, elevation of temperature, sleeplessness 
 and emaciation. 
 
 Treatment. Hydrozone is the best remedy for use here, though 
 constitutional treatment may be required to assist its action. The 
 ulcers should be treated locally with it, either by spraying the gums 
 or by applying it witn a swab, and the excavations along the fangs 
 of the teeth should be deeply syringed with it by the aid of a hypo- 
 dermic syringe. In addition, a wash of it should be used in the 
 mouth, for general cleansing purposes. The drug may be diluted 
 with one or two parts of water, though at first full strength may be 
 used, for cleansing deep excavations. In connection with this, ten or 
 fifteen drops of a reliable preparation of echinacea should be adminis- 
 tered, for its systemic effect, and repeated every hour or two.
 
 DISEASES OF THE MOUTH. 361 
 
 Berber is aquifolium is a remedy which should not be forgotten in 
 these cases. Chlorate of potassium has its ardent admirers, though I 
 am of the opinion that it has been overrated. I have never tried 
 the local influence of grindelia robusta here, but believe, from its ef- 
 fects in other forms of ulceration, that it would prove highly benefi- 
 cial in foetid stomatitis. 
 
 The diet should be liquid in form, and unirritating. Milk, raw 
 eggs, custards and other semi-solid and easily-digested foods may be 
 be taken during convalesence. 
 
 MERCURIAL STOMATITIS. 
 
 Definition. An inflammation of the mouth due to the specific 
 influence of mercury upon the tissues. 
 
 Etiology. Mercurial ptyalism is a common affection with the 
 patients of many allopathic physicians, The idea that mercury 
 should be pushed until the gums are "touched" is yet in favor with 
 many of them, and with those who do not believe that ptyalism is 
 essential belief in the curative effects of mercury in many conditions 
 is a common one. Consequently, mercurial poisoning frequently oc- 
 curs, and occasionally an Eclectic is called upon to administer relief 
 in such cases. 
 
 Symptoms. The patient may complain of a metallic taste and 
 profuse dribbling of saliva. Upon inspection the gums will be found 
 swollen, reddened, dusky and sensitive upon mastication. The breath 
 is offensive, and ptyalism soon becomes a disgusting annoyance to the 
 patient. As the disease continues the tongue becomes swollen, the 
 submaxillary glands enlarged and tender, and the gums may ulcerate 
 along their gingival margins. Caries of the aveoli, with frequently 
 recurring gum-boils and premature decay of the teeth, is likely to 
 be a remote result. 
 
 Treatment. Minute doses of jaborandi offer as good results as 
 any remedy. Add from ten to fifteen drops of specific jaborandi to 
 half a glass of water and order a teaspoonful every two or three hours. 
 Phytolacca is also an excellent remedy, though not as reliable as jabo- 
 raudi. Add twenty drops of the saturated tincture to half a glass of 
 water and order a teaspoonful every three hours. Chlorate of pot as- 
 sium, used as a wash, is in great favor with some, and it is claimed 
 that it exerts an antidotal influence against mercury. Diluted hydro- 
 zone should not be forgotten, and if other remedies fail try grindelia 
 robusta. fy Specific robusta gii, aqua fiv. Gargle frequently. 
 
 The diet should be bland and unirritating, and of such form as to 
 be easily masticated. In bad cases the diet should be liquid in form, 
 and free from acids and high seasoning.
 
 352 DISEASES OF THE DIGESTIVE ORGANS. 
 
 ECZEMA OF THE TONGUE. 
 
 Synonyms. Map Tongue ; Geographical Tongue. 
 
 Definition. A desquamation of the epithelium of the tongue, 
 which occurs in circinate patches, imparting to the surface of the 
 organ a map-like appearance. 
 
 Etiology. The etiology is obscure, ordinary causes of eczema 
 of the skin being at the foundation of the trouble. It occurs most 
 frequently in children, though adults are subject to it. Some regard 
 it as a gouty manifestation, though this is not probable. Indigestion 
 may attend it, and possibly the condition may be due to gastric dis- 
 turbances. 
 
 Symptoms. The patchy tongue presents a striking appearance, 
 and attention is thus often called to it. Sometimes there is itching 
 and heat upon the affected surface, but mental perturbation, from 
 fear of more serious developments, is the unpleasant feature of many 
 cases. 
 
 Treatment. Thus far treatment for this affection has afforded 
 little satisfaction. The continued use of berberis aquifolium may re- 
 lieve the burning, when this is present, and even restore the normal 
 appearance. Graphites has relieved one case which I have observed, 
 though it has proven futile in others. Calc. phos. 3x is worthy of a 
 trial. "Where specific remedies fail to relieve, attention to the gen- 
 eral health will be commendable. Such cases are chronic, and nat- 
 urally recuperate slowly. 
 
 PARASITIC STOMATITIS. 
 
 Synonyms. Thrush; Muguet; Soor. 
 
 Definition. A fungous disease of the mucous membrane of the 
 mouth. 
 
 Etiology. Thrush is a fungous growth which develops from 
 transplantation of the oidium albicans, a yeast-like fungus, which af- 
 fects children most commonly, but to which adults, when greatly 
 debilitated, may become subject. 
 
 Pathology. The development of the oidium albicans and its 
 parasitic companion studs the mucous membrane of the mouth with 
 patches of pultaceous, creamy masses, which may coalesce until the 
 surface of the tongue and buccal cavities are largely covered with it. 
 In children the palate is a favorite place for its lodgment. The epi- 
 thelium of the mucous membrane becomes loosened, secretion is 
 arrested, and the part becomes dry and dusky. The oidium albicans 
 consists of spores and filaments resembling the yeast plant in certain 
 respects.
 
 DISEASES OF THE MOUTH. 353 
 
 Symptoms. The mouth becomes hot and sensitive. There is 
 dryness of the mucous membrane, though the action of the salivary 
 glands may be increased, with acidity of the secretion. The mucous 
 membrane becomes swollen, the lips everted. Patches of thrush in- 
 crease in size, thus forming a membrane which can be scraped off, 
 leaving the mucous surface more or less excoriated and sensitive. 
 The buccal mucous membrane, the lips, the roof of the mouth and 
 even the fauces and tonsils may become affected, the whitish incrus- 
 tation covering more or less of their surface with ragged patches. 
 Sometimes the disease extends to the oesophagus, and even the 
 stomach and bowels may be invaded and troublesome diarrhoea, 
 with flatulence and green stools, attend. 
 
 A microscopical examination will settle disputes in diagnosis, the 
 distinctive features of the oidium albicans being thus determined. 
 
 Treatment. Careful attention must be paid to the diet, espe- 
 cially in cases of children fed upon the bottle. Everything should 
 be kept carefully cleansed bottles, tubes and nipples and no sour 
 or fermented food should be allowed. Sometimes a radical change 
 in the character of the food used will be imperative. The substitu- 
 tion of a wet nurse may sometimes be necessary. Antiseptic mouth- 
 washes must be assiduously employed, and diluted listerine, weak 
 lime-water, or weak solutions of bicarbonate of sodium may be used. 
 In adults, weak solutions of equal parts of carbolic acid and glycerine 
 or diluted hydrozone may be needed, to cleanse the mouth frequently. 
 
 Constitutional treatment is important, special remedies adapted 
 to particular cases being called for. Hygienic surroundings are 
 desirable, and where many children have been crowded together 
 isolation in healthy localities is desirable. Care should be observed 
 in the use of spoons, nursing-bottles and other feeding implements, 
 that the contagium be not conveyed to healthy subjects. Aconite 
 and phytolacca will be appropriate to relieve the irritation of the 
 mucous membrane. 
 
 GANGRENOUS STOMATITIS. 
 
 Synonyms. Cancrum Oris; Noma. 
 
 Definition. An affection occurring in children, characterized by 
 rapid and progressive gangrene of the side of the face, having for its 
 starting point the gums or cheek. 
 
 Etiology. This hideous malady has for its principal factor the 
 effects of mercury. Allopathic authorities fail to state this fact in 
 their treatises on medical practice, but I have never known it to occur 
 except in children who have been previously mercurialized. The 
 prostration following acute fevers may favor its development and 
 21
 
 354 DISEASES OF THE DIGESTIVE ORGANS. 
 
 ravages, as may also unsanitary conditions, but the irritating and 
 debilitating influence of mercury on the tissues involved in the start 
 undoubtedly gives rise to it. 
 
 Symptoms. The mucous membrane of the gums or cheek of 
 the affected side is first attacked by ulceration of phagedenic charac- 
 ter, a deep, sloughy ulcer in the part being the first symptom noticed. 
 As this rapidly spreads, the adjacent skin and underlying tissues 
 become indurated and purplish, and the sloughing continues to ex- 
 tend until the cheek is perforated. Sometimes the entire cheek melts 
 away, the ulceratiou extending to the chin and tongue, and even the 
 eyelids and ears may be involved. 
 
 Marked constitutional symptoms are developed as the ee pro- 
 gresses. The temperature rises to 103 to 104 R, the pulse becomes 
 accelerated, and grows feeble later on, nausea and diarrhoea super- 
 vene and profound prostration and death finally follow. In other 
 cases the sloughing gradually ceases, leaving the patient with ;i ghast- 
 ly, grinning, skeleton-like aspect upon one side, the teeth and gums 
 being exposed as far back as the angle of the lower jaw. Other cases 
 may be arrested before the destructive action has progressed so far. 
 
 Treatment. Eckinacea, both locally and internally, is the best 
 agent with which I have had extended experience in phagedenic ulcer- 
 ation. In such a case as this the system should be well saturated 
 with it, and it should be applied to the part constantly. Ten drops 
 may be administered every hour, and a twenty-five per cent dilution 
 in water should be kept in contact with the part, on compresses. 
 Hydrozone spray is another excellent local remedy. 
 
 From the very favorable reports received of the use of preserved 
 bovine blood (bovinine) in phagedenic ulceratiou, I would expect it 
 to benefit here. It might be used locally, either on antiseptic gauze 
 or injected into the affected tissues, while the proper dose was 
 employed internally. It might be used in connection with echinacea 
 (or Lloyd's echafolta). Griudelia robusta ji to aqua fii might be 
 found a useful adjunct, if applied locally. 
 
 PYOBRHCEA ALVEOLARIS. 
 
 Definition. This term strictly signifies suppuration of the alve- 
 oli, but is here limited to a peculiar kind of inflammation of the alve- 
 oli and surrounding soft structures characterized by the deposit of 
 a dark, slate-colored material on the roots of the teeth, with rather 
 wide-spread inflammation of an insidious character, the teeth becom- 
 ing loosened and the gums destroyed, without much pain or well- 
 marked sensitiveness. It is distinct from the disease caused by the 
 depositation of calcareous material about the fangs of the teeth (tar-
 
 DISEASES OF THE MOUTH. 355 
 
 tar) and distinct from alveolar abscess, which is usually confined to 
 the space lying at the extremity of a single fang. 
 
 Etiology. The exciting cause of the disease is the slate-colored 
 deposit, the origin of which is still in doubt. It has been ascribed 
 to serumal deposit of a gouty nature, from the fact that uric acid has 
 sometimes been found in it, but this is insisted on as being accidental 
 by competent persons, and the theory of a gouty origin now seems to 
 be pretty well disposed of in the negative. The practice of adminis- 
 tering mercury to salivation doubtless has something to do with a 
 loss of vitality about the affected parts, which predisposes them to 
 afford lodgment to the incrustation, and the impaction of particles 
 of food may cause thrombus of the pericementum, with subsequent 
 transformation of the arrested blood into earthy material. It seems 
 to involve the entire thickness of the pericementum, and is firmly 
 attached to the cementum (which invests the dentine of the faug). 
 
 Pathology. The concretion usually scales off the cementum 
 readily about the shaft of the fang, but at its point or extremity the 
 cementum is roughened, and the removal of the morbid accumula- 
 tion requires the assistance of chemicals, in addition to instrumental 
 means. The presence of the foreign body gives rise to irritation of 
 the gingival margin, and the gum gradually shrinks away from the 
 fang, leaving it exposed and finally revealing the dark incrusta- 
 tion. The soft tissues in the sockets become gradually involved, and 
 the bone is attacked later, concealed pockets of pus forming about 
 the fangs in the aveoli, until the teeth become loosened, the gingival 
 margins soft and spongy and the soft structures about the apices of 
 the fangs honeycombed by burrowing suppurative action. The teeth 
 may finally drop out, the patient suffering so little pain as to scarcely 
 realize that they are being destroyed. 
 
 Symptoms. The disease is insidious. Slight reddening of the 
 edges of the gums will be the first symptom noticed, and if these are 
 now slightly retracted the slate-colored deposits will be found just 
 below the gingival margin, out of sight of superficial inspection. 
 These are small at first, but they gradually involve more or less of 
 the entire surface of the fang, spreading destruction to the structures 
 of the sockets as they advance, though there is little pain or ten- 
 derness to attract attention. Sponginess of the gums and loosening 
 of the teeth are later developments, and finally the teeth fall out from 
 destruction of their attachment. If a probe be passed down along 
 the sides of the teeth, cavities will be found between the fangs and 
 alveoli and extending into the gums. 
 
 Treatment. The best plan to pursue is to refer the patient to 
 a competent dentist. However, there may be circumstances where 
 it will not be practical for the patient to reach a dental office, and
 
 356 DISEASES OF THE DIGESTIVE ORGANS. 
 
 the physician, in such cases, should know how to manage the affec- 
 tion. 
 
 Destruction of the pus and cleansing and stimulating of the cavi- 
 ties should be a prominent part of the treatment The removal of 
 the incrustation is imperative, in order that a cure may follow. 
 Hydrozone should be injected into all the cavities by means of a hypo- 
 dermic syringe, the needle of which may be converted into a blunt 
 tube by removal of the point. The hydrozone may be diluted by the 
 addition of an equal part of boiled water at first, if it causes pain in 
 full strength, and it should be warmed before use, as cold solutions 
 are unpleasant to the sensitive structures. Removal of the incrusta- 
 tion must be accomplished with minute scrapers or chisels, obtain- 
 able at any dental depot. The scraper is curved near the point and 
 the fang is raked from the point toward the crown, while the chisel 
 is straight and the motion is from the crown toward the extremity of 
 the fang. Repeated operations should be practiced in order to ac- 
 complish the complete removal of the accumulation, a delicacy of 
 touch thus being attained which will enable the operator to detect 
 the presence of a particle of the accumulation when it cannot be 
 seen. The repeated use of hydrozone will gradually loosen masses 
 which are at first firmly adhered, and every treatment with it should 
 be followed with a search over each affected fang for incrustations. 
 Finally each operation should be concluded by the insertion of a 
 mixture of equal parts of fluid extract of quercus alba and oil of cinna- 
 mon into every cavity and along the fang of every affected tooth, the 
 application being made by dipping a small chisel into the mixture 
 before each probing. 
 
 Success in treatment depends on perseverance and attention to 
 details. Several weeks of the use of hydrozone and search for incrus- 
 tations are necessary, the applications being made every other day 
 at least. As treatment progresses the swelling of the gums subsides, 
 the teeth become more firmly fixed and tenderness disappears. The 
 teeth should be inspected at intervals, however, for a long time after- 
 ward, in order to avoid a return of the disease. 
 
 IL DISEASES OF THE SALIVAEY GLANDS. 
 
 HYPERSECRETION OF THE SALIVABY GLANDS. 
 
 Synonym. Ptyalism. 
 
 Etiology. Ptyalism occurs under a number of conditions. One 
 of the most common causes is the abuse of mercury, weeks of excess- 
 ive salivary action following some cases of unfortunate mercurializa- 
 tion. Pregnancy is another condition where excessive action of the
 
 DISEASES OF THE MOUTH. 357 
 
 salivary glands may prove a source of annoyance. Some vegetable 
 agents provoke ptyalism, jaborandi, muscarin and tobacco being 
 notable examples, though their effects are usually transient. Ptyal- 
 ism may occur during the course of some acute fevers, though the 
 opposite is the rule. Small-pox is occasionally attended by it. 
 
 Symptoms. The symptoms are unmistakable. The mouth, 
 however frequently emptied, continues to fill with saliva, which is 
 thin and watery, dribbles upon the chin and is thus a source of con- 
 tinual vexation. Irritation of the mouth and lips often attends, and 
 speech is interfered with by the provoking presence of excessive fluid 
 in the buccal cavity. 
 
 Treatment. The successful treatment of the ptyalism from 
 mercury is often attended by a great deal of difficulty. The salivary 
 glands frequently seem so debilitated and relaxed that ordinary reme- 
 dies for pytalism fail to produce much effect. Small doses of jabo- 
 randi, repeated frequently, sometimes succeed. R Specific jabo- 
 randi gtt. x. aqua fiv. M. Sig. A teaspoonful every two hours. 
 Hydrastis does well here, though it will often fail. The galvanic cur- 
 rent sometimes succeeds rapidly, and is usually very successful in the 
 ptyalism of pregnancy. Take an ordinary tongue depressor and, lay- 
 ing it on the tongue of the patient, bring in contact with the other 
 part (if it be metal) the metal terminal of a conducting cord con- 
 nected with the negative pole of a galvanic battery, the patient hold- 
 ing, meantime, a wetted sponge attached to the positive pole in one 
 of her hands. The current should be about four or five milliamperes 
 in strength (about eight or ten four-ounce zinc-carbon cells, in good 
 order). After holding it there a few seconds remove it, to allow the 
 patient to rest the tongue, then repeat once or twice afterward in the 
 same order. Repeat this treatment every other day for a week or 
 more. Sometimes the positive to the tongue will be more satisfac- 
 tory. Faradism, used in the same manner, sometimes succeeds, 
 though it is not as positive as galvanism. 
 
 ARREST OF THE SALIVARY SECRETION. 
 
 Synonym. Xerostoma. 
 
 Etiology. This is supposed to be due to disturbance of the 
 function of the salivary nerve center. A majority of the cases which 
 have occurred have been in female subjects and accompanied by 
 nervous phenomena. The disease is very rare. 
 
 Symptoms. The symptoms are purely local, the general health 
 rarely being disturbed. There is remarkable dryness of the tongue, 
 mucous membrane of the cheek and palate. The tongue is parched 
 and dry, sometimes cracked, and the remaining mucous membrane
 
 358 DISEASES OF THE DIGESTIVE ORGANS. 
 
 of the mouth is smooth, dry and shining. Mastication and degluti- 
 tion are attended with difficulty, the mouth becoming clogged by 
 remnants of food adhering to the gums. 
 
 Treatment. The only successful treatment that leaves perma- 
 nent results is by the use of galvanism as described under the treat- 
 ment of ptyalism. Here the negative pole should invariably be ap- 
 plied to the tongue. Jaborandi may temporarily promote the action 
 of the salivary glands, though here it is given in ten-drop doses of 
 the specific medicine, or in still larger quantities. 
 
 INFLAMMATION OF THE SALIVARY GLANDS. 
 
 THIS may occur under different circumstances and require consid- 
 eration from various standpoints. Specific parotitis has already been 
 discussed among the specific infectious diseases. Symptomatic paro- 
 titis occurs from a variety of influences. It may arise during the 
 infectious fevers, either from continuity of oral inflammation along 
 the salivary duct or from septic inflammation through the blood. Sup- 
 puration usually attends an inflammation of this character, active 
 inflammatory action following. Another condition in which sympto- 
 matic parotitis may ensue is that following facial paralysis with 
 peripheral neuritis. 
 
 Injuries or disease of the abdomen, pelvis, kidueys or genital 
 organs are sometimes attended by parotitis, also such diseases as 
 ulceration of the stomach and such injuries as blows upon the testi- 
 cles, the introduction of a pessary, a surgical operation on these parts 
 or other pelvic, genital or abdominal organs. In these cases the eti- 
 ology is not well defined, though probably the causes are septic in 
 nature. 
 
 In the treatment of such cases small doses of Jaborandi or potas- 
 sium chloride 3x, in connection with a mild current of galvanism or 
 faradism, may bring about resolution and avert suppuration. When 
 this becomes inevitable, warm poultices should be employed until 
 evidences of suppuration are present, and early incision for the evac- 
 uation of pus should then be practiced. 
 
 in. DISEASES OF THE PHARYNX. 
 
 ACUTE PHARYNGITIS. 
 
 Definition, An acute inflammation of the mucous membrane 
 of the pharynx and adjacent surfaces. 
 
 Etiology. This is a catarrhal condition, due to sudden changes 
 which give rise to colds, the pharynx being a favorite place for the 
 location of the irritation in those who are apt to clear the throat
 
 DISEASES OF THE PHARYNX. 359 
 
 often by hawking and empty swallowing, when there exists a slight 
 irritation there. In some instances the disease may occur as an epi- 
 demic, though here, probably, there is some specific cause at work, 
 and the condition a form of specific infectious disease rather than a 
 purely local inflammation. In the exanthematous fevers, such as 
 small-pox, scarlatina, rubeola, etc., an exanthematous inflammation 
 of the pharynx attends as a part of the febrile condition. Erysipela- 
 tous inflammation of the pharynx may originate as an extension of 
 facial erysipelas through the auditory meatus or nasal duct, or it 
 may arise independently, from direct erysipelatous infection of the 
 part. 
 
 Symptoms. Pain in the pharynx, with a disagreeable sensation 
 of dryness, irritation, fullness and difficulty of swallowing, mark the 
 outset of the disease, these symptoms coming on a few hours after 
 exposure to draughts or dampness. The patient frequently attempts 
 to clear the throat by hawking and swallowing. The voice is muffled 
 and there is a short, dry cough. There may be slight febrile dis- 
 turbance, especially in children. The extent and severity of the in- 
 flammatory action is best determined by inspection of the throat. 
 Sometimes the inflammatory blush (redness) extends forward, involv- 
 ing the palate and pillars of the fauces. The posterior uares are 
 often involved, the patient complaining of burning there and making 
 frequent efforts to clear the passages of screatus. Headache is now 
 a frequent symptom, this continuing for several days until the acute 
 symptoms have subsided. The uvula is often involved and it may be 
 cedematous and elongated. 
 
 Acute pharygitis is occasionally erysipelatous in character, and 
 then there is a peculiar bright redness to the affected part, the 
 inflammation extending rapidly and widely, oedema and puffing of 
 the inflamed area being marked and constitutional symptoms severe. 
 
 Treatment. Ordinary cases of acute pharyngitis recover rap- 
 idly on the following prescription: $ Green-root tinct. of phyto- 
 lacca 31, Lloyd's or other reliable fluid ex-tract of aconite gtt. v x, 
 water ziv. Mix, and order a teaspoonful every hour. Where the in- 
 flammation is severe and stubborn, the addition of <;i of jaborandi to 
 the preceding prescription will be of much service, and often much 
 advantage will attend the use of a gargle of one part of echinacea to 
 four or five of water, its use being repeated frequently every half- 
 or quarter-hour. In erysipelatous pharyngitis the internal use of 
 echinacea is essential, two or three drachms of the specific medicine 
 being added to half a glass of water and a teaspoonful ordered every 
 hour. Jaboraudi does well here in combination with the echinacea, 
 in about the quantity already indicated. Erysipelatous pharyngitis 
 with puffiness of the tissue especially indicates minute doses of apis.
 
 360 DISEASES OF THE DIGESTIVE ORGANS. 
 
 When the vault of the pharynx and the posterior iiares are severe- 
 ly affected, the following prescription may answer better than the 
 treatment first suggested: H Specific apocynum caimabium 3!, aco- 
 nite gtt. v-x, water, ?iv. M. Sig. Take a spoonful every hour. lu 
 other cases of this kind sambucus canadensis may be used in place of 
 the apocynum, in the same quantity. 
 
 Cold water packs are the best local application in this affection, 
 though some prefer heating fomentations. A small towel may be 
 wrung out of cold water and folded to the appropriate size, and the 
 throat bandaged with it, the application being renewed every three 
 or four hours. 
 
 In connection with the treatment the patient should be enjoined 
 to avoid empty swallowing, hawking and attempts at forcible removal 
 of screatus from the posterior nares. 
 
 Should the uvula become elongated and oedematous during the 
 course of acute pharyngitis it should not be excised at that time, as 
 the operation would be liable to aggravate the local difficulty and 
 serious results might happen, especially in erysipelatous pharyngitis. 
 
 PHLEGMONOUS PHARYNGITIS. 
 
 RETRO- PHABYNGEAL abscess, attended by severe inflammatory ac- 
 tion, occasionally occurs. It may be due to local injury, such as the 
 irritating influence of hot food or penetration by spiculse of bone, 
 though it usually depends upon caries of the cervical vertebrae. The 
 inflammatory action may be treated by phytolaccca and aconite, as in 
 simple acute pharyngitis, pus being evacuated early. Silica 3x 
 should then be thought of. 
 
 GANGRENOUS PHARYNGITIS. 
 
 THIS may occur in connection with diphtheria, small-pox or other 
 infectious disease. In addition to the gangrenous local condition, 
 there are usually typhoid symptoms and profound prostration, with, 
 in many cases, fatal results. Echinacea, lacJiesis, baptisia and other 
 remedies of their class should be thought of early. Frequent spray- 
 ing with diluted echinacea may accompany its internal use. 
 
 CHRONIC PHARYNGITIS. 
 
 Synynoms. Pharyngeal Catarrh; Clergyman's Sore Throat; 
 Pharyngitis Sicca. 
 
 Etiology. This condition may be developed from repeated at- 
 tacks of acute pharyngitis, or it may rise imperceptibly from sub- 
 acute inflammation of the part. It is common in public speakers, 
 auctioneers and hucksters, who overstrain the voice. Excessive
 
 DISEASES OF THE PHARYNX. 361 
 
 smokers and drinkers are also specially liable to suffer with it. It 
 may be brought on by persistent efforts to clear the throat by empty 
 swallowing, hawking, removal of screatus from the posterior nares, 
 and such causes. 
 
 Pathology. The mucous membrane of the naso-pharynx arid 
 posterior wall of the pharynx are relaxed, the venules are dilated and 
 the mucous glands are each surrounded by proliferation of lymph- 
 tissue. When this is very abundant, the functions of the glands are 
 destroyed and the mucous membrane becomes dry and glistening, 
 constituting pharyngitis sicca. 
 
 Symptoms. The patient may not manifest much discomfort, 
 though often there is dryness of the throat on awaking in the morn- 
 ing, with sensation as of a foreign body in the part, provoking hawk- 
 ing and empty swallowing. The mucous membrane of the posterior 
 pharyngeal wall is usually dusky, the veins are enlarged and in fol- 
 licular pharyngitis there are raised points of bright, reddened tissue 
 distributed upon its surface. A mass of tenacious mucus will usu- 
 ally be found adhering to the posterior pharyngeal wall, extending 
 downward from behind the soft palate. If destruction of the mucous 
 follicles has been accomplished the surrounding mucous membrane 
 will be found dry and shining. A short, dry cough indicates more 
 or less irritation of the larynx. In many cases the uvula is congested 
 and elongated and becomes an additional cause of laryngeal irrita- 
 tion, cough being a common symptom, 
 
 Treatment. The treatment of the catarrhal form of chronic 
 pharyngitis is neither difficult nor tedious. Galvanism, applied to 
 the affected part, two or three times a week for a month or more, 
 produces excellent results, if not a complete cure. Confirmation of 
 cure is but a question of time; persevere in the treatment and the 
 cure is sure to follow, if the patient gives the part rest from hawk- 
 ing and unnecessary empty swallowing. An electrode may be im- 
 provised w r ith the aid of 
 a section of copper wire, 
 a piece of rubber tubing 
 
 IMPROVISED PHABYNGEAL ELZCTBODE. and a pledget of absorb- 
 
 ent cotton, which will answer the purpose admirably. A loop is bent 
 upon one end of the wire, for purpose of connection, the tubing is 
 then drawn on so as to leave about three-fourths of an inch of the 
 further extremity exposed, and this is turned up at right angles, for 
 the attachment of the absorbent cotton, which, when wetted in plain 
 water, constitutes an excellent applicator. When in use, the loop is 
 to be placed and held in contact with the tip of a conducting cord 
 attached to a galvanic battery, while the patient holds a moistened 
 sponge connected with the opposite pole in one hand (after the cot-
 
 362 DISEASES OF THE DIGESTIVE ORGANS. 
 
 ton-carrier hag been placed in position in the throat). A current of 
 three or four milliamperes (six or eight four-ounce carbon-zinc cells 
 in active condition) should be used in this case. The patient may 
 not be able to endure the electrode in the throat for more than a 
 few seconds at a time as it is liable to produce retching, but the 
 application should be made two or three times at each sitting and re- 
 peated twice a week. The hooked portion of the applicator should 
 be carried up behind the soft palate so as to bring the current in 
 contact with that part, where the trouble is almost always most se- 
 vere. Sometimes the operator may advantageously apply the wetted 
 sponge to the angle of the jaw on each side, that the current may be 
 sent directly through the wall of the pharynx. 
 
 The pole to be applied must be selected with reference to the 
 condition of the part, though the negative will usually be most effec- 
 tive. However, if there is great relaxation with profuse catarrhal 
 discharge or if there is marked irritability, the positive may answer 
 better. 
 
 In connection with this treatment, considerable benefit may be 
 derived from collinsortia, penthorum sedoides or cistus canadensis. Ten 
 drops of specific medicine of either agent may be administered at a 
 dose in a little water before meals and at bedtime. Such agents, 
 assisted by sprays and gargles of different kinds, may alone accom- 
 plish cures, though results are not ordinarily satisfactory, 
 
 In follicular pharyngitis and in other forms where hypertrophic 
 spots are apparent, gcdvano-cautery may be used to destroy them, ap- 
 propriate medicines being taken, meanwhile, to promote a healthy 
 condition of the mucous membrane. 
 
 In pharyngitis sicca jaborandi possesses specific properties. Ten 
 drops of the specific medicine should be used at a dose persistently 
 four or five times daily for months, attention being paid to the con- 
 stitutional condition of the patient as well. Guaiacum also Dossesses 
 considerable virtue here, in minute doses. 
 
 If the uvula is elongated or relaxed it should be caught with a 
 rat-tooth catch forceps at the tip, drawn slightly forward and half or 
 more of its length snipped off with scissors curved on the flat. This 
 will ensure the permanent removal of one source of irritation. 
 
 Arduous use of the voice should be discontinued; smokers affected 
 with the disease should abandon the habit, and those addicted to al- 
 coholism should abstain from all alcoholic liquors. 
 
 The habit of wearing a cold wet pack on the throat at night is an 
 excellent one. 
 
 ULCERATION OF THE PHARYNX. 
 
 Etiology. Ulcers of the pharynx may depend upon a number of 
 causes. Among them may be named: (1) Those which arise from
 
 DISEASES OF THE PHARYNX. 363 
 
 follicular pharyngitis; (2) those from syphilis; (3) those from cancer; 
 (4) those from tuberculosis. 
 
 Symptoms. Follicular ulceration is easily detected. The raised, 
 isolated points on the posterior pharyngeal wall, one or more of them 
 being the seat of superficial ulceration without induration or ten- 
 dency to deep, destructive action, distinguish them from other forms. 
 They should be treated with galvano-caidcry, or fuming nitric acid ap- 
 plied with a pine stick. 
 
 Syphilitic ulceration of the throat is more chronic and less painful, 
 the ulcers of secondary syphilis being multiple, while those of ter- 
 tiary syphilis are deeper and usually single, denoting the erosion of 
 a gumma. The history of the case will assist the practitioner to a 
 clear diagnosis where syphilitic ulceration is present. Galvanism is 
 the proper agent for the successful treatment of such cases. The 
 negative pole is applied to the ulcer or ulcers twice a week, the pa- 
 tient holding a positive sponge- electrode in the hand. To assist the 
 local agent the following prescription will be found an important 
 aid: R Specific corydalis fss, specific berberis (or Parke, Davis & 
 Co.'s fluid extract) 3!, simple elixir ad ?iv. Sig. Take a teaspoonful 
 four or five times daily. When the ulcers are tertiary in character, 
 the addition of iodide of potassium to this prescription may occa- 
 sionally be desirable. 
 
 It may be difficult to always distinguish cancerous ulceration from 
 that of syphilis, though it is to be remembered that the ulceration of 
 cancer is usually extremely painful, while that of syphilis is compar- 
 atively painless. Cancerous ulceration, moreover, is steadily pro- 
 gressive, while syphilitic ulceration, after developing, is usually sta- 
 tionary. The history of the case will afford additional light upon the 
 subject. The best that can be advised for cancerous ulceration of 
 the pharynx is treatment to relieve the pain. Opiates are of little 
 value, and the only remedy of much use is echinacea, which usually 
 renders the condition a comparatively painless one, while the patient 
 retains consciousness and the use of his mental faculties to the last. 
 From ten to twenty drops of the specific medicine may be adminis- 
 tered at a dose in a little water every three or four hours during the 
 day. The local application of grinclelia robusta, repeated often, is to 
 be highly commended here. R Grindelia robusta -$n to aqua siv. It 
 may be applied with a spray apparatus. 
 
 Tuberculous ulceration occurs in some cases of advanced phthisis. 
 The ulcers are ragged and irregular, with ill-defined edges and yel- 
 lowish-gray bottoms, and are intensely painful. The general condi- 
 tion of the patient and the history of the case will suffice for a diag- 
 nosis. The ulcers should be frequently sprayed with bovinine, and the 
 same agent should be administered internally in appropriate doses.
 
 364 DISEASES OF THE DIGESTIVE ORGANS. 
 
 An excellent application to this as well as to all other pharyngeal 
 ulcers will be found in Jiydrozone. 
 
 LUDWIG'S ANGINA. 
 
 Synonyms. Angina Ludovici; Cellulitis of the Neck. 
 
 Definition. A cellular inflammation of the tissues of the neck 
 encountered during medical practice as a complication of specific in- 
 fectious diseases, especially diphtheria and scarlatina. 
 
 Etiology. In addition to the infection of streptococci, which 
 originates it in the specific fevers, it may arise as a result of trauma- 
 tisni and may even occur idiopathically. In every case it is even 
 possibly due, eventually, to infection from streptococci. 
 
 Symptoms. Swelling begins about the submaxillary gland of 
 one side at first, but it soon becomes general, septicaemia, oedema, 
 glottidis, secondary pneumonia or gangrene of the affected parts 
 proving fatal in many cases in a short time. Termination by abscess 
 is the most desirable end to be expected. 
 
 Treatment. Echinacea, lachesis and baptlsia, combined with 
 prompt surgical interference whenever practicable. 
 
 IV. DISEASES OF THE TONSILS. 
 
 FOLLICDLAR TONSILLITIS. 
 
 Synonym. Lacunar Tonsillitis. 
 
 Definition. A form of acute tonsillitis in which the inflamma- 
 tion involves the mucous membrane covering the glands and lining 
 the crypts or follicles of the tonsils. 
 
 Etiology. Children and youug adults are more liable to be af- 
 fected by this disease than elderly persons, and it is rare during in- 
 fantile life. Exposure to wet and cold is the common cause, though 
 bad hygienic surroundings, such as defective drainage, malaria, sewer- 
 gas, etc., are believed to exert some influence in its causation. Some 
 believe that there is a relationship between this disease and rheuma- 
 tism that the two are liable to coexist and some even claim that 
 follicular tonsillitis is a phase of rheumatism which affects children. 
 While these are facts which lend support to the theory that rheuma- 
 tism is allied, etiologically, to catarrhal disturbance, it is not proba- 
 ble that tonsillitis sustains any more relation to it than other acute 
 catarrhal affections. 
 
 Pathology. The mucous membrane lining the crypts is most 
 severely inflamed, though that covering the external portion of the 
 tonsil is also affected. The follicles exude a whitish material, con- 
 sisting of pus-cells, epithelial cells, bacteria and mucus, which appears
 
 DISEASES OF THE TONSILS. 365 
 
 at the mouths of the lacunae as circumscribed white spots resembling 
 the exudation of diphtheria in general appearance but differing from 
 it materially iu true character, as it lacks the fibrin found in the ex- 
 udation of that disease. 
 
 Symptoms. The constitutional symptoms of follicular tonsillitis 
 are often out of proportion to the local trouble. There is usually an 
 initiatory chill with rapid pulse, the temperature rising as high as 
 103 or 104 F. and sometimes higher. Muscular pain is a usual 
 symptom in greater or less degree and is often marked. There is 
 severe aching in the muscles of the neck and head, which may extend 
 along the back, the muscular pain assuming the proportions of mus- 
 cular rheumatism and demanding special therapeutic attention. The 
 throat is now stiffened and swollen, the tonsils enlarged and their sur- 
 faces dotted with spots of creamy-white exudate occupying the mouths 
 of the crypts, and they may be so abundant as to coalesce in some 
 places, though this condition is not common. The cervical lymphat- 
 ics are slightly though not markedly enlarged. Respiration is more 
 or less impeded, the breath is foul and swallowing difficult. The 
 tongue is loaded with a pasty-white fur, the bowels are constipated 
 and the urine is scanty and throws down urates. Prostration is a 
 marked symptom at first, though with proper treatment the weakness 
 abates within three or four days, the swelling subsides and the fever 
 and muscular pain disappear. Recurring attacks, however, are not 
 uncommon upon slight exposure. 
 
 Diagnosis. The diagnosis between follicular tonsillitis and mild 
 cases of diphtheria is not always an easy matter. Diphtheria may 
 begin in the follicles of the tonsil and the first appearance of the part 
 may be that of lacunar tonsillitis. It is to be remembered, however, 
 that the exudate of diphtheria spreads with greater .or less rapidity 
 and soon creeps along the tonsillar surface to the pharynx and spreads 
 upon its walls. It is ashen-gray in color, in contrast with the creamy- 
 white color of the exudation of tonsillitis. The enlargement of the 
 cervical glands is also much more marked in diphtheria, while there 
 is hardly ever so much elevation of temperature as there is in tonsil- 
 litis. Bacteriologists presume to differentiate with the microscope, 
 and assert that the presence of the Klebs-Loffler bacillus is diagnos- 
 tic of diphtheria, but my own experience has shown me that grave 
 errors arise when this is made the principal means of diagnosis. 
 
 Prognosis. Follicular tonsillitis is usually readily controlled by 
 Eclectic treatment. Even a few hours of proper medication find the 
 patient much more comfortable and a couple of days suffices to con- 
 trol nearly all unpleasantness, only slight local discomfort remaining. 
 
 Treatment. Aconite and phytolacca will soon relieve the urgent 
 symptoms. The following prescription, for an adult, is the proper
 
 366 DISEASES OF THE DIGESTIVE ORGANS. 
 
 thing: U Green-root tincture (or specific) phytolacca 31, Lloyd's 
 aconite gtt. v-x, aqua ad fiv. S. Take a teaspoonful every hour. 
 This will soon control the fever and assuage the local irritation, and 
 the principal requirement then is to relieve the muscular pain. This 
 is readily accomplished with, macrotys or rhamnus cali/ornica. I pre- 
 fer to use these agents in the form of decoction, in half or full wine- 
 glass doses, macrotys being preferable where the bowels are sensitive 
 to the cathartic action of the rhamnus. One of these agents should 
 be administered steadily until the muscular pain has subsided. 
 Where the rhamnus causes catharsis or the cimicifuga causes head- 
 ache the dose should be considerably lessened. 
 
 Periodicity is a common attendant of follicular tonsillitis in mala- 
 rious districts, and satisfactory treatment demands that this element 
 shall be properly managed. The antiperiodic action of quinia sul- 
 phas may here be sought by the common method, or three-grain 
 doses of arseniate of quinia 3x, repeated every four hours for two or 
 three days, may be used instead. When the patient is robust and the 
 system is in a proper condition for the administration of quiiiia, it 
 will produce the most prompt results. The arseniate is more pleas- 
 ant, but requires a longer time to produce the effect. 
 
 The compound tincture of guaiacum or powdered gum guaiac is 
 an excellent remedy in this disease, though with aconite and phyto- 
 lacca we will hardly care to make use of it, as the combination is un- 
 equalled in pleasantness and efficiency for its effect on tonsillar in- 
 flammation of this character. Where the patient seems predisposed 
 to frequent recurrences of the disease the protracted use of baryta 
 carb. 3x will assist in fortifying the parts against later invasion. 
 
 Local applications are not of much use except for their mental 
 influence, though sometimes this is not to be neglected. Thus, vine- 
 gar packs may be employed or even tepid-water packs. Hot appli- 
 cations might favor suppurative action, and are to be avoided. 
 
 PEBITONSILLAB ABSCESS. 
 
 Synonyms Quinsy; Amygdalitis. 
 
 Definition. An inflammation of the connective tissue external 
 to the tonsil. 
 
 Etiology. Any of the causes of follicular tonsillitis may give 
 rise to peritousillar abscess, though it may arise from infection orig- 
 inated by that disease. When quinsy has once occurred, the subject 
 is especially prone to later attacks upon slight provocation, a perma- 
 nent susceptibility seeming to remain for years. 
 
 Pathology. Suppurative inflammation occurs in the connective 
 tissue surrounding the tonsil, the upper portion being usually affect-
 
 DISEASES OF THE TONSILS. 367 
 
 ed, as the dense structure at the lower anterior part of the gland is 
 more resisting. The abscess usually extends upwards between the 
 pillars of the fauces and sometimes backward and downward along 
 the posterior pillar. 
 
 Symptoms. These are usually severe, the affected part being 
 swollen and sensitive, that side of the neck being stiffened and en- 
 larged externally. The jaws soon become so swollen as to prevent 
 opening of the mouth, and deglutition is extremely difficult and pain- 
 ful. The voice becomes muffled and nasal, and complete inability to 
 swallow often results from the extensive tumefaction about the fauces. 
 Throbbing in the affected part begins early, the tensive pain being 
 varied by alternate dartings in the middle ear. Chilliness at inter- 
 vals heralds the advent oE suppuration, which begins within two or 
 three days after the initiation of the active symptoms; and the pa- 
 tient is now only able to open the jaws sufficiently to protrude the 
 tongue with great difficulty. If examined early the tonsil will pre- 
 sent a lateral tumefaction, which crowds the soft palate upward and 
 and the tongue downward on the affected side and bulges into the 
 opening of the fauces, sometimes nearly closing it, the mucous mem- 
 brane presenting an angry, reddened appearance. As suppuration 
 proceeds a prominent bulging point may be distinguished just beneath 
 the soft palate of the affected side, indicating the near approach of 
 pus to the surface. 
 
 The tongue is usually heavily coated with a pasty-white, offensive 
 fur, the breath is foetid, and constant accumulation of tenacious mucus 
 in the throat gives rise to frequent hawking and other efforts to clear 
 the passage. There is usually elevation of temperature, the ther- 
 mometer often indicating from 102 to 104 F. The bowels are con- 
 stipated, the urine scanty and high colored, the skin dry and husky 
 and the patient is restless and uneasy, his sleep being noisy and 
 stertorous. 
 
 Diagnosis. Eetro-pharyngeal abscess might be mistaken for 
 quinsy, though palpation of the affected side at the angle of the jaw 
 and examination with the finger within the throat will remove all 
 doubt. 
 
 Prognosis. There is some danger of escape of pus into the 
 larynx at the moment of discharge, especially if it occurs with the 
 patient in the recumbent position. CEclematous laryngitis is among 
 the possible complications, and this may render asphyxia imminent. 
 However, with good treatment a favorable termination may usually 
 be anticipated. 
 
 Treatment. An excellent prophylactic, where the quinsy-habit 
 has become established, is the protracted use of baryta, carb. 3x, and 
 this is especially commendable upon the first appearance of the
 
 368 DISEASES OF THE DIGESTIVE ORGANS. 
 
 symptoms of an attack. The early use of potassium chloride 3x is 
 also commendable, as, if begun early, it promises to arrest the forma- 
 tion of pus and abort the disease. When follicular tonsillitis occurs 
 coincidently, as is sometimes the case, phytolacca and aconite may be 
 alternated with one of these remedies. Two grains of the 3x tritura- 
 tion of baryta carb. may be administered every two hours when used 
 to abort the disease, or every three or four when used to fortify the 
 tonsil against future attacks. If potassium chloride is to be used 
 dissolve five grains of the 3x trituration in half a common tumbler of 
 water and give a teaspoonful every one or two hours. 
 
 Early puncture with an aseptic bistoury is the best treatment 
 after suppuration has been established. Even if pus be not already 
 formed early evacuation of blood relieves painful tumefaction and 
 
 the incision facilitates prompt escape of the 
 earliest formation of purulent material. The 
 puncture should be made near the upper por- 
 tion of the tonsil, just below the soft palate, 
 in a horizontal direction, nearly backward, 
 rather toward the median line of the throat. 
 ABSCESS. In the absence of a tonsil bistoury a common 
 P, point for puncture. straight bistoury may be guarded, except at 
 the point, with a wrapping of linen or cotton cloth, and serve an 
 equally good purpose. 
 
 The patient may be nourished, in event of inability to swallow, 
 by injecting milk or other liquid food into the oesophagus with a 
 Davidson syringe through a gum-elastic catheter. 
 
 CHRONIC TONSILLITIS. 
 
 Synonym. Hypertrophy of the Tonsils. 
 
 Definition. Chronic enlargement of the tonsils, usually occur- 
 ring in children. 
 
 Etiology. Chronic tonsillitis may arise from repeated attacks 
 of follicular tonsillitis or may come on insidiously. Members of cer- 
 tain families are especially prone to its development, those of lym- 
 phatic temperament being probably most liable. Children of syphi- 
 litic, tubercular or rheumatic history are often subjects of chronic 
 tonsillitis. It is also liable to follow attacks of scarlatina, diphtheria, 
 rubella, measles and other severe infectious diseases, especially those 
 which are attended by faucial irritation. It is most common between 
 the ages of three and five, though older children may be affected by 
 it. After the age of fifteen there is a general tendency for the glands 
 to undergo atrophy, the process being slow, however, and often con- 
 tinuing to the thirtieth year.
 
 DISEASES OF THE TONSILS. 369 
 
 Pathology. All the tissues of the tonsils increase in size, the 
 number of lymphoid cells being especially augmented. The follicles 
 become deepened and dilated, their orifices being visible to the naked 
 eye upon superficial inspection, the gaping openings often disclosing 
 the presence of a yellowish-white, offensive, curdy material within. 
 The lax structure permits of the rapid growth of adventitious tissue 
 in the tonsils, and rapid enlargement usually results when the hyper- 
 trophic processes begin, the fauces being soon blocked by the pro- 
 truding organs. 
 
 Symptoms. A subject of hypertrophic tonsillitis is constantly 
 annoyed with a sensation as of a foreign body in the throat. The 
 voice is muffled and husky and deglutition is impaired though not 
 severely, except when an attack of acute tonsillitis occurs in connec- 
 tion with it, which, however, is often the case. Respiration is through 
 the mouth, and sleep is usually characterized by chokings and start- 
 ings which are many times alarming to parents, strangulation being 
 frequently suggested at night, though not at all imminent. Hearing 
 is often impaired from tumefaction about the orifices of the Eustach- 
 ian tubes. Upon inspection the glands will be found dusky and swol- 
 len, obstructing the fauces to greater or less extent and presenting 
 the gaping orifices with curdy contents as described under pathology, 
 the breath being foetid and offensive. 
 
 The habit of mouth-breathing entails more or less pharyngeal and 
 laryngeal irritation, manifested by hawking, empty swallowing and 
 hacking cough. Obstructed respiration and resultant defective oxy- 
 genation of the blood are liable to terminate in deterioration of the 
 general health. Long-continued post-nasal obstruction may give rise 
 to a stupid, dejected cast of countenance so peculiar to this form of 
 tonsillitis, and the conformation of the thorax may finally become 
 altered, the chest being flattened at the sides and bulged forward at 
 the sternum. 
 
 Diagnosis. Malignant disease of the part might be mistaken 
 during its early stage for chronic tonsillitis, though the bright red 
 color, severe pain and lateral character of malignant disease (one 
 side being affected rather than both) would afford clearly defined 
 diagnostic differentiation. As the disease advanced to a later stage 
 there should be no chance for confusion. 
 
 Prognosis. As the hypertrophy continues there is increased 
 danger of permanent damage to the voice as well as to the general 
 health. Even though atrophy may be expected to begin at puberty, 
 it is not advisable to neglect the present condition. There is in- 
 creased liability to such infectious diseases as diphtheria, scarlatina, 
 etc., when the follicles are enlarged, and treatment for a radical cure 
 is therefore additionally important. 
 
 25
 
 370 DISEASES OF THE DIGESTIVE ORGANS. 
 
 Treatment. Certain remedies influence the tonsils and reduce 
 enlargement in hypertrophied conditions. Baryta carb. is excellent 
 for this purpose, two or three grains of the 3x trituration three or 
 four times daily answering a good purpose when persevered in for 
 several months at a time. The iodide of barium is also an excellent 
 remedy employed in the same manner. A reliable auxiliary is the 
 galvanic current, which may be applied twice weekly by holding a 
 positive electrode against the tonsil in the throat and the negative 
 sponge upon the outer surface over the affected region. The patient 
 will be able to bear the current only a second or two at a time, but 
 it may be repeated two or three times at each sitting. Interstitial 
 injections of ergot, thuja, and iodine into the tonsils have been success- 
 fully used by some. Perhaps the local application of galvano-cautery 
 may prove more reliable still, deep cauterization being followed by 
 cicatrization and contraction of the part. When such measures fail, 
 amputation of the organs may be in order, the operation being simple 
 and of little danger, while loss of the tonsils involves no serious re- 
 sults to the general system. A small volsellum forceps may be used 
 to steady the diseased part while a strong scissors (curved on the 
 flat) is employed to excise it. Or, a tonsil bistoury may be used in- 
 stead. The Matthieu tonsillotome is an excellent instrument for re- 
 moval of the tonsil, when intelligently employed. The operation is 
 so simple that the ordinary practitioner need not hesitate to attempt 
 it, little hemorrhage following, though in small children anaesthe- 
 sia may be necessary. 
 
 Adenoid growths upon the vault of the pharynx (the third tonsil) 
 are sometimes complicated with chronic tonsillitis and require re- 
 moval as well as the tonsils. A special cutting forceps is manufac- 
 tured for this purpose. 
 
 Dr. H. W. Kendall, of Quincy, 111., describes a method which he 
 has used with advantage for ten years: "We have an efficient cauter- 
 ant and at the same time an antiseptic and alterant in pure hydro- 
 chloric acid, which is always friendly to human flesh. This is the 
 agent that I have found so efficient in reducing enlarged glands in all 
 parts of the body, but the method of using it is the particular point 
 that I wish to present in this short paper. My method is the use of 
 capillary glass tubes (Bohemian or Whitall & Tatum's glass) one- 
 eighth of an inch calibre heated in a Bunsen flame and drawn to a 
 point, the shaft of the drawn part two inches long, with calibre one- 
 sixty-fourth of an inch, broken off and fire polished. Now, if the 
 shaft of the tube is five inches long the drawn part will hold, after 
 dipping in the fluid, one minim ; if the larger shaft is increased in 
 length it will hold more. When the point of this tube touches any
 
 DISEASES OF THE (ESOPHAGUS. 371 
 
 substance it will deposit a fraction of the drop; by long contact it will 
 deposit all that it contains. 
 
 "I dip these tubes into pure fuming hydrochloric acid and push 
 them into the excretory ducts of the glands, three in each gland at 
 each sitting twice a week. This operation is painless and produces 
 no inflammation or swelling. Five or six applications are sufficient 
 for moderately enlarged glands." 
 
 V. DISEASES OF THE (ESOPHAGUS. 
 
 CESOPHAGITIS. 
 
 Synonym. Inflammatory Dysphagia. 
 
 Definition. A catarrhal inflammation of a part or the whole of 
 the mucous membrane of the oesophagus. 
 
 Etiology. Acute inflammation of the oesophagus is usually due 
 to the action of acrid fluids or solids in their passage to the stomach. 
 The incautious swallowing of scalding fluids, such as hot chocolate, 
 coffee, or of hot food, occasionally causes it. Children sometimes 
 swallow lye or carbolic acid, or the latter substance is taken with 
 suicidal intent. The accidental lodgment of spiculae of bone, arti- 
 ficial teeth or other foreign bodies in the oesophagus, sometimes re- 
 sults in inflammation of acute character, which is followed by long- 
 continued subacute or chronic inflammation. The excessive use of 
 alcohol, extension of pharyngitis or other inflammation of the throat 
 to the oesophagus, tuberculosis and other exciting and predisposing 
 causes might be named. Chronic cesophagitis may follow an acute 
 attack, be developed from a tuberculous or syphilitic condition or 
 be due to the irritation of a foreign body lodged along the tube. 
 Diphtheritic infection, scarlatina, cholera, pyaemia, septicaemia or 
 other infectious diseases may give rise to membranous cesophagitis. 
 
 Pathology. In acute cesophagitis the mucous membrane is high- 
 ly reddened and covered with a layer of muco-pus and detached epi- 
 thelium, and the tissues are swollen and softened. In the chronic 
 form the mucous membrane is darkened to a slaty-blue color, the 
 submucous tissue is swollen and the surface is covered with a thick, 
 tenacious mixture of mucus and pus. The cesophageal walls gener- 
 ally are thickened, arid a part or the whole of the tube above the 
 location of an ulcer, which will mark a narrowing, will be dilated or 
 there may be several constrictions and dilations. Sometimes exten- 
 sive diverticula are formed and there may be hernia of the mucous 
 membrane through the muscular wall, with final perforation. The 
 ulceration usually occurs at the seat of most prominent irritation.
 
 372 DISEASES OF THE DIGESTIVE ORGANS. 
 
 In membranous inflammation the morbid changes common to snch 
 inflammation upon other mucous surfaces will appear. 
 
 Symptoms. In acute cesophagitis burning aud gnawing sensa- 
 tions are experienced along the oesophagus, behind the sternum, 
 through the mediastinum and between the shoulders, aggravated by 
 attempts to swallow even the most bland liquids. Extreme thirst, 
 great depression and anxiety, attended by slight febrile disturbance, 
 are present in the acute form. In chronic oesophagitis there is not 
 much pain except when solids are swallowed, though if ulceration 
 exist there is occasionally vomiting of vicid mucus mixed with pus 
 and tinged with blood. 
 
 Diagnosis. Knowledge of the provoking cause will enable the 
 practitioner in acute cases to arrive at a correct diagnosis. Chronic 
 oesophagitis may be confounded with cancer, but here the severity 
 of the pain, which is severe when the part is at rest, the rapid prog- 
 ress of the symptoms and the marked cachexia, will render the diag- 
 nosis clear. 
 
 Prognosis. In acute cesophagitis the damage to the stomach 
 and other associate organs should be taken into consideration in sum- 
 ming up the probable outcome. In croupous oesophagitis the sys- 
 temic condition of the patient the severity of the attending case 
 will determine, more than the local condition, the probable result. 
 Chronic and subacute cesophagitis, where deep-seated stricture is 
 not present, are amenable to curative treatment. 
 
 Treatment. Where cesophagitis is due to the presence of for- 
 eign bodies in the oesophagus their removal is the first matter to be 
 considered. Inflammation of acute character should be treated with 
 veratrum or jaborandi in ordinary sedative doses. EcJtinacea may be 
 
 advantageously com- 
 bined with either or 
 both these agents. 
 Bichromate of potas- 
 sium, in the 2x or 3x 
 trituration, acts well 
 'in subacute inflam- 
 mation, and la^hesis 
 or wq/a, in homeo- 
 pathic attenuations, may relieve the burning, stabbing pain. After 
 the acute symptoms have subsided a flexible galvanic electrode, con- 
 sisting of an elongated shaft of spirally coiled brass spring-wire 
 (eighteen or twenty inches in length) covered and insulated with a 
 section of rubber tubing, having a bulb-shaped nickel- or silver- 
 plated metal terminal at one end and a screw clamp attachment at 
 the other, connected with the negative cord, may be passed down-
 
 DISEASES OF THE (ESOPHAGUS. 373 
 
 ward and upward along the oesophagus twice a week (two or three 
 times) with a current of from five to ten milliamperes (or eight to 
 sixteen cells of an ordinary portable carbon-zinc battery). This is 
 an excellent means of permanently relieving the irritation and excori- 
 ation. The patient should take the positive pole, consisting of a 
 wetted sponge, in the hand only after the bulb has passed into the 
 O3sophagus, as unpleasant shock is thus averted. 
 
 A liquid diet should be used, and movement of the part avoided 
 so far as possible. 
 
 OBSTRUCTION or THE (ESOPHAGUS. 
 
 Etiology. This condition may arise from a variety of causes, 
 which may be arranged under the following heads: (1) Those which 
 are due to organic changes in the walls of the O3sophagus from 
 cancerous infiltration; hypertrophy of the coats generally from in- 
 flammatory action, the submucous coat being generally involved; 
 fibroid changes due to chronic inflammation; localized thickening 
 due to cicatrization after wounds, lesions and ulcers; syphilitic dis- 
 ease. (2) External pressure from various causes, such as broncho- 
 cele; enlargement of the cervical or thoracic lymphatics; cancerous 
 or fibroid tumors; aneurisms; abscesses; great tension of the peri- 
 cardium with fluids. (3) Growths within the O3sophagus, such as 
 fibroid tumors, etc. 
 
 Pathology, Obstruction at any point finally gives rise to dilata- 
 tion and hypertrophy of the oesophagus above, accumulation of food 
 tending to distend the walls of the part, while the necessary resist- 
 ance favors thickening of the muscular structure. Continued disten- 
 tion, however, may result in rupture of the muscular wall with her- 
 nia of the mucous membrane; or ulceration may finally occur at some 
 point, with possible perforation. 
 
 Symptoms. Difficulty of swallowing is the most prominent 
 symptom, pain and sensation of stoppage occurring when the food 
 reaches the point of obstruction, this most commonly being behind 
 the upper portion of the sternum. The disease is progressive, the 
 difficulty of swallowing becoming more and more marked until it 
 is impossible for even the smallest particle of solid food to reach 
 the stomach. Liquids and soft, pulpy food-substances pass the 
 obstruction best. When food cannot pass it is soon rejected, either 
 by gradual regurgitation or sudden spasmodic action; or, being 
 retained for a time, it is discharged in large quantities of alkaline, 
 sodden material, mingled with mucus and pus and, perhaps, tinged 
 with blood. If the condition be due to cancerous infiltration severe 
 pain usually attends, both during the taking of food and between
 
 374 DISEASES OF THE DIGESTIVE ORGANS. 
 
 times as well, and debility, emaciation, waxy color and other symp- 
 toms of cancerous cachexia develop. In ordinary ulceration there 
 is not much pain except during efforts at deglutition, and not even 
 then unless the ulcer be irritable. Another cause of emaciation and 
 debility besides that of cancer may be that of starvation from inabil- 
 ity to swallow sufficient food to meet the demands of the body. If 
 perforation occur sudden collapse or symptoms of septicaemia may 
 follow. 
 
 Treatment. Soft strictures those involving only the mucous 
 and submucous structures may be benefited if not wholly relieved 
 by the patient use of graduated dilators, employed at intervals and 
 passed cautiously to avoid irritation. In the beginning anaesthesia 
 may be employed and afterward a full dose of bromide of potassium 
 may be administered an hour beforehand to quiet irritability and 
 facilitate the operation. Cicatricial strictures will not yield to such 
 treatment, however, and had better not be irritated by efforts to dilate 
 them. Attention to the diet and such other palliative measures as 
 individual cases may demand are all that can be adopted, unless 
 a gastric fistula for the introduction of food directly into the stomach 
 is established. 
 
 Cancerous stricture should not be disturbed, as irritation usually 
 augments the rapidity of its development; all that we can expect to 
 do here is to relieve the pain which attends, and we may accomplish 
 this usually with ten- or fifteen-drop doses of echinacea. Silica 3x 
 is an excellent remedy for this purpose, three-grain doses of the trit- 
 uration being used three or four times a day, though it is second to 
 echinacea in value. Where the ulceration which causes the obstruc- 
 tion is non-malignant a stomach-pump may sometimes be used suc- 
 cessfully in introducing nourishment. 
 
 Chelidonium majus has recently attracted attention as an internal 
 remedy for curative effects in cancer generally. Cures of unmistak- 
 able cancer of the oesophagus and stomach have been reported by 
 apparently respectable authority. Small doses, frequently repeated, 
 for a long time, were required to remove the morbid growths. 
 
 Syphilis, bronchocele, hydropericardium and other special causes 
 of cesophageal obstruction will demand special treatment, adapted to 
 the condition present. 
 
 FUNCTIONAL DISEASE OF THE (ESOPHAGUS. 
 
 PARALYSIS of the O3sophagus sometimes attends diphtheria and 
 hysteria, and arises from glosso-pharyugeal paralysis and general 
 paralysis of the insane. It also attends progressive muscular paral- 
 ysis and certain diseases of the brain.
 
 DISEASES OF THE (ESOPHAGUS. 375 
 
 Symptoms. Djsphagia is the only prominent symptom. The 
 food may escape and pass into the larynx, producing serious respira- 
 tory embarrassment, this being especially true of liquids. Degluti- 
 tion is facilitated by the erect posture. 
 
 (ESOPHAGISMUS, or spasm of the oasophagus, may occur in hys- 
 teria, in hypochondria, in muscular rheumatism or from an irritable 
 ulcer in the passage. It may also be caused by the bolting of large 
 lumps of solid food, by swallowing extremely hot or cold food, or by 
 the abuse of alcohol. Irritation of the oesophageal nerves may also 
 be a cause, and dyspeptic symptoms are sometimes attended by it. 
 Rectal irritation, lacerated cervix uteri, adherent prepuce or clitoris 
 and other orificial lesions may be accountable for it. 
 
 Prominent among the symptoms is a sensation of obstruction as 
 from a solid substance in the gullet; and when food is taken there is 
 stoppage of the bolus upon swallowing at some point in the passage. 
 These symptoms are temporary and appear erratically, as the excit- 
 ing cause provokes spasmodic action. There may be quite long in- 
 tervals during which there is no difficulty whatever in swallowing. 
 If a bougie be passed while the spasmodic action is on its course is 
 arrested at the point of contraction, but if steady pressure be main- 
 tained against it at the place of resistance there is soon yielding and 
 the instrument passes the obstruction easily. During severe attacks 
 there is a sensation of constriction and suffocation about the throat 
 due, probably, to spasm of the cervical muscles. When it occurs in 
 muscular rheumatism it is due to metastasis of the rheumatic affec- 
 tion, pain then attending the sense of obstruction and suffocation. 
 The upper portion of the oasophagus is usually involved. Little con- 
 stitutional disturbance is present, the patient appearing well nour- 
 ished, though dyspeptic, hysterical and hypochondriacal symptoms 
 are common in most such cases. 
 
 Treatment. Bromide of potassium allays spasm and hyperses- 
 thesia of the oesophagus and is almost always an appropriate remedy 
 in cesophagismus. From ten to twenty grains may be administered 
 every two or three hours while the active symptoms continue. It 
 rarely affords permanent relief, but it is useful to relieve speedily. 
 Markedly hysterical cases should receive specific gossypium in ten- 
 drop doses four or five times daily until the spasmodic symptoms 
 subside. Valerianate of ammonium, tincture of valerian and valerian- 
 ate of zinc are all useful. Naja relieves spasm of the oasophagus 
 where the oesophageal nerves are irritated. Rheumatic complications 
 demand cimicifuga or rhamnus californica. Faradism often does good, 
 the positive pole being applied to the tongue with a metal tongue- 
 depressor while a wetted sponge attached to the negative is held 
 against the epigastrium.
 
 376 DISEASES OF THE DIGESTIVE ORGANS. 
 
 In all these cases careful inspection of the rectum, cervix uteri 
 and other orifices should be made to detect any irritation there, and 
 if this be found present the removal of the difficulty by proper ori- 
 ficial surgery is the correct course to pursue. 
 
 VI. DISEASES OF THE STOMACH. 
 
 ACUTE GASTRITIS. 
 
 Synonyms. Acute Gastric Catarrh; Acute Dyspepsia. 
 
 Definition. An acute inflammation of the mucous membrane 
 of the stomacn. 
 
 Etiology. Ordinary causes of inflammation of the mucous 
 membranes generally, such as sudden arrest of secretion from cold 
 while the person is relaxed, may excite this condition in people who 
 ar delicate in respect to the state of the digestive organs. The ac- 
 tion of hot or cold articles of food is calculated to bring on acute 
 gastritis, and certain chemicals, such as alcohol, strong acids, arsenic, 
 etc., may excite a high grade of inflammatory action when allowed to 
 enter the stomach in concentrated form. Some diseases incline to 
 bring about the condition; as, for instance, cholera morbus, cholera, 
 yellow fever, etc. Acute gastritis attended by febrile symptoms some- 
 times occurs epidemically. The predisposing conditions are dis- 
 ordered states of the gastric mucosa, which place its vitality below 
 par, as in elderly persons or delicate women and children, in whom the 
 stomach is in an enfeebled condition, the disease being here pro- 
 voked by indiscretions in diet. 
 
 Pathology. There are different grades of acute gastritis. Ex- 
 posure of the mucous membrane of the stomach through a gastric 
 fistula has afforded opportunity to watch the condition of the mucous 
 membrane during life when inflamed, and it has been seen that the 
 part is reddened and that a coating of mucus is thrown out over the 
 reddened surface. The redness in moderate cases occurs in patches, 
 the hyperaemia being punctiform or capillary in character; but when 
 irritant poisoning occurs the entire mucous membrane is highly red- 
 dened and swollen, that upon the summits of the rugae suffering 
 most. Small extravasations may appear, and minute ulcers and fol- 
 licular erosions are not uncommon. In very severe cases suppura- 
 tion and sloughing of the submucous structure may occur. The pep- 
 tic and mucous glands are also involved, the cells aud nuclei being 
 enlarged and increased in number, the tubules being elongated and 
 prominent. The secretion of gastric juice is thus interfered with, an 
 alkaline, ropy mucus covering the surface. The lymphoid elements 
 between the glands are increased in number and hypertrophied.
 
 DISEASES OF THE STOMACH. 377 
 
 Many mild cases of gastritis occur in which such marked changes are 
 absent, a punctiform redness of the mucous membrane with increase 
 of catarrhal secretion being the extent of the morbid condition. 
 
 Symptoms. These vary widely, according to the severity of the 
 inflammation. In mild cases there are symptoms of indigestion, such 
 as unpleasant sensations in the epigastric region burning, nausea, 
 eructations, and vomiting which is followed by relief. Constipation 
 may attend, though there is sometimes diarrhoea, especially in chil- 
 dren. The tougue is coated and there is an excessive amount of 
 saliva, attended by metallic taste. Such cases subside within twenty- 
 four hours usually, as they result from slight causes and depend on 
 individual susceptibility. Severe cases are marked by burning pains, 
 often of excruciating character, which invade the epigastric region 
 and radiate throughout the entire abdomen, colicky sensations alter- 
 nating. The inflammation may be marked by a chill and febrile ac- 
 tion (102 104 R). Vomiting is a common symptom and is re- 
 peated frequently, the tongue being furred and the breath offensive. 
 Food is ejected at first, but bile mixed with mucus and watery fluids 
 appears in the ejections later, there being absence of hydrochloric 
 acid, a presence of lactic and fatty acids and a superabundance of 
 mucus. The urine presents the usual characteristics of febrile ac- 
 tion, an abundant deposit of urates being thrown down. 
 
 In gastritis from toxic poisoning there is burning pain in the 
 mouth, throat, ossophagus, stomach and bowels, watery diarrhoea 
 (when arsenical), ptyalism, difficult deglutition and frequent vomiting 
 (the ejections containing blood and sometimes portions 'of mucous 
 membrane), while the abdomen is swollen and tender upon pressure. 
 In extreme cases collapse may occur, the pulse being thready, the 
 respiration labored, the skin cold and covered with clammy sweat 
 and the patient extremely restless and anxious. 
 
 Diagnosis. When the disease occurs without any well-pro- 
 nounced cause, it may at first be mistaken for some form of infectious 
 fever announced by active gastric irritation, as is sometimes the case 
 in scarlatina and other infections. Later developments, however, 
 will distinguish it from these affections. "When irritating drugs have 
 been swallowed a knowledge of this fact will enable us to decide as 
 to the character of the complaint. The experience of delicately con- 
 stituted persons who suffer from gastritis from slight causes will 
 assist the physician in most cases in arriving at a correct diagnosis. 
 
 Prognosis. Snch cases as are marked by dietary indiscretions 
 usually recover within two or three days. Others may run a still 
 more violent course, depending on the gravity of the exciting cause, 
 a chronic gastric catarrh being finally established. Poisoning with 
 arsenic or other corrosive poisons is liable to run a still more severe
 
 378 DISEASES OF THE DIGESTIVE ORGANS. 
 
 course, the symptoms of toxic poisoning being sometimes of grave 
 and fatal character. 
 
 Treatment. In mild cases of acute gastritis diluents may be 
 used to favor emesis. These may be warm water, flax-seed tea, 
 slippery-elm water or some other soothing agent. Following this 
 a decoction of the bark of peach-tree shoots, a weak infusion of 
 hydrastis or (what is better) the following prescription may be admin- 
 istered: R Green plant tincture rhus tox. gtt. xv, specific ipecac gtt. 
 x, water ?iv. M. Sig. Take a teaspoonful every hour. Sometimes 
 two grains of subnitrate of bismuth every hour will serve a better pur- 
 pose. For the treatment of poisoning the reader is referred to 
 works on toxicology. 
 
 PHLEGMONOUS GASTRITIS. 
 
 Symptom. Suppurative Lenitis. 
 
 Definition. A suppurative inflammation of the submucous 
 (areolar) tissue of the stomach. 
 
 Etiology. This disease is rare and usually occurs between the 
 ages of twenty and forty years. It may arise from the infection of 
 pyaemia, septicaemia, typhoid or typhus fever, or diarrhoea as a sec- 
 ondary affection or may occur idiopathically. Traumatism may be 
 an occasional cause. 
 
 Pathology. The inflammation may be circumscribed or dif- 
 fused. The wall of the stomach at the point of inflammatory action 
 is thickened, oadematous and friable, with infiltration of the areolar 
 tissue with sero-fibrinous and purulent material. In the diffused 
 form the mucous membrane may be thinned and perforated in num- 
 erous places, affording exit to pus from a variety of irregularly shaped 
 cavities located in the submucous tissue. The mucous surface is 
 reddened, sometimes dusky in hue, and gangrenous spots may appear 
 in various places. Sometimes the peritoneal coat is involved, the 
 condition then assuming the characteristics of acute peritonitis. 
 Pus may perforate this membrane and escape into the peritoneal 
 cavity. Gastric ulcers may arise from perforation of the mucous 
 membrane. 
 
 Symptoms. Active febrile symptoms usher in this disease. 
 There is a chill, followed by febrile reaction, the temperature rising 
 as high as 104 or 106 F. There is intense pain in the epigastric re- 
 gion, with loss of appetite and consuming thirst. Persistent vomiting 
 of a dark colored, bitter fluid containing more or less pus succeeds 
 early upon the initial chill, the patient is rapidly prostrated and be- 
 comes anxious and watchful. Delirium with jaundice soon follows, and 
 typhoid symptoms with muttering, wandering or stupor precede the
 
 DISEASES OF THE STOMACH. 379 
 
 period of collapse (which is soon developed), the patient dying in a 
 comatose condition. 
 
 Diagnosis. This is very difficult, and the disease is usually 
 unrecognized during life, autopsies supplying the most that has been 
 known upon the subject. 
 
 Prognosis. This is always unfavorable. The majority of cases 
 prove fatal within the first week, especially if the inflammation be 
 diffused. Circumscribed inflammation here may not prove so rapidly 
 fatal, the patient surviving for two or three weeks. Secondary 
 abscess of the liver and peritonitis may attend. 
 
 Treatment. This is principally palliative, hypodermic injec- 
 tions of morphia being most reliable to relieve the pain. Hypoder- 
 mic injections of ecliafolta might be tried for the control of the in- 
 flammatory action and to prevent extreme destruction of tissue. 
 
 PARASITIC GASTRITIS. 
 
 FUNGI occasionally develop in the stomach and excite inflamma- 
 tion. Sarcinse and yeast fungi are probably perpetuating causes of 
 chronic gastritis, and occasionally a case of acute gastritis seems 
 ascribable to the presence of parasitic growths. The anthrax bacil- 
 lus has been known to develop in the gastric mucous membrane and 
 Klebs has described a bacillus gastricus which develops in the gas- 
 tric tubules and excites acute gastritis. The larvae of certain insects 
 has been known to cause gastritis. Diphtheria, tuberculosis and 
 syphilis may attack the gastric mucous membrane. 
 
 CHRONIC GASTRITIS. 
 
 Synynoms. Chronic Gastric Catarrh; Chronic Dyspepsia. 
 
 Definition. It is a disturbance of digestion attended by an 
 excess of gastric mucous secretion, with vitiation of the digestive 
 juices from fermentative products, and finally alteration of the struc- 
 tural integrity of the stomachal walls. 
 
 Etiology The causes of this condition are numerous and varied 
 in character, but all tend to one result difficult and protracted 
 chymification, with formation, within the stomach, of fermentative 
 material. This may result from acute gastritis, though it is more 
 apt to come on from indiscretions in diet, such as the use of highly 
 seasoned or indigestible food; irregular and hasty eating; gourman- 
 dizing; addiction to the excessive use of tea, coffee, alcohol or tobac- 
 co or from the habit of using iced foods or drinks during meals. It 
 may develop from rectal, prostatic or uterine irritation and such con- 
 stitutional diseases as gout, anaemia, chlorosis, tuberculosis and dia-
 
 380 DISEASES OF THE DIGESTIVE ORGANS. 
 
 betes, and malarial cachexia may be attended or preceded by it 
 Pulmonary tuberculosis or chronic interstitial nephritis may be her- 
 alded for months by gastric catarrh long before the pending causal 
 disease has Ijeen fully developed, slow and inadequate digestion en- 
 couraging the growth of the yeast plant, sarcina and other elements 
 of gastric fermentation, thus giving rise to and perpetuating irrita- 
 tion of the gastric mucosa. Portal obstruction, by causing engorge- 
 ment of the gastric capillaries, may retard digestion and, finally, 
 through disturbance of the functions of the gastric tubules and re- 
 sultant slow and feeble digestion, permit the accumulation of suffi- 
 cient provoking cause to bring on a chronic catarrh, it therefore be- 
 ing frequently associated with active or passive hepatic congestion, 
 hepatic cirrhosis, splenic hypertrophy, pancreatic disease or cardiac 
 or pulmonary engorgement. Also, it may be associated with various 
 local diseases of the stomach, such, for example, as cancer, ulcera- 
 tion or dilatation. 
 
 Pathology. Pathologists recognize two forms of chronic gas- 
 tritis: (1) The simple or common, and (2) the sclerotic the second 
 being rare. The simple form is attended by hypertrophy of the in- 
 tertubular mucous membrane with consequent choking out of the 
 gastric tubules; while the second is attended by atrophy of the entire 
 mucous membrane as well as of the secreting structures. The first 
 is marked by profuse secretion of mucus with restriction of the nor- 
 mal amount of gastric juice, the lining of the stomach being covered 
 with a tenacious coating which mechanically and chemically inter- 
 feres with normal chymification, while the second is characterized by 
 dryness and lack of secretion not only of gastric juice but of mucus, 
 the organ being dilated, its walls thinned and atrophied, with fatty 
 degeneration of its glandular elements. In another sclerotic form 
 (which is exceedingly rare) there is fibrous degeneration of the gas- 
 tric walls, the muscular structure being thickened with fibrous growth 
 from hyperplasia of the connective tissue until the coats are con- 
 tracted and hardened, the viscus being lessened in size and concen- 
 trated until its outlines may be traced by palpation through the ab- 
 dominal walls. 
 
 In the common form removal of the tenacious gray mucus cover- 
 ing the interior of the stomach will reveal more or less alteration of 
 structure in the mucous membrane, the amount and character depend- 
 ing upon the duration and severity of the disease. CEdematous spots 
 covered with granulations, ecchymoses and more or less extensive 
 areas of pigmentation are distributed over the surface. Thickening 
 of the mucous membrane is prominent, especially about the pylorus, 
 and this may be so extensive as to obstruct the opening, the stenosis 
 resulting in gradual dilatation gastrectasia. In some cases the sub-
 
 DISEASES OF THE STOMACH. 381 
 
 mucous tissue is implicated, the thickening being attended by infil- 
 tration of the structure with migrating connective-tissue cells and 
 development of adventitious fibrous growth, which renders the walls 
 firm and unwieldy and interferes greatly with normal peristaltic 
 action. Mammillation of the surface of the mucous membrane 
 due to obstruction of the tubules by pressure from intertubular 
 hypertrophy, and consequent distention by accumulation of their 
 secretions until they stand out prominently, may sometimes be ob- 
 served. Another form of mammillation is that which attends hyper- 
 trophy of the peptic glands, this resulting in an increased area of 
 mucous surface, which being more voluminous than the basement 
 membrane is thrown into folds or corrugations. As the disease con- 
 tinues the muscular coats may become still more involved in the 
 thickeniug process and the peristaltic movements will become fur- 
 ther impeded. Finally, the serous layer may be involved and ad- 
 hesions occur between opposing surfaces of the reflected peritonaeum. 
 
 In long-standing cases the mucous membrane near the pylorus is 
 very liable to be the seat of abrasions, superficial ulcers of circular 
 shape, varying from half an inch to an inch in diameter, occupying 
 this region, the intervening mucous membrane being reddened and 
 osdematous. The ulcers are superficial, rarely extending deeper than 
 the mucous membrane, their bases being covered with mucous cells, 
 epithelium and nuclei. Minute points of ulceration may appear, 
 scattered about over the entire surface, marking the locations of 
 similarly affected solitary and lenticular glands. The inflammation 
 usually extends to the duodenal mucous membrane, similar changes 
 occurring here, and the common bile duct may be involved during 
 aggravations, icteric symptoms from obstruction at various intervals 
 signalizing such complication. Dilatation of the stomach may attend 
 some cases and contraction of its wsdls others, as varying pathologi- 
 cal changes predominate. Amyloid degeneration of the walls of the 
 stomach, secondary to waxy changes in the liver and spleen, may 
 occur in advanced stages. Fatty infiltration of the tubules is detected 
 under the microscope, and occasionally fatty degeneration of the tub- 
 ular structures. 
 
 Symptoms. Indigestion is the prominent symptom, a great 
 variety of unpleasant accompaniments being liable to attend. Heart- 
 burn, associated with weight and fullness in the epigastric region, 
 follows eating and continues for hours as soon as the disease devel- 
 ops. Later on there is actual pain of a burning, acrid nature, at- 
 tended by eructations of gases and fluids, sour risings and tenderness 
 on pressure over the epigastrium. Darting pains radiate from the 
 stomach into the pectoral region and backward toward the scapulae, 
 and these may be aggravated by pressure over the epigastrium.
 
 382 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 Burning along the oesophagus and in the throat and mouth, with in- 
 creased secretion, is common, the lips and tongue sharing in the un- 
 pleasant sensation. The tongue is often red and slick, the papillae 
 being elevated and the tip pointed, though in other cases the general 
 appearance of the organ may be normal. Craving for food (boulimia) 
 is a frequent symptom, this amounting in many instances to an almost 
 constant, unsatisfied, gnawing sensation in the epigastrium, though a 
 small portion of food may satisfy it for a short time, during which 
 the torments of difficult and painful digestion are experienced. A 
 metallic taste is frequently present between periods of eating. 
 
 In aggravated cases vomiting is a frequent symptom, the material 
 ejected consisting of partially digested food mixed with a large quan- 
 tity of mucus, among which may be detected sarcinee ventriculi, toru- 
 l?e and varieties of bacilli and micrococci. There is absence of hydro- 
 chloric acid here in most cases, lactic acid, associated with butyric 
 or acetic acid replacing it, though in rare cases there may be excess- 
 ive secretion of hydrochloric acid. Digestion is necessarily retarded 
 
 under these circumstances, and 
 if the stomach be irrigated and 
 siphoned seven hours after eat- 
 ing undigested food will still 
 be found in the washings. 
 
 The bowels are usually con- 
 stipated, though the reverse 
 may be the case, undigested 
 food then passing thiough the 
 intestinal canal soon after it is 
 swallowed (lientery). 
 
 Cardiac palpitation fre- 
 quently attends the digestive 
 process and the tumultuous 
 throbbing may seem to be com- 
 municated to the sensitive 
 stomach, accumulation of gases 
 aggravating the difficulty and eructation affording only temporary 
 relief. Stitching pains in the cardiac region may be added to the 
 tumultuous action and vertigo is often associated with it "Stomach 
 cough," due to pharyngeal irritation partly and partly, in many cases, 
 to voluntary efforts of the sufferer in seeking relief from prsecordial 
 oppression and epigastric discomfort, often attends. 
 
 Among the sympathetic symptoms are headache, langour, mel- 
 ancholy and emaciation. Where atropy of the gastric tubules is 
 present anaemia is prominent. 
 
 Diagnosis. The use of the stomach-tube will afford the best 
 
 MICROSCOPICAL DEBRIS FROM CATARRHAL STOMACH. 
 
 a, Rarcinae ventriculi. 
 
 b, yenst plant. 
 
 c, bacteria and cocci, 
 cl, epithelial cells. 
 
 e, leucocytes. 
 
 f, starch granules, 
 
 g, fat globules. 
 
 h, muscular fiber. 
 i, fat needles, 
 k, vegetable cells.
 
 DISEASES OF THE STOMACH. 383 
 
 means of diagnosis. If siphonage be practiced an Lour or so after 
 eating hydrochloric acid will usually be absent, and lactic acid asso- 
 ciated with fatty acids appears, a large amount of rnucus being pres- 
 ent. If siphonage be practiced seven hours after eating undigested 
 food will be found still remaining in the stomach, while in cases of 
 functional dyspepsia it will have disappeared. Malignant disease 
 will be excluded by lack of cachexia, absence of perceptible tumor 
 upon palpation and by the character of the vomit, coffee-ground 
 material soon appearing in cancer. In gastric ulcer a diagnostic 
 feature is hematemesis of bright blood. 
 
 Prognosis. Chronic gastritis will usually improve readily 
 under rational treatment, unless there be associated with it gastric 
 ulcer, cancer, gastrectasia or organic, hepatic, renal or pulmonary dis- 
 ease. When neglected it may continue for years and eventually ter- 
 minate in ulcer or pyloric stenosis, with resultant perforation or dil- 
 atation. A sympathethic disease of the supra-renal capsules is not 
 an unfrequent complication, the supra-renal bodies seeming to sus- 
 tain a peculiar relation of this nature to gastric irritation. The 
 marked emaciation which attends long-continued cases renders the 
 patient susceptible to attacks of acute disease and he is liable to suc- 
 cumb suddenly to some onset of this kind, to hematemesis or to the 
 immediate results of pyloric stricture. 
 
 Treatment. An important part of treatment is the abandon- 
 ment, so far as possible, of all exciting or perpetuating causes. If 
 the subject has been in the habit of using alcoholic liquors he should 
 do away with them at once and forever. As a substitute three parts 
 of Howe's viburnum cordial and one part of specific avena saliva 
 should be combined, and recourse be had to this mixture in accept- 
 able doses repeated as often as necessary until all depression and 
 craving for the accustomed stimulant have passed away. A habit of 
 using ice-water or iced drinks or foods should be dispensed with 
 under all circumstances, warm foods and drinks of bland and digesti- 
 ble character being most applicable to restorative processes. Over- 
 eating and the use of objectionable food should be avoided and this 
 will be no easy trial for the patient if he be permitted to dine in 
 the company of healthy persons, as the food they may be' accus- 
 tomed to may not be applicable to his case, and the power of associa- 
 tion may be so strong as to lead him to transgress again and again 
 to the complete defeat of curative measures. It will be better for 
 him to eat alone and confine himself to small quantities of judiciously 
 selected foods taken at shorter intervals than in health, with slow 
 mastication. Fats and carbo-hydrates should be generally avoided 
 as well as pastries, griddle-cakes and cheese. 
 
 Sometimes, when there is nephritic or cardiac complication (and
 
 384 DISEASES OF THE DIGESTIVE ORGANS. 
 
 even in severe cases without complication), a milk diet adheied to 
 strictly for several weeks will afford the best results. In order to 
 prevent the formation of hard curds the milk should be diluted with 
 soda-water, lime-water or other alkaline fluid. Where there is atro- 
 phy of the peptic glands pancreatized milk will be more appropriate. 
 Sometimes, when the stomach is very weak and the milk causes 
 nausea, it may be necessary to remove the cream before it is taken. 
 Many persons will prefer butter-milk, and this may be allowed freely 
 in such cases. From one to two quarts of milk or butter-milk may 
 be taken every twenty-four hours, four ounces being allowed at a 
 time with two-hour intervals, the amount being gradually increased 
 and the intervals lengthened as improvement succeeds. 
 
 When milk does not sustain the strength (though such cases will 
 be rare) underdone beef or, what is better, raw scraped beef may be 
 allowed in connection with it, one or two ounces at a time two or 
 three times a day being sufficient, though the amount may be in- 
 creased as the patient's ability to digest food improves. Broths and 
 soups should be avoided and tea, coffee and cocoa should be taken 
 sparingly if at all and without milk or sugar. Oysters raw, broiled 
 or panned are allowable and also stale bread without butter or with 
 but a sparing quantity. Where there is an excessive amount of 
 hydrochloric acid secreted the patient will live best on rare roast 
 beef, rare steaks or the breast of chicken eaten with stale bread. 
 Eggs should be thoroughly cooked for such persons and will then be 
 well tolerated. If an egg be boiled for an hour the yolk, with a lit- 
 tle salt added, will agree with the most delicate stomach. Where 
 there is a strong tendency for food to undergo decomposition in the 
 stomach salted and smoked meats and fish may sometimes agree bet- 
 ter than other articles of diet. Here cream codfish, dried beef, jerked 
 venison, caviar, etc., may be carefully tried in succession in small 
 quantities, that the diet be varied. Cured meats may be employed 
 for the manufacture of cream gravy to be eaten on toast or stale 
 bread, the solid part being rejected. 
 
 Confusion as to a proper course of diet may be avoided if 
 the patient can be induced to adhere to a strictly dry diet. This 
 should consist only of stale bread, to be taken ad libitum with two or 
 three ounces at a time of plain claret, which should not be repeated 
 oftener than five or six times each twenty-four hours. No tea, cof- 
 fee, water, milk or other fluid should be allowed, and no butter, meat 
 or other food, except the plain, stale bread, should be consumed. 
 This may seem a hardship at first, but adherence to the regimen 
 brings abundant satisfaction by the end of ten or twelve weeks. 
 There will be a provoking thirst for the first few days, after which 
 this source of annoyance will have subsided. Upon this allowance
 
 DISEASES OF THE STOMACH. 385 
 
 the patient will not over-eat and, though he may become emaciated 
 and weakened somewhat, he will not starve, and will recuperate rap- 
 idly when a gradual return to ordinary diet is allowed, while the 
 gastric disturbance will have subsided if other proper measures 
 have been applied in the meantime. 
 
 Saccharine, starchy and farinaceous foods are almost certain to 
 undergo lactic and butyric acid fermentation in the stomach before 
 their digestion can be completed, producing flatulency with eructa- 
 tion of gasee and sour fluids. A person afflicted with chronic gas- 
 tritis should endeavor to live carefully and abstemiously after re- 
 covery throughout his life, as it is not a difficult matter to prov, ke 
 a return of the disease. During treatment, business cares and all 
 other responsibilities should be avoided, that no expenditure of en- 
 ergy be made in an unnecessary direction, neither physical nor men- 
 tal exertion being conducive to improvement. The case of Louis 
 Cornaro, the Venetian, is not to be forgotten in this connection, for 
 it illustrates the remarkable effect of careful living upon those seem- 
 ingly hopelessly affected with gastric derangements. 
 
 Though my information does not justify me in asserting that he 
 was a sufferer from chronic gastritis, the narrative suggests such a 
 condition. Born with wealth, he was endowed with means and leis- 
 ure to abandon himself to high and prodigal living; but a weak con- 
 stitution, broken down at the age of thirty-five from riotous living 
 and other excesses, rendered life a burden to him. The next five 
 years were passed in almost constant misery, and at the age of forty 
 his physician informed him that nothing could prolong his life more 
 than two or three years, and temperate habits were advised as the 
 means to relieve his sufferings during that time. He now began to 
 gradually reduce the amount of food, both liquid and solid, consumed, 
 until he at length took only what nature absolutely required. This, 
 according to his own statement, was a difficult course to pursue and 
 he often relapsed to over-eating; but he finally succeeded (within a 
 year) in adopting permanently a spare and moderate system of diet, 
 and was, at the end of this time, already restored to perfect health. 
 
 Being now an enthusiast, he proceeded from moderation to abste- 
 miousness and diminished his daily allowance until the yolk of an 
 egg sufficed him for a meal. Health and spirits improved and he 
 soon became able to derive more pleasure from a small meal of dry 
 bread than the most tempting viands of a richly-laden table had 
 afforded him in his days of excesses. Such a course persevered in, 
 with the avoidance of extremes of heat and cold, enabled him, after 
 almost ending his life at thirty-five, to recuperate and become a cen- 
 tenarian. Modern experiences often acquaint us with similar cases, 
 where individuals in desperation, after a prolonged treatment for 
 
 26
 
 386 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 indigestion without benefit, recover under prolonged self-imposed 
 starvation. 
 
 Constant and prolonged fermentation is the principal factor in 
 the perpetuation of the disease, and the cleansing of the stomach of 
 mucus and fermentative products is the direct way out of the diffi- 
 culty. Modern times have afforded us superior advantages in this 
 respect, and there is now little difficulty in curing uncomplicated 
 cases of chronic gastritis even of long standing. If complications 
 exist they should be removed if possible and the problem then be- 
 comes as clear as ever. The tenacious mucus, which serves as a 
 nidus for fermentative products, must be removed and the interior 
 of the stomach kept cleansed, when a little other treatment, except a 
 proper regimen, is required. We possess two effective measures for 
 this purpose, which may be employed singly or combined. I refer 
 to (1) lavage and (2) disinfection and cleansing with hydrozone. 
 
 Lavage is an efficient means of cleansing the stomachal cavity. It 
 is performed by the aid of an elongated, soft-rubber tube, to one end 
 of which is attached a glass funnel. Dealers in rubber goods furnish 
 these tubes upon application, with open lower end, fenestrated sides, 
 and raised ridge to indicate the point of sufficient introduction, this 
 being at the lips when the tube is in situ. In order to introduce it 
 it is first coiled in a bowl containing warm or cold milk, according 
 to the preference of the patient, and the fenestrated extremity is 
 
 LAVAOE: IRRIGATION AND SIPHON AOK. 
 
 then passed over the protruded tongue into the lower part of the 
 pharynx, the patient assisting its onward motion by efforts at swal- 
 lowing accompanied by deep inspirations. Steady pushing will now 
 carry the instrument into the oesophagus and it will then glide easily 
 along until the lower end passes into the stomach, when the funnel 
 should be affixed. It may be necessary for the physician to assist
 
 DISEASES OF THE STOMACH. 387 
 
 in the introduction for four or five times, after which the patient will 
 be able to attend to it for himself. After initiation the patient holds 
 the funnel in his left hand and a flask of the fluid to be used in the 
 right, fills the funnel and raises it above his head, when the contents 
 flow into the stomach (irrigation). The funnel is immediately after- 
 ward depressed below the level of the stomach, when the principle 
 of siphonage operates to withdraw the liquid contents, which are al- 
 lowed to flow into a pail placed between the patient's feet. Lavage 
 is therefore divided into two stages, viz.: Irrigation and siphonage. 
 
 Reflex irritation, such as nausea and vomiting with dyspnoea, 
 which may attend the beginning of this measure, may usually be 
 quieted by the administration of a single dose of twenty grains of 
 bromide of potassium taken an hour or so beforehand. Where the 
 presence of the tube in the stomach provokes vomiting, the imme- 
 diate introduction of a little fluid to remove the gastric wall from 
 contact with the extremity of the tube will be sufficient, usually, to 
 quiet the reflex. 
 
 The amount of fluid to be used at a time should be small at first, 
 as vomiting is easily excited; and until the stomach has become used 
 to the maneuver a pint will be sufficient. As treatment progresses, 
 however, one, two or three quarts may be used at a time without 
 inconvenience, treatment to be repeated each morning before eating. 
 
 The solutions should be warm (98.5 F. or thereabout) and may 
 consist of simple alkaline drenches, a drachm and a half of Glauber's 
 salts to a quart of water constituting a popular fluid for the purpose. 
 I find weak solutions of asepsin excellent and have used boracic acid 
 as a medicament with satisfaction. Long-standing cases of uncom- 
 plicated chronic gastritis recover completely in a few months on this 
 treatment without the assistance of other measures except proper 
 attention to dieting. Mucus and retained fermentative elements and 
 products are thus removed and the mucous membrane is aroused to 
 normal action, the hypersetnia subsiding and the irritated surface 
 returning to a healthy condition. 
 
 The introduction of hydrozone as a remedy in this condition was 
 another innovation of remarkable value. A drachm of Marchand's 
 hydrozone added to four ounces of boiled water and drank while the 
 stomach is empty exerts a powerful influence in dissolving and re- 
 moving the tenacious mucus, destroying microbic elements of fermen- 
 tation and stimulating normal action in the diseased mucous struc- 
 ture. The best results folloAv its use in the morning before break- 
 fast, the patient taking it while in bed and remaining on the left side 
 for ten minutes before rising. It may be taken oftener, but once a 
 day will suffice, and it may be advantageously used in this manner 
 after the practice of lavage.
 
 388 DISEASES OF THE DIGESTIVE ORGANS. 
 
 The hydrozone may produce acrid sensations in the throat and 
 stomach at first and the patient may complain of an unpleasant taste 
 following its action; but as the irritated gastric surface becomes 
 toned under its influence thia will pass away and sensitiveness to its 
 effect will subside. Where there seems to be very much objection 
 the amount may be considerably lessened until the patient becomes 
 accustomed to its action and until the sensitive mucous surface be- 
 comes more tolerant. 
 
 The important step in chronic gastric catarrh (as iu catarrh of all 
 other mucous cavities) is the cleansing of the part from ropy mucus, 
 which clogs the glandular organs and serves as a nidus for the opera- 
 tion of agents of fermentation. Glycozone may sometimes be pre- 
 ferred, glycerine possessing individual virtue in certain cases of indi- 
 gestion from fermentation. 
 
 With attention to such details as have already been described, 
 little more is necessary in the treatment of this disease. Some ad- 
 vise, in the absence or lack of the normal amount of hydrochloric 
 acid, that this drug be supplied, in suitable doses, well diluted with 
 water. Benefit may sometimes follow this measure, but with the 
 removal of morbid accumulations a normal amount of hydrochloric 
 acid will soon be supplied by nature all that will be required for 
 the limited diet which the nature of the case demands. The effi- 
 ciency of bitter tonics is doubtful when they are administered upon 
 "general principles," though some of them may specifically improve 
 the recuperative forces of the gastric mucous membrane and aid in 
 a restoration of normal conditions. I believe berberis aquifolium to 
 be one of these, its beneficial influence in catarrh of mucous mem- 
 branes generally adapting it here, while it is an acknowledged stom- 
 achic of superior virtue. Ten-drop doses of a reliable fluid prepara- 
 tion repeated thrice daily will often assist materially in restoring a 
 normal condition of the gastric mucous membrane and digestive 
 glands, aiding digestion, banishing boulimia and promoting a normal 
 appetite. 
 
 When catarrhal accumulation is a marked feature and there is a 
 yellow coating on the tongue persistently bichromate of potassium in 
 minute doses (two or three grains of the 3x) repeated three or four 
 times daily will assist the local treatment. Nux vomica may relieve 
 some of the local unpleasantness, and there are those who assert that 
 it specifically ameliorates the catarrhal condition. The specific indi- 
 cations need not be referred to here, but the dose should be minute. 
 Hydrastis, pulsatilla, robinia, antimouinm crudem, bismuth (both 
 the subnitrate and liquor) and many other remedies have their 
 advocates. 
 
 In anaemic persons, where catarrhal tendencies are strong, calcium
 
 DISEASES OF THE STOMACH. 389 
 
 phos. 3x in two- or three-grain doses repeated three or four times a 
 day will lessen the ropy secretion and lessen anaemic tendencies. 
 Protonuclein is a drug that promises much as a restorative here. 
 
 Where chronic gastritis attends malarial cachexia that group of 
 remedies which tend toward lessening the pressure in the radicles of 
 the portal vein will be efficient in relieving the congestion of the gas- 
 tric mucosa. Of the four principal ones of these polymnia, ceano- 
 thus, carduus and grindelia squarrossa grindelia squarrosa is iny 
 favorite. Improvement in digestion under favorable circumstances 
 almost invariably follows its use. From five to ten drops of a sat- 
 urated tincture of the genuine plant administered in a swallow of 
 water and repeated three times a day insure marked benefit within 
 a few days. Chionanthus in ten-drop doses may be advantageously 
 combined with it in most cases, especially where icteric symptoms 
 are present. 
 
 Sometimes we may be urged to administer agents for the relief 
 of cardiac palpitation and associate gastric distress. Cactus grandi- 
 florus and pulsatilla possess an established reputation and they will 
 occasionally answer us well. The best remedy I have ever tried, 
 however, is a saturated tincture of aploppapus laricifolius in from 
 two- to ten-drop doses, one or two doses at a time being sufficient 
 for temporary relief. It calms erethism of the sympathetic nervous 
 system, promotes rest, strengthens cardiac action, lessens pain, re- 
 lieves praecordial oppression, favors evacuation of the bowels and 
 aids digestion. Minute doses of aconite and rhus tox. are not to be 
 despised for this condition, that reliable gastric sedative combina- 
 tion being very serviceable, even sometimes in chronic irritation. 
 
 Where constipation is present enemata will be found preferable 
 to laxative medicines, the salt-water galvanic enema being an excel- 
 lent aid in stubborn cases, it not being necessary to repeat it more 
 than once or twice a week. The positive pole should here be applied 
 with a moistened sponge over the epigastrium. 
 
 Local applications over the epigastrium are sometimes of excel- 
 lent service and in intractable cases should be tried. The compound 
 tar plaster of our forefathers, worn over the epigastrium until pustu- 
 lation begins, to be removed for a few days and its use repeated 
 again and again to perpetuate a superficial irritation, has many able 
 advocates even at the present day; and I have known it to effect 
 most excellent results. A vinegar pack or girdle, worn upon the epi- 
 gastrium, is hardly less effective. Equal parts of vinegar and water 
 may be employed to moisten an epigastric pad, which should be 
 wrung as dry as possible two or three times within the twenty-four 
 hours and worn constantly, the clothing being protected by an oiled 
 silk covering.
 
 390 DISEASES OF THE DIGESTIVE ORGANS. 
 
 As the disease is a long time in becoming established, it should 
 be expected that several months will be required to overcome it. 
 
 DILATATION OF THE STOMACH. 
 
 Synonym. Gastrectasis. 
 
 Definition. Permanent enlargement of the cavity of the stom- 
 ach due to stretching of its walls, with degeneration of the muscular 
 coat. 
 
 Etiology. Gastrectasis may occur in an acute or chronic form, 
 acute gastrectasis, however, being very rare. The acute form may 
 occur as the result of the ingestion of an enormous quantity of ali- 
 ment at a single meal, paralytic dilatation resulting. The usual form 
 of dilatation occurs from causes which bring about a gradual enlarge- 
 ment of the stomach, the most common being pyloric stenosis. 
 Pyloric stenosis may result from thickening of the walls of the pyloris 
 as the result of acute or chronic inflammation, cancerous infiltration, 
 non-malignant ulceration or fibroid induration of the pylorus. Other 
 cases of gastrectasis may be due to atony of the muscular walls from 
 habitual over-distention of that organ, as is common with gourmands" 
 and beer-drinkers. Paralysis of the nerve-supply, attended by im- 
 pairment of normal peristalsis, is another cause of this condition, 
 this sometimes occurring from suppurations about the stomach, such 
 as empyaema or suppurative pericarditis; and parenchymatous degen- 
 eration, occurring as a result of scarlet fever, may impair permanently 
 the tonicity of the gastric muscles. A somewhat rare cause of this 
 condition may be hernia, which operates by dragging the organ 
 downward, adhesions also sometimes acting in a similar manner. 
 Middle-aged or elderly persons are most liable to be affected, though 
 dilatation of the stomach may occur in children, associated with 
 rickets. 
 
 Pathology. The amount and character of the dilatation differ 
 materially in different cases. Sometimes the enlargement is regular, 
 
 the walls being evenly stretched so that the 
 \ cardiac extremity is carried toward the left 
 } and upward, this usually being the case when 
 / there is pyloric stenosis without localized 
 / weakness of any particular part of the organ. 
 In other cases there may be some local 
 DILATATION OF THE STOMACH WITH weakness, due to ulceration or erosion of the 
 
 PTTLOBIC STENOSIS. . -i i 
 
 Dotted line represents dilatation. Wall, Circumscribed pat 'llCS yielding to foi'lll 
 
 pouches or diverticula. Stenosis is at first followed by hypertrophy 
 of the walls of the stomach, this after ward be ing attended by atrophy 
 and dilatation. The muscles may now be so thinned and stretched
 
 DISEASES OF THE STOMACH. 391 
 
 as to be scarcely discernible, and fatty degeneration of its fibers may 
 attend. Muscular atrophy is most marked where atony of the mus- 
 cular wall arises independently of stenosis. Here the rugse of the 
 mucous membrane may have disappeared and the covering become 
 pale and atrophied. 
 
 Symptoms. Indigestion and gastric discomfort are the first 
 symptoms noted. In acute dilatation there is sharp pain in the epi- 
 gastric region, tenderness upon pressure and prsecordial oppression 
 with sensations of fullness. As these symptoms subside indications 
 of chronic dilatation manifest themselves. Vomiting at intervals of 
 enormous quantities (from one to three gallons) of food and liquid is 
 the most usual symptom of this condition. The intervals may be 
 two or three days in length, the material ejected usually being the 
 major portion of what has been ingested during such periods. The 
 vomitus consists of mucus and remnants of food, all of which has 
 undergone decomposition, the mass exhaling a foetid odor, presenting 
 a frothy, yeasty appearance and being acid in reaction. Various 
 resisting substances, such as cherry stones, grape seeds, etc., may 
 be found. Upon microscopic examination abundance of the yeast 
 plant and sarcina ventriculi will be found and also various bacteria. 
 Lactic and butyric acids with various gases may be present; and 
 hydrochloric acid may or may not be found, it sometimes existing in 
 excess. 
 
 Pyrosis, eructations of foetid and acrid material, heartburn with 
 epigastric weight and pain and other gastric disturbances are almost 
 constantly manifest. Emaciation progresses, nutrition suffering 
 much, the skin becoming harsh and dry, the bowels constipated 
 and the urine scanty. Muscular cramps, sometimes amounting to 
 spasms, usually attend aggravated cases, the muscles of the calves, 
 hands and arms being most affected. The appetite may be vora- 
 cious or there may be anorexia. Usually there is a voracious 
 appetite. 
 
 Upon inspection an eminence will be observed just above the 
 umbilical region with a depression in the epigastrium, which may 
 become filled after taking meals or draughts of fluid. Sometimes 
 the stomach may be outlined by palpation, the prominence of the 
 pylorus and gastric peristaltic action being detected. Percussion 
 may reveal a tympanitic sound over the epigastric region when the 
 stomach is empty and an area of dullness when it is distended, over 
 an abnormally large space. Auscultation may reveal succussion or 
 splashing of fluids when the abdomen is shaken, and the falling of 
 fluids into the gastric cavity when these are swallowed. 
 
 Diagnosis. The habitual vomiting of large quantities of decom- 
 posed food and mucus at two- or three-day intervals, with emaciation
 
 392 DISEASES OF THE DIGESTIVE ORGANS. 
 
 and gastric discomfort, is sufficient to establish a diagnosis. Inspec- 
 tion of the material ejected may assist in doubtful cases. 
 
 Prognosis. Therapeutic resources are usually futile in the 
 management of such cases. Where pyloric stenosis is the perpetu- 
 ating cause a cure may follow longitudinal incision and transverse 
 stitching at the point of narrowing, this serving to widen the open- 
 ing and afford a ready passage for the food. When an abstemious 
 regimen is followed, dilatation due to simple stenosis may not inter- 
 fere greatly with average longevity. 
 
 Treatment. Lavage, with warm water and asepsin, is an im- 
 portant part of treatment. This should be repeated sufficiently 
 often to prevent decomposition of food and avert large accumula- 
 tions, thus providing against disteution and weight. Instead of asep- 
 sin hydrozone may be used to medicate the cleansing fluid. 
 
 Strychnia, nux vomica, galvanism and faradistn are all recom- 
 mended to stimulate contraction of the relaxed muscular walls. 
 Where the mucous membrane is atrophied berberis aquifolium is 
 worthy of lengthened trial. 
 
 The food should be taken in small quantities and be of fluid and 
 concentrated form. Not more than six ounces of drink should be 
 allowed at one meal, and in bad cases no drinks at all should be 
 allowed at meal-time, a tumblerful of hot water being taken half an 
 hour before eating that it may pass into the duodenum and be 
 absorbed before the food is introduced into the stomach. Ferment- 
 able foods, such as starchy articles and sugars and fruits which con- 
 tain much water and vegetable acids (which are apt to disagree), 
 should be avoided. Peptonized milk, scraped beef, lean beef free 
 from coarse fibrin, fresh vegetables and dry bread comprise the kind 
 of food to be taken. Some prefer a dry diet, only enough being 
 allowed to meet the most urgent demands of the body. Fats should 
 be discarded. 
 
 PEPTIC ULCER. 
 
 Synonyms. Round Ulcer; Chronic Gastric Ulcer. 
 
 Definition. An ulcer, usually single though sometimes multi- 
 ple, which arises from the action of the gastric juice upon a limited 
 region of the gastric or duodenal mucous membrane, in which nutri- 
 tional disturbance has lessened the resistant capacity of the tissues 
 involved. 
 
 Etiology. More than twice as many cases occur among women as 
 among men, this being due, possibly, to the fact that women are more 
 apt to follow occupations necessitating a stooping posture whereby 
 there is crowding of the short ribs against the pyloric extremity of
 
 DISEASES OF THE STOMACH. 393 
 
 the stomach. Possibly the habit of wearing corsets and of lacing 
 may bear somewhat upon the etiology. The most active period of 
 life between the ages of fourteen and thirty is the time of greatest 
 liability, though it may occur in the new-born babe and in the octo- 
 genarian. Anything which tends to cause thrombus of the gastric 
 vessels predisposes to it. It is also liable to occur in chronic gas- 
 tritis, hepatic and renal cirrhosis and other conditions involving 
 obstruction of the circulation in the gastric mucous membrane. 
 Anaemia and chlorosis are constitutional states in which there is a 
 tendency to it. A habitual stooping posture has already been re- 
 ferred to as a probable predisposing cause, and it may be mentioned 
 iii this connection that it is more frequent among milliners, seam- 
 stresses, shoemakers and others whose employment calls much of 
 the time for a bending position. 
 
 Pathology, The ulcer occurs upon the posterior wall of the 
 stomach near the pylorus, in a large majority of cases, though it may 
 develop upon the anterior wall. Occasionally a peptic ulcer may 
 develop in the duodenum and manifest the characteristics of a per- 
 forating ulcer of the stomach. Peptic ulcers vary in size from half 
 an inch to two inches in diameter and are usually round, though 
 they may be oblong or oval, and, when formed of several small ones, 
 irregular in contour. They begin in the mucous 
 membrane and excavate a sharply defined border, 
 the opening appearing, upon autopsy, as though 
 punched through the mucous membrane with a 
 sharp instrument. As the ulceration grows deeper 
 the circles grow less regular and smaller, the exca- 
 vation assuming a funnel shape, until, when the 
 peritoneum is reached, the opening may be a mere 
 , perforation. point. During the perforating process there is no 
 
 b, mucous membrane. , . / . u in i e it 
 
 active inflammatory action,, though the edges of the 
 ulcer may sometimes be thickened and indurated, while in other 
 cases the surrounding tissues may be normal. Usually the entire 
 mucous membrane of the stomach is involved in a chronic catarrhal 
 condition, though sometimes the catarrh is confined to the vicinity 
 of the ulcer. 
 
 Perforation occurs in only about one-eighth of the cases affected 
 with round ulcer, recuperative processes often accomplishing a res- 
 toration of the breach of continuity, a permanent cicatrix remaining. 
 The cicatrix sometimes contracts so as to obstruct the pyloric open- 
 ing or cause other deformity of the stomach. 
 
 The ulcerative process may meet with important bloodvessels in 
 its course, and profuse hematemesis be the result of their destruc- 
 tion. As the ulcer approaches the peritoneal surface of the stomach
 
 394 DISEASES OF THE DIGESTIVE ORGANS. 
 
 a circumscribed peritonitis is liable to be excited in the neighbor- 
 hood and adhesions may take place between the part and such an ad- 
 joining viscus as the liver, pancreas, mesentery or spleen, and the 
 fatal results of perforation thus be stayed. 
 
 Various deviations from the usual course of the ulceration may 
 attend. The base of the ulcer may be covered with a mass of black 
 blood, which adheres to the surface, or there maybe petechial extrav- 
 asations around the ulcerated space or suppuration in the coats of 
 the stomach, with resultant phlebitis. In other cases villous growths 
 may spring up about the base of the ulcer, upon the surrounding 
 mucous membrane. 
 
 Though the posterior wall of the stomach is the usual location of 
 the ulcer, it sometimes attacks the anterior wall, and perforation is 
 much more liable to occur in this instance, as there is less probability 
 of adhesions. 
 
 Perforation is attended by escape of some of the contents of the 
 stomach into the peritoneal cavity, with rapidly succeeding peritoni- 
 tis. If adhesions prevent the escape of the contents local peritoni- 
 tis, suppuration and burrowing abscesses may follow, with fistulous 
 openings into the pleural sac, lung, intestine, gall-bladder or other 
 viscus. 
 
 Symptoms. The symptoms in the beginning are often obscure. 
 Indigestion, attended by burning, gnawing sensations, pyrosis and 
 gastric catarrh, with jaundice and even nausea and vomiting, may be 
 developed. Pain soon becomes a noticeable symptom and grows 
 more and more obstinate. Though dull at first it soon becomes lan- 
 cinating and attends the period of digestion, coming on soon after 
 eating and continuing until the stomach is empty; though sometimes 
 it does not appear until an hour or so after food is taken. After 
 a time there develops a pain in the dorsal region, which is said to be 
 peculiar to this disease in that it is constant, is located in the eighth 
 or ninth dorsal vertebra, and does not come on for several months 
 after the epigastric pain becomes established. The epigastric pain 
 may not be severe at first, but it soon becomes excruciating during 
 digestion, and is often relieved by change of position, pressure some- 
 times affording comfort the patient finding relief by lying across a 
 chair or with the epigastrium upon a hard pillow flat on the floor. 
 The pain may be paroxysmal, being very severe for weeks, then dis- 
 appearing for a time, with another protracted period of intense suf- 
 fering. Tenderness on pressure is usually present, the patient wear- 
 ing the clothing loose and objecting to anything snug about the 
 waist. The point of tenderness is usually small, not larger than a 
 silver dollar, and is felt on deep pressure just above the umbilicus
 
 DISEASES OF THE STOMACH. 395 
 
 (in the majority of instances) and over the eighth or ninth dorsal 
 vertebra. 
 
 Vomiting is another prominent symptom, the rejection of food 
 occurring in a large number of cases. This occurs after the pain has 
 become severe, the rejection of the food being usually followed by 
 alleviation. The food is mixed with gastric juice of highly acid 
 nature, with more or less bile, biliary material becoming quite plen- 
 tiful as the disease progresses. Sometimes a patient will vomit after 
 each meal, sometimes once a day, while in other instances two or 
 three days may elapse between attacks. 
 
 Hsematemesis is another symptom which occurs frequently, 
 though not invariably. It appears in serious form after the ulcera- 
 tion has advanced so as to destroy the walls of arterial twigs, slight 
 capillary hemorrhage not attracting much attention previously, the 
 blood then passing away with the stools. When an important vessel 
 is disintegrated, however, a large quantity of clotted blood, of bright 
 red color, is vomited, the patient previously experiencing a sensation 
 of faintness ; and even collapse may attend, the first hemorrhage 
 sometimes proving fatal. Repeated hemorrhages are followed by 
 anaemia, debility and cachetic symptoms, the features becoming 
 drawn and the skin sometimes assuming an icteric or waxy hue. 
 
 Where diarrhoea exists, as is sometimes the case, the stools are 
 mixed with a dark, tarry material consisting of decomposed blood, 
 to which the term "melsena" is applied. 
 
 Diagnosis. -The diagnosis is sometimes obscure. Gastralgia 
 may be readily confounded with this disease where hemorrhage is 
 not present, as dyspeptic symptoms, vomiting, pain and even tender- 
 ness on pressure may be present in both. Where hseinatemesis 
 occurs there can be no possibility of an error in this respect, as it is 
 absent in gastralgia. In cancer there is lack or absence of free 
 hydrochloric acid in the stomach, while in peptic ulcer there is an 
 excess of this. The epigastric tumor of cancer is absent in ulcer 
 and pain is much aggravated by eating, while pain of cancer is sel- 
 dom thus provoked. Cancer of the stomach is most apt to occur in 
 those of middle or past-middle life, while perforating ulcer is more 
 apt to attack younger persons. The hemorrhage of cancer also differs in 
 character, the blood being of coffee-ground appearance, while in peptic 
 ulcer it is bright red if the clots be broken. The cachexia of cancer is 
 more marked than that of peptic ulcer early, and the vomiting does 
 not always occur with immediate reference to the presence of food in 
 the stomach. It is impossible to differentiate between a duodenal 
 and gastric peptic ulcer during life. 
 
 Prognosis. It is asserted by good authority that more than 
 half the cases of peptic ulcer recover. Some terminate fatally in a
 
 39G DISEASES OF THE DIGESTIVE OKGAKS. 
 
 few weeks, while others may continue many months to finally recover 
 or afterward terminate fatally. Those of feeble constitution are less 
 apt to resist the inroads of the disease, senile subjects and delicate 
 women being the most unfortunate victims. 
 
 Treatment. Congestive conditions hyperaemia of the portal 
 circulation should be corrected as much as possible by the use of 
 such agents as grindelia squarrosa, polymnia, carduus marianus and 
 ceanothus. These agents may assist in removing blood-pressure upon 
 thrombi and restoring a normal circulation in the gastric mucous 
 membrane. 
 
 As curative agents we must think of those remedies which exert 
 a plastic influence upon the diseased structures. Such special reme- 
 dies as kali bichromicum 3x, argentum nit. 6x and nitrate of uranium 3x 
 are appropriate members of this group. Berberis aquifolium is an 
 excellent remedy as in all other cases of chronic ulceration; and at 
 the same time it is an excellent restorative of the general system, pro- 
 moting digestion, assimilation and blood-making. 
 
 I have had excellent results from three-grain doses of kali bi- 
 chromicum 3x repeated every four hours during the day. It certainly 
 exerts a healing influence in such cases, and if used faithfully before 
 too much progress has been made I believe it will cure. 
 
 The Schuessler remedies promise better results than ordinary 
 treatment in this affection and should receive the practitioner's 
 respectful attention in stubborn cases. The following experiences 
 are from a paper on "Biochemistry," read before the Oregon State 
 Medical Association September 23, 1898, by A. A. Leonard, M. D., 
 and will apply here: 
 
 "Case III. Miss H., aet. 19, German descent; domestic; family 
 history good; personal history, healthy up to a year previous to con- 
 sulting me, when she began to run down, had indigestion and lost 
 flesh and strength. On previous New Year's Day (this was in March) 
 she had vomited, she said, about a quart of blood. This, of course, 
 was an exaggeration. Since that time she had suffered pain after 
 eating, often vomited her meals, had acid eructations and continually 
 lost strength. Her symptoms at the time of calling were the same, 
 except that that morning she had thrown up a quantity of blood, and 
 was in consequence very weak. I diagnosed gastric ulcer. 
 
 "For the three prominent symptoms hemorrhage, acid indiges- 
 tion and anaemia I gave ferrum phos., natrum phos. and calcium 
 phos. She had no other remedies except rest and regulated diet. 
 There was no more haematemesia and after a few days I left off the 
 ferrum phos. and continued the natrum phos. and calc. phos. for two 
 weeks longer. The result was a surprise to me, for she gained in 
 every way beyond my expectations. In fact, inside of two months
 
 DISEASES OF THE STOMACH. 397 
 
 she was the picture of health, her appetite excellent and she was 
 stronger and healthier in every way than she had been for several 
 years. The cure was permanent, for I heard from her a year and a 
 half later and she was still in good health. 
 
 "Case IV. Miss K. D., aet. 20, American. Occupation, teacher. 
 History of stomach-pain, occasional gnawing in stomach with some 
 soreness for the past year. Sent for me Christmas Day, '97. I 
 found her suffering with hsematemesis, which was somewhat alarm- 
 ing. The vomiting had come on at night and had continued at inter- 
 vals during the day, until she was quite weak. 
 
 "I diagnosed gastric ulcer, and to meet the first indication, the 
 arrest of the hemorrhage, I gave her glonoin and hyoscyamine suffi- 
 cient to keep the skin flushed for the first twenty-four hours. I might 
 have stopped the hemorrhage with ferrum phos., perhaps, but hardly 
 dared to risk it. She was put to bed with strict injunctions to stay 
 there and remain as quiet as possible, and was allowed atablespoon- 
 ful of milk every two hours for the first day, gradually increased as 
 the symptoms abated. After the first day I put her on natrum phos. 
 and calc. phos., the same as Case III. She steadily improved from 
 the first and rapidly recovered. She was kept on these remedies for 
 about four weeks. I have recently heard from her and she has had 
 no relapse, and is now in robust health." 
 
 Subnitrate of bismuth exerts a local influence that is worthy of 
 consideration, though little permanent benefit can be expected from 
 it as a rule. 
 
 Minute doses of aconite and rhus. tox. may be tried where the 
 vomiting is intractable, arid in event of the failure of this measure 
 resort may be had to lavage. 
 
 In incurable cases opiates may be required to alleviate the pain. 
 Hemorrhage should be treated by the recumbent posture and the 
 administration of ten-drop doses of erigeron canadense, hypodermic 
 injections of ergotine in two- or three-grain doses or other astringents. 
 
 The patient should remain quiet in bed to insure rest and a re- 
 cunibent position, and the diet should be liquid, bland in character 
 and should be administered in small quantities, in order to avoid 
 distension of the stomach and risk of perforation. After hsematem- 
 esis the stomach should be allowed to remain quiet for a time, and 
 food should be introduced into the rectum in the form of nutrient 
 enemata. When food is taken into the stomach, a milk diet is appro- 
 priate, though care must be observed that it be not taken so as to 
 result in the formation of firm curds. On this account Horlick's 
 malted milk may be preferable, though the addition of a tablespoon- 
 ful of lime-water to a pint of raw milk will provide against this to 
 considerable extent. Where acceptable, butter-milk or koumiss will
 
 398 DISEASES OF THE DIGESTIVE ORGANS. 
 
 be appropriate for nourishment, and all danger of curds will be 
 avoided. Almost any form of liquid diet which will not irritate deli- 
 cate structures will be proper, and rotation among several kinds will 
 encourage the patient to take sufficient for sustenance. After hem- 
 orrhage the quantity taken at a time should be limited to a few tea- 
 spoonfuls, larger and larger quantities being given gradually until 
 three or four ounces are administered at a time as bleeding ceases. 
 Milk, beef-juice, broths, malt extracts and other fluid foods may 
 be allowed until convalescence is announced, when scraped beef, 
 chicken, fresh sweetbread, tapioca and rice pudding, e.tc., may be 
 allowed in small quantities, the patient remaining quiet in bed for 
 another month, in order to allow the new structure to acquire appro- 
 priate strength. A recent addition to the materia medica, and at 
 the same time an excellent nutrient, is preserved beef's blood 
 bovinine. Thirty drops of this in a cup of hot water, repeated every 
 three or four hours, may afford good results. 
 
 CANCER OF THE STOMACH. 
 
 Etiology. Age and location are probably prominent among the 
 etiological factors of gastric cancer. As in cancer in other locations, 
 those past middle life are most liable to this kind, about one-third 
 of all cases of primary cancer having their origin in the stomach. 
 Osier states that cancer of the stomach is only second in frequency 
 to that of uterine cancer. It is more frequent in males than females, 
 in the ratio of about five to four. Local irritation, doubtless, con- 
 tributes to the predisposition of this part to malignant disease, the 
 almost constant disturbance which it undergoes as the active organ 
 in receiving and reducing food for digestion probably being contrib- 
 utory, while accidental irritation from indigestible and acrid mater- 
 ials which are swallowed, and the pernicious habit of prescribing 
 irritating cathartics so fashionable among a large class of physicians, 
 assists in contributing to the cancerous tendency. Long-con- 
 tinued irritation of such kind may finally give rise to the develop- 
 ment of the new growth, the disease being rare in children and 
 uncommon before the age of forty. 
 
 The favorite seat of gastric cancer is the pylorus and when located 
 here the upper portion of the duodenum also is usually involved. The 
 next point in frequency of attack is the cardiac extremity arid lesser 
 curvature, the lower portion of the oasophagus then usually being 
 implicated. Cancer of the stomach is a common disease in tfyis coun- 
 try, and should be suspected in all cases of gastric trouble attended 
 by rapidly encroaching debility and emaciation. 
 
 Family tendency is somewhat marked, something like one-seventh
 
 DISEASES OF THE STOMACH. 399 
 
 of the cases occurring probably belonging to this class. It is con- 
 sidered, by good authority, doubttul that depressing emotions, mode 
 of life or previous disease exert any influence in the etiology of the 
 affection. Various popular beliefs exist that cancer is due to the 
 influence of certain foods. For example, many believe that the eat- 
 ing of tomatoes predisposes to cancer, a proposition which seems 
 ridiculous from a scientific point of view. 
 
 Pathology, While the pylorus is the most frequent seat of 
 cancer and the cardiac extremity next, the curvatures, fundus and 
 body may all be affected by the primary growth. There is a differ- 
 ence of opinion among medical authors as to which form is most 
 common, some asserting that scirrhous cancer is most frequent and 
 others claiming the supremacy for epithelioid. My own experience 
 leads me to favor the opinion that scirrhous is most often found, 
 although I have no statistics to offer. Epithelioma occurs fre- 
 quently, and all forms may become colloid or gelatiniform in char- 
 acter during their progress. In many instances the morbid growth 
 may be a combination of several varieties. 
 
 Scirrkosis of the stomach develops in the submucous structure, 
 small, grayish nodules enveloping the extremities of off-shoots of the 
 gastric tubules which have pushed their way into the submucous tis- 
 sue, the character of the growth then being, in reality, epithelial, 
 though the fibrous stroma is greatly in excess of the cell-element 
 As the disease progresses the fibrous structure encroaches upon the 
 mucous membrane, puckering it into nodules and pushing them out- 
 ward into the cavity of the stomach in polypoid forms, rapid increase 
 of new tissue thickening the pyloric wall and narrowing the lumen, 
 the growth extending along the greater and lesser curvatures toward 
 the dilated portion of the stomach. The muscular and areolar lay- 
 ers become fused into an indistinguishable mass after a time, the 
 surface of a fresh cut presenting a whitish, glistening appearance, 
 with pearly settings, the individuality of the mucous, submucous and 
 muscular layers being entirely lost. As the pylorus becomes oc- 
 cluded the unaffected portion of the stomach becomes dilated, though 
 sometimes its walls are shriveled and contracted with leathery thick- 
 ening of the entire structure. Chronic gastritis may arise from 
 pressure of the indurated part against the unaffected mucous mem- 
 brane and the usual appearance of such condition may be manifested 
 beyond the cancerous mass. As ulceration develops there is liability 
 to perforation of the gastric wall, the opening sometimes entering 
 the peritoneal cavity, sometimes penetrating the duodenum or other 
 neighboring organ and sometimes even forming an external opening 
 through the anterior wall of the abdomen. Secondary cancerous 
 deposits are common, the liver being most frequently involved, then
 
 400 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 the lymphatic glands and neighboring intestines, especially the rec- 
 tum. The kidneys, pancreas, spleen, bladder and other abdominal 
 and pelvic organs, as well as those of the thorax, are liable to be 
 secondarily involved. 
 
 Encephaloid cancer begins in the submucous tissue, though the 
 nodules are much softer, the stroma being less abundant and the 
 cells more numerous. It develops more rapidly than scirrhus and is 
 more vascular, large fleshy spongy excrescenses projecting into the 
 gastric cavity. 
 
 Colloid cancer of the stomach is rare. It is said to begin in the 
 glandular structure of the gastric wall, though t invades all the coats 
 with great rapidity and also involves neighboring organs in the same 
 manner. It does not appear in the form of nodules but as an irreg- 
 ular mass of gummy, glistening material inclosed in large alveoli. 
 The entire structure of the stomach is much thickened, and on the 
 inner surface there are closely-set cavities of honey-comb appearance 
 marking empty alveoli, which have discharged their contents. 
 
 Symptoms. Rapid loss of flesh and strength with dyspeptic 
 symptoms is sufficient to warrant suspicion of cancer of the stomach. 
 Sometimes the gastric symptoms are more marked and there will be 
 anorexia, nausea and vomiting and pain after eating. Anaemia of a 
 peculiar character soon develops, the skin presenting a peculiar sal- 
 low, clayey or waxy appearance and being leathery and inelastic to 
 
 the feel. The pulse is increased 
 in frequency and becomes small 
 and feeble, and these symptoms 
 are steadily aggravated in spite 
 of treatment. In colloid can- 
 cer, where the entire stomach 
 is sometimes involved, there 
 may be tumultuous peristaltic 
 action of that organ at times, 
 though this is not common. 
 Where the pylorus is mostly 
 affected a tumor may soon be 
 felt just above the umbilicus, 
 which is hard, firm and immov- 
 
 CANCKR OF THE STOMACH. 
 
 a, pylorus. 
 
 b, duodenum . 
 
 c, pBgage through cancerous growth. 
 
 d, cut surface of cancf r. 
 
 e, diseased mucous mei.ibrane. 
 
 f, normal mucous membrane wrinkled transversely able and \\hicll USUally pulsates 
 from cancerous contraction. , . , . . , , , 
 
 from the impact of the abdomi- 
 nal aorta. When the cardiac extremity is the part involved, the 
 tumor is not perceptible upon palpation. 
 
 Dyspeptic symptoms are so common in other cases that they are 
 not highly suggestive of cancer, aud as cancer patients are liable to 
 be dyspeptic subjects long before the malignant disease develops,
 
 DISEASES OF THE STOMACH. 401 
 
 these do not attract much attention until they become extreme. 
 Vomiting, however, soon draws attention to the gravity of the case. 
 This may occur only occasionally at first, perhaps not oftener than 
 once every three or four days, but it usually increases rapidly in fre- 
 quency arid after a few weeks may recur several times a day. It is 
 most apt to be severe when the malignant growth is about the ori- 
 fices, vomiting occurring soon after eating when the cardiac orifice is 
 affected and after a considerable interval where the growth is about 
 the pylorus. The vomiting consists of food and mucus mixed with 
 various acids and exhaling a sour and foetid odor. After ulceration 
 of the morbid growth begins hsematemesis is not uncommon, the 
 blood being mixed with other material or so altered by the secretions 
 as to present a dark brown or black appearance, then termed 
 "coffee-ground" vomit. The yeast plant, various bacteria and sarcinse 
 ventriculi are present, though not so common as in gastrectasis. 
 
 Much stress is placed by many diagnosticians upon the absence 
 of free hydrochloric acid from the gastric secretions. To determine 
 this administer a test meal, consisting of a breakfast of a Vienna roll 
 with a cup of tea without sugar or milk, and after an hour remove 
 some of the contents with a stomach-tube for examination. The 
 method of Gunsburg for detecting hydrochloric acid is simple and 
 effective: Mix phloroglucin two parts, vanillin one part and alcohol 
 thirty parts. Add a drop of this to a drop of the gastric contents 
 (filtered) on a porcelain plate and evaporate to dryness, watching 
 the reaction. If free hydrochloric or other mineral acid be present 
 a handsome rose-red color begins to appear at the edges. As hydro- 
 chloric acid may be present under other circumstances as, for instance, 
 when there is atrophy of the gastric tubules, this symptom cannot be 
 considered diagnostic and may only be taken as corroborative when 
 other indications of cancer attend. 
 
 Pain is a common symptom of gastric cancer, though quite a num- 
 ber of cases run their course without unless it be that which attends 
 peritonitis after perforation has occurred. The pain varies in its 
 situation, though it is most commonly in the epigastrium. Some- 
 times it is almost confined in the dorsal region, sometimes it is felt 
 most under the scapulae, and occasionly it lingers about the loins. It 
 is burning and dragging in character, hardly ever being lancinating 
 or excruciating, as in peptic ulcer. 
 
 Dropsical symptoms are likely to appear during the advanced 
 stage of gastric ulcer. They are first observed about the ankles and 
 legs, these becoming swollen and cedematous, especially after the 
 patient has been upon his feet for a few hours in the morning. As 
 further progress is made, ascites or anasarca may arise. 
 
 The wasting of flesh affects the heart muscle and its debility is 
 
 27
 
 402 DISEASES OF THE DIGESTIVE ORGANS. 
 
 marked during the last stages of the disease, the pulse being weak 
 and rapid; and it may seem, from the acceleration of the pulse and 
 hot skin, that febrile symptoms are present. Indeed, this may some- 
 times be the case, chills and fever, with elevation of temperature to 
 102 104 F. (followed by profuse sweats) arising temporarily, 
 though the temperature is usually normal or subnormal. The febrile 
 paroxysms are probably due to suppurative action and are not com- 
 mon among the early developments of the disease. 
 
 As secondary cancer involves other organs a marked modifica- 
 tion of the symptoms may result. Cancer of the liver may give rise 
 to jaundice, with enlargement, pain and tenderness in the right hypo- 
 chondrium. Ascites may now be a direct result of this condition 
 through obstruction of the portal circulation. Extension of the can- 
 cerous infiltration to the peritoneum may give rise to widely diffused 
 pain over the abdominal region, and obstruction of the vena cava 
 ascendens results in dilatation of the superficial epigastric and other 
 subcutaneous abdominal veins. 
 
 Diagnosis. In ordinary cases, especially where the pylorus is 
 the seat of the affection, the diagnosis is comparatively easy. The 
 gastric disturbance with vomiting, the rapid loss of flesh and strength, 
 the epigastric tumor readily felt through the attenuated abdominal 
 wall as a hard, immovable body (pulsating with the aortic impact), 
 with the constant, burning pain, can hardly be mistaken for symp- 
 toms of any other disease. In other cases, however, the tumor may 
 be so located that it cannot be discovered by palpation, the gastric 
 disturbance may be slight and the constitutional symptoms may 
 readily be taken for those of pernicious anaemia. In other cases the 
 constitutional symptoms may not appear prominently until near the 
 last and the local symptoms may be mistaken for those of chronic 
 gastritis or gastrectasis until the "coffee-ground" vomit appears. 
 Secondary affection of adjacent organs early may also obscure the 
 diagnosis. 
 
 Prognosis. Invariably unfavorable. The most that can be 
 promised is temporary palliation of the pain and other unpleasant 
 symptoms. The average duration of cancer is two years, though as 
 the disease will have progressed considerably before a diagnosis can 
 be made it is estimated that few survive more than a year after 
 that time. Some cases run a rapid course, a fatal termination 
 being reached in from three to six mouths. A cure is barely 
 possible. 
 
 Treatment. In pyloric cancer with stenosis lavage may afford 
 some relief from the gastric unpleasantness by neutralizing accumu- 
 lated fermentative products and removing superfluous mucus. Hydro- 
 zone or asepsin may be employed for this purpose as directed under
 
 DISEASES OF THE STOMACH. 403 
 
 chronic gastritis. As there is some danger of perforating the weak- 
 ened wall of the stomach, discretion should be observed in the use 
 of the stomach tube, hydrozone alone sufficing to remove the mucus 
 without lavage. Cundurango assists in relieving the pain and vomit- 
 ing in some cases and is always worthy of trial. Echinacea is almost 
 a specific in the pain of cancer and should be tried here early, though 
 it may not be reliable to quiet the vomiting. Bovinine is another 
 agent that is worthy of trial, as its nutrient qualities are combined 
 with excellent anodyne and calmative properties. Some cases may 
 justify abdominal section and resection of the pylorus, though a 
 fatal result may be expected within a few days in most instances. 
 The use of opiates freely is fully justifiable during the last stage, 
 though echiuacea is more reliable as a pain reliever. 
 
 One or two drops of carbolic acid mixed with glycerine and diluted 
 with water will often prove exceptionally valuable in controlling the 
 vomiting. 
 
 Chelidonium has recently promised much curatively in this dis- 
 ease and it will probably act best in combination with echinacea. 
 The dose may vary from fifteen to twenty drops of the specific medi- 
 cine. Another measure promising much is that of Cutter a strict 
 diet of chopped beef and hot water, without tea, coffee or milk. 
 
 A still later acquisition to the list of curatives in cancer is euca- 
 lyptus, which might be tried here, an approximate dose being ten 
 drops of a saturated tincture of the fresh leaves. 
 
 The dietetic treatment of cancer of the stomach is very important. 
 Solid food, after the disease has progressed appreciably, should be 
 discarded altogether for fear of perforation or hemorrhage. Even 
 such liquids as require stomach digestion ought to be largely avoided 
 and reliance for nourishment had upon liquid predigested food, such 
 as beef peptonoids or pancreatinized or peptonized milk. However, 
 as these may become distasteful after protracted use without varia- 
 tion, rice-water and various vegetable and animal soups may be alter- 
 nated to vary the routine. If chopped-beef diet is to be employed 
 it should be begun early and the beef should be minced exceedingly 
 fine. Black tea and coffee without milk may be allowed sparingly. 
 If the patient desires a small amount of claret or port wine may be 
 taken, unless it provokes gastric discomfort. 
 
 NON-MALIGNANT TUMORS OF THE STOMACH. 
 
 THESE growths are seldom found, and when present are small 
 and cause little trouble. Polypi are the most common variety. 
 They are usually multiple and may be very numerous, as many as a 
 hundred and twenty having been reported in a single case. They
 
 404 DISEASES OF THE DIGESTIVE ORGANS. 
 
 consist of hypertrophied mucous follicles, which become peduncu- 
 lated. Fibromata and lipomata are seldom met with. Lymphomata 
 may develop during the progress of leukaemia. Foreign bodies in 
 the stomach may he mistaken for tumors when palpation alone is 
 relied upon. 
 
 H^MATEMESIS. 
 
 Synonym. Gastorrhagia. 
 
 Etiology. Many causes conspire to bring about vomiting of 
 blood, though the most common one is rupture of the bloodvessels 
 of the stomach. The capillaries of the vessels are most frequently 
 ruptured, though bleeding often occurs from rupture of branches of 
 the gastric artery. The exciting causes may be divided into: 
 
 Traumatic, produced mechanically from perforation by a stom- 
 ach-tube, by hard food, by irritant chemicals or by external violence. 
 
 Diseases of the blood, as occurs in such infectious diseases as yel- 
 low fever, malaria, typhoid and typhus, etc. 
 
 Congestion of the gastric mucous membrane, as occurs in acute 
 gastritis and vicarious menstruation; in active congestion and the 
 passive congestion which attends obstruction of the portal circulation, 
 as in hepatic cirrhosis, thrombosis of the portal vein and other 
 causes of retardation of the flow of blood through the liver or along 
 the branches of the portal vein, such as pressure from abdominal 
 tumors, etc. Hepatic or pulmonary diseases obstructing the return 
 of venous blood to the right auricle may also operate in this direc- 
 tion through backward pressure. Similar effects may arise from 
 omental hernia when this exerts a dragging influence upon the 
 stomach. 
 
 Local diseases of the stomach may be attended by ulcerative 
 abrasion of the gastric vessels, as in ulceration from chronic catarrh, 
 peptic ulcer or cancer. Varicose conditions of the gastric veins or 
 aneurism of a branch of the gastric or splenic artery may result in 
 rupture, or such an accident may occur during violent retching or 
 vomiting. 
 
 Nervous conditions, such as progressive paralysis of the insane, 
 epilepsy or hysteria, the character of the accident then sometimes 
 beiug inexplicable. Sometimes the blood may be swallowed as a 
 result of bleeding in the pharynx, nasal passages, larynx or resoph- 
 agus and afterward vomited. Malingerers and hysterical persons 
 sometimes swallow the blood of animals and afterward vomit it up 
 for mercenary purposes or to excite sympathy. 
 
 Pathology, A variety of conditions may be found after death 
 from haematemesis. In hsemateniesis from cirrhosis of the liver no
 
 DISEASES OF THE STOMACH. 405 
 
 local lesion can be found, the blood having probably passed into the 
 stomach by diapedesis from the gastric capillaries. Or there may 
 be a rupture of a submucous vein and the erosion of the mucous 
 membrane escape notice on account of the minute size and post-mor- 
 tem changes. Miliary aneurisms may communicate with the cavity 
 of the stomach by pin-hole perforations and post-mortem appear- 
 ance afford no explanation of the morbid condition. When the hem- 
 orrhage results from portal obstruction no lesion is observable, 
 except that the mucous membrane is smooth and pale in appearance. 
 Intestinal ulcers tell their own stories. 
 
 Symptoms. Hemorrhage and later anaemia are the prominent 
 symptoms. There are cases, however, where neither of these symp- 
 toms is manifest, either because the quantity of blood is so small 
 that it does not cause emesis or because the amount is so large that 
 immediately fatal results occur before it becomes developed. The 
 blood may be ejected by regurgitation or by severe vomiting and by 
 all grades between. The amount may vary from a few streaks in the 
 vomited material to as much as three or four pounds in twenty-four 
 hours. In nearly all cases a portion of the blood may pass into the 
 intestines and in some cases the entire amount will be discharged 
 this way, the stools then presenting the dark tarry appearance 
 observed in hemorrhage from the upper intestinal canal. The secre- 
 tions of the stomach destroy the fresh appearance of blood in the 
 stomach after a little while, and when it remains in the stomach for 
 a while it is dark and grumous (like coffee-grounds) and the clots, if 
 any appear, are dark and irregular when vomited; but if ejected 
 soon after leaving the bloodvessels its appearance is little altered. 
 The anaemia varies in degree, according to the amount of blood lost. 
 
 Diagnosis. Care must be observed not to confound haematem- 
 esis with haemoptysis. Attention to the following points will afford 
 valuable assistance in this direction: In haematemesis the blood is 
 expelled by vomiting and if there be any cough present it occurs after 
 vomiting, while in haemoptysis the cough occurs in the beginning and if 
 vomiting comes on afterward it is excited by the coughing. In haema- 
 temesis the blood is liable to be mixed with particles of food, while 
 in haemoptysis the blood is clear and frothy and rales may afterward 
 be heard over the lungs. In haematemesis the blood is expelled in 
 quantities with complete intervals, while in haemoptysis there is 
 repeated and frequent expectoration of blood with cough after the 
 principal amount has been expelled. Physical examination should 
 be made in all cases where there is any doubt, auscultation of the 
 chest assisting in determining any question in the matter. 
 
 Prognosis. Fatal result may attend aneurism or the rupture 
 of a large vein in the gastric walls, but other gastric hemorrhages
 
 406 DISEASES OF THE DIGESTIVE ORGANS. 
 
 are seldom fatal. Hemorrhages from cirrhosis of the liver or other 
 portal obstruction are more dangerous than those from ulcer or 
 cancer. 
 
 Treatment. Absolute rest in the recumbent position is an 
 important element of treatment. All food by the mouth should be 
 discontinued, the patient being supported by rectal alimentation, and 
 thirst should be relieved by sucking small pieces of ice, drinking 
 being avoided. Ergotin and morphia may be given hypodermically 
 to constringe the bloodvessels and promote rest from peristalsis. 
 In extreme cases brandy per rectum will assist against collapse. 
 After the active symptoms subside food should be liquid in form and 
 only small quantities should be taken at a time until eroded vessels 
 have had time to heal. When portal obstruction is the cause of the 
 hemorrhage, efforts should be made to relieve the condition, fullness 
 of the abdominal capillaries being restrained in some measure by 
 such remedies as polymnia, ceanothus and carduus mariauus. In 
 malarial haematemesis grindelia squarrosa would be preferable. 
 Ulceration of the stomach should be met by appropriate treatment. 
 
 FUNCTIONAL GASTRIC DYSPEPSIA. 
 
 Synonym. Nervous Dyspepsia. 
 
 Definition. Indigestion in which there is no observable organic 
 lesion to account for the disturbance. 
 
 Etiology. The causes of this form of indigestion are numerous, 
 and usually of reflex character. Nervous dyspepsia is a common 
 accompaniment of uterine lacerations and almost a constant symp- 
 tom in greater or less degree of such rectal irritation as that 
 attending hemorrhoids, rectal pockets and papillae. It may be brought 
 on by severe mental occupation associated with sedentary habits or 
 by depressing influences continued for a lengthened period. Rheum- 
 atic affection of the muscular walls of the stomach may be attended 
 by difficult and painful digestion, it then being termed gastralgia or 
 gastrodynia. Impairment of the functions of the secreting glands 
 of the stomach may also arise, subacidity or hyperacidity being the 
 condition. Anaemia and neurastheeuia are commonly attended by 
 functional dyspepsia, and malaria may be an important factor. 
 
 Pathology. Careful examination will determine the absence of 
 auy structural disease; though digestion is attended by various 
 kinds of discomfort there is lack of any local structural change to 
 account for it. Often the irritation is at a remote distance from the 
 stomach, and so far as its structural character is concerned of a tri- 
 fling nature, but such as to constantly tease the terminals of sympa- 
 thetic nerves.
 
 DISEASES OF THE STOMACH. 407 
 
 Symptoms. The symptoms will vary according to the special 
 character of the affection, though there is much in common with them 
 all. Pain of burning character often attends, though instead of 
 scalding sensations in the stomach there may be sharp, lancinating 
 distress of neuralgic character. Sometimes there is aching in the 
 epigastric region with sensation as though there was a hardened ball 
 in the stomach, and again the painful sensation may be that as of a 
 gnawing in the part. An unpleasant sensation of fullness in the 
 epigastric region follows eating in most cases, accompanied by prse- 
 cordial distress and dyspnoea. Eructations of food and acid material 
 are common, and peristaltic unrest, attended by gurgling, borboryg- 
 mus and abdominal pain, is a frequent symptom. In many instances 
 there is pectoral and cardiac pain during digestion. Irritability of 
 temper and melancholia commonly attend. Vomiting attends some 
 cases, the food being ejected from the stomach soon after meals. 
 
 Diagnosis. The diagnosis of nervous dyspepsia from organic 
 affections of the stomach is not always easy. In functional dyspep- 
 sia, however, it should be recollected that though much distress may 
 attend the process of digestion, it is completed during the physio- 
 logical time-limit. Seven hours after the iugestion of food the 
 stomach should be found empty. A careful inspection of the con- 
 tents of the stomach during digestion may throw much light upon 
 the character of the affection as regards hyperacidity, subacidity, etc. 
 
 Prognosis. Every case of functional dyspepsia ought to be 
 cured, as there is usually a removable cause, and it remains for the 
 physician to search this out and correct it. 
 
 Treatment. The practitioner should inquire carefully into the 
 habits of his patient to determine whether or not the condition depends 
 upon some indiscretion of diet, mental taxation, sexual excess or abuse 
 or other avoidable cause. If such exist a cure depends much upon a 
 radical and permanent reform in this direction. The diet should be 
 carefully selected with reference to the avoidance of articles that are 
 known to disagree; fats, starches, sugars, tea and coffee being 
 avoided, and the general health attended to by judicious application 
 of exercise, genial companionship and pleasant surroundings. Mala- 
 rious conditions attended by dyspepsia will demand the employment 
 of grindelia squarrosa, polymnia, chionanthus or carduus marianus; and 
 constipation must be properly treated, the use of copious enemata of 
 salt water being efficacious for this purpose, daily irrigation of the 
 rectum and colon being sufficient to afford relief. A careful exam- 
 ination of the orifices of the body should be instituted to determine 
 their condition and enable the practitioner to decide as to the neces- 
 sity of surgical interference. Lacerated cervix, rectal pockets, papillae, 
 hemorrhoids, etc., should be suspected (if not inducing the condition)
 
 408 DISEASES OF THE DIGESTIVE ORGANS. 
 
 whenever present The vomiting of food, which attends some cases 
 of the kind, will almost always disappear upon the removal of rectal 
 or uterine irritation, of which gastric symptoms are but reflexes. 
 
 Sometimes functional dyspepsia depends upon the presence of 
 prostatic irritation and demands the judicious employment of galvan- 
 ism, with the aid of such sexual tonics as saw palmetto, salix nigra and 
 viburnum. 
 
 Berberis aquifolium and piper methysticum are especially valuable 
 as encouragers of the digestive functions. The dose of either may 
 vary from ten to fifteen drops of the specific medicine or some other 
 reliable preparation administered in a little water before each meal 
 and at bedtime. 
 
 Self-massage immediately upon rising in the morning is an excel- 
 lent practice for nervous dyspeptics. All the muscles of the body 
 should be thoroughly rubbed and kneaded, to be afterward well 
 pounded with the fists, the epigastric region receiving special atten- 
 tion of this kind. The effect of such treatment upon all the organs 
 of digestion is excellent, and superior to that of drugs alone. 
 
 Praecordial oppression yields to small doses of aploppapus lar., 
 one or two being taken soon after eating (five or ten drops of the 
 tincture) an hour or more apart. 
 
 Painful conditions of the stomach may require the use of caulo~ 
 phyllin (3x trituration), a decoction of cimicifuga, specific colocynth, 
 dioscorea or other especially demanded drug. 
 
 HYPERSECRETION AND HYPERACIDITY. 
 
 NORMALLY, the gastric juice is secreted only during the process 
 of digestion. When its secretion occurs between such times, it con- 
 stitutes hypersecretion. It is usually associated with some nervous 
 disorder, such as locomotor ataxia or neurasthenia. Hyperacidity 
 is a more common condition and is an aggravating attendant of gas- 
 tric ulcer. 
 
 Symptoms. There is burning, gnawing pain in the stomach 
 and substernal region with acid eructations which set the teeth on 
 edge. In aggravated cases vomiting of gastric juice may occur. 
 All these symptoms are ameliorated by eating. The eructations and 
 sour risings of chronic gastritis, dilatation, etc., occur after eating, 
 while in this case they occur during fasting, and there is no admix- 
 ture of food in the eructations as in those cases. Starchy food is 
 digested slowly. 
 
 Diagnosis. A test-breakfast of a Vienna roll and a cup of tea 
 without milk or sugar may be ordered and an hour afterward some 
 of the contents removed through a stomach-tube may be subjected to
 
 DISEASES OF THE STOMACH. 409 
 
 quantitive analysis to determine the question of hyperacidity. If 
 there be hypersecretion the presence of hydrochloric acid in the 
 stomach during fasting hours will determine the matter. 
 
 Treatment. In hypersecretiou lavage with weak alkaline solu- 
 tions should be practiced every day, the irrigation to occur before 
 the principal meal. Minute doses oijaborandi, hydrastis or menisper- 
 mum canadense should be administered for their tonic influence upon 
 the gastric tubules. Where hyperacidity is present an alkaline treat- 
 ment should be administered, and a diet consisting principally of 
 proteids, such as lean meat, largely adhered to, the patient also 
 taking plenty of out-door exercise and occupying the mind with active 
 diversion. Berberis aquifolium is an excellent remedy where there is 
 excessive activity of the gastric tubules, the dose ranging from five to 
 ten drops of a reliable fluid extract three or four times daily. Cac- 
 tus grandiflorus is another remedy which sometimes proves useful 
 in such cases, the dose being from three to five drops three or four 
 times daily. 
 
 GASTRALGIA. 
 
 Synonym. Gastrodynia. 
 
 Definition. Pain in the stomach without organic disease or 
 disturbance of digestion. 
 
 Etiology. Gastralgia is due to a variety of causes. It may be 
 neuralgic or muscular, many cases being due to the fact that the sub- 
 ject is prone to attacks of muscular rheumatism, the disease fre- 
 quently involving the muscular walls of the stomach. In other cases 
 it may occur as the leading symptom of an attack of malaria, the paiii 
 coming on periodically and being amenable to the curative action of 
 antiperiodics. In other cases it may be purely reflex, depending 
 upon uterine irritation, such as laceration of the cervix uteri, in 
 which case it is likely to appear coincideutally with the menstrual 
 period. Or, rectal irritation may give rise to it through reflex 
 action, aggravation of the local irritation being transferred to the 
 stomach instead of being appreciated at the actual point of disturb- 
 ance. Some persons of gouty tendency are liable to such attacks, 
 and lead poisoning may manifest itself in severe paroxysms of gas- 
 trodynia. The abuse of narcotics, such as tobacco and tea, may* lead 
 to attacks of this kind. 
 
 Symptoms. Sudden and excruciating pain in the epigastric 
 region is the initial symptom in the majority of cases, though there 
 may be premonitory loss of appetite, nausea and other gastric 
 unpleasantness for a few hours prior to the attack. The pain may 
 be burning, boring, griping or aching in character and it may radiate
 
 410 DISEASES OF THE DIGESTIVE ORGANS. 
 
 to the back and around the waist, the paiu being constant or inter- 
 mittent. Eating sometimes relieves and hardly ever aggravates, 
 unless it be in gastralgia of rheumatic type, when eating may pro- 
 voke aggravation. Pressure may aggravate if firm, though light 
 pressure may afford comfort. Subjects of gastralgia are usually per- 
 sons of highly nervous temperament. 
 
 Diagnosis. This consists of the exclusion of organic disease. 
 
 Prognosis. The cause is usually detectable by an intelligent 
 and properly educated physician, and its removal will insure 
 recovery. 
 
 Treatment. The first demand is for temporary relief from an 
 attack. Evacuation of the bowels with enemata and the application 
 over the epigastrium of a folded handkerchief moistened with chloro- 
 form and covered with a towel wrung out of hot water will usually 
 afford relief, though an internal administration of morphine may 
 sometimes be required. Darting, radiating pains sometimes yield to 
 j)iper methystictim and sometimes to colocynth, dioscorea or bryonia. 
 Copious draughts of hot water sometimes afford relief. A lacerated 
 uterus should be repaired and rectal pockets, ulcers, papillae, hemor- 
 rhoids and spasmodic stricture should be properly treated when 
 present in any persistent case. Periodical attacks may require anti- 
 periodic doses of quinine followed by the prolonged administration 
 of grindelia squarrosa in appropriate doses. If lead poisoning be 
 suspected the proper remedies for this condition should be pre- 
 scribed. In persistent cases a radical change of climate may suc- 
 ceed in relieving when other treatment fails. 
 
 Many cases of gastralgia are rheumatoid in character and occur 
 in persons subject to muscular rheumatism. In these cases we will 
 get prompt results in most instances from generous doses of cimici- 
 fuga. A strong decoction of the recently dried root in wine-glassful 
 doses repeated every few hours will usually relieve acute cases 
 within a short time. Smaller doses continued for a few days at 
 longer intervals will usually confirm the cure. In malarious regions 
 its action, however, may need to be supplemented by that of a prop- 
 erly selected antimalarial agent. In other cases, especially those 
 which have reached a more chronic stage, minute doses of caulophyl- 
 lin may be more efficacious and at the same time more acceptable. 
 Two or three grains of the 2x or 3x trituration of a good article of 
 caulophyllin should then be administered every three or four hours 
 during the day for a week or more. Sometimes rhamnus californica 
 will serve a better purpose and afford more prompt relief. A table- 
 spoonful of a strong decoction of the bark maybe administered every 
 two hours until a laxative effect becomes manifest, after which the 
 dose should be lessened or the remedy discontinued altogether.
 
 DISEASES OF THE INTESTINES. 411 
 
 NERVOUS VOMITING. 
 
 THIS sometimes occurs when there is no organic disease to cause 
 it, the patient being unable to retain food of the simplest character 
 in the stomach. It is usually reflex in character, the vomiting of 
 pregnancy and sea-sickness being familiar examples. In other cases, 
 however, the cause may be more obscure and the condition may be 
 so persistent as to threaten inanition. In one case of this kind, 
 where the patient had been consigned to death by her physicians 
 under the diagnosis of cancer of the stomach, I afforded prompt and 
 permanent relief by simply stretching the sphincter ani with the 
 thumbs. Doubtless most of these cases may be referred to reflex 
 rectal irritation, though some may be due to uterine irritation or 
 other reflexes. In managing them the physician should examine for 
 all possible sources of reflex disturbance, and when a probable cause 
 is found it should be corrected at once. If this fail further investi- 
 tion should be pursued. 
 
 PERISTALTIC UNREST. 
 
 SOME persons, more especially women, are subject to loud gur- 
 gling or splashing sounds in the epigastric or left hypochondriac 
 region, due to peristaltic unrest of the stomach. This is probably a 
 reflex due to some distant disturbance and is not incompatible with 
 average health. General tonic faradic treatment with local faradiza- 
 tion of the affected region is beneficial, though permanent relief 
 is not always accomplished. 
 
 KUMINATION. 
 
 HYSTERICAL and feeble-minded persons sometimes regurgitate 
 and chew the food like cud-chewing animals. It is a disgusting 
 practice and difficult to cure, though there is little danger of evil 
 effects from it. 
 
 VII. DISEASES OF THE INTESTINES. 
 
 MORNING DIARRHOEA. 
 
 THIS is a functional affection, the etiology and pathology of which 
 are obscure. It consists of a diarrhoea, which comes on during the 
 early morning hours, sometimes rousing the subject from slumber, 
 the evacuation being usually preceded by more or less severe grip- 
 ing pain in the abdomen. In many cases one evacuation ends the 
 trouble for the day, though several may follow, the diarrhoea extend- 
 ing well into the forenoon.
 
 412 DISEASES OF THE DIGESTIVE ORGANS. 
 
 It is possibly due to mental disturbance, such as worry or over- 
 work, and is apt to be aggravated by late hours with evening lunch- 
 ing. Irritation of the defecatory center may arise from prolonged 
 riding over rough roads, as is the lot of many country doctors who 
 suffer from jar of the spine. Rectal irritation may be a cause through 
 reflex action. Sometimes the trouble may cease for weeks or months, 
 to return upon deterioration of the general health. 
 
 Treatment. Late hours of dissipation should be carefully 
 avoided and a very light supper, if any, should be taken, and this not 
 after six r. M. Mental strain should be prevented, the patient taking 
 exercise on foot in moderation but refraining from riding or any 
 exercise which incurs jarring of the spine. Careful inspection of 
 the rectum should be made to detect and correct any local lesions, 
 if any exist. Massage of the abdomen and faradization of the entire 
 abdominal surface with the negative pole of a faradic battery the 
 positive pole being held at the nape of the neck should be repeated 
 twice a week. Minute doses of nux vomica (one drop of the tincture 
 in a glass of water before each meal) may be tried with some assur- 
 ance of benefit. A radical change of climate will promote the best 
 results. 
 
 ACUTE INTESTINAL CATARRH. 
 
 Synonyms. Acute Catarrhal Enteritis; Acute Entero-colitis; 
 Acute Diarrhoea. 
 
 Definition. An inflammation of the intestinal canal involving 
 the small intestine and in many cases the upper portion of the large 
 bowel, attended by catarrhal symptoms signalized by mucous diar- 
 rhoea with griping pains. 
 
 Etiology. The causes have been divided into primary and 
 secondary. 
 
 Primary causes may be (1) toxic or irritating foods or drugs of 
 alkaline, acid or corrosive nature. (2) Errors in food either in 
 quantity or quality, some articles of diet proving especially detri- 
 mental to certain individuals. (3) Impure drinking-water may con- 
 tain elements which give rise to intestinal irritation and inflamma- 
 tion. (4) Certain changes in the intestinal secretions are believed 
 to result in enteritis. (5) Sudden changes in temperature, resulting 
 in congestion of the mucous membrane, similar to that which causes 
 "colds" to center upon the pulmonary mucous membrane. 
 
 Secondary causes are: (1) The irritation resulting from some of 
 the infectious diseases, such as typhoid fever. (2) Certain cachetic 
 conditions, such as tuberculosis, Bright's disease, cancer, anaemia, 
 etc., may be complicated by acute attacks of enteritis. (3) Chronic
 
 DISEASES OF THE INTESTINES. 413 
 
 congestion of the portal circulation. (4) Peritonitis, cancer of the 
 intestines, intestinal ulcer, hernia, etc. 
 
 Among the toxic or irritating articles of food may be mentioned 
 the toxines developed by the decomposition of cheese and milk. 
 Arsenic, mercury arid other mineral substances act in a similar way. 
 Unripe fruit, green corn and other such materials are common 
 causes of the disease during the heated months of summer and early 
 autumn. Excessive secretion of bile is supposed to be one of the 
 causes of this disease, and mental emotions may give rise to such a 
 disturbance of the intestinal mucous membrane as to provoke irri- 
 tative diarrhoea. 
 
 Pathology The branches of the mesenteric artery distributed 
 to the intestinal mucous membrane are injected and swollen, the 
 entire mucous membrane is reddened and engorged and the surface 
 is covered with au excessive amount of mucus. The solitary and 
 agminated glands are enlarged and stand prominently out upon the 
 mucous membrane and ulceration of the follicles and mucous surface 
 may occur. After death the reddened mucous membrane becomes 
 grayish, sodden and flabby. 
 
 Symptoms. Colicky pains announce the advent of the disease 
 the pains preceding the evacuations for a few seconds, the call to 
 stool being urgent and the evacuations forceful and, if the lower 
 bowel is involved, marked by rectal tenesmus. More or less tym- 
 panites and borborygmus occur during the attack, these usually being 
 most marked shortly prior to evacuating. There are loss of appe- 
 tite, nausea, thirst, diyness of the tongue and sense of debility and 
 prostration. The skin is dry and harsh in some cases, though a 
 relaxed sweat may attend the demand for evacuation. Slight fever 
 may appear, though the temperature is more commonly normal. 
 The evacuations vary, their condition depending upon the period of 
 the disease, the portion of the intestine most involved and the amount 
 of ingested food in the canal. They are thin and gruel-like in con- 
 sists. cy and vary in color in proportion to the amount of bile con- 
 tained in them. They may contain portions of undigested food 
 (lienteria) and much mucus, especially when the colon is affected. 
 From five to twenty evacuations may occur in a day. 
 
 Treatment. The recumbent position is to be strictly main- 
 tained throughout the progress of the disease, as frequent rising to 
 stool proves a continual aggravation. The therapeutic effect of the 
 best remedies may be entirely lost if the patient is not kept down. 
 A bed-pan is to be used and the patient enjoined to make as little 
 exertion as possible. Aconite and ipecac, in combination, is the ideal 
 prescription where a large portion of the intestine is involved. The 
 dose should be small and frequently repeated, and relief of perma-
 
 414 DISEASES OF THE DIGESTIVE ORGANS. 
 
 nent character will follow within a few hours at least within a day 
 or two. The following combination represents the proper propor- 
 tions: R Lloyd's or Wordeu's aconite gtt. v-x, specific or normal 
 tincture ipecac gtt. x-xx, water fiv. M., and order a teaspoonful 
 every hour. 
 
 Where the upper portion of the intestine is principally involved, 
 kali bichrom. 2x or arsenicum 3x may be more efficacious. Two grains 
 may be administered every two hours. The 2x trituration of podo- 
 phyllin sometimes acts especially well here also, the same directions 
 as to dose and frequency of administration being observed. 
 
 Rhus aromatica acts better than any of these remedies during 
 some attacks, especially where provoked by hot weather and ferment- 
 ative processes. From two to ten drops of the specific medicine may 
 be administered every hour and repeated until benefit follows, then 
 every two hours until complete relief is obtained. 
 
 Where the lower intestine is the part principally involved mer- 
 rius cor. 6x may be expected to yield better results than any of the 
 remedies already named. Five or ten drops of the dilution or, two 
 or three drops of the trituration may be administered every two 
 hours until the disease is controlled. 
 
 Colocyntli should take preference of all other remedies where pain 
 is the prominent symptom. It is especially indicated where there is 
 intense griping pain about the umbilicus accompanied by spas- 
 modic cramps of the abdominal muscles just prior to the evacuations. 
 Half a teaspoonful of the 2x or 3x dilution may be added to half a 
 tumblerful of water and a teaspoonful administered every half-hour 
 or hour until relief follows. It may be necessary to follow relief 
 from pain with one of the remedies already named to complete a 
 cure, though this will not always be necessary, colocynth frequently 
 being curative as well as palliative. 
 
 Where typhoid symptoms appear and the patient is delirious, 
 with dry, reddened tongue, nausea and vomiting, rhus tox. should be 
 combined with the properly selected remedy. Where the discharges 
 are dark and offensive, suggesting putrid conditions of the intestinal 
 mucous membrane, echinacea, baptisia or sulpho-carbolate of sodium may 
 be required. The sodium salt may be administered in quarter-grain 
 doses repeated every three hours. 
 
 Arseniate of copper 3x is strongly indicated where the evacuations 
 are watery and are voided with a forcible gush. One-grain doses of 
 the trituration may be administered at one- or two-hour intervals. 
 Small doses of the 3x dilution of veratrum album answer as well if 
 not better in some cases, and sometimes wineglassful doses of a 
 decoction of the fresh plant erigeron can. repeated every half-hour or 
 hour may succeed better.
 
 DISEASES OF THE INTESTINES. 416 
 
 Some allopathic practitioners advise the administration of cathar- 
 tic doses of castor oil or calomel in the beginning, to be followed by 
 bismuth and astringents, with opiates to control the pain a very 
 unsatisfactory manner of management in most cases when compared 
 with the treatment I have already suggested. When there is great 
 relaxation, and the discharges persist in spite of the treatment advised 
 and an astringent seems desirable, a decoction of erigeron canadense 
 may be employed for such purpose, as it does not irritate the intes- 
 tinal mucous membrane. When the plant cannot be obtained, two- 
 or three-drop doses of the specific medicine diluted in water may be 
 tried. 
 
 The general management of enteritis is an important subject. 
 The patient should not be permitted to rise to stool, however urgent, 
 ly he may request it, as every time the erect position is assumed the 
 intestinal irritation is increased and the frequency of the evacuations 
 encouraged. Abed-pan should be employed to receive the evacua- 
 tions, and the patient should be enjoined to avoid defecation as long 
 as possible in order to encourage rest and quiet for the bowels. 
 
 The diet should consist of mutton broth, pancreatinized milk or 
 milk and lime-water (two or three ounces of lime-water to the pint 
 of miik). After the disease has been arrested the yolk of eggs which 
 have been boiled an hour or partially cooked (soft-boiled) eggs, raw 
 oysters, scraped b ef with toast and well boiled rice may be given, 
 care being observed, if the case has been a severe one and the diar- 
 rhoea has continued until the patient has become prostrated, to return 
 to a solid diet cautiously. 
 
 Care should be observed to prohibit an early return to active 
 habits for fear of provoking a relapse. During the active stage of 
 the disease the patient should refrain from drinking much water, as 
 this is apt to increase the number and frequency of the evacuations. 
 Thirst may be appeased by allowing small portions of ice held in the 
 mouth, or by minute doses of rhus tox. 
 
 In malarious districts the practitioner should be on the alert for 
 malarial complications, properly selected remedies often failing under 
 such circumstances to produce their specific effects. It is always a 
 safe plan, when there is the least suspicion of malaria, to administer 
 a two- or three-grain dose of arseniate of quinia 3x three times daily, 
 in alternation with other remedies. 
 
 CHRONIC INTESTINAL CATARRH. 
 
 Synonyms. Chronic Catarrhal Enteritis; Chronic Diarrhosa; 
 Chronic Catarrhal Entero-colitis. 
 
 Etiology Chronic enteritis is due in the majority of cases to
 
 416 DISEASES OF THE DIGESTIVE ORGANS. 
 
 long-continued use of improper food under unhygienic circumstances. 
 Old soldiers, who have been compelled to subsist during arduous 
 campaigns upon hard-tack, salt-pork, underdone beans and such diet 
 while sleeping on the ground and exposed to wet and cold, are the 
 ones most subject to the disease. Repeated acute attacks badly 
 treated may be followed finally by chronic diarrhoaa; and certain 
 cachetic conditions, such as gout, may predispose an individual to 
 it. It often arises as a complication of chronic disturbance of the 
 portal circulation, such as that arising from hepatic cirrhosis or 
 splenic hypertrophy. Cancerous or tubercular disease of the intes- 
 tines may be attended by it. 
 
 Pathology. The small intestine and, usually, a portion of the 
 large bowel are involved in the morbid change. The entire wall of 
 the intestine is frequently thickened by hypertrophy of its coats, and 
 the mucous membrane is reddened and congested and covered with a 
 layer of tenacious mucus. The glandular elements are also hype*> 
 trophied and stand out in relief, ulceration of the follicles occasion- 
 ally occurring. Sometimes atrophy of the intestinal canal is present 
 instead of hypertrophy, and the mucous membrane is leaden-gray in 
 color and the glandular elements shrunken. The villi may be pig- 
 mented in patches, imparting a "shaven beard" appearance to the 
 mucous membrane. Where ulceration of the follicles is general the 
 intestine may be perforated with a honey-comb suppurating surface, 
 and perforation or hemorrhage may be the result. Adhesions of the 
 peritoneal surfaces of the intestines may occur and serous exudation 
 may give rise to ascitic accumulation in the peritoneal sac. 
 
 Symptoms. The symptoms resemble those of acute enteritis, 
 though there may be periods of constipation, during which there is 
 more than usually severe distress. Attacks of diarrhoea follow indis- 
 cretions in diet in mild cases ana food of any kind provokes distress, 
 gastric and intestinal, when the condition is aggravated. The stools 
 are thin and gruel-like, containing mucus and debris of undigested 
 food, with streaks of blood and pus whenever there is extensive 
 ulceration. The evacuations are preceded and accompanied by 
 severe griping pain in the abdomen, and painful tenesmus attends 
 when the irritation extends low in the bowel, it nearly always ap- 
 pearing two or three hours after eating. There may be from one to 
 eight evacuations during the day, and during aggravations, which 
 may arise from cold or dietary indiscretion, there may be a much 
 larger number. Flatulence and borborygmus are common to such 
 cases and hypochondriasis and melancholia are frequently present. 
 Gradual failing of health and strength result and during advanced 
 stages the patient may become extremely emaciated and prostrated. 
 Ascites may then arise, especially where there is hepatic complica-
 
 DISEASES OF THE INTESTINES. 417 
 
 lion; and later anasarca may occur. The skin becomes sallow and 
 pallid, the pulse feeble and rapid, and the patient may finally die 
 with typhoid symptoms. 
 
 Prognosis. There is little hope in aggravated cases, though 
 recovery may follow treatment begun at an early period. Perforation 
 of the bowel is an occasional accident. 
 
 Treatment. Attention to diet is one of the most important 
 matters to be considered in treatment. Food should be liquid in 
 form, and skimmed milk is probably most appropriate when diluted 
 with lime-water. Sometimes the milk is more acceptable when boiled. 
 An excellent plan is to put the patient upon an exclusive milk diet 
 for several weeks until curative treatment is under way. Beef pep- 
 tonoids, scraped raw beef, beef meal and similar articles are useful. 
 Fatty and saccharine kinds of food should be avoided and only a 
 small amount of farinaceous food should be allowed. In the treat- 
 ment of such cases the practitioner should consult standard authori- 
 ties on dietetics for a variety of foods. Fats, sugar, very rich milk, 
 green vegetables, acid fruits and dried fruits, nuts, shell-fish, pork, 
 veal, coarse bread, pastries, cakes and desserts of every description 
 should be discarded. 
 
 This is an excellent place for the administration of the dry diet. 
 From some limited experience I am convinced that severe cases may 
 be thus controlled, provided they be not too far advanced. If the 
 patient can be induced to persevere in this for a few weeks little 
 medicine may be needed to perfect a cure. The great difficulty is to 
 imbue the subject with enough faith to hold out to the end. The 
 diet should consist of stale bread, thoroughly masticated, with two 
 ounces of plain claret four or five times a day, and nothing else. All 
 fluids should be sedulously avoided as well as solids. 
 
 To remove accumulations of tenacious mucus, liydrozone may be 
 of service, a drachm being diluted with four ounces of distilled or 
 boiled water, two ounces of the amount being taken before break- 
 fast for two or three consecutive mornings, the agent to be repeated 
 as circumstances seem to demand. Glycozone may sometimes be sub- 
 stituted with advantage. 
 
 To encourage reparation of the diseased mucous membrane, ber- 
 beris aquifolium is an excellent remedy, especially if there be ulcera- 
 tion to contend with. Epilobium continued for a long time often 
 affords satisfactory results in cases not too far advanced. Kalci is 
 another remedy of especial service for this purpose, especially when 
 a recent preparation can be obtained. Rims aromatica is also an 
 excellent remedy, especially to relieve acute aggravations. Mercu- 
 rius dulcis or corrosivus 6x may be relied upon to alleviate irrita- 
 tion of the colon and heal abraded surfaces there. Severe colicky 
 
 28
 
 418 DISEASES OF THE DIGESTIVE ORGANS. 
 
 pains may call for cdocynth, especially when the neurosis is about 
 the umbilicus, and collinsonia if the rectal or hypochondriac region 
 is the seat of pain. Reference to Dynamical Therapeutics will afford 
 more information as to details in the use of these remedies. 
 
 The tissue remedies sometimes exert an excellent influence in 
 these cases. Where there is emaciation and anaemia calcium phos. 
 3x may prove an excellent remedy. Calcium sulphate 3x may be 
 applicable to cases where there is profuse purulency, and natrum 
 chlor. 3x where there is much watery discharge. 
 
 Massage over the abdominal region, where there is not too much 
 tenderness, and general massage, as well as local and general faradi- 
 zation, are useful to assist in a cure. The skin should be protected 
 with flannel and sudden changes should be avoided. A winter resi- 
 dence in a warm climate is always appropriate. 
 
 PHLEGMONOUS ENTERITIS. 
 
 THIS is a very grave disease and one that usually terminates 
 fatally. The abdomen is distended, tympanitic and very tender 
 to touch, there are pain and tormina in an intense degree, the patient 
 breaking out into profuse perspiration, with frequent and violent 
 vomiting, the ejected material becoming fecal in most cases late in 
 the disease. The pulse is small, rapid and compressible and the 
 temperature elevated (103 to 105 F.). There is marked and rap- 
 idly progressive prostration in fatal cases, the countenance becoming 
 shriveled and the extremities cold, hiccough and jactitation coming 
 on later, and finally collapse and death. In favorable cases diarrhoea 
 sets in, the tongue becoming dry, red and glazed and the patient 
 greatly prostrated for a time, the symptoms afterward gradually 
 ameliorating and slow recovery following. 
 
 Treatment. Potassium chloride 3x, echinacea and baptisia are 
 the most rational remedies. Solid food should be avoided and the 
 patient should maintain the horizontal position until convalescence. 
 
 PSEUDO-MEMBRANOUS ENTERITIS. 
 
 Synonyms. Diphtheritic Enteritis; Croupous Enteritis. 
 
 Definition. An intense inflammation of the intestine, charac- 
 terized by an exudate and destructive processes involving the mucous 
 and submucous structures. 
 
 Etiology. Many causes may result in this form of intestinal 
 inflammation. It is not an unfrequent attendant of the infectious 
 fevers, especially of typhoid fever, scarlatina, pyaemia, etc. It may 
 attend the last stages of such chronic affections as cirrhosis of the
 
 DISEASES OF THE INTESTINES. 419 
 
 liver, cancer, Bright's disease and other cachetic conditions, and may 
 be present in poisoning from various mineral agents, such as mer- 
 cury, arsenic and lead. 
 
 Pathology. The exudate is thrown out upon the mucous sur- 
 face, involving it in in a state of coagulation necrosis. Sometimes it 
 is extensive and crust-like and at other times it may constitute a 
 thin film, the mucous membrane being necrotic in both instances. 
 In other cases the exudation appears in small amount about the 
 openings of the solitary follicles, small ulcers corresponding to 
 these openings being scattered about over the mucous surface. 
 Sometimes the follicles are capped with a raised diphtheritic mem- 
 brane. 
 
 Symptoms. The symptoms vary greatly in character and 
 severity. Sometimes, as when the exudation occurs in the termi- 
 nal stages of infectious fevers and other constitutional conditions, 
 there may not be much inconvenience from it, while in toxic 
 cases intense pain, with diarrhoea, may attend. Sometimes the 
 presence of the disease will not be suspected until accidentally 
 observed during autopsy. Shreds of membrane may be voided in 
 the faeces. 
 
 Treatment. Echinacea and lachesis fortify the system against 
 necrosis, and potassium chloride against plastic exudation. Colocynth 
 alleviates intestinal pain and tenesmus. A liquid diet provides 
 against danger of perforation and destructive mechanical action, and 
 rest in the recumbent posture favors restoration by providing 
 against undue peristalsis. 
 
 Mucous COLITIS. 
 
 Synonyms. Membranous Enteritis; Tubular Diarrhoea; Mu- 
 cous Colic. 
 
 Definition. A chronic disease of the colon of mild character, 
 characterized by the formation of masses of tenacious mucus, which 
 may be voided in long, stringy, irregular masses or in the form of 
 tubular membranes. 
 
 Etiology. Some derangement of the mucous glands of the 
 colon is the cause of the peculiar secretion. What the exact patho- 
 logical condition is remains a question, rectal pockets and papillae 
 often being attended by it. It is most common in women of nerv- 
 ous, excitable temperament, hysterical women or neurasthenic men 
 being favorable subjects, though it may occur occasionally in 
 children. 
 
 Pathology, There are few if any pathological changes to be 
 bserved, though the lower inch of the rectal mucosa may be con-
 
 420 DISEASES OF THE DIGESTIVE ORGANS. 
 
 gested. The masses of mucus may often be seen through the spec- 
 ulum, sometimes deposited in irregular layers, sometimes in flakes 
 and sometimes in tubular form. 
 
 Symptoms. Paroxysms, characterized by abdominal pain and 
 rectal tenesmus, come on at intervals of a month or more, sometimes 
 lasting for several days, during which the mucus is voided. The 
 subjects are usually hysterical or neurasthenic and they are fre- 
 quently hypochondriacal. There is no fever. 
 
 Prognosis. The disease runs a chronic course and may con- 
 tinue for years without serious results to the general health, though 
 the patient may be in a condition of semi-invalidism through the 
 attending neurasthenia.. Much benefit, and often a cure, may result 
 from rational treatment. 
 
 Treatment. As rectal irritation is liable to be the chief pro- 
 voking cause, careful search must be made for concealed rectal pock- 
 ets, papillae and ulcers. When such pathological conditions are 
 found they must be radically treated, the pockets and papillae being 
 excised and the ulcers healed. This treatment should be followed 
 by daily copious flushing of the lower bowel with a saturated solu- 
 tion of sodium chloride in water, the water to be lukewarm, espe- 
 cially in female subjects, the daily flushing being continued for a 
 year. Electrolysis of the lower bowel through the salt-water injec- 
 tion is an excellent curative measure. It should be applied twice 
 weekly. Internally, the following prescription may be used steadily 
 for months: R Specific sambucus canadensis 31!, specific phytolacca 
 ^i, fluid extract berberis aquifolium f i, fluid extract grindelia squar- 
 rosa f i, aqua ad $ vi. 8. Take a teaspoonful before each meal and at 
 bedtime four times daily. 
 
 ULCEBATIVE ENTERITIS. 
 
 ULCERATTON of the intestines may arise from numerous causes. 
 Sometimes the symptoms are prominent and sometimes hardly 
 detectable, the disease running a latent course and the condition fin- 
 ally being accidentally observed during autopsy, this being the first 
 revelation of the existence of a lesion. The following kinds of 
 intestinal ulceration have been noted: 
 
 Peptic or round ulcer of the duodenum occurs in about one in 
 forty of the cases observed, the majority affecting the stomach. There 
 is less vomiting here than in peptic ulcer of the stomach, and the 
 pain which follows eating comes on later than in the gastric variety 
 and is not so severe. There is tenderness over the right hypochon- 
 drium and in about one-third of the cases hemorrhage ensues. lu 
 other cases there is little pain or discomfort and the disease runs a
 
 DISEASES OF THE INTESTINES. 421 
 
 latent course, sudden death following perforation of the intestine, 
 the cause of demise being determined by autopsy only. Stenosis of 
 the pylorus with gastrectasis may occur, or peritonitis with or with- 
 out peritoneal abscess. Sometimes there is obstruction of the com- 
 mon bile duct or pancreatic duct. Perforation is usually announced 
 by several days' severe continuous pain in the right hypochondrium. 
 The prognosis is more serious than that of gastric peptic ulcer. The 
 treatment should be followed on similar lines. 
 
 Duodenal ulceration may follow extensive burns of the skin. This 
 depends upon some peculiar sympathy which is not well understood. 
 The intestinal complication comes on in one or two weeks after the 
 burn in the form of irregular patches of congestion and ulceration of 
 the duodenal mucous membrane, the ulceration proceeding to de- 
 structive action upon the intestinal walls, attended by hemorrhage 
 and perforation with fatal result. The prognosis is unfavorable 
 almost invariably. 
 
 Embolic ulcers of the small intestine may arise from obstruction 
 of a branch of the superior mesenteric artery, the colon almost always 
 escaping this form of ulceration. Small necrotic areas appear upon 
 the intestinal wall at points corresponding to the terminations of the 
 obstructed vessels, infarction of the mucous membrane and deeper 
 structures producing them. Extensive suppuratior. of the intestinal 
 wall, followed by peritonitis and perforation, may follow. Intense 
 pain, with profuse, foetid discharges, typhoid symptoms of rapid rise, 
 collapse and death are the usual symptoms. 
 
 Amyloid degeneration of the terminal arteries of the mesentery 
 may be followed by ulcers, which progress steadily to a fatal termi- 
 nation. Permanent obstruction of the arterial supply renders resto- 
 ration impossible. 
 
 Catarrhal &ndfollicular ulcers may occur in the alimentary canal, 
 either in acute or chronic form. Catarrhal ulcers are superficial ero- 
 sions of the mucous membrane of the colon, sometimes spreading 
 widely, resulting, in chronic cases, in induration of the intestinal 
 wall and tending, on recovery, to cicatrization and narrowing of the 
 passage. Follicular ulcers may occur in either the large or small 
 bowel. They consist of single ulcers with excavated edges, but may 
 extend so as to communicate with one another or perforate the 
 bowel. When extensive, they are seldom repaired. 
 
 Stercoral ulcers are the result of abrasions caused by irritating 
 fecal material. They are usually found where hardened fecal mater- 
 ial is liable to be retained for a long time, as above intestinal stric- 
 tures, in the caecum, flexures of the colon, sigmoid flexure or in the 
 rectum. Destruction of the mucous surface with purulent infiltra- 
 tration occurs at points of continued pressure.
 
 422 DISEASES OP THE DIGESTIVE ORGANS. 
 
 Tubercular ulceration of the intestine is of common occurrence 
 in tubercular subjects, secondary infection resulting in pulmonary or 
 genito-urinary tuberculosis. In other cases direct infection may 
 arise from the ingestion of food contaminated with tubercle bacilli, 
 as in the instance of infected milk. Tubercles first develop in the 
 solitary or agminated glands of the ileum and spread from there up- 
 ward and downward, involving the entire intestinal canal. The mes- 
 enteric vessels become involved and the intestine becomes girdled 
 with tubercular deposits, which form along the course of these chan- 
 nels and break down, leaving ulcerated surfaces encircling the intes- 
 tine at right angles with the longitude of its lumen. The peritoneal 
 surface of the intestine becomes studded with tubercles and the 
 inflammatory exudation furnishes adhesive material to weld the 
 opposing peritoneal surfaces together. Tubercular deposits spread 
 to the mesenteric glands and these become enlarged and nodular. 
 The "girdle" character of the ulcers serves to distinguish them from 
 other forms. Perforation of the bowel sometimes occurs, and heal- 
 ing by cicatrization has been possible. 
 
 Syphilitic ulcers occur, in the adult, almost exclusively in the rec- 
 tum, where they cause progressive fibrous stricture. They are most 
 frequently found in women. Syphilitic ulceration of the small 
 intestine may occur in congenital syphilis. Gummata sometimes 
 form in the intestinal wall, their dissolution being followed by obsti- 
 nate ulcers. 
 
 [frcemic ulcers occur in connection with advanced nephritis, some- 
 times of gangrenous character, sometimes follicular and again as a 
 result of pseudo-membranous enteritis. 
 
 Mercurial ulcers follow poisoning by mercury and are left after 
 the pseudo-membranous enteritis, which then arises. 
 
 The ulceration which attends typhoid fever, diphtheria, anthrax 
 and other infectious diseases has already been referred to. 
 
 Peritoneal erosion from the pressure of abdominal tumors may 
 result in intestinal ulcers, and a neighboring abscess may perforate 
 the intestine from its external surface and cause ulceration. 
 
 Cancerous ulceration of the intestine will be referred to later. 
 
 The symptoms of intestinal ulceration vary greatly, the location 
 and character of the condition determining its nature and gravity. 
 Limited ulceration of any part of the intestine may be attended by 
 constipation, but diarrhoea is a common symptom when ulceratiou is 
 extensive. Hemorrhage is a common symptom, though its amount 
 will depend upon the depth of the ulcerative action. Typhoid ulcers 
 and those occurring in the duodenum are attended by the greatest 
 amount of hemorrhage, though perforations of the intestine from 
 without are liable to be followed by extensive hemorrhage. Pus is
 
 DISEASES OF THE INTESTINES. 423 
 
 always present and its presence is diagnostic. Sometimes it is so 
 limited in quantity as to require microscopical inspection of the 
 faeces to detect it, and at other times it may be present in large quan- 
 tity, casual inspection affording evidence of it. Profuse evacuations 
 of pus indicate the discharge of an abscess into the intestinal canal. 
 Pus mixed with blood and mucus indicates the presence of an irri- 
 table ulcer near the lower outlet, such as that of cancer of the 
 sigmoid flexure or rectum. In tubercular ulceratiou tubercle bacilli 
 are liable to be found in the evacuations, and shreds of mucous 
 membrane suggest rapid and extensive ulceration, though care 
 must be exercised that portions of undigested food be not mistaken 
 for them. 
 
 Pain may or may not be present. Sometimes intestinal ulcers 
 run a latent course and the patient does not experience any pain 
 throughout. Sometimes colicky pains of spasmodic character may 
 attend and are aggravated by taking food. Sometimes the pain is 
 forceful and tenesmic in character, suggesting irritation in the 
 colon or rectum, and is aggravated by motion of the bowels. 
 Sometimes the pain is constant, suggesting peritoneal tenderness. 
 Tenderness may or may not be present. When a small area is sen- 
 sitive to pressure the symptom is valuable as localizing the seat of 
 ulceration. 
 
 Fever and emaciation may be present, depending upon the extent 
 and character of the ulceration. Intestinal obstruction from cicatri- 
 zation, localized peritonitis, peritoneal abscess and perforative peri- 
 tonitis are among the complications of intestinal ulceration. 
 
 Treatment. A properly selected diet stands first among con- 
 siderations of treatment. A milk diet is best in most cases, though 
 provision should be made against the formation of hard curds by the 
 addition of lime-water. As the upright position encourages peri- 
 stalsis and thus tends to aggravate intestinal disease, rest in bed is 
 the best course to pursue during treatment. The yolks of eggs 
 boiled for an hour and taken with a little salt may be alternated 
 with the milk diet when this becomes too irksome, and after im- 
 provement begins soft-boiled eggs, raw oysters, minced beef and 
 chicken, soda crackers, bread and milk, toast, blanc-mange, custard, 
 junket and wine-jelly may be allowed. Acids, pickles, raw fruits and 
 all indigestible foods should be prohibited, and meals should be 
 limited as to quantity, the patient being fed often and a little at a 
 time five or six times a day. 
 
 When the ulceration is in the upper portion of the alimentary 
 canal, two ounces of diluted Jiydrozonc one or two parts to thirty- 
 two of distilled or sterilized water should be given two or three 
 times daily to destroy pus microbes, disinfect the alimentary canal
 
 424 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 and stimulate reparative action in the ulcers. When the lower bowel 
 is affected, high injections of the same agent may prove serviceable. 
 The constitutional influence of berberis aquifollum in ulceration of the 
 soft tissues should be made avail of, and if the ulceration should be 
 syphilitic it may be advantageously combined with corydalisjormofsa. 
 When the small intestines are ulcerated, kaki may be of service, and 
 also epilobium. Salicylate and subnitrate of bismuth are to be remem- 
 bered. Tubercular ulceration should be treated with bovinlne, such 
 auxiliary treatment as special cases demand being added. Ulcera- 
 tion of the colon and rectum may demand the use of the salt-water 
 electrode with galvanism applied every second or third day for 
 months. Colicky pains may demand colocynth, dioscorea or stannum 3x. 
 In follicular ulceration of the small intestine kali bichrom. 3x may 
 be of service, and mercurius cor. 6x exerts a similar influence upon 
 the colon. The pain of cancerous ulceration demands echinacea. 
 
 The galvanic rectal douche is a simple arrangement for conveying 
 electricity directly to the interior of the bowel. In ulceration of 
 this part, and in pns pockets communicating with the lower bowel, 
 it is a superior means of treatment. However, it is efficacious in 
 confirmed torpidity of the lower bowel, proving curative in long- 
 
 standing constipation as well as in chronic catarrhal conditions of 
 the rectum and colon. 
 
 In addition to an ordinary galvanic battery with the usual sponge 
 electrode, the apparatus consists of two yards of half-inch rubber
 
 DISEASES OF THE INTESTINES. 425 
 
 hose, three yards of copper wire (the size of an ordinary knitting 
 needle) and a small glass, rubber or tin funnel (glass or hard rub- 
 ber being preferable to the metal on account of non-conducting 
 properties). 
 
 In using the patient is instructed to lie, either on a cot or on a 
 rug on the floor, in the Sims position, the floor being better. One 
 end of the rubber hose is oiled and inserted into the rectum an inch 
 or two and the funnel is adjusted to the other end to facilitate the 
 introduction of the water when all is ready. The copper wire is now 
 passed through the funnel and into the tube and carried along until 
 the lower end reaches the lower extremity of the tube, though it 
 should not protrude from it, as a painful effect may result from the 
 current when the metal is in contact with the mucous membrane of 
 the bowel. The upper end of the wire, which should be a yard or 
 more longer than the tube, should be attached to one pole of the 
 battery to be used, the selection to be made according to the condi- 
 tion to be treated. A conducting cord should now be fastened to a 
 moistened sponge electrode and attached to the opposite pole, when 
 all is ready for operation. After the tube has been introduced a 
 strong solution of warm salt water should be poured into the ele- 
 vated funnel, the patient meanwhile holding the sponge upon the 
 naked abdomen and stroking it backward and forward over the entire 
 abdominal surface. As long as the water flows into the tube freely 
 it should be gradually added, a gallon sometimes being received 
 without much discomfort. The current may be ten or twelve inilli- 
 amperes in strength all that a common portable 32-cell Mclntosh 
 battery can generate, and the seance can be continued for twenty 
 minutes or half an hour. Powerful tenesmus may attend, but the 
 patient should be instructed to resist this and retain the fluid as long 
 as possible in order to derive the full benefit of the treatment. Its 
 value in many morbid states of the lower bowel and pelvis is not 
 half appreciated. 
 
 DYSENTERY. 
 
 Synoii3*ms Bloody Flux; Recto-Colitis. 
 
 Treatment. A specific and non-specific inflammation of the 
 large intestine, attended by fever, tormina and tenesmus, and charac- 
 terized by frequent evacuations of tenacious mucus mixed with more 
 or less blood. 
 
 Etiologj". Dysentery is divided into non-specific or that form 
 for which a specific cause has not been determined, and specific, 
 tropical or amoebic dysentery, due to the presence of the amcelta 
 coli in the bowel. The drinking of stagnant water is believed to
 
 426 DISEASES OF THE DIGESTIVE ORGANS. 
 
 originate the disease, and epidemics arising during the late summer 
 and early autumn, when the dry season is prevailing, may be due to 
 low, stagnant water from which the drinking supplies are obtained. 
 This is especially liable to be the case, the dysentery being of severe 
 form, when many are congregated together, as in military camps, the 
 disease probably being spread by contamination of the drinking 
 water from neighboring cesspools. Doubtless the same causes pre- 
 vail in a more restricted degree in rural districts, where sanitary 
 provisions do not insure immunity from contamination of this kind. 
 Dr. W. C. Cooper (Eclectic Medical Gleaner) has recently reported 
 that the precaution of boiling the drinking water in an epidemic of 
 the disease where he practiced (in 1896) did not prevent it from 
 spreading to those who confined themselves to the use of that water 
 after the epidemic began; but it is to be recollected that the founda- 
 tion may have been laid for weeks before the disease manifested 
 itself that those who suffered from attacks might have all been con- 
 taminated before the first case became known. The germs of the 
 disease seem to sometimes exist in fruits and vegetables, especially 
 unripe fruits, or there must be a variety which may arise from fer- 
 mentation and local irritation, outside of any specific microbic cause, 
 from eating unripe fruits and such vegetables as cucumbers, as 
 attacks often follow so soon upon the eating of such articles as to 
 render it obvious that their use has direct connection with the mal- 
 ady. After an attack of dysentery one is apt to suffer regularly at 
 the same season year after year, unless successfully treated early for 
 one or two seasons. Sudden arrest of the cutaneous secretion may 
 precipitate an attack of dysentery, especially during the heated term. 
 Antihygienic surroundings other than those already mentioned, such 
 as foul air, depressing agencies, malarial influences and acute febrile 
 attacks, seem to predispose to it. 
 
 Pathology. In follicular dysentery the membrane of the lower 
 colon and rectum becomes congested, swollen and reddened, the red- 
 ness varying in intensity in different portions of its surface from a 
 bright-red color to a dusky or purplish hue; the entire surface is cov- 
 ered with tenacious mucus, and the follicles are enlarged from serous 
 infiltration and proliferation of the new epithelial elements. As the 
 inflammation progresses destructive action follows, and necrosis may 
 begin in the follicles and small ulcers form. As these spread several 
 may coalesce to form irregular ragged ulcers, and in severe cases 
 these may undermine the mucous membrane and penetrate the sub- 
 mucous and muscular coats. Complete perforation of the peritotfeal 
 coat occurs in rare instances. In epidemics of typhoid dysentery 
 there is apt to be marked necrotic tendency about the affected tis- 
 sues, and the destructive action is much more extensive than in spo-
 
 DISEASES OF THE INTESTINES. 427 
 
 radio cases. The pathological changes in amoebic dysenterv are also 
 liable to be of serious character. 
 
 Diphtheritic dysentery sometimes occurs, when the ulcers arise 
 independently from the follicles and are more extensive and destruc- 
 tive. The ulcers are covered with a yellowish, fibrinous exudation, 
 the longitudinal axis corresponding to the fold of mucous membrane 
 between the pouches, and the first layer is penetrated and the sub- 
 mucous coat infiltrated with pus. Serious undermining of the mem- 
 brane is apt to occur in this form, it being more destructive than fol- 
 licular dyesentery. Sometimes tubular casts of a considerable por- 
 tion of the colon may be formed by the pseudo-membrane. 
 
 In amoebic dysentery the amoebi are found in the bottoms of the 
 ulcers and in the neighboring bloodvessels and lymph-channels. 
 Purulency is not marked in this form, and destructive local action is 
 not so liable to prove serious as secondary abscesses, which develop 
 in the liver, apparently from the transmission of the amoeba coli 
 through the portal capillaries. Abscess of the liver occurs in about 
 one-iifth of all cases of tropical dysentery. 
 
 Symptoms. The location of the inflammatory action deter- 
 mines, considerably, the character of the symptoms. In a large 
 majority of all the cases the lower part of the colon and the rectum 
 are principally involved, and the symptoms are more local than con- 
 stitutional, while, if the upper colon is exclusively involved, as is 
 sometimes the case, there are few local symptoms, while such consti- 
 tutional manifestations as chill and febrile action are marked. 
 
 In that form which affects the lower portion of the large gut tor- 
 mina and teuesmus are frequent and urgent symptoms, the periods 
 of tenesmus being attended by the evacuation of a tenacious, glairy 
 mucus resembling the white of an ego; in appearance and consistency, 
 and being more or less tinged with blood. The blood varies in 
 quantity, sometimes being mere streaks of pink color in the clear 
 mucus, and in other cases constituting the principal portion of the 
 stool. The tenesmus is sometimes so severe as to cause extreme 
 suffering, the patient remaining constantly on the stool or bed-pan, 
 straining, as though there were a foreign body in the rectum to be 
 evacuated, and returning almost immediately after leaving it, in 
 response to the intense dragging sensation in the rectum. The tor- 
 mina or griping is usually correspondingly severe, the pain ranging 
 along the course of the colon, but being most common along the trans- 
 verse colon just above the umbilicus. The rectum is usually the 
 seat of severe burning pain, arid the rectal mucous membrane is sen- 
 sitive to the touch of the finger, a rectal speculum or the tube of a 
 syringe. Sometimes, especially in children, there is complete pro- 
 lapse of the rectum during the tenesmus, and the anus in most cases
 
 428 DISEASES OF THE DIGESTIVE ORGANS. 
 
 presents a purplish, swollen, ecchymotic appearance. The bladder 
 and urethra sympathize, and the rectal evacuation may be accom- 
 panied by the passage of a few drops of scalding urine accompanied 
 by vesical tenesmus. Fecal material may appear among the mucus 
 during the first evacuations, and often the disease begins with a fec- 
 ulent diarrhoea; but soon there is constipation, the evacuations being 
 limited to blood and mucus at first, with muco-purulent passages at 
 a later stage of the disease. There may be from ten to two hun- 
 dred evacuations in twenty-four hours. 
 
 There are more or less constitutional symptoms which attend, 
 and sometimes precede, the local disturbance. Sometimes there is 
 loss of appetite, furred tongue, nausea, headache, dry skin and alter- 
 nating diarrhoea and constipation for several days prior to the devel- 
 opment of the disease proper. As the dysentery becomes developed 
 the temperatures rises to 102 or 103 F., and it may rise as high as 
 105. If the upper portion of the colon is exclusively involved the 
 disease may be ushered in with a marked chill, though when the re- 
 gion of the rectum is principally involved this is rare. Typhoid 
 symptoms are common in epidemic dysentery, and the patient be- 
 comes delirious, the delirium usually being of the muttering, somno- 
 lent variety, the evacuations being dark, resembling prune juice in 
 appearance, often containing shreds of broken down mucous mem- 
 brane, and emitting a cadaverous odor. The tongue becomes brown 
 and dry, the patient dozes with the mouth open, the pulse becomes 
 feeble and rapid, the respiration hurried, the eyes appear sunken, 
 and serious prospects seem to be in store. 
 
 Other varieties of evacuations than those already described are the 
 large, watery, feculent stools which occur, without pain or tenesmus, 
 when the dysentery is confined to the upper colon; and the masses of 
 mushy, boiled-sage material which are frequently observed, and 
 which consist of semi-digested starch granules which have passed 
 the alimentary canal without complete disintregatioii. The stools 
 of amoeboid dysentery may sometimes consist of bloody mucus, but 
 they are most commonly fluid of a yellowish-gray color, in which 
 are the actively moving amoebae. There is less tormina and teues- 
 rnus than in catarrhal dysentery, and hepatic complication is more 
 common. 
 
 Malarial complication is common in malarious districts, the tor- 
 mina and frequency of the evacuations being regularly better aud 
 worse at stated periods of the twenty-four hours, corresponding to 
 the exacerbations and remissions of a malarial fever. 
 
 Scrobutic dysentery is a complication of dysenteric inflammation 
 with the ordinary symptoms of scurvy. In this form profuse hemor-
 
 DISEASES OF THE INTESTINES. 429 
 
 rhages are common, and fatal results are extremely liable to occur 
 within a few days after the onset. 
 
 Diagnosis. There is little danger of confounding dysentery 
 with acute proctitis, as there is scant evacuation in that disease, no 
 elevation of temperature, and little disturbance of digestion. The 
 long-continued intestinal obstruction and general marasmus would 
 distinguish rectal cancer. In diarrhoea complicated with hemor- 
 rhoids there might be rectal tenesmus and colicky pains, but there 
 would be an absence of febrile symptoms, and an examination would 
 detect the exciting cause of the tenesmus in the hamorrhoidal 
 tumors. 
 
 Prognosis. Catarrhal dysentery of non-malignant type is usu- 
 ally a disease of favorable prospects unless bunglingly treated or the 
 patient has advanced far in years. Epidemics of dysentery are some- 
 times malignant in character, and the prognosis should be guarded, 
 especially in elderly persons. 
 
 Diphtheritic dysentery is a much more severe form of the disease 
 than catarrhal dysentery, and fatal results are more common, especi- 
 ally when malignant. Amoebic dysentery always carries with it 
 the suggestion of possible hepatic abscess, with future doubtful 
 contingencies. 
 
 Treatment. The treatment of dysentery will vary, according 
 to the demands of individual cases. Many mild sporadic cases may 
 be aborted by the use of cathartic doses of podophyllin. Half a grain 
 may be administered to an adult at a dose, and repeated every three 
 or four hours until its cathartic action is manifested. When this 
 passes off the disease will, in favorable cases, have been arrested. 
 Broken doses of sulphate of magnesium answer a similar purpose. In 
 all cases of sporadic dysentery where constipation exists, it is a good 
 plan to precede other treatment with the use of a cathartic. 
 
 In epidemics, however, this treatment will fail, and often there 
 will be aggravation from it. We must then rely upon remedies, 
 which act more slowly, but which conserve normal processes and 
 tend to restore structure. Opiates and astringents are worse than 
 no treatment at all, as they only temporarily palliate the pain and 
 lessen the discharges, while the opiates finally aggravate the cousti- 
 tional difficulty by arresting secretion, and the astringents increase 
 the local inflammation. The pain will be controlled better, in the 
 majority of cases, by minute doses of colocynth or dioscorfn, and the 
 local inflammation will be benefited at the same time. A combina- 
 tion of one of these with aconite is usually valuable, as the aconite 
 controls the febrile action to a considerable extent and at the same 
 time specifically soothes the intestinal mucous membrane. Ipecac is 
 also a valuable remedy here, it being probably the most generally
 
 430 DISEASES OF THE DIGESTIVE ORGANS. 
 
 applicable agent we possess in intestinal irritation of this character. 
 As a general proposition then we will prescribe in ordinary cases the 
 following combination: # Specific aconite gtt. vii-x, specific colo- 
 cynth gtt. i-ii, specific ipecac gtt. x-xv, water fiv. M., and order a 
 teaspoonful every hour. In all cases the patient must be enjoined 
 to maintain the recumbent posture, using the bed-pan and avoiding 
 straining, as aggravation is almost certain to follow unless these 
 injunctions are observed. 
 
 Sometimes colocynth will answer alone, especially if the tormina 
 is the leading feature of the case and there is much blood evacuated. 
 Sometimes the tongue is pointed and reddened at the tip and there 
 is constant nausea and restlessness. Here we will expect good 
 results from a combination of aconite and rlius tox., especially when 
 the nervous disturbance amounts to delirium. Twenty drops of spe- 
 cific rhus tox to ten of aconite in four ounces of water, teaspoonful 
 at a dose, will be appropriate proportions. Typhoid dysentery may 
 demand the use of echinacea, especially where there is evidence of 
 extensive destruction of the intestinal mucous membrane as suggested 
 by prune-juice discharges or shreddy material in the stools with 
 cadaveric odor. The dirty pasty coating on the tongue may demand 
 sulphite of sodium, the brown coating may call for sulphurous acid, and 
 the beefy tongue may call for muriatic acid. Baptisia may be substi- 
 tuted advantageously for echinacea at times probably, the specific 
 indications recognized for it by many being the prune-juice character 
 of the intestinal discharges. Excessive hemorrhage may suggest the 
 need of rhus aromatica, and persistent ulceration, as indicated by the 
 presence of pus in the stools, may require the use of attenuations of 
 mercurius corrosivus. .The rectal injection of laudanum constitutes 
 an old-fashioned measure which had better be avoided, as narcosis 
 and other unpleasant results follow, while no curative action can be 
 expected from it. 
 
 The use of hydrozone, both as enemata and internally, is highly 
 recommended in dysentery. A drachm of Marchand's hydrozone 
 may be added to four ounces of sterilized water and two closes made 
 of it, one being taken in the morning and the other in the evening. 
 Where it seems necessary to disinfect the lower bowel it may be used 
 as an enema, the patient lying on the right side to facilitate its pass- 
 age into the intestine. High injections of large quantities of the 
 same strength may be used for similar purposes. It destroys accum- 
 ulated mucus and disease-germs, thus arresting suppuration and fer- 
 mentation, and does not interfere with other means. 
 
 Periodicity in dysentery should be recognized, and proper anti- 
 periodic treatment be combined with the measures recommended for 
 the control of the dysenteric symptoms.
 
 DISEASES OF THE INTESTINES. 431 
 
 The diet should be carefully regulated. Horlick's malted milk 
 will supply every purpose when it can be taken without objection 
 from the patient. Scraped raw beef is preferred by some and may 
 be allowed once a day where desired, and plain milk, boiled and 
 diluted with lime-water to prevent hard curds is excellent. Some 
 allow the albumen of raw egg, beaten in sherry wine. Starchy food 
 should not be given, as the digestion of starch seems to be interfered 
 with during the disease. The quantity of food allowed should be 
 very small at one time, and no cold food should be taken, the 
 drinks also consisting of warm mint tea and other bland decoctions 
 or infusions administered warm. Keturn to solid food should be 
 gradual, and fruits should be taken with caution for a time and only 
 after having been cooked. 
 
 CHOLERA MOBBUS. 
 
 Synonyms. Cholera Nostras; Sporadic Cholera; English 
 Cholera. 
 
 Definition. An emetoi-catharsis, characterized by simultane- 
 ous vomiting and purging of watery material, with intense thirst, 
 pain in the abdomen and legs, coldness in the extremities and 
 prostration. 
 
 Etiology. Cholera morbus is a disease of hot weather, and is 
 usually due to some disturbance of the digestive processes from the 
 eating of unripe or over-ripe fruits or vegetables in season at such 
 times, though indigestible food may excite it in susceptible persons 
 at any time of the year. Sudden checking of perspiration by expos- 
 ure to draughts while heated, or by drinking iced liquids, may bring 
 it on, and contaminated drinking water doubtless causes it, hot, dry 
 weather being the time when the source of water supply is most apt 
 to suffer from stagnation. Sometimes the disease seems to assume 
 epidemic proportions, though it is usually sporadic. Males are 
 more frequently affected than females, and extreme old age provides 
 considerable exemption. 
 
 Pathology. This varies considerably, there sometimes being 
 no ocular evidence of structural change or vascular disturbance, 
 while again evidence of acute enteritis may be present. Cerebral 
 anaemia is sometimes found upon autopsy, and effusion into the ven- 
 tricles may attend. Few opportunities of autopsy have been afforded, 
 as the disease is seldom fatal, and little study therefore has been 
 made of post-mortem appearances. As the disease is of short dura- 
 tion, what changes take place are liable to be largely vascular. 
 
 Symptoms. The attack usually comes on at night, and is an- 
 nounced bv vomiting and purging, this sometimes being preceded by
 
 432 DISEASES OF THE DIGESTIVE ORGANS. 
 
 several hours of premonitory symptoms, such as nausea, headache 
 and vague abdominal distress. The vomiting is violent and pro- 
 jectile, and comes on suddenly and without premonition, and the 
 retching is often accompanied by simultaneous gushes of serous diar- 
 rhoaa of acid or bilious character. Though the patient is thirsty and 
 drinka greedily the fluid is immediately rejected, and solid food is 
 also vomited as soon as swallowed. Gushing evacuations from the 
 bowels follow one another in quick succession, the evacuations being 
 watery and of a mouse-like odor. The evacuations are sometimes 
 large and light colored, and at others small and dark in appearance. 
 Abdominal pain accompanies and precedes the evacuations and vom- 
 iting, and, in severe cases, cramps in the lower extremities, especially 
 in the calves of the legs and feet, attend. The urinary discharge 
 becomes arrested, this probably being due to excessive drainage 
 through the bowels, though albumin and desquamated epithelium 
 may be found in the renal secretion. Prostration may become 
 marked, and it may seem as though a speedily fatal termination 
 might be imminent, but after a few hours the symptoms suddenly 
 and spontaneously abate and the patient recovers without interrup- 
 tion, being apparently as well as usual in a day or two. In some 
 cases, however, the pulse becomes feeble and flickering, the respira- 
 tion and voice feeble and the surface icy cold, and the patient passes 
 into a stage of collapse and dies, the mind being clear throughout. 
 Febrile symptoms are absent, except when pyrexial action attends a 
 sh< rt period of convalesence,this sometimes occurring, the symptoms 
 being mildly typhoid in character, the condition being termed the 
 reactionary fever. The stools usually become normal within a day 
 after the attack. 
 
 Diagnosis. There is little danger of confounding this disease 
 with anything except Asiatic cholera, and this would occur only 
 when Asiatic cholera was prevailing as an epidemic. In Asiatic 
 cholera it is to be remembered that there is no fecal odor to the 
 stools, which are rice-water in appearance from the commencement, 
 while in cholera morbus the stools are at first fecal. Irritative 
 poisoning may present us with symptoms similar to those of chol- 
 era morbus, but the history of the case will probably afford light on 
 the subject; the mouth and pharynx are liable to be hypersemic, and 
 the evacuations will contain more or less blood, a condition never 
 found in cholera morbus. Analysis of the vomited material may 
 decide the question, through detection of the presence of corrosive 
 drugs. 
 
 Prognosis. Cholera morbus is seldom fatal. Though a severe 
 disease it is likely to terminate spontaneously is a few hours; though 
 treatment will usually arrest it promptly and prevent a very unpleas-
 
 DISEASES OF THE INTESTINES. 433 
 
 ant experience for the patient. Elderly persons are the ones in 
 whom there is the most danger of serious results, and if collapse or 
 the algid state should be developed the danger is imminent. The 
 prevalence of an epidemic of intestinal disease coincident with an 
 attack increases its gravity. 
 
 Treatment. The treatment of cholera morbus is simple and 
 effective. As soon as the stomach and bowels are ridden of irritat- 
 iug food and fecal material, and even before, the following prescrip- 
 tion may be administered in teaspoonful doses every fifteen minutes, 
 until the vomiting and purging cease: R Specific rhus tox. gtt. xv, 
 Lloyd's aconite gtt. x, sterilized water fiv. Mix. 
 
 The following prescription may be useful to destroy fermentative 
 products and cleanse the alimentary canal of irritating material: 
 R Marchand's hydrozone 31, sterilized water fii. Mix, and admin- 
 ister at a single dose. 
 
 Heating and stimulating applications to the extremities may be 
 required when there is great coldness of the surface with other 
 symptoms of collapse, and in malarial districts recovery from the 
 active symptoms should be followed by the administration of fif- 
 teen-drop doses of the green-plant tincture of grindelia squarrosa, 
 repeated three or four times daily and continued for a week or more. 
 
 CANCER OF THE INTESTINE. 
 
 PRIMARY cancer of the intestine occurs in from four to eight 
 per cent of all cases of cancer, the colon being most frequently in- 
 volved, the rectum being the next most common seat of location, then 
 the anus, caecum and sigmoid flexure. The duodenum and jeju- 
 num, finally, are involved, coming last in order of frequency. 
 
 Etiology. Intestinal cancer seldom arises before middle age, 
 though it occasionally occurs before thirty. Its usual subjects are 
 between forty and sixty, both sexes being liable to it, though it 
 is stated that rectal caucar is more common among males than 
 females. It is impossible to ascribe a specific etiological factor, 
 long-continued irritation probably predisposing to it. Thus, a per- 
 son who has long been the subject of rectal ulceration, hemor- 
 rhoids, pockets or papillae is more liable to finally develop rectal 
 cancer than one who has been previously without irritation there. 
 The sigmoid flexure and caecum, on account of peculiar location 
 and shape, are certainly more subject to irritation from fecal move- 
 ment than some other parts of the intestinal canal. Without doubt 
 the pernicious habit of administering cholagogues, which has been 
 in vogue so long, has something to do, occasionally, at least, with 
 
 29
 
 434 DISEASES OF THE DIGESTIVE ORGANS. 
 
 the occurrence of cancer of the upper portion of the intestinal 
 canal. 
 
 Pathology. The growth commonly arises in the mucous mem- 
 brane and develops in the submucous tissues, the infiltration ex- 
 tending around the intestine and forming a baud of constriction, 
 which narrows, more or less, the calibre of the gut. The cou- 
 stricting band may vary from an inch to three or four inches iu 
 width, the intestinal wall becoming infiltrated and indurated about 
 the narrowed portion. In some cases there may be projections 
 of ragged masses into the bowel, especially about the rectum, and 
 fungous growths may project from the anus. Prior to ulceration, 
 scirrhous cancer presents a firm, smooth, nodulated appearance; en- 
 cephaloid, a soft, vascular aspect, without much tendency to ulcer- 
 ate or obstruct the bowel. When ulceration occurs, scirrhous is 
 marked by smooth ulcerations with hard, deep edges, and encepha- 
 loid by fungoid masses which spring up over the ulcerated surface, 
 interspersed with nodulated and lobulated tumors. In many cases 
 scirrhous and encephaloid may be mingled in the 
 same growth. Secondary cancer is apt to arise in 
 neighboring organs, and the rapid growth of these 
 may obscure the symptoms of the primary tumor. 
 The liver is a favorite location for secondary carci- 
 nomatous development, and when this occurs the in- 
 testinal disease may come to nearly a standstill, the 
 concentration of pathological energy seeming to be 
 transposed to the seat of secondary growth. Stric- 
 ture of the intestine is a common condition in scir- 
 rhus, and distension of the bowel above this point 
 from impacted feces usually attends. Catarrh of the intestinal 
 mucous membrane in the neighborhood of the cancer is common. 
 Rapid infiltration of the mesentery and neighboring organs may 
 bind the affected part to surrounding tissues, dragging and confining 
 various parts in a firm mat; perforation may ensue from rapid ulcer- 
 ation; fistulse are sometimes formed between the neighboring vis- 
 cera; hemorrhage may arise from destruction of branches of intestinal 
 arteries, and various other sequelae and complications may arise from 
 the extension of the cancerous growth to new localities. 
 
 Symptoms. The symptoms may best be described by dealing 
 with various portions of the intestine separately. 
 
 Duodenal &ndjejunal cancer are marked by symptoms similar to 
 those of cancer in the pylorus. There is often vomiting, though 
 it comes on several hours after eating. The ejected material is cof- 
 fee-ground in appearance, there is a movable, pulsating tumor in 
 the epigastrium resembling that of pyloric cancer to the touch, and
 
 DISEASES OF THE INTESTINES. 435 
 
 there is cancerous cachexia with or without marked icteric symp- 
 toms, due to obstruction in the biliary duct. Hemorrhages mav 
 occur and haematemesis or melaena follow, though the bleeding is 
 rarely profuse. 
 
 Cancer of the caecum is signalized by pain in the region of the 
 caecum, with the presence of a prominent tumor, consisting of accu- 
 mulated feces and cancerous growth, the local symptoms being 
 accompanied by debility, waxy color and other constitutional evi- 
 dences of cancer. Manipulation may assist the retarded feces past 
 the point of obstruction and lessen the size of the tumor, but the 
 cancerous deposit is still perceptible on palpation. The obstruc- 
 tion is progressive, and permanent impaction of feces finally ensues. 
 Tympauitic dullness is elicited by percussion over the tumor. 
 
 Rectal cancer and cancer of the sigmoid flexure present symptoms 
 so much in common that differentiation is not easy. Constipation, 
 due to stricture, is usually the first cause of complaint, the bowels 
 moving with difficulty, the faeces being thin and ribbon-like, the 
 evacuations attended by severe burning pain and tenesmus. The 
 pain is often most severe in the sacral region, and from here it radi- 
 ates along the sciatic nerves into the lower extremities. This is 
 darting in character, and may be so intense as to render existence 
 miserable. In some cases instead of constipation there may be an 
 irregular diarrhoea, signalized by the passage of faecal material mixed 
 with mucus, pus and blood, the evacuations being attended by 
 severe tenesmus and pain. Fistulae may be established into the 
 bladder, vagina or urethra, and liquid faeces may escape through 
 these channels. As the sphincter becomes involved it loses its 
 function, and liquid faeces and cancerous products dribble through 
 to excoriate the parts and render the surroundings offensive. On 
 examination the affected part will usually be found to be obstructed 
 by a firm, fibrous band, through which it may be difficult to pass 
 even a small gum-elastic bougie, on account of the rigid and tortuous 
 character of the passage. However, sometimes the rectal walls are 
 relaxed and dilated. In epithelioma of the rectum there may not 
 be much obstruction for a long time after its first development, pain, 
 cachexia and obstruction coming on only at a late period. Obstruc- 
 tion of the colon is indicated by distension of the organ, with hard- 
 ened faeces, its course being traceable under the fingers through the 
 attenuated abdominal walls. Wh^n the sigmoid flexure or upper 
 portion of the colon is the seat of infiltration, the pain may be 
 located in the left iliac fossa and loins much of the time, and when 
 in the rectum in the upper part of the thighs, testes and loins. 
 
 In most cases of intestinal cancer cachexia develops early. The 
 patient rapidly loses flesh and strength, there is occasional vomiting,
 
 436 DISEASES OF THE DIGESTIVE ORGANS. 
 
 and constipation is soon marked, though cancer high up in the 
 colon may be attended by diarrhoea. The skin assumes a dirty 
 greenish or waxy pallor and becomes dry, harsh and leathery, 
 remaining wrinkled for several seconds when pinched into rolls; the 
 hair is dry and brittle and the pulse small and feeble. Emaciation 
 progresses swiftly, death from exhaustion being a frequent cause 
 of fatal termination. Profuse hemorrhage is rare in any form of 
 intestinal cancer. 
 
 Diagnosis. The unmistakable symptoms of intestinal cancer 
 are pain, cachexia, constipation and the presence of a tumor within 
 the abdominal cavity; though intestinal cancer may run its course 
 without the detectable tumor. Duodenal cancer is so closely asso- 
 ciated with the pylorus and pancreas that confusion may arise as 
 to identity. The character and time of occurrence of vomiting after 
 meals and the fact that the tumor is more movable than that of 
 pyloric or pancreatic tumor will serve some diagnostic purpose. The 
 pancreas is more deeply seated and less movable, and vomiting is 
 not so liable to occur when it is cancerous. A pulsating duodenal 
 cancer may be distinguished from aneurism of the abdominal aorta 
 by the fact that the abdominal aneurism will transmit its disturb- 
 ance to the femoral artery, while the pulsations of that vessel 
 remain undisturbed in duodenal cancer. In cancer of the small in- 
 testine the tumor may be more or less displaced by adhesions and 
 contracting bands, assisted by the weight of the tumor, and this 
 is also true of the transverse colon; but the caecum, sigmoid flexure 
 and ascending colon are firmly fixed and not so liable to be misplaced. 
 In rectal cancer, after the ulceration has begun, the peculiar foetid 
 odor of the discharge is important in making a diagnosis. 
 
 Prognosis. The prognosis is invariably unfavorable, the patient 
 succumbing within from eighteen months to four years, depending 
 on the amount of cachexia and intestinal obstruction. Where sur- 
 gical measures are adopted early in rectal cancer life may sometimes 
 be prolonged. 
 
 Treatment. Where duodenal cancer occasions pyloric obstruc- 
 tion benefit may be derived by the use of hydrozone to cleanse the 
 stomach of mucus and other accumulation, and this may be followed 
 by lavage. In any event the use of hydrozone provides for the 
 destruction of purulent accumulation in the intestine and removes 
 accumulated mucus occasioned by the catarahal condition of the 
 neighboring mucous membrane. Bovinine supports the strength and 
 lessens the pain, though echinacea is the most promising agent we 
 possess for the purposes of alleviating the pain of cancer (ten or fif- 
 teen drops of a prime preparation every three or four hours). 
 Chelidonium promises much toward a radical cure early; ten drops
 
 DISEASES OF THE INTESTINES. 437 
 
 of the homeopathic tincture or specific medicine four times daily. 
 Where the rectum is the part affected an operation for the removal 
 of the cancerous mass may be undertaken early when the growth is 
 low, and obstruction, in cases in which this seems inexpedient, may 
 be counteracted through the establishment of an artificial anus by 
 colotomy. 
 
 The patient should remain quietly in bed to insure a minimum 
 amount of peristalsis, and the food should be liqu d in form and con- 
 centrated in quality. 
 
 INTESTINAL OBSTRUCTION. 
 
 Definition. A mechanical impediment to the onward move- 
 ment of the intestinal contents from compression, twisting, invag- 
 ination of the bowel, or from the presence of foreign bodies in 
 the passage. 
 
 Etiology and Pathology. Internal strangulation of the in- 
 testine is the cause of at least a third of the cases of intestinal 
 obstruction which occur in adults. Adhesive bands connecting 
 portions of the intestine to the abdominal wall may form loops, into 
 which a section of the intestine may enter and finally become strang- 
 ulated, Meckel's diverticulum may adhere to the abdominal wall 
 to form a loop of this character, and such nooses frequently result 
 from abdominal section, a portion of the bowel remaining adher- 
 ent to the abdominal wound, or the pedicle of a tumor serving to aid 
 in forming an entangling loop. Other openings, such as the fora- 
 men of Winslow, or accidental perforations in the mesentery 
 or omentum, may afford opportunities for strangulation. 
 This accident is most likely to occur to the small intestine. 
 A more frequent cause among children is intussusception or 
 invagiuation of the intestine, the bowel being telescoped from 
 above downward, so that from an inch to a foot of the gut is 
 incased within the same length below. The ileo-caecal valve 
 i g mos ^ commonly telescoped into the colon, though the acci- 
 Ttcs ' dent may occur to any portion of the bowel, the condition 
 being due to irregular peristaltic action. As in strangulation the 
 part soon becomes congested and swollen, and peritoneal exudation 
 agglutinates the invaginated part so completely that reduction be- 
 comes impossible, the inner section sometimes separating and being 
 discharged per rectum. Necrosis and sloughing of the entire affected 
 part is the most probable termination. This accident is more com- 
 mon among males than females, and more than fifty per cent of the 
 cases are among children. 
 
 Volvulus, or twisting of the bowel upon itself, is an occasional
 
 438 DISEASES OF THE DIGESTIVE ORGANS. 
 
 cause of intestinal obstruction. This accident is most liable to 
 occur about the sigmoid flexure, a relaxed state of the mesentery 
 favoring such circumstance, and half a turn being sufficient to cause 
 obstruction. Sometimes two coils of intestine unite to form a knot, 
 which becomes fixed and permanently agglutinated. In old persons 
 shrinking of the mesentery may give rise to twisting of the sigmoid 
 flexure, and resultant obstruction. 
 
 Foreign bodies in the intestine sometimes become permanently 
 lodged and so impacted as to cause serious obstruction. False teeth 
 (accidentally, or purposely swallowed by the insane) may cause fatal 
 obstruction, the ileo-caecal valve being the point which offers the 
 most resistance. Sometimes buttons, nickels and other coins are 
 swallowed by children and cause blocking of the intestinal passage, 
 though such accidents in children are singularly free from serious 
 results, the foreign material most commonly appearing in the stools 
 after a safe passage through the gut. Large gall-stones some- 
 times block the passage and give rise to serious obstruction. Some 
 drugs, as bismuth, magnesia and other powders, may combine with 
 faecal material and form firm masses, which produce obstruction. 
 
 Stricture of the bowel from cancerous infiltration has already 
 been referred to. Pressure from tumors, as well as stricture from 
 chronic conditions, is progressive and gradual in character, and the 
 pathological changes are slow in developing and the symptoms 
 are not at first urgent, as in strangulation, intussusception and 
 volvulus. 
 
 Symptoms. Sudden obstruction of the bowel usually occurs 
 while the patient is walking about, and is announced by severe col- 
 icky pain, which is localized and intermittent. As the pain con- 
 tinues it becomes more steady in character and increases in severity 
 in its original location, while it is soon more or less diffused 
 throughout the abdomen. Vomiting soon begins and becomes con- 
 stant and distressing, the vomited material first consisting of the 
 contents of the stomach, then of bile and mucus, and later of sterco- 
 raceous material. Obstinate hiccough arises after the vomiting has 
 continued for a time, and the vomiting may finally cease entirely to 
 be replaced by hiccough, which continues until a fatal termination. 
 Stercoraceous material is vomited only when the obstruction arises 
 below the upper third of the ileum. An intestinal evacuation may 
 occur immediately after the obstruction arises, the operation 
 emptying the bowel below the point of obstruction, but constipa- 
 tion afterward attends, all efforts to produce an evacuation prov- 
 ing futile. Tenesmus may arise when the obstruction is low in the 
 alimentary canal, and blood and mucus may be discharged when 
 there is invagination. Tympanites suggests the location of the
 
 DISEASES OF THE INTESTINES. 439 
 
 obstruction low in the alimentary canal. There is little pain on 
 pressure at first, but later the entire abdominal surface becomes 
 intensely sensitive. 
 
 The face presents an anxious, pallid appearance, the surface and 
 extremities are cold, the patient lies on his back with the lower limbs 
 drawn up to avoid strain upon the abdominal muscles and carefully 
 jivoids motion for fear of exciting vomiting and abdominal pain. 
 Enteritis of violent character attends volvulus. The mind is clear 
 to the last. 
 
 Diagnosis. In diagnosing intestinal obstruction it is to be 
 recollected that intussusception is most liable to occur in children, and 
 when a child who has been previously well is seized with sudden and 
 severe pain followed by vomiting and constipation succeeded by dis- 
 charges of bloody mucus with tenesmus, the pain and vomiting being 
 urgent and persistent, there are good grounds for suspecting intes- 
 tinal obstruction of this character. If, in addition to these symptoms, 
 a sausage-shaped tumor appears in the region of the ascending or 
 transverse colon within a day or two, the diagnosis is still more clear. 
 In this form faecal vomiting is not so common as in some other varie- 
 ties of intestinal obstruction. 
 
 Sudden attacks of similar character in adults with paroxysmal 
 pain at a fixed point, attended by faecal vomiting and rapidly devel- 
 oping tympanites with constipation, will point decidedly to internal 
 strangulation. A history of prior injury, surgical operation or peri- 
 tonitis, suggesting the presence of adhesions forming entangling 
 loops, will assist in a rational conclusion as to condition. The pres- 
 ence of a tumor is not to be expected here and, though constipation 
 is absolute, there will not be tenesmus or bloody discharges. 
 
 Volvulus is more obscure in character, though if the sigmoid flex- 
 ure is involved it may be suspected by the pain in that vicinity, the 
 marked tenesmus, and mucus and bloody evacuations during the 
 advanced stage. 
 
 Obstruction by foreign bodies is liable to afford a history of the 
 swallowing of some indigestible, bulky article, and the lodgment is 
 most liable to be made at the ilio-caecal valve. In faecal impaction 
 there is a firm, hard tumor in the csecal region, without vomiting 
 until at a late period, with prior history of constipation. Peritonitis 
 is attended by rise in temperature, while in intestinal obstruction 
 the temperature is not elevated, and is likely to "be subnormal. 
 Vomiting is not so liable to attend peritonitis as obstruction, and 
 in peritonitis there is marked abdominal tenderness early. In 
 hepatic colic the pain radiates from the right hypochondriac region, 
 the patient is jaundiced, and there are clay-colored stools with con- 
 stipation but not obstruction, and the urine contains bile. There is
 
 440 DISEASES OF THE DIGESTIVE ORGANS. 
 
 no faecal vomiting here and no tympanites. In renal colic the pain radi- 
 ates from the lumbar region along the ureters to the penis and 
 testes, and there is no interruption to normal intestinal evacuation. 
 A concealed inguinal or femoral hernia may be mistaken for intes- 
 tinal strangulation, unless a careful examination of the suspected 
 rupture be made. 
 
 Prognosis. This will vary, according to the acuteness of the 
 attack. Chronic obstruction in the adult may exist for many weeks 
 before fatal termination ends the scene, while intussusception of the 
 bowel in a weakly child may cause death within a few hours. Vol- 
 vulus and internal strangulation are more rapidly fatal than intus- 
 susception, and obstruction by large gall-stoues and enteroliths is 
 more rapidly fatal than stricture, compression or intussusception. 
 There is possibility that sloughing may occur in intussusception 
 and the lower portion of the invaginated bowel be cast off, with 
 union of the remainder with the regular course of the alimentery 
 canal, with recovery, and there is a possibility that it may be 
 reduced to its normal position if effort be made in the right direction 
 before the parts become agglutinated. On the whole, however, the 
 prognosis is almost invariably unfavorable to recovery. 
 
 Such complications as enteritis, peritonitis, perforation, ulcera- 
 tion, gangrene, septicaemia, fistula and phlebitis are among the 
 probabilities. 
 
 Treatment. Under no circumstances is attempt to force a faecal 
 evacuation by catharsis advisable. If there be simply faecal accumu- 
 lation the proper use of enemata assisted by the salt-water rectal 
 electrode will more assuredly remove the impaction than the action 
 of cathartics, and its use is permissible when there is actual obstruc- 
 tion. This measure should be tried with both galvanism and farad- 
 ism, if necessary, the faradic current increasing inverted peristaltic 
 action and thus favoring the relief of volvulus and invagination. A 
 strong decoction of cimicifuga root is relaxing and quieting to the 
 intestines, and should be given in wine-glassful doses every hour for 
 a few hours where obstruction is suspected. Inversion of the patient, 
 the body being elevated by the heels to nearly the upright position 
 aud maintained there for a time, is highly recommended in intussus- 
 ception and volvulus, and in this position copious enemata of warm 
 water should be tried. Air, introduced by attaching a rectal tube to 
 a siphon-bottle of carbonated water, may be forced into the bowel, 
 this sometimes serving to relieve an invagination or volvulus, though 
 there is danger of rupturing the gut by incautious application of the 
 measure. After forty-eight hours adhesions are presumed to have 
 taken place, when attempts to remove the fixation will be fruitless. 
 Opiates early are highly recommended, though with doubtful philos-
 
 DISEASES OF THE INTESTINES. 44i 
 
 ophy; but at a late stage they may be administered freely to allay 
 the pain. Abdominal section is justifiable where the diagnosis is 
 confirmed, and it should not be delayed until the strangulation 
 has gone on to gangrene. 
 
 INTESTINAL HEMORRHAGE. 
 
 Synonyms. Euterorrhagia. 
 
 Etiology. Among the principal causes of intestinal hemorrhage 
 are intestinal ulcers attended by erosion of vessels, and cirrhosis or 
 atrophy of the liver causing obstruction of the portal circulation. 
 Erosion may also be caused by strong drugs, and venous obstruction 
 may arise from pressure by tumors, foreign bodies or hardened 
 faeces. Profuse intestinal hemorrhage may occur from the rupture 
 of an aneurism, and one of the common symptoms of internal hemor- 
 rhoids is profuse bleeding from the bowel. The engorgement due 
 to iuvaginatiou and volvulus is liable to be attended by bloody evacu- 
 ations, as also are severe inflammations of the intestinal mucous 
 membrane, as in dysentery, enteritis and typhoid fever. Embolism 
 of the mesenteric artery may be a cause of intestinal hemorrhage. 
 A number of constitutional diseases may originate bleeding from 
 the bowels. Among these may be mentioned purpura hemorrhag- 
 ica, scorbutus, pernicious anaemia, leukaemia, pseudo-leukaemia, sep- 
 ticaemia, jaundice and phosphorus poisoning. The aged maybe sub- 
 ject to passive intestinal hemorrhage of obscure nature, men being 
 more liable than women. Melaena neonatorum, or hemorrhage in 
 new-born children, may be due to degeneration of the arteries from 
 syphilitic, fatty or amyloid changes, from puerperal infection and 
 from haemophilia. 
 
 Pathology. When examined soon after death the intestinal 
 mucous membrane may be hyperaemic or anaemic, depending upon 
 the amount of blood discharged. The intestine usually contains 
 small clots of grumous blood, and when hemorrhage occurs from 
 the surface of ulcers coagula are generally found adhering to them. 
 When the hemorrhage is due to obstruction of the portal circulation 
 there is usually little change from normal in the appearance of the 
 mucous membrane. 
 
 Symptoms. The constitutional symptoms are those of hemor- 
 rhage in general. There are sensations of faintness, coldness of the 
 surface, ringing in the ears and syncope, with feeble pulse, pallor, 
 and coma which may end in death. Preceding, attending or follow- 
 ing these symptoms, there is an evacuation of blood from the bowels, 
 and this may be attended by pain or other abnormal sensations,
 
 442 DISEASES OF THE DIGESTIVE ORGANS. 
 
 such, for instance, as though warm water was being poured into the 
 abdominal cavity. 
 
 The blood varies in color and consistency as it comes from differ- 
 ent portions of the intestinal tract. That which issues from the 
 walls of the duodenum is black and tarry in appearance and tena- 
 cious in consistency. That from the ileum is usually dark, but it 
 is brighter than that from the duodenum, and returns to its normal 
 color when the clots are dissolved in water. The blood from the 
 large intestine is usually bright-red and fluid. The dark color of 
 the faeces caused by hemorrhage from the duodenum is not to be 
 confounded with the appearance produced by eating huckleberries 
 or taking iron or bismuth. The quantity may vary from a few streaks 
 in the faeces in some cases to an immense quantity sufficient to 
 cause death in a few minutes, the blood piling up in large heaps 
 between the nates and thighs, in some cases of fatal hemorrhage in 
 typhoid fever. 
 
 Diagnosis. The diagnosis is not difficult, the patieut usually 
 finding that ha is bleeding from the anus before other attention is 
 called to it, unless it be in inflammatory conditions of the bowel, 
 where the nurse and physician are expecting and dreading it. The 
 location of the hemorrhage may be pretty definitely ascertained by 
 examination of the blood as soon as it is voided, by the general his- 
 tory of the case, and by considering the physical signs referable to 
 the abdomen. When the blood is bright red in color when voided, 
 careful examination of the rectum under chloroform if necessary 
 should be made to determine whether or not the seat of hemorrhage 
 is within reach of local treatment. 
 
 Profuse hemorrhage during the advanced stage of acute infec- 
 tious fevers, such as typhoid, yellow and malarial fevers, is an 
 unfavorable symptom, though capillary hemorrhage is far less seri- 
 ous in nature than arterial. General enfeeblement of the constitu- 
 tional powers is an unfavorable condition for hemorrhage to occur 
 in, fatal results being much more liable to follow than in the robust. 
 A single large hemorrhage may prove fatal, as also may many slight 
 ones. 
 
 Treatment. The treatment will vary, different conditions 
 demanding appropriate measures. Acute inflammatory conditions, 
 attended by destruction of the mucous membrane, will demand a 
 special class of remedies. For instance, the hemorrhage of acute 
 enteritis will be amenable to ipecac, colocynth, aconite and echinaeea, 
 in minute doses frequently repeated, or rlius aromatica (specific medi- 
 cine gtt. x-xx). That of dysentery, when the symptoms are acute, 
 may be benefited by similar treatment. Ulcerative action in the 
 large intestine attended by hemorrhage may be treated with minute
 
 DISEASES OF THE INTESTINES. 443 
 
 doses of mercurius dulcis, though profuse enterorrhaghia may call 
 for more active astringents, such as a decoction of the fresh erigeron 
 plant taken freely, or ten-drop doses of the oil on sugar, or ergot in 
 appropriate doses. Tannic and gallic acid, in two- or three-grain 
 doses repeated every hour, assist materially in arresting pro/use 
 hemorrhage from the bowels. Sometimes the lesion is in the rec- 
 tum, where the injection of the bleeding point with a hemostatic 
 (1-4 carbolized oil) through a hypodermic syringe will arrest the 
 hemorrhage at once, when internal remedies may prove of little avail. 
 When there is persistent dribbling from capillary hemorrhoids, 
 they should be systematically treated with interstitial injections of 
 diluted carbolic acid (1-4 of olive oil and glycerine, aa.). In urgent 
 cases of rectal hemorrhage euemata of a saturated solution of alum 
 may be retained for their astringent effect until permanent measures 
 succeed. Tamponage may sometimes be resorted to, and scorbutic 
 conditions should be properly met. 
 
 Absolute rest in bed is as important as medicine, tho recumbent 
 position being strenuously insisted upon all evacuations being 
 attended to without assuming the upright position and even turn- 
 ing in bed should be restricted. It may sometimes, in non-inflam- 
 matory conditions, be advisable to restrict peristalsis with opiates, 
 though general adherence to this usage is objectionable. 
 
 The diet should be liquid and nutritious, and it should be admin- 
 istered frequently and in small quantities. Cold applications favor 
 arrest of hemorrhage, and cold drinks and fluid foods are better than 
 warm. In extreme cases ice-bags may be placed upon the abdomen 
 for a limited time. 
 
 TYPHLITIS. 
 
 Definition. Inflammation of the caecum. The terms perityph- 
 litis and paratypTilitis are employed to designate, respectively, in- 
 flammation of the peritoneal covering of the caecum (perityphlitis) 
 and inflammation of the connective tissue surrounding it (paratyph- 
 litis). As these conditions are, however, usually complications of 
 appendicitis they are not employed by the best authors as desigua- 
 tive of separate diseases. Inflammation of the caecum may arise as 
 a complication of appendicitis, but the term is here used to designate 
 inflammation of the part, independent from appendical trouble. 
 
 Etiology. Inpaction of freces is the common cause of typhlitis, 
 the term '-typhlitis stercoralis" often being used to designate the 
 condition. Errors in diet are probably the exciting cause, though 
 repeated attacks may be diie to colds following an established irrita- 
 tion. The disease is most common among young persons, boys
 
 444 DISEASES OF THE DIGESTIVE ORGANS. 
 
 being more frequently affected than girls. It is always associated 
 with constipation. 
 
 Pathology. The anatomical condition has not been determined, 
 as few if any fatal cases occur. 
 
 Symptoms. Pain in the right iliac fossa, with enlargement, 
 the prominence taking the form of a sausage-shaped tumor, loss of 
 appetite and sometimes nausea and vomiting, are the principal symp- 
 toms. There is usually little if any fever, though the temperature 
 may be elevated one or two degrees. The pain and fullness may be 
 accompanied by tenderness on pressure, and there is usually dullness 
 on percussion. The patient lies upon the back, and may flex the 
 right thigh to relieve tension of the abdominal muscles in the affected 
 region. The symptoms are all mild, and gradually subside within 
 three or four days or a week. 
 
 Diagnosis. The diagnosis between this disease and mild cases 
 of catarrhal appendicitis is rather difficult, though the sausage-shaped 
 tumor is regarded by some as a diagnostic feature of typhlitis. 
 Others, however, assert that this symptom occurs as a secondary 
 feature of appendicitis. 
 
 Treatment. Nausea and vomiting may be controlled by 
 minute doses of aconite and rkus fox., and potassium chloride 3x may 
 be administered as a safeguard against plastic exudation. Cold appli- 
 cations may be used over the affected part, though if these are un- 
 pleasant they may be dispensed with, warm or hot applications being 
 carefully avoided. Rectal injections of tepid salt water may be em- 
 ployed to assist normal evacuation and, in stubborn cases, the salt- 
 water electrode with galvanism may be used in the lower bowel. The 
 diet should be liquid in form and sparing in quantity, and the patient 
 should be kept quiet in bed until a regular condition of the bowels 
 has been established and the pain and fullness have subsided. 
 
 APPENDICITIS. 
 
 Definition. Inflammation of the appendix vermiformis. 
 
 Etiology. Appendicitis is most liable to arise in those of early 
 adult life, though it may occur in childhood, even in rare cases dur- 
 ing infancy, while it is exceedingly uncommon in advanced age. It 
 has been estimated by some writers that sixty per cent of all cases 
 occur between the ages of sixteen and thirty. Both sexes are liable 
 to it, statisticians differing as to which is most frequently affected. 
 Foreign bodies, such as grape-seeds, orange-pits and other foreign 
 bodies, are probably often causal factors. Some peculiarity of shape 
 or position possibly contributes to the irritation produced by such 
 agents after lodgment there, but where the condition of the part is
 
 DISEASES OF THE INTESTINES. 445 
 
 normal and there is present no microbic element of disease, the mere 
 presence of foreign bodies cannot be considered an inevitable pre- 
 cursor. Irritation, amounting to abrasion, in such cases, may afford 
 entrance of microbes into the capillaries of the appendix to arouse 
 inflammatory action in which case foreign bodies would certainly 
 be predisposing causes. Adhesions of the appendix to adjacent vis- 
 cera might result in teasing tension, which would finally excite 
 inflammatory action. Many cases arise suddenly after the lifting of 
 heavy weights, and such appendicitis is probably thus brought about. 
 Over-eating is liable to be a provoking cause, especially when im- 
 proper food is taken, this being a frequent cause of the recurrence 
 of the disease after recovery from a first attack. Irritation of the 
 caecal extremity of the appendix may result in gradual closure of the 
 opening until complete obliteration occurs, a hermetically sealed cavity 
 remaining in the appendix, which may contain elements of fermentation 
 or suppuration. 
 
 Pathology. Two forms of acute appendicitis are ' recognized, 
 namely, catarrhal and suppurative. 
 
 In catarrhal appendicitis the mucous membrane is thickened and 
 engorged, and covered with a coating of tenacious mucus, while the 
 
 cavity contains serum and one or more 
 masses of hardened fecal concretion, and 
 is usually narrowed in its lumen, espe- 
 cially at its caecal extremity. The entire 
 organ is enlarged, rigid and club-shaped, 
 with its outer extremity expanded, and the 
 peritoneal covering is congested or coated 
 with fibrinous material and adherent to 
 adjacent peritoneal surfaces. When slit 
 APPENDICITIS. longitudinally the mucous membrane rolls 
 
 b, iieum. outward and the peritoneal covering in- 
 
 ward, a position afterward persistently 
 maintained when not interfered with. 
 
 Suppiirative appendicitis is marked by the presence of serum and 
 pus in the walls of the appendix and upon its outer surface. When 
 the suppurative action is not rapidly destructive, the neighboring 
 peritoneum becomes inflamed and covered with adhesive fibrino-pur- 
 ulent material, which binds the folds together in the form of a sur- 
 rounding wall, and incloses a cavity that becomes distended with pus. 
 Burrowing may now occur and, if the cavity be not drained by proper 
 surgical procedures, purulent material may infiltrate the connective 
 tissue of the mesentery and invade the retroperitoneal tissues, the 
 pus then descending along the psoas or iliac fascia and, appearing 
 externally below Poupart's ligament as an external abscess, burrow
 
 446 DISEASES OF THE DIGESTIVE ORGANS. 
 
 to the peri-nephritic structure, or descend into the pelvis and involve 
 the peri-rectal tissue. In rare cases the pus may penetrate the 
 obturator membrane, pass through the obturator foramen and appinr 
 as a gluteal abscess. In most cases the abpcess is likely to burst 
 into the peritoneal cavity and cause general peritoneal septicaemia; 
 or, without actual rupture, diffuse suppurative peritonitis may occur. 
 The pus may be profuse or limited in quantity, and when the amount 
 is small it may be circumscribed, and if surrounded by a large 
 amount of inflammatory tissue may remain localized, to undergo 
 absorption or other change. When the amount is very small absorp- 
 tion is possible, though rare. 
 
 In other cases there is such rapid and extensive suppuration that 
 sloughing of the appendix occurs, and its necrotic (gangrenous) frag- 
 ments, along with the contents of the cavity, are discharged into the 
 peritoneal cavity before a limiting abscess- wall is formed, and a vir- 
 ulent peritoneal sepsis is set up, which rapidly ends the scene. 
 
 Symptoms. -- The symptoms vary, according to the gravity of 
 the pathological condition. Where catarrhal appendicitis is not 
 severe there is constipation, pain and tenderness in the region of 
 the caecum, nausea and loss of appetite, and where the inflammation 
 is somewhat pronounced there is more or less induration of the 
 abdominal tissues about the caBcal region. Sometimes the symptoms 
 are so slight that the earlier stages pass unnoticed, there being merely 
 slight local pain and tenderness in the right iliac region, In most 
 cases, however, there is an initiatory chill, followed by vomiting and 
 fever. Severe pain usually begins in the right iliac fossa, either 
 steady or of paroxysmal character, and marked tenderness under 
 pressure is found at some localized point in the iliac region, often at 
 McBurney's point, situated on a line with the umbilicus about an 
 inch and a half or two inches from the right anterior spine of the 
 ilium. The temperature varies from 101 to 103 F., and continues 
 elevated for three or four days when, in favorable cases, it slowly 
 declines, the indurati> n gradually passing away, the bowels moving 
 spontaneously and the pain and tenderness disappearing. In severer 
 cases the pain becomes more marked, sharp and diffused, announcing 
 involvement of the peritoneum. The right thigh is drawn up to 
 relieve the abdominal muscles of that side from tension, and in walk- 
 ing the patient bends forward, the erect posture causing pain. The 
 pain may now be radiated, extending over a large portion of the 
 abdomen and involving the bladder, testes, rectum and other viscera. 
 Retention of the urine may occur. The tongue becomes furred, and 
 diarrhoea may set in, especially in children. As unfavorable condi- 
 tions progress the tongue becomes dry and brown, sordes appear on 
 the lips and teeth, and symptoms of exhaustion supervene. SOUK-
 
 DISEASES OF THE INTESTINES. 447 
 
 times, when the appendix turns backward, it is difficult to detect a 
 tumor in the iliac region, a vaginal or rectal examination enabling 
 the practitioner to detect the affected point deep in the abdomen. 
 Where a large amount of pus accumulates within the limiting 
 abscess-wall the abdominal tumefaction may be a marked feature of 
 the case the abdomen in the region of the caecum being enormously 
 distended. 
 
 The position of the appendix will determine, to considerable 
 extent, the local symptoms and conditions. When it is turned back- 
 ward, as is often the case, post- peritoneal abscess is very liable to 
 follow suppurative action, and enlargement of the csecal region is not 
 likely to be noticed. In gangrenous appendicitis the symptoms are 
 abrupt and severe from the start. There is a chill followed by fever, 
 with excruciating abdominal pain marking the rapid spread of peri- 
 toneal inflammation, prolonged vomiting of watery fluids, rapid, flut- 
 tering pulse, and delirium followed by coma. 
 
 Diagnosis. When persistent pain in the caecal region attended 
 by elevation of temperature and constipation occurs in patients under 
 thirty years of age, with tumefaction of the part and pain at McBur- 
 ney's point, there is little danger of confounding appendicitis with 
 any other affection except typhlitis; and here an error of diagnosis 
 would not be serious if radical surgical measures were not attempted 
 too early. The presence of vomiting would add to the probability 
 of appendicitis, and the absence of tumor would not militate against 
 it if other symptoms were marked. When an enlargement in the 
 iliac region with dullness on percussion pointed to purulent accumu- 
 lation, an aseptic hypodermic needle might be used to decide the 
 question, though due caution as to sepsis and repeated puncture 
 should attend such a procedure. Great haste to decide the question 
 is not necessary, unless the case be one of gangrenous appendicitis, 
 and here it is doubtful whether a diagnosis could be made sufficiently 
 early to afford substantial relief by operation. 
 
 Prognosis. The prognosis of acute catarrhal appendicitis is 
 favorable as to present recovery, though remaining adhesions are lia- 
 ble to perpetuate the difficulty and induce frequent subcequeut 
 attacks. Under skillful surgical treatment many cases of suppnrativo 
 appendicitis otherwise necessarily fatal recover, though the ^rryvity 
 of the disease is not to be underestimated. When the peritonaeum 
 is widely involved the chances of recovery are very much lessened, 
 and exhaustive suppuration and final demise are liable to succeed bur- 
 rowing abscesses when the post-peritoneal structures are invaded. 
 Perforation of the intestine may be followed by recovery, and the 
 pus may find an external opening in front, and the patient recover 
 without surgical aid. However, since the disease has received special
 
 448 DISEASES OF THE DIGESTIVE ORGANS. 
 
 attention from a surgical standpoint and prompt measures for an 
 early evacuation of the pus have been adopted, it has become much 
 less formidable than before. 
 
 Treatment. While appendicitis is a disease in which a knowl- 
 edge of surgery is an important requirement for its successful man- 
 agement, the physician is also capable of bringing important aid to 
 bear, often rendering surgical aid unnecessary. In recent times, 
 thanks to Schiissler, we possess a remedy which exerts a potent influ- 
 ence against the deposition of fibrinous plastic material, and with it 
 we may be able to avert the pernicious adhesions remaining after 
 ordinary cases of catarrhal appendicitis, as well as even prevent sup- 
 puration, if the purulent form be at hand. Limited experience with 
 potassium chloride 3x has suggested to me the probability that a large 
 number of surgical cases may be aborted before they become marked, 
 and otherwise portentous states brought to a successful termination 
 by the early and faithful exhibition of this remedy. In all cases it 
 is a perfectly safe one to say the worst of it, and its power to accom- 
 plish good is remarkable. In several cases of the kind I have seen 
 the abdominal tumefaction, obstinate constipation, cffical pain and 
 elevated temperature gradually subside under its influence when, in 
 the opinion of old and experienced surgeons, an operation was urg- 
 ently demanded. It is perfectly safe to depend upon when there is 
 appreciable (even though slow) improvement of all the symptoms. 
 Three to five grains of potassium chloride 3x should be added to 
 four ounces of water, a teaspoonful of the mixture to be ordered 
 every hour. When this is begun early, and the symptoms continue 
 to increase in severity for two or three days, the probabilities are that 
 the disease is beyond its control, though it can do no harm to con- 
 tinue it until operative procedures are adopted, as no other remedy 
 promises so much, and it must somewhat lessen the amount of 
 destructive action. 
 
 In the meantime the patient should remain quietly in bed and the 
 diet should be limited to liquid food, administered sparingly. Cathar- 
 tics should under no circumstances be allowed, but daily efforts to 
 evacuate the bowels with warm and soothing enemata should be 
 made. Hot applications are to be avoided, and very cold ones are 
 not commendable. Opiates may be allowed in moderate doses, 
 though the patient is better off without them if the pain is bearable. 
 If febrile action is marked properly selected sedatives should be 
 administered in small doses, and where there is prominent sugges- 
 tion of gangrenous tendency echinacea should constitute an important 
 feature of the medication. If the pain and tumefaction increase, in 
 spite of medical measures, surgical aid should be invoked early, and
 
 DISEASES OF THE INTESTINES. 449 
 
 this should constitute the first resource in gangrenous Appendicitis, 
 which may prove fatal in a few hours without. 
 
 PROCTITIS. 
 
 Synonym. Rectitis. 
 
 Definition, A catarrhal inflammation of the rectum, due to 
 local exciting causes, differing from that attending dysentery by the 
 absence of constitutional symptoms. 
 
 Etiology. Sometimes indigestible substances, such as fish 
 bones, particles of skewer, etc., may be accidentally swallowed with 
 the food and pass through tlio alimentary canal, to become lodged in 
 the rectum, to there excite inflammatory action. This is not an un- 
 common occurrence when persons who are intoxicated partake of 
 food containing such debris. Several cases of the kind have occurred 
 in my experience, and occasionally an instance has been followed by 
 severe inflammation, resulting in deep-seated abscess in the part. 
 Other foreign substances, such as particles of apple-core, berry- 
 seeds, plum-pits, etc., mc.y also result in such irritation. Hardened 
 faeces, hemorrhoids, sitting long on very cold substances and other 
 exciting causes may be named. 
 
 Symptoms. Tenesmuc is the first symptom, and frequently it 
 is the prominent one throughout. Sometimes there are evacuations 
 of bloody mucus attended by straining at stool, burning in the part 
 and shooting pains in the back and loins, or into the lower extremi- 
 ties. A persistent sensation as of a foreign body in the rectum gives 
 rise to repeated efforts at evacuation, and anal prolapsus is very lia- 
 ble to finally result. Hemorrhoids, strangury, headache and other 
 constitutional symptoms and even chronic rectitis may finally attend. 
 Hardened faeces sometimes play an important part in this affection, 
 the rectum becoming impacted with a hard mass, which is too large 
 to pass the anal outlet, and the colon may become filled withsterco- 
 raceous material which may be traced along the course of the large 
 intestine by irregular masses felt externally. 
 
 Chronic rectitis is attended by the daily discharge of mucus, pus 
 and sanious material, with more or less tenesmus. Erosion and 
 induration of the rectal mucous membrane exists, and the finger 
 detects a hardened, rigid condition upon digital examination. Con- 
 stipation attends, the fecal material voided being hardened and 
 impacted. 
 
 Diagnosis. In proctitis from local causes there is no fever, 
 while in that which arises in dysentery the thermometer shows an 
 elevation of three or four degrees. The pain of proctitis is also dif- 
 ferent in character, it usually being confined to the region of the 
 
 30
 
 460 DISEASES OF THE DIGESTIVE ORGANS. 
 
 rectum or radiating to the back or loins, while that of dysentery 
 usually lingers along the course of the colon and is frequently near 
 the umbilicus and paroxysmal, corresponding to the periods of evac- 
 uation. An inspection of the rectum will decide whether the symp- 
 toms arise from hemorrhoids, and rectal cancer comes on so slowly 
 that it cannot be mistaken for proctitis, while the presence of the 
 characteristic cachexia precedes extreme local irritation. 
 
 Prognosis. The prognosis is good when the disease is prop- 
 erly managed. If the exciting cause be some hard and irritating 
 substance and its removal be neglected, deep-seated abscess, fistula 
 or chronic proctitis may result. Erosions left behind may give rise 
 to chronic rectal catarrh or rectal stricture. 
 
 Treatment. The first important step is to decide whether there 
 be any foreign body present which may be causing the difficulty. If 
 so it should be carefully removed at once, and treatment afterward 
 instituted to control the remaining inflammation. In such cases the 
 finger will be the most reliable and least objectionable exploring 
 agent, and also the best means by which to remove offending sub- 
 stances without injury to the part. Small doses of aconite and rhus 
 tox. t combined with collinsonia, will assist in controlling the local 
 inflammation. R Lloyd's or Worden's aconite gtt. v-vii, green-plant 
 tincture rhus tox. gtt. x-xv, specific collinsonia gtt. x, water f iv. M., 
 and order a teaspoonful every hour. Locally, the following may be 
 used as an enema, to be retained until absorbed and repeated every 
 hour or two, according to the urgency of the case: R Echafolta ^i, 
 water fii. Mix. The patient should remain quiet in bed and be 
 allowed only a liquid diet for several days. In chronic proctitis the 
 enema of echafolta should be employed three or four times a day, 
 and collinsonia and echofalta should be administered internally three 
 or four times daily in appropriate doses. Berberis aquifolium con- 
 tinued for a long time, in connection with collinsonia or negundium, 
 will be of considerable service as an internal agent. 
 
 PERIPROCTITIS. 
 
 Definition. Periproctitis is an inflammation usually suppu- 
 rative of the connective tissue surrounding the rectum. 
 
 Etiology. The inflammation may be coextensive with that of 
 proctitis or of other diseases which may affect the rectal mucous 
 membrane, such as cancer, ulceration, etc. It occasionally occurs as 
 a result of tubercular infection of the part, or of pyaemic metastasis. 
 Traumatism is its most common cause, the lodgement and neglect 
 of some foreign body in the rectum, or blows near the anus being 
 very liable to result in such a condition.
 
 DISEASES OF THE INTESTINES. 451 
 
 Pathology. Suppurative inflammation of the connective tissue 
 occurs at some localized point, and fluctuation may by felt through 
 the rectal wall as the destructive action progresses, the soft part 
 bulging into the rectum. The pus may burrow in the vaginal or vesi- 
 cal wall and establish fistulae, or a track of suppuration may form 
 completely around the rectum. In other instances the abscess may 
 open into the rectum and a permanent suppurating sinus become 
 established. Proliferation of new connective tissue may result in 
 stricture of the rectum, or proliferating epithelial elements may 
 line the abnormal cavities with mucous membrane similar to that 
 of the rectum. 
 
 Symptoms. Severe pain of throbbing, burning or tensive char- 
 acter, attended by a sense of fullness in the rectum, is the prominent 
 symptom. If the inflammation involve structures near the anus, a 
 reddened prominence, of fluctuating, sensitive character soon devel- 
 ops. Nausea and vomiting may attend severe cases. An exami- 
 nation of the affected part will discover the local signs of abscess, 
 the finger detecting a fluctuating tumor, sensitive to the touch, 
 extending into the rectum. Upon rupture the contents of the 
 abscess are extremely offensive in odor, and they may be mixed with 
 faecal material. 
 
 Treatment. The most important object is to insure evacuation 
 of the abscess, not into the rectum but through the true skin, near 
 the anus. This demands proper surgical acumen. If treatment is 
 begun early there may be a possibility of avoiding the abscess, espe- 
 cially if it be of traumatic origin and the provoking cause has been 
 removed in the start. For this purpose potassium chloride 3x may be 
 administered in the usual manner. The special sedatives, especially 
 aconite and rhus fox., are excellent to control serious constitutional 
 symptoms, and if septic conditions arise baptisia and echinacca should 
 not be forgotten. If chronic purulency, too high for the pus-pockets 
 to be reached from below exist, the persistent use of the salt-water 
 galvanic electrode promises much, if begun at an early date and 
 faithfully used for several mouths three or four times a week. 
 In such cases the general condition of ths patient should not be neg- 
 lected, appropriate adjuvant treatment being employed as demanded. 
 Calcium sulphide, berberis aquifolium or other antisuppurative may be 
 needed to bring prolonged suppuration to a close. 
 
 HEMORRHOIDS. 
 
 Synonym. Piles. 
 
 Definition. A disease characterized by the formation of vascu-
 
 452 DISEASES OF THE DIGESTIVE ORGANS. 
 
 lar tumors in the lower rectum and about the anus, from varicosities 
 of the hemorrhoidal veins with subsequent inflammatory change. 
 
 Etiology. Straining at stool often causes rupture of one or 
 more of the coats of the hemorrhoidal veins, and this may b^ fol- 
 lowed by permanent hemorrhoidal tumors at the points of greatest 
 dilatation. Biding over rough roads or sitting on cold seats for a 
 long time may cause it by inducing congestion. Pregnancy is often 
 attended by hemorrhoids due to pressure on the pelvic veins, and 
 parturition may be attended by such forcible straining as to result 
 in a permanent hemorrhoidal condition. Constipation is a common 
 cause, both the straining during defecation and faecal pressure upon 
 the hemorrhoidal veins tending to such result. It is most common 
 in persons beyond middle life, though younger ones are not exempt 
 when exposed to exciting causes. It is more common in single 
 women those who have not borne children after the menopause, 
 this period frequently being immediately followed by the appearance 
 of hemorrhoids. Obstruction of the portal circulation from such dis- 
 eases of the liver as cirrhosis, atrophy or passive hyperaemia, is 
 almost certain to eventuate in hemorrhoids; and influences which 
 cause engorgement of the vena cava, such as cardiac or pulmonary 
 obstruction, are very liable to be followed by it. The abuse of 
 drastic cathartics is often provocative of piles, large doses of colo- 
 cynth, aloes, etc., frequently bringing on the disease. 
 
 Pathology, Acute hemorrhoids may be nothing more than 
 dilated, inflamed veins, sometimes containing thrombi of coagulated 
 blood. As they continue without proper treatment, however, they 
 may gradually become surrounded by bloodvessels, and the vasa 
 vasorum, from inflammatory action, may become hypertrophied, until 
 the tumors consist of aggregations of dilated bloodvessels with firm 
 fibrous coats, constituting permanent and more or less firm enlarge- 
 ments which, however, increase or diminish in size as their vascular- 
 ity fluctuates. 
 
 Various divisions of hemorrhoids have been made. Those which 
 arise within the sphincter ani and which can be returned to the rec- 
 tum, to remain there, if prolapsed, are termed internal hemorrhoids ; 
 while those which arise without the sphincter ani and cannot be car- 
 ried up, or which immediately return when lifted above the sphinc- 
 ter, are termed external hemorrhoids. External hemorrhoids commonly 
 occur just at the verge of the anus, upon the mucous membrane. 
 Sometimes straining at stool is followed by rupture of one of the 
 external hemorrhoidal veins with the formation of a blood-clot 
 within the point of rupture which, if not soon evacuated, is after- 
 ward absorbed, the dilated sack afterward becoming shriveled and 
 remaining as a wrinkled tab of muco-cutaneous tissue. Internal
 
 DISEASES OF THE INTESTINES. 453 
 
 hemorrhoids are sometimes dark blue, livid and non-fluctuating, 
 more rarely bright red and pulsating, suggesting the presence of 
 one or more arterioles, and, when punctured, project a stream of 
 bright red blood in jets. Internal hemorrhoids, then, may be either 
 venous or arterial. Another form of internal hemorrhoids consists 
 of flat mucous surfaces covered by bright red capillary loops (capil- 
 lary hemorrhoids), which bleed easily and frequently, the amount of 
 blood, though small in quantity in a given time, constituting finally a 
 serious loss to the system. The hemorrhage which occurs in hemor- 
 rhoids almost universally proceeds from above the sphincter (inter- 
 nal piles) and usually from capillary hemorrhoids, though the coat of 
 an arterial or venous hemorrhoid may be so attenuated as to give 
 way and allow of considerable loss of blood in a short time, at fre- 
 quent intervals. Rupture of venous internal hemorrhoids is not 
 rare, aud sufferers sometimes rupture them with their fingers, believ- 
 ing that it will afford them temporary relief from pain. The 
 sphincter ani is usually irritable, and when internal hemorrhoids are 
 prolapsed, as often occurs during defecation, spasmodic contraction 
 of the sphincter about them above the protruding masses may cause 
 strangulation, unless the prolapsed tissues are replaced. In other 
 cases, however, the sphincter may be relaxed, and chronic prolapsus 
 of the hemorrhoids may persist. 
 
 Symptoms. Unless strangulation or severe inflammation, with 
 septic absorption occur, hemorrhoids afford only local symptoms. 
 There is a sensation as of some foreign body in the rectum, with 
 pain in different cases, of widely varying character. Sometimes this 
 is dull and aching with dragging sensations about the anus, some- 
 times it is sharp and piercing as though there were a sharp instru- 
 ment driven into the anus, and sometimes it is throbbing as though 
 an abscess were forming. In some cases of internal piles the pain 
 is almost confined to the lumbar and sacral regions, and in others 
 it may radiate to the hips and lower extremities. Most cases, if 
 not all, are subject to periods of intense excerbation, due to cold, 
 constipation, riding over rough roads, severe exertion, etc., in 
 which the patient suffers severely, while there are varying peri- 
 ods in which not much discomfort may be experienced. When the 
 disease becomes well advanced and there are extreme changes of 
 structure, the patient becomes a constant sufferer, every period of 
 defecation being one of anguish, prolapse of a mass of distended 
 tumors often attending the exit of the stool and necessitating its 
 return, a performance at which the sufferer after a time becomes 
 an adept. Hemorrhage is common at these times, and, if consti- 
 pation attend, the suffering is prolonged and intense. 
 
 When there is considerable hemorrhage the patient becomes
 
 454 DISEASES OF THE DIGESTIVE ORGANS. 
 
 anaemic after a time, and dyspeptic symptoms are common, probably 
 from reflex irritation. The bladder and urethra commonly sympa- 
 thise in severe cases, and urination may be difficult and painful. 
 Vesical tenesmus may be almost a constant symptom. In females 
 vaginal pain may be due to such cause. Hemorrhoidal persons are 
 frequently melancholy and morose. Constipation is the rule, though 
 many are subject to diarrhoea. 
 
 Diagnosis. A rectal examination can hardly fail to result in a 
 correct diagnosis. The only rectal tumor liable to be confounded 
 with hemorrhoids is a rectal polypus, which is colorless, prediculated 
 and painless. Venereal growths occur at the edge of the anus but 
 are not painful, and other symptoms of syphilis usually observable 
 will aid in distinguishing this disease from hemorrhoidal tumors, 
 which are smooth, tense and shiny, and usually purplish in color, 
 more or less sensitive to the touch and commonly painful. Hemor- 
 rhoids bleed easily, while other rectal growths are not liable to. 
 Capillary hemorrhoids are found within the sphincter and consist of 
 patches of bright red capillary loops, which bleed easily upon being 
 disturbed. 
 
 Prognosis. When hemorrhoids are treated early, before in- 
 flammatory changes occur, there is good prospect that specific con- 
 stitutional treatment may succeed in effecting a cure at least that 
 the difficulty may be banished for years before it will again appear, 
 unless the patient is continually exposed to its causes. After 
 inflammatory changes have occurred, radical surgical measures are 
 demanded, and medicines by mouth can be palliative only. Capil- 
 lary hemorrhoids demand radical treatment from the start, and 
 should not be allowed to continue, as stubborn ansemia may arise, 
 to continue for years after the completion of a cure of the local 
 trouble. 
 
 Treatment. Though usually classed as a surgical disease, 
 hemorrhoids may often be successfully treated by the physician 
 with internal remedies. Collinsonia specifically influences the tis- 
 sues of the rectum, and many cases of acute and subacute piles may 
 be permanently relieved by its internal administration. Where con- 
 stipation attends the following prescription is an excellent one: 
 R Green-plant tincture of collinsonia ^i-ii, fluid extract cascara fi, 
 simple elixir ad fiv. Sig. Teaspoonful every three or four hours 
 during the day. Where there is profusion of venous piles below 
 the sphincter external hemorrhoids hamamelis sometimes answers 
 a better purpose, and two or three drachms of the distilled extract 
 may be substituted for the collinsonia in the prescription just 
 named. Where a local application is essential to relieve pain, the 
 following may be employed : R Fluid extract belladonna jii, oil of
 
 DISEASES OF THE INTESTINES. 455 
 
 erigeron canadense ^iv, oleum olivae ad fi. Sig. Apply morning and 
 evening and at times of defecation. In stubborn cases cesculus hip. 
 pocastum may be studied. Fullness, dryness and sense of constric- 
 tion, with aching pain and weakness in the sacro-lumbar region is 
 the accepted picture for its use, some asserting that it is specific, 
 when there is absence of constipation. There are other remedies 
 but these are the leading ones. When prolapsus attends defecation 
 the use of a copious injection of weak salt water prior to the attempt 
 at evacuation may assist in preventing this accident. Sometimes 
 small doses of the 2x or 3x trituration of podophy llin may be used for 
 this condition (prolapsus). 
 
 Dr. O. S. Laws (Dynamical Therapeutics) recommends a new 
 remedy Negundium Americanum (box elder) above all others for 
 specific action in hemorrhoids. He uses ten or fifteen grains of the 
 powdered bark of the roots of yearling plants, or tablespoonful or more 
 doses of a decoction several times daily. "Recent cases of hemor- 
 rhoids can be completely cured in this way and the old hard ones 
 temporarily relieved." He considers it far superior to collinsonia 
 in this place. Probably a saturated tincture of the bark could also 
 be relied upon, and it would be a more stable form. It is hopeful 
 that it will be supplied to our drug market. 
 
 After permanent tumors of large size become established and 
 organized, internal medication can only modify unpleasant symp- 
 toms more radical treatment must then be employed. The White- 
 head operation will come into use when the entire lower inch of the 
 rectum becomes a mass of liemorrhoidal tumors, though hypodermic 
 injections of carbolized glycerine and olive oil will cure most cases, 
 when patiently tried. The sphincter should be stretched to prevent 
 strangulation of the prolapsed mass after a treatment of this kind, 
 though if care be exercised this may be avoided by putting the tumor 
 up after an operation, and the divulsion may be allowed to go until 
 the latter part of the treatment. 
 
 The diet should be spare and devoid of indigestible substances, 
 and so selected as to encourage relaxation of the bowels. 
 
 AMYLOID DEGENERATION OF THE BOWELS. 
 
 THIS is a disease of rare occurrence, and when it appears it is 
 usually secondary to phthisis or chronic suppuration, especially long- 
 standing suppuration of bone. The degenerative action begins in 
 the terminal branches of the mesenteric arteries and involves the 
 intestinal wall later, sometimes affecting the entire thickness of the 
 part, and being marked by ulceration of the mucous membrane.
 
 456 DISEASES OF THE DIGESTIVE ORGANS. 
 
 Both the large and small intestine may be involved, though the 
 lower portion of the ileum is most susceptible. 
 
 The symptoms are obscure, there being a painless, chronic diar- 
 rhoea, without local tenderness or fever, with gradual loss of strength. 
 If there is ulceration of the mucous membrane there will be blood 
 and pus in the stools, and such symptoms attended by phthisis, 
 chronic suppuration, or other wasting disease may be interpreted as 
 belonging to the condition under consideration. An autopsy will 
 usually disclose accompanying amyloid degeneration of the liver and 
 spleen. 
 
 Nothing but palliative treatment, on general principles, can be sug- 
 gested, as fatal results sooner or later follow. 
 
 DlABBH(EA- 
 
 Definition. The term diarrhoea literally signifies "I flow," and 
 is applied to a condition in which there is a frequent discharge of 
 fluid or semi-fluid faeces, unattended by tenesmus. 
 
 Etiology. Diarrhoea may be irritative, symptomatic, mechan- 
 ical, nervous, choleraic, vicarious, critical, colliquative or functional 
 in character. It attends many diseases under one of these guises, 
 and sometimes exists as an independent affection due to functional 
 disturbance of the alimentary canal or of the digestive processes. 
 
 Irritative diarrhoea attends all cases marked by inflammatory 
 invasion of the intestinal mucous membrane, such as the various 
 forms of enteritis, typhoid fever, certain cases of mineral poisoning, 
 intestinal worms, excessive biliary discharges, drastic catharsis, 
 improper food, etc. 
 
 Symptomatic diarrhoea may be the result of certain acute and 
 chronic affections, such as Bright's disease, the exanthemata, pyaemia, 
 leukaemia, etc. 
 
 Mechanical diarrhoea is the result of obstruction to the portal cir- 
 culation, causing transudation of serum from the bloodvessels into 
 the intestinal canal. This may occur in hepatic, cardiac or pulmo- 
 nary affections. 
 
 Nervous diarrhoea may be due to grief, great anxiety, fright or 
 severe shock or pain. The discharges are then largely serous, 
 though if the exciting cause appear soon after eating there may be 
 evacuation of undigested food (lienteric diarrhoea). 
 
 Choleraic diarrhcea is the term applied to the watery evacuations 
 which pass with a gush, during cholera, cholera morbus and chol- 
 era infantum. 
 
 Vicarious diarrhoea is the result of sudden arrest of secretion, 
 usually of the skin, the diarrhoea being compensatory. It may fol-
 
 DISEASES OF THE INTESTINES. 457 
 
 low sudden chilling of the surface, or may attend undue indulgence 
 in diet during hot summer weather In other cases, it may be due 
 to overeating. 
 
 Symptoms. Under this head several divisions of diarrhoea 
 have been suggested. In simple fcecal diarrhoea the evacuations are 
 normal as to character, but increased in quantity and fluidity. In 
 bilious diarrhoea the discharges are greenish-yellow, suggesting an 
 abnormal amount of bile, though bismuth or other drugs mav cause 
 similar appearances, and due allowance should be made for medica- 
 tion to which the patient may have been previously subjected. 
 When the evacuations are largely water the condition is termed 
 serous diarrhoea, while mucous and muco-purulent evacuations may 
 afford mucous diarrhoea. Fatty diarrhoea may attend faulty pancre- 
 atic action, and crapulous diarrhoea may follow immediately upon 
 overindulgence at the table. A critical diarrhoea may attend the crisis 
 of a disease, disappearing after the crisis is over, and a colliquative 
 diarrhoea (profuse and serous) may attend the close of such wasting 
 diseases as Bright's disease, phthisis, cancer, etc. 
 
 Frequent large evacuations mark an attack of diarrhoea, though 
 the size of the discharges diminishes as the disease continues. The 
 evacuations are often expelled with a gush, especially if the dis- 
 charges be watery in character, though in other cases they may 
 not be forcible. Serous diarrhoea is often attended by cramps in the 
 extremities, and colicky pains and the expulsion of flatus may occur, 
 though in some cases it may be painless. Febrile action may attend 
 some cases, and thirst, chilliness and anorexia be present. Serous 
 diarrhoea is usuallv attended by scanty urinary secretion, and the 
 urine may be albuminous and highly acid. Large quantities of free 
 fat may be found in the stools of fatty diarrhoea. Some cases of 
 diarrhoea may result beneficially, though usually rapid prostration 
 attends protracted cases. Digestion and assimilation are interfered 
 with, and the patient loses flesh rapidly, the skin becoming dry and 
 harsh, and the individual irritable and despondent. 
 
 Chronic diarrhoea is dependent upon some structural disease of 
 the alimentary canal, such as chronic enteritis, intestinal ulceration, 
 tubercular or syphilitic disease of the intestines, scurvy, malaria, etc. 
 
 Treatment. The treatment of diarrhoea will depend upon the 
 cause and the condition of the patient at the the time of attack. If 
 the diarrhoea depend upon the presence of irritating food some uuir- 
 ritating but active cathartic, such as the compound powder of jalap 
 and senna, may be used to assist in its removal. Following this a 
 soothing agent, such as kaki, epilobium, bismuth, rhus aromatica or 
 other remedy, should be administered, in appropriate doses. Some- 
 times potassium b^hrom. 3x will serve a better purpose. When
 
 458 DISEASES OF THE DIGESTIVE ORGANS. 
 
 serous diarrhoea is present, two possibilities as to cause are pre- 
 sented, namely, obstruction to the portal circulation, and relaxation 
 of the intestinal capillaries. In the first attention must be paid to 
 the hepatic, cardiac and pulmonary circulation, and in the other co/> 
 illary astringents, such as erigeron, cinnamon, achillea or other agent, 
 should be employed. In bilious diarrhoea chelidonium, bryonia, 
 podophyllin in minute doses and, in some cases, mercurius dulcis 3x 
 may be thought of. Oxide of zinc has been highly recommended in 
 nervous diarrhoea. Fatty diarrhoea is best treated with olive oil 
 and a diet composed largely of pickled olives. A wineglassful of 
 olive oil should be taken three or four times daily, and pickled 
 olives taken freely with each meal. Lienteric diarrhoea may require 
 the use of ipecac, aconite, rhus tox. or other sedative. In all cases 
 fermentation should be prevented by the frequent use of half- 
 drachm doses of Marchand's hydrozone, diluted at the time of admin- 
 istration with two ounces of distilled or boiled water. Malarial 
 diarrhoea will call for arseniate of quiiiia 3x, quinine or other anti- 
 malarial agent. A bland diet and the recumbent position are 
 important. 
 
 CONSTIPATION. 
 
 Definition. Constipation is a term applied properly to reten- 
 tion of faeces from any cause, though here it is intended to refer to 
 a condition where the retention is due to functional derangement of 
 the bowels and where the obstruction is purely faecal in character. 
 
 Etiology. Habits and modes of life often give rise to habitual 
 constipation. Among these may be mentioned sedentary habits, 
 neglect to attend promptly to daily evacuation, habitual use of opi- 
 ates and alcohol, sparing ingestion of fluids, etc. Hepatic torpor may 
 be provocative of it, many dark persons suffering habitual constipa- 
 tion all their lives from this cause. Certain chronic diseases, as 
 neurasthenia, anaemia, hysteria and structural derangement of the 
 brain and spinal cord may cause it. Uterine affections attended by 
 irritation and congestion are common causes of the condition among 
 women, and prostatic hypertrophy among old men frequently results 
 in it. Certain articles of diet may cause faecal impaction at first, 
 and if this condition persists for a long time a constipation habit is 
 finally established, through permanent perversion of the intestinal 
 secretions. Atony of the bowels may be due to long-continued dis- 
 tention, and when this condition is relieved the intestinal torpor may 
 be so established as to demand vigorous measures for its permanent 
 cure. Diseased conditions of the mucosa may result in persistent 
 dryness in some portion of the intestinal canal, faecal accumulation 
 stubbornly occurring there. Prolonged mental labor, melancholia,
 
 DISEASES OF THE INTESTINES. 459 
 
 insanity and other disturbances of the brain are not unlikely to be 
 attended by constipation. However, by far the most common cause 
 and one which gives rise to conditions just suggested as etiological 
 factors, is orificial irritation rectal pockets, papillae, fissures of the 
 anus, hemorrhoids, etc. 
 
 Pathology. Though no lesion may appear at first, long impac- 
 tion of faeces may result in dilatation of the intestine, with thicken- 
 ing of its walls. Pressure and irritation of hardened faeces may give 
 rise to ulceration of the mucous membrane, and perforation some- 
 times occurs, both from ulceration and increased peristaltic action. 
 The dilatation which occurs moot markedly about the sigmoid flex- 
 ure may result in paralysis of the muscular coat of the intestine, and 
 pouches containing faecal material and mucus may form along the 
 colon. The impacted faeces sometimes become so hardened as to 
 resist the edge of a knife. Various accidental substances, such as 
 the stones of various fruits, hair, pebblos, gall-stones, etc., may form 
 the nuclei of such impactions, and though not formidable enough to 
 cause obstruction by themselves, they may assist in the formation of 
 masses which may resist all efforts at dislodgment. Such diseases 
 as hemorrhoids, rectal abscess, fistula, etc., may complicate cases of 
 severe and long-continued constipation, and be the result, as well 
 as the cause of them. 
 
 Symptoms. The symptoms of constipation are so varied that 
 the only one that can be relied upon is absence of regular faecal evac- 
 uation, without severe local and constitutional symptoms. Subjects 
 of the disease are liable to be dyspeptics, to have headaches, erratic 
 appetites, insomnia, and be melancholic and despondent. Sympa- 
 thetic disturbance of the hepatic functions, with slight symptoms of 
 jaundice, is liable to attend. Periodical migraine and colic are com- 
 mon with such individuals. After long continuance the skin becomes 
 torpid, dry and scaly or shriveled, the secretions generally rank and 
 offensive, and the breath foetid. Cardiac palpitation occurs at inter- 
 vals, and there is often pectoral pain or aching under the scapula. 
 Where the colon is distended pain in the region of the distention is 
 almost a constant symptom, this usually being of a dull, aching char- 
 acter, though there may periods of acute aggravation. Neuralgic 
 pains in the testicles, groins, down the thighs and in the lumbar 
 region may be referable to impaction of the lower portion of the 
 colon. Sometimes symptoms of intestinal obstruction may occur, 
 and vomiting and cramping in the abdomen and other grave features 
 appear. In many cases the bowels will move with difficulty every 
 three or four days, the faeces being tenacious and pasty in char- 
 acter or consisting of hardened lumps which are evacuated with pain. 
 Sometimes diarrhoea is alternated with constipation, the irritation of
 
 460 DISEASES OF THE DIGESTIVE ORGANS. 
 
 the hardened faeces giving rise to periodical catarrh of the intestinal 
 mucous membrane. Tunneling of hardened faeces may sometimes 
 occur and the impaction persist, while faecal material from above is 
 passed through the hardened ring. Impaction may be detected by 
 palpation, the ftecal accumulations forming large nodulated masses 
 which are located along the course of the large intestine, forming 
 movable tumors when located in the colon. When impaction exists 
 near the sigmoid flexure tenesmus may attend, without power to 
 evacuate the mass. 
 
 Diagnosis. Constipation is a chronic condition hardly likely 
 to be mistaken for intestinal obstruction, as that comes on suddenly 
 unless it depends upon organic stricture of malignant or syphilitic 
 character. Faecal impaction may be attended by severe pain and 
 vomiting similar to the symptoms of intestinal obstruction, but when 
 it occurs it is not so likely to be persistent and severe. In such 
 cases there is apt to be a history of long-continued constipation 
 leading up to it. 
 
 Prognosis. Functional retention of faeces is almost always 
 amenable to treatment, few cases persisting if rationally managed. 
 In extreme old age it may be difficult to completely overcome the 
 intestinal torpor, though by judicious treatment faecal impaction may 
 be broken up and the bowels kept in a fairly active state. 
 
 Treatment. The habitual use of cathartics to overcome con- 
 stipation is usually pernicious. Innervation of the alimentary canal, 
 that peristalsis may be encouraged, should be aided by such means 
 as morning and evening massage, the abdomen being kneaded and 
 well slapped over the bare skin for five or more minutes on each 
 occasion. Exercise should be promoted where sedentary habits are 
 necessary to any occupation, and plenty of fluids should be taken, 
 with avoidance of tea and coffee. A cup of hot water before break- 
 fast, with a cup of weak cocoa at that meal, will assist in promoting 
 daily evacuation, especially if attention be paid to regular and daily 
 effort at stool. Where there is intestinal torpor a single drop of 
 tincture or fluid extract of nux vomica in the morning, taken in a 
 glass of cold or hot water, is useful. Copious enemata of strong 
 salt water, employed just after breakfast or dinner, regularly every 
 day, may be tried in stubborn cases. The use of galvanism with the 
 salt-water electrode is the most effective agent known in permanently 
 curing intestinal torpor. It should be employed once or twice a 
 week for several months, and afterward once a fortnight for a few 
 times, until its good effect becomes permanent. 
 
 The common cause of chronic constipation is orificial irritation. 
 All bad cases should be subjected to a rigid examination, for the 
 purpose of detecting and correcting such a condition. After this
 
 DISEASES OF THE INTESTINES. 461 
 
 has been accomplished the use of the salt-water electrode should 
 follow, as has already been suggested. Faecal impaction may some- 
 times be broken up by judicious manipulation of the hardened masses 
 through the abdominal walls, frequent use being made, meantime, of 
 the salt-water electrode with galvanism. Where impacted faeces 
 accumulate in the rectum and cannot otherwise be dislodged, they 
 should be broken up with the finger, while the patient is under gen- 
 eral anaesthesia. 
 
 The diet should consist largely of vegetables, coarsely ground 
 cereals, fruits, especially cooked fruits, and plenty of water. Much 
 lean meat should be avoided, as well as eggs, milk, sweets, puddings, 
 pastries, fried foods, condiments, rich gravies, curry, sauces, pickles, 
 nuts, tea and all alcoholic liquors. 
 
 INTESTINAL COLIC. 
 
 Definition. Pain in the intestines of functional origin arising 
 from spasmodic contraction of the muscular coats of the bowel. 
 
 Etiology. Intestinal colic is a neurosis, due to hypersesthesia 
 of the nerves supplying the intestinal canal arising from some excit- 
 ing influence, such as the presence of irritating secretions or indiges- 
 tible substances in the alimentary tract, dilatation of some part by 
 fsecal accumulation, gases, intestinal worms, congestion from cold, 
 rheumatism, gout, or hypersesthesia of the terminal nerves through 
 the effect of systemic poisoning by lead, copper, or alcohol. Liabil- 
 ity to it decreases with advancing age. Women are more subject to 
 it than men. 
 
 Pathology. No appreciable morbid changes occur. 
 
 Symptoms. The attack is usually abrupt, though it may be 
 preceded by flatulence, nausea, borborygmus, chilliness and irrita- 
 bility of temper. The pain is abrupt in its onset, and, though it 
 may be continuous, is marked by excerbations, during which the 
 patient is beut forward or rolls about in agony, with groanings and 
 cries of pain. The abdominal muscles are now rigid, the bowels are 
 knotted and the face is drawn. The patient seeks to find relief by 
 pressure upon the abdomen, either with his hands or by lying on 
 hia face. The abdomen is not sensitive to pressure and there is no 
 soreness after the subsidence of the attack. There is absence of 
 fever, the pulse is small and feeble and the extremities aro often 
 cold, especially during the paroxysms. The kidneys may be dis- 
 turbed, a great quantity of limpid urine being voided during the 
 attack and there may even be vesical tenesmus. There is some- 
 times vomiting (bilious colic) and constipation is the general rule, 
 hough diarrhoea may be present. If allowed to continue the dis-
 
 462 DISEASES OF THE DIGESTIVE ORGANS. 
 
 ease will usually terminate iu the escape of flatus, either alone or 
 accompanied by diarrhoea. Symptoms of collapse may attend aggra- 
 vated cases. In malarious districts the attacks may be periodical, 
 returning as regularly as an attack of ague, lasting several hours and 
 then disappearing, until the second or third day afterward. In 
 rheumatic colic there are usually accompanying pains in other parts, 
 with tendency to metastasis. Bilious colic is the form in which 
 nausoa and vomiting are prominent symptoms. Vitiated secretions 
 or gastric complications are responsible for this phase. The vomited 
 matters are greenish or yellow. The tongue may be coated, and 
 there may be slight fever, suggesting more or less constitutional dis- 
 turbance. This form may be more persistent than ordinary flatulent 
 colic, and jaundice may appear during its development, the hepatic 
 symptoms persisting for several days. It is most common in malari- 
 ous districts. Colic frequently arises from a rheumatic condition, 
 in which case metastasis to other parts is likely to occur. 
 
 Colica pictonum or lead colic affects those who have been using 
 lead in some avocation for a long time, such as painters, composi- 
 tors, type founders, stereotypers or lead miners. Sometimes acci- 
 dental poisoning may occur from the use of water which has been 
 carried through a lead pipe or in some such way. The pain comes 
 on gradually in this form of colic, the paroxysms being moderately 
 severe at first, but increasing in severity and frequency until intense 
 paroxysms follow each other with rapidity. The colic is located 
 principally about the navel, and cramps of the extremities may attend 
 the paroxysms. The abdomen is flattened and hardened, the intes- 
 tines are knotted and rigid, and there is obstinate constipation, 
 which resists the action of all ordinary cathartics. Kelapses are 
 easily excited by the least indiscretion in diet or exposure to changes 
 of temperature. The patient is sallow, anaemic, more or less debili- 
 tated, and the pulse is slow. A distinctive feature of the case is a 
 deep blue dotted line along the margins of the gums, formed by a 
 combination of sulpheretted hydrogen arising from decomposing food 
 with the lead in the circulation. There is often paralysis of the 
 extensors of the forearm, causing the wrist to drop when the arm is 
 extended, or optic neuritis resulting in amaurosis, and tendency to 
 epileptic convulsions. 
 
 Copper colic differs from lead colic in that the pain is increased 
 by pressure, there is diarrhoea of greenish evacuations instead of 
 constipation, and the abdomen is distended instead of contracted. 
 The line along the edge of the gums is purplish instead of blue, and 
 the specific influence of copper upon the laryngeal and bronchial 
 muscles is manifested by spasm of these organs attended by dysp-
 
 DISEASES OF THE INTESTINES. 463 
 
 ncea. In both lead aiid copper poisoning there are elements of chro- 
 nicity not observed in flatulent colic. 
 
 Diagnosis. Peritonitis will hardly be confounded with colic, 
 as it is a disease attended by marked febrile reaction and a tense, 
 wiry pulse, with tenderness 011 pressure, while the opposite is tha 
 case in colic, the pain being paroxysmal instead of steady as in peri- 
 tonitis; and these peculiarities will distinguish the disease from all 
 other abdominal complaints. 
 
 Prognosis, The prognosis is almost universally, favorable. 
 Convulsions may terminate unfavorably in children, though such a 
 result is rare, and rupture of the intestine may occur in exceptional 
 cases from violent distention of gases. 
 
 Treatment. A specific remedy in most cases of flatulent colic 
 is colocyntli. The second or third decimal dilution of the specific 
 medicine may be used, half a traspoonful being added to four ounces 
 of water and a teaspoonful of the mixture being administered every 
 fifteen minutes until the pain ceases, which will usually be after the 
 second or third dose. Many Eclectics prefer to employ the old 
 remedy, dioscorea; and this is indeed good, the dose being ten or 
 fifteen drops of the specific medicine in a little water every fifteen 
 minutes, until relief follows. 
 
 In rheumatic colic full doses of a strong decoction of cimicifuga root 
 is best, the decoction being administered in wineglassful doses every 
 half-hour, until its full effects are exerted upon the system. An 
 alcoholic vapor or cabinet vapor bath assists materially here in shorten- 
 ing the course of treatment. Where periodicity is marked and the 
 attacks persistently return with regularity, the use of antiperiodic 
 doses of quinine or other antiperiodic is eminently demanded. When 
 constipation is present a decoction of rhamnus cal. is more relia- 
 ble and speedier in action than cimicifuga in rheumatic colic. The 
 decoction may be taken in wineglassful doses, repeated every hour 
 until its cathartic action is developed; then at longer periods. 
 Gouty colic depends upon a gradually acquired constitutional con- 
 dition which requires long-continued treatment for the gouty habit, 
 as suggested under that disease. 
 
 Lead colic demands, for relief, prompt and urgent measures, and 
 rigid abstinence from avocations or surroundings which tend to fur- 
 ther contaminate the system. The obstinate constipation must be 
 relieved, and for this purpose it is useless to depend upon ordinary 
 cathartics. Croton oil is about the only drug that will accomplish 
 the purpose here, and it should be giveii cautiously, in small but oft- 
 repeated doses, until the purpose is attained. One drop of croton 
 oil and one grain of powdered opium may be combined, and a dose 
 given every two hours until the desired action occurs. Valuable
 
 464 DISEASES OF THE DIGESTIVE OKGANS. 
 
 assistance may be derived from the use of galvanism with the salt- 
 water electrode in the lower bowel, though this is not necessary. 
 Dioscorea, in combination with gelsemium (sp. med. dioscorea gtt. 
 xv, sp. med. gelsemium gtt. x), is excellent to alternate with the cro- 
 ton oil to alleviate the severe pains. As soon as the bowels move the 
 pain ceases for the time, and further treatment should be directed to 
 the prevention of a recurring attack. The salt-water enema with 
 galvanism should be employed to promote regular evacuations, and 
 a milk diet should be used for weeks until the lead has been re- 
 moved from the system. This is supposed to be furthered by the 
 action of iodide of potassium, which combines with the lead in the 
 system to form a soluble lead salt, which may be removed by the 
 kidneys. If the patient cannot abandon his avocation or remove 
 from the influences of surroundings which expose him to possibility 
 of contamination, he should try to prevent the entrance of the drug 
 into the system. As this is liable to occur during eating, a small 
 dose of diluted sulphuric acid should be tak n during or after 
 meals, this uniting with the lead in the stomach to form an in- 
 soluble compound of the metal, which cannot enter the circulation. 
 Copper colic should be treated similarly to other forms, except 
 that as there is diarrhoea there will be no call for cathartics. Sul- 
 phur vapor batJis may assist in removing the copper from the system, 
 and cabinet vapor baths will alleviate, to some extent, the severe 
 pain. A milk diet should be adhered to for a long time after con- 
 valescence. 
 
 ESTIVAL INFANTILE ENTERITIS. 
 
 Synonym. Summer Complaint of Children. 
 
 Etiology. Infants are peculiarly liable to diarrhoeal diseases 
 during the hot months of summer and early fall, mauy perishing 
 every season from different forms of enteritis. The death rate begins 
 in May and gradually rises into July, when it curves downward 
 through August and September. Three important factors operate to 
 bring about this state of affairs, namely, the want of development of 
 the digestive organs, the character of the food consumed, and the 
 development of bacteria in the intestinal canal. Until the deciduary 
 teeth are developed the salivary glands of infants are incapable of 
 digesting starchy food, and artificially fed children those most lia- 
 ble to be affected with summer diarrhoea are very apt to receive 
 such aliment, unless the mother or nurse has been well instructed 
 upon the subject; and this is not apt to be the case among the 
 ignorant and poor, the class of people most liable to suffer. Hot 
 weather encourages fermentation the development of bacteria
 
 DISEASES OF THE INTESTINES. 465 
 
 which may prove provocative of serious intestinal disease. Milk 
 or other food that is least tainted is almost sure to contain many 
 varieties of microbes, which, when they develop within the aliment- 
 ary canal, originate toxines which may prove rapidly destructive to 
 life. Most cases of mortality from infantile diarrhoea occur between 
 the ages of six and eighteen months, and a very large majority in 
 artificially fed children; the percentage of babies fed exclusively at 
 the mother's breast affected being insignificant. The stools of 
 healthy nursing children contain numerous bacilli and micrococci 
 which seen to thrive when an exclusive milk diet is used, and this 
 without detriment to the host, milk diet seeming to be the provision 
 under which they exist; one species, the bacterium lactis serogenes, 
 being supposed to subsist upon the sugar of milk, while it devel- 
 ops in the upper portion of the alimentary canal. Another promi- 
 nent form is the bacterium coli commune, which develops in the 
 lower intestine. Other forms are present in health, but when en- 
 teritis arises the number is greatly increased, the morbid products 
 then developed probably acting as toxines, as infantile diarrhoea 
 in most cases is evidently more than a local disease.' It* children 
 of the poor in cities, where fresh milk is difficult to obtain and 
 where artificial foods are largely used, . is where infantile diar- 
 rhoea marks its greatest ravages, though bottle-fed babies in rural 
 districts are also frequently affected. Pure air, containing a large 
 amount of ozone, neutralizes to considerable extent the virulence of 
 the seasonal influence. On the sea coast and in mountain altitudes 
 the disease is much less common. Around San Francisco Bay there 
 is almost a complete absence of summer complaint among children, 
 and when it occurs it must be managed very badly if the disease 
 do not prove readily amenable. Oakland, on San Francisco Bay, 
 it seems to me, is a paradise for bottle-fed babies. 
 
 Pathology, The mucous membrane of both large and small in- 
 testines is swollen and covered with catarrhal secretion, and the 
 lymph-follicles are enlarged, filled with proliferating cells and, in 
 protracted cases, ulcerated. Occasionally there is croupous exuda- 
 tion on the mucous membrane of the colon and lower ileum, and, 
 in such cases, extensive ulceration may occur. Lesions of the nerv- 
 ous system are not common, though -in fatal cases effusion often 
 occurs prior to death. The spleen and lungs may be congested, 
 though such complications are not common. The liver and mesen- 
 teric glands are often congested. 
 
 Three varieties of summer complaint are described, all being due 
 to similar causes, and all presenting similar puthological conditions, 
 though the symptoms are markedly at variance. They are (1) acute 
 dyspeptic diarrhoea, (2) cholera infant um and (3) acute entero-colitis. 
 
 31
 
 466 DISEASES OF THE DIGESTIVE ORGANS. 
 
 ACUTE DYSPEPTIC DIARRHCEA. This form of summer complaint is 
 characterized by the presence of undigested foods and curds in the 
 evacuations, which are more frequent than normal, and of abnormal 
 color, being sometimes greenish, sometimes greenish-yellow, again 
 grayish-yellow, and often of a variety of colors. The disease comes 
 on gradually, the patient being peevish, craving food and manifest- 
 ing restlessness at night. In other cases the onset may be' abrupt, 
 and there may be colicky pains, vomiting and rapid rise of tempera- 
 ture, until 104 or 105 F. is reached. Sometimes active determina- 
 tion of blood to the brain with convulsions marks the onset. After 
 the initiatory symptoms the case may continue in the form of lien- 
 teric diarrhoea, with greenish, tenacious discharges of faecal material, 
 mixed with gas and undigested food, or it may finally merge into a 
 case of cholera infautum or entero-colitis. Such attacks may occur 
 in very young infants as the result of improperly prepared cow's 
 milk, or in older infants as the result of the ingestion of starchy or 
 farinaceous food, or unripe fruit. In this disease the stools are tena- 
 cious and pasty, with occasional mixture of serous fluid, mucus rarely 
 being present. ' Though there may be griping pain at the time of 
 evacuation, there is no tenesmus. 
 
 CHOLERA INFANTUM. In this form of summer complaint there are 
 profuse watery evacuations, which are expelled forcibly with a gush, 
 and the vomiting, which usually attends, is projectile, the ejected 
 material being also watery in character. The disease is not very 
 common as compared with the number of other cases of summer 
 complaint which occur, though it is the gravest form of the disease. 
 
 The sympioms are very much like those of cholera morbus in 
 adults, though the disease is more likely to terminate fatally. There 
 are simultaneous vomiting and purging in many instances, though at 
 other times the vomiting may precede the purging. The stools may 
 contain faecal material and be offensive in odor at first, but they soon 
 become watery and odorless, and the patient becomes rapidly pros- 
 trated. The extremities become cold, the skin wrinkled, cold and 
 clammy, the nails blue, the countenance pinched and pallid and the 
 tissues greatly shrunken. Though the surface is cold the rectal tem- 
 perature varies from 102 to 107 F. and the pulse is rapid and 
 thready. There is extreme thirst and restlessness, and the patient 
 may scream with agony from severe cramping pain at the time of 
 evacuation. Liquids, foods and medicines are ejected as soon as 
 swallowed in many instances, even a teaspoonful of water exciting 
 responsive vomiting. As the disease progresses cerebral symptoms 
 may appear, the temperature becoming very high, and the patient 
 may die in convulsions within a few hours. In other cases the vom- 
 iting and purging may cease and the child pass into a comatose con.
 
 DISEASES OF THE INTESTINES. 467 
 
 dition, in which state it may remain for several days without 
 change, lying with the head retracted, with irregular respiration and 
 convulsive symptoms (hydroencephalon). 
 
 ACUTE ENTERO-COLITIS. This form of summer complaint is marked 
 by the frequent evacuation of dejections of mucus mixed with faecal 
 material, and often streaked with blood, the evacuations being at- 
 tended by painful straining (tenesmus) and preceded by pains along 
 the course of the colon or about the umbilicus. Frequently there is 
 gastric irritability, the tongue being red at the tip and pointed, fluids 
 and foods being rejected. This is the common form which estival 
 infantile enteritis assumes, and it usually follows acute dyspeptic 
 diarrhoea. The follicles of the ileum and colon are the anatomical 
 parts most involved in pathological chauge, and the term "follicular 
 enteritis" is occasionally applied to it. Though usually a disease of 
 hot weather, this form of enteritis may occur at any time of the year. 
 The symptoms vary according to the portion of the intestine affected, 
 evacuation without marked tenesmus attending when the irritation is 
 in the lower portion of the colon or in the rectum. After the disease 
 becomes established the evacuations are almost entirely mucus and 
 blood, while there is nearly complete arrest of faecal evacuation. 
 Sometimes the inflammation of the rectum and colon is so severe 
 that, instead of streaks of blood in the mucous evacuations the dis- 
 charges appear to be nearly all blood, and there is more than ordi- 
 narily severe pain and tenesmus at time of evacuation. Colicky pains 
 about the navel precede and announce the time of evacuation. The 
 temperature is not usually so high as in cholera infantum, but there 
 is constant elevation of temperature, this sometimes assuming a 
 periodical character and manifesting remissions and excerbations, 
 the severity of the intestinal trouble corresponding with the period- 
 icity. The number of evacuations vary from ten to thirty in twenty- 
 four hours. 
 
 As the disease progresses the patient becomes peevish and fret- 
 ful, and gradual emaciation ensues. When badly treated the disease 
 may continue for weeks, the evacuations gradually becoming puru- 
 lent and general wasting of the tissues (marasmus) attending, the 
 skin becoming dry and wrinkled, the eyes sunken, the face pallid with 
 hectic flush, and the child generally prostrated, with irritable stom- 
 ach. Death from convulsions frequently closes the scene. 
 
 Treatment. An important consideration in the treatment of 
 any form of summer complaint of children is rest for the alimentary 
 canal. As milk, otherwise than human breast milk, is almost certain 
 to curdle in the stomach and remain, to considerable extent, undi- 
 gested thereafter unless pancreatinized before administration, and as 
 such food doubtless contains many causal elements of the disease (if
 
 468 DISEASES OF THE DIGESTIVE ORGANS. 
 
 not the specific elements), it is a wise plan to withdraw it entirely 
 for a time as a diet and substitute such food as cannot furnish 
 any solid material during digestion to irritate the alimentary canal. 
 Barly-ioater or rice-water may be substituted for the first thirty-six 
 hours or longer, in children a year or more of age, these, to say the 
 least, contributing no additional source of danger. Strict attention 
 should be paid to the avoidance of fermentative action, all food being 
 kept in a refrigerator, or sterilized each time before use. When the 
 disease is severe and protracted, fresh meat broths may be sub- 
 stituted. In younger children the use of Horlick's malted milk 
 (which is so combined with cereals as to prevent coagulation) may 
 sometimes prove better than broths or barley-water, the food being 
 carefully sterilized at each feeding, and the periods being regulated 
 to the requirements of individual cases, and not allowed too often. 
 Eudoxine or ghjcozone may assist in arresting fermentation. 
 
 The milk of pregnant mothers is sometimes very injurious, occa- 
 sionally, apparently, being a provoking cause of the complaint. I 
 have found it necessary to remove the child from the breast on this 
 account, and in one case where death seemed imminent immediate 
 improvement followed when Mellin's food was substituted for the 
 mother's breast. When cow's milk is to be used, it should be care- 
 fully sterilized and afterward combined with lime-water, in order that 
 the curd may be well broken up and acidity removed a tablespoon- 
 ful of lime-water to eight ounces of milk. Nothing but milk sugar 
 should be used for sweetening the food of bottle-fed babies less 
 than a year old. 
 
 The medicinal treatment of dyspeptic diarrhoea will consist of im- 
 mediate evacuation of the bowels, the neutralizing cordial of the 
 Ameri* an Dispensatory being an excellent article for this purpose. 
 Following this, one or two drops of hydrozone in a drachm of dis- 
 tilled water may be administered three or four times daily to neu- 
 tralize fermentation and destroy toxic germs. If the greenish, tena- 
 cious stools persist after this, two-grain doses of mercurius dulcis 
 may be administered every three or four hours until several doses 
 have been administered, this remedy usually being capable of alter- 
 ing the conditions so that return to normal fsecal evacuations follows. 
 Sometimes two- or three-drop doses of the 3x dilution of mercurius 
 cor. will answer better, and at others five grains of sodium sulph. in 
 four ounces of water, dose a teaspoonful every hour, will answer bet- 
 ter. Minute doses of sulpho-carlonate of zinc are also excellent here. 
 
 In cholera infantum the hydrozone should be used as already sug- 
 gested, and to arrest the gushing discharges and projectile vomiting 
 half a drachm of veratrum album, 3x dilution, may be added to four 
 ounces of distilled water and a teaspoonful administered every fif-
 
 DISEASES OF THE INTESTINES. 469 
 
 teen minutes or half-hour. If this fails to control the watery dis- 
 charges, or if it is not immediately obtainable, a decoction of the 
 fresh trigeron canadense plant may be allowed, the child here drink- 
 ing it with avidity. It may be given often and freely. The specific 
 medicine may answer as well, though I have never tried it for the 
 purpose. When hydroencephaloid symptoms appear aconite and rlius 
 tox. should be administered, two or three drops of Lloyd's aconite 
 and eight or ten drops of rlius tox. being added to four ounces of 
 water and a teaspoonful given every hour. Where symptoms of coma 
 are marked and the pulse is small, feeble and compressible, two or 
 three drops of specific belladonna may be used instead after the 
 same manner as the aconite and rhus tox. In other words, two or 
 three drops of specific belladonna may be added to a half glass of 
 water, a teaspoonful of this to be given every hour until comatose 
 symptoms subside. 
 
 In the treatment of entero-colitis quite a wide range of remedies 
 may be required, though a few are usually sufficient. Aconite and 
 ipecac answer, with proper feeding, in relieving most cases and per- 
 fecting a cure. Add two or three drops of aconite and ten or fifteen 
 of specific ipecac to four ounces of water and order a teaspoonful 
 every hour. Sometimes the abdominal pain is excessive and attracts 
 special attention, demanding something more specific for its relief. 
 Then we will administer colocynth 3x dilution, half a drachm in four 
 ounces of water, a teaspoonful every hour or oftener if desired, until 
 this phase is removed. Colocynth is especially desirable if there be 
 much blood in the stools. In these cases time is an essential ele- 
 ment of success. Several days may be required to effect a cure, 
 the first favorable symptom being a lessening of the severity of the 
 Buffering during and between stools, and the next adimunition in the 
 number of stools. In malarious districts there will be a marked 
 periodicity which will demand arseniate of quinia 3x, and this remedy 
 may be used with good judgment in any case where malaria is liable 
 to be present. 
 
 Sometimes there is evidence of necrotic tendency, the evacua- 
 tions containing shreds of mucous membrane, false membrane and 
 dark sanious discharges (prune-juice), and the patient evincing typhoid 
 symptoms. Here we may think of baptisia or ec/tinacea, the latter 
 remedy being usually more appropriate, though sulpho-carbolate of 
 sodium may often supersede other remedies in such instances. 
 
 Where the disease runs into a chronic form and the discharges 
 become thin and watery with muco-purulent admixture, the patient 
 thin and emaciated with wrinkled skin, constant fretfulness and other 
 symptoms of marasmus, tncrcurius cor. 6x is an excellent remedy for 
 its relief. It is also excellent in the early stages, where the stools
 
 470 DISEASES OF THE DIGESTIVE ORGANS. 
 
 are greenish in color. In marasmus following this condition an al- 
 most indispensable element of rapid and satisfactory success is the 
 tonic farad ic treatment, general arrest of all unpleasant symptoms 
 rapidly following its adoption. 
 
 Several other important remedies for this disease and cholera 
 infautum may be found in Dynamical Therapeutics, a work almost 
 indispensable for the study of modern materia medica. 
 
 VIH. DISEASES OF THE MESENTERY. 
 
 MISCELLANEOUS AFFECTIONS. 
 
 THE mesentery is liable to serious affections, which are of suffi- 
 cient importance to merit attention in a work of this character. 
 
 The mesenteric arteries are subject to embolism and thrombosis, 
 and when this occurs the bowel in the territory supplied by an 
 affected vessel undergoes a condition of infarction. When only a 
 small branch is affected the condition may not be serious, and restor- 
 ation may occur without the development of serious symptoms. 
 When larger vessels are blocked, however, severe pain in the abdo- 
 men, with tympanities, nausea and vomiting, soon arises. Diar- 
 rhoea occurs as a rule, the stools being thin and watery and some- 
 times tinged with blood. Thrombosis of the superior meseuteric 
 artery is followed by infarction of nearly the entire length of the 
 small bowel, and rapidly fatal conditions follow. The treatment can 
 only be of a surgical nature, resection of the bowel being suggested. 
 Where the infarction involves but a small section of the intestine 
 resection offers hopes of relief. 
 
 The meseuteric veins are subject to dilatation, sacculatiou and 
 calcification, distention being due to portal obstruction. This may 
 occur in cirrhosis of the liver or in any other condition in which 
 the onward motion of the blood toward the portal circulation is 
 impeded. 
 
 Suppuration of the mesenteric veins is also liable to occur, and 
 it is a usual attendant of inflammation of the vena portae. Ex- 
 treme dilatation of the mesenteric veins then follows, and large 
 quantities of pus accumulate, until the mesentery appears, upon 
 inspection, like a bag of pus. Upon careful examination, however, 
 the pus will be found to be confined within venous channels which 
 have undergone great dilatation. The symptoms resemble those 
 of pylephlebitis, though there is greater abdominal distention. Treat- 
 ment is of little avail. 
 
 Cysls of the mesentery are not of unfrequent occurrence. Quite
 
 DISEASES OF THE LIVER. 471 
 
 a variety of morbid formations of this character may occur here. 
 They may be chylous, serous, sanguineous, hyatid or dermoid. They 
 may vary, from the size of an orange to immense masses occupy- 
 ing and distending the entire abdomen. They may develop slowly 
 or rapidly, from a few months to ten or twelve years being the 
 varying time occupied in their growth in different cases. The gen- 
 eral health is not much affected in these cases, colicky pains and 
 constipation, with enlargement of the abdomen, being the princi- 
 pal symptoms. The diagnosis is obscure, such diseases as ovarian 
 tumor, floating kidney, hydronephrosis and ornental cysts being 
 liable to be confounded with it. No specific treatment is kuown. 
 
 The chyle vessels are subject to various morbid conditions. En- 
 largement of the ducts in the mucous and submucous tissues of 
 the intestine and stomach occasionally occur. Sometimes these 
 are cystic, sometimes varicose, and sometimes cavernous. Extrav- 
 asation of chyle into the tissues of the mesentery sometimes occurs. 
 
 IX. DISEASES OP THE LIVER. 
 
 JAUNDICE. 
 
 Synonym. Icterus. 
 
 Definition. Jaundice can hardly be classed as a distinct dis- 
 ease, as it may depend upon a variety of pathological conditions. 
 However, as it is a striking condition of the system frequently pres- 
 eut, a consideration of the various phases attending it under one 
 grouping will be not only proper, but essential. The term "jaun- 
 dice" or "icterus" belongs to conditions of the system marked by 
 the presence of bilirubin in the general circulation and in certain 
 of the secretions, such as the urine and perspiration, and character- 
 ized by yellow hue of the skin, conjunctiva, hard palate, etc. 
 
 Etiology, Two forms of jaundice occur, one being due to 
 obstruction of the bile-ducts and the other to imperfect service of 
 the hepatic cells. When the bile is secreted by the hepatic cells 
 but is retained in the biliary ducts, to be afterward absorbed by the 
 lymphatics and carried to the blood through the thoracic duct, the 
 condition is termed "hepatogenous or obstructive jaundice." This 
 may be due to tumefaction of the mucous membrane lining the bili- 
 ary ducts, especially of the common bile-duct that portion which 
 lies in the wall of the duodenum the condition often being the 
 result of inward extension of congestion of the intestinal nmcosa. 
 At other times the obstruction may be due to lodgment of biliary 
 calculi, or iu exceptional instances to such parasites as the distoma
 
 472 DISEASES OF THE DIGESTIVE ORGANS. 
 
 hepaticum or echiuococcus iii the common bile-duct, and again to 
 pressure from tumors, such as cancer of the pylorus, tumors of the 
 pancreas, liver, or other abdominal tumors. The gravid uterus may 
 exert such pressure, as well as aneurisms. Inspissated mucus may 
 obstruct the opening of the biliary ducts where there is catarrh 
 of their liuiug membrane, it being remembered that the bile-pressure 
 from the secretory action of the cells in the ducts is very low, and 
 that the lymphatics readily take it up if there does not exist a favor- 
 able way of exit. 
 
 When there is lack of power upon the part of the biliary cells 
 to separate the coloring material from the hepatic circulation the 
 condition is termed "hematogenous or uonobstrusive jaundice." 
 In this form there may be an excess of blood destruction, as in mala- 
 ria, yellow and typhoid fever, epidemic jaundice, pyaemia, snake- 
 poisoning and poisoning from phosphorus and other drugs, the 
 hematoidin resulting being identical with the coloring material of 
 the bile (bilirubin). Necrosis of the hepatic cells may prevent sep- 
 aration of this substance, as in case of acute yellow atrophy, yel- 
 low fever, or such other infectious diseases as pyaemia, etc.; or, the 
 destruction of red blood-corpuscles may be so extensive that an over- 
 flow occurs, and, while a normal amount may be separated, a suffi- 
 cient quantity appears in the general circulation to give rise to a 
 jaundiced condition of the tissues. 
 
 In icterus neonatorum or the jaundice in infants, the first few days 
 succeeding birth may be attended by jaundice due to effective clos- 
 ure of the ductus venosus, or to lack of pressure in the branches of 
 the portal vein due to arrest of the placental circulation. In grave 
 forms of infantile jaundice congenital syphilitic hepatitis may be a 
 cause of obstruction, there may be congenital closure or absence of 
 the biliary duct, or there may be septicaemia phlebitis of the hepatic 
 veins from infection of the umbilical cord. 
 
 It is a question with many whether true jaundice can exist unless 
 the hepatic cells have formed the bile previous to its admixture with 
 the blood whether such a disease as hematogenous jaundice can 
 occur. While the coloring material of the bile is identical with 
 hematoidin, which may be formed withoiit passage through the liver, 
 the bile-salts (glycocholate and taurocholate of soda) never exist 
 unless elaborated by the hepatic cells. At least, then, there is a 
 marked difference between hepatogenous and hematogenous jaun- 
 dice in that in the one true bile circulates in the blood, while in the 
 other only the coloring material, identical with that of bile, is pres- 
 ent without other biliary constituents. 
 
 In Weil's disease (an acute infectious fever attended by jaundice, 
 duly considered under specific infectious diseases) there is obstruc-
 
 DISEASES OF THE LIVER. 473 
 
 tion of the biliary ducts from swelling of the liver, the clay- colored 
 stools attesting absence of the coloring material of the bile from the 
 intestinal canal. 
 
 Pathology. The morbid change which follows the continued 
 presence of the bile in the blood in hepatogenons jaundice is effusion 
 of bile-stained serum which yellows nearly all the tissues of the 
 body. It is asserted that the humors of the eye and substance of 
 the brain usually escape. Even the bones and teeth may be colored, 
 as well as new pathological formations. The presence of the foreign 
 material may be tolerated for a time, but cltolcemia or cholestercemia 
 is finally likely to result, a poison being generated which sets up 
 typhoid symptoms attended by fever and succeeded by coma, delirium 
 or convulsions. 
 
 The diversified conditions attending various forms of hematogen- 
 ous jaundice will be referred to under the special diseases in which 
 they occur. 
 
 Symptoms. The staining of the tissues is most marked in 
 hepatogenous jaundice. The tint may vary from a lemon-yellow to a 
 deep olive-green or bronze, the tint depending upon the permanency 
 of the obstruction of the biliary ducts. As catarrhal jaundice usually 
 terminates within a few days, the extreme depth of color reached in 
 more serious obstruction, as where permanent organic change exists, 
 does not here occur. 
 
 The skin and conjunctiva are markedly colored, the bright-red 
 mucus membrane, such as that of the lips, tongue and buccal sur- 
 faces, not showing the stain to auy great extent, though a distinct 
 yellowness of the hard palate may, in some instances, be observed. 
 
 Of the secretions, those most deeply colored are the urine and 
 perspiration. The color of the urine, in which the pigment may be 
 found before it is apparent in the skin or conjunctiva, may vary 
 from a light greenish-yellow to a deep black-green. A chemical 
 test may be made for it bv placing a few drops of the urine on a 
 white porcelain plate and adding a drop or two of nitric acid, when, 
 if bile be present, a rapid play of colors is produced, various shades 
 of violet, yellow, green and red interchanging. The urine colors 
 white linen yellow, and the perspiration, especially in the axillae and 
 groins, may stain the underclothing a similar color. In long-stand- 
 ing cases the urine may contain albumin and bile-stained tube-casts. 
 The tears, saliva and milk are not usually stained, although the 
 expectoration may be colored when inflammatory action in the pul- 
 monary tissues exists along with jaundice. Usually, however, the 
 sputum is not affected. Arrest of the usual flow of bile into the 
 intestine is attested by clay-colored, foetid stools, constipation or 
 diarrhoea.
 
 474 DISEASES OF THE DIGESTIVE ORGANS. 
 
 Pruritis of the skin is a frequent symptom of long-standing 
 cases, and it may be present in brief catarrhal jaundice, though it is 
 not apt to appear until the condition has become somewhat pro- 
 tracted. Various eruptions may develop upon the skin, such as 
 boils, wheals, lichen and urticaria. Sweating of the abdomen and 
 palms of the hands is sometimes a persistent symptom. 
 
 The pulse is often markedly reduced in frequency in obstructive 
 jaundice, the action of the heart falling to forty, thirty and even 
 twenty pulsations per minute. It is not considered a serious symp- 
 tom, however, being probably due to temporary impression of the 
 biliary material upon the cardiac nerves. 
 
 The effects of the biliary element upon the nervous system are 
 variously manifested. Drowsiness is frequently present, jaundiced 
 subjects being inclined to lethargy and sleep. During waking hours, 
 irritability and melancholia may be marked. Delirium, coma or 
 convulsions are liable to develop suddenly in any case of protracted 
 jaundice, and typhoid symptoms frequently terminate such cases. 
 Such cases are more apt to attend hematogenous than hepatogenous 
 jaundice, however, though long-continued presence of bile in the 
 blood in the latter form is liable to at length develop cholsemia or 
 cholestersemia, with grave symptoms. 
 
 In hematogenous jaundice there is not so marked discoloration 
 of the skin as in obstructive jaundice, and febrile symptoms with 
 rapid pulse are common. Bile-pigment is not so common in the 
 urine, though the urinary pigments may be increased, and the stools 
 are not clay-colored as in the obstructive form. Cerebral symptoms 
 are more liable to be marked here than in hepatogenous jaundice, 
 toxic forms being marked by delirium, coma, convulsions and 
 speedy demise. 
 
 The treatment of jaundice, in its various forms, will be considered 
 under the different diseases giving rise to it. In some cases treat- 
 ment is effective and highly satisfactory in its results, while in 
 others, on account of the pathological changes present, even tem- 
 porary relief is impossible. 
 
 INFANTJLE JAUNDICE. 
 
 Synonym. Icterus Neonatorum. 
 
 Etiology. The causes of infantile jaundice have already been 
 referred to. Reduction of blood-pressure in the hepatic capillaries 
 due to arrest of the umbilical circulation may prevent proper action 
 of the hepatic cells for a brief time, or temporary communication 
 between the portal and general circulation may account for mild 
 cases which recover spontaneously. In the severe forms there may
 
 DISEASES OF THE LIVER. 475 
 
 be congenital closure or absence of the common bile-duct, hepatic 
 syphilis of congenital form, or phlebitis from septicaemia infection 
 of the remains of the veins in the stump of the umbilical cord. 
 
 Symptoms. It is frequently the case that new-born children 
 become jaundiced within the first two or three days of life and in- 
 cline to drowse continually. The skin presents a deep, yellowish- 
 red color, instead of the reddish tint usually observed. The urine 
 stains the diapers yellow and the faeces, after the passage of the me- 
 conium, are colorless. The child may nurse, however, digest its 
 food faily well and not manifest any symptoms of distress. The 
 well-meaning but misinformed nurse may now administer a decoction 
 of saffron to "clear up the skin," and in a few days the jaundice dis- 
 appears a result which nature would have accomplished as well 
 without the "saffron tea" as with it. 
 
 Infantile jaundice from atresia of the bile-ducts is a rare condi- 
 tion, though several children of the same parents have been known 
 to be similarly affected. The attendant jaundice may not be appre- 
 ciable to sight for a week or fortnight, or even more. The skin, con- 
 junctiva and hard palate become yellow, and the tint rapidly grows 
 darker. The liver enlarges, the abdomen becoming protuberant and 
 distended, the swelling being largely due to hepatic and splenic con- 
 gestion, though intestinal gases and ascitic fluid may contribute to 
 the enlargement. Swelling of the hemorrhoidal veins and bleeding 
 from the navel may attend, the latter symptom being especially no- 
 ticeable, often beginning soon after the fall of the navel-string and 
 continuing to ooze until death, the discharge probably being due to 
 obstruction of the portal circulation from the swelling of the liver. 
 When umbilical hemorrhage is combined with infantile jaundice from 
 atresia, death follows within a few days, though jaundice from con- 
 genital atresia may otherwise continue for several months before a 
 fatal termination, the child taking food well, but gradually wasting 
 away, death possibly occurring finally from s.ome accidental compli- 
 cation, such as bronchitis or pneumonia. 
 
 Where infantile jaundice is due to syphilitic inflammation of the 
 liver, there are such suggestions of syphilis as skin eruptions, snuf- 
 fles, etc. The jaundice appears at birth, the liver is much enlarged, 
 and there is bleeding from the umbilicus and bowels, and extravasa- 
 tion into the skin. Kapid wasting and loss of strength are followed 
 by subnormal temperature, convulsions and death. 
 
 When the jaundice is due to umbilical phlebitis the yellow dis- 
 coloration of the skin comes on a few days after birth and is attend- 
 ed by fever, vomiting and complete loss of appetite. The child re- 
 fuses the breast, appears piuched and haggard, the tongue becomes 
 dry, and the hands and feet purple. The abdomen swells rapidly
 
 476 DISEASES OF THE DIGESTIVE ORGANS. 
 
 and is tender upon pressure, and there is more or less distinct fluc- 
 tuation, while blood and sanious pus ooze from the navel. The 
 jaundice is marked, and the urine may be intensely yellow, though 
 the stools may not be affected. Convulsions or coma may precede 
 death. 
 
 Treatment. Little benefit can be expected from treatment. 
 Iii mild infantile jaundice minute doses of chionanthiis may sometimes 
 assist in removing the coloring material from the circulation, though 
 probably a safer plan would be to leave the case to the unassisted 
 efforts of nature. In the jaundice from atresia and syphilis nothing 
 can be expected, though echinacea and lachesis may be thought of 
 in umbilical phlebitis. 
 
 MALTGNANT JAUNDICE. 
 
 Synonyms. Icterus Gravis; Acute Yellow Atrophy of the 
 Liver. 
 
 Definition. A grave form of jaundice characterized by cerebral 
 symptoms and distinguished by extensive drstruction of the cells of 
 the liver, with the deposit of leucin and tyrosin in the urine. Exten- 
 sive necrosis of the liver-cells is attended by marked reduction in 
 the size of the organ. 
 
 Etiology. This is a rare disease, and one which seems more 
 common in Europe than in this country. The rapid and extensive 
 necrosis which affects the hepatic cells suggests a powerfully toxic 
 influence which can hardly be ascribed to any other cause than that 
 of bacterial origin. Pregnant women seem to be especially suscep- 
 tible to it, as quite a large proportion of those affected have been of 
 this class, though males are also subject. A majority of cases occurs 
 in individuals between twenty and thirty years of age, though it may 
 affect children. It is said to have followed sudden fright or pro- 
 found thought, excesses in venery and poor living. 
 
 Pathology. The liver is remarkably reduced in size in most 
 cases, a thinning of the organ being a feature. When cut the sur- 
 face is yellowish-brown or reddish-brown, and microscopical exam- 
 ination discovers more or less complete destruction of the hepatic 
 cells through the entire extent of the organ. Complete destruc- 
 tion of the cells may be discovered in some places, while partially 
 destroyed structures remain in others. Granular debris, containing 
 pigment and crystals of leucin and tyrosin, occupy the devastated 
 sites. The capsule of the organ is wrinkled, the bulk having 
 shrunken to a half or a third of its original size and weight. Micro- 
 organisms have been found in the liver-tissues by various observers. 
 The kidneys are liable to be involved, granular degeneration of the
 
 DISEASES OF THE LIVER 477 
 
 epithelium occurring. The spleen is enlarged, and the heart is apt 
 to undergo fatty degeneration. Various organs are stained with bile 
 and extravasated with blood. The bile-ducts and gall-bladder are 
 empty. 
 
 Symptoms. The symptoms may not be severe in the begin- 
 ning, the condition resembling at first a mild case of obstructive 
 jaundice complicated with gastro-duodenal catarrh. Continuing in 
 this way for from a few days to two or three weeks, a period arrives 
 at which all the symptoms become suddenly aggravated. There is 
 vomiting, persistent and constant; frequent hematemesis; and hem- 
 orrhaghes may occur into the skin, conjunctiva and other parts. 
 Nervous symptoms are now a marked feature, there being intense 
 headache, trembling of the muscles, often delirium, and even con- 
 vulsions. A marked increase of the icteric symptoms attends this 
 aggravation, febrile conditions are assumed, the temperature rises, 
 the pulse becomes rapid, and typhoid symptoms, such as dryness of 
 the tongue with brown coating and sordes on the teeth and lips, and 
 muttering delirium or coma follow. However, pyrexia is not always 
 present. 
 
 The stools are clay-colored, showing that no bile enters the in- 
 testine, and the urine contains bile, tube-casts, leucin and tyrosin. 
 
 Diagnosis. Jaundice, with delirium and diminution of the size 
 of the liver, suggests the presence of this disease. Delirium may 
 attend hypertrophic cirrhosis, but enlargement of the liver will there 
 serve to distinguish it, and febrile symptoms are more constant. 
 Phosphorus poisoning may simulate this disease, as there are jaun- 
 dice, hypertrophy of the liver and purpura; but leucin and tyrosin 
 are absent from the urine and the gastric symptoms are more con- 
 stant from the start. 
 
 Prognosis. The disease is usually fatal under old-school treat- 
 ment, and Eclectics have recorded little experience with it. 
 
 Treatment. Goss advises minute doses of aconite and ipecac to 
 control the vomiting and hsematemesis, and chionanthus and berberis 
 vulgaris for the biliary symptoms. Behind the symptoms, however, 
 lies an important pathological change destruction of the liver-cells 
 by necrosis which demands first attention. A small group of rem- 
 edies gives us positive effects in many similar conditions, and may 
 be relied upon here with good prospects, if begun early. This 
 group comprises such remedies as echinacea, baptisia and lachesis. 
 If the disease is diagnosed early, potassium chloride 3x, as usually 
 employed, may prove a serviceable remedy. An easily digested 
 liquid diet should be adhered to, such articles as peptonized milk, 
 meat broths, buttermilk, clam broth and Horlick's malted milk con- 
 stituting its basis.
 
 478 DISEASES OF THE DIGESTIVE ORGANS. 
 
 ABNORMALITIES OF THE HEPATIC CIRCULATION. 
 
 ACTIVE HYPEB^MIA. This may follow meals as a physiological 
 act, the rapid absorption of the portal vessels resulting in vascular 
 fullness of the liver. When overeating is habitually indulged in, a 
 condition of chronic hyperaemia may finally follow, with functional 
 disturbance; and when alcohol is indulged in to large extent cir- 
 rhotic changes may arise. The principal symptom is a sense of full- 
 ness in the right hypochondriac region, with dypsnoea dependent 
 upon difficulty in drawing the diaphragm downward, this passing off 
 after time of digestion has gone by. Regulation of the diet is obvi- 
 ously the most important part of treatment, though aploppapus larici- 
 folius will afford temporary relief (saturated tincture, gtt. v-x, in a 
 swallow of water at a single dose). 
 
 PASSIVE CONGESTION. This involves the sublobular branches of 
 the hepatic veins, and is due to backward pressure from the general 
 circulation. Obstruction in the right heart or lungs, and tricuspid 
 insufficiency may be causes any condition attended by venous sta- 
 sis in the right side of the heart, emphysema, pulmonary cirrhosis, 
 intrathoracic tumors or chronic valvular disease being prominent 
 among the clinical causes. Chronic pressure from cardiac impact 
 may give rise to gradual dilatation of the sub-lobular and intra-lobu- 
 lar vessels, the intra-lobular capillaries compressing the hepatic cells 
 until they may finally become atrophied, a cut section of the organ 
 presenting a mottled appearance due to the large amount of venous 
 blood in the central capillaries, deposit of pigment and augmen- 
 tation of connective tissue; the condition being termed "nutmeg 
 liver." Among the symptoms may be pulsation of the liver due to 
 impact from the cardiac systole, gastro-intestinal catarrh, with oc- 
 casional hsematemesis. Ascites may finally appear as a result of 
 obstruction to the portal circulation, and icteric staining of the skin 
 attends, with bile-pigment in the urine and clay-colored stools. The 
 liver is appreciably enlarged, the organ being crowded downward 
 and rolling outward beneath the ribs, imparting, upon palpation, 
 a sensation of firmness to pressure. 
 
 Treatment is not very satisfactory, as the disease is secondary, 
 usually, to organic change of the heart or lungs, and a cure must 
 depend upon a removal of the exciting cause. To lessen pressure in 
 the portal vein, such remedies as carduus marianus, polymnia, ceano- 
 thus and grindelia squarrosa should be thought of. Aploppapus larici- 
 foliiis is an excellent remedy in some cases for this purpose. The 
 withdrawal of fifteen or twenty ounces of blood from the liver by 
 aspiration has been recommended, but the result must necessarily 
 be temporary, and would hardly, it seems, justify such a procedure.
 
 DISEASES OF THE LIVER. 479 
 
 Depletion of the portal circulation might be brought about by the 
 free administration of hydragogue cathartics, though the gastro- 
 intestinal catarrh would contraindicate the use of irritants here, the 
 salines being more appropriate. Attention must be paid to the con- 
 dition of the pulmonary and cardiac circulation, appropriate reme- 
 dies being directed to abnormal states in these parts. 
 
 DISEASES OF THE PORTAL VEIN. Chronic portal obstruction may 
 arise from chronic congestion of the liver, the etiology of which 
 has already been considered. Local causes are cirrhosis, pressure 
 from tumors involving the liver or located in the vicinity of the 
 portal vein, compression from proliferative peritonitis, or from 
 thrombosis. 
 
 Thrombosis or adhesive pylephlebids of the portal vein occurs second- 
 arily, from pressure upon the portal vein or one of its branches from 
 tumors, perforation of the vein by gall-stone or invasion by cancer. 
 When it occurs primarily it is during moribund processes, and is 
 not of importance. When occurring secondarily, the clot becomes 
 organized, grows pale and firm, and may finally become converted 
 into connective tissue. It may become perforated and permit of the 
 passage of a limited quantity of blood, a permanent narrowing re- 
 maining and modifying the attending symptoms. 
 
 The symptoms are announced by vomiting with diarrhoea, usually 
 attended by haematemesis and enterorrhagia. Dilatation of the por- 
 tal vein behind the point of obstruction rapidly follows, with rapidly 
 accumulating ascites. Dyspnoea, anorexia, prostration and heart 
 failure result, a fatal termination usually following within a week or 
 ten days. When some small branch only is involved, a collateral 
 circulation may be established and the patient may live for years, 
 though in indifferent health, general emaciation and prostration with 
 occasional gastric or intestinal hemorrhage attending. The diagno- 
 sis is difficult, and the prognosis is exceedingly bad. Treatment is un- 
 satisfactory, temporary relief, in all cases in which collateral cir- 
 culation is not established, being all that can be expected. The 
 ascitic accumulation should be removed by paracentsis, and the diet 
 sliouM be sparing. Diuretics and cathartics are recommended, but 
 cathartics would be liable to provoke more discomfort than they 
 would assuage. Restriction of the diet to almost a point of starva- 
 tion would be the most rational measure to pursue. 
 
 Septic thrombosis or suppurative pylephlebitis of the portal vein 
 is characterized by the formation of a thrombus in the portal vein 
 with subsequent breaking down, from the presence of infective ma- 
 terial. In this case the thrombus is not due to pressure, but arises 
 from localized inflammation of the vein, caused by intestinal ulcera- 
 tion, abdominal abscess, or such penetrating bodies as spiculae of
 
 480 DISEASES OF THE DIGESTIVE ORGANS. 
 
 bone, pins, needles, tacks, etc., which have been accidentally swal- 
 lowed and which penetrate the intestine, and later the portal vein. 
 In infants septic material may enter from the way of the navel, and 
 give rise to similar conditions. A clot forms at the point of pene- 
 tration, to afterward break down from suppurative action. Emboli 
 may be distributed to the liver from here, septic abscesses be scat- 
 tered through its substance, and even general pyaemia may attend, 
 the emboli sometimes passing the lobular circulation. Symptoms of 
 portal obstruction, septicaemia, pyaemia, and multiple abscesses of 
 the liver occur. Fatal results invariably attend within ten days or 
 two weeks, and treatment can be palliative only. 
 
 Affections of the hepatic vein are rare, its peculiar structure serving 
 to protect it greatly against infection or embolusfrom the abdominal 
 circulation. Enlargement of the right heart results in its dilatation, 
 and stenosis may arise at the orifices of its branches, general en- 
 largement and induration of the liver being the result. 
 
 Dilatation of the hepatic artery may attend cirrhosis of the liver, 
 and it may be sclerosed, or be the seat of aneurism. 
 
 INTERSTITIAL HEPATITIS. 
 
 Synonyms. Cirrhosis of the Liver; Sclerosis of the Liver; 
 Gin-drinker's Liver; Hob-nailed Liver. The term "cirrhosis" was 
 applied by Laennec, on account of the yellow color of the diseased 
 organ. 
 
 Definition. An inflammation of the connective-tissue of the 
 liver, attended by strangulation of the hepatic circulation, and conse- 
 quent destruction of the hepatic cells. 
 
 Etiology. Influences which originate and perpetuate irritation 
 of the capillaries of the hepatic circulation predispose to this condi- 
 tion. The most common is probably alcoholic addiction, the habit 
 of taking spirituous liquors on an empty stomach being especially 
 liable to produce it, as the stimulating influence of the alcohol on the 
 hepatic circulation is then most pronounced. Highly seasoned food 
 containing stimulating condiments is liable to result in a similar con- 
 dition, when indulged in for a long time. The acute infectious dis- 
 eases, notably scarlet fever, may inaugurate interstitial hepatitis. 
 Gout, syphilis and rheumatism may be included among the pre- 
 disposing causes. Malaria, by producing continued engorgement of 
 the portal circulation, is not an infrequent cause. Cardiac and pul- 
 monary obstruction may be attended by sufficient backward hepatic 
 impact to result in final cirrhosis. It often attends tuberculosis of 
 the liver. Anthracosis of the Irver is said to be a cause among min- 
 ers and workers in coal.
 
 DISEASES OF THE LIVER. 481 
 
 Pathology. The coimective tissue surrounding the smaller twigs 
 of the portal vein is usually first involved, the inflammation gradu- 
 ally extending to the larger branches. The rapid proliferation of 
 embryonic cells results at first in a soft, reddened, pulpy mass, which 
 distends the portal canals and increases the volume of the entire 
 liver. As the new cells undergo organization into permanent fibrous 
 material contraction follows, and compression is exerted upon the 
 portal, interlobular and central vessels, arresting their functions. 
 Nutrition of the lobules is thus cut off, and the pressure exerted en- 
 croaches upon the hepatic cells, aiding in causing atropy and degen- 
 eration of their structure. The outer cells of the lobules undergo 
 fatty degeneration at first, though complete obliteration of the lobules 
 may follow, their places being filled, in some instances, with newly- 
 formed connective tissue. The cells surrounding the central vein 
 are degenerated, atrophic and deeply stained with bile. The portal 
 canals present, upon the surface of the liver, depressions from con- 
 traction of fibrous tissue, the intervening lobules imparting a granu- 
 lated impression, and, as the contraction proceeds, the entire organ 
 may become corrugated and nodular upon the surface, affording 
 the condition known as hob-nailed. 
 
 If a section of the organ be made during the early stage of the 
 disease, the cut surface presents a hypersemic, pulpy appearance and 
 the entire organ is enlarged; but in a later stage the tissues are firm 
 and fibrous, cut with resistance, and the section presents a mottled, 
 yellow surface, upon which may be seen yellow spots stained with 
 bile-pigment, representing the central portions of lobules surrounded 
 by lighter colored zones of fatty degeneration, with surrounding 
 areas of slaty-gray, fibrous material. The smaller portal vessels are 
 shrunken, convoluted and twisted, and their lumen may be complete- 
 ly obstructed, new channels sometimes being formed between the 
 portal and hepatic veins. Separate branches from the hepatic artery 
 are sometimes traceable in the newly-formed connective tissue, and 
 the main artery is dilated and tortuous. 
 
 In hypertrophic (fatty) cirrhosis, the new connective tissue in- 
 sinuates itself about the bile-ducts and within the lobules, imparting 
 a firmness which occurs coincidentally with the development of con- 
 nective tissue in the portal channels, and resists contraction, the vol- 
 ume of the organ being permanently augmented by the growth of 
 connective tissue in its minute structure and the deposition of fat in 
 the parenchyma of the lobules. Another form of hypertrophic cir- 
 rhosis (biliary cirrhosis) is marked by early obstruction of the small 
 biliary-ducts and their radicles, these becoming permanently dis- 
 tended and infiltrated with bile-pigment. Coincidently with this 
 there is an abundant development of new connective tissue, but the
 
 482 DISEASES OF THE DIGESTIVE ORGANS. 
 
 biliary engorgement offers an obstacle to contraction, and the organ 
 not only retains its size but becomes augmented in bulk. 
 
 Syphilitic cirrhosis may result in atrophy or hypertrophy of the 
 liver. When the capsule is largely involved, contraction of the 
 organ results, and it may be diminished in size, the general ana- 
 tomical condition resembling that of cirrhosis from other causes. In 
 diffuse syphilitic hepatitis there may be permanent enlargement 
 of the organ, large bands of puckered fibrous tissue, visible to the 
 naked eye, appearing in isolated patches, and gummata being more 
 or less numerous, scattered through the substance, the fresh gum- 
 mata presenting a reddish-gray, translucent appearance, and the 
 older ones being surrounded by connective- tissue capsules, their 
 centers being broken down into puriform material or transformed 
 into fibrous, cheesy or calcerous masses. 
 
 Anatomically, four forms of hepatic cirrhosis have been recog- 
 nized: (1) The atrophic cirrhosis of Laennec; (2) perihepatitis or 
 Glissonian cirrhosis; (3) fatty cirrhosis; and (4) hypertrophic cir- 
 rhosis. Two of these forms, viz., the atrophic cirrhosis of Laennec 
 and Glissonian cirrhosis, are attended by final atrophy, and two, 
 fatty cirrhosis and hypertrophic cirrhosis, are attended by permanent 
 enlargement. 
 
 In the atrophic cirrhosis oj Laennec the liver, in advanced stages, 
 is very much diminished in size, and its tissues are remarkably firm 
 and resistant to the knife when cut. Its outer surface is granulated, 
 the contraction which it has undergone may have resulted in deform- 
 ity of shape, and its weight may be reduced to a third or a fourth 
 of its normal amount. When the cut surface is examined critically, 
 it will be seen to present isolated, greenish-yellow spots, surrounded 
 by grayish-white fibrous tissue* 
 
 In Glissonian cirrhosis there is remarkable development and 
 fibrous degeneration of Glisson's capsule, due to localized peritonitis 
 involving the perihepatic membrane. The capsule is hardened, 
 almost cartilaginous in consistency, and adhered to surrounding or- 
 gans. Sometimes the hepatic tissue underneath it may appear unal- 
 tered, though it is compressed, the bulk of the entire organ shrunken, 
 and there is usually extensive destruction of the lobules. Some- 
 times the fibrous growth occurs most extensively in the interior 
 of the organ, its prolongations along the portal canals being princi- 
 pally involved. Perihepatitis is common in syphilitic cirrhosis, the 
 capsule being thickened and adherent to surrounding organs, while 
 fibrous bands pass into the substance of the liver, undergoing con- 
 traction, causing deformity and resulting in fibrous scars. These 
 scars represent the sites of gummatous deposite, these being most 
 numerous along the attachment of the suspensory ligament.
 
 DISEASES OF THE LIVER. 483 
 
 Infatty cirrhosis the size of the liver is permanently increased, 
 the surface presenting a smooth or slightly granular condition with 
 yellowish-white or anaemic hue, the general appearance being that of 
 a fatty liver, though when cut its resistance to the knife determines 
 the difference, evincing the presence of a large amount of fibrous tis- 
 sue. The excessive amount of fat deposited in the lobules accounts 
 for its bulky appearance, though this is not a distinctive feature 
 as fatty degeneration occurs in the peripheral zone of the lobules 
 in all forms of cirrhosis. 
 
 Hypertrophic cirrhosis proper, or biliary cirrhosis, is characterized 
 by the retention of bile in the small biliary passages and their radi- 
 cles, with infiltration of pigment into the lobules and connective tis- 
 tue. Fibrous deposits in the lobular capillaries impart an early 
 firmness which resists contraction and results in permanent enlarge- 
 ment, and pigmentation imparts a deep-brown or black color to the 
 affected tissues. The obstruction to the portal circulation gives rise 
 to numerous pathological conditions about the tissues drained by its 
 radicles. Without an extensive collateral circulation speedily fatal 
 results must soon follow. In spite of this, engorgement of the gas- 
 tro-intestinal radicles results in catarrh of the stomach and bowels, 
 exudation of blood into the alimentary canal signalized by haemate- 
 mesis and melsena, and effusion of serum into the peritoneal cavity 
 (ascites). 
 
 Such changes however, are modified by collateral venous con- 
 nection between the general and portal venous systems, this some- 
 times being very extensive an^d at other times very restricted. The 
 hemorrhoidal plexus communicates with radicles of the portal sys- 
 tem and of the internal iliac, through which the surcharged portal 
 vessels may find some relief. The left renal vein anastomoses with 
 the radicles of the duodenum and colon. The phrenic vein may 
 anastomose with superficial branches of the portal vein. New chan- 
 nels are sometimes formed within the liver, between the portal and 
 hepatic veins. Adhesions which may form between the liver and 
 other organs may develop branches of sufficient size to convey con- 
 siderable of the obstructed blood. A venae comites of the obliter- 
 ated umbilical vein may become dilated and accompany the round 
 ligament to the umbilicus, and this may anastomose with the inter- 
 nal mammary and epigastric veins. When this anastomosis is well 
 marked, a circle of dilated veins (caput Medusae) is to be observed 
 around the umbilicus. Other branches accompany the suspensory 
 ligament and become enlarged, anastomosing with the diaphragmatic 
 veins, and thus joining the azygous veins. The oesophageal and gas- 
 tric venous radicles also anastomose, thus affording an additional 
 channel for the escape of the obstructed portal circulation.
 
 484 DISEASES OF THE DIGESTIVE ORGANS. 
 
 Symptoms. The extent of the collateral circulation will deter- 
 tine, to considerable degree, the severity of the symptoms. When 
 this is extensive, a subject of hepatic cirrhosis may not suffer 
 marked disturbance, and may continue in comparative comfort for a 
 long time. However, this is not usually the case. Hepatic con- 
 gestion is soon announced by sensation of fullness and weight in the 
 right hypochondrium with dypsnoea, from crowding beneath the dia- 
 phragm; the hepatic region is protuberant, tender upon pressure, 
 and the area of dullness about the liver is increased, while pal- 
 pation may detect the hard edge of the organ a hand's breadth below 
 the ribs. General malaise, with headache, anorexia, nausea, furred 
 tongue, and disgust for meats, soon attends. Gastric irritation now 
 develops, the patient being attacked with retching and empty vomit- 
 ing, especially in the morning upon waking from slumber, varying 
 attacks of diarrhoea being interspersed. The digestion of food is 
 soon attended by all the distress of gastric catarrh, and the tongue 
 may become red and pointed. The countenance assumes a muddy, 
 icteric hue (though not a markedly jaundiced one), the skin becomes 
 dry and harsh, the spleen enlarged, hemorrhoids appear, and a caput 
 Medusae, with enlargement of the superficial abdominal veins, may 
 be observed. Emaciation and cachexia rapidly encroach, and the 
 patient may be subject to vertigo, prostration, and occasional pangs 
 of acute pain in the right hypochondrium due to intercurrent attacks 
 of perihepatitis. 
 
 As the disease continues, hsematemesis and melaena occasionally 
 occur, and the gastric symptoms become still more aggravated. 
 Palpation of the right hypochondriac region may now enable one to 
 detect a lessening in the size of the liver, a sense of hardness and 
 irregularity of the surface being imparted to the touch. Tympanites 
 of the abdomen appears, and ascites follows at a later stage, while 
 oedema of the feet and ankles, and, finally, general anasarca, may be 
 developed. Jaundice is not a marked symptom except in biliary 
 cirrhosis, as, though there is obstruction to the secretion of bile, the 
 ducts remain open for its discharge into the intestine. The mind 
 usually remains clear to the last, though delirium or coma may at- 
 tend the closing scene. 
 
 The symptoms of biliary cirrhosis are distinctive. The hypo- 
 chondric fullness is marked, and jaundice is an early feature. 
 (Edema of the face and limbs, profuse sweats, hemorrhages, with in- 
 creasing jaundice, though without marked emaciation, attend. Ascites 
 is not so common as in the atrophic forms, and the hepatic enlarge- 
 ment is progressive, the enlarged liver being smooth and rounded. 
 Enlargement of the spleen is noticeable. After a time fhe disease 
 is likely to terminate with symptoms of acute febrile jaundice, a
 
 DISEASES OF THE LIVER. 485 
 
 cliill ushering in febrile symptoms, with delirium, coma, convulsions, 
 and death. The disease may exist in the chronic form for two years 
 or more, the acute termination lasting ten days or two weeks. 
 
 Diagnosis. The former habits of the patient will aid in a 
 diagnosis. An individual addicted to alcohol who suffers with 
 hepatic enlargement, gastric disturbance, hemorrhages from the 
 stomach and bowels aud ascites, is probably a subject of cirrhosis. 
 The firm, hard or nodulated liver, felt upon palpation during the 
 second stage, with evident contraction of bulk, is a strong suggestion 
 of the disease. Palpation should here be made after paracentesis, 
 in order to examine the organ carefully. Enlargement of the spleen 
 existing coincidentally, is additional evidence of cirrhosis. A his- 
 tory of syphilis with the preceding developments may be considered 
 confirmatory of a suspicion of cirrhosis, and young children with 
 syphilitic antecedents are liable to it. Cancer of the liver will be 
 differentiated by the marked cancer cachexia and rapid loss of 
 strength, which is more evident than in cirrhosis. Obstruction of 
 the portal vein by fibrous thrombosis may be difficult to distinguish 
 from cirrhosis, as the symptoms are very similar. The enlargement 
 which attends the early stage may be difficult to distinguish from 
 fatty liver, though there is absence of pain and gastric com- 
 plication. 
 
 Prognosis. The prognosis is usually unfavorable, though 
 where there is extraordinary collateral circulation the subject may 
 survive for years. However, hepatic cirrhosis terminates fatally 
 within a few years in most cases, and it may run its course in a few 
 mouths. After ascites and hematemesis appear there is little hope 
 of a favorable termination, though if the disease be diagnosed early 
 and proper treatment be employed there is considerable probability 
 of improvement. 
 
 Treatment. All exciting causes should be avoided. Alcoholic 
 liquors must not be allowed under any circumstances, and stimulat- 
 ing and highly seasoned food should be forbidden. The most bland 
 and uuirritating food should be chosen, a milk diet with crackers 
 and stale bread being preferable. To relieve gastric disturbances, 
 plenty of hot water should be taken, aerated waters being benefi- 
 cial. A careful study of some reliable work on diet will be useful 
 to the patient, that he may possess an intelligent idea of what is 
 best suited to his case. Sometimes milk causes "biliousness," and 
 other footl may be required, buttermilk, koumiss, whey, or malted 
 milk being preferable. After ascites has appeared fluids had better 
 be dispensed with, as they tend to increase the amount of dropsical 
 accumulation. A dry diet, consisting of stale bread with a small 
 quantity of meat, such as the white flesh of fish, oysters, sweetbread,
 
 486 DISEASES OF THE DIGESTIVE ORGANS. 
 
 liver, roast or broiled beef, and eggs, may be consumed, in limited 
 quantities. Tea and coffee should be avoided. Certain vegetables, 
 such as radishes, onions, garlic, etc., stimulate the liver; though 
 others, as spinach, asparagus, tomato, squash, pumpkin, celery, let- 
 tuce, oyster plant, etc., are allowable. Fruits are commendable to 
 encourage normal evacuation, though they should be selected with 
 a view of avoiding a stimulating influence upon the liver. Straw- 
 berries, grapes, oranges, apples, and peaches may be eaten. The 
 same precaution should be taken as in gastric catarrh; the food 
 should be taken slowly and thoroughly masticated, and its amount 
 should be limited to only enough to supply the needs of the body, 
 it being better for the meals to be taken alone. 
 
 When treatment is begun at an early stage of the disease, while 
 the liver is hypersemic, much benefit will follow the use of potassium 
 chloride 3x, five grains in half a glass of water, dose, a teaspoonful 
 every two hours, while awake. This will effectually prevent the 
 organization of the newly-formed plastic material, and tend to per- 
 manent recovery. After the advanced stage has been reached, med- 
 ication is of little use except to temporarily relieve aggravated 
 symptoms. 
 
 Gastric fermentation may be temporarily relieved by lavage or 
 by the use of hydrozone, and nausea and vomiting may be treated 
 with minute doses of aconite and rhus tox. When ascites becomes 
 so extreme as to cause much discomfort, paracentesis abdominalis 
 should be resorted to, and this should be repeated sufficiently often 
 to prevent unpleasant crowding of the abdominal cavity. Chioiian- 
 thus and chelidonium may afford some benefit in biliary cirrhosis. 
 Syphilitic cirrhosis should be treated with iodide of potassium. 
 Protonuclein may be found of service here, administered early. 
 
 ABSCESS OF THE LIVER. 
 
 Synonym. Suppurative Hepatitis. 
 
 Etiology. Abscess of the liver occurs as a single, large accu- 
 mulation of pus in one lobe of the organ, or as numerous small, sep- 
 arate accumulations of purulent material, scattered throughout the 
 liver-tissue. 
 
 Large or single abscess of the liver occurs most frequently in 
 tropical regions, either idiopathically or as a sequel to dysentery, 
 and the fact that the amoeba coli is invariably found in the pus in 
 such cases points strongly to its influence as an etiological factor. 
 It is a common disease in India, especially among Europeans who 
 indulge freely in the use of alcoholic drinks, and is not rare in the 
 southern states of our own country. Large single abscesses of the
 
 DISEASES OF THE LIVER. 487 
 
 liver may result from traumatism, blows received about the middle 
 of the body and falling upon the organ frequently result in sup- 
 puration. Pugilists and railroad brakemen are most liable to suffer 
 from this form, the crushing effect of injuries received while coup- 
 ling cars rendering the vocation of brakeman especially hazardous 
 in this respect. It is extremely rare among women, not more than 
 four or five per cent, of all cases occurring in females. 
 
 Multiple abscess of the liver is usually due to dissemination of 
 purulent material along the portal canals from infection of the por- 
 tal blood outside of the liver, though the suppuration is sometimes 
 due to irritation of the bile-passages from gall-stones (suppurative 
 cholangitis); parasites in the liver, such as the echinococcus, intes- 
 tinal worms, or the fluke-worm; tuberculosis of the liver; or pene- 
 tration of its substance by such foreign body as a needle or fish- 
 bone, which has perforated the oesophagus and wandered into the 
 hepatic tissues. 
 
 Embolic or pycemic abscesses of the liver may develop from gen- 
 eral pyaemia, the infection entering through the hepatic artery ; or it 
 may arise from causes originating among the radicles of the portal 
 vein or in the vein itself, when suppurative thrombosis of that ves- 
 sel occurs. The ulceration of typhoid fever may afford a nidus from 
 which infective material may enter the portal vein and reach the 
 liver. Dysentery, rectal disease, appendicitis, or pelvic abscess 
 may furnish the element of multiple suppuration of the liver, the 
 ramifications of the portal vein distributing it throughout the organ. 
 In new-born children the infection may enter through the umbilicus. 
 
 Pathology. In single abscess of the liver the right lobe is the 
 usual seat of suppuration, an extensive area of destruction being 
 involved. Sometimes several quarts of pus may be discharged from 
 an abscess of this character at one time. Instead of a single abscess, 
 two or more large ones may exist, these either remaining single or, 
 as the disease progresses, coalescing. The pus may be limited by 
 an abscess- wall or not, there frequently being no limiting membrane, 
 the confines being irregular projections of semi-disorganized liver- 
 tissue, projecting into the abscess-cavity. The purulent material 
 varies according to the origin of the disease, that of tropical abscess 
 being of a reddish-brown color, resembling anchovy sauce, pos- 
 sessing a peculiar odor resembling that of chyme, and containing 
 amoebae coli in great numbers. In traumatic cases, the pus may be 
 flocculeut and thin, or thick, creamy, and yellowish-green or brick- 
 red in color, from the staining of bile or bilirubiu. In traumatic 
 abscess the pus is sterile of microorganisms. 
 
 As the disease continues, the pus gradually works its way toward 
 the surface of the liver and finally perforates the limiting structures,
 
 488 DISEASES OP THE DIGESTIVE ORGANS. 
 
 sometimes opening into the pleural cavity, sometimes perforating 
 the diaphragm and discharging through the lung, sometimes pene- 
 trating the pericardium, vena cava, intestine, stomach, kidney, gall- 
 bladder, or peritoneal sac. Adhesion of the peritoneal surfaces may 
 occur, and the pus burrow its way to the surface through the 
 abdominal or thoracic wall. Nine per cent of all cases discharge 
 through the right lung, and five per cent empty into the right pleura. 
 With modern surgical knowledge, spontaneous discharge of pus will 
 be anticipated, in these cases, by early evacuation. 
 
 Multiple abscesses arising from pylephlebitis are distributed to the 
 ramifications of the portal vein, the abscesses usually lying near the 
 capsule. Numerous white points frequently appear beneath the cap- 
 sule, marking the locations of purulent deposits, and if these be 
 traced by probing they are found to communicate with the portal 
 veins. The liver, especially the right lobe, is markedly enlarged, 
 the organ rising into the thorax and extending as much as a hand's 
 breadth below the margin of the ribs. The suppuration may extend 
 along the branches of the portal vein, even into the main branch, 
 and thrombi may be distributed to its branches, in various parts of 
 the liver. In obstruction by gall-stones, the biliary ducts and gall- 
 bladder may be filled with purulent material. The pus is foetid, 
 greenish-yellow, and it may be flocculent, though it is frequently 
 thick and laudable. Large abscesses may form about hydatid cysts, 
 the presence of echinococci indicating their morbid character. 
 
 Symptoms. In rare cases, tropical abscess may arise insid- 
 iously and rupture without warning, sudden death occurring from an 
 unsuspected cause. Usually, however, the onset of the disease will 
 be announced by chills, following a short period of malaise, during 
 which the temperature may be subnormal. The chills may occur 
 periodically, and be followed by paroxysms of fever which decline 
 by sweating, the disease resembling an attack of ague, the tendency 
 to perspiration being marked, especially while the patient is sleep- 
 ing. Sometimes there is but the one chill, the succeeding fever 
 being remittent, and rising in the afternoon. In other cases, there 
 may be no febrile action, this occurring most commonly in chronic 
 cases. The temperature rises, in febrile cases, as high as 103 or 
 104 F. during the afternoon, declining toward morning. Pain, full- 
 ness, weight, and tenderness in the right hypochondrium attend 
 these symptoms, the area of liver-dullness in the right thorax being 
 enlarged, and the liver extending downward into the abdomen a 
 hand's breadth below the margin of the ribs. Fluctuation may occa- 
 sionally be detected upon palpation. Respiration is impeded by 
 the encroachment upon the thoracic space, and full inspirations are 
 attended by increase of pain in the right hypochondrium. The pain
 
 DISEASES OF THE LIVER. 489 
 
 varies in character, to correspond with the location of the abscess, 
 it being dull and aching when deeply seated, and sharp and lancinat- 
 ing when so near the surface as to affect the peritoneal covering. 
 Pain at the point of the shoulder or angle of the scapula is a frequent 
 symptom. Sometimes diffuse peritonitis may arise, and the lancin- 
 ating pain become severe and wide-spread. 
 
 Gastric irritation may attend, the tongue being heavily loaded; 
 and the countenance is dull and expressionless and presents a 
 muddy, icteric hue. Typhoid symptoms appear early; and delirium, 
 typhomania, coma, or convulsions may soon develop. 
 
 When the purulent accumulation points toward the thorax, char- 
 acteristic symptoms arise. If the lung be perforated, a violent and 
 harassino- cough arises, and soon the purulent discharge is expecto- 
 rated, the reddish, characteristic material resembling anchovy sauce, 
 denoting the condition in tropical abscess. When the thorax is 
 invaded within the pleural cavity, symptoms of pyothorax arise. 
 
 In multiple abscess of the liver the symptoms may not be so 
 active, pyaemic symptoms attending, the liver presenting enlarge- 
 ment, and the skin assuming an icteroid hue. The pain and tender- 
 ness may not be so acute as in single abscess, though there is appre- 
 ciable enlargement. The disease runs a more chronic course, but is 
 more likely to prove fatal from septicsemic complication. 
 
 Diagnosis. The chills, febrile symptoms, and enlargement of 
 the liver, with pain and tenderness, will usually call attention to the 
 liver as the seat of inflammatory disease. Aspiration will decide as 
 to whether there is an accumulation of pus. It is to be recollected 
 that hepatic abscesses involve the upper portion of the organ in 
 most instances, and here is the place to aspirate for pus, several 
 trials being sometimes necessary in multiple abscess in order to 
 intersect one, and locate it with the point of the needle. 
 
 Prognosis. The prognosis of pysemic abscess of the liver is 
 invariably unfavorable. Single abscess, under modern surgical 
 methods, may often be brought to a favorable termination. If the 
 disease be diagnosed early, and potassium chloride 3x be adminis- 
 tered early and perseveringly, arrest of suppurative action may be 
 accomplished in many cases of traumatic, if not in tropical abscess. 
 
 Treatment. The early administration of potassium chloride 3x, 
 five grains in half a glass of water, dose, a teaspoonful every hour, 
 is the proper medication for the early stages. If expectoration of 
 pus suggest the discharge of the abscess through the lung, a con- 
 servative course may be better than a radical one, the complications 
 being met as they arise and aspiration of the lung postponed. The 
 general treatment of septicaemia will be applicable after there has 
 been purulent accumulation.
 
 490 DISEASES OF THE DIGESTIVE ORGANS. 
 
 Section of the abdominal muscles, down to the liver, with subse- 
 quent stitching of the liver-tissue to the abdominal wall, so that a 
 surface is left for opening, and free drainage of the abscess, is prob- 
 ably the most successful method of treating this disease. The open 
 abscess then becomes an ulcer which is easily treated until com- 
 plete recovery results. 
 
 The diet should be free from fats and liquors, and consist of 
 small quantities of fluid, predigested food, such as pancreatinized 
 milk and malted milk, and animal broths free from fat. If there 
 does not seem to be enough nourishment in such diet, eggs, beaten 
 in milk, may be used sparingly, food being taken in small quantities 
 at a time, every three hours. 
 
 NEW GROWTHS IN THE LIVER. 
 
 THE principal new growths which occur in the liver are carcino- 
 mata, sarcomata, angiomata, and adenomata. To these may be 
 added cystic accumulations, which, though not strictly new growths, 
 are usually considered in this relation. 
 
 Carcinoma of the liver may occur as a primary affection, and 
 secondarily from infection by continuity of other organs, through 
 the lymphatics, and, at an advanced stage of the disorder, through 
 the portal vein or hepatic artery. Women are more liable to it than 
 men, and it is rare before the middle of life, tendency to it increas- 
 ing after that time to the sixty-fifth year. 
 
 Pathology. Cancerous growth occurring near the entrance of 
 the portal vein may so obstruct the circulation as to result in asci- 
 tes and dilatation of the radicles of its collateral branches. In 
 some cases the cancer-growth may be localized in a small portion of 
 the liver as a primary growth, and numerous nodules, of later devel- 
 opment, arise secondarily. In other instances, the entire organ may 
 be involved in primary cancerous growth (massive cancer). Infil- 
 tration of the liver with cancerous elements is common in secondary 
 infection from the lymphatics or portal vein, the development of 
 fibrous growths about the cancer deposits causing a general resem- 
 blance to cirrhosis. The shape of the liver may be variously 
 altered; one large growth may be' surrounded by numerous smaller 
 distributed nodules, or the entire surface may be covered with 
 with small, irregular nodules, sometimes projecting from the sur- 
 face, at others imperceptibly grading into the general surface, and, in 
 other instances, presenting crater-like depressions. Hemorrhages 
 may occur into the nodules, and suppuration occasioually, though 
 rarely, ensues. Pressure upon the biliary passages, from contraction 
 or nodular crowding, is not an uncommon condition, retention of bile
 
 DISEASES OF THE LIVER 491 
 
 and hepatogenous jaundice resulting. In secondary cancer of the 
 liver, the organ is often enormously enlarged, its weight sometimes 
 exceeding twenty pounds. The nodules project beneath the capsule, 
 and may be plainly felt through the attenuated abdominal walls. 
 Various degenerative changes may occur in the morbid structures, 
 such as hyaline or fatty degeneration, or sclerosis. When the dis- 
 ease originates in the bile-passages, it is usually associated with 
 irritation from gall-stones, and the cancerous growth frequently 
 arises in the base of the gall-bladder. Biliary obstruction from 
 extension of the process to the common or hepatic duct is liable to 
 arise, with retention of bile. In some cases the disease arises pri- 
 marily in the ducts. Localized peritonitis often gives rise to adhe- 
 sions of the capsule to surrounding peritoneal surfaces. 
 
 Symptoms. The symptoms of hepatic cancer may be obscure 
 in the beginning, pain, fullness, and icterus being attendants of vari- 
 ous other hepatic disturbances. The cancer cachexia, however, 
 becomes marked before long, and gastric symptoms attend, as well 
 as those of biliary and portal obstruction. A knowledge of primary 
 cancer preexisting in some other part, such as the rectum, uterus, 
 pylorus, or mamma, renders the diagnosis of secondary cancer of 
 the liver easy, but primary cancer of the organ requires more care. 
 When the cancerous growth is located near the periphery of the 
 liver, the nodulated surface, with its crater-like depressions, may be 
 palpated through the attenuated abdominal walls, and this, in con- 
 nection with the loss of strength and flesh, cachectic pallor of coun- 
 tenance, aud tendency to rejection of food by the stomach, with pain 
 in the right hypochondrium or beneath the right shoulder or in the 
 dorsal region opposite, suggests the condition strongly. Ascites 
 usually arises as a result of obstruction to the portal circulation, 
 and oadema of the feet appears at a late stage. 
 
 Though hepatic cancer may run its course without pain, jaundice, 
 or ascites, these are usually prominent symptoms. The pain is 
 often lancinating, this being due to involvement of the peritoneal 
 surface. The temperature is normal or subnormal and the pulse 
 small and rapid. 
 
 Enlargement of the cervical and inguinal lymphatics is often 
 present from cancerous infiltration, and there are hematemesis and 
 mehena, and hemorrhages from the mouth and vagina. Eccbymotic 
 spots may appear on the skin. 
 
 Diagnosis. The enlarged, irregular-shaped liver suggests the 
 condition, and umbilication of the nodules establishes the diagnosis 
 without question. When palpation fails to distinguish this, the can- 
 cerous cachexia, in connection with the local disturbances, such as 
 pain, irregular enlargement of the liver, and persistent gastric dis-
 
 492 DISEASES OF THE DIGESTIVE ORGANS. 
 
 turbance, can hardly be mistaken. Aspiration will exclude abscess 
 from the diagnosis. 
 
 Prognosis. The prognosis of hepatic cancer is invariably 
 unfavorable. The pain and other discomfort, however, may be mod- 
 ified by rational treatment, and much suffering thus prevented. 
 Medullary cancer of the liver is a rapidly fatal disease, usually ter- 
 minating within from two weeks to four months. The average dura- 
 tion of cancer of the liver is one year. 
 
 Treatment. If treatment is begun early, and properly perse- 
 vered in, many of the severe symptoms may be averted, and the 
 progress of the disease stayed considerably. Eclnnacea not only 
 relieves the pain of cancer, but it seems to fortify the system against 
 the rapid inroads of the disease, retard the rapidity of cancerous 
 growth, improve assimilation, and prevent the rapid dissemination 
 of the cancer-elements, while it lessens anaemia and cachexia A 
 steady use of this remedy is therefore advisable, ten or fifteen drops 
 of the saturated tincture of the recent plant being administered 
 every four hours. Chelidonium may be alternated with this, five or 
 ten drops of the specific medicine being administered every four 
 hours.' Besides a supposedly antidotal influence against cancer, 
 this remedy encourages normal hepatic processes, and assists in the 
 elimination of bile from the biliary passages, thus guarding, in some 
 degree, against hepatogenous jaundice. The diet should be nutri- 
 tious and digestible. 
 
 Sarcoma of the liver is a rare disease, though it occurs in a few 
 cases primarily, and somewhat more frequently secondarily. It 
 may occur in the form of lympho-sarcoma, myxo-sarcoma, or glio- 
 sarcoma. Melano-sarcoma is a variety in which the morbid tissues 
 are pigmented, presenting the appearance of dark granite or deep 
 black, mottled with streaks of white like dark marble ; and this is 
 the form usually prevailing. It occurs as a secondary affection fol- 
 lowing sarcoma of the eye or skin. The liver becomes much 
 enlarged, and is either uniformly infiltrated with the morbid growth 
 or nodular masses may be distributed through its structure, the sur- 
 face, however, presenting a uniformly smooth appearance. As the 
 blood distributes sarcoma readily, numerous metastases are liaHr 
 to attend the liver-affection early, many other organs being involved. 
 The disease is most liable to affect the young and those before mid- 
 dle life. 
 
 Adenomata of the liver occur occasionally, appearing in the form 
 of small encapsulated tumors, having the structure of the liver. 
 Their presence is, however, rare. 
 
 Angiomata of the liver is most liable to occur in children, and 
 consist of masses of dilated blood-vessels about the size of a walnut,
 
 DISEASES OF THE LIVER. 493 
 
 of dark reddish color. They sometimes attaiii a much larger size, 
 increasing the bulk of the liver, though the liver-tissue is not 
 altered. They usually occur singly. 
 
 Cysts of the liver may be single or multiple, and usually occur 
 in connection with congenital cystic kidneys. Hydatid cysts (from 
 echinococci ) will be considered in another place. 
 
 The diagnosis of sarcoma is often difficult, the pain and enlarge- 
 ment being common to other morbid conditions of the liver, though 
 accompanying sarcoma of the stin or eye will furnish a valuable 
 suggestion. Angiomata and adenomata are recognized with difficulty, 
 though an adenomatous condition generally would lend color to a 
 suspicion of adenomatous growths in the liver if hepatic disturbance 
 attended. Persistent hepatogenous jaundice, due to pressure upon 
 the biliary ducts, gastric disturbance, and enlargement of the liver, 
 are among the constant symptoms of all new growths of the liver. 
 
 The treatment cannot be specified. Such urgent symptoms as 
 may arise should be met by the judicious administration of what, 
 according to our knowledge of materia medica, seemed to be most 
 urgently demanded, care being taken to avoid opiates, so far as pos- 
 sible. If angionia be diagnosed, calcium fluoride 3x may be admin- 
 istered with some hope of benefit. 
 
 FATTY LIVER. 
 
 Etiology and Pathology. Fatty liver, in some form, is of 
 frequent occurrence. It may occur as an infiltration or a degenera- 
 tion under abnormal conditions, and physiological infiltration of the 
 cells is constantly present during health, and increased after the 
 ingestion of fatty food. The liver-cells which lie near the branches 
 of the portal vein, i. e., the circumferential cells of the lobules, 
 receive the fatty deposit first, and, in abnormal infiltration, here is 
 where the process is most observable. For the disposal of fat in the 
 portal blood, active oxidation must occur before it can be received 
 by the hepatic cells, and to lack of proper balance between fat-sup- 
 ply and oxidation is referable abnormal infiltration of the liver with 
 this material. (1) An excess of non-nitrogenous material in the 
 blood may defeat the efforts of normal oxidation, and an undue 
 amount of fat thus be left to be taken into the hepatic cells, this 
 condition accompanying excessive deposit of fat in other parts of the 
 body and constituting general obesity, a condition not necessarily 
 attended by impairment of function or danger to hepatic integrity. 
 (2) A normal or even small amount of fatty material in the portal 
 circulation may result in fatty infiltration when there is lack of a 
 proper supply of oxygen for its consumption ; and fatty infiltration
 
 494 DISEASES OF THE DIGESTIVE ORGANS. 
 
 of the liver is not rare in phthisis, anaemia, and other cachexiae, the 
 deposition of fat then occurring in the liver while other parts of 
 the body are undergoing emaciation. 
 
 Fatty degeneration or fatty metamorphosis implies a destruction 
 of the individuality of the hepatic cells and the occupation of their 
 sites with fat-globules and debris of the preexisting cells. This is 
 a much more serious condition ; for, when general, it implies cessa- 
 tion of hepatic function. It is due to iupairment of the vitality of 
 the hepatic cells, through the local influence of irritating or poison- 
 ous substances, such as toxines and phosphorus, and from lack of 
 nutrition, as when the normal blood-supply to a lobule or group of 
 lobules is impoverished or cut off, as in anaemia, cirrhosis, etc. 
 
 The fatty liver is uniformly increased in size, and its surface is 
 smooth and presents a bloodless, pale appearance. On section, it 
 is dry, and it cuts as though greasy, and leaves a fatty coating on 
 the knife. Sections, and even the entire organ, though greatly 
 enlarged and increased in weight, may float in water. 
 
 Symptoms. The symptoms are not very striking or definite. 
 Enlargement in the right hypochondrium is present, the edge of the 
 enlarged organ sometimes being distinguishable by palpation below 
 the navel, soft and doughy on pressure. It is not, however, painful or 
 sensitive. Gastro-iutestinal symptoms, referable to pressure and 
 portal obstruction, are frequently prominent; for, though there may 
 not be sufficient pressure upon the portal canals to originate ascites 
 or splenic enlargement, there is enough to congest the gastro-intes- 
 tinal mucous membrane and interfere with the digestive functions. 
 There may be vomiting, with gastric catarrh, attacks of diarrhoea, 
 and other symptoms of gastro-intestinal dyspepsia, with loss of 
 strength, anaemia, drowsiness, and despondency. Dyspnoea arises, 
 both from debility, and pressure upon the diaphragm. The skin 
 has a peculiar smooth, "velvety" feel, and the tissues are flabby and 
 inelastic. The biliary functions are not interfered with unless 
 there is extensive destruction from metamorphosis of the hepatic 
 cells, and jaundice is seldom noticeable. . When metamorphosis of 
 the hepatic cells is extensive, rapid anaemia, exhaustion, delirium, 
 and collapse are liable to occur at any time, the stools presenting a 
 pale, clay-colored appearance, attacks of diarrhoea then frequently 
 occurring. 
 
 Diagnosis. The large, rounded liver, with smooth surface and 
 inelastic tissues, will not be confounded with cirrhosis or cancer, in 
 which nodular or granulated projections are distinguishable. The 
 only disease liable to be confounded with it is waxy liver, and here 
 the skin is dry and pale, while in fatty liver, it is soft, velvety, 
 moist and shining. In fatty liver the blood is hydrsemic, while in
 
 DISEASES OF THE LIVER. 495 
 
 waxy liver it is leukaemic. The history of waxy liver may also 
 assist in determining the matter, as syphilis is liable to result in 
 waxy liver, while fatty liver seldom follows it. The waxy liver is 
 hard and firm, while the fatty liver is soft and doughy. In fatty 
 liver the urine is normal, while in waxy liver it is albuminous, and 
 often contains casts. The spleen is enlarged in waxy liver, but 
 remains normal in fatty liver. 
 
 Prognosis. The character of the fatty accumulation will 
 determine its gravity. Fatty infiltration is not a serious condition, 
 but fatty metamorphosis, when extensive, is of serious nature. 
 
 Treatment. An abstemious diet and active occupation are 
 conducive to recovery in all curable cases. Plenty of out-door exer- 
 cise in elevated regions, under sanitary conditions, is an imperative 
 part of treatment. Oxygen gas, either by inhalation or by rectum, 
 improves the power of the portal blood to dispose of fatty material, 
 and is always to be commended. Phthisis, syphilis, and other con- 
 ditions predisposing will demand special treatment. Sugar, starch, 
 fats, malt liquors and alcoholic drinks should be considered as per- 
 nicious, as a rule, though fatty liver may exist in anaemic or pros- 
 trated conditions where a judicious use of some of these substances 
 may be required. Herberts aquifolium may be employed to improve 
 the digestive power, and gastric catarrh may require hydrozone or 
 lavage to prevent fermentative action. 
 
 AMYLOID LIVER. 
 
 Synonym. Waxy Liver. 
 
 Etiology. The principal cause of waxy liver is syphilis. It 
 occurs most frequently in males between twenty-five and fifty years 
 of age. Prolonged suppuration, and chronic diseases of bone, are 
 other prominent causes, phthisis, ulceration of the bowels from 
 chronic dysentery, chronic pyelitis, and rickets, being most fre- 
 quently predisposing causes after syphilis. Prolonged convalescence 
 from infectious diseases, especially malaria, and any form of cachexia 
 attended by wasting and impoverishment of the blood may finally 
 develop amyloid degeneration of the liver. 
 
 Pathology. The amyloid change begins in the radicles mid- 
 way between the center and periphery of the lobules, and extends to 
 the minute branches of the hepatic artery. A material of nitroge- 
 nous, homogenous, translucent appearance, with dull, glistening sur- 
 face infiltrates the walls of the capillaries in the median zone of the 
 lobules, and extends to the iuterlobular vessels and connective-tis- 
 sue, the cells being but little involved. "When the affected tissues 
 are stained with iodine, the morbid deposit assumes a rich mahog-
 
 196 DISEASES OF THE DIGESTIVE ORGANS. 
 
 any-brown. The entire liver is enlarged, firm and resistant, the 
 edges sharply defined and the surface smooth. 
 
 Symptoms. Enlargement of the liver, causing bulging in the 
 right hypochoudrium, with increased area of liver-dullness, without 
 pain or tenderness, is the principal symptom. There is no biliary 
 obstruction, and jaundice is absent, though the stools may be light- 
 colored. The spleen is occasionally involved, its bulk being 
 augmented. 
 
 Diagnosis. This is usually easy, as the history of the case 
 will account for the gradual and progressive enlargement of the liver 
 without pain or tenderness. Long-standing suppuration, syphilitic 
 antecedents or persistent cachexia, followed by such symptoms, will 
 naturally support a theory of amyloid degeneration. 
 
 Prognosis. Unfavorable. Syphilitic cases may be modified 
 and life prolonged by proper treatment, but the inevitable result 
 will finally be death. The disease runs a slow course, and may 
 drag along for months, and sometimes years, such complications as 
 diarrhoea, purulent peritonitis, perihepatitis, fatty or waxy kidney, 
 pulmonary oedema, pulmonary gangrene, etc., appearing meanwhile. 
 Death may finally result from exhaustion, anasarca, diarrhoea, urae- 
 mia, or other causes arising from varying complications. 
 
 Treatment. Syphilis should be properly treated, and causes 
 of prolonged suppuration removed if possible. Primary diseases 
 should be rectified when practicable, and anaemia and cachexia cor- 
 rected by all available measures. Each case will suggest its medi- 
 cinal treatment, it being recollected that no specific remedy can be 
 recommended for amyloid degeneration. All that can be done is to 
 strive to correct the dyscrasia upon which the morbid change 
 depends. 
 
 The diet should be considered, and sugars and starch avoided, 
 and, when the stomach is fairly active, lean beef should be the prin- 
 cipal diet. When digestion is greatly impaired, predigested foods 
 may be required, beef peptonoids and pancreatinized milk being 
 representative forms of diet When the disease has advanced suffi- 
 ciently far to be readily diagnosed, little time will usually be left 
 for treatment, a fatal termination soon attending. 
 
 TUBERCULOSIS OF THE LIVER. 
 
 TUBERCLES may be deposited in the liver during the course of 
 general tuberculosis, and in connection with tubercular disease of 
 the intestines and mesenteric glands, though there are few distinct- 
 ive features attending, ami they attract little more than pathological 
 interest. In miliary tuberculosis, they are distributed throughout
 
 DISEASES OF THE BILE PASSAGES. 497 
 
 the liver-tissue in small masses, while in the chronic forms they may 
 occur as a few large tubercular deposits. In chronic tuberculosis 
 of the liver there is usually considerable increase in the amount of 
 connective tissue, and the deposits are liable to be associated with 
 chronic perihepatitis or peritonitis. On account of the extensive 
 proliferation of fibrous-tissue atttending, chronic tuberculosis of the 
 liver is usually designated as "tubercular cirrhosis." 
 
 VIII. DISEASES OF THE BILE PASSAGES. 
 
 CATARRHAL INFLAMMATION OF THE BILIARY PASSAGES. 
 
 Synonym, Catarrhal Jaundice. 
 
 Etiology and Pathology. Eeference to this disease has 
 been made under jaundice, but completeness demands notice of it 
 here. It arises from congestion of the mucous membrane of the 
 common bile duct in most cases, though it has been asserted that 
 the inflammation may begin in the smaller passages and extend to 
 the larger canal. Duodenal catarrh, accompanied by indigestion, 
 usually originates it, the inflammatory action extending inward, 
 from the intestinal mucous membrane. Obstruction of the biliary 
 passage may be due to accumulated and inspissated mucus in the 
 passages, or in the common duct alone, the common point of 
 obstruction being in the pars intestinalis, that portion which extends 
 into the intestine. It occurs frequently in young persons, though 
 all ages are liable to it, indiscretions in diet, colds, malarial attacks, 
 and all causes which predispose to portal obstruction, being liable 
 to be followed by it. It sometimes occurs in fevers, pneumonia, etc. 
 Emotional disturbances are sometimes followed by jaundice sup- 
 posed to be due to this condition, and it may occur epidemically, from 
 unknown causes. 
 
 Symptoms. Where the disease is due to continuity of intesti- 
 nal irritation, it is apt to be preceded or attended by indigestion, 
 flatulence, and constipation. The skin rapidly assumes an icteric 
 hue, the color being bright yellow, and never the greenish tint 
 observed in some cases of grave or long-continued jaundice. Slight 
 fever may attend, though the temperature is rarely above 101 or 
 102 F., and it may not be elevated at all. In the epidemic form, 
 however, there is liable to be an initiatory chill, followed by fever 
 and headache. The bowels are constipated and the stools are clay- 
 colored, while the urine contains bile pigment. Though the pulse 
 maybe quickened in the epidemic variety, and may sometimes be 
 normal in other cases, it is usually abnormally slow, falling as low 
 as forty, thirty, or even twenty beats per minute. Slight enlarge-
 
 498 DISEASES OF THE DIGESTIVE ORGANS. 
 
 ment of the liver may occur, though its size may be normal or con- 
 siderably enlarged. The duration of the disease varies from two to 
 twelve weeks, the first indication of returning health being a return 
 of the normal color of the stools. General malaise, muscular pains, 
 nausea and anorexia, dizziness, drowsiness, and indisposition to 
 exercise, are frequently present. 
 
 Diagnosis. The symptoms are of such a mild nature and occur 
 so suddenly, while the patient is about, or follows suddenly upon 
 an acute attack of gastro-intestinal irritation, that there is little dan- 
 ger of a mistaken diagnosis. Other forms of jaundice come on 
 gradually, or are much more severe in their symptoms. In jaundice 
 from organic disease of the liver, there is emaciation, ascites, and 
 other indications of portal obstruction! Weil's disease and malig- 
 nant jaundice present characteristic symptoms. 
 
 Prognosis. The prognosis is favorable, rational treatment 
 usually bringing the disease to a speedy close. Even badly treated 
 cases may recover after a time, without serious complication or 
 sequelae. 
 
 Treatment. The treatment of this form of inflammation will 
 depend upon the conditions presented. If febrile symptoms appear, 
 aconite and rhus tox., or other appropriate sedative treatment may be 
 employed in the beginning. Malarial manifestations must be appro- 
 priately met, periodicity being interrupted with quinine and this 
 may be followed by ten-drop doses of grindelia squarrosa (green 
 plant tincture), repeated every four hours during the day and eve- 
 ning. The most appropriate remedies for the biliary obstruction 
 are chelidonium and chionanthus, either in combination or singly. 
 Enemata are useful to assist the action of the chologagues, and the 
 use of the salt water galvanic electrode in the lower bowel, with the 
 positive pole applied over the hypochondriac region, is an excellent 
 aid, and even curative measure, in a large majority of cases in which 
 it is tried. 
 
 GALL-STONES. 
 
 Synonyms. Cholelithiasis; Biliary Calculi. 
 
 Definition. Concretions which form in the gall-bladder, due 
 to inspissation or concentration of the bile, from long retention. 
 
 Etiology. It is believed that defect in the sodium salts favors 
 the precipitation of cholesterin, of which the concretions largely 
 consist. Inactivity of a person tends to the production of biliary 
 calculi, those of sedentary habits being most prone to them, the 
 majority of cases (75 per cent) occurring in women. Pressure upon 
 the cystic duct doubtless favors their formation by obstructing the 
 free flow of bile, lacing and pregnancy thus rendering women excep-
 
 DISEASES OF THE BILE PASSAGES. 
 
 tionally prone to the disease, about 90 per cent of the cases occur- 
 ring in women affecting those who have borne children. It has been 
 asserted that twenty-five per cent of all women past sixty-five years 
 of age are subject to gall-stones. The majority occur after middle- 
 life, the disease being rare in persons less than thirty-five years of 
 age. A fatty diet, an excess of animal food, and alcoholic drinks are 
 supposed to figure as causal factors. 
 
 Pathology. The number of gall-stones in the cyst and biliary 
 passages may vary from one to a thousand. "Where there are great 
 numbers, they may be very small not larger than a small bird-shot. 
 Where there is but one it may be very large, sometimes the size of 
 a lemon, and one five inches in length has been reported. The very 
 small concretions may form" in the small bile-ducts, but the large 
 ones originate in the gall-bladder. When there are numbers of 
 these concretions in the gall-bladder they are marked with facets, 
 due to pressure or friction from one another being polygonal in 
 form. When there is but one, or a few which are not crowded, they 
 may be oval or globular in shape. If a smooth section of a gall- 
 stone be made through its center, it will be seen to consist of con- 
 centric layers, surrounding a nucleus, which may consist of bile-pig- 
 ment, a cast of an hepatic duct, crystals of cholestrein, cholate of lime, 
 a blood-clot, a fluke-worm or other parasite, etc. The separating 
 lines between the layers or concentric rings may be crossed by crys- 
 talline radiations of cholesterin; however, this substance constitutes 
 about eighty per cent of all gall-stones. In some cases there may 
 be no radiation, the concentric layers being distinctly separate. 
 The external crust varies in character and consistency, though the 
 internal structure is composed largely of cholesterin. Sometimes it 
 may be composed principally of carbonate of lime, and will then be 
 rough and of whitish color, while in other cases it may consist of a 
 mixture of cholesterin and pigment, the color being of a greenish- 
 yellow or brownish color, and smooth. It is seldom that they 
 undergo erosion or disintegration, their structure remaining perma- 
 nent, unless they increase in size by the addition of material to their 
 surfaces. The gall-bladder resists the local influence of the concre- 
 tions for a long time, and may not be very much altered by their 
 presence, though the mucous membrane may finally become catarrhal 
 and eroded, and finally the entire wall may become thickened 
 and fibrous, the cyst beiug contracted and hardened with fibrous 
 deposits, or converted by calcareous degeneration into an unyield- 
 ing, stony mass. When the gall-bladder is impacted with calculi 
 its walls may be ulcerated, and perforation may occur with escape 
 of the calculi through the abdominal wall. 
 
 Various peculiar changes follow the impaction of a calculus in
 
 500 DISEASES OF THE DIGESTIVE ORGANS. 
 
 the cystic duct. Ulceration and perforation of the duct with escape 
 of the calculus into the abdominal cavity may attend. Dropsy of 
 the gall-bladder is among the possibilities of the case, the cyst 
 becoming enormously distended with a thin mucoid fluid, several 
 pints being sometimes pent up in its cavity, giving rise to a circum- 
 scribed tumor, which may be mistaken for an ovarian cyst. When 
 the calculus passes through the cystic duct, its motion is rotary, 
 from the peculiar spiral arrangement of the mucous folds of this 
 passage. When impaction of the cystic duct occurs, symptoms of 
 jaundice may be entirely absent, while impaction of the common 
 bile-duct would be attended by pronounced hepatogenous jaundice, 
 the bile being retained and absorbed into the circulation. Ulcera- 
 tion and perforation of this duct may result from a retained and 
 impacted gall-stone, as well as in the case of the cystic duct. From 
 such a source may arise fistulse opening through the abdominal walls, 
 into the duodenum, colon, stomach, ureter, pleural cavity, venacava, 
 vagina, and other organs, leading from the point of exit of the calcu- 
 lus through the wall of the gall-bladder, cystic duct, ductus com- 
 munis choledochus, etc. 
 
 Symptoms. The most common symptom of gall-stone is bili- 
 ary colic, the occasional passage of a calculus being attended by 
 excruciating pain, of paroxysmal character, during its course along 
 the bile-ducts to the intestine. The first experience of this kind 
 usually marks the establishment of the "gall-stone habit," the 
 patient being subject to more or less frequent attacks of hepatic 
 colic for months or years, unless proper treatment be instituted to 
 arrest the tendency to their formation. Biliary colic usually arises 
 after some peculiar provoking cause which produces engagement of 
 a calculus in the biliary passage, the predisposing cause probably 
 being pressure from behind, due to accumulation of fluid in the 
 cyst. A full meal, a ride over a rough road attended by jolting, 
 active exercise, etc., being immediately followed by sudden and 
 severe pain in the right hypochondrium, which is aggravated by 
 change of position and pressure, and which radiates to the epigas- 
 trium, along the diaphragm, and to the scapulae, the entire upper 
 portion of the abdomen being sometimes involved. The pain is bor- 
 ing or tearing in character, and comes on in paroxysms, these often 
 being preceded by yawning, rigors, nausea, vomiting, and profuse 
 sweating. The face becomes pallid and clammy, and the patient 
 becomes faint and prostrated ; the abdominal muscles are rigid, the 
 pulse is small and oppressed, and the patient rolls about or screams 
 with agony. In a few seconds the extreme pain may subside for a 
 short interval, to return again, this continuing for several hours or a 
 day, when, as the calculus reaches the intestine, the pain suddenly
 
 DISEASES OF THE BILE PASSAGES. 501 
 
 ceases, and the patient becomes comfortable, though prostrated, and 
 rapidly returns to an ordinary condition of health, with prospects, 
 however, of another attack, within a few weeks, at least. Symptoms 
 of hepatogenous jaundice may attend and follow the attack, the 
 stools being clay-colored, and the skin and conjunctive icteric in hue. 
 When the calculi are small and arise in the biliary ducts, the symp- 
 toms of jaundice are more prominent than when the single calculus 
 originates in the gall-bladder, and enlargement of the liver is more 
 prominent, distention of the gall-bladder relieving the accumulation 
 when the common bile-duct and cystic duct are involved. Soreness 
 in the right hypochondrium attends and follows the attack for a few 
 hours. 
 
 Hy drops vesicce fettece, or dropsy of the gall-bladder, arises from 
 chronic obstruction of the cystic duct by gall-stones. The bile is 
 now replaced by a clear, thin, mucoid fluid, which may accumulate 
 in large quantity, the entire abdominal cavity being sometimes filled, 
 the enlargement resembling an ovarian cyst, and sometimes being 
 mistaken for it, adhesion to the broad ligament having been reported. 
 Little if any pain attends, and jaundice is not likely to be present. 
 
 Empymcea of the gall-bladder occasionally occurs, a collection of 
 pus accumulating in its cavity, and this is usually associated with 
 gall-stones. An enormous amount of pus may thus accumulate, the 
 quantity sometimes amounting to more than a pint. Final perfora- 
 tion of the cystic walls is liable to occur, with the formation of mul- 
 tiple abscesses in the neighborhood. 
 
 Calcification of the gall-bladder sometimes occurs, this usually 
 being a sequel of empysema. The cystic walls become stony and 
 unyielding, the mucous membrane and sometimes the entire struc- 
 ture becoming infiltrated with lime salts. 
 
 Phlegmonous suppuration of the walls of the gall-bladder occurs, 
 though it is rare. The symptoms are of grave character, death soon 
 following hyperpyrexia, intense abdominal pain, rapid prostration 
 and peritonitis. 
 
 Atrophy of the gall-bladder is an occasional sequel of irritation 
 from gall-stones. The walls become contracted until the cyst is 
 shrunken to a mere fibrous cord, or a nipple-like protuberance not 
 larger than a pea. Sometimes the cyst is firmly drawn upon a 
 gall-stone. 
 
 Divert icida are sometimes formed in the gall-bladder, in which 
 are found biliary concretions. 
 
 In chronic obstruction of the common duct enlargement of the 
 gall-bladder is not common, a thin, clear mucus being found in the 
 passages. The symptoms of this condition are, paroxysms of chills, 
 fever,and sweating, not unlike those of ague, attended by jaundice,
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 which deepens in color after each paroxysm, and may continue for 
 months and even years, the paroxysms being attended by severe 
 pain in the hypochondriac region, with gastric irritation and vomit- 
 ing. Suppurative cholangitis may follow several years of this 
 condition. 
 
 Suppurative cholangitis is attended by remittent fever, followed 
 by hepatic abscess, or perforation of the gall-bladder, with abscess 
 between the liver and stomach, with tenderness of the abdomen and 
 septicaemia. 
 
 Treatment. The treatment of biliary colic should be directed 
 to the relief of the severe pain during the paroxysms, and to the pre- 
 vention of the formation of more concretions in the gall-bladder. If 
 the latter proposition can be carried out, the need of treatment for 
 more serious conditions will probably be done away with. 
 
 During the passage of a calculus, a napkin, moistened with chlo- 
 roform may be laid against the hypochondrium, and, after the part 
 becomes accustomed to it, may be allowed to remain there, though 
 it may be necessary to remove it every few seconds, at first, on 
 account of the severe burning sensation it may cause. The parox- 
 ysms are very much alleviated by this local application. Large 
 doses of dioscorea and gelsemium should be administered every hour. 
 fy Specific dioscorea, gtt. xv, specific gelsemium, gtt. x. M. and 
 administer in a swallow of water at a dose. During the paroxysms, 
 the inhalation of chloroform may be practiced, or morphia sulph. 
 may be injected hypodermically, though this drug hardly suffices to 
 allay the pain, in safe doses. Chdidonium and chionanthus have been 
 recommended as remedies for relief, though large doses of dioscorea 
 and gelsemium will be preferable. 
 
 After the gall-stone habit has been detected, preparations of /////- 
 turn should be regularly administered through a period of several 
 months, to arrest their formation. Dr. Waterhouse recommends the 
 benzoate of lithium, used by dissolving ten grains of the drug in an 
 ounce of water and administering a teaspoonful of the mixture every 
 three or four hours. Others recommend from three to five grains of 
 the carbonate of lithium, stirred in a glass of water, and taken at a 
 dose, three or four times a day. Olive oil, taken in tablespoonful or 
 wine-glassful doses three or four times daily, is an old and reliable 
 remedy for the habit. The galvanic, salt-water electrode, used in the 
 lower bowel with the negative pole, the positive being applied over 
 the right hypochondrium, is an excellent measure to promote fluid 7 
 ity of the bile and encourage normal biliary function. In the treat- 
 ment of chronic obstruction from biliary calcuji, the conditions of 
 each case must decide the course to pursue. In serious affections 
 of the gall-bladder, cholecystotomy is the proper measure.
 
 DISEASES OF THE PANCREAS. 503 
 
 MISCELLANEOUS AFFECTIONS OF THE BILIABY- PASSAGES. 
 
 Cancer of the gall-bladder may occur as an independent affection, 
 either primarily or secondarily, though there are many difficulties 
 in the way of diagnosing it from cancer of the liver, and there is lit- 
 tle clinical need of this. It usually arises from the irritation of 
 impacted biliary calculi. 
 
 Stenosis of the biliary ducts may exist, either congenitally or 
 acquired from the irritation pf impacted gall-stones, though the con- 
 dition is very rare in either case. When the occlusion is acquired, 
 it usually exists low down in the common duct. Foreign bodies may 
 obstruct the biliary passages, intestinal worms, fluke-worms, echino- 
 cocci, the seeds of various fruits and other accidental substances, 
 being most common factors. 
 
 Obstruction from pressure from without is more common than 
 obstruction from internal causes. Carcinomatous growths from neigh- 
 boring viscera are the usual causes of such obstruction. The pylo- 
 rus, head of the pancreas, neighboring lymphatic glands, stomach 
 and other abdominal organs, may be the seat of malignant growths, 
 which exercise pressure upon the common bile-duct, to occlude it. 
 The symptoms are those of deeply marked icterus, with or without 
 hepatic intermittent fever; and hepatic colic, more or less severe, 
 alternates with painless periods and gastric disturbances, with grad- 
 ual progression toward a fatal termination, unless the obstruction is 
 removable. The diagnosis is obscure, and is usually determined by 
 an autopsy. 
 
 XI. DISEASES OF THE PANCREAS. 
 
 HEMOERHAGE. 
 
 Etiology. The causes of non-inflammatory hemorrhage of the 
 pancreas are somewhat obscure. Traumatism undoubtedly figures 
 as a causal factor at times, and self-digestion may occasionally be 
 responsible for it. Hemophilia and purpura may also be reckoned 
 among occasional causes. 
 
 Pathology. Diffused blood may invade the parenchyma of the 
 organ, and the cellular tissue. Sometimes the hemorrhage is con- 
 fined to a portion of the gland, while at other times the entire struc- 
 ture of the pancreas may be invaded. 
 
 Symptoms. The principal symptom is that of marked and 
 rapid prostration, amounting to collapse. Pain in the epigastric 
 region may be present, and sometimes vomiting, with subnormal 
 temperature. If death does not soon follow, inflammation sets in
 
 504 DISEASES OF THE DIGESTIVE ORGANS. 
 
 about the hemorrhagic areas. Death is likely to occur within from 
 half an hour to a few hours. Should inflammation arise the case 
 may be somewhat prolonged, acute hemorrhagic pancreatitis being 
 then developed. 
 
 Treatment. Little can be expected from treatment. Stimu- 
 lants, such as hypodermic injections of strychnia (gr. l-50th every 
 half hour until two or three doses have been administered), and 
 brandy per mouth may be tried, to bring about reaction from the col- 
 lapse. Should reaction follow and inflammation arise, the treatment 
 will be that for hemorrhagic pancreatitis. 
 
 ACUTE PANCREATITIS. 
 
 Synonym. Acute Hemorrhagic Pancreatitis. 
 
 Etiology. This may arise from traumatism, alcoholisinus, gas- 
 tro-duodeuitis, or as a result of non-inflammatory hemorrhage of the 
 pancreas. It sometimes follows typhoid fever, pyaemia, septicaemia, 
 acute tuberculosis, and parotitis (metastasis). Mercury may some- 
 times be responsible for it, especially when its use has been pro- 
 longed. 
 
 Pathology. The organ is hyperaemic, firm in consistency, en- 
 larged, and its substance is infiltrated with scattered areas of small 
 hemorrhages. Sometimes the hemorrhage is more extensive, and 
 infiltrates the omentum and contiguous parts. If suppuration has 
 occurred, small abscesses are found. In febrile diseases, paren- 
 chymatous changes may take place through the entire organ. Sur- 
 rounding parts may be involved, abscesses arising in the surround- 
 ing connective tissue and lymphatic glands, and sometimes the pan- 
 creas may be surrounded by pus, which may finally burrow into the 
 stomach, duodenum, peritoneal cavity or through the abdominal 
 wall. Tension of the nerves of the coaliac plexus may give rise to 
 intense pain. Fat necrosis seems a peculiarly common pathologi- 
 cal condition in pancreatic disease and it is sometimes found here, 
 the areas of necrosis varying in size from that of a pin-head to 
 that of a hen's egg, scattered through the pancreas, omentum and 
 other abdominal organs. Gangrene sometimes occurs, cases having 
 been reported where the pancreas was entirely sequestrated, and dis- 
 charged as a slough from the bowels. 
 
 Symptoms. Pain of colicky nature, over the region of the pan- 
 creas, with prostration, restlessness and anxiety, are the leading 
 symptoms. The pain is intense, deep-seated, and radiates to the 
 back, shoulders and diaphragm. There is difficult and sighing res- 
 piration, with prostration, nausea and vomiting, distentlon of the 
 epigastrium, clammy skin and cold sweat on the forehead. Con-
 
 DISEASES OF THE PANCREAS. 606 
 
 stipation is the rule, though diarrhoea may occur as a metastasis 
 of the inflammatory action to the intestine. 
 
 Diagnosis. The diagnosis is difficult. Acute perforative peri- 
 tonitis or intestinal obstruction is more liable to be suspected. 
 The sudden onset and intense pain seated deeply in the pancreatic 
 region, due, probably, to tension of the nerves of the cceliac plexus 
 would suggest the condition, especially if rapid prostration with 
 Tomitiug and constipation supervened, though these symptoms might 
 also be present in obstruction of the intestinal canal. 
 
 Prognosis, Fatal results usually follow in from one to four 
 days, though recovery occasionally results. 
 
 Treatment. The therapeutics of acute disease of the pancreas 
 are not in an entirely satisfactory condition. Iodine, in minute 
 doses (3x or 6x), has been used with some satisfaction, and iris ver- 
 sicolor specifically improves the recuperative power of the part. 
 Both remedies may be thought of and tried in cases which offer any 
 hope of even a few hours' lease of life. Best in the recumbent 
 posture, and a mild and unstimulating liquid diet, must be en- 
 joined, with such supporting measures as the extreme prostration 
 demands. Strychnia, hypodermically, will be the ideal stimulant, 
 care being exercised to employ it within efficient bounds. 
 
 When hemorrhage seems to be profuse, as indicated by symptoms 
 of excessive prostration, erigeron, rhiis aromatica or lycopus may be 
 thought of. When gangrene is suspected the use of echinacea might 
 be advisable. 
 
 CHRONIC PANCREATITIS. 
 
 Etiology. This disease is frequently an accr ipaniment of dia- 
 betes; whether as a coincidence, result or cause is not yet clearly es- 
 tablished. Calculi may originate chronic inflammation and indura- 
 tion, as also may pressure from tumors. Chronic inflammation may 
 invade the organ from other parts, as in ulceration of the duodenum, 
 stomach and other neighboring viscera. Syphilitic infection some- 
 times gives rise to chronic inflammation of the pancreas. 
 
 Pathology. There is increase of the interstitial connective 
 tissue, as in cirrhosis. Increase of the connective tissue is attended 
 by atrophy of the glandular structure, the organ becoming con- 
 tracted, and firmer in consistency than normal. Closure of the 
 duct, calculi and cystic formations in the substance of the organ may 
 be results of constriction. Interstitial hemorrhages are likely to 
 occur and, in the suppurative form, pus may infiltrate the organ, or 
 one or two small abscesses may be found. Adhesions frequently 
 bind the organ to adjacent parts.
 
 506 DISEASES OF THE DIGESTIVE ORGANS. 
 
 Symptoms. Arrest of normal function may interfere with the 
 digestion of fats, and indigestion attended by fatty stools will nat- 
 urally suggest the condition. The presence of a transverse tumor 
 in the epigastrium, deeply seated, will add to the symptoms. Mel- 
 lituria, neuralgia, emaciation, etc., followed (as pressure interferes 
 with the portal circulation) by ascites, will complete the picture. 
 
 Treatment. When fatty stools appear, the free use of olive oil, 
 with a spare diet free from fats, in which pickled olives may be al- 
 lowed ad lib., may prove not only temporarily beneficial, but perma- 
 nently curative. Two or three ounces of olive oil should be admin- 
 istered at a dose, three or four times daily, until the fatty stools are 
 replaced by healthy evacuations. Meantime, minute doses of iris 
 versicolor and iodine may be alternated, each being taken three or 
 four times in twenty-four hours. 
 
 If the inflammatory condition be recognized early, much benefit 
 may follow the use of potassium chloride 3x, through its influence in 
 controlling plastic exudation. 
 
 FATTY DEGENERATION. 
 
 FATTY infiltration and fatty degeneration both occur in the pan- 
 creas, under varying circumstances. In fatty infiltration the connec- 
 tive tissue becomes involved by the deposition of fat, and the press- 
 ure causes gradual disappearance of the gland-cells of the organ, 
 complete disappearance of secreting structure resulting , until the 
 whole gland becomes a mass of fat, with the duct constituting a 
 central canal. In j<My degeneration the gland-cells are primarily in- 
 volved, the destruction not including the cupsule, septa and blood- 
 vessels, which remain to constitute a soft, wasted, flaccid body, 
 resembling the pancreas in shape, but lacking its secreting power. 
 The causes of these conditions are similar, being alcoholism, general 
 obesity and, in degeneration, heart disease and obstruction to the 
 escape of the pancreatic secretion. 
 
 The symptoms are obscure, the principal ones being those which 
 arise from gradual loss of function. 
 
 WAXY DEGENERATION. 
 
 .WAXY degeneration of the pancreas is a very rare disease, and 
 one of the rarest of diseases of the pancreas. It arise* from the 
 usual causes of amyloid degeneration, such as chronic ulceration of 
 bone, prolonged suppuration, syphilis, etc. The diagnosis is ob- 
 scure, and treatment is of little avail, a fatal termination within a 
 few months being inevitable.
 
 DISEASES OP THE PANCREAS. 507 
 
 CANCER OF THE PANCREAS. 
 
 Etiology. Little is known except that the disease occurs most 
 frequently in men after the fortieth year of age. It occurs both as 
 n primary and secondary disease, though it is not frequent in either 
 form. 
 
 Pathology. Scirrlms is the common variety, and there is a ten- 
 dency to inyolvement of adjacent organs. The head is most fre- 
 quently affected first, and pressure upon the bile-duct may then oc- 
 cur, resulting in jaundice. The large blood-vessels in the vicinity may 
 be obstructed, crowding upon the portal vein, giving rise to accumu- 
 lation of ascitic fluid. The canal of Wirsung may be obstructed and 
 cysts form, from tension of retained secretion. Ulceration into 
 neighboring structures may occur, as breaking down proceeds. 
 
 Symptoms. The symptoms are varied and often obscure, the 
 variation depending upon the complications which arise from affec- 
 tion of neighboring organs. Where the head is largely involved, in 
 thiii persons, a deep tumor may be recognized in the pyloric region. 
 Dyspeptic symptoms, intense neuralgic pains of paroxysmal charac- 
 ter in the pyloric belt, and possibly, though not necessarily, fatty 
 stools, are among the prominent symptoms. Kapid emaciation and 
 loss of strength, with speedy development of cancer cachexia, soon 
 proclaim the malignant character of the disease, which only re- 
 quires to be located. The presence of free hydrochloric acid and 
 absence of coffee-ground material in the vomit will remove suspicion 
 of gastric cancer, and the presence of stearrhoea will confirm suspi- 
 cion of disease of the pancreas. Jaundice with these distinguishing 
 features may render diagnosis between cancer o^ the pancreas and 
 liver difficult. Marked pulsation of the aorta, communicated to the 
 epigastrium, would be a diagnostic aid in this case, suggesting an 
 impulse communicated by the hardened pancreas. 
 
 Treatment. Little can be done to stay the course of the dis- 
 ease, and death usually occurs within a year. The intensity of the 
 suffering may be modified by the regular administration of ten-drop 
 doses of specific echinacea, repeated three or four times daily. To 
 each dose one or two drops of specific iris may sometimes be added 
 with benefit. A spare and bland diet, consisting of pancreatinized 
 meat and milk should be employed, and the patient should re- 
 main quiet in bed. 
 
 CALCULI AND CYSTS. 
 
 CONCRETIONS in the pancreatic ducts occasionally obstruct their 
 lumen and cause great dilatation and distention behind the point 
 of obstruction, with atrophy of the gland structure. Pancreatic con-
 
 608 DISEASES OF THE DIGESTIVE ORGANS. 
 
 cretions are usually formed chiefly of carbonate of lime, are round 
 or oval, with rough or spinous surfaces, and present a white or 
 opaque white color. When numerous they cause serious dilatation 
 of the pancreatic ducts, cystic formations arising in consequence. 
 They seldom give rise to abscess. Obscure colicky pains may attend 
 their presence, though the diagnosis is difficult. Fatty stools and 
 glycosuria may be present, though not necessary symptoms. Proba- 
 bly pancreatic calculi occasionally pass in the stools. 
 
 Pancreatic cysts commonly result from impaction of the ducts 
 with calculi. Biliary calculi, lodging at the orifice of the common 
 duct, may obstruct the duct of Wirsung, and pancreatic concretions 
 within this duct or its branches may constitute causal factors. Other 
 causes of obstruction of the pancreatic duct leading to similar results 
 are cicatricial contraction af the duct of Wirsung and misplace- 
 ments, by which a passage is doubled upon itself. Cicatricial con- 
 traction and misplacements may be due to injuries. 
 
 A pancreatic cyst may attain an immense size and be mistaken 
 for an ovarian tumor, though usually it remains in the epigastric re- 
 gion and is perceptible upon palpation as a smooth, lobulated tumor, 
 either occupying the median portion or one side. Aspiration of the 
 contents of the tumor will aid in diagnosing the case, as the fluid 
 will emulsify fat and convert starch into sugar. Disturbance of di- 
 gestion, with fatty stools and glycosuria, may be present. 
 
 SARCOMA, syphilis and tuberculosis occasionally involve the pan- 
 creas. 
 
 XII. DISEASES OF THE PERITONEUM. 
 
 ACUTE GENERAL PERITONITIS. 
 
 Definition. Acute inflammation of the peritonaeum. 
 
 Etiology. This disease may be (1) idiopathic (primary), or 
 (2) symptomatic (secondary). Primary peritonitis is of rare occur- 
 rence, though it may arise from sudden chilling of the surface. 
 To this form the term "rheumatic peritonitis" has been applied. 
 For some inexplicable reason the peritonaeum is not nearly so liable 
 to primary inflammation as the pleura and pericardium. The usual 
 cause of acute peritonitis is disease of some abdominal or pelvic vis- 
 cus (secondary peritonitis). Traumatism, perforation of the stom- 
 ach or bowel, typhlitis, metritis, ovaritis, rupture of the gall-blad- 
 der or of the cystic or common bile duct, surgical operations attend- 
 ed by opening in the peritoneal cavity, etc., are causes of secondary 
 peritonitis.
 
 DISEASES OF THE PERITONAEUM. 509 
 
 Pathology. The inflammation commonly begins in some cir- 
 cumscribed place and afterward becomes more or less rapidly dif- 
 fused over the entire membrane. A mottled appearance is observ- 
 able early, but the bright redness soon becomes general, the glisten- 
 ing surface of the membrane disappearing and a grayish layer of 
 fibrillated fibrin exuding, which later becomes infiltrated with pus- 
 cells. The bowels are inflated with gases, and, in the event of 
 abdominal incision, they are restrained with difficulty from escaping 
 from the opening. The subserous tissues become swollen and 
 oedema-tous, and filled with migrating leucocytes and such microbic 
 forms as the proteus vulgaris, streptococcus pyogenes, bacillus coli 
 communis, and pneumococcus, which are also found in the exuda- 
 tion. Adhesion of tlie approximated surfaces occurs, the intestines 
 becoming glued together, to other viscera and to the abdominal 
 walls, the peristole becoming thus impaired. Loops, in which the 
 bowel may be incarcerated, may form. The character and amount 
 of the exudation varies, there sometimes being a preponderance of 
 fibrin and sometimes a preponderance of serum. The fibrinous ex- 
 udation may be so excessive and the serum so scanty as to con- 
 stitute the condition sometimes termed "dry peritonitis," while in 
 other cases there is a large amount of serous exudation, the peri- 
 toneal cavity being distended by a considerable amount of thin, 
 watery fluid, which may be mixed with pus or blood-corpuscles. 
 Thus, the exudation may be largely fibrinous, serous, fibrino-puru- 
 lent, sero-fibrinous or sero-purulent, etc. The appearance of the 
 fluid mav vary. In some cases it may be clear and colorless; in 
 others (sero-fibrinous) it may be yellowish; in others (purulent) thin 
 and greenish-yellow or thick, opaque and creamy; in others (putrid) 
 grayish-green, with putrid odor, the latter condition being the result 
 of cancerous disease or the presence of fecal or other material due 
 to intestinal or other visceral perforation and escape of septic fluids 
 from the digestive cavity. 
 
 Symptoms. The disease may develop gradually, several days 
 being occupied in the appearance of the general and local symptoms 
 before they are fully declared; or it may arise suddenly, this being 
 the usual course. In the latter case a chill is apt to indicate the 
 onset. Pain, of burning, lancinating character, is always present, 
 localized at first, but becoming diffused with more or less rapidity 
 all over the abdomen. Excerbations, sometimes amounting to spasms, 
 alternate with periods of less severe suffering, though there are con- 
 tinual burning and shooting pains, which are aggravated by move- 
 ments of the diaphragm, coughing, sneezing, vomiting, deep inspira- 
 tion, and even upon motion of the body. The abdomen becomes more 
 or less swollen, from accumulated fluids and intestinal gases, and
 
 510 DISEASES OF THE DIGESTIVE ORGANS. 
 
 exceedingly tender to pressure, flexion of the lower extremities usu- 
 ally being resorted to to allay tension of the abdominal muscles. 
 
 Vomiting frequently occurs, and dyspnoea is an invariable symp- 
 tom, this being due to the fullness of the abdomen and aggravation 
 of pain upon forced descent of the diaphragm. The temperature, 
 during the reaction following the chill, may rise to 104 or 105 F. 
 for a short time, but it afterward falls to a slight elevation above 
 normal and remains there, or at least it seldom afterward rises above 
 102 or 103. Sometimes there is no appreciable elevation of tem- 
 perature during the course of a case. The pulse is rapid, small and 
 hard (wiry), often running as high as 130 or 140 per minute, and 
 ranging from 110 to 150. The tongue is coated white at first, but 
 becomes dry and fissured later, of deep-red color when clean and 
 dark-brown when coated. The bowels are liable to be loose at first, 
 though constipation soon follows. The urine is scanty and high- 
 colored and contains a marked quantity of indican. Micturition is 
 usually frequent, though enuresis may be present instead. 
 
 The decubitus and general appearance of the sufferer, when acute 
 general peritonitis is established, is characteristic. The patient lies 
 upon the back with the knees drawn up, with the abdomen greatly 
 swollen. The skin over the face is shriveled and leaden in hue, the 
 eyes are sunken, the nose is sharp, and there is a worn and anxious 
 expression about the countenance. The ears are cold and drawn, 
 and their lobes are turned out. Tympanites is marked, the intestines 
 being distended with gases and crowded under the diaphragm, dis- 
 placing the heart, liver and lungs upward, so that the apex beat 
 may be heard in the fourth intercostal space and the usual area 
 of liver dullness is tympanitic. Accumulation of ascitic fluid may 
 give rise to dullness and fluctuation in the flanks. 
 
 Diagnosis. The previous history of a case will assist materi- 
 ally in arriving at a correct diagnosis. A knowledge of former 
 appendicitis, pelvic inflammation, typhoid fevr, or gastric ulcer, 
 would be suggestive, when active symptoms afterward arose. Peri- 
 tonitis may be mistaken for intestinal obstruction, colic, abdomi- 
 nal neuralgia, enteritis, rheumatism of the abdominal muscles or 
 organs, renal or biliary colic, suppurative cellulitis of the abdom- 
 inal muscles, or the imaginary peritonitis of hysterical persons. In 
 intestinal obstruction there is subnormal temperature, vomiting of 
 fecal material and localized pain continually, while in peritonitis 
 the pain soon becomes diffused. In abdominal neuralgia there is no 
 tympany, no rise in temperature and no tenderness upon pressure, 
 except at the root of the spinal nerve effected, while the sensation as 
 of a cord drawn tightly about the abdomen prevails. If tympanites 
 attends enteritis it comes on slowly, while in peritonitis it develops
 
 DISEASES OF THE PERITONEUM. 611 
 
 rapidly; vomiting is a common and frequent symptom in enteritis, 
 while in peritonitis it is rare and the vomit consists of spinach- 
 green material. In abdominal rheumatism there is no disturbance of 
 the temperature, the pain is most severe at the point of insertion of 
 the muscles, there is no tympanites, unless the intestinal muscularis 
 is involved and then it is not extreme, no vomiting, and no tendency 
 to collapse. In biliary and renal colic the pain is located near the 
 part involved, is peculiarly paroxysmal, unattended by fever, and there 
 is absence of tympanites and tenderness. In biliary colic symptoms 
 of jaundice appear after twenty-four hours, and in renal colic the 
 pain radiates along the ureter to the testicle, which is retracted. 
 In suppuration of the abdominal walls there is not such intense 
 pain nor such marked constitutional symptoms. 
 
 Prognosis. Acute diffuse peritonitis is usually rapidly fatal, 
 death occurring in four or five days in many cases, and almost in- 
 variably within ten. Intense forms result in death within thirty- 
 six hours. Feeble action of the heart, with irregular action, shal- 
 low respiration, livid pallor of the countenance, and coldness of the 
 extremities, with high rectal temperature, indicate impending dis- 
 solution. 
 
 Treatment. The plastic exudation is to be controlled, if pos- 
 sible, and for this purpose potassium chloride 3x should be admin- 
 istered in small and frequently-repeated doses. Ten grains may be 
 added to half a glass of water, a teaspoonful being administered from 
 this every hour. In this place the potassium chloride proves a 
 sedative, lowering the temperature and controlling excessive action 
 of the pulse. A pack of towels wrung out of tepid water should 
 be applied over the abdomen and changed every hour or two. This 
 treatment promises the best results of any known to the writer. 
 
 Some old school authors advocate the use of opium in full 
 doses, repeated sufficiently often to maintain complete control of 
 peristalsis, and depend upon the use of this remedy alone, in con- 
 nection with packs. Where septic accumulation in the peritoneal 
 cavity is evidently present, abdominal section and cleansing, with 
 subsequent drainage, is practiced by many, though results are not 
 usually very flattering. In all cases of acute diffuse peritonitis, a 
 guarded prognosis must be made. 
 
 In puerperal and pelvic peritonitis especial attention is to be 
 paid to the condition of the uterus and its appendages, proper 
 douching of the uterine cavity and vagina, being considered in- 
 dispensable. 
 
 Care must be exercised about the diet. If there be vomiting all 
 attempts to administer food or drink by the mouth must be avoid- 
 ed, and nutrient enemata employed. Where vomiting is not present
 
 512 DISEASES OF THE DIGESTIVE ORGANS. 
 
 very small quantities of precligested milk may be swallowed fre- 
 quently, only a little being allowed at a time, for fear of exciting 
 peristalsis and the accumulation of gases. If water be allowed 
 but little should be taken at a time. 
 
 PERITONITIS IN INFANTS. 
 
 INFANTS are occasionally subject to peritonitis, congenital syphilis 
 being the most frequent cause. In this instance the disease may so 
 develop during the prenatal state as to result in constriction of the 
 bowel from fibrinous adhesions. A cause of peritonitis in the new 
 born is irritation of the umbilical cord, that condition extending 
 to the abdomen and giving rise to septic peritoneal inflammation. 
 
 Peritonitis in older children is liable to result from injuries re- 
 ceived at boisterous play, or from kicks, blows or bruises about 
 the abdomen. It has several times been known to occur as an epi- 
 demic among children in schools, and has been attributed to the 
 effects of sewer-gas poisoning. 
 
 The symptoms of septic peritonitis in the new-born are those 
 which usually arise in other forms of peritonitis, complicated with 
 symptoms of malignant jaundice. There is marked distentionof the 
 abdomen, shallow breathing, evident pain upon pressure and motion 
 and marked jaundice, with, perhaps, convulsions or coma. 
 
 Little can be expected from treatment. Echinacea or echafolta, 
 in minute doses, may neutralize some of the septic conditions, 
 though the accompanying phlebitis will usually prove intractable 
 to treatment. 
 
 LOCALIZED PERITONITIS. 
 
 PELVIC PERITONITIS. This usually arises from inflammation of the 
 uterus and Fallopian tubes, due to puerperal septicffimia, gonorrhoeal 
 infection, or tuberculosis. Sometimes, when a former inflammation 
 has existed in the pelvis, sitting on cold surfaces or sudden chilling 
 may give rise to the inflammatory condition leading to it. In other 
 cases the incautious use of instruments during curettage of the uter- 
 us or other intra-uterine operations may result in pelvic peritonitis. 
 The disease is most liable to arise in the tubes, the fimbriated ex- 
 tremity becoming inflamed, swollen and covered with exudate which 
 glues the affected part to the ovary and drags surrounding tissues 
 together into an unrecognizable mass, the broad ligament becoming 
 infiltrated with pus, and purulent accumulation distending the Fal- 
 lopian tubes, sometimes to the extent of bursting. Rupture of one 
 of the Fallopian tubes or of an abscess of the broad ligament may 
 cause general peritonitis. Tuberculosis of the pelvic tissues may
 
 DISEASES OF THE PERITONEUM. 613 
 
 give rise to localized peritonitis. The symptoms are localized pain, 
 with swelling and tenderness of the parts, slight elevation of temper- 
 ature, especially in the evening, chilly sensations, and hectic fever. 
 There is more or less obstruction of the bowels, loss of appetite and 
 general derangement of the stomach. Throbbing sensations in the 
 pelvis soon attend. The only successful plan of treatment is the 
 early and steady use of potassium chloride 3x. When this is begun 
 early and persevered in, the affection can usually be controlled 
 before the formation of pus, and the inflammation subsides by reso- 
 lution. Add ten grains of potassium chloride 3x to half a glass of 
 water and order a teaspoonful every hour. Follow this day after day 
 for three or four weeks. A liquid diet should be prescribed, and 
 an occasional mild laxative of salts or decoction of rhamnus cali- 
 fornica bark. 
 
 APPENDICULAB PERITONITIS. This is the most frequent form of 
 localized peritonitis in the male. Appendicitis has already been 
 fully considered, and the reader is referred to that article for the 
 pathology, symptoms and treatment. 
 
 SUBPHBENIC PERITONITIS. The lesser peritonaeum may be involved 
 in localized inflammation arising from perforations of certain parts 
 of the stomach, colon or duodenum, inflammation of the pancreas, 
 or pyo-thorax. The lesser peritonaeum may become distended with 
 fluids, forming a tumor which may be mistaken for cyst of the 
 pancreas. Accumulations of pus may occur here (perihepatic ab- 
 scess), and even distention of the part with air, the latter condition 
 being due to communication with the lung, stomach or bowel. In 
 some cases traumatic perforations are followed by a similar con- 
 dition. The symptoms are characterized by severe localized pain 
 confined to the epigastrium, which may be abrupt in its onset, par- 
 ticularly when due to perforation of the stomach or bowel, and this 
 is often accompanied by vomiting of bilious or sanious material. 
 With these symptoms develop fever, chills, emaciation, and suppura- 
 tion. Perforation into the lung is announced by cough and profuse 
 expectoration. The prognosis in such cases is doubtful, surgical 
 interference offering the only hopeful prospect. 
 
 CHRONIC PERITONITIS. 
 
 Etiology. Chronic peritonitis may follow an attack of acute 
 peritonitis, or may arise gradually from irritation of an abdominal 
 viscus. It is believed that it sometimes arises idiopathically, though 
 such cases are probably really due to new growths, such as cancer 
 or tubercle. The following varieties of chronic peritonitis may be 
 
 34
 
 614 DISEASES OF THE DIGESTIVE ORGANS. 
 
 mentioned: (1) Local adhesive, (2) diffuse adhesive, (3) prolifer- 
 ative and (4) hemorrhagic. 
 
 Local adhesive peritonitis arises as secondary to inflammatory dis- 
 ease of one of the abdominal viscera. Its favorite locality is about 
 the liver and spleen. The symptoms are not marked, though per- 
 sistent abdominal pain may attend some cases, others occasioning no 
 inconvenience and being overlooked, unless discovered accidentally 
 upon autopsy. Sometimes loops are formed by adhesions, into 
 which the intestines may be incarcerated, giving rise to intestinal 
 obstruction. 
 
 Diffuse adhesive peritonitis results from acute inflammation of the 
 peritonaeum. Here the peritonaeum may be completely obliterated, 
 th visceral and abdominal layers being welded together and the 
 intestines matted, the adhesions usually involving the liver and 
 spleen. 
 
 Proliferative peritonitis is characterized by remarkable thickening 
 of the peritonaeum, without adhesion of its surfaces. It occurs in 
 cancer and tuberculosis of the peritonaeum, and in cirrhotic con- 
 ditions of the liver or portions of the intestinal canal, often in 
 subjects of chronic alcoholism. The peritonaeum is white and 
 opaque in appearance, generally thickened, though there are patches 
 where the thickening is greatly exaggerated. About the liver and 
 spleen this may be marked, a layer of gristly connective tissue half 
 an inch or more in thickness sometimes enveloping these organs. 
 Constriction of the inclosed viscera attends, and they become much 
 reduced in size. Sometimes the constriction results in obstruction 
 to the portal vein. Thickening of the intestinal walls may occur, and 
 the abdominal viscera may be drawn up into a ball not much 
 larger than a child's head. There may be moderate effusion and 
 sometimes marked ascites, though in other cases the peritonaeum 
 may be divided into several sacs, each containing circumscribed 
 fluid. Friction-sounds in these cases are usually heard in the upper 
 portion of the abdomen. Nodular thickening has been observed in 
 rare cases, which has been determined to be neither tubercular nor 
 cancerous, and which has been supposed to be due to the presence 
 of parasites. Nodules of this character may be disseminated through 
 the liver. A Japanese investigator asserts that the nodules contain 
 the ova of a parasite. 
 
 Chronic hemorrhagic peritonitis is characterized by the successive 
 formation of new connective tissue upon the surface of the periton- 
 aeum containing open blood-vessels, from which exude blood-stained 
 effusions. The hemorrhagic formations are usually circumscribed, 
 and commonly occur in cancer and tuberculosis. 
 
 Treatment. With our present means of treatment little can be
 
 DISEASES OF THE PERITONEUM. 515 
 
 done for chronic peritonitis, except to keep the patient quiet and 
 enjoin the use of a spare animal diet, with almost complete avoidance 
 of vegetables and starchy food. Potassium chloride 3x may sometimes 
 assist in controlling plastic exudation, especially when used patiently 
 and persistently for a long time. An important step is the preven- 
 tion of ascitic accumulations in the intestines, and careful attention 
 to diet will accomplish the most of this, vegetables, sugars and 
 starches being objectionable. Broiled tender chops, steaks, white 
 meat of fish or chicken, in small quantities and carefully and slowly 
 masticated, are best adapted. When the stomach digests them eggs, 
 milk and cream may be taken. To alleviate the formation of gases 
 half a drachm of listerine or five grains of eudoxine may be adminis- 
 tered half an hour or so after eating. 
 
 NEW GROWTHS IN THE PERITONEUM. 
 
 THE peritonaeum may be the seat of tubercular and cancerous 
 growths, as well as of nodules resulting from the presence of 
 echinococci. 
 
 Tubercular peritonitis may be primary and local. It may attend 
 tuberculosis of the lungs or follow an attack of acute miliary tuber- 
 culosis. It is common in children, more frequent in males than in 
 females, and is most apt to be found between the ages of twenty and 
 forty, though it may occur in advanced life. Extensive thickening 
 aud adhesions occur, the omentum being puckered and bunched and 
 drawn across the upper portion of the abdomen. Sacs are formed, 
 in which accumulations of sero-purulent or purulent material are 
 found, the amount varying, though the entire abdomen may be dis- 
 tended, as in ascites. Localized abdominal tumors may represent 
 omaller collections. General wasting of flesh, digestive disorders, 
 and more or less abdominal pain are the leading symptoms. The 
 temperature is remarkably prone to be subnormal, a morning range 
 of 95.5 F. often being found. Treatment can accomplish little here, 
 palliative measures only being applicable. Opiates, dietary regula- 
 tions and, in some cases, surgical relief of distended accumulations 
 are the principal means to be relied upon. 
 
 Cancerous growths in the peritonaeum may be primary or second- 
 ary, the latter condition being the rule and simplifying the diagnosis. 
 When occurring secondarily the stomach or ovary is usually the 
 starting point. Cancerous nodules are distributed- over the peri- 
 toneal surface, and the omentum becomes puckered and drawn up as 
 in tuberculous peritonitis, forming a transverse tumor across the 
 upper portion of the abdomen. The disease is disseminated by con- 
 tact of opposing surfaces (transplanted) or through lymph currents
 
 616 DISEASES OF THE DIGESTIVE ORGANS. 
 
 which carry the cancer cells to different parts. The diagnosis is not 
 difficult when the disease is secondary to localized cancer, but when 
 primary there is so much resemblance to tuberculous peritonitis in 
 many respects that there may be confusion. Cancer, however, pre- 
 sents more marked nodulation, this being apparent on palpation 
 when ascitic fluids have been evacuated. There is greater pain in 
 cancer usually, and the cancerous cachexia is more or less apparent. 
 Treatment is not highly satisfactory. Echinacea may be tried for the 
 pain, paracentesis will relieve oppressive distention of the abdomen, 
 and rest and proper diet may assist in prolonging life. 
 
 Echinococci give rise to nodular growths on the peritonaeum, these 
 occurring in connection with hydatids of the liver. There is not much 
 danger of confounding this affection with cancer or tubercle, as the 
 general health is not much involved, the principal trouble arising 
 from pressure of the morbid growth. The enlarged liver will origi- 
 nate the leading symptoms, which will be mechanical. 
 
 A8CITE8. 
 
 Synonyms. Abdominal Dropsy; Hydroperitonaeum. 
 
 Definition. An accumulation of serum in the abdominal cavity. 
 
 Etiology. Ascites may occur during the late period of general 
 dropsy, though it usually arises from portal obstruction, the vis a 
 tergo from the abdominal arteries then forcing the serum from the 
 capillaries into the peritoneal cavity. Allforms.of peritoneal inflam- 
 mation are attended by more or less effusion into the peritoneal cav- 
 ity due to capillary changes, and sometimes the amount may be suf- 
 ficient to distend the peritoneal sac to its utmost limits. Diseases 
 of the heart or lungs which contribute to obstruction in the venae 
 cavaa may be attended by ascites, though general dropsy is more 
 liable to attend such condition. The common causes of ascites are 
 those which give rise to portal obstruction, such as cirrhosis of the 
 liver, hepatic cancer, biliary obstruction, pressure from tumors or 
 cicatricial bands and thrombus of the portal vein. Asthenic condi- 
 tions may be attended by ascites when there is no obstruction to 
 the circulation, as in hydraemic states of the blood due to anaemia, 
 chlorosiw, malarial cachexia, purpura, chronic arsenical poisoning, 
 chronic Bright's disease, and senility or great exhaustion, the condition 
 then being considered asthenic or cachectic ascitet. Sudden arrest 
 of secretion from chilling of the surface, especially during menstrua- 
 tion, or the sudden suppression of cutaneous affections, may be fol- 
 lowed by it. Tuberculous or cancerous disease of the peritonaeum 
 is apt, after degenerative changes have become well established, to 
 be attended by dropsy.
 
 DISEASES OF THE PERITONEUM. 517 
 
 Pathology. The endotbelia of the peritonaeum are swollen, 
 and manifest more or less fatty degeneration. They appear turbid, 
 and the subserous tissue is increased in bulk, the entire membrane 
 appearing soggy and inelastic. The fluid in the abdominal cavity 
 varies from a few ounces to five or six gallons. It may be viscid or 
 watery in consistence, and is usually of a yellowish straw color with 
 an opalescent greenish tint, though if there be an admixture of blood 
 it may be dark, while in disease of the lymphatics it may be milky. 
 Sometimes it is as clear and as limpid as water. Chylous fluid may 
 depend upon perforation of the thoracic duct from cancerous disease, 
 or upon filariae. The specific gravity varies from high to low, though 
 it is usually as low as 1.010 or 1.015. The blood of ascitic patients 
 is usually hydrsemic and poor in albumen. 
 
 Symptoms. Gradual increase in the size of the abdomen is the 
 characteristic symptom of ascites. With this will be associated the 
 symptoms which attend the particular etiological factor of each indi- 
 vidual case. Portal obstruction, various forms of peritonitis, ca- 
 chexise and other provoking conditions manifest themselves in con- 
 junction. Where there is biliary obstruction there may be marked 
 symptoms of jaundice. In other cases the patient may present a 
 pallid appearance, or the waxy color of cancer may be prominent. 
 
 Physical signs are important as diagnostic symptoms. Palpation 
 imparts a peculiar wave to the fingers, which, without doubt, attests 
 the presence of fluid in the cavity. The fingers of one hand should 
 be placed upon one side of the abdomen while a sharp tap is given 
 upon the opposite side with the other hand. A distinct wave passes 
 across and imparts its shock, whenever there is fluid in the abdo- 
 men, to the stationary fingers. Percussion elicits information of fur- 
 ther value; change of position alters the relative location of the 
 fluids, which impart dullness, and the intestines, which give reso- 
 nance. In the upright position the fluid gravitates to the lower part 
 of the abdomen, and the intestines rise toward the diaphragm, dull- 
 ness being found upon percussion of the lower part of the abdomen 
 and resonance when percussion is made higher up over tha intes- 
 tines. When the patient is in the dorsal position the dullness will 
 be in the flanks and the tympanitic sounds over the middle-line of 
 the abdomen. When the patient is turned upon the side the dull- 
 ness will be over the lower flank and the tympanitic sound over the 
 upper one. Change of position will thus be followed by change of 
 location of dullness and resonance, corresponding to the shifting 
 of the fluid and intestines due to gravity. In case there is a very 
 small amount of fluid the knee-chest position may be necessary to 
 detect it. 
 
 Ascites should be differentiated from a large ovarian tumor cen-
 
 518 DISEASES OF THE DIGESTIVE ORGANS 
 
 trslly placed, which remains fixed centrally and pushes the intestines 
 into the flanks. Here the points of dullness are reversed when 
 the patient is in the dorsal position from those of ascites. A dis- 
 tended bladder may be mistaken for abdominal dropsy, and the 
 awkward act of plunging a trocar into the viscus has been committed 
 by surgeons in the past, though this may seem an incredible error. 
 The condition of the bladder should always be determined before 
 the operation of paracentisis. Pancreatic and hydatid cysts have been 
 confused with ascites, though such errors should not occur with 
 careful attention to diagnostic points. 
 
 Treatment. The treatment of ascites should be adapted to in- 
 dividual cases. The causal or provoking factor should receive first 
 attention. Portal obstruction, if amenable to treatment, should be 
 removed, and, in malarial cachexia, spleen remedies should be admin- 
 istered to assist normal portal circulation. Hydraemic conditions 
 may require calcium phos. 3x, calcarea carb. 3x, preparations of iron, 
 change of climate or other provision. The diet should be generous, 
 unless digestion is seriously impaired, and as small an amount of 
 fluid as possible should be taken. Heroic measures for the removal 
 of abdominal fluids should be avoided. Hot or steam baths are not 
 adapted to this condition. Active cathartics seldom accomplish 
 permanent good, and prove debilitating from the start. Sometimes, 
 when there is not serious organic disease present, cathartic doses of 
 elaterium, employed for a few hours at intervals, remove the fluid, and 
 judicious after-management prevents its return. The use of diuretics 
 and diaphoretics is favored by many, but such measures seldom 
 accomplish much. Apocynum cannabinum, in five- or ten-drop doses 
 of the specific medicine, four or five times daily, may prove success- 
 ful. In other cases benefit might follow the use of convallaria mo/oZtff, 
 in five-drop doses repeated every three or four hours during the day. 
 Sometimes, when the accumulation is due to arrested cutaneous ex- 
 udation, a change of climate will serve the purpose. In the case of 
 an old sea captain with enormous ascitic accumulation, a prolonged 
 residence in the interior of California resulted in a permanent cure. 
 Of course, in this case there was no organic disease or portal 
 obstruction. 
 
 Most cases finally become so distressing from distention as to 
 need paracentisis, and this may require repetition a number of times, 
 whatever the ultimate result. Important considerations in such 
 cases are precautions as to asepsis of instruments employed, and 
 care not to injure any of the abdominal viscera.
 
 INDEX. 
 
 ABDOMINAL DROPSY 516 
 
 ABNORMALITIES OF THE HEPATIC 
 
 CIRCULATION 478 
 
 ABSCESS OF THE LIVER 486 
 
 Synonym, 486. 
 
 Etiology, 486. 
 
 Pathology, 487. 
 
 Symptoms, 488. 
 
 Diagnosis, 489. 
 
 Prognosis, 489. 
 
 Treatment, 489. 
 
 ABSCESS, PERITONSILLAR 366 
 
 ACTINOMYCOSIS 291 
 
 Synonyms, 291. 
 
 Definition, 291. 
 
 Etiology, 291. 
 
 Pathology, 291. 
 
 Symptoms, 291. 
 
 Diagnosis, 291. 
 
 Prognosis, 292. 
 
 Treatment, 293. 
 ACUTE ARTICULAR RHEUMATISM . 302 
 
 Synonyms, 302. 
 
 Definition, 302. 
 
 Etiology, 302. 
 
 Pathology, 302. 
 
 Symptoms, 302. 
 
 Diagnosis, 303. 
 
 Prognosis, 304. 
 
 Treatment, 304. 
 ACUTE CATARRHAL ENTERITIS. ..412 
 
 ACUTE DIARRHCEA 412 
 
 ACUTE DYSPEPSIA 376 
 
 ACUTE DYSPEPTIC DIARRHCEA 466 
 
 ACUTE ENTERO-COLITIS 412 
 
 ACUTE ENTERO-COLITIS (INFAN- 
 TILE) 467 
 
 ACUTE GASTRIC CATARRH 376 
 
 Synonyms, 376. 
 
 Definition, 376. 
 
 Etiology, 376. 
 
 Pathology, 376. 
 
 Symptoms, 376. 
 
 ACUTE GASTRIC CATARRH, CONT'ED. 
 
 Diagnosis, 377. 
 
 Prognosis, 377. 
 
 Treatment, 378. 
 ACUTE GENERAL PERITONITIS. ...508 
 
 Definition, 508. 
 
 Etiology, 508. 
 
 Pathology, 509. 
 
 Symptoms, 509. 
 
 Diagnosis, 510. 
 
 Treatment, 511. 
 ACUTE GENERAL TuBERCULOSis.,268 
 
 Synonyms, 268. 
 
 Definition, 268. 
 
 Etiology, 268. 
 
 Pathology, 270. 
 
 Symptoms, 271. 
 
 Diagnosis, 272. 
 
 Prognosis, 272. 
 
 Treatment, 272. 
 
 ACUTE HEMORRHAGIC PANCREA- 
 TITIS 504 
 
 ACUTE INFECTIOUS JAUNDICE.... 295 
 ACUTE INTESTINAL CATARRH 412 
 
 Synonyms, 412. 
 
 Definition, 412. 
 
 Etiology, 412. 
 
 Pathology, 413. 
 
 Symptoms, 413. 
 
 Treatment, 413. 
 
 ACUTE MILIARY TUBERCULOSIS. ..268 
 ACUTE PANCREATITIS 504 
 
 Synonym, 504. 
 
 Etiology, 504. 
 
 Pathology, 504. 
 
 Symptoms, 504. 
 
 Diagnosis, 505. 
 
 Prognosis, 505. 
 
 Treatment, 505. 
 ACUTE PHARYNGITIS 358 
 
 Definition, 358. 
 
 Etiology, 358. 
 
 Symptoms, 359.
 
 520 
 
 INDEX. 
 
 ACUTE PHARYNGITIS, CONT'D 358 
 
 Treatment, 359. 
 
 ACUTE RHEUMATISM 302 
 
 ACUTE YELLOW ATROPHY OF THE 
 
 LIVER 476 
 
 ADENOMATA OF THE LIVER 492 
 
 AFRICAN FEVER 165 
 
 AGUE 222 
 
 AMYLOID DEGENERATION OF THE 
 
 BOWELS 455 
 
 AMYLOID LIVER 495 
 
 Synonyms, 495. 
 Etiology, 495. 
 Pathology, 495. 
 Symptoms, 496. 
 Diagnosis, 496. 
 Prognosis, 496. 
 Treatment, 496. 
 
 ANGINA LUDOVICI 364 
 
 ANGINA MALIGNA 167 
 
 ANGINA SUFFOCATA 167 
 
 ANGIOMATA OF THE LIVER 492 
 
 ANTHRAX 258 
 
 Synonyms, 258. 
 Definition, 258. 
 Etiology, 258. 
 External, 258. 
 Internal, 259. 
 Treatment, 260. 
 
 APPENDICITIS 444 
 
 Definition, 444. 
 Etiology, 444. 
 Pathology, 445. 
 Symptoms, 446. 
 Diagnosis, 447. 
 Prognosis, 447. 
 Treatment, 448. 
 
 APPENDICULAR PERITONITIS 513 
 
 APHTHA 349 
 
 APHTHOUS STOMATITIS... 349 
 
 Synonyms, 349. 
 Definition, 349. 
 Etiology, 349. 
 Pathology, 349. 
 Symptoms, 349. 
 Treatment, 349. 
 
 ARREST OF SALIVARY SECRETION..357 
 Synonym, 357. 
 Etiology, 357. 
 Symptoms, 357. 
 Treatment, 358. 
 ARTHRITIS DEFORMANS. . . . .311 
 
 ARTHRITIS DEFORMANS, CONT'D.. 311 
 Synonyms, 311. 
 Definition, 311. 
 Etiology, 312. 
 Pathology, 312. 
 Symptoms, 313. 
 Diagnosis, 314. 
 Prognosis, 314. 
 Treatment, 314. 
 
 ASCITES. 516 
 
 Synonyms, 516. 
 Definition, 516. 
 Pathology, 517. 
 Symptoms, 517. 
 Treatment, 518. 
 
 ASIATIC CHOLERA 200 
 
 Synonyms, 200. 
 Definition, 200. 
 Historical Note, 200. 
 Etiology, 201. 
 Pathology, 202. 
 Symptoms, 203. 
 Complications, 205. 
 Diagnosis, 205. 
 Prognosis, 205. 
 Treatment, 206. 
 
 ATROPHIC CIRRHOSIS 482 
 
 ATROPHY 36 
 
 ATROPHY OF THE GALL-BLADDER.. 501 
 
 BACILLI, PATHOGENIC 67 
 
 BACTERIOLOGY 60 
 
 Technology of, 60. 
 Staining, Preparing, 62. 
 Biology of, 64. 
 
 BARLOW'S DISEASE 341 
 
 BIG JAW H'.u 
 
 BILIARY COLIC 500 
 
 BILIOUS REMITTENT FEVER i^'.t 
 
 BILIOUS TYPHOID OF GREISIN- 
 
 GER 295 
 
 BLACK VOMIT 208 
 
 BLATTER 108 
 
 BLITZ CATARRH 161 
 
 BLOODY FLUX 425 
 
 BOWELS, AMYLOID DEGENERA- 
 TION OF 455 
 
 BOWELS, INFLAMMATION OF 
 
 412, 413, 419, 420, 42T, 
 
 BLOODVESSELS OF LIVER, DIS- 
 EASES OF 478 
 
 BRAUNE PRUNA. . ..167
 
 INDEX. 
 
 621 
 
 CAECUM, INFLAMMATION OF 443 
 
 CALCULOUS DEGENERATION 46 
 
 CALCULI, BILIARY 498 
 
 CALCULI OF THE PANCREAS 507 
 
 CANCER OF THE GALL BLADDER..503 
 CANCER OF THE INTESTINES 433 
 
 Etiology, 433. 
 
 Pathology, 434. 
 
 Symptoms, 434. 
 
 Diagnosis, 436. 
 
 Prognosis, 436. 
 
 Treatment, 436. 
 CANCER OF THE LIVER 490 
 
 Pathology, 490. 
 
 Symptoms, 491. 
 
 Diagnosis, 491. 
 
 Prognosis, 492. 
 
 Treatment, 492. 
 CANCER OF THE PANCREAS 507 
 
 Etiology, 507. 
 
 Pathology, 507. 
 
 Symptoms, 507. 
 
 Diagnosis, 507. 
 
 Treatment, 507. 
 
 CANCER OF THE PERITONAEUM... .515 
 CANCER OF THE STOMACH 398 
 
 Etiology, 398. 
 
 Pathology, 399. 
 
 Symptoms, 400. 
 
 Diagnosis, 402. 
 
 Prognosis, 402. 
 
 Treatment, 402. 
 
 C ANCRUM ORIS 353 
 
 CARTILAGE, INFLAMMATION OF.. 24 
 
 CATARRH. ACUTE GASTRIC 376 
 
 CATARRH, ACUTE INTESTINAL . . .412 
 
 CATARRH, BLITZ 161 
 
 CATARRHAL FEVER 161 
 
 CATARRHAL INFLAMMATION OF 
 
 THE BILIARY PASSAGES 4!7 
 
 Synonym, 497. , 
 
 Etiology and Pathology, 497. 
 
 Symptoms, 498. 
 
 Diagnosis, 498. 
 
 Prognosis, 498. 
 
 Treatment, 498. 
 CATARRHAL ENTERITIS, ACUTE.. 412 
 
 CELLULITIS OF THE NECK 364 
 
 CEREBRO-SPINAL FEVER 101 
 
 Synonyms, 101. 
 
 Definition, 101. 
 
 Historical Note, 101. 
 
 CEREBRO-SPINAL FEVER, CONT'D...IOI 
 
 Etiology, 101. 
 
 Pathology, 101. 
 
 Symptoms, 102. 
 
 Diagnosis, 105. 
 
 Prognosis, 106. 
 
 Treatment, 106. 
 
 CEREBRO-SPINAL MENINGITIS ____ 101 
 CHICKEN Pox ..................... 123 
 
 Synonym, 123. 
 
 Definition, 123. 
 
 Etiology, 123. 
 
 Pathology, 124. 
 
 Symptoms, 125. 
 
 Diagnosis, 126. 
 
 Prognosis, 127. 
 
 Treatment, 127. 
 CHILLS AND FEVER ............... 222 
 
 CHOLERA, ASIATIC ................. 206 
 
 CHOLERA INFANTUM .............. 461 
 
 CHOLERA MORBUS ................ 403 
 
 Synonyms, 431. 
 
 Definition, 431. 
 
 Etiology, 431. 
 
 Pathology, 431. 
 
 Symptoms, 431. 
 
 Diagnosis, 432. 
 
 Prognosis, 432. 
 
 Treatment, 433. 
 CHOLERA NOSTRAS ................ 431 
 
 CHRONIC ARTICULAR RHEUMA- 
 
 TISM ........................... 307 
 
 Synonym, 307. 
 
 Definition, 307. 
 
 Pathology, 307. 
 
 Symptoms, 307. 
 
 Diagnosis, 308. 
 
 Prognosis, 308. 
 
 Treatment, 308. 
 
 CHRONIC CATARRHAL ENTERITIS . .415 
 CHRONIC ENTERO-COLITIS . ....... 415 
 
 CHRONIC DIARRHCEA ............. 4 1.~> 
 
 CHRONIC DYSPEPSIA .............. .".TH 
 
 CHRONIC GASTRIC CATARRH ...... 379 
 
 CHRONIC GASTRITIS ............... 379 
 
 Synonyms, 379. 
 
 Definition, 379. 
 
 Etiology, 379. 
 
 Pathology, 380. 
 
 Symptoms, 381. 
 
 Diagnosis, 382.
 
 522 
 
 INDEX. 
 
 CHRONIC GASTRITIS, CONT'D 379 
 
 Treatment, 383. 
 
 Prognosis, 383. 
 
 CHRONIC GASTRIC ULCER 392 
 
 CHRONIC INFLAMMATION 25 
 
 CHRONIC INTESTINAL CATARRH.. 415 
 
 Synonyms, 415. 
 
 Etiology, 415. 
 
 Pathology, 416. 
 
 Symptoms, 416. 
 
 Diagnosis, 416. 
 
 Prognosis, 417. 
 
 Treatment, 417. 
 CHRONIC MALARIAL FEVER 251 
 
 Synonyms, 251. 
 
 Definition, 251. 
 
 Etiology, 251. 
 
 Pathology, 251. 
 
 Symptoms, 251. 
 
 Diagnosis, 252. 
 
 Prognosis, 253. 
 
 Treatment, 253. 
 CHRONIC PANCREATITIS 505 
 
 Etiology, 505. 
 
 Pathology, 505. 
 
 Symptoms, 505. 
 
 Treatment, 506. 
 CHRONIC PERITONITIS 513 
 
 Etiology, 513. 
 
 Treatment, 513. 
 
 CHRONIC HEMORRHAGIC PERITO- 
 NITIS 514 
 
 CHRONIC PHARYNGITIS 360 
 
 CHRONIC TONSILLITIS 368 
 
 Synonyms, 368. 
 
 Definition, 368. 
 
 Etiology, 368. 
 
 Pathology, 369. 
 
 Symptoms, 369. 
 
 Diagnosis, 369. 
 
 Prognosis, 369. 
 
 Treatment, 370. 
 
 CIRRHOSIS 27 
 
 CIRRHOSIS OF THE LIVER 480 
 
 CLERYMAN'S SORE THROAT 360 
 
 Cocci, PATHOGENIC 66 
 
 COLIC, BILIARY 500 
 
 COLIC, BILIOUS 461 
 
 COLIC, COPPER 462 
 
 COLIC, INTESTINAL 461 
 
 COLIC, LEAD 462 
 
 COLLOID, DEGENERATION 44 
 
 CONGESTION OF THE LIVER, PASS- 
 IVE 478 
 
 CONGESTIVE FEVER 235 
 
 CONSTIPATION 458 
 
 Definition, 458. 
 
 Etiology, 458. 
 
 Pathology, 459. 
 
 Symptoms, 459. 
 
 Diagnosis, 459. 
 
 Prognosis, 459. 
 
 Treatment, 459. 
 
 CONTAGIOUS C ATABRH 161 
 
 CONTINUED MALARIAL FEVER... 243 
 
 COPPER COLIC 462 
 
 CORNEA, INFLAMMATION OF 24 
 
 CROUPOUS ENTERITIS 418 
 
 CROUPOUS STOMATITIS 349 
 
 CYSTS OF THE LIVER 493 
 
 CYSTS OF THE PANCREAS 507 
 
 DANDY FEVER 165 
 
 DEGENERATIONS 41 
 
 " AMYLOID 45 
 
 " CALCAREOUS 46 
 
 " COLLOID 44 
 
 " MUCOID 44 
 
 " PARENCHYMAT'S. 42 
 
 " PIGMENTARY 47 
 
 DENGUE 165 
 
 DENGUE FEVER 165 
 
 Synonyms, 165. 
 
 Definition, 165. 
 
 Etiology, 165. 
 
 Pathology, 166. 
 
 Symptoms, 166. 
 
 Diagnosis, 166. 
 
 Prognosis, 167. 
 
 Treatment, 167. 
 DIABETES INSIPIDUS 331 
 
 Synonyms, 331. 
 
 Definition, 331. 
 
 Etiology, 331. 
 
 Pathology, 333. 
 
 Symptoms, 332. 
 
 Diagnosis, 332. 
 
 Prognosis, 333. 
 
 Treatment, 333. 
 DIABETES MELLITUS 326 
 
 Synonyms, 326. 
 
 Definition, 326. 
 
 Etiology, 326. 
 
 Pathology, 326.
 
 INDEX. 
 
 623 
 
 DIABETES MELLITUS, CONT'D 326 
 
 Symptoms, 327. 
 
 Diagnosis, 329. 
 
 Prognosis, 329. 
 
 Treatment, 329. 
 DIARRHCEA 456 
 
 Definition, 456. 
 
 Etiology, 456. 
 
 Symptoms, 457. 
 
 Treatment, 457. 
 
 DIARRHCEA, CHRONIC 415 
 
 DILATATION OP THE STOMACH. . .390 
 
 Synonym, 390. 
 
 Definition, 390. 
 
 Etiology, 390. 
 
 Pathology, 390. 
 
 Symptoms, 391. 
 
 Diagnosis, 391 
 
 Prognosis, 392. 
 
 Treatment, 392. 
 
 DlTHTHERIA 167 
 
 Synonyms, 167. 
 
 Definition, 167. 
 
 Historical Note, 168. 
 
 Etiology, 168. 
 
 Pathology, 171. 
 
 Nature of, 173. 
 
 Symptoms, 174. 
 
 Diagnosis, 178. 
 
 Prognosis, 179. 
 
 Treatment, 179. 
 
 DlTHTHERITIC ENTERITIS 418 
 
 DISEASES OF THE MESENTERY ... 470 
 
 DROPSY, ABDOMINAL 516 
 
 DRY DIET 54 
 
 DUKE OF WURTEMBERG'S CURE. . . 54 
 DYSENTERY 425 
 
 Synonyms, 425. 
 
 Definition, 425. 
 
 Etiology, 425. 
 
 Pathology, 426. 
 
 Symptoms, 427. 
 
 Diagnosis, 427. 
 
 Prognosis, 427. 
 
 Treatment, 427. 
 DYSPEPSIA, CHRONIC 379 
 
 ECHINOCOCCI OF THE PERITO- 
 NAEUM 516 
 
 ECZEMA OF THE TONGUE 352 
 
 Synonyms, 352. 
 Definition, 352. 
 
 ECZEMA OF THE TONGUE, CON. . .352 
 
 Etiology, 352. 
 
 Symptoms, 352. 
 
 Treatment, 352. 
 
 ELEPHANTIASIS 286 
 
 ENGLISH CHOLERA 431 
 
 ENTERIC FEVER 69 
 
 ENTERITIS, ACUTE CATARRHAL. .412 
 ENTERITIS, CHRONIC CATARRHAL 415 
 
 ENTERITIS, CROUPOUS 418 
 
 ENTERITIS, MEMBRANOUS 418 
 
 ENTERO-COLITIS, CHRONIC 415 
 
 ENTERO-COLITIS (INFANTILE) . . . .467 
 
 ENTERORRHAGIA 441 
 
 EPIDEMIC CATARRH 161 
 
 EPIDEMIC CHOLERA 200 
 
 EPIDEMIC INFLUENZA 161 
 
 Synonyms, 161. 
 
 Definition, 161. 
 
 Historical Note, 161. 
 
 Etiology, 162. 
 
 Pathology, 162. 
 
 Symptoms, 162. 
 
 Treatment, 162. 
 
 EPIDEMIC ROSEOLA 150 
 
 ERYSIPELAS 187 
 
 Synonyms, 187. 
 
 Definition, 187. 
 
 Etiology, 187. 
 
 Pathology, 188. 
 
 Symptoms, 189. 
 
 Diagnosis, 190. 
 
 Prognosis, 191. 
 
 Treatment, 191. 
 ESTIVAL INFANTILE ENTERITIS. .464 
 
 Synonyms, 464. 
 
 Etiology, 464. 
 
 Pathology, 465. 
 
 FAMINE FEVER 97 
 
 FARCY 289 
 
 FATTY CIRRHOSIS 483 
 
 " DEGENERATION 43 
 
 " " OF THE 
 
 PANCREAS 506 
 
 FATTY INFILTRATION 42 
 
 " LIVER 493 
 
 Etiology and Pathology, 493. 
 Symptoms, 494. 
 Diagnosis, 494. 
 Prognosis, 495. 
 Treatment, 495.
 
 524 
 
 INDEX. 
 
 FEBRICULA 293 
 
 FEBRIS FLAVA 208 
 
 FEVER 1 
 
 Synonyms, 1. 
 
 Definition, 1. 
 
 Detection, 1. 
 
 Classification, 1. 
 
 Thermometry, 2. 
 
 Stages, 2. 
 
 Termination, 3. 
 
 Remissions, 3. 
 
 Causes, 3. 
 
 Parasitic Origin, 4. 
 
 Symptoms, 5. 
 
 Tissue Changes, 7. 
 
 General Treatment, 7. 
 
 Ventilation, 8. 
 
 Diet, 8. 
 
 Special Sedatives, 10. 
 
 Antiseptic Sedatives, 12. 
 
 Antiperiodics, 14. 
 
 Opiates, 16. 
 
 Muscular Pain, 17. 
 
 Cathartics, 17. 
 
 FEVER, CATARRHAL 161 
 
 CEREBRO-SPINAL 101 
 
 CONGESTIVE 235 
 
 DANDY 165 
 
 DENGUE 165 
 
 CHRONIC MALARIAL 251 
 
 CONTINUED MALARIAL. . .243 
 
 MALARIAL.. 316 
 
 PERNICIOUS MALARI AL . . 235 
 REMITTENT MALARIAL . .229 
 
 " RELAPSING 97 
 
 SCARLET 128 
 
 TYPHOID 69 
 
 TYPHO-MALARIAL. 243 
 
 TYPHUS 90 
 
 " YELLOW 208 
 
 FCETID STOMATITIS 350 
 
 Synonyms, 350. 
 
 Definition, 350. 
 
 Symptoms, 350. 
 
 Treatment, 350. 
 
 FOLLICULAR STOMATITIS 349 
 
 FOLLICULAR TONSILLITIS. 364 
 
 Synonym, 364. 
 
 Definition, 364. 
 
 Etiology, 364. 
 
 Pathology, 364. 
 
 Symptoms, 365. 
 
 FOLLICULAR TONSILLITIS, CON... 364 
 
 Diagnosis, 365. 
 
 Prognosis, 365. 
 
 Treatment, 365. 
 FUNCTIONAL GASTRIC DYSPEPSIA. 406 
 
 Synonym, 406. 
 
 Definition, 406. 
 
 Etiology, 406. 
 
 Pathology, 406. 
 
 Symptoms, 407. 
 
 Diagnosis, 407. 
 
 Prognosis, 407. 
 
 Treatment, 407. 
 
 GALL-STONES 
 
 Synonyms, 498. 
 
 Definition, 498. 
 
 Etiology, 498. 
 
 Pathology, 499. 
 
 Symptoms, 500. 
 
 Treatment, 502. 
 GANGRENOUS STOMATITIS 
 
 Synonyms, 353. 
 
 Definition, 353. 
 
 Etiology, 353. 
 
 Symptoms, 354. 
 
 Treatment, 354. 
 GANGRENOUS PHARYNGITIS 
 
 GARROTILLO 
 
 GASTRALGIA 
 
 Synonym, 409. 
 
 Definition, 409. 
 
 Etiology, 409. 
 
 Pathology, 409. 
 
 Symptoms, 409. 
 
 Diagnosis, 410. 
 
 Prognosis, 410. 
 
 Treatment, 410. 
 
 GASTRECTASIS 
 
 GASTRIC CATARRH, ACUTE 
 
 GASTRIC CATARRH, CHRONIC.. 
 GASTRITIS, ACUTE 
 
 " CHRONIC 
 
 " PARASITIC 
 
 GASTRITIS, PHLEGMONOUS 
 
 Synonym, 378. 
 
 Definition, 378. 
 
 Etiology, 378. 
 
 Pathology, 378. 
 
 Symptoms, 378. 
 
 Diagnosis, 379. 
 
 Prognosis, 379. 
 
 .498 
 
 .353 
 
 .360 
 .167 
 409 
 
 .390 
 .378 
 
 .379 
 .376 
 .379 
 .379 
 .378
 
 INDEX. 
 
 625 
 
 GASTRITIS, PHLEGMONOUS, CON. .378 
 
 Treatment, 379. 
 
 GASTRODYNIA 409 
 
 GASTRORRHAG IA 404 
 
 GENERAL, REMARKS ON FEVER 
 
 AND INFLAMMATION l 
 
 GEOGRAPHICAL TONGUE 352 
 
 GERMAN MEASLE& 150 
 
 GIN- DRINKER'S LIVER 480 
 
 GLANDS, INFLAMMATION OF SALI- 
 VARY 358 
 
 GLANDERS 289 
 
 Synonym, 289. 
 
 Definition, 289. 
 
 Etiology, 289. 
 
 Pathology, 289. 
 
 Symptoms, 290. 
 
 Diagnosis, 290. 
 
 Prognosis, 291. 
 
 Treatment, 291. 
 
 GLISSONIAN CIRRHOSIS 482 
 
 GLUCOSURIA 326 
 
 GLYCOSURIA 326 
 
 GONORRHCEAL RHEUMATISM 315 
 
 Definition, 315. 
 
 Etiology, 315. 
 
 Pathology, 315. 
 
 Symptoms, 315. 
 
 Diagnosis, 316. 
 
 Prognosis, 316. 
 
 Treatment, 316. 
 GOUT 316 
 
 Synonym, 316. 
 
 Definition, 316. 
 
 Etiology, 316. 
 
 Pathology, 317. 
 
 Symptoms, 318. 
 
 Diagnosis, 320. 
 
 Prognosis, 321. 
 
 Treatment, 321. 
 
 GRANULATED TISSUE 26 
 
 GROWTHS OF PERITONAEUM 515 
 
 " " " CAN- 
 CEROUS 515 
 
 GROWTHS OF PERITONAEUM, NOD- 
 ULAR. ., ..515 
 
 H^EMATEMESIS 
 
 Synonym, 404. 
 Etiology, 404. 
 Pathology, 404. 
 Symptoms, 405. 
 
 .404 
 
 H^EMATEMESIS, CONT'D 404 
 
 Diagnosis, 405. 
 Prognosis, 405. 
 Treatment, 405. 
 
 HAEMOPHILIA 346 
 
 Definition, 346. 
 
 Etiology, 346. 
 
 Pathology, 346. 
 
 Symptoms, 346. 
 
 Diagnosis, 347. 
 
 Prognosis, 347. 
 
 Treatment, 347. 
 
 HEMORRHAGE, INTESTINAL 441 
 
 " FROM THE PAN- 
 CREAS 503 
 
 Etiology, 503. 
 
 Pathology, 503. 
 
 Symptoms, 503. 
 
 Treatment, 504. 
 
 HEMORRHAGIC, CHRONIC PERITO- 
 NITIS 514 
 
 HEMORRHOIDS 451 
 
 Synonym, 451. 
 
 Definition, 451. 
 
 Etiology, 452. 
 
 Pathology, 452. 
 
 Symptoms, 453. 
 
 Diagnosis, 454. 
 
 Prognosis, 454. 
 
 Treatment, 454. 
 
 HEPATITIS, INTERSTITIAL 480 
 
 HERPES LABIALIS 348 
 
 HOB-NAILED LIVER 480 
 
 HYDROPERITON^UM 516 
 
 HYDROPHOBIA 260 
 
 Synonyms, 260. 
 
 Definition, 260. 
 
 Etiology, 260. 
 
 Pathology, 261. 
 
 Symptoms, 261. 
 
 Diagnosis, 262. 
 
 Treatment, 263. 
 
 HUNGERPEST 97 
 
 HYPER^EMIA OF LIVER, ACTIVE.. 478 
 HYPERSECRETION AND HYPERACID- 
 ITY OF GASTRIC JUICE 408 
 
 Symptoms, 408. 
 
 Diagnosis, 408. 
 
 Treatment, 408. 
 
 HYPERSECRETION OF THE SALI- 
 VARY GLANDS 356 
 
 Synonym, 356.
 
 526 
 
 INDEX. 
 
 HYPERSECRETION OF THE SALT- 
 VARY GLANDS, CONTINUED. ...356 
 Etiology, 356. 
 Symptoms, 357. 
 Treatment, 357. 
 
 HYPERTROPHY 36 
 
 HYPERTROPHY OF THE TONSILS..368 
 HYPODERMIC INJECTION OF QUIN- 
 INE IN MALARIAL FEVER 241 
 
 ICTERUS 474 
 
 ICTERUS GRAVIS 476 
 
 ICTERUS NEONATORUM 474 
 
 INFANTS, PERITONITIS IN 512 
 
 INFANTILE ESTIVAL ENTERITIS... 464 
 
 INFANTILE JAUNDICE 474 
 
 INFLAMMATION 17 
 
 Synonyms, 17. 
 
 Definition, 17. 
 
 Etiology, 17. 
 
 Pathology, 18. 
 
 Histological Elements Involved, 18 
 
 Bloodvessels, 18. 
 
 Blood Corpuscles, 18. 
 
 Fixed Tissue Cells, 20. 
 
 Exudation, 21. 
 
 Exudation of Serous Mem- 
 brane, 21. 
 
 Exudation of Mucous Mem- 
 brane, 21. 
 
 Histological Changes, 23. 
 
 Terminations, 26. 
 
 Symptoms, 27. 
 
 Treatment, 30. 
 
 Dieting, 35. 
 
 INFLAMMATION OF THE CAECUM.. .443 
 INFLAMMATION OF THE SALIVARY 
 
 GLANDS ." 358 
 
 INFLAMMATORY RHEUMATISM 302 
 
 INFLUENZA, EPIDEMIC 161 
 
 INTERMITTENT FEVER. 222 
 
 Synonym, 222. 
 
 Definition, 222. 
 
 Etiology, 222. 
 
 Symptoms, 223. 
 
 Diagnosis, 224. 
 
 Treatment, 225. 
 
 INTERMITTENT FEVER, MASKED.. 228 
 INTESTINAL COLIC 461 
 
 Definition, 461. 
 
 Etiology, 461. 
 
 Pathology, 461. 
 
 INTESTINAL COLIC, CONT'D 461 
 
 Symptoms, 462. 
 
 Diagnosis, 463. 
 
 Prognosis, 463. 
 
 Treatment, 463. 
 INTESTINAL HEMORRHAGE 441 
 
 Synonym, 441. 
 
 Etiology, 441. 
 
 Pathology, 441. 
 
 Symptoms, 441. 
 
 Diagnosis, 442. 
 
 Treatment, 442. 
 INTESTINAL OBSTRUCTION 437 
 
 Definition, 437. 
 
 Etiology and Pathology, 437. 
 
 Symptoms, 438. 
 
 Diagnosis, 439. 
 
 Prognosis, 440. 
 
 Treatment, 440. 
 INTERSTITIAL HEPATITIS 4 
 
 Synonyms, 480. 
 
 Definition, 480. 
 
 Etiology, 480. 
 
 Pathology, 481. 
 
 Symptoms, 484. 
 
 Diagnosis, 485. 
 
 Prognosis, 485. 
 
 Treatment, 485. 
 
 JAIL FEVER 
 
 JAUNDICE 
 
 Synonym, 471. 
 
 Definition, 471. 
 
 Etiology, 471. 
 
 Pathology, 472. 
 
 Symptoms, 473. 
 JAUNDICE, INFANTILE.. 
 
 Synonym, 474. 
 
 Etiology, 474. 
 
 Symptoms, 475. 
 
 Treatment, 476. 
 JAUNDICE, MALIGNANT. 
 
 Synonyms, 476. 
 
 Etiology, 476. 
 
 Pathology, 476. 
 
 Symptoms, 477. 
 
 Diagnosis, 477. 
 
 Prognosis, 477. 
 
 Treatment, 477. 
 JUNGLE FEVER.. 
 
 . 90 
 .471 
 
 .474 
 
 ,/.476 
 
 KARYOKINESIS 
 
 .229 
 36
 
 INDEX. 
 
 627 
 
 LA GRIPPE 161 
 
 LEPRA 286 
 
 LEPROSY 286 
 
 Synonyms, 286. 
 
 Definition, 286. 
 
 Etiology, 286. 
 
 Pathology, 287. 
 
 Symptoms, 288. 
 
 Diagnosis, 288. 
 
 Prognosis, 288. 
 
 Treatment, 289. 
 LIVER, ABSCESS OF 486 
 
 Synonym, 486. 
 
 Etiology, 486. 
 
 Pathology, 487. 
 
 Symptoms, 488. 
 
 Diagnosis, 489. 
 
 Treatment, 489. 
 LIVER, ACTIVE HYPER^EMIA OF.. 478 
 
 " ADENOMATA OF 492 
 
 " ANGIOMATA OF 492 
 
 " CANCER OF 490 
 
 " CIRRHOSIS OF THE 480 
 
 " CONGESTION OF 478 
 
 " CYSTS OF... 493 
 
 " FATTY 493 
 
 " GIN-DRINKER'S 480 
 
 " HOB-NAILED 480 
 
 " TUBERCULOUS 496 
 
 LlTH^MIA 323 
 
 Definition, 323. 
 
 Etiology, 323. 
 
 Pathology, 324. 
 
 Symptoms, 324. 
 
 Diagnosis, 325. 
 
 Prognosis, 325. 
 
 Treatment, 325. 
 LOCAL ADHESIVE PERITONITIS.. . .514 
 
 LOCALIZED PERITONITIS 512 
 
 LOCKJAW 264 
 
 LUES VENEREA 273 
 
 LUMPY JAW 291 
 
 LYSSA 260 
 
 MALARIAL CACHEXIA 251 
 
 MALARIAL FEVER 216 
 
 Synonyms, 216. 
 
 Definition, 216. 
 
 Etiology, 216. 
 
 Conditions Which Oppose. 219.' 
 
 Conditions Which Predis- 
 pose, 219. 
 
 MALARIAL FEVER, CON 297 
 
 General Pathology, 220. 
 MALARIAL FEVER, CHRONIC 251 
 
 Synonym, 251. 
 
 Etiology, 251. 
 
 Pathology, 251. 
 
 Symptoms, 251. 
 
 Diagnosis, 252. 
 
 Prognosis, 252. 
 
 Treatment, 253. 
 
 MALARIAL FEVER, CONTINUED.. .243 
 " " PERNICIOUS... 235 
 
 Synonyms, 235. 
 
 Definition, 235. 
 
 Etiology, 235. 
 
 Pathology, 235. 
 
 Symptoms, 235. 
 
 Diagnosis, 239. 
 
 Treatment, 235. 
 
 MALARIAL FEVER, REMITTENT . . .229 
 MALIGNANT CHOLERA 200 
 
 " CEDEMA 258 
 
 MALIGNANT JAUNDICE 476 
 
 Synonyms, 476. 
 
 Etiology, 476. 
 
 Pathology, 476. 
 
 Symptoms, 477. 
 
 Diagnosis, 477. 
 
 Prognosis, 477. 
 
 Treatment, 477. 
 MALIGNANT PURPURIC FEVER 344 
 
 " PUSTULE 258 
 
 MALTA FEVER 298 
 
 Synonyms, 298. 
 
 Definition, 298. 
 
 Etiology, 298. 
 
 Pathology, 299. 
 
 Symptoms, 299. 
 
 Treatment, 299. 
 
 MAP TONGUE -352 
 
 MARSH FEVER 216 
 
 MASKED INTERMITTENT FEVER.. 228 
 MEASLES 141 
 
 Synonyms, 141. 
 
 Definition, 141. 
 
 Etiology, 141. 
 
 Pathology, 141. 
 
 Symptoms, 142. 
 
 Atypical Course, 144. 
 
 Complications and Sequelae, 144. 
 
 Diagnosis. M">. 
 
 Prognosis, 146.
 
 528 
 
 INDEX. 
 
 MEASLES, CONTINUED 141 
 
 Treatment, 146. 
 
 MEASLES, GERMAN 150 
 
 MEDITERRANEAN FEVER 298 
 
 MELLITURIA 328 
 
 MEMBRANOUS ENTERITIS 418 
 
 MERCURIAL STOMATITIS 351 
 
 Definition, 351. 
 
 Etiology, 351. 
 
 Symptoms, 351. 
 
 Treatment, 351. 
 MESENTERY, DISEASES OF THE... 470 
 
 MILIARY FEVER 299 
 
 MILK SICKNESS 297 
 
 Definition, 297. 
 
 Etiology, 297. 
 
 Pathology, 298. 
 
 Symptoms, 298. 
 
 Diagnosis, 298. 
 
 Prognosis, 298. 
 
 Treatment, 298. 
 
 MORBILLI 141 
 
 MORNING DIARRHCEA 411 
 
 MOUNTAIN FEVER 300 
 
 MUCOID DEGENERATION. . 44 
 
 Mucous COLIC 419 
 
 Mucous COLITIS 419 
 
 Synonyms, 419. 
 
 Definition, 419. 
 
 Etiology, 419. 
 
 Pathology, 419. 
 
 Symptoms, 420. 
 
 Diagnosis, 420. 
 
 Treatment, 420. 
 
 MUGUET 352 
 
 MUMPS ... .153 
 
 Synonyms, 153. 
 
 Definition, 153. 
 
 Etiology, 153. 
 
 Pathology, 153. 
 
 Symptoms, 154. 
 
 Treatment, 155. 
 MUSCULAR RHEUMATISM 809 
 
 Synonym, 309. 
 
 Definition, 309. 
 
 Etiology, 309. 
 
 Pathology, 309. 
 
 Symptoms, 309. 
 
 Diagnosis, 310. 
 
 Prognosis, 310. 
 
 Treatment, 310. 
 MYALGIA.. ....309 
 
 MYCOSIS INTESTINALIS 259 
 
 NEAPOLITAN FEVER 298 
 
 NECROSIS 48 
 
 NERVOUS DYSPEPSIA 406 
 
 NEW GROWTHS IN THE LIVER 490 
 
 NEW GROWTHS IN PERITONAEUM.. 515 
 NODULAR GROWTHS IN THE PERI- 
 TONAEUM 515 
 
 NOMA 353 
 
 NON-MALIGNANT TUMORS OF THE 
 STOMACH 453 
 
 OBSTRUCTION OF BILIARY DUCT. .503 
 
 OBSTRUCTION OF THE BOWEL 437 
 
 (ESOPHAGUS, INFLAMMATION OF.. 371 
 
 " OBSTRUCTION OF. . .373 
 
 Etiology, 373. 
 
 Pathology, 373. 
 
 Symptoms, 373. 
 
 Treatment, 374. 
 
 (ESOPHAGUS, FUNCTIONAL DIS- 
 EASE OF 374 
 
 CESOPHAGITIS 371 
 
 Synonym, 371. 
 
 Definition, 371. 
 
 Etiology, 371. 
 
 Pathology, 371. 
 
 Symptoms, 372. 
 
 Diagnosis, 372. 
 
 Prognosis, 372. 
 
 Treatment, 372. 
 
 PALUDAL FEVER 216 
 
 PANCREAS, ACUTE lNFLAMMAT'N..504 
 
 " CALCULI 507 
 
 " CANCER OF 507 
 
 " CHRONIC INFLAMMA- 
 TION OF 505 
 
 PANCREAS, CYSTS 507 
 
 " DISEASES OF 503 
 
 (i FATTY DEGENERATI'N.506 
 " HEMORRHAGE FROM... 503 
 " WAXY DEGENERATI'N.508 
 
 PARASITIC GASTRITIS 379 
 
 " STOMATITIS 352 
 
 Synonyms, 352. 
 Definition, 352. 
 Etiology, 352. 
 Pathology, 352. 
 Symptoms, 353. 
 Treatment, 353.
 
 529 
 
 PAKENCHYMATOUS DEGENERA- 
 TION* 4~2 
 
 PATHOGENIC BACILLI 67 
 
 " Cocci 66 
 
 " SPIRILLI 67 
 
 PEPTIC ULCER 392 
 
 Synonyms, 392. 
 
 Definition, 392. 
 
 Etiology, 392. 
 
 Pathology, 393. 
 
 Symptoms, 394. 
 
 Diagnosis, 395. 
 
 Prognosis, 395. 
 
 Treatment, 3%. 
 PERIPROCTITIS 450 
 
 Definition, 450. 
 
 Etiology, 450. 
 
 Pathology, 451. 
 
 Symptoms, 451. 
 
 Treatment, 451. 
 
 PERISTALTIC UNREST 411 
 
 PERITONAEUM, ACUTE INFLAMMA- 
 TION OF 508 
 
 PERITONAEUM, INFLAMMATION OF.508 
 PERITONAEUM, NEW GROWTHS IN. 515 
 PERITONAEUM, NODULAR GROWTHS 
 
 IN THE 514 
 
 PERITONAEUM, TUBERCULOSIS OF..515 
 PERITONITIS, LOCAL ADHESIVE. . .514 
 
 " APPENDICULAR 513 
 
 " CHRONIC 513 
 
 " CHRONIC HEMOR- 
 
 RHAGIC 514 
 
 PERITONITIS, DIFFUSE 514 
 
 " IN INFANTS 512 
 
 " LOCALIZED 512 
 
 PELVIC 512 
 
 " PROLIFERATIVE 514 
 
 " SUBPHRENIC 513 
 
 PERNICIOUS FEVER 235 
 
 PERNICIOUS MALARIAL FEVER.... 23"> 
 
 Synonyms, 235. 
 
 Definition, 2.S.". 
 
 Etiology, 235. 
 
 Pathology, 235. 
 
 Symptoms, 235. 
 
 Diagnosis, 23S). 
 
 Treatment, 235. 
 
 PERTUSSIS 156 
 
 PETECHI AL FEVER 1 < ' l 
 
 PHARYNGEAL CATARRH 360 
 
 Synonym, 360. 
 
 34 
 
 PHARYNGEAL CATARRH, cox :wo 
 
 Etiology, 360. 
 Pathology, 361. 
 Symptoms, 361. 
 Treatment, 361. 
 
 PHARYNGITIS, PHLEGMONOUS 360 
 
 " SICCA 
 
 PHARYNX, ABSCESS OF ::r.n 
 
 " ACUTE INFLAMMATION.:;:.^ 
 " CHRONIC INFLAMMAT'N :n;o 
 
 " GANGRENE OF 360 
 
 " ULCERATION OF 362 
 
 PHLEGMCNOUS ENTERITIS 418 
 
 " GASTRITIS 378 
 
 Synonym, 378. 
 Definition, 378. 
 Etiology, 378. 
 Pathology, 378. 
 Symptoms, 378. 
 Diagnosis, 379. 
 Prognosis, 379. 
 Treatment, 379. 
 POCKEN 108 
 
 PODAGRA 316 
 
 PORTAL VEIN, DISEASES OF 479 
 
 Pox 273 
 
 PROCTITIS 449 
 
 Synonyms, 449. 
 
 Definition, 449. 
 
 Etiology, 449. 
 
 Pathology, 449. 
 
 Symptoms, 449. 
 
 Diagnosis, 449. 
 
 Prognosis, 450. 
 
 Treatment, 450. 
 
 PROLIFERATIVE PERITONITIS.. ..514 
 PSEUDO-MEMBRANOUS ENT ERiTis.418 
 
 Synonyms, 418. 
 
 Definition, 418. 
 
 Etiology, 418. 
 
 Pathology, 419. 
 
 Symptoms, 419. 
 
 Treatment, 419. 
 
 PTYALISM 
 
 PURPURA 
 
 " HEMORRHAGICA. . . -'M-'5 
 
 Symptoms, 344. 
 
 Treatment, 344. 
 PURPURIC FEYKK. MALIGNANT . :!44 
 
 PUSTULE, MALIGNAXT 
 
 Pus 
 
 PUTRID SORE MOUTH :'*">o
 
 530 
 
 INDEX. 
 
 PYAEMIA 
 
 Synonym, 196. 
 
 Definition, 196. 
 
 Etiology, 196. 
 
 Pathology, 197. 
 
 Symptoms, 198. 
 
 Diagnosis, 199. 
 
 Prognosis, 199. 
 
 Treatment, 199. 
 PYORRHCEA ALVEOLARIS. 
 
 Definition, 354. 
 
 Etiology, 355. 
 
 Pathology, 355. 
 
 Symptoms, 355. 
 
 Treatment, 355. 
 
 QUINSY 
 
 Synonyms, 36. 
 Definition, 366. 
 Etiology, 366. 
 Pathology, 366. 
 Symptoms, 367. 
 Diagnosis, 367. 
 Prognosis, 367. 
 Treatment, 367. 
 
 196 
 
 .354 
 
 .366 
 
 RABIES 
 
 RACHITIS 
 
 RECTITIS 
 
 RECTO-COLITIS 
 
 RECTUM, INFLAMMATION OP 
 
 RELAPSING FEVER 
 
 Synonyms, 97. 
 
 Definition, 97. 
 
 Etiology, 97. 
 
 Pathology, 97. 
 
 Symptoms, 98. 
 
 Diagnosis, 99. 
 
 Prognosis, 100. 
 
 Treatment, 100. 
 REMITTENT FEVER 
 
 Synonyms, 229. 
 
 Definition, 229. 
 
 Etiology, 229. 
 
 Pathology, 229. 
 
 Symptoms, 230. 
 
 Diagnosis, 231. 
 
 Prognosis, 232. 
 
 Treatment, 232. 
 REMITTENT MALARIAL FEVER. 
 
 REMITTO-TYPHUS FEVER 
 
 RETROPHARYNOEAL ABSCESS. . 
 
 .260 
 .333 
 .449 
 .425 
 .449 
 . 97 
 
 .229 
 
 .229 
 .343 
 .360 
 
 RHACHITIS 333 
 
 RHEUMATISM :;ui 
 
 Definition, 301. 
 
 Etiology, 301. 
 
 RHEUMATISM., ACUTE ARTICU- 
 LAR :jo^ 
 
 RHEUMATISM, CHRONIC ARTICU- 
 LAR 307 
 
 RHEUMATISM, INFLAMMATORY 302 
 
 " GONORRHCEAL 315 
 
 " MUSCULAR 309 
 
 " SUBACUTE ARTIC- 
 ULAR 306 
 
 RHEUMATIC FEVER 302 
 
 " GOUT 316 
 
 RHEUMATOID ARTHRITIS 311 
 
 RICKETS 333 
 
 Synonym, 333. 
 
 Definition, 333. 
 
 Historical Note, 333. 
 
 Etiology, 334. 
 
 Pathology, 335. 
 
 Symptoms, 335. 
 
 Diagnosis, 337. 
 
 Prognosis, 337. 
 
 Treatment, 337. 
 
 ROCK FEVER _!'* 
 
 ROSE -187 
 
 ROTHELN 150 
 
 ROUND ULCER 392 
 
 RUBELLA 150 
 
 RUBEOLA 141 
 
 Synonym, 141. 
 
 Definition, 141. 
 
 Etiology, 141. 
 
 Pathology, 141. 
 
 Symptoms, 142. 
 
 Diagnosis, 145. 
 
 Prognosis, 146. 
 
 Treatment, 146. 
 RUMINATION 411 
 
 SALIVA, ARREST OF 357 
 
 " HYPERSECRETION OF 356 
 
 SALIVARY GLANDS, INFLAMMATI'NSSS 
 
 SARCOMA OF THE LIVER 492 
 
 SCARLATINA 128 
 
 SCARLET FEVER 128 
 
 Synonyms, 128. 
 
 Definition, 128. 
 
 Etiology, 128. 
 
 Pathology, 129.
 
 INDEX. 
 
 531 
 
 SCARLET FEVER, CONTINUED. 
 
 Symptoms, 130. 
 
 Complications and Sequelae, 
 
 Diagnosis, 136. 
 
 Prognosis, 137. 
 
 Treatment, 137. 
 
 SCARLET BASH 
 
 SCLEROSIS OF THE LIVER 
 
 SCORBUTUS 
 
 SCROFULA 
 
 Definition, 344. 
 
 Etiology, 344. 
 
 Symptoms, 345. 
 
 Diagnosis, 345. 
 
 Prognosis, 345. 
 
 Treatment, 345. 
 SCURVY 
 
 Synonym, 338. 
 
 Definition, 338. 
 
 Etiology, 338. 
 
 Pathology, 339. 
 
 Symptoms, 339. 
 
 Diagnosis, 340. 
 
 Prognosis, 340. 
 
 Treatment, 340. 
 SCURVY, INFANTILE 
 
 Treatment, 342. 
 SEPTICAEMIA 
 
 Definition, 193. 
 
 Etiology, 194. 
 
 Symptoms, 194. 
 
 Diagnosis, 195. 
 
 Prognosis, 195. 
 
 Treatment, 196. 
 
 SHIP FEVER 
 
 SIMPLE CONTINUED FEVER 
 
 Synonyms, 293. 
 
 Definition, 293. 
 
 Etiology, 293. 
 
 Symptoms, 294. 
 
 Diagnosis, 295. 
 
 Prognosis, 295. 
 
 Treatment, 295 
 
 SIMPLE STOMATITIS 
 
 SLOUGH 
 
 SMALL-POX , 
 
 Synonyms, 108. 
 
 Definition, 108. 
 
 Etiology, 108. 
 
 Pathology, 109. 
 
 Symptoms, 111. 
 
 Diagnosis, 116. 
 
 ..128 
 135. 
 
 .128 
 .480 
 .338 
 .344 
 
 .341 
 . 193 
 
 . 90 
 .293 
 
 .348 
 . 26 
 .108 
 
 SMALL-POX, CONTINUED 108 
 
 Prognosis, 116. 
 Treatment, 117. 
 
 SOOR 352 
 
 SPASMODIC CHOLERA 200 
 
 SPIRILLI, PATHOGENIC 117 
 
 SPIRILLUM FEVER 97 
 
 SPLENIC FEVER i">8 
 
 SPORADIC CHOLERA 4:11 
 
 SPOTTED FEVER 101 
 
 ST. ANTHONY'S FIRE 187 
 
 STENOSIS OF THE BILIAKY 1 >r< -rs ..:><>.{ 
 STOMACH, ACUTE INFLAMMATI'N..:^*; 
 
 AMYLOID .4:11 
 
 " CANCKR OF 
 
 " CHRONIC INFLAMMAT'N :!7'.i 
 
 " DILATATION OF 3!H) 
 
 FUNCTIONAL DiSEASEs.406 
 HEMORRHAGE FROM . . 4<>4 
 NON-MALIGN'T TUMORS 40:: 
 PARASITIC INFLAMMA- 
 TION OF :<7<i 
 
 STOMACH, PHLKCMOXOVS INFLAM- 
 MATION OF :!7s 
 
 STOMACH, TUMORS OF 403 
 
 STOMATITIS 348 
 
 " APHTHOUS 349 
 
 ' FOETID :::.<> 
 
 GANGRENOUS 353 
 
 " MERCURIAL 351 
 
 " PARASITIC -'t.~>2 
 
 " SIMPLE 
 
 STRUMA 344 
 
 SUBACUTE ARTICULAR KHKIMA- 
 
 TISM 306 
 
 SUBPHRENIC PERITONITIS 
 
 SUMMER COMPLAINT OF CHILDR'X 4r>4 
 
 SUPPURATIVE HEPATITIS 486 
 
 " LENITIS 378 
 
 SWAMP FEVER 
 
 SYPHILIS 273 
 
 Synonyms; 27.'.. 
 
 Definition, 273. 
 
 Histori -al Note, 273. 
 
 Etiology, 274. 
 
 General Pathology. -2~'>. 
 
 Acquired Pathology and Symp- 
 toms, 276. 
 
 Congenital Pathology and 
 Symptoms, 27t>. 
 
 (Jrnrnil Diagnosis, 283. 
 
 Prognosis, 284.
 
 532 
 
 INDEX. 
 
 SYPHILIS, CONTINUED 27:j 
 
 Treatment, 284. 
 SYPHILITIC CIRRHOSIS 482 
 
 TETANUS 264 
 
 Synonyms, 264. 
 
 Definition, 264. 
 
 Etiology, 264. 
 
 Pathology, 264. 
 
 Symptoms, 266. 
 
 Diagnosis, 266. 
 
 Prognosis, 266. 
 
 Treatment, 266. 
 
 THRUSH 352 
 
 TONSILS, ABSCESS OF 366 
 
 " CHRONIC INFLAMMAT'N. 366 
 " FOLLICULAR INFLAMMA- 
 TION OF 364 
 
 TRISMUS 264 
 
 TROPICAL TYPHOID FEVER 235 
 
 TUBERCULOSIS 50 
 
 " OF THE LIVER 496 
 
 TUBERCULAR PERITONITIS 515 
 
 TUBULAR DIARHHCEA 419 
 
 Tussis CONVULSIVA 156 
 
 TYPHLITIS 443 
 
 Definition, 443. 
 
 Etiology, 443. 
 
 Pathology, 444. 
 
 Symptoms, 444. 
 
 Diagnosis, 444. 
 
 Treatment, 444. 
 TYPOHID FEVER t>9 
 
 Synonyms, 69. 
 
 Definition, 69. 
 
 Historical Note, 69. 
 
 Etiology, 69. 
 
 Pathology, 71. 
 
 Symptoms, 74. 
 
 Temperature, 77. 
 
 Relapses, 80. 
 
 Diagnosis, 80. 
 
 Prognosis, 81. 
 
 Treatment, 81. 
 
 Hyperpyrexia, 84. 
 
 Delirium, 86. 
 
 Gastric Complications, 87. 
 
 Special Septic Conditions, 87. 
 
 Diarrhoea, 88. 
 
 Tympanites, 88. 
 
 Intestinal Hemorrhage, 83. 
 
 Constipation, 89. 
 
 TYPHOID FEVER, CON. 69 
 
 Convalesence, 89. 
 TYPHO-MALARIAL FEVER "... .243 
 
 Synonyms, 243. 
 
 Definition, 24.'5. 
 
 Nature Of, 211. 
 
 Etiology, 245. 
 
 Symptoms, 246. 
 
 Diagnosis, 248. 
 
 Prognosis, 249. 
 
 Treatment, 24! . 
 
 TYPHOID TUBERCULOSIS 2<>s 
 
 TYPHUS FEVER 90 
 
 Synonyms, 90. 
 
 Definition, 90. 
 
 Etiology, 90. 
 
 Pathology, 91. 
 
 Symptoms, 92. 
 
 Temperature, 93. 
 
 Diagnosis, 95. 
 
 Prognosis, 95. 
 
 Treatment, 96. 
 TYPHUS ICTERODES. ...208 
 
 ULCER, AMYLOID 421 
 
 " CANCEROUS 422 
 
 " CATARRHAL AND FOLLIC- 
 ULAR 421 
 
 ULCER, DUODENAL -121 
 
 " EMBOLIC .421 
 
 " MERCURIAL.. 421 
 
 PEPTIC 420 
 
 PERITONEAL 422 
 
 " ROUND, OF STOMACH :t!t2 
 
 " STERCORAL 42! 
 
 " SYPHILITIC 422 
 
 TUBERCULAR 422 
 
 " UR^EMIC 422 
 
 ULCERATION 2r> 
 
 OF INTESTINES 42< 
 
 OF PHARYNX :t<>2 
 
 Etiology, 362. 
 Symptoms, 363. 
 ULCERATIVE STOMATITIS -T)0 
 
 VACCINATION 120 
 
 History, 120. 
 
 Definition, 120. 
 
 Development of Vesicle, 122. 
 
 Method, 122. 
 
 VOMITO NEGRO -"' 
 
 VARICELLA 123 
 
 i
 
 INDEX. 
 
 VARIOLA. 
 
 108 
 
 WAXY" DEGENERATION OF THE 
 
 PANCREAS 506 
 
 WEIL'S DISEASE 295 
 
 Synonyms, 295. 
 
 Definition, 295. 
 
 Etiology, 296. 
 
 Pathology. 296. 
 
 Symptoms, 296. 
 
 Diagnosis, 296. 
 
 Prognosis, 296. 
 
 Treatment, 297. 
 WHOOPING COUGH 156 
 
 Synonyms, 156. 
 
 Definition, 156. 
 
 Historical Note, 156. 
 
 Etiology, 156. 
 
 Pathology, 157. 
 
 \VHOOPING COUGH, CONTINUED i.,>. 
 
 Symptoms, 157. 
 
 Complications and Sequel :i>. l.V.i. 
 
 Treatment, 159. 
 WOOL-SORTER'S DISEASE.. . iMo 
 
 XEROSTOMA.. 
 
 YELLOW FEVER 
 
 Synonyms, 208. 
 
 Definition, 208. 
 
 Etiology, 208. 
 
 Pathology. 2>!. 
 
 Symptoms. 21 1. 
 
 Diagnosis, 213. 
 
 Prognosis, 213. 
 
 Treatment, 214. 
 YELLOW JACK.. 
 
 .381 
 
 .208
 
 A Book Every Stndent and Practitioner of Medicine 
 
 Should Possess. 
 
 DYNAMICAL 
 THERA PEUTICS 
 
 A Work Devoted to the Theory and Practice of Specific Medication, with 
 Special Reference to the Newer Remedies; 
 
 WITH A CLINICAL, INDEX, ADAPTING IT TO THE NEEDS OP THE BUSY 
 
 PRACTITIONER; 
 
 BY 
 
 HERBERT T. WEBSTER, M. D., 
 
 Professor of the Principles and Practice of Medicine and Pathology in California 
 Medical College; Author of "New Eclectic Medical Practice;" 
 
 WITH ' 
 
 Notes on Practical Pharmacy 
 
 BY 
 
 PROF. ./. U. LLOYD, 
 
 AND 
 
 Therapeutics of the Eye and Ear 
 
 BY 
 
 PROF. KENT 0. FOLTZ, M. D. 
 
 SECOND EDITION, REVISED AND ENLARGED. 
 
 WEBSTER MEDICAL PUBLISHING COMPANY, 
 
 230 DOUGLASS STREET, SAN FRANCISCO, CAL. 
 
 This is the most extensive work on Specific Medication ever published. It 
 contains 984 pages, inclusive of Index, with a large amount of positive therapeutic 
 knowledge, condensed, methodically arranged and ready of access, with an intro- 
 ductory part on principles and technicalities, making the entire subject clear. The 
 universal verdict of those who have used the first edition is, "I prize it above all 
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 edition by purchasers: 
 
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 In the book -case. It; represents just the method of practice which I have evolved 
 out of the various schools, even to the dosage that you give, for my own use, so 
 I find it especially valuable." DR. H. P. NOTTAGE, Westport, Mass. 
 
 "I am a great admirer and user of your work, 'Dynamical Therapeutics.' It 
 lies on my desk in almost hourly use. It would be about the last work in my 
 library that I would part with. The copy that I have (cloth, copyright 1893) is 
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 a copy bound in half morrocco, in the most substantial manner that it can be put 
 up. Please be kind enough to state particulars and pi-ice." W. FRANK ROSS, 
 M. D., Knoxville, Tenn.
 
 Date Due 
 
 
 
 m 
 
 i 
 
 i 
 
 PRINTED IN U.S.*. 
 
 CAT. NO. 24 161
 
 WB920 
 W3T9n 
 
 1899 
 Webster, Herbert T 
 
 Nev eclectic medical practice 
 
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 UNIVERSITY OF CALIFORNIA, IRVINE 
 
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