The practice of medicine

Front matter

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Section I. General Diseases

CHAPTEE I.

DISEASES OF THE BLOOD AND OF THE DUCTLESS GLANDS.

PAGE

General Considerations — Simple Anaemia — Chlorosis — Pernicious Anaemia — Leukocytosis — Leukaemia — Chloroma — Pseudo-Leukaemia — Myeloma — Hemorrhagic Diathesis — Haemophilia — Scurvy — Purpura — Rheumatic Purpura — Henoch's Purpura — Purpura Haemorrhagica — Haemoglobinaemia — Diseases of the Spleen — Movable Spleen — Splenoptosis— Embolism and Abscess of the Spleen — Diseases of the Thyroid Gland — Goitre, Bronchocele, Struma — Exophthalmic Goitre — Myxcedema — Tumors of the Thyroid— Diseases of the Thymus Gland— Tumors of the Thymus Gland — Diseases of the Adrenal Glands — Addison's Disease 1

CHAPTEE II.

LOCOMOTOR AND CONSTITUTIONAL DISEASES.

Myositis— Acute Polymyositis — Primary Myopathy — Pseudo-Hypertrophic Myopathy — Atrophic Myopathy — Thomsen's Disease — Rickets — Hemorrhagic Rickets — Osteomalacia — Obesity — Acute Articular Rheumatism — Gonorrhceal Rheumatism — Chronic Articular Rheumatism — Arthritis Deformans — Muscular Rheumatism — Gout — Lithaemia— Diabetes Mellitus— Diabetes Insipidus . . 44

CHAPTEE III.

INFECTIOUS DISEASES.

Scarlet Fever — Measles— German Measles — Chicken-Pox — Small-Pox — Cow-Pox — Miliary Fever — Typhoid Fever — Typhus Fever — Relapsing Fever — Infectious Jaundice — Cerebro-Spinal Meningitis — Influenza — Dengue —Plague — Diphtheria — Whooping-Cough — Mumps — Erysipelas — Septicaemia — Pyaemia — Tetanus — Malarial Diseases — Dysentery — Cholera — Cholera Nostras — Yellow Fever — Actinomycosis — Mycetoma — Rabies — Anthrax — Foot-and-Mouth Disease — Glanders — Tuberculosis, General and Local — Lupus — Scrofula — Leprosy

—Syphilis 95

v vi

CONTENTS.

CHAPTER IV.

DISEASES DUE TO ANIMAL PARASITES.

PAGE

Protozoa — Amoeba coli— Sporozoa — Hsematozoon malarige— Coccidium oviforme — Psorosperms — Infusoria — Megastoma entericum — Cercomonas — Trichomonas — Balantidium coli — Helminthiasis — Taeniae, Tape-worms — Taenia solium — Taenia saginata — Bothriocephalus latus — Cysticercus cellulosse — Echinococcus — Trematodes — Flukes — Distoma haematobium — Distoma pulmonale — Distoma hepaticum — Anellides, Leeches — Nematodes, Sound and Thread Worms — Ascaris lumbricoides — Oxyuris vermicularis — Eustrongylus gigas — Strongylus longivaginatus — Ankylostoma duodenale — Tricocephalus dispar — Filaria medinensis — Filaria sanguinis hominis — Hsematochyluria, Lymph-Scrotum — Trichina spiralis— Arthropodes — Pentastoma denticulatum— Sarcoptes hominis — Parasitic Insects — Pediculus capitis, vestimentorum, pubis— Cimex lectularius — Pulex irritans — Sarcopsylla penetrans — Myiasis, Maggots 321

CHAPTER V.

POISONING.

Acute Poisoning.

Narcotics : Opium, Alcohol, Chloral, Chloroform and Ether, Illuminating Gas, Prussic Acid, Mtrobenzol, Carbolic Acid, Oil of Tansy, Santonin, Belladonna, Hyoscyamus, Datura, Jamestown (" Jimson") Weed, Cannabis Indica, Hyoscine, and Cocaine. — Convulsants : Strychnine, Cocaine. — Paralyzants : Chloral, Calabar Bean, the Nitrites, Gelsemium, Lobelia, Coniine, Woorari, Pelletierine. — Cardiants : Digitalis, Veratrum Viride, Aconite, the Nitrites, Antimony. — Irritants : Mineral Acids and Vegetable Acids, Oxalic Acid, Cantharides, Irritant Oils, Savine, Phosphorus 350

Chronic Poisoning.

Lead, Arsenic, Antimony, Alcohol, Delirium Tremens, Opium, Cocaine 362

Chapter I. General Symptomatology

Disturbances of Motion— Disturbances of Coordination — Disturbances of Sensation— Vaso-Motor and Trophic Disturbances— Disturbances of Intellection . . 377

Chapter II. Functional Nervous Diseases

Insanity— General Considerations— Constitutional Insanities— Pure Insanities- Melancholia — Mania — Confusional Insanity — Terminal Dementia — N europathic Insanities — Paranoia — Periodical Insanity — Neurasthenia — Hysteria — Astasia Abasia— Singultus— Vertigo— Epilepsy— Periodic Paralysis— Laryngismus Stridulus— Convulsions — Local Spasms— St, Vitus' s Dance — Reflex Chorea

CONTENTS.

vii

— Chorea of Pregnancy — Convulsive Choreas— Automatic Chorea— Hereditary- Chorea — Tetany — Paramyoclonus Multiplex — Paralysis Agitans — Traumatic Neurosis — Caisson Disease— Heat Exhaustion — Thermic Fever — Occupation Neuroses— Headaches— Migraine — Sleep, its Disorders and Accidents — Correlated Disorders of Memory and Consciousness — Neuralgia 389

Chapter III. Organic Diseases Of The Brain And Its Membranes

Cerebral Localization — Motion — Sensation — Athetosis — Aphasia — Cerebellar Localization — Diseases of the Membranes of the Brain — Pachymeningitis — Leptomeningitis — Acute Meningitis— Tubercular Meningitis — Chronic Meningitis — Disorders of the Cerebral Circulation — Cerebral Anaemia — Cerebral Hyperemia — Diseases of the Blood-Vessels of the Brain— Cerebral Thrombosis and Embolism — Cerebral Aneurisms — Thrombosis of Cerebral Sinuses— Cerebral Hemorrhage— Cerebral Palsy of Children— Diseases of the Brain— Acute Hemorrhagic Encephalitis— Suppurative Encephalitis — Hydrocephalus— Acute Periencephalitis— Chronic Periencephalitis — Disseminated Sclerosis — Intracranial Tumors — Cerebral Syphilis 471

CHAPTEE IV.

DISEASES OF THE MEDULLA OBLONGATA.

General Considerations — Glosso-Labial Paralysis 536

Chapter V. Organic Diseases Of The Spinal Cord And Its Membranes

Spinal Localization — Spinal Hemorrhage — Spinal Embolism and Thrombosis — Spinal Anaemia — Plyperaemia of the Spinal Cord — Acute Spinal Meningitis — Chronic Spinal Meningitis — Spinal Abscess — Spinal Tumor — Acute Ascending Paralysis — Acute Myelitis — Chronic Myelitis — Compression Myelitis— Acute Poliomyelitis — Chronic Poliomyelitis — Syringomyelia — Locomotor Ataxia — Antero-Lateral Sclerosis — Combined Sclerosis — Friedreich's Ataxia — Syphilis of the Spinal Cord and its Membranes ... 540

Chapter VI. Organic Diseases Of The Nerves

Local Paralyses of Motion — Neuritis — Simple Neuritis — Parenchymatous Neuritis— Mesoneuritis — Multiple Neuritis— Sciatica — Inflammation of the Facial Nerve— Inflammation of the Trigeminal Nerve — Neuritic Muscular Atrophy — Neuroma — Syphilis of the Nerve 594

Chapter VII. Vaso Motor And Trophic Diseases

Raynaud's Disease — Perforating Ulcer — Angioneurotic (Edema — Scleroderma — Morphoea — Facial Hemiatrophy — Xeroderma pigmentosum — Sclerema neonatorum — (Edema neonatorum — Acromegaly 619 viii

CONTENTS.

Section III. Diseases Of The Circulatory Apparatus

CHAPTEE I.

DISEASES OF THE PERICARDIUM.

PAGE

CHAPTER II.

DISEASES OF THE HEART AND MYOCARDIUM.

Malformation — Hypertrophy — Dilatation — Fatty Infiltration — Fatty Degeneration — Acute Myocarditis — Chronic Myocarditis — Thrombosis— Cardiac Aneurism — Rupture — Tumors 637

CHAPTEE III.

DISEASES OF THE ENDOCARDIUM.

Acute Endocarditis— Chronic Endocarditis— Chronic Valvular Diseases — Mitral Insufficiency — Mitral Stenosis — Aortic Insufficiency — Aortic Stenosis — Tricuspid Insufficiency — Tricuspid Stenosis — Pulmonary Insufficiency — Pulmonary Stenosis — Treatment of Chronic Heart Disease — Cardiac Neuroses — Palpitation — Irregularity — Tachycardia— Bradycardia — Arhythmia — Angina Pectoris 651

CHAPTEE IV.

DISEASES OF THE ARTERIES.

Arterio-Sclerosis — Aneurism 686

Section IV. Diseases Of The Respiratory Apparatus

CHAPTEE I.

DISEASES OF THE NOSE, LARYNX, TRACHEA, AND BRONCHI.

Diseases of the Nose — Epistasis — Phinitis — Autumnal Catarrh — Diseases of the Larynx — Laryngitis— True and False Croup — Tumors — Spasm — Diseases of the Trachea and Bronchi — Trachitis — Acute Bronchitis— Chronic Bronchitis — Membranous Bronchitis — Bronchiectasis — Bronchial Obstruction — Asthma 700

CHAPTEE II.

DISEASES OF THE LUNGS.

Congestion — Haemoptysis — Thrombosis and Embolism — (Edema — Atelectasis — Emphysema— Acute Pneumonia — Chronic Fibrous Pneumonia — Broncho- Pneumonia — Gangrene — Abscess — Tumors— Cancer 730

CONTENTS.

ix

CHAPTER III.

DISEASES OF THE PLEURA AND OF THE MEDIASTINUM.

PAGE

Diseases of the Pleura — Pneumothorax — Hydrothorax — Hemothorax — Acute Pleurisy — Chronic Pleurisy — Empyema — Tumors — Diseases of the Mediastinum — Mediastinitis — Tumors 770

Chapter I. Diseases Of The Mouth, Pharynx, And Cesophagus

Diseases of the Mouth, Tongue, and Salivary Glands — Stomatitis — Glossitis — Psoriasis of the Tongue— Eanula — Parotitis — Diseases of the Pharynx and Tonsils — Acute Pharyngitis — Chronic Pharyngitis — Angina Ludovici — Retropharyngeal Abscess — Acute Tonsillitis— Chronic Tonsillitis— Diseases of the (Esophagus — Malformation — Stenosis — Dilatation — Diverticula — Perforation — Rupture — Oesophagitis — Tumors— Cancer— Spasm — Paralysis 791

Chapter II. Diseases Of The Stomach

Methods of Examination — Gastroptosis — Dilatation — Perforation — Rupture — Hemorrhage — Acute Gastritis — Pseudo-membranous Gastritis — Phlegmonous Gastritis — Chronic Gastritis — Ulcer — Tumors — Cancer — Neuroses — Nervous Dyspepsia 817

Chapter III. Diseases Of The Intestine

Enteroptosis — Hemorrhage — Acute Enteritis — Chronic Catarrhal Enteritis — Pseudo-membranous Enteritis — Ulcerative Enteritis — Diphtheritic Enteritis — Phlegmonous Enteritis — Appendicitis — Intestinal Obstruction — Intussusception — Cancer — Constipation — Typhlitis — Colitis — Proctitis — Ulcer — Tumors — Neuroses 855

Chapter IV. Diseases Of The Liver, Gall-bladder, And Bile-ducts

Diseases of the Liver— Malformation — Malposition — Fatty Infiltration — Congestion — Perihepatitis, Acute and Chronic — Subphrenic Abscess — Acute Yellow Atrophy — Acute Suppurative Hepatitis — Abscess of the Liver — Chronic Fibrous Hepatitis — Hypertrophic Cirrhosis — Amyloid Degeneration — Cancer- Tumors — Diseases of the Gall-Bladder and Bile-Ducts — Jaundice — Cholangitis — Cholecystitis — Cholelithiasis — Tumors— Cancer 909

X

CONTENTS.

CHAPTEE V.

DISEASES OF THE PANCREAS AND OF THE PERITONEUM.

PAGE

Diseases of the Pancreas — Hemorrhage — Acute Pancreatitis — Chronic Pancreatitis — Calculi — Cysts — Cancer — Tumors — Diseases of the Peritoneum — Hemorrhage — Ascites — Acute Peritonitis — Chronic Peritonitis — Chronic Serous Peritonitis—Cancer — Tumors 950

Section VI. Diseases Of The Urinary Apparatus

CHAPTEE I.

DISEASES OF THE KIDNEYS.

Anomalies of Shape and Position — Fused Kidney — Movable Kidney — Disorders of Secretion — Hematuria — Hemoglobinuria — Urobilinuria — Indicanuria — Melanuria — Alkaptonuria, Brenzkatechinuria, Hydrochinonuria — Chyluria, Lipuria — Albuminuria, Globulinuria, Nucleoalbuminuria (Mucinuria), Albumosuria, Peptonuria — Fibrinuria — Lithuria, Uraturia, Uricaciduria — Oxaluria — Phosphaturia — Cystinuria — Glycosuria, Melituria — Acetonuria, Diaceticaciduria — Lipaciduria — Hydrothionuria — Casts — Pyuria — Uraemia — Dropsy — Congestion — Thrombosis and Embolism — Acute Nephritis — Chronic Nephritis — Chronic Diffuse Nephritis — Chronic Fibrous Nephritis — Amyloid Degeneration — Suppurative Nephritis, Abscess of the Kidney 989

CHAPTEE II.

CYSTS AND TUMORS OF THE KIDNEY AND DISEASES OF THE RENAL PELVIS AND THE BLADDER.

Eenal Cysts— Multilocular Cystic Kidney— Tumors— Pyelitis, Pyelonephritis — Hydronephrosis, Pyonephrosis — Suppurative Paranephritis — Nephrolithiasis — Renal Colic — Diseases of the Bladder — Enuresis, Incontinence of Urine — Neuralgia of the Bladder, Irritable Bladder— Cystitis 1041 formulary

Charts of Temperature

THE PRACTICE OF MEDICINE.

Chapter I

DISEASES OF THE BLOOD AND OF THE DUCTLESS GLANDS. GENERAL CONSIDERATIONS.

Although the composition of the blood is variously altered in many diseases, yet there are only certain conditions in which the constancy of the changes and their importance in the production of symptoms are such as to be sufficiently characteristic. Especial attention is, therefore, to be paid to variations in the quality and quantity of the blood- corpuscles and to the amount of haemoglobin present. The total number of red and of white blood- corpuscles is to be estimated and their proportion determined. The morphological characteristics of the red and white corpuscles are to be ascertained, and the latter are to be classified in accordance with intrinsic differences which are to be observed by especial methods of preparation, and the ratio of such differentiated leukocytes to each other is to be calculated. Furthermore, the percentage of haemoglobin is to be ascertained. Herz calls attention to the possibility of a further inquiry into the specific gravity of the red blood-corpuscles and of the plasma, by means of which additional modifications in the characteristics of the red blood- corpuscles may be determined.

For practical purposes the examination of the blood is limited to the recognition of the number of red and white blood- corpuscles present in the cubic millimetre and the percentage of haemoglobin. The blood-corpuscles are to be counted by means of the Thoma-Zeiss or Gowers counting apparatus, or by the haematokrit, as advocated by Daland. Normal blood contains about five million red corpuscles and six thousand white corpuscles in the cubic millimetre. Variations in the result of the calculation of the total number of red corpuscles to the extent of two hundred ) l

GENERAL DISEASES.

thousand in a cubic millimetre and of the white corpuscles to the extent of one thousand are possible even to accurate observers, and are, therefore, of no practical significance. Daland asserts that less time, skill, and fatigue are necessary if the haematokrit is employed. Its use is objected to as requiring more blood, a cut in the thumb, and a bulky instrument. Fleischer s apparatus is most frequently used for the determination of the percentage of haemoglobin, although the value of such estimates is merely relative.

In the examination of the red blood- corpuscles attention is to be paid to variations in size and shape, and a distinction is to be drawn between corpuscles of normal size and those which are large, — macrocytes, — or small, — microcytes, — or irregularly shaped, — poikilocytes. Nucleated red blood- corpuscles — normoblasts — may be found in small numbers in normal blood, but are increased in anaemia, while large nucleated red blood- corpuscles — macro-, megalo-, or giganto-blasts— are found to any considerable extent only in pernicious anaemia. Poikilocytosis occurs in a variety of diseases in which there are serious disturbances of nutrition. The white blood-corpuscles, — leukocytes, — according to peculiarities made evident by staining, especially by the Ehrlich-Biondi method, are divided into lymphocytes, mononuclear, transitional, and polynuclear leukocytes, and eosinophiles or eosinophilous leukocytes. They occur in normal blood in the following proportions :

Lymphocytes, twenty to thirty per cent.

Polynuclear leukocytes, sixty to eighty per cent.

Mononuclear and transitional leukocytes, six per cent.

Eosinophiles, two to four per cent.

A considerable deficiency of red blood-corpuscles produces a series of symptoms due essentially to a diminution in the quantity of haemoglobin in the blood. Like symptoms occur when the quantity of haemoglobin is diminished, although the total number of red blood- corpuscles may be normal. A distinction is thus drawn between anaemias, in which the total number of red blood- corpuscles is diminished, and chlorosis, in which the percentage of haemoglobin is diminished, although the, total number of red blood-corpuscles may be relatively normal. Such a distinction is not absolute, since in the severer varieties of chlorosis the number of red blood- corpuscles is usually diminished.

A diminution in the total number of red blood- corpuscles occurs under a variety of conditions, some of which are readily apparent, as a visible hemorrhage ; others are obscure or unknown : hence a distinction is drawn between anaemia or simple anaemia, chlorosis, and pernicious anaemia.

ANAEMIA OR SIMPLE ANEMIA.

Simple anaemia is usually secondary to some obvious cause, as hemorrhage, serious disturbance of nutrition (whether from disease, insufficient or improper food, unwholesome occupation, or faulty hygienic surround-

DISEASES OF THE BLOOD.

ings), or from the action of poisons, as lead, mercury, and arsenic. Eesidence in the tropics often produces a pallor of the skin called tropical anaemia, but Glogner and others find in such cases that the red blood-corpuscles and haemoglobin are not diminished. The above-mentioned causes of anaemia are especially active, according to Weiss and Monti, when affecting young children.

Symptoms. — In all varieties of anaemia there are certain symptoms in common, although varying in severity and in rapidity of development. They are dependent partly upon a deficiency of haemoglobin, partly upon unknown modifications in the composition of the blood. Such symptoms are mild or severe, may begin as the former and end as the latter, or may be severe from the outset. Shortness of breath and palpitation are indicative of disturbance in oxygenation. Headache, backache, neuralgia, dizziness, obscured vision, ringing in the ears, fainting, mental and bodily weakness, are the effects of anaemia upon the nervous system. Loss of appetite, epigastric discomfort after eating, belching, flatulence, and constipation are the evidences of an altered digestion. Disturbances of menstruation are frequent, the catamenia being irregular or suppressed, scanty or profuse, often painful and exhausting, and the discharge light-colored. The skin, lips, and tongue are pale. Emaciation may or may not be present. A systolic souffle is often to be heard both at the base and at the apex of the heart, there is accentuation of the pulmonic second sound, and a venous hum is usually present at the base of the neck. The pulse is rapid, compressible, and of diminished volume. The temperature is frequently elevated, usually to a slight degree, and the course is often irregular. The urine may be pale or high-colored, but is generally of lowered specific gravity. The blood-count shows a deficiency of red blood- corpuscles and a proportionate diminution in the percentage of haemoglobin.

Diagnosis. — Simple or secondary anaemia is to be recognized by the appreciation of an obvious cause for the deficiency of red blood-corpuscles and haemoglobin.

Prognosis. — The prognosis is favorable when the cause can be removed, provided its action has not been excessively prolonged.

Treatment. — The treatment of simple anaemia, after removal of the cause, consists in the administration of iron with strychnine and other bitter tonics to aid in digestion, with laxatives if constipation be produced.

It has been shown by the various chemists working under the control of Robert that the administration by the mouth of the ordinary preparations of iron does not perceptibly affect the elimination of iron by the kidneys, although after the hypodermic injection of iron and sodium citrate (one milligramme for seven kilogrammes of weight) forty per cent, of the preparation can be obtained from the urine unaltered. It would seem, therefore, that the iron should be used hypodermically. It

GENERAL DISEASES.

was found, however, that unless the dose is very small it produces great renal irritation : so that the quantity mentioned above should never be exceeded. Further, it has been proved by Moerner, Gottlieb, Carl Jacobi, and others that iron is eliminated through the intestinal tract very freely : so that the question whether it does or does not escape from the kidneys is of comparatively little importance. The theory of Bunge, that the value of iron in chlorosis is due to a peculiar chemical action in the alimentary tract, which causes the natural albuminous iron compounds in the food to be absorbed, is certainly unproved and improbable. The discovery by Busch that the administration of pure or impure haemoglobin distinctly increases the elimination of iron from the urine, in conjunction with results already quoted, and with judicious advertisement by interested pharmacists, has led to the large use of haemoglobin compounds or derivatives.

The chemical work which has been done upon the absorption and elimination of iron is, however, at this time of no practical value. The fact that a certain preparation of iron yields a large percentage to the urine is no proof of its superiority. It is the iron which remains, and not that which escapes from the body, that does good ; and it may well be that a preparation which is absorbed easily and which escapes easily is of less value than one which is absorbed slowly and does not escape at all. Clinical experience is the only guide in this matter ; it is possible that manganese may be of service in simple or chlorotic anaemia, and that the pepto-manganates of iron may have especial value ; but our experience is that the older and simpler preparations will effect all that can be achieved by the more modern, complex, and expensive forms of iron. Among solid preparations fit for exhibition in pill may be mentioned, as being as free as may be from astringency, pilulae ferri carbonatis, pills of ferrous carbonate, Blaud's pill, dose one to two pills ; and ferrum reductum, reduced iron, dose two to five grains. For exhibition in solution we would recommend ferri et ammonii citras, iron and ammonium citrate, dose three to six grains ; also ferri et ammonii tartras, iron and ammonium tartrate, dose three to six grains. All the sulphates of iron are highly astringent. The tincture of the chloride is astringent, and very deleterious to the teeth.

CHLOROSIS.

This variety of anaemia, sometimes called the green sickness, is so named from x^P^, "pale green,'' and is usually regarded as a primary disease of the blood. It is conventionally characterized by a marked deficiency of haemoglobin without a corresponding diminution in the number of red blood- corpuscles.

Etiology. — Chlorosis usually occurs in females, especially among blondes, generally at or soon after the age of puberty, although Eieder reports typical cases occurring in persons between thirty and forty-two years of age. It is probable that a congenital predisposition to this

DISEASES OF THE BLOOD.

affection may exist dependent upon debility or disease of the parents. Faulty hygienic surroundings, as bad air, unwholesome food, overwork, mental, moral, and physical strain or excesses, are important as exciting causes. Meinert has found gastroptosis in forty cases of chlorosis, and regards this condition as a cause of the disease, attributing its occurrence to the use of corsets during the developmental changes at puberty. The etiological importance of the development of the sexual function is generally recognized from the frequent occurrence of chlorosis at or about the age of puberty, and especially in those in whom irregularities exist in the development of this function. Sir Andrew Clark has suggested that the absorption in the colon of toxic products from retained faeces is important in the etiology, while Pick attributes a like effect to toxic absorption from the dilated stomach which he frequently finds in chlorosis. Yon Noorden, however, disputes the theory that chlorosis is due to the absorption of putrefactive products in the intestine. Enlargement of the spleen, found by Jacobi in severe cases, has been observed by Chvostek and Clement in many cases, and the latter regards chlorosis as of infectious origin.

Morbid Anatomy. — An anatomical basis for chlorosis was first rendered probable by the researches of Yirchow, who frequently found a hypoplasia of the arteries. This was especially characterized by a thin, narrow, and elastic aorta, with irregular origin of its primary branches, especially of the intercostal and lumbar arteries, and by a superficial, spotted, fatty degeneration of its intima. Hypoplasia of the heart, uterus, and ovaries is frequently associated, although in the adult secondary hypertrophy of the heart and hyperplasia of the uterus may be present.

Symptoms. — The patient suffers from symptoms of a mild or severe anemia, chiefly attributable to the deficiency of haemoglobin. Headache, dizziness, fainting-fits, blurring of vision, and ringing in the ears often occur. Backache, neuralgia, hebetude, and muscular weakness may supervene, and hysterical paroxysms are frequent. Palpitation and dyspnoea on slight exertion or in consequence of emotional excitement are present. Slight elevations of temperature without apparent cause are not uncommon, and may continue for days or weeks. Digestive disturbances are conspicuous, and an abnormal appetite for pickles, slate-pencils, and chalk, an excessive fondness for sweets, a lack of appetite for nutritious foods, epigastric distress after meals, frequent eructations of gas, occasional vomiting, and persistent constipation are noticeable. Oswald and others find that an excess of free hydrochloric acid in the stomach is the rule, and this observer attributes the digestive disturbance to a lack of motor activity, a view which is favored by the noticeable occurrence in this disease of a displaced and dilated stomach. The secretion of urine is but little affected. It is usually pale, sometimes alkaline, its specific gravity about 1015, with a slight diminution in the elimination of urea. Menstrual disturbances are frequent, especially amenor-

GENERAL DISEASES.

rhoea, or a scanty flow, and dysmenorrhea. Displacements of the uterus and ovaries are common, and chlorotic women are usually early subjected to gynaecological treatment. The patients often appear well nourished, although puffiness of the eyelids and ankles may occur, especially after the symptoms have existed for some time. Pallor of the skin, mouth, and tongue is conspicuous. The occasional occurrence of a greenish or greenish-yellow tint has already been indicated, and flushing of the cheeks from emotional excitement is often of ready occurrence. The impulse of the heart, especially when rapid, is visible and palpable over an increased area, and a systolic souffle is frequently to be heard either over both base and apex or over one or more valves, especially the pulmonary valve, the second sound of which is usually accentuated. A carotid pulse is often visible, and a murmur is, as a rule, easily heard on auscultation of this artery. Auscultation of the internal jugular vein, especially the right, at the base of the neck usually reveals the venous hum or bruit de diable, which, however, is to be heard in other than chlorotic individuals. The pulse varies in frequency in accordance with the degree of excitability of the patient, and is of moderate volume and diminished tension.

The examination of the blood shows that the red blood- corpuscles are not especially modified in number, although during the course of the disease and especially in the severer types there may be oligocythemia to the extent of less than one-half the normal number of red corpuscles. They are often noticeably pale in color, vary considerably in size and shape, and the nucleated forms are relatively numerous. The percentage of haemoglobin may be reduced to thirty-five per cent, even when there is no considerable diminution in the number of red blood- corpuscles. It may be as low as twenty-five per cent, when there is a considerable reduction in the number of red corpuscles. The alkalinity of the blood is stated to be diminished.

The symptoms of chlorosis are often prolonged over a period of months or years, in the latter case temporary improvement and repeated occurrences of the symptoms being frequent. Serious complications may arise, the most frequent of which is ulcer of the stomach, this affection being often found in young women who have previously suffered from chlorotic symptoms, especially from gastralgia. In fatal cases of chronic tuberculosis and chronic diffuse nephritis hypoplasia of the aorta is frequently found, and the suggestion is direct that such affections may pursue a more severe course when occurring in chlorotic patients. Dieulafoy and Hanot report cases of transitory nephritis in the course of chlorosis. Thrombosis of the peripheral veins and of the cerebral sinuses has occurred in the later stages of severe chlorosis, and may prove the immediate cause of death.

Diagnosis. — Since chlorosis is a disease in which anaemia is a condition, the diagnosis largely depends upon the time when the symptoms

DISEASES OF THE BLOOD.

occur and upon the absence of causes of a secondary anaemia. The diagnosis is to be confirmed by the examination of the blood, since most writers regard as essential an excessive diminution of the haemoglobin in the blood without a proportionate loss of red blood-corpuscles. In the advanced stages of chlorosis the number of red blood-corpuscles as well as the percentage of haemoglobin may be largely lowered, in which case a knowledge of the etiology and course of the symptoms is essential in order to make a correct diagnosis. Henry maintains that in one series of cases the number and size of the red blood-corpuscles may be normal while the haemoglobin is deficient, in a second series with a normal number of red corpuscles there may be a diminution of their size while the percentage of haemoglobin is normal, and in a third series with a diminution in the number of red blood- corpuscles there may be a diminished or an increased quantity of haemoglobin.

In cases of doubt chlorosis is to be differentiated from secondary anaemias by the etiology of the latter, and from pernicious anaemia by the progressive course of this disease, of which retinal hemorrhages and the examination of the blood furnish additional evidence.

Prognosis. — Chlorosis is rarely fatal, and then usually from such complications as venous thrombosis or ulcer of the stomach. Recurrent attacks are frequent, especially in the autumn and winter, and are sometimes induced by pregnancy, which condition may also relieve the symptoms.

Treatment. — The treatment of a case of chlorosis must vary in many ways in accordance with the individual needs of the case. In the mildest form of the affection it may be simply necessary to turn the patient out- doors in the country, to give nutritious, easily digested diet, and to administer iron and arsenic. On the other hand, in the severest case a strict rest-cure (see page 402) may be required. Between these extremes every grade of case exists. Whenever it is practicable, the city girl should be sent to the country, put into warm but light clothing, and required to spend many hours a day in the open air, and the most of the remainder in bed. The exercise must be in proportion to the strength of the patient : any exertion which produces exhaustion or sleeplessness at night, or increased apathy or indifference to exertion the next day, is in all probability deleterious. Complete change of climate, from the mountains to the sea-shore, or from the sea-shore to the mountains, is often very serviceable. Better results are also obtained when the vacation from the city is spent partly in the mountains and partly at the sea- shore. The diet must be varied according to the individual case : the fat chlorotic girl should use carbo-hydrates and fats in moderation ; the lean girl, on the other hand, should be given butter, cream, sweet oil, cod-liver oil, and similar substances to the point of gastric tolerance.

Alcohol should never be given in excess, but the moderate use of red wine or of malt liquors at meals may be distinctly beneficial. If, how-

GEXEBAL DISEASES.

ever, they produce flushing of the face, or disturb the stomach, they should be altogether withdrawn.

Two medicines which are essential in the treatment of chlorosis are iron and arsenic, but other drugs are frequently beneficial. Thus, laxatives, preferably vegetable, should be used unless there is already a tendency to looseness of the bowels : bitter tonics and strychnine should be employed when, as is commonly the ase, there is failure of appetite, with inactivity of the digestive organs ; quinine in moderate doses is often useful, but in large doses may do harm. Active treatment of the amenorrhea is not often effective or judicious, the suppression of the menstruation being probably a secondary and not a primary phenomenon, which is remedied by the return of health. We have never had satisfaction in the use of apiol, potassium permanganate, or other lauded emmenagogues ; the old-fashioned Dewees's emmenagogue mixture (see formula 1) has in our hands given the greatest benefit of any remedy of the class. If at any time a menstrual flow appear, immediate absolute rest in bed should be enforced, with the use of the hot hip bath, an active aloetic or podophyllin purge, and the drinking of hot ginger or other tea. Except in rare cases, local treatment of the pelvic organs, other than the use of douches, is unjustifiable.