A woman, apparently about 40, seen at hotel at 6 P. M. , 
unconscious. Semi-dilated pupils, equal and responding to very 
strong light stimulus; pale; pulse 90, regular, rather small and 
soft. Respiration very superficial with an occasional deep in- 
spiration, Temperature normal. No hlood or froth on lips; 
no odor to 'breath. No disparity between sides of face. Limbs 
flaccid, but firm supraorbital pressure causes motion in one or 
another extremity; so also firm pinching of leg muscles. No 
reflexes, deep or superficial; no oedema; no glands. Old, white, 
irregular scars seen.near foot of nose, on forehead, and right 
cheek. Physical examination of thorax and abdomen negative. 
Urine by catheter, 1017, acid, no albumen, no sugar. 
In the absence cf all friends, the housekeeper states 
that the patient and her husband came there from a neighboring 
town the evening before. The husband was awakened in the night 
by some noise to find his wife unconscious. Later, she vomited 
but had no convulsion as far as known. CLINICAL MEDICINE. 
DIFFERENTIAL DIAGNOSIS. 
R.C.Cabot M.D, 
CASE 1.Differential diagnosis. The diseascss to be considered are: 
I.Post epileptic cora. g. Cerebral syphilis, s.Cerebral hemorrhage 
or embolism, 4,Hysteria. 5. Uraemia. 6.Opium poisoning. 7. Alcohol 
ic coma, 8. Gas poisoning. 9. Diabetic coma. 
Diabetes may be ruled out by the fact that there is no sugar in 
the urine. Gas poisoning may be ruled out by the fact that there 
si no odor of gas in the room,and the husband escaped. Alcoholic 
coma.The coma is too deep,and there is no odor to the breath and 
there is no positive history;the reflexes are absent. Opium;again- 
st this v/e have dilated pupils, superficial re spiral 1 on-no t deep or 
slow. Uraemia; ruled out by absence of high tension pulse,and al- 
though the urine is not absolutely incompatible with a chronic in- 
terstitial nephritis,the absence of cardiac enlargement is strong-* 
ly against this, Hysterla;The age,sex,pulse and temperature,lacb 
of paralysis -and normal urine all favor hysteria. Against hysteria 
Is the length of coma,the time of onset,absent reflexes.{They are 
usually exaggerated.) cerebral hemorrhage and embolism;ruled out 
by the normal condition of the heart and the reflexes. Post-epilep 
tic coma;nocturnal epilepsy is common,and coma follows it. The 
presence of scars on the forehead favors epilepsy,The absence of bloody froth on the lips Is of slight significance,Against epilep- 
sy is the fact that the attach seems too long and the reflexes are 
lost♦Also the lack of history of previous attacks.Albuminuria is 
at times present in epilepsy. Cerebral syphilis ; cannot be ex- 
cluded from consideration;!!!© scars might be due to old specific 
disease.Condition of reflexes, and pupils could be explained in 
brum 
this way.Hemorrhage into the cerelMHriiM» is usually unilateral and 
reflexes are increased on the opposite side. Hemorrhage Into the 
cerebellum could only be excluded by autopsy. 
Diagnosis, CEREBRAL SYPHILIS. 
Prognosis. For life,fairly good. For repltltAon of the trouble,it 
depends somewhat upon the treatment. 
f 
Treatment. 
R 
Potassli lodldl oz. vllj 
aq.Destill. oz. viitj 
mm. slg. Take 15 drops t.l.d. 
increasing 5 drops a day up 
to 60 drops t.l.d. 
General hygienic treatment should be enforced. 
A.MJ* A woman of 35, married 10 years, 5 children. Kas had 
considerable womb trouble and been treated for it by local physi- 
cian. Of late, it has been less troublesome. Father died of can- 
cer, mother of "a decline”. For a year lias had much to worry her, 
and has been running down and getting nervous. Is troubled with 
sour eructations after meals, especially in the morning. Bowels 
rather costive. Appetite as good as usual. Lost no flesh. Occa- 
sional severe headache, frontal and occipital. Sleeps poorly. 
"Hot flushes” frequent. For the last day or two (since coming to 
Boston) vomiting a good deal greenish stuff. 
Wien seen, was drawn and pinched in the face and nause- 
ated. Complained of general abdominal pain but. no tenderness could 
be found, and physical exarairiation was negative eoccept a sharply 
accented aortic 2d sound. At times quite hysterical, after which 
she passed a large amount of pale urine. Very nervous, restless, 
and alarmed about herself. No fever; pulse 110. Complained at 
times of headache. Knee jerks increased; no clonus. Uterus retro- 
flexed and bound down with adhesion. Case 2. To be considered are: 1.Neuraesthenia.2.Retroversion.5. 
Anaemia.4.Gastrio neurosis,including hyperacidity,chronic gastri- 
tis and gastroptosis. 5.Early menopause. 6.Pregnancy.7.Nephritis. 
The symptoms are consistent with a chronic interstitial nephritis 
with a developing uraemia,but we rule It out from a lack of albu- 
min in the urine. Pregnancy. There are no positive signs and the 
condition of the uterus is against it. Menopause. Lack of history 
of stoppage of menses. The gastric neuroses are ruled out by lack 
of positive signs. Nor would they explain all the symptoms,such as 
the hot flushes,accentuated pulmonic 2d..etc. Anaemia is ruled out 
by a lack of positive evidence from the blood. Retroversion of the 
uterus will explain roost of the symptoms producing a condition of 
neuraesthenia with which almost all the symptoms are perfectly com 
patlble. Dr.Cabot:” This was a case,gentlemen,which occurred durln 
my term as house-officer,here,and Dr.Shattuck and I made the diag- 
nosis of neuraesthenia. The woman died in g> days. Examination of t 
the urine was overlooked by the junior.The woman died of uraemia, 
with which condition all the symptoms are markedly compatible,and 
I need hardly remark,I think,that in view of this,we should always 
examine the urine,and remember that severe abdominal pain without 
tenderness is a symptom of uraemia.* 
Diagnosis. uraemia. Prognosis. Bad,but depending somewhat 
upon rapid and thorough treatment. Treatment. Are three things to be aimed at: (l) Diaphoresis.{2) 
Diuresis. (5) Catharsis. Diaphoresis. Give the patient a hot air 
bath by placing under a rubber blanket tent made on the bed.Haise 
the temperature as high as possible,anyway to ISO * Keep here for 
5 minutes,then If they do not perspire give hot drinks,if at the 
end of 5 minutes more,the patient does not perspire give pilocar- 
plne—gx. l/s if conscious,and considerably less if unconscious. 
Do not keep patient In longer than l/& to l/s hour,and not oftener 
than once in 2 days. In the interim*administer diuretics iPotass* 
citrate,acetate,and cream of tartar water. Purge with saline purge 
in order to irritate the bowel so as to draw water from the sys- 
tem— 
H 
Magnesli sulph. oss.vli;]. 
Slg. Tablespoonful In a demi- 
tasse of coffee,before break 
fast. 
Bleeding By venesection. Open one of the large veins in the fore- 
arm and let out 12 to 16 oss. of blood. It Is good to run in some 
normal salt sol. after letting out the blood. Dentist, 42 years old, always well until within four 
days when, after a hard day!s work, was taken at night with a chill, 
vomiting, and epigastric pain. Temperature 102 deg. Next day, 
temperature 99.4 deg., hut vomiting continues and was so exhausting 
that a morphia suhcut. 1/4 gr. was given. Pain not so severe as 
the night before, hut considerable epigastric tenderness. Kept 
his bed. Temperature 101.4 deg. in P. M. 
On the third day, the one previous to that on which I 
sav/ him, the vomiting was less persistent and temperature a little 
lower, but he felt very weak and faint; wanted no light or sound 
in his room, and desired to be left alone and not disturbed. 
Slight tenderness over the whole abdomen now developed, with per- 
haps a little more on the right iliac region. Bowels have been 
moved by cathartics each day. Today, feels as if there 
was a mass in the rectum. Urine very scanty in the last three 
days. Was examined a week ago and found normal. There has been 
no oedema. Has been working very hard of late. 
Exam. Tongue clean; temp. 99.2 deg. at 8 P. M.; 
pulse 68, good strength. Pale, and looks exhausted and in pain. 
Thorax negative. Slight general abdominal tenderness, not local- 
ized, but slightly greater in the epigastrium. No enlarged 
glands. Rectal examination negative. case S* DIFFERENTIAL DIAGNOSIS* To be considered are—1* Gastric 
ulcer g. cerebral tumor. ;•’>, LaGrippe. 4. Cholecystitis* 5* Cholan- 
gitis, 6*Millary tuberculosis, 7.uraer la, 8. Pancreatitis, 9.Malar 
ia. 10. Appendicitis with or without G,P, 11.Belly Ache, 12 Typhoid 
Gastric ulcer. Against this are the age and sex,the pain and 
tenderness are not localised, there has been no haemat ernes is, the 
chill is against it. If there were a perforation of a gastric ulce 
the symptoms would be much more severe and improvement impossible* 
The temperature Is also against this. Cerebral tumor. Not at all 
likely. La Grippe, The onset is In favor of thisbut it is not like 
ly as there is no heaclache*backache,and respiratory symptoms are 
lacking,also the low pulse and the existence of pain. Cholecysti- 
tis and chdlangitis favored by tenderness,vomiting,acute onset,ch 
chill*temp,,age,and objection to voice and light. Against it,pain 
not localized ,lack of jaundice,absence of bile pigment in arrine, 
and feces not clay oolored.Miliary tuberculosis;against this are 
the acute onset,the lack of evidence of T.B, elsewhere,and the ab- 
sence of tumor of omentum. Uraemia is not likely on acc. of the 
absence of edema and a negative urine. Pancreatitis, Not severe 
enough. Malaria. The chill and epigastric pain suggest it;the ab- 
sence of spleen enlargement and the positive blood exam, are again 
st it,Typhoid. It is rare to have a sudden onset of this disease, 
and the temperature falling Immediately after the onset, it might 
be the and of a walking typhoid,the widol is necessary to make the 
diagnosis. OA.SE (Continued.) Appendicitis. The mental state Is against 
this. The tenderness is the hey to the situation,and It is not lo- 
calized. Then65 is no muscular spasm. The blood exam, would help 
here* Dr.Cahot;" This case,gentlemen,I saw with a female physician 
She had given this, poor man large and repeated doses of a drastic 
purge,and to this method of treatment,the abdominal symptoms are 
undoubtedly due* The case is one of holly ache*" A female domestic, 29 years old, single, lost her 
father, a dissipated man, from phthisis. Her family history is 
otherwise negative. She herself has never been very strong, was 
chlorotic for a time five years ago, hut has never had any serious 
illness. A year ago, before coming to this country, she took a 
very severe cold, and a few days thereafter experienced a sudden 
and intense pain in the left lower axillary region. This pain 
was accompanied and followed by cough, with little or no expecto- 
ration. She was not long laid up, but has been short of breath 
on exertion ever since. She denies persistent cough, and states 
that it is present only when she takes cold; expectoration at these 
times is scanty, but several times has been blood streaked. She 
think’s she lias lost no flash and has not been feverish. She has 
been and is now continually employed. Sometimes when she makes 
certain motions, she hears a queer noise under her left breast. 
Her employer sends her to be looked at while the physician is 
visiting a member of the family. 
The general appearance is that of health. The 
pulse and temperature are normal. She complains of shortness 
of breath, especially when mounting stairs, dry cough, and inappe- 
tence. The chest is well formed and symmetrical; the interspaces 
are equally defined on the two sides; no cardiac impulse is visi- 
ble; the left chest dilates less than the right on full inspira- 
tion. The heart sounds are loudest, and the impulse can be best 
felt, just below the ensiform cartilage; the sounds are normal. 
The cardiac dulness seems to extend farther than usual to the right 
of the sternum. The right chest is hyperreaonant throughout with 
puerile respiration. Percussion is tympanitic all over the left 
chest, including the cardiac area, with very feeble respiration 
and absence of vocal fremitus. In the left lower axilla and under 
the breast there is faint amphoric breathing and whisper, with 
occasional metallic tinkle. CASE d, DIFFERENTIAL DIAGNOSIS. To be considered are:- 1. Inter 
costal Neuralgia, The signs are not accounted for,although the 
good state of the general health and the general character of the 
pain seem consist ant with It. 2, Emphysema, This is usually seen 
in old people and there is also a chronic cough; the Pact that the 
whole left chest is tympanitic and the vocal fremitus is dimin- 
ished Is in favor,The signs are not explained on this diagnosis, 
h, Thickened Pleura. Here we generally have dim inched resonance on 
percussion,4, Pulmonary Syphilis, Not to be diagnosed during life, 
b, Pleuritic effusion. The heart is displaced but tympanitic res- 
onance cannot be heard over pleurisy. 6.Pneumothorax. Ruled out by 
the suocuslon sounds*the only evidence of which however,is the 
curious noises heard by the patient. All the other signs point to 
i 
this disease, 7, Pneumohydrothorax. In favor we have the queer 
noises made by the presence of air and vat or in ti e chest*the dim- 
inished vocal fremitus and the faint breathing,Against it is the 
physical condition and the fact that there Is no fulness.This lat- 
ter condition is the one explaining the signs and symptoms best 
although it is by no means absolutely satisfactory,The lack od dul 
nese is due to the small amount o ' fluid present. The general con- 
dition is against the diagnosis of pulmonary tuberculosis but In 
favor of It are the family history,the chlorosis and the former 
attack.Diagnosis. PNEUMOHYDHOTHORAX ARISING THOM RUPTURED2 LUNfi 
DUE TO PULKi 'MARY TUBERCULOSIS * WITH TUBERCULAR PLEURISY* A stock broker of 2Gy ofmoderately alcoholic habits, but 
with no venereal history. Has always been well. Been under a 
physician’s care for last three days for Grippe and taken whiskey 
and ammo no 1. On the third day, Saturday, he took two whiskies and 
then went to ride on horse back. The horse shied and threw him. 
His head struck on a rock, the blow affecting the region just above 
and in front of the right parietal eminence. He was unconscious for 
ten minutes, and after being carried home he vomited and complained 
of pain in the occipital region. There was numbness of the right 
hand. The temperature was 104o, the pulse 90. Next day it was 
103o in the morning and 103.80 in the evening, Monday it was 102* 
with a pulse of 85. There has been no movement of the bowels. 
Patient has fully regained consciousness but is still somewhat dazed 
and dull. There is no evidence of fracture or suppuration anywhere, 
but there is numbness along the ulnar side of the right hand. 
Seen in consultation Tuesday, very bright end energetic, sat 
up strongly in bed to shake hands. Laughed and talked. Wants to 
get up, but temperature still 102, cask 5.To be cons Headed are 1,Grippe. 2. Concussion, ft. Cere- 
bral r emorrhage.( contra—coup, ) 4. Constipation, b. Injury to the 
*lncr 5 erve. 6. fenieres Disease. 7. Fracture of the ease. b, Men- 
ingitis. 9. Typhoid Fever. Dr.Cabot;M I saw this cane,gentles, 
in cons alt at ion t. 1th Dr. c. A. Porter. The diagnosis was not clear to 
either of our :.rinds, lost of the above conditions suggested them- 
selves to u.sfand in order to arrive at a correct diagnosis. v:e de- 
er..ined to give the -nan a thorough physical examination. The head 
especially at the point of Injury was examined and no evidence of 
fracture of either table of the skull. The eyes were examined and 
•o abnormalities were found.The heart and lungs were examined but 
gave no evidence of disease.The fact that the man sat up in bed 
excluded fr otur : of the base to our minds. A surgical pneumonia 
due to Injury suggested itself but the lungs ware negative. The 
bureis rare moved to pity but the temperature still emalned up. 
'Tie abdomen gave no external sign of typhoid,The urine was 
neootlve. Blood shov/ed no leuoocyt osis.The mental condition was 
cle--r.v.;c were now on the hog aa far as diagnosis was concerned.but 
I. ’ontle ians.deterr ined In or ler to exclude t phoid to try the 
serum test. In order to make this ofi value I inquired for a pro- 
ve ius typhoid history. This was negative. A typical Widol was pres 
ont. The man was in the second week of typhoid. J. B. , male, aged 32, occupation cook, came to the 
out-patient department of the Hospital, January 6, 1899, complain- 
ing of pains in the "body and limbs, accompanied by fever. His 
family history was negative and previous history good, giving no 
history of syphilis; he admitted, however, having had a urethritis 
some years previously. He had never had an attack similar in 
character to this. The present illness he dated from December 
30, 1898, 8 days before applying for relief at the Hospital. The 
first symptoms seemed to have come on rather suddenly with a rigor 
of marked severity, followed by fever, and later by profuse sweat- 
ing. Almost immediately afterward he was seised with intense 
muscular pains, extending over the trunk and limbs; these pains 
were agonising in character, increased on the slightest exertion 
and had been present, with degrees of severity, until his 
admission. They prevented him sleeping, and were spoken of by the 
patient as being not unlike rheumatism, i, e. , diill and aching; 
while he was in the recumbent posture becoming intensely lancinat- 
ing as soon as the slightest exercise was attempted. His appetite 
which had previously been of the best, was absolutely lost and he 
had eaten nothing for three days. With the exception of some 
slight frequency of micturition and a slight cough, with expectora- 
tion, there was nothing else of imxjortance in the history of the 
illness. 
Examination: The patient is rather a large, well- 
formed man; the mucous membranes of good color; tongue moist and 
with a slight white fur. The eyes are markedly injected, the 
e3relids slightly but distinctly edematous and an erythematous area 
above the swelling, negative results were everywhere on ausculta- 
tion and percussion, except at the bases of both lungs behind, 
where a few moist rales were made out. The heart sounds were 
quite clear. The liver and spleen were not palpable, the abdomen 
was soft and natural in appearance, negative results being obtained 
on palpation* Ho rose spots were seen. There was no superficial 
glandular enlargement and edema. Pulse was 100, respiration 
24 to the minute, temperature 103 deg, E, The urine was normal, 
yellow in color, acid, specific gravity 1026. Microscopically it 
showed pus-corpuscles in considerable quantity, epithelial cells, 
and a few mucous evlinaers. CASE VI* 
Diagnosis, Trichinosis, This is a typical history of 
the disease. The oedema of the eyes is a constant symptom. The eo- 
slnophilla Is also diagnostic,hut we must remember that an eosln- 
op'nilia may be found in these conditions as well: asthma,leucae- 
mia-and ancylostomiasis (resulting from the anhylostoma duodenale) 
Prognosis. A great many cases recover,in the present case the symp 
toms are fairly mild so that it may be set down as fairly favorabl 
Treatment, Relieve the pain and give general supporting treatment. A contractor of 50 served in the navy through the civil 
war and has been a very active and successful man. He is of heavy 
build, stout, and red in the face., For several years he has had 
violent cough in the winter, accompanied by vomiting, and he went 
to Bermuda two winters in succession, with Benefit. A daughter of 
16 some years ago ran off with a mar! and got married. He took to 
his bed, cursed, cried, called for his pistols, and was going to 
kill the husband, but he calmed down soon and the young people were 
sent for. His physician thinks he does not use alcohol in notable 
excess. Two weeks ago he began to complain of tearing and cutting 
pains in his legs, accompanied by slight oedema and for several 
days now he has been in his bed, Fever has been absent. There has 
been some vomiting, not specially characteristic in any way. Mental 
excitement has been a prominent symptom; he has threatened to kill 
all Democrats. Sleep has been poor. The pains in the legs have 
continued, but less severely since he took to bed. 
The pulse is 80, regular, the tongue heavily coated. 
Thorax negative. The edge of the liver can bo felt two inches be- 
low the costal border, apparently smooth of surface. Motion and 
tactile sensibility in the legs seem normal, but the leg muscles 
are tender when firmly handled and the knee jerks are very slight, 
even on reinforcement. The urine is reported as negative. A Medical Case. 
Discussion. 
The Important facts of the history are; 
50 years of age. The winter cough and vomiting.The sudden unreason 
ing anger which suddenly disappeared.The onset of acute pain,with 
tenderness and. edema,without fever. The wild threat without attempt 
to carry it out. 
The important points in the physical examination are; 
The diminished knee jerk. The enlarged liver. The normal heart,iitR 
lungs and urine. 
The mental condition is of first importance,the condition dates 
back to the elopement of his daughter,we have a strong healthy man 
who has been a man of action,taking to his bed and calling for his 
pistols,cursing and crying,doing just what a normal man of his 
training would not do,making no actual attempt to avenge himself, 
and on top of this he suddenly forgives,Later we see him without e 
cause lying in bed and making a v/iid threat against a supposed 
enemy,He is in a state of causeless excitement and sleeps poorly. 
This mental state,one of quick change from anger to mildness and 
of threats without cause,suggests very strongly general paresis. 
The sudden onset of acute pain in the legs without fever,when con- 
sidered with the decrease of the knee jerks indicates tabes dorsal 
is,the vomiting might also be due to a gastric crisis in this dis- 
ease,in order for this to be made certain,the pupils should be ex- 
amined for the Argyl-Robinson,and the Rhomberg sign should be look 
ed for. 
The age of the patient is in favor of either one of these diseases, 
the mental state does not suggest to me any of the acute psychoses; 
it is a condition of dementia. The diagnosis of tabes is not at all 
certain in the absence of the cardinal signs,it will explain the 
pains and the gastric condition and the knee jerks,it can not be 
excluded from consideration. 
The large liver,seen in a man of this age and one who has lead the 
life qf a seaman and afterwards of a contractor,even in the absence 
of a definite alcoholic history,! take it means alcoh&lic ci\iri%sjs 
he is in all probability a man v/ho has been a steady drinker all 
along,never going to excess but still drinking enough each day to 
keepup his spirits.The winter cough and the vomiting I think are 
dependent on this explanation.The lungs or bronchi play no part in 
the cough as they are normal,In the absence of definite history to the contrary I consider the cough due to chronic pharyngitis(proba 
bly alcoholic) and the vomiting due to a chronic passive congestion 
of the stomach due to the liver obstructing the portal circulation 
and a gastritis of alcoholic origin. 
The edema of the legs may be due to the kidney in spite of the 
fact that the urine is reported as normal,in men of this age and 
habit there is usually a chronic interstitial process,this may haw 
escaped the man who examined the urine. 
The tenderness is slight and I do not consider it of any impor- 
tance. 
Diagnosis 
General Paresis, associated with a beginning Tabes Dorsalis, 
Hypertrophic cktrkosis of the Liver(alcoholic), 
(The assumption of an alcoholic history makes stronger my diagno- 
sis of G.P, and Tabes) 
Prognosis 
As to life indefinite.As to recovery absolutely bad. 
Treatment, 
The patient should be kept under strict watch,his accounts should 
be managed for him.a trained male nurse should be employed to look 
after him or he should be sent to a suitable institution,as to 
medication nothing but symptomatic treatment is required. Sing He lady, 57 years old* always more or less of a nervous 
invalid, consults a physician for palpitation and dyspnoea on exer- 
tion. The menopause occurred five years ago, and since then has 
been getting very stout and disinclined to exertion. She is thirsty 
and her skin is dry and perspires very little. Of late, the feet 
have been swelling and her face seems puffy all the time, not special 
ly unaer the eyes* She is troubled a great deal with headaches, 
worse at nights, and her hair has been coming out of late* ITo sore 
threat. The bowels are very costive. Appetite capricious. 
Sleep disturoed by headache. Her memory is very poor and she takes 
little interest in anything. 
Physical Exam. Heart*s area can not be marked out on 
account of the great layer of fat here and also around the neck 
and shoulaers. The apex is not seen or felt. Best heard in sixth 
space, one inch outside nipple. Sounds heard feeblyj action irreg- 
ular. Pulmonic second plus j no murmur0 Lungs and abdomen negative. 
Temp. 97.8 , Pulse 100. Urine 1018, acid, large trace of albumen, 
no sugar. Amount two quarts. Sediment; Hyaline, granular casts, 
small diameter, some with renal cells adherent. Blood: Red 
6,000,000; white 12,000, Oedema of ankles. Hands and feet cold* CASE VII, 
To be considered are: Myxedema,Nephritis,Syphilis,Myooard 
it is. Obesity with Nephritis. In favor of myxedema are most of the 
points on the paper and these in addition which are net mentioned, 
the color of the skin is not said to be waxy,nor is there a flush 
to the dheeks. Nothing said as to whether the edema pits on pres- 
sure. Her tongue is not said to be thick nor- her speech husky and 
her finger nails are not said to bo dry and cracked. 
Nephritis alone# The urine and the edema are all right and 
this coupled with obesity would explain the symptoms#The pulmonic 
second is plus and this is in favor of nephritis. 
Syphilis is not probable.XX She has headache at night ana als 
falling hair and this would soon to fafcor it but there Is nothing 
positive for syphilis. 
myocarditis;there is present here a large weak heart which is 
due to malnutrition from some other cause. 
The diagnosis evidently lies between myxedema and Obesity wit 
Nephritis and either is plausible and explains all the symptoms 
amd signs. There remains the therapeutic test and this was applied 
in the present instance with a marked, improvement under the thy- 
roid extract,so that there was no doubt of the diagnosis being 
Myedema 
PROGNOSIS. Excellent. 
TREATMENT# Park Davis’ thyroid extract.2 to 3 gr. tab. tid to 10 
grains watching carefully for thyroidism,rapid heart,palpitation. A rather nervous gentleman, 43 years old, both of 
whose parents died of cancer, married, about a year before his 
present illness began* About the same time he moved from the 
city to the country, and became quite active out doors, with ben— 
efit to his appetite and general health* The winter snows, how- 
ever, forced him to be more sedentary- When first seen in con- 
sultation with the family physician, who had been called only four 
days before, he complained of obstinate constipation. For six 
weeks he had had darting pains in the lower abdomen, worse at 
night, but relieved by walking,. Por two weeks he had been conr'. 
stipated* The physician had first prescribed a mild laxitive 
pill, which caused some griping but no dejection. The next night 
he sat bending forward in pain most of the night, getting relief 
from an hypodermic of one quarter grain of morphia, twice repeated* 
At that time the bowels were soft, except for resistance corre- 
sponding to the ascending, and particularly the transverse, colon. 
The next night he had an ounce each of glycerine and castor oil, 
but was rather worse the following day Some flatus escaped on 
the day of the consultation, but no faecal matter had come away 
for at least four days* The temperature had remained normal* 
There was no vomiting* 
Physical examination showed a spare man of middle 
age with a somewhat anxious face* Rectal examination was nega- 
tive* The abdomen was distended with gas and somewhat tense, but 
no77here especially tender. /When the patientTs attention was 
diverted, the same resistance could be felt v/hich has been already 
described. The pulse was not remarkable at first . After the 
examination 7/as concluded, however, it became much more rapid and 
feeble, but improved again after a little brandy* CASK VIII, 
weuraesthenia Is suggested by the history,Tabes by the 
pain,but the pains are in no way typical of tabes. Gall stones is 
suggested by pain but these are not present in the lower abdomen 
nor are they relieved by walking,Hernia explains the constipation 
but there is nothing else to suggest it. Typhoid,the onset,temp, 
and pulse do not correspond to It.Appendicitis,the pain suggests 
it but the absence of vomiting,the absence of tenderness and the 
temp,and pulse easily exclude it. Lead poisoning,the presence of a 
line and lead in the urine necessary. Suggested by pain although 
the history is against lt;it may have come from the drinking water 
There is no lead encephalopathy or epileptiform convulsion,nor sev 
ere headache,colic,anaemia,nephritis or paralysis. On the con- 
trary we have a tumoB and abdominal distension. Oonstipatlon,his s 
sedentary life Sumx£fcBXXa»*xXJ0&x»X8Xisu favors it but on the other 
hand the fact that laxatives made the pain worse and that morphia 
relieved,as well as that he was never constipated before and that 
his pulse went up,are all against it. 
Intestinal obstruction. Not severe enough;there is no fever 
and no obvious cause;the fact that his pulse took a sudden jump 
up suggests a possible collapse* 
Dr,Cabot;*’ as one reads the case over the facts seem to clear 
up;the man had an annular stricture due to a carcinoma of the big 
Intestine which shut down gradually.The fact that the stricture Is 
low down explains the lack of vomiting;the relief caused by the 
■ ( case vli;).) 
morphia is very important” 
PROGNOSIS. Depends on what was found at operation as the glands 
might or might not be involved; also the prospect of making an 
artificial anus, 
TREATMENT. A thorough high enema of about eight oz. of oil should 
be given with a tube. Stimulation and operation. Peb. 16j a married lady of 30 is seen in consultation. 
During the eight years of her married life she has had four chil- 
dren, the youngest four months old. After her second confinement 
had puerperal septicaemia, and the catheter was used for some time. 
Cystitis apparently followed as irrigation of the bladder was prac- 
ticed. Vesical symptoms were troublesome after this, and five sep- 
arate times she underwent prolonged treatment under an eminent 
gynaecologist. Finally, discouraged by the persistence of her 
symptoms, she resorted to the "mind cure", with marked relief. 
During her last pregnancy she was unusually well and her confine- 
ment was easy, but was followed by a return of vesicle symptoms. 
Per the last five or six weeks she has suffered from more or less 
indigestion, and has had frequent watery stools preceded by abdom- 
inal nain. January 23d she came to Boston, hoping to be benefited 
by the change; and, acting on the advice of her "mind cure" friend, 
shopped, went to the theatre, and was generally very active. Dur- 
ing this treatment, she ate scarcely anything, and at the end of 
five days, returned home. The next day vomiting appeared, and by 
Peb. 1st, when she called her physician, the stomach retained 
nothing. The vomiting ceased within two days, and has not since 
recurred. The bowels have continued loose, moving two to five times 
daily without notable pain. Por two weeks there has been some 
cough, with little or no expectoration. Since her physician was 
called, pyrexia has been constant, as a rule, higher at night, 
though sometimes higher in the morning, ranging broadly between 
101 deg. and 104 deg. The pulse has ranged between 110 and 140. 
ITo delirium. 
The hands are cold and clammy, the color of the face is 
good, the eye bright, the mind clear, the knee jerks lively. The 
chest and abdomen are negative except that some medium rales are 
heard at both bases, and there is some tenderness along the colon 
and in both flanks. The urine is said to be negative. It is 
stated that she is a very reticent person, and has never been 
known to be hysterical. CASE IX. 
The conditions to be considered are: Typhoid F ever. Tuber- 
culosls,Gastro-enterltls,Hysteria. The following were suggested; 
Uraemia,Nephritis,Dyspepsia,Pregnancy,Malignant Endocarditis. 
PREGNANCY. There are no positive data,although the vomiting sug- 
gests it. CYSTITIS. She has had It,but at present there is no 
blood nor pain and it does not account for the general symptoms 
which are too severe for cystitis. GRIPPE is suggested by the fe- 
ver,pulse, gastric and lung symptoms. The manner of onset and the 
absence of headache and backache are against it. MALARIA. It might 
be the aestlvo-autumnal form. It is not the time of year unless it 
be a relapse and there is no big spleen nor any positive blood 
examination. URAEMIA and NEPHRITIS; diarrhoea is the constant symp 
tom with these but the urine is not given,nor would either of thes 
account for the continued high temperature, malignant endocarditis 
There are no heart signs,no chills and no leucooytosls. HYSTERIA. 
(Suggested by Dr.Myers of now Haven Hospital.) The "mind cure” is 
all that suggests it. Fever is against it. TUBERCULOSIS. Could on- 
ly be the acute miliary form and in that case the mental symptoms 
would be more severe; also there is no focus of infection, we 
would expect that in tuberculosis there would be a peritonitis 
with fluid. ENTERITIS. Too much fever,no pain and no blood in the 
stools. TYPHOID. There is no widol and the case is not fresh, very 
much against it. The diagnosis was in doubt until another Widol 
was made and was positive thus establishing diagnosis.Atypical. CASE X. 
harried woman 45 yrs.old, Mother's family consumptive; a 
brother a* sister died catarrhal pneumonia,father of cancer. Never 
had a physician till Sep.5,**87, For year had some dull pain in le 
ft side of abdomen,Burning sensation in lower part of chest not 
connected with meals.Sep,*87 severe attack of pain in region of 
stomach,passed off s vomiting.Jan,9 *88.After severe shock prev- 
ious day from fall on ice,rode 1 mile in omnibus. Again had pain 
for few hrs. Morph, subcu. Feb.19 similar attack c vomiting of " 
phlegm”, symptoms very troublesome till Mar.1.pain first ev. 5d 
day (’almost always at night),then ev. 2d day,then ev.day. As it be 
came more frequent,it began to come in A.M.about 5 hrs.p.o. but 
not after each meal.Opiates to quiet it,so that duration unknown. 
Vomited but once when was no pain & then after taking beef tea. 
vomit green and bitter. No blood. Often had gas after pain.when* 
seen had been living on nutr.enemata for 8 days,but had borne lit- 
tle rice & barley water. Been obliged to lie on left side for she 
felt a pulling sensation on back or rt, slde.No chill or fever.Du- 
ring attack transient yellowness of skin but none of conjunct,;0ol 
or appeared & disapp'd suddenly.urine h.but no greenish tinge.Puls 
not plus even when pain was most severe. Patient looked well. Bit- 
ter taste in mouth,Tongue covered c thin white fur.Appetite good. 
Howels reg, before attacks.0*t'a. ceased n#ly 2 yrs.ago fefore ill 
ness.Lost some flesh,strength good.No pain or abnormal cond. in 
epigastrium. CASE X. 
Points In the case.I. Recurrent epigastric pain with vomit- 
ing without reference to food and without.blood.2, Dull pain in 
the left abdomen and burning in the lower chest. 5. Transient yel- 
lowness of skin. 4. Left decubitus. 6. Eructation of gas after 
eating. 6. Periodicity of the attacks. 7. Opiate to relieve pain. 
This is very important. Dr.OabdtfHIn this case the pain rolls up 
and up;due to morphine poisoning.The absence tf the greenish tinge 
to the urine is of no importanoe.Bile gives a golden color. I 
should s£y that the age of thepatlent is an Important,as is also 
the tubercular history. The absence of chill and fever are against 
malaria and gall stones. The absence of blood in the vomitus is ag 
alnst cancer and ulcer. The fact that the patient appears well 
rules out an acute infectious disease.* 
DIFFERENTIAL DIAGNOSIS. Tabes,ruled out by absence of signs and . 
the sex, ed out by absence of headaches and other 
Nervous Dyspepsia,condition is too severe and does not explain all 
the symptoms and signs satisfactorily. Cancer,lack of blood in the 
vomitus,and other positive evidence in favor of it. Malaria ruled 
out by lack of positive evidence and no chills and n o blood exam 
Enteroptosis;the condition is too severe to be explained on the 
diagnosis of enteroptosis. Morphinelsm,this uncomplicated will not 
account for all the symptoms. Gall stones;in favor of it is the 
fact that she is 42 yrs of age and that she may be fat,and the 
more or loss periodic and characteristic attacks. The absence of of jaundice is doubtful and the urine examination Is not positive. 
The diagnosis is therefore,Gall-stones complicated by the 
frequent use of morphine. Manufacturer, 66 years old, previously well and 
actively engaged in both private and public business- For eight 
years, subject at times to what he called asthma, from which his 
father had also suffered. More recently, attacks of severe pain, 
substemal, in the Jaws, in the left arm and elbow, during which 
the face would as-suxne an expression of great anxiety, become nashy 
palen, and the dyspnoea would be very urgent, every breath being, 
perhaps, accompanied by a groan. But, independent of these at- 
tacks of pain, dyspnoea would, at times, be extreme, amounting to 
orhtopnoea. In the intervals between the paroxysms of pain and 
dyspnoea, he attended to his business, appeared well, and had a 
fair appetite. Bowels generally regular. When seen in March, 
1881, he looked well- Color good. No swelling anywhere. Pulse 
ICO, strong, regular, and well sustained- Micturition had, at 
times, been very frequent, generally once in the night. The quan- 
tity of urine varied much at different times and under different 
circumstances, but no very accurate data were obtained in regard 
to this point. The specific gravity was generally low when the 
amount was normal. Some albumen for the first few days follow- 
ing the paroxysms described, but none afterwards. Hyaline 
casts at times. Heart acting strongly, but without any heaving 
impulse. Second aortal sound sharp and distinct- A slight 
souffle to the left of the nipple. Over the right side, in 
front, resonance good to about the fourth intercostal space; 
below that,dulness; on the left side, good to the cardiac region, 
but the dulness of this was prolonged to the left, where it be- 
came continuous with that of the side, at about the same level 
as on the right. Behind, dulness below the lo?;er angles of the 
scapula, most marked on the right side, and rather more exten- 
sive. Fine, moist rales, over the dull regions, most numerous 
at base. CASE XII. 
A middle aged man Is seen writhing In intense pain 
referred to the epigastrium. Vomiting of greenish fluid took place 
there were loose discharges from the bowels,small ira amount.-This 
state of things lasted with omly short remissions lasted for two 
days,until a small dose of morphia which for special reasons had 
been hitherto withheld, although ashed for,was administered aft<er 
which there was complete relief for many days* The pupils were 
dilated,the pulse regular,and of normal character. Nothing special 
has been eaten or drunk to cause the irritation of the stomach. 
The abdominal walls ere neither distended nor retBaoted,no in- 
tra abdominal tumor was detected nor was there any excessive ten- 
derness on pressure* It was afterward learned that he had had sev- 
eral such attacks and that for many months and perhaps years his 1 
legs had been weak and tnat he had had neuralgia and numbness In 
them and that he stumbled in walking abd staggered in walking. 
what further examination should be made ? 
what is the nature of the acute attack ? 
The knee jerk and the Argyll-Bobinson pupil should be looked for CASE XIII. 
A boy,14 years old of gouty family history,complains for 
1 year of frontal headache*not very severe but persistent and wear 
ing,Appetite excellent,but digestion not as good as It has been. 
Has grown suddenly very irritable,having been previously sweet 
tempered. Has lost a good deal of flesh during the year and seems 
listless and weak. Sleeps well. Bowels are somewhat costive. Is 
getting pale. Heart,lungs and abdomen are negative, K-J are not 
easily obtained,but the gait shows only weakness, urine,normal ool 
or,acid,1028,no albumin. Sediment negative. Temp. 98. Pulse 96. No 
oedema. Blood is negative. CASE XIII. 
Consider: Masturbation,Diabetes lellitus,Arsenical Pois- 
oning, T.B,Meningitis,Eye-strain,Cerebral Tumor,Adenoids,Anaemia, 
SyphilioAdolesoence.’’General Debility”, 
Masturbation cannot be ruled out but it Is not enough and 
should not satisfy us until we have excluded other things. Diabe- 
tes . In favor are the headache,especially the irritability,loss 
of flesh and negative physical, we should need the test for sugar 
before making a diagnosis. 
Arsenic, Not common in children and ruled out by constipation 
T.B.Meningitis. Has existed too long and mental symptoms do 
not correspond. 
Eye-strain. Is too severe for eye-strain. 
Cerebral tumor. Is suggested by the headache,and irritability 
» 
and some disturbance of digestion. Id ruled out by not being sev- 
ere enough,no vomiting,nor inequality of pupils.K-J would be in- 
creased , 
Adenoids, would have been known long ago. 
Anaemia. Blood is negative. 
Syphilis. Nothing to suggest it,except possibly head symptoms 
Adolescence, Too severe for this. 
General debility. Is a SYMPTOM and is only made as a diagno- 
sis at the last cesort. Are many cases where this is the only thin 
that we can say and we must never accept it without a most consol 
encious examination to exclude everything possible. CASE XIII. 
PROGNOSIS.Absolutely bad. As a rule such canes don*t 
live more than two years at the most. Dr.Gabot;* This case,gentle- 
men Is a most remarkable one. He lived to be 33 that Is for at 
least 9.0 years after the onset of the disease. I have never seen o 
heard of any such case before or since. The reason that he lived s 
so long in that he was a remarkably consciencibus man in dieting 
and as long as he lived he was always faithful. From the time he 
was 16 to the age of 19 he was practically sugar free,but after 
that there was no time time whenK he did not have sugar in the 
urine.H 
TREATMENT. Diet. Sod. carbonate one or two tablespoonfuls t.l.d. 
to neutralize the acid. Morph, is not indicated. A young man of 21 is seen in consultation January 10. At the age of 
12 he had very severe scarlet fever, followed hy endocarditis for the re- 
sults of which he was under medical care for about three years. Of re- 
cent years his health has been very good and he has ridden the wheel fast 
and far without inconvenience. Bather more than two months ago he went 
to the doctor’s office for a "cold1*-- temperature normal. A few days 
later he returned with a temperature of 103°, and said he had had night 
sweats. He was sent home, sat about the house for two days, and then 
took to his bed which he has not left since. A four hourly chart has, 
been kept for sixty-two days and shows a continuous fever ranging from 
101 to 104, usually higher in the afternoon. On the seventh and tenth 
days after taking to his bed he had nose-bleed. This he had occasionally 
when well. Cough has been a fairly constant though not prominent symptom 
and twice has led to vomiting. The bowels have been regular with the aid 
of an occasional enema. Delirium has been practically absent. Early in 
his illness there were a few doubtful rose-spots. The spleen has never 
been palpable. He has once or twice complained of some pain in his shoul- 
ders, but has had no other articular symptoms. 
The pulse was about 90 at first, regular, of good strength. It has 
lately become irregular and rapid, some of the heart heats not reaching 
the wrist. Under digitalis, brandy and strychnia the pulse has improved 
very much and is now regular, 100. Ever since he took to his bed he has 
been under an exclusive milk diet. The urine is sufficient in quantity 
with a good trace of albumin, granular and hyaline casts, sp. gr. 1015. 
The patient is pale, lies on his back, has a clear tongue, complains 
only of weakness. 
On physical examination the lungs seem clear. The heart’s impulse 
is in the fifth space, half an inch to the left of the nipple. A systolic 
murmur is heard at a maximum intensity over the impulse, transmitted into 
the axilla. Inside the left nipple is a doubtful presyatolio murmur. 
The pulmonic second sound is accentuated, with second sound clear. The 
belly is slightly distended, duller at the flanks 'chan in the centre, the 
dullness and resonance shifting somewhat with change of position. The 
blood shows a moderate leucocytes is and no \Tvidal reaction. Han, 50 years old, a hard drinker except during the past 
year. No family history obtained. For two or three years he 
has had pain after taking food, occasional vomiting, and progres- 
sive loss of flesh and strength. For the past 8 or 10 weeks, 
he has complained of frequent and severe pain of a "stretching" 
character in the right hypochondrium, but without much tenderness 
there. For the last 2 weeks he has been deeply jaundiced. He 
has been confined to bed for a week and is much emaciated and 
prostrated. His nights are much disturbed by pain. The liver 
is greatly enlarged, hard, irregular, and nodulated, the lower 
edge reaching to the anterior spine of the ilium; it also extends 
to the left of the median line about two inches. It is slightly 
tender. There is little or no ascites. Pulse 92. Temp, 98,5. 
Urine rather scanty and very dark. Ho itching of skin. Man,-66 years old, lias been complaining for fif- 
teen months of pain which was for the first month or two referred 
to the region of the right hip and battuck. Later, the pain was 
felt also in the small of the bade and in both scapular regions; 
for the last six months, pain has been felt in the other nip as 
well. Pain occasionally shoots into the legs, but is generally 
confined to the bade. 
Por a month or two has been having considerable 
cough,-with white or yellow sputum, occasionally streaked witn 
blood. He has always been finicky about his food but complained 
of no special digestive disturbance, except loss of appetite ana 
constipation, which have been continuous through his illness and. 
have been accompanied by'considerable loss of flesh- Used to be 
very fat before the beginning of this illness- Of late, has had 
several attacks of retention of urine, which needed cathenzation. 
Exam. Rather spare but by no means emaciated; 
arcus senilis well marked • Heart negative. Scattered patches 
of rales in both backs and in the right axilla- Abdomen negative. 
Knee jerks normal;.-no tenderness or loss of sensation. Spine 
straight and not tender. 
Urine 1016; alkaline, trace of albumen, consider- 
able pus and squamous cells* 
Temp.- 99; pulse 90; resp- 22. A lady, 63 years old, had serious spinal trouble when a girl, 
which has left an angular projection in the lumbar region. Other- 
wise she has always enjoyed good health* Her catamenia ceased 18 
years ago. Her present illness dates from 3 months ago. Hot feel- 
ing quite so vigorous as usual she had gone into the country for a 
change, when she was prostrated with nausea and vomiting, although 
unable to think of any especial error in diet.. 
Since that time she has become decidedly feeble; so that she 
spends much of the day-time on a lounge. Occasionally she takes a 
short drive. Her appetite is much impaired. Her digestion is ca- 
pricious; vomiting may occur after eating and also without relation 
to meals• Sometimes there is diarrhoea. There is no pain, except 
some headache, in the vertex. There are alarming attacks of dizzi- 
ness and faintness which seem to be getting worse. She has never 
lost consciousness. The patient calls attention to a brownish pig- 
mentation which has recently appeared on the backs of her hands and 
on the knuckles, and which is confined to these places. The face 
is pale, but with a muddy rather than a transparent complexion. The 
tongue is not remarkable. 
The heart is feeble, but not enlarged nor displaced. The lungs 
and abdomen are negative. The urine is normal. The blood shows a 
moderate anaemia. The vomitus contains free hydrochloric acid. A well developed and fairly well nourished man, 18 years old, is 
seen for the first time February 26. His father died of consumption, 
his mother of rheumatism and heart disease. He has never drunk stead- 
ily, though occasionally to excess. He chews 5 cents worth of tobacco 
and smokes 20 cigarettes daily. For 18 months, -ending 7 months ago, 
he had almost daily coitus. For the last 6 months he has had gonor- 
rhoea. When a child he had diphtheria, at 14 typhoid, for the past 
7 months pain in the epigastrium, on rising, and latterly some pains 
about the head. Ten days ago, when he tried to get up, he had vertigo, 
chilliness, sweating and a feeling of unsteadiness. He has been in 
bed most of the time since. 
The symptoms were: weakness, backache, epigastric pain (without 
nausea or vomiting), cough with whitish expectoration, thirst, head- 
ache, and constipation. His chief complaint now is weakness, next to 
that headache and dizziness. There is some dyspnoea, but the cough is 
not troublesome. There has been no nosebleed. The patient is pale. 
His pupils are equal and react to light. The tongue is protruded 
promptly and in a straight line, is not particularly tremulous, and 
bears a slight white coat. Both sides of the chest move equally, 
there are no areas of marked dulness or of increased vocal resonance 
or bronchial breathing. A few coarse moist rales are heard at the 
right apex. The heart's apex is in the fourth space in the nipple 
line. There is no murmur nor enlargement. The pectoral muscle con- 
tracts when percussed. The skin flushes easily. The abdomen is en- 
larged, tympanitic, not tender. There is gurgling in the right iliac 
fossa. The spleen can .not be felt, its area is tympanitic. The he- 
patic area is normal. Thera are no rose spots. The knee-jerks are 
lively. A few glands are felt in the left side of the neck, and on 
the right side is a scar. The white cells number 3,600. Temperature 
101°, pulse 80, respirations 25. The urine has a slight trace of al- 
bumen, with a sediment containing pus and squamous epithelium. Ho 
diazo reaction is present. No tubercle bacilli are found in the spu- 
tum. 
During the next 5 days the temperature is irregular, varying be- 
tween 99° and 103°. The pulse gradually falls to 70. The respira- 
tions rise slightly, to 30. On March 1st a faint diazo reaction is 
obtained. The headache ceases after February 29th. The mental dul-. 
ness deepens to stupor. Constipation persists. On March 2d the phy- 
sical examination is the same as on February 26th. On March 3d there 
are involuntary micturition, difficulty in swallowing, Cheyne-Stokes 
respiration, and external strabismus. Nothing peculiar is noticed 
about the neck. The arras are at times rigid and contracted. There is 
ankle-clonus. CLINICAL MICROSCOPY 
LECTURES AND LABORATORY WORK. 
w.F.Whitney m.d. 
LECTURE 1. 
Articles needed In the course. 1 pair small toothed for- 
ceps*! pair small curved scissors.1 razor or microtome knife. 2 
needles for teasing. Slides and cover glasses. Methyl green. Aceti 
acid,Glycerine. Tincture of Iodine and special stains will be sup- 
plied as needed. 
Fresh specimens shown. Amputated lower leg.Gangrene.Usual causes 
of gangrene ? Leg shows much narrowed and stiffened arteries which 
is probably due to syphilitic endarteritis. In the present case, 
Dr.Mixter amputated without the tourniquet * in order not to crush 
the arteries and thereby injure and impede the circulation in the 
flaps. Cancer of the breast. Seat of disease is in the upper & 
Inner quadrant, section of the cancer nests or nodes shows the fol 
lowing very characteristic features of the dlsease:diinpllng of the 
skin as It is bound down and does not slide over the underlying 
tlssues*retraotion. If the tumor be deep this may not be seen. Is 
not seen in benign growths. 
TUMORS OF THE VASCULAR SYSTEM- 
Are characterized by the formation of new blood vessels. The 
conditions produced by disease of the blood vessels,as aneurysms, 
varicose veins and so forth are not Included, ANGIOMATA 
(a) Haemangioma (or angioma.) 
(B) Lymphangioma. 
Haemangioma has two classes. (1) Teleanglectatlo.a formation of 
new blood vessels between the connective tissue spaces without dis 
tlnct walls. Illustrated in the common congenital condition*Known 
as naevus.They are easily compressible,the blood can be squeezed 
out,and vary in size from a pin point to very large growths.May re 
semble adenomata,histologically. (s) Cavernous4in which the 
eels are large and compose a spongy network$ the blood,having 
found its way into the connective tissue,and there made a bed for 
Itself. The vessel walls are not well formed.This variety is the 
more common*The liver is a very common seat for the cavernous var~ 
iety*The condition starts in the portal system at the periphery of 
the lobules and Invades the capillaries,destroying them.There is 
extensive loss of substance and the liver is misshapen. 
Haematoma is distinguished from angioma by the fact that the 
blood does not circulate In It,although It may stay there fluid;it 
is generally due to injury and is often seen in the tunica vagina- 
lis. Haemorrhagic pachymeningitis,when chronic,Is almost a forma** 
tion of new blood vessels. 
Lymphangioma are less easily recognized* Have no walls and are 
simply an endothelial tube,generally collapsed.Sometimes the ves- 
sels are large and like blood vessels,and ramify at. will without 
any sydtem.Often dilated. Are difficult to remove.Apt to recur. 
May be very extensive and are not satisfactory surgically. LECTURE 2. 
TUMORS Z OF THE OSSEOUS SYSTEM* 
Pure bone tumors are always associated with bony structures. 
There are two varieties.as follows- 
(1) Firm laminated bone. 
(2) Spongy bone,as seen in epiphyses and vertebrae* 
Structure. Pure bony tumors have the structure of true bone.Tn the 
ivory bone we have a very dense compact substahoe. Osteomata may 
grov/ anywhere from the medullary or central part of the bone or 
from the periosteum.(The latter is the commonest) The tumors also 
grow in the flat bones,as from the scapula. The point of union of 
shaft and head is another favorite piace.Are very apt to be found 
mixed with cartilage. An OSTEOMA is a round circumscribed nodular 
growth without relation to the bone on which it lies. An EXOSTOSIS 
on the other hand is in relation to bones but more especially it 
is found where tendons are inserted into bones, various names have 
been given to the exostoses,as leaf-like exostoses,stalactites, 
stalagmites,etc. Those tumors which are found In tendons and in 
fascia are to be regarded as exostoses rather than true bone tu- 
mors. HYPEROSTOSIS is where the whole bone .is uniformly enlarged, 
a circumscribed regular enlargement. 
v 
CAUSES OF EXOSTOSES. May be unknown in majority of cases.Often oc- 
cur after injuries of the soft parts,especially burns. Those which 
are seen at junction of epiphysis and diaphysis often congenital. AKHOMKGALY is an overgrowth of bone (irregular) associated 
with a lack of development of the pituitary body.The whole bone Is 
Involved but the terminal phalanges are much larger than the rest* 
This condition is not a true bone tumor. It has occurred after 
pneumonia. 
The frontal sinus is a favorite seat of the growth of the Iv- 
ory ostemata,and in one case the eye was dislocated almost complet 
ly out of the socket by the growth* In operating for these it is 
well to remember the danger of concussion of the brain in employ- 
ing violence,as in ehIselling,when the tumor rests upon the brain* 
ODONTOMA* A peculiar class of bony tumors found most frequently In 
the jaw. Are like teeth and are covered by a substance similar to 
enamel. 
CARTILAGINOUS TUMORS. OH ON DR OM AT A. 
These are associated with bony overgrowths and the two are 
considered together. Histologically,cartilaginous tumors are char- 
acterised by an Irregular growth of the cells. 
Changes of various sorts way take place In the cartilaginous 
growths as calcification* The substance between the cells often 
breaks down and liquefaction results* we then get a homogeneous mass in which we see the cartilage cells lying* Both hyaline and 
mucous degeneration of cartilage Is very common*and we often see a 
a result of thlB*large cystic cavities* PROGNOSIS* In exostoses* 
is generally good,unless the exostosis he frontal* Good also in an 
chondromata. In the latter*however*there is more of a tendency to 
infiltrate*and the muscles may become atrophied from pressure.This 
infiltration is not a true one*however*like that seen in malignant 
growths,cells are nevertheless often found detached and growing at 
some, distance from the main growth; occasionally these sells get 
into the veins and are lodged in the lungs most commonly*or in the 
liver &c« ENOHONDROMfcTA are often mixed with osteomat&*consti 
tutlng osteo-chondromata*and this mixed form is commoner than the 
simple bony or simple cartilage tumors* They are found growing at 
the seats of true cartilage or of congenital misplacement of cart! 
1age*The epiphysis is common in the long hones*especially in the 
distal end of the phalanges in the hand. LECTURE £, BONE TUMORS (con.) True malignant tumors of bone are 
few In number;they are divided into two classes,! 1)Those arising 
from the medulla,and (9) These arising from the periosteum. The 
periosteum is really a fibrous tissue growth but tumors arising 
from it are called true borne tumors,The medullary tumors are real- 
ly destructive to bone substance,and have very little bone forming 
tissue,There Is a deposit of bone In the periphery. Histologically 
in the medullary sarcoma of bone,we see giant cells,If such a tu- 
mor be punctured we get a bloody grumous fluid and the cells are 
mono-nucleated with many nucleated bodies also present« 
These are similar to myeloplaques in normal bone. These tu- 
mors are usually found in the epiphyses,rarely in the shaft,This 
change may take place in the flat tones as well,and in the upper 
and lower jaw,This turner is Known as Myelogenous Sarcoma, 
we occasionally find multiple tumors in the bone;and soft mushy 
tumors with no tendency to enlargement,The latter are very inact- 
ive and do not grow at all rapidly. In the multiple tumors with 
many nodules,we have cells which resemble plasma cells of a lymph- 
old nature,Multipie sarcoma of bone Is accompanied by albumin in 
the urine,This form attacks the vertebrae especially,knickling It 
like Pott*s Disease. canckf OF bonk# Really or epithelial origin,hence v/e would 
not expect to find it In bone as that is not epithelial in charac- 
ter, It usually occurs without much action in the hone,generally 
resulting in a simple fracture. The first symptom of bone tumor is 
often a spontaneous fracture;this generally means sarcoma,K8IXX&XX 
FOLLICULAR ODONTOMA, It is lihe a spindle cell sarcoma of tubular 
character, ( see drawing, ) 
PERIOSTEAL TUivORS. Spicules ox bene at right angles to the long 
tone. 
LECTURE *. Endothelioma of the bone Is a very rare condit1on-Dr. 
Whitney has only seen one.True cancers are metafetatlc in origin 
and endothelioma may be confused with cancer. 
CYSTS. 
(1) RETENTION CYSTS. 
(2) FOLLICULAR " 
In the Retention cysts we have a retained secretion or glands hav- 
ing no excretory ducts. Simplest forms are those seen In the sKin 
as "Milium" or "Comedo". The wen is in this Klass as well. This 
occurs on the head and is loosely connected with the parts under- 
neath.These forms are regarded as retention cysts of the glands as 
a whole•a minute opening can often be seen in them. There is a- 
nother theory of origin that they zre epidermal inclusions. Epidermal inclusion. 
The cells that are cut off undergo a fatty degeneration and liquef/ 
wens in all probability belong to this class. 
Dermoids.These growths are to be distinguished from Kpldermolds as 
the later contain nothing but epidermal structures,whereas Derm- 
oids contain all the elements of true skin, hey are found in the 
median line where the foetal layers came together,They are "Dermal 
inclusions" and contain hair,teeth,in fact any or all of the skin 
elements,and a fluid of a dark brown color and of the consistency 
of honey. 
Branchial Clefts, These occasionally pres1st in man congenitally, 
they are lined with cylindrical epithelium,the external end,the in 
ternal end,or both may be closed,giving rise to a cyst in the neck 
which contains fluid,Hydrocele of the Keck is another form of cyst 
Originating in either a branchial cleft or the remains of lymph 
sinuses,this form may radiate to the scapula or the mediastinum. 
Kami a. This a condition of cystic dilatation of the ducts of the 
submaxillary gland,giving rise to a swelling under the tongue. 
Nasal Polypi. These are retention cysts in the nose. Lecture 5. Cysts. 
Thyroid Gland ,It is a ductless gland and may become enlarged as a 
result of excess of secreted material.lt may be filled with small 
cavities and contains gtalry fluld,l.e.Cystoaden®Tna of the thyroid 
This fluid can be told from mucin by the fact that it does not 
coagulate and turn white with alcohol; it is called colloid. The 
breaking down and coalescence of the tubular walls in the cyst wll 
give a condition like the following. 
It contains a chocolate brown fluid which 
contains cholesterln and cells, no re# 
semblance to the thyroid. The cyst has also 
the faculty of taking up lime salts thereby 
forming hard masses which resemble bone when first out down upon, 
CHEST. In the chest we have no important cysts,with the exception 
of oesophageal diverticula in which the muscular substance of the 
oesophagus has given way allowing he mucous membrane to form a 
sort of pouoh or hernia as it were. These may be of a consider- 
able size. There we see the phenomena of "rumination M as it is 
called. ECHINOCOCCUS CYSTS are rare and need only be mentioned, 
AHDQVKN. Here we have the socriled enterocysts which are formed by 
a portion of the intestine being cut off at birth. 
FETFOPEHITONRAL CYSTS. These are occasional elongated tumors ly- 
ing beneath the peritoneum and having no connection with the sur- 
rounding tissues.Have a thin fluid much like the cysts of broad 
ligament.probably to be refereed to the remains of the omphalo- mesenteric (factand Wolffian bodies although It Is not proven, 
MKSenTERTO GLAhPS, Cysts may occur here although they are rare, 
we may get unexplained cysts. One large one was found In the right 
hypochondrium and contained s gallons of a bloody fluld.lt seemed 
like an Inflamed ovarian cyst and was not In any way connected 
with the Kidney. 
LIVER. Cysts of the gall bladder and the cystic duct are eomnen 
when the duct Is blocked and no bile gets in,at the same time no 
secretion getting out.The fluid comes from the lining membrane of 
the gall bladder. Cystadenomata of the liver are very rare, 
PA? cm:: as. Retention cysts from retained secret ion.The organ may be 
much dilated. If the obstruction be complete,the tumor does not 
grow- to a very latge size but if it be incompletefthus allowing a 
continued accumulation of secretion with subsequent release,the 
tumor enlarges a little at a time and may then grow to a very 
large size indded. This condition of enlargement is seen very well 
in the kidney in hydronephrosis and nearly as well in the pancreas 
Congenital cysts of the pancreas are uncommon but are sometimes 
seen. The cause of a cystic and dilated pancreas may be found In 
a stone which is lodged In the duct thereby blocking it. LECTURE 6. 
ABDOhENAL CYSTS ,NOYSTED PERITONITIS and EUTEROCOELE. 
HEPATIC CYSTS* Dilated gall bladder and cynic-adenoma of the liver 
PANCREATIC CYSTS. 
Occasional cysts are foujhd In the region of the spleen. Are lymph 
cysts covered with a thin sac* They may come from a lymphangiec- 
tasia of the spleen. 
RENAL CYSTS. These are frequent,and are next to the ovary in fre- 
quency* Are 1'iultilocular or congenital cysts,strongly resembling 
the ovarian cysts. They are filled with fluids or. various kinds. 
This however does not contain urea and we conclude that the> do 
not secrete urine. They are almost always bilateral and in Is shoul 
XX XX 
lead us to be very Sarfittl in performing nephrectomy for if both 
Kidneys arc Involved and one or the other do reruoveo, tne remaining 
one may not be able to do the worn* 
UNILOCULAR CYSTS of the KIDNEY arise from one end ox the err,an and 
contain a thin watery fluid. Nephrectomy s not necessary in these 
cases.In order to differentiate these from a cystic hydro, ephrosis 
wo rust remember that a hydronephrosis comes in two way octrois a 
constant or nearly constant closure of the ureter;the Kidney sub- 
stance becomes destroyed and the organ is greatly dilated by Tie 
water which Is dammed back.Again where the closure is made ry the 
formation of a valve,and where the Kidney is able to perulot.ily 
empty itself occasionally.in the latter,the Kidney is ver> large. Vay have a condition of double ureter* The deposit© of lime ; 
salts is common. Cysts of the adrenals very uncommon. 
CYSTS of the URACHUS, it is occasionally out off while still per- 
vious and forms a cyst. 
cysts of the Q.vKhtum are very rare* 
CYSTS caused by PAHISITHS. KCHINOCOGGUS*omused by the tape worn of 
the dog* Once taken into the alminentary canal it (the egg) is dig 
ested and the embryo is set free; this or aw is thro* the intestine & 
then to the liver.The booklets drop off and he sconces cause a 
cyst. 
The fluid Cron these cysts is of low specific gravity and contain 
j.mch water. The cysts may be numerous. Next to the iver in fre- 
quency comes the lung* 
"CYSTICIRCUS CELL! JLOSAE" Found in "meanley. pork*** It should no ■ be 
found iji man as it is the larval condition of the tape-worm* Rare 
oases do occur in v.hioh a man has been reinfected by* the tape worm 
which he himself has passed. This may occur in n Insane persons 
who oat thir own feces. -These do not usually make a large central 
ca tty. if numerous they often cause a honey combed appearance. QTTCSTIOWS * V->3Wfl?S IN DISK ASKS 0* 7HK 
1. How does fright's diseases affect the eyes ? Mont frequently 
flame 
we nee the shaped retinal hnnorrhage,lean frequently there in 
a diffuse retinitis or a papillitis.Nay he midden blindness with- 
out retinal change called uraemic amaurosis.Diplopia is a rare e- 
vent • 
9, what are the symptoms of paralysis of the third pair of nerves'? 
Paralysis of all the ocular muscles except the superior oblique * 
the external rectus.The eye can he moved outward and a little down 
ward and inward.There is divergent strabismus. There is a ptosis 
of the upper eyelid owing to paralysis of the levator palpebrae. 
The pupil is usually dilated and does not react to light;accomoda- 
tion is lost.There is diplopia. 
8. Describe Iritis and its consequences ? Iritis properly speaking 
is inflammation of the iris alone;however as the iris is only a 
part of the choroid coat.it is common to find the inf 1 aromatic 
is not confined to the iris alone,but extends to the ciliary body 
forming the Recalled "irido-oyclitis" the rest of the choroid coat 
is not as frequently involved. Causes. ( k )Constitutional.( n ) 
Traumatic and (o) Idiopathic, (a) May be due to siphylls,( l/% case 
T.H. rheumatism and gonorrhoea,rarely acute Infectious dif^ease,oc- 
casionally with diabetes, (u) Result from wounds involving the cor 
nea,as the result of a blow causing hemorrhage and inflammation of hte iris, ’ay follow a wound Into the cornea,thro*which a portion 
of the iris Is roroed, symtoms. Congestion surrounding the cornea 
most marked at the edge; It is deep and more or less bluish because 
the vessels lie deep beneath the conjunctiva which Is not trans- 
parent ;It Is not always well defined; there is usually also a con- 
gestion of the conjunctiva* the bulbar conjunct .being swollen and 
oedema tons. The mobility of the Iris Is Impaired; Its tissues are 
more or less swollen,so that the ridges which are more or less 
wen defined In the healthy Iris are almost obliterated.Often the 
color changes.If there is exudation Into the anterior chamber,It 
is seen as a film,cloud,or gelatinous mass across the pupil;there 
is likely to be an exudate Into the Posterior chamber as well.rjie 
posterior surface of the Iris with its doiible layer of pigment 
cells may become attached to the anterior surface of the lens cap- 
sule so that when mydrlatlcs are given,we get an irregular pupil, 
with blackish pigment jutting from the edge where the adhesions 
are.There Is a faint haze In or seeingly In the oornea,Deoemetitl 
in a large no. of oases.{little circular dots deposited in the 
membrane of Decenet.) :subjective symptoms.Pain.photophobia.and dim 
ness of vision, varieties. (1) serous, (p) Plastic, (5) spongy . 
(4) Syphilitic, Consequences. Due mainly to the exudate which is 
likely to become attached to the. lens capsule,and if It becomes 
so attached all the way around cuts off communication between the 
anterior and posterior chambers,with increased intra-ocular tenslo 
finally resulting In hazi?iess of the cornea and pressure blindness "Seluston" ans "Occlusion* of the pupil, a diagnostic sign of a pa 
past iritis 1b the presence of pigment granules attached to the 
capsule of the 1 ene.Treatment.Mydriasis 1b the moat Important, 
From l/f to 9 ■■/* used acc. to amt. o.f iwflamm at Ion, Large doses to 
get the pupil Hlated and give as small doses as possible,to Keep 
it so. If hot well borne,use scoparlne,or hyosclne.Hot fomenta- 
tions.Use water as hot as It can be borne.xn syphilitic Iritis, 
specific treatment. Inunctions. Prognosis and OompllcatIons. Syu~ 
pathetic ophthalmia 1b a very serious condition;signs» of irrita 
tlon of the 9A eye are sensitiveness to light,a little indlstlnc- 
tnea of night,lachyrmation.Irritability of eye for near work. It 
may come on without warning,usually cornea on during the active in- 
flammation of the first eye, \% may occur 10 days to b moo after 
injury. 40 yrs. In a recorded case, course. Few days to a few 
weeks usually the latter*Prognosis depends on cause and on whether 
treatment were commenced before adhesions formed. 
4. Describe trachoma and the changes It causes on the eyeball ? 
a chronic contagolus disease of the conjunctiva. Usually capillary 
hypertrophy of the conjunctiva,with which we find,largely on the 
tarsal conjunctiva,elevations which seem to be simple,hypertrophy 
of the mucous membrane.They are circular masses composed mainly of 
lymphoid cells often crowded together to form the socalled velvety 
surface.generally t nicons or muco-purulent secretion;a large amount 
of granules may be present without causing much d Is comfort if ther Is little seorg>tlon..Sub1eotlve symptoms. Photophobia,some pain, 
may be of the lids,where the hypertrophy Is groat there may 
bo drooping of the lids;the bulbar conjunctiva la rarely affected, 
the region od the cornea or the cornea Itself nay have granules 
but this Is rare. Disturbances of vision may occur due in part to 
root at Ions on the cornea,ln front or the pupil or changes in the 
cornea Itself,The development of vessels,branches of the conjunc- 
tival vessels Into the tissues or the oornea,produolng the- condi- 
tion v.iown as **p annus *,coning from above downward,Its lower bor- 
der forming a horizontal line.hay cover whole cornea,giving It a 
red,flesh like appearance, Prognosis. The disease Is fluently a 
chronic one and when severe means Irradlcable changes;the gran- 
ules change Into connective tissue which shrinks,the destroyed mu- 
cous membrane being replaced by thin cicatrices;on drawing the lid 
down vertical folds may appear,running from the edge of the cor- 
nea to the edge o ' the lid,The movements of the eye are diminished 
also the amount of moisture, in a very severe case,when the Infil- 
tration extends to the tarsus,the whole lid nay be curved In to- 
ward the eyeball,the Inner edge rounder! off.The lashes In some 
cases curve inward and rub across the eyes,entropion.After the pan 
nus has extended a certain distance,the vessels may come from othe 
parts,destroying the typical shape of the pannus;nay be recurrent 
ulcerations at the edge of the pannus,which may be nearly entirely 
absorbed.Hay leave prominent opacities or perforations of cornea. xerosis. finally eye gets dry and Is Irritated by the inturning 
1 ashes;conjunct. in nevere oases in changed from mucous membrane 
to a tissue resembling skin covered by secretions of Meibomian 
glands;sheds water and remains always dry. Treatment,If the secre- 
tion is abundant use protagol or elver nitrate 1-2 'A.vot ulcer a- 
tions,atropia for pain and ‘o prevent extension to the iris* Use a 
•■'ash of 7nSO or uoracic powder dusted in P.i.d. or t.l.d, Hygiene 
4 
and cleanliness are nece ?sary.0auees. Occurs as epidemics in bar- 
rack c orphan asylums,etc. Racial-very common among the Irish,fun- 
sinns,and Poles; dirt and bad hygiene. 
6. Symptoms of Ophthalmia neonatorum 9 Arises usually during birth 
appearing from the first to the third or fourth day nad probably 
in the majority of cases due to the gonococcus, uegins as a red- 
ness, swelling, oedema, and feeling of heat in the lids. The conjunc- 
tiva is congested,there is increased secretion,looking like beef- 
Juice;the lids become heavy,stiff,and firm.After a day or two,pus 
Is poured out;then the lids become less boardlike,and more easily 
opened.The conjunctiva may be pushed up like a rubber ball around 
the cornea, \fter the pus has subsided the tissues are less vascu- 
lar,The course of disease is usually from 4 to 6 weeks,Ulcer at ion 
of tb* cornea may take piace.Treatment.Apply coif constantly and 
wash with non-irritating solutions;use protagol two to three times 
a day,After suppuration has ceased,use a zinc sulphate wash.Oompll 
catioris. Swelling of glands in front of ear.Ulcer at ion of cornea. Infection oC the Interior or tho eye giving ophthalmitis, If there 
in ulceration of the cornea or much pain,use 1 /?, ■% atropine,! drop 
p.r.n. to keep the iris and ciliary body at rent and no prevent th 
inflammation from extending to then, 
8, how nay the cornea become diseased as the result of conjuncti- 
vitis. it nay take place in three ways, (1) Hy direct extension an 
in inflammation or conjunctiva extending to the corneafphyotenular 
keratitis,( 2) Deprivation of the cornea of its nourlahment, as a 
result or processes In the conjunctiva, (*”) uy such changes In the 
oonjuotlva as cause constant Irritation of the cornea,as is seen 
In entropion,the result of trachoma, 
7. In what circumstances Is atropia useful 7 'hen avoid it ? In 
any case where it is desired to keep the pupil dilated as in a he 
ginning iritis especially where there is much exudate*in order to 
prevent the iris adhering to the lens,in exam inatIons,and in some 
operations on the eye,where it is desired to paralyze accomodation 
or where the op thalrno scope is to he used in order to get as full a 
view of the retina aif possible, -‘/lien there is pain as the result 
or an ulcerative process on the cornea or conjunctiva. In sympathe 
tic ophthalmia,or where it is feared,in order to keep the iris and 
ciliary process as quiet as possible,so th t inflammation may not 
extend to the sound eye, it should NO? he used where increase in 
Intraocular tension is not desired as in glaucoma. Neither mydria- 
tic s nor myotios should he used where important diagnostic evidenc B. That conditions or Mobility of the pupil are indicative of lo- 
cal and general lesions ? Lftfobl lesions affecting mobility. 
l.Irl tin, either from a hyperaenla%or from a pi ant in exudate bind- 
ing Iris down to lens,seclusion and occlusion of pun11.General 
Le: Aons. feningitis,tabes,irritation of sympathetic, anaea la,mor- 
phine and atropine polsonlng,cerebral disease. 
p. Pint are the synptoms,prognosis of acute glaucoma 9 
( a) Typical acute glaucoma. Patient feels first a slight blurring 
of the sight,sees a rainbow around the burning lamp;there nay be a 
little pits and the °yeball nay be slightly reddened.This attach 
passes off and another and* another and more pronounce# attack fol 
lows.These become more and ifre frequent and sight gradually falls 
After i tine,there Is a very severe attack with pain and redness, 
the pain running out to the side of the head. Then thfcre is a clr- 
cuncorneal congestion;oedema and general congestion of the eonjunc 
tlva and considerable loss of sight.Hammered granite appearance on 
the anterior corneal epithelium.Finally the eye becomes blind,as 
the result of pressure on the retina. Fulminating cases,In which 
blindness is produced In an hour or two without previous attack. 
Treatment.Dlreoted toward reducing Intra-ocular tension.Kserine 
l/lO and Pilocarpine 1/2 i*. Operative measures, iridectomy—usu- 
ally effective • Sclerotomy Is sometimes tried. Fulminating oases 
are little amenable to any form of treatment . (k) Chronic glaucoma or nrt simplex" The attacks of pain and 
other symptoms are rery slight end night falls gradually. any pa- 
tients never have any pain,field of vision gradually oontracts,us- 
ually Irregularly,and finally blindness ensues. Formation of the 
soc ailed "glaucomatous cup M In the retina. Little amenable to tr 
e tment, Iridectomy does net check the disease,Our theory as to 
the cause of glaucoma Is that the " filtration angle "between the 
sol era, cornea, and Iris Is blocked off so that the flow of ly ph to 
the canal of Solemn does not take place,The disease is usually 
n In old people, ( rj) ‘secondary Glaucoma. Increased tension v It 
or without palntin seclusion of the pupil. (?) Staphyloma or he - 
orrhaglc retlnltls*After nos. or yrs. attacks of glaucoma come on, 
and sight Is lost,If It has not hee lost already, ?reatment.Knu- 
cleatlon Is often the only means of stopping the pain, 
10, -9hat morbid conditions of the ocular tissues nay result from 
syphilis,congenital or acquired ? ( a) Acquired. Iritis,both ever, 
in 3/4 of cases;a plastic Iritis. rjyolltls, and choroiditis,and 
retinitis.All secondary lesions. Keratitis Is very rare In acquir- 
er! disease. Tertiary lesions.Oculo-motor paralyses,There may he 
gummatous Involvement of the optic nerve,chiasm or tract. 
(u) inherited syphilis. Choroiditis or retinitis as In acquired. 
Iritis also. Keratitis, is conncnC6-15 yrs.) Tertiary lesion.. Ooulo 
motor palsies are very rare In Inherited syphilis. II. Jhat Is the source of blood supply The arteries are derived 
from the long and the anterior ciliary and from the vessels In 
the ciliary processes. They are branches of the ophthalmic artery, 
iv Ich Is a branch of the Internal carotid. 
It. Describe the mechanism of accomodation. Accomodation Is due 
entirely to a change In the refracting power or Index of the lens, 
according as the eye accomodates for near or distant objects.The 
lens Is elastic,and Is held in place by a membrane extending from 
the ciliary process to Its equator.This Is always under a certain 
tenslon,normally, Relaxation of this • lembrane causes an Increased 
convexity of the lens and vice versa.This change in tension Is 
effected by the ciliary nuscle;therefore the curvature or convex- 
ity of the lens Is increased raid divergent rays are brought to a 
focus on the retina, we agree with Dr,Wadsworth Tin placing no con- 
fidence in the worthless and utterly groundless theories of other 
parties and no credence can be placed In them by any self respect- 
ing ophthalmologist.n.R. this Is for swiping purposes. Associated 
with accomodation in the eye,are two other changestvlj*. the axes 
of the two eyes are converged upon the near object so that the lin- 
age is formed so as to fall upon the corresponding points of the 
two retinae. The pupil becomes contracted,thus reducing the 
of the pencil of rays that enters the eye.The pencil of rays will 
be refracted to a common focus;strictly speaking the outer rays of 
the pencil win be refracted more and will be focused sooner than those lying sear the axis,hence it Is of Importance to have these 
outside rays cut off In order to get a clear Image, see diagram. 
This -til enlighten the Ignorant hope, but not 
1C he happen to he one of the few unfortunates who have been ob- 
it eh by unforeseen clroumntancea or stupidity or what not,to take 
nr, Wadsworth* s boresome and unnecessary percolations and perorating 
15. What diseases of the eye are likely to cause a development of 
blood vessels in the cornea. ? What Indications as to diagnosis 
may be drawn as to their situation and character,? 7rachona.Inter- 
stitial keratltis.phyclenular keratitis,foreign body,entropion,use 
of very Irritating nedlnlnal applications. If the pannus grown or 
extends from above down,so that Its lower border In horizontal,It 
may be said to be diagnostic of trachoma. If the vessels are small 
and thickly set In patches, and the cornea has an certain haziness, 
the vessels appearing dull,reddish pink In color,this Is the so- 
called wsalmon patch ” of Hutchinson,and Indicates Interstitial 
keratitis. In the other forms,the 'pannus cannot be s Id to be at 
all characteristic. !*• keratitis ? At flrnt there appears a grayish or* 
whitish pat oh Just beneath the epithelium.pushing it forward; the 
epithelium Is finally thrown off and a snail shallow ulcer In for- 
and. It nay bo small and heal rapidly or It may extend and deepen, 
finally vrlth perforation of tho cornea, me consider It probable 
in thin latter Instance that a secondary Infection has taken place 
y-err much pain and photophobia,Increase of tears,rubbing of 
the eves with resulting excema of the lids. ?he arms of children 
rave to be tlrd down to prevent their rubbing the eyes, bo not 
confine patients In a ’ark room as the sennitlvenesn is not due to 
sensitiveness of the retina, occasionally leucocytes are heaped 
ip under the epithelium and are absorbed without the formation of 
an ulcer, Prognosis.Hesul t Is an opaooty,the more persistent and 
pronoun© pd, the longer the ulcer remained .the further It was from 
the ege and the deeper It had goneA pannus way form, Treatment. 
Atropine relieves the pain.dilates the pupil,and lets In more 
light. at the same time diminishing the photophobia. Y el low oxide 
of heronry may be used, 
l*s, *T)ifferentlal diagnosis between catarrhal conjunctivitis and 
Iritis. Iritis results from one of three things,constitutional die 
ease,as syphilis,trauma,and AtA Idiopathic, Conjunctivitis results 
from at -io spheric s bacillus,pneumococcus, etc, ,e.xan 
themata,etc, Iritis Is characterised by certain changes.see r ft. 
Conjunctivitis Is characterised by congestion of the conjunctival vessels,of the lid,and of the fold or transmission. The bulbar 
conjunctiva In little affected unlean a a the result o i? Iritis.The 
lids nay he stuck together In the morning an there la abundant se- 
ore Mon, -Then It la more severe the bulbar conjunctiva la oongec- 
tel and the congestion may extend to the edge of the cornea. There 
Is swelling and oedema or the conjunctiva. The lids nay he a lit- 
tle swollen, subjective symptoms. Hurnlng and smarting as if ther 
were l ricks In the eye. Photophovia, vision Is likely to he Impaire 
Intermltt'Citly due to the flakes of mucous jn front of the eye. 
Duration 1". 10 days to h weeks. Complications. Hi ephar It is t super- 
ficial ulcerations of the cornea. Treat?.tent.cold applications at 
the beginning constantly for 9,A to as hrn, protagol 4. to H *> once 
or twice a hay,later zinc sulph. sol. l/lQ to l/4 4 Keep the lids 
smeared with some simple olnt.to keep then from adhering. 
le. Ocular symptom of locomotor ataxia 9. Optic atrophy occurs 
in 10 £ of cases,Gradual loss of vision and in the majority or 
cases complete blindness. Ptosis,single or double.paralysis of one 
or all the eye muscle**. Loss of Iris ref lex, the pupils are very 
srn r l 1 ( sp i j 1a 1 rnyo sis, ) 
lr'. interstitial Keratitis, Comes on In children usually from 0-4 
to $30 yrs.and is a manifestation of Inherited syphilis. It begins 
as a grayish zone of Infiltration along v/lth circumoorneal conges- 
tion and usually more or less pain and photophobia.The opacity 
si art s from one side to v/ar * the center and its general appearance is that of m diffuse graylnh are developed In th# sub 
stance of the oornea.The vessels appear nearly parallel and are 
rather Indistinct on account, of the haziness and are of a dull red 
color.The epithelioid on the outside being still retained and not 
t* rov»n off bedomes roughened and looks like fine, hammered granite. 
The opacity fades at the periphery hut becomes more dense at he 
centre,'.’he iris to likely to he Implicated,in some cases a pannus 
develops hut It Is not the typical pannus of trachoma.noth eyes 
are usually affected. A form of keratitis may occur In adults 
vhere there Is no reason to suspect syphilis. (me don't believe 
this,however.as we think the burden of ptoof always rests upon the 
accused to prove that he has not syphilis. See the case of Allison 
and waterman vs. one wm,r,roos,State Archives for •<** vol. XX.) 
Pro gnosis The opacity never disappears,the vessels usually do so 
ax*r as oblique light Is concerned or the magnifying glass ; with 
reflected light,a fine dark line marks their formeroourse. 
Treatment. Atropine should be used from the begInning*both for 
the pain md to prevent Iritis. 
18. Hyper i drop la an! presbyopia. fyopla and hypermetropia. In these two conditions,the range of 
accomodation in not normal; they depend upon a pathological cond 1- 
tlon ml unduly eyeball.When the eye in at rest In fclth 
or oondltlon,dlstant objects are seen Indistinctly but It In pos- 
sible "or trio hypermetropic eye to accomodate no an to see trip ob- 
jects plainly,while In the myopic eyefthls In not possible,since 
thP iPne cannot bo made less convex than thP normal a position at 
rest, that la th or e lo no ant 1 thesis to accomod at Ion; any attempt on 
thP part of a myopia eye to accomod nt-e only makes matt Pro worse, 
on op th p myopp 1b always aware of hie Inf lrmlty,wh Proas the hy- 
pnrmPtropp may not know It until headache and fatigue and a train 
of nervous symptoms from constantly accowed at Ing for everything 
drive him to the ophthalmic surgeon.( Jhr. Wadsworth* a office hour* 
are from 1 to P,k, fpp 25,oo) 
Presbyopia# The 1 pub loses Its elasticity with age.It usually be- 
glue to ittract attention at about 45 yrs. of age, Condition Is 
remedied by the use of convex glasses. Occasionally people who 
have experienced this condition discard their glasses In old age 
and read without them but this Is not a return In accomodation but 
is due to a change of refraction In the lens or a contraction of 
the pupil shutting out the side rays. 
19. How examine a cose of blindness to determine the nature of the 
legion ? fO. Symptoms and appearance In opt to atrophy. (nfirvfi,) The d isk in 
too white or it may be bluish, grayish, or yellowish.The central 
retinal ff'HsP.Us may be shrunken or of full slzejthe choroidal 
boundary a ay be too sharply defined or too hazy; it may be circu- 
lar or irregular,The change is one of color only without ȣ unnat- 
ural '1stinctness,loss of transparency,or disturbance of ~ tline. 
v-ptoms, Patients with atrophy complain of loss of sight,-dien 
one eye is affected,the other being healthy,the pupil of? the amau 
ratio eye has no action to light and is often a little larger than 
Its f.- llov ,rhe visual field is generally contracted;color blind- 
ness is a . - so’; ed symptom,green being the first lost,next red, 
si. A stone cutter at work reels something strike his eye,On .the 
outer head of his tool is found a small fresh fracture. How rteter- 
nne if the steel has entered the eye v Find—(1) If there is a 
wound, (?) if the body producing it has entered the yye and is re- 
gaining there.a very small body might enter the conjunctiva or 
sclera without leading a perceptible wound after an hour or two,or 
if there was a slight swelling of the conjunctiva,In such casesfth 
ophthalmosoope would be the only means of discovering the wound* 
Ordinarily a wound thro! the sclera causes a diminished tension in 
the eyeball, '/here the object has struck the cornea i;e may see it 
by oblique light if not b|r ordinary Inspection,Its path is marked 
by a grayish line;the opthalnoscope will show a foreign body in th 
eye unless there has been hemorrhage into the vitreous which v ill h i • e It.If the body has wound0.1 the cornea*in almost all canes it 
has Injure 1 the deeper parte the lone md the iris. If there In a 
hole tn the trie we get an additional rod dot In addition to the 
rod circle of tho pupil with the opht halrao scope. Foreign hod ion 
remaining in tho oyo will eventually don troy it and there in groat 
danger of losing the other oyo frosn sympathetic ophthalmia. 
, iOthodn of examination to dotormino tho existence of a catar- 
act ? ObJootlvo symptoms 9 By illumination of tho pupil when If 
there bo a cataract.the rod circle of light from tho totina will b 
bo more or less opaque and modified according to the opacity of 
the lone. The color of the pupil 1b changed and becomes at first 
less black (without artificial light.) If the cataract i« very o- 
paque the pupil becomes a milky white. The pupil is apt to bo lar- 
ger because the light 1b cut off and the reaction to light I.b loco 
£ii many cages there is myopia. This in probably duo to changes in 
the refractive index of the lens. Some people think this is second 
night as the myopia my come on when the opacity of the lens' 1b bo 
slight that the.sharpness of vision 1b little interfered with• 
/ariotios of cataract. Anterior polar.posterior o ap mil ar, spindle, 
cataract a punctata, zonular cataract (partial cataract of youth.), 
senile c tar act. congenital cataract.cataracta nigra.diabe ic cat. 
comminuted cataract.The ctaraot of youth in much BOfter than the 
one of age and can often be removed by means of miction or by the 
use of neeiie punctures and absorption by the anueoun humor. 25. Describe the ophthalmic appearance In albuminuric retinitis. 
A general or grayish tint la neen In the central region of th 
retIna;whIt1ah patches and a swelling of the dink.This changes and 
’vn find a number ofpure white dots,spots or patches In the hayy 
region especially around the yellow spot.They are sharply defin- 
ed and of a pure opaque white color, almost glistening. Hemorrhages 
•■ire present*and are usually striated;sometimes an artery Is seen 
5heathed by a dense white coating. The next stage Is that of at- 
sorption and atrophy;the spots disappear and the blood patches are 
slowly absorbed. The disease Is almost Invariably symmetrical. 
'V-. Hordeolum and chalazion. Dlffernetlal diagnosis and treatment. 
‘ or-teolun is the ordinary stye, and In a suppurating process of the 
sebaceous glands tls a small boll at the margin of the lid. Treat. 
Warm fomentations till it begins to point and then relieve the pus 
Oh alas Ion or Meibomian cyst Is an Inflammation of the glands; Is a 
chronic Irritation In the beginning; at first there Is a prolif- 
eration of the lining membrane of the gland and of the tarsus also 
giving a soft granulation tumor;generally comes on slowly and ther 
is sometimes considerable irritation giving rise to pain and oede 
ma. The process may become large and Is felt as a hard painless lu 
lump,causing some deformity but otherwise giving rise to no troubl 
The skin Is easily movable over the tumor but when it is moved the 
whole lid loves with it. Treatment. Remo veal. Thro* the conjunctiva 
or thro the skin.wedge shaped piece removed,or by scraping granula 
tions. ' 2b. Phyctenular conjunctlvltie.Olose to the limbus of the cornea 
but In the conjunctiva Is a slightly rounded, swelling with conges 
ted vessels extending out toward the fold giving a fan shaped area 
or congestion;the epltheliim is thrown off the summit leaving a 
shallow ulcer, in mild forms healing takes place In a week. Is 
Is liable to recurrence.Due to bad hygiene and Is usually seen In 
children.There Is usually considerable amount of catarrhal oonjunc 
tivitis accompanying It as well as pain and photophobia. Treatment 
hood hygiene. Locally oleanllnessfboraclo sol, and fine calo tel 
powder. (don’t use calomel and ki at the sane time.) Yellow oxi< r 
of Hg. 1/2 yi Is often used. 
ef., Ulcerative keratitis, very common. A large part of -oases In 
children result from phlyctenula,in older persons from wounds find 
infections, a grayish look co es on later becoming yellowish. May 
be swelling and the formation of towlns with the destruction of 
tissues and throwing off. Strepto-pnemno-and staphylococci are the 
ordianary causes, wot every ulcer of the cornea Is malignant;nost 
will yield readily with cleanliness; th "eepent ulcer* however 
i 
which Is due to the pneumococcus 1b more serious and the Infiltra- 
tion is more pronounced and the pneumococci push thir way*thro* th 
lymph spaces involving the different parts of the cornea progres- 
sively ; we get then the complications oC Iritis and hypopyon early 
whereas tVyex are late in the other forms. The serpent ulcer re- 
quires very vigorous treatment as tlact, of Iodine 95 A Carbolic or V ° actual cautery. washing out the eyes with a fine no7%Ie 
byrlnge, opening the ant or 1 >r ehairtbor to relieve the hypopyon.The 
other forms do not require thin radical treatment♦ Treatment consl 
sts o' cleansing washes and atropine. Atropine is Indicated. In any 
■Insane 0f the cornea—It acts In two ways,relieves pain,Irrita- 
tion and photophobia*and Keeps the iris quiet, corneal ulcers nay 
be due to paralysis of the orbicularis, a facial palsy,or a lagoph- 
thalmos* Or In severe diseases as typhoid or the puerpural state 
where the patient lies with half closes eyes. To paralysis of the 
hth nerve with suit of sensitiveness of the eye. In all these con- 
ditions the naln thing Is ro protect the eye. The ulcerations do n 
not spread deeply and there Is little danger of hypopyon, vellow 
oxide of mercury l/p -I with atropine nay he used*If the eye Is 
bandaged the bandage should be changed often In order to prevent 
the retention of secretion. To a wan of pr.w1 s antiseptic 1 It 
see*.is hardly necessary to mention this fact,hut he deems It nee ess 
ary nevertheless to enlighten the foolish reader. 
P7, syphilitic Iritis. Diagnosis and treatment.Xn syphilitic iriti 
are yellowish or brownish rounded elevations close to the 
puolllary edge which Increase rapidly,reach a certain sine and 
then ;uhslde. They are probably of a gummatous nature. Are some- 
tines called papillomata. Occasionally are bright yeilo'.v and the 
r ;r5els are bright red. Iritis generally cones on with the seoortd- 
xry synotons but nay cone on later. ?r eati ent.S’pecif io treat sent,by inunctlon.OtherwiBe,locally as In 
a ay iritis.see preceding questions. 
P,8. Laoryiial abac ess. Inflsnnatlons of the 1 aehryn al gland are 
vary rare. Affect Iona of the nuc are ; nich more co tnon;the lachry- 
mal abscess is always preceeded for a Ion# tine by aynptons of 
stoppage of the duct. .Syraptons. Redness,swelling,excessive pain. 
->) jeti -os extending over the side of the head,fever and oedema. 
Later pointing and evacuation o£ the material. Treatment. Evacuate 
early and go In with the Knife straight toward the bone,sticking 
to the ilddle of a line running to the outer canthus from the alae 
nasi, (yo In upward lnward,and backward. Keep the wound open until 
suppuration has ceased. 
pQ, Describe astigmatism. hue to an Irregularity in the curvature 
or the ”erract lag media,usually M r cornea, e.g. the raius of the 
ye-rtical Is shorter than the horixontal,called,"with the rule"; If 
the reverse,"against the rule " if curvature in the vertical Is 
greatest, the rays are bro't to a focus in front of ret Ins, while 
th • ye passing thro* the horizontal are focussed behln<l the retina, 
fhis makes an imago of a series of horizontal lines.If the .rove, 
the triage Is of vertical lines. If the retina be between the two 
fOoi,t I iage will bo mad# up of circles. .Accomodation cannot pro 
duoe a clear t-.iage under these c lrcunstonee«#The error nay bo in 
part In the Uus. aid If so oan*t be corrected.  -nettgsatinn. fha meridians of greatest and least refyao- 
tlY6 power are at rlfgt angles to each other, Xr re.gi11 ar as11..,*g■ ■ at. 
The curvatures vary, simple Aetjg, srmjetropic in on* principal aer 
idian and hypermetropio or myopld in the other, oompoiuid asti&■;at. 
npermetropia or myopia in both merid lone hut groat or In on* than 
l/i th* other.Oo monest Cor’-1. Ixed «vntlariat ism.On* yopic ■ n " the 
other hypermetropic, Treatment, The lens required Cor the tremi- 
nent o? regular astigmatism require t*at they ho instead of por- 
tions of spheres portions of cylinders, 
bO. Symptoms,prognosis,and treatment in diphtheritic conjunctivi- 
tis ? It may begin as does the gonorrheal form*but the discharge 
Is not so promise at the beginning nor do on it so rapidly become 
purulent, * grayish membrane appears In patches in from one to ty/o 
days,mainly on the conjunctiva of the lid,possibly on the bulbar 
co/ij mctiva* Examine Cor the k-Xj bacillus;If found,give anti-toxin 
2hief danger is to the corn6a;ulceration sometimes occurs,and the 
cornea seesingly melts away. 
;•»!, Describe briefly,the ciliary made. Innervation and action, 
Consists of unstriped fibresjforrno a gray,seni-tran«parent,circu- 
iar band,about x/h In,broad on the outer surface and fore part of 
the choroid;thickest in fro?it gradually becoming thinner behind# 
sets of fibres,circulating and radiating;the radiating,the 
•lor* hu serous,arising at the point of junction of cornea nn scler otic.and passing backward are attached to the choroid opposite the 
ciliary processes. The circular fibres are Internal to the radial 
and haue a circular course around the attachment od the iris, dill 
ary muscle Is the chief agent In accomodation. It Is supplied by 
the lenticular or opthalnlc ganglion which Is formed of fibres of 
the ;5rd.Bth.and cavernous plexus of the sympathetic, 
5°. Differential diagnosis betvreen strabismus and paralysis ? The 
conditions -ate very different;there is no loss of motility of 
either eye In strablsMis.one eye being habitually directed to the 
left or right of the other.but usually the total movement from sid 
to side is the same Tor both eyes;this couplet! with a thorough 
\hov’leige of the conditions existing In both oases such as hr, . 
ywsrssos will enable anyone.even the most ardent tyro, after* yrs. 
o' experience. uv» '-avlug rx vast no. of oases, to make the lif- 
T eeeatlal easily, it Is to be remembered in this connection that 
t'ie common condition,known as show case eye.any simulate both as- 
tigmatism and. paralysis. 
Finis, 
Die Fnde 
The end, 
0 op yr Igh t. .19 01 by 
Nathaniel Allison. 
and 
Harold belling ton Jones, SYPHILIS. 
Hy Abn rr Pc rt, . f. (' arv ard, ) 
dry forms of late or tertiary syphilis are not cent ag i ou s * any 
sort of Tate fora is probably not oontaglous;but tbere are except 1 
ons In which the very late forms seen to have prorogated the dis- 
ease. This is very hard to prove,as deception in so common# 
who iaay take It ? There Is practically no immunity 
It may attack all classes,healthy or unhealthy# 9«s > of all cases 
cone fro i the sexual act. Probably the contagion does not pene- 
trate the sound skin*certainly not in the majority of cases . he 
occasionally see lesions on the skin but usually so ie lesion pre- 
ceded it or occurred at the same time# Whether it can ulcerate 
through if left on sound skin is disputed,if left or. sound mucous 
membrane it will probably penetrate in tine, reside being trans- 
■ 'tied Immediately it can be carried by almost any riediun.PKRIOD o 
of x^o7JPATIOM. This always exists,the length of tine varying;the 
average for artificial inoculation Is pe days*the average after 
exposure*? to a Taylor puts it from 10 to 70 days but this 
is a «ride range,g to a weeks is the best average,The length of tin 
nay help in making a diagnosis*it however may be very doubtful. 
This nay also be important in dtemining when a nan got it*a 
hi tory of :*> to A weeks is always suspicious, syphilis always ap- 
hg 
pears first at thepoint of inoculation and always first as a chan- chr e, There are a certain number o£ woman in whom the chancre in n 
never found. It In often hard to find.In certain men the primary 
sore in not found • It may be in the urethra or anywh ere. Chancre 
itself to very variable,In extent and duration. After the appear- 
ance of the chancre this alone is the only evidence of the disease 
for o or 7 weeks except the involvement of the lymphatic glands. 
The term chancre does not designate absolutely the primary lesion 
of syphilis,with some it means any sore of venereal origin.To uvol 
amglguity,use wsyphilitic chancre” or "priraory lesion of syphilis” 
or ’’infective chancre”, it is a neoplasm of integument surrounded 
by an Induration, It is a lesion of slight extent,of no special 
form,tending to be an oval or circle,has no marked border,surface 
smooth and reddish in apyearanoe,base is indurated,suppurates 
slightly, commences as a very slight lesion;it appears first as a 
reddened spot of slight importance,the merest little pimple or er~ 
osion,the novice would call it nothing; only when it is older,an u 
ulceration more extensive,would it be narked. Surface is excor- 
iated or eroded and when it heals it disappears and leaves no sign 
rural ion of chancre, no fixed time for its durst ion, ordinarily it 
re ains 6—8 weeks,common to Find it when secondaries begin,and 
then it may begin to elective,but many exceptions, occur and it may 
be wholly healed when secondaries come, it is now as frequent as 
chancroid,-?,It is usually not painful;it may be either single or mu 
multiple—the chancroid is often a multiple, hot alt all rare to s 
see two or three primary lesions at once in different places as on the penis and tongue and thumb.lt is multiple in about l/;s of the 
6ises,.syphilis sores when multiple are multiple from the start. 
Chancroid keeps increasing in numburs.Chancre is not autc-inoou- 
table,chancre corning In contact with another part of bearer does 
not inoculate him. Chancroid Is auto-inooulable,The reason why 
this is not used as a diagnostic means is that a few believe that 
the chancre has a stage of 3—4 days when it it is auto-inoculablo 
Lintons .11 lupus are not auto-inooulable, confrent at Ion If bring 
Ing together the persons mho have given andt taken, information 
obtained in thin way in not always good, remember, that 3—4 reeks 
have passed since the giver gave, confrontation is net very ex- 
tended in use as a person changes in the meantime and if there is 
more than one chancre of Infection It is hard to get them all to- 
gether. uubo 
htthq They are not inflaromatory,chancroid has a suppurating bubo. 
There are a series of enlarged, glands,2—e usually;they need not 
be very much enlarged*as a rule they are separate and not bound 
down.There is no tendency to suppuration as a rule;the glandular 
enlargement ir the groin belongs to the primary sore and is sepa- 
A 
rate from the general glandular enlargement, eubo comes In the 
second week usually,90 $ of buboes are in the groin.Enlarged and 
hardener? glands in the vicinity of the sore are exceedingly char- 
act eristic, occasionally we find one gland enlarged and tender. which appears as If It ware going to suppurate,hut usually It 
quiets down,occasionally it nay suppurate,the suppuration as a 
rule is not very extensive,often they are operated on unnecoegarll 
cicatrices in the groin in later life are engarrassing. 
}>IA0*-Qsr-. nftoognltIon of the chancre In the first four days 1st 
not possible as* there is nothing diagnostic In it;some persons 
will give decided opinions out they don’t amount to much. Chancrol 
moot closely chanore.Herpes progenltal 1 b Is life herpes 
of the lips,seen In persons who have it elsewhere and in those who 
do not, ' er:-e« oraei>u11 a11 s occurs more often In women than In men 
and occurs In little groups of vesicles which may occur on any 
Part of the genitals* On the sound skin we see It with the blis- 
ters unbroken. On men’s we see simply excoriation from which the 
skin has been removed,they occur in groups of l/p. dojsen about the 
size of a pin. The excoriation is slight. On the sound skin the 
i 1 agnosia Is easy as e get the group with the blisters unbroken. 
It is hard to tell on men especially when v.-e get one erosion. A 
group of vesicles 'hat run together give a characteristic outline. 
Herpes lasts about a week and recurs often. 
l*e. recurrent herpes. h erpes zoster, nay 
occur o/i the penis with vedcles running the whole length. Herpes 
in womn 1b moat con von on the lahla najora. Treatment Any simple 
drying powder or unirritating ointment;the chief danger 1b that It 
leaves an open door for syphilis. Ch.".noro 1 d, Known by various names,with some epople the term ”ohane 
ore” Is applied both to the true chancre and the oh oneroid; It Is 
a ell to call It the primary lesion of syphilis If it be such* 
Char act er Is t ics o f chancro Id. Pr act leal ly wl thout tncubat 1 on—9—g 
days,It is believed to be due to a specific bacillus,At any rate 
It is -hie to a pus producing or ; anism, It is an ulceration. There 
is a nestructlon of tissue not seen In chancre,its edges are under 
mined,its surface yello-v and. discharge ;purulent and abundant, 
■’’hereas froia oh abler e the dl is slight,in chancroid the unde 
lying induration is absent.nubo is eithcvf absent or Inflammatory 
c-s contrasted wit?, non-inClammatory bubo of syphilis. 
i 
i 
DIFFERENTIAL 
Number 
Chancroid 
Syphilis, 
M\ 111 ip 1 e (u bii al 1 y. ) 
wane Irregular 
Ulcer 
yellow discharge. 
E dg es und er; a In ed • 
Pus, 
Ease not Indurated 
S ingle. (usually} 
base not Irregular but regualar 
Erosion, 
Discharge reddish. 
Not undemined, 
S!fcrrohd&fc#ty 
Induration, 
hi ibo- ab s ent or si ippii r at ing Hubo -no n- si ippiir at lng. 
forbid Evolutions of syphilis, Distinction between chancre and 
chancroid la definite when symptoms develop and It 1?? not bad to 
wait In practise for the secondaries In all ■ «edloo level cases; it 
is possible :o be readily deceived otherwise*There la the possib- 
ility of the inoculation of both at the same time,This May take 
place simultaneously or one after the other.The sores may be to- 
gether side by side or one may develop in a sore which started as the other, The number of mixed chancres Is email hut they do occur 
The ..e.at of the primary sore, Locally:- Can constitutional 
symptoms he presented, hy the destruction of the primary sore vpri- 
mary sores were destroyed hy caustics and some got well,others wen 
on to second ary. These were then thought not to he completely de- 
stroyed, Later.it appeared that syphilis came when syphilis was 
Inoculated.always. certain men excise the primary sore;In the case 
that escape after the destruction of the primary sore,the incuba- 
tion stage was only from one to fourteen days and it was evident 
that the person never had syphilis * therefore excision seems not at 
all effentire.probably once inoculated,syphilis cannot he removed 
as a constitutional trouble.In most cases the primary sore cannot 
he removed until the period of Inoculation has passed. Even in the 
those cases exposed and Immediately destroyed,constitutional symp- 
toms have developed,if it can’t he removed by excision It certain?* 
ly can’t he removed by cauterisation* Still some believe that It 
Is of use and so should he cons Id er ed, Th e immediate destruction of 
the point of Inoculation hy the cautery or otherwise is fully 
warrant el if the lesion Is recognized at once before Incubation, 
Cauterization Is not practised as much as formerly. Apt to lead to 
suppurating buboes,Sloughing chanchroids are now better treated by 
corrosive baths find antiseptics. The reat disadvantage of chan 
crold is that it spreads rapidly, uaths of corrosive,carbolic, 
permanganate,and other antiseptics are excellent. Iodoform seems 
to have a special action on the e sores. It was introduced as a ■- enereal remedy but its use has spread,Its odor however is simple- 
ions.Xo loform suspended in collodion mokes a good treatment. Treat 
chancroids the sane as sores anywhere and keep them in a condition 
so that pus shall wot flourish. The sane treatment applies in the 
treatment of chancres,In syphilitic sores any preparation which 
contains Hg. is especially good.Calomel ' lakes excellent powder and 
unguentum Hydrarg. is especially good, iodoform is also good, sore 
that Is treated, wit calomel generally does extremely veil. 
Concerned Seres. Kener.th the prepuce.Phimosis is caused at times 
by a concealed sore.which may have to be incised but It is best 
not to incise when there is a sore underneath an the incision is 
apt to be infected, it may be necessary however, Kubo of hyph.ilis. 
seldom needs any .pedal "'-are. it very loin .-juppurates anc if so 
a small incision Is enough. They nay threaten but they usually 
quint down -'1th mat and a few hot applications. They sometimes 
Indicate that you should begin constitutional treatment, Often it 
1- 1 fitter not to -operate as the patient has to rest then and own 
up. So ratines a trocar through a snail incision is to be preferred 
emn if it io es not stay long .you avoid a suspicious soar. 
The chancre disappears after a tine .Formerly with cauterisation, 
it left a soar,but now with less oauterisation.it frequently ils* 
appe rs. Xn orrtain cases it breaks down again;this renewal of ul- 
ceration lay occur in a C ew days or ■••ithin a mo nth or two.lt need. 
not moan that things are going wrong.it may deceive the doctor by 
, y" 
making hin think that the patient has reinfectred himself; it nay break down In the centre and act like a syphilitic gumma. 
Recurr e.nt in- jurat Ion, v-ay take place in the seat of the old sore 
at any time for years,The primary lesion lasts till the appearance 
of the general yphilIde, chancre and bubo forming the 
first stage it le proper to nay that primary stage lasts as long, 
r> no other enlfestatlon exists. Period from primary sore to 
general syphilis which appears about 45 days after chancre is some 
t Aries call el secondary incubation stage, secondary manifest at Ions 
very rare after 90 days. Any time after weaks exceptional .Fallen 
treated in the primary may have secondaries postponed, secondary 
i. no i J.b at ton s t age. Nothing marks the existence of the disease up t 
to the appearance of the general symptoms as a rule.some show ev- 
idence of serious disease by excessive anaemia and loss of streng 
th. vs secondaries draw near,the patient Is troubled with pains of 
a neuralgic character In the head at night often preventing sleep 
till near morningjthese are cot confined to the head alone,but may 
exist In the bones and muscles.Occasionally secondaries are usher- 
ed. In by febrile manifestatIons,but not as a rule. This varies 
when It occurs very decided I1 ,so as to mimic other diseases, as 
typhoid. In a few days the diagnosis Is made clear, sometimes pain 
1IKe acute rheumatism occurs or It may resemble malaria as general 
disease Is ushered in. Or It often simulate i grip. Occasionally 
the initial headaches are taken for neuralgia. Secondary Perlod. 
This comprises manifestations which are superficial, benign and • hay/'owe-.fnr show itself Internally aQ v’eii as external- 
ly.Lesions o' the sic. In and mcoua membranes and thA appendages of 
th*' fr.'Li miioh ;s onychia and Ions of hair. Pains in the hear? and 
toIni ?■ * arthralgias* a.1 enopth 1 an*pieurodynlas .per i ost It Is, arthropath 
1 e«jf irltl-:*eijidy limitis*anaemia* i eb 11 tty.trouble« of internal or- 
;vii;h nervous troublec%t r<Tiblen with the piscent a*with result 1 ny 
death of the fetus and abortion. This stage I?? of about 9 years 
d rr-atton*such tine is not definttefco?apr lees only the stage In a 
largrt number of patients. 
l;’lrst Stuns of the secondary St aye. Look in the first plane Tor 
•.anlfe*? tat Ions on the akin*these are multiple* and the majority are 
superficial aril to not ulcerate.they are apyretio as a rule.When 
there la fever they differ from the dinerses which they resenble. 
Often manifestations on the nYAn is all that there is to attract 
attention, majority of shin man If eat atlone do not Itch* a few do. 
a oar patients ra that It does Itch > t >"e dcn*t see t'-r scratch, 
r.arb.n. brunt ion Is copper colored but varies nn different sKlns. 
Ocrp°r color ruonly **•*!th eruptions to at have run for sore 
t i. •.*?, Ther - In a t endenoy to arran emerf in Incomplete circles.The 
fact that T’y, cures these frrnptionn Is Import ant .Put because Kg. 
cures i’nptIon,does not make It nyph Ills*as perhaps nothing else 
would ouro It as welljnae it with core. Treat merit o" Syphilis, What can he done while a diagnosis la 
pending In a doubtful c ase ?such patients should be kept on g er— 
rl tonic??,meet serious outbreaks of syphilis occur In alcoholics, 
so Hr It the use of loohol, In any oases prohibit It,hut In acme 
It should not be prohibited, in thane suffering from chronic cough 
treat the ooughjgive exercise to those who are sedentary.The t^eat 
ent of syphi lie conn tats in the administration of 9. drugs. g e^cury 
and Iodide.r.-?he very name of mercury brings forth protests from 
many patients.The objections spring from the abuse of the drug in 
former years. There is a temptation to push the drug to exce.-.a;not 
v 'ry long ago cures v ere attempted by Inunction alone,and this be- 
came so distasteful to the patients that an ant 1 hoercurial sect 
:rose. i '*rcury certainly causes the symtoms to disappear,some have 
aryaed that Hg, causes the late tertiary lesions,but any knowledge 
of the subject removes this belief, Indians without treatment, 
showed these late symptoms in their worst form, since Hg.has germi 
clde properties,there is a basis for its use, xt certainly is the 
most valuable remedy we have,it Is as near rm specific as exists, 
no t 
It Is In certain 
cases it fails.Quinine is slightly more of a specific, Xt may be 
administered In any way; by the mouth,per skin,by baths and hypo- 
derm 1,cally,All forms of administration have their advocates,mid to 
t? en theirs in the only ray,Good results are obtained iron g In al- 
most any form of administration, intravenous injections of blohior- 
Ide solution is of value in some cases. All t nese ways • isy cause deleterious effects sho* n in e( 1) salivation {%) action on the 
digestive tract,pain and diarrhoea, (ft) deprssing effect* Inflam- 
nation or the mouth gives salivation*swelling or the gum*soreness 
of the teeth with ulo ex* at Ion* sloughing and loosening and final 
loss of the teeth. Salivation is to be avoided and not sought for; 
it is less coramon now to push even to slight salivation. In some 
cases y-n get very severe abdominal pain often with diarrhoea which 
1 ■ excessive,watery and weakening, occasionally * severe -epression 
Is -;.een. bet hod a of administration. (X) Inunction ; at present is 
different fro. the old forms*its object i~ absorption. Two prep- 
arations are co ncnly In use; UnguKydrarp:. and cleates of Kg. rng. 
dydrarg.is to be thoroughly rubbed in (20 m.) so that It can be 
absorbed. Discoloration say occur but the oint- ent Is mostly gone. 
Friction at ni ht and skin washed off in the morning;often the 
akin must be annolntef uc it may be irritating. Different places 
should be used at fiff rent tiraes. This is disagreeable to some as 
it is dlrty*many of the cases don't wash until the end of the week 
Certain individuals instead of rubbing put it on a cloth and apply 
it In that way;certain doctors put it in the stockings. Cleates ar 
are more agreeable as they are not so dirty,but they have not foun 
favor*as they do not seen no efricaoious.bone for lioj.uMo,; is 
from rtru.l/s to drn.l. a dr an maker a large dose for sore people, 
vercurial rathe Fither sublimates or some other form used;baths 
have been used in inherited syphilis with great success. The power of absorption of mercurialised water varies very much.and in the 
majority of cases it In very small. Of not much value in general b 
but In certain lesions iaay oe good. Insufflat ion, Fumes of Hg.in 
no/ie Corn, are inhaled.slightly dangerous.it in cumbersome and in 
Practically out of use, subcutaneous in,jections. Has come into use 
of lute years,it allows the doctor to give a dose that is definite 
and gives quicker effects than r-jubou.in -'.my other forms. Causes 
great pain at tines and sometimes sloughing.{1) holution.( 2) In- 
soluble form.to be taken up gradually, ' any solutions have bee/i 
used but v?e have mostly come down to the bichloride solution. It 
causes very great pain which lasts dor hours and leaves a nodule 
rhich is acre for days.Most insert the needle for Its whole length 
in the gluteal region or near the tro oh enters for the best effect. 
It is very disagreeable to many patients and is not as has been sa 
said.the only way of proper treatment, it requires daily visits 
and these get very tiresome. Recurrence of syphilis occurs after 
all forms of treatment. It Is perhaps sure but certainly is valu- 
able and should be spared for those cases in which there is intol- 
erance of the stomach or where the integrity of the eye or some 
other organ Is threatehed.Of the deposit of the insoluble substan- 
ces subcu. there is so much to say;it has been followed by severer 
•:tcol '-eatb thah subcu. of solutions and in practice is /lot very 
good.Tine bichloride solutions for subcu. gr.vj to the oz. Rave the 
needle sterile,look out that the bichloride does not came in con- tact with, oetal 0 f any sort any more than Is nee canary, x/10 or 
l/le gr,once a ’ay Is a noderate lone. 
Intro inn ■: io a by the stomach. ?ho natural net hoi and it has the 
least number of Unagreeable oomoquences going with it.'any forms 
Ray be given in t! In may*Practically they have cor.e down now to 
bichloride and prot iodide,caloviel occasionally wed, her it nets on 
the oweln;blue pill Is user! with cone effect* Tannate varies -nth 
the j ionnlnct irers. Bichloride is soluble, Irr it at Ing»especially to 
the .-‘to. ach and be 'els. ProtIodide is less Irritating and 1.3 acre 
apt to show effects on the mouth. Either in ay be used and the dose 
l/l5 yr.of ft ft oh 1 o r 1 d e, • iak 1 ng it a little smal 1 ~r If the man or 
woman be snail.T.I.D. Must be -non diluted;oan be given in woter 
or diluted "vita ra 111c#the mouth Trust be protected» Prot :lodjde done 
l/b - 1/4 and 1/e gre;lntt.:l. •* bichloride cannot be. use •: 1n 1. 
letr. well * as ahO) the coat ■•-’/a ahen 0 ff "O get concentrate" bichlor- 
ide of the etc *00?: wall*Oon be made into pills with an Inert sub- 
stance -nixed with it, as a bolsis# 
ppr acf tito t optpe e form of Iodine tnost usedfother lodldep? nay 
}yr- iodide of and amonlun anr- also iodide of Fe.{ Ui 
last is of slight v alne, )Xod Ide of potassium Is very valuable es~ 
peelally In tin tertiary stge, It is especially good In syphilis 
o■' the nervous ays* v.,hrthor* carl’-- cr 1 atetsyphilis of the bonen, 
neurit is, and in certain Ion ions cf the mucous tnenbr ahes . It Is pe- 
culiar in the result s which sometimes follow Its Ingest ion* and i? 
valuable in Itself a})art from everything else,even in persons who have never taken Iodide should nevnr be used when the dtag— 
nosl; of the primary more is still In doubt Tor it gives rise to 
certain unusual appearances In the akin by liis-elf, yost patients 
can take it •without 'trouble while some can* t take even -ft 
without troubl e. r*o ;n varies frora b to 100 grains. There in almost 
always an odor in the breath,rben less n.-irked simply a metal tafcte 
‘"like an old copper cent*** hext there in . cold in the head which 
simulates an ordinary col'Vthls is common and you iay not be able 
to tell it fron an ordinary cold. The common thing Is a slight none 
hr; not in no Pro i Iodide vary very much* they occur in .per non a e»pe c— 
tally apt to have none,.The coryza gone on at ti e ; to swelling of 
the Caen a.-id disturbances of br eat bin : and nay sinulate the grippe 
It cones on a few hours aPt.hr the done*and nay simulate a»thma. 
Often startles a -patient and a different doctor from the one who 
prescribed nay be troubled about the cause, occasionally Iodide 
produces certain furuncle * which resemble some of the gur-oiata of 
syphilis and cannot be distinguished by beginners. 
•,- -b rvt -Treat rent, hg. and the Iodides clinic ally work to d vantage 
many per no ns think that mixed treat- ent means both in the same 
pre-crlution;but It means that Vne drugs are given separately ;t 
fire s-./r.p time.nonimonest way Is Iodide by the lonth and kg.by in- 
unction. Iodide is advant ageously added when in the early cases 
there are headac}res*neuraigias^rheumatold pains*or pains In the 
legs.either rnyalglc or periosteal, nood when lesions resemble the 
tertiary for) a and In very severe fori as as well as In nerve syphlll How treat the individual oggp v Treatment 1b by mercurials large- 
ly. when bog In ° Don’t begin for the primary sore when It la doubt 
ful,begin to administer mercury when you ares sure your patient 
h syphilis;in many oases this 1b only after the secondaries appe 
ar.but not al /aya,if buoy the oattent cannot long follow up the 
subcu. treat-<ent. In certain oar,on the stomach must be saved and 
here 1b \vuere you use Inunctions.lTse either the bichloride ot the 
protolodlde,g:',l/4 in pill i.d. protlodide less apt to dis- 
turb the stomach; both about alike as regards the 1 outh.Watch the 
patient’s aouth even when giving & or 4 1/4 gr,doses of the prot- 
ion id e in a day.ue ready to stop for a few days; insist on hygiene 
of the icuth and teeth, Hichlorlde has Its advantages, It 1b sol- 
uble and my be civen In water* or milk,or In a pill with a large 
amount of inert substance as ext.of cinchona and gentian. Dr.Post 
f urors bichloride In any oases.Patients should be under supervi- 
sion for two years t le ist.lt Is not a good rule to keep on mer- 
curials all the tine; after the first no nth or two continue It with 
breaks.giving it a week and then leaving It off for a week,or two 
weeks on and two weeks off, according to the way they bear it. It 
le not good to push ercurials beyond the therapeutic doses,keep 
it up foe at least two years with these interruptions;’lore to pre- 
vent other late appearances than to prevent recurrence of the old 
symptons.lt should be best to use Iodide at the least appearance 
of u'rve 'rouble,pain in the head, bones, vague pains in the body. five Iodide in the Interval6 between mermtrialr. This mixed 
treatment will mat•'Totally benefit almost all oases.Many attempts 
hm/e been ■,ad"' to substitute vegetable compound for Hg*and Iodide, 
to ay oomo fro? 4 laercantlle and. not. from scientific points of view* 
They of course occasionally help* o«jn of hot springs should he 
considered;these exist in every country,as hot springs of Art.ansa 
,nd the patients there are treated not only by baths but by Inun- 
ctions and In a any cases Iodides, some cases appear to be benefited 
by these springs*but more from the thorough treatment there than 
from the water.Syphilis returns after treatment there as much as 
after treatment at other places*the c ;re Is no shorter*the imag- 
inative or depressed should not be sent to hot springs* Poes mod- 
ern therapeutics add anything to the treatment of syphilis ? Ex- 
periments on ml mis hare not been successful*though further ex- 
perimentation has been encouraged and there may be some adjuvants 
to Hg.and Iodide brought forth in the future. 
and ppm?" 1L or SYPHILIS* In Europe this Is done by 
controlling the prostitutes,but the officers who have charge of 
this work awe charmed with favoritism* and It Is sal to 'ey or un- 
licensed prostitution, The*contagious disease act* took the place 
of these laws In Kngland*but they worf repealed thro* the agency 
of a certain cl ss of women who oppose everything* so much opposi- 
tion has arisen In England and in other places that It would he 
practically Impossible to ever license prostitutes and get than in control,The police have the powere to suppres* solicitation on the 
public streets and to arrest drunks. A large amount of the con- 
trol .>■ ependo on the ledioul prof-esslon,physicians should be better 
educated in the i1 agues is of syphilis and should strive to educate 
public. '.’■'•ere should also he syphilitic hosplta'ls where the 
victins viouid /o for refuge and not imprisonment. 
■I 
syphilis In the I 00 Phi1. Accidental oases,the innocent wife from 
t■ r guilty husband and vice versa,;\nd hereditary syphilis,among re 
al -n one net of stat lotion about %0 \> were innocent,among males 
the h was mch small 0% It sometimes appears in ep idem ion from an 
Innocently inoculated midwife. Accidental or con-venereal i.nocu- 
lu'. nn .Abort 7 to B h in nuiiber;probably reaching; IQ an the 
primary core 1b often in such a place an to carry it elsewhere 
than to syphilis clinic. It nay be 1.no elated on any part of 
the body usually In the mouth, anywhere from the Ups to the back 
of the pharynx, generally on the lips,next in frequency on the f in- 
.Kera,then the breast, the ar i ( from vaccination,) Pipes carry 
the disease very often, it may go into the trade an in gl ass-blow in 
Inoculation ay be direct as from month to mouth or by so* -e intrr- 
medlate object,Chancre o' the lips may be seen on the lips and 
is seen on the skin and mucous membrane.lt is like a cold sore at 
irat,but refuses to heal and has glands under the 3aw.Often is 
mistaken for * • oitbel 1 oma.Pi»'f erential Ma-.nosio fvor: cancer. Cancer 
In the old,chancre in the young,Cancer of the lips is rare in fe- 
males, glandular involvement in p,~x weeks In ohanore;4.-5 in cancer. chancre shown by outbreak of constitutional symptoms* £MX»e*xKX«XX 
smooth surface, regular. poll shod, distinct edge, does not bleed. In 
osneer.the Is rapid.the surface Is Irregular and bleeds 
ocslly. olury'! can be squeezed out.and the thing requires months for 
gro v• th.syph 111c of the Tonsil varies much in appearance.it is iiKe 
chancre in other plac'bv.as to indurat Ion. ulcer at ion. etc, syphllio 
on the Cheek or an: other part of the face may come from a Kiss or 
a Mte. Lesions of this sort on the sound shin are usually covered 
by a ‘-cab, chancre of the nr cast occurs in females during lacta- 
tion, few cases come from Kisses, Many cases of one series arose 
from a woman who made it a practise to draw out the breasts of 
-'omen who were undeveloped or had retracted nipples. Chancres oc- 
curring during lactation are apt to be on both breats or on each 
side of one breast.whui from a Kiss.they are usually single, wet- 
nurses also give syphilis to the innocent. Foundlings often give 
it to set-nurses.Chancre of the Finger.seen oftenest on doctors or 
medical at ten^ants.occurs usually at the edge of the nail, when it 
occurs where it can taV.e forrn.lt is rounded and indurated, such 
chancres vre apt to lead to very serious results in the wav of 
propagation.Midwives seem to proagate it more.The rubber cot may 
help tie surgeon or the patient. Inoculation of syphilis with Vac- 
cination. Till within a few years.vaccination was carried from one 
to another and. in this ray many got syohllis.To avoid this we now 
use animal virus which renders it perfectly safe to use. An$rivacclnation is ts Bay that this in not preventive.as the scratch 
lag scalpel nay carry the infectionjnsiny the ooint itself or a 
needle sterilised over a la*dp away with tnis or gui ent.Vacc 1 - 
nation appears in o-4 days;syphilis appears in <5-4 weeks. Vaccina- 
tion i • all over before syphilis beg ins. Eruption comes in 8-9 week 
after vaccination if It is syphilis.Accident .« inoculation on the 
gen itals may possibly come from dirty Instruments used by the 
doctor, xxai* 
PhOd*:dhIS in SYPHILIS. In children it in very grave as 
many o' the children who have congenital syphilis die very young. 
In .adults it does not seem any more fatal than id regularly ac- 
quired, it is the cane di sense, her ever it may be contracted. 
r«r/' \llhH dYPhlLXS. Inf hits may acquire the disease as well as an. 
adult,the 1 eginning Is the saroe as In adults*these cases are rare* 
the disease la usually hereditary. In hereditary disease there 1,c 
no chancre* the child being syphilitic from the start.The early 
syiptoms last through infancy and childhood*the late lesions cone 
later and are known as late her dilatory symptoms. Syphilitic 
fathers and healthy mothers have given rise to both healthy and 
syp ■ iiitlc children. If well treated they give rise to healthy 
children; at tines however.the child ia ■syphilitic and gives it to 
the mother;this is the great danger and constitutes a large class 
of the cases*a healthy father and a syphilitic mother give rise in most car>eo to a syphilitic child. If the is recent in th e 
parent?! It in aticf a re;If old and • oil treated .the child bar 
■.or*' c; cice. t v both are d i b ear? eri # the chi If I i» altaost to 
it .There ore said to he exertional oases, Allthece case* 
depend on the length of time that nan elapsed a? id nine upon the 
efficiency of the megt.aent. nr,Poet belfceven that non who have 
had iyphi'.;is f> or e yearn ago ■'•hioh was veil treated 'and who have 
healthy wives.produce healthy children. If the mother is healthy 
anc * he child in (f.isealed*what 1b her chance v The child nay piio* 
le her with impunity when she In apparently healthy,This f•••ct was 
Uncovered by oolles and if? known m * coll n law”. Man y of the 
gc on apparently healthy.this is explained by Baying that the won- 
on has undergone gome change and is really Immune. Kxi)eriinent« 
h vft been made in France and the women have been found to be 
me to other ccr.rces.The origin of this change 1b said to be in t 
the placenta which breaks down. Some o .sec taken syphilis in 
pregnancy who have not been inoculated before. Pont concord, tonal 
I no ci ~lat tonal The mother 1b inoculated after she becomes preg- 
nant and in all the can no practically the child is affected with 
the d in ease, but it boots to differ in come ways fron pr e-concep t lo 
al canes as the child mem less likely to die. First results* of 
fresh inoculation in a series of abortions and prenature leliver- 
les.lt seems to confine itself to certain ayatms in different 
persons;in then0 to the generative o.tgand. There to r-.pt to be a gradual betterment*!,Abort \on.2*Pre iature.3. 
fix-11 * vho lives 3—4 lays*4* One who lives -maths. 
sr.-otc-v-‘ i-i the child* Horn with the snuffles. They are emaciated; 
If they show a rash*it 1b h erpetlc-llhe, and the ve«ioler ulcerate 
easily, Thef :hoe excoriations about the nates and fssures about 
the aouth;they Ion11! 11?p long as a rule* If they are horn v 1th 
the they are almost sure to ■ !!*, The majority of those 
born syphilitic -.re born apparently healthy an! they shov the <Ur- 
ease the first three '.months isu ally* the Majority In onn month* 
many in three first the snuffle%no isy hr oath in.-: becoming 
gra»5--tally mouth-breathins with discharge which -Tries on the lips 
ab, '•.loro . looba *p th r'M-6, This May show itself only at nu:r~ 
Bin-; as the baby Keeps lotting* f .o to get his 1 -r b:.th*uaually due to 
smelling o 54 the nose; sometimes to excoriation and ulcgraVion*uay 
go on to loo of nasal bones*this is unusual however in Infanta. 
Oft on there in -ale oration in the no we,? couth and throat, whl oh cor- 
responds to mens patches,these are more extensive than 1m the 
adult* they are multiple a fid give rise to oracKs in the lips and 
mu oh saliva; this -Ives rise to the great danger ox* infection from 
a syphilitic oh lid. The eruption in these oases Is macular* as In 
a 1 Its and in usually most rfmndont about the buttocks. Taylor say 
the condition of the glands 1 f, of no value, nr. Post says that aXter 
a her, mouth.**the condition of the glands in children Is as valua- 
ble as la adults,In well marked oases there is slight general 
sin glandular enlarge* nnt.Alopecia .show* Itself in infants as - all as 
In •••Uilto.There i ; very Marked thinning of the hair,the ? - no of 
h'-r eye ' rows do rare valuable than of the other halr.WakefYaiiieoc 
if another syripton.Ths children perhaps have headaches, dentition 
lo d hi ay ed, the «th,ldth or 11th Month before the first teeth corbie. 
They are friable and. lost early,but this condition nay exist in 
other 'is**-.-. -e.# Dir.gnosis ±*-- often very hard;enlarged liver and 
spleen are other helpful points in the diagnosis. 
Tv,'Aat.-;r y-/# seeding 1 r. Import ant tth e :ncther1 s breast In better, 
if it ban to be helped out,then exclusive artificial feedIng,ne.for 
dire a ret /nr e. Inunction ia :ood in core canes, /ng.: ydrarg. dil- 
uted «;i th petTOlatuii , put Inside the i riiy band.hy• <• it.- 
chalK la ’•.'ettrr in -oi e o.?es;.;ive it In gr.l/p tablets t.i.d. or 
4.1.d, it ii broken up with water or milk in a rrpoon and put on 
the -aby»e tongue, a1chior1d ef gr. 1/SOD In often used. The 4 of 
children of syphilitica that diefio enor. nun. 
LavK te :^'T'lTAHY At presenttsignifies all those 
or hereditary syphilis that nhow ny iptons after inf raicy. 
applied to those who chewed svMptovis only «'hnn 'ell alon : In child 
hood.Thene show often the effects of the disease on their growth. 
.All the do not occur In each indivi/Ur l.Kf iv-ctr: on t,h 
Retardation of growth*very Marked*teeth are late in naKlng apprtr- 
ance, helKht puberty and rental development are all retardfd. rsoge 
are bright as the ordinary child.cental retardation has given rise to thn f nrr, Mt?-.Pant11 nls'* Dwarv-**#5 ,m at t syphilitic 
0v 1 f 1 /1»T)nr*or: 111y o.C ton tonfi In Hon’K nj ; to o first g«t. /*oe »y v<=ry 
" 5lly but slow not'rlnr • • xr':-■* 1; 1/ n oouoi tnntn av,n firvni in ;uj dA- 
~or* p‘!. fayto.g^o.n an :m.oonf inrO to thn jrvld.ln Incisors 
o' thn onconrt or loth Hay In ;iihtootng, tin reason Tor this 
i« not known,T>ut It i.» rPgarrtni fy ootm 0 a part of :-;nnnj*aX 
rot .riotIon i.yi fr^ovth# 
rh e t o o t h 1 ]) eg * ed f 
nnd dofiotent 1 n ejja iel Mon:ial hutchinsonian Teeth. 
and sometimes the dentine in worn oCf by use. At times the teeth 
r*e cep amted from each other and are Irregularly placed.These 
teeth o a our In a era 11 proportion or th e cuae- of hfreditary syph- 
ilis. One tootli may -e notched and the other broken off. ihoy very 
ouicfciy hear so that the notch May b* lent at ?0 year.- of age 
Found often In connection vrlth soft decayed teeth.Teeth with ridge 
on the • ar- found In this as in many other run do an conditions, 
nth these teeth there is lack of development or the J?wtX300t 
nQSK. It may be sunken or have various defor11t 1 es;at tlme.s it la 
flott eneri, 
fa- jJ" rgiHs :>■" !.hfi HhAP. These are comp iratlreiy frequent. .The 
•trcilght high forehead and the Infantile face.The boat nheped he- 
i’ot; ;i ty and bulging of t he frontal ernine <nnn a ,o to exostoses, ay 
have exostoses ■ elsewhere on * he hend. 
There may be an apparent curvature of the tibia due to swel- 
ling of the anterior portion.Look also Cor 'igns of previous ulcer atlon*,'»?1.:id pits md cicatrices about th6 buttoefc>»,;irr*c an i yeni- 
tain*ptrare cicatrices 17 ioo\ir hye h ■ wev ~r, very o v- t~ 
rllch? about the lips point to :7 Insures ov ulrre- at ions and iih’C&ly 
RUfyost nyphili 1,?: e lesions the -.m elver? of late her editor 
d i/•• ” p r t'.o X- ■;• o ny-'ipto' a,They pro the dstruct 1 y ' ind# On 
th'in.Uhey ore tubercular cyphHide,this occurs in v: mt 1/5 of 
the cot 71.a 1 ‘hriuriB are on the taco a id rcy iblo lupus. in 
the v:roat . loni.ono .*r° , ,>rc coTnucn, an yuiafiat-s on tr.o hard and soft 
pal t Those are i e* t rue t :lv % t h ay per for at e cjulclcly and may 70 or. 
to deoroy the usual boner: a• d c ire deformity. rully one.' half of 
the •’■’"o'Lfi/i donv no are cor.ycnltal 7n crlyln. 
HTvh 1>"- la tv -rt T?AL .win;TT..IS, Interstitial heratlt-la In the 
oo- v -.on•-■•!+ *,'.11 :■■’-•■'none may be complete for .,i ttao.Thtc tales place 
1.of, we a; 7 and h 3/0ire or more oonrno.nl"' between 13. and le and af~ 
foots both eyes. 
vat. tttt-rS In MOr - ;■ vr: ft nvuiryit. cor ion. OtUln irvU.i 
O.C '• p X ohrjvnoi t } iay occur; it in not d Inti net lye or. 
There 1.1 a cowing on suddenly which bccor-iCc aXrost corn- 
piety without hnor'n le«5iontbut this In wo co j in:i Ui the 
ac nlvod "’or: 1 oC the di ccacc)* 
’ uto‘..ins."».!i point nd yi that ■ ut fi hnconl an tool," f InternMtlnl 
• ratlt! • , •:(' Irou’li* with the earn occur o ft on together a: A rhcn 
f.ov 'i’o c:q occur together arc distinctive or cou-onltal ;yp" IX in, 
renown if? MHutohln^on,'f Tut ad ♦» of Jones and Allison, Glares ;',tp affect erl In here!if: ary v ei 1 as In accirlren * those of 
tf.e ; no>: ■ r >■■ often alien, b any of t/ip<y ylands rtp tubercular but 
on- . si nally w find ??■ a-li h&rd chronic glands whIch %c away with 
|| # - _,;T. |. : . ig p >n ■ * titli Olt 0 st It A s, Tib In is 
oo,-, icnly affected, next 1 i i'roaiency the irssep nan’ of t ’ • r hUT-rws 
Cbl'i,-' it/i . n■ i.<><o i f i:; o-‘ a0 tlb i• •. I ? sunpic1ows; if both tibiae 
are affect '■ ■ t ■’ ,.t s syphll is, Joints. hydro-arthrItla of the 
knee is quite no!:inon. bore apt to ho on th e bo no near tne y 
th. n in •;.:*■•» Joint, Itself. ~'erv-'->v.s '\v It e no ; non an ' o ay 
olaulatn rj tubercul -*p Tienl. lb It 1 o which yets well on syphilitic 
treat jess, )oonolofiallV \ case of hydrocephalus 1« syphilitic. 
V;,1 n])By t • .till one com.: pi. Inf nttl 1.. occur a beV*«en 
t}i.n -r-. of B 1V. In sore cases. The child In all rlpht t first 
but ' t?ils ' ■ bio irtia onto In which gr -.'.dually 1 scones complete. 
Sap 11 » in ':o l e suspect ed In n~T'rous diseases vv,eri the symptonc 
are irreaaiar or a number of facto are necessary to nape & dlsg- 
.ao>, I*-*., ■ a ly cases are thought to ■)' scrofula wh 1 ch am due to the 
i i 5 >.■ f ■■ *■ ivc*■ rhe f~ '.1 nr*t t■'P1 ca,-?esh’.a.v he a 
mlpose. Treatment In the same •, y uou; l.KI v/orvf> an 
•may bo -;i r&yi In X nrye Iona ; to mil children;It 1n oft to 
,l,vl v,'t;i n e "onr i al 3 • I n o:’ rva:r- 11*11 lo fv0 ’ 'r~ 
talit v of "irl if ha In v oat, ‘r-rnnlny froT't 50 vf» to 100 ■ - • npon— 
Ol/i- oi i ;.•• at rnt. fha yonerat Ive oryann nee not ally prone to 
attv.oK In jr-vtaln P■'elllea.polyrortalltv,In loi-blful cahffs Is very 
stroa: evidence of the existence of syphilis In suspected children Accidental Inooulatii ■ eh when brought together,they con 
•'ti tutr- c; to r ijni '-y* at ca.nec,i iret oprnrtucitv to in 1 t.e nrc- 
na e at hlrth. r.Poct dona not believe that Inoculation of a. ? 'hxl~ 
thy oh lid la It • ihaaavh' thro* the vagina can occur. There weald 
+ p (iT i s*>,.* ■jiVf-*'' rVpi l.nv.’Od bv a.-'1 'eiVj"ot 1 C.C. In '-JI f-.fO’— 
mtlv }a althy if til born of a nypnllltlc uot?.er t In h:v: ae Pro- ■ It a 
if'Othfr ■> rxr.Po.-it believe- that Oollc.n law ror)C8 both vr.yr • and' 
that It cainot pet It In tlaf: vay, Meet prlnary screr? in children 
conn or: the nouth,uay ccae from sroplica,fror a art nurse, or fro 
r inf ni \ to) hr at ha came hrea«t*Hay he indirect rrora the 
nn-npr inPectin•; the nlpplojothfr chi.Id""on ire no> .ntl r-• -hma'oroh "■ 
r*;v:r'ianlr ■ on t* e • and cr .i.'-ilnal oaunti h.ti* -.re the eon roe 
o;■ ■ v-.-' r>■ ■■ c ,, upo lattfir ol nr? m?;' ?’irlnfro 1 : relief f:h?f 
f»n; oppp.; ,.r»o •■-• ■>->.-v7v by int',rvT*coarse ' it; a virgin. 
INQ hTimu 7-0 » y-T-in L Fro'i'1 vaccination very rare • t 
clrra ■ o“I■■'-ton ■- oactl* a" a o.vi;3P.f ITuatacl an oath*** or, an1'’ ovw 
pr: uof:r' " I o t hr " t tr . • c a -4 p' r ar- a raT: source* \o«m1.r*tf 
;;v:iv'i ? i -, i n * ■-.c child tt the cane oourne --a in the oault, 
o-nrtr *t ti inn to ilnti.i-voilBn tatnonri acqalrnd and Inherit on rM,r,~ 
- 11 
n-n.,a to -] a n ion l.n oona^'ilta'1 before the child to 5 aontra* old %ln 
acqnl red 4 m eruptton cannot co: e before the end of the aeconf 
ino.nl a. tan * ani tal canon arc non ally veaK and emaciated air1 havr 
sofcysa# po phtirao to peculiar to children ao a m an If at ton o~ 
oyohllla. with the destruction of the palate In a child of IP.,It t is to say whether the disease 1:; conyenitai or acquired 
■ - ix* a t; 1t 1 f: la • a en only in con a en 11 a. 1J t h er a i ay l > e ex c op t. .1 o n s • t o t} i 
this. Pro Co-1;v.i leafness cominy on with other signs 1b always due 
to hereditary, riutohinsonian teeth congenital, mortality 1b better 
In acquire!., than l/i her el it ary. Treat aw usual except In doses 
proportionate to the child. ho* late may hereditarily show Itself ? 
Oases may go on Into well adult life,ulcers oh the leg may be seen 
first In the twenties. Pare cases are reported showing first symp- 
toms as late as 30. 24 years la the latest age seen by pp.Poat. 
Doer, syphilis go oeyond one general ion ?No cne c.- .n nay that 
syphills may not go on to the ohi.lire- of hereditary syphilit- 
ic* . hr.Poet has never neon it carried on so far,hut some syphil- 
c, raphero think, that it dees but they cannot prove it. If it In 
handed on at all to the 3d generation. It -rust be very rare. 
pig vv~>’t~ c -! ihT; ;pw. p These are net really syphIXiylo,but go 
along with it and re- not amenable to syphilitic treatment;ayphil- 
ls is cne of possible canes. Pigmentary nyphilide or leuooderma is 
one of these, Tabes,general paralysis and seine fores of muscular 
atrophy, o ertaln forms of rl eke* n, in Cant ilism, and hydroeeph r lus are 
others, Leucqdernn appears in the first or second year In the bach 
of the necK. usually like a collar. It la recognised an due to 
syphilis and is somewhat amenable to treatment , The paraeyphll.it- 
lc affections show the* no elves meetly In the nervous system, n eur- 
aestnenla In :nr of these, it differs In no respect free, that 
trouble without syphilis but occurs so often it that It can't be  -ully l/h of thn tertiary lesions arr ndr/ous. 14our- 
asthenia nay simulate tabes but of course the prognosis if? differ- 
/it • ida JiO‘5»' a,/ *..i t al a; iUptOiis oi. qa•-■'•?* r: 1/1>iJ.x\.'pi ioh.1 a .lf~ 
1 -:■ .:• 7or:. vhich the neurasthenia taKes in '.any of triune cases. To 
thenf in at-ied at tl es & icroiiriaXophoMa; it 1? rarG to find 
the*? Inf too 00- if.ined.Paracyphlittle hysteria fh>na not hitter 
f "C!.. or ii..iar*• 1lyster 1;.... Gfri. > epilepsy &r-e the 
..oot 1 portant of this class. Tiber, . ,.*y have other cause, 
Gon.Paralysis recognizor syphilis is can if not thn only onrh 
Kpllepsy "ollc^■■- syphilis frequent ly.Thorn Is also a ’.‘hole series 
of disat tines ascoolated in ouch, a *$ay that there sens »r to 
1 nor- than an accidental connection. Z.H.Diabote? and H&e 'gl'la 
Syphilis ’elayo the growth and retards tl n development of the 
fe+us > \it fatal the - no anattraical reasons for dyiny.These 
that (5hoo inf ant 11 ir-i. Fourni er hell eves that certain congen- 
ital nalforuat lone are in part due to syph iXls*fiol: r$8 is at t tries 
'. -yoc i at v*jth tr e disease. A certain ironic* of Idiots hare rvph. 
crifyln.1 y-•ror*-a2>.,’aXus is ofte;i seen in syphilitic fatiilies, a cer— 
t A ■: :•. nhor of ghilnyitir conerr are also probably duo to it. 
spas11 o ■ > ar o.> 1 r 1 n. >. nlo.'vs fi 1 co t o t hIs cl ass • !Jli tMXX 
thin -/a ii r-cocnpany '• ji"* ortbr'hik o" syphilis. Glannular aystnro 
th« bt! -O Is a OhV.f 'I part Of the ylanlUllT ln,r0?h-re» 1 Out t';>rohrfnXy a 
:i anlarre-ient on thro*out secondary Intubation* Appears 
oh nit the tij -n r»c the ecorv-ary. outbreak or a sreoh or* no later*. Fret far pianir on the the antoi.1v*n\d In the npitrooh- 
gently 
lp:vr o;>aon??,r-ol fcr t ny ar»n sup erftotal.Elands near the 
cure are larger than c thorn ;hy th * c v/n can pick out the 
or-1 c " t'-'C core at tl.- an, ?hn deep glando r:x*f eh own to he enlar- 
ge’ at ?x* opsy. Xn case of core or- the per.1c, the'* o lo r fine line 
of glando or ’the dorrum of that orpan, It 1 ; ,<o a -oh an parilyv.pr- 
c tlc r celling es a tru* enlarge tent of the glands;belongs *rith the 
prt 1 eaten and Is not eiimftned I syi ilXj alon • urlng thf 
secondary ct:;g* vfp occasionally find a lymphat to oerd onlarguo ,,-a 
to-.dcr ‘?o-:';C’"horp about the thigh* and in ronon oooantonally 1 on oath 
the breasts* 
a r-nrl. ) 
Complied from original not nr of Br. Post,by nathanloi Allison vrA 
Haro Ir* w, ,t o no* , n oc afa nr f In oo. QUKSTIOKS and in DISKASKS of the kaB, 
1,Describe the anatomy of the sound conducting mechanism of the 
ildd.le ear, Ann. This consists of the drum head or nembrana tympan 
and. the chain of ossicles*the malleus*incus and stapes. The drum- 
head Is an elastic vibrating membrane forming the greater part of 
the outer wall of the tympanic cavity*and placed, obliquely with 
the long axis of the external auditory neatun,so th at the infer- 
ior and anterior walls of the canal are longer than the superior 
walls,The membrane Is attached to the groove In the bony canal 
called the sulcus tygjpanicus. It is concavo-convex,and is of a 
pearly gray color In the normal state, vig.i 
It consists or three layers,external,or dermal♦ m iddl e,or fi- 
brous,and int ernal , or mucous, The malleus has a head ar<: lo* .la- ing 
with the incus,a short process,a processus gracilis,and a manu- 
brInn which is inserted between the layers of the drum membrane £- 
endin.-? at the umbo, The Incus has a body resembling the crown of a 
molar tooth and a.long process which articulates with the head of 
the stapes,and a short process attached by a fan shaped ligament 
to the lower angle of the mastoid antrum, The stapes .has a he ad, two 
crura and a foot plate,the latter Inserter? Into the foramen ovale 
’ y the annular ligament,Between these bones are joints lined vmth 
synovial membrane and surrounded by capsules. The ligaments holdl 
ing these bones in place are the anterior and suspensory ligaments 
of the malleus,the posterior and suspensory ligaments of the Incus 2, What is the function of the Tensor Tympanl muscle ? it arises f 
from the under surface of the petrous portion of the temporal*from 
the cartilaginous portion of the Eustachian Tube*and from the os- 
seous canal In which it Is contained*Its tendon enters the tympa- 
num making a sharp bend outward round the extremity of the process 
us cochleaformis aiid is inserted into the handle of malleus near 
its root and is supplied by a branch oC the otic ganglion.When it 
contracts* It pulls the tympanic membrane Inward making the iamb ran 
more tense.This increase of tension of the membrane seems to a- 
dapt it better to the more rapid vibrations of high musical notes. 
One of Its effects Is probably to bring closely together the 
malleus and incus so as to ensure the least possible loss of vi- 
bratory motion. 
45. Describe "he origin * insert ion * innerv at ion, po sit Ion* and. funct Ion 
of the stapedius muscle. The stapedius arises from the side of a 
conical cavity hollowed out of the Interior of the pyramid;Its ten 
don emerges from the orifice at the apex of the pyramid and -pas- 
sing rorward,ls Inserted into the neck of the stapes. Its tendon 
occasionally contains a slender hony spine, it Is supplied by the 
ty: -panic branch of the facial nerye.lts position Is close to the 
Inner 
wall of the tympanum near the fenestra emails,Contrac- 
tion causes a slight rotation of the stapes around a vertical axis 
the back of the foot plate going In and the front coming out,thus 
reducing the pressure on the perilymph.(rhIs Is disputed.) 4. what anatomical structures are in danger in the operation of 
opening the mastoid process,and what precautions are necessary to 
avoid them 9 The facial nerve, the external semicircular canal,the 
later-*! sinus and the dura mater, the latter In either the-poster- 
ior or "he ruddle fodsae of the skull. Operation. The bone being 
exposed,a horizontal line is drawn backward from the spina supra 
meatus and. the opening Is made with Its upper edge ;s rom. below thi 
line aadi its anterior edge 5 mm behind the teatus. This seat of 
election is narked in most bones by a flat depressionfvin. the 
/ 
rods a n as to idea. With a gouge and mallet the surface of the bone 
is removed over an area of *7 to 10 mm. in diameter always keeping 
parallel with the meatus. On penetration careful search should be 
made vnth a probe to determine the roof of the mastoid and poster- 
ior fossa of the skull. The ant run is reached at not over the dep- 
the of 1 l/p. cm. 
5« Describe the course of the Facial Nerve and its relations to 
the auditory nerve,the Internal and middle ear. At Its origin*the 
auditory nerve lies to Its outer side,separated from It by the par 
interned la. The two nerves run side by side tfer the Internal audi- 
tory i eat ns the racial being firmer, rounder and mailer, within 
the leatns the racial lies within a nroove along the upper and an- 
ter lor part of the auditory nerve; the pare Intermedia separating 
them,At the bottom of the meatus the facial nerve enters the a.rue- 
duo tus Fallopii*and follows the serpentine course or that canal 5. { continued.) and makes its exitat the stylo mastoid foranen.lt 
Is first directed outward toward the inner wall of the tympanian. 
,vhere it forms the geniculate ganglion and, is joined by several 
nerves,then bending suddenly backward it runs in the internal wall 
of the tympanum above the fenestra ovails*and at the back of that 
cavity.passes vertically behind the tympanum to the stylo mastoid 
foramen.Within the aqueductus rallopil.it gives off the tympanic 
and chorda tynpani.The tympanic branch arises from the nerve oppo- 
site the pyramid and passes through a small canal in the pyramid t 
supply the stapedius muscle. The chorda tympani is given off from 
the facial as It passes vertically downwards at the back of the 
tympanum. 1/4. in.before its exit from the stylo-mastoid foramen. It 
passes upward and forward in a distinct canaland enters the tympa- 
num through the iter chordae posterius.passes forward thro* the 
cavity of the typanum between the handle of the malleus and the 
vertical ramus of the incus leaving the cavity at the inner end of 
the elassertan fissure by the iter chordae ant erius. 
6 The ana tony and physiology of the Eustachian Tube ? Runs down- 
ward, forward, and inward.connecting the tympanum with the pharynx; 
1 1/2 to ?, in. in length*partly bone and partly cartilage,The os- 
seous portion is about l/s in. long and runs from the lower* part of 
the anterior wall of the tympanum to an oval dilated opening at 
the junction of the petrous and squamous port ions* its extremityhas 
a jagged margin for the attachment of the cartilaginous portion. 6*( con. ) The oartl 1 ay 1 notis portlon 1b formed of a tr 1 angt11ar p 1 ate 
of elastic fibro-oartil p;e curled upon Itself*leaving and interval 
below*filled wit - fibrous and inuncular tissue.The canal 1 narrow 
behind* wide and trumpet shaped in front terminating in an oval or- 
ifice at the upper part and side of the pharynx behind the inferio 
meatus of the no ne* it Is lined with mucous membrane covered ■ ith 
dilate epithelium. Physiology* It serves to equalise the pres- 
sure on the two sides of the drum membrane by allowing the access 
of air to the tympanum* thus permitting the free move mnt of the 
..ambrana tympani. The pharyngeal opening of the Eustachian Tube is 
probably normally closed but It can be easily made to open by In- 
crease or -leech?ease of air in the pharynx by which the pressure is 
relatively Increased or decreased and consequently the air either 
enters or leaves the tympanum thin equalising the pressure. The 
lower end of the tube is normally open during the act of swallow- 
ing end at thi ■ icment*the intra-and extra-tympanic pressures are 
equalized.. 
7* with what portion of the tympanum does the mastoid cavity direc 
tly communicate ? what 1b the communicating opening called ? 
The mastoid ceils communicate with the attic or epitynpanitlc 
op ace by means of an opening called the antrum* 
h. pescribe the attic. The attic or epltynpanio space is that por- 
tion of the tynannum above the level of the processus breds of th 
malleus* and 1b divided Into an Internal and an external attic by by the head and suspensory ligament of the malleus.This external 
ext ernal 
ttic is again divided by the ligament of the malleus, 
■ut + la off the portion known as Prussak's space which lies betw- 
een the short process and the the external ligament of the malleus 
and Sohrapnel.Vs membrane. 
9. 'vhat are the principal sources of the blood supply of the drum? 
They are six in number ,the three .larger- are, 1,Tympanic branch of 
Internal uaxillary,supplying drum head, 9,Vidian and Stylo Mastoid 
branch of Posterior Auricular supplying back part of drum and mas- 
told cells. Si galler hranches 1, The petrosal branch of Middle ■ an- 
in*eal entering hiatus Fallopii;P, A branch from Ascending Pharyn- 
geal and another >om vidian passing up Fustachian Tube; ?, Tympan- 
ic branch from Internal Carotid given off fron Carotid Canal and 
perforating the thin anterior wall of the tympanum. VKIMS, They 
terminate in the Ternpor o-maxi 11 ary vein and in the superior petro- 
sal sinus. 
10. Describe the appearance on inspection and the structure or* the 
per i' rpna tympani, The normal drum membrane 1b of a pearl or gray- 
ish color somewhat oval In shape and drawn inward,the greatest 
point of concavity being at the umbo,at which point the inferior 
extremity of the manubrium in attached.lt resembles a gold beater 
skin.The surface of the membrane 1b not flat but is runnel shaped* 
and moreover lines drawn from the centre to the margin would not b 
be straight but would be curved slightly the convexity outward. The membrane throughout the greater part of Its circumference,is 
Inserted in a bony ring set In the wall of the auditory canal,but 
a small arc at Its superior portion Is a'tached, to the wall of the 
canal directly. The segment of membrane corresponding to tits arc 
si known as the membrane flaccid a. seen thro* the aural specdum th 
the handle of the malleus or manubrium shows as an opaque ridge, 
running from near the upper anterior margin downward and backward 
and ending In the umbo,At the top of the manubrium Is a shining 
spot,the reflection of the short process of the malleus,From this 
point two d oil cate folds of membrane run to- the periphery, end o~ 
clng Scrapnei« membrane or the- meribram flaccid a. A bright ref lec- 
tion of triangular shape known as the pyramid of light 1b seen In 
the lower quadrant of the tympanic membrane,Its apex being at the 
tip of the manubrium and its base at the periphery of the membrane 
Posterior and parallel to the manubrium the long process of the 
incus can sometimes be seen as a shadowy reflection. 
II. Describe the inner wall of the tympanum ? It is vertical in 
direction and looks directly outward;It presents the feestrae oval 
1b and rotunda,the ridge of the aqueduotus Fallopll end and the 
Promontory,The f.ovalls 1b a kidney shaped opening leading to the 
vestibule;Its convex border 1b upwards. It :1b occupied by the sta- 
pes which 1b connected to Its margin by an annular ligament. The 
f.rotunda 1b an aperture placed at the bottom of a funnel shaped 
depression leading to the cochlea;It 1b situated rather below and 
behind the fenestra ovalis from which It Is separated by a rounded eminence called the promontory;it Is closed by the nrmbrana tyropan 
1 secondarta consisting of three layers mucous,fibrous,an 1 serous. 
The promontory is a hollow prominence formed by the first turn of 
the cochlea; it Is pi nee1 between the fo.nest me a ad is ;fu r rowed by 
three s'call grooves which lodge branches of the tympanic nl.exus. 
The ridge of the agueductus Fallopli. traverses the inner wall of 
the tympanum above the fenestra ovalis and behind that opening 
curves nearly vertically downward along the posterior wall. 
IP,. The naliens and Its attachment to the membrana tympani.Pecribe 
It consists or a head, neck and three processes,the handle or man- 
ubrium, the processus gracilis,and the processus brevis.The head is 
the large upper extremity of the bone,oval in shape,and articulate 
costeriorly with the incus* The neck in the narrow constricted par 
just beneath the head,and below it is a promineoe from which the 
various processes spring.The manubrium is a vertical process of 
bone connected by its outer margin with the mabrana tympani,being 
included in the fibrous layers of that membrane, it decreases in 
siy,e toward its extremity which is curved slightly -forward an * 
flattened, from within outward. On the inner surface,near its upper 
end is a slight projection into which the tendon of the tensor 
tympani is inserted. The processus gracilis is a long and very 
delicate process passing from the eminence below the neck forward 
and, outward to the dlassertan fissure to which it is connected by 
bone and llga entous fibres. The processus brevis is a slight con* 
leal projection which springs from the root of the manubrium and lies in contact with the membrane tympanl. 
. :lve the relationship between the tympanum and the jugular 
fos -a. The floor of the tympanum corresponds to the jugular fossa, 
which lies directly below It. 
14. what are attached to the walls ox the bustaohtan Tube 
an' *.here 9 X. The tensor tyarnan 1.havIng one of Its three origins 
from the cartilaginous portion at the inner end, >>, The Tensor 
Ual .tl*arising Cron the under surface of the sphenoid,Prom the ex- 
tre ii ty of the cartilaginous hook, and the membranous wall of the c 
cartllaglnous portion of the tube.lt passes around the hamulus 
pterygoideus and -spreads cut into a fibrous proIon/at ton on the 
hard pal at ft. 3. The Levator Palatl arisen from the surface of the 
petrous hone next to the carotid canzljln Its course parallel to 
the Kustachlan Tube It In joined by some connective tissue fibres 
to the membraneous portion which forms the base of the tube,and 
also to the cartilaginous plate; It Is Inserted below the pharyn- 
geal opening of the tube Into the soft palate. Actions. The tensor 
separates the outer or membranous wall together with the cartilag- 
inous hook*from the inner wall. The levator Increases the trans- 
verse diameter of the cartilaginous canal by pulling the lower tv 
wall of the tube tip ward and backward. 1ft.Describe the Processus Coohleaformis. It Is the thin horizontal 
Plate of bone which separates the orifice of the canal for the 
tensor tympani from the orifice of the Eustachian tube. 
in. Describe the anterior wall of the tympanum. The anterior wall 
corresponds to the carotid canal from which It In separated by a 
thin plate of bene.it presents the canal for the tensor tynpani 
muscle.the origin of the Eustachian tube and the Processus coch~ 
leaformls.( described In d 1ft.) The canal for the tensor tympani Is 
the s iperlor and smaller of the two openings ; it Is rounded and 
lies beneath the upper surface of the petrous bone close to the 
hiatus orifice of the Knstach.tube is at the lower 
part of the anterior wall of the tympanum. 
17.Diagnostic signs,subJactive and objective, of acute inflammation 
of the :-ilddle ear,? { simple or catarrhal inflammation. ) 
Subjective. Feeling of fullness about the ear .pain, either sharp or 
stinglng,and quite severe at night.Infante are liable to scream 
and put the hand to the side of the head, headache at times*.Pain 
may radiate and shoots toward the teeth. Patient may complain of 
pain on opening mouth and just below lobule.Duration of pain varie 
with severity of disease, tinnitus of a hissing,singing or pulsate 
inn character, Deafness.Autophony. Hearing of emsame note double. 
Object lye. Fever, e»p ec 1 al ly In chi 1 dr en. cornet imes d el tr turn and 
convulsions. In lees severe cases,the draw-head appears congested, 
especially about Sohrapnell*s membrane and the manubrium. The hony canal may or may not he Involved, in severe cases the 
whole membrane is of a reddish angry looking color and frequently 
has a gray appearanoe,chie to Infiltration of the dermal layer; the 
short process,the only landmark,appears as a red or yellowish whit 
point. The posterior quadrant of the membrane may present a bul- 
ging appearance and in some oases there may be vesicles or intra- 
lameilar abscesses,Sohrapne.il• s membrane or the posterior Inferior 
quadrant of the drum head may bulge, hte to the presence of fluid* 
When resolution begins,the membrane becomes grayish and the conges 
tIon disappears,regaining longest along the handle of the hammer, 
and In Schrapnell* s membrane, t 
lb. Causes anl symtoms of serous effusions In the middle ear ? 
Sero-fiticons catarrh or hydrops ex vacuo 1b caused by closure o• ’ 
the Kustachlan tube at Its faucial end due usually to connection 
and awelling,following generally Inflammation of the naso-pharynx. 
The drum head nay he slightly congested and retracted;when the 
mambrane ls translucent the line of the fluid can he seen*the lev- 
el of the fluid changing on change of position or the. head,If the 
fluid he serum; and air bubbles nay he -.con on the '>in he* a ?, ’! er 
Infla*Ion#Symptoms are very slight pain,sense of fullness or pres— 
cure in the ear,tInnltus,Interwlt tent,autophony,crackling sounds 
In the ear,more or deafness, increased bone conduction on the 
affected side,uniess the labyrinth Is Involved, 19. Treatment of furuncular and of diffused. Inf lariat ion of the 
external auditory canal ? furuncular* In early stage,where pain is 
u ev er e-a r t if 1. dal leech,or Letter# a coll .When dnei seated, and very 
Painful——free Incision,as wen as In oases where the furuncles 
are ruptured spontaneously thro * a small opening—enlarge it. Then 
clean out meatus with corroslvefand tell patient to instil 
I 
into ear a warn saturated*4‘*> boric acid. solution,frequently during 
the day,Patient should paint canal with carbolic glycerine* 1 
menthol in often iced,Look out for general health,etc. Treat the 
Itching afterward wit’- boric acid ointment applied to canal, 
not 
n if filled, ••/here pain is severe, a boric acid i« instilled into 
ear freq rently.Por severe Inflammation,artificial leech applied 
close to the trains and drops of a 4 r> sol, of cocaine;where the 
canal in narrowed from swelling,free incisions thro* shin and per- 
iod eon. After acute symptoms,clean up ear,Insufflate boric acid 
powder,or boric and zn.o.Where disease gets chronic and granula- 
tions appear* scrape with a sharp spoon to renove or cauterize with 
Ag.uo or chromic Acid fused on a probe. 
90. nescr Ibe the coniplioatlons and consequences of supprative in- 
flarmmtion of the middle ear# Oounlicationr.. periosteal layer in- 
volved*an> the mastoid cells inpl teat of, facial ery sip el as, non in- 
git is,pyeraia, septicemia* trirorabosls of the cerebral sinuses,hem- 
orrhage Cron the Internal jugular *eln%or carotid artery due to 
caries of tniporal bone*cerebral and epidural abscess,abscess of parotid gland, sequelae. Chronic otitis media,adhesions between 
the ossicula and tympanic wall,opacities,calcareous deposits,atro- 
phic changes,thickening of the dr;in head,cables of ossicles,per- 
foration of dram head,and lastly permanent and perhaps total deaf- 
ness from Involvement of the labyrinth. 
81.If a vibrating tuning fork is placed, upon the forehead or ver- 
tex in the median line and is heard rettr'~* in the worse hearing; 
ear,what is to be fir awn for an inference as to the cause of d eaf - 
ness and why ? weber*s rest. The Inference is that the bone con- 
duction being better on the affected side,that there is a pathol- 
ogical process In the middle ear on that side which prevents the 
vfar ations from esc-pln : and consequently make the Impression upon 
the hearing apparatus of greater intensity;we also nay presume 
that there Is no affect ion of the auditory nerve. 
22. In case of facial paralysis consequent upon middle ear disease 
by what symptoms and where would you locate the lesion In the 
nerve V The location of the lesion in the nerve would he Indicated 
in cane the chorda tympanl in not affected,as being below the ex- 
it of the nerve at the st.ylo-raae toid foramen;or in case the chor- 
da alone is involved, we can tell the location and extent of injury 
to the racial by the condition which in limited to the distribu- 
tion of the cnorda,vix.the submaxillary glands and anterior pj'6 of 
the tongue.(the sense or taste. );lastly if the function of the 
chorda is lost and the face in addition,is paralysed,then we can conclude that the paralysis is due to middle ear disease involving 
the nerve above or at the point of distribution of the chorda tyr;- 
panl ? 
85. PO’ sible complications of suppuration In the mastoid ? in case 
trip disease is primary, we nay have all the complications and se- 
quelae of a later developing otitis media; If secondary to otitis 
media as It usually is, we may expect any of the complications 
following upon a collect ion of pus as set forth in 4 20. 
24-, Describe the treatment of simple,uncomplicated*acute otitis 
media pun-lent a ? Keep patient in the house, at least. If severe in 
bed with a 11 fit diet.Light catharsis by calomel l/lO gr.ev.hr, 
for « doses.Where there i« great hyperaemla,artificial leech. 
ith children hot v/ater instilled Into the ear often affords relie 
ae '-hu as touching the ear every hour with a warm boric acid ;ol- 
tinn. Dry heat by means oC a hot water bag; or a salt bag is often 
success *ui, /i i > sol.of cocaine dropped into the ear often gives 
great relief.Watch the pharynx and naso-pharynx.using sprays of 
boric acid.carbolic acid*or corrosive l ; 5000# Karly incision in 
the arum head necessary—use a bistoury,not a needle, Phe line of 
Inc is5 on extending from just behind the stapes to the lower border 
of the drum head close to the bony auditory canal—then promote 
discharge by frequent douching with boric acid—1 firm.to B oss.of 
water or 1 + 5000 corrosive solution.After douching Introduce a 
wick of boric acid or iodoform gauze down to the roembrana tympanl. If the membrane has ruptured spontaneously*enlarge the opening. If 
the discharge 1b thick and tenaoeous,force it from the ear by 
Polliter's method. After the acute stage instil hot boracio sol. 
several times a day* after removing the discharge by syringing or 
by a cotton applicator,or the dry method cleansing the auditory 
canal*insufflate boraoic powder. Injections of war: water thro* 
the catheter is recommended, by the man Pclltsser* in eases in which 
the pain :1s persistent and does not yield to usual treatment, 
05. In what general diseases may we expect ear complications and 
shat are those comp11catIons likely to be ? Kxanthemta, d iphtherla 
t forrouio ;is and syphilis,pneinaoiiia, typhoid .meningitis, influenza, 
•;al a* la, nep hr it is, diabet es ,n»uraps, t abes * leukaemia. 
Sar complications are otitis media scuta purulent a acuta et chron- 
ica, cat arrh alls chronica st scut a, mast o Id i 11 , d is ease of the lab— 
yrlnth,henlers disease,especially in syphilis,and disease of the 
organ of Oorti,ln tabes especially. 
pe/vhat are the common lesions of the ear acco>tpanyln„t sc net 
fever in childhood ? Suppuration in the riddle ear extending to th 
Mastoid and labyrinth and rapidly producing deafness,as well as 
the connlicatiom '.ad nemil&e which attend these coni 11v-no. 27, Give the symptoms and treatment of serous accumulation In the 
Id He ear( tor symptoms nee < 18, ) Treatment, The fluid can sometl 
■ne.n fe made to din appear by r>o litters method or by oath et er In at Ion 
It Is better however,to puncture the drum head In the poetero—In- 
ferlor ; and force the fluid out by Inflation or by Siegels 
otoscope,pock to the general health.Catheterization In better than 
the PolItnnr methodfbut In nervous chlldren,PolitK°r in bent. In- 
flate the ear once a day for several days and then every other day 
and finally p.r.n. If the mucus in the ear Is touch and stringy, 
make free Incision In the drum head and Inject sod,bicarb, coin. 
88,What is Meniere*s disease *> symptoms and treatment 7 This Is 
a d in ease of the s 1 c i.r ci /1 ar canals, even ext endin >\ into the veo— 
tibul e,These Is sudden effusion of blood into the canals canning 
u pathesn, g 1 dd 1 nesn, t lm11111a, a »t aggering gait, naiibea and vo* 111 ing• 
There may be premonitory symptoms or the patient may fall sudden- 
ly to thp ground from loss of consciousness followed by pallor of 
the perspiration,extreme deafness.Disease attache the 
healthy as well as the weak,neafness is very narked,bone conductio 
is much Impaired or lost A positive diagnosis! of this disease 
can only be made if the surgeon knows that the patient before the 
attack had normal hearing and that an examination of the ear show 
kustachiantu.be and drum head to be normal a short tine after attac 
Treatment, Use of cold compresses and belter's coil.Calomel In sna 
small doses,Sinapisms to neck and calves,Host in bed,Light diet. Some men recommend iodide of Potash; others large doses of quinine, 
the best results seen to he attained from the use of a 2 %■ sol, of 
P11 o orpine, injected thro* the catheter into the tympanum or iron 
the sub on, injection of the same solution. Continue treatment for 
at least 4 weeks especial attention being paid to the general oond 
f9. For oh at diseases of the ear is the muriate of Pilocarpine use 
erd how given fin - enter1 s disease,in syphilis of the labyrinth,ad 
ministered subcu.in a o > sol.( see above quest.) gradually inoreas 
in.-: the lose fro™ 4 ot e drops until the patient experiences the 
Physiological actions of the drug. Used also in chronic catarrhal 
otitis media. 
oO* Difxerentlal diagnosis between mastoidi/His and superficial 
mastoid perlostit is f Mastoiditis Is genially the result or ctlt i 
media,but !i'ty be primary, fiU*3 last, per ion* It Is 1b generally in he~ 
pendent o? the middle ear, and if the cause is known it is sx+ ernal 
In ;,h« Corner the pain 1b deeper seated than in the latter, The 
hParing in the periostitis is unimpaired and ther is no change in 
thp dr»i<:i r «ad a3 1b r>pt to bn the case w 11h a deop rnar-10idi.ti3, 
op p;iMi a? inci -;ion is the only thing that will settle the diaf— 
no. ip it in always well in t/ios° oases to open the cell -#ln or- 
par to see if pub has bepp formed. Hi. Describe the (n-iu.no of simple acute Inflamnation of tho middle 
ear 1,i adult. whaf In ff -ppropr late treat*'.not ? Oanse-—-Mont 
frequently follows a cold In ’.he head, or It may bo due to lone 
ox...‘••■ri'.r«r» ?.o net and cold or sea bathlnn\or( especially In the child 
the e; ’-'.t-'-o.- fa, it if ay follow almost any acuta 1 nffo ftous di .sense 
an t• f••erid.o b 18,i>uer;>>*.ital sepal q, renlnyi t j a and, qyoh Ills. Top - oe 
of t •!e nasal douche i s another cause and,”sniff 1 ny up” salt 
for the -pi in: of annul cat'arrh. Treat:lent• *rf, If iclal 1 nerfv ap— 
nil n*< early In front of the t r ati i a, bor 1 o ho If sol/soured Into + he 
pirxr —l-y.X to the pt. ev,n-f hr a, Dry heat by hot salt or water 
bay, Where trn're is nr. co-ph • iry nyl ti q ,us e appropriate 0 nr ay a. After 
the Inf lor ‘:i-f ory ntaee.une cc.thetor or Pol User -’ethod to destroy 
adhesions sod to restore the penbrnne to its now u 1 position* If 
the dlspy.ee follow a cold, calomel to slight catharsis--!enp tie 
patient in tb° bonne on a llybt diet.Tnclllatlone of a a •/* sol,of 
cocaine ins Indicated In 00 ie cases.Avoid opium and quinine ar: re- 
:ndie«# kpep up the general health.When the neibrane bulges, 
yestl/iy the presence of ’lull,puncture It. 1,1 vi.ny 1 n overheate<i 
roo 0 In a frequent source for thin condition• 
, tbe oo'T'On forrc of cyphlllf-lc disease of the ear v 
Oondyicmatr*ulcerations or pvi ;tr.t a of the external auditory canal, 
r'.,; 111 t, 1O ■]< ■fl’Ul H . vinV rq£f> * Vt el?’ a* v0PriT0.?1CP 0/1 the dT*DO—h r <» 
sp v.y l-:'ri to stricture of ff o nal.On the auricle, there bo 
cho-icms nr yu^r-K:l,ta,papuloT/pustular and oquainouc eruptions nay bn h ay be seen on the auricle;chronic catarrhal otitis media nay be 
; 
caused by it,as well v acute purulent*and*Its compileat ions. Syph 
Ills of the labyrinth may be secondary or tertiary;!! is usually 
tertiary and may accompany the middle ear catarrh or purulent in- 
flammation. There is plastic exudation into the labyrinth as a re- 
sult of middle ear affect ion. The foot plate of the stapes is fixe 
there is deafness which generally comes on suddenly—and consid- 
erable tinnituo-but little pain. Hereditary syphilis may manifest 
itself bv middle ear disease and disease of the labyrinth. 1 
33, Describe a case of othaematoma and outline treatment • It In \ 
• i. 
a bluish red swelling duo to sudden effusion of blood hot won the 
j V \ 
cartilage and the p erlchondrlum caused usually by « blow upon the 
</{ \ 
r c: and 1b often neon In boxers and among the Insane—In the lat- 
> i ■ 
ter It In probably not due to 111 treatment but to changes In the 
/. jv \ 
auricle. Spontaneous othaematoma la rarely o f large size but v'hen 
■\ \ 
A\ \ 
due to traunatisr.it nay Involve the entire auricle and occlude 
the external neatus.lt hnuld be differentiated from perichqndrltIs 
auriculae which, does not cone on suddenly. Treat ent Then the 
jy 
swelling in slight apply cooling lotions—if large,Incise the tu- 
lor and turn out the Mood clots treating the wound anti septic ally 
i 
34, Describe a case of a out e Infl an-nation wi.Vn.ln the mastoid pro- 
' /.. 'A 
cpgs and outline the twat -ent , For causes see * 80. -Pain on the 
; 
mastoid the most prominent symptom.mreat tenderness 
on pressure,usually limited to the ration over the motftold ah trim but pain nay be absent in some cases.Fever is by no means a con- 
st-ant symptom but is more common in children than in adults.Leuco- 
oytosis nay or nay not exist.The pus may extenf (a) Outward thro* 
external cortex,wlth resulting oedema subpewlosteal abscess on 
the outer surface of the bone, (b) Forward to the meatus with cede 
ma and subperiosteal abscess in the meatus. ( c) TTpward thro* the 
roof of the mastoid v/lth extra dural abscess as a result, in the 
cerebrum. (d) Inward thro the inner cortex of the mastoid with 
Phlebitis of thn lateral sinus and extra dural abscess and Its 
results In the cere' ellun. ( e) Downward thro* the floor of the nan 
t )lu with cellulitis beneath the ddep cervical fascia. Treat) . 
The sensitiveness of the bone that In often present In the first 
3 or a days does not necessarily require treatment but i ' it con- 
tinues the Letter*a ice coil or ice %ag 3 or 4 days,taking care to 
/; 
Keep the bone thoroughly chilled.Is useful. Spragues In the bent 
form of Ice bag. For severe pain three or four 3.eoch.es over* the 
mastoid sometlines are efficacious. If the sensitiveness of the 
bone continues for •? or h days there in true mastoiditis;hut if no 
urgent symptoms show the* is elves, ice and tympanic treatment may be 
continued,gradualXy producing subsidence of the sensitiveness of t 
the bone, should urgent synptoras appear,035en the bone as descri- 
bed in r* d. rTrgent symptoms are appearances pointing to extension 
of 'he pus to the adjacent organs,vIb, oedema or spelling over 
the r.sto id,great oedema of the w m eatus,swelling below the tip 
of the mastoid,severe pain,continuous over the mastoid, sep tic syntons and any disturbance of the sensorlun pointing to either 
the cerebrum or cerebellum. 
rsh. what are the pathologic at changes occurring In the middle Par 
as a result of otitis vied la ? The oondlt ion usually Involves the 
'■•’to le moo ms m-f branIncluding the Eustachian tube* the drum nenbr 
ane, and mat old cells. It Is characterised by extra n hyp ere la, 
followed by serous condition of the tissues which separates the 
f.lbrillae of the connective tissue, then by a free secretion of 
-.pus nixed with mcue,and finally by an enormous swelling of the 
■■tissues Iron round oen Inflltratlon. The fate of this Inflltratlo 
, -determines the result of the disease,the cells way be absorbed and 
the vie: brane return to normal;there iay be liquefaction of the 
/ 
cells with ulceration of tissue; the cells may be organised with 
a resulting hyperplasia of tissue. The Inflammation may extend to 
the hone and carles and necrosis nay result or -where there Is or- 
ganlzatlon,-ee nay have a hyperostosis.The inflammation nay also 
extend to the labyrinth.generally by the blood vessels,with all 
the characterl tics of the original inflammation. Pupture of the 
Irmn me -.brane, i mi ally from pressure,but occasionally from a rwpe 
is the rule. 3f>#T)escrlT'>& the application of the Eustachian datheter, noth hard, 
rubber and catheters are uoedfthe latter’ being the better. 
The oafnc'- or should ha ve a double ourva as recommended by uiabejlt 
should have a probe point to avoid discomfort and laceration of ■ 
the part a. "pray the nasal passage ’1th a 4- */. .sol, of oon-lnp, lot 
• at hod, Patient oppslte surgeon with the head against bach of ohal 
p ; surgeon places dingers of l.hand on Corehead gently pushing up 
tip o n none v/lth thnrnh of sane hand, .War-a catheters and on sot with, 
oil;Introduce point carefully,holding catheter In rt,hand,Push • 
point along lower wall of nasal passage to post. pharyngeal wall; 
then turn It obliquely outward about 4b ” but not horizontal,into 
Posennfdller * s fossa;then withdraw ’die point,at sane tine raising 
the probe point,and the latter will be felt to glide over the pos- 
terior lip of the Eustachian tube;then turn it outwar and up,so 
that the? metal ring fastened to* its posterior extremity Is 
pointing to the outer can thus of the eye of the same side, 
9.6 method. The catheter is Introduced as In the 1st net hod,but in- 
stead of turning the point outward it should be turned Inward go 
that t? e extremity points toward the other Eustachian orifice, xt 
Is brought to a horizontal position as Is determined by the metal- 
lic ring on the other end. of the catheter;It Is then withdrawn 
until the curved portion reaches the posterior border fdf the 
n s•>.I septum, The point of the catheter now describes a complete 
semicircle and It thus enters the pharyngeal orifice and enters 
the tube as by the first methekd* 3v. -/hat would bn the effect upon the hearing power of the paraly- 
sis of the stapedius muscle and why 9 The stapedius being supposed 
ly antagonistic In Its action to the tensor tympanl,a paralysis of 
this ■•to, sc in would allow the tensor to overact thus increasing the 
tension of the drum head and allowing the ear to hear high tones 
or those with a large no. of vibrations per second. The muscle1 n 
being paralysed would also probably result in the tension on the 
perilymph not being reduced by the foot of the stapes being drawn 
away the fenestra ovralefas is the case normally when the mus- 
cle contracts,)which would of course contribute to the same genera 
result,i,e.the perception of high tones only,while those of low 
pitch would be heard with difficulty or not at all. 
33. Describe the usual tents for hearing In the adult. Aerial non- 
diction.The watch and Polit2er* ; acoumeter are used principally. 
It Is best to have two watches for this purpose, First of all test 
the distance for the normal ear,-this nmaber will repres*>nt the e- 
nonl; ator.The patient •» normal ear should bn stopped with a. racistn 
ned finger; then thn watch should be held at thn normal d 1st anon & 
brought gro.diw.illy In, thn patient * n eyes being closed;It Is v-'ell to 
let thn patient hear thn watch tick before thn test is ooia;menced; 
this mini) nr will bn thn '.uMerator.Polltzer * s acoumet nr pro due ns a 
sound which Is always thn sawn and therefore produces a sound 
which is better than thn watch tick,which varies with different 
watch ns. Ob J notion Is that it is heard at a great d 1st anon, ( 4.5 ft.) 
bearing distance for acoumet er should be measured by a tape. The patient's hearing power for speech should be tested as none- 
times a person hears a watch lastly and falls to hoar speech and 
vice versa.Whispered apeech Is hoard by an average normal oar In 
:.n absolutely still room at a distance of 50 Coot. Timing ■ « 
f ■ It on whist la, a Xpm v. 
s, ;0 PA 51?. v, s, ; 0 4 th 20*8 v. s. Also several shrill whistles 
and .steal Instruments Cor testing those extremely deaf. Uy means 
of the tuning fork,a diagnosis nan be made between the disease of 
the -riddle and internal ears.where only one tuning fork is to be 
used the Hlake 51? v, s. is to be preferred1. The dalton whistle and 
the Konig• s rods ate used to determine the power of hearing of 
very nigh notes-the whistle pro duel rig vibrations of from 5000 to 
50,000 an1 the Konig*s rods from ?0,000 to 80,000 v,s. none con- 
duction Is inch diminished in old age, hlnnem? ?es+ Place the 
tuning fork against the side of the skull or mastoid process — 
when the sound is no looser perceived by bone conduct bon, the Cork 
should be held close to the auricle without again striking It;if 
heard again, this is the positive Rinne and is normal, If not,/heard 
it Is a negative Rinne, This is valuable in deafness due to ini I- 
die ear olfactions but the deafness must be considerable.weber *.s 
T-est, a vibrating tuning Cork,usually 51? v,s, is held in the med- 
ian line of the skull;It Is heard?, better In the affected ear If 
there Is middle ear disease. ’ghat aTR the precautions to b-e observed In removlug Inanimate 
foreign boding r>o 1 the ear ? The majority can bn renoved by sin- 
Pin syringing 1C they have not been Impacted by injudicious manip- 
ulation.! f thny ,*re liable to gv7n.ll Cron thn moisture,the surgeon 
should bn on ady to practise instrumental removal immediately aft nr 
syrIngin .An Inanimate body lying loosely in thn meatus is ham- 
l6ss.'**hen firmly impacted,the pressure nywptomsjthe Impac- 
tion may bn at thn junction of thn cartlagihour and osseous port- 
ions, thn narrowest spot,in thn angle between thnlovnr wall and thn 
>rum membrane,in thn drum membrane Itself,or wltliln thn tympanum. 
Impacted hading require instruments for their removal;a small blun 
hoc]- Cor bna-n and similar objects; a sharp hoc): Cor peas beans or 
soft substanceg; thn wire loop of a snare and thn angular toothed 
forceps Cor bits of v;ood,*c. In difficult casn the armamentar iun 
is .ionn too large;no general ruin can bn Ivrn, ive an anesthet- 
io if neobssary.lt is cometimes imaossible to remove it from thn 
meatus dun to swelling of the object or to impact ion , and in such 
cases displace the auricle and cart 11 ap:inoi 10 meatus forward and 
extract thn body a foreign body man ires removal as It will even- 
tually cause trouble;but tunedi,ate removal 1b neons:’! ry only with 
live insects; syringing alone will succeed in most cases,pen11 yi 1 oh. 
it fir bier In anyway, with live insects,hill by drowning by let tin 
the patient Incline the head and filling It with warn water;tho 
insect win often float out,if not remove by syringe or forceps. 40. Prognosis,treatment ani pathology of chronic supp'.rratIon of 
the tympanum. Suppuration due to the ordinary pyogenic microbes; 
the chronic char act er in fine to the infected foci of influimation 
vfnich keeps up their vegetative action and continually reinfect 
one another.These foci, nay he of inspissated pr.s or cho 1 estatoma- 
touc :-asneg# if in the hone,they 3 ay he Unit ed to a small foot on 
the ochicles or raay involve a large part of the t rmporal hone.The 
moons membrane l - usually changed into a thick oedema tons cushion 
Us epithel iur being often d est roved and. the entire membrane chan- 
ged 1 ntc r. granulating connective tissue;it often ulcerates expos- 
1 nr 4 he bone;and the hone Itself nay he o&rAift!CMic7he perforation of 
thp drum-membrane :ay he of any si%e up to the loos of the entire 
MO-.-.i r.'riiP :>o;'t ulceration of the edges of the original perforation. 
The last portions to he destroyed are those best nourished along 
the posterior edge of the manubrium and at the periphery, Due to 
the contraction of the tensor tympani%the perforated membrane nay 
xdhere even to the labyrinthine v?all. Carious ossicles are generall 
the result of this,and may he so extensively diseased as to he 
practically sequestra. Treatment.A cure of caries can rnly occur 
by getting rid of the diseased bone;where caries of the epltyircanu 
as well as of the ossicles exists,do an evisceratio n of the en- 
tire tympanum ;r--'Move the whole drum head , the malleus and the Incus 
Operation. (1) separation of the drum membrane as near the tym- 
panic ring as possible. {9.) Tenotomy of the tensor tyrnpani by the 
Schwarts tentotorne. (g) disarticulation of the inoudo-stapedial joint by means of a sharp pointed Knife,net at nearly a right an- 
gle xa*\H)CXV*KXXXXXXX* with the shaft. (■*) Removal of the ml- 
lens Pith a strong forceps,seizing It at or near the short process 
(a) Removal of the Incus by passing Ludwig * s Incus book upward In* 
to the epitynpamr* and sweeping’ it backward thus bringing the in- 
cus into th i.ieatuo and then withdrawing It with forceps, clean out 
all gr anul at Ions, a-c. miring the operation Took out for the facial 
nerve,a general anaesthetic Is necessary.. Prognosis. Deafness 
oft on e; .Ins stationary after the cess at Ion of the discharge; In 
other cases,the degree of deafness progresses steadily,as long as 
there is a discharge from the ear,the patient should be impressed 
with the -importance of having the ear properly cared for,as ne- 
glect wixi bring on any one of the serious sequelae,a patient In 
,pom health will stand a better chance than one suffering from a 
chip on 1c wasting disease, unfavorable syraptoms are di.schgfrge of 
long standing,especially If it has a fetid odor,centisued painfnar 
rowing of the external meatus*a brownish discharge^and the pres- 
ence of cheesy masses in the discharge,grannlatIons,or polypi. 
41. Und er wnat cond Itions is the Kuataohlan catheter preferable to 
the uollt air douche V (X) It is desired to inflate but 
earf an ] where v;o wish to gauge the ament of the Inflation, 
(P) In cases “in which the drum head Is thin,as the method 
.-lay uupture( 3) as a general rule*In adults,the Eustachian catheter 
Is the better Instrument to use,in children and nervous persons, 
the Politeer bag. 4P. the symptoms,fmbjeot ive and objective,which suggest 
the advisability of paracentesis oC the drum head,and t; ■ ■ precau- 
tions to bo taken in the opera* ion,It is a safe prooeedure,and Is 
good surgery to perform paracentesis of the drum head in any case 
v.'h'ere v!A have the symptoms, subi ective and obi active,of an acute 
process in the middle ear,the earXi er,the better,a£ soon as there 
is bulging of the drum membrane, operation. ?he object is to get 
- gaping opening in the lower posterior quadrant of the drum ne; > 
brane;to accomplish this,the incision should be Hade so as to cut 
both the circular and ra Hal fibres of the me- ibrane.uefore the op- 
eration, the /qea%us should be sterilised by wiping gently with a 
corrosive sublimate solution, 1 : 5000* tTndsar illumination with 
the head.H'itrror the lent to should' -be inserted a little above ftXK *• 
posterior to the lower end of the rnambrlun,and a straight Inoi- 
nlon carried downward and slightly backward nearly to the periph- 
ery. urinary etherization insures freedom from pain and. ivnobil- 
iaation of the head.xn some cases,the most bulging point in at 
another place than the posterior inferior quadrant,for Instance at 
the upper post erior or lower anterior quadrants, or the membrane 
"laccida. In such cases it may be necessity to Incise the most pro 
trading portion. Remember the anatomical relations in making your 
incision and be sure not to thrust the knife in too deeply , 4-?, -niat affections of the Internal earziaay occur as the result 
o* chronic Interstitial nephritis *> The labyrinth becomes Involved 
especially the organ of Oorti and semicircular canals,so that com- 
plete results,analogous to the changer. In the eye; or an 
extension of middle ear %% disease to the labyrinth may occur as 
a result of a lowering of the general health In this disease and a 
de-teio']) 1 ng n 1 dd 1 e ear disease. 
44. ’t 1-*5 the fundton of the terminal apparatus of the 
co- ilc i.rcu 1 ar canals v The canals occupying the planes of space, 
an a priori conclusion would he that they govern our sense of po-~ 
1 tlo i In space,or, our tense of equilibrium*and experiments on the 
Tower animals justify this concluslon,for a pigeon,whose sen-loir- 
coiar canals have been destroyed, flops about In Much the rane way 
an does a cnlcicen Phone head has been cut off, The canals are no 
err an nod, that any possible movement of the head produces an Increa 
•-e of endolyr-iph pressure upon the hair cells In one ampulla and ce 
creaepn it In the parallel can cl on the other s id e, and every 
chan-e yr position will be accompanied by an- Irritation of def- 
inite ampullae,wlf i definite degrees of excitement, dames found 
that denf nutes In v/hom the internal ear was at fault .were not 
nade di--r:y by rapid rotation in an ordinary swing.On the other 
hand,diseases which may be supposed to alter Intra-labyrlnthlne 
pressure have vertigo and Incoordination as synptoms. 4-B.gIvp the Indications and describe tha operation of ty:npano-mas- 
ton’ yhlc \r> called the sclrrar tze-y,aufal or tha 
Soh*?artr,e-Staoi:e%or the "Radical* operation,and in adapted to cane 
in i i l(M ostitis,or cholentlatoviatous collections Involvr more 
than the mastoid, X !; ''onai, ate in trenufarring ''‘ e Viaf>ial-’f rntrum, 
a*‘Ituc,attic, and ?• entiu;,In*o one lamf‘ continuous cavity with per- 
'ectly a. -ooth and healthy walls,and havin, it heel,not by granula- 
tions miing up the cavity,but by epidermis rilling up the v, 0X0 
■}j?Ar‘r m Th e steps of tho operation are an follows- (1) Forviat Ion of 
a. ll j a,cne •.■ " pe lei ourn and onn of chin;the Incision begins at 
about l/S In, above the anterior superior Ins nr ion of the auricle, 
an i ; n. Ion- ea at the a distance fro 1 the auricle down to the 
very tip o' the ■ onto Id, backward half an Inch, thence up along the 
post ~rlor border f the aastold to Its extra me. upper part, (P.) Ex- 
tirpation of the posterior and superior lining of the oar,ecus se- 
at an, (d) Opening of the antrum and removal of the posterior wall 
of thCT a.eatuc with removal of the drum membrane as well an the nal 
Lea- and Incur If present; (1) Removal of the epltynpanum. x(u|x 
{ 5) bx enter at Ion of the entire mast o If, antrum, and n)ttyaipanan.( n ) 
Splitting of the membranous meattle from the concha throughout if : 
:ntIre length don ids ■.•••'cterlor wall,(7) Stitching and banfa*> 
1 :, (n) a -’ter treat lent,conn 1 sting of keeping the cavity packed 
in every crevice with gauze,till It becomes covered with fine 
uremiaM.ons and again till there are covered with epidemic. THEORY AHD PRACTICE 
DH« RICHARD C, CABOT 
compiled "by 
Nathaniel Allison 
3d# year 
HARVARD MEDICAL SCHOOL 
1399 - 1900 CLINICAL DIAGNOSIS 
I. CAUSE a, Race,age,sex,residence,season,work* 
h. Heredity h, 
c, 
d, Past history 
e, onset 
II.—COURSE I Acute or chronic 
2 Sudden or insideous 
3 Progressive or intermittant 
III. .SYMPTOMS.. I Nervous 
2 Respiratory 
3 Digestive 
4 Circulatory 
5 Urinary 
6 Genitals 
TMuscular 
8 Special senses 
IV. PHYSICAL HXAMINATXQN. -TOP to TOE- 
V* COMPLICATIONS. 
VI. PROGNOSIS As to LIFE, RECOVERY, DURATION, RELAPSE, PALLIATION 
VII. treatment 
1 ANAEMIA 
The symptoms common to all forms ofAnaemla in general 
I. ON NERVOUS SYSTEM# 
a, Brain- Painting,loss of memoryRepression,del 
erium,headache, at "base of "brain and 
over eyes 
b, Special senses Bjiazing in ears,flashes hefor 
c, e eyes 
Reflexes Increased knee jerk,cramps,vertigo, 
intercostal neuralgia. 
II# ON. _VASO-MOTOR SYSTEM Hands and feet cold,regardless of surround 
ing temperature,color white# 
III, .ail ,.gmaUMTQEY gysm A systolic murmur heard best in 2d right 
interspace "The region of romance" 
palpitation and shortness of breath# 
IV. ON DIG- 1ST I OX Boss of appetite, nausia and vomiting, pain after 
eating,wind on stomach,helching,acidity of stoma 
ch-“Heart bum"- 
Constipation is almost a constant symptom# 
V. IN MEN sexual weakness 
IN WOMEN amenorrhoea dismenorrhoea and rarely 
menorrhagia# 
VI. ON kidney Pale urine of low specific gravity. 
A fR I-°IRRITABLE WEAKNESS11 COVERS THE SYMPTOM COMPLEX# 
THE FORMS OP ANAEMIA know 
Primary anaemia --Where we do, the cause 
SECONDARY anaenia—Where we do know the cause. 
2 S.ICO'IAAIY A1TAH[,II,A 
p A7TOT?« 
- ij. 
I. Hemorrhage 
a,Hemorrhoids acommon caaso — )r.Maurice Richard 
son makes a diagnosis of piles hy 
patients appe aranc0 
Disease,Fibroid tumor the commonest 
Post parturn hemorrhage 
Hyperclastic endometritis 
e, ULCER G-a 31 r i c or duo donal 
1, PUL’ ICTT ARY D i 3 ease 
II. 
DRAINS Oil THD BLOOD 
a, Ohronic suppurati on 
d,Pro1ong e d 1a ctati on. 
c,Cjrrhosis of the liver, 
IT,3, Hephritis is not a drain as the amount of urine 
is small "There the albumen is large 
[II* TOXIC AMA2iS.IIA 
t i 
a, Infectious diseases Siibarcnlosis,tvphod 
Bciite artlhular i vh 
e umat 1 sn , sy pli ills. 
Ta,Drugs and poisons, nephritis,lead,arsenic 
ne r oury, pi 10 spe ron; >, 1 CO 
pimnacotlne an I coal 
tar anti pyx*e t i os 
IV. INANITION. 
a, \ 7h e r 3 not ©no ugh i s t 1 ik 0 n i n h 
Stenosis of tract,gasiric catarr 
To rnch or too little gastric so 
eretion* 
*b, Whore enough Is taken in hut not ah 
sorbed, 
T 1 s 3 s sinal catarrh, dysentery, :li ahetes 
7,. LADIGHAjTY GROWTHS- 
Carcinoma of "breast. 
VI* PARA3ITR3 Important in tropical countries 
The tape wo me does not cause anaemia 
VI 13 !<vn.i>v',on3 o.f anaemia In general 
,PRPftHOSI3 Depend3 on the underiving cause 
3 PRIMARY ANAEMIA 
I* CHLOROSIS* 
The so calledngreen sicknessMof young girls Itis a dis- 
ease of girls exclusively,ocurrs usually between the 15 
th.and 23d.yoars,It begins usually just after menstruat 
ion has started. 
SYMPTOMS, 
Nervous system not affected.Color the yellow green of 
the impressionist painters*Digestive system,poculiar 
appetite due to hypersecretion of gastric juice 
Nutrition not affected,gir|b is well nourished and well 
developed.There is no tendency to phthisis*Spleen may 
be inlarged*Temperature,patient is cold asa rule, 
though she may run a slight elevation,avoid cold baths. 
PROGNOSIS. 
Thrombosis often ocurrs and may cause death;otherwise 
death never ocurrs from chlorosis 
DIFFERENTIAL DIAGNOSIS* 
From secondary anaemia There is no difference in red 
"blood cells either in number or forms*The Leucocytes 
show no marked changes in chlorosis,in secondary anaemi 
a when due to chronic suppuration,hemorrhage or carcin 
oma they are increased* 
Cause is the diagnostic point 
From pulmonary tuberculosis Examine lungs and sputum, 
and use tuberculins test,a good thing* 
From icterus,examine conjunctivas and urine# 
From heart diseaspfpalpitation and shortness of "breath 
suggest heart disease and murmurs confirm,examine the 
blood 
From examine the urine* 
TREATMENT. 
Patient must have plenty of good appetizing food, 
change of scene and plenty of sunshine* 
IRON forthe blood,-dont give the tine*of chloride ever. 
BLAUM PILL*Ist.week 5gr*pill 2pills T.I*D* 
2d.week Sgr.pill Spills,T.I.D* 
To increase the appetite; 
R/. 
R/. 
Tinc.Nucis Vomicae *2/III* 
Tine.Centianae IV* Or 
0 M 
Sig.Take ateaspoon full in 
-J- awine glassof water "before 
meals* 
Strychnia sulph. gr*ji 
Pul*Ipecac gr. 
Capsicum g r*I. 
M 
Fiat in pillulem tales No* 
XX* 
Sig.Take one pill "before 
meals* 
Or give mix.straight 5gtt*rim it 
up* 
Or R/. 
Tannate of Orexine grs*V* 
Fiat in tabulem no*XX 
Slg* Take one "before meals* ■2BIHARY MmAlA 
II. 
PERNICIOUS ANAEMIA. 
Cause.Unknown. 
Symptoms,Haemoglobin is relatively increased,!.e,if 
as astandard 5,000,000.red blood corpuscles 
represent 100$ haemoglobin,in pernicious 
anaemia 2,000,000.red cells represent 50$. 
This is characteristic of the disease. 
The diameter of the red cells is increased, 
-this is more important than the presence of 
megloblasts- Amegaloblast is a large red cell 
with a neucleus# 
The White cells are normal or decreased in no, 
separating this disease from secondary anaemi 
An avarage number of reds isi,200,000.this 
varies greatly.The whites are usually about 
1000.The reds change their staning reaction 
developing Polychromatophelia. 
A Characteristic Blood. 
a, 
b, Relatively increased he smoglobin. 
c, Megalob lasts and normoblasts, 
d, 
Appearance of Patient. 
Face an even lemon color,well nourished as 
fat layer is preserved in cases where there 
is little vomiting or diarrhoea,hemorrhages 
in retina are common ,sudden paroxysms of 
vomiting and diarrhoea# 
Course of Disease. 
Patient has remissions,he returns to health, 
recovery is unknown,the disease comes in 
paroxysms# 
Cord Changes, 
Tabes dorsalis,spastic paraplegia,or diffuse 
myelitis may be closely or exactl y simulated. 
Prognosis. 
Absolutely bad. 
Treatment. 
Do all possible to promote good hygene and 
good digestion.Keep bowels open* 
Arsenic,in Fowlers solution I—20 gtt.TID* 
Caution patient to look out for gastro intest 
inal disturbance and puffiness about eyes to 
avoid legal complications. 
5  
Cause, 
unknown. 
Symptoms, 
Patient discovers a lump in his side,which causes him 
pain ,this pain is du* to the enlarged spleen stretching 
its capsule. Dr aging on the diaphragm causes shortness o-£ 
breath,The patient is weak and has all the symptoms of 
anaemia;there may be no anaemia ,usually there is none 
when the patient is first seen.Eplstaxis is acommon 
symptom. 
Blood, 
The whites are enormously increased,Dr.Cabot has seen 
over a million,An avarage is about 250,000,of these 25- 
are mono-nuclear neutrophiles,this is characteristic 
The reds have normoblasts and myelocytes in a normal 
count,yhis isdestinctive. 
The Spleen by growing pushes the heart up causing ven- 
ous engorgement,serous effusions and edema,There is 
nausia vomiting and diarrhoea which may cause death 
and dyspnoea. 
Physical Examination, 
Spleen is inlarged and palpable,!,e,a smooth surface 
with sharp edge and notched in the anterior border, 
destinguished from kidney by inflating the colon ,it 
passes over kidney and under spleen. 
Causes of enlarged spleen. 
Malaria,Sago-spleen,Idiopathic, 
Syphilis(diffuse fibrous;amyloid) 
Chronic suppuration,cirrhosis of liver, 
passive congestion,rickets,carcinoma of 
breast,(rare) 
Course of the Disease# 
The whites may drop to normal hut the myelocytes still 
remain,these remissions may last a couple of months, 
the spleen may grow smaller ,The liver is often enlarg 
ed it can he felt helow the costal border and petcussed 
above the 6 th, rib,No change in hone marrow,Uric acid is 
increased in the urine,Cerebral hemorrhage very likely 
tooccur,Priapism a symptom,Leuchemic retinitis,common, 
it Is an infiltration of cells and hemorrhages into the 
retina. 
Prognosis# 
absolutely bad;3 to 4 year course# 
Treatment# 
Arsenic, Fowlers solution#1-20 gtt.T.I.D* 
Look out for neuritis and skin bronzing. 
6 MCHMIAj lymphatic. 
CAUSE 
Unknown. 
SYMPTOMS, 
Lumps in the neck,groin and axillae.Hemorrhage and general 
debility.Mediastinal and mesenteric glands may he inlarged 
The spleen is enlarged so that it may he felt,there may he 
exceptions to this .Lymph tumors may exist in every tissue 
or organ in the body with symptoms accordingly* 
BLOOD 
The reds are usually deminished ,anaemia is more common in 
this disease than in spleno medullary foriji,there are no 
neucleated reds unless there is anaemia # 
The whites number from 15000 to 90 ooo on an avarage,of 
these 90^,are lymphocytes,large and small,where the lacge 
form is present the disease is called Acute lymphatic 
leuchemia# 
ACUTE FORM , 
Large lymphocites. 
Fever 
Hemorrhage. 
DIFFERENTIAL DIAGNOSIS, 
A Blood examination separates it from all other diseases# 
mams 
The pathology and symptoms are the same as lymphatic leu- 
chemia hut the blood is normal blood* 
SBMNIC MAMLAm 
At times the spleen only is enlarged and there is consider 
able anaemia Dr. Fits recognizes this as splenic anaemia. .HEART DISHASE*PERICARDITIS^ 
ETIOLOGY 
Rheumatism,the commonest cause,the disease is nessessarily 
secondary the cause may not be discoverable,thedisease its 
self is often overlooked. 
Pneumonia as acause is second in frequency. 
Then Septic diseases,Streptococcus*staphlococcus*parturitio 
Scarlet fever and gonorrhoea. 
Pericarditis by extension*from injury to and diseases of 
the oesophagus*cancer of the stomach,Absceas of the liver. 
SYMPTOMS, 
Haemo- and Hydro-pericarditis of no clinical importance. 
Subjectivepain is the only symptom and it is rare. 
Objective,listen to the heart fricton rub may be heard. 
Pericardial friction*heard all over precordia or in a small 
area 3d,or 4th, left intercostal spaces at sternum the 
favorite spot,The sound may be heard at any time in the car 
diac cycle* it does not coincide with valvular sounds, 
(Dr, Cabot compares the sound to that of an old man in 
loose slippers shuffling along,) 
It may be heard at one time and not at another,pressure on 
stethoscope increases the sound,it sounds like rubbing the 
stethoscope over the skin,A rough grating sound the rubbin 
of two rough surfaces together,Destinguished from pleural 
friction by fact that pleural rub stops when breath is heid 
exception to this ,when pericarbium is rubbed by pleura 
this is rare, 
PIiUID is now poured out ,First subjective symptoms,due to 
pressure on Trachea *cough and dyspnoea. 
on lungjbronchc-yesichular breathing dull tympany 
percussion note. 
On laryngeal nerves, aphonia. 
On oesophagus* dysphagia. 
DIFFERENTIAL DIAGNOSIS. 
Objective,area of dullness changed*no splashing. 
From enlarged hea»t,in pericarditis the line of dullness 
extends far outside the apex beat*the triangle of dullness 
has its base down,The history,Tapping is absolute. 
Adherent pericardium,the terminal stage rare and unimportant 
the heart is weak. 
COURSE, 
May never "be discovered,often comes and goes in aweek*if 
there is an effusion it will run a couple of weeks* 
purulent cases killin a few weeks, cases have recovered 
where pus was present after surgical treatment washed out 
and drained like any abscess cavity* 
PROGNOSIS* 
Depends on the variety of the inflammation* 
8 TTRABT I)I3TCASEf?mTf!ABT)TTTR. 
TREATMENT , 
Dry pericarditis,treat the underlying cause, if there is 
pain treat the pain in one of the proper ways* 
Pericarditis with effusionrTAP^ 
Points for tapping, 
Costo-xiphoid angle,as far up in the angle as 
possible. 
Just outside the apex -this is dangerous as the 
pericardium may be missed* 
Rotche’s Point,5th. intercostal space to right 
of sternum# 
Indications for tapping,$reat dyspnoea,weak pulse when alarming 
tap. 
Use a trochar and canula ,not a needle,as there is danger of 
piercing the heart. 
ZRSAmSNT. HE. PAIII Hi .GMERMu 
I. Counter irritation,hot water,mustard leaf,dry cup,&c. 
Il.Coal tar antipyretics. 
Phenacetine,IO gr.pill for an adult. 
5gr. pill for a child* 
Anti-febrine,same dose. 
Lactophenine,same dose. 
III.Morphine, last, use only in acute disease,never in chronic* 
unless absolutely necessary*always give it sub-cue* HEART mSEASB.ElIDOCARDITIS 
ACUTE ENDOCARDITIS,Benign. Unimportant clinically,secondary to 
Rheumatism,Gonorrhoea,Typhoid ect. ' 
DIAGNOSIS, 
7 
Sudden rise in temperature with no aggravation of joint 
affection,and the presence of murmurs* 
PHYSICAL SIGNS. 
Difficulty arises in destinguishing functional murmurs 
from organic murmurs,A diastolic murmur is exceedingly 
rarely functional,a systolic murmur may be either,func- 
tional murmurs are usually limited to the second right 
interspace,nThe region of romance®*Functional murmurs a 
as a rule are trancient*A musical murmur is generally 
organic.Gardio-respiratory murmurs stop when the breath 
is held*Enlargement of the heart is an important sign. 
The etiology also gives an important clew* 
The vegitation on the valves may cause valvular heart 
disease or may clear up*Embolism is the important com- 
plication; an embolus may travel to the brain,kidney, 
spleen,(not to the lung or left heart ,unless there is 
a patent foramen ovale)*Emboli from the entire venous 
system and right heart may go to the lung*Emboli from 
the left heart may go to the entire arterial circula- 
tion. 
Emboli in the kidney cause pain and haematuria. 
Course, 
8 8 M spleen 8 8 B enlargement,(rare) 
8 8 “brain 8 paralysis and aphasia. 
These symptoms may pass of in a day or last six monthd* 
TREATMENT, 
w 
Expectant,!.e.none at all*prepare the family* 
Acute endocarditis,Malignant. 
Secondary to I.Gonorrhoea.II.Pneumonia*III.Pyogenic 
cocci,strepto-, and staphlo-coccus.IV.Puerpural sta$9* 
V*Necrosis of bone*VI.Carbuncle*VII.Abscess and gangren 
ofthe lung* 
DIAGNOSIS, 
Differentiated from typhoid by absence of Wedal and 
leucocytosis* 
Prom Multiple Abscess,by ragged temperature,sweats and 
chills with leucocytosis 
COURSE 
Long or short,from 1-2,days to 6-8 months. 
PROGNOSIS 
Recovery takes place only in those ceses where the dia- 
nosis was doubtful,it is a rare disease,about 90jfcl.ie. 
The heart is the same in this disease as in the benign 
form* 
Chronic endocarditis is valvular heart disease. 
T A 
10 -HEART DISE A SE T VAIWTJTj AT? 
ETIOLOGY, 
Rheumatism,the commonest cause.Arterio-sclerosis,chorea 
gonorrhoea,septic disease,alcohol,strain(rare),latent 
disease# The mitral valve is attacked most often by 
rheumatism and chorea. The aortic most often by alcohol 
and arterio-sclerosls# 
SYMPTOMS, 
When compensation is good, there are none# 
When compensation is broken, s 
a, Respiratory symptoms,Dyspnoea,orthopnoea,cough,cyanosi 
rales at both bases,oedema of the lungs,pleural effus- 
ion,bronchial breathing,haemoptosis,cardiac asthma# 
b, Digestive symptoms,enlargement of the liver,gas and 
pain on the stomach,vomiting,passive congestion of the 
spleen,diarrhoe^ornstipation. 
c, Circulatory symptoms,effusions into serous cavities, 
asci tes,hydro thorax, anascarca, oedema,very marked in 
genitals,pulseirregular,palpitation. 
d, Urinary symptoms,small quantity,high color,albumen and 
casts# 
e, symptoms,fretful,sleepless,suicidal tendencies 
flashes before the eyes# 
f, Generative organs,in women-menorrhagia and metorrhagia 
MITRAL INSUFFICIENCY, 
Signs, A systolic murmur at the apex,transmitted to the 
axilla and hack,heard at the angle of the scapula, 
heart enlarged in its transverse diameter,a heart mur - 
mur heard in chorea is usually this# 
Course,aseries of breaks in compensation# 
MITRAL STMOSIS, 
Signs,A thrill like a cat’s pur at the apex,a presystol 
ic murmur,rat tattat,like the roll of a drumtending in 
the first sound which is very destinct,the second sound 
is not heard at the apex# " Shock" 
Course,more common in women than in exist as a 
pure mitral stenosis for years# 
AORTIC INSUFFICIENCY, 
Signs,Dyastolic murmur heard "best in the 3d. and 4th. 
left costal cartileges,transmitted downward,in this 
affection we get the largest heart,Corrigan pulse, 
pistol shot ingroin,capillary pulse,The Flint murmur is 
a pre systolic murmur with athrill ,cannot he told from 
mitral stenosis* 
Course,great liability to sudden death# 
11 MART DISEASErVALVTJT,A^ 
AORTIC STENOSIS, 
Signs,Enlarged heart,systolic murmur in 2d,right inter- 
space, transmitted up into the neckjvery rough,sometimes 
thereis a thrill with the murmur-Pulse rarus,parvus, 
tardus,-with out this pulse no diagnosis of this lesion 
can he maderlt is the rarest of heart lesions -he care- 
ful in making a diagnosis-Eunctional murmurs,endocardi- 
tls,aneurism,rougtoess of t5ie aortic valves,may give 
the same symptoms ,except the pulse. 
TRICUSPID INSUFFICIENCY, 
Signs,Found at the end of all left heart disease where 
the left heart heart is dilated.Systolic murmur heard 
over the lower sternum,pulsations in the veins of the 
neck and in the liver. 
PULSE,its Important features# 
Rate, regularity, force, rythm# 
A good pulse is regular,not too fast,wave big enough 
and sharp enough,and not dicrotic# 
Compressability,jested with three fingers,in nephritis 
ehard to compress,in heart weakness easy to 
compress# 
ARTERIAL WAIL,quality. 
straight,twisted or calcified, Some people have small 
arteries,others have large.Arteriea are often misplaced 
Calcification is defined by passing the finger up and 
down the arteity,a succesion of humps will be felt,as 
the calcification takes place in a spiral# 
PROGNOSIS OP ALL LESIONS. 
Mitral regurgitation is the least dangerous of left 
heart lesions;-At the Mass.Gen.Hospital Dr#Cabot sent 
postal cards to ten mitral and ten aortic cases which 
he had treated the summer before,asking them to come 
the hospital,all the mitral cases came about the sam?, 
not a single aortic case showed up,instead he received 
the news of the death of most of them#- 
Aortic disease is always dangerous. 
AGE, a child with mitral disease does not grow up# 
old men with had arteries do not last long# 
SEX,&RAGE,make no difference in the prognosis. 
WEALTH,poor and laboring class have had prognosis. 
rich and idle have a much better chance, 
Pregnancy and high altitudes are hard on the heart. 
Willingness and ability to submit to treatment alters 
the prognosis# 
HISTORY,of rheumatism,complicating disease,frequent 
failures of compensation,&good treatment,give bad prog# 
12 -HEART DTSEA HE r VAT,vi rr. at? 
Treatment 
, Absolute Rest in bed ,-Do not allow patient to get 
up to pass his watertUse a bed xest.-A chair placed on 
the bed with pillows put through the rounds makes an 
excellent bed rest,have the patient’s feet braced 
against the foot of the bed,and the foot of the bed 
slightly raised. 
Diet.Depends on the patient's digestive power,if he 
can stand it ,keep him as near his regular diet as pos 
sible,avoid liquids as much as possible. 
Drugs,Digitalis,-as a general rule all drugs shond be 
given before meals,digitalis however should be given 
after meals,well diluted,as it is irritating.- 
R/. 
Tine,Digitalis, q, s. 
Sig,take V.gtt.every four hours. 
If the stomach wont stand this,give- 
s/. 
Solid ext.digitalis, gr,2/3. 
Make piIs,ad no XX, 
Sig,take one pill every four hours. 
And take as a stimulant when needed. 
R/. 
Strychnine gr,I/4, 
Ext.Digitalis gr.2/3. 
Nitroglycerine gr,l/I00, 
M. 
Strophantus,is not nearly so good as digitalis and 
should he used only when digitalis cannot he taken, 
Strychnine,is good when these don’t go,1/40 gr,t.i,d. 
Nitroglycerine,is the "best stimulant to pull a pat- 
ent through on. 
Dropsy,to remove it,I.Cathartics,MgS04 in from -J--I dr, 
doses in as little water as possible,or in black cof- 
fee on an empty stomach in the morning, 
II,Diuretics,Diuretine if the patient can stand it* 
7 gr,every four hours. Calomel,gr.I. every 2-3,hrs, 
- never give this if the kidney is affected. 
Caffeine is good. 
Tapping.Tan any serous cavity where effusion is, 
do not scarify tillall else has failed,put a dozen lee 
ches over a sore liver to remove the blood-to make thg 
bite put milk on the skin,- .HEART iUBBASE -MYQCARPI TIS 
Etiology, 
( Chronic-interstitial) 
I. Toxines,II# Arterio-sclerosis# 
Symptoms, 
I. none, II. dyspnoea,swellingof the feet,congestion. 
Signs, 
I.Enlargment of the heart,II#Weak heart sounds, 
III#murmurs,(relative mitral insufficiency) 
IV# irregular heart# 
i 
Made from evidence of failing compensation and no mur- 
murs,the history is also important#Ghyne-Stokes res- 
piration,mental wandering,and restlessness, 
N#B. The worse the case is the less likely are there to 
be murmurs and visa versa,These heart eases are unlike 
others in that they do not tend to improve between 
attacks of faulty compensation# 
Diagnosis, 
Prognosis, 
heath in about two to three years# 
Treatment, 
a. In compensation,"baths and light exercise,KI in gr.X 
doses t.i.d.and nitroglycerine in gr# I/IOO doses tld 
"b. In failing compensation,stimulate as in other heart 
affections# 
MARI. 3ISSASE,Mfi:CIQMAL» 
Etiology, 
Tea 8c coffee,tobaco,alcohol, sexual excess,overexertion 
in athletics* 
Symptoms, 
Pain, palpitation. 
Signs, 
Prognosis, 
Irregular heart. 
Good if the cause is removed. 
Treatment, 
Cut off the injurious substance, give KBr# 
N#B# An irregular heart is found in all cases of fail- 
ing compensation# 
Etiology, 
Idiopathic,(real cause not known.) 
Varieties, 
I# regular, II.paroxysmal# 
N.B. It is diagnostic of exopthalmic goitre# 
TtBADYflATmiA- 
Etiology,!, recovery from acute fevers,puerpural state,etc, 
II# Tumors of the "brain,injuries to the head and "brain# 
III# Jaundice, idiopathic,and myocarditis (rare)# 
iT#B#If in injuries to the head the pulse goes down rap- 
idly, it means intra-cranial pressure from hemorrhage# ■HEART JDlSEASErAHSIMA PECTORIS. 
ETIOLOGY, 
Miyocarditis,as a result of arterio-sclerosis. 
Aortic regurgitation. 
Inherited, 
SYMPTOMS, 
I.extreme pain,II,sense of impending death,III,constri- 
ction of the precordia,IV,may be lossof consciousness, 
the pain only lasts a minute or two# 
DIFFERENTIAL DIAGNOSIS FROM FALSE ANGINA. 
True angina, : False angina, 
1 pain very severe : I pain not so severe 
2 pain lasts a minute t 2 Pain may last half-hour. 
3 pain brought on by strain: Scomes on at any time, 
4 commonest in men : 4 commonest in women, 
5 always arterio-sclerosis t 5 arterio-sclerosis not 
l necessary. 
PROGNOSIS, 
Always fatal* 
TREATMENT, 
For the paroxysms,nitro-glycerine gr*l/lOO -don*t use 
amyl nitrite,- 
Prophylaxis,have the patient avoid irritation of all 
kinds# 
aiaSASE, ILL m 
ETIOLOGY, 
I. Alcohol, II, Syphilis, III, Old age. 
SEQUELAE, 
I* Chronic interstitial nephritis, II*Infarction of the 
brain,(thrombosis), III, Miliary aneurism of the brain, 
causing hemorrhage* 
SYMPTOMS, 
a, In large arteries,- I. dilatation of the aorta, 
2.aneurism, 3. "breaking of a lime plate causing embol- 
ism or thrombosis, 4, murmurs* 
b, small arteries,I* end arteritis and narrowing, 
II. formation of calcarous plates,III* arteries become 
stiff and tortuous* 
c, In the heart, I* enlargement, 2. loud aortic second 
sound* ■i ££. Jag MSSL&S, aneui lI sm» 
ANEURISM OP THE AORTA, 
TYPES, I.Latent, 2. Causing pressure symptoms,3*Causing 
tumor. 
or 
a, of the ascending arch,(commonest). b,of the 
descending arch, c, of the transverse arch. 
a, 
OF THE ASCENDING- ARCH, 
Symptoms, I. tumor in the second right interspace,2. pain. 
Signs, I.Pulsating tumor, 
IT.3. this occurs also in -displaced heart,empyema 
necessatatis,neoplasm,retracted lung in T.B. 
DIFFERENTIAL DIAGNOSIS from EMPYEMA NEC.and TUMOR. 
jmmim s mym rnKssmiis 
1. no fever, : I. fever 
2. no leucocytes, : 2, marked leucocytosls, 
AMRIS! : TUMOR 
1. a thrill on palpation, : I. no thrill, 
2. a murmur on auscultation, : 2. no murmur, 
t>, : 
OP THE DESCENDING ARCH, 
Symptoms, very obscure,results in erosion of the vertebrae from 
pressure,intercostal neuralgia,turn or in the back, 
pressure on the oesophagus. 
c, 
0F THE TRANSVERSE ARCH, 
Symptoms, those of pressure,Dyspnoea,Ringing cough,Loss of voice 
Chylous hydro thorax, (from pressiire on thoracic duct.) 
Sympathetic disturbances,(unequal pupils,etc.),Hydro- 
thorax ,Atalectasis,Dysphagia,Irregular pulse, 
THE COURSE OF ANEURISM, 
As a rule about 3-4 years,may run as long as 15 yrs. 
ANEURISM OF THE ABDOMINAL AORTA 
Symptoms and Signs,(it is rare),Pulsating tumor,pain in the back 
shooting down into the leggs,obliteration of the femor 
al pulse, 
N.B.If there is any doubt of aneurism it is not an an- 
eurism. 
RUPTURE may take place into the Pericardium,Pleurae,Bronchi,Tra- 
chea,or externally in the order mentioned.Death does not as a 
rule take place for a day or two;in some recorded instances the 
individual lived a week. DISEASE HE...IHB. 
TREATMENT OF ANEURISM, 
Absolute rest in bed,reduce system to its lowest terms 
Have no irritation or disturbance.Bleed(?),KI in mod- 
erate doses,Surgery, 
¥ireing,Pass a fine trochar into the aneurism,intro- 
duce through this trochar a large amount of fine piano 
wire,in such a way that the wire willcurl up in the 
aneurism,then pass an electric current along the wire, 
this aids the clotting.—THis method is applicable 
only to a sacular aneurism,it1s good results are very 
doubtful, of the tkpee four cases thus treated,three 
died# 
Gelatin injections, sudden death has followed this tre 
atment,as there is great danger of causing too great 
coagulatability of the blood, its use is not justified DISEASE OF THE RESpIM'i'ohV SVSMM, 
■HEY. FEVER ( Autumnal catarrh, rose cold,) 
ETIOLOGY, 
I. Neurotic temperament,2. IRRITANT,3. Abnormality of 
nasal passage,4. Spring and fall*(The irritant may be 
almost anything,as horses,artificial flowers,etc.) 
SYMPTOMS, 
Begins with coryza,-eyes running,cough,sneezing,- 
Pharyngitis,laryngi t i s,asthma* 
PROGNOSIS, 
As to life,good- as to recovery,bad.- the disease is 
cured by removal of the cause,the attacks last about a 
month* 
TREATMENT, 
Change,-send patient to the mountains or the sea shore 
or on a sea voyage;first however, send him to a nose 
man to have possible nasal deformity diagnosed. 
Do not use cocaine in treatment* 
EfISXAKIS, 
ETIOLOGY, 
Traumatism,plethora,haemophilia,onset of typhoid,scurvy 
pur pur a, vicarious men struat ion, puller a,-may 
be fatal,-uremia,- Nature here seems to be making an 
effort to rid herself of a toxine,Don*t stop her;Dr.C*- 
TREATMENT, 
AS a rule the bleeding is not dangerous,-Keep the pat- 
ient on his back,arms over his headjapply alum or tan- 
nic acid,or cocaine hydrochloride,plug the anterior nar 
es with gauze,if this does not stop it,plug the poster- 
ior nares,To pack the posterior nares,-put a soft rub- 
ber catheter into the nostril,pass it back until it 
appears in the pharynx,seize it with a pair of forceps 
m and pull it out through the mouth until a piece of gau?- 
ze can be tied to it, then pull it back through the 
nares* 
imm. CATARRHAL LARYNGITIS, 
TREATMENT , 
Steam, a hig vessle of boiling water,add to this a lit- 
tle tincture of benzoin, breathe the steam under a tent 
for one half hour,T*I*D. - a lost voice will return in 
half an hour with this treatment* 
SPASMODIC LARYNGITIS,-CROUP. 
SYMPTOMS, 
THe mother notices that the child acts differently,has 
a queer hoauseness and a barking,brassy,cotigh during 
the day; at night it has dyspnoea,cyanosis,& acough wi£ 
a whoop, 
PROGNOSIS,absolutely good* 
TREATMENT, Prompt emesis, ahig dose of Ipicac,or mustard,Ifthe 
18. child cant swallow give, #005 apomorphine* DISEASE OP THE RESPIRATORY SYSTEM 
LARYNGISMUS STRIDULUS. 
A more frequent affection than ordinary croup,it is not so severe, 
it comes on at any time of day,while croup comes on only at night, 
it frequently complicates rickets. 
ETIOLOGY, 
Complication of most lung diseases,measles,pertussis, 
and beginning typhoid. 
Signs, 
Evidence positiveis the presence of rales, they are nec- 
essary and are all one needs for a diagnosis. 
DIFFERENTIAL DIAGNOSIS, 
Phthisis ruled out hy the sputum exam, and the presence 
of hemorrhage,also acute bronchitis is never unilateral, 
this is an important fact. 
Pneumonia easily ruled out hy the physical signs. 
COURSE, 
one to two weeks. 
TREATMENT , 
Heroine, I/I2 gr. pill T.I.D. is the best.Dovers powders 
or Codeine in gr.-J- doses .Hot foot hath,hot lemonade,hed 
inhalations are good,ordinary diet. 
N.B. Rales and muscle sounds are often confounded,it is important 
to learn to destinguish between them,the normal muscle sound 
can he learned hy listening over the contracting biceps with 
a stethoscope. 
ACUTE BRONCHITIS. 
ETIOLOGY, 
Old men,renal disease,asthma,emphysema,arterio-sclerosis 
SYMPTOMS, 
No fever, cough, sputum raised. 
PHYSICAL SIGNS, 
Barrel shaped chest,chest wall moves as one piece, 
decreased fremitus,hyperresonance,area of cardiac 
dullness decreased,liver also.Hales,mostly dry,some 
moiste,decreased vocal sounds.Feehle respiration, 
prolonSed expiration. 
PROGNOSIS, For life good,for recovery had,unless patient has a 
decided change of air. 
TREATMENT, Change,send patient south,give KI and Heroine. 
moimBcaAaifr 
Dilatation of a 'bronchus. DISEASE OF THE RESPIRATORY SYSTEM, 
JBROMCSHIAEi, ASTHMA, 
A symptom of cardiac or renal disease,-always examine the heart 
and kidneys# 
PHYSICAL SIGNS, 
Sudden attack of wheezing and dyspnoea,coming on at nig£ 
rales can be felt with the hand,they are high,low,squee- 
ks,ete# Hyperresonance,heart rate rapid,temp.normal, 
pulse good. 
TREATMENT, 
Morphia sub-cu. atonce,Potassium nitrate,and stramonium, 
burned together ina dish letting patient inhale the 
fumes,nitro-glycerine.In the intermission give KI and 
Fowler’s solution,gtt.3, up# 
TREATMENT OF COUCH IN GENERAL. 
Put patient to bed if he has a temperature,-the idea that whiskey 
and quinine are good is entirely erroneous,-Inhalations of steam 
with turpentine are good# 
A good cough mixture is. 
Morphine sulph# gr#I 
Chloroform gtt#XX# 
Syr#Acacia 
Syr.Pruni Virgin#aa %/11 
M# 
Sig# shake. Take a teaspoon full every 
four hours# 
Chloroform water is good only when the inflammation is high up in 
the throat# 
Terrobine gtt. V, on a lump of sugar# 
Heroine, I/I2 gr.pill T.I.D# DISEASE OF THE RESPIRATORY SYSTEM 
.ELBURISY, 
VARITIES, 
Dry,plastic or fibronous. Serous, Purulent* 
ETIOLOGY, 
DUE to organisms,the pneumococcus,streptococcus,staphlo- 
coccus aurious and albus,the tubercle bacillus or any 
infective process inthe lung#it is associated wlthpneu- 
monia in moSt cases,outside of the pneumonia cases the 
etiology is hidden in 95% of the cases# 
It is usually dry in the beginning,causing the pain whip 
comes on at the end of a pneumonia case# It may be due 
to a purulent empyema,puncturing wounds,fractured ribs. 
In children the purulent class is the most common,at 
times it is associated with rheumatism* 
SYMPTOMS, 
May be none,Pain the only one,found in the side behind 
the nipple, 
PHYSICAL SIGNS, 
Inspection,-shallow breathing*Palpation,-rub can be felt 
at times#Percussion,-no change#Auscultation,-friction 
rub heard in the axilla,may be mistaken for a dry rale, 
a pericardial rub,amuscle sound,or the slipping of the 
stethoscope,- put water on the bell of the stethoscope 
or vaseline. Pressure on the end of the stethoscope will 
intensify the sound,the rub may appear and disappear# 
Thickening and adherance may take place,or it may go on 
to effusion# There may be fever or no fever# 
PROGNOSIS, 
Lasts four or five days. 
TREATMENT, 
A swathe of adhesive plaster,10 -12,inches wide;or a can 
ton flannel swathe#Put it on so tight that the patient 
complains of it,tell hima to wait 15 minutes,he never 
complains then#The swaithe releives the pain#Coufeter ir- 
ritants such as iodine,mustard,or turpentine# no inter- 
nal medicine* 
DRY PLEURISY, 
PLEURISY WITH EFFUSION, 
SYMPTOMS, 
Pain,shortness of "breath,-perhaps have lasted,3-4 weeks, 
cough,perhapsa chill with fever,thirst,nausia,constipa- 
tion,headache# 
PHYSICAL SIGHS, 
Inspection,-Interspaces may he obliterated,-they never 
bulge in any disease#-Loss of expansion,apex 
impulse displaced,hurried breathing,cyanosis 
absense of Litton1s sign# 
Palpation, Tactile fremitus greatly diminished or abs# 
this is a sure sign#Lack of swelling on ins- 
piration# DISEASE OF THE RESPIRATORY SYSTEM, 
EMURISY,., 
PLEURISY WITH EFPUSION,con, 
PHYSICAL SIGHS, 
Percussion, Flatness,hyperresonanceabove the fluid,the S 
curve of Garland,heart displacedif effusion 
is on the left,if on the right not much dis- 
placed* 
Auscultation,nothing heard as arule,some times bronchial 
breathing,very faint and diatant;rarely a 
whispered voice,fremitus may be present,Tym- 
pany may be heard rarelytransmitted from a 
distended stomach*fremitus will differentiate 
from pneumonia* 
Blood, there may or may not be a leucocytosis, 
DIAGNOSIS, 
A thickened pleura must be ruled out,this is hard* 
A neoplasm may give all the signs of effusion. 
The position of the heart is an important sign* 
PROGNOSIS, 
Depends on the treatment,3 weeks if well treated* 
TREATMENT, 
Starve the patient as to liquids,diophoresis,catharsis, 
diuresis, then TAP,-slowly and let all the fluid run out 
Method of Tapping, Clean up the chest surgically,select 
a point in the mid-axillary line,at about the 8th,space; 
have the arm held up,cocaine I*f sol, for local anaesth- 
esia, then cut with a knife about -J- inch wellthrough the 
skin,separate the fat,then thrust in the trochar;have 
the vacuum so arrainged that a small stream will run out 
stop if the patient has pain or begins to cough,Put one 
stitch in,dry dressing and cocoon*Have a sub-cue ready 
with morphine for excessive cough, 
N,B, Sp,Gr,of 1019-1020 means pleurisy with effusion as 
we have an exudate, 
Sp,Gr, of I0I0-I020 means oedema, of the lungs,as we 
have a transudate. 
TiTTTOH* S SIAM. 
Put patient's feet to the window,stand at the sidelooking at an 
angle of about 45° with his median line;the shadow of the moving 
moving diaphragm may be seeh;its absence is suggestive* 
flARLAHD'S -S. CURV-E. 
This curve is the line of dullness which marks the top of the pleu 
ral effusion*It "begins at the vetebral column and extends around 
to the sternum, its highest point is in the mid- sLxillary line* DISEASE OF THE RESPIRATORY ORGANS 
PHEUMPTHQBAy, 
ETIOLOGY, 
Tuberculosis,and a hole coughed through the lung. 
SYMPTOMS, 
Pain, dyspnoea. 
PHYSICAL EXAMINATION, 
Inspection,-dyspnoea,no movement,displaced heart. 
Palpation,- fremitus usually absent,or greatly deminish- 
ed. 
P er cus s i on,-tympany. 
Auscultation,-nothing heard* 
PROGNOSIS, 
Depends on the T.B.process,usually not good, 
TREATMENT, 
Tap, and treat the T.B. 
sMosjsm, mz. 
ETIOLOGY, 
T.B.cavity, aspiration and deglutition,embolism,perfor- 
ation from stomach and oesophagus,hronchiectatic cavity, 
wounds, a rare sequele of pneumonia. 
SYMPTOMS, 
Cough,signs of toxemia, temperature ,nausia,haemoptosis, 
cachexia. 
PHYSICAL SIGNS, 
Rales as in bronchitis,cavity or area of consolidation, 
DIAGNOSIS, 
Odor of breath and sputum,-don*t confuse with bronchiec- 
tasis. 
PROGNOSIS, 
A case may terminate in recovery,they usually die, 
TREATMENT, 
Surgical at times. Thymol,3 -4 gtt.ln capsules for the 
odor. 
ABSCESS OF THE 
ETIOLOGY, 
same as that of gangrene. 
SYMPTOMS, 
Bad odor,though not so had as that of gangrene,expector- 
ation odC pur e pus-empyema does the same,differentiated 
hy signs of empyema,and etiology. 
TREATMENT, 
Surgical,at times. 
ME. GROWTH m. m imt> 
DIAGNOSIS, 
Haemothorax comes from either cancer or T.B. DISEASE OP THE RESPIRATORY SYSTEM 
SQSMA JMfi., 
ETIOLOGY, 
Same as that of edema anywhere* 
PHYSICAL SIGNS, 
A few crackling rales at the base,which change position 
when the patient changes position* 
BRnNCHn-PNEHMONT A y 
ETIOLOGY, 
i the children that die are carried of hy this affection 
the other i die of diarrhoea*The disease may he primary, 
or secondary to measles,pertussis,diphtheria,deglutition 
etc* 
SYMPTOMS, 
Temperature, cough, cyano si s, dyspnoea* 
PHYSICAL SIGNS, 
Not destinctive,child is too sick to have bronchitis* 
PROGNOSIS, 
Depends on the etiology,had in cases due to deglutition, 
N*B* In old men this disease is called "Capillary Bron- 
chitis“-it is very hard to make a diagnosis* 
TREATMENT, 
Strychnia,-for a child of one year,I/100gr*doses*Look 
out for the hahies nutrition,cold haths every 4 hours, 
starting the water at 95° and running down to 80°; 
don*t give hrandy in milk as the child may go hack on 
the milk ,his food*In old men,stimulate and feed* 
■flflBOMlfl INTERSTITIAL JSMMOMA* 
(pneumoconiosis) 
ETIOLOHY, 
DuBt,-stone,street,coal,metal,-End stage of pneumonia, 
fibroid changes in the lung* 
PHYSICAL SIGNS, 
Chest drawn together and fallen in,area of solidifica- 
tion,heart displaeed,-he careful here,there may he true 
or pseudo-retraction of the heart# 
PROGNOSIS, 
Bad for recovery,for lifeuncertain. 
TREATMENT, 
Try to improve general eonditton,that is all that can he 
done* DISEASE OF THE DIGESTIVE SYSTEM 
I.APTHUS STOMATITIS,fcancre) 
ETIOLOGY, 
Usually hahies affected,prohahly herpes of the mouth, 
depends on the general condition# 
DIAGNOSIS, 
begins as a vesicle which breaks,leaving a small white 
ulcer,with greyish base and a sharp round red edge# 
TREATMENT, 
Ag N03 stick,touch each give KC103 # 
II#ULCSRATIVE ST0MATI5JS, 
SYMPTOMS, 
The gums are necrosed at their free margins;bad breath, 
salivation# 
DIAGNOSIS, 
Scurvy has an etiology and set of symptoms outside the 
mouth# 
TREATMENT, 
KC103 -for an infant of one year,gr.X T#I.D#- Use it as 
a mouth wash as well and as a powder for the gums# 
III# 
GANGRENOUS STOMATITIS, -NOMA,rare- 
SIGNS, 
A big gangrenous hole breaks through the cheek at the cor 
ner of the mouth,without appearant cause;it is quickly 
fatal in most cases# 
TREATMENT, 
Surgical , cut a big hole in the surrounding tissue# 
IV• MERCURIAL STOMATITIS, 
It is the same as ulcerative stomatitis in character,it a 
is to be suspected after medicinal doseswhen there is ob- 
struction of the urine,tenderness of the teeth,N#B*never 
give calomel to a nephritic,Prophylaxis,keep the teeth 
and mouth clean-much more calomel can be given in this 
way# 
ssoMmgis, 
ECZEMA .OF- _THE TONGUE # 
SIGNS, 
Socalled geographical tongue,raised white patches on ton- 
gue# 
LEUSQFLASIA BUCgALIS, 
SIGNS, Often the starting place of cancer. 
One white spot on the tongue, 
TREATMENT, 
Cut it out as soon as the diagnosis is made* DISEASE BB THE DIGESTIVE SYSTEM 
ACUTE PHARYNGITIS, 
ETIOLOGY, 
Fatigue,exposure to cold,irregular meals.(House-officer1s 
disease) 
SYMPTOMS, 
Irr 11 at ed, smar t ing /burning, r ed, thr oat ; cough* 
SIGNS, 
Red throatwijh swollen,whitish streaks,which look like 
membrane* 
TREATMENT, 
Hot milk gargle,at night;lozenges are good-Mariani lozen- 
ges for private practice,for one*self glycerine lozenges. 
sxEmis. .mmaiTis, 
ETIOLOGY, 
Smooking and Hrinking,the cough of the chronic alcoholic* 
TREATMENT , 
Remove the cause. 
Ulcerations in the pharynx,due to T.B. or syphilis. 
Rma-raAmasAL, abscess. 
ETIOLOGY, 
In children,sore throat,loss of apetite* 
SIGNS, 
Tumor bulges forward,it is therefore hard to see,feel for 
it always* 
TREATMENT, 
Open,turning child upside down* 
gQLLICNM1RTQNSILITI2, 
LOCAL SYMPTOMS, 
Pain in the throat,difficulty in swallowing,grey spots 
on a red background* 
GENERAL SYMPTOMS, 
High fever,great prostration,headache,back and legache* 
Diagnosis, 
The diphtheretic membrane is continuous,tjj&t of tonsitit- 
is,is spotted* This affection often accompanies articular 
rheumatism*Common at the menstrual period* 
PROGNOSIS, 
Good,both for life and recovery* 
TREATMENT, 
Phenacetine,gr X. repeat in 2 hrs. if not releived* 
DIAGNOSIS, 
Local symptoms more marked than in the follicular form, 
pain is more intense and is steady-infolllcular formpain 
exists only on swallowing -,the pain often runs to the 
ear,there is extreme prostration and high temperature. 
TREATMENT,-Open the abscess as soon as the diagnosis is made* 
SUPPURATIVE TONSlLlTLSy DISEASE OF THE DIGESTIVE SYSTEM, 
SYMPTOMS, 
Adenoid facies,mouth open,stupid,nose pinched,alae nasi 
working,coughs,colds,night sweats,!# the mouth,high arch- 
ed palate,big faucial tonsils* 
Development retarded,deafness,irritability,stupid; 
From lack of air,Pigeon breast,-chest pushed out* 
Funnel breast,-chest pushed in* 
Barrell chest* 
TREATMENT, 
Remove the adenoid* 
JSHRQM1C TONSILLITIS, 
SEA5M ££ JSfiL QflfiQFHAflUS, 
ETIOLOGY, 
It may be genuine,usually it is hysteria,-called “Globus- 
Hystericus, 
SYMPTOMS, 
Regurgitation of food* 
DIAGNOSIS, 
Differentiated from true stenosis by the fact that true 
stenosis is the same toward food at all times,that a pro- 
bang will halt at a true stenosis,but will pass through 
a spasm*The history of the case is important* 
.smssHRE. sul jm. 
ETIOLOGY, 
Cancer,outside pressure,syphilis,corrosive poisons,contra 
cted cicatrix* 
SYMPTOMS, 
Pain,marasmus,steady advance of the stenosis* 
SEQUELAE, 
Dilatation above the stricture,retention of food,rupture* 
PROGNOSIS, 
Absolutely bad,one year course* 
TREATMENT, 
Jntubation,passing the probang* 
TOBRjgLfflffiAfi SXE. HSL .OflSQFMSUS, 
Occur in the upper part on the posterior wall as a rule* 
ETIOLOGY, 
Gongenital,pulsion and traction,stenosis* 
N*B*Be careful about passing the sound as it may be an 
aneuri sm* 
TREATMENT, 
Surgical,or none* DISEASE OF THE DIESSTIVE SYSTEM* 
mute aasrams. 
ETIOLOGY, 
Alcohol the commonest cause,bad diet,Imprudent eating, 
toxines and corrosives. 
SYMPTOMS, 
Vomiting,fever,prostration,bad pulse at times,headache, 
vertigo,palpi tat ion,gastric pain# 
TREATMENT , 
STARVATION DIET,encourage vomiting unless it has become 
excessive,if so,controls it with morphine#go slowly when 
diet is begun# 
DIAGNOSIS, 
Exclude the gastric crises of tabes,by knee-jerk and Arg- 
yl-Robinson pupil. 
exclude lead colic,by lead line,urine,and occupation# 
sumsmsi frAsrams, 
ETIOLOGY, 
Over-,fast-,and Irregular eating.Alcoho1,constitutional 
disease,l,e,diabetes,rickets,gout,anaemia,etc*passive 
congestion from heart and liver disease* 
PATHOLOGY,THREE TYPES, 
I.Ateophy, II*Hypertrophy* III*Mucous. 
SYMPTOMS, 
Fermentation causing gas,which in turn causes,Belching, 
flatulance, "lump in the stomach11-always wind* 
head ache,vertigo,coated tongue,mal-nutrition. 
prognosis;, 
Depends on the underlying disease,and the extent of the 
anatomical changesjon the willingness and ability on the 
patient*s part to carry uut the treatment;if due to con- 
gest ion, onthe cause of the congestionjBad prognosis in 
the atrophic form,better in the mucous form,good where 
due to imprudence,and the man will stop* 
TREATMENT, 
Remove the cause if possible,have the drinking and eating 
restrictedjbrace up the heart if the cause is there;givd 
TTni-Wash! A*M*and P.M. clean out the stomach thoroughly,if 
washing is too disagreeable,have the patient drink large 
quantities of water* 
DRUGS, 
Give a bitter tonic, 
v- 
Tinc.Nucis Yom* II.-IV. 
Tine. Gentian* A? II#-IV. 
Sig.take before meals# 
Give antifermentative drugs,-RESORCINE, gr#I0-I5,T.I.D# 
r/# : 
Bata Napthol gr#SS# : B/% 
Sod Bicarb# : Sod.bicarb. II# 
Bismuth sub-nit# aa gg V. • Ginger. 
Sig. T ID. s Gentian aa IV. 
Sig.take before meals# DISEASE OF THE DIGESTIVE SYSTEM 
DIET. 
Find out what the patient thinks agrees with him,he generally 
knows what he can best stand. 
a, diet,do not have the milk cold,and give 3—5 pints a day. 
Blitter milk,Koumis, (line water,I To milk,3. )Peptogenic milk is 
very good,(Fairchilde1s peptogenic milk Powder.-follow the dir 
actions on the box.) Curds and jimkett,whey,to these add some 
sparkling water,put in a little salt;or enough tea or coffee 
to flavor it. 
b, Gruels, Oat meal,barley,flour and cracker crumbs,corn meal, 
farina,rice water,potato gruels are good in the mentioned orde 
c,Soups, when the plate can be seen through a soup the soup is nor 
good.Have thick soup,have no fat in it-let soup cool,skim off 
the fat,and then heat again-Chicken soup,Mutton soup,Betff , 
Clam and oyster chowder without the clams or oysters. 
d, juice, have a good meat press,give it either cold or luke 
warm. 
e, Solids,1st. to be given; Eggs on toast,raw chopped beef,chickg 
fish, toast and water crackers* 
N.B. A good trick for delirious patients,is albumen water;cut 
the white of an egg in small pieces,put it in a glass of water 
a good deal of nutrition can be given in this way. 
JBHRQMIC, ,OAS mELS^ 
ETIOLOGY, 
1st. Atony of the stomach wall,caused "by disease or over- 
distension. 
2d, Obstruction of the pyloric orifice,caused most often 
by cancer,hypertrophic stenosis,spasm or idiopathic, 
cicatrix contraction,pressure from without by a neoplasm. 
SYMPTOMS, 
Two definite,the vomiting of enormnus quantities of food, 
the vomiting of food eaten several days before,Thi»st as 
water is not absorbed from the stomach. 
PHYSICAL EXAMINATION, 
Inspection,tumor below umbilicus,wave of peristalsis seen 
at times. 
Palpation,splash. 
Percussion,tympany or dullness changeing with position , 
Tube, fill stomach with water,air,or gas.diagnosis clear. 
PROGNOSIS, 
Depends on the caus e of the dilatation;bad in malignant 
disease,atonic dilatation can be brought down with wash- 
ing, in hypertrophic stenosis of the pyloris it depends on 
the surgeon.depends on the degree of the dilatation and 
the willingness and ability to carry out the treatment. 
TREATMENT, 
Wash, give Hcl,and concentrated food,beef juice,for the 
thirst which is very constant and disagreeable,give water 
sub-cu or by the rectum*Massage is good. Washing breaks 
up the vicious circle Recomposition, gas, dilatation. 
DILATATION QF THE STOMACH, DIET. 
BREAKFAST 
Oatmeal (or Farina, Cracked Wheat, Indian or Rye Meal), with Milk. 
Steak (a Chop, or Soft Boiled Eggs.) 
Toast (or stale Bread.) 
Cocoa (or weak Coffee) 
Fruit. 
DINNER. 
(NOON OR NIGHT.) 
Soup (Puree of Potato, Peas, Flour Soup, Beef or Chicken Broth.) 
Beef Roast (or Lamb, Mutton, Chicken, Sweetbread, Calf’s Brain, 
Ham, Beef Stew, or Fish; Perch, Halibut, Sole, Cod.) 
Potato Mashed, Macaroni, Spinach (or Beans, Peas, Carrots, Lettuce, 
Lentils, Squash, Turnips.) 
Custard (or Bread Pudding, cooked Fruit, Berries, Currants, Prunes, 
Figs, Tamarinds, Melons, Ice Cream, Tapioca, Rice.) 
SUPPER OR LUNCH. 
Oysters (or Chop, Steak, Cold Meat, Fish) with Potato or Spinach, 
Bread. 
Stewed Fruit (or Berries, Figs, Prunes, Tamarinds, Cocoa). 
Form 63. DISEASE OF THE DIGESTIVE SYSTEM 
msiQ \smu 
ETIOLOGY, 
Gastric ulcer in women,duodenal ulcer in men,occurs more 
frequently in late youth,more common in New England, 
there is usually anaemia# 
SYMPTOMS, Ist# type#Pain,sharp and localized just below the ensifor 
coming on just after meals,albuminoids which call out thw 
HC1 cause it most,it is paroxysmal;tenderness in space 
the size of a half doliar*pressure relieves the pain# 
Extreme haemetemesis at times# 
2d* type.No symptoms till perforation, or none at all# 
3d# type#The commonest,simple dyspepsia winding up in 
perforation or hemorrhage# 
DIAGNOSIS, 
Hard,treat all doubtful cases as ulcer* 
PROGNOSIS, 
Depends on the willingness and ability of the patient to 
carry out the treatment#Depends on the probability of re- 
lapse,depends on the promptness of surgical aid 
in case of perforation#As to life -PAIR, As to relapse, 
VERY UNCERTAIN, 
TREATMENT, 
Peed by the rectum# enema of 5 ounces to start with,every 
four hours, push this up to 14 oZ# every eight hours. 
Mix up enema in a pitcher,have it warm,get patient into 
the left Simm!s,put stomach tube up the rectum very slow- 
ly for 8 inches,pour in the enema,and withdraw the tube 
very slowlyjplace a folded towel over the anus and hold 
it tightly for ten minutes# 
Some patients cant stand these enemeta,put in 6 - 10 gtt# 
of tine* of Opium# Have a cleansing enema given each mom 
ing# 
For pain give big doses of Sod, Bicarb# When feeding by 
the mouth is begun,don1t drop enema suddenly,begin with 
peptogenic milk and come back very gradually# 
ENEMA# 
V* 
Peptogenic milk oz# III. 
Beef juice oz# I# 
Eggs I# 
M DISEASE OP THE DIGESTIVE SYSTEM 
DIFFERENTIAL DIAGNOSIS BETWEEN 
OATAERH 
A 
ULCER 
.. _ . . . s 
CAtICER 
AGE 
• 
• 
s 
t 
Any age 
: 
Young people : 
• 
After 40 years 
SEX 
• 
: 
Either 
♦ 
Women : 
Men 
HISTORY 
i 
i 
Depends on the 
i 
Sudden onset,quick: 
Sudden onset. 
: 
cause,usually of 
recovery,except in: 
rather long durat 
: 
rather long durat- 
case of relapse# : 
ion#1f a man of 
: 
ion# 
• 
• 
50 has sudden dys 
• 
I 
pepsia without a 
: 
: 
change of hahits- 
: 
: 
Cancer!! 
• 
A PPEARANCB 
Lack of nutrition 
i 
Anaemia : 
Cachexia 
PAIN 
• 
: 
At all tines or at 
• 
Increases on taking 
All the time# 
: 
any time* 
food,Sod*Bicarb# : 
: 
: 
)S 
releives the pain#: 
LOCALIZEl 
Not localised. 
» 
A definite point : 
May or may not he 
PAIN 
: 
: 
• 
usually# 
just "below the en-: 
siform# : 
present# 
VOMITUS 
i 
: 
No hlood,HC1.dinin 
• 
Bright hlood, : 
Dark hlood. 
: 
ished usually,may 
hyperacidity, : 
anacidity,lactic 
: 
he lactic.Mucus# 
no lactic# : 
present,cells may 
: 
: 
# 
• 
: 
come away# 
BLOOD 
: 
: 
No digestive leu- 
t 
Digestive leucoc- : 
Nodigestive leu- 
EXAM. 
: 
cocytosis# 
ytosis always pres4 
cocytosis.anaemi a 
t 
: 
i 
ent# : 
1 
: 
with normoblasts# 
i 
• 
• 
JL 
: 
i 
L. DISEASE OF THE DIGESTIVE SYSTEM 
2/3 of all cases,especially in women# 
I s t # HYPERESTHESIA, 
Etiology,the most common of all the neuroses,a nervous 
perament,nervous debility,the patient feels things 
she should not feel. 
Diagnosis,made by excluding evry thing else#Sxamine the 
TENTS,mobility,and dilatation# 
Treatment,Put patient right as to habits,remove the cause, 
a good talk is the best thing# 
2d, HYPERSECRETION, 
means too much acid at all times,Hyperacidity means 
too much acid at meal times# 
Etiology,doubtful,anaemia seems to be a factor,it is mtt 
with in chlorotic girls# 
Symptoms#one character!Stic,pain releived by taking food. 
Diagnosis,made by the tube,-The phloroglucin-vanillin tes$, 
take a drop of the reagent and a drop pf the con- 
tents,place them on a porcellean dish together,a 
rose pink color 
Treatment, Have the patient take 6-8 meals a day# 
3d#ACHYLIA GASTRICA NERVOSA,-No acid,diagnosed by the tupe# 
4th#ANOREXIS NERVOSA,-dependent on hysteria. 
5th#BULIMIA, -Excessive hunger# 
6th, AKORIA, -Absense of the sense of repletion# 
7th#MOTOR NEUROSES,-a, increased peristalsis# b,lack of peristalsis# 
TREATMENT,OF Conditions 3 to 7 
Treat the debility,make an attempt to remove the cause 
Neuroses of. the STQMACHt DISEASE OFbTHE DIGESTIVE SYSTEM 
ETIOLOGY, 
Bad food,changes in the weather,anxiety and excitement,con- 
stitutional disease,l,e,Bright,s disease,syphilis,T.3. rick- 
ets, etc«-whereever the vitality is weakened. 
SYMPTOMS. 
CATARRHAL BBfBBRITISj. 
Large Intestine, 
Mucus in stools 
Fresh "blood in stools 
Ho gripes. 
Pain comes and goes,before,during 
and after movement# 
Tenesmus, 
Stools more frequent and 
smaller# 
Small Intestine. 
No mucus in stools, 
Changed blood in the stools 
Terrible gripes,discharge of 
gas and fluid*pain before 
releived by movement* 
Np tenesmus* 
Catarrh of the large intestine is more frequent than of the 
small intestine* 
PROGNOSIS* 
In the primary form it depends on the condition,in the secon- 
ary form it may and often does carry patients off who have 
chronic disease* 
TREATMENT, 
If the patient is seen In the 1st* 24 hrs* or if thereis a 
doubt as to whether he is clear or not*give him a good dose /( 
of castor the stomach is not in order,-give calo- 
mel,gr,II* with In-carb* of soda#The castor oil tends to leag 
the patient constipated*Bismuth Sub-nit. -iVafter every 
movement* Paregoric is an excellent after every 
movement* Pill G.O.T*—camp,opium,and tannin-^&SquiVb1 s mix# 
Rest and warmth, warmth is a great thing in the treatment of 
diarrhoea*Boiled milk should not be continued long.After the 
cleansing out is complete,put in the Opium* 
i.xmmmxm diabrhqea, 
SYMPTOMS, 
Green di schargec, fever, vomit ing,belly swellsbaby cries at nig 
The number of movements is not large usually, 
TI-ILEQ-GQLIT1S- 
SYMPTOMS, 
Usually follows fermentative diarrhoea,Mucus and blood in the 
stools with tenderness along the colonfthe stools are more 
frequent,and the general symptoms worse, 
III, CHOLERA INFAMTIM.. 
SYMPTOMS, 
Great prostration in a short time,infant looks pinched and 
thin,rice water stools,temp,I04°-I05°- or sub-normal,profuse 
vomiting. 
in ommm. Vi biiLfUiE Ur THE DIGESTIVE SYSTEM 
PROGNOSIS, 
In the fermentative form,good for both life and recovery if 
the treatment is carried out# 
In Cholera infantum,Bad,does not depend on the treatment# 
TREATMENT , 
Correct the food and hygenic surrounding»,send the baby out 
into the country or on a sail#Make a change in the food no 
matter what it is,put the child on modified milk or take it 
off it as the case may bejPairchild1s peptogenic milk powder 
is good,(follow the directions on the box),it is a good plan 
to starve a well nourished baby for 24 hrs# 
Medicines, purge with calomel,l/lOgr#every hour for ten doses 
Bismuth Sub-nitrate,5 gr#after every movement#Paregoric# 
If the vomiting is extreme,wash out the stomach# 
In Ileo-colitis,do the above,and wash out the colon,-have the 
baby on its back with its hips raised,and leaning to the left 
side#the amount put in makes no difference,never mind the fus 
the baby may make# 
In Cholera Infantum,try to support the babies strength,give 
opium,stimulate and feed# 
ENTERITIS IN flHILDREN, 
■HLQffiATiYjB, mmm s# 
ETIOLOGY, 
The usual intestinal trouble in chronic cases. Typhoid,amoeb- 
ic dysentery,cancer,T#3# Peritonitis, follicular ulcers,fecal 
ulcers^yphilis# 
DIAGNOSIS, 
Made from t$e stools,Blood,pus mucus andshreads, 
PROGNOSIS, 
Hard to cure,depends on the underlying cause,may run a long 
course# 
TREATMENT, 
Ikiqtlid diet absolutely,irrigation from below,surgical treat- 
ment has been resorted to with good results,an artificial an- 
us is made and the colon given a rest,and irrigated to an ex- 
cessive degree with AgNOg (1-1000 in all ordinary cases,) 
-the irrigation is often very painful at first# DISEASE OF THE DIGESTIVE SYSTEM 
appmdicitis. 
ETIOLOGY, 
More common in men ,and in young adults# 
SYMPTOMS, 
Extreme pain,constipation,vomiting,fever,high pulse rate,pain 
starts general and becomes local,or visa versa,LOCAL TENDER- 
NESS, anuria, or polyuria;Muscular Spasmof 1st* the abdominal 
wall,then the legs are drawn up,the patient walks with a list 
to starboard#RSCTAL EXAM#very important,shows great tendemeg 
The pain may be in the epigastrium,in the crotch or sharply 
localized at Me* point#LEUCOCYTOSIS,and TUMOR# 
DIFFERENTIAL DIAGNOSIS, 
Think of Belly ache in men,and of the Tubes in women# 
FROM BELLY-ACHE,common in malaria,ruled out by lack of local- 
ized tenderness,and blood exam,and temp# anenema will releive 
a belly ache ,it will not affect appendicitis# 
FROM RENAL COLIC,no temp#nospasm,no leucocytosis,pain in back 
FROM TYPHOID FEVER,bacilli in the stools,No leucocytosis in 
typhoid,no localized tenderness,Widal reaction# 
FROM CHOLI-LYTHIASIS,AND GHOLI-CYSTITIS, by jaundice when 
present,by age,person,and sex#No leucocytosis,nothing by the 
rectum,history of stone,pain not localized in the same spot, 
by the character of the spasm and tenderness# 
FROM SALPINGITIS AND OVARIAN CYST WITH A TWISTED PEDICLE 
by negative vaginal,and history# 
TREATMENT, 
The Surgical treatment -tooperate is the best, 
Medical treatment, absolutely starve the patient until the 
symptoms subsideto prevent peristalsis; give morphine. 
The symptoms usually go down in a week# 
mmQEgQS I&, 
Two forms,that with symptoms;and that without symptoms;the latter is 
usually the worst as far as displacement goes* 
ETIOLOGY, 
Frequent pregnencies,neurasthenia,sudden loss of weight# 
SYMPTOMS, 
Those of nervous dyspepsia# 
TREATMENT, 
That of neurasthenia, a support is good in some cases# 
An unknown disease, 
SYMPTOMS, Pain and the passage of mucus,patient comes with mucus in a 
“bottle,he thinks he has cancer,hard disease to cure,drugs 
,do no good,must he treated as neurasthenia# 
MUGQUS GQLITlSf DISEASE OF THE DIGESTIVE SYSTEM 
ETIOLOGY, 
STRANGULATION,the commonest form in adults 
INTUSUBCEPTION," " " " children 
Knots and twists,hernia with strangulation,strictures,tumors, 
foreign “bodies,tumors outside,fecal impaction# 
SYMPTOMS , 
Constipation.Bloody discharge in intussusception,which may 
follow an enema.Pain,Vomiting of a stercoraceous nature is 
characteristic# tympany, tumor, symptoms of col lapse, usually no fever 
DIAGNOSIS, 
General peritonitis gives these symptoms,it is differentiated 
“by the temp#“being higher,greater and mow® diffuse pain,ahdo- 
men more rigid# 
Acute Pancreatitis, and Thrombosis,of the mjpsenterlc artery# 
are diagnosed only “by incision# 
PROGNOSIS, 
Dep- nds on the cause,and on the promptness of operation.The 
higher the lesion the worse the prognosis,the prognosis is 
“better in cases dependent on tumors and foreign “bodies. 
TREATMENT, 
Depends on the cause,operate in all cases,except where due to 
fecal impaction,here use an ice cream soda spoon and clean 
out the rectum,“being careful not to puncture the intestine. 
Give an oil enema,-I pint of olive oil high. 
N.B. 
The mass in fecal impaction is moveable;press on it with the thun® 
for ten minutes,then wait for awhile,and feel again,the indentatig 
is easily felt# 
A common stricture due to cancer of the sigmoid is recognized “by 
the small rihbon like fecal mass that is passed# 
INTESTINAL OBSTRUCTION. 
GOWaMPmOM, 
FORMS, 
Two - that with symptoms ,and that with out symptoms# 
TREATMENT, 
Have the patient make regular attempts to move the “bowels, 
Diet,such that will stimulate the intestines,-fruit and “brown 
“bread# "All strings,all stones,all skin and “bones# "-Bramwell# 
Exercisers a very important thing,it will produce movements 
often where nothing else will,massage is good#5ater “before 
going to “bed and “before “breakfast# 
Drugs,Cascara II-IIIgr# pill T.I.D.of the dried extract# 
Senna is good as a tea.mlnoral waters,Rhei pills. Comp.Liq, 
powder. A#S#& B.pills( 1/60 strychnine.) 
miusmas joe. m 
ETIOLOGY, 
Congenital or Acquired,Idiopathic, found in children,6-I0 yrs 
old# 
SYMPTOMS, Chi Id strutting around with a hig “belly and enormous consti- 
pation# Surgical treatment. 36. DISEASE JOE. mi LLVm 
JAUNDICE, -OBSTRUCTIVE AND TOXIC- 
a, OBSTRUCTIVE JAUNDICE, 
CAUSES, -in order of frequency. 
Catarrh,gall stones,malignant disease,cirrhosis of the liver, 
heart disease,with passive congestion#Rare causes-stricture 
or obliteration of the duct,pregnancy,-very rare,Fecal accu- 
mulations,parasites,disease of the liver,colangitis,etc.etc# 
b, TOXIC JAUNDICE, 
Yellow fever,malaria,where ever the blood corpuscles are S*H 
up by a disease, WEIL’S DISEASE,in fact all infectious diseas 
es which are not understood and are accompanied by jaundice# 
c, Neonatorum, 
Probably an obstructive form. 
SYMPTOMS OP JAUNDICE IN GENERAL 
Coloration of the skin,urine,conjunctivae,and sweat:the feces 
are clay colored.Cerebral symptoms,patient is depressed,blue 
and melancholic. There is intense itching of the shin,there i 
is a tendency to hemorrhage after injury. 
CATARRHAL JAUNDIGET 
SYMPTOMS, 
It is the commonest of all forms,is caused by gastro-enteritj 
Gastric disturbances with its general symptoms,always watch 
the conjunctivae in gastric cases,you ought to see it before 
the family.The dyspeptic symptoms last a few days,the jaundig 
runs on about six weeks.it ought to clear up in that time. 
PROGNOSIS 
The acute symptoms disappear in 10 days,the color runs along. 
TREATMENT, 
Treat the gastric symptoms,move the bowels;as soon as the gas 
trie symptoms are over give pil, Fel-Bovis gr.3-6 ,3-5 pills 
T.I.D. For the ithhing give a dusting powder—ZnO drachms# 
Starch II OZ#—or a 2$ sol. of carbolic acid# An alkaline bgt 
a cup of soda bicarb.in a sitz bath# Don’t keep thh patient 
the in bed unless he has fever#cheer him up# 
Asutfl, YELLOW mm jal J&s. MYER# 
A very rare disease,the name gives the whole thing away,it is exactly 
what its name implies# 
SYMPTOMS, 
Cerebral symptoms of a very marked character,fever,the urine 
contains leucin and tyrosine;the jaundice is very marked# 
PROGNOSIS, 
Absolutely had,lasts about two weeks at the outside# 
TREATMENT, 
Symptomatic# DISEASE OP THE LIVER 
GHOJiBLITHIAfiTS, 
ETIOLOGY, 
Prom some sourse,probably bacterial,a catarrh is started up 
in the doct,bile salts are deposited and a stone is formed# 
It occurs more often in women after forty years of age; 
Dr#Bigelow1 s aphorism,-Pat, Old, women#" 
SYMPTOMS, 
There may be none,if there are any they depend on where the 
stone is loggdd# 
a, STONE IN THE COMMON DUCT# 
I, Those whicfe occlude the duct# 
Intense jaundice,and If does not vary,the gall bladder is not 
filled up,there is no inflammatory condition,we have obstruc- 
tion only,there are the general symptoms of jaundice,gall « 
stone colic,intense pain with its symptoms#If nothing is done 
the man may die,if the stone passes on,all right,if operated, 
all right;if it breaks through,there may be formed an 
nal biliary fistula most commonly,or a rupture may take place 
into the peritoneal cavity,into the colon,liver substance, 
through the pleura,or another opening may be made into the 
intestine# 
II, Those which do not occlude the duct# 
The general syffljitoms of jaundice are present,the jaundice is 
less intense,and does not remain a steady hue; the gall bladd|i 
is filled up,colic,chills,& fever,sweating# 
The inflammatory symptoms arelst#Non-suppurative,-2d,Suppura- 
tive# In the suppurative,the fever is up all the time,the 
symptoms run right along,there Results suppuration in the llv 
er,multiple abscess if the liver follows colangitis,In the 
non-suppurative form,the symptoms come on in paroxysms,the 
patient is alright in the interval,- this is the form for w 
which operation is most often done# 
b, STOHIIN THE CYSTIC DUCT, 
SYMPTOMS, Never any Jaundice,the gall bladder is enlarged to an enor- 
mous degree,it can be felt,the symptoms of colic are presen t# 
c, STONE IN THE HEPATIC DUCT, 
SYMPTOMS, The same as those of the common duct,JAUNDICE# DISEASE OF THE LIVER 
gHQLAflams, 
An incomplete obstruction with suppuration. 
SYMPTOMS, 
Those of a suppurative process#The liver is enlarged and ten- 
der# The physical signs are like those of empyema# 
■SflQIiBCIISmLTIS# 
Stones in the gall bladder with or without suppuration# 
SYMPTOMS, 
Pain,tenderness,tumor,fever,no colic# 
The stones may ulcerate through into the intestine and cause 
oh struct ion. They may become solid and oUliterate the gall 
■bladder,-this is a good thing to have happen# 
TREATMENT OP GALL STONE COLIC# 
Morphine for the pain,-don’t give much as the pain is often 
trancient,and pain is the antidote for morphine#Counter irri- 
tation and chloroform,and the treatment of jaundice in gener- 
al# Surgery is indicated to remove the cause# 
PROGNOSIS, 
Depends on the location and size of the sto the stone 
is in t&e cystic duct there is a better prognosis than when 
it is elsewhere#There is great likelyhood of recurrence# 
Prognosis is surgical# 
quqsdsi s sxl m jam. 
CLINICAL GLASSIFICATION. 
I.Alcoholic,II.Hanot1 s Disease,III.Syphilitic,IV.Perihepititl 
SYMPTOMS, C 
of Alcoholic cirrhosis,it occurs in two forms,Big & small# 
There may he no symptoms,ahoixt half the cases have none#where 
there are symptoms they are due to one cause,congestion of 
the portal circulation.-enlarged spleen,congestion of the 
stomach with indigestion and hemorrhage.Caput meduca,an 
attempt at compensation hy the superficial circulation# 
General oedema,ascites,dyspnoea,intestinal hemorrhage,pain 
caused hy stretching the capsulefhemorrhoids,jaundice in many 
cases# 
PHYSICAL SIGNS, Hypocratic facies,ascites with flatness in the flanks 
and tympany in the median lina,wave transmit ted, liver enlargg 
heart displaced,liver not tender,may he normal or small,shown 
hy percussion# 
PROGNOSIS, Hopeless ultimately,the disease may lessen in severity,the 
patient only lives two years after compensation is broken as 
shown hy ascites#They die of exhaustion or hemorrhage from 
the stomach may he fatal at any time# 
TREATMENT, Tapp for the ascites,-have the bladder empty,select a poin 
about two iinches ahovethe pubes in the median line.use a good 
sized trochar#permanent drainage cannot he established# 
Surgery has been employed and adhesions encouraged to produce 
compensation. DISEASE OP THE LIVER 
CIRRHOSIS, 
III#SYPHILITIC CIRRHOSIS# 
At autopsy the liver is covered with large noduJ.es,the disease 
improves with KI treatment#It is not curablej the history gives 
the clue to the diagnosis# 
IV.CAPSULAR CIRRHOSIS,(PERIHSPITITIS). 
It is never diagnosed during life,when ascites appears in a 
young person,it is to be suspected.lt is a rare affection.At 
autopsy the liver appear% as if frosted over# 
ETIOLOGY 
ABSCESS SSL mi IiIVER, 
Some infectious agent, of ten the amoeba coli,or it may come 
from the systemic circulation,a septic embolusjmay come from 
the gall duct by extension# 
TROPICALnABSCESS , 
Is common in the south,found in the right lobe,a large absces 
the etiology is uncertain# s 
DIAGNOSIS, 
Pain,liver enlarged,leucocytosis,|ms temp# septic pulse,chilj 
sweating,cachexia,tenderness,may be mistaken for empyema,or 
typhoid,malaria,#the line of dullness is not Garland*s curve# 
COURSE, 
Tropical abscess may exist for years,it may evacuate external 
ly,or through the diaghpragm or pleurae# Multiple abscess may 
follow,it only lasts a few days,is always fatal# 
TREATMENT, Surg i cal only# 
NSQRLASSI. M. m LLYiSR# 
Secondary usually to cancer of the stomach,or bile duct jit may be pri 
mary# There is marked ,pain,cachexia, tumor# 
FaJbta, INFILTRATION JOE. m LLY.ER# 
The Beer drinkers liver 
FA my DBGSMIAZIQH, HE. M JjI30BR, 
Follows phosperous,antimony poisoning ,and Acute Yellow Atrophy# 
AMMM1D IiIlMU 
Big,smooth liver,in syphilis orr suppuration# 
N#B# It is important to remember that the liver may be anomalous in 
form, so that its percussion area and palpation are much changed DISEASE OF THE PANCREAS 
Any acute affection with sudden,violent,and intense symptoms,points 
to the pancreas after the exclusion of other causes* 
SYMPTOMS and PHYSICAL SIGNS. 
There is tenderness ofeth the anatomical position of the pancre- 
as. there is a tumor above the stomach and below the colon,or 
between the two. Glycosuria,Fatty stools.Collapse, and hemorrhage 
with its symptoms. 
AGm PAIIQRSAnXIS, 
Fever and chill# 
Glycosuria and fatty stools,little points of tenderness all over 
the abdomen point to the pancreas,due to fat necrosis. 
swsmsL pancreatitis. 
Neoplasm of the PANgRRAS . 
Of surgical importance only. 
cyst mi pancreas. 
Diagnosed by the tapped fluid,which will give the digestive te| 
of the pancreatic fluid# 
DISEASE OPnTHE KIDNEY 
ESBimSRLna, ABSCESS , 
SYMPTOMS, 
Pain "below the ribs behind,tenderness,constitutional distur b 
ance. 
DIAGNOSIS, 
Prom hydronephrosis by the symptoms,always examine for lumba- 
go, 
PROGNOSIS, 
The abscess usually points out,not bad if then opened*it may 
break into the kidney or abdominal cavity# 
TREATMENT , Surgical# JBBRIZQHITIP,ACUTE .GENERAL. 
ETIOLOGY, 
GENERAL CAUSES,-waisting disease,tuberculosis,nephritis,syph- 
ilis,diabetes,gout,general septicaemia,malignant endocarditis 
LOCAL CAUSES,-a,Dlge stive svstemfI,Stomach,perforat1on of ul- 
cer, cancerjuiceration of the intestinal tract,appendicitis, 
typhoid,dysentery,T.B,syphilis,hemorrhoids,cancer of the rec- 
diverticulumstarting up a suppuration*Embolism 
of the dysenteric artery,hernia,obstruction,trauma from gall 
Stone* bjFemale Generative Organs,endometritis,gonorrhoea,pel 
vie peritonitis, rupture of the uterus,abscess of the ovary, 
extra-uterine pregnancy,rupture of the vagina,ovarian cyst 
with a twisted pedicle* c,Bladder,rupture,cancer,nr suppurat- 
ion, d. Liver, gall stone,and disease of the liver* e. Spleen 
abscess* f, Pancreay, abscess and acute pancreatitis, 
g,Wounds, from operation and injury. hjj&aaa* psoas, and bone 
abscess* 
SYMPTOMS, 
Pain,depending on motion,especially on vomitihg & at stool. 
great. 
Distension ojiJSiJSidity, tympany, dyspnoea, palp it at ion. 
Pulse,easily compressible,high rate. Facies,mental condition 
clear to the end,Temp, not character!stic,Urine contains Indi 
can. Constipation, Faecal Vomiting,constant and distressing, 
it rolls up. Liver dullness decreased or absent in front,nor- 
mal at back and sides* 
DIFFERENTIAL DIAGNOSIS, 
Acute pancreatitis ruled out by the stools,tumor,glycosuria, 
and localized pain* Obstruction,by history,less sudden onset, 
less fever.Ovarian cyst with twisted pedicle,Embolism of the 
mysenteric artery, 
PROGNOSIS, Almost always fatal,depends on the cause,-the bug-,a rup- 
tured tube gives fairly good prog*In perforation of the intes 
tine,the higher the perforation the better the prognosis* 
A cloudy prognosis fluid is better than other products. 
TREATMENT, Surgical, open up ! no case is hopeless. 
CANCER mL M PSRIIQMJM* 
Many small tumors with cachexia and ascites. 
DIAGNOSIS, 
A wave of fluctuation transmitted through the abdominal cavit 
from side to side,not through the abdominal wall*Dullness 
the flanks,tympany in the median line;this changes with 
of position* 
Causes, Portal obstruction,cardiac and renal disease* 
DIFFERENTIAL DIAGNOSIS, 
T*B* peritonitis ruled out by history,evidences of T.B,else- 
where, and temperature is up in T.B.never is in ascites* 
Ovarian cyst by the physical signs* 
AafiMJSg, DISEASE OP THE KIDNEY 
URAEMIA, 
SYMPTOMS, 
I symptoms,- headache, vomiting, twitching, convulsions 
delerium,coma,amaurosis(suddehblindness) ,with normal eye-sigh 
returning.mental symptoms,hemiplegia due to toxines* 
IT - Circulatory symptoms, oedema, from the vessles and lymphatig 
the normal current is delayed;it usually begins in the face* 
anasarca,oedema of the hrain and serous cavities,-pleurae, 
peritoneum,pericardium and lungs* 
III* Skin, either dry or very sweaty* 
IV* Eye symptoms, retinitis,new and old hemorrhages* 
V* Blood, secondary anaemia often severe, a leucocytosis may 
in uraemia. 
•VI* Diarrhoea,hemorrhages, epistaxis, foul breath,-chronic urae 
mia is hard to diagnose,the symptoms are those of debility* 
THE HEART IN KIDNEY DISEASE, 
It may be greatly hypertrophied,this hypertrophy is most mark 
ed in chronic interstitial,next in chronic perenchymatous.lt 
is found in acute nephritis,the pulse is hard and has high 
tension.The heart dilates,causing mitral regurgitation as the 
most common lesion,wlth all its symptoms* 
ACUTE NEPHRITIS, 
First Stage, Amount —very low* 
Color — high or dark, (reds & "browns) 
Sp„ G-r*-- usually high* 
Albumen - Pius* 
Sediment,—Blood in all varieties,free and on 
casts,brown granular casts,epithelial 
casts* fatty casts appear late* 
Second stage,Amount increases,all other elements decrease hut 
fat,which increases throttgh convalescence* 
CHRONIC DIFFUSE NEPHRITIS, 
Amount, — small, 400 - 600 cc* 
COLOR — pale 
sp» Or- — low 
Albunfm, — i/b - 1/4 % 
Sediment, — fatty casts in large numbirr3,hlood 
not found* 
CHRONIC INTERSTITIAL NEPHRITIS, 
Amount —large,more night than day* 
Color. — pale 
— low 
Albumen —a trace 
Sediment —Hyaline & finely granular casts* 
N*B* Almost every man shows the urine of Chronic interstitial after 
he is fifty years old* DISEASE OP THE KIDNEY 
Mmiiu* 
THE APPEARANCE OF URAEMIA IN NEPHRITIS, 
In, acute nenhritisr apt to come on early,may be 1st. symptom; 
may appear late. 
In chronic interstitial,it occurs at the end if it occurs at all 
In chronic Uraemia is seen most frequently here,it comg 
with low amounts,it is early and presistent 
thisis the typical form of the disease where 
dropsy is seen# 
ETIOLOGY, 
Exposure to cold,scarlet fever,yellow fever,diphtheria.salol, 
KclOj, turpentine • Acute nephritis,most common cause is 
pregnency . chronic diffuse,-no etiology known, chronic in- 
terstitial, arterio-sclerosis,resulting from alcohol,& syphil 
is.also lead poisoning. 
COURSE, a, acTfte nephritis,- recovery in about two months,the patien 
may die in two days or at any time during the course . 
b, chronic diffuse, -19 months ,the average duration# 
c, chronic interstitial,- may run for years,patient 
dies of an intercurrent affection. 
TREATMENT, 
a, Acute nephritisTI« Diet,-apure milk diet as it is an excel 
lent diuretic and is least irritating. 
IJ,-Purging,-J- -I oz. MgS04 in black coffee,every second day. 
III. -Hot air bath,-f hour,if the patient sweats,with whiskey 
and plenty of water,every two days. 
IV. Pilocarpine,except in cases of lung disease or unconscious 
ness, 
V. letting,-if the above donft work,take out one pint. 
VI. Diuresis, potassium citrate,cream of tartar water,diuretin 
water. 
b, Diffuse nephritis,I* G-ood food and lots of it.treat 
the anaemia with iron.and the high tension pulse with nitro- 
glycerine. 
Interstitial Nephritis## same treatment. 
The presence of blood corpuscles in the urine. 
LOCAL CAUSES, in the kidney;trauma,neoplasm,stone,especially oxilates 
in the bladder; 1 B H cystitia. 
in the urethra, 1 • 
GENERAL &&U8BS, 
Acute nephritis,exaccerbation of a chronic nephritis,toxines 
of infectious fevers,malaria,-the commonest cause.any fever 
may produce it.poisons -cantharades,Kcl03, turpentine,hemorrlu- 
agic diseases-scurvy,purpura,haemophelia,In about fflOjk of all 
cases there is no known cause. 
HAMAXURIA# DISEASE OF THE KIDNEY 
■ HAMQ GLQBINUR1 A 
The presence of blood pigment in the urine# 
PAROXYSMAL TYPE, no known cause,it is the one disease that cold seems 
to be the etiological factor in#It is toeompanied by chill 
and fever# 
TOXIC FORM, Results from CO,and the eoal tar anti-pyretics, 
snake poisons and malaria# 
Emms, 
ETIOLOGY, 
It usually exists aa a complication,as a result of an infect- 
ion of the kidney itself or a process spreading up from below 
It is found in infective processes where the bacteria are 
eliminated by the kidney#stone and T#B# are the commonest « 
causes# 
Diagnosis, 
Pain and tenderness in the region of the kidney,constitution- 
al symptoms of a septic process.Sediment,pus with blood,the 
cells don*t mean any thing, differentiated from new growth,by 
lack of tumor,presence of tadiment and symptoms of sepsis,and 
less blood# 
PROGNOSIS, Depends on the physical condition of the patient and cause 
TREATMENT, Surg leal# 
HYDRONEPHROSIS# 
ETIOLOGY, Obstruction of theureter,congenital cystic kidney# 
SYMPTOMS, Tumor in the kidney region,no fever,periodically polyuria 
with the tumor disappearing# 
DIAGNOSIS,Told from spleen hy lack of edge with notches,and the splee 
moves on respiration#Mallgnant disease id ruled out hy lack n 
of constitutional disturbance,age, pain and hleeding#Prom 
pyonephrosis,hy urine exam# and general symptoms# 
PROGNOSIS, Depends on the cause# 
TREATMENT, Surgi cal# 
mm. calculus# 
Uric acid,phosphatic,or oxalic stones. 
SYMPTOMS,Intense paroxysmal pain,running down into the testis and 
thigh,sometimes up#sudden stoppage of urine followed hy haema 
turia#large quantities of uric acid crystals in the urine,the 
patient gives history of gouty diathesis# 
DIAGNOSIS, differentiated from malignant disease hy tumor,character 
of the pain,and general condition,neuralgia and colic occur 
without cause,the X ray helps# 
tumor m. m mm, 
ETIOLOGY, In children and after forty years of age# 
SYMPTOMS, THose of kidney trouble,sarcoma!s the commonest form in kig 
PROGNOSIS, Surgical,recurrence is very probabje* QQMSTITtfTIOHAIt JttaSASBS, 
arthritis imams 
FORMS, three, 
a, Haberdens nodesfswellings on the backs and sides of the last 
phalanges, here the disease stops,perhaps there is a little pain 
b, Spindle every thing in the joint is destroyed,when it 
once gets into a joint it never leaves it,there is an effusion, 
it spreads from joint to joint,the muscles atrophy;there is so 
pain as a rule,though at times it is severe,usually no fever. 
This form of the disease is common in young neurotic women.It 
has an acute stage and a final stage of contractures,the fingers 
are deflected to the ulnar side. 
c, Qsteo-arthritic,a symetrical new formation of hone in partic- 
ularly inconvenient places,causeing locking of the joints hy 
exostoses,this form is seen in elderly men,finally one position 
must he maintained.The spine is affected,Spondilitis Deformans. 
PROGNOSIS, 
Life unaffected,recovery impossible,surgery has of late been h 
helping by the removal of the exostoses with a chisel and by the 
excision of the joints-aflail joint is better than a rigid one# 
TREATMENT, 
a. none for the Haberdens nodes, 
b. For the spindle joints,massage,hygene,increased and better 
diet,tonics, hot air is a good thing,-a baking machine. 
c. For the osteo-arthritic form,surgery,and hot air for the pain 
a,CHRONIC RHEUMATISM, 
Never make a diagnosis of this disease without excluding every 
thing else first.No pathology,not understood,usually senile « 
Symptoms,pain,excited hy motion and had weather,stiff joints* 
Treatment, heat,massage,don1t let an old person go to bed. 
h, MUSCULAR RHEUMATISM, a pain in the muscles. 
Lumbago is a form ,pain catches the patient when he moves sudden 
ly,as in stooping over,or getting out of a chair.exercise Letter 
Treatriifcftt, it. 
Massage,cupping,heat,mechanical support.directions-"Go to a man 
who deals in leather,get a piece about 8M wide and as broad as 
your backfget your wife to pad this,lace it up in front,tight." 
rheimatism. 
ETIOLOGY, rare,hnt8 cases at the M.G.H# since start, food, dr ink,men, 
foriign hirth. 
Acute form, 1st.joint of great toe,swollen and very tender,worse at 
night,runs 6 to 8 days. 
Chronic formrT6r>hi on the fingers and ears,little pieces of chalk*the 
English Prime Ministers could write their names with their flnge 
Arterio-sclerosis,explains all the othersymptoms of gout,i.e.uraemia, 
myocardi t i s,hemorrhage# 
Treatment, Remove had hah its, support and laudnum for the joint,morph- 
ine for the pain* 
flOUT T -PODAGRA- . CONSTITUTIONAL DISEASES 
diasbbbs mams , 
SYMPTOMS, 
The direct symptoms are self evident,such as hunger thirst,poly- 
uria, etc* the indirect symptoms,which should lead to a urine test 
are important,these are,— 
Emation in a young person,JjkjLa*pruritis,exzema of the vulva,bal- 
anitis,skin rough and dry,dry hair,alopecia,perforating ulcer, 
gangrene,furunculosis,carbtmcle,slow repair after an injury* 
g,er.fihr,al and Nervous TRetinitis,cataract,neuralgia,siatica,inter 
costal, and diffuse head neuralgia*neuritis,pains like those of 
tabes,atrophy of the optic nerve* 
Sexual symptoms, impotence and amenorrhofta.Pulmonary^rdithisis 
and pneumonia*Ranal,alhuminuria* Circulatory arterio-sclerosis 
and hypertrophyed heart* Bowels,usually constipated obstinately* 
Mouthy dry, thrush and stomatitis, .jlflffla* characterized by a peculi- 
ar dyspnoea, 8air hunger®,and sweetish odor of the breath* 
Qthersf loss of knee jer$,facial paralysis,changes in disposit- 
ion* 
DIAGNOSIS, 
Any permanent glycosuria,is diabetes mellitus* 
TESTS for SUGAR in the URINE* 
Qualitative test,Pehling!s test* 
Quantitative test,Fermentation test*-take 6 to 8 oz*of urine, 
note Sp.Gr* put it in an open flask or dish*add i cake of yeast, 
let if stand in a warm place over night,or until the sugar test 
is absent,then note the Sp*Gr* multiply every degree lost by«237 
this gives an accurate result in the percentage of sugar* 
PROGNOSIS, 
Depends on the age,a thin young person,BAD*a fat old person,GOOD 
for life in both cases,for recovery in all cases bad*young peo- 
ple live two years,steadily progressing to death*Where a cause 
like tumor of the brain or syphilis can be removed the prognosis 
is better* 
TREATMENT, 
DIET, a. Things the patient must fiat * Fat aj-pnrkjhannny ham, fat bee 
3 oz*butter a day*cream,2 tablespoons full of olive oil a Hay,on 
a salad,olives,green cheese,almonds,sardines,mackerel* 
b, TiUflgS ,th£L patient Kay..-fia.t|~Meats,eggs,fish,clams,shell fish, 
oysters without their livers,clear soups,vegetables,lettuce,cu- 
cumb ers,radi shes , french peas ,asparagus, cabbage ,miIk* 
For sweatening,use saccharine,all they want* 
Drinks,cut down alcohol to any extent,light wine and small beer 
may be taken* 
Carbohydrates,are denied because the sugar consuming cells must 
be rested,the symptoms,polyuri a,and thirst are removed,and the 
liability to such complications as gangrene,cataract,etc,are les 
bread^gluten bread is hard to get,Dr*Cabot1s bread,-equal parts8 
graham flour and fresh bran,mix,of this take one cup full,add 3 
eggs,I teaspoon full of baking powder*make a thin batter and b 
bake in buttered pans into rolls* CONSTITUTIONAL DISEASES 
DIABETES MSLLITUS , 
TREATMENT, 
Medicinal treatment. Opium and codeine help stop the sugar excre 
tion in advanced cases,Bromides often help nervous casesjno drug 
is of any value*Exercise does good in cases where the muscles 
are good*Severe cases,make themdiet and watch their urine* 
Mild cases,have them diet 3 periods of 3 weeks each a year* 
Rich cases often improve with the strict life of a spa* 
COMA* give an *8% - *9% salt sol* intravenously,the patient will 
often recover enough to make a will,acetone and fliacetic acid 
predict the approach of coma* 
DIABETES, INSIPIDUS, 
The passage of a large amount of urine which does not contain sugar, 
it has nothing to do with diabetes mellltus* 
prognosis, good* treatment, none* 
SYMPTOMS, 
The rickety rosary*thickening of the epiphyses at the ankle and 
wrists,failure to ossify,late closure of the fontanelles,cranio- 
tabes,the square richitlc head,big frontal eminences,pigeon and 
funnel breast,protruding belly,liver and spjeen enlarged,blood 
shows an anaemia,urine no change# 
sweating,boreing of the head into the pillow,wearing hair off 
the back,bed clothes thrown off,digestive disturbances# 
COURSE, 
Well in two years if the faulty feeding,-lack of lime salts and 
fat- is remedied# 
PROGNOSIS, 
Favorable,depends on return to good feeding# 
TREATMENT, 
Proper diet,out of doors life#One drug of service,Phosperous, 
gr# 1/100 in pill,T#I,D# 
RICHITIS, (RICKETS) INFECTIOUS DISEASES 
ETIOLOGY, 
The TYPHOID BACILLUS, from drinking water,mi Ik, oysters and other 
food,flies and insects carry it,dust,most common in the autum, 
males and females alike,more common in young adults# 
SYMPTOMS, 
Prodromal stage, patient feels mean and tired,poor apetite,poor 
sleep,slight fever,constipated in most cases,headache,nose bleed 
bronchitis,-look out for this in diagnosis, 
Ist»wsek, Patient in bed,fever,headache,no local symptoms,weak 
pulse but not fast,morning remission in temperature# 
2d, and 3d* week#Rose spots,spleen enlarged,¥edal reaction, 
Diazo react ion,patient dull and heavy,running into low muttering 
delirium,carphologia,sub-sultus tendinum* 
ad finem# Lose flesh,temp keeps up,great abdominal tenderness* 
mam jams. 
TEMPERATURE CHART , TYPI GAL* 
Ist.week 
2d* week 
3d. week 
4thweek 
COMPLICATIONS, 
The HEART,weakened,Ist* sound becomes valvular in later weekswhen 
the heart is fatty# 
HEMORRHAGE,recognized bybrise in pulse and fall in temp*b!ood 
seenin the discharges,ocurrs in 25$ of all cases in middle week 
PERFOHATION,pain,di s t ens1on,t end ernes s,puls e up,t emp* down,r egid2 
ity,tenderness local becoming general# 
APPENDICITIS,if perforation takes place here,better prognosis 
than elsewhere* 
THROMBOSIS,venous trunks swollen and tenderto the touch# 
PNEUMONIA,due to the typhoid bacillus or other bug taking advan- 
tage of the weakened resistance* 
CYSTITIS, In about i of the cases* 
NEPHRITIS, rare* 
PAROTITIS,PLEORALnEFFUSION,MENINGITIS,The SPLEEN may be so enlar 
ged as to cause pain*PERIOSTITIS,and OSTEO-MYELITIS are sequelae 
RELAPSE, 
"kick ups11 in the temp*after it has reached normal are 
called recrudescences,due to excitement or error in diet.a kick- 
up on an elevated temp*is a reinfection*Y/Iien after the temp is 
down it rises again in the typical way ,we have a relapse,these 
relapses are not so severe as the first attack but we have all 
the symptoms* INFECTIOUS DISEASES 
MIS, JSSSM., 
DIFFERENTIAL DIAGNOSIS, 
In all affections characterized by pyrexia,think of typhoid. 
Malaria*ThAestivo-autumnale form is often confusing,the "blood ex- 
amination shows the presence of malarial organism# In the Span- 
ish War,Dr#Oabot went to Peurto Rico on the hospital ship,Bay- 
State,at Pounce,a military hospital contained 600 patients,all 
of whom were getting quinine,T#I#D#for malaria,With six assist- 
ants Dr#0 went over the "blood with n microscope,finding 560 of 
the cases typhoid,and 40 malaria# 
Malignant Endocarditis, the positive signs of typhoid are absent, 
there is a leucocytesis,bacteria are seen in the blood,temp#is 
more irregular with chills and sweating,tendency to embolism# 
the heart lesions are demonstrable# 
Pvemiafthere are the constitutional manifestations of a local absc- 
ess,leucocytosis,and the other features of endocarditis without 
embolism or heart lesion# 
Append!citiSy Pain may exist in typhoid,but the positive signs are 
lacking,spleen enlarged,rose spots absent,local abscess,rectal 
exanugives tumor in the region,leucocytosis# 
Enteritis^positive signs adsent,fever not as continuous,no mental 
dullness,-hard to separate at times# 
MeningitisfGerebro-spinaL signa lacking,mental dullness 
greater,headache more presistant,strabismus,irregular pupils, 
head retracted,deep coma,leucocytosis always presen^Kernig1s 
sign#lumbar puncture# 
Pne-umQniafmental state different,sputum even in central cases,leu- 
cocytosls,positive signs absent,rapid respiration# 
rnfinertpositive signs absent,short course,may confuse for a few 
days# 
Yellow Fever,mind clear,slow pulse,severe nephritis,jaundice,no pos 
itive signs# 
Miliary T*3,.A focus can be found in lung#testis,or bone#mind clear, 
cyanosis,positive signs absent# 
Insipient phthlsis*and T*B*peritonitis>tuberculine test,history# 
Trichinosiaf A large $ of eosinephiles,muscular tenderness and pain 
rose spots and spleen may be present,other signs abs#Take a pigo 
of the muscle and examine it with n microscope# 
PROGNOSIS, 
Age;children rarely die,old people usually#A drunkard or a per- 
son weakened by disease has a poor chance#Fat people bad#Early 
and presistently high temp#weak heart,dicrotic pulse,sub-sultus 
tendinum,carphologia,relaxed spineters,all bad# 10 to 20$ die# INFECTIOUS DISEASES 
TY?HQLD, WM* 
treatment. 
Bed from the first,liquid dlet-6 oz# every four hours day and 
night,wake the patient to take food#cleansing enemata everySd# 
day for the bowels#Laxatives# 
TEE HEART,when it shows signs of dierotism or flagging,give a 
stimulant,whiskey i oz#strychnia,l/40gr#eve ry 4 hours# Tine# 
digitalis,sub-cu# or Tby the drachm#give it full length of 
the needle straight down ihto the tissues,do these things to 9 
pull a patient through# 
Hn)RO-THERAPY,bath every four hours,if temp# reaches I02#5°# 
a full hath is better than a sponge,have the temp# of the hath 
80° down to 70°#keep patient in for twenty minutes,one person 
ruhhing another person sponging#keep patient’s head cool# 
DISTENSION,is very troubelsome#give a turpentine stoop,rectal 
tube,or enema of turpentine,-I- drachm# 
HEMORRHAGE,large doses of morphine,if it keeps up give enough to 
bring the respirations down to 10 a minute#give it in i gr#dose 
withhold food# 
PERFORATION,treat surgically,open up,close the intestine# 
THROMBOSIS, absolute rest,hot poultice to the part# INFECTIOUS DISEASES 
ETIOI0GY , 
Pneumococcus in most caseSjFriedlander* s and the Influenza bacill 
lus in some cases#Sarly spring,both sexes,all ages,any climate, 
exposeure seems to he an exciting cause# 
SYMPTOM®, 
Patient has a cold in some cases ,then they have a chill,temp#is 
elevated,painful cough,catching them in the side,respirations 
are quickened and difficult#Apetite is lost,vomiting, thirst, 
headache# 
PHYSICAL SIGNS, 
Insnect 1 onTHemes lahialis(seen most frequently here),patient 
sitting up,hreathing hard,hright anxious face,a little cyanosed, 
rarely pale,usually painfulcoughing,expiratory moan,one side of 
the chest moves more than the other,sputum is absolutely charac- 
ter! stic,Husty sputum or the Orange Juice sputum,visold,cannot 
he poured out when the cup is turned upside down# 
PnipationjIncreased temp#and fremitus on the affected side# 
Percussion*Early nothing is found,afterwards dullness all over 
Skoda1s resonance above the dullness# 
Auscultationflioiid high pitched respi rat ion,bronchial in type, 
rales as a rule are not heard,voice sounds increased(use the 
whispered voice as it does not tire the patient out#)In atypical 
cases,where the bronchi are plugged,all signs may be adsent,ex>- 
cept dullness,a case of this kind resembles pleuritic effusion# 
-theorgans are not displaced and the dullness is loss intense# 
When the resolution has begun we get the "crepitans redux" rales 
all over the area# 
In General, 
Pain in the side may be severe and hard to treatjCough is bad 
only when there is pain,Temp# is between 102 and 104 till the 
crisis,on the 6 to the 10 day#It falls then to normal or sub- 
normal# Wandering pneumonia,is due to the influenza bacillus,« 
comes down by lysis# Delirium at times is very violent,patients 
often die from exhaustion from working at restraint# 
COMPLICATIONS, 
JSaBXflffla# comes on at the end when resolution should have taken 
place,tapping may cure it without taking out a rib (Eslander1 
Menlngitlflj.0cirrrs in one case in five,due to the pneumococcus# 
~Paricard!tiflj.mav be latent# 
FindocarditiSjis malignant with embolism and heart failure# 
PECULIAR FORMS, 
In old people, there may be no chill,sometimes no temp#usually 
no pain#An old man gets sick ,you exam in . routine,finding one 
base solid,-great surprise# 
In children, often no pain ,no cough# 
Surgical pneumonia, follows injury,surprise when seen,always log 
for it,signs the same# 
Central pneumonia, no physical signs,suspect it when the ration 
al signs are present and no other disease seems to fit,examine 
the sputum for the pneumococci# 
IiQdBAR. .PMlMftilA, INFECTIOUS DISEASES 
TjQBAR PHEUMomA. 
prognosis. 
Depends on the age of the patient,fatal in old people,bad in £ 
drunkards,fat people,and where it comes on as a complication, 
apex cases worse,the more lobes the worse,bad pulse and pain w 
worse* 
mE AMENT, 
Unsatisfactory as a rule,feed them as much as they can eat accor 
ding to their digestive power 
Stimulation,give it when needed,strychnin# 1/10 gr*sub-cu*T*I*D* 
Alcohol some good,hegin with -J- drachm every 4 hours come up to 
one oz* every hour*Digitalis as a routine drug,have plenty of 
fresh air,an open fire in the room,keep th» windows open,oxygen 
does no good in the majority of cases* 
Pain in the side,-tweat with a swathe,put it on tightly,have the 
stand it for 15 minutes,they will not eomplain afterthat* 
Ice bag on the chest,especially in children*bathes,cold sponging 
patient has to sit up as a rule, 
cough,give Heroine,codeine or nothing at all* 
Bowels,usually take care of themselves* dBREHRQ -SPINAL MENINGITISf EPIDEMIC,. 
ETIOLOGY, 
The Diplo-coccus intercellular!s,found in the exudate,origin is 
not known,it is epidemic,but not contageous# The onset is the 
most sudden of any disease known in America# 
SYMPTOMS, 
Onset like that of grippe,headache,presistent and intensejback- 
ache,vomi ting,eyes affected in the first 48 hrs#the pupils are 
changed,there is a squint and aretinitis;delirium,photophobia, 
head and neck are retracted and the body stiff fa man can be lift 
ed by his neck)Coma may be very deep# 
Lumber puncture,gives the dlplococcus in the exudate# 
Spleen may be enlarged# 
Always a leucocytosis# 
Temperature is yery irregular,more so than in any other disease# 
PROGNOSIS, 
70$ to 80$ die,most of them in the fiwst few days,children are 
more likely to recover than adults#If the acute stage is surviv- 
ed we have the chronic stage,in which the patient is very ematl- 
ated,weak,temp#normal shooting up for a day or two#mental torpor 
some times the senses are lost# 
TREATMENT, 
Lumbal puncture,-bend the patient into a bow,stick the needle in 
between the second and third lumbar vertebrae,till the fluid * 
comes# 
Dr# Cutler thinks that Ergot is good# 
Releive the pain with morphine, feed the patient# 
infectiouTSiS? 
ETIOLOGY, 
The organism Ismotile,seen in the red corpuscles of fresh blood, 
there are also dots of pigment,looking like a swarm of flies;the 
hyaline forms are hard to see,avoid them# 
Tertian and Aestlvo-autumnale are the common forms,quart!an is 
rare except in the south#The organism of the aestlvo-autumnale 
is hard to see in the first week,after that we get a crescent 
moon with a big black blotch in it#The mosquito is the etiolog- 
ical factor of the disease.Don*t look for the organism during a 
chiJJL,take the blood 4 to 8 hrs#before or after# 
SYMPTOMS, 
In tertian,fever,chill,sweating,every other dayjor every day in 
double tertian#In aestivo-autumnale,there are no rational symp- 
toms, temp# like typhoid,vomiting,diarrhoea,blood test and spleen 
the only diagnostic points#In children we have what is called 
"dumb ague,"no chill,recurrent head ache,vomiting,bellyache, 
-suspect malaria whereever there is bellyache-Sudden delerium 
or semi-coma may be the first symptom#The sjbleen is enlarged,* 
hard with « sharp edge#Anaemia develops in all malarias,millions 
of reds are destroyed at each chill# INFECTIOUS DISEASES 
PROGNOSIS, 
In tertian,£ood,the disease will run on indefinitely unless qui- 
nine be taken,or climate is changed*The affection is liable to 
Rector on change of climate*If a person stays in a malarial coun- 
try with the disease and does not take quinine,he will develops 
a condition known as 1 chronic malarial cachexia” a very large 
spleen,-ague cake-,profound anaemia,and debility* 
In Aeativo-autumnal,good if it does not go on toolong and the 
dose of bugs is not to big,patient may die before the quinine 
can do any good,The cerebral capillaries are stuffed with bugs, 
DIFFERENTIAL DIAGNOSIS, 
The blood exam is the point,it will separate malaria from pus. 
The bellyache and vomiting eases are often taken for indigestion 
Phthisis Is the commonest mi stake, look out for the physical sign 
TREATMENT, 
QUININE,give it in unseated tablets,If the patient has Just ha d 
a chill,when fastigium is reached,give gr,5 repeat every hr,till 
20 gr are given,do this again on the 3d* Hay when the time of 
the chill is approaching,then give gr,X*on the 7,14,21,28th,days 
from the time of the last chill. 
Or start eight hrs,before the chill is expected andgive gr,V 
every two hrs,tQwn give gr*IY*T*I*D.for three days, 
TREAT the anaemia with arsenic, sol,- gtt,II*up*and 
iron. 
MALARIA, 
TOBERomtAR 
ETIOLOGY, 
Onset slow compared to other forms,very insideous*Usually i£ 
children, 
SYMPTOMS, 
Headachepmental dullness,hyperaesthesia,vomiting regardless of 
food*unexplained fever,eyes squint,pupils change,ch ild gets 
comatose,neck and head retracted,still Jakes food,but pays no 
attention,abdomen retracted,lies on side with hack a little arch 
ed,coma becomes deeper and deeper,and child dies.Kernlg1s sign 
does not appear,the temp*is Irregular and elevated,lumbar punct* 
ure showa the exudate • 
PROGNOSIS, 
Absolutely fatal, 
TR RAIMENT, 
Hone, INFECTIOUS DISEASES 
’nmERmrr.nsTH m? nro t 
As a rule no diagnosis is made,it runs the course of an ordinary 
pleurisy,and gets well;or is seen at autopsy#It may develops ihto ph- 
thisis# 
PROGNOSIS and TREATEEHT, 
That of ordinary pleurisy# 
TtfmSUMR PMMI1S 
PICTURE, 
Young boy or girl with a "belly full of fliiid, feeling perfectly 
well,always think of this when a child is seen with ascites# 
COURSE, 
Comes on gradually,no pain,no tenderness,the belly gets larger, 
marked distension causes pain#Runs weeks or months,the child 
gradually ematating# 
SIGHS, 
The omentum is rolled up,forming a sausage like tumor extending 
across the abdomen above the umbilicus,this is easily palpable 
after tapping,not tender,sometimes the glands are enlarged# 
Usually there is fever,it is not high enough however to prevent 
the tuberculins test#If there is a pleurisy,the diagnosis is 
made stronger# 
On tapping,the tubercle bacillus may be found in the fluid,the 
fluid is of high Sp#Gr# and contains more albumen than that 
other varieties# 
PROGNOSIS,Hot bad if the treatment is good,and T#3#is absent elsq-. 
where# 
TREATMENT, 
Tap once,then if the fluid returns operate#~open up and let the 
sunshine in# 
■nmmmr.nr.TH nf tha lymphatics 
The glands are usually found around the bronchi,the mmesynteric 
glands next, then the cervical, then the axillary glands# 
the treatment is a surgical and hygeinic matter# INFECTIOUS DISEASES 
METHODS of ONSET, 
ajThe neglected cold8#the eommonest,begins as a “bronchitis# 
b, haemoptosis,from to 50fo of cases with haomoptosis » 
never have T#3# A patient may come to you with haemoptosis and 
you may no# he able to discover anything in the lungs,the haeifr- 
optosis may exist through life,later the signs may develop# 
c, Anaemia and Debility,rales may he found at one apex,and T#B# 
in the sputum later# in any case where there is debility and fev|i 
suspect T#B# 
d, Malaria# with chills regular,no cough# 
PHYSICAL SIGNS, 
The tuherculine reaction before any other sign,the X ray is said 
to show the process#Sputum will often show the bacillus when the 
lungs are negative,it often looks like saliva,and several exams# 
show nothing# it is of the greatest importance#A few crackling 
rales over one clavicle or over the spine of the scapula are 
very significant,make the patient cough hard then listen,or make 
him count 100 in one breath,then listen#Or#VII# XI T#I#D#for 3 
or 4 days,will bring out the rales and the sputum test#A sligh t 
reduction in the movement of the dif®hragm by Litton1 s sign# 
Cogg-wheel breathing at one spot if i t presistd is a sign# 
With slight consolidation,the diagnosis Is easy at the left apex 
it is hard at the right apex which is normally abnormal, don *t 
make a diagnosis on the right apex without confirmatory signs# 
Fremitus will be slightly increased,the signs of consolidation 
may extend rapidly as far down as the 4th#rib ,then go slowly & 
never reach the base,the other lung will be involved early# 
Cavity is an unimportant thing,it must be a large cavity,near 
the chest and stiff to be diagnosed,they are seldom 
recognized and their presence means nothing#The “cracked pot sou 
nd does not sound like a cracked pot#Amphoric respiration,coarse 
gurgling rales,sometimes a metallic tinkle,these will change as 
the cavity fills and empties# 
When the PLEURA is thickened,we get dullness,dimini shed voice 
and resonance,no marked consolidation,diagnosis made by the 
sputum test,there may be pain in this form# 
In some cases half a lung is gone and there are no symptoms# 
In other cases there are no physical signs of the disease and 
the patient is wry sick# 
SYMBTOMS, 
patient is generally run down,has chi11s,sweats,fever,and is 
progressively ematiated# INFECTIOUS DISEASES 
mmMRY mmaiMsis, 
PROGNOSIS, 
Depends on the mode of acquisition,if the tendency is inherited 
the prognosis is worse than where it is contracted without pre- 
disposition* it is worse in young people,it depends on the condit 
ion of the patient when it is contracted;and on the presence of 
other disease,as it may run a very raplH couase after an exanth 
em or coexisting with diabetes#It depends on the wealth of the 
patient,the ability to buy railway tickets and pay hotel bills 
also on his willingness to go#and on his temperament,some patien 
ts die of loneliness#It depends on the treatment,better with 
good care,it depends on*tlie advance of the lesion to a certain 
extent. The stomach is Import ant, if the patient can take lots of 
nourishment he stands a better chance,The rapidity of the pulse 
is important,a pulse over 100 is bad«A temp*continously high is 
a bad sign,breaking down of the lung is a bad sign# 
TREATMENT, 
When send a patient away,and where send him?send all insipient 
cases away*A patient with a high pulse cannot stand a high alti- 
tude,nor can an advanced case nor an excitable person,high place 
are better than low# 3 
Keep patients out of doors 24 hours out of the 24 if possible, 
have then sleep out doors even in zero weather,rest in the open 
air is the thing,the sleigh and the canoe# 
Peed them six meals a day,regardless of their appetite#give them 
diabetic diet without cutting down the carbohydrates,butter,creg 
olive oil,cheese,etc# 
Pulmonary gymnastics should be indulged in in the low altitudes 
have the patient stand out doorsand take 20 to 30 full breaths, 
avoiding fatigue# 
Medicines,only for the symptoms,Tanate of Orexine,gr#IV before 
meals.Treat indigestion as in other forms,batanapthol,resorcine, 
regulate the bowels# Night sweats,keep the patient out doors at 
night or if this is impossible give him cold baths#Give Atropine 
1/llDO gr,at bed time*l/6 gr,extract of Agarocine,gtt#X aromatic 
H SO •IV oz*of cold sage tea# 
Tf 
For the cough,sprays,lozenges,chloroform water,heroine,codeine# 
or B/m 
Morphine gr.I 
Chloroform gtt.XX 
Syr, acacia 
Syr,Wild cherry, aa oz#II 
M. 
SIg*shake the buttle. 
Hemorrhage, absolute quiet,not a word,nor mot ion,morphine down to 
10 respirations a minute. 
Recovery in about all insipient cases at a sanitarium.In of 
the cases the disease is arrested,the other j? die. 
The mortality has dropped off 50$ in 50 years. IHFECTIOUS DISEASES 
SgHUiIS, 
PRIMARY LESION, 21 to 31 days after exposure,easily recognized if on 
an exposed part,grissly hard edge,-herpes and chancroid spread- 
it may come inside the urethra or prepuse,the patient may not 
know it,it may appear on the lip,tonsil or hand# 
SECONDARY LESION,6 to 12 weeks after primary,a "bubo may come now or 
"before#This is a marked and constant groupjwhite,kidney shaped 
patches in the mouth,stay the same size and in the same place# 
Skin,a macular irruption all over the body,red turning brown, 
falling hair,shin pains,headaches,worse atwnight, fever and leu- 
cocytosis,iritis,conjunctivitis, 
with these or after them come the 
TERTIARY LESIONS, in 2 years as a rule# THE GUMMA,appears on the skin 
or mucous membrane as a rule,when in the brain it gives charac- 
teristic symptoms,-paralysis and coma#In the liver,cut up the 
liver#In the heart,may kill through rupture.In thr lungs,ofted 
thought to be T#3# 
Tertiary rashes,-rupia,and pustular rashes# 
PARA-SYPHILITIC SYMPTOMS,Tabes,general paralysis,myocarditis,chronic 
interstitial processes, 
very marked anae- 
mia#and abortion at the 3d# or 4th.month habitually#it is possi- 
ble to omit the second stage all together# 
CONGENITAL SYPHILIS, baby has the snuffles,can11 nurse well,rash on 
the palms and soles,usually macular .Fissures around the mouth & 
anus,gummata,Hutchinsonian teeth-2d.set-Ear and eye trouble,big 
liver and spleen,intense anaemia,nasel bones fall in#May not 
appear till the child is 5 or 6 years old. 
PROGNOSIS, 
Depends on the constitution of the individual,when he got it and 
how long he has let it run untreated# 
TREATMENT, 
Ung.Hydrag.-a piece as large as the thumb nail in one side of 
the chest,then in the other, then in one leg,then in the other# 
X/24 gr#Corrosive sublimate,T#I.D# by the mouth#watching for sal 
ivation,clean the teeth carefully,snap them together T.I.D. for 
any sign of tenderness# 
In the secondary and tertiary stages use KI#-sat,sol#gives gr#I 
to the gtt#-Give from I0gr#to drachms#I«T*I.D.in half a glass of 
mi Ik, working up and down, letting the patient rest in the inter - 
val.Get the patient in good general condition,iron,food,open air 
Keep up the treatment,for a number of months after the last sym>- 
ptem has disappeared# ETIOLOGY, 
Nothing known definitely,it is related to chorea and tonsillitis 
endocarditis may appear "before it ,these three diseases play off 
* in all combinations in relation to rheumatism#It is most common 
inyoung male adults# 
A TYPICAL CASE, 
Onset sudden,all the symptoms of an infectious disease,pain,red- 
ness, swelling, tenderness,and heat in one or more joints,usually 
begins in the smaller joints,spreads rapidly,affecting many join 
ts at a time; the pain is intense,moving increases it,movement sin 
bed are a torture#sweating more than in any other disease#Pevor 
is irregular,I02°-I00°,up and down as the joints are affected# 
the joints are swollen but as a rule there is no effusion#Sore 
throat may be present#Nodules about the joints are important,* 
they feel like shot under the skin,always frel for them# 
Urterica,erythema,and hemorrhagic conditions are seen around the 
joints# 
Endocarditis is signified by a shoot up in temp#and the presence 
of mitral murmurs,-regurgitation# 
COURSE 
On an average it runs six weeks# 
Treatment does not shorten the course# 
PROGNOSIS, 
Good except where there is hyperexia^pyrexia,embolism rarely • 
causes death# 
TREATMENT, 
Take the sheets of the bed,let him have blankets,Peed him accor- 
ding to his digestive power. 
Salicylates,in big doses and fast,-X toXV#gr doses anhour of the 
Sodium sal# watch the patient for toxic symptoms,such as ring- 
ing in the ears,nausia,and skin irruptions# 
Alkaline treatment, acetate or citrate of potassium,-Jdr# every 
2 or 3 hours#till the urine is alkaline# 
Treat the Joints locally;with hot water# laudnum,-half and half, 
in twt or three thicknesses of flannel on the joints#frequently 
reapply,placing oiled silk over#If this gives no releif give 
morphine gr#i in the first 24 hours# 
After the attack the patient is all right but is predisposed to 
another attack# 
Aciaa AaamtMR HflsuMmai mosimiv. 
Don*t forget it ,nor overlook it,as it is a curable affection# 
PICTURE, 
It is a cratenoid condition,ocurring in women at the menopause# 
The patient feels dull,stupid and heavy,the facial expression 
changes,it becomes flattened out,nolines, lips are thickened, 
the nose becomes thickened on the sidesjthe deposits takes place 
all over the body,the tongue is enlarged,sometimes can*t be draw 
into the mouth,hair is apt to fall out,supra-clavicular pads o ? 
fat#The skin changes,becomes dry,coarse,rough;hands chap and 
crack,nails get brittle and brown,and fall out#Mental symptoms, 
dullness,heaviness,difficulty in recalling names,or in thinking, 
££ resembles dementia#Patients complain of cold,as they have a 
characteristic sub-normal temp#There is no pitting on pressure, 
the deposits gives the mucin reaction# 
DIFFERENTIAL DIAGNOSIS, 
OBESITY, The skin changes are not seen,sub-normal temp#absent, 
facial expression not so changed,the affect of thyroid ex#treat# 
examine the urine,oedema pitts on pressure,skin and 
mental changes absent# 
TiflENOPAUse,Mentai symptoms different,no skin or face changes are 
characteristic# 
The skin hair and face changes are absent# treatment 
with the thyroid extract settles it definitely# 
PROGNOSIS, 
Under the proper treatment it is absolutely good,with out the 
proper treatment it will run on from bad to worse# 
TKE ATHENT# 
THYROID EXTRACT, -Wyeth1 s or Armors tablets,-begin with gr,I 
tablet T#I*D* and push it up to gr#V tablet T#I*D# Watch the 
pulse for palpitation,stop the dose when seen,this gives the d 
dose#An average dose gr#III T#I«D# 
This is the same condition in children,it may he congenital or not 
appear till the child is three or four years old. 
The child is a dwarf,and the facial expression is marked 
It exists endemically,and sporadically# SYMPTOMS 
The name gives two of them,the third is *and the * 
tremor*Any two of these is sufficient for a diagnosis*There is 
also,sweating,diarrhoea,flushing,cold hands and feet,slight feve 
all the symptoms are those of terror*The thyroid is enlarged anfi 
this enlargement may be due to increase in vascular,fibrous, 
cystic,or colloid tissue*or to perenchymatous increase,or to 
combinations of any or all of these*It may be one sided only,it 
may cause pressure symptoms from its size* 
COURSE, 
It may run a chronic course with variations up and down,recovery 
is not impossible,though the majority of cases do not get well* 
THEORY, 
IT IS DUE TO EITHER ALTERED OR SUPPRESSED THYROID SECRETION* 
TREATMENT , 
Keep the patient away from excitement and worry,don*t let him 
live in a hospital,have her go off in the country.They ought to 
have galvanism,-large electrode over the neck-*Tinc of Belledona 
X min*T.I.D. run up a min*a day till there is dryness in the 4 
thraat*Eor the rapid heart,local ice and Digitalis*Operations 
have d»ne good,in some cases,by taking otit the gland in small 
pieces* 
this affection is called. 
GRAVE1 S DISEASE or PARRY* S DISEASE* 
A secondary form may occur in pregnancy* 
MM 
This affection has a tendehcy to he epidemic in certain countr- 
ies,it is an enlargement of the gland,when small causing no 
symptoms,when large causing pressure symptoms 
It is a curable disease,give thyroid extract,iodine,or operate* 
Kocher has done many operations,he gives the patient a course of 
treatment before he operates* A symptom not a disease# 
SYMPTOMATIC PURPURA, re suiting from other disease# 
PURPURA SIMPLEX,not severe alone# 
PURPURA HEMORRHAGIC A, no known cause, very severe# 
I# SYMPTOMATIC PURPURA, 
a, Due to infectious disease,-'Black measles,scarlet fever,small- 
pox, etc# there a»e hemorrhages into the skin# Tyjflms fever and 
meningitls#and infectious diseases ingeneral.and septis diseases 
b, to poisons,bromides,iodides,and most important the salicy- 
lates# 
c, to cachexia, in any such disease as phthisis, cancemdia- 
betes,cirrhosis of the liver,sourvy etc# 
II#PURPURA SIMPLEX, 
little purpuric spots,with little fever and constitutional dis- 
turbance# Sometimes the joints are affected,and we have the pur- 
pura rheumatica,it has nothing to do with rhammatism# 
III#PURPURA HEMORRHAGICA, 
Lots of hemorrhage,not merely into the skin but also into the 
organs,serous cavities and joints,there is coufehing and vomiting 
of blood,patient is very sick# 
Tliis affection must be destinguished from,haemophelia,and acute 
lymphatic leuchemia#there are no blood changes nor are the ves- 
sles changed or injured# 
Nervous Purpura, 
The stigmata of hysteria, 
scars on the feet and hands like those of Christ,seen in relig- 
ious people# 
■Emma 
nmmimiA, 
The tendency to bleed on slight provocation,it is hereditary entirely 
it comes through the females to the males,“The people who have it 
can’t give itjand the people who give it can’t have it#“ 
PATHOLOGY, 
Nothing known,there are no changes in the blood vessles,it start 
with an injury,cut or bruise#if the individual lives past child- 
hood,he has a chance,he usually dies before puberty# 
TREATMENT, 
Gauze,pressure,styptics,blood of other people,cautery,ergot# coma 
DIFFERENTIA!. DBAONOSIS, 
I# CONCUSSION, 
Soon gets well of itself,breif and not deep,the "knock out, * 
11 COMPRESSION, 
Rapidly increasing unconciousness,not coming on suddenly,ending 
in complete coma,with spasms,hemoplegia,pupils usually unequal 
and not reacting to light,~All these may he seen in Jacksonian 
epilepsy-the pulse gets progressively slower,20 heats an hour# 
Diagnosis rests on the slowing of the pulse,the presence of foc- 
al symptoms a:bsence of other disease# important, operate I 
III# 
APOPLEXY’, 
the same symptoms as above with a cause,usually a man with arter 
io-sclerosis,and a heart lesion# 
IV#DIABETIC COMA, 
air hunger is present in half the cases,presence and history of 
diabetes,acetone and diacetic acid#convulsions and focal symptom 
may exist# 
V. UREMIC COMA, 
generally gradual,may come on suddenly,convulsions before or 4 
during it,may be focal symptoms,strabismus,or conjugate deviatio 
albumen in the urine,enlargement of the heart,high tension pulsS 
retinal hemorrhages,urinous breath# 
VI. SUN STROKE# 
temp# 107° to 115° patient unconcious,red all over,this is when 
the medical man must hurry,ice just as fast as possible allover# 
bring the temp#down to 101° the stop and put the patient in bed 
Heat exhaustion is not like this,the patient is pale,clamy skin 
feeble pulse,stimulate him and give him warmth,alcohol# 
VII#OPIUM COMA, 
Detective evidence,pin point pupils,slow respirations,pulse and 
temp#vary#Draw of the urin« to prevent reabsorbtion,wash out the 
stomach for an hour,artificial respirations,atropin?P*in, 
VIII#ILLUMINATING- OAS, 
The circumstances,smell,take the lood and get spectroscopic test 
and the history,Give them air and time, 
IX#POST EPILEPTIC COMA, 
Important, a cut showing fall,bromide irruption,old scars on the 
tongue and face,bloody froth at lips,sphincters relaxed# 
X. ALCOHOLIC COMA, 
"Drunk or Dying?" it is hard to tell#the histary,the small,pat- 
can generally be aroused,coma not complete,pupils generally di- 
lated,pulse good,vomiting,no focal symptoms,no sugar or albumen# 
64 A M K D I C A L CASK. 
A 1j CO HOLISM 
with 
D K L I R I U M T R K M K N S 
Nathaniel Allison 
1901 ALCOHOLISM with DKLIHIUM TRKkHNS 
George Connors,came In to the Boston City Hospital on iteburary tne 
thirteenth,he was put in Ward K,Koom 10.bed 4.He was assigned to 
me on the fifteenth,! made my first visit on the seventeenth. 
I found a large muscular man in a state of mental excitement,he 
regarded me with suspicion at once,was restless and very anxious 
about the outcome of his disease,when i asked him questions about 
himself,he was sure that I was the representative of a life in- 
surance company seeking information to ruin his policy,after care- 
ful questioning and repeated reassurances I got the following 
history. 
Ago 32 years,born in South Boston,married 9 years,the father of 3 
children,employed till a month ago as a waiter,his father died of 
rheumatism,his mother lived to the age of 69 years,the cause of 
her death not known.He has had the ordinary diseases. 
Has never had any venerial trouble.Has always been well and worked 
hard. 
Present illness. 
A. month ago he lost his position as a waiter because of drunken- 
then went of a prolonged debauch,was under the influence 
of alcohol to a greater pr less degree all the time.The last thing 
he remembers before he woke up in the Hospital is that he fell in 
the street somewhere.One of the other patients in room 10.volun- 
teered the information that he was crazy when he came in,he cried out about a large and variagated assottment of “Cats'’ andMbirds” 
that were troubling him,Connors himself could not remember any sudfc 
conduct,he acknowledges that he must. have”had'em bad". 
Physical Examination. 
Large ,well developed man,well nourished. 
Head,no loss of hair,no scars on forhead,no eruption,no facial par 
alysis.Ears,normal,good hearing.Eyes,pupils,equal,react normally 
both to light and distance,no jaundice.Mouth,teeth in good conditi 
ion ,no line on gums,no ulcerations,Tongue,coated and tremulous 
when protruded. 
Jeck.no scars,no glands. 
Skin,of good quality,moist,no eruption. 
Chest,Insp ection,nothing abnorma1. 
Palpation, Fremitus normal,sides move equally. 
Percussion,normal resonance,back and front. 
Auscultation,breathing and voice sounds normal. 
Heart,Apex in the 5th.space in the nipple line,no dullness to the 
right of the sternum.Sounds clear,no murmur. 
Abdomen,no tumor,no tenderness,Liver,lower border no felt,upper b© 
border normal.Spleen not enlarged,No glands in groins. 
Genitals,no rma1. 
Legs,knee jirk present,no scars over tibia,normal Babinski. 
Hands,slight tremor when held out. 
Pulse.64. Respirations,22, Temperature,99,2 Feb.18th.second visit. 
Patient up,mental condition very much improved though still very 
restless and anxious,wants to go home and fears he has some fatal 
disease.Specimine of Urine obtanied. 
Urine Analysis. 
Color,normal. Reaction,acid. 
Sp,Or,1011. Bile Pig,absent 
Sugar,Absent Albumen,SI.Possible trace. 
Sediment,Rarely a finely granular cast,an occasional round cell. 
Diagnosis 
The conditions which suggest themselves are 
Typhoid delirium. 
General paresis. 
Acute mania. 
Delirium tremens resulting from Chronic alcoholism. 
Against the first we have the history,and the absence of the signs 
of typhoid,the character of the delirium,in typhoid the delirium js 
usually of the low muttering variety. 
The patient is too young for general paresis,and his mental state 
is decidedly different from that of the general paretic. 
Acute mania would not explain the mental symptoms nor the recovery. 
Chronic Alcoholism with delirium tremens,The history of prolonged 
drunkenness with the negative physical examination,the character 
of the delirium,the tremor of the hands and tongue,the restless- 
ness, the vain imaginings and fears,the hallucinations of cats and birds.with the urine of an active hyperaemia of mild character,- 
due probably to the irritation of the alcohol-all join hands to 
make this clearly the diagnosis. 
Feb.19th.Patient discharged well. 
Prognosis. 
For the recovery from the delirium the prognosis is good,for re- 
covery from the alcoholism it is very poor,the patient will in all 
probability have another prolonged debauch ending in delirium in 
the near future,as the victims of this habit are not likely to 
reform,each attack in the future will be more serious,the danger 
of complications will be greater,with death from exhaustion during 
delirium or the condition of mental aberration known as Alcoholic 
Insanity as an ultimate result. The prognosis for recovery complete 
depends entirely on the patient's ability and willingness to give 
up alcohol,In this case I think the chances that the patient will 
reform are very poor. 
Complications. 
In this case there were none,when present they make the chance of 
life much less.Disease of the liver and kidneys should be carefuljr 
watched for,pneumonia,the most serious,should not be overlooked. 
Surgical injuries,accompanied by shock make the chance of death 
greater.In this case the physical examination excluded all of these 
probabilities. TREATtWNT 
The treatment of this case divides itself into 
a. The treatment of Delirium tremens 
b. treatment of Alcoholism 
Under the »'irst head we must observe the several conditions which 
require treatment,the first of these is restraint,the patient must 
be kept from injuring himself and others,in order to do this we caa 
employ one of two methods,he may be restrained by having a nurse 
with him constantly,one that will quiet his fears;or by properly 
strapping the patient in bed so that he can be left alone in safe- 
ty. I consider the strapping the best treatment as the presence of 
of anyone is in the majority of cases a disadvantage td> the pat- 
ient must be used as to the necessities of the individ- 
ual case,in the presence of complications it is often better to 
have an attendant stay with the patient,but in the ordinary case 
the patient should be securly tied in bed and left alone in abso- 
lute quiet.In this case where there is little danger of the pat- 
ient exhausting himself,! should employ strapping. 
The second condition is the support of the system,by highly nutri- 
tious foods of a stimulating character,the alcohol should be imme- 
diately withdrawn,there is a variance of opinion on this point but 
I think other stimulants can be substituted which have not the 
poisonous effect on the system,it is the pjbison,so withdraw it. 
MiIk,soups,and beef tea with eggs should be given often,highly 
seasoned foods are of great service to the stomach accustomed to 
alcohol.Rectal feeding is necessary where the stomach will not stand food. 
The third condition to treat is the engorgement of the abdominal 
organs,this can be accomplished by the administration of Apo- 
morphine in 1/IOgr.doses,under the skin,until emesis is produced, 
or by giving a gr.8 pill of ipecacuannha every fifteen minutes. 
Igr.doses of calomel should be given every hour till free purgat- 
ion. For the congestion of the kidneys Citrate of potassium in grx*. 
doses should be give in some effervescent drink every 2hours. 
The. fourth conditionis,to quiet the nervous system and produce 
sleep,this can be done by the administration ofBromide of potassium 
in gr.xxx doses every two hours,Hyoscine hydrobromate is also a 
good drug to use it should be given in doses of gr.1/50.sub-cut. 
every four hours.TO produce sleep a combination of chloral and 
morphine. K/. 
Chloral hyd. gr. xx. 
Morphine Sulp. gr.1/4. 
m. 
Sig.Take at bed time and repeat same pro re nata 
The fifth condition is to supply the stmulation needed by the sys- 
tem,! do not consider it good practice to continue alcohol,it is 
surely not necessary in this case,though it may be necessary at 
times in order to save a feeble patient's life.Strychnine is good, 
given in as large closes as the case seems to need and watching caie 
fully for any sign of over stimulation. 
In case there had been complications in this case they would have 
to be met with the ordinary treatment. During the acute delirium the above treatment should be carried 
out,remembering that the important thing in a case like this is to 
obtain rest for the patient,as the mental state clears up the 
treatment should be cut down to proper food and reassurance.The 
patient is now in need of strong moral support,he is liable to 
think that all is lost,that he cannot reform,even if he should try. 
The treatment of Alcoholism is dependent on the will power to a 
great extent,one thing the patient must understand is that drink 
means death or insanity for him.There are institutions in every 
large city where the drunkard can go and be cured of his habit, 
The treatment at these places is largely devotee to convincing the 
patient that he can do without alcohol,that he must do without it. 
In this case ,were it possible for the patient to do so,l should 
advise him to try one or several of these “cures1*hoping that he 
might overcame his tendencies,which in the end if unbridled lead 
to death during delirium,permanent insanity after deleriura . [Form No. 37.] 
Permit No. 
RETURN OP DEATH. 
BOSTON. 
Year, 
.Month, 
Day, 
Years, 
Months, 
Days. 
Da te of death 
Year, 
Month, 
Day, 
Birth 
Age 
Name in full, Residence, 
Maiden name, 
Male. 
Female. 
Single. 
Married. 
Widowed. 
Divorced. 
White. 
Blach {Negro or mired). 
Indian. 
Chinese. 
Japanese. 
Sex 
Conjugal condition 
Color 
Wife of Widow of 
Place of death 
Street, 
Number, 
Place of birth, 
Occupation, 
Name of Father, Maiden Name of Mother, 
Birthplace of Father, Birthplace of Mother, 
Place of interment. 
Undertaker. 
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH. 
Boston, 190 
Name and age of deceasedAge, years. 
Date and\ place of death,* 
| Chief cause, 
I Contributing cause, 
Disease 
Chief cause... 
Contributing can se. 
Duration 
I certify that the above is true, to the best of ray knowledge and belief. 
Name and residence 
of physician, 
. M D. 
*If in an institution, state how lonjr an inmate and previous residence. 
The office of the Board of Health will be open for the granting of permits for burial, as follows: — Saturdays, 9 A.M. till I P.M ., except during the months of June, 
July, August and September, when the office will ba closed on Saturdays at 12 M.; Sundays, 10 A.M. till 12 M.; Holidays, from 10 A.M. till 12 M.; other 
days, from 9 A.M till 5 P.M. fJgSTTONS * AHSWKRS in MKDTCAli JUKISPHITDKHOK. 
1. Differential diagnosis between rcchynosns and cadaveric llvliit 
The, outlines of llvidity are fairly well defined,hut those of ec- 
ohywoaeg are sharply defined,A change in the position of a body 
not too long dead will oauae the llvidity to gravitate.j.lvidlty to 
.'oa.ii i on the moot part of the body. The eoohyrnoses are 
infiltrated with blood while the iivldtties are not.The lividitioe 
appear h to 10 hr a, after death perhaps a little earlier 1 i ohil- 
- ren, 
3. What In the nature of the contract between physicians and ti elr 
P -.t lento, and what decree of sKill and care does the lav; exact un> 
ter In contract? The definition of physician under the com ion 
■ is*" Anyone who ad-linin', ere ledtclne to 'he nick and, calls : In 
celf a doctor * Thin 1 s regulated In most stater; by statute, /hi oh 
requires the presentation of a diploma from a recognized school.In 
ass. the statute requires three things. (1) Proof of having lived 
ul years. ( °) flood noral character, (;• ) ft 80.00. It Is necessary 
to iu. ; ■ nonln 1 examination. Physicians practising v»it -iou - 
trot Ion are liable to a fine of 50*00 to * 100*00. Having establis 
hed yourself.are you obliged to answer every call ? Lav/ oaxmot 
coupei you to go but having once gone you are under a binding con- 
law requiring that you Whow a reaonahle amount of knowl— 
5 e. that 90 ordinary cure and exercise your best judgement. 
Also that you shall not leave till another physician comes The patient w?t Inf or i the doctor of oil conditions nee-1in, treat 
rent \nd ■ rust obey his instructions;the doctor only has to use 
what 'niovlodge ho has but there •‘•runt bn a reasonable a:lount o ’ it, 
y tery »*ot or negligence resulting in the death of tun potion 
1' nanslaughter#even tho# due to ignorance, Always report contag- 
Ions d in naan to the board of health. In conn of insanity,liavn a co 
■• urn lit tion and sign a certifto tin, The consulting physician 
should not bo a member of an asylum or )ital ‘ . In case of 
criminal abort ion,have a consult at ion and report it to the police# 
There io a law regarding the administration of drug-? and. Inhala- 
tions where the patient cannot live; you have no right to shorten 
his life;after death the physician who last attended the case mst 
make out within 16 days a report of the death and its cause. In or 
<er to si :n a le*th certificate you roust be present at the death* 
o" the individual or els iow thoroughly about the case, 
,3, Give none examples of death from suffocation arid the post— ior- 
tei spur'-.ranee cor ion to them all# (!•) Accidental Causes, Panics 
in a crowd%caving in of embankments on workmen,bales falling upon 
the chest.burled to the neck in sand or grain bins*in fires#from 
inhaling moke and CO*drunks die in cells from inhaling vonitu. , 
things shallowed into the trachea while eating*anaesthesia,infants 
by bedclothes on the face, ( p.) suicide,rare except by gan*han oc- 
curred under the bedclothes and in trunks and boxes, ($) Homicide# 
7 h e victims are usually women,babies*arid ion under the in flu- enc* of liquor.The common method is known as •xurking ” In which 
th* vlcflTn is thrown and the murderer kneeling on his chest .plugs 
the iouth of the unfortunate. The vast no. of cases are In/ants 
; tn bed by their drunken parents. Poet-mortal. (1) Fxtern 
al. Skin o" the face and neok livid,lips,neck,tongue and nails are 
blue. Conjunctiva* reddened,bloody eochymoses on the neck and. ches 
due to the struggle,If there was one, XX (?.) Internal. Those signs 
of anphyxU,,rt.heart full of blood,hyperaf*aia of solid viscera,sub 
pleural ecohymoses,looking as If red ink had been spattered on the 
surface. These spots also show on the pla. If due to homicide ther 
are apt to be pressure eigne about the none such as scratches and 
bruises; If due to particles of food we ay fin' the part ides .ex- 
ternal traumatic lesions on the chest are marked when It is du* to 
cro’ \ pressure, 
4, uhat /appearances In an adult skeleton nay help to ’etermlnr— 
(a) the sex,and (b) the personal Identity ? (a) The sex can be 
tol ' s regards the anatomical points only of the pelvis, the * work- 
ings, and length of the long bones, (b) The personal idea can 
be determined by measuring the height of the skeleton and adding 
1/ in. e0r soft parts,and *s 1 /p. in. for Intervertebral disks, 
face am be told by the type of the skull. Look for Injuries as 
fraotures.diceased spine md other deferilties. The finding of 
rings , but tons, or of j>%mm of clothing is weighty evidence.For the 
t e>. h a leal uolnts see Dwight on the Identity of the skeleton. b. What conditions in their associate op nation, favor the rapid 
development of putrefaction 9 It la accelerated by warm moist air, 
moisture,as fluids in dropsy,anrl drowning. Also by the agency of 
insects,being uncovered in the open air,and the presence of bac- 
teria. 
f>. Describe the principle of the spectroscope and its application 
to the identification of hi man blood. A spectroscope Is an appar- 
atu ! "or producing aid observing a spectra i.The observations are 
»#de with the aid of & telescope, Dy plant;, iy solution which 
gives absorption bands in front of the spectrum, so that the light 
has to traverse it,the spectrum,when observed thro* the telescope 
will show one or more broad or narrow black bands which are char- 
acteristic of the subst moes in the solution. Artificial It jht in 
used in' a low power; the material is placed in a shallow tube,a 
>op or two being enough,and the dark bands known as the haemoglo- 
bin hands will appear in the spectrum;this simply shows the pres- 
ence of blood but does not detect HUMAN blood. Teiohmann's Hae- 
rln Teat. Take a little blood or stain,place on a sl ide; heat to 
dryness gently,with a little NaOl.; then place a hair between the 
cover glass and the slide,and allow a drop of acetic acid to run 
under. I" the substance be blood,on heating till bubbles appear, 
and allowing to cool,the characteristic rhombic crystals of haenin 
vill appear and all the more noticeably if the hair has been intro 
luce". This is an extremely reliable and positive test. 7. Describe the centre of ossi "teatIon In the Iowpt epiphysis of 
the 'f*rur with reference to its uRfi an evidence in determining 
foetal age, The centre of ossification in the lower end of the frw 
rur in important in determining the age of a dead child; at full 
term it in about the sise of a pea.The child must at leant 4Q 
v/eeks old. 
h, nive your estimate of the efficacy of drugs for the induction 
of a. ortion. All sorts of drugs have been used from arsenic down t 
to camomile tea,including the corroniven,the oils of tansy.penny- 
royal.and savin,fluid ext,Of cotton root hark,and ergot, These 
have no specific action. Krgot dll cause contractions after they 
have been started up. The question is; "Can drugs produce function 
al disturbance© resulting in abortion,M"’h*'vy nay Kill th p or 
the foetus by the circulation or they may produce such vomiting as 
to cause death, 
9. Describe the appearances of the foetal lungs and the changes 
wro if t In ! by respiration. The lungs of a child who has never 
breathed are s all,dense,ajid of a maroon color. The lobular bodies 
may be made out but no air in present, If placed in water they 
will sink. This last observation is not always correct,The lur. 
after expansion are distended and large, light red or pink,crepi- 
tant and covering the pericardium,surface showing expanded air cel 
ceils/.‘hen cut and err water, we have bubbles. Vascular structures 
seen licrosoopioally.Thev do not sink when placed in water but v* *-hls 1? not always ttup, 
IO. < Ive ;oran examples of death by syncope with post norten appear- 
a. ion , This nn. not Ion covers so yiuoh ground. Including as It dona, 
so iany or the causes or death that we deen It Inadvisable to In- 
elude the answer hern,since parts or* It,If not tho whole,rill bn 
v nmd la the dollowlng pages. 
ll..nfhat me sums would you, taV.e "or thn resuscitation of a p nr son 
apparently drowned ? (1) restore an Inal heat* (f) Artificial resp- 
ir fclon. (;5) Stimulate thn heart. (*) Arouse thn nervous centres. 
(S) Counteract oorTplloatlona. ,s/ork upon* the p nr non on thn spot,and 
t.um thn "ace downward,open thn icuth and dr w out th.n tongue,r)6H 
renove the cloth no and wipe the body dry,iaa)ce rythmical tract Iona 
on thn tongue. Method* it up till thn person lo 
breathIn * normally and. thn lips am a good color, tor an ho- r at 
least. If no -:q: p • appear; manwhlle supply hnat with heaters and 
brandy .n ’ nthnr subcu.during unconsciousness and when conscious- 
an--. . -nt,- •, i by thn mouth.Coffee nd other at. 1mlants. 
IP, hat microscopic characters distinguish the rnd blood corpus- 
ales dr O' i those of birds ? The blood globules of n annals with the 
exception or* the camel am to bn distinguished from those of tetxx 
blrds/oy the fact that they are small, *&?&*)& XX, and non-nucleatnd, 
while those of birds show a snail oval nucleus. 13. Make, a report of autopay In a case of death by manual strangu- 
latIon.Find, woman. 19 yrs. old. Face, swollen and livid,tongue 
protruding,froth at the mouth, marks upon the neck,as If made by a 
rope.chest punctate ecchymoses. Internal. Emphysema of the lungs, 
froth In the air passages,reddened rne.fbrahe of the larynx,blood 
dark and fluid. Conjunotlvae reddened and Injeoted.TTne tissues of 
the neok upon dissection show extravasations and injuries to the 
/ousel es. 
14. Name some of the rules that should guide the medical witness 
regarding his conduct In the courtroom. (1) Accurate observation 
and notes. (£) Good memory. (5) Candor and truthfulness. (4) well 
balanced temper, (ft) Good manner of presenting facts, (e) TUiprejud 
ced mind. In general the expert should know his subject and be a 
good Interpreter of medicine,not dogmatic, and ruggedly honest.Do 
not act as a prompter to the cross examiner. 
1ft. Give the differential diagnosis between Idiopathic catarrhal 
vulvitis and traumatic vulvitis,(rape) in a girl of 10 years. 
Hape. The region of the vulva shows an Increased degree of tender- 
ness; when traumata are present we may have peritonitis,the dis- 
charge Is purulent greenlsh,and appears on the third day.Causes a 
pruritus vulcae.The little girl's nervous condition and the appar- 
ent truthfulness of her story are to be considered, vulvitis is 
much milder and has a slight discharge from the mucous membrane. le. what excuses a physician from court whan he has been regularly 
summoned 9 
19. What Is the ordinary rate of cooling for the dead hody ex pres- 
sed In degrees of Fahrenheit scale and what conditions favor rapid 
cooling 9 cooling Is progressive;It Is most rapid just after death 
especially If the temperature was high. The temperature may drop 
1.55 deg. In an hour. Taylor says It takes \p to pa hours for the 
hody to cool. It Is promoted in the absence of clothing,currenta 
of air,lying on a cool surface,In cold water,old age,and hemorr- 
hage, 
18, In the medical proof of the rape of a vlrgln,ls the laceration 
of the hymen necessary evidence In order to convict of the crime ? 
no,since,first the hymen may have been ruptured from other causes, 
second,evidence of penetration Is not necessary to convict of the 
crime. The evidences of struggle*coupled with the presence of sem- 
inal stains on the girl's clothing are enough to convince. 
19. Make a formal report of an autopsy In a case of death by drown- 
ing*. Girl,Froth at the mouth and nostrils.Injnotion of the blood- 
vessels of the conjunotlva,X3W»xaaxXXjmr»XtMKX«XXlttX)lK blanching 
of the skin of the palms and soles,Face usually pale, Outls anser- 
Inun on the thighs.Internal. Froth and water In bronchi,congestlon 
of the lungs, emphy sera a, water In pleural cavities and stomach, sub- pleural ecohymoses,hypera**nlc condition of the liver,spleen,and 
peritoneum. 
20. Give a comprehensive definition of legal medicine. Legal med- 
icine teaches the application of every branch of medical Knowl- 
edge to the requirements of the law,whether civil or criminal, 
81. Mention some of the anatomical malformations which simulate 
hermaphrodism. A condition known as hypospadla,here the urethra 
opens beneath the penis,perhaps as far back as the perinaeum,and 
there may be a fldsure which resembles the vagina closesly;thin is 
especially so if the scrotum is cleft and the penis Is undeveloped 
resembling a clltorls.lf In such an Individual we find testicles 
and no uterus or suggestion of one,and no history of menstruation, 
we call It a male.A large clltdrls Is another malformation,nay be 
due to masturbation,Lateral hermaphrodite where the male organs 
are on one side and the female on the other. Transverse where the 
external organs are of one sex and the Internal of the other. 
eq. To what extent is the medical witness allowed by the rules of 
law to use notes when giving testimony In the courts 9 He is allow 
ed to use the original notes,taken at the time of the occurrence 
and as soon after as possible (notes &ose in value directly as the 
time passes since the occurrence) and merely to refresh his memory 
during the testimony. may not use a copy or an improved draft 
nor read any thing of this sort at length. £3. Make a formal report of a medico-legal autopsy in a case of 
death by hanging. 
LPK STHKPT HOSPITAL,CAMHRIDGP• 
G•H.Towne, supt. 
Nora Crosby,Matron. 
MKDICO-LPGAL AUTOPSY RHPORT- 
Par old w.Jones M.D. Kxamlner 
Nathaniel Allison M.D. Amanuensis. 
Jan.£3,1901. 
Nane-’vllllara Frederic hoos. Age,3£ German. 
1.About the neck a groove following line of chln,l/£ in.wide, 
a knot mark below the left ear. 
£.Praia not examined. 
3. Abdomen liver and spleen considerably congested. 
4. Chest.Lungs congested,right heart full of fluid dark blood, 
ft.Axis dislocated on theatlas,with fracture of the odontoid. 
e.Klstory-Pody found at 4 P.M.on the £lst Inst.,hangl*ig in a 
ohurohyard. Height-6 ft. weight-195 lbs. 
ohurcUylade and ears swollen and livid.Tongue swollen and protru- 
ding. Crystalline lens In both eyes fractured. Genitals show 
marked turgessence, 
( signal.) PA, In a case of death by homicidal pot coning* What part or the 
body should he cent to the chemist for analysis*and what precau- 
tions should he observed In their preservation‘and transmission ? 
You cannot easily send too much as the stomach Is not sufficient* 
since It contains the lnsoluhle*rather than the soluble poisons; 
there should be six (b) bottles- (1) Liver, (p) spleen and Kidneys 
(3) Stomach and contents. (4) Intestines and contents. (5) urain. 
(b) Urine. (7) Muscular tissue. Precautions- Use preserving jars* 
and have nothing but glass come In contact with the organs. The 
bottles should be labeled*the jara placed in a box*the box locked* 
and the key put In the pathologist's pocket. 
PP>• Upon the discovery of the dead body of an unknown man,of what 
would you take note*for the purpose of establishing Identity ? 
H eight * weight * general appearancetcolor of eyes and hair. Teeth. 
Minutiae of clothing. Contents of pockets In detail. General de- 
velopment of body*defor iltles*blrthrnarks*scars*wounds. 
PB. describe rigor mortis and some of the conditions which promote 
its early access,Its long dnratlon*and Its greatest degree. pIgor 
laortls Is a condition of rigidity marking the onset of molecular 
death;probably due to a chemical change -an undue amount of sarco- 
lactlc acid changing the myoslnogen Into myosls and causing a co- 
agulatlon analogous to that taking place In the blood. It can be 
broken up and then It does not return. It Is marked by great rigid ity. Its early appearance is Influenced "by the fact of death from 
violent poisons,wasting diseases,and hydrophobia. It In retarded 
in canes where there is no fatigue,wounds and hfw>rrhage, and where 
the body In kept In a cool and dry place. Normally It begins 3 to 
« hours after death. It In short In Infancy and old age;after ph- 
thisis, wasting disease,strychnia polslnlng,death In battle,It Is 
marked. Its duration Is shortened by all causes which hasten de- 
composition, is prolonged in death following suffocation,after rap- 
id diseases and In strychnia poisoning. The average time varies 
from le to hB hours, it Is short In summer nad long in winter. 
ec.What organs other than the lungs In a newborn child give evi- 
dence that the child was born alive and survived Its birth ? The 
condition of the circulatory organs helps us very little except In 
confirmatory evidence,since the foramen ovale,ductus nenosus and 
arteriosus do not always close for a number of days.The formation 
of a line of demarcation,a suppurative process around the cord 
which has been out,are signs of a vital process;the stomach If it 
has food in It Is of Importance,Air In the Intestines Is a proof 
that the child has lived;absence of meconium proves that the child 
was alive. Kidneys-There is a uric acid infarction which comes on 
Tom the v to the 10th day. if we find air In the middle ear It 
shown the child was born alive and survived birth,since the patenc 
of the Kustachian tube and disappearance of the gelatinous mass in 
it shows that the child must have breathed Cor some time. PB. What appearances on the skin would Indicate the entrance wound 
of a bullet from a pistol whose mussle was held at a distance of 
six Inches Crow the wound c> we would nee smooching of the shin, 
singing of the hair; If the hammer was held up the smudge will he 
above the wound,If down,below the wound;this Is due to the recoil, 
The unexploded powder grains produce tatoolng on the shin, 
pa, How would you distinguish on a dead body,an Incised wound made 
10 hours before the person's death ? One made 10 hours after death 
and both made with the same weapon In the same situation. If the 
wound was Inflicted 10 hrs,before death there would be signs of 
repair or o ' duppur at Ion; there would be signs of free bleeding, 
blood clotting,and the edges of the wound would be retracted , 
swollen and Injected,while B hrs, after death,there Is little hnn- 
blood Is dark and there is no swelling and laif lit ratio 
50. what Is adlpocere and what conditions favor its formation ? 
It Is an Impure ammoniacal soap,having a rancid odor of old cheese 
It Is brown and soft and melts at PlP deg, it Is a combination of 
oleic and palmatlc acids with There Is something In priv- 
ies and cesspools which favors Its fornatlon.lt in the or- 
gand In the following order,larynx,trachea,intestines,lungs and 
stomach,lastly In bones,Requires 1 yr. linn water and 5 In earth. 51. That are the signs of rape upon a young won an, previously a vlr 
gin and In good health p Vulva- swollen,hot,tender,vannular Injec- 
membrane nay be lacerated and ecohymoses nay be In the 
surrounding parts.May be a vesloo-vaginal lesion;If the hymen is 
present it is a valuable sign as it will be atom. The perlnaeum 
may be ruptured, Seminal stains are very inport ant. S Ign m ofi a stm 
groins 
gfvle and bruises on other parts of the body,as In the gxftt#,wrist, 
and t,'root. Also,venereal disease,All these together with a 
story which corresponds ?aake out a strong case, 
i 
SP. Define the difference between ordinary .and expert testimony. 
Ordinary testimony concerns Itself with the facts of evidence in 
the case,while expert testimony has to do with matters of opinion 
and the expert may not Know any facts concerning the particular 
cases In which he testifies. Fees—ordinary > l.fSO.Kxpert - P.5,up 
5f5. Give the signs of mature foetal development In a new born chll 
Average length PO to Pi In. Average wt.7 lbs, body well rounded 
skin has lost its red color,lanugo mostly disappeared, walls pro- 
ject beyond finger tlps,vernlx caseosa on skin,testes have descend 
ed into scrotum,while labia majora are In contact. 
M#Pescrlbe the condition of the blood after death by drowning and 
give an explanation of the abnormalities found. 54. ( oo n. ) The blodd Is fluid and dark due to 1 a ok of oxygenation 
and It hart taken up some of the water as the red count in reduced 
one fourth. 
55. Give your estimate oC* the total quantity of blood In the adult 
human body , Modern observers state that It la l/l5 body wt. and 
in a child l/lo of wt. 
55. What determines the amount of separation of an Indeed wound 
of the skin, The gaping varies according whther tha out be a per- 
pendicular or an oblique one. The gaping shows no relation to the 
shape of the instrument but varies with the contraction of the 
muscles, whether it Is cut with or across the fibres.the condition 
oC the skin as regards elasticity.the amount of subcutaneous fat. 
or whether It Is over a bone,The kind of weapon cannot be inferred 
from the wound; we can only say It Is a "cutting Instrument " 
57. Describe a corpus luteum.and give your opinion of its value in 
determining Coetal age. The ovary is made up of oraaflan follicles 
which contain an ovum;the preparation of this takes from 5 to e 
weeks. If it be discharged, a corpus hoaorrhagloijm results.but if 
Impregnation takes place,in from .*=> to e weeks a corpus luteum ap- 
pears resembling a yellow clot with convoluted walls l/ie of an In 
t:- lok. Authorities differ as to Its value, Taylor says: "It is not 
to be accepted as evidence unless backed up by reliable obstetri- 
cians." Dr,D,says "I have found then where there was no pregnancy 58. How does the gas which is used for art if total light in.* when 
inhaled and what are the post inert en appearances when so Inhaled 9 
we get the ordinary symptoms of suffocation and in addition those 
of poisoning,as follows—red patches are seen in the dependant per 
tions nd the tissues are bright,the blood is thin and resembles 
carmine ink,(CO poisoning.) There is a very stable union of the 
CO with the blood Coming met-haeroaglobIn,which Is much stronger 
than oxyhaeioglobin and consequently the blood cannot be oxygenat- 
ed. It lessens the amount of* carbon dioxide in the expired air and 
leaves the blood the same as in asphyxia. Our present gas is 50 $ 
CO instead as formerly, 7 
oh•59, How are wounds classified according to legal medicine 9 
(1) wounds by cutting instruments,incised wounds. (9) hv crushing 
contused, (5) Hy stabs#p\inotiired, (a) wounds by tears*lacerated. 
(5) ny guns and pistols,gunshot wound. 
*0. that part if any do the superior laryngeal nerves play In stran 
gulation ? Hoffmann says that the pressure on these nerves has an 
influence on resptration,probably depressing it. story of the prie 
st who choked his mistress, 
41. Tinder what conditions are the declaration of dying persons acc 
eptel as eridonoe In the courts. It must be s$own that the person 
believed himself about to die. Also that he was sane, Tell the pa- 
tient he cannot live and get him to admit that he understands you. no not press the ptlent to talk lout act as a placid listener; al- 
low him to say all that ho will and record it on the spot,so that 
you can produce H In the courts. 
40. 
■ 
• • irTnITQ • • 
Representing the latest and most careful work 
that has ever boon done In the science and art 
i 
of medicine In all Its application to the law 
. 
of tho land and calculated to ho of the utmost 
vain« both to the student and to the practitioner 
0? medicine. ‘7111 bft found of usft In any case of 
medical jurisprudence*as questions of rape,arson* 
poisoning*etc, that frequently oorne under the 
notice of the pysiclan.Copyright In America 
by ‘Harold u,,Tones of Oarobrldge*N assachusetts* 
and Hathanlei Allison*of St.Louis*Missour! 
Students of Medicine at the Medical school 
of Harvard University*Cambridge*Mass. 
"It Is apis pot and a blgone" 
Seneca. 
that QjJHSTXQNS AWP ANS VKRS JN jJF TtiKQAT A MQSK. 
1. "#iat is the usual difference In appearance between the ulcera- 
tion due to tuberculosis a/id that due to syphilis of the larynx ? 
syphilitic ulcerations are differentiated from tubercular ul- 
cers by their more rapid format ion,their deeper excavation and the 
greater elevation and more regular boundary zone or congest ion,en- 
circling them,and by their greater amount of secretion. The fail- 
ure to find t.h. in tve srutun and the physical signs in the lungs 
confirms the diagnosis of syphilis. 
2, To what is dysphagia in laryngeal tuberculosis due ? What would 
you do to relieve it 9 pysphagia is due to the extreme pain and 
swelling resulting i?rom the situation of the tubercular ulcer on 
the epiglottis or in the areyepiglottic folds.Deglutition is at 
tlines so painful that a patient will often go for 24 to 56 hours 
without eating,rather than suffer the excruciating pain accompany- 
ing deglutition. If the ulcer* be limited to the vocal cords or 
ventricular binds,deglutition nay be perfectly normal. Treatment.' 
An alkaline spray such as— K. Sod.bicarb gr.X. Aq. oz. j.add a 
teaspoonful of Listerine,should be used to free the ulcers of the 
secret ion; the part should then be anaesthetized with a 20 CA sol. o 
of cocaine, with the Heryng curette the ulcer should then be thor- 
oughly curretted and lactic acid applied. Iodoform insufflated in- 
to the larynx with a powder blower often assists in healing. u/here deglutition Is very painful and the weak condition does not 
justify operation he should be made an comfortable an possible,in- 
sufflate a mass the size of a pea*night and morning with a powder- 
blow er o" the following—Morphine gr.x. Comp.stearate of Zn.gr. 
XX. A 10 CA sol.of cocaine sprayer] into the larynx 10 or .15 min. 
before food may diminish the pain of deglutition. This is not ob- 
jectionable as the patient has only a few days to live, Liquids 
are usually the only substances that can be swallowed and loe-oold 
liquids are more grateful than those which are warm. Sucking small 
pieces of Ice after cooainizatlon oC the parts may make degluti- 
tion more easy. Patients sometimes suck food up thro* a glass tube 
with the head hanging over the side of the bed with less pain than 
when lying on the back. In extreme case a small stomach tube may 
be Inserted.Rectal feeding Is the last report. 
.'5.What are the more common appearances In the larynx on attempted 
phonation In a case of "nervous* or functional aphonia. This Is 
bilateral adductor paralysis or bilateral paralysis of the orlc»- 
arytenoldel later all* and usually the arytenoldeus as well, various 
as regards the position and. mobility of the vocal cords 
may be seen. The usual picture;the vocal cords do not approximate 
in the median line when attempts at phonatlon are made,although 
they move considerably from the position they had on taking an 
insplratlon.Durlng resplratlon*the vocal cords may move normally, 
they may during pho nation* come quite together and yet no sound be made, wo Inflammation or the larynx Is usually present. 
4. What nay cause paralysis of the left recurrent laryngeal nerved 
Of the right ? What effect has paralysis of one nerve have on the 
vocal cord of that side 9 What Is the appearance of the glottis 
on quiet respiration and on phonatlon 9 On the left,the nerve 
is more commonly affected,owing to Its passage around the arch of 
the aorta where It Is Involved In aneurism. On the right,It may be 
implicated In aneurism of the Innominate or of the subclavian ar- 
tery or be Included In a pleuritic exudate at the apex of that 
lung,the subsequent organisation of the exudate producing a com- 
pression neuritis,Either of the nerves may be Involved by any tu- 
mor in their course,or they may both be involved in the same tumor 
as cancer of the oesophagus,glands of the neck, abscess of the neck 
mediastinal tumors,goitre,or gummata. Central Pauses, Tabes,syph- 
ilitic tumors of the base of the braln,bulbar paralysis,diphtheria 
toxin,and lead poisoning. In unilateral paralysis,the vocal cord 
on the affected side Is In the cadaveric position;It does not move 
either In phonatlon or in resplratlonjlts Inner margin Is curved, 
the concavity toward the median line.The other cord moves normally 
and this gives the glottis an oblique direction from before back 
toward the paralysed side. 6. Symptoms of the hypertrophy of the adenoid tlsmxe at the vault 
of the pharynx 9 hull expression of the face, open mouth * thick lips 
plnohed nose, absence of groove over the alae nasi* enlarged, trans- 
verse vein at the root of the nose,Inability to blow the none,and 
therefore a thick tenacious mucus obstructing the nasal cavity and 
a nasal twang to the voice, The mother gives a history of snoring 
at night*great restlessness*continual Kicking off of the clothes, 
and frequent attacks of cold In the head. The child Is not robust* 
stature Is usually below the average*and at school they are behind 
children of their age. Indigestion Is the rule, various reflex 
neuroses such as nocturnal eneuresis*spasm and twitching of the 
muscles during sleep*convulsions.chorea,laryngismus stridulus, 
coughing*hawking*stammerIng and stuttering, Uosebleed Is common. 
The lymph glands at the angle of the 3aw are usually enlarged. Ear 
ache and suppurative conditions of the middle car are frequent. 
e. Method of removal of adenoids ? HQaovlng them by the finger- 
nail Is not good surgery. Ohlld etherised. Instruments have the 
Lowenberg forceps and the uottsteln curette, ohlld held by an as- 
sistant In the lap. Insert a mouth gag.**eel for the growth to as- 
certain position. Depress tongue If necessary,Betract soft palate. 
Insert forces closed*In median line and carry to vault of pharynx 
and seize the growth In the median line avoiding the Eustachian 
e lnences*also taking care not to go too high and by so doing to 
include the septum.Close forceps on the mass and extract with a rocking not Ion. Then examine with the finger; If any Is left, remove 
as before,Then insert the curette and make the first sweep In the 
median line,The next sweep outward toward Rosenmller* s fossa and 
aft similar sweep on the other side, continue this method until the 
vault in cl ear. Hemorrhage may be brisk; during operation, the assis- 
tant should nee that none of the blood in inspired, and also that 
the child be not too deeply anaesthetized. Hemorrhage is rarely 
severe enough to require special treatment.After treatment,rest in 
bed till danger of hemorrhage is past.During the cold winter non, 
it is well to keep child In doors for a week.Avoid sprays as a ml 
unless there be purulent discharge and constitutional evidence of 
sepsis. In such a case,employ ant,nasal syringe and seller's tab- 
lets. After recovery tell parents to insist on nose breathing. 
6. Diagnosis between follicular tonsllitis and diphtheria 9 
1,Suddan onset. 
9.Chill. 
5.Temp. 105 to 105 « 
4. Vomiting occasional, 
ft,Albuminuria rare, 
5. Tonsil considerably enlarged. 
7.Membrane easily removed, 
leaving no bleeding surface, 
b, eibrane does not reform, 
hyperemia of soft pal. 
10.Pus producing bacteria. 
DIPTHKKIA. 
l.More gradual onset. 
8. Chill Is rare. 
5.Temp. 101 to 105 M 
4-, vomiting Is common. 
5. Albuminuria If? common, 
e.Tonsil about Ita former size. 
7.Membrane very adherent, d enu - 
ded surface bloods 
B.Membrane reforms In row hours 
9. soft palate almost nor r,\ In 
appearance except for spots, 
10.K1ebs-Loeff1er bac1111. 
ALWAYS MAKE 4 HAOTKHtOLOOI0AL EXAMINATION JM RTTSPE07KD CASKS. 7• Syphilitic ulceration of the larynx. Treatment ? constituttonal* 
KI in largo doses and In doses of from 40 to BO gr,per day. In 
sonn oases l/*50 gr.corrosive sublimate t.l.d. Util id iip the general 
health. Local treatment. Remove forst the thickened and adherent 
secretlone from the ulcere by spraying with an alkaline solution 
and then apply Aguo. (BO gr. to 1 oz. of water.) to the ulcer. 
Look out for a tendency towards oedena of the larynx*to diminish 
this tendency,keep the patient In a warn moist room,In bed*having 
him breathe steam from a croup kettle in which a teaspoonful of 
conp.tlnct. of benzoin and one-half a teaspoonful of turpentine to 
each quart of water have been placed,. 
8. Nerve supply oC the larynx*sensory and motor ? Blood supply ? 
Nerves are,the superior laryngeal*and the Inferior or recurrent 
laryngeal,branches of the pneumogantrlc,joined by filaments from 
the sympathetic, The superior laryngeal supplies the mucous mem- 
Vrne an’ the crlco-thyrold muscle, The Inferior laryngeal supplies 
the remaining jouscles, The arytenoid made Is supplier! by both 
nerves. Blood suoolv. The arteries are the laryngeal branches derl 
ved from the superior and Inferior thyroid. 
9, entlon some of the causes of chronic nasal and post nasal ca- 
tarrh which can be removed by operation and describe the operation 
Menolds.( for operation see above.) spurs of the septum, removed by 
sawing.Polypi*removed by the cold wire or the galvano-cautery snare.Deviations of the septum, which can he corrected as follows. 
The Asch operation. A 10 i* sol. of cocaine is mployed and ap- 
plied on pledgets df cotton so as to come in contact with the en- 
tire surface of the septum or better a general anaesthetic. The 
Instruments are a straight scissors,an angular scissors,forceps, 
a gouge,an elevator and splints. Introduce the forefinger into the 
nostril in which the convexity exists. Make the first cut in the 
direction of and at the point of greatest deviation;do not make it 
too near the floor or too near the bridge, Make a clean cut thro1 
the septum;now make a second incision at right angles with the 
first,as in the following figure, 
with the finger,fracture the 
four segments toward the 
open nostril;lntroduce a tube 
Into the nostril where the convexity existed. Keep clean. Hyper- 
trophy of the turbinals. Cauterization by the galvano cautery,by 
?richloracetio acid or chromic acid, 
bodies 
10.Symptoms of foreign in the nose and method of removal ? In a 
child old enough to talk,the pain and sense of discomfort nay be 
enough to make it call the parent's attention to the nose, sneez- 
ing and watery discharge from one nostril often occur soon after 
introduction. In two or three days the discharge becomes thicker, 
Tfiuco-purdlent and possibly fetid.Mouth breathing, snoring, ear-ache, 
and suffusion of the eyes are the common symptoms. Removal.or hard or rounded foreign bodies,employ a silver probe, 
bent at one eigth from its tip so as to form a right angle;wlth 
this Introduced carefully along the septum beyond the body,and 
rotated and pulled forward,the foreign body can be hooked out,if 
the operator be at all skilful.A hair pin Is almost.as good for 
tils purpose;If the body Is far back,push it back Into the naso- 
pharynx with a cotton wound applicator. Recently Introduced for- 
eign bodies may be removed by placing a piece of cheese cloth aero 
the open mouth of the patient stopping the open nostril and blow- 
ing Into the patient’s mouth. 
11.Describe the normal laryngescoplo Image. Rhinosooplc Image. 
(ood for 
19. Give the appearances in acute catarrhal laryngitis.treatment ? 
The mucous membrane of the epiglottis la reddened and the blood 
vessels are dlstended.In mild oases,the vocal cords are perfectly 
normal in appearanoejin severe oases,they are light pink,with hero 
and there a dilated blood-vessel, in the very severest forms,they 
may be so reddened as to be scarcely dlstlngulshable,the ventric- 
ular bands and aryepiglottio folds being congested and oedematous. 
There are usually appearances of Inflammation in the nose,naso- 
pharynx, and pharynx as weH.fThe phonatory position is better them respiratory position Tor observation, ) Treat. }ent.( a) Constitution- 
al- Knf*p patient indoors in a warn room, In nevere canes in bed. 
Free evacuation of the bowels by cal ora el at night t followed by salt 
in the mornlng-Qlve patient a glass of,hot milk as soon as he a- 
wakes in the morning to loosen the mucous accumulation In the lar- 
ynx. ror cough-Codeine- i/p. gr.ev,4 hrs. or Heroin l/l9, ev. 4. hrs 
Ammonium chloride is good as an expectorant. {B) Local- Absolute 
rest dor the voice, Count er-lrrit at Ion over the larynx and upper 
part of the chest—turpentine either In full strength or with a 
Ixture of sweet oil—gives great relief. The application of cold 
to the larynx by compresses or by a cold coll diminishes the swel- 
ling. Local applications to the larynx do little or no good.An 
oily spray may be used*the patient inspiring when the bulb 11 com- 
pressed, 
13.Chronic catarrhal laryngitis. Appearances V Are three kinds, 
(a) Diffuse hypertrophic, mucous membrane is red,swollen find con- 
gested, with secretion deposited here and there on the surface of 
thr ventricular bands.Inter-arytenoid region on the posterior lar- 
yngeal wall.The color of the cords varies according to the inten- 
sity o the process from slight pink to deep red. In severe and 
long standing oases, their Inner* edge may be slightly Irregular and 
uneven. The vocal cords are often sluggish in action,and do not 
approximate during vocalization. Treatment.search out the predis- 
posing factors. The internal administration of s line laxatives using a teaspoonful of OarlsbA salts In a tumblerful of water, 
half an hour before breakfast each morning for two or three weeks 
1.4 - .illy give?? excellent results, s inking Indoors should be pro- 
hibited and the excessive use of alcohol abandoned.Local.Swab the 
larynx with a 10 i» sol. of cocaine and at the end of 5 minutes,a 
sol. of Zinc chloride (gr.x to the oz. of water) in to be applied 
to the laryngeal mucous membrane. If this fail,use silver nitrate 
In the same strength. Have the patient go to a warm Southern cli- 
mate in the inter, (h) sub-glottic hypertrophic laryngitis. Inme 
dlately below and parallel to the /■coal cords,are seen two oval, 
usually pain masses;there may or may not be swelling and oedana of 
the aryepiglottlc folds. The vocal cords move sluggishly,and are 
not approximated properly on phonal Ion. Treatment The Intern ,1 ad- 
inistratlvo ofKI gr,'< t.i.d. nay assist in taking down the hyper 
trophy.Local applications of caustics—silver nitrate or trichlor- 
acetic acid,or even the galvano-caut cry,have been used.They re- 
c Hire great care, a 9.0 >£ sol.of cocaine- should be used for anaes- 
thesia and the patient should br made accustomed to laryngeal Inst 
ruments before the caustics are used,The caustic should be .c rried 
in an instrument which conceals It until it is opposite tha point 
to bn cauterized. The Introduction of large sized Intubation tubes 
oft da does good, we ready to do a tracheotomy at any moment. 
In) Oorditls Nodosa.or Traoho la of the vocal Cords, slight whit- 
ish, grayish or very light pink elevations are seen near the Inter- 
nal margins of the vocal cords.Muoous manbrane in the immediate vicinity is slightly reddened. Treatment.frive the voice absolute 
rest.This often affects a cure in light oases in from three to 
six souths. Zinc chloride applied assists in the absorption of the 
nodules. For large nodules,cocainize the larynx with a 20 (A sol 
. 1 
of cocaine and remove the node with a laryngeal forceps.Af- 
ter treatment of this operation is to touch thebase with a 2tnc 
chloride solution. 
14.*rive a short clinical history of an acute peritonsillar abscess 
Patient ±53 usually between the ages of 16 and &0;has probably had 
an attacK of acute tonsilltis exposing himself during the attack, 
getting his feet wet.ve has aohill,rise in temperature, very in tens 
pain radiating to the ear,on the affected side. At the end of 46 
hours he cannot open the jaws more than 1/4 of an inch 5 deglut it ion 
is excessively painful. Saliva “dribbles'" from the partially open- 
ed -iouth. The high temperature and poor nourishment produce weak- 
ness and emaciation;the voice is hoarse.nouth breathing,dyspnoea, 
stiff neck and enlarged islands.Examination. Xs difficult to open 
the mouth;the anterior pillar of the fauces and the soft palate 
are intensely red,often purplish,*swollen,and project further for- 
ward than the anterior pillar of the opposite side;tonsils are 
somewhat enlarged,yellowish cheesy matter in the mouths of the la- 
cunae; uvula in much elongated and curved toward the diseased tons! 
fluctuation con be detected with the finger. Treatment. Incision 
should be made as soon as discovered;make a vertical Incision across the point or greatest swellIng,using a sharp pointed bis- 
toury with the blade wound with cotton*leaving a half-Inch of the 
point exposed, a 10 CA sol.of cocaine Is sprayed over the palate, 
ne c areful not to cut the tonguepaaXe a dree Incision.Pus nay or 
nay not he found.01ean the abscess cavity with 1:100 carbolic and 
Insert iodoform gflifl dor dralnage.Use cleansing sprays;have a hot 
pultlce on the neck. 
IB. Differential diagnosis between secondary and late syphilis of 
the pharyjix ? secondary symptoms. Patient will give a histowy of 
very bad sore throat lasting several we*ks;hot fluids and spices 
aggravate the pain. Inquire closely Into the venereal history.The 
usual conditions—the raucous patch,a faint whitish area,Irregular 
in outline,situated on the uvula,plllar of the fauces,tonsils,lips 
and Margin od the tougue.lt is not elevated abobe the mucous mem- 
brcuiejlt is bordered by an extremely narrov zone of hypermia,liKe 
a faint pencilling of vermilion;It has a corresponding lesion on 
the other side,symmetrically situated. syphilitic erythema,a red- 
dened and mottle*! appearance of the entire moons membrane od the 
Piicrynx. A rare secondary manifest at lonare warty like, excrescences 
) on the tenure and tonsils. Tertiary Manifestations are gum at a, and 
ulcer,The ulcerp results from the gumma as a rule.The gumma Is a 
regular rounded msa,elevated and redder than the surrounding tis- 
sue; It Is dim to the "eel. The ulcer—a round variety,looking an 
id it 4?ere punch eft, and the serpiginous form with Its margins con. sidercBly elevated and covered with a thick dough. 
* 
Ifi. entlon come of the more common causes to the obstruction to 
nasal breathing. (A) Large spurs,atresia,(post-opera- 
tlve or congenital.)thaematom and abscess of the septum*foreign 
body,rhinol1th,non-mallgnant and malignant growths* ( *) hilaTKKaL. 
acute* purulent, chronic hypertrophic * atrophic*meribranouc, vase-motor 
rhinitis;nasal dtphtheriaideviattons of the septum; syphilis;?.H,; 
cide-i.->idfj;jr...lignant and non-malignant growths of the pharynxjart- 
heMlons of soft palatejretro-pharyngeal abscess;double perttonsil- 
1 ar absc es s;enon non sly hypertroph1ed tonsils. 
1*7. Diagnosis,pro gnosis, and treatment of atrophic rhinitis ''The 
etiology is unfcnown.The nose is continually blocked with crust for 
nation.The fnuoous membrane of the nose is completely atrophied*the 
normal mucous membrane being replaced with stratified epithelium* 
the underlying tissues are replaced, by dense connective tissue; 
frequently the inferior turbiante disappears,of the middle only a 
stump is left at its posterior end.There is a fetid odor to the 
secretion;the patient has a foul breath.Constant picking of the 
nose produces ulcer ami subsequent perforation. The larynx and 
Pharynx are Irritated;the crusts are blackish or greenish in ap- 
pearance, syphilis and tuberculosis,and empyema of the accessory 
sinuses are to be different later). The history and the presence of 
crusts eliminate the first two..Sinus disease is shown by a period- io discharge of pus or muoo-pus,thro* the nose and the physical 
signs of suppuration in the sinuses,The prognosis is had as Tar 
as a cure is concerned hut faithful treatment v?iii greatly amelior 
ate the disagreeable symptoms.Treatment. Thoro*ly cleanse the none 
and try to prevent crust formation using the v/h it all-Tatum nasal 
douche, pint sise,or the ordinary douche bag. hake four table-spoon- 
fus of baking powder and two of salt,mix thoroughly,and fill the 
bottle ft/4 mi with luke warn water;to this add 9/ft of a table- 
spoonful of the nixture;kenp the mouth open and let the fluid run 
in the left nostril and out the right;elevate the bottle about '> 
to > in.above the level of the nose. ,o this morning noon,an * night 
Look out Cor the general health.Have the patient use the following 
spray after each washing—Menthol—gr XX Aristol—gr.xxx. Henzoin- 
ol— oz.l. Swabbing out the nose with —Carbolic acid and glycer- 
ine of e oh 07. once a week is good. The patient should report 
once a month for Inspection. 
Ik. The symptoms of acute tonsilitis 9 (See article on periton- 
sillar abscess,question 14. ) 
19. Differential diagnosis between syphilis and cancer of throat ? 
Syphilis is dlffentlated from cancer by the age of patient,the 
history,slower growth,absense of severe pain,or cachexia,absence 
of bloody or muco-purulent discharge,the presence of syphilitic 
lesions elsewhere,and the efficacy of syphilitic treatment,-as well 
as microscopical examination. fO. The diagnosis and treatment of papilloma of the larynx ? pap- 
illomata consist of connective ttonne in various stagey of organ- 
ic at ion, in the iesh.es 0f which in found round cell infiltration, 
their surfaces being warty or cauliflower In appearance .They m-y 
be either pedunculated or attached to a broad base.They are sin- 
fT-° or multiple;their color ranges from pale pink to bright red. 
tt on ally spring from the vocal cords, ventricular band s, subglot 11c 
region, ary epiglottic folds,and epiglottic.They should be removed 
in the manner most likely to effect a cure,either by lntra-1 aryn- 
£eat or extra-laryngeal operation. Intra-laryngeal operations are 
under a TO # cocaine anaesthesia. Use the ooakeiy laryngeal 
forceps with the serrated or cutting edges. Absolute alcohol spray 
en into the back of the throat and inhaled into the larynx twice a 
day as suggested by peiavan.The gal vane-cautery 1b nsec! but lo not 
advisable as its use is very dangerous. 
el. pencribe spurs of the nasal septum. They may be an outgrowth 
of cartilage or bone or of both combined being sufficiently narked 
to stand out prominently from the septum.Their position is 
by ajs a probe with the point bent to an obtuse mgle.Thls also 
tells the presence of adhesions between the spur and the mucosa; 
they are of hard consistency,usually found in the naterlor third 
of the septum.Long standing spurs are much denser than those of 
recent origin.Spurs on the posterior part of the septum are usual* 
r?malesgsed of very hard and dense bone.kore common in males thru; r>o# Describe and give treatment 'or nasal moons polypus. They 
nn'ifi up or loose connective tissue infiltrated with round cells a* 
o clear flu 1* .usually containing moons secreting glands.They are 
frequently seen protruding Iron the nostril,With the speculum we 
see a large mass wedged In between the septum and the outer wall 
of the nose,snail polypi are seen betv/een the middle turbinate and 
outer wall of the nose or attached to the bulla ethmoidalis.They 
referable an oyster In color,The probe gives us the position of the 
polypi and posterior rhinoscopy nay show polypi either filling up 
the choanae or pro jeotln n Into the naso-poharynx. Treatment. 
The cold wire snare.The loop should be made a little larger than 
the estimate! size of the polypus;spray the nose with a 9 .* sol.of 
cocaine.widely dilate the nostril.pass in the loop between the pol 
yp and the septum, then rotate the handle toward the outer wall of 
thexxaix»x none so that the lower border is made to pass underneath 
the polyp,give a gentle rooking motion directing the loop toward 
'e middle meatus,making pressure upward;then contract the loop 
and remove the snare;control the bleeding.Spray the nose,night and 
morning with seller’s tablets in sol. Cauterants at the bas- are 
not necessary. Thorough curetting of the region whence the polyps 
6 will In some cases effect a permanent oure.Tjse arunwald curet 
This operation is quite painful at times and care must be taken to 
void the accessory sinuses of the cribriform plate or- 
bit. 9*. The \o rp common causes and the treatment of ep1staxis V They 
are—(a) LOCAL.slows on the nose;frequent attacks are due to the 
thin called veins situated on the cartilaginous part of the sep- 
tum just within the nares and a quarter of an inch above the floor 
and these are by "pick 1. ng "the nose, flight hemorrhage may 
occur In acute rhinitis or in chronic hypertrophic. In atrophic, 
where ulcers exist .Ulcers of any kind what evere produce blowing, 
as do both malignant and non-mallgnant growths, ( H ) TTI Oh AL 
The onset o’ infectious diseases.typhoid.pnemonla.grippe,meisles, 
scarlet rpvor.psrtussls. erysipelas* and diphtheria. AS a symptom of 
cardiac hyper trophy.with Increased arterial tehslon or where there 
is obstruction to the return flow of blood*Common in cirrhosis 
the liver and v 1 the constituents of the bl&od are iter 
(d—anaeila,chlorosis. 1 eukaeml a .purpura*malaria*scurvy, and haeno- 
phllla.Tt occurs as an Indication of weak vessels and may precede 
he, 1 -login, . Coif or hot applications over the nose. 
and absorbent cotton 1n the nares is often enough to stop slight 
bleeding;If the bleeding still continues dilate the nostril and 
look Cor the blfeeding point.Thoroughly cocainize this area and 
cauterize It:If the bleeding Is so profuse that this cannot be f 
done, jack the nostril with cotton dipped In a solution of tannic 
cl l of h syrupy co no latency; perchlori.de of Iron Is recommended. 
If bleeding Is so pro.fi:se that the patient shows constitutional 
symptoms,put patient to bed and Inject salt sol .Pack post.nares. r>A, The oausn ; and sy rptons of empyema of* the maxillary sinus 9 
Follows severe acute Inflammation Involving the nasal rnuooue mem- 
bra ie is In Inflnenaa. Is ort,en secondary to suppuration around 
the roots of the blcufjpld and molar tooth,rarely in the canine 
teeth.hecrosis, syfchlll8,or otherwise,involving the middle turblant 
or ethmoidal cells,where the secretions are damned hack is a cause 
Masai polypi which coupletely block the nose and purulent inflama 
tlon or the 'rental sinus may cause involvement or the antrum,The 
’•.y ip to-as are two narked—Pain and presence of ail abundant purulent 
discharge from one nasal cavity,The secretion Is very foul In old 
oases hut In recent oases It nay he odorless.Pain Is referred to 
various portions of the head usually to the malar hone immediate-* 
1' below the eye,to the hack of the orbit,above the eye,or neur- 
algic pain Involving the whole side of the head,and occasionally 
occipital pain. If due to carles oC the teeth,the patient cannot 
chew on the affected side,The temperature may be elevated In acute 
car . It Is normal In long standing oases, 
pfs. The results 1? untreated,of adenoid vegetations v Frequent at- 
tacks of otitis media,causing eventual Impairment or hearing. They 
is a tendency for these growths to deorese In size after the Ls th 
year.This,together with the great enlargement of the naso-pharynx 
at this time may partially restore nasal resplratlon.Is not safe 
to wait Cor thl« change,as the child's general health,hearing,and 
development,may be verlastingly Impaired In the meantime. 96, The clinical history of lupus or the pharynx 3 x 5 usually 
found in connection with lupus In other parts of the body and Is 
lore son .on In young adults.and In females than In rains. The ;u- 
cous•membrane and sub?*? cons tissue Is Inf 1 it rat ed with small round 
cells which hunch together and Com nodules on the surf ace; these 
undergo a slight form of ulceration. Tubercle bacilli are r -rely 
in the nodules .The posterior pharyngeal wall 'Is rarely af- 
fected. The soft palate rali are the usual seat ft. The nodules 
ini'ergo dealing after ulceration 'and show cicatrice.--:, tn one area, 
ill three ferns of the lesion nay be seen,nodules.ulcers.and ci- 
catrices.The sy iptons are stiffness and Inflexibility of the soft 
palate with inpalrernt of swallowing.The voice has a X twang. 
There is little pain and the parts are usually anaesthetic;the 
glands in the neck are not necessarily enlarged.The treatment con- 
sists in establishing nutrition at ‘.he highest possible point;send 
the patient to Southern California,or New uexico.Locally apply the 
gal/ano-cautery to the nodules,following it with an application of 
lactic acid.Curetting may be eioployed to remove the Infiltrated 
ar m.Tuberculin May be administered hypodermically.with great ear 
£♦/. The function of the thyro-arytenoid muscles ? This muscle is 
a broad flat muscle lying parallel with the outer side of the true 
vocal cord.It arises from the low“r h-.If of the receding angle of 
the thyroid car til a art frort t he or ico-thyroid membrane, its 
fibres oass backward and outward and are inserted into the aryte— not1 ye, donsists or two fastmili,the Inn or portion Is 1 nr? fir 
t Ofi Into the vocal process at the ha no of the arytenol i cartilages 
and lloi parallel with the true vocal cord with which It la adher- 
ent .?ho out or faslculus Is Inserted Into the outer border of the 
cartilage,above the preceding fibres# The action of t; ese is to 
draw 'he arytenoids forward and thus relax the vocal cords*hut the 
cords nay be also approximated and their thickness aiid elasticity 
ex t oneIv ely rno 11 fted. 
eh. Perforations of the nasal septum. Seat and nature ? They are 
livid ed Into two classes—(a) Perforation of the cartilaginous 
portion r.jrl (u)Perf oral Ion )f the bony 'portion. The -common form Is 
a perforation or the cartilaginous portion varying in size Pron a 
,11 hole to one large enough to adult the end of the finger. Xt 
1 ay ren -It ?ro:n necrosis of the cartilage in abscef?ntbut usu lly 
i , 
from constant picking of scabs off the septan.Perforations nay re- 
sult from coldent i luring operation. Perforations of Pony septum. 
Are Invariably the result of necrosis of the bone,flue to syphilis 
s uile;rorely from tuberculosis, 
Pharyngo-rayco«i», Ktlology and diagnosis f Xt is a parasitic 
dlsep.se of the mcous ie?:branetd\ie to the presence of fungi,oh the 
class Mycosis—the leptothrlx buccal1b is the most corner*. It oocu 
rn most frequently between the ages of 20 and The peptothrlx 
penetrates the glands ni&Ktf on the posterior pharyngeal wall ; active multiplication of threads tabes plane and wp have whitish 
graylsh,or slightly yellowish conical elevations,the sljse varying 
fro a ere speck to that oC a mustard seed or a grain of sloe, 
iv lorosooolcally, small rod-llke Taasses are found,which turn blue 
in T.ugol* e sol. anH contain spores.The saliva In < hts affection In 
often quite acid In react Ion; the rnuoons membrane Is not Inflamed. 
Treatment Is removing them one at a tine by the galvano-cwutery in 
eertlng the point deeply into the mass and spraying the throat 
It- a 1:300> corrosive sol. 
bO.Causes of an l appearances in,oedema of the larynx nay be 
( O Local, (h) Constitutional. Local Causes.app1icatIon of caus- 
tics, In,ieotlons oC creosote,foreign bodies In the sub-glottic re- 
,the s .'allowing of hot liquids,or of strong spirituous Honors 
Inhalations of dense steam and Irritating smoke*prolongerl shouting 
Indian- < at Ion aooonanylng eryslpeinB, diphtheria, Influenza, hmslu i, 
sc-;.riet fever ,pertuacla,ulcerative cond.ltIons,as tuberculosis,sy- 
P.‘ Ills,and malign, mt growths,abscess,perlohondrltlBtand peritonei! 
1; r abscess, constitutional Causes. Hrlg/its dine se,Diabetes,car- 
diac lea tone, Ludwig* is angina* and lafg<9 doaea of k:c. examination 
f ovs large,palefusually gray swellings completely distending the 
aryepiglottic folds,the elevations of the cartilages narking the 
position ofx the cartilages of Santorini and Wrlaberg are effaced, 
mere the oedema is sub-glottic,the wallings are seen beneath the 
vocal cords. Treatment.Cocaine 20 yw. Scarify availing with a con- coaled laryngeal this falls a,id? the cyanosis deepensthe 
ready to do a ‘raoheoto* y. 
cl. Describe the action of the larynx In the production of sound., 
•/hen the voice la sounded,the op ace between the curtilages of San- 
torini In obliterated,and the vocal processes and cord#? are brough 
together, *?he »rhole rim of the glottis or the vocal cords alone nay 
be seen to vibrate according to the pitch of the note,The proniin- 
cla’lon of "g" or "he tt usually five the beat view;saying MAr"or ” 
**V or "Ha" will give a good view If at the same time the patient 
:of;-s not arch his tongue. The glottis is closed by the following 
usd es— or loo-ary mold el lateralis* the muscles 
which regulate the tension of the vocal cords are the crlco-thy- 
rold6l*which tenses and elongates then and the thro-arytenoidel, 
which relax and shorten then.The arytenotdeus fills up trie post- 
erior surface o<? the arytenoid cartilages,arises from the posterlo 
urfaoe and outer border of one arytenoid cartilage and Is Inser- 
ted Into the corresponding surface In the opposite cartilage, rt c 
consists of transverse and oblique fibres.The orlco-arytenol-leus 
lateralis Is an oblong muscle arising Prom the upper border of the 
side of the cricoid cartilage,and passing obliquely upward and bac 
ard is inserted into the muscular process at base of arytenoid. */'. Ktiology -md symptoms of ha# fewer, or vaso Motor rhi.nltin ? 
peculiar nerotic condition of the system. (h) a spec- 
ial susceptibility and a very Irritable condition of the mucous 
aeabrane of the nose and of the conjunctlvae. (C) Some irritating 
atanoe -'hioh is the exciting cause. People igno have thi» din- 
ease have a nervous tenpera?aent,more common in the highly educated 
overworked people of the city and in men than in women and in adul 
than in children, it freouent Ly nine in ifaJailles.it is hard to 
cay what lesion most frequently predisposes to an at tack, hyper- 
rophic rhinitis, thickening of the septal moons me».>rane%tdevia- 
tions of the septum,spurs,adhesions between the mucous membrane of 
the septum said that cohering the turbinals,polypi,and adenoids are 
ovb'b of the disease.some patients exhibit no pathological pro- 
cess except here and there especially sensitive areas which give 
rise to paroxysmal sneezing when touched with a probe.The exciting 
causes are divided into two classes,the May and June class and the 
August class, .’he pollen of plants being accredited as the irrit - 
ting substances—the odor of stables,dust and irritating gases,may 
act as 1 idividual fc* excitants. Symptoms, aegins with a sense o * 
drying and burning In the nose and In a few hours the nasal mu- 
cous membrane is swollem so as to cause mouth breathlng,and at 
about this tiiae sneezing and a watery discharge from the mo#th,no« 
and eyns.rh.e sneering begins as a single" sneeze and rapidly pro- 
gresses to freouent paroxysms.There is froiatal headache and a 
sense o(? suffocating,exhaustion fron the excessive sneezing. The patient Is free from paroxysms at night;prolonged attacks of 
h-iy "ever nay produce symptoms of bronchial asthma which runs on 
into t' e winter months. 
The symptoms and treatment of enlarged tonsils ? They are us- 
ually associated with adenoids and we get the same symptoms as In 
adenoids. vae voice in usually thick and the patient talks as If 
’.oath were Cull.There i* an Irritable hacking cough,and diges- 
tive disturbances are oommon.The breath is foul,and the patients 
expectorate every few days little cheesy pearls,smelling like a 
very ofChiclve Limburg cheese.The patient t* subject to acute ton- 
sillitis and perltclnslllar abscess and to the acute Infective fe- 
especially diphtheria. Treatment. Consists In removing ; s 
much of the tonsillar tl sue ns possible, (i) ay the tonslllotone, 
( ", il '. Is to be employed In children. ) (9.) The galvano-oautery 
snare, (’bnl In adults where the tonsil Is soft.) (;>) ny cauter- 
isation with the g ;lvano-cautery elect-ode, (used here the ton- 
sillar hypertrophy is slight,and where the breath is foul and ther 
are cheesy •lasses and pharyngeal. Irritation. OPKFaTIONS In the 
yon.i: tfstinrm vtfG ether;In older ones,a 10 a sol, of cocaine re- 
plied to the tonsils. Insert a mouth gag and use the path leu ton- 
■ lUotome,selecting a sl«e which fttd the tonsil: break up any ad- 
hesions ’filch nay exist between the tonsils and the fauces with 
the Asch elevator ; always direct the spear points of the Instru- 
ment to a-"' the ieitan line, ?rannflx and excise the tonsil bv one- oulok stroke,control excessive fcltMtng and give a fluid diat.ioe 
orPan is very grateful, 
;54. Describe retro-pharyngeal ahacess. A collection or pus in the 
connective tissue beneath the mucous rimbrane of the pharynx; conw- 
on In children rare In adults, Predisposing causes are o.u. and 
syphilis#!! often follws the a ante infectious diseases*septic in- 
wall 
jury to the posterior pharyngeal nay cause it. It May be due to 
o rle<5 or the oervlo.-.a vertebrae.lt In believed that suppuration 
originates In a dew lymph glands found In Infancy beneath the iau- 
co i ; nenbra?ie of the pharynx, These glands usually atrophy before 
the nth yr. The collection of pus way spread behind the mucous 
neribrane not only of the entire oro-pharynx but way dissect up- 
’ \rc and downward*involving the naso-or 1 aryngo-pharynx, Trie his- 
tory is not definite olng to the age of the child.The child is 
t txAn sick%has Cover*and cries considerably, its crier? way resm- 
ble trie quacking of a duck..Soon the child refuses the breast or 
mottle* ay iyspnoea*great restlessness and coughing*with the symp- 
toms analogous to those of croup,Tort1-oollls and stiff necp are 
serrn;there is wouth breathing and a nasal twand to the voice;the 
lymphatic glands are enlarged, *,x an in at ion shows the posterior phar 
>>xgeal all bulging forward pushing the soft palate and the uvu&fc 
for ard.Fluctuation is usually detected by the finger.Trealment. 
The abscess should be pvacuatert*as any otheT- abscess,wick A- clean. 
At tines they must be opened from the outside. . Vosees o? septum, Describe, a collection of pus in the mu- 
*cmbrane an1 underlying structures of the septum*Results usu- 
‘ I • . ay hollow OP69P«tlon or ulcer*If allowed /.: to 
go in treated. It may cause necrosis of the cartilage and bone,when 
It ice: arge , or Is opened t per for at Ion Is often found.TTsually one, 
sometimes both nostrils are occluded,there Is pain,In the anterior 
part of the nares;thn local,and perhaps the body temperature Is 
oo' »eir at rained,from one to three degrees, Kxewlnatlon shows n 
fluctuating enlargement visible in one or both nasal cavities;the 
?olor may be reddish or yellowish.The prognosis depends* on the 
t1 'av the abscess has existed,necrosis may be sufficient to produce 
the deformity known as saddle back nose,Treatment consists In ana 
b heti 'iog with cocaine,evacuating the pus, ashing out the cavity 
it; . 1:40 or 1:3000 carbolic and corrosive respectively,.and pack- 
i i the nostril.! f the abscess Is large. Insert a small wick for 
drainage. 
Anemia.Causes and prognosis. The sense of smell depend- on 
(1) a healthy state of the olfactory nerve and of the Olfactory 
?■- ct. (e) a patent condition of the nasal cavities,that substan- 
ces may reach’ the endings of the olfactory nerve in the upper pair! 
of the nasal cavity. Tinder the first head,any cause which destroys 
the nerve,tract,or cortex of the brain In the region of the unci- 
n t gyrus,permanently destroys smell.syphilitic or other forms of 
u lceration In the nose,and tumors from pressure,and _ the sclerosis of atrophic rhinitis nay destroy the nerve endings. The nerve nn>i- 
ings iay become 'aligned from the long perception or oup odor, Tu- 
mors at ;he base of the brain or pressure on the cortex nay dent- 
roy the conducting and pare Hiving appreratus. Under Ihf iNJeond hf 
ng—Any cause of nasal obstruct ion*by which air In prevented i’ron 
reaching the middle meatus results in the loss of the sense or 
r.i i*•' 11. Prognosis.If it in due to destruction or the nerve or the 
pathway to th** brain,recovery in very rare. If due to nasal obstruc 
tion,unless loot for a long time, it can be removed by removing the 
a- of "ho ob itnxotion. 
m. Lingual ton all, symptoras and treatment when hypertrophied* V 
An increase in the amount of M$5>iXtf&XUOCXX lymphoid tissue found at 
the root of the tongue*behind the oircumvallate papillae just be- 
Inf the epiglottis.T* ere is a sense of fu.Hne.as in the htroat,of- 
ten an of a lump,which la not relieved by swallowing»Th#re is o - 
ten tickling sensation and oough.Patients usually refer the 
sympto in to a point lower down in the neoK#There is a tendency for 
solid food to enter the Xarynx.hoarseness of the voice*due to the 
on -est 1.o/i moons membrane,Treatmfait Thoroughly cocainize 
the region and cauterize the growth with a curved galvano-cautery 
electrode,-phin usually tah.es from B to 10 sittings at periods of 
from a weeK to 10 days before the growth Is reduoed; the cold wire 
e 1m at time* of use ; After treatment consists of spray in?; • 
the throat and apply! u y& sol. of cocaine to relieve pain on Laryngoscopies appearance of tubercular laryngitis when the 
symptoms are* (a) aphonio. (1)) dysphagia, JlPHOnIO, a tubercle nay 
be present In the inter arytenoid region and the vocal cords are 
not properly approximated due to the oedema of the ary epiglottic 
..'old, hfoerole nay be found, on the vocal cords causing an unevenne 
ii ‘5aa In their contour, rhiok tenacious menus brought up fro » the 
:o ay be deposited upon the vooal cords. The muscles of the la 
ynx may be interfere: with,so that their contraction is somewhat 
■interferes with. The recurrent laryngeal nerve on one side usually 
; r >'lght My be Imbedded In a pleuritic exudate, giving a paraly- 
il ;1 of -.he msoles on that side. Due to weakness,the column of at 
may be inoufficlent to vibrate the cords, (« causes.) 
j,/->-■■ Dysphaglo symptoms are generally caused ’ey the presence 
of ulcerd on ’he epiglottic or in the aryeplglottlo.fold. 
ipertrophy of the turbinated bodies. Anterior and posterior 
■It i diagnosis and treat-ient. The general condition o' %m hyper 
trophic rhinitis Includes hypertrophy of the turbinates, (1) The 
mucous membrane is bright pInk1sh,spongy,and dries not pit on probe 
Application of cocaine causes the swelling to disappear. 
Treat*ient. A saline spray or an oily If these fail after 
fair trial, cuter is? e lightly, the surface of the inferior nad middle 
turbinates with the galvano-cautery or trlchloract etc acid or 
C" o 1c acid,ruse on the end of a probe being careful not ' o touch 
au> tissue at/ er than the one desired to treat. (?) 4 rather pale pink mcous meabrane,firmer than variety (1) and 
pit;; on probe pressure* pari tally disappearing on the vine of* cooaln 
r^rr.trio/it, The use of the gal vano-cautery making the groove x/b 
Inch dpsnp ;.t one sitting In the only valuable treatment 'or thin 
variety, (o) The lower border of the Inferior turbinate Is touch- 
ing the floor of the none;It moves freely with the probe;mucous In 
found entrapped be; he outer border of the nose,Thin 1 
in best treated by removal of th- lower portion of the inferior 
turbinate by means of the cold wire snare; the loop should be hori- 
zontal. (4) Posterior rhinoscopy shows a large rounded j-.ass%pale, 
uneven ml mulberry like,or reddish In nolo?’,occupying 3th e 
tlon o.f the posterior end of the Inferior turbinate. Trent:-jentThe 
coif wire or the g*lv«no~oautery snare, hemorrhage In this variety 
is liable to be jerere* (o) a thickened pendulous membrane on 
the under surface of the inferior turbinate. The probe shows It to 
be movable but with a very broad attachment running ant ero-post er- 
ly, treat:lent. The pendulous portion and this portion only should 
be removed by the cold wire snare.The use of oau ter ants. Is some- 
v-h t d n erous since the veins communicate with the dura, 
AO, e IglosBlt Is, glossitis, ranual. Describe. Treat* i °nt * '.lone It Is 
la an Inflammation of the tongue to which has been applied the va- 
rolus of Meeographlcal tongue** "Leukoplakia" "Wappy t ’ etc. 
Kanula Is a term applied to the deformity produced by a cystic tu- 
mor In the floor of the mouth giving the appearance union s ggests a frog’s louth due to the slimy secret Ion. The cyst nay bo or con- 
olderable sXr.fi and there nay bo a numb or or thorn, speech, su alter- 
ing and respiration are affected. Treatment. Entirely surgicalfare 
throe lethods—partial excision of the sac;the Introduction of the 
oetonjand the Infection of Irritating fluids, 
11. The c in'a or chronic follicular, pecjjrlbe and give treatment. 
Chronic granular pharyngitis or clergyman's sore throat. is char« 
acterlsed by a ohronlo Inflammation of the pharyngeal mucous -ft,- 
>• ne,v lth an Increase In size of the ly iph follicles, nsunlly as- 
sociated with hypertrophic pharyngitis*and has the none causes , 
Its enpeolal factor to be an Inproper use of the voloe*?he 
granules are found to be masses or lymphoid cells;they nay vary in 
number from two to three to where they thickly cover the mooua 
rombrane, Dll at ed gains nay be seen radiating Crow them. Most com- 
lonly seated on the lateral "'all of the oro-pharynx,just behind 
tv pillar : of the Causes, There Is cough and a tickling sensation 
in the throat,worse at night,so that the patient loses Much re t. 
Fhe voice Is hoarse and the wnooue nanbrane la congealed : deglu- 
tition nay become difficult. These hypertrophies can usually be re 
»ovrd 1th very little difficulty, treat i vt, Shoul I be count 1- 
t!it tonal ri7 they should learn how to use the voice properly. 10 g 
if X5C Internally and Fowler's aol, lo drops t.l.d, are good. Trie 
[•oca! tr eatroent*.0ocalnise throat with * f sol, touc oh point 
•if a g .Ivano-cautery eiect.r oderor Silver nitrate, burette or pane 
f or c ej> s ay ben» ed, 4i*M )htl critic paralysis of the fauo . e paralytic usually ajfw 
P°oto tha palate firsthand liquid© regurgitate and cone fron 
the n<$#e In the act or ©wallowing• 7he voice becomes change ■ 
: la/rillar -.anal par alyoao ara <Tuppoeed to 'a prospers 
by the action of the toxins on the nerve oentreajthey last from •. 
few weeks to e no a. and aye uaaia Xy entirely recovered from* 
Oonplled original oouroeo 
and with Infinite oare and eolloltude 
hy yoi it hunl la ;< arv ant rs, pi Pol 1 o,l -r r; * 
hr. hathanlol 4111eon of Saint Louie,mo. 
Pr.Tiaroli '?ell In,.-ton Jonen ofCambridge,