Chapter LXIV: Part II: , Showing Predominance of Malarial Element . . . . 617 (63)

Of internal antipyretic agents quinia enjoys a deservedly high repute. In the remitting forms of fever it may be administered in five-grain doses at intervals of four to six hours. Given thus in medium doses, it moderates the fever, diminishes the sweating, and in most patients lessens gastric and intestinal disturbances. In continued fevers it should, on the contrary, be given in a single dose large enough to procure a distinct remission. By making a break in the febrile symptoms, if only of a few hours' duration, a retardation of the destructive processes is accomplished. At the first administration twenty to thirty grains may be given. In favorable cases the temperature falls in the course of a few hours below 101°. When the high temperature is only temporarily held in check, at the end of twenty-four hours, if all symptoms of cinchonism have disappeared, the same dose should be repeated. If the doses mentioned, given in the manner prescribed, produce no perceptible effect upon the fever, their continuance may be regarded as unnecessary.

C. Braun and Richter speak favorably of the action of salicylate of sodium.[74] It possesses antipyretic properties, though in a less degree than quinia. It is, however, rapidly absorbed, circulates through all the parenchymatous organs, and finally is discharged unchanged in the urine. It is said by Binz, in small doses, to hinder the action of the disease-producing ferments, while it leaves untouched the normal ferments of the organism. It is of special service where quinia is not well tolerated, or when given fifteen to twenty grains at a time every four to six hours as {1033} an adjuvant to large single doses of quinia. The remedy should be continued until all traces of febrile disturbance have disappeared.

[Footnote 74: Richter, "Ueber intrauterine Injectionen," etc., _Zeitschr. für Geburtsk. und Gynaek._, Bd. ii. Heft 1, p. 146.]

A more powerful remedy than salicylic acid, where quinia has failed, is the Warburg's tincture. Some patients find, however, that it is somewhat difficult to retain upon the stomach.

Not many years ago, owing to the encomiums of Fordyce Barker,[75] the tincture of veratrum viride was in great favor in puerperal fever as a means of reducing the excited pulse of inflammation. The plan recommended was to administer five drops hourly, in conjunction usually with morphia, until the pulse was brought down to 70 or 80 beats to the minute. If the pulse had once been reduced, then three, two, or one drop hourly would be found sufficient to control it. Vomiting and collapse from its use were no cause for alarm, as they were temporary symptoms, and were followed by a fall of the pulse to 30 or 40 a minute, which was rather of favorable prognostic significance. In the rapid pulse of exhaustion, however, veratrum should not be given. Since the introduction of the thermometer into practice the reduction of the pulse by veratrum has been found to be associated with a fall in the temperature of the body. Of late, however, veratrum has gone rather out of vogue, not because it is not a very effective agent, but because its administration is an art to be acquired, and cannot safely be entrusted to an unskilled assistant. Then, too, in the last ten years there has grown up a better acquaintance with less dangerous remedies.

[Footnote 75: _The Puerperal Diseases_, p. 347.]

Braun recommends in severe cases, where quinia alone is without effect, to give in addition from twelve to twenty-four grains of digitalis in infusion per diem until its specific action is produced. Unlike veratrum, digitalis effects a permanent slowing of the heart. By prolonging the cardiac diastole and contracting the arterioles it allows the left ventricle to fill, restores the arterial tension, diminishes correspondingly the intravenous pressure, and promotes absorption. Its tendency to produce gastric disturbances and the distrust felt as to its safety have prevented its becoming popular in practice.

Alcohol as an adjuvant to treatment is indicated in all cases, whether quinia or salicylic acid or veratrum be simultaneously employed. It stimulates and sustains the heart, it retards tissue-waste, and is in itself an antipyretic of no mean value. Usually I give it in conjunction with quinia, one or two teaspoonfuls hourly of either whiskey, rum, or brandy, in accordance with the recommendation of Breisky.[76] But many years before I had learned from my friend Prof. Barker that the specific influence of veratrum was in many cases not obtained until the use of alcohol was combined with it.

[Footnote 76: _Ueber Alcohol und Chinin-behandlung_, Bern, 1875.]

The antipyretic action of drugs is probably due for the most part to some direct influence they exert upon the oxygenation of the tissues. Of course the less the fire the less the heat. It is well, however, to support their internal administration by the external employment of cold. Cold owes its effect in fevers partly to the abstraction of heat from the body-surface, and in a still more important degree to the impression which it produces upon the nervous system. In healthy persons the action of cold is to increase the consumption of oxygen and the production of carbonic {1034} acid. The additional heat thus generated renders it possible to sustain the vicissitudes of climate. In fevers the primary effect of cold is similar in character. Its main therapeutical action is derived from its secondary influence upon the nerve-centre which regulates the body-heat. If the cold employed be sufficiently intense or sufficiently prolonged, there follows, not always immediately, but in the course of an hour or two, a marked lowering of the temperature, which can only be accounted for by assuming an indirect influence exerted through the sympathetic nerve and the medulla oblongata. This peculiarity renders the external application of cold a most valuable addition to the therapeutical resources available in fevers.

In cases of moderate severity frequently sponging the patient with cold water will be found to be a grateful practice. An ice-cap to the head, where the blood lies near the surface, will often affect the entire temperature of the body. From immemorial times it has been employed to control delirium and promote sleep. An ice-bag placed over the inguinal region is locally beneficial to deep-seated pelvic inflammations, and, according to Braun, is capable of effecting a rapid fall of temperature. Ice-cold drinks should be freely allowed.

Schroeder recommends a permanent stream of cold water in the uterine cavity by means of a large irrigator and a drainage-tube; others advise cold rectal injections maintained for long periods by the aid of a tube with a double current.

In fevers of great violence the systematic application of cold by means of baths or the wet pack is capable in some cases of rendering important service. The temperature of the bath should range from 70° to 80°. Its duration should not exceed ten minutes. The patient should, when removed to the bed, be wrapped in a sheet without drying, and should be comfortably covered. In employing the wet pack two beds should be placed side by side. The body and thighs of the patient should be wrapped in a sheet wrung out in cold water, and be allowed to remain in the pack from ten to twenty minutes. As the sheet becomes heated the patient should be placed in a fresh one upon the second bed, and the transfers should be continued until the desired fall of temperature is effected. Braun claims that four packs are equivalent in action to one full bath.

Both these methods are, however, open to the objection that they cannot be carried out without considerable disturbance of the patient--a point of no small importance in cases of peritonitis. G. B. Kibbie has invented a fever-cot which obviates the ordinary difficulties of this mode of treatment. The cot is covered with "a strong, elastic cotton netting, manufactured for the purpose, through which water readily passes to the bottom below, which is of rubber cloth so adjusted as to convey it to a vessel at the foot." T. G. Thomas,[77] who has employed this apparatus extensively to reduce high temperatures after ovariotomies, explains as follows the modus operandi: "Upon this cot a folded blanket is laid, so as to protect the patient's body from cutting by the cords of the netting, and at one end is placed a pillow covered with india-rubber cloth, and a folded sheet is laid across the middle of the cot about two-thirds of its extent. Upon this the patient is now laid; her {1035} clothing is lifted up to the armpits, and the body enveloped by the folded sheet, which extends from the axillæ to a little below the trochanters. The legs are covered by flannel drawers and the feet by warm woollen stockings, and against the soles of the latter bottles of warm water are placed. Two blankets are then placed over her, and the application of water is made. Turning the blankets down below the pelvis, the physician now takes a large pitcher of water, at from 75° to 80°, and pours it gently over the sheet. This it saturates, and then, percolating the network, it is caught by the india-rubber apron beneath, and, running down the gutter formed by this, is received in a tub placed at its extremity for that purpose. Water at higher or lower degrees of heat than this may be used. As a rule, it is better to begin with a high temperature, 85°, or even 90°, and gradually diminish it. The patient now lies in a thoroughly soaked sheet, with warm bottles to her feet, and is covered up carefully with dry blankets. Neither the portion of the thorax above the shoulders nor the inferior extremities are wet at all. The water is applied only to the trunk. The first effect of the affusion is often to elevate the temperature--a fact noticed by Currie himself--but the next affusion, practised at the end of an hour, pretty surely brings it down. It is better to pour water at a moderate degree of coldness over the surface for ten or fifteen minutes than to pour a colder fluid for a shorter time. The water slowly poured robs the body of heat more surely than when used in the other way. The water collected in the tub at the foot of the bed, having passed over the body, is usually 8° or 10° warmer than it was when poured from the pitcher. On one occasion Dr. Van Vorst, my assistant, tells me that it had gained 12°. At the end of every hour the result of the affusion is tested by the thermometer, and if the temperature has not fallen another affusion is practised, and this is kept up until the temperature comes down to 100°, or even less. It must be appreciated that the patient lies constantly in a cold wet sheet, but this never becomes a fomentation, for the reason that as soon as it abstracts from the body sufficient heat to do so it is again wet with cold water and goes on still with its work of heat-abstraction. I have kept patients upon this cot enveloped in the wet sheet for two and three weeks, without discomfort to them and with the most marked control over the degree of animal heat. Ordinarily, after the temperature has come down to 99° or 100°, four or five hours will pass before affusion again becomes necessary."

[Footnote 77: "The Most Effectual Method of Controlling the High Temperature occurring after Ovariotomy," _N.Y. Med. Jour._, August, 1878.]

Since reading this account, I have made a good many trials of the method upon puerperal women, and have not found that it agrees with all in an equal degree. In some instances the affusions have been followed, in spite of hot bottles to the feet and the administration of stimulants, by such a degree of depression and impairment of cardiac force, as shown by the persistent coldness of the extremities, that it has been necessary to discontinue them. On the other hand, I can look back upon cases, apparently so desperate that the condition of the patients was looked upon as hopeless, where they proved the means of saving life as by a miracle. Of course, the difference depends upon whether the high temperature is the sole cause of the alarming symptoms, or whether the latter are in part due to blood-dissolution and secondary changes in the parenchymatous organs.

{1036} The use of the coil in fever, whether of rubber or of metal tubing, I can highly recommend. Either the night-dress or a towel should be placed between the coil and the skin. A current of cold water passing through the tube rapidly abstracts the surface heat, and is usually grateful to the patient. The lowering of the temperature by this means is much slower than by cold affusions. Disturbance of the patient is, however, avoided, and the method, so far as I have tried it, has been free from the objections incident to the direct application of water to the skin.

It is hardly necessary to state that in puerperal, as in other fevers, the patient's strength requires to be sustained and the waste of tissue to be repaired, as far as possible, by the regulated administration of liquid food, as milk and beef-tea, in such quantities as can be borne by the stomach, and at one to two hours' intervals.

In the treatment of encysted peritoneal effusions, and in inflammatory exudations into the pelvic and adjacent cellular tissue, after the acute symptoms have subsided the attention should be directed to the afternoon fever and to promoting the assimilation of food. So soon as the sweating and fever are checked the absorption of the plastic materials begins. The most important agents for accomplishing this object are quinia, in moderate doses, combined with some form of alcohol and with tepid sponging. Deep-seated pain in the iliac region is best relieved by a large blister upon the side over the point where the tenderness is felt. Prolonged rest in bed should be enjoined. Even after convalescence is well advanced, so long as the exudation remains unabsorbed the resumption of household duties is pretty certain to be followed by a relapse or by the development of a chronic condition of a most intractable description. The sooner the patient's stomach can be got to digest and absorb beefsteak and iron the more speedy will be her recovery.

In pelvic exudations the hot vaginal douche, warm baths, and the application of flannels wrung out in water to the abdomen aid in diminishing the local pain, and, perhaps, in causing a disappearance of the tumor. The action of mercurials or of iodide of potassium in melting away plastic inflammatory materials is sometimes very striking, but more frequently they either do no good or else do harm by disturbing the digestion.

If fever, chills, and sweating announce the presence of pus, the most careful exploration should be made to determine, if possible, the seat of suppuration. It is of great advantage to treat pelvic abscesses as abscesses are treated elsewhere in the body. If the redness of the skin above Poupart's ligament indicates a tendency to point in that direction, an aspirator-needle should be introduced to make sure of the diagnosis. If the sac is near the surface, a free incision should be made and the pus should be allowed to escape. In many cases I make these incisions three to four inches in length. The redness of the external skin makes it certain that the abscess has become adherent to the abdominal wall, and that the incision consequently will not communicate with the peritoneum. After the abscess has been opened it should be cleansed twice daily, and the cavity should be filled with oakum. If, after a time, the granulations become flabby, Peruvian balsam or iodoform should be introduced into the sac at each change of the dressing. I can recommend this plan as essentially a mild procedure. With a large opening for the discharge of {1037} pus the fever and sweating disappear, the appetite returns, and the abscess fills rapidly by granulation. With a small incision hectic is apt to persist, and the abscess to end in the formation of interminable fistulæ.

If softening and bagginess or distinct fluctuation indicate that the pus can be reached through the vaginal cul-de-sac, the aspirator-needle should be inserted deeply at the suspected point, and if a large amount of pus is detected, an incision should be made with a long-handled bistoury, using the needle as a director, and making the opening large enough to permit the introduction of a drainage-tube. I prefer for this purpose a self-retaining Nélaton catheter, which is easily passed by means of a uterine sound inserted into the eye at the extremity. Through the tube--without disturbing the patient--the pus-cavity can be washed as frequently as required, and with drainage and cleanliness cases of the longest standing may be expected to recover.

P. F. Mundé[78] has reported a number of cases of chronic character where the aspiration of pus has been followed by rapid absorption of the intra-pelvic exudation. The presence of pus was suspected because of a boggy, doughy feeling in the exudation tumor.

[Footnote 78: "Diagnosis and Treatment of Obscure Pelvic Abscess," etc., _Arch. of Med._, December, 1880.]

{1038}

BERIBERI.

BY DUANE B. SIMMONS, M.D.

DEFINITION.--Beriberi is a disease of inanition, most common in tropical countries, though found in high latitudes (41° N.), especially in low-lying seaboard towns, during the summer months, and is both endemic and epidemic. It is usually chronic in form, but is subject to exacerbations of varying degrees, and has for its characteristic symptoms anæsthesia of the skin, hyperæsthesia and paralysis of the muscles, anasarca, palpitation, cardiac and arterial murmurs (in the wet form), præcordial oppression, and abdominal pulsation.

HISTORY AND GEOGRAPHICAL DISTRIBUTION.--It was for a long time confounded with a great variety of other diseases. The Anglo-Indian physicians of Ceylon and the Malabar coast were no doubt the first to recognize the specific nature of the disease, though it is claimed that Chinese medical works of the thirteenth century contain a fairly accurate description of it.

The literature of beriberi, at the first glance, appears to be very meagre, as some of the most popular medical works make no mention of the disease at all, while others only give it a passing notice. Its bibliography, however, is very considerable, as may be seen in the exhaustive list in Billings' _Index Catalogue_, but for want of space we refer only to the most recent contributions to the subject. These are--an article by A. LeRoy de Mericourt;[1] an essay by Tarissan, entitled _Beriberi in Brazil_; an article by Anderson,[2] and an essay by myself.[3]

[Footnote 1: _Dictionnaire Encyclopédique des Sciences Médicales_, Paris, 1876.]

[Footnote 2: _Guy's Hospital Reports_.]

[Footnote 3: _Chinese Maritime Customs Medical Report_ (1880).]

For a long time beriberi was supposed to have a peculiar territorial limitation. It is now known to be more or less prevalent on all the islands and shores of Eastern Asia and Africa from Japan to the Cape of Good Hope, and in Brazil.

ETIOLOGY.--I know of no disease in regard to which a greater diversity of opinion exists as to its cause. Indeed, as one has observed, "autant d'auteurs, autant d'opinions diverses." Ten years' study and observation of the malady under a great variety of circumstances and conditions have led me to the definite conclusion that its exciting cause is a specific poison or germ, having many striking resemblances in its mode of production to paludal or marsh miasm, though entirely distinct and separate from it. A great variety of predisposing causes, however, exert a powerful influence in rendering individuals or classes susceptible to the {1039} disease, such as age, sex,[4] occupation, race, mode of life, diet, and climate.

[Footnote 4: Women suffer from the disease much less frequently than men.]

CLINICAL HISTORY AND SYMPTOMS.--There are three forms of the disease: 1st. Beriberi hydrops (wet beriberi), in which there is a hydræmic condition of the blood, distension of the general areolar tissue, with serum, and effusion into the serous cavities. 2d. Beriberi atrophia (dry or atrophic beriberi), in which there is a notable deficiency of fluids in the vessels and areolar tissue, and atrophy of the muscles. 3d. Mixed beriberi, in which the above forms lose the sharp lines of distinction and merge into each other. Cases complicated with dysentery, diarrhoea, and especially with continued fevers of the typhoid type, are not uncommon.[5] These last, besides being of grave prognosis, are frequently very embarrassing and difficult of diagnosis.

[Footnote 5: Some authors have designated fatty or convulsive forms of the disease, which I think unnecessary.]

In general terms, wet beriberi may be divided into two stages--the prodromic stage and the stage of attack; and into several types--the acute or pernicious, and the chronic. From the very insidious nature of the approach of the disease, sometimes extending over a period of several weeks, it is often very difficult, or even impossible, to determine the exact time of its invasion. It is generally admitted that a residence of some weeks in an infected locality is necessary before any decided symptoms make their appearance. As in many other diseases of slow development, the symptoms of the prodromic stage are certain not easily defined feelings of indisposition, such as an occasional sense of chilliness, inaptitude for mental exertion, and especially a tired feeling in the lower extremities. A period of uncertain length now intervenes, during which the characteristic symptoms appear and constitute the stage of attack. The first of these symptoms is, generally, anæsthesia of the skin over the anterior tibial muscles, in the tips of the fingers, and around the mouth, in the order given. Paralysis in varying degrees next declares itself in certain groups of muscles, usually those immediately underlying the regions of anæsthesia. One of the consequences of this is a drooping of the toes, causing the patient while walking to lift the feet high so as to clear the ground, thus occasioning the peculiar gait noticed by many observers as characteristic of the disease. A sense of constriction in the muscles of the calves is experienced at the same time, arising from a veritable contraction, which causes their apparent enlargement and hardening, with tension of the tendo achillis. A feeling of tightness in the chest usually accompanies this condition, due, no doubt, to partial paralysis of the muscles of respiration. If firm pressure be now made upon the muscles in various parts of the body, a greater or less degree of tenderness will be found to exist in many of them, and especially those occupying the posterior part of the leg, back of the forearm, inside of the arm, and upper part of the chest. Tenderness of the periosteum of the long bones and a peculiar roughness of their surfaces often exist also. Palpitation of the heart, especially on making any considerable exertion, is a frequent and often troublesome symptom, even at this stage of the disease.

Up to this point the above symptoms are common to both the wet and {1040} dry forms of the malady, and to them the characteristic features either of beriberi hydrops or atrophia are now added. The first manifestation of anasarca, the pathognomonic symptom of wet beriberi, is in an oedematous condition of the areolar tissue of the anterior part of the legs. This, in reality, is more or less general even at an early stage of the disease, as is evident from the plump appearance of the patient and a certain sallow-white color of the skin, especially of that of the face. In uncomplicated cases the temperature is normal, or it may be at times a little below the normal point. There is also little or no increase in the frequency of the pulse. Its quality, however, is changed, and somewhat characteristic for both forms of the disease. Thus in the wet form it is full, large, and easily compressible, indicating a great diminution of arterial tone, while in the dry form there is nearly an opposite condition. If the heart be now examined, a decided systolic murmur will be heard, most distinctly over the pulmonary valves; and in most cases of wet beriberi it exists in all the large arterial trunks. The heart furnishes the usual signs of dilatation and want of tone. In the dry form the cardiac murmurs are either slight or wanting altogether, and the area of cardiac dulness is variable, and frequently diminishes as the disease advances.

In both wet and dry beriberi the appetite is little impaired in the earlier stages, but if in the former the stomach is over-distended, there is increased præcordial oppression, and sometimes sudden death. The bowels in the wet form are sluggish, and urine scanty; in the other there is but little deviation from the normal in these respects.

The cases of the subacute type are by far the most numerous. From this it is evident that the acute or pernicious type of the malady is, in most cases, only an exaggeration of the subacute, as observed in some other diseases, notably rheumatism and those of marsh malarial origin. The term pernicious is, strictly speaking, applicable to the wet form of the disease only, as the dry form is rarely, if ever, rapidly fatal. A marked case of wet beriberi is always to be regarded as dangerous, from the suddenness with which pernicious symptoms often declare themselves. In these the anasarca (which, as has been stated, constitutes the leading clinical difference between the two forms of the malady) plays an important rôle. It often happens that in the course of a few hours the local oedema in the extremities and the slight puffiness of the face become general and extreme, and the neck is enormously swollen by the distension of the veins, both deep and superficial. The pleural and pericardial sacs are more or less distended with serum, thus mechanically embarrassing the action of the organs they contain. The action of the heart now becomes laborious, the lungs oedematous and filled with coarse râles, and a terrible sense of suffocation comes over the patient, causing him to seek relief by constant change of position. The stomach is irritable, a greenish-yellow fluid is vomited, and death closes the scene. The acute stage of dry beriberi, on the contrary, is characterized by a rapid diminution of the fluids of the body and muscular atrophy.

The annual appearance in the same individual of either wet or dry beriberi, and its long continuance, constitute the chronic type of the disease.

MORBID ANATOMY.--The morbid anatomical changes in beriberi vary considerably with its form. Few, if any, observers claim seriously to {1041} have found in either the wet or dry form of the disease evidences of acute inflammatory action in any of the tissues or organs. The blood undoubtedly undergoes important morbid changes, whereby its nutritive and oxygenating power is impaired, indicating that this is a disease of inanition. This shows itself most markedly in necrobiotic and degenerative changes, especially in the muscular tissues, which are the seat of the leading morbid phenomena in all stages of both forms of this disease. The respiratory, digestive, and glandular systems rarely undergo morbid changes other than those of a secondary or passive kind, such as engorgement with serum and venous blood.

The condition of the organs contained in the cranial and spinal cavities is variable and inconstant. According to some observers, the substance of the brain and spinal cord is hardened. The greater number by far, however, have found it more or less softened.[6] The heart in wet beriberi is habitually large and flabby, its muscular tissue softened and of a pale-yellow and macerated appearance. Its cavities are engorged with dark blood, sometimes fluid, but more often clotted. These clots are often voluminous in the right heart, semi-fibrinous, and extend into the pulmonary artery and great venous trunks, which are enormously enlarged. The cardiac muscular tissue I always found to have undergone metamorphic changes, varying from granular clouding to advanced fatty degeneration.[7] The tissue of the paralyzed voluntary muscles undergoes degenerative changes in both forms of the disease. In the extreme atrophy of dry beriberi I have not unfrequently found many of the sarcolemma sheaths completely emptied of their contents. The power of regeneration in these cases is often wonderfully displayed by an almost complete restoration of the lost elements, and, in a corresponding degree, of the function of the part.

[Footnote 6: The former condition was undoubtedly observed in autopsies made of the dry or atrophic form of the disease, though this fact is not mentioned. The latter, or softened, condition of the cerebro-spinal contents belongs to the wet form of the disease (my own cases being of this kind). I regard this softening as not ante-mortem, but as consecutive to serous imbibition (as observed by Eismann and Sanders in chlorosis), and as taking place during the last moments of life or after death, when the vital forces no longer oppose themselves to the mechanical disintegrating power of the fluid with which the nervous as well as all the other tissues of the body are engorged.]

[Footnote 7: I believe this to be the condition of the heart-muscle in all cases of death from the wet form of beriberi. In this opinion I am supported by Oudenhoven and many of the Dutch observers.]

It would appear that in wet beriberi the heart is first weakened by paresis of the cardiac ganglia, with consequent incomplete emptying of its cavities. This, in connection with rapid degenerative changes in its muscular tissue, causes the walls to yield to the blood-pressure, producing dilatation and tricuspid insufficiency, with regurgitation and consequent capillary stasis and dropsy. Vaso-motor nerve-paralysis, acting at the same time on the pulmonary artery and arterioles, and on other large arterial trunks, probably gives rise to the murmurs heard in them. In the dry form of the disease the vaso-motor nerve-paralysis is less pronounced, and the degenerative changes in the muscular tissue of the heart slower, while the marked decrease in the fluids of the system and the great failure of nutrition tend toward atrophic changes. From this it follows that we usually have, instead of a large dilated heart, a small weak one, with a narrow tricuspid orifice instead of a dilated one; little or no {1042} intercostal pulsation, and hence less cardiac dulness; no venous distension or capillary stasis, and hence no dropsy.

PROGNOSIS.--In temperate climates the prognosis of uncomplicated beriberi is favorable in a majority of cases. In seasons of its epidemic prevalence, however, all cases of the wet form of the disease must be carefully watched, as it not unfrequently happens that grave symptoms suddenly appear at a time when no danger has been anticipated. An unfavorable prognosis may be ventured when, in a case of wet beriberi, relief is not obtained by free purging or when vomiting sets in. In dry beriberi the termination in death is exceedingly rare as a direct result of the action of the poison producing the disease, so that when death does occur it is chiefly from exhaustion. The time of recovery depends on the amount of muscular degeneration, and also upon the season of the year when the attack occurred, as all cases of both forms of beriberi usually get well without treatment during the winter months.

TREATMENT.--The well-established fact of the influence of certain localities in the production of beriberi makes the removal of the patient from them a hygienic measure of great importance, and this is frequently the only treatment necessary if it can be done early. The effect of the change is often almost magical, especially if it be made to an elevated locality and among the mountains.

Diet is an important element in the treatment of beriberi. At the head of the list of foods to be avoided is rice. Coarsely prepared grains, such as wheat, barley, certain kinds of beans,[8] apparently because of more or less laxative properties, are preferable as articles of food.

[Footnote 8: A small red bean called adzuke, possessing both laxative and diuretic properties, is a favorite remedy with the Japanese for beriberi. It is used alone or mixed with rice, and is not unfrequently the only means resorted to for the successful cure of mild cases.]

No drug has been discovered possessing specific properties in this disease. In the wet form, medication consists in the administration of drugs calculated to draw off the excess of serum in the areolar tissues and in the serous sacs. First in point of efficacy for this purpose are the hydragogue cathartics. In my own practice the sulphate of magnesia, in large and repeated doses, has given the best results; elaterium, a powder of jalap, squill, and digitalis, and, in fact, any medicine which will give frequent and copious stools, are sure to afford marked relief to the more urgent symptoms, and in many cases will alone effect a cure. Care must be taken, however, not to exhaust the patient, though I have never seen the judicious use of this method of treatment do harm.

Copious bleeding is recommended by Anderson, especially in the stage of greatest danger, but I have never been able to convince myself of its safety.

The almost specific virtue claimed by the old Indian physicians for treeak farook is no doubt due to its cathartic properties.

Diuretics are indicated for the same reason as cathartics, and any of the more active are productive of good results. They are too slow in their action, however, to be relied on otherwise than as adjuvants to cathartics. I have found juniper gin to answer an excellent purpose, both as a stimulant and diuretic, where there was danger of exhaustion from the free use of cathartics.

The medical treatment of dry beriberi differs materially from that of {1043} the wet disease. Cathartics and diuretics are alike useless, and the former injurious. The ordinary means, such as electricity, strychnia, frictions, etc., employed in cases of muscular atrophy and paralysis from other causes, are indicated when the active stage has passed, but they are useless, and even injurious, before this time. The muscular hyperæsthesia common to both forms of the disease may be generally greatly relieved by anodyne liniments containing aconite. The internal use of the latter is highly recommended by some. Hypodermic injections of morphia afford relief to the painful sense of constriction in the calves of the legs so often complained of.

{1045}

INDEX TO VOLUME I.

A.

Abdomen, state of, in cholera, 741
in general peritonitis of puerperal fever, 1010
in relapsing fever, 390
in septicæmia, 977
in septicæmia lymphatica, 1011
in septicæmia venosa, 1012

Abdominal cavity, lesions of, in general peritonitis of puerperal
fever, 989
glands, lesions of, in typhoid fever, 264
organs, alterations of, in scarlet fever, 531

Abortion from septicæmia, 972

Abortive form of the plague, 777
of relapsing fever, 395
of typhoid fever, 298
of typhus fever, 354

Abortive treatment of erysipelas, value, 638

Abscess in symptomatic parotitis, date of pointing, 627
metastatic, of lungs, complicating relapsing fever, 404

Abscesses complicating cholera, 735
variola, 445
following the plague, 781
frequency of, in pyæmia, 976
in erysipelas, treatment, 638
in para- and perimetritis, 1008
in puerperal fever, 989
metastatic, of pyæmia, modes of production, 963
of pyæmia, treatment, 981
pelvic, of puerperal fever, treatment, 1036
pulmonary, in puerperal fever, 989

Acids, mineral, use of, in cholera, 768

Aconite, use of, in rubeola, 580
in scarlet fever, 543
in yellow fever, 651

Acute diseases, relation of, to rubeola, 561
form of glanders in man, 920
in horse, 914

Adenitis complicating scarlet fever, 511
vaccination, 468

Adenopathy complicating erysipelas, 634

Adhesions from infiltration, 55

Adulteration of food, 197

Adynamic form of typhus fever, 354

Age, influence of, on causation of anthrax in man, 940
of cerebro-spinal meningitis, 802
of diphtheria, 680
of erysipelas, 630
of influenza, 860
of idiopathic parotitis, 620
of the plague, 775
of pertussis, 839
of relapsing fever, 371
of rötheln, 583
of rubeola, 561
of typhoid fever, 242
of typhus fever, 342
proper for vaccination, 477

Aged, typhoid fever in the, 301

Agminated glands, lesions of, in cholera, 745

Air, amount supplied in ventilation, 179
carbonic acid as a cause of impurity, 177
-currents, direction of, test, 178
distribution of, in ventilation, 180
estimation of carbonic acid, 178
fresh, value of, in convalescence, 206
humidity of, as a cause of disease, 133
impure, as a cause of disease, 177
influence of, on causation of glanders, 912
impurities of, due to offensive effluvia, 181
sources of impurity, 177
standards of impurity, 178
transmission of the plague by, 776
velocity of, in ventilation, 180
vitiated, as a cause of pyæmia, 959
supply, method of calculating amount of, in ventilation, 179

Albuminoid infiltration, 72

Albuminuria complicating diphtheria, 674
relapsing fever, 407
scarlet fever, 525
typhus fever, 355
following rubeola, 574
in typhoid fever, treatment, 334

Alcohol, use of, in algid form of pernicious malarial fever, 608
in anthrax, 938, 944
in cerebro-spinal meningitis, 831
in cholera, 767
in influenza, 876
in puerperal fever, 1033
in pyæmia, 982
in scarlet fever, 544
in typhoid fever, 324
in typhus fever, 366

Algid form of pernicious malarial fever, 606
causes of death, 607
frequency, 607
mortality-rate, 607
symptoms, 606
treatment, 607

Alum, use of, in pertussis, 845

Ammonium bromide, use of, in pertussis, 846
carbonate, use of, in scarlet fever, 544
chloride, use of, in diphtheria, 704, 705

Amyloid bodies, 86
degeneration, 84

Anæsthesia of skin in beriberi, 1039
significance of, in general diagnosis, 165

Anæsthetic form of leprosy, 790

Analysis of urine, importance of, in general diagnosis, 165

Anasarca, 69
complicating scarlet fever, 529
date of appearance in scarlet fever, 529
in beriberi, 1040

Anginose form of anthrax, 941
of scarlet fever, 510

Animals, cerebro-spinal meningitis in, 804
diphtheria in, 683
transmission of diphtheria from, 683

Animal vaccine, advantages, 475

Anodyne liniments, use of, in beriberi, 1043

Anorexia in relapsing fever, 389
in typhoid fever, 285
in typhus fever, 350
significance of, in general diagnosis, 162

ANTHRAX, OR MALIGNANT PUSTULE, 926
Synonyms, 926
Definition, 926
History, 926
Geographical distribution, 926
Etiology--specific origin, 928
Modes of transmission, 928
Transmission from eating flesh of anthrax animals, 928
by milk, 929
by insects, 929
by alkaline soils, 929
Season, relation of, to causation, 931
Plethora, relation of, to causation, 931
Sex, relation of, to causation, 931
Age, relation of, to causation, 931
Bacillus, 931
relation to causation, 931
physical characters, 932
effect of heat and cold on activity, 933
effect of oxygen on activity, 933
mode of entering body, 933
effect on blood-vessels, 934
Forms, 934
Symptoms--Incubation period, 934
duration of, 934
Apoplectiform form, 934
Anthrax fever, 934
Localized external anthrax, 935
Character and seat of lesions, 935
Morbid anatomy--changes in blood, 935
Spleen, 935
Lymphatic glands, 935
Connective tissue and muscles, 935
Gastro-intestinal tract, 936
Vagina and uterus, 936
Liver and kidneys, 936
Diagnosis--from other bacteridian diseases, 936
Swine plague, 936
Prognosis, 936
Mortality, 936
Treatment, 937
Preventive, 936
Drainage of anthrax soil, 937
Disinfection of stables, etc., 937
Disposal of carcases of sick animals, 937
Isolation, 937
By inoculation, 937
Methods of, 937
Pasteur's method, 937
Dangers in, 938
General, alcohol, 938
Use of carbolic acid, 938
nitro-muriatic acid, 938
potassium iodide, hypodermically, 938
quinia sulphate, hypodermically, 938
Local, 938
Cauterization, 938
Incision of nodule, 938

_Anthrax or Malignant Pustule in Man_, 939
Synonyms, 939
History, 939
Etiology, 939
Origin from lower animals, 939
Modes of infection, 939
direct, 939
by handling sick animals, 939
by insect-bites, etc., 939
by food, 939
by blood, 939
by air, 939
Occupation, relation of, to causation, 939
Age and sex, relation of, to causation, 940
Relative susceptibility of man and animals, 940
Forms, 940
Symptoms--of incubation period, 940
Local lesions, 940
Temperature, 940
Relation of, to local lesions, 940
Malignant anthrax, 940
Symptoms, 940
local, 940, 941
general, 941
Anthrax intestinalis, 941
Symptoms, 941
general, 941
eruptions, 941
gastro-intestinal tract, 941
nervous system, 941
Duration, 941
Anthrax angina, 941
Symptoms, 941
general, 941
local, 941
Duration, 941
Morbid anatomy, 941
Changes in blood, 942
Spleen, 942
Lymphatic glands, 942
Liver and kidneys, 942
Skin and mucous membranes, 942
Appearance of pustule, 942
Position of bacillus, 942
Diagnosis--signs, pathognomonic of, 942
From bites of insects, 942
Boils and carbuncles, 942
Plague-boil, 942
Glanderous nodule, 942
Importance of detection of bacillus, 942
Of malignant anthrax oedema, 942
Internal anthrax, 943
Prognosis, 943
Mortality, 943
Treatment--Preventive, 943
Disinfection, 943
Local, 943
Cauterization of preliminary papule in external form, 943
Method of cauterization, 943
Excision of parent nucleus, 943
Caustics used in, 943
Hypodermic injections into swelling, 943
Constitutional, 944
Carbolic acid, use of, 944
Alcohol, use of, 944
Diet, 944
Of anthrax oedema, 944

Antipyretics, use of, in relapsing fever, 428
in cerebro-spinal meningitis, 833

Antisepsis in septicæmia, 983
value of, in prevention of puerperal fever, 1024

Antiseptic treatment of scarlet fever, 545

Antiseptics, use of, in cholera, 770
in glanders in man, 924
in pyæmia, 980

Aphasia in cerebro-spinal meningitis, 810

Apoplectic form of anthrax in animals, 934

Appetite in cerebro-spinal meningitis, 814
as a guide to necessary amount of food, 195
loss of, significance, in general diagnosis, 162

Arcus senilis, significance, in general diagnosis, 151

Argyria, 93

Arsenic, use of, in relapsing fever, 427

Arsenical poison as cause of obscure diseases, 193

Arterial emboli, 63
murmur in beriberi, 1040
thrombosis following typhoid fever, 293

Arteritis from thrombosis, 61
in pyæmia, 967

Articular enlargement, significance of, in general diagnosis, 160

Artificial alimentation in diphtheria, 713

Asthenic form of simple continued fever, 233
of inflammation, 46

Ataxic form of typhus fever, 354

Ataxo-adynamic form of typhus fever, 354

Atmosphere, impure, influence of, on causation of puerperal fever,
1013, 1014
necessity of, for prevention of pyæmia and septicæmia, 980

Atmospheric variations as a cause of diphtheria, 682

Atrophy following diphtheritic paralysis, 676

Atropia, use of, in relapsing fever, 429

Auditory nerve, lesion of, in cerebro-spinal meningitis, 824

B.

Bacillus of anthrax, characters of, 931, 932
mode of entering body, 933
of glanders, 914
of pearly distemper, innocuousness of, from cooking, 105
species of, 142
tuberculosis, 99 _et seq._
description, 100
duration of effects, 104
cultivation, 100
local and general effects of invasion, 103
methods of detection, 102
milk as a means of dissemination, 105
mode of entrance into intestinal canal, 104
into respiratory organs, 104
typhosus, 258

Bacteria in healthy bodies, 144
influence of, on causation of pyæmia, 958
liability to error, from minuteness, 143
of cholera, 748
of leprosy, 791
of puerperal fever, 995

Bacterium termo as a cause of putrefaction, 142

Barometric variations, influence of, on course and causation of
disease, 134

Bartholini's glands, suppuration of, complicating typhoid fever, 296

Baths, cold, use of, in puerperal fever, 1034
in relapsing fever, 428
warm, use of, in hydrophobia, 907
in variola, 453

Bed-linen, as a means of disseminating typhoid fever, 253

Bed-sores, complicating relapsing fever, 400
typhoid fever, 297
typhus fever, 355
in typhoid fever, treatment of, 335

Belladonna as a prophylactic in scarlet fever, 536
use of, in cerebro-spinal meningitis, 833
in pertussis, 846

Benignant tumors, 114

Benzoic acid as a prophylactic in scarlet fever, 537

BERIBERI, 1038
Definition, 1038
Geographical distribution, 1038
History, 1038
Etiology--Specific poison, 1038
resemblance of, to marsh-miasm, 1038
Predisposing causes, 1039
Varieties, 1039
Symptoms--Anæsthesia of skin, 1039
Muscular paralysis, 1039
Peculiarity of gait, 1039
Cramps, 1039
Muscular tenderness, 1039
Periosteal tenderness, 1039
Palpitation of heart, 1039
Symptoms, special--Of wet form, 1040
Anasarca, 1040
Quality of pulse, 1040
Cardiac murmur, 1040
Arterial murmur, 1040
Of dry form, 1040
Quality of pulse, 1040
Condition of heart, 1040
Morbid anatomy, 1040
Alterations in blood, 1041
Heart, 1041
Muscles, 1041
Prognosis, 1042
Treatment--By change of residence, 1042
By diet, 1042
Of wet form by hydragogue cathartics, 1042
Sulphate of magnesium, 1042
Elaterium, 1042
Treeak farook, 1042
Diuretics, 1042
Juniper gin, 1042
Of the dry form by electricity, 1043
Strychnia, 1043
Frictions, 1043
Use of anodyne liniments, 1043
Use of hypodermics of morphia, 1043

Bites of rabid dogs, treatment, 905

Bladder, diphtheria of, general sepsis from, 674
lesions of, in rabies, 903
in relapsing fever, 414
symptoms of diphtheria of, 674

Blindness in cerebro-spinal meningitis, 811

Blisters, use of, in cerebro-spinal meningitis, 830

Blood, alterations of, in anthrax, 935-942
in beriberi, 1041
in cerebro-spinal meningitis, 824
in cholera, 747
in pyæmia, 968
in relapsing fever, 411
in scarlet fever, 530
in septicæmia, 971
in typhoid fever, 268
in typhus fever, 356
altered, as a cause of symptomatic parotitis, 626
condition of, in pyæmia, 963
contamination of, sources, in pyæmia, 958
degeneration of, complicating diphtheria, 675

Blood-vessels, calcification of, 88, 90
changes in inflammation, 43
lesions of, in typhoid fever, 267
new formation of, 55

Body, portion of, most suitable for vaccinating, 477

Bones, chronic diseases of, following rubeola, 574
cranial, lesions of, in symptomatic parotitis, 626
in glanders, 922
in pyæmia, 967

Bone-marrow, lesions of, in relapsing fever, 417

Boric acid, use of, in diphtheria, 709

Bovine vaccine, 473

Bowels, state of, in relapsing fever, 390
in remittent fever, 602
condition of, in typhus fever, 350

Brain, lesions of, in cerebro-spinal meningitis, 823
in cholera, 746
in glanders, 923
in relapsing fever, 413
in typhoid fever, 266
in typhus fever, 358
and membranes, lesions of, in cerebro-spinal meningitis, 822
in pyæmia, 966
and spinal cord, lesions of, in rabies and hydrophobia, 903
softening of, following cerebro-spinal meningitis, 820

Breath, odor of, in typhus fever, 353

Bright's disease, aggravation of, by influenza, 870

Bromine, use of, in diphtheria, 708

Bromide of potassium, use of, in relapsing fever, 430

Bronchi, lesions of, in rabies and hydrophobia, 902
symptoms of formation of diphtheritic membrane, 671

Bronchial glands, lesions of, in influenza, 872

Bronchitis, complicating influenza, 868
rubeola, 571
typhoid fever, 294
typhus fever, 355
frequency of, in typhoid fever, 277
in rubeola, treatment, 581
in septicæmia, 977
in typhus fever, 353, 354

Broncho-pneumonia, complicating diphtheria, 672

Bryce's test of vaccinal infection, 461

Buboes, characters of, in grave form of the plague, 778
date of appearance of, in grave form of the plague, 778
of the plague, treatment, 784
pathology of, in the plague, 781
seat of, in grave form of the plague, 778

C.

Cadaveric rigidity after cholera, 741

Cæcum and colon, lesions of, in typhoid fever, 263

Calcification, 87
causes, 87
of blood-vessels, 88, 90
of thrombi, 60, 89

Calabar bean, use of, in cerebro-spinal meningitis, 834

Calm stage of yellow fever, 645

Calomel as a specific in typhoid fever, 336
use of, in cholera, 766
in hemorrhagic form of pernicious malarial fever, 613

Camphor, use of, in cholera, 768

Cancer, 117, 123
hereditary nature, 129
relation of, to epithelial tumors, 118

Capillary bronchitis, complicating influenza, 868

Capillaries, intestinal, lesions of, in cholera, 745

Carbolic acid, use of, in anthrax, 938
in diphtheria, 707
in glanders, 924
in scarlet fever, 545

Carbonic acid, as a cause of impure air, 177
amount of, in pure and impure air, 178

Carbuncles, character of, in grave form of the plague, 778
seat of, in grave form of plague, 778

Cardiac degeneration, complicating diphtheria, 675
following typhoid fever, 293
complicating typhus fever, 355
dilatation, complicating scarlet fever, 523
inflammation, complicating scarlet fever, 522
murmur in beriberi, 1040
sounds in typhoid fever, 276
thrombi in diphtheria, 687

Caseation, 79

Cataract, hereditary, nature, 129

Catarrh, absence of, in rubeola, 568
of influenza, treatment, 874

Catarrhal affections as predisposing causes of pertussis, 839
inflammation, 52
pneumonia, complicating influenza, 869
pock in vaccinia, 463
symptoms in influenza, 866
in prodromal stage of rubeola, 564

Causes of otitis in scarlet fever, 520

Caustics, use of, in hydrophobia, 905

Cauterization, use of, in external anthrax, 938, 943

Cathartics, use of, in wet beriberi, 1042
in scarlet fever, 554

Cellular tissue, lesions of, in pyæmia, 966

Cellulitis, pelvic, in puerperal fever, 988

Cerebral softening from embolism, 65
symptoms in yellow fever, 644

Cerebro-spinal meningitis, 795

Certificates of death, duty of a physician in regard to, 210

Cesspools beneath dwellings, dangers of, 192
contamination of water by, 192
evils of, 126

Change of residence as cause of typhoid fever, 244

Cheesy degeneration, 79
metamorphosis, 79

Chicken-pox, 481

Child-bed fever, relation to erysipelas, 630

Childhood, influence of, on occurrence of pertussis, 839

Children, causes of frequency of diphtheria in, 682
typhoid fever in, 301

Chills in pyæmia, 973

Chinolin, use of, in diphtheria, 703

Chloral hydrate, use of, in cerebro-spinal meningitis, 834
in hydrophobia, 907
in pertussis, 846
in relapsing fever, 430

Chloride test for detecting pollution of water-supply, 192

Chloroform, use of, in cholera, 768
in hydrophobia, 907
in relapsing fever, 431

CHOLERA, 715
Definition, 715
Synonyms, 715
History, 715 _et seq._
Etiology--predisposing causes, 720
Influence of high temperature in origin and spread, 720
Season, influence of, on causation, 720
Over-crowding and filth as causes, 720
Intemperance as a cause, 721
Contagiousness, 721
Modes of transmission, 721
Channels of entrance into system, 721
Propagation of, by fomites, 721
by drinking-water, 723
Cases illustrating spread of, by drinking-water, 724
Influence of height of subsoil-water on prevalence, 722
Humidity of soil as a cause, 722
Special fomites of, 723
Cases illustrating spread of, by fomites, 727
Cases illustrating contagiousness, 728
Objections to contagious nature, 729
Individual immunity, 730
Different grades of, from intensity of poison, 731
Specific origin, 747
Nature of poison, 748
Influence of bacteria in production, 748
Koch's investigations in regard to bacilli, 745, 749
Symptoms, 731
Mild forms, 732
"Cholerine" stage, 732
Number of stools in mild forms, 732
Character of stools in mild forms, 732
Grave forms, 733
Physiognomy in grave forms, 733
Stools in grave forms, 733
Typhoid state, 734
Stage of collapse, 734
Reaction, 734
Convalescence, 735
Temperature, 736
Difference between axillary, vaginal, and rectal temperature, 736
Special symptoms--Low temperature of mouth, 736
Condition of skin, 736
Color of skin, 737
Condition of heart and pulse, 737
Veins, 737
Vomiting, 738
Character of vomit, 738
Diarrhoea, 738
Results of diarrhoea, 738
Characters of stools, 739
Condition of urine, 739
Cramps, 740
Causes of cramps, 740
State of abdomen, 741
of nervous system, 741
Complications and sequelæ, 735
Complicated by diphtheritic exudations, 735
Inflammation of parotid and submaxillary glands, 735
Abscesses and ulcers, 735
Cutaneous eruptions, 735
Morbid anatomy--general appearance after death, 741
Cadaveric rigidity, 741
Muscular contractions after death, 741
Appearance, post-mortem, of abdominal cavity, 743
Changes in stomach, 743
Intestinal canal, 743
Intestinal mucous membrane, 743
Nature of exfoliation from intestinal canal, 744
Changes in isolated and agminated glands, 745
Capillaries and veins of intestinal canal, 745
Liver, 745
Gall-bladder, 746
Spleen, 746
Heart, 746
Pericardium, 747
Lungs, 746
Brain and spinal marrow, 746
Kidneys, 746
Blood, 747
Diagnosis--from cholera morbus, 750
from irritant poisoning, 752
Order of symptoms as a ground for, 753
Prognosis, 753
Symptoms indicating favorable and unfavorable, 754
Mortality--in different epidemics, 754
Influence of age, 754
Sex, 754
Social condition, 754
Treatment, 759
Preventive, 755
Disinfection, 758
Modes of applying disinfectants, 758
Importance of maintaining high degree of health during
epidemics, 758
Quarantine and sanitary cordons for prevention, 755 _et seq._
Mode of carrying out quarantine, 757
Cases illustrating value of quarantine, 757
Use of drinking-water during epidemics, 759
General management, 760
Importance of early recognition, 732
Necessity of rest, 760
of prompt, 760
Diarrhoea, 760
Vomiting, 761
Hiccough, 762
Injection of sodium chloride into veins, 762
Stage of collapse, 763
Diet of stage of reaction, 763
For restoration of circulation in stage of collapse, 763
Stage of reaction, 763
Undue reaction, 764
Urinary suppression in stage of reaction, 764
Convalescence, 764
Use of venesection in, 764
Emetics, 765
Calomel, 766
Alcohol, 767
Opiates, 767
Mineral acids, 768
Camphor, 768
Chloroform, 768
Intravenous injections, 768
Hot applications, 769
Cold affusions, 769
Of cramps, 769
Necessity of cold water to allay thirst, 770
Use of antiseptic remedies, 770

Cholerine, 732

Chorea, following typhoid fever, 293

Chronic diseases, relation of, to rubeola, 561
forms of erysipelas, 634
of glanders, 915, 923

Cicatrix, condition during incubation of hydrophobia, 895
in hydrophobia, excision, 906-908
in vaccinia, description, 460

Classification of puerperal inflammations, 986

Cleanliness, importance of, in prevention of pyæmia, 980
in variola, 454

Climate, as a cause of disease, 185
definition of term, 185
influence of, on causation of influenza, 860
on causation of rabies and hydrophobia, 887
of rubeola, 560

Clinical history of influenza, 864

Clothing as a cause of disease, 198

Cloudy swelling, 72

Coagulation of exudations, 43

Cohnheim's theory of production of morbid growths, 106

Colchicum, use of, in dengue, 885

Cold as a cause of disease, 133
and damp, influence of, on causation of glanders, 912
bath, use of, in diphtheria, 702
in puerperal fever, 1034
in typhoid fever, 327
Contra-indications to use of, in diphtheria, 703
Use of, in algid form of pernicious malarial fever, 608
in cerebro-spinal meningitis, 830
in cholera, 769
in diphtheria, 702
in puerperal fever, 1033
in the hyperpyrexia of scarlet fever, 541
in scarlet fever, 542
in yellow fever, 651
water, intra-uterine injections of, in puerperal fever, 1034
mode of applying, in scarlet fever, 542

Cold stage of intermittent fever, 592
of intermittent fever, theory of cause, 593
treatment, 594
of yellow fever, treatment, 653

Cold water, use of, in typhus fever, 364

Collapse in cerebro-spinal meningitis, treatment, 831
in cholera, 734
treatment, 763
of lungs, complicating influenza, 869

Collections of water, influence on health of a community, 187

Colloid degeneration, 83
metamorphosis, 83

Color of skin, significance of, in general diagnosis, 159

Coma, in cerebro-spinal meningitis, 812
significance of, in general diagnosis, 166

Comatose form of pernicious malarial fever, 608
Diagnosis, 609
Symptoms, 609
Treatment, 609

Coma-vigil in typhus fever, 349

Compresses, hot water, use of, in variola, 453