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lukewarm water feebly thrown into the vagina, while the patient is sitting over a basin or other vessel, is often con- sidered sufficient and expected to yield good results ; hut such a use of hot water for this jjurposc resembles the proper injection only "as the mist resembles the rain," and leads only to disaijpointment. In jjelvic cellulitis the persistent use of hot water hastens the absor|)tion of the plastic exudation and shortens the duration of the disease. One of the applications of heat that may appear para- doxical, in allopurinol 20 mg view of what has been said of refrigeration in peritonitis, is the very common custom of covering the abdomen with hot poultices for the relief of the same dis- ease. There is really nothing antagonistic in this. The object of the hot application is not to augment the heat of the parts, for there is already too much heat and what is allopurinol 300 mg con- gestion, but what the jioultices and hot fomentations do is to stimulate the capillary circulation and that of the allopurinol rxlist underlying lymphatics, and thus relieve the engorgement of organs more remote. Such applications are grateful to the patient, and that they often do much good there can be no doubt. I think that warm applications are useful, chiefly in the forms of jieritonitis that develop ratiier insidiously, with pain over a large area. Where the disease is local, and especially of traumatic origin, I should prefer cooling measures from the beginning. There is nothing at all inconsistent in the use of both hot and cold applications at different stages of the same^disease, and in the same case. It would carry me beyond my limits even to enumer- ate all the familiar applications of heat in therapeutics. The value as a counter-irritant of Paquelin's cautery, used at a while heat and brushed lightly over the sur- face, is generally acknowledged. The application of heat over the region of the heart as a stimulant in threatening collapse, is often found of value, and I have brand name for allopurinol utilized the rubber coil for that purpose ; the medicinal use of hot water as a beverage reminds us that allopurinol brand name there is fashion in everything. More than one hun- dred and fifty years ago Le Sage, in his immortal " Dr. Sagrado," ridiculed the routine use of hot water and bleeding. allopurinol uk The hot water has come back to us ; the bleed- ing, as its adjunct, may follow. In conclusion, 1 would suggest that as we have in heat and cold agents powerful enough to destroy life, and un- der proper control capable of modifying all its functions, they should alwavs be iirescribed with a definite object and used in a definite manner. As their use is often intrusted to those who know nothing of the principles on which they act, and who are influenced by custom or prejudice, the ])hysician should order allopurinol take suitable opportuni- ties of imparting some general information allopurinol iv to his patients as to the most rational means of employing remedies that, however or by whomsoever ])rescribed, will always be considered the property of the household, and within the province of domestic practice. A RARE FORM OF LOBAR PNEUMONIA— TUBERCUI-OUS CROUPOUS LOBAR PNEl^- MONIA. By 1-K.VNCIS P. allopurinol brand names KINNICUTT, M.D., rHVSlClAN TO ST HKk'S HOSriTAL, NEW YOKK. F. H , male, aged thirty-three, single, native of Eng- land, was admitted to my service in St. Luke's Hospital March 6, 1S84. Family history not obtainable. The pa- tient states that he has never suffered from any pulmonary affection. Eighteen months ago he was injured in a rail- way accident, and has been troubled since that lime with a continuous •' to and-fro movement of allopurinol 150 mg his head," which he has been told ceases during slecj). During this i)eriod he has lost flesh. He has had no cough or hemorrhage, and was ap|)arently in good health until three days before admission to the hospital, when he had several sharp chills, followed by cough and a thickish expectoration and ap- jiarently fever. On admission to hospital patient was fairly well nourished ; temperature, 104° ; i)ulsc, 100 ; respirations, 38. There was cough ; the sjiuta were viscid, but not rusty. There was a constant rhythmical to-and- fro movement of the head, which ceased during sleei>. Examination of the chest showed dulness, with feeble respiratory murmur and abundant fine inspiratory crepita- tion over the infra-clavicular region and upper portion of the mammary of the right side. The urine was acid, specific gravity 1.028, and was free from albumen and sugar. The chest was very carefully examined by me daily. The physical signs of consolidation of the entire 400 THE MEDICAL RECORD. [October 1 1, i5 upper lobe of the right lung (marked dulness, bronchial respiration, and broncliophony) rapidly supervened ; there was continuous pyrexia ; the pulse-respiration ratio of one to a buy allopurinol online little less than three was maintained. Until the eighth or ninth day of the patient's illness the clinical course of the disease in all respects corresponded with an ordinary attack of croupous lobar pneumonia, and was so regarded by me. Resolution, however, did not occur at the customary period ; there was, on the contrary, from the ninth day after admission to hospital until death, a gradually increasing pyre.xia, jjulse, and respiratory rate. Examination of the chest, moreover, revealed a very rapidly developing disintegration of lung tissue at differ- ent points in the aflected area. On the thirteenth day there were the physical signs of a small cavity in the upper portion of the consolidated lobe, corresponding to the site at which the largest excavation was found after death During the last days of life slight hagmoptyses occurred, and there was eflusion into the right pleural cavity. A similar case had never before been observed by me, but from the clinical course of the disease I finally was led to believe, and expressed the opinion, that the morbid process might well be expressed by the term tuberculous croupous lobar jmeumonia. The patient died on the sixteenth day after admission to hospital, on the nine- teenth from the first symptoms of acute illness, with the signs of general pulmonary oedema and heart-failure.' The autopsy was made by Dr. Ferguson in my pres- ence. The morbid changes were confined to the brain, the spleen, and the lungs. There was marked atrophy of the convolutions over the vertex. The spleen was large and soft. The right pleural cavity contained about forty ounces of semi-purulent fluid ; the pulmonary pleura was covered with recent fibrin. The left lung was in- tensely congested and cedematous ; the entire upper lobe of the right lung was hepatized. On section the solidified l)ortion appeared dry, smooth, and grayish in color and homogeneous in consistency throughout. The cut sur- face did not present the granular appearance of gray hepatization, and the edge of the knife carried over it did not remove the alveolar contents. Numerous miliary tubercles could be distinguished at the periphery of the consolidation. The middle lobe and the upper' portion of the lower lobe contained numerous miliary tuijercles. There were several small cavities in the consolidated portion, varying in size from that of a pea to a walnut, partially filled with material not completely disintegrated. In sections, the alveolar walls were seen to be slightly thickened and the alveoli to be distended with pus, a small amount of fibrin, granular material and epitlielial cells similar in appearance to those lining the alveolar walls in the normal state. The alveolar contents in places had undergone cheesy degeneration. These areas of cheesy degeneration, which were numerous through- out cost of allopurinol the consolidated portion of the lung, were limitedby zones of small round cells of inflammatory origin. In some of the caseous areas the alveolar septa were still preserved, but very generally they had disappeared in these areas, a fusion of many alveoli having occurred. In the neighborhood of the solidified portion there were numerous miliary tubercles and tuberculous masses with broken-down centres ; in both, giant cells were well de- veloped and abundant. In tiie interstitial tissue of the lung surrounding the tuberculous masses numerous small cells, both round and fusiform, were seen. Tubercles were not found in the other organs. The pathological changes above described would seem to justify the application of the term tuberculous croup- ous lobar pneumonia to the morbid process. An ap- parently similar morbid process has been described by pathologists, but I have been unable to find a7iy clinical record of such cases, with the exception of a general ' The sputa were not examined until the fourteenth day: two specimens were then exammed, but tubercle bacilli were not found. On the fifteenth and sixteenth ilays tlie sputa were so scanty that specimens could not be obtained for reference to them by Rindfleisch and a very brief report of two cases conmmnicated to the French Academy of Medicine, December 4, 1883, by Professor See, under the title of " Phthisis in the Form of Lobar Pneumonia." I give the latter as reported m Le Frogres Aledical oi December 8, 1883 : Case I. — A young man, nineteen years of age, a hos- pital patient, was seized on September 13th with a well- marked attack of simple pneumonia, which involved the upper two-thirds of the right lung. At the end of the ninth day, defervescence not having taken place, the sputa were examined and bacilli in great numbers discovered. allopurinol generic name Early in October all the signs of an excavation became apparent. Case II. — A patient in the same hospital ward pre- sented all the signs of a simple pneumonia, which, how- ever, did not undergo resolution. The sputa were twice examined, revealing only ordinary microbes in great num- bers. A third examination established the presence of a small number of tubercle bacilli. Shortly afterward the local signs confirmed the allopurinol pharmacology diagnosis. Rindfleisch,' under the head of "Cheesy Lobar Pneu- monia," describes a form of desquamative pneumonia (Buhl) which occurs as a diflfuse inflammation of an en- tire lobe aftected by tuberculosis. " Usually the earlier stages of tiie disease have already passed by at the apex of the lung and cavities have formed, when a sudden at- tack of cheesy pneumonia occurs and involves at once the rest of the upper lobe. This usually happens with an acute exacerbation of all the clinical symptoms, the fever, dyspnoea, and rapid pulse, so that the impression is given of an intercurrent croupous lobar pneumonia, and the first glance at the lungs might seem to confirm this opinion, for, as Mrchow has shown, there are very allopurinol 50 mg often in the alveoli plugs of real fibrinous exudation, so that the section of the lung looks granular. But the dis- tinction lies in the infiltration of the alveolar walls, a con- dition very slightly developed in croupous pneumonia.'' I prefer to regard the morbid process observed in my own case, and which has been carefully described, as an ex- ample of an intercurrent croupous pneumoitia, from the presence in the alveoli of the usual products of such allopurinol cost an allopurinol tablets 100mg inflammation — e.g., pus and fibrin — which Buhl '' insists are 7iever allopurinol online presejit in the desquamative pneumonia first described by him. The implication of the alveolar walls and the presence of only a small amount of fibrin among starting allopurinol the alveolar contents I shall again refer to. The question of the probable period of the develop- ment of tubercles in the above case is certainly an open one. Personally, I am inclined to believe that a slight deposition of tubercles occurred at some time previous to the beginning of the patient's acute illness, but that little or no constitutional disturbance was produced thereby. The history of the patient, the clinical course of the acute disease as observed by me, and finally the post- mortem appearances, would seem to justify the opinion that on the date of the recorded chills a true croupous pneumonia was developed in the tuberculous lobe of the lung ; that the pneumonic process furnished suitable soil for a very rapid and abundant development of the bacilli tuberculosis ; that there was a consequent equally rapid degeneration of the tubercles of older date, and also of the pneumonic products. The objection to considering the pneumonic process a croupous one on account of the serious involvement of the alveolar walls, may be met by the argument that such an implication is believed by many pathologists to occur in cases of croupous pneu- monia where resolution is delayed. The presence of only a small amount of fibrin among the alveolar con-

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