WBK; G258p! 1899 \ i IE ; fy.y'"':• •'«<> .v<>..\v.v.; ,.v: ».•.-.'.•.'.•.',<,-,■.'.•/ 'X' .''V > 1 POCKET-BOOK OF MEDICAI^PRACTICE (tATCHELL I JUI 31 (900 i [ • ! 1 :. ■ POCKET-BOOK of MEDICAL PRACTICE INCLUDING DISEASES OF THE KIDNEYS, SKIN, NERYES, EYE, EAR, NOSE AND THROAT, AND SSTETBICS, GYNECOLOGY, SUEGEEY BY SPECIAL AUTHORS BY [ Ch. J&atchell, M.D. AUTHOR OF "KEY-NOTES OP MEDICAL PRACTICE;" ED1TOB OF "MEDICAL ERA;" BOFESSOB OF DISEASES OP THE CHEST AND PHYSICAL DIAGNOSIS IN THE CHICAGO HOMOEOPATHIC MEDICAL COLLEGE; ATTEND- ING PHYSICIAN TO COOK COUNTY HOSPITAL. CHICAGO: FOBMEELY PBOFESSOB OF THE PBINCIPLES AND PBACTICE OF MEDICINE IN THE UNIVERSITY OF MICHIGAN. CHICAGO ERA PUBLISHING COMPANY 1899 WBK &Z5Sp 1893 r COPYRIGHT KKA PUBLISHING CO. 1S99 PREFACE This work is designed to be a pocket-companion for the general practitioner. The presumption is that those who make use of it already have a thorough and compre- hensive knowledge of medicine, and refer to it only for the purpose of refreshing the memor}'. Thus it becomes a book for ready-reference, and prompts to the study of larger volumes at greater leisure. A departure has been made by including all the "spe- cialties." Although this is often done in large "sys- tems" of medicine, never before has it been attempted in a •* Pocket-Book. *' Here again the effort has been to present that part of each subject of which the general practitioner would be most apt to be in need. To this end the author has been favored by the assistance of well-known specialists, who are experts in their several lines. This gives to the work a range and a value im- possible of attainment in the product of a single author. In addition to the indicated medicines recommended in each disease, careful attention is given to adjuvant treat- ment. Still another feature is that the dosage of each medicine is given, in connection with the name of the drug itself. It must be understood, however, that this expresses only the practice and preference of the several authors. It is not intended to be arbitrary. It must be accepted as being merely suggestive. The recommenda- tion is submitted, to those who use the book, that the dosage be varied in accordance with the results of indi- vidual experience. Although standard literature has been widely con- sulted, yet, in a work of this character, with its con- densed style, it has not been thought necessary to make reference to sources. Hence all such quotations have been omitted. Dr. Leslie W. Beebe desires to acknowledge the kindness of Dr. Chas. Adams and Dr. A. G. Beebe in favoring him with criticisms of his work. To Drs. Williamson, Laidlaw, Thomas, Coffin, Horner, Swan, Copeland, Garrison, Korndoerfer, Willard and Beebe, the author makes grateful acknowl- edgment. Their cheerful co-operation and many ex- pressions of interest have rendered his task a delight and the association a personal pleasure. The high value of their carefully prepared contributions, which he him- self fully appreciates, will, he is assured, be fully at- tested by the profession, to whose hands the work is now committed. Ch. G. Chicago, September, i8qq. SPECIAL AUTHORS KIDNEYS.—By Geo. F. Laidlaw, M.D., New York. Formerly. Lecturer on Pathology, New York Homoe- opathic Medical Colleg-e. STOMACH.—By Arthur E. Thomas, M.D., Chicago. Professor of Principles and Practice of Medicine and Clinical Medicine, Chicago Homoeopathic Medical Col- lege and Hospital. SKIN.—By John L. Coffin, M.D., Boston. Professor of Diseases of the Skin, Boston University School of Medicine. MENTAL DISEASES.—By A. P. Williamson, M.D., Minneapolis. Professor of Mental and Nervous Diseases, Homoeo- pathic Medical College of the University of Minnesota. NERVOUS SYSTEM.—By J. Richey Horner, M.D., Cleveland. Professor of Neurology and Electrology in the Cleveland Homoeopathic Medical College. EYE.—By C. J. Swan, M.D., Chicago. Adjunct Professor of the Diseases of the Eye and Ear, Hahnemann Medical College and Hospital, Chicago. EAR.—By R. S. Copeland, M. D., Ann Arbor. Professor of Ophthalmology and Otology, Homoeopathic Medical College of the University of Michigan. NOSE AND THROAT.—By John B. Garrison, M.D., New York. Surgeon, Throat Department, New York Ophthalmic Hospital; Laryngologist to the Hahnemann Hospital, and to the Lama Franklin Free Hospital for Children. OBSTETRICS.—By Aug. Korndoerfer, Jr., M.D., Philadelphia. Demonstrator of Obstetrics, Hahnemann Medical College and Hospital, Philadelphia. GYNECOLOGY.—By Wm. G. Willard, M.D., Chicago. Professor of Medical and Surgical Diseases of Women, Chicago Homoeopathic Medical College and Hospital. SURGERY; VENEREAL.—By Leslie W. Beebe, M.D., Chicago. Adjunct Professor, Principles and Practice of Surgery, Chicago Homoeopathic Medical College and Hospital, CONTENTS SECTION PAGE I.—Diseases of Children..................... 7 II.—Diseases of the Lungs and Plur.k......37 HI.—Diseases of the Heart................... 59 IV.—Fevers.................................... 70 V.—Constitutional Diseases................. 83 VI.—The Intoxications.......................90 VII.—Diseases of the Blood....................96 VIII.—Diseases of the Liver....................101 IX.—Diseases'of the Intestines..............112 X.—Diseases of the Stomach................124 XI.—Diseases of the Kidneys.................138 XII.—Mental Diseases.........................152 XIII.—The Nervous System.....................157 XIV.—Diseases of the Skin.....................174 XV.—Diseases of the Eye......................183 I XVI.—Diseases of the Ear......................190 XVII.—Nose, Throat and Larynx...............198 XVIII.—Obstetrics................................218 XIX.—Gynecology...............................238 XX.—Surgery...................................263 XXI.—The Venereal............................357 XXII.—Appendix.............••...................367 MEDICAL PRACTICE. SECTION I. DISEASES OF CHILDREN. MPHTHEKIA. (DIPHTHERITIS.) Etiology.—Infection by the Klebs-Lceffler bacillus. Contagion.—It is communicated from person to person, by fomites, by a portion of membrane or secretion, and It is capable of conveyance by inoculation. Incubation.—Two to five days; rarely eight to twelve. Diagnosis.—The appearance of the false membrane is the pathognomonic symptom, though this may be absent in mild cases. The exudate is first a thin, whitish pellicle, usually on the fauces or tonsils; it rapidly increases in thickness, and spreads in area; it is firmly adherent to the underlying mucous membrane. Demon- stration of the specific bacillus is confirmatory. Differential Diagnosis.—Follicular Tonsillitis:—The secretion is confined to the tonsils; it is not an adherent membrane, but occupies the crypts of the tonsils, and is easily separated without hemorrhage. Other Diseases that have been confounded T„-ith diph- theria are: Pharyngitis of the following forms—scarla- tinal, herpetic, ulcero-membranous, pultaceous and gan- grenous; also faucial erysipelas and pseudo-membranous croup. Also pseudo-diphtheria, streptococcus-pharyngitis. Important Symptoms.—Patcllar-tendon Reflex: — It is usually lost early; it is of great diagnostic value. Lymph nodes:—Those especially about the neck are enlarged early. Fever:—The temperature is not a reliable guide. Pulse:—When weak and irregular, it is of grave import. Albuminuria:—Occurs in one-half to two-thirds of all cases; from a trace to a large quantity; the latter is un- favorable. Paralysis:—As a rule it is a late symptom; pharyngeal and palatal are most common; the heart, or any muscle of the body may suffer. Complications.—Otitis; parotitis; broncho-pneumonia; pleuritis; emphysema; myocarditis; endocarditis; peri- carditis; thrombosis; embolism; hemorrhages; nephritis; entero-colitis. Sequelae.—Chronic catarrh; anemia; cardiac affections; multiple neuritis; paralysis. Prognosis. —Always guarded. Unfavorable Symptoms: —Persistent vomiting; membrane extensive; laryngeal or nasal forms; great adenitis; offensive odor; scanty urine; much albumen; multiple paralysis; weak heart's action; irregular pulse; broncho-pneumonia; hemorrhage; toxemia; mixed infection. Causes of Death.—Cardiac paralysis; laryngeal sten- osis; uremia; toxemia; edema of the lungs; asthenia; inanition. fi DIPHTHERIA-TREATMENT-MBDICINAL-LOCAI POCKET-BOOK OF MEDICAL PRACTICE_________ TREATMENT. Antitoxin.—It should be given in all cases as soon as the diagnosis is made. After the third day reaction is de- ficient, owing to cumulative effect and to mixed infection. Dose.—Age, one year: Mild case, 500 U.; severe, 1,000 TJ.; grave, 1,500-2,000 U. Two years: Mild, 1,000 U.; severe, 1,500 U.; grave, 2,000—2,500 U. Three years and older: Minimum, 1,500 U., up to maximum of 3,000 U. Repetition.—Do not repeat so long as improvement con- tinues; if there is no improvement, repeat in 8 to 12 hours. Injection.— Location:—Thigh, outer aspect; sides of the abdomen; inter-scapular region. Inject slowly. Use strict aseptic precautions. Note.—Many physicians make favorable reports of Antitoxin ad- ministered internally. It is worthy of trial. The Syringe.—Cleanse with carbolic acid; boil, and cleanse again before using. Mercurius cyan.3x—Malignant diphtheria; extreme prostration, early; pulse intermittent, small, quick and high—130-140-1-; moist skin; fetid breath; saliva thick; tongue coated, brown or black; membrane extensive, yellow, brown or black; also, croupous form; nasal form, with great prostration. Kali bich. 2x—Especially in nasal and in laryngeal diphtheria. The pseudo-membrane is thick and yellow- ish; the secretions are tough and stringy. Sthenic or asthenic cases. Merc. iod.3x—Much swelling of the cervical glands; much tenacious mucus; ulcers; tonsils much swollen; great putridity. Cantharis.lx—Mucous membrane dark red; and as if blistered; burning pain in the throat; sense of constric- tion; blood in the expectoration; extreme prostration; cold extremities; urine scanty, bloody, or albuminous. Apis.3x—Tissues of the throat edematous, with sting- ing pains, dryness and burning; mucous membrane glossy and purple; exudation dirty gray; edematous swelling of the face and neck; scanty urine. Great prostration; sometimes stupor. Bromine.Tr—Laryngeal diphtheria; croupy cough, with dyspnea; asthenic cases. Arsenicum.3x—Cases in which there is blood poison- ing, with great prostration; the throat much swollen; pseudo-membrane dark; great fetor; thin, excoriating discharge from the nose; restlessness; scanty urine; offensive diarrhea. Arsenicum is not related to the diphtheritic process, but to the toxemia, clue to secondary st reptococcU9-gepsis. Muriatic acid.1*—Excoriating secretions. Phytolacca.Tr—Great aching pain in the back. Lachesis.3x—Mucous membrane dark purple. Gelseinium.lx—This is the leading remedy for post- diphtheritic paralysis, especially in ocular paralysis, pharyngeal or laryngeal paralysis, cardiac paresis, or paralysis of small muscles. Dose:—Three drops of lx every three hours. L0CAL TREATMENT. Object.—The object of local treatment is to (1) favor DIPHTHERIA-TREATMENT-LOCAL-GENBRAL 9 POCKET-BOOK OF MEDICAL PRACTICE separation of the membrane; and (2) disinfect the parts. Note.—Local applications have no specific effect on the disease process; they only dissolve the membrane or disinfect the parts. Steam.—The steam atomizer should be used persist- ently; it favors separation of the membrane. Use a soft towel, overlaid with rubber-cloth or oil-silk, to pro- tect the face and neck of the patient from the cool mois- ture caused by the condensed steam. Papoid.—Papoid will promptly dissolve the membrane. It may be applied (a) on a swab; (b) by insufflation, or [c) hot-water gargle. Use several grains each time. Hydrogen-Peroxide.—It will dissolve the membrane. Use fifteen volume solution. It is not a germicide. Kali bicll.—As a disinfectant use Potassium bichro- mate; make a watery solution, gr. j. tooz.j. Use in hand- atomizer or steam-atomizer. Use persistently, especially in the laryngeal for)>i. Kali pcrman.—In the nasal form use Potassium per- man., one grain to the ounce. Nasal.—In nasal diphtheria cleanse the nares thor- oughly and frequently; every hour. Use the nasal douche when possible; or, spray apparatus, with saline, or weak permanganate solution. Laryngeal.—With threatening laryngeal stenosis in- tubate at once. GENERAL MEASURES. Quarantine.—Isolate the patient; maintain rigid quar- antine. Remove other children from the house. Sick-Room.—Use an airy, upper room. Remove car- pets, rugs, drapery, upholstery; good ventilation; keep a moist atmosphere; temperature about 73° F.; burn all rags and soiled linen. Attendants.—Physician, nurses, and those coming into contact with the sick should gargle several times daily with dilute alcohol. Prophylaxis.—Children who have been exposed should receive a dose of 300 U. Antitoxin. Disinfection.—Sterilize all articles used by the patient, by boiling. Put all secretions, and the like, into car- bolic solution, 1: 20, or bichloride, 1:1,000. Attendants should wash the hands in carbolic solution, 1: 40. Let no milk or food stand in the sick-room. The Patient.—Until convalescence is established keep the patient quiet, and recumbent; if the heart is weak or irregular, much longer. Guard the patient from drafts of air or changes of temperature. Diet.—It is of the utmost importance to keep the patient well nourished. Let the diet be liquid in form, highly nutritious, easily digestible, and of sufficient variety to tempt the appetite. Milk.—Give in an}' form, raw, boiled, or peptonized. Egg-nogg:—tKr\ egg beaten up in a glass of milk; sweeten, and spice with nutmeg; add a teaspoon of whisky. Omit the yolk if the patient prefers. Punch:—Equal parts milk and hot water, with one teaspoon whisky to the glass. Mutton broth; chicken broth; oyster broth; beef peptonoids; trophonine; panada. A glass of scalded 10 SCARLATINA-SYMPTOMS-DIAGNOSIS-TREATMENT POCKET-BOOK OF MEDICAL PRACTICE milk, with one tablespoon of coffee; sweeten. Give plenty of water to slake thirst. Precaution.—If there is pharyngeal paralysis, do not let the patient take a mouthful of solid food until the muscles are fully restored. If impossible to nourish by the stomach, use nutrient enemata. Cardiac Paresis.—Watch the heart; if paresis threatens give stimulants. Indications:—Faint second sound; pulse —weak, dicrotic, irregular or intermittent. Cyanosis. Stimulants.—Alcoholic:—Whisky ;brandy; wine(sherry; tokay; wine-whey). Dose:—From 1 to 4 drams, accord- ing to urgency. Dilute the brandy or whisky with 4 to 8 parts water. Strychnin sulph.—To be use J when the condition is urgent. Dose:—^0 gr. every 2 or 3 hrs.; reduce to da gr. as the effect is obtained. Glonoin.—Dose:—?lo~£s m. Oxygen.—By inhalation in cyanosis from respiratory embarrassment. -------- SCARLET FEVER. (scarlatina). Contagion.—The period of contagion is from the first appearance of the eruption till desquamation is com- plete; contagion may last as long as there is post-scarla- tinal dropsy. Contaminated objects may infect years after (period of twenty years well authenticated). Incubation.—From two to eight days; exceptionally from a few hours *o several weeks. Stages.—Incubation; prodromal; eruption; desquama- tion. Varieties. —(I.) Regular Form; (II.) Irregular Form; (III.) Malignant Form. Symptom*.—Onset:—{a) chill; [b) vomiting; or (Y) convul- sions. Rash:—Appears first about neck, chest and shoulders; extends over trunk and extremities; reaches height on second, sometimes third, day; disappears in reverse order. Desquamation:—Usually begins on fifth day; may anticipate or delay; lasts 7 to 10 days or more. Complications.—Convulsions; ulcerative or gangrenous angina; otitis media; adenitis; cellulitis; pleurisy; endo- carditis; pericarditis; peritonitis; articular rheumatism; nephritis; uremia. Nephritis.—May appear at any stage; usually latter half of first or early in second week, or later. No patient is safe till six weeks after convalescence. Prognosis.—Always guarded. Unfavorable:—Persist- ent vomiting; hyperpyrexia (106°+); nervous disturb- ances; diphtheritic or gangrenous complications; early nephritis, or much albumen. Prognosis more grave in the very young. Causes of Death.—Usually from: (a) Earlymalignancy; (b) septic cases, with asthenia or severe local complica- tion; (c) late nephritis. TREATMENT Gclsemiuin.1*—Early in the disease; the patient is dull and apathetic; prostration; weak pulse. SCARLET FEVER-MEDICINAL TREATMENT 11 ^___ POCKET-BOOK OF MEDICAL PRACTICE______________ Belladonna.lx—Violent vomiting with the onset; rash, Bmooth, bright red; great restlessness; cerebral conges- tion, with brain irritation, the symptoms varying from startings in sleep and twitching of groups of muscles, to violent delirium, with shrieking and jumping out of bed. The throat symptoms severe; fauces and tonsils bright red, glistening; tongue with characteristic "straw- berry " appearance; or, thin coating, the elevated papil- la: showing through. Pulse, full, strong, accelerated. Glands of the neck may be swollen. Sleep is disturbed, the muscles twitch, there is grinding of the teeth; chew- ing motion of the mouth. Belladonna is of use only in sthenic cases; in the malig-nant or adynamic other remedies must be sought. Rhus tox.2*—When in the regular form of scarlatina, the eruption is miliary, the rash containing small red points, or fine vesicles. In scarlatina with a typhoid- like condition; eruption dark and mottled; high tempera- ture; parotid and cervical glands enlarged; tongue red and glazed, or brown, dry and cracked; sordes form on lips and teeth; restlessness; low, muttering delirium; epistaxis; thin, offensive discharges from the bowels. In adynamic cases. Apis mel.3x—In adynamic cases, with high tempera- ture, drowsiness, great restlessness and nervousness; throat very red, or purplish, and swollen, with fine ves- icles on the mucous surface, followed by ulceration; tongue cracked, sore, ulcerated; miliary rash, with irri- tation of the skin; early prostration; stupor; urine scanty; albuminuria; edematous swelling. Adynamic cases, and for the nephritis. Ammonium carb.lx—Miliary rash; throat swollen; dark red, with tendency to ulceration; lymphatic glands of the neck, and the parotids swollen; with involvement of the cellular tissue; adynamic cases, with somnolence. Mercurius iodatus.3*—Ulceration of the throat; much glandular swelling; fetor; salivation; great prostration. Ailauthus.lx—Scarlatina maligna; rapid and severe onset, with violent vomiting, headache, photophobia, face dark red and hot; pulse small and rapid; delirium; stupor; dark, livid, miliary rash, in patches; excoriating discharges from mouth and nose; swelling of the throat. Arsenicum.3x—The eruption is delayed; or, having appeared, there is sudden retrocession with pale and cold surface, small pulse, great prostration. With the retrocession of the eruption the child may have convul- sions, with stupor, and moaning and restlessness. Also, cases marked by putrid sore throat, scanty urine, fetid, involuntary diarrhea. Also, for nephritis, of the sub- acute form. Cuprum aceticum.2x—Disappearance of the eruption; with violent convulsions, spasms of the flexors; face red or purple; frothing at the mouth; teeth clenched; dis- tortion of the face. Lachesis.6x—Great prostration; swelling of the throat, with ulceration; fetid breath; quick, feeble pulse; low, muttering delirium. 12 SCARLATINA-GENERAL MEASURES—MEASLES POCKET-BOOK OF MEDICAL PRACTICE____________ Muriatic acid.1*—Rash scattered, interspersed with petechias; skin bluish or purplish; feet blue; thin, ex- coriating discharge from the nose; vesicles about the nose and mouth; throat raw; breath fetid. Cantharis.Tr—Nephritis, with acute symptoms; urine scanty and high colored; albuminuria; threatened ure- mia. Dose:—Ten drops of Tr. in ]/z glass water; tea- spoon every 1 or 2 hours. Aconite.Tr—Scanty urine, with congestion of the kid- neys; high fever; rapid pulse; thirst and restlessness; great nervous erethism. Repertory.—Malig?iant Form:— Ailanth.; Merc, cyan.; Cuprum acet.; Hydrocyanic acid. Anginose Form:— Merc. iod.; Apis; Arsen.; Ammon. carb.; Muriatic ac.; Lachesis; Rhus. Toxemia:—Arsenicum; Rhus ; Lach- esis. Retrocession of Eruption:—Arsen.; Cuprum ac; Camphor. Nephritis:—Canth.; Apis; Arsen. Adenitis: —Rhus; Lach.; Merc. iod. Otitis Media:—Bell.; Gels.; Hepar s.; Merc. Ulceration and Gangrene:—Arsen.; Merc. cyan. GENERAL MEASURES. Quarantine.—Isolate and quarantine the patient. Re- move other children from the house. The nurse should be quarantined with the patient. The physician should remove his coat and overcoat, and put on a rubber coat, or a muslin gown, when he visits the sick-room. On leaving he should wash face and hands, and use Formalin disinfectant to his clothing. The virus of scarlatina is extremely persistent; excessive measures of disinfection are demanded during and after the attack. The Patient.—Allay itching of the skin by sponging with a mild carbolic solution. During desquamation give a daily warm soda bath; use Vaseline with 5% Boric acid inunction to the skin. To guard against nephritis keep the child in bed one week after the fever has subsided. Preventing the patient "taking cold " is of paramount importance in this disease. Retrocession of Eruption.—Put the patient in a hot bath (100°) for ten minutes; take out and wrap in warm blankets. Repeat if necessary. Hyperpyrexia.—With a sustained temperature of 104° or 105° F., give cool sponging, or the soda bath. In sep- tic cases, or with cerebral symptoms, repeat the soda baths so as to keep the temperature below 103° F. Diet.—During the course of the disease a sustaining diet; after the attack, to favor free action of the kidneys, preferably a liquid diet, with plenty of pure water, for several weeks. The Throat.—In ulcerous or gangrenous forms use antiseptic sprays and gargles. MEASLES. (MORBILLi; RUBEOLA.) Contagion.—It is highly contagious, from the beginning of the catarrhal symptoms; the infective period lasts four weeks from the onset. Children at the breast usually MEASLES-MEDICINAL TREATMENT-REPERTORY 13 ______________POCKET-HOOIC OT MEDICAL PKACTICK escape. All others are very susceptible. Conveyance is usually direct. Incubation.—The period varies from seven to twenty- one days; average, twelve days. Stages.—Invasion; Eruption; Desquamation. Early Diagnosis.—Several days before the appearance of the eruption diagnosis can be made by Koplik's sign; On the buccal mucosa, especially opposite the back teeth, from six to twenty small, bluish-white, rounded, slightly elevated macules. They last six or seven days. Complications. — Purulent conjunctivitis; stomatitis; diphtheritic pharyngitis; membranous laryngitis; rheu- matism; endocarditis; cancrum oris; gastro-intestinal catarrh; ileo-colitis; broncho-pneumonia. Sequelae.—Purulent otitis; ophthalmia; enlarged lymph- nodes; phthisis pulmonalis. Prognosis.—Generally favorable. Unfavorable symp- toms:—Malignant character; diphtheritic pharyngitis; dysentery; broncho-pneumonia, usually indicated by per- sistent high temperature after disappearance of the erup- tion. Broncho-pneumonia most common cause of death. TREATMENT. Aconite.lx—For the early fever, with hot skin; injected eyes; photophobia; restlessness. In mild cases no other medicine is needed. Gelsemium.Tr—In the early stage; fever active; cory- za, with excoriating discharge; hoarseness; croupy cough; patient lethargic and drowsy. Pulsatilla.1*—In mild cases, when the catarrhal symp- toms are pronounced; fluent coryza and profuse lachry- mation; loose cough; entero-colitis. Euphrasia.Tr—Eyes and nose much affected; profuse lachrymation, the discharges hot and burning; profuse bland discharge from the nose (if it is acrid, Arsenicum). Dose of Euphrasia:—Forty drops of Tr. in y2 glass water; teaspoon every hour. Veratrum vir.Tr—The eruption delays, and convul- sions occur. Also in the febrile stage, congestion of the lungs. Dose:—One drop of Tr. every hour. Ipecac.3x—Vomiting when the eruption is delayed or suppressed. Epistaxis. Camphor.Tr—Fulminant variety; sudden collapse; the surface cold and livid; stiffness of the body; great pros- tration. Dose:—1 m., frequently repeated. Bryonia.1-8—The eruption delayed, or suddenly sup- pressed, with labored breathing, oppression of the chest, dry cough; stitching pains. Arsenicum.3x—In malignant cases, or those that be- come adynamic, with hot skin, pulse quick and small; great anxiety, restlessness, prostration. Tart. emet.2x—Retrocession of the eruption, with cyan- osis; sopor; rales in the lungs. Also, for a complicating broncho-pneumonia. Repertory.—Retrocession of Eruption:—Bryonia; Cam- phor; Ver at. vir. Eyes:—Euphrasia; Pulsatilla. Bron- cho-Pneumonia:—Tart.emet.; Phosphorus. Laryngitis:— 14. VARICELLA-CEREBRO-SPINAL FEVER POCKST-BOOK OF MEDICAL PRACTICE Kali bich.; Gelsem. Cerebral Congestion:—Belladonna; Cuorum acet. Low Fever:—Rhus tox.; Baptisia. Aden- itis:—Merc. iod. Pulmonary Congestion:—Verat. vir.; Bell- GENERAL MEASURES. Sick-Room.—Keep an equable temperature, 75° F. Good ventilation; the patient must be supplied with plenty of pure air. Isolate the patient. The Patient.—Keep the child in bed; avoid exposure and changes of temperature. For itching and burning of the skin, carbolized Vaseline. For high fever, cool sponging or cold pack. Eyes.—Protect from strong light by screens or shades. Use collyrium of Euphrasia Fl. Ext., oz. ss. to aqua oz. viij. Anointedgesof the lids with Vaseline. If the inflam- mation is intense, the eyes hot and burning, apply iced cloths. Retrocession of Eruption.—Put the patient into a hot mustard bath for ten minutes; take out and wrap in warm blankets. The Mouth.—Cleanse the mouth with swab or mouth- wash, using dilute Listerine. The Lungs*—The greatest danger is to the lungs. Ex- amine daily. During the disease, and in convalescence, protect from exposure to the infection of pneumonia and tuberculosis. ^ „^—— . RUBELLA. (ROTHELN; GERMAN MEASLES.) Diagnosis.—The eruption resembles measles, and some- times scarlatina. Swelling of the post-cervical glands is one of the most constant features. Treatment.—Little is required; Aconite or Belladonna may slightly modify. Isolation may be observed. VARICELLA. (CHICKEN-POX.) Diagnosis.—The vesicles are not apt to become pustules except in those of depraved constitution, from infection due to scratching. The eruption is never confluent. The back is the favorite seat. It appears on the hairy scalp, and often several are found on the mucous membrane of the mouth or pharynx. Treatment.—Rhus tox 3x; Mercurius3x; Tartar em.3x General.—Isolate. To allay itching, sponge with weak Carbolic-acid solution, or apply carbolized Vaseline. Bathe to keep the skin clean. Prevent scratching. CEREBROSPINAL FEVER. (EPIDEMIC CEKEBRO-SPINAL MENINGITIS.) Etiology.—It is due to infection by the diplococcus in- tracellularis (Weichselbaum). Varieties, —(a) Abortive; {b) Intermittent; [c) Fulminant. Symptoms.— Onset:—Sudden; chill; vomiting; excruci- ating pains in head, back, extremities; fever; delirium; stupor or coma. Nervous:—Opisthotonos; hyperesthesia; nystagmus; ptosis; strabismus; blindness. Fever:—It- regular; sometimes hyperpyrexia (106°-107°F.) Skin:— CEREBRO-SPINAL FEVER—DIAGNOSIS-TREATMENT 15 _______________POCKET-BOOK OF MEDICAL PRACTICE Petechial (sometimes purpuric) rash; herpes facialis. Kernig's Sign.—With the thigh at right-angles to the body (the patient either on his back, or sitting on the edge of the bed) the leg cannot be extended, owing to marked flexor contractures. This sign is diagnostic. Lumbar Puncture.—For purposes of diagnosis make microscopical and bacteriological examination of the spinal fluid. Method:—Sterilize the patient's back in the lumbar region, the hands of the operator, and the needle. Use an antitoxin needle 4 cm. long, 1 mm. in diameter. Use a longer needle in adults. Place the patient on his right side, with knees drawn up, the uppermost shoulder being depressed. The operator should press the thumb of his left hand between the spinous processes of the second and third lumbar verte- brae. Enter the point of the needle about 1 cm. to the right of the median line, level with the thumb nail. The direction of the needle must be slightly upward, and toward the median line. At a depth of 3 or 4 cm. (in adults 7 or 8 cm.) the needle enters the subarachnoid space; the spinal fluid begins to flow drop by drop. It should be caught in a sterile test tube. In order to ob- tain a larger quantity the syringe may be attached to the needle and the fluid aspirated. Precaution.—In inserting- the needle, if it meets with bony obstruc- tion, withdraw it somewhat, and thrust again, directing- the point toward the median ine. Never " work around " with the needle-point. Complications.—Bronchitis; pulmonary edema, or hy- postasis; atelectasis; broncho-pneumonia; parenchyma- tous degeneration of liver or kidneys; arthritis; inflam- mation of eyes or ears. Duration.—In abortive and fulminant, one to three days; others, two to three weeks. Convalescence.—Often interrupted and protracted. Prognosis.—Always guarded; often grave. Unfavor- able:—Violent onset; involvement of lungs; active cere- bral symptoms; coma; inactive pupils; purpura; con- stantly rapid pulse. The mortality rate is high. Sequelae.—Paralysis of various kinds; persistent ceph- alalgia; deafness from otitis media, or inflammation of the auditory nerve; defects of vision. Causes of Death.—Often occurs in coma; asphyxia; pul- monary edema; necremia. TREATMENT. Veratrum vir.Tr- — The attack comes on with violent vomiting; severe cephalalgia; pain in epigastrium; con- vulsions; head retracted; pupils dilated; pulse slow; heart's action irregular and labored. Violent onset, with vomiting and headache. Gelsemium.Tr—Onset with languor and drowsiness; fever; dimness of vision; eyes injected; vertigo; pulse soft and feeble; sighing respiration; general muscular weak- ness; dry skin. Dose:—Give freely until perspiration is induced; j drops Tr. every hour. Cicuta.Tr- — Nystagmus, with dilated pupils; convul- sions; twitching of the facial muscles; jerking of the hands and arms; hyperesthesia; deafness; face pale; 16 CEREBRO-SPINAL FEVER-WHOOPING-COUGH POCKKT-BOOK OF MEDICAL PRACTICE retraction of the head; dysphagia; coma. Convulsions and insensibility. Belladonna.Tr—Violent headache, especially at the base of the brain; head retracted; throbbing carotids; face congested; cutaneous hyperesthesia; sensitive to noise and light; grinding of the teeth; spasm of muscles; pupils dilated; vision lost; unconsciousness. Intense cerebral congestion, convulsions, delirium, stupor. Cuprum acet. 2x—Violent headache; vomiting; convul- sions; cold perspiration; unequal pupils; muscular rigid- ity; trismus. Cerebral symptoms prominent; collapse. Rhus tox.3x — Low, typhoid-like condition; mind dull and clouded; great prostration; dry, brown tongue; diar- rhea. After the first tveek. Arsenicum.3x—Purpura; diarrhea, with foul discharges; great prostration; irritable stomach; nervous restlessness. Hclleborns.Tr—Coma, from cerebral effusion. Camphor.Tr—Collapse at the onset. Opium.Tr—Deep coma; slow breathing; fixed eyes. Actea rac.1*—Late pains and spasms. GENERAL MEASURES. Preventive.—Wholesome food; pure air; good sanita- tion; proper hygiene. Sick-Room.—Keep it quiet, darkened, but well ventilated. Hot Bath.—At the onset, with high fever and hot, dry skin, with or without convulsions, it is important at once to induce free diaphoresis. Immerse the patient in a hot bath—105° F.—for about ten minutes; remove him to a bed and wrap in warm blankets, and give Gelsemium, until there is free perspiration. Then dry with soft towels. Repeat when the condition again demands it. In a number of cases I have had favorable results with this method. Ice-Bag.—When there is intense cerebral congestion and severe cephalalgia apply an ice-cap or cold water bag to the head and back of the neck. Always remove cold applications when temperature approaches normal. Leeches.—With intense cerebral congestion, apply two leeches back of each ear. I have several times seen great relief follow this measure. Diet.—Nourishing, regular diet is important; give broths and milk. Nutrient enemata if necessary. Nursing.—Guard against bed-sores; watch the bladder, and catheterize when necessary. The bowels should be regularly evacuated. Precautions.—Watch the lungs, the bladder, nervous symptoms, and the special senses. Electricity.—After the attack: Galvanism to the spine; Faradism to paralyzed muscles. Convalescence.—It demands critical attention. It is apt to be prolonged, it has many sequela?, and relapses are common. PERTUSSIS. (WHOOPING-COUGH.) Contagion.—Infective period may last three months. Stapes, — (a) Incubation (seven to fourteen days); {b) catarrhal; [c) paroxysmal; (d) decline. PERTUSSIS-TRE ATMENT-MUMPS-TREATMENT 11 _______POCKET-BOOK OF MEDICAL PRACTICE Complications.—Broncho-pneumonia; emphysema; col- lapse of lung; epistaxis, hemoptysis, and other hemor- rhages; convulsions. High temperature denotes broncho- pneumonia. Sequelae.—Bronchitis; pulmonary phthisis. Prognosis.—Unfavorable:—In infants; the cachectic. TREATMENT. Belladonna.13—Early stage; violent cough, without ex- pectoration; worse at night; sore throat; injected eyes; epistaxis; cerebral congestion. Ipecac.2x—Violent cough; the child stiffens; loses its breath; face pale or blue; followed by severe retching, or vomiting of mucus. Drosera.Tr—With the cough constriction of the chest; violent paroxysms of cough; worse at night; after the cough, vomiting. Naphthalin.13—Spasmodic stage; violent and frequent paroxysms. Carbolic acid.13—In the spasmodic stage; paroxysms of dry, hard, spasmodic cough. Cuprum acet.2*—The violent paroxysms of cough excite convulsions; face cyanotic; vomiting. Coccus cacti.3x—Secretion of thick mucus. CoralIium.3x—Short, quick, ringing cough. Hyoscyamus.Tr—Nightly paroxysms. GENERAL MEASURES. Inhalants.—The vapor of Vapo-cresolene; Terebene; creasote; carbolic acid (with caution). Bromine vapor. The Patient.—Observe quarantine. Protect the child from exposure; use warm flannel clothing; young infants must be held in the arms during paroxysms. Diet.—Nourishing food is important: milk, eggs, broths. Stimulants in depression. Enemata if necessary. Fresh Air.—Free ventilation, with open windows; out- door air when the weather permits. Convalescence.—Avoid exposure to the influences of pneumonia or tuberculosis. In tedious convalescence change of climate often has a magic effect. MUMPS. (EPIDEMIC PAROTITIS.) Period of Contagion.—From the earliest symptoms to at least ten days after subsidence of the swelling. Diagnosis.—In parotitis the swelling is in front of the ear; in enlarged lymph nodes the swelling is below the ear.' Complications:—In the male, orchitis; in females, congestion and swelling of the mammae, ovaries, or labia majora. Sequela:— Nephritis; nervous affections; deaf- ness; otitis media; suppuration of the parotid (due to accidental infection). All these are of rare occurrence. TREATMENT. Aconite.13—For the early fever, and later hyperpyrexia. Belladonna.15—Delirium; cerebral congestion. Merc. iod.3x—Gland much swollen, red and painful. Rhus tox.3x—Dark red swelling; much accompanying edema of the tissues. 18 MUMPS-SPASMODIC CROUP-TREATMENT '__________POCKET-BOOK OF MEDICAL PRACTICE.__________ Pulsatilla.33—Orchitis; mastitis. Hepar sulph.3x— Threatened suppuration. Snphur.6x—Slow resolution. Baryta carb.3x—Induration. GENERAL MEASURES. Patient.—Confine the patient to the house, and, if much affected, to bed. Local.—To the swollen gland, a light protective com- press; if it is painful, a hot compress moistened with a lotion of dilute Veratrum viride. Testicles.—Apply a suspensory bandage, and, if or- chitis appears, keep the patient at absolute rest. Mammae.—If signs of inflammation appear, apply sup- porting bandages. Diet.—Liquid food; swallowing is painful. CATARRHAL LARYNGITIS. (SPASMODIC croup; false CROUP.) Diagnosis.—Usually of sudden onset, often waking the child from sleep; short, barking cough, with stridulous, crowing inspirations ; intense dyspnea; clutching at the throat; face congested; moist skin; rapid pulse; the dyspnea lasts for a minute or more, then gradually sub- sides. Such paroxysms are repeated several times in the night. During the day absence of paroxysms and marked remission of all symptoms. This history re- peated for several successive nights. Prognosis.—Almost always favorable; very rarely, severe and fatal. The chief clinical difference between this disease and true croup, is that in the latter the on- set is more insidious, the development of symptoms more gradual and continues both day and night. In false croup, as a rule, the symptoms subside to a great extent through the day. In true croup a "croupy " cough sets in early, and is soon followed by aphonia. TREATMENT. Iodide-of-Lime.— If given early, this will cut short the attack in almost all cases. Dose:—Give the crude Iodide-of-Lime (not Calc. iod.); X to >£ grain, repeated every 15 to 30 minutes. When the dry cough becomes moist, then use other indicated medicines. Aconite.^—Active fever; dry, metallic cough; dry, hot skin; thirst and restlessness. Belladonna.13—Cerebral congestion; the skin red-, hot and moist; the child drowsy. Iodine.lx—Violent spasmodic cough, with seemingly threatened suffocation, the patient becoming blue in the face; dryness of the larynx. Hepar sulph.2x—Hoarseness after the attack; secre- tion of mucus; child weak, with moist skin; with the cough, rattling of mucus in the larynx. Kali bich.3x—Stage of resolution; accumulation of tough, stringy mucus. Benzoin.13—Hoarseness, with raw feeling in the fauces and larynx. GENERAL MEASURES. Compress.—Put a cold compress to the child's throat. Take a small, soft towel, or a napkin; wring it out of PSEUDO-MEMBRANOUS CROUP-INTUBATION 19 POCKET-BOOK OF MEDICAL PRACTICE cold water; fold it, and cover the child's throat with it, all except the back of the neck; cover all with a dry cloth, and pin in place. When this becomes hot, remove, and apply another cold compress. A full, hot bath is often helpful. Sick-room.—Keep the atmosphere constantly saturated with moisture by the use of a steam atomizer, or other apparatus. Dry air irritates the larynx. PSEUDO-MEMBRANOUS LARYNGITIS (TRUE CROUP.) Etiology.—The majority of cases are diphtheritic, and due to Klebs-Loeffler bacillus infection; in others, the in- fecting agent is usually the streptococcus. Diagnosis.—At the onset the symptoms are mild, with gradual increase in severity, both night and day; fever is generally moderate; voice hoarse; later, aphonia; harsh, smothered cough; stridulous, sawing breathing, with in- creasing dyspnea, and finally laryngeal stenosis; in 50 per cent of cases, false membrane appears on the fauces or pharynx. Finally, if not earlier relieved, cyanosis, cold, clammy perspiration; clouding of the mind, and death. Duration:—From two to seven days, or more. Prognosis.—Always grave; but proper treatment will save many lives that would otherwise be lost. TREATMENT. Antitoxin.—This is by far the most important remedy; should be given early in all cases. Dose:—800 to 1,000 U. Iodide-of-Lime.—In some cases this will cure if given at the beginning of the attack. Dose:—One-half grain every 15 or 30 minutes. Kali bi.3x—Gradual onset; hoarse, dry, barking cough; tonsils red and swollen; wrheezing breathing; thick and tenacious secretions; tongue with thick, yellowish coating; irritable stomach. Dose:—3x or 6x dilution. Iodine.—Dry, short, wheezing cough; in scrofulous sub- jects. Dose:—2x; 3 drops of a fresh solution, every 30 minutes. Bromine.—Rattling of secretions with the cough; great prostration early. Dose:—2x dilution, freshly prepared. GENERAL MEASURES. Quarantine.—Since it is difficult to determine early in the disease which cases are diphtheritic and which non- diphtheritic, all cases should be isolated. Diet.—Feed withcare, to maintain the patient's strength. If there is much prostration, use alcoholic stimulants. Intubation.—Called for in almost all cases. INTUBATION. Importance.—Above all other diseases pseudo-mem- branous croup is the one in which many lives are saved by intubation. Indications.—Do not wait too long. Do not wait until cyanosis appears. If dyspnea steadily increases and the temperature continues to rise, operate without delay. Instruments.—(a) Tubes, gold-plated or hard rubber; 20 INTUBATION-METHOD-ACCIDENTS POCKET-BOOK OF MEDICAL PRACTICE____________ [b) gauge; (c) introductor; (d) mouth-gag; (e) extractor. (Keep all instruments in an aseptic condition.) The Patient.—Wrap the child in a blanket, with its arms to its sides and its legs well confined, to prevent struggling. Assistants.—The child is placed in the lap of one as- sistant, with its head against the assistant's left shoul- der. The second assistant, standing behind, holds the child's head firmly. The Tube.—Select a tube corresponding to the child's age, as indicated by the gauge. If it is a very large child, use a tube belonging to a child one year older. Thread the tube with a loop of silk about a foot long. The Gag.—Place the gag at the left angle of the child's mouth, and open it as widely as possible. Let it be held in position by the second assistant. Tho Operator, seated on the edge of a chair, takes a position directly facing the child. Hold the introductor, with tube attached, in the right hand. Introduction of the Tube.—Work all the time in the middle line of the patient's body, and work quickly. Use the index finger of the left hand as a guide. Pass the finger well back into the pharynx, then bring it for- ward until the upper part of the cricoid cartilage is felt as a hard nodule. In front the epiglottis and opening of the larynx will be felt. Pass the tube along the palmar surface of the left index finger, and guide it into the larynx, with an upward sweep of the handle of the intro- ductor. Disengage the tube. Remove the gag. Success will be indicated by sudden relief of the dyspnea, and a paroxysm of cough. Removal of Thread.—When the tube is known to be in proper position, remove the thread. First, see that there is no twist in it. With scissors cut the lower strand well into the mouth. Place the index finger on the head of the tube for an instant as the thread is with- drawn. POSSIBLE ACCIDENTS. Tube in the Esophatrus.—The tube may be inserted in the esophagus instead of in the larynx. This is due to the child's head being held too far forward or too far back. It is indicated by absence of relief of dyspnea. When it occurs, withdraw the tube by means of the thread, wait several minutes for the child to rest, then make proper insertion. False Passage in Larynx.—The tube may be pushed into one of the ventricles of the larynx. This is due to failure to keep in the median line, and to too much force being used in the introduction of the tube. Only gentle effort should ever be made. The accident is recognized by the fact that the head of the tube projects above the epiglottis. Membrane below the Tube. — Loosened flakes of mem- brane may be crowded down ahead of the tube. This unfortunate accident is announced by sudden and alarm- ing dyspnea, with stoppage of breath and cyanosis. The tube must be quickly withdrawn, by means of the INTUBATION-AFTER-TREATMENT-BRONCHITIS 21 POCKET-BOOK OF MEDICAL PRACTICE______________ thread, and the mouth-gag removed. The child must be inverted, and every effort made to excite cough. Artifi- cial respiration, followed by tracheotomy, must be re- sorted to if the child does not at once revive. Dislodgment of the Tube.—The tube may be coughed up and expelled, or swallowed. Neither accident is very serious. A tube in size next larger should be introduced. A swallowed tube will pass through the intestines with- out harm. When the tube is coughed up wait for a return of dyspnea before re-introducing. Apnea. —Prolonged attempts to insert the tube may cause apnea. It should not take more than five seconds to complete the operation. AFTER-TREATMENT. Feeding the Patient.—This requires care. A nursing infant can usually continue at the breast. Older chil- dren should lie supine, on the edge of a couch, or on the nurse's lap, with the head and shoulders suspended to- ward the floor. In this position feed with a spoon. Give soft, semi-solid food —bread moistened in milk; junket; corn-starch; wine jelly; soft poached egg. Time of Wearing the Tube.—In pseudo-membranous laryngitis, leave in from four to seven days. In very young children, longer. Removal of the Tube.—For two hours prior to time of removal let no food be taken by the patient. Prepare the child as for its introduction. With the left index finger feel the head of the tube, steadying it with the thumb of the left hand over the larynx outside the neck. Introduce the extractor, and withdraw quickly but gently. ------- CAPILLARY BRONCHITIS.* (BRONCHIOLITIS.) Diagnosis. —The significant symptoms are -.—Widely dis- tributed sub-crepitant rftles; feeble respiratory murmur; moderate fever; rapid respiration; drowsiness; cyanosis; feeble, rapid pulse; cool, clammy sweat. As broncho- pneumonia supervenes, all these symptoms become inten- sified, with rise of temperature. TREATMENT. Belladonua.23—Early in the attack. Intense conges- tion of the lungs; convulsions; skin red and hot, though moist; alternating stupor and delirium; eyes red and injected; throbbing carotids. The use of Belladonna must be limited to the congestive stage. Tartar emet.23—This is the most important remedy. Loud rales; intense dyspnea; threatened suffocation; wheezing, and rattling of mucus; cyanosis; skin livid, with cool perspiration; drowsiness; threatened paralysis of the lungs. Ipecac.33—Mucous rales; spasmodic cough; in violent paroxysms, with retching and vomiting. The child be- comes blue in the face in the paroxysms of suffocative ♦Although, clinically, it is difficult to distinguish this affection from broncho-pneumonia, yet since it is for the most part a disease of infancy, and as such is much more grave than when it occurs in the adult, its separate consideration in this connection is of practical advantage. 22 CAPILLARY BRONCHITIS-TREATMENT POCKET-BOOK OF MEDICAL PRACTICE__________ cough. Special indications:—The retching and vomiting determine the choice of Ipecac. The cold surface, cyano- sis and prostration are not as marked as in Tart. emet. Veratrum album. Tr—Rattling of mucus in the lungs; cold sweat; bluesurface; great prostration; weak heart's action; involuntary micturition with the cough; attacks sometimes accompanied by vomiting and diarrhea. Special indications:—The great prostration, cold, blue surface, weak heart and threatened collapse. Arsenicum.^3—Excessive anxiety; face gray, pinched, or edematous; constant restlessness, the child changing from bed to lap, and back again; burning heat; great thirst. Ammonium carb.—In a late stage of the disease. Great accumulation of mucus in the lungs; continual cough, but nothing is raised; rattling of large bubbles of mucus; great prostration, with cold and blue surface, and feeble pulse. This belongs to the treatment of a more extreme condition than the one calling for Tart. emet. Its ad- ministration will sometimes bring about a favorable re- action. Dose:—One grain, in solution, well diluted. Cuprum ars.^3—For accompanying vomiting, pain and diarrhea. Senega.?3—Cough almost incessant, with viscid mucus secretion, and pains all over the chest. Ferrum phos.23—With the onset of the disease, in ca- chectic subjects. Strychnin.—Threatened heart-failure in extreme con- ditions. Dose: — ^0 to ^ grain; repeat in 4 hours. In children use strychnin with caution. GENERAL MEASURES. The general management of a case of this disease is of the utmost importance. Sick-Room.—Temperature about 72°. The air should be kept moist by steam atomizer or a vaporizer. Ven- tilate thoroughly. The Patient.—Change the position of the child fre- quently, from side to side in the crib, or take it up occa- sionally. If there is free secretion, at times hold it in a position with the head lower than the chest, to favor gravitation of matter towards the larynx. When respira- tion is embarrassed, work and knead the muscles of the chest; if the condition is critical, do so with vigor enough to make the child cry. Diet.—Keep up nutrition by careful feeding. Give plenty of water. Do not let the stomach become distended with gas. C uard against constipation; a glycerin enema if there is accumulation in the lower bowel. Applications.—Avoid the use of poultices, and imper- vious applications covered with oil-silk. A soft flannel shirt, tied with tapes in front, is sufficient. If there is acute pleuritic pain, apply a hot compress over the part affected. Bath.—As soon as there are slight signs of respiratory failure, cyanosis, livid skin or drowsiness, give a hot bath. Put the child for a few. moments into water of ACUTE MILK-INFECTION-TREATMENT 23 ______________POCKET-BOOK OF MEDICAL PRACTICE 100° to 110°. Take it out and wrap it in a warm blanket. Repeat as indicated. Stimulation.—For weak heart, with small, flickering pulse, give alcoholic stimulant; J£ oz. of brandy to 3 oz. water: 2 teaspoonfuls every half-hour. Oxygen.—For suffocation and respiratory failure, in- halation of oxygen. Give freely and frequently. ACUTE MILK-INFECTION. (cholera infantum; choleriform diarrhea.) Etiology.—It is a toxemia due to the effects of a poison generated by the action of bacteria in milk, occurring in hot weather. Symptoms.—Sudden onset, with severe vomiting and purging ; vomit, first contents of stomach, then mucus and bile; stools, first contents of bowels, then serum ; rapid emaciation; intense thirst; restlessness ; weak, rapid pulse; cool surface; high rectal temperature; depressed fontanelles ; stupor. Characterized by sudden onset and rapid development of all the symptoms. TREATMENT. Veratrum alb.Tr—Vomiting and/ purging, the latter predominating ; great exhaustion, or even a state of col- lapse ; cold sweat on the forehead ; colic, and cramps in the legs; stools profuse and watery. Camphor.Tr-—Early and sudden collapse, with cold, blue surface; the child almost unconscious; voice weak and hoarse ; stools painless; cold sweat on the face. Arsenicum. 3x—Great prostration; extreme restlessness; unquenchable thirst; cool skin; face pale and cadaveric; vomiting and purging; frequent watery, offensive stools. Zincum met. 6x—Late in the attack, a state of collapse ; sunken features; open eyes; sunken fontanelles; defi- cient nerve power; absence of reaction ; subnormal temper- ature. Differentiation.—Camphor is for collapse occurring early, with a sudden and violent onset of the disease ; Veratrum alb., an attack accompanied by pain—colic and cramps; Zincum, profound collapse, with a condition of hydro- cephaloid and an absence of reaction; Arsenicum, rest- lessness and intense thirst. Note.—Medicines will act more promptly if given inhot water, instead of cold. Repeat frequently. Hydrocyanic acid.—Paresis of the intestines; fluids roll audibly ; respirations at long intervals, slow, deep, gasp- ing. Dose:—The dilute C. P. acid, drop doses. Secale. lx— Profuse, watery stools after the violence of the attack has passed; great prostration; cold surface; aversion to being covered. ('antharis. 3x—Continued suppression of urine after the attack. GENERAL MEASURES. Diet.—Stop the milk. Give no milk whatever, of any kind, to a patient with cholera infantum. During the attack give no food. The stomach cannot care for it. The child can well go 24 hours without it. When feed- ing is resumed the best article is a mixture of barley- water and cream. 24 MILK-INFECTION -DIARRHEAS ______________POCKET-HOOK OF MEDICAL PRACTICE______________ Sick-Room.—This is a hot-weather disease. Do not keep the child in the close atmosphere of a hot room. Seek the airiest and coolest upper room in the house. Warmth.—Apply warmth to the surf ace. Surround the patient with hot-water bags or hot bottles. Put a hot dry flannel compress along each side of the chest, extend- ing into the axilla, changing frequently. Put a hot- water bag between the thighs. Give hot-water rectal in- jections. Thirst.—If drinking cold water excites vomiting, try hot water. Bits of ice are allowable. Loss of Fluids.—To. supply loss of fluids due to serous discharges, give subcutaneous injections of normal saline solution. In one pint of sterilized water dissolve 45 grains of sodium chloride. Inject warm into the cellular tissue of the abdominal wall, the buttocks, thighs or back. At least half a pint should be given, in divided portions, in the course of every 12 hours. Method:—Attach the needle of a hypodermic syringe to a few inches of rubber tubing, and this to the nozzle of a bulb syringe. Sterilize the syringe. Make the injection slowly. Inject no air. Each time measure the quantity injected. Indications:— Use this method always in collapse, in shrinking of the body, and in weak heart's action from loss of fluids. Stimulation.—Give stimulants freely in states of ex- haustion and collapse, with weak, soft, compressible pulse. Iced champagne; brandy or whisky in hot water; wine-whey. For infants under one year, brandy must be diluted with eight parts water; four years old, twice that strength. Convalescence.—Return to the usual diet with care. Daily inunctions of olive oil to the wasted body. Plenty of fresh air and sunlight. Removal to lake, seashore or mountain will promote rapid recovery. THE DIARRHEAS OF CHILDREN. (GASTRO-ENTERIC INFECTION; ENTEKO-COLITIS ; "SUMMERDIARRHEA." This includes several distinct conditions, pathologic- ally, yet the treatment is essentially the same in all. TREATMENT. Aconite.13—Early in the attack; after exposure to cold; or getting wet; tenesmus ; restlessness; thirst; fever; full, hard, quick pulse. Ipecac.^3—Only in recent cases, before there is loss of flesh and exhaustion; continuous nausea is most char- acteristic ; stools—green, and as if fermented ; vomiting; there may be violent colic. Podophyllin.33—The attack is painless; stools—profuse and gushing; prolapse of the anus with the stool; empty retching. Croton tig.33—Yellow, watery stool; expelled suddenly and with great force; aggravated by food and drink. Camphor.Tr—The attack comes on suddenly; rapid sinking; stupor; prostration; face pale, livid; skin cold; vomiting. Cuprum ars.3*—Great frequency of the stools ; cramps of the muscles of the legs ; violent colic. DIARRHEAS OF CHILDREN-STOMATITIS 25 _______________POCKET-BOOK OF MEDICAL PRACTICE Chamomilla.33—Only in recent cases; the child is fretful, peevish and cross ; only quieted by being carried; flatulent colic, with eructations ; stools, small, frequent, offensive. Belladonna.13—Recent cases, with fever; dry heat of the skin; drowsiness; sudden starting in sleep ; frequent thirst; head hot; stools, green mucus, or bloody mucus. Apis mel.3x—Absence of thirst; abdomen sensitive to pressure; tongue dry; skin hot; stupor, with shrill cries; involuntary stools; hydrocephaloid. Calcarea carb.63—Open fontanelles ; face wrinkled and old-looking; profuse sweat on the head during sleep; cold extremities; emaciation; bloated abdomen; strong- smelling urine ; stool large, watery, yellow; in "scrof- ulous " subjects; during dentition. Veratrum alb.13—Vomiting and purging ; severe colic; profuse, watery stools ; great exhaustion; cold sweat. Arsenicum.63—Great prostration; extreme restlessness and unquenchable thirst; cold extremities; face pale and cadaveric; skin dry and shriveled; stools thick, dark- green, or dark, watery, offensive. Rheum.3x—Mucous stools; sour; fetid ; yellow ; colic ; sour smell of the whole body. Mercurius.33—Stools green, slimy, bloody; cutting colic; swollen gums; tongue coated, white or yellow; thirst; sweat. GENERAL MEASURES. Diet.—In acute diarrhea, if the child is not already feeble or exhausted, for twenty-four hours give no food whatever. When feeding is resumed begin with barley- water, or barley-water and cream. Other articles of diet may be:—meat-juice; toast-water; albumen-water; wine-whey; koumiss. Return to a milk diet with caution. Lavage.—At the beginning of treatment, wash out the stomach. Give a free enema, hot water with boracic acid; repeat once or twice a day. Clothing.—In hot weather dress the child in a single cotton garment, with suitable additions at night, or when out-doors. Napkins.—Remove as soon as soiled, and place in a dis- infectant solution: Zinc-chloride, lib.; water, 2 gallons. The Skin.—For excoriations of the folds of the skin, dust with:—Boric acid, 1 part; powdered starch, 9 parts. Baths.—When the child is hot and restless, give a sponge-bath of tepid water with one-quarter part alcohol. Fresh Air.—Keep the child in a.cool, shaded place, with an abundance of fresh air. If in the hot city, take the patient to the country, to the seashore, lakes or mountains. Keep it in the open-air most of the day. STOMATITIS. CATARRHAL STOMATITIS. TREATMENT. Aconite.13—When fever accompanies. Belladonua.23—Bright redness, with dryness of the mucous membrane. 26 STOMATITIS -APHTHOUS-ULCERATIVE-NOMA POCKET-BOOK OF MEDICAL PRACTICE___________^^ Arum tri.3x—The mucous membrane red and hot, with much pain and sensitiveness. Mercurius Sol.3x—Mucous membrane and gums much swollen; profuse salivation; swollen glands. Sulphur.33—Gastro-intestinal disturbance, with diar- rhea. Local.—Absolute cleanliness of the mouth; in cleansing avoid friction that will injure the membrane. Gently wash the mouth with:—R. Boric acid, grs. 10, to water, oz. j. Generally cold food is least painful; in some in- stances this does not hold true. APHTHOUS STOMATITIS. TREATMENT. Borax.33—An important remedy in this form. Mouth hot and sensitive, with easily-bleeding ulcers. Thirst, and vomiting. Kali chlor.13—Obstinate follicular stomatitis, with ex- treme fetor; tough, stringy saliva; mucous membrane red and swollen; grayish ulcers. Hydrastin.2x—Vesicles,or aphthous ulcers; tongue swol- len, with yellow coating; viscid secretions. Local.—Maintain absolute cleanliness. As cleansing washes use:—Borax, 10 grs. to the oz. of water; Kali chlor., 5 grs. to the oz. ULCERATIVE STOMATITIS. TREATMENT. Mercurius sol.3x—The most important remedy for this form. Great fetor; tongue swollen and indented; profuse salivation; offensive breath; teeth loose. Argentum nit.23—Accompanied by gastric symptoms; eructations of gas from the stomach. Dose:—2x dilution, freshly prepared. Baptisia.Tr—Intolerable fetor of the breath; mucous membrane dark purple; gums loose, flabby; watery, foul stools; feeble state and great prostration. Hepar sulph.23—Mercurial stomatitis. General Measures.—Careful constitutional treatment; give an anti-scorbutic diet. In obstinate cases, look for disease of the teeth or the alveolar processes. Local.—Cleanse the mouth carefully and thoroughly. Use hydrogen peroxide, 1 part, to water, 10 parts. Fol- low with pure water; repeat several times daily. Mouth-Washes.—Potassium chlorate, 3 grs. to the oz. Baptisia, tincture, % to water %. GANGRENOUS STOMATITIS. (noma; canckum oris.) TREATMENT. Arsenicum.33—For the general condition only. The local condition must have local treatment. General.—Isolate the patient so that other children may not become affected. Give a supporting diet, and use stimulants in depression. Local.—No time must be lost in experimental treatment. Begin at once to destroy the gangrenous area. Rule:— Destroy not only the affected tissue, but also adjacent healthy tissue. Methods:—Excise or curette thoroughly, RETROPHARYNGEAL ABSCESS-TREATMENT 27 POCKET-BOOK OF MEDICAL PRACTICE then cauterize with Nitric acid fortior. Or, use the Paguelin cautery. After operation, dress the wound with Iodoform, Ichthyol or Aristol. Cleanse the mouth with Hydrogen peroxide, or Kali permanganatum. THRUSH. (STOMATITIS MYCOSA.) Etiology.—Due to a fungus, the saccharomyces albi- cans; conveyed to the child's mouth by the nipple or the nursing-bottle. Diagnosis.—On the mucous membrane of the mouth a spot of grayish-white, or creamy color appears, elevated above the general surface; removal requires some vio- lence, leaving a spot denuded of epithelium. The fungus spreads rapidly, and may assume the appearance of a layer of curdled milk. It generally appears in cachectic or debilitated subjects. TREATMENT. Local.—Cleanse the mouth, immediately after nursing or feeding, and at frequent intervals between, with an alkaline solution, applied by means of a soft cloth, using the finger or a swab. Solutions.—Sodium sulphite, 1 dram; water, oz. iv. Sodium bicarbonate, a dram to the ounce. RETROPHARYNGEAL ADENITIS. (RETROPHARYNGEAL ABSCESS.) Etiology.—It occurs in children of tuberculous diathe- sis, in the syphilitic, and after scarlatina, measles, etc. It has followed middle-ear suppuration (pus breaking through the anterior wall of the tympanic cavity, or through the semi-circular canal); also, scalding liquids; caustics; traumatism (fish-bone). Diagnosis.—General:—Loss of appetite; restlessness ; painful deglutition; dyspnea, gradually increasing; fever (more especially in adults); position of the head suggests torticollis. Local:—Congestion of the soft palate and tonsils, with tumefaction. When the tumor is high:— Nasal respiration obstructed; palpation detects a soft mass, feeling like adenoids; the rhinoscopicmirror reveals the tumefaction. When posterior to the base of the tongue, the tongue-depressor brings it into view. When it is behind the glottis it causes dysphagia, and press- ure on the epiglottis may cause dangerous dyspnea. In all three locations it is usually to one side of the median ^"e- TREATMENT. Medicinal.—Belladonna.^—Swelling sudden and rapid; throbbing pains. Hepar sulphM—To hasten suppura- tion; Hepar sulph.30*—To abort the process when seen early; chills and sharp sore pains. MercuriusM—When pus has formed, to hasten suppuration; swelling of sur- rounding glands. For the Pre-disposition:—Calc. carb. *3 Ferrum phos.33 Silicea.63 Kali hyd.13 Calc. iod.33 General.—Build up the general health by baths, diet, exercise. Local.—When seen early, ice-bags to the neck. When fluctuation appears:—Open without delay with a guarded 28 CONVULSIONS-CAUSES-DIAGNOSIS -TREATMENT POCKET-BOOK OF MEUICAL PRACTICE______________ bistoury. Paint the part with 4% Cocain. At the lowest point, make a small incision first, so that the pus will escape gradually. Immediately on withdrawing the knife invert the child, to prevent pus finding its way into the larynx (fatal strangulation has occurred from spon- taneous rupture, especially during sleep.) The opening can be enlarged with forceps-blades after the first free flow of pus, still keeping the child's head dependent. After-Treatment.—Provide for drainage by keeping the incision patent until suppuration has ceased. Injections are usually unnecessary._______ .CONVULSIONS. Predisposing Causes.—(1) Disturbances of Nutrition: — Rickets; anemia; malnutrition; syphilis; debility (from exhausting diseases). (2) Heredity:—"Nervous" temperament. Exciting Causes.—Direct Irritation:—Cerebral men- ingitis, hemorrhage, tumor, abscess, embolism, or thrombosis. Reflex Irritation: — Stomach or intestines (undi- gested food; worms); retention of urine; phimosis; burns; enlarged thymus; dentition. Toxemia:—Uremia; the poisons of—scarlatina; pneu- monia; malaria; gastro-enteritis; measles; typhoid; diphtheria; pertussis. Diagnostic Hints: Constitution.—If the child is weakly, wasted and ca- chectic, the irritation causing the convulsions is prob- ably in the brain; if it is robust and apparently healthy, the conditions are probably reflex. Urine.—Examine the urine in every case of doubtful origin, whether or not dropsy is present. Dentition.—"Teething" is a rare cause of convulsions, except in children markedly rachitic. Onset of Acute Diseases.—Convulsions in a child pre- viously well, with no premonition, coming on suddenly, accompanied by fever, almost alwa3rs indicates the onset of some acute disease—pneumonia, scarlatina, etc. Brain Disease. — Convulsions occurring in brain dis- ease are marked by focal symptoms—localized paralysis or rigidity; changes in the pupils; strabismus. Except- ing in acute meningitis, it is not often marked by rise of temperature. Stomach and Intestines.— Irritation of the alimentary tract is a frequent cause. Examine for constipation, improper feeding; worms; fits of passion. Epilepsy. — Rare in young children. Indicated by- History of previous attacks; aura; sudden onset, with cry or a fall; biting the tongue; tonic spasm, then clonic. Convulsions with fever are rarely epileptic. Entozoa.—The tape-worm and round worm sometimes act as the irritant. Their demonstrated presence is the only absolutely diagnostic sign. Asphyxia.—This may be the exciting cause in:—New- born; pertussis; laryngitis; laryngismus stridulus; late in pneumonia. CONVULSIONS -TREATMENT-SPASM OF GLOTTIS 29 ______________POCKET-BOOK OF MEDICAL PRACTICE____________ Prognosis.—The convulsions of childhood are seldom fatal. Unfavorable features are:—Convulsions prolonged, or frequently recurring; great prostration; feeble pulse; cyanosis; stupor. TREATMENT. Belladonna.l3—Cerebral congestion; face hot and fl u shed; violent throbbing of the carotids; starting and jerking in sleep. Ignotia.23—Tonjc spasms, in those of highly nervous temperament; from fright or grief; dentition. Chamomilla.63—Great irritability and "nervousness"; bowels bloated; restlessness, with moaning and groaning; one cheek red and hot; convulsions after a fit of anger. Opium.33—From fright. Cicuta.33—From injury. San- tonin. I3—From worms. Nux vom.23—From indigestion. Verat. vir.Tr—Onset of pneumonia. Cuprum.33—Reper- cussion of eruptions. Phosphorus.33—For the rachitic. GENERAL MEASURES. Room.—Keep the child quiet; darkened room. Bath.—Strip the child and put it in a warm bath (90° F.), with a cold sponge to the head (if the head is hot); let it remain in the water about 10 minutes. Mustard may be added to the bath. Head.—Never make cold applications to the head if the face is pale and the head cool. Mustard Pack.—To one quart of warm water add one tablespoonful of ground mustard, mixing thoroughly; dip into this a small folded sheet or large towel; take out, and while the towel is still dripping wrap the naked child in it; thus wrapped, lay the child on a blanket, and wrap the blanket about it, snugly. Let it remain until the skin is reddened—10 or IS minutes. Repeat if the convulsions recur. The mustard pack is often preferable to the bath. Digestive Disorders.—If there is undigested food in stomach and intestines, create vomiting by irritating the fauces with the finger, or by an emetic. Unload the lower bowel by a free enema. Chloroform.—Chloroform, judiciously administered, may be used to stop the spasms if they are persistent in spite of other efforts. Chloral hydrate.—If the convulsions are long continued, or of frequent recurrence, give chloral hydrate. Dose:— 6 months, 4 grs.; 1 year, 6 grs.; 2 years, 8 grs. Dissolve in 1 oz. warm milk, inject high through a catheter, and re- tain by compression on the buttocks. It may be re- peated, if necessary, in one hour. Amyl nitrite.—By inhalation in the epileptic. Glonoin.—When there is violent congestion of the head. After-Treatment.—Regulate the diet; prevent over-feed- ing-; correct constipation; in the rachitic, proper diet, plenty of fresh air and sunshine. LARYNGYSMUS STRIDULUS. (SPASM OF THE GLOTTIS.) Etiology.—It generally occurs in rickety subjects. Diagnosis.—The "crowing" inspiration, with absence 30 POLIOMYELITIS ANTERIOR ACUTA-TREATMENT POCKET-BOOK OF MEDICAL PRACTICE____________ of hoarseness, cough and fever will distinguish it from croup. Prognosis.—Generally favorable. Unfavorable:—In the very young; general convulsions; increasing frequency of the paroxysms; broncho-pneumonia. TREATMENT. Chlorine.—This is the most efficient agent. Dose:— Make a weak solution in water so that the odor is just detected; give teaspoon doses, p. r. n. Inhalation of Chlo- rine gas is also useful. Iodine.Tr—In markedly rachitic subjects ; or when there is enlargement of the thymus. Sambucus.Tr—The face red and hot; hands and feet cold. Cuprum.—Tetanic spasms; cyanosis. GENERAL MEASURES. Hydrotherapy.—Dash cold water into the face, or upon the chest. Apply a hot compress to the throat. Immerse the child for a few minutes in a warm bath (96° F.). Ice to the epigastrium, for a moment, during the spasm. The Patient.—Keep the child semi-recumbent; make traction on the tongue; artificial respiration if breathing is suspended; plenty of fresh air at all times. Intervals.—Treat for rachitis:—An open-air life, with abundance of pure, nourishing food. Treat sources of local irritation:—Enlarged lymph-nodes: adenoids; ton- sils; thymus; uvula. INFANTILE SPINAL PARALYSIS. (POLIOMYELITIS ANTERIOR ACUTA.) Diagnosis.—Three modes of onset: (1.) No premonitory symptoms ; the child goes to bed apparently well; slightly restless in the night; the next morning the characteristic paralysis is discovered. (2.) Sudden vomiting; pains in the legs; hyperesthesia; fever 101° to 103°; in from 1 to 4 days paralysis is complete. (3.) In a small number of cases, convulsions; delirium; fever 103°, 104°; prostra- tion ; constipation; severe pains in the back and legs; in several da3rs paralysis appears. Age.—Under 5 years; most cases, in the second year. Paralysis.—Most cases, one leg; next, both legs. The arms may be involved. Symptoms.—Motor paralysis; loss of reflexes; atrophy of the involved muscles; relaxation of ligaments, and sub- laxation of the joint. Prognosis.—Little danger to life ; complete recovery of the paralyzed muscles is rare ; as a rule the chances are to be judged according to the degree of faradic contract- ility. TREATMENT. Aconite.l3—Early ; fever ; restlessness; thirst; dry, hot skin ; pains in the back and limbs; child screams when touched. Generally the period when this remedy is indi- cated has passed when the physician sees the case. Belladonna. I3—Cerebral congestion ; face flushed ; pu- pils dilated; sudden onset and high degree of inflam- mation. POLIOMYELITIS-TUBERCULOUS MENINGITIS 31 __________POCKET-BOOK OF M EPICAL PRACTICE Gelsemium.Tr—This is the most important remedy early in the disease. Pain in the back of the head and spine; disturbances of vision; loss or voluntary motion. Causticum. 33—Bruised pain when touched; numbness of lower extremities; slow pulse. This remedy has been often found useful. Plumbum. 3x—In chronic cases ; paralysis ; atrophy of the muscles. This is the chief remedy after the acute stage has passed. Electricity.—Electrical treatment should be used per- sistently, so long as there are the slightest signs of im- provement. Never use this agent in the acute stage; only after inflammation has completely subsided. Galvanism.—Strength of current:—Just enough to excite contractions,, and no more. Poles:—The anode, with a large flat electrode, over the spine; the cathode to the motor points of the affected muscles. Use an interrupt- ing handle on the cathode, and make interruptions twice a second, about twenty-five times. Exercise each muscle in this way. Do not over-stimulate the muscles by too strong a current or too long an application. Give treat- ments, daily, or every other day. Massage.—Friction, kneading and passive exercise of the muscles is of benefit in promoting nutrition; give daily treatments. Baths.—Bathe in hot water twice a day to stimulate the circulation. Orthopedics.—Myotomy and tenotomy, and braces and other apparatus, for deformed limbs. TUBERCULOUS~MENINGITIS. (ACUTE HYDROCEPHALUS.) Diagnosis.—Usually, pre-existing tuberculosis of some other part of the body. Early symptoms :— Fretfulness; irritability; drowsiness; loss of appetite; constipation; headache; grinding of the teeth; vomiting; sharp cry in sleep. Attack:—Convulsions; stupor; cutaneous hy- peresthesia; exaggerated reflexes; muscles of extremities, and of neck, rigid, with the head drawn back; pupils contracted; nystagmus; pulse slow, irregular; slight irregularity of respiration; temperature, 99° to 101° F. Later:—Coma; irregular pupils; strabismus; muscular twitchings; opisthotonos; retracted abdomen; tache cere'- brale; pulse slow; Cheyne-Stokes respiration ; toward the end, high temperature, 104°, 106°, or even higher. Death usually occurs in a state of deep coma, though sometimes in convulsions. (There are many variations from the course here indicated.) Prognosis.—Always grave; recovery is exceedingly rare- TREATMENT. Iodoform.—This is the most important remedy, and is credited with having effected a number of cures. Most of the reported cures have followed the use of Iodo- form ointment, used as an inunction to the scalp, the entire head having been shaved. It can also be given internally. Dose .'—2x trit.; a tablet every hour. 32HYDROCEPHALUS-RICKETS-SCORBUTUS-TREATMENT POCKET-BOOK OF MEDICAL PRACTICE_____________ Helleborus. Tr—it belongs to the period of beginning paralysis; there is a state of general apathy. Boring of the back of the head into the pillow; eyes rolled up; lids half closed; head hot; slow, sighing breathing; sluggish action of the pupils; soporous sleep, with moaning and starting; automatic motions of one arm and one leg; twitching of muscles. Apis.3x—In the early stage of irritability. Convulsions; soporous sleep, interrupted by piercing shrieks; strabis- mus; spasm of individual muscles; grating of the teeth. Bryonia.33—Stage effusion. Opium.33—Deep coma. Calcarea carb.63, Sulphur^3, Calcarea phos.33—For the strumous diathesis predisposing to the disease. GENERAL MEASURES. Sick-It»om.—This must be kept absolutely quiei, dark, and well ventilated. The Patient.— Keep at absolute rest. Shave the head; apply cold compresses to the head so long as there is ex- citement, or the head is hot. Use with caution, and do not apply after the stage of depression has set in. Keep the extremities warm by hot-water bags, or hot flannels. Diet.—Give bits of ice, and cold water. A sustaining diet—milk and broths. ________ RICKETS. (RACHITIS.) Etiology.—Due to errors in diet and hygiene. It follows feeding with impoverished mother's-milk, from prolonged lactation; condensed milk; proprietary foods; foods con- taining an excess of carbohydrates, but deficient id fat and proteids. Symptoms.—Chiefly in the bones. Large head; narrow chest; prominent abdomen; swelling of the epiphyses of the wrists and ankles; curvature of the long bones; bead- ing of the ribs; cranio-tabes. Sweating, especially about the head; constipation; marked restlessness during sleep. Various deformities. Anemia. TREATMENT. Dietetic—Reduce the diet of carbohydrates:—Starches, sugars, proprietary foods. Give proteids:—Milk, eggs; red meats; cream; fats; fresh fruits. Hygienic.—An abundance of fresh air and sunshine; cold sponge-baths; exercise. Orthopedics.—Treat deformities surgically. Medicinal.—Calcarea carb.te; calcarea phos.ta; Ferrum phos.33; Phosphorus.33________ SCORBUTUS. (INFANTILE SCURVY.) Etiology.—It is always due to faulty nutrition, from improper feeding, especially with condensed milk and proprietary foods. Diagnosis.—Hyperesthesia, with acute pain on motion, about the knees and legs (it has been mistaken for rheu- matism) ; the gums swollen and easily bleeding; arthritic swelling; ecchymoses; hemorrhages; cachexia; anemia. Severe pain in the legs usually first attracts attention. ENURESIS TREATMENT-GENERAL MEASURES 33 POCKET-BOOK OK MEDICAL PRACTICE TREATMENT. Dietetic.—Give fresh cow's-milk; cream; beef-juice; orange-juice; lemon-juice; bread-and-butter; baked po- tato (if the child is over one year). Medicines.—These are of secondary importance: Mer- curius; Ferrum phos.; Muriatic acid; Phosphorus; Ar- senicum. ENURESIS. '.'INCONTINENCE OF URINE.) Causes.—The ordinary enuresis of childhood is a neu- rosis. It may be due to irritation of the nervous system in anemia; chlorosis; malnutrition; neurasthenia; chorea; epilepsy; hysteria; headache; neuralgia. Related to thegeuito-urinary organs:—cystitis; calculus; acid urine; phimosis; balanitis; constricted meatus; vulvo-vaginitis; adherent clitoris. Pin-worms, and fissure, or rectal polypus. Lastly, inheritance; and habit—acqntinuance of the infantile condition. TREATMENT. Sulphur. 6x—If there is no distinct condition calling for other treatment, it is well to begin the treatment with Sulphur. Many cures will be effected. Belladonna.Tr—For nocturnal enuresis; "habit" enu- resis ; want of control of sphincter vesicae. Restless sleep; twitching of the muscles. Dose:—Drop doses of tincture; may be increased to 3 drops if necessary. Santonin. lx—This will effect a cure in most cases due to worms. Equisetum.Tr—This will cure many cases, even when due to vesical irritation. Tenderness over vesical region; frequent urging, with pain after micturition; inconti- nence of urine in old men; dribbling of urine in the in- sane. Diurnal, as well as nocturnal enuresis. Dose:— Give 6 drops of Tr. 4 times daily. Causticum. 33—Weakness of sphincter vesicae ; urine passes in first sleep. In the day urine passes on the slightest excitement; escape of urine when coughing. Calcarea carb. 6x—In children of "scrofulous" dia- thesis—glandular enlargement; fair complexion; in- clined to fat; the head sweats; prominent abdomen. Benzoic acid.—Nocturnal enuresis, with dark, offensive urine. Dose:—Dissolve 1 part pure crystals in 9 parts alcohol; 3 drops at a dose. Valerianate of Ammonia.—Nervous, hysterical children. Dose:—10 drops. Pulsatilla.33—In girls; involuntary, at night; profuse flow of pale, watery urine. Gelsemium. Tr—Partial or complete paralysis of the sphincter vesicae; enuresis in nervous children. Dose:— Tr. or 2x. GENERAL MEASURES. General Health.—Attend to general condition with ref- erence to :—Air; exercise; regular habits; avoidance of excitement; plenty of sleep; bathing, etc. Do not use a soft mattress, or heavy, warm covering. Remove sources of irritation in any part of the body. The bowels should be kept free. A 34- VACCINATION-HEREDITARY SYPHILIS-TREATMENT _______________I'OCKET-BOOK OK MEDICAL PRACTICE Diet.—Easily digested food; light suppers; little drink late in the day; avoid meats, sweetmeats, condiments, tea, coffee. Surgical.—Operate in cases of phimosis ; paraphi- mosis; constricted meatus; adherent prepuce; vesical calculus, etc. VACCINATION. Age.—Vaccinate every child in infancy, and revacci- nate at the age of puberty. After that, whenever expos- ure is liable to occur. Location.—In boys, on the arm; in girls, for cosmetic reasons, on the leg, over the junction of the two heads of the gastrocnemius. Material.—Use pure bovine virus, preserved in glycer- ine in sealed glass tubes. Technique.—Make hands and instrument surgically clean. Make the part surgically clean, with soap and water, bichloride solution, and alcohol. "With the sharp edge of the blade of a lancet scrape the skin down to the papillary layer, until serum exudes, but not so as to draw blood. Rub the abraded surface with theglycerin- ated vaccine. Let it dry; protect with gauze, and se- cure with strips of plaster. Course: 3rd day.— Papule appears. 10th day.— Areola begins to 6th day.—Vesicle with cen- fade. tral depression. J4th day-~A brownmahog- 8th day.— Vesicle distended any crust haa with lymph, and formed. it has a wide, red 23rd day.— Crust becomes __. . areola. detached. Mixed Infection.—If through accidents beyond the con- trol of the physician, mixed infection occurs, the infected wound must be burned out with pure Carbolic acid and treated as any other ulcer. thff^^fll* a?d m-ixed infection. ^cept in the case of accident, are the fault of the physician. In twenty-five years' practice, including two epidemics of smaU-pox, I have never had any hut typical results? HEREDITARY"^ YPHILIS. (CONGENITAL SYPHILIS.) Diagnosis.— Infection:— The infection may come from either one, or both, parents. A healthy mother can bear a syphilitic child by an infected father.* Symptoms.— Lrenerally the infant appears healthy at birth. First symptoms usually appear from second to sixth week. If they do not appear before three months, the child is apt to be safe. The earliest symptom is usually persistent coryza-"snuffles"; then, skin eruption; mucous patches; hssures; tenderness of joints; emaciation; face wrinkled, drawn, and 'old ' looking; sallow skin; onychia. Later symptoms:-Hutchinson teeth; osteoperiostitis; inter- stitial keratitis; subcutaneous gummata. *Colles' law. rrognosis.-More unfavorable than the acquired form in adults. ^ RING-WORM-ENTOZOA-TREATMENT 35 ___________POCKET-BOOK OF MEDICAL PRACTICE TREATMENT. Mercurius. — Give this medicine systematically and persistently. Dose:—Merc, dulcis^3; one tablet every 3 hours. Inunction:—Blue ointment, two drams; spread on a flannel binder, wrap about the body. Let it re- main 3 days; wash the skin and re-apply. The mercu- rial treatment should be continued for one year. Kali hyd.—For changes belonging to tertiary syphilis. Dose:—Give to the verge of tolerance in each case. Form:—Saturated solution. Graduated dose. TINEA TONSURANS. (RING-WORM OF THE SCALP.) Diagnosis.—Due to a fungus, the tricophyton tonsurans. First, a papule surrounding a hair; it increases to a patch one to two inches in diameter, sharply outlined, with rounded border. The hairs become brittle, and break off close to the scalp, leaving a bald spot. Treatment.—Cut the hair short over the spot and for an inch about it. Wash thoroughly with carbolic soap, every second day. Apply a germicide-tincture of Iodine; Mercuric bichloride, Ichthyol. As a base for ointment use Lanoline 3 parts to Olive oil 1 part. Have the child wear an oil-silk cap. ENTOZOA. (INTESTINAL WORMS.) TJENI^E. (TAPE-WORM.) Taenia Saginata.—From beef; the most common form. T. Solium.—From pork; rare. T. Elliptica.—From lice on dogs and cats; sometimes found, especially in infants. Diagnosis.—The only certain sign is the discovery of the links in the stools. The symptoms are vague and in- definite. Sometimes, though rarely, symptoms resembling pernicious anemia develop. TREATMENT. Filix mas. (Oil of Male Fern).—Take Ol. Filic Maris, one dram. Divide into four capsules. Mode of Administration.—Let the patient eat a light supper—bread-and-milk; no breakfast; give a saline lax- ative (Citrate of magnesia); after action of the bowels, give one capsule, following with the three others at inter- vals of an hour; after the last one give Castor oil, one* half ounce. Punica gran. (Pomegranate root).—Use the Pelletierine tannate. Dose:—1 to 5 grains. Make an emulsion with water and syrup. Give in the manner described for Filix mas. Kamala (Roltlera).-Dose :—1 to 2 drams. Give sus- pended in syrup. Give fasting, and follow by Castor oil. Caution.—If, after giving an anthelmintic the head of the worm is not found, repeat the treatment several days later. Cucurbita peposemen (Pumpkin-seed).—Take the fresh seed; hull them; beat to a paste with powdered sugar; 36 ROUND WORM-PIN-WORM-TREATMENT 00 POCKET-BOOK OF MEDICAL PRACTICE___ dilute with milk. Give in divided doses, fasting; follow with Oil. ASCAKIS LUMBRICOIDES. (ROUND WORM.) Santonin.— Dose:— The lx trit. may be persistently given; or, to young children, tablets containing from ^ to V« grain; to adults, 1 to 2 grains at a dose. Naphthalin.—£> Indications.—Fibrinous exudation and inflammation of the lungs, with high temperature, in "scrofulous" sub- jects; absence of pain; rapid emaciation; enlarged glands; excessive irritability and sensitiveness; albuminuria. Also an accompanying pericarditis or endocarditis. Precaution— Always use afresh preparation of C. P. Iodine. Phosphorus.3*—This, in importance, is second only to Bryonia. A pneumonia that runs an uncomplicated course can readily becarried through with Bryonia, but when pneumonia deviates from its typical course, Phosphorus'must be considered. It belongs to the treat- ment of the sc*x>nd stage, that of consolidation, and also its use extends into the period of resolution. It finds its chief sphere in pneumonia in delicate, feeble or cachectic subjects, and those cases in which there is preat exhaustion and depression. With Bryonia the attack may have beenbroughton by "catching cold"; with Phosphorus there is an absence of such exciting cause. With Phosphorus the pains are not intense and acute, but are moderate, and vaguely localized. In the third stage of the disease it favors fatty metamorphosis of the formed elements. It should also be given when there are signs of suppuration, indicated by muco-purulent expectoration, with some blood, sweats and hectic. When the pleura is especially affected, Phosphorus is not indicated. Complications.—Phosphorus is indicated in collateral edema of the lungs; "typhoid pneumonia"; "bilious pneumonia"; and pneumonia with extensive accompany- ing bronchitis. Indications.—Stages of hepatization and resolution. Pain not very severe—vaguely localized stitches. Great prostration. Great weight and oppression of chest; severe embarrassment of respiration ; extensive mucous r⩽ cough, with bloody, muco-sanguinolent, or sanguino- purulent, difficult expectoration. Very useful in severe cases, asthenic pneumonia, and "typhoid-pneumonia." Collateral edema. Precaution.—Always use a fresh preparation of Phosphorus. Tartar emet.2x—It is not indicated in typical pneumo- nia. When the disease deviates from its normal course, or in subjects debilitated, or feeble from exhaustion, or from infancy or extreme ape, Tartar emetic is called for. Its place is in threatened pulmonary paresis, when the lungs are embarrassed by the abundance of its secretions, as indicated by extensive coarse rales and rattling of mucus, while, at the same time, owing- to weakness, notwithstanding the loose cough, but little sputum is raised; this condition is accompanied by great dyspnea, oppression of the chest, general prostration, cyanosis, cold surface, and clammy sweat; also, collateral edema. In general, Tartar emetic belongs to the treatment of asthenic cases of pneumonia complicated by bronchitis, with profuse secretion, and pneu- monia secondary to inlluenza, measles, whooping-cough, and other affec- tions of the respiratory mucous membrane. Indications.—Commencing resolution. Increased fre- quency of pulse; great anxiety and restlessness; copious, cool perspiration; pallid countenance; cyanosis; suffoca- tive- spells, great dyspnea; loose, rattling cough, as if much would be expectorated, but nothing comes. Im- pending paralysis of the lungs. Collateral edema. Precaution.—It must not be used in doses large enough to produce its depressing toxic effects. Antimonium ars.2x—The class of cases to which it be- longs are the pneumonias of elderly people, especially those cases secondary to epidemic influenza. It is especially applicable to cases in which there is precedent organic disease of the heart or kidneys. Jt is also indicated PNEUMONIC FEVER-CARDIAC PARESIS 39 ____________pocket-book ok medical practice in pneumonia secondary to emphysema. The condition demanding its use is threatened "paralysis of the lungs." Indications.—Intense dyspnea; loud rattling in the bronchial tubes; frothy, watery sputa, expectorated with difficulty; inability to clear the bronchial tubes; feeble, rapid pulse; failing circulation. Sulphur.3x—Delayed resolution; the latter part of the second stage, and the third stage; delayed crisis; or, pseudo-crisis, great vascular excitement. Sulphur will now hasten the crisis. Again, in the third stage, after the crisis, resolution is slow; lung remains solid, with no signs of clearing. Sulphur will now bring about a reaction, and promote resolution. Phosphorus is the remedy from which it is most important to differen- tiate Sulphur. The distinction is thus expressed: Sulphur. Phosphorus. 1. Amount of exudative ma- 1. Amount of exudative ma- terial great. terial small. 2. Consolidation pronounced. 2. Consolidation not extreme. 3. Catarrh not marked. 3. Much mucous secretion. 4. Vascular symptoms promi- 4. Nervous symptoms promi- nent, nent. 5. Little or no expectoration. 5. Muco-purulent expectora- tion. 6. Sthenic state; it is a condi- _ 6. Adynamic state; typhoid- tion of suspense; reaction does not like symptoms; or, signs of suppu- promptly occur. ration. Indications.—Sthenic cases, with delayed resolution; vascular excitement; fever; disposition to perspire;dysp- nea; sensation of heat in the chest; "flushes " of heat, hot hands and feet; aggravation in the forenoon. Men- ingitis. Rhustox.2*—In so-called "typhoid-pneumonia" this is the chief remed3-. There is auto-intoxication, from retrograde tissue met- amorphosis, with active fever, loss of flesh and great prostration. Indications. —Low delirium, with nervous restlessness; lips and tongue dry, brown and cracked; besotted ex- pression; swelling of the parotids; bronchial catarrh; "prune-juice" expectoration; emaciation; weak pulse; rheumatoid pains in various parts; tympanites; sensitive- ness of the abdomen; putrid diarrhea. IIyoscyamus.lx—Acute mania, not due to cerebral in- flammation. Belladonna.3x—Active delirium, with cerebral conges- tion. Convulsions in children; intense pulmonary con- gestion. Dry cough. Agaricus.Tr-— Indications.—Wild mania, with restless- ness, tremor, and effort to escape. Veratrum alb.Tr—In states of collapse, with cold sur- face, and weak heart's action, due to general exhaustion, especially when from diarrhea. Indications.— Weak heart, with general exhaustion, due to toxemia, asthenia, or to inability to take food on account of gastric disturbance. Emaciation; anorexia; diarrhea; pulse, weak, soft, compressible, irregular, and its rapidity increased; all the heart-sounds feeble; low temperature; pallor of the skin; cold extremities. CARDIAC PARESIS. This condition creates an emergency which must be met by prompt stimulation. Indications.— A dicrotic pulse, or a rapid, weak, compressible, irregular or intermittent pulse, calls for stimulation of the patient. Effect.—The results of stimulation are to be judged by improvement in the character of the pulse. 4ft HEART-STIMULANTS-GENERAL MEASURES *" pocket-book of medical practice____________ /Vr/orf.—Following the crisis; but in alcoholics, in the feeble and the aeed, it may be called for early. HEART-STIMULANTS. Alcohol.—To be used when the heart shares in the con- dition of general asthenia, as in secondary pneumonia, ' 'typhoid-pneumonia,'' and pneumonia of the aged, as well as in children. Indications.—Weak heart, with general exhaustion, due to toxemia or asthenia; all the heart-sounds feeble. Forms.—Brandy; whisky; wine (sherry, tokay, cham- pagne); wine-whey. Dose.—Brandy or whisky; the dose may vaor from a dram to an ounce, according to the urgency of the symptoms and the results obtained; re- peat at intervals of one, two or three hours. Do not give in too concen- trated form^dilutc with four to eight parts water. If the stomach will permit, it may be given in milk-pUnch or egg-nogg. Sherry or Tokay may be given in a similar manner to the above, but in correspondingly larger doses. Champafne.—When the stomach is intolerant of other forms of alcohol, champagne can often be taken. ... Dose.—A pint may be given, in divided doses, inside of five or six hours, or, in urgent cases, as high as a quart. Wine-whey.—This is a good form for use in the case of children. Caution. — Better results will follow the use of full doses of alcohol, than to drag along with insufficient quantities. Glonoiu.2x—This is the best stimulant when the em- barrassment is from engorgement of the right heart. Indications.—Extensive consolidation of the lungs; cyanosis; signs of general venous congestion; jugular veins full; small radial pulse; faint pulmonic second sound. Strychnin sulph.—This is a powerful and promptly act- ing stimulant; it should be used in urgent cases. It is adapted both to cases in which there is threatened fail- ure from engorgement of the right heart, and in weakness of the entire organ from the poisonous effects of toxine, or from asthenia. Dose.—In the most urgent cases a dose of one-fiftieth of a grain may be given subcutaneously at intervals of every two or three hours, length- ening the interval, and reducing the dose to one-hundredth grain aa the desired effect is produced. Oxygen.—This is of service when there is deficient oxidation of the blood from respiratory failure, in extens- ive consolidation with accompanying bronchial catarrh, or collateral edema, as evidenced by severe dyspnea, cyanosis, cold surface, feeble pulse, and mental hebetude. Dose.—Give the gas freely; several gallons per hour may be adminis- tered. If the patient is much depressed, do not demand any effort on his part, but let it escape in such manner that he will inhale it freely. GENERAL MEASURES. Sick-Room.—Let this be a large, well ventilated apart- ment. Temperature.—Keep the air at about 74° F.; slightly lower rather than higher. Humidity.—Keep the atmosphere moist. Rest.—Absolute rest is all-important. Applications.—Do not use poultices. To keep an equable temperature use a soft cotton jacket, open in front and tied with tapes, permitting ready access to the chest. Relief of Pain.—For sharp pleuritic pain use hot com- presses to the painful spot, as hot as can be borne. Do not use a wet compress. The best is several folds of flannel; PNEUMONITIS-BRONCHO-PNEUMONIA-TREATMENT 41 ____________pocket-book of medical practice sprinkle one surface with warm water, quickly run a hot flat-iron over it until it steams. Apply quickly and change frequently. Hydrotherapy.—For purposes of cleanliness, as well as for sedative effect, sponging with warm or tepid water may be employed, according to the demands of the case. Bathing.—When there is high temperature, hot skin, nervous erethism, severe dyspnea, and commencing car- diac weakness, sponging, of the surface with cool water (70° F.) for ten or fifteen minutes will reduce the tempera- ture, quiet the patient, and have a tonic effect. If, with- out too much distress to the patient—embarrassing the respiration or the heart's action—he can be turned partly on one side, and then on the other, so that the back can receive a cool sponging, this will do most to reduce tem- perature. In any event, the front and sides of the chest, and the axillae, should be bathed in the manner indi- cated. Repeat the cool sponging as often as indications require it. Diet.—In asthenic cases, give a carefully regulated, nutritious diet. In well-nourished patients, a light diet. Especially avoid anything that will distend thestomach, and so embarrass respiration. In pneumonia this is too often overlooked. The Bowels.—Give strict attention to the bowels. An overloaded colon or rectum will seriously depress the hearfs action. Let an enema be given daily. Demulcents.—Demulcent drinks are grateful; slippery- elm water, or gum-Arabic water, with a little lemon- juice. If stimulation is sought add a little rock candy and whisky. _______ BRONCHO-PNEUMONIA. (catarrhal pneumonia; lobular pneumonia.) Etiology.—Infection by various micro-organisms. Age.—Most frequent in children and the aged. Varieties.—I. Primary; II. Secondary: (a) as a sequel in infectious fevers; (b) aspiration-pneumonia. Note.—In children cerebral symptoms sometimes mask the pulmonary; examine the lungs critically. TREATE1ENT. Belladonna.3x—Especially in children, and only in the early stage of the disease. Much accompanying con- gestion; active fever; moist skin; respiration rapid; moan- ing; cerebral excitement. Aconite.11—This is to be used when with the local in- flammation there is accompanying systemic fever, with high tempera- ture and circulatory excitement. Hence, it is most often called for early in the attack. But it need not be limited to this period, for so long as there continues to be febrile action, Aconite will aid the action of other medicines by calming the nervous erethism. Indications.—Fever; rapid pulse; painful cough, with sensitiveness to inspired air; hoarseness; expectoration blood-streaked, the blood being bright red; respiration impeded; anxiety; stitching pains in the chest. Special Indications.—Feverish action, witli yaso-motor disturbance; restlessness, from nervous erethism. Dry cough; or, expectoration tinged with bright-red blood. 42 BRONCHO-PNEUMONIA-ACUTE BRONCHITIS pocket-book of medical practice Ferrum phos.2x—The action is limited to the early stage, when there is active congestion of the lungs, with its attendant symptoms. This is the key to its use—a state of engorgement, before the later pathological changes, such as abundant catarrhal secretion, etc., have taken place. Aconite has a similar sphere, but the fever is more active, with restlessness and great nervous erethism, and a hard pulse. Indications.—Congestion of the lungs; moderate fever; pulse full and soft; chest feels sore and bruised; scanty, blood-streaked sputum; sonorous and sibilant rales. Phosphoru8.2x—This is to be used especially when the disease occurs in cachectic, delicate subjects, and in secondary broncho- pneumonia after exhausting diseases; in subjectsof Bright's disease, dia- betes, and in fatty degeneration of organs. Also, in cases that sink into a low, typhoid-like condition. Indications.—Cachexia, or typhoid-like state; moderate fever; great oppression of the chest; rawness in larynx and trachea; expectoration purulent, or muco-purulent; mucus streaked with dark blood; abundant rales; sticky perspiration; weak, soft pulse; emaciation and prostration. Tartar enict.2x—The most important remedy ,'n the treatment of this affection. Indications.—Fine and coarse mucous rales; rapid res- piration; oppressed breathing; cyanosis; lips blue; cool surface; sweat; feeble heart's action. Antimonium ars.2x—Broncho-pneumonia of the aged, with loud rales and feeble heart. Bryonia.lx—Accompanying pleurisy, with stitching pains; soreness in the chest; children cry when coughing. GENERAL MEASURES. Sick-Roonu—A well-ventilated apartment; temperature 70° F. Absolute rest in bed, but frequent change of position. Chest.—Bathe the chest at intervals with hot water, and dry carefully. Avoid the use of poultices. Kneading and manipulation of the muscles of the chest aid in the respiratory effort. Diet.—Patients with this disease are generally much reduced, hence a liberal and nutritious diet should be systematically given. Heart.—In threatened heart-failure, stimulants. Convalescence.—Until there is complete resolution of the inflamed lung the patient's condition is still precarious. Persist in the use of active hygienic measures. ACUTE BRONCHITIS. Diagnosis.—Harsh murmur, followed by moist rales, heard on both sides of the chest. Secondary broncho- pneumonia is attended by rise of temperature, increased dyspnea, circumscribed areas of dulness, and broncho- vesicular breathing. Prognosis.—Almost always favorable. Unfavorable conditions are the capillary bronchitis of children, and the suffocative catarrh of the aged. Grave symptoms are: Respirations, 60 or over; pulse, 140 or over; quality, small, threadlike, irregular; cyanosis. TREATMENT. Aconite.ix—This is applicable only in the early stage; after the disease is once established, it is of no use. ACUTE BRONCHITIS-TREATMENT 43 pocket-book op medical practice Indications:—Fever; dry, hot skin, restlessness and thirst; short, hard, tickling cough, with constant laryngeal irritation; dryness of the mucous membranes. Bryonia.1*—Catarrhal inflammation of the mucous membrane of the trachea and larger bronchi; it is of no use when the smaller bronchi are invaded. Indications: —Dry cough, with stitches in the chest; short, labored respiration; feeling of oppression of the chest; with the cough determination of blood to the head, with headache, and great turgescence of the face. Belladonna.^*—When bronchitis sets in with violent fever, and intense congestion of the lungs, Belladonna will do more to control it than Aconite will. Indications: —Spasmodic cough, in short paroxysms; violent cough, worse at night; no expectoration, or tenacious, blood- streaked sputum; respiration oppressed and irregular; sensation of fullness in the chest. Ipecac.3x — Especially for the bronchial catarrh of chil- dren. Indications:—Asthmatic breathing; much nausea and vomiting of mucus; rattling of mucus in the bron- chial tubes; face livid during cough; loud, mucous rales, with wheezing respiration; severe gastric ailments and intestinal catarrh; pallid or bluish or bloated counte- nance. Kali bich.3x—Cough, with expectoration of tough mucus, that can be drawn out in strings; thick coating on the tongue; loathing of food; burning pain in the trachea. For bronchorrhea, with abundant purulent expectoration, give Kali bi., 2 grains in 4 ounces of water, by inhalation, in steam atomizer. Tartar emet.2*—The chief indication for Tartar emetic is profuse secretion of mucus in the bronchial tubes, which it is difficult to raise. Indications:—Great op- pression and suffocative breathing; extensive mucous rales; great rattling of mucus with the cough, but nothing is raised; also symptoms of incipient carbonic acid poi- soning—sopor, delirium, pallor, bloated countenance; also, profuse sweat without relief; disposition to vomiting and diarrhea; paroxysms of rattling cough, ending in vomiting. For capillary bronchitis of children, and pneu- monia notha of the aged. Antimonium ars.2*—Abundant secretion of mucus; with loud rales; difficult breathing; skin cyanotic, with cool perspiration; the patient anxious and restless. Veratrum album.1*—Especially in the later stages of capillary bronchitis of children, with failing strength; pulse rapid and irregular; abundant secretion of mucus, which the child is unable to raise; cold, moist skin. Bromine.^—Acute bronchitis, with catarrhal inflam- mation of the larynx and trachea, with hoarse, croupy cough; the patient is weak and perspiring; the cough is tight, hard and spasmodic. It is the spasmodic cough that is characteristic; it is attended by suffocative at- tacks, and rattling of mucus in the larynx. Ammonium carb.—In capillary bronchitis of children, or in the bronchitis of the aged, Ammonium carb. is 44 ACUTE BRONCHITIS-CHROMIC BRONCHITIS pocket-book of medical practice___________ called for when there is marked failure of the respiratory or circulatory functions. Indications:—Accumulation of mucus in the bronchi, which it is difficult to raise; great oppression of the chest; loud, coarse rales; great pros- tration, with falling temperature. Dose:—It must be given low; put grs. x of Ammon. carb. in one-half glass water; give teaspoonful dose every 15 to 30 minutes. GENERAL MEASURES. Fomentations.—For great oppression of the chest and dyspnea, apply hot fomentations, frequently repeated. Room.—Let the room be large, airy and well ventilated; temperature, 70° to 75° F. Keep the air moist by use of a steam generator. Position.—If there is much secretion, at intervals have the patient lie with the head and shoulders low, to favor gravitation and expectoration. Bowels.—In both children and adults, give daily at- tention to the bowels. When necessary, use enema of water, or of glycerin. Diet.—When there is fever, diet as in fevers generally. When there is profuse expectoration, nourishing, albu- minous food, milk, gruel, barley-water. All food should be hot. To soothe the throat, give demulcent drinks. CHRONIC BRONCHITIS. Etiology. — The primary form is rare; usually it is secondary to constitutional diathetic conditions (Bright's, alcoholism, etc.) or to affections of the lungs or heart. As a rule it is a disease of advanced life. Sequelae.—Asthma; emphysema, phthisis ; heart lesions. TREATMENT. Sulphur.3*—Gouty subjects, or the tuberculous diathe- sis; bronchorrhea. Kali hi.2*—"Dry" bronchial catarrh; hard cough; viscid sputum; hoarseness; aphonia. Iodine.?*—Delicate, "phthisical" subjects; dry cough; sputum bloody, emaciation; enlarged lymph-nodes. Antimon. iod.2*— Phthisical subjects; much muco-pur- ulent sputum; emaciation; night-sweats; (Goodno). Grindelia.1*—Asthmatic breathing; dry rales. Kali hyd.1*—In syphilitic subjects. Silica.6*—Sputum purulent; fever; night-sweats; ema- ciation; dyspnea. Rachitic children. Drosera.Tr—Hard paroxysms of cough, exciting vomit- ing; emphysema. Arsenicum.3*— Dyspnea; debility; emaciation; dry, wheezing cough; scanty expectoration; heart-disease. Hyoscyamus.Tr—Dry, irritable cough at night. Phosphorus.3*—Cachectic subjects; dry, hacking cough, with/»az'«or "tightness" in the chest; hoarseness. Ammon. carb.1*—Copious secretion; incessant cough. Heart or kidney affections. Rumex.Tr—Dry cough; irritable mucous membrane. Calc. carb.6*—With emphysema or bronchiectasis; pur- ulent, fetid expectoration. "Scrofulous " diathesis. Merc. sol.3*—Diarrhea; stomach and liver involved. ACUTE BRONCHITIS -CONGESTION-EDEMA 45 pocket-book of medical practice Hepar sulph.1*—Loose cough; muco-purulent sputum. Aconite.1*—Dry cough, with dyspnea. Arsen. iod.2*—Debility; anemia; emaciation. Sanguinaria.2*—Fever; flushed cheeks; much sputum. Tart. em.2x—Moist rales; free expectoration. Cyanosis. Staniuun.2*—Much mucopurulent expectoration. Spongia.3*—Dry, laryngeal catarrh. Note.—In making prescription in chronic bronchitis give attention to the constitutional condition and the primary disease. GENERAL MEASURES. Inhalations.—Use various inhalants: Eucalyptus; Iodine; Kali bi.; Balsam; Creosote. Hygiene.—Avoid exposure to cold and damp ; wear warm woolen clothing. Avoid vitiated air; seek warm, dry air and sunshine. Climate.—In confirmed cases remove to a warm, dry, equable climate. CONGESTION OF THE LUNGS. (active hyperemia.) TREATMENT. Aconite.1*—When due to inhaling cold air, to chilling of the body, or to violent exercise. Indications:—Violent heart's action; pulse quick and hard; burning, pressing pains in the chest; anxiety and restlessness, especially in plethoric subjects. Belladonna.2*—Intense congestion; rapid breathing; flushed face; skin red; throbbing carotids; voice hoarse; dry cough. Veratrum \ir.Tr—Pulse full and hard; heart's beat loud and strong; great arterial excitement; faint feeling at the stomach; nausea. i'actus.2*—Hyperemia of the lungs secondary to heart disease; respiration much oppressed; acute pains; feel- ing of constriction. Phosphorus.3*—In cachectic subjects; anxious panting; great oppression under the sternum; threatened edema. GENERAL MEASURES. Local.—Put a large hot compress over the chest. Hot foot-bath, with mustard in the water. When the condition is urgent, ice-bag to the spine. Inhalations of oxygen. Keep the bowels clear. EDEMA OF THE LUNGS. iauses.—It usually occurs as part of general anasarca, secondary to diseases of the lungs, heart or kidneys. It may be collateral or inflammatory. Symptoms.—Intense dyspnea; loud, bubbling rales; bilateral dulness; abundant watery, frothy expectora- tion: cyanosis; cold surface. Prognosis.—Usually unfavorable; it depends on the primary condition. J TREATMENT Indications.—Must be directed to the primary disease. Tartar emet.2*—Useful in acute edema, as well as in the secondary form. Loud, coarse rales; intense dyspnea; 46 LUNGS: EDEMA-ABSCESS-HEMOPTYSIS pocket-book of medical practice the bronchial tubes contain a large quantity of serous fluid; imminent suffocation. Phosphorus.3*—The use of this remedy is limited to the treatment of collateral edema occurring as a complication in congestion of the lungs or in pneumonia. Indications:— Great oppression of the chest; violent, strangling cough; expectoration blood-tinged. Ammonium earb.—Feeble heart's action; cyanosis; drowsiness; great accumulation of serous fluid in the lungs, which the patient is too feeble to expectorate. This marks an extreme condition; reaction may in some instances be brought about by Amm. carb., which acts as a respiratory and cardiac stimulant. Dose:—Each dose should consist of 2 grains of fresh Amm. carb., dis- solved in one ounce of water; repeat at 30-minute in- tervals. GENERAL MEASURES. Local.—Warmth to the extremities; favor diaphoresis. Apply dry cups to the chest, the back and sides; a dozen or more can be put on. Change the patient's position at in- tervals. Patient.—If a large quantity of watery fluid accumu- lates in the lungs, difficult to raise, let the patient hang over the edge of the bed, in an inverted position. When the heart's action is feeble, stimulate, giving alcohol, or Digitalis, 5 to 10 drops of the tincture at a dose. If there is congestion of the kidneys and scanty urine, apply over the loins a poultice of Digitalis leaves. Promote the action of the skin, kidneys and bowels. ABSCESS OF THE LUNG. Diagnosis.—Purulent sputum containing lung tissue or elastic fibres. Of a confined abscess there is no abso- lutely diagnostic sign; all other possible conditions must be excluded. Confirm suspicions by persistent search with the exploring needle. Prognosis.—Often favorable when secondary to pneu- monia; unfavorable if complicating general pyemia. TREATMENT. Hepar sulph.; Silicea; Arsenicum; Chin. ars.; Ars. iod , Mercurius. GENERAL MEASURES. Diet.—A nourishing and supporting diet. Operation.—When the abscess is located by the needle, make an intercostal incision; explore with the finger; open the abscess with a scalpel, and evacuate the pus; pack with iodoform gauze; treat on surgical principles. HEMOPTYSIS. Causes.—May be due to:—(a) Congestion; (b) Infarc- tion; (c) Pneumonia; (d) Phthisis (most common); (e) Ulcer; (/) Carcinoma; {g) Gangrene. TREATMENT. Aconite.1*—Bright red blood; incessant, hacking cough; warm feeling in the chest; red face; great anx- iety; arterial excitement. HEMOPTYSIS—TREATMENT-GENERAL MEASURES 47 ____________pocket-book of medical practice Ipecac.2*—Sensation of bubbling in the chest, followed by copious bleeding; tickling beneath the sternum; spit- ting of blood after the least effort; nausea. Hamainelis.Tr—Venous hemorrhage; blood dark, thin, coming into the mouth without effort, like a warm cur- rent. Millefolium.1*—Profuse flow of thin, bright-red blood; oppression; palpitation; not much cough. Cactus.2*—Hemoptysis, with over-action of the heart; secondary to heart disease ; sensation of constriction. Yeratruin vir.Tr—Violent congestion, with full, hard, bounding pulse. Phosphorus.3*—Hemoptysis occurring in the course of low fevers; also, inflammatory symptoms following an attack of hemoptysis. Tight feeling in the chest, with dry, tight cough, followed by hemorrhage. Ferrum phos,2*—Hemorrhage of bright, red blood, oc- curring in the course of phthisis. Geranium.'rr—Bright, red blood; persistent, freeflow. Sulphuric acid.—Persistent hemorrhage of dark blood; quantity slight; a continuous oozing; in feeble and anemic subjects. Dose:—Ten drops of the C. P. acid in a glass of water; teaspoonful dose every hour. Hydrastin hydrochlorate.2*—In subjects of old bron- chial catarrhs; with friable mucous membrane. Digitalis.'1^-—Secondary to obstructive heart lesions; feeble action of the heart. This drug must be used with caution. Its too free use favors separation of thrombi and pulmonary inf Jrct. Chin, ars.1*—For the anemia following excessive loss of blood. GENERAL MEASURES. Rest.—Make this absolute; command quiet surround- ings. Position.—Semi-recumbent; head and shoulders ele- vated. Room.—Moderate temperature—65° F. Ice.—Bits of ice may be given. Salt.—In the absence of medicines, a small pinch of salt on the tongue. Cough.—Encourage moderate effort at cough while the hemorrhage lasts; when it ceases, seek to allay the cough. Feet.—Apply hot-water bag. Bandaging.—Esmarch bandage to the upper thighs. Back.—Hot-water bag (120° F.) over the cervical spine. Fainting.—If but little blood has been lost and the pa- tient faints, make no immediate active efforts to revive him; fainting is salutary. Injections.—If much blood has been lost, use injection of normal salt solution. Caution.—Alcohol, Ergot and astringents do no good; they may do harm. After-Treatment.—Use inhalations of Carbolic acid, Listerine, or other antiseptic spray, to prevent decom- position of retained clots. 48 EMPHYSEMA-TREATMENT-ASTHMA ____________pocket-book of medical practice EMPHYSEMA. Diagnosis.—Chest "barrel-shaped"; sternum and costal cartilages prominent; clavicles and sterno-cleido-mastoid prominent; curve of spine increased; back rounded. In- spiration short and quick; expiration prolonged. Reso- nance on percussion. ^ Prognosis.—Unfavorable as to recovery, but the pa- tient's condition may be improved. TREATMENT. Indications.—Treatment should be directed to (1) the chronic bronchitis that always accompanies; (2) improve- ment of the nutrition. Antimonium ars.2*—Advanced stages, with excessive dyspnea, and severe paroxysmal cough; asthmatic attacks. Antimonium tart.2*—Moist cough; digestive disorders. Calcarea carb.6*—Chronic bronchitis in fat subjects; much perspiration; in women, profuse menstruation. Calcarea phos.2*—In advanced life, subjects of arterio- sclerosis. Phosphorus.2*—Subjects of fatty degeneration of tis- sues. Lycopodium.6*—Flatulent dyspepsia; lithemia. Aurum mur.3*—In nervous subjects, with urine of low specific gravity; arterio-sclerosis. Glonoin.2*—Asthmatic attacks, with high arterial tension. GENERAL MEASURES. Oxygen.—When there is intense dyspnea, and cyanosis, oxygen relieves. Aerodynamics.—The use of the pneumatic cabinet is of marked benefit in some cases. Climate.—A mild and equable 'climate, permitting out- door life. Diet.—It is important to regulate the diet so as to correct digestive disturbances and improve nutrition. Give an easily digested, nutritious diet. The exclusive milk diet, for a while, in some cases, is beneficial. Avoid the use of drugs, stimulants and tobacco. ASTHMA. Etiology.—True asthma is a pure neurosis. Exciting causes:—Bronchitis; respiratory irritants (dust, etc.); re- flex from nasal, gastric, or other irritation; secondary to cardiac disease; gout; rheumatism; Bright's, etc. Heredity predisposes. TREATMENT. Aconite.1*—Only for recent cases, to be given at the time of the attack. Attack excited by exposure to cold air; bronchial catarrh. Bryonia.1*—Recent cases only, with catarrhal bron- chitis, and stitching pains in the chest. Dose:—lx, fre- quently repeated, during paroxysm. Ipecac.Tr—Co-existing bronchitis; attack excited by dust and odors; the cough causes gagging and vomiting. Arsenicum.3*—This is to be given in the intervals be- tween the paroxysms, for the primary condition. But in such cases it may also be tried during the paroxysm, in ASTHMA-TREATMENT-GENERAL MEASURES 49 ____________pocket-book .of medical practice __________ frequently repeated doses. Chronic cases, with bron- chitis; also, cases with co-existing emphysema or heart disease. Indications:—Arsenicum is indicated by the severity of the attack; painful and distressing restless- ness; loud wheezing; patient seems to be on the point of suffocating. This is accompanied by livid countenance, cold sweat, frequent, small pulse, palpitation. Great prostration after the attack. Dose:—Persist in its use. Nux Tom.—To be used for uncomplicated "spasmodic" asthma; no bronchial lesion; attacks excited by irrita- tion of the pneumogastric, especially through the stomach. Coated tongue; irritable stomach; constipation; afterthe attack disturbance of digestive organs; slight nausea and flatulence. Dose:—Tr. During the attack give frequently repeated doses. In the intervals persist in its use. Strychnin is equally efficacious: 3x trit. Grindelia.2*—Asthma attended by bronchial catarrh; acute cases; also "nervous" asthma. Lobelia.Tr—"Nervous" asthma; vertigo; nausea; vomiting; sensation of emptiness in the stomach. Dose: —Tr. Use at.time of the attack. Sambueus.3*—The asthma of children; nightly attacks of dyspnea, with profuse perspiration. Sulphur.6*—For gouty or lithemic subjects. Cuprum ars.3*—Chronic asthma of bronchial variety; more or less dyspnea constantly, with severe paroxysms at intervals. Quin. bisulph.—In "nervous" asthma. Old cases, with complications of heart, lungs or stomach. Dose;— One-grain pill, three times daily. GENERAL MEASURES. Hygiene.—Attention to proper exercise, air, clothing, bathing, regular habits, are necessary to aid in a cure. Diet.—Important; asthmatics are dyspeptics; food must be digestible, taken regularly, the stomach never over- loaded; light evening meals. Climate.—Change to dry, elevated region often grants relief. Tho Paroxysm.—Supply an abundance of fresh air. Let the atmosphere of the apartment be kept moist. For Relief.—Various sedatives and anti-spasmodics will relieve. Amyl nitrite, 5 drops on a handkerchief; Ipecac, drop doses of tincture; coffee, a cup of very strong; Stramonium, the dried leaves smoked in a pipe; Potassic nitrate, make strong solution, soak blotting-paper, let it dry, burn this and inhale the fumes. Nitro-glycerin, in "cardiac asthma." Paroxysms can be temporarily relieved by inhalations of chloroform or ether, or hypodermic injection of mor- phine ()i gr.), but such measures are of no permanent value, and should be resorted to only in exceptional and extreme cases. Their persistent use is harmful. Cocain.—Solution (4%) sprayed into the nose, some- times stops the paroxysm. Its use is not without risk. Note.—The expedients here named will never cure asthma; their continued use confirms the disease. Each case should be studied and treated on its merits. 50 PULMONARY TUBERCULOSIS _____________pocket-book of medical practice PULMONARY TUBERCULOSIST (I-—Acute Pneumonic Phthisis. Varieties.-j II.—Chronic Pulmonary Tuberculosis. ( III.—Fibroid Phthisis. I. ACUTE PNEUMONIC PHTHISIS. i ("GALLOPrNG consumption;" phthisis Florida.) Etiology.—It may be primary or secondary; it is most common in early life; relatively more frequent in child- hood. Pathology.—Two forms:—(a) Pneumonic:—One lobe, or an entire lung, becomes solidified, resembling acute lobar pneumonia with hepatization; (b) Broncho-Pneumonic:— The process begins in the upper lobes and spreads down- wards, in appearance resembling broncho-pneumonia; scattered caseous masses are found. The latter form is more common in children. Symptoms. (a) Pneumonic Form:—Onset, usually sudden; chill, following exposure; pain in the side; fever; cough; bloody expectoration, or bronchial hemorrhage; dyspnea; fever, 104° F or more; night-sweats; rapid emaciation; great prostration; late, the sputum ismuco-purulent. Physical signs:—Similar to those of acute lobar pneumonia, indi- cative of consolidation of one or more lobes. Course:— Rapid, usually two or three weeks. Diagnosis:—From lobar pneumonia, the presence of the bacillus tuberculosis in the sputum. Duration:—Usually, two to six weeks. Prognosis:—Unfavorable. (b) Broncho-pneumonic Form:—Onset, gradual, usually with previously impaired health, or, in children, follow- ing pertussis, measles and other infectious diseases. Early, repeated chills; then fever, remittent in type; rapid pulse; muco-purulent expectoration; hemoptysis. later, drenching night-sweats; emaciation; prostration; gradually passing into a typhoid-like condition. Physical signs:—Similar to those of diffuse bronchitis or broncho- pneumonia; later, softening with cavity formation. Course:—Progressive; duration, two to eight weeks. Prognosis, generally unfavorable, though recovery may follow, or, chronic tuberculosis as a sequel. TREATMENT. Medicinal. — Iodine.3*— Arsenicum.3*— Baptisia.Tr— Antimonium tart.3* General.—The patient should have a sustaining diet, and be cared for as in acute diseases generally. II. CHRONIC PULMONARY TUBERCULOSIS. (phthisis pulmonalis; "consumption.") Etiology.—Infection by the bacillus tuberculosis (Koch); the infected subject must first have a low equation of re- sistcLiicc Early Symptoms.—General:—Slight fever; irritable pulse; emaciation; malaise; capricious appetite; anorexia; "dyspepsia" ; anemia; sweats. Local:—Cough; expectoration; pain in the chest; adeno- pathy; bronchial catarrh; hemoptysis; dilated pupil of the eye of the affected side. PHTHISIS-PHYSICAL SIGNS-TREATMENT 51 ____________pocket-book ok medical practice Physical Signs.— Inspection:—Flat and narrow chest (not in all cases); prominent clavicles; "winged" scapu- la?; defective expansion over one apex; enlarged precor- dial area (when the left apex is affected); skin anemic. Palpation:—Deficient expansion; increased vocal frem- itus. Percussion:—Dulness in the infra-clavicular and supra-scapular spaces; high-pitched note; "wooden" dulness if there is much fibroid change. Auscultation:—Feeble breath-sounds; or, harsh, pro- longed expiration, high-pitched; interrupted respiration; crepitant rales; broncho-vesicular respiration; broncho- phony; pleuritic friction, in some cases. [Note.—Only early signs are here given; not those of extensive con- solidation or cavity-formation.] Diagnosis.—The crucial test is the demonstration of the specific bacillus in the sputum. Early, when there is no expectoration, have the patient make forcible cough against a clean glass plate, held in front of the mouth. In the particles of spray adhering to the glass bacilli may often be demonstrated by the usual method. The sweat of a tuberculous subject contains tuberculin; it can be demonstrated on an infected guinea pig. The radiograph reveals consolidated areas. Tuberculin Test.—A positive diagnosis can always be made by the tuberculin test, but, since it may cause a latent tuberculosis to become active, it is not without danger. Prevalence.—One-seventh of all deaths are due to sep- ticemia from streptococcus-infection, secondary to pul- monary tuberculosis. One-third of all subjects, post- mortem, are found with signs of healed tubercular lesions. Heredity.—Tuberculosis is not transmitted from parent to offspring. But a constitution with low equation of resistance to infection by the specific bacillus is trans- mitted. Hence, the tuberculous should not marry; or, if married, should remain childless. The children of the tuberculous should have early and continued attention given to lung-development, open-air exercise, and proper nutrition. A tuberculous mother must not nurse her babe. Complications.—Larynx.—Ulceration. Lungs.—Pneu- monia; emphysema; pleuritis. Heart.—Endocarditis. Gastro-intestinal.—"Dyspepsia"; diarrhea. TREATMENT. Arsenicum iod.3x—The most important remedy in incip- ient phthisis, especially when there is rapid loss of weight. Fever; cough; dyspnea; muco-purulent expec- toration; prostration; diarrhea. Phosphorus. 3*-*x—Especially in phthisis following pneumonia. Adapted to tall, thin, "hollow-chested" subjects. Symptoms:—Dry cough; soreness in the lar- ynx and trachea; long-continued hoarseness; pain in the stomach after meals; diarrhea, especially after meals; palpitation; blood-streaked sputum; sweats; loss of strength; emaciation; pale skin. 52 PHTHISIS-MEDICINAL TREATMENT pocket-book of medical practice Kali carb.3x—Sharp, stitching pains in the chest; cough dry, or with scanty expectoration; or, in advanced cases, profuse expectoration, with sharp stitching pains. Iodine.Tr—Tuberculosis in those of previously "scrof- ulous " habit; enlarged lymph-nodes; fair skin; per- sistent, short, hacking cough; night-sweats; morbid appe- tite; fever. Iodide of Anthnony.2x—It may with advantage be sub- stituted for Iodine. Ferrum phos.2*—Of use only in the early stages. Ex- acerbation of the pulmonary condition from exposure; congestion of the lungs, with blood-stained expectoration. N'ux vomica.2x—For the digestive disturbances, some- times a prominent symptom in phthisis; morning head- ache; sour or bitter taste; vomiting, or violent retching; gastralgia; constipation, with ineffectual urging. Strychnin.2X—With the symptoms of indigestion, as for Nux vom., Strychnin often has prompt action. Baptisia.Tr—As an intercurrent remedy, late in the disease, when tfiere is fever; morning chills, followed by fever and perspiration; anorexia. Stannuin.3*—Cough attended by profuse, greenish or muco-purulent expectoration; hectic and emaciation; coarse rales; soreness in the chest after coughing; sense of weakness in the chest; talking causes fatigue; expec- toration sweetish in taste. Calcarea carb.3^-In incipient phthisis, in those of fat and flabby flesh; inability to take fat food; acid eructa- tions; "acid dyspepsia"; free perspiration; rapid emaciation; loose, rattling cough; soreness of the chest, which is painful on pressure; persistent hoarseness; diar- rhea; amenorrhea. Bryonia.lx—Sharp pleuritic pains, with accompanying fever Silicea 6x—The presence of cavities; profuse expectora- tion of pus or muco-pus; fever and profuse sweat. ^ Arsenicum.3x-In advanced cases, with fever, anxiety and Sessness; diarrhea, due to intestinal ulceration Arseniate of quinine. *-In ad^anc^\cha5sse!;urhave a condition described under Arsenicum, this will have a "tonic "effect, rendering the patient's state more com- f0C«pbr«m ars^-Cramps in the abdomen, with vomiting and diarrhea, following stomach disturbance A<-aricin.ix-For the night-sweats of phthisis. ^: OnT-gran tablet at bedtime; sometimes necessary to give two or three doses during the latter part of the day and purulent expectoration; night-sweats. _ Pilocarpine.^-Profuse sweats occurring in the of acute phthisis. exhausting Atropinc-In extreme cases, to check^ trie ex sweats. Atropine may be used as a palliative, PHTHISIS-CLIMATE-ALTITUDE kq _____________POCKET-BOOK of medical, practice curative in its action. Dose:—One one-hundredth of a grain, by hypodermic injection, given at bedtime. Aconite. 1*—For slight hemoptysis occurring in the early stages, with fever and excitement of the circulation. Antimonium iod.2*—Fever; cough, with profuse muco- purulent expectoration, Ferrum ars.lx—In cases with marked anemia; pale skin, and lips; in females, amenorrhea. REPERTORY. Cough.—Phosphorus; .Nitric acid; Stannum; Hyos- cyamus; Belladonna. Night-Sweats.—Agaricin; Phos. acid; Arsenicum; Cin- chona; Silicea; Atropin. Feter.—Arsenic iod.; Baptisia; Ferrum phos.; Chin. ars.; Silicea. Digestive Disorders.—Nux vom.; Strychnin; Arsenicum; Cuprum ars.; Ferrum ars. Paiuinthe Chest.—Bryonia; Aconite; Kali carb.; Cimi- cifuga. Insomnia.—Caffein; Digitalis. Hemoptysis.—Millefolium; Phosphorus; Ferrum phos.; Acalypha. Empirical Measures.—Kreasote has no specific action, and is not curative. Cod-liver oil, except for the con- tained Iodine, has no advantage over other fats. GENERAL MEASURES. Climate.—Change of climate is important in all cases, imperative in many. The earlier the. change is made, the better. Conditions.—The patient's new environments should provide mental rest (freedom from worry and anxiety) and favorable hygienic and sanitary surroundings. Qualities.—The most favorable climate should possess: — (a) Small amount of humidity; (b) Equable and mod- erate temperature; (c) Great amount of sunshine; (d) Purity of atmosphere; (e) Altitude. Altitude.—The effect of altitude is to:—(a) Compel deep and full respiratory movements; (b) Increase the exhala- tion of watery vapor and COa; (c) Increase the amount of hemoglobin in the blood; (d) Strengthen the heart's action; (e) Increase the activity of the skin; (f) Increase the appetite and the amount of food taken; (g) Improve nutrition; (h) Strengthen the muscles of the chest. Elevation.—The altitude may vary from 1,500 to 5,000 feet. It should not greatly exceed the latter. Gradual Approach.—In severe cases, do not make sudden change from low level to great altitude; gradual approach is followed by better results. Contra-indications.—Great altitude should be avoided in patients with:—Weak heart; nervous symptoms; ad- vanced age; extreme weakness. Localities.—North America.—The Adirondacks (1,500 to 2,500 feet); the Alleghanies—Western Virginia, East Tennessee, Western North Carolina, Northern Georgia (1,500-to 2,500 feet); the Rocky Mountains—Colorado, New Mexico, Arizona (3,000 to 5,000 feet). There is no region in the world equal to the high, dry interior at the B3« CLIMATE-LUNG DEVELOPMENT _______________POCKET-BOOK OF MEDICAL PRACTICE base of the Rocky Mountains, extending from Colorado to Old Mexico. Europe.—Switzerland.—Davos; Arosa; St Moritz; Wiesen; Leysin; Les Avants. Nostalgia.—The benefits to be derived from change of climate are apt to be lost if the patient suffers from home- sickness, or worry and anxiety. Return to Low Country.—The length of time of residence at a great altitude, before returning to the low country, is to be determfned by the stage of the disease from which the patient suffered, and by the rapidity of recovery. If it is a case of incipient phthisis, recovery will usually take place in one year; the patient should remain one year longer, to confirm the cure, and then he may, in almost all cases, return in safety. As a rule, remain one year after recovery. If there has been much destruction of lung tissue, remain at the great altitude permanently. Warm Climates.—In cases with bilateral disease, and cavity-formation, with little hope of cure, warm climates may be selected. Lung-Development.—The patient must take regular and systematic exercise in lung-development and chest ex- pansion. Method:—Practice (a) abdominal and (b) costal breathing. Abdominal:—With all clothing perfectly free, lie upon the back on a firm, level surface; expel the air from the lungs, and depress the epigastrium to its extreme limit; then fill the lungs, causing the epigas- trium to rise, making as great an excursion as possible. Repeat this ten times. Exercise in this way several times daily. Costal breathing:—The best way to develop the upper part of the chest is by exercises with two rings suspended from the ceiling by ropes. They should be on pulleys, so as to be adjusted to different heights. (A) With the rings on a level with the shoulders, let the patient grasp the rings with the hands; with the feet fixed, lean far forward, extending the arms outward and backward, at the same time gradually inflating the lungs as the motion is made. As the body is drawn back to the erect position, expel the air from the lungs. Repeat this many times. (B) Raise the rings above the head. Slowly draw the body up on tip-toe, and let down again, inhaling and exhaling as the two motions are made. (C) Many times daily, when in the open-air, go through with this exercise:—Place the hands on the hips, the fingers forward and the thumbs backward; stand erect, and throw the shoulders and elbows well back; inflate the lungs fully, beginning by abdominal expansion, and ex- tending to the. upper chest; close the glottis; hold for a moment. While holding the air in the lungs, make forc- ible effort at retraction of the abdominal muscles, press- ing the diaphragm upwards. Then suddenly and forc- ibly expel the air. Do this many times daily. Continue all these exercises for years after recovery. Exercise. — Exercise should never be pushed to the point of fatigue. Massage.—Massage of the muscles of the chest and abdomen, with passive arm movements, is very beneficial. ALIMENTATION-FORCED FEEDING 53ft ^( POCKET-BOOK OF MEDICAL PRACTICE " Rest.—During the afternoon fever the patient should rest quietly on a couch on a veranda in the open air. Alimentation.—A liberal and nutritious diet is of para- mount importance. So far as possible the patient should become the subject of forced feeding. The most effective method is by increasing the number of meals per day. Mixed Diet.—The diet should be mixed, with a due proportion of proteids, starches and fats. Proteids.—Beef; mutton; lamb; spring chicken; game; sweetbread; milk; koumys; eggs; fish; oysters; cod-fish (creamed); lobster a la Newburg. Starches.—Potato; rice; whole-wheat bread; hominy; samp; sweet potato; sago; cornstarch. For relish:— Celery; lettuce; asparagus; tomatoes; onions; spinach. Fruit.—Grapes; oranges; apples; bananas; prunes; pineapple; berries. Fats.—Cream; butter; olive oil; beef-suet (thoroughly cooked and hot, eaten in small quantity with rare beef). Meals.—Four a. m.—If the patient suffers from night- sweats, awaken him at 4 a. m., or at whatever hour the sweat is apt to occur, and give a glass of warm milk. In many cases this will prevent the sweat. Seven A. m.—Give a glass of warm milk. A table- spoon of strong coffee may be added. Or, give an egg- nogg; or koumys. Breakfast.—8:30 A. m. Mutton-chop, or eggs (poached or boiled); baked potato; buttered toast; cafe-au-lait; orange, grapes, or baked apple. Luncheon.—11a. m. A cup of cocoa, koumys, or cafe- au-lait; toast, or a shredded-wheat biscuit. Dinner.—1:30 p. m. Make this the hearty meal of the day:—Rare roast-beef; fresh vegetables; fruits. Tea.—5 p. M. A cup of cocoa, and a slice of buttered toast, or the equivalent of these. Supper.—7 p. m. No meat; tea (weak); corn-meal por- ridge, with milk; whole-wheat bread and marmalade; or fruit jellies. Bed-time. A glass of warm milk; or, koumys. Note.—This regimen may be varied to suit each case, but the main object—feeding the patient to the limit of his powers of digestion—must be kept in view. But do not overtax the stomach ! Use discretion. Forced Feeding.—Debove method:—This may be used in cases of laryngeal tuberculosis, when swallowing is painful, and the taking of food is followed by vomiting. First, wash out the stomach; then, through the stomach- tube, give milk and beef-powder. Sanatorium Treatment.—When the patient cannot go far from home, it is best to send him to a well regulated sanatorium, where he will be constantly under the intelli- gent care of a competent physician. Home Treatment.—If the patient cannot leave home, provide an upper piazza or balcony, inclosed only by wire screen, with southern exposure when possible, and on this let him live and sleep, even in cold weather, when it is not storming. Depend upon bed-clothing to retain ^ 53f OPEN-AIR - SUNSHINE - CAMPING _______________POCKET-BOOK OF MEDICAL PRACTICE body heat while sleeping. The sleeping-room should be always cool, with open window when it is not storming. Open-air.—The patient should live in the open-air. Camp life is best. Or, travel on wheel or in the saddle from place to place. If living in a house, the sleeping couch should be on an upper piazza, protected only by wire screen. Neither cough, fever, night-sweats, nor hemoptysis contra-indicate open-air exposure. In sum- mer, let the patient be out 11 or 12 hours; in winter, 6 or 8 hours. If the patient is weak, place him in a reclining chair, in the sunshine, on a balcony, veranda, or on the lawn. Protect, from feet to head, with shawls or wraps when cool weather demands. Sunshine.—Spend as much time as possible in the sun- light. In the patient's home, or in a sanatorium, a so- larium should be arranged so that the entire body can be exposed to direct sunlight. Give sun-baths daily. Camp-life.—Nothing equals camp-life to restore the pulmonary invalid. Recovery will follow this method when all others may faiL As to locality, a dry climate, or dry season, is the most important condition to seek. Bathing.—A cold sponge-bath (water 56° F.) to the chest should be taken every morning on rising. Night-sweats.—Give alcohol rubbings. Inhalants.—Inhalants have no power of destroying the bacillus, but they are of service for mental effect, and in compelling deep breathing. Formaldehyd, 4%, is a use- ful agent. The Sputum.—The patient should always cover the mouth with a handkerchief (or cloth, to be afterwards burned) when coughing. Expectorated matter should be received into a cup containing carbolic solution (1:20); or, on a cloth or paper, to be burned. Septicemia.— In septicemia from streptococcus infection —so-called "advanced phthisis"—when there is exten- sive destruction of lung tissue, great exhaustion and emaciation, a different course from that already indi- cated must be pursued. What must be sought is simply a peaceful euthanasia. Now alcohol can be used freely. Arsenicum can be given for its tonic effect. To give re- lief from the distressing cough, .nothing is superior to Codeine. (R. Codeina:; Ammon. chlor., aa grs. viij; Syr. Prun. Virg., oz. jv; mix. Dose:—1 dr. ev. 4 hrs.) The patient should be kept at home, with family and friends, and a general sedative treatment pursued. HI. FIBROID PHTHISIS. Pathology.—Fibroid induration of the lung, due to pro- liferation of connective tissue. The fibrosis may be pri- mary, or secondary to the tuberculosis. Symptoms.—Physical signs:—Chest sunken; shoulder lowered; heart displaced; increased fremitus; bronchial breathing; cavernous sounds. Course:—Chronic; may terminate in 3 years; may last 10, 20 or more. Perma- nent cure is possible. Treatment.—In general as in the ulcerative form. Climatic treatment is followed by favorable results. LUNGS - SYPHILIS-HYDATIDS NEOPLASMS 53d POCKET-BOOK OF MEDICAL TKACTlCli SYPHILIS OF THE LUNGS?" Varieties.—(a) "White pneumonia" of the fetus; (b) Gummata; (c) Interstitial pneumonia. Lesions.— White pneumonia:—In the fetus (and even sometimes when the child is born alive) large areas, or an entire lung, is firm, heavy, grayish-white. Gum- mata:—In the adult; the nodules are in size from a pea to a lemon; irregularly scattered; most numerous about the root. Interstitial:—Fibrous bands, usually radiating from the root of the lung, but sometimes from the pleura; bronchiectasis may be present. Syphilis of the lung is of rare occurrence. Symptoms.—The symptoms are usually those of bron- chiectasis, or of chronic interstitial pneumonia. Treatment.—Specific. PNEUMONOKONIOSIS. Tarieties.—[a) Anthracosis (coal-miner's disease); (b) Siderosis (from metallic dust, steel, etc.); (c) Chalicosis (from silica, in stone-cutters). Lesions.—The dust becomes deposited in the lung- tissue, leading finally to fibrous induration. Symptoms.-^-Bronchiectasis; emphysema; bronchial catarrh; characteristic sputum (in Anthracosis, "black spit"). Prognosis.—Favorable, if the cause is removed early. Treatment.—Prophylactic; and as for chronic bron- chitis and emphysema. HYDATID CYST OF THE LUNG. Origin.—Usually secondary (especially from the liver); primary is exceedingly rare. Symptoms.—Varied and obscure; pain; dyspnea; cough; bloody sputum (rare). Physical signs of a solid body in the lung. Diagnosis.—It depends entirely upon the appearance of scolices, membrane, or hooklets in the sputum. Ex- amine the liver. Prognosis. —Grave. Treatment.—Surgical measures if the growth is near the surface; otherwise, palliative treatment. Injection might be tried (see p. 107). NEOPLASMS IN THE LUNGS. Varieties.—Carcinoma (encephaloid; scirrhus; epithe- lioma—most common); sarcoma; enchondroma (rare). Etiology.—Primary new-growths are rare (sarcoma is sometimes so found); secondary growths are due to metastasis, or occur by extension. Symptoms.—Vary with the size and location of the tumor; pain if the pleura is involved; bronchitis; dyspnea; cyanosis. Prognosis.—Fatal. Duration.—From several months to 1 or (rarely) 2 > ears. 54 ACUTE PLEURISY-DIAGNOSIS-TREATMENT POCKET-BOOK OF MEDICAL PRACTICE_______ ACUTE PLEURISY. (PLEURITIS.) Varieties. — (a) Acute plastic; {b) Sero-fibrinous; (c) Purulent (Empyema); (d) Chronic adhesive. Etiology.—Due to various bacteria, or to their toxins. '' Cold '' acts as an exciting cause. Many cases are tu- berculous. Diagnosis.—In dry pleurisy, friction sound; with effu- sion, displacement of the heart (Bacelli'ssign), S. Koda's sign. Exploratory puncture is always decisive. Differ- ential:—Intercostal neuralgia, painful pressure-points; pleurodynia, absence of physical signs; pneumonia, dis- placement of the heart is most significant in favor of pleurisy. Puncture will decide. TREATMENT. Aconite.lx—To be of service Aconite must be given early. Its place is in the treatment of acute, uncompli- cated pleurisy. Indications: —Acute pleurisy, coming on with chill, followed by fever; thirst; quick and rapid pulse; skin hot and dry; rapid respiration; great nervous restlessness; stitching pains in the chest; dry cough. Bryonia, ix—This is* the leading remedy for plastic pleurisy; it is no longer of use after serous effusion has begun. Indications:—Plastic pleurisy, with acute, stitch- ing pains, greatly aggravated by breathing, or the slightest motion; respirations short and rapid. Also, for the "dry" pleurisies accompanying pneumonia and phthisis. Cantharis.Tr—This is the most efficient remedy, fol- lowing Bryonia, when there is serous effusion or sero- fibrinous exudation. Sensation of heat and burning in the chest; characteristic urinary symptoms. Apis.3x—For the stage of effusion, to promote reabsorp- tion, especially when the effusion is of recent origin; also, in pleurisy following scarlatina. Absence of thirst; dark and scanty urine; edema of the chest wall; severe, burning pain in a circumscribed spot. Colchicine.&c—Acute, general pleurisy, in rheumatic or gouty subjects. A peculiarity of the condition calling for this medicine is often:—Aversion to the smell of food, which causes nausea and loathing. Arsenic.3x—In the later period of the stage of effusion, which has failed to yield to other remedies. There is great dyspnea, with but little pain; much prostration, the patient being weak and cachectic; cyanosis; restless anxiety. Hepar sulph.3x—Persistent plastic pleurisy. Great sensitiveness to the open air; moist skin; the patient easily perspires. Rhus tox.3x—Acute attack coming on after exposure to cold and damp; after a wetting while heated and per- spiring. Muscular pains in various parts; pains in the extremities; disposition to change the position of the parts, which is followed by relief. Sulphur.3x—Plastic exudation, slow to disappear. Also, in cases of serous effusion, coming on insidiously, ACUTE PLEURISY-GENERAL MEASURES EMPYEMA 55 ______________POCKET-BOOK OF MEDICAL PRACTICE_______________ and lingering. Great need of fresh air; feet and head hot; hands and feet burn; palpitation; atonic dyspepsia. Kali carb.—Dry pleurisy complicating phthisis. Mer- curius corr.—Pleurisy complicating Bright's. Phos- phorus.—Pleuro-pneumonia. Iodine.—In "scrofulous" subjects it replaces Bryonia. GENERAL MEASURES. The Patient.—However mild the attack, insist upon the patient's remaining in bed. Absolute rest promotes re- covery. Let the patient seek the most comfortable po- sition, but remain quiet. Give attention to the state of the bowels. Room.—Dry, well ventilated; about 70° F. Pain. —For relief of pain, hot compresses—as hot as the patient can bear, frequently changed. (Poultices are an abomination.) Cold applications should not be used. Thoracentesis.—If the amount of effusion is great, thoracentesis is called for. Indications:—(1) Great dis- tention; (2) Pressure-symptoms, such as increasing dyspnea or embarrassed heart's action; (3) Effusion re- mains stationary. Method:—Use aspirator; strictest aseptic precautions, so as not to change a serous effu- sion to a purulent one. Withdraw slowly; only a por- tion of the fluid at one time. Stop on the appearance of cough, dyspnea or faintness. Stimulate if the latter occurs. Keep the patient recumbent. For further de- tails of the operation see "Empyema." Diet.—Give nourishing diet, liquid in form. Avoid over-loading the stomach. Convalescence.—If the lung is embarrassed in its ac- tion after the attack, order systematic lung gymnastics. Massage of the chest-walls. EMPYEMA. (PYOTHORAX.) Etiology.—It may be secondary to pleurisy; acute in- fectious diseases; extension from neighboring organs; injuries. Bacteriology.—The most common organisms are: Mi- crococcus lanceolatus; streptococcus; staphylococcus; bacillus tuberculosis. Diagnosis.—Physical signs are the same as in pleurisy with effusion, except absence of Bacelli's sign. If in doubt exploratory puncture should always be made, using strictest antiseptic precautions. Differential:—Pulsating empyema must be carefully distinguished from aortic aneurism. TREATMENT. Medicinal.—Hepar s.3x Silicea.6x Arsenic3* Mercu- rius. 3x Calcarea.6x Phosphorus.3x And others related to the suppurative process, as well as to the constitu- tional condition. SURGICAL MEASURES. Indications.—Pus in the pleural sac is essentially an abscess, and should be promptly treated as such. In 56 EMPYEMA-TREATMENT-SURGICAL-TH0RACENTE3IS POCKET-BOOK OF MEDICAL PKACTICE___ children, in whom the tendency is often to recovery, the demand is not so urgent; thoracentesis may be tried. But in adults, unless there is some special contrary rea- son, operation should be resorted to without delay. Methods. —(I.) Thoracentesis; (II.,). Simple incision; (III.) Resection of rib; (IV.) Siphon drainage; (V.) Thoracoplasty. L THORACENTESIS. Indications.—This method has but limited use; in the great majority of cases the radical operation is de- manded, and is necessary to a cure. When Called for.—Thoracentesis may be resorted to:— (A) In mild cases, when there is no apparent danger from delay. Limitations. — Unless prompt improvement follows.only one or two aspirations should be used; if at the end of one week the temperature is not reduced to normal, adopt radical measures. Note.—In children, if the fluid obtained by exploratory puncture shows pneumococci only; or, in adults, if it shows the bacillus tubercu- losis only, treatment by thoracentesis may be followed. (B) In urgent cases, when immediate relief of dangerous symptoms is demanded. Conditions. — Edema of the lungs, marked dyspnea, extreme weakness, or threatened syncope are indication for prompt aspiration. But this should be followed by operation in a few hours. Instrument.—The aspirator, including the needle and tubing, should be boiled and then immersed in an anti- septic solution. Skin.—The skin in the field of operation and in the ax- illa, should be rendered thoroughly aseptic by being washed, scrubbed, and disinfected with Mercuric bichlo- ride solution (1 :2,000). The hands of the operator should be similarly treated. Position of Patient.—Let the patient be supported by pillows in a semi-recumbent position, with the arm raised over the head; the patient should be lowered a9 the fluid is gradually withdrawn. Precautions.—Give alcoholic stimulants before and dur- ing operation, to anticipate cardiac weakness. Watch the pulse and respiration; if the pulse becomes feeble, stop the withdrawal of the iluid, promptly push stimu- lants and lower the patient to the supine position. Anesthetics.—Never use general anesthesia. At the point of puncture anesthetize the skin by a spray of Ether, or, preferably, Chloride-of-ethyL A drop of Carbolic acid will accomplish the purpose. Point of Puncture.—If there is any doubt, determine this by previous puncture with the exploring needle. Usually it will be where the dulness on percussion is most marked; or there will sometimes be a point of bulg- ing in the intercostal space. When the fluid is not cir- cumscribed make puncture in the mid-axillary line, just in front of the border of the latissimus dorsi muscle, in the fifth intercostal space on the right side, the sixth on the left, and just above the upper border of the lowermost rib of the selected space. EMPYEMA-INCISION-RESECTION 57 POCKET-HOOK OK MEDICAL PKACTICE Introducing the Needle.—In the entire process be care- ful to admit no air. Draw the skin up, make a slight preliminary incision, and then introduce the needle. This method provides a valve-like opening. Caution:— Do not injure the liver, lung or other viscera. Removal of the Fluid.—Withdraw slowly. If there is sudden stoppage of the flow, which is apt to be due to a plug of fibrin or caseous pus, remove it by introducing a stylet, previously rendered aseptic. Or, under precau- tions to prevent the entrance of air, a small quantity of an antiseptic fluid may be slowly injected, to remove the obstruction. Amount to be Withdrawn.—This depends upon the amount present, and the condition of the patient. If there is a large quantity, withdraw only one-half. As soon as the patient begins to cough, or becomes faint, or the pulse feeble, stop. After-Treatment.—Seal the wound by cleansing the surface again, placing over it a thin layer of sterile cotton and painting with Collodion. Keep the patient perfectly quiet. Irrigation of. the chest cavity is never to be adopted unless the contents are fetid. In the ordinary case, treat- ment by irrigation prolongs the disease process, and, moreover, is sqmetinaes attended by fatal accident. II. INCISION, i Indications.—It is the preferable operation in chil- dren; in adults, when general anesthesia cannot be used. Location.—In the axillary line, 4th, Sth or 6th inter- space; or, just below the angle of the scapula (in this location the.diaphragm is apt to rise and interfere with drainage). Patient. -Have the patient in the lateral semi-recum- bent posture, with the arm raised above the head. Incision.—Render the skin aseptic. Anesthetize the surface witu Ethyl-chloride. Cut near the upper border Of the lower rib of the two. The knife may be thrust through all the tissues, and then the opening enlarged by means of a sinus dilator. When the incision is com- plete, insert one or two fingers into the opening to prevent the too rapid escape of the pus. Evacuate slowly. Drainage. -Insert a drain, and dressings, as described on next page. m rebeotion. Indications.—In adults, when general anesthesia is ad- missible. It is still called for even after spontaneous evacuation has; occurred, whether through the lung or the chest wall. The percentage of recoveries by this method is greater than by any other. Anesthetic—Chloroform is to be preferred. Do not turn the patient after he is unconscious. The Incision.—Prepare the patient as for other methods. Over the middle line of the chosen rib make a single cut, three inches long, exposing the rib. Hold the wound open by retractors. Crowd the periosteum to each side, for a length of two inches, expending the process to the edges and inner surface of the rib. At the lower edge 58 EMPYEMA-DRAINAGE-THORACOPLASTY POCKBT-BOQK OF MEDICAL PRACTICE_______ carefully separate the intercostal artery with the perios- teum. The pleura is still intact. Grasp the bared rib with strong forceps, and cut out a piece 1% in. lonj with bone-forceps or a rib-cutter. Evacuation.—Now open the jpleura by a small incision, insert the finger and sweep it about in all directions to clear away pockets or clumps. Let the pus escape slowly. When the patient has partially recovered, change his position to favor evacuation. The Wound.—After thorough evacuation, insert a rub- ber drainage-tube the size of the finger; dust it with iodoform; secure it with safety-pins. Close the external wound on each side by two or three deep stitches. Dressing.—Put Iodoform gauze between the safety-pins and the skin. Cover all with Iodoform-gauze, sterilized gauze, and a large pad of sterilized cotton, reaching from the axilla to the crest of the ilium. Secure in posi- tion with bandages. After-Treatment.—The dressings may remain until their removal is demanded by (a) rise of temperature; or (b), saturation with pus. Generally this is in one or two days (in rare instances, a week). The second dressing can usually remain longer than the first. Only in ex- ceptional cases is it necessary to dress daily. Drainage.—By Posture: Have the patient on the affected side, in the lateral posture; raise the hips and lower the shoulders; then reverse this motion; do this several times. Repeat the process four times daily in the first week; later, two or three times a day. The Tube.—At each successive dressing, shorten it Its final removal is determined by the amount of dis- charge, and by careful probing of the fistula with a soft catheter. IV. SIPHON DRAINAGE. Method.—Under local anesthesia, puncture the chest with a large trocar (6 to 13 mm.). Withdraw most of the pus, slowly. Then insert a soft-rubber catheter, through the canula, withdrawing the canula over the catheter. Attach a long rubber tube to the end of the catheter, let- ting the other end of the tube pass into a large bottle, partly filled with an antiseptic solution (carbolic acid). Indications.—Good results have been obtained by this method. It is especially applicable to chronic tuber- culous empyema, and to the pneumococcus variety in adults. Special Conditions.—If there is already an existing perforation, operate without regard to it, selecting the usual location. In encapsulated empyema, make the in- cision over the seat of the pocket. In double empyema, oper- ate on one side, and on the other side five to ten days later. Re-expansion of the Lungs.—Use Wolff's bottles; light chest gymnastics; hill-climbing. ¥ .. .. V. THORACOPLASTY. Indications.—In old cases that resist the usual methods; the fistula continues to discharge for months. It is a serious operation, and should be resorted to only to save life. It consists in the resection of several ribs. For the method, refer to Surgery. SECTION III. DISEASES OF THE HEAKT AND THORACIC AORTA. PEKICARDITIS. Varieties.—Fibrinous; Sero-fibrinous; Purulent; Hemor- rhagic; Tuberculous. Diagnosis.—Before effusion:—A "to-and-fro" friction- sound, made more distinct on pressure with the stetho- scope, or on the patient's leaning forward. After effus- ion:—Palpation: Apex beat feeble or absent; heart's impulse absent. Percussion:—Triangular flat area. Auscultation:—First sound distant, and muffled. Fric- tion, if present, confined to the base. Prognosis.—Generally favorable; modified by the na- ture and severity of the primary disease. TREATMENT. Aconite.1*—Especially for pericarditis complicating acute rheumatism. Fever; great anxiety and restless- ness; precordial pain. Spigelia.Tr—This is an important remedy for peri- carditis. Pain and violent action of the heart are its chief characteristics. Violent palpitation, so severe that the walls of the chest are raised; severe stitching or stab- bing pains; great oppression, the least motion almost producing suffocation; irregular pulse. Colchicine — Given in the course of an attack of rheu- matism, it acts as a prophylactic against the develop- ment of pericarditis. Arsenicum.3*—The chief remedy in the stage of ef- fusion; restlessness and anxiety; suffocative attacks; violent and irregular palpitation; cold surface; thirst; anguish and apprehension of death. Digitalis.3*—For the stage of effusion, with feeble heart's action. Insidious approach of the pericarditis. Short duration of friction sound; pain; palpitation; pulse feeble, intermittent, not synchronous with the heart's action; face livid, with blue lips; hyperemia of the liver; great anxiety, but without restlessness. Bryonia.1*—Pericarditis complicating pleurisy or pneu- monia, with plastic exudation. It is of no use when effusion is present. Colchicum.2*—Rheumatic pericarditis; also, complicat- ing Bright's disease. Sulphur.3*—Protracted plastic peri- carditis. Cannabis.3"—Lancinating pains in the pre- cordial region. Kali carb.2*—Persistent stitching pains. Kali hyd.1*—To promote absorption. Merc. corr.3*— Purulent effusion. (59) 60 PERICARDITIS-ENDOCARDITIS-TREATMENT POCKET-BOOK OF MEDICAL PRACTICE GENERAL MEASURES. Rest.—The most important provision is absolute rest. Avoid all mental excitement or physical exertion. Local Applications.—Hot compresses, light in weight, over the precordial region. Put dry flannel next the skin, and the compress over it. Cold applications are to be avoided. Bed.—Let the patient lie between blankets, and wear only flannel clothing. Paracentesis.—If the amount of effusion is such as to embarrass the heart's action, or if it is purulent, para- centesis is indicated. Method:—Make exploratory punc- ture, with hypodermic needle, in the left fifth intercostal space, the region of the apex beat, to confirm the diag- nosis. Operation: Location—in the fourth or fifth inter- costal space, near the margin of the sternum. Make an incision in the chest wall, and expose the pericardium. Puncture the pericardium with a fine trocar and canula, taking care to avoid wounding the heart. ENDOCARDITIS. Varieties.—(a) Simple; (b) Ulcerative. Diagnosis.—Heart's impulse forcible early, but later it is feeble; on auscultation, prolongation of the first sound; a soft, blowing, systolic murmur at the apex, developing under observation. TREATMENT. Aconite.Tr—This is the leading remedy in acute en- docarditis. It is safe practice to rely chiefly upon it in the treatment of all cases, but especially in rheumatic endocarditis. Characteristic symptoms are: Fever; rest- lessness; rheumatic pain and swelling of the joints; con- gestion of the lungs. Spigelia.Tr—Second in importance only to Aconite. The characteristic symptoms are pain and violent palpi- tation. Cactus.1*—Sense of constriction about the heart; sharp pain; oppressed breathing; great palpitation; pulse quick, tense; violent occipital pain. Veratrum vir.Tr—Violent action of the heart, with con- gestion of the lungs; pulse full and bounding. Colchicum.Tr—For the endocarditis complicating acute rheumatism. Violent action of the heart, tearing pain in the precordial region; pulse weak, small and rapid. Arsenicum.3*—Late in the course of the disease. Pulse soft, weak and irregular; dyspnea; congestion of the liver; edema of loose cellular tissue; anxiety and rest- lessness. Bryonia.1*—In rheumatic endocarditis only, on indica- tions furnished by the general condition. JJeIladouna.2x_in the rheumatic endocarditis of chil- dren, accompanied by congestion of the lungs; heart's action rapid; pulse full; peripheral vessels dilated; cere- bral congestion. Digitalis.—This drug should never be given in physio- logical doses in endocarditis, or in myocarditis; it will do harm. J ENDOCARDITIS-HYPERTROPHY-TREATMENT 61 POCKET-BOOK OF MEDICAL PRACTICE GENERAL MEASURES. Rest.—As in pericarditis, this is all-important, not only during the acute attack, but for weeks after, until the heart has fully regained its integrity. Observe strictest caution so long as the slightest murmur is heard; or so long as there is any weakness of the heart's action, any rapidity, or excitability of the pulse. Clothing.—Every precaution should be taken to pre- vent chilling of the surface of the body. The patient should lie between blankets, and wear flannel garments. Applications.—Hot compresses over the precordial re- gion give relief. Do not let them be oppressive in weight. Baths.—An occasional warm bath (100°) helps to re- lieve the embarrassed central circulation, and is sooth- ing to the nervous system. Do not let the patient make any exertion. CARDIAC HYPERTROPHY. Diagnosis.—Bulging of the precordium; forcible, heav- ing impulse; apex-beat may be in the 6th, 7th or 8th in- terspace, and 1 to 3 inches to left of the nipple; on per- cussion, an ovoid area of dullness as high as the second interspace, and, transversely, from 1 to 3 inches to the left of the nipple line. On auscultation, first sound prolonged and dull; second sound clear and loud. Pulse, regular, full, strong, and of high tension. TREATMENT. Aconite.1*—Acute attacks of violent palpitation, with severe congestion; cardiac spasm. Naja.3*—Palpitation and feeling of oppression. Cactus.1*—Palpitation and congestion; feeling of con- striction. Arnica. 2*—Hypertrophy caused by long-continued over-exertion. Rhus tox.3*—Hypertrophy, without valvular lesion; in rheumatic subjects, caused by overexertion. Bromine.2*—Palpitation after slight exertion; feeling of precordial oppression. Aurum.2*—Powerful action of the heart, with rush of blood to the head and chest. Glonoin.3*—Palpitation, with feeling of pulsation in the whole body. Lilium.Tr—In females, with palpitation and conges- tions; pain, as if the heart were grasped. Caffein.2x — Palpitation of nervous origin. GENERAL MEASURES. Mode of Life. — Avoid everything that tends to excite the heart's action; avoid mental excitement, over-exertion, over-eating, and the use of stimulants. Lead a quiet life. . . .,,,.. Bowels.—A condition of constipation is deleterious; straining at stool is harmful. Diet.—This should be as "light" as consistent with maintenance of the general health. Drinks should be taken in moderation. Avoid the starchy foods. Prohibit tea, coffee, tobacco and alcohol. 62 CARDIECTASIS-TREATMENT-GENERAL MEASURES POCKET-BOOK OF MEDICAL PRACTICE CARDIAC DILATATIONT Diagnosis.— Z>w/««.s—Increased area upward and out- ward, on one or both sides; action of the heart weak and irregular, with indistinct apex-beat; First sound, short, sharp and feeble; Pulse weak, irregular, intermittent. Asystolism. TREATMENT. Digitalis.1*—Heart's action weak; pulse small, weak, irregular and intermittent; feeling of anxiety in the car- diac region; oppressed breathing; feeling of "want of air;" cannot fill the lungs; faint, sinking feeling in the epigastrium; at times there may be cyanosis. Thefeeble, irregular pulse, with feelings of anxiety and oppression, are characteristic. Dose.—Five drops, lx, several times daily. Even if no immediate effect is observed, persist in its use for a long- time—weeks or several months. The ultimate effect will be better than if physiological doses be given early. Strophanthus.1*—If Digitalis does not give favorable results, or if it disturbs digestion. Arsenicum iod.3*—Dyspnea on slight exertion; precor- dial pain; weak heart's action; rapid, irregular pulse; general weakness, prostration and restlessness; nervous irritability; precordial anxiety; a state of arterio- sclerosis. ConYallaria.Tr-orl*—Feeble, irregular action of the heart; soft, irregular pulse; dyspnea; palpitation; weak heart, with dyspnea; edema; scanty urine. Spartein sulph.1*—Weak heart in nervous or hysterical subjects; feeble action of the heart, with small, weak pulse, Agaricin.1*—Weak heart, feeble, irregular pulse; vio- lent palpitation; twitching of muscles; profuse sweat; cardiac dilatation associated with emphysema. Agaricin is also a useful remedy in the irritable heart of tea- and coffee-drinkers and users of tobacco. Also, the weak heart following acute debilitating diseases. Cactus.Tr—Sensation of constriction about the heart; pain; sometimes acute, stitching or shooting pains; pal- pitation, brought on by mental excitement, with deep inspiration. Ferrum.3*—In anemic subjects; palpitation, with sen- sation of oppression about the heart; full, soft pulse; vaso- motor irritability, indicated by flushings of the face. GENERAL MEASURES. Rest.—This is of paramount importance. There must be absolute rest in bed, excepting for passive exercise. Continue the rest treatment for a long time. Avoid all excitement or strain. Diet.—The diet must be nutritious, and concentrated. Foods:—Eggs; preparations of milk; nourishing broths; fish; scraped beef; beef-steak; rare roast-beef. Avoid- fats, sugars and starches. Let it be as dry a diet as the patient can stand. Let the patient take but little into the stomach at one time; avoid all that may cause distension of the stomach with gas; give light, but nutri- tious food. Little at a time, but at more frequent inter- vals. DIGITALIg-STROPHANTHUS-CRATiEGUS-ALCOHOL 63 POCKKT-BOOK OF MEDICAL PRACTICE ACTIVE CARDIAC STIMULANTS. Cardiac Stimulants.—In all ordinary cases, if properly treated, active stimulants will not be demanded. In asthenic cases they may sometimes be called for. The most useful are the following: Digitalis.Tr—Physiological action:—Heart. Its direct action is stimulant upon the cardiac ganglia and the muscular fibres of the heart, causing a strong, firm, slow beat. It also stimulates the vaso-motor center in the medulla and the ganglia in the muscular coats of the blood-vessels, causing arterial contraction, with increased tension. The slow action of the heart is due to stimu- lation of both the roots and ends of the cardiac vagus. Stomach.—Digitalis is a gastro-intestinal irritant, in sufficient dose causing nausea, vomiting and diarrhea. The drug is slowly eliminated, hence its action is cumu- lative. fndications:—Failure of compensation; faint second sound; or, asystolism; blue finger-nails; edema of the ankles; dyspnea. It should not be used in fully or over-compensated heart, advanced muscular degeneration, or mechanical defects of high degree. Dose:—Tincture (Norwood's), five to ten drops. Strophanthus.Tr—Physiological action:—On the heart its action is very similar to that of Digitalis. But it dif- fers in the following important particulars: (1) absence of vaso-constrictor effects; (2) greater diuretic power; (3) absence of cumulative effect; (4) no digestive disturbance. Indications:—The same as for Digitalis, but it is pref- erable to that drug, because of absence of vaso-con- strictor effect, and of disturbance of digestion. It is useful for weak and dilated heart generally; but especially for: ■ (1) Mitral stenosis, controlling the irregular rhythm, ner- vous dyspnea, and pains; (2) palpitation in irritable or tobacco heart; (3) heart-failure in the aged, with arterio- '. sclerosis; (4) in the heart affections of children it is safer '. than Digitalis. Dose:—Five drops of a reliableiTr., t.i.d. Crataegus.Tr—This drug is very similar in its action to Strophanthus. Through the cardio-inhibitory action of the vagus it slows and strengthens the heart. Indications:—After failure of compensation, even with a considerable degree of dropsy, it will give new tone to the lagging heart, and much reduce the dropsy. Dose:— Tincture, five drops, t. i. d. Alcohol.— Physiological action:—When taken into the stomach it stimulates the heart by reflex. The effect persists after the alcohol is absorbed. The heart's ac- tion becomes more rapid and forcible, by direct irrita- tion of the accelerator center in the medulla, and of the heart-muscle itself. Arterial tension is raised, though the blood-vessels, especially of the skin, are dilated, owing to depression of the vaso-motor nerves in the ves- sel walls. Excessive doses depress and paralyze the heart. RA CARDIAC DILATATION-TREATMENT "" POCKET-BOOK OF MEDICAL PRACTICE Indications .-—Alcohol is a diffusible stimulant. It ia called for in cases of weak heart with accompanying general exhaustion, or asthenia. Dose:—Of brandy or whisky, from a dram to an ounce, according to the urgency, and the results desired. Dilute it with four to eight parts water. BAD NAUHEIM TREATMENT. Description.—The Bad Nauheim, or Schott, method of treatment of chronic heart diseases, more especially dila- tation, consists of a series of saline and effervescent baths, conjoined with passive exercise. Its application requires intelligent care and attention to detail, but the beneficial results are often very marked. Indications.—To be used in cases of dilatation, pri- mary or secondary; fatty degeneration; myocarditis; angina pectoris; Grave's disease; remains of old effu- sions and products of inflammation; tachycardia. Contra-Indications.—Aneurism; Bright's disease; ar- terio-sclerosis. ________ SALINE BATHS. ( FIRST SERIES.) First Baths.—Water, 40or 50gallons; Sodium-chloride, 5 lbs.; Calcium-chloride, l/z lb. In the series of 20 baths the Sodium-chloride is to be gradually increased to 10 lbs. and the Calcium-chloride to 1 lb. Temperature.—First bath, 92° F. After each series of 3 baths, lower by 1 degree, but in the end do not let the temperature go below 83°. Duration.—In the first bath let the patient remain S to 8 minutes. In each successive bath increase by 1 minute, until a limit of 20 minutes is reached, with which dura- tion they may be continued. Precautions.—The physician should supervise thegiving of the first few baths. In the bath, guard against syncope. If the patient suffers from chill, take him at once from the bath. If the bath chills, give the next bath of a higher temperature. In the hath the patient must remain abso- lutely motionless. Never give a bath soon after eating. After the Bath.—On coming from the bath do not let the patient stand. Place him recumbent on a bed o; couch, and dry him off. Then, in a warm bed let him sleep for an hour or two. Number of Baths.—Give three baths on three successive days; then wait one day, and give three more. Continue in this way until 20 or 25 baths are given. EFFERVESCENT BATHS. (SECOND SERIES.) Prepare the bath with Sodium-chloride and Calcium- chloride, as for the saline bath. Add Sodium-bicarb., and HC1. Begin with a mild bath, and gradually in- crease to the strong. Mild.—Sodium-bicarb., ^ lb.; HC1 (25%), % lb. Medium.—Sodium-bicarb., 1 lb.;HCl (25%), 1% lb. Stro7ig.—Sodium-bicarb., 2 lbs.; HC1 (25%), 3 lbs. CARDIECTASIA-BAD-NAUHEIM TREATMENT 65^ ________ POCKET-BOOK OK MEDICAL PRACTICE The Acid.—To add the acid—loosen the stopper of the bottle, invert the bottle with the mouth just below the surface of the water, and withdraw the stopper; move the bottle about so as to diffuse the acid generally over the surface of the water. Method.—Let the patient remain 5 to 8 minutes. Give three baths, wait one day, and give three more. Gradually increase from mild to strong. First bath at 92° F.; gradually lower the temperature. When 20 baths have been given in this way, stop for several weeks (1 to 3) and give another series, being guided by the effects produced and the demands of the case. Note.—No rule is invariable. The time, temperature, strength of bath, periods of rest, etc., must be regulated by the intelligence of the careful physician. PASSIVE EXERCISE. Method. — It consists in resisted movements, the patient moving a limb, or a part, the operator opposing gentle resistance. The design is to obtain exercise without fatigue. RULES. Frequency. — Once daily. Parts. — Extremities; head; trunk. Motions.—Flexion; extension; adduction; abduction; rotation. Sequence.—Bring different sets of muscles into action at different times. Time. — Of seance, 30 to 40 minutes. Time. — Of single movement, 30 to 40 seconds. Rest. — Rest an equal period between. Motion. —Slow and resisted. Cautions. — Do not grasp a limb; do not compress blood- vessels; regulate the resistance to the condition of the patient; watch respiration, pulse, palpitation. Respira- tion or pulse must not be much quickened. If they are, or if the patient yawns, stop and rest. Proceed again cautiously. Results.—The Bad Nauheim treatment:—The heart is reduced in size; the pulse beats slower and with more force; the arteries are filled; the veins depleted; the urine is increased; dropsy is reduced. thorackTaneurism. (ANEURISM OI- THE THORACIC AORTA.) Etiology.—Predisposing:—Arterio-sclerosis; secondary to syphilis, gout, rheumatism, Bright's. Exciting:— Strain; obstructed arterial circulation. Age:—30 to 50, most common. Sex:—Male more than female. Location.—Ascending Aorta (60%):—Symptoms:—Ex- pansile tumor, in 2nd and 3rd right intercostal spaces; blowing murmur; dulness to right; thrill; pressure on descending vena cava, with venous congestion of head and right arm; heart is displaced to the left; pressure on right recurrent laryngeal, with dyspnea, aphonia, "brassy " cough; usually much pain. Transverse Portion of slrch (30%):—Tumor behind the manubrium; blowing murmur; thrill; dulness; tracheal 66 ANEURISM-THORACIC-PULMONARY POCKET-BOOK OF MEDICAL PRACTICE tugging; Bacelli's sign; pressure-symptoms of the—tra- chea; esophagus; thoracic duct; bronchi; lungs; cervical sympathetic; left recurrent laryngeal. Descending Aorta:—Tumor to the left of the sternum; blowing murmur; thrill, heard also in the back; dulness' pressure on the spinal column (sometimes with erosion of the vertebrae); esophagus; left bronchus; lung. Rupture.—It may rupture into the pleura; peri- cardium; heart; mediastinum; trachea; bronchi; esoph- agus; externally. Small hemorrhages, due to "weep- ing," may precede final rupture. When external, there is previous erosion of the ribs and soft tissues of the chest-wall. Pulse.—Volume lessened; difference in time of the two radials; or, one obliterated. Differential Diagnosis.—Aneurism must be differenti- ated from: — Pulsating empyema; solid tumors (enlarged lymph-nodes;,sarcoma; carcinoma). Prognosis.—Almost invariably fatal; in rare instances spontaneous recovery has taken place, and also followed the rest and dry-diet method (Tufnell's). TREATMENT. Rest.—Absolute rest in bed for from eight to twelve weeks. Diet.—A restricted, dry diet:—Breakfast, Bread-and- butter, 2 oz.; milk, 2 oz. Dinner, meat, 2 or 3 oz.; milk, 3 or 4 oz. Supper, same as breakfast. When this diet cannot be rigidly maintained, approach it as nearly as possible. Potassium iodide.—This drug, given to the point of tol- erance, has some repute. Its beneficial results are prob- ably gained in cases of specific origin. PULMONARY ANEURISM. (ANEURISM OF THE PULMONARY ARTERY.) Etiology.—Obstruction to the pulmonary circulation (asthma, emphysema, fibrosis); congenital defect in the walls of the pulmonary artery, the media being absent (this form is most commonly found in children; rare in adults). Diagnosis.—Expansile pulsation; diastolic shock, and thrill, in the second left interspace; dulness; loud, blow- ing and "booming" superficial systolic murmur, if it is large. Rupture is usually into the pericardium. Treatment.—The same as in the aortic form. ANGINA PECTORIS. v . .. (stenocardia; breast-pang.) Varieties.—(a) Angina pectoris vera; (b) Pseudo-angina; (c) Angina pectoris vaso-motoria. ANGINA PECTORIS VERA. TREATMENT. Arsemcum.3x—To be used only in the intervals of the attacks, for the constitutional state. It is sometimes curative when the disease is a pure neurosis. Debility and prostration; extreme dyspnea; feeble and irregular ANGINA PECTORIS-DIAGNOSIS-TREATMENT 67 _______________POCKET-BOOK OF MEDICAL PRACTICE DIFFERENTIAL DIAGNOSIS. ANGINA VERA. PSEUDO-ANGINA. Etiology.—Generally (tho' not al- Etiology. — Usually associated ways) associated with some lesion with various neuroses—neurasthe- —arterio-sclerosis; aortic incompe- nia, hysteria, etc. tency; hypertrophy; fatty degen- eration, etc. Age.— As a rule, over 40. Age —Any age. Sex.—Males predominate. Sex.—Females predominate. Exciting Cause.—Mental emotion Exciting Cause.—Arise spontan- or violent exertion. eously; are often periodic, and noc- turnal. Pain.— Intense;constricting. Du- Pain.—Severe, but less intense. ration, one or two minutes. Duration, half-hour or longer. Location.—Under the sternum . Location.—Over the chest. and to the left. Position.— Body fixed ; patient Position.—Patient restless and silent. emotional. Prognosis.—Grave. Prognosis.—Favorable. (TREATMENT CONTINUED.) Strontium iodide.—The use of this medicine has been followed by favorable results in some cases of angina dependent upon organic disease of the heart. Sodium iodide.—This one of the iodides has also been successfully used in the same class of cases as the above. Dose:—Five to twenty grains daily. Aurum muriaticum.2x—For the constitutional state in cases due to neuritis or to arterio-sclerosis. To be per- sisted in for a long time. Spigelia. 2*—Violent palpitation; severe stabbing stitches in the region of the heart at every beat; irregu- lar pulse; tendency to syncope. PSEUDO-ANGINA PECTORIS. Cactus.1*—Constrictive cardiac pain. Lilium.2x—in subjects with uterine complications; the heart feels as if tightly grasped. Kux \oin.2x—In gouty or hemorrhoidal subjects. Aconitiu.3x—Recent cases in plethoric subjects. GENERAL MEASURES. Electricity.—This has proved helpful in some cases, but more especially in pseudo-angina. One pole is to be applied over the sternum, and the other over the cervical spine. Use the Faradic current. Ice-bag.—The spinal ice-bag, once a day, for 40 minutes, applied from the fourth dorsal to the third lumbar vertebra, has proved curative. Oxygen.—Its inhalation gives relief. Hygiene.—In the intervals, attend to the general health of the patient. Emotional excitement and muscular exer- tion must be prohibited. Walking against a wind, or to the extent of becoming tired, often excites an attack. Avoid errors of diet and over-loading the stomach. The use of tobacco must be prohibited. The Attack.—Loosen the clothing; provide for fresh air; apply hot fomentations over the cardiac region; warmth to the extremities. SPECIAL REMEDIES. Amyl nitrite.—With the first signs of the oncoming attack the patient should inhale Amyl nitrite, 3 to 5 drops on a handkerchief. The patient should carry con- fift EXOPHTHALMIC GOITRE-TREATMENT 00 » POCKET-BOOK OF MEDICAL PRACTICE__________ stantly with him pcrles of the Amyl nitrite. High arterial tension is an indication for this drug. Nitroglycerin.—High arterial tension also serves as an indication for Nitroglycerin. Give by hypodermic injection, 1 to 3 minims of a 1% solution at.a dose. Chloroform.—This may be cautiously given by inhala- Ether.—If there is weak heart, to be preferred to chloroform. Brandy.—If none of the medicinal agents already named are at hand, give teaspoonful doses of brandy or whisky, frequently repeated. Morphine.—Its use is not free from danger. Hydrotherapy.—To quiet tumultuous heart's action, rest in bed, and the application of the ice-bag over the cardiac region, or over the lower part of the neck and upper part of the sternum. The spinal ice-bag, daily. The wet pack, followed by massage. j)iet.—This should be carefully selected and nutritious. Operative.—Operative measures are still on trial. In some cases recovery has followed the removal of nasal hy- pertrophies. -------- EXOPHTHALMIC GOITRE. (parry's disease; grave's disease; Basedow's disease.) Diagnosis.—Exophthalmos; tachycardia; enlarged thy- roid; tremor. Other symptoms:—Anemia; emaciation; slight fever; and in some cases, vomiting and diarrhea. One of the cardinal symptoms may be absent, e. g., exoph- thalmos. Prognosis.—Generally unfavorable; when cure is ac- complished it usually requires several years. TREATMENT. Lycopus.Tr—For cases in which the heart symptoms are most pronounced. Rapid and tumultuous action of the heart; pain and tenderness in the cardiac region; ir- ritable, intermittent pulse; rheumatoid pains in various parts; nervous erethism; feeling of oppression about the heart. Dose:—Tr. 5 drops, every 3 hours. Iodine.3x—Thyroid much enlarged; emaciation; palpi- tation; precordial anxiety; mental depression and de- spondency, but with irritability; restlessness; tremor; voracious appetite. Auruui.3x—Great mental depression; violent palpita- tion; precordial oppression; cardiac hypertrophy; brown patches on the skin; nasal obstructions; coryza. Ferrum phos.2x—Anemia • emaciation; congestive headache, with violent throbbing and flushed face; pro- truding eyes; violent palpitation of the heart; great restlessness and nervousness; trembling; vomiting; diarrhea; oppression of chest and dyspnea; edema of the extremities. Dose:—2x; 2 grains every 3 hours; or, Dialyzed iron. Belladonna.1*— Early in the disease; throbbing of the carotids; sensation of beating in the head; eyes staring and projecting; enlarged thyroid; powerful action of the heart, with increased frequency. CARDIAC NEUROSES-TREATMENT 69 POCKET-BOOK OF MEDICAL PRACTICE______________ To be Consulted.—Bromine; Spartein sulphate; Arsen- icum; Calcarea carb. ; Glonoin; Arsen. iod.; Colchicum. GENERAL MEASURES. Rest-Cure.—Rest is all-important. The patient must not lead an active life, and all bodily exertion must be avoided. Absolute and long-continued rest in bed is best, when possible. A quiet and calm mental state also must be sought. Electrotherapy.—This has cured some cases, and should be tried in all. Method:—Use a galvanic current of medium strength. Place the Cathode beside the spine above the seventh cervical vertebra; place the Anode be- neath the ear; hold it for a minute, then make applica- tion along the inner edge of the sterno-cleido-mastoid for several minutes. Now place the Anode above the seventh cervical vertebra, and transfer the Cathode over the solar plexus; pass a strong current for one or two minutes. Persist in the use of electric treatment for several months. CARDIAC NEUROSES. Palpitation.—Causes:—Mental and emotional; toxemia; anemia; gastric disturbances; irritants (tobacco, alco- hol, tea, coffee); pelvic disorders in the female. Arrythmia.—Causes:—(a) Central; (6) reflex; (c) toxic (drugs, tobacco, etc.); (d) heart lesions. Tachycardia.—(Rapid heart.) Due to paresis of the vagus, or irritation of the sympathetic. Brachycardia.— (Slow heart.) Most common after acute infectious diseases. TREATMENT. Ferrum.3x—Anemia; chlorosis. Ignatia.3x—Depression from grief. Moschus.lx—Hysterical palpitation. Nux vont.2x—Palpitation of indigestion. Gelsemiom.1*—From the abuse of tobacco. Cactus.lx—Palpitation of plethoric subjects. Sepia.3x—Nervous palpitation; mental emotion. Tabacum.3x—Palpitation with fainting attacks. Coffea.2x—Nervous palpitation; precordial pain. Zincum.3x—Violent palpitation; shocks and jerks. Spigelia.2x—Nervous palpitation, violent, with pain. Lilium.2x—Palpitation infemales, with pelvic disorders. Chamomilla.3x—Palpitation with faintness; pain as of a weight. Veratrum alb.1*—Brachycardia, following acute dis- eases* feeble subjects. China.2X—Palpitation due to excessive tea drinking; also, anemia; flatulent dyspepsia. Aconite.lx—Disturbance of the heart's action following a fright, or shock, with anguish and anxiety. GENERAL MEASURES. Rest.—Absolute rest, recumbent, and mental calm, are essential. „. . ,, Local.—In some cases hot applications over the region of the heart; in others, the ice-bag. Drug.—In an acute attack of hysterical palpitation, Valerianate of Ammonia, one-grain dose, at frequent intervals. SECTION IV. FEVERS. FEVER AND CHILL TEMPERATURES. 122° Fahr.—Highest ever recorded. 107° or over—Death. . . 106° to 107°—Almost always fatal; except in intermittent. 105° to 106°—Intense feVer; recovery doubtful. 104° to 105°—High fever: dangerous if long continued. 102° to 104"—Active fever; recovery the rule. 101° to 102°— Moderate fever. 100° to 101°—Slight fever. 99° to 100°—Feverishness. 98.6°— Normal. 97° to 98°—Subnormal; not grave. 95° to 97^—Collapse; in itself without danger. 93° to 95°— Algid collapse; great danger—recovery possible. 92° to 93s—Fatal collapse. TYPHOID FEVER. (enteric fever; abdominal typhus.) Etiology.—Infection by the bacillus typhi (Eberth). Diagnosis.—Depends upon:—Mode of onset (gradual); temperature curve; enlarged spleen; rose-colored spots; characteristic stools; Widal's test (in 95 percent of cases it holds good). Complications.—Pneumonitis; pleuritis; peritonitis; in- testinal perforation; hemorrhage; abscesses; parotiditis; venous thrombosis; thrush; arthritis; epistaxis. Prognosis.—L 'nfavorable symptoms:—Long continuance of intestinal symptoms; rapid pulse, with feeble apex beat and indistinct first sound; broncho-pneumonia; in- testinal hemorrhage; high temperature, long sustained. Examination.—At each visit note particularly:—Tem- perature; pulse; nature of heart-beat; state of abdomen; number and character of stools; state of the lungs. TREATMENT. Bryonia.lx—In the early stage, generally through the first week, before the intestinal s3*mptoms have devel- oped. Violent headache; confusion of mind and mild delirium; tongue with yellowish coating; parched lips; great thirst; tenderness at pit of the stomach; dry, irri- tative cough; lassitude and weakness; wants to be quiet. In the absence of complications this remedy alone can be relied upon to the time that diarrhea begins. Baptisia.Tr—For cases in which the diarrhea appears early, with offensive character of all discharges. Be- sotted expression; tongue heavily coated, dry; very offen- sive breath; pulse full and soft. Gelsemiuin.Tr—Early, great prostration; general sore and bruised feeling; trembling; great nervous weakness; insomnia; absence of delirium. Belladonna.3x—Severe frontal headache, from cerebral congestion; delirium; face red; pupils dilated; eyes in- jected. r r (70) TYPHOID FEVER-TREATMENT 71 _______________POCKET-BOOK OP M EPICAL PRACTICE_________ Hyoscyamus.2x—Delirium; an apathetic state; delusions and hallucinations; indistinct muttering; subsultustendi- num. Also, active, furious delirium if Bell, fails to re- lieve. Hyoscine hydrobroinate.3x—Furious excitement, sleep- lessness; haggard face; failing pulse. Agaricine.^—Constant delirium; tremulous tongue; muscular tremor; in alcoholics; rigidity of the limbs; imbecile look. Hydrastis.Tr—Gastric and bilious symptoms promi- nent; tongue heavily coated; nausea; epigastric faint- ness; constipation. Rhus tox.3x—This belongs especially to the stage of ul- ceration of the intestines, with the accompanying diar- rhea. Mind dull and clouded; incoherent muttering, or active delirium; headache; epistaxis, tongue brown and dry, with red tip; lips, teeth and tongue covered with sordes; skin clammy; general trembling; debility and prostration; severe pains in the back and extremities; pulse weak and slow; abdomen bloated; frequent invol- untary, copious, yellowish evacuations. Also in pneumo- typhus, with epistaxis; severe bronchial affections; dirty- looking, sanguinolent expectoration. Cantharis.1*—Great irritability of the mucous mem- branes; tongue, red, raw, cracked or glazed; irritable stomach; intense thirst; stools offensive and watery, with shreds; characteristic urinary symptoms. Arsenicum.3x—In order to be effective this medicine must be given early, without waiting for the disease to develop its pernicious character. Symptoms;—Extreme prostration, and great emaciation; face pale and shrunk- en; falling of lower jaw; tongue dry and cracked, black, with inability to protrude it; mouth covered with sordes; great thirst; decubitus; sopor; picking at bed-clothes; distended abdomen; pulse small, almost imperceptible; irregular action of the heart, with indistinctness of first sound; violent, almost continuous relaxation of bowels; discharge very fetid; breathing short and anxious; rat- tling cough; fetid breath. Symptoms of decomposition of the blood set in early, such as nose-bleed, bloody diar- rhea, bloody sputum, petechiae on the skin. Terebinth.—For intestinal hemorrhage. Extreme tym- panites; prostration and emaciation; tongue bright red, smooth and* glossy; mouth dry; scanty urine, with blood. Drop doses. Haniamelis.lx—Intestinal hemorrhage. Dark, pitchlike blood; bruised, sore feeling in the lower part of the ab- domen. Dose:—lx, 10 drops, at 30-minute intervals. Muriatic aclx—Rapid degeneration of the muscular system is the chief feature. Extreme prostration; patient stupid and unconscious; sliding down in the bed; low, muttering delirium; picking at flocks; inability to pro- trude the tongue; depression of lower jaw; turning up of the e3res; involuntary stools and urine. Cuprum ars.3x—Frequent, thin, or bloody stools, with pain; debility; twitching, jerking of the limbs. 17 TYPHOID FEVER—TREATMENT ,£- POCKET-BOOK OF MEDICAL PRACTICE__________ Mercurius.3x—The abdominal symptoms predominate, but this medicine should be discontinued as soon as the tongue becomes dry, or delirium sets in. Tongue loaded with thick, moist, creamy coating; painful sensibility of whole abdomen; diarrhea; stools copious, liquid, floccu- lent, sometimes a little bloody; clammy, fetid perspiration, Phosphoric acid.3x—The abdominal symptoms, pointing to a state of catarrhal enteritis, are most characteristic. Quiet delirium; unintelligible muttering; apathy; abdo- men distended, with gurgling and rumbling, with yel- lowish watery stools; absence of prostration, notwith- standing the drain upon the system. REPERTORY. Fever.—Bryonia; Gelsemium; Rhus; Baptisia; Arseni- cum. Delirium.—Belladonna; Hyoscyamus; Agaricus; Stra- monium. Hemorrhage.—Terebinth; Hamamelis; Nitric acid. Gastric.—Hydrastis; Cantharis; Pulsatilla. Diarrhea.—Rhus; Mercurius; Cuprum ars.; Phos. acid. Headache.—Belladonna p Acetanelidix; Hyoscyamus. Pneumonia.—Phosphorus; Ant. tart.; Sulphur. Epistaxis.—Aconite; Hamamelis; Ipecac; Crocus. Nervous.—Agaricus; Ignatia; Acetanelid; Hyoscyamus; Belladonna. Peritonitis.—Arsenicum; Belladonna; Rhus; Terebinth. Bilious.—Hydrastis; Mercurius. Tympanites.—Terebinth; Rhus; Phos. ac.; Arsenicum. GENERAL MEASURES. Sick-Room.—Ventilate thoroughly, at stated intervals. Remove all carpets and upholstery. Sunny exposure. If possible have two narrow beds; by placing them side- by-side, change the patient from one to the other, as each is cleaned and freshened. In so doing, lift the pa- tient on a sheet. The Patient.—Put him to bed early; keep him continu- ouslyrecumbent. At intervals, turn from side to side. Use air-cushion or water-bag if bed-sores threaten; bathe the back, hips and heels with a mixture of alum- and-salt in dilute alcohol. The Mouth.—Do not permit sordes to gather. Cleanse the mouth and tongue several times daily with Z% solu- tion of Boric acid. When the lips and tongue are dry and parched, moisten with glycerin and water, equal parts. Disinfection.—Stools.— Use chloride-of-lime, 6 oz., to water, 1 gal. Put 1 pint into the bed-pan; after the discharge is received, add one pint more; mix thoroughly; let it stand 3 hours, then empty. (Carbolic acid, S% so- lution, may be used.) The urine, vomited matter and sputum must be similarly treated. Clothing and Bed-linen.—Change as often as soiled. Protect the mattress with a rubber sheet. In washing all linen, boil foi half an hour. The Skin.— Cleanse the patient, after each discharge, with solution mercuric-bichloride, 1:2000. TYPHOID FEVER-GENERAL MEASURES 73 ______________POCKET-BOOK OK MEDICAL PRACTICE Diet.—As a rule, milk is the best food. Kind: fresh, unskimmed. Quantity: Not less than three pints in 24 hours. Give enough, but do not over-feed. Intervals— about 6 oz. every 2 hours, day and night (in sleep this rule is not invariable). Modified: May add—plain water; lime-water; brandy; coffee. Test of digestibility: If curds or fat-globules appear in the stools, digestion is impaired. Then give the milk peptonized; or, substitute: Other Foods.—When sufficient milk cannot be taken, replace wholly or in part by—wine-whey; buttermilk; koumys; albumin-water; broths (of mutton or beef, strained); clam-broth; barley-water; junket; gruels. If emaciation is rapid and extreme, give farinaceous gruels, well cooked. Drinks.—To slake thirst, give pure cold water at regular intervals. Do not wait for the patient to call for it. Aerated waters, effervescent or acid drinks should be avoided. Other Drinks: Weak tea; coffee and milk; cocoa; malt extracts. The systematic giving of water in large aggregate quantity is salutary. Give between the taking of food. Rectal Alimentation.—When the stomach rejects food : resort must be had to enemata. Give:—Peptonized milk, .- 3 oz.; meat-juice, 1 oz.; egg-white, % oz- '■> mix> Wash the bowel, and inject every four hours. Convalescence.—Dishes for this period: Broths; rice (thoroughly cooked); milk-toast; junket; soft egg; whipped i? cream; blanc-mange; soft part of oysters; scraped beef; wine jelly; baked potato; tapioca; mush-and-milk. No solid food until the temperature has been normal for a week. If at any time the temperature rises above 100° F., return at once to liquid diet. Stimulants.—Indications for the use of alcohol:—Great • general depression; weak heart; irregular pulse; dry, " tremulous tongue; delirium. Form:—Whisky, brandy, port, sherry. Dose—Vary according to the conditions, - from % oz. to 2 oz. in 24 hours, in divided doses. In - repetition, be guided by the effect produced. In threat- 2: ened collapse, % oz. brandy, repeated hourly. ~: Hydrotherapy.—Object of baths:—Reduction of tempera- ture. Indications: —High fever (103°+); increasing de- -. lirium; or, deepening stupor; weak heart. Conlra-indica- r: lions: — Intestinal hemorrhage; peritonitis; extremacar- &■ diac weakness. (The indiscriminate use of the Brand ^- method does harm in some cases.) Sponge-bath.—When the patient is hot and restless. ~ To water the temperature of the air, add % part alcohol. '■-■ With a large sponge bathe the entire body. Continue :- until the patient's temperature is reduced to 101°, 102Q. Cold Pack. —This is preferable to the tub bath. ■'-Method:—Spread a comfort on a cot; over this two blankets; over these a sheet wrung out of cold (50°) 2 water. Place the patient, stripped, in the cold sheet -' (the slight shock of first contact will do no harm). Bring up the sheet, and wrap the patient with it, snugly. (■> Bring up the edges of the blankets, and tuck all in. Put 7. TYPHUS FEVER-TREATMENT •* POCKET-BOOK OF MEDICAL PRACTICE____________ a cold cloth on the head. Often the patient will sleep. Let him remain % to 1 hour. When the clothing is re- moved the patient is generally perspiring. Dry off, and put him into a fresh bed. Constipation.—Persistent constipation should be re- lieved by soap-and-water enema. Procure an evacua- tion every second day. Diarrhea.—Four movements a day are not excessive. When this is exceeded, scrutinize the diet. Hemorrhage.—Keep the patient absolutely at rest. For 12 hours restrict the amount of food. If loss of blood per- sists, give a dose of morph. sulph., % or % gr., hypoder- mically. Repeat p. r. n. Tympanites.—When excessive, introduce a long rectal tube, and let the gas escape. Change from milk diet to liquid peptonoids, broths, or albumin-water. Perforation.—Operate as soon as reaction from the shock occurs. A sufficient number of recoveries have fol- lowed to justify this course. TYPHUS FEVER. (ship-fever; jail-fever.) Etiology.—Due to an infective agent. The disease is highly contagious. DIFFERENTIAL DIAGNOSIS. Typhoid. ENDEMIC. Advent insidious, with general malaise; headache; chill rare; it is several days before the patient takes to bed. Temperature.—Little rise at on- set; maximum about 7th day; ex- acerbates. Eruption.—L e n t i c u 1 a r spots, bright rose color; successive crops; Location, abdomen. Delirium appears late; low mut- tering-. Countenance pale, olive, leaden. Emaciation great. Bowels.—Tympanites, and " pea-soup " diarrhea. Duration, 21 to 40 days. Terminates by lysis. Typhus. EPIDEMIC Advent sudden, with intense chill; steadily increasing head- ache, with great prostration. Temperature.—2d day 104°; 105° to 107° on the 3d day; it remains high to the end. Eruption.—Small, slightly ele- vated, called "mulberry rash"; it remains throughout the disease; Location, sides ol the chest and the extremities. Delirium active from the first. Countenance dull, heavy; late, mahogany color. Emaciation slight. Bowels.—Constipation; no tym- panites. Duration, 14 days. Terminates by crisis. Complications. —Pneumonia, and swollen parotids. Prognosis.—Always grave. Unfavorable:—High tem- perature; frequent pulse; early, furious delirium, or early stupor; previous debility; in alcoholics usually fatal. Favorable: Youth; moderate temperature and pulse, and mild nervous symptoms. Causes of Death.—Death may result from meningitis; pneumonitis; capillary bronchitis; gangrene; asthenia, and paralysis of the heart; nephritis. TREATMENT. Medicinal. —Baptisia.Tr—Phosphoric acid.2x—Phos- phorus. 3x—Arsenicum.3x—Belladonna. 3*—Rhus tox.3*- O-num.ix TYPHUS-INTERMITTENT FEVER 75 _______________POCKET-BOOK OF MEDICAL PRACTICE GENERAL MEASURES. Sick-Room. —Strictly quarantine the patient. Observe all sanitary precautions. Give an abundance of fresh air; remove all windows, regardless of cold, and keep the patient well protected with blankets. Guard against bed-sores. In noisy streets, stuff the patient's ears with cotton. Baths.—If the temperature rise to over 104° F., put the patient in a bath ten degrees below the temperature of the body, and gradually reduce the temperature of the water to 70° F., till the bodily temperature falls to 101° or 102° F. Heart.—If the heart's action is weak, with much pros- tration and feeble circulation, give an occasional dose of brandy, or other heart-stimulant. Diet.—Of greatest importance to aid nutrition. Begin early, and give small quantities of very nutritious food regularly and persistently. Milk is the best. Also use beef-tea and broths. If necessary, support by nutrient enemata. INTERMITTENT FEVER. (ague; chills-and-fever.) Varieties.—Tertian; Quartan; Quotidian; Double Ter- tian, Quartan or Quotidian. The double varieties are due to two groups of the Plasmodium. Etiology.—It is due to the presence in the blood of the Plasmodium malaria: (Laveran). Symptoms.—Periodically recurring paroxysms of chill, fever and sweat; enlarged spleen; melanemia. In chil- . dren convulsions may replace the initiatory chill. TREATMENT. Quiniuae bisulphas.lx—To begin the treatment in all recent cases. The characteristic symptoms are:—Parox- ysm preceded by headache, hunger, palpitation. Each stage well marked—first the chill, which is severe, and the principal feature of the attack, with violent shivering, and aching pains; then the fever, followed by violent thirst, and sweat, which is sometimes profuse and ex- - hausting. Apyrexia:—Patient suffers but little—feels al- most in ordinary health. Dose:—Begin with 2-grain doses of the lx, every 2 -hours. If there is no recurrence, continue the medicine .;In decreasing dose. On the contrary, if a second parox- ism appears, increase the dose; give grs. x of the crude 'drug, 3 or 4 hours before the expected appearance of the next paroxysm. In some cases, when the Bisulphate alone has no effect, the disease will yield to a pill con- taining 1 gr. each of Quin. bisulph., Chinoidinum, Cap- .'sicum. Repeat every 3 hours. Quinine should be given on an empty stomach. Ipecac.2x—Nausea, vomiting, and other gastric disturb- ances, occurring before and during the chill and heat; tongue thickly coated with yellowish, moist fur; great oppression of the chest; nausea and vomiting predominate. 76 INTERMITTENT FEVER-TREATMENT POCKET-HOOK OF MEDICAL PRACTICE____________ Apyrexia:—More or less gastric disturbance. Usefulin mild forms of tertian. Arsenicum.3*—The paroxysm is imperfectly developed; before the chill, vertigo, headache, yawning, stretching, and general sense of discomfort; chill and heat inter- mingled; oppressed breathing; nausea, sometimes vomit- ing; small, feeble pulse, even during the hot stage. One of the stages often absent—sometimes the sweat, but usually the chill. Tendency to increase in the severity of the paroxysms, and rapid and excessive prostration. Urgent thirst throughout. Apyrexia: — Prostration; nausea; pains in the stomach and bowels; dropsical swellings. Nux Y.2*—Chill long-lasting and hard; fever severe; sweat profuse; both chill and fever accompanied by much gastric and bilious disturbance; distressing pains in head, back, and legs. Nux, in alteration with Ipec, for im- pure intermittents in non-aguish districts. Natrum niur.6*— Chill beginning in the feet or small of the back; blue nails; thirst; bursting headache, relieved by sweating; bilious vomiting before and during the chill. Eupatorium perf.Tr—Thirst several hours before the chill, continuing during the chill and heat. Chill short, hot stage protracted, and sweat slight. Vomiting of bile at end of the chill. During the chill and heat, the back aches violently, as if it would break. Veratrum alb.1*—Predominance of external coldness; cold, clammy perspiration; great thirst, especially during chill and sweating; great exhaustion and sinking of strength; vomiting and diarrhea, with griping, and pain in the back and loins. Phosphoric sic.!*—Profuse sweat. Gelsemium.Tr—Severe nervous symptoms. Aconite.Tr—Recent cases in plethoric subjects. Cedron.lx—Chills recur with marked regularity. Ignatia.2x—Chill relieved by external warmth; thirst only after the paroxysm. Capsicum. Tr—The sweat coincides with the heat, in- stead of following it. Pulsatilla.3*—Gastric symptoms, and resulting chloro- sis and hydremia. Hydrastis.Tr—Cachectic subjects, with hepatic and gastric symptoms. GENERAL MEASURES. During the paroxj'sm give Aconite to mitigate its sever- ity. Apply artificial heat during the chill, cooling drinks during the hot stage, and warm, dry clothing after the sweat. In malarial districts, avoid out-door air after sun-down; sleep in an upper room. PERNICIOUS INTERMITTENT-TREATMENT 77 ______________POCKET-BOOK OF MEDICAL PRACTICE PERNICIOUS INTERMITTENT. (CONGESTIVE CHILL.) Varieties.—I. Cerebral:—fa) Comatose; (b) Delir- ious; II. Gastro-Knteric:—(a) Algid; (b) Icteric. Symptoms.—The onset in some cases is sudden; in others there will first be several paroxysms of ordinary intermittent. In the cerebral form the coma is not due to congestion, but to the intensity of the infection. Prognosis.—It is always grave. Recovery is rare if more than two paroxysms occur. TREATMENT. Urgency.—Treatment must be prompt and energetic. Quinin must be pushed till the patient is thoroughly cin- chonized. Quinin hydrobromate.—The Hydrobromate of quinin is more soluble than the sulphate, which latter requires for its solution a mineral acid. The Hydrobromate is soluble in 54 parts water and 0.6 part alcohol. Quinin bisulphate.—The bisulphate can be made in solution in the following manner: ft. Bisulphate of quinin.............50 grains. Dilute sulphuric acid............1 drachm. Carbolic acid, liq.,........1...... 5 minins. Water, to make.................. 1 ounce. Dissolve the bisulphate in the sulphuric acid and wa- ter, by the aid of heat; filter, and add the carbolic acid. Ten drops contain one grain of bisulphate. Dose.—Give either one of these solutions by hypo- ■ dermic injection. Give 5 grs. every 2 hours; or 3 grs. every hour, till signs of reaction occur; then 2 grs. every 3 hours till time for another paroxysm is past. GENERAL MEASURES. Stimulants.—During the chill, apply heat to the sur- face, use hot mustard foot-baths, and give stimulants freely—brandy or whisky if there is much prostration. Strychnin if the heart's action is weak. If food cannot be taken by the stomach, give rectal nourishment. When ■ thirst is great give finely pounded ice, in champagne if there is prostration. Between paroxysms, if possible remove the patient to a non-malarial district. REMITTENT FEVER. (iESTIVO-AUTUMNAL FEVER J BILIOUS-REMITTKNT FEVER.) Etiology.—Due to Plasmodium; found most in the in- - ternal organs (liver, spleen). Symptoms.—It varies in intensity from mild to severe; the fever remits, but does not intermit. Prognosis.—Favorable. Duration, one to two weeks. TREATMENT. Gelsemium.Tr—The attack is marked by great lan- guor and muscular weakness. Congestion of the head; flushed face; chilliness; pulse full, quick and soft; dull pain in the head, back and limbs. Pulsatilla.3x — Whitish coating on the tongue; bitter eructations; bitter vomiting; chilliness; thirstlessn^ss. 7Q REMITTENT FEVER-DENGUE '° POCKET-BOOK OF MEDICAL PRACTICE____________ There is no remedy equal to Pulsatilla for protracted intermittent fever; the case drags from day to day, with no signs of reaction. In such cases Pulsatilla often has a prompt effect. If the patient does not respond to the 3x, use the tincture. Belladonna.3*—For initiatory fever, bevere chill, with vomiting and retching; violent fever, which is especially high at night. China.**—Great prostration; fluctuating pulse; hum- ming in the ears; marked remission. Ipecac3*—Gastric disturbance; headache; yellow or white-coated tongue; bitter taste, vomiting, and continued nausea. Mercurius.3*—Thick, yellow, pasty coating on the tongue; earthy color of face; bitter taste; soreness in liver. Bryonia.1*—Pressive or tearing pains in chest; better when at rest. Thin coating on tongue; bitter taste; con- stipation. Distinctly marked febrile motion. Rhus tox.3*—The fever degenerates into a low typhoid state, with adynamia; diarrhea; dry, brown tongue. Arsenicum.3* — Great emaciation; prostration; restless- ness; thirst; diarrhea, with dark, fetid discharges. GENERAL MEASURES. Nursing.—The course is generally favorable; the nurs- ing is simple, except when the case takes on a low, typhoid-like state, when it should be the same as for that disease. ________ SIMPLE CONTINUED FEVER. (FEBRICULA; EPHEMERAL FEVER.) Treatment.—Aconite, i*—Belladonna. 3x—Gelsemium.1* — Rhus tox.3x— Ipecac.3x—Pulsatilla.1*—Bryonia.1* General Measures.—Simple nursing is usually all that is required. Recovery always occurs. DENGUE. (BREAK-BONE FEVER.) Symptoms.—The characteristic symptom is intense pain in the joints and muscles. There is initial chill, fol- lowed by high fever. Sometimes gastro-intestinal symp- toms predominate, sometimes cerebral. There is an eruption, which is not distinctive. The duration is about five days. The crisis is often attended by profuse sweat or diarrhea. Convalescence is usually very tedious and protracted. Dengue scarcely ever results fatally. TREATMENT. Aconite.1*—The early fever. Bryonia.1*—Muscular pains. Eupatorium.Tr—Violent backache. Ipecac.3*—Nausea and vomiting. Nux vonv2x—Flatulence. Arsenicum.3*—Diarrhea. Cantharis.2*—Renal hemorrhage. China.2*—After hemorrhage. General Measures.—Simple nursing, with rest in bed, careful diet and cooling drinks. YELLOW FEVER-TREATMENT 79 ______________POCKET-BOOK OF MEDICAL PRACTICE__________ ~ YELLOW-FEVER. (febris icterodes; fiebke de borras.) Diagnosis.—An absolute diagnosis cannot be made before the third or fourth day. The most significant symptoms upon which to base a diagnosis are:—The remission from the first period, followed by the sudden elevation of temperature of the second period, in conjunc- tion with albuminuria, icterus, and hemorrhages (black vomit, bloody stools). The symptoms above enumerated are the most typical of the disease. Immunity.—One attack grants immunity. Symptoms.—Incubation:—One day, to three weeks. First stage:—Chill; fever, 103°-105° F.; headache; severe backache; flushed face; eyes suffused; vomiting; albuminuria. This stage may last 2 or 3 days, when the symptoms subside. Second stage:—Remission. Duration, about 24 hours. ; Third stage:—There are signs of collapse; cold surface; . yellow skin; weak pulse; "black vomit "; black stools; various hemorrhages; dry, brown tongue. The dura- tion of the entire attack is about one week. Convales- cence is usually protracted. Prognosis.—Unfavorable:—Intense capillary conges- tion in the first stage; intense jaundice; suppression of urine; uremic toxemia; black vomit. TREATMENT. Camphor.Tr—For the chill marking the onset. Dose: - —Give drop doses of the tincture every 10 minutes. Aconite.Tr—First "stage, after reaction from chill; fever; burning heat; dry skin; full, hard and rapid pulse; violent thirst; red face; headache; restlessness; prostration and vomiting. Belladonua.Tr—Cerebral congestion; headache; throb- bing of the carotids; face scarlet-red, shining and swol- len; eyes red and sparkling; active delirium; pain in stomach, with nausea and vomiting. Dose:—Drs. Holcombe and Fallig-ant, both in a wide experience, used ~Acon. and Bell, in alternation in the final stage. Repeat frequently. i- Bryonia.1*—After cerebro-spinal symptoms have sub- sided, and the gastric symptoms are prominent. Splitting ; headache; eyes red and sparkling; tongue yellow coated; lips parched, dry, and cracked; great irritability, and vomiting. Argentum nit.3*—Vomiting of brownish mass, mixed -with coffee-ground-like flakes. Cantharis.3*—The most important remedy for the sup- pression of urine. Burning pains in the stomach; slow pulse; hemorrhages; cold sweat of the hands and feet. Crotalus.3*—Hemorrhage from eyes, nose, mouth, stom- ach, and intestines—from all the orifices of the body, ;ven to bloody sweat. Lachesis.3*—Delirium; slow, difficult speech; red face; :ongue heavy, trembling, dry, and brown; nausea; vomit- ng; irregular, weak pulse; urine almost black. Arsenicum.3*—Pulse small and tremulous; skin cold; :old, clammy perspiration; rapid prostration, and vomit- nn YELLOW FEVER-VARIOLA ou pocket-book of medical practice ing of a brown, turbid matter, mixed with mucus, and sometimes stained with blood. The vomiting of the third stage. Hemorrhage from the bladder or uterus. Sabina,Tr- Secale.3*—Threatened abortion. Hyoscyamus,Tr- Coffea.2*—Nervous sleeplessness at night. Antimonium tart.2*—Prolonged and incessant nausea. Veratrum alb.Tr—Vomiting and abdominal pains. Phosphorus, 3x Mercurius.3x— Resulting diarrhea or dysentery. Ipecac.3*—Continued nausea; vomiting of glairy mucus. GENERAL MEASURES. Quarantine.—Adopt the strictest quarantine measures. Disinfect all excreta. The Patient.—Put the patient to bed early; let there be absolute quiet, and perfect rest. The most judicious nursing is important. Diet.—Owing to the gastro-intestinal irritation, feeding demands the most critical care. Give gruels and broths, cautiously. If the stomach is too irritable, nourish by rectal enemata. If there is depression, give alcoholic stimulants—brandy, whisky, champagne. RELAPSING FEVER. (famine-fever; spirillum fever.) Etiology.—Due to the spirochcete of Obermeier. Symptoms.—Chill; fever for 5 to 7 days; intermission, 5 to 6 days; then fever for 5 to 7 days. Usually only 2 paroxysms; sometimes 3 or 4. Intense pain in the head, back and limbs; sometimes jaundice. Treatment. —Medicinal: —Aconite.1*—Bryonia.lx—Bap- tisia. 1* — Cimicifuga.Tr---Eupatorium. 1* — Arsenic3* General:—As in fevers generall}'. VARIOLA. (small-pox; varioloid.) Varieties.—I. Variola Vera (discrete and confluent), II. V. Hemorrhagica. III. Varioloid. Incubation.—5-20 days—average 10 days. Stages.—Incubation; eruption; suppuration; desicca- tion. Invasion.—Chilliness; severe pain in the back and head, Fever.—Temperature even of Vdba, with bounding pulse, pain in head and back—relief from eruption. Secondary fever—very high on 8th day—and falls slowly. Cerebral symptoms frequent—delirium about 3rd day, Convulsions in children. Eruption.—On 3d or 4th day; appears first at edge rf hair, lips, palate, or fauces. First macule, then vesicL pustule, which may slough, and leave cicatrix, or form scab. The macule has a "shotty " feel. Desquamation.—Scabs, crusts, and thick scales; violent itching. Face flushed, anxious; photophobia. Tongue coated, swollen, with red edges. Duration.—4-5 weeks. Crisis about 21st day. VARIOLA-TREATMENT-GENERAL MEASURES 81^ POCKET-BOOK OF MEDICAL PRACTICE Sequelae.—Chronic diarrhea; abscesses: glandular en- largements; various diseases of eyeball and eyelids. Prognosis.—Depends on the type of the disease. In variola discreta, uncomplicated, favorable. In variola confluentes, grave. Unfavorable:—In the intemperate; syphilitic; extremes of life (recovery rare after sixty); lung complications;: inflammation of skin betiveen the pustules; epistaxis and other hemorrhages; scanty urine early; intense secondary fever between ninth and twelfth days. In variola hemorrhagica, recovery rare. Causes of Death.—(Edema glottidis; general bronchitis; pneumonitis; acute fatty degeneration of the kidneys; asthenia. TREATMENT. Variola Discreta.—Bell.; Gels.; Tart. emet.; Sulph.; Bapt. Variola Confluentes.—Sulph.; Ars.; Phos.; Merc. Variola Hemorrhagica.—Phos.; Ars.; Lach.; Crot.; Ham. Acouite.lx—The stage of invasion, with the early fever. Tartar emet.3*—The leading remedy; it reduces the fever, the pustules run their normal course. It is also especially useful in pulmonary complications, and for gastric disturbances. Given early, it mitigates the severity of the disease. Belladonna.2x—High fever; severe local symptoms; throbbing carotids; injected eyes; photophobia; sore throat; severe pain in back; starting and jumping in sleep; delirium. Mercurius.3*—It will modify the suppurative process, if given early. Moist, swollen tongue; ulcerated throat; fetid breath; salivation; dysentery. Rhus tox.2*—Papular and vesicular stage, with severe burning and itching. Sulphur.3x_For stage of desiccation; pustules become hemorrhagic. Hydrastis.Tr—Pustules in the throat. Arsenicum.3*—Hemorrhagic form; eruption dark; skin blue; great loss of strength; small, frequent pulse; thirst: anguish and restlessness. SPECIAL CONDITIONS. Pneumonia.—Ant. tart.; Phos.; Sulph. Glandular Swellings.—Merc, iod.; Rhus. Low, Typhoid State.—Bapt.; Ars.; Rhus. Boils.—Hep. sulph.; Sulph.; Phos. Ophthalmia.—Merc, cor.; Sulph. Delirium.—Bell.; Stram.; Verat. vir. Dropsical Swellings.—Apis; Ars.; Canth. Congestion of Lungs.—Verat. vir.; Aeon.; Bry. Repercussion of Eruption.—Camph.; Ars.; Sulph. GENERAL MEASURES. Vaccination.—As soon as the diagnosis is made, vacci- nate the patient with a good preparation of calf's-lymph. Some give the vaccine virus internally, and claim good results. A SMALL-POX-GENERAL MEASURES POCKET-BOOK OF MEDICAL PRACTICE____________ _Sick-Room.—Free ventilation; keep the windows open night and day. The Patient.—Strictest isolation and quarantine. Give frequent sponge-baths. Do not injure the pustules. Lightly bandage the handsof children to present scratch- ing. Let adults wear loose gloves. To prevent pitting the pustules must not be broken or irritated, and should be protected from contact with the air. Anoint with carbo- - lized vaseline. To allay burning pain, cold-water com- presses to the face or other part. For ulcer in the mouth, bits of ice, and Hydrastis gargle. Diet.—Give a sustaining diet—milk, eggs, broths; re- freshing drinks of fruit syrups. CALENTURA. Habitat.—Manila, the Philippine Islands, and other parts of the tropics. Season.—It prevails in the " dry " season. Etiology.—It is supposed to be excited by exposure tc the direct rays of the sun, in the case of newcomers and the unacclimated. Symptoms.—Prodroma.—Usually absent (there may be slight chilliness). Onset.—Sudden accession of fever (102°-103° F.). Temperature.— Gradual rise to 104° or 105° F.; the fever is of the continued type. Other symp- toms:—Anorexia; nausea; vomiting; severe headache; muscular pains; thirst; restlessness; marked asthenia. Duration.—About seven days. Prognosis.—Favorable. TREATMENT. Prophylaxis.—Avoid exposure to the sun; wear a large, light, cool helmet; carry a large, white umbrella; dress in light, loose, cotton or linen clothes. Those who take these precautions escape the fever. THERAPEUTICS. Aconite.Tr—This remedy, given early, will usually reduce the temperature to normal (in about 24 hours), and shorten the duration of the attack to 3 or 4 days. Dose.—Two drops of the Tr., every 2 to 4 hours, accord- ing to the effect produced. Stop when the temperature reaches normal, or when the action of the drug is suffi- ciently pronounced. GENERAL MEASURES. Hydrotherapy.—Give cool baths to favor refrigeration. Bowels.—With the onset, if there is constipation, give a saline laxative. Rest.—The patient must remain in bed, owing to the marked asthenia, until strength returns. Diet.—After the subsidence of the fever srive a sustain- ing diet. SECTION V. CONSTITUTIONAL DISEASES. ACUTE ARTICULAR RHEUMATISM. (rheumatic fever.) Etiology.—Probably of bacterial origin; cold, wet and damp predispose. Diagnosis.—Chill, fever, with inflammation of the joints, and other structures rich in white fibrous tissue. The joint affection is often fugacious. Complications.—The most common is inflammation of the heart—endocarditis (in 25 per cent of cases; pericar- ditis; myocarditis. In the acute articular rheumatism of children endocarditis is much more frequent than in the adult. In both children and adults the endocarditis of this affection is the cause of a majority of cases of chronic heart-disease. Prognosis.—Generally favorable. Unfavorable symp- toms are: Hyperpyrexia; urine low in solids; previously existing heart-disease; delirium and coma. TREATMENT. Aconite.1*—This is the leading remedy, especially when there is active fever. The pulse full and strong; great thirst, anxiety, and restlessness. Especially for inflammation of large joints, which are red, swollen, and exceedingly sensitive to contact. Bryonia.1*—Fever of adynamic form; the articular swelling pale, or dark-red, and exceedingly painful, ag- gravated by contact or the slightest motion; irritable stomach; thirst; nausea on rising up; constipation. Rhus tox.2*—This is a remedy that will accomplish much. It is especially indicated when the patient is im- pelled to move the parts, regardless of the pain. Adyn- amic fever; great restlessness; parts red and swollen; pains drawing, tearing, burning; feels worse when at rest; better on continued motion. Especially lower ex- tremities, and when brought on by getting wet. Mercurius.3*—High fever; quick, hard pulse; obstinate inflammation of a single joint; puffy swelling, pale or light-red; tearing, burning pains; deep-seated, as if periosteum affected; much worse at night; sour perspira- tion, without relief; breath foul; tongue with thick, yellow coating; appetite gone; very sensitive to cold. Pulsatilla.3*—Sub-acute cases, with little fever, the pains shifting frequently from part to part; pains violent, drawing, and jerking; not much redness or swelling; chilliness. Colchicine.—Goodno is enthusiastic in his recommen- dation of Colchicine for "typical acute articular rheu- matism." Dose:—1 gr. Merck's Colchicine to 1 oz. alco- hol, 3 to 5 drops, repeated every 2 to 4 hours. Reduce this dose if it causes disturbance of the gastro-intestinal tract. (83) A Ed RHEUMATISM-GENERAL MEASURES °* POCKET-BOOK OF MEDICAL PRACTICE_____________ Belladonna.2*—Red, shining swelling; throbbing pains. For insomnia at night, give frequent doses. Cimicifuga.3*—The pains are wandering; muscles of the limbs and trunk; also, articular rheumatism of the lower extremities. Pleurodynia. Rheumatic affections in nervous and hysterical women. Caulophyllum.3x—Rheumatism of small joints (wrists; fingers) with cutting pains. Cactus.^*—Rheumatism of the diaphragm. Arnica.2*—Sharp pain and bruised soreness in the muscles. . . Spigelia.Tr__Pericarditis or endocarditis of rheumatic fever. Kalmia.2*—Pains shifting from joint to joint. Ledum.Tr—Arthritic nodosities; small joints affected; joints not hot or swollen; pains begin below and travel up- ward. Ranunculus.2*—Rheumatism of the chest; intercostals; great soreness to pressure. Phytolacca.Tr—Periosteal rheumatism of long bones, and tendinous attachments of muscles. Sulphur.6*—In chronic rheumatism; pains worse at night; burning heat of the feat. Synovitis, with effu- sion. GENERAL MEASURES. Sick-room.—Well ventilated, but free from drafts; 75° F. A high, narrow bed or cot; a soft, but firm mattress; only blankets as bedclothing; flannel pillow-slips (no linen or muslin anywhere). The Patient.—Insist upon his going to bed without de- lay; keep atabsolute rest; flannel night-dresses, open the entire front. Envelop all joints in raw cotton, retained by flannel bandages; keep a folded blanket under, to be changed as often as it is wet with perspiration. Bathing.—Every third day, 1 joint at atime, remove the cotton, with care not to expose the joint to cool air, bathe with hot water, and re-apply. Local Applications.—If there is excessive pain, use—ft. Carbonate of potash, 1 oz.; Tr. Opium, 6 oz.; warm water, 1 pint. Apply flannel compress moistened with this, and cover with dry cotton. The Bowels.—Procure evacuation at least every second day; glycerin suppository. Use the bed-pan. Diet.—During the acute stage, chiefly milk:—bread- and-milk;milk porridge;milk-toast; koumis;butter-milk; junket; cottage-cheese; milk and seltzer. For variety:— barley soup; gruel; clam broth; oyster broth; vegetable soup. In convalescence farinaceous foods may be taken. Avoid sugar; take no meats until recovery is complete, then begin sparingly. Drinks.—Pure, soft water in large quantities. Lemon- ade, tamarind-water; effervescent waters are allowable. Alcohol is prohibited. Caution.— Examine the heart at each visit. GOUT-TREATMENT-GENERAL MEASURES 85 ______________POCKET-BOOK OF MEDICAL PRACTICE GOUT. (PODAGRA.) Etiology.—Excess in eating (proteids) and drinking (alcohol); heredity; middle life; men > women. Diathesis.—The "gouty" areliableto—eczema^catarrh; headache; epistaxis; acid and flatulent dyspepsia; con- stipation; lithiasis; melancholia. Acute Attack.—It may or may not be preceded by '' dys- pepsia." Onset—often sudden (at night); pain at the base of the great toe (or arch of the foot); it is excruciat- ing, biting, tearing, grinding; redness, heat and swell- ing, and general fever. Duration of attack, several hours. Such paroxysms may be repeated every night for a week. Recurrence:—The attack may not recur for months; sometimes, years. Chronic Gout.—It follows repeated acute attacks; or, it may develop without. Joints:—Any number may become affected, or various ones in succession, even the spinal articulations. The joints become edematous and in- filtrated, and tophi (cretaceous concretions) form. Viscera. — Any organ may become affected.—The heart (functional or organic); lungs (bronchitis, asthma); stomach (gastritis); liver (cirrhosis); kidneys (cirrhosis); or, the nerves; arteries (sclerosis); organs of special sense. Prognosis.—In most cases, unfavorable as regards re- covery, especially in cases with the hereditary factor. TREATMENT. Colchicum.Tr—For the acute attack. Dose:—From 3 to 10 drops Tr., repeated every 2 hours. Colchicine**- may be used. Aconite.1*—High fever and great restlessness in the acute attack. Mercurius dulcis.1*—Sensitiveness of the stomach, with coated, flabby tongue. Bryonia.1*—Stitching pains in the affected joints, worse on motion. Berberis.Tr—In catarrh of the bladder; also, oxaluria; lithuria. Benzoin.Tr—Affection of the finger joints, with little redness or swelling. Nux vom.2*—For the gastric disorders; constipation. GENERAL'MEASURES. The Patient.—In the acute attack, confine the patient to bed; elevate the affected foot, wrap it in cotton and en- velop in oil-silk. Give a saline cathartic to move the bowels. Diet.—Everything depends upon this. Character:—It must be non-nitrogenous, and moderate; no meats; take only milk, cereals, vegetables and fruits; soft water, freely. Avoid sugar and starches, and acid fruits; also, tea, coffee and alcohol. Hygiene.—Out-door exercise, to promote oxidation of the tissues; baths. A 86 LITHEMIA-ARTHRITIS DEFORMANS-DIABETES POCKET-BOOK OF MEDICAL PRACTICE LITHEMIA. (URIC-ACID DIATHESIS; LATENT GOUT.) Etiology.—It is due to deficient oxidation of nitrogen- ous matter, causing an excess of uric acid in the blood; causes:—over-eating; impaired digestion; lack of exer- cise; mental strain. Symptoms.—The symptoms are gastro-intestinal, nerv- ous, circulatory and urinary. Acid urates ("redsand") in the urine. Complications.—Arterio-sclerosis; interstitial nephritis; hepatic cirrhosis; gastritis; renal or vesical calculus. Prognosis.—Favorable before secondary degenerations have occurred. TREATMENT. Medicinal.—Remedies as in Gout. General.—Diet:—It must be abstemious; small propor- tion of nitrogenous food; starches and sugars are diffi- cult of digestion; avoid fats, heavy meats, sweets, alco- holic beverages. Exercise.—This is important; open-air life. Baths.—Salt-water baths, with friction to the skin. ARTHRITIS DEFORMANS. (rheumatoid arthritis.) Symptoms.—Any joints may be affected; usually first, the fingers; the joint swells; pain absent, or moderate; deformity; the adjacent muscles waste, contract, and cause flexions. General symptoms—gastro-intestinal; constipation. TREATMENT. Medicinal. —Colchicine.2*—Benzoic acid.2x—Pulsatil- la.3*—Sepia. 6*—Calcarea carb. 6* General.—Diet abundant and nourishing. Warm baths, Change of climate. DIABETES. (diabetes mellitus.) Symptoms.—General:— Appetite abnormally great (bu- limia) ; thirst excessive; tongue, dry; saliva, scanty; car- buncles; pruritus; peripheral neuritis; arterio-sclerosis; cataract; hypochondriasis; loss of flesh and strength; coma. Urinary Symptoms.— Amount:—4 or 5 pints to 4 or 5 gallons; sp. gr., 1020 to 1050; color, pale; reaction, acid; sugar, 1 to 2%, to 5 to 10%; urea, increased; albumin, slight. Prognosis. — Always guarded; unfavorable: —large amount of sugar; the disease in early life. TREATMENT. Uranium nitrate. 1*—Cases in which gastric symptoms are prominent; great thirst. Phosphoric acid.2*—Cases of nervous origin; prostration; emaciation; mental apathy. Arsenicum iod.3*—Rapid loss of flesh and strength; gastro-intestinal symptoms. DIABETES-TREATMENT-POLYURIA 87 _______________POCKET-BOOK OF MEDICAL PRACTICE Plumbum iodide.3* — Urinary condition pointing to nephritis — slight albuminuria; tube-casts; uric acid crystals. • Auruin mur.2*—Subjectsof neurasthenia; nervous symp- toms; arterio-sclerosis. Kreasote.—Gastric irritability; flatulence; emaciation; pulmonary tuberculosis. Dose:—Give by inhalation, 3 times daily. Repertory. Gastro-intestinal.—Nux vom.—Bryonia.—Leptandrin. —Lycopodium.—Lactic acid.—Calc. carb.—Arsenicum. Nervous Symptoms.—Calcarea carb.—Phos. acid.— Aurum mur.—Strych. ars.—Arsenicum. GENERAL MEASURES. Diet.—Of first importance. An exclusive milk diet is beneficial in some cases. The fundamental principle is that the diet must, so far as possible, be free from the carbo-hydrates—sugars and starches. This cannot be carried out arbitrarily in all cases. Principle:—Give a diet free from the hydrocarbons, and thus reduce the amount of sugar excreted, providing this course does not unfavorably affect the patient's general condition. On the contrary, if it is followed by rapid emaciation, the rigid diet must be modified. Avoid.— Vegetables:—Arrowroot, vermicelli, bread, biscuit, beans, beets, crackers, carrots, macaroni, oat meal, pastry, potatoes, peas, rice, sago, sugar, turnips, tapioca. Fruit:—Apples, grapes, pears, bananas, peaches, plums, pineapples, raspberries, and other sweet fruits. Beverages:—Wine, beer, brandy, ale, cider, and all alcoholic and sweet drinks. Allowable.— Vegetables:—Artichokes, cabbage, celery, cresses, cucumbers, olives, greens, lettuce, pickles, spin- ach, mushrooms, tomatoes, asparagus, onions. Fruits:—Lemons, cherries (sour), currants, gooseber- ries, strawberries, and acid fruits generally. Meats:—Beef, mutton, poultry, game, fish, oysters, cheese, clams, shrimps, eggs, etc. Substitutes for Bread.—Gluten bread; bran-cake; rusk; the crust of Vienna loaf. Water. -An abundance of pure water, for the thirst. DIABETES INSIPIDUS. (polyuria; hydruria.) Etiology.—Nervous shock; traumatism (the head); after acute infectious diseases; heredity; syphilis. Symptoms.—Large quantity of urine—as high as 8 to 10 quarts; pale; watery; sp. gr. 1001-1005; total solids about normal; albumin or sugar rare. General symp- toms:—Insatiable thirst; appetite not affected; dry, harsh skin; dry tongue; constipation; nervous phenomena. Prognosis.—Usually favorable; duration indefinite. TREATMENT. Medicinal.—Phosphoric acid.3*—Argentum mur.2x— Arsenic.3*—Strophanthus. 1*—Scilla.2* ^ 88 EPIDEMIC INFLUENZA-TREATMENT _______________POCKET-BOOK OF MEDICAL PRACTICE _____ General.—Restricting the water taken does no good; open-air exercise is beneficial. Depression.—Stimulants and supporting treatment. EPIDEMIC INFLUENZA. (LA GRIPPE.) Etiology.—Infection by the bacillus of Pfeiffer. Types.—Respiratory; gastro-intestinal; Nervous; Fe- brile (Typhoid); Rheumatoid. Symptoms.—The symptoms vary with the type. The characteristic is—profound prostration, out of proportion to the intensity of the disease. Incubation.—Two or three days. Onset.—Distinct chill, or chilly sensations; fever (104°- 105° F.); intense headache; aching pains; great prostra- tion. Complications.— Lungs: — Broncho-pneumonia; lobar pneumonia; congestion and ec?enia; abscess; gangrene; pleurisy. Heart:—Paresis; endocarditis; pericarditis. Stomach and Intestines:—Gastro-enteritis; hemorrhages; catarrhal jaundice. Nervous:—Perineuritis; delirium; insanity. Kidneys: —Neph r it is. Eyes:—Conjunctivitis; iritis; optic neuritis. Testicles: —O r ch itis. Skin:—Herpes; purpura. Sequelae.—Chronic bronchitis; pulmonary phthisis; tachycardia; angina pectoris; chronic nephritis; cystitis; gastro-intestinal catarrh; insomnia;neuralgia;migraine; tabes dorsalis. Ear:—Otitis media; mastoid abscess. Eye:— Conjunctivitis; keratitis, irido-choroiditis, glau- coma. TREATMENT. Arsenicum iod.3*—Great prostration, with severe sys- temic infection. Fluent coryza; discharge irritating and corrosive. Gelsemium.Tr—For the fever, attended by great general prostration. Acouite.Tr—Acute fever early, with great nervous erethism. Eupatorium.Tr—Severe pains in the back, and limbs. Bryonia.1*—Pulmonary type, with bronchial catarrh or pleuntis. Rhus tox.2*—Rheumatoid pains in the extremities; also the typhoid-like form. Antiinon. iod.2*—Bronchitis, with muco-purulent expec- toration. Tart. emet.2x—Secondary broncho-pneumonia. Cuprum ars.3*—G astro-intestinal type. Chin. ars.2*—Debility in convalescence. GENERAL MEASURES. *hTh(LPafieilt"~Confine the P^ient to bed, however mild tne attack. The aged and the cachectic are especially liable to succumb. Nourishing diet; careful nursing. TRICHINIASIS-DIAGNOSIS-TREATMENT 89^ pocket-book of medical practice TRICHINIASIS. (trichinosis ) Cause.—The ingestion of the trichina spiralis. Symptoms.—In 2 to 3 days, gastro-intestinal symptoms —vomiting, diarrhea, colic; extreme muscular weak- ness; about the tenth day, chills; fever; the muscles .if, tense, swollen, painful (acute myositis); pain on moving any muscle; edema; sweat; skin affections; emaciation; anemia; eosinophilia; typhoid-like state. Course.—Mild cases, 2 weeks; severe, several months. Prognosis.—Guarded ; mortality, 5 to 35 per cent. Diagnosis.—Must be differentiated from muscular rheumatism, and typhoid. Eosinophilia is significant. Treatment.—Prophylaxis is most important. If tri- ohinous meat has been eaten, at once resort to active purgation of the bowels. This must be very thorough. Follow this by doses of. glycerine. After the embryo have entered the muscles treatment must be symptomatic. Absolute rest is important. SECTION VI. THE INTOXICATIONS. CHRONIC ALCOHOLISM. (ALCOHOLIC inebriety.) Nature.—It is a diseased condition, beyond the control of the victim, and should be so treated. Regimen.—Alcohol should be absolutely withdrawn, at once. No "tapering off " is to be permitted. Substitute.—For the sake of " habit " an innocent sub- stitute is allowable. Substitutes:—In some cases, cold drinks; in others, hot water, flavored with lemon-juice, cinnamon, ginger; or, coffee; tea; cocoa; milk. After several days these can be diminished, and finally stopped. Gastric Disturbance.—Following withdrawal of the liquor, there is usually gastric irritability—nausea, vom- iting, anorexia—lasting a week or ten days. For this give effervescent drinks, in milk, and Nux vom.2* Diet.—As the sickness diminishes, give peptonized milk, broths, gruels, gradually adding easily digested meats, and wholesome fruits and vegetables; especially a liberal supply of juicy fruits—oranges, grapes, melons. Enemata.—In some cases there is complete anorexia; if food is not taken, nutrient enemata must be resorted to. Nausea.—To allay nausea:—Sip hot water; or, in other cases, take bits of ice. Wet Pack.—When there is great nervous irritability, or insomnia, the wet-sheet pack is most serviceable. MEDICINAL AGENTS. Strychnin nitrate.2*—For "tonic" effect, when the system suffers from exhaustion, this is the best agent. Dose:—The 2x; or, Jj gr., p. r. n. Hydrastis. Tr—For the chronic gastric catarrh often occurring in these cases. Dose:—Tr., 3 drops, p. r. n. Capsicum.Tr—For atony of the stomach. Kali hyd.—If there is a luetic taint. GENERAL MEASURES. Hygiene.—Perfect control of the patient is absolutely necessary. Often this can be obtained only in an insti- tution. He must have the benefit of nourishing food, fresh air, baths, exercise, occupation and mental diver- sion. Moral restraint has its place in the treatment. DELIRIUM TREMENS. (mania-a-potu.) Management.—Not a drop of alcohol, in any shape, must be given. The patient must be kept in bed in a quiet room, undisturbed by noise, excitement or visitors. Gentle efforts only at restraint should be used. Resort to mild persuasion, and make efforts to control by calm- ing and soothing the patient. But vigilance must not be relaxed for an instant. Windows must be secured, to (90) DELIRIUM TREMENS-MORPHINISM 91 _____________pocket-book of medical practice guard against accident. Leather handcuffs, secured to the sides of the bed, may be used in extremely violent cases. Diet.—This must be stimulating and nourishing. Give milk and eggs; cafe-au-lait; soups and broths, seasoned highly with pepper. Feed every 3 hours. Sustaining diet is an important part of the treatment. Baths.—The wet-sheet pack, to induce perspiration, is beneficial if the necessary restraint does not irritate the patient and lead to struggling. Stomach.—For irritability of the stomach give sips of hot water; or effervescent drinks with crushed ice. Suppression of Urine.—Hot fomentations to the loins; Arsenicum. MEDICINAL AGENTS. Hyosciue hydrobromate. — For the insomnia. Dose: —Grain j£0 ; every 4 hours. Arsenicum.3*—For the depression; gastric symptoms; and for suppression of urine. Strychnin nitrate.2*—For weak heart's action, with faint second sound. Antimonium tart.2x—Much mucous gastric disturbance; also, pneumonitis. Hyoscyamus.Tr—For the characteristic delirium; lo- quacious, incoherent muttering. Belladonna.2x—Active delirium, with much cerebral congestion. Liquor ammonii acetatis.—To promote elimination. Dose:—2 drams, given in sweetened water. It should be freshly prepared when used. Precautions.—Watch the heart, the kidneys, and the lungs ; the heart for paresis ; the kidneys for albuminuria and suppression; the lungs for pneumonitis. MORPHINISM. Control.—The first essential, without which it is use- less to attempt treatment, is to gain absolute control of the patient. Usually this is possible only in an institu- tion. Withdrawal.—In some cases the drug is entirely with- drawn at once. But this should be done only in cases not of long standing, and in which the amount is not great. Rapid withdrawal—one week—is too severe for many cases. Gradual withdrawal—three weeks—is best for the patient. First, diminish the amount one-half ; then, by insensible degrees, for 3 weeks, till none is taken. Be guided by the conditions of each case. The Patient.—During the early period the patient should be confined to bed, and cared for by a watchful and faithful attendant. Gastric Disturbance.—There is often much irritability of the stomach. Give aerated waters ; seltzer and milk ; malted milk; peptonized milk; beef-tea; broths; gruels. Gradually add to this a variety of articles of wholesome food—easily digested meats and vegetables. Lavage of the stomach. 92 PLUMBISM-HEAT-STROKE pocket-book of medical practice PLUMBISM. (lead-poisoning; saturnism.) Absorption.—It enters by the skin, or by the respiratory tract, but chiefly by the alimentary canal. Elimination is chiefly by the urine. Symptoms.—Anemia (due to disturbance of blood-mak- ing function of the bone marrow); blue line on the gum (deposit of lead sulphide in the tissues); abdominal colic; obstipation; arterio-sclerosis; "wrist-drop" (paralysis of the extensors);nephritis; encephalopathy; coma; some- times there is pyrexia, sometimes not. Diagnosis.—(a) "Lead-colic;" (b) anemia; (<:) blue line; (d) musculo-spiral paralysis. Prognosis.—Generally favorable. Unfavorable signs: —Recurring attacks; mental symptoms: coma. TREATMENT. Opium.—To be given for the colic, in sufficient dose to relieve the pain. Morph. sulph., ~%, }£ gr. Iodide of potassium.—It promotes the elimination of the lead from the system. Dose:—3 grs, 3 times daily. GENERAL MEASURES. Massage.—This favors the elimination of the lead. Electricity.—For the paralyzed muscles, galvanism; anode to the sternum, the cathode to the affected mus- cles. Diet.—Milk diet helps elimination. Drink freely of soft water. HEAT-STROKE. Etiology. — Exposure to intense heat; Sources: — Sun; furnaces; glass-works; baker's-oven; steam laundries; fire-rooms, etc. Sympt»ms.—Onset usually sudden; headache; sense of fullness in the epigastrium; nausea; vomiting; hot, dry skin; weakness; vertigo; obscuration of vision; finally unconsciousness, with stertorous breathing. The heart (syncope), lungs (asphyxia), or cerebro-spinal (apoplec- tic) system may be chiefly affected. Prognosis.—A high rate of mortality. TREATMENT. Prophylaxis.—In the hot sun, light straw hat, with a green leaf, or wet cloth in it; light clothing; drink water freely; frequent intervals of rest. If perspiration ceases, rest and a cool bath at once. The Attack.—At once (do not wait for removal to a hospital) place in the shade; remove all clothing; ice, or cold water to the head; repeated douches of cold water or ice-water to all parts of the body; use ice freely if it can be had; rub with ice. The indication is to reduce the excessively high bodily temperature as quickly as possible. Caution.—Do not reduce the temperature too much; when it falls to 102° F., rub the patient dry; if it rises, PTOMAIN-POISONING-CARCINOMA qo .________ pocket-book of medical practice bring it down again with cold bath, ice rubbings, cold pack, or cold-water enemata. Syncope.—If there is weak pulse, give heart-stimulant. PTOMAIN-POISONINGr. (food infection.) Causes.—Poisoning by ptomains, or toxalbumins de- veloped in decaying foods:—milk; meats; fish; oysters. Canned goods are especially liable. Symptoms.—Usually violent gastro-enteritis; vomiting; purging; intense colicky pains; fever; prostration. Some- times subnormal temperature, extreme depression and collapse. Prognosis.—There are many fatal cases. TREATMENT. Elimination.—Give emetics (if the stomach has not already emptied itself) and purgatives to clear the in- testinal canal. Lavage of the stomach and irrigation of the colon when called for. Stimulants.—Treat depression and weak-heart symp- tomatically. Permanganate of potash.—Make a solution (port wine color) and have the patient drink half a glass (about 3 ozs.). If rejected, repeat. CARCINOMA. THE TREATMENT OF CANCER BY TEE MITCHELL METHOD. (originated by the late J. s. MITCHELL, M. D., OF CHICAGO.) Nature of Action.—This method of the treatment of can- cer is based upon the fact that normal tissue resists the irritant action of Arsenious acid, while the tissues of new growths, having less resisting power, undergo a re- active degeneration, the cells suffer necrosis, they break down, and there is complete destruction of the neoplasm, leaving the normal tissue intact, and in a condition to heal. Class of Cases.—This method is limited to the treat- ment of external cancers—those over which the skin or mucous membrane has ulcerated, leaving an exposed surface; hence, epitheliomata, cancer of the mammas, the uterus, or of other accessible parts or organs. To create an ulcerated surface, by the use of eschar- otics, where one has not already spontaneously formed, is not advisable. Arsenious acid.2^4* —The agent used is Arsenious acid, 2%-k trit. Experience shows that the 2x is too active; the 3x fails to have effect. A trituration of equal parts of the 2x and 3x makes what is called the 2%x, which meets the conditions perfectly. But there may be an occasional case in which the 2%s. is either not active enough, or too active. Then the 2x, or the 3x, may be tried. Preparation.—The method of application is as follows: First, with a blunt-edged curette go over the ulcerated surface, removing all pieces of necrosed tissue and debris r 94 CARCINOMA-TREATMENT-MITCHELL METHOD PO . KET-BOOK OF MEDICAL PRACTICE_____________ that will readily come away, without exciting pain, or creating hemorrhage. Poultice.—When necessary a warm Elm-bark poultice, applied the day before, will create a condition favoring the removal of dead tissue. Carbolized Oil.—After the ulcerated surface has been thus cleansed, with a camel's-hair brush paint it over lightly, up to the margin of the healthy skin, with Car- bolized Linseed-oil (carbolic acid, 5%). Application.—The Arsenicum powder is now applied generally over the surface, in sufficient quantity to cover it. Dressing.—The surface is now to be covered by a thin pad of absorbent cotton. This may be secured in posi- tion by gauze bandages, or, if the area is small, and properly located, by painting over the surface and edges with Collodion. Intervals.—The dressings should be changed every 24 hours. The Arsenicum is to be applied every 24 or 48 hours, as determined by the degree of irritation produced. Effects.—The effect of the action of the Arsenicum is to excite inflammation, which is accompanied by edematous swelling (with or without pain), a serous discharge, and subsequent necrosis of tissue, with the formation of sloughs. Serous Discharge.—In some cases this is slight, in some profuse. It becomes less in amount as the case pro- gresses. Inflammation.—The degree of inflammation, with ede- matous swelling, varies in different cases. Pain.—The effect with reference to pain, varies. If, in the given case, there has previously been much pain, great relief usually follows. In other cases, previously pain- less, pain is sometimes excited, but it soon subsides. As a rule, the effect of the treatment is to give great relief from pain. Odor.—Cancers previously foul, lose their bad odor. This change is usually marked, and is a great comfort to the patient. Treatment.—At each treatment, remove the dressings. With a curette remove sloughs and all loose tissue that readily comes away. Apply carbolized oil, Arsenicum, and dress as before. Course.—The rapidity of destruction of the cancerous tissue varies in different cases. In some the neoplasm is entirely destroyed in several weeks; in others, it requires several months. With a little experience the physician will learn when to push treatment, and when to relax. Healing.—As the cancerous tissue is destroyed, heal- ing takes place from the surrounding cutaneous edges; and by the growth of healthy granulation-tissue in the base of the former ulcer. When entirely healed, scar- tissue marks the spot. Precaution.—Care should be taken that the scar-tissue is not injured. Traumatism, as from a blow, will some- times excite the carcinomatous process anew. CARCINOMA-TREATMENT-MITCHELL METHOD 95 POCKET-BOOK OF MEDICAL PRACTICE Uterine Carcinoma.—This method is applicable to the treatment of uterine carcinoma, as well as of cancers on external surfaces. In the early stage of cancer of theos healing will take place, though competent surgical ad- vice should be sought and deferred to. In advanced and inoperable cases the treatment will still make the patient's condition much more bearable by relieving pain, destroying odor, and prolonging life. After the application of the Arsenical powder, as already de- scribed, plug the vagina with tampons of cotton. SECTIQX VII. DISEASES OfThE BLOOD AND DUCTLESS GLANDS. ANEMIA. Nature.—It may involve' Oligocythemia—reduction in the number of red blood corpuscles; or, Oligochromemia —diminished amount of hemoglobin. Varieties.—(a) Symptomatic (Secondary); [b) Essential (Primary). SYMPTOMATIC ANEMIA. Causes.—Unhygienic surroundings; low diet; hemor- rhages; parasites (bothriocephalatus latus) ; infectious diseases (malaria, syphilis, tuberculosis); toxic agents (lead, mercury, zinc, copper); organic diseases (gastritis; gastric ulcer; aortic regurgitation; chronic nephritis; rickets; malignant tumors). Symptoms.—Skin, pallid, whitish, yellowish, grayish, sometimes icteric; emaciation, in some conditions; gastro- intestinal disorders common; heart, rapid; pulse, weak; palpitation; neuralgias; general weakness and depres- sion. Blood.—Insymptomaticanemiasthe condition is usually one of oligochromemia; percentage of hemoglobin, 75, 60, 50, 40, 20, 15 (Fleischel hemometer). Albumin, low; water, high. TREATMENT. Medicinal.—It is determined by the primary condition. Remedies:—China1*; Arsenicum3*; Ferrum3*; Calc. carb. 6*; Helonias^*; Plumbum^*; Phosphorus.3* General.—Liberal diet; fresh air; tonic bathing; mas- sage. ESSENTIAL ANEMIAS. (PRIMARY ANEMIAS.) CHLOROSIS. (ciiloranemia; gkeen-sickness.) Etiology.—Sex, female (rarely in the male); age, about puberty (chlorosis tarda, rarely); heredity; "delicate" constitution; bad air; insufficient food; nervous strain; fright; nostalgia; following infectious fevers. Symptoms. — Onset, gradual or sudden; skin, pale, ashen, or "greenish"; acne; cheeks sometimes flushed (vaso-motor dilatation); sclera, steel-blue; subcutaneous fat increased sometimes; palpitation; hemic murmurs; cold extremities; enlarged thyroid; epistaxis; dyspnea on exertion; gastro-intestinal disorders; nervous affec- tions; urine, pale; polyuria; amenorrhea. Prognosis.—Generally favorable. Complications.—Endocarditis; excessive hemorrhages; venous thrombosis; gastric ulcer; nephritis; tuberculosis; enlarged thyroid. (96) ^ CHLOROSIS-TREATMENT-PERNICIOUS ANEMIA 97 ____________pocket-book of medical practice Blood.—Characteristic feature, diminished percentage of hemoglobin. TREATMENT. Ferrum redactum.2*—This is the most useful remedy, and will effect a cure in many cases. Pale skin ; sudden flushings; gastralgia; chilliness ; headache; amenor- rhea, or excessive menstruation. Pulsatilla.3*—Suppression of or scanty menses ; the patient is of a mild, gentle disposition, inclined to weep- ing ; chilliness; feels oppressed in a warm room ; better in the open air ; tremulousness ; weariness ; insomnia. Graphites.3*—Menses scanty ; dry, harsh, rough skin; constipation ; acrid leucorrhea. Calcarea carb.6*—Neuralgias ; sweat about the head ; cold feet ; leucorrhea; enlarged lymph-nodes. GENERAL MEASURES. Rest.—Absolute rest in bed in severe cases, with mas- sage ; at the same time, an abundant supply of fresh air, by proper ventilation. In milder case, out-door life. Sun-baths.—Exposure of the entire body to the direct rays of the sun in a solarium. Climate.—Change to the mountains or sea shore, with open-air life, and mild exercise in cases not too weak. Diet.—Nutritious ; milk, eggs, meat and vegetables, with regard to the state of digestion. The Bowels.—Must be kept regular, and a constipated habit corrected. Hygiene.—The best hygienic and sanitary measures in all particulars. PROGRESSIVE PERNICIOUS ANEMIA. (IDIOPATHIC anemia.) Etiology.—Contributing causes are—unhygienic condi- tions; nervous shock; prolonged lactation; digestive dis- orders. Symptoms.—Onset, usually insidious; skin, a waxen- white pallor; in rare cases, transient icterus; little ema- ciation; the tissues soft and flabby; weakness and lassi- tude; some rise of temperature. Heart:—Palpitation; dilatation; attacks of syncope; dyspnea on slight exertion; digestive disturbances; anorexia; tendency to diarrhea; mental operations slow. Course.—Progressive; duration, from several weeks to several years. Blood.—Characteristic feature, great reduction in the number of the red cells. Prognosis.—Always grave; recovery is very rare. TREATMENT. Arsenicum.2*—Favorable results have followed its use. The dose must be varied in different cases; in some, give Fowler's solution, 5 to 10 drops. Avoid causing irrita- tion of the stomach. The effect upon the blood is the best criterion of the beneficial action of the Arsenic. Bone-marrow.—This may be tried. ^ 98 LEUKEMIA-HODGKIN'S DISEASE-PURPURA POCKET-BOOK OF MEDICAL PRACTICE GENERAL MEASURES. Rest.—Absolute rest, with systematic massage is helpful. Diet.—Nutritious and carefully selected; give food at frequent intervals—six meals daily. Lavage.—Lavage of the stomach and colon flushings, with saline solution; also, dermoclysis. LEUKEMIA.' (LEUCOCYTHEMIA.) Nature.—It is a disease involving disturbance of hem- atogenesis, affecting chiefly the bone-marrow, lymphatic glands, and the spleen. Etiology.—Supposed to be an infection. Symptoms.—Onset, usually insidious (rarely, abrupt); begins sometimes with pain in the spleen; or, pallor; or, fever; sometimes early symptoms are:—hemorrhages; priapism. Skin—pallid, lemon-yellow, or dusky; eczema; acne; furuncles; pruritus; subcutaneous fat well pre- served; edema; palpitation; dyspnea; enlarged lymphatic glands (the cervical most frequently); enlarged spleen; enlarged liver; gastro-intestinal symptoms. Blood.—Characteristic feature, great increase in the number of leucocytes. Course.—Essentially chronic; rarely a rapid course. Prognosis.—It is almost always fatal. TREATMENT. Medicinal.—There is no remedy having positive action. Arsenic has some advocates. Oxygen, by inhalation, is favored. Treatment is symptomatic. • General.—As in other forms of anemia. HODGKIN'S DISEASE. (PSEUDOLEUKEMIA.) Nature.—Enlarged lymphatic glands and spleen, with anemia. Symptoms.—In many respects it resembles leukemia, but is to be distinguished by examination of the blood: in pseudoleukemia the red cells are slightly reduced in number, while the leucocytes do not vary much from normal. The most striking clinical feature is shown in the enlarged lymphatic glands, the cervical glands usually being much enlarged, and strings of glands in various parts. Prognosis.—Unfavorable. Treatment.—Symptomatic and hygienic. PURPURA. Classes.—I. Primary; II. Secondary. Secondary.—It occurs in connection with:—(a)Variola; scarlatina; typhus; septicemia; cellulitis; osteomyelitis; (p)atheroma; phlebitis; thrombosis; {c) jaundice; perni- cious anemia; cachexia; (d) brain lesions. Primary. — Varieties:—1. Purpura simplex; 2. P. Rheumatica; 3. P. Hemorrhagica; 4. Hemophilia. PURPURA-HEMORRHAGIC A-HEMOPHILIA 9 9 POCKET-BOOK OF MEDICAL PRACTICE PURPURA SIMPLEX. Symptoms.—Usually small petechia? (sometimes larger spots) on the legs and other parts; it occurs most fre- quently in the anemic; ill-developed; aged; insane. The face is rarely involved. Color, first red, then brownish, green, yellow. Usually tkere are no constitutional symptoms. Treatment, symptomatic. PURPURA RHEUMATICA. (PELIOSIS RHEUMATICA.) Symptoms.—Most common in male, adults; sometimes (not always) there is a previous history of rheumatism; onset, slight prodrome; then, stiffness in muscles; pain in joints; purpuric spots, petechias and macules appear on the extensor surfaces of the legs and arms, thickest about the joints, which are swollen, red and hot; slight febrile action; urticaria; sometimes edema. Course, mild; duration, a week or two. Treatment:—Aconite; Bryonia; Rhus. _______ PURPURA HEMORRHAGICA. (MORBUS MACULOSUS WERLHOFII.) Symptoms.—Onset, often abrupt, with violent epistaxis; in other cases, slight prodrome—anorexia; gastric pain; weakness; constipation; vertigo; then petechia? and ecchy- moses in the skin—ankles, legs, thighs, body, rarely the face; mucous membranes also affected; profuse hemorrhages from the nose, stomach, bowels; in serous sacs; eye; membranes of the brain. The general condi- tion is not so serious as the great loss of blood would seem to create, tho' there is a progressive state of anemia. Course, of a single attack, 2 to 5 weeks; these may be repeated at intervals for months or years. Prognosis.—Always guarded. HEMOPHILIA. (" bleeder's disease.") Nature.—Spontaneous hemorrhage on trivial injury. Etiology.—Heredity is the chief factor. Symptoms.—The hemorrhage may be (a) traumatic; or (b) spontaneous, (a) Traumatic: — Slight injuries, as pin-scratch; extraction of a tooth; snipping the frenum; circumcision; etc. The loss of blood may be enormous, ceasing only on the occurrence of syncope, or death from cerebral anemia, (b) Spontaneous:—Epistaxis; hemate- mesis; enterorrhagia; menorrhagia; hematuria; hemor- rhages in the serous sacs, and under the skin. After the hemorrhage, anemia; exhaustion; palpitation; dyspnea; vertigo. Course:—The disease usually continues through- out life. TREATMENT. Medicinal.—In the various forms consult:—Hamamelis; Phosphorus; Mercurius; Arsenicum; Crotalus; Lachesis; Millefolium; Secale. A 100 HEMOPHILIA-GOITRE -ADDISON'S DISEASE POCKET-BOOK OF MEDICAL PRACTICE GENERAL MEASURES. Prophylaxis.—In subjects of hemophilia, avoid circum cision, vaccination; extraction of teeth, lancing gums, or other operation, however slight. "Bleeders" should never marry. Management.—In all the forms of purpura, with hemor- rhage:—Put the patient to bed; head lowered (except in epistaxis); apply ice, styptics, or compression. In epistaxis, plug the nostrils. When the patient is exsan- guine, enteroclysis, or saline injection. (Do not insert needle through the skin in hemophilia.) GOITRE. (BRONCHOCELE.) Diagnosis.—This, as a rule, is not difficult; one or both lobes may be involved. Vertical movement during deglu- tition is characteristic. TREATMENT. Iodide-of-lime.1*—In my hands this has been the most efficient remedy. I have cured several cases with it. Give the lx, 2 grs. at a dose, four times daily. Iodine.1*—A persistent course of Iodine has cured some cases, especially recent, soft goitres. Calcarea carb.6*—In scrofulous subjects. Phytolacca.Tr—Nodulated tumor; jerking, lancinating pains. Hydriodic acid.—Fair-haired subjects. Syrup of hy- driodic acid, teaspoon 3 times daily. GENERAL MEASURES. Electrolysis.—The negative pole by needle in the gland; positive to a flat electrode to another part of the gland. Injection.—Injections of Iodine.Tr- Caution—Do not penetrate a vein or the trachea. Application.—Mercurial ointment (the biniodide) by inunction. Operation.—If life is threatened by pressure-symptoms, removal is called for. ADDISON'S DISEASE. Nature.—Tuberculosis of the adrenals in most cases; degeneration of the solar plexus and semilunar ganglia of the abdominal sympathetic is thought to bear a re- lation. Symptoms.—"Bronzed skin"; pigmentation, yellowish, olive, bronze, greenish-brown, or black; deepest hue on exposed portions; mucous membrane of the lips, mouth, conjunctiva and vagina also pigmented. General symp- toms:—Progressive asthenia; gastro-intestinal symptoms —nausea; vomiting; diarrhea. Prognosis.—Unfavorable; duration, 1 or 2 years. Treatment.—Extract of supra-renal gland may be tried. Argentum nit. may relieve. SECTION VIII. DISEASES OF THE LIVER AND GALL-BLADDER. HYPEREMIA OF THE LIVER. Varieties.—(a) Active; (b) Passive. Active Hyperemia.—Causes;—Indigestible and irritat- ing food; gout; the infections of typhoid, malaria, dysen- tery; toxic agents—alcohol, mercury, carbolic acid, arsenic, nicotine; nervous shock; climate (tropical hy- peremia). Symptoms.— When acute:—Tension in the right hypo- chondrium; slight chill; fever; headache; dyspepsia, even to nausea and vomiting; diarrhea; jaundice; urine scant; high sp. gr.; increased urea; weakness; emaciation. Physical signs, those belonging to enlarged liver; some- times enlarged spleen. Diagnosis.—Active congestion is to be differentiated from hypertrophic cirrhosis by examination of the urine: in congestion there is increase of urea; in cirrhosis, de- crease. TREATMENT. Hydrastis.Tr—Pale, clay-colored stool; congestion of the liver, secondary to gastro-intestinal catarrh ; jaun- dice ; constipation ; bitter taste ; yellow-coated tongue; "gone" feeling in the epigastrium. Podophyllin.1*—Feelingof fullness in the right side, with acute pain in one spot; active congestion, with pronounced bilious symptoms; diarrhea; prolapsus ani; bitter taste; jaundice. Nux vom.2*—Enlargement and induration of the liver; shooting, pulsating pains; excessive tenderness in the region of the liver; pressure in the epigastrium and hypo- chondria, with shortness of breath; constipation; active congestion, from excess of stimulating food or alcohol. Leptandrin.2*—Aching pains in the liver, yellow-coated tongue; profuse, papescent, tar-like, very fetid stools; constant dull pain in the region of the gall-bladder; much soreness in the head and eyeballs. Mercurius dulcis.2*—Liver enlarged and sensitive; tongue with thick, yellow coating; gums swollen ; sali- vation ; fetid breath; abdomen tympanitic; jaundice; clay-colored stools; or, mucous stools, with tenesmus. Also, Merc. vivusM Iris.Tr—Pain over the liver; crampy pain in the back; flatulence in the bowels; griping pains; headache; vomit- ing; lassitude; prostration. It excites the biliary secre- tion. Sulphur 3*—Chronic cases, hepatic cases from portal engorgement. Constipation, or early morning diarrhea; frequent weak faint spells, with flashes of heat. Sepia.3*—Replaces Sulphur in women at the climac- teric. (101) 102 LIVER-HYPEREMIA-PERIHEPATITIS POCKET-BOOK OF MEDICAL PRACTICE____________ Chelidonium.Tr—Chronic congestion. Constant pain under the inner angle of the right shoulder blade; sallow skin; yellow-coated tongue; dull headache; constipation; fullness in the region of the liver. China.Tr—When of malarial origin. Magnesia inur.3*—The enlarged liver ot rachitic children. GENERAL MEASURES. DJet.—During the activ.e symptoms of an acute attack it is best to give no food for a day or two. If any food is given, let it be nothing but skimmed milk. During the active stage, this may be diluted with water. When an increase of nourishment is demanded, keep the patient on a strictly milk diet. For variety, give Vichy and milk. The patient should drink an abundance of pure water. In convalescence, and to prevent a recurrence, avoid meats, pastries, and rich and indigestible foods, as well as alcohol. Let the diet, for the most part, consist of fruits, fresh vegetables, cereals and milk. PASSIVE HYPEREMIA OF THE LIVER. Causes.—It isduetoobstructionto flowof the blood in the inferior vena cava, secondary to disease of the (1) Heart: —Valvular lesions; muscular degeneration (myocarditis; pericarditis; adhesions); Arteries:—Aneurism; arterio- sclerosis ; Lungs:—Emphysema ; asthma; fibroid degen- eration; pleurisy with effusion. Symptoms.—Enlargement of the liver; pain (dull, and deep); hepatic pulse (when secondary to tricuspid in- sufficiency); ascites (sometimes); symptoms of gastro- intestinal catarrh (secondary); hemorrhoids; and, most distinctive, the signs of the primary lesion in the heart, arteries, or lungs. Treatment.—This must be directed to the primary lesion. At the same time all extra burden should be taken off the liver by regulation of the diet. PERIHEPATITIS. Varieties.—(a) Dry; (b) Suppurative; (c) Tuberculous. DRY PERIHEPATITIS. (EXUDATIVE, OR ADHERfc-NT, PERIHEPATITIS.) Causes.—It is almost always secondary. Follows:— Traumatism (blows; tight lacing); interstitial inflam- mation; inflammation of adjacent organs (stomach; duo- denum; colon; kidneys); right-sided pleurisy. Symptoms.—Sometimes the symptoms are not pro- nounced. In other cases:—Chill; fever; pain (sharp), in- creased by motion; radiating to the angle of the scapula (the course of the phrenic nerve); hiccough (inflammation of the diaphragmatic peritoneum); friction-fremitus or friction-murmur. In rare cases, icterus. TREATMENT. Aconite.1*—Chill, followed by fever, and acute pain. It must be given early. Bryonia.1*—Acute, sharp, stitching pains, worse by motion; coated tongue, with bitter taste; constipation. HEPATITIS-PERIHEPATITIS 103 ______________POCKET-BOOK OF MEDICAL PRACTICE Mercurius dulc.2*—Swollen tongue, with imprints of the teeth; soreness of the gums; salivation; anorexia; per- spiration. Chelidonium.2*—Sharp, stitching pains, radiating to the right shoulder; abdomen sensitive; anorexia; alter- nating diarrhea and constipation. Sulphur.lx—Slow convalescence; signs of unresolved exudation. Hemorrhoids. Kali iod.—When of syphilitic origin. General Measures.—For the acute pain, hot compresses. Complete rest. Milk diet. SUPPURATIVE PERIHEPATITIS. (SUBPHRENIC ABSCESS.) Nature.—A collection of pus between the upper convex surface of the liver and the under surface of the dia- phragm. Note.—Abscess may be infra-hepatic, but, as it is in the nature of an encysted suppurative peritonitis, it will be left out of consideration. Causes.—Streptococcus infection, following—Trauma- tism; superficial hepatic abscess; echinococcus cyst (sup- purative); perforation of bile-duct; ulceration of the stom- ach or duodenum; appendicitis; empyema (right side); pyemia; septicemia. Complications. Empyema; pericarditis; perforation of the lung. Symptoms.—General:—The onset may be insidious, or abrupt. Pain, extending to the shoulder; rapid respira- tion. Connected with the abdomen—Meteorism; vomiting; hiccough. Chills, with fever, intermittent in type. Ob- jective:—Swelling (way be absent); sense of fluctuation (sometimes); on percussion, dulness in an upward-curved line, as high as the fourth rib. Perforation.—The abscess may perforate internally or externally. The latter is rare. Internal:—Into the stom- ach or intestines (when adhesions favor); peritoneal cav- ity; thoracic cavity; lung; pericardium {rare). TREATMENT. Medicinal.—Hepar. sulph.—Mercurius.—Silicea. Surgical.—It soon becomes a surgical condition, and should be so treated. TUBERCULOUS PERIHEPATITIS. Nature.—Usually it is secondary to tuberculosis else- where—the peritoneum, or acute miliary tuberculosis. In some cases it may be primary. The symptoms are similar to those of suppurative perihepatitis. The treat- ment should be as for tuberculous peritonitis. ACUTE SUPPURATIVE HEPATITIS (ABSCESS OF THE LIVER.) Etiology.—It is due to infection by various micro- organisms, the streptococcus, staphylococcus, bacillus coli, bacillus fetidus, and others. Climate (tropical) predisposes. Malaria is not a determining cause. Mode of entrance:—In most cases it is secondary to dysentery, the bacteria being conveyed to the liver from intestinal 104 ACUTE HEPATITIS-TREATMENT POCKET-BOQK OF MEDICAL PRACTICE_____________ ulcers by means of the portal circulation. (In 314 cases of hepatic abscess dysentery co-existed in 268.) Infec- tion may be—Direct, as in stab-wound ; traumatism; by metastasis:—venous emboli from any purulen. focus in the trunk of the portal vein, as suppurating hemorrhoids; suppurative inflammation of the spleen, kidneys, pan- creas, stomach, intestines, uterus, ovaries, appendicitis, or purulent inflammation of the portal vein itself. The embolus may consist of necrotic tissue, masses of pus, or bacteria alone. Intestinal ulcers are the most common sources ; tuberculous ulcer never, since they produce obliteration of the veins ; typhoid ulcers rarely. Other sources:—Suppuration of bones; biliary calculus; pyemia. Arterial metastasis:—From septic endocar- ditis ; pulmonary abscess. The New-Boru.—Hepatic abscess in the new-born is due to suppurative phlebitis of the umbilical vein. Symptoms.—In some cases the symptoms are obscure, and the hepatic abscess is undetected. In others, there is a quotidian fever, resemblingthe paroxysms of malaria. Absence of the Plasmodium in the blood will distin- guish. In other cases, the symptoms make the case re- semble typhoid. Characteristic Symptoms:—Fullness in the right hypo- chondrium; friction-fremitus; pain, increased by press- ure or motion; bilious vomiting; slight jaundice {% of cases); perspiration. The local signs (enlargement, pain, etc.) are most important in diagnosis. The urine shows hypoazoturia. Sub-acute and chronic forms of hepatitis also occur. Diagnosis.—When the symptoms are not clear, confirm the diagnosis by use of the exploring-needle. Insert the needle :—(a) Over a distinct tumor ; (b) in the absence of tumefaction, where there is a spot of distinct pain on pressure, edema of the skin, or obliteration of an inter- costal space ; (c) no local signs, but every evidence from the general symptoms. Use all antiseptic precautions. Course.—Recovery, with reabsorption of the pus some- times, though rarely, occurs. Usually the abscess opens, either externally or into other parts. External:—Usu- ally, through the skin over the hepatic region. It may open elsewhere—the axilla, umbilicus, inguinal ring. Internal:—Thoracic cavity; lungs; abdominal cavity; stomach; colon; pelvis of the right kidney; ascending vena cava; pericardium. Prognosis.—Always guarded. The mortality rate is very high. Multiple abscess is especially unfavorable. TREATMENT. Belladonna.2*—Early in the attack; throbbing, and op- pressive pain in the region of the liver, extending to the shoulders; worse on motion; nausea; retching; vomiting; fever. Mercurius vivus. 2*—Fullness in the right hypochon- drium; burning pain; anorexia; thirst; jaundice; sweat- ing, without relief. CIRRHOSIS OF THE LIVER-TREATMENT |05 _______________POCKET-BOOK OF MEDICAL PRACTICE Bryonia.1*—Sharp, stitching pains, indicating inflam- mation of the peritoneal covering. Of no use for the suppuration. Hepar sulph. 6*—To favor reabsorption of pus. Lachesis.3*—In cases with enlarged liver, especially in alcoholics. Quin. ars.2*—When there are chills, fever and sweat. GENERAL MEASURES. Applications.—For the acute pain, hot fomentations. Or, the ice-bag, which also will tend to retard suppura- tion. Diet.--A nourishing and supporting diet, chiefly of milk and broths. Surgical.—As soon as the presence of abscess is dem- onstrated, operate at once. Make a free opening directly over the purulent focus, cleanse with antiseptic solution, and provide drainage. In multiple abscess, do not operate! CIRRHOSIS OF THE LIVER. (CHRONIC INTERSTITIAL HEPATITIS; HOB-NAIL LIVER.) Nature.—It is due to chronic inflammation, with prolif- eration, of the interstitial connective tissue of the liver, and hypertrophy. This is followed later by secondary contraction and sclerosis. Etiology.—The determining factors are:—Alcohol (the more concentrated the form of alcohol, the more intense its action); toxic agents—lead, copper; infective agents— malaria, syphilis; auto-intoxicants, from intestinal prod- ucts (skatol, indol). It is suggested that alcohol acts in- directly, by first producing intestinal indigestion, result- ing in the formation of ptomains, which act as irritants to the liver. Symptoms.—In some cases the disease pursues a latent course. In the primary stage—hypertrophy—attention may not be directed to the liver. Early symptoms:— Loss of appetite; sense of weight in the epigastrium; gastric and intestinal indigestion; eructations; vomiting; constipation, or alternating diarrhea. Severe pain in the hypochondrium if there is perihepatitis. Liver—in this stage—enlarged. Later:—Atrophy of the liver; caput medusae; ascites; enlarged spleen; gastric and intestinal hemorrhages; scanty urine; emaciation; edema of the lower limbs. Duration.—Most cases, 12 to 18 months; rarely, many years (10-15). Causes of Death.—Asthenia; or from one of the compli- cations. Prognosis.—Generally fatal; but in the early stage re- covery is possible. Complications.—Pneumonitis; pleurisy; dysentery; erysipelas; peritonitis; hemorrhages. TREATMENT. Arsenicum.3*—For the gastric catarrh, in alcoholics; irritable stomach. 10R LIVER-CIRRHOSIS-MALARIAL-SYPHILIS '"" POCKET-BOOK OF MEDICAL PRACTICE______________ Nux rom.2*—For the gastric complications in high livers. Mercurius dulcis.2*—Intestinal catarrh. Podophyllum.2*— As an intercurrent. Phosphorus.3*—This has the reputation of having aided in the cure of a number of cases. Aurum uiur.2*—It is adapted to the sclerotic process. Iodine.1*—A persistent course of Iodine has been curative. Kali hyd.—In syphilitics. GENERAL MEASURES. Rest. —Keep the patient at rest. Stop the use of alcohol, spices, and rich and hearty food of all kinds. [)iet.—put the patient on an absolute milk diet. Give the milk in any form in which it can be taken, and per- sist in its use. Much depends upon this. Lavage.—In irritable stomach, lavage is useful. Ascites.—Remove the fluid by paracentesis, if it cannot be kept down by saline purgatives. Do not wait until there is great accumulation. Paracentesis.—Cleanse the skin of the abdomen, making it aseptic. See that the bladder is empty. Introduce aspirator needle, or trocar-and-canula, at a point in the median line midway between the umbilicus and the pubes. Use local anesthesia. Put a broad binder about the abdomen, with the ends crossed behind, and draw upon this, compressing the abdomen, as the fluid is withdrawn. Climate.—Removal to a cool, dry, non-malarial climate will promote the cure.________ MALARIAL LIVER. Nature.—It is an intense hyperemia of the liver, with enlargement, caused by malarial infection. It may be acute or chronic. Acute:—Great enlargement of the liver, with pain; fever, intermittent or remittent; gastro-intesti- nal symptoms; icterus; enterorrhagia; meteorism; en- larged spleen; sometimes ascites; scanty, acid urine. Chronic:—Liver enlarged; slight jaundice; cachexia; en- larged spleen; urobilinuria. The acute form is often fatal. Treatment.—Quinine; Arsenic; milk diet. Inthechronic form, change of climate. SYPHILITIC LIVER. Occurrence.—Of the organs of the body, after the testi- cles and brain, the liver suffers most frequently from spe- cific infection. It may occur in infants (in the hereditary form), or in the adult, after infection. Forms.—Affection of the liver in the secondary stage is rare; it takes the form of catarrh of the bile-ducts. In the tertiary stage, when it is most common, it occurs as gummatous nodular hepatitis. Symptoms.—Secondary form:—Icterus; fever; lassitude; headache; enlarged liver. The symptoms resemble those of catarrhal icterus, and must be differentiated from LIVER-TUBERCULOSIS-ECHINOCOCCUS 107 POCKET-BOOK OF MEDICAL PRACTICE them—by history of specific infection; absence of gastro- intestinal symptoms. Duration—a few weeks to several months. Tertiary Form.—Gummatous hepatitis. It may run a latent course. Generally, there is:—Progressive emaci- ation; malaise; digestive disturbances; local pain, slight and dragging, or severe and lancinating; prominence of the right hypochondrium; ascites; slight jaundice. Pal- pation:—Liver irregularly enlarged, with a hard nodular surface; the anterior border distorted with eminences and grooves. Hereditary Form.—When the fetus is affected, hydram- nion in the mother. Post-natal symptoms, as in heredi- tary syphilis (page 34), with the addition of a much en- larged liver. Treatment.—This should be anti-syphilitic, with Mer- cury and Kali iod., p.r.n. Favorable results may be looked for. TUBERCULOUS LIVER. Nature.—When the liver becomes tuberculous it is usually secondary to tuberculosis of other of the digestive organs. Diagnosis depends upon careful physical ex- amination. It is somewhat enlarged; pressure causes pain. The spleen is also usually enlarged. ECHINOCOCCUS OF THE LIVER. Cause.—Accidental ingestion of the ova of the Tcenia echinococcus, through contact with dogs. Symptoms.—Latent:—It may pass undetacted if the cysts are small and deep-seated. When large and superficial: —A smooth, elastic tumor in the right hypochondrium; by palpation fluctuation may be felt; on percussion, a dull area, continuous with liver substance. When on the convex surface, development is upward into thoracic cavity; on the postero-inferior surface, it develops down- ward into the cavity of the abdomen. General Symptoms: —There is an absence of symptoms of hepatic insuffi- ciency. Urticaria is common. Course.—Spontaneous resolution may occur (this is rare). Suppuration with signs of abscess. Rupture: —This is the usual mode of termination. It may be into the peritoneal cavity; or, if there have been adhesions, into other parts, or externally. Diagnosis.—The diagnosis is not always clear. Intro- duce needle and secure some of the fluid. Inquire into history of contact with dogs. Treatment.—Surgical methods alone will accomplish anything. The cyst should be completely evacuated by aspiration. Or withdraw 7}^ drams of the cystic fluid, and inject 5 drams solution Merc, bichlor., 1:1000. Op- erative procedure involves a laparotomy. NEOPLASMS OF THE LIVER. Varieties.—Carcinoma; Adenoma; Sarcoma; Fibroma; Angioma. 108 LIVER-CANCER-YELLOW ATROPHY POCKET-BOOK OF MEDICAL PRACTICE CANCER OF THE LIVER. Etiology.—(a) Primary; (b) Secondary. Primary.—It occurs generally in the aged; men more than women. Secondary.—Usually secondary to cancers in the realm of the portal system—stomach; rectum; intestines; pan- creas. Or, by arterial metastasis, from the breast; uterus; testicles. Symptoms.—(a) Cachexia; (b) Progressive hypertrophy. Cachexia:—This is characteristic, with profound ema- ciation, and a thin, straw-colored skin. Hypertrophy:— The liver rapidly enlarges, sometimes to enormous size; the surface is irregular and nodular; hard, early; late, when there is broken-down tissue, soft. Pain, some- times vague; at others, piercing and lancinating. Icte- rus, sometimes to a greenish or bronze hue. Ascites (3 in 5). Gastro-intestinal symptoms are common. Phlegmasia alba dolens. The blood shows progressive anemia. Late, there is fever, from absorption of toxic products. Death is from asthenia. Treatment is purely symptomatic; Morphine for the re- lief of pain is demanded. ACUTE YELLOW ATROPHY. (ICTERUS GRAVIS; PERNICIOUS JAUNDICE.) Etiology.—It sometimes occurs after septic fevers; syphilis; in pregnancy; depressing emotions; sometimes endemic; poisoning by phosphorus, arsenic, antimony. The disease iis probably due to a toxic agent, at present not identified. Liver.—It is reduced in size to % or H of normal. If death occurs early, there is but little atrophy. Symptoms.—Early stage:—Anorexia; nausea; vomiting; diarrhea; dull pain in the liver; jaundice. These pro- dromal symptoms may be absent. The disease is marked by—Intense headache; chill; depression; diffuse pains; vomiting; fever; icterus; hemorrhages; petechia?; restless- ness; insomnia; sometimes delirium. Objective:—Di- minished area of dulness over the liver; the spleen is much enlarged. Diagnosis.—This depends upon:—Jaundice; nervous symptoms (headache, delirium; coma); hemorrhages; atrophyof liver; enlarged spleen; hypoazoturia. Duration.—Exceptionally, death occurs in a few days; often it runs its course in about two weeks. There are very few recoveries. Treatment.—Give Phosphorus,3* persistently. A rigid milk diet. Otherwise, treat symptomatically. LIVER—AMYLOID DEGENERATION. Nature.—It is secondary to various cachectic conditions (tuberculosis; Bright's; syphilis); especially following long-continued suppuration of the bones, and"other parts or organs. LIVER-CATARRHAL JAUNDICE-TREATMENT ing ______________POCKET-BOOK OF MEDICAL PRACTICE Symptoms.—It may run a latent course. The signs are chiefly objective, there being few general symptoms until late. Liver.—It is much increased in size, sometimes enor- mously; the surface smooth, and hard. Late there are intestinal symptoms—profuse mucous diarrhea; anemia; marasmus; death from asthenia. Treatment must be directed to the primary condition. CATARRHAL JAUNDICE. Cause.—Catarrhal inflammation of the mucous mem- brane of the larger bile ducts, by extension from the duodenum. Due to irritation from ill-regulated diet. Symptoms.—Nausea; vomiting; eructations of gas; acid- ity; gastralgia; diarrhea or constipation; urobilin; stools clay colored; yellowish skin; slow pulse; cutaneous pru- ritus; xanthopsia. Local:—the liver sensitive; the gall- bladder distended. ,J Diagnosis.—In the jaundice of hypertrophic biliary cirrhosis the stools are always colored with bile; in catarrhal jaundice they are clay-colored and cretace- ous. In old age an increasing icterus after 4 or S weeks, indicates a malignant neoplasm of the liver. Duration.—Usually from one.to two weeks. If pro- tracted, nutrition is impaired, and the patient becomes weak and depressed. Prognosis.—Almost always favorable. TREATMENT. Mercurius dulcis.2*—Duodenal catarrh, with extension of the inflammation to bile ducts ; complete jaundice; skin very yellow; thickly coated, flabby tongue ; nausea; vomiting; loathing of food; grayish-white feces; diar- rhea ; tenesmus ; urine scanty and dark-red ; pain in the region of liver; icterus neonatorum. Chelidonium,2x—Yellowness of eyes and skin ; pain in the liver and right shoulder; bitter taste ; tongue clean, of deep-red color; stool white; urine dark-red ; the re- gion of the liver distended and painful. China.3*—Gastro-duodenal catarrh, particularly after great loss of animal fluids, or in malarial jaundice; op- pressive headache; perverse appetite, with canine hun- ger ; dingy-yellow complexion ; liver swollen, hard, and tender, with spasmodic, stitching pains. Hydrastis.Tr—Gastro-duodenal catarrh ; sense of sink- ing and prostration at epigastrium, with violent and continued palpitation of the heart. Podophyllin.^—Enlargement of the liver, with severe pain; urine scanty, and dark-yellow ; stools clay-colored; nausea and vertigo. In complication with gall-stones. Duodenal catarrh. Aconite.1*—Fever; stitches in the liver; yellow skin; scanty, dark urine ; clay-colored stools ; local pain; in- flammatory symptoms; or, prostration ; vomiting ; op- pression of chest ; blue nails; cadaverous countenance ; cold extremities ; feeble pulse ; collapse. 110 JAUNDICE-CHOLELITHIASIS-TREATMENT "V POCKET-BOOK OF MEDICAL PRACTICE______ Nux. voin.2*—Gastric symptoms; after errors in diet; subjects of chronic constipation. Kali hi.3*—Nausea ; yellow-coated tongue. GENERAL MEASURES. Diet.—This must be simple; let it, if possible, consist entirely of skimmed milk. Give pure water freely. The Bowels.—Use irrigation of the colon. Naphthalin, 2 grs., in capsule, as a disinfecting agent. Baths.—A warm bath each night. CHOLELITHIASIS. (GALL-STONES 5 BILIARY CALCULUS.) Size.—From "gravel," to the size of a pea, pigeon's egg, or hen's egg. Number.—One, to many ; shape, round, or faceted, from mutual attrition. Frequency.—About /5 of all persons have gall-stones, for the most part undetected during life. Women suffer more frequently than men. Impaction of a stone causes "gall-stone colic." Location.—Impaction may occur :—(a) In the cystic duct; (b) in the hepatic duct; (c) in the ductus communis choledicus. r Symptoms. —Distention of the gall-bladder, but no impac- tion:—Sense of discomfort in the right hypochondrium, of increasing severity; vomiting; pain (but not colic) extend- ing to the scapula; tympany; obstipation. Impaction in the cystic duct:—Severe, colicky pain in the right hypo- chondrium, reaching its height in a few hours; nausea and vomiting; no jaundice; lessened diaphragmatic respi- ration; rigidity of the muscles of the hypochondrium. The colic may persist for hours, or, sometimes, days, when there is sudden relief with the escape of the stone. In the hepatic duct:—The symptoms are similar to the previous, but without the colicky pains; jaundice in some cases. In the ductus choledicus:—Sudden onset of intense colicky pain; nausea; vomiting; sensitiveness of the right hypochondrium; weak pulse; depression; cold, clammy skin; sometimes collapse; jaundice. In all instances the diagnosis is confirmed by detection of the calculus in the stool, after the attack. Complications.—There may be local infection, and ab- scess; rupture of the duct; permanent occlusion. Prognosis.—In majority of cases, favorable termination in a week or more. TREATMENT. Berberis.Tr—Give at the time of the attack. Also, after, for pain, soreness and burning. Arsenicum.3*—To excite reaction after a severe attack. China.—To correct the tendency to the formation of gall- stones, give according to the following method:—China,1** six pills twice a day, till ten doses are taken; then six pills every other day, till ten doses are taken; then every third day, till ten doses are taken; and so on, till at length the dose is taken only once a month. "I have not CHOLELITHIASIS-GENERAL MEASURES HI ___________ POCKET-BOOK OF MEDICAL PRACTICE failed to cure, in a single instance, permanently and radically, every patient with gall-stone colic who has taken the remedy as directed."—Dr. David Thayer. Chelidonium.1*—This has acted curatively in numerous cases. Nux vom.2*—Gastric symptoms, characteristic of the drug. Calc. carb.6*—In women who put on fat; local sweats; profuse menstruation. GENERAL MEASURES. Object.—[a) To relieve pain; (b) prevent recurrence. Pain.—Chloroform, by inhalation, just enough to give relief. Morphine, %-yz gr. Theuseof this agent should be avoided when possible. Applications.—Hot compresses; hot poultices. Baths.—Hot baths; hot-water rectal irri- gation. Recurrence.—Diet:—Reduce the amount of sugar,starch and fat. Water:—Alkaline waters—Saratoga; Manitou; White Sulphur; Carlsbad; Vichy; Kissingen. Drink large quantities, from 2 to 4 qts. a day. Operation.—In protracted and threatening cases surgi- cal measures must be considered. SECTION IX. DISEASES OF THE INTESTINES AND PERITONEI1}!. CATARRHAL ENTERITIS. (INTESTINAL CATARRH; DIARRHEA.) Varieties.—Acute; Chronic. Etiology.—Acute:—Due to various irritants, which ex- cite catarrhal inflammation of the intestinal mucous membrane. Chronic.—Follows acute; or, chronic from the outset, as a result of frequently repeated irritation; or, secondary to other diseased conditions. Symptoms.—Pathognomonic sign—diarrhea (this may be absent in catarrh of the upper intestine; or, if the colon performs its function and solidifies the intestinal contents). Other symptoms—abdominal pain; pressure and fullness; anorexia; malaise. In the chronic form there may be atrophy of the mucous membrane, with anemia and debility. Location.—Duodenum:—Jaundice; in the absence of jaundice—tenderness in the right hypochondrium; much mucus in the stools. Jejunum and ileum:—The pres- ence of indican in the urine. Colon:—^Colicky pains in the right iliac fossa; itching and burning at the anus; passage of blood-streaked mucus. TREATMENT. Aconite.1*—After cold or damp; or checked perspira- tion, frequent, scanty, loose, green stools, with tenesmus, fever, and restlessness. Gelsemiuin.Tr—Diarrhea in nervous subjects; excited by sudden depressing emotions. Ferrum phos.2*—Caused by checked perspiration; slight fever. Cuprum ars.2*—Crampy, colicky pains; restless toss- ing; tenesmus of the rectum and bladder. Aloes.3*—Pain and rumbling in *he bowels before stool; escape of great quantities of flatus with stool; con- stant urging to stool; stool involuntary, with escape of flatus; stool seems to pass without exertion; after stool sensation as if more in the rectum. Veratnun alb.1*—Diarrhea, violent, painful, copious, with profuse perspiration; stools watery, sudden, invol- untary. It is useless in painless cases. Arsenicum.3*—Watery, mucous, or bloody discharge; great weakness, faintness, and rapid exhaustion; thirst and restlessness; burning in the rectum; emaciation; pallor; sunken cheeks; stools watery, fetid, painless; great restlessness and exhaustion after the stool; sticky perspiration. Antimonium.2*—Stools watery and profuse, with dis- ordered stomach and white-coated tongue; alternate con- stipation and diarrhea. Gastric symptoms predominate. (112) CATARRHAL ENTERITIS-TREATMENT u] _______________POCKET-BOOK OF MEDICAL PRACTICE Apis mel.3*—Stools greenish, yellowish, slimy mucus, or yellow watery ; tongue dry and slimy; little or no thirst ; hands blue and cold. Absence of thirst, with dry tongue, and dry, hot skin, are characteristic. Colocynth.1*—Severe colic, relieved by bending double. Bryonia.1*—Diarrhea in hot weather; stools brown, thin, fecal, or containing undigested matter; aggrava- tion in the morning as soon as he moves. Dulcamara. 2*—Stools yellowish, greenish, watery, with colic. From "taking cold" in cold, damp weather. Ipecac.3*—Stools as if fermented, green, with nausea and colic ; frequent stools of greenish mucus. Continuous nausea is the most constant distinctive symptom. Ckamomilla.3*—Green, watery passages, often mixed with feces and mucus. Early childhood, during the process of teething, and from taking cold. Iris.Tr—Bilious stools and bilious vomiting, with nausea and headache, in hot weather, with much ex- haustion and debility. Croton.3*—Yellow, watery, or greenish-yellow stools, expelled with great force. Characteristic symptoms, yellow watery stool, sudden expulsion and aggravation from food and drink. Mercurius dulc.2*—Stools slimy, bloody, brownish, whitish-gray, acrid, and burning ; cutting, pinching pain in abdomen, with chilliness ; bilious stool, pre- ceded by colic, followed by tenesmus. Argentnm nit.2*—Eructations from the stomach; mucus, but little tenesmus. Podophyllin.6*—Early morning diarrhea; stool fre- quent; painless, yellow liquid, with meal-like sediment. Sulphur.3*—Diarrhea some hours after midnight, or driving patient out of bed early in the morning. Stools pappy, greenish-yellow, fetid, slimy. Early morning diarrhea very characteristic. China.2*—Frequent, watery stools, containing undi- gested matter, with pinching colic, occurring especially at night. Phosphoric ac.3*—Diarrhea not debilitating, though of long continuance; involuntary, with emission of flatus; stool thin, whitish-gray. Gummi gutt.3*—Yellow or green stools, mixed with mucus, preceded by excessive cutting about the umbilicus; sudden expulsion; morning aggravation. Calcarea carb.6*—Scrofulous subjects; distended abdo- men, with emaciation; whitish or watery stools; chronic diarrhea, with chalk-like stools. GENERAL MEASURES. Diet.—This must receive first attention; in acute at- tacks, the less food the better; no solid food; withhold all food for 12 hours; then give barley-water, gruel; later, mutton-broth, whrch may be thickened with rice or cracker-crumbs. Make gradual return to ordinary diet. Rest.—Absolute rest on the back. 4. DUODENAL ULCER-CONSTIPATION ' '*" rOCKET-BOOK OK MEDICAL PRACTICE______________ ULCER OF THE DUODENUM. Cause.—Peptic digestion of a spot impaired in its nu- trition owing to circumscribed failure of circulation. Symptoms.—In many cases, no signs; discovered only on autopsy. In others, intense pain at the right lower border of the liver; comes on 2to 3 hours after a meal; radiates towards epigastrium and sacrum; a spot sensi- tive on pressure, to right of the parasternal line. The most important diagnostic symptom is hemorrhage, by the bowels, or hematemesis. Diagnosis during life is rarely made. The symptoms most resemble gall-stone colic. Proguosis.—Contraction and stenosis usually follow healing; fatal hemorrhage may occur. Treatment.—Essentially the same as for ulcer of the stomach. Give Kali bich.3* HABITUAL CONSTIPATION. Causes.—Various; faults of diet; irregular habits; sedentary life; intestinal inertia; portal congestion; pelvic growths or adhesions. TREATMENT. Sulphur.3*—Portal congestion; hemorrhoids; itching and burning of the anus and rectum; hyperemia of the liver; sense of fullness, tightness in the abdomen; reple- tion after taking a small quantity of food; alternate con- stipation and diarrhea; flushes of heat; frequent weak, faint spells. The tincture of Sulphur may be used. Nux voin.2*—Gastric disturbances, due to rich and abun- dant diet; sedentary life; after abuse of drugs; frequent, ineffectual urging; stool large, hard, passed with diffi- culty; hemorrhoids. Plumbum acet.0* — Retraction of the abdomen, the muscles hard and tense; cramp-like pains; sense of con- striction of the sphincter ani; stools dry and hard; the chief indication is the constant presence of a spasmodic, cramp-like pain. Opium.Tr—A complete torpor of the bowels, and intes- tinal paresis; abdomen much distended; stools hard and lumpy. Obstipation after acute diseases. Lycopodiuin.6*—Acidity and heartburn ; rumbling in the bowels; distension of the abdomen; ineffectual urg- ing; stools hard, scant, and passed with difficulty. Hydrastis.Tr-—Headache; hemorrhoids; severe pain in the rectum after stool for hours; after abuse of purga- tives; hard stool, coated with mucus; sinking feeling in the epigastrium. Dose:—Drop of Tr. once daily before breakfast for a week. Platina.6*—Difficult expulsion of soft stool; frequent urging, great straining, passing but small quantities; putty-like stool, sticking to the anus; constipation while traveling. Graphites.6*—Stools large, hard, and knotty; tendency to cutaneous disorders. ^_____________________________________ CONSTIPATION-INTESTINAL OBSTRUCTION 11b _______________POCKET-BOOK OF MEDICAL PRACTICE______________ ■Esculus.Tr—Dryness of rectum, feeling as if full of small sticks; painful hemorrhoids,with severe backache. Bryonia.1*—Hard, large, dry stools; chilliness; pain about the liver; rheumatic tendency, accompanied by symptoms of indigestion; frequent eructations after meals; headache. Nitric ac.3*—Stools hard, dry and scant, and passed without pain; headache; sour or bitter taste after eating; sour eructations; excessive flatulence. Ignatia.2*—Constipation, with prolapsus of rectum on slight effort to evacuate; creeping, itching sensation in the abdomen. Collinsouia.Tr—Hemorrhoids ; sharp, sticking pains in the rectum ; stool slightly blood-tinged. , GENERAL MEASURES. Diet.—Drink a glass of oatmeal-water every morning on rising; take effervescent drinks ; drink an abundance of water; eat butter and fats; take fresh fruits and vegetables ; brown-bread; wheaten-grits ; sauer-kraut. Avoid—Tea, coffee, wine, beer, pork, veal, salt meats, cheese, beans, cakes, pastry, pickles, biscuit, fresh bread, muffins, griddle-cakes. Baths.—Cool sitz-bath ; sponge-bath to the abdomen, using warm and cold water alternately, in rapid succes- sion. Massage.—Kneading of the abdomen, especially follow- ing the line of the colon. Electricity.—The sinusoidal current is very effective; the galvanic or faradic may be used. Posture.—The squatting position, over a low vessel, instead of on a raised seat, is of much aid. Habit.—Persist in regularity of habit. Enemata.—Injections should not be relied upon ; they lose their effect, and in time a condition of paresis re- sults. Exercise.—Those of sedentary habit must indulge in active exercise. ________ INTESTINAL OBSTRUCTION. (ILEUS.) Varieties.—(a) Internal incarceration (peritoneal bands; adhesions; Meckel's diverticulum; mesenteric perfora- tions; internal hernia); (b) Volvulus (twisting); (c) In- tussusception (invagination); (d) Obturation (gall-stones; enteroliths); (e) Compression; (/) Paralysis (circum- scribed). Symptoms.—Onset, usually colicky pain; meteorism; dyspnea; weak pulse; eructations of gas; vomiting—food, bile, fecal matter; cold sweat; dry mouth; great thirst; whispering, hoarse voice; cold extremities; pinched face; sunken eyes; collapse. TREATMENT. Purgatives.—Never to be given. Morphine.—If the pain is severe, give an opiate, sub- cutaneously; never by the mouth. Dose:—}i, l/i gr. 116 ILEUS-HEMORRHOIDS- TREATMENT POCKET-BOOK OF MEDICAL PRACTICE Irrigation.—Irrigate the lower bowel freely; repeat. Lavage.—Lavage of the stomach relieves distressing symptoms; repeat. Massage.—Be very cautious in its use. Diet.—Give supporting diet and stimulants persist- entty; per rectum if necessary. Water.—May be given freely. Reposition.—If there is prolapse at the rectum, reposit with the oiled finger. Operation.—Call in a competent surgeon early; after the second day the mortality is much increased. Indications.—Operate early with:—Sudden onset; vio- lent pain, with much distension; vomiting early, profuse, stercoraceous vomiting. Collapse.—Early profound collapse does not contra-in- dicate operation. Sigmoid.—In complete volvulus of the sigmoid (indica- tions:—Intense pain near the umbilicus; great and rapidly increasing tympanites; tenderness on pressure in the left iliac fossa) operate immediately. HEMORRHOIDS. (PILES.) Varieties.—External:—Arising from the subcutaneous connective tissue of the anus. Internal:—Arising from the submucous tissue of the mucous membrane, above the internal sphincter. Etiology.—Secondary to portal congestion, from (a) sed- entary habits, or (b) over-eating. Also, pressure of the gravid uterus, or other bodies; hepatic cirrhosis; any stasis in the vena cava inferior. Diagnosis.—Confirm by local examination. TREATMENT. Sulphur.TiwBleeding, burning and frequent protru- sion of the piles; stinging, burning and soreness in and about the anus; itching and tenesmus after a soft or bloody stool; alternate constipation, and discharge of blood-streaked mucus. iEsculus hip.Tr._Hemorrhoids of a purple color, very painful, with burning sensation; itching, burning pains, with sensation of fullness and dryness of rectum; slight hemorrhage; severe aching pains in back; constant and severe backache, extending to sacrum and hips; stool hard and dry, passed with difficulty, followed by sensa- tions of constriction, fullness, dryness and pricking pains in the rectum. Hamamelis.Tr—Profusely bleeding hemorrhoids. Burn- ing, itching and rawness of anus; weakness of back— feels as if it would break; discharge of large quantities of dark blood. True varicosis, with excessive hemor- rhage. Collinsonia.Tr—Blind or bleeding piles, with sticking pains in the rectum; obstinate and habitual constipation; stools lumpy and light-colored; uterine disorders; con- gestive inertia of the lower bowel. PILES-TREATMENT—CHOLERA MORBUS 117 _______________POCKET-BOOK OF MEDICAL PRACTICE Aloes.Tr—Hemorrhoids, with flow of hot, blackish blood; hemorrhoids protrude, like bunch of grapes, with constant bearing-down in the rectum; great heat and tenderness of the tumors, relieved by cold water; heat in the bowels, and heat and painful pressure in the liver; painful inflammation of the tumors. Nux v.2*—For blind or bleeding piles. From abuse of spirituous liquors, or sedentary habits; bleeding, burn- ing and frequent protrusion of the piles; abdominal plethora; tearing, pressing, bruised pain in small of back; habitual constipation. Capsicum.3*—Burning and itching. Ferrum.^ — Ca- chectic constitutions. Aconite A*—Inflammation of tumors. Hepar sulph.Z*—Chronic hepatic affection. Arsenicum.3* —Emaciated subjects; burning pain. Podophyllin.!*-— Portal congestion; bilious subjects. GENERAL MEASURES. Hygiene.—Open-air exercise; restricted diet; regular habits; avoid soft cushions and feather-beds. Go to stool shortly before bedtime. Diet.—Avoid coffee, peppers, spices, stimulating or highly-seasoned food, beer, wine, spirits; and do not over-eat. During attack, no meats; vegetables and fruits are best. Women.—Uterine disorders must be corrected. Local.—Excoriations:—Ointment, Vaseline and Boracic acid. Inflammation:—Belladonna cerate; injections of ice-water; or, hot compresses; or, sit over steam vapor; injections of hot water and Hamamelis. Suppositories.—Suppositories containing—Collinsonia; iEsculus; Hamamelis; Aloes, according to indications. Operation.—If it resists treatment—operate. Indica- tions:—Pain; strangulation; prolapse; interference with defecation. _______ CHOLERA MORBUS. (CHOLERA NOSTRAS; INDIGENOUS GASTRO-ENTERITIS.) Causes.—The toxic effects of partly decomposed food of various kinds. Symptoms.— Prodrome:—Moderate diarrhea; nausea; abdominal pains; flatulence. Or, sudden onset, with:— Abdominal pain; malaise; nausea; vomiting; diarrhea; first, the contents of the stomach and the bowels, then vomiting and purging of watery fluid. Cramps; weak- ness and faintness; husky voice; cold skin; cyanosis; clammy perspiration; small pulse. Prognosis.—Almost always favorable. The duration is brief—one or two days. TREATMENT. Medicinal.—Arsenicum.3*—Veratrum alb.Tr—Cuprum ars.2x—These remedies can be given according to the in- dications under Asiatic cholera. Iris vers.1*—Bile in the vomited matter and stools. Colchicum.Tr—Little pain, but rapid prostration. Podophyllum3*—Profuse, watery stools, without great prostration. lift CHOLERA MORBUS-DYSENTERY-TREATMENT "° POCKET-BOOK OF MEDICAL PRACTICE________ GENERAL MEASURES. Lavage.—If the patient is seen early enough, lavage of the stomach, and irrigation of the bowels. Add a small amount of Kali permang. to the water. With much loss of fluid, inject normal salt solution. In general, nurse as in Cholera Asiatica. DYSENTERY. (COLITIS! BLOODY-FLUX.) Varieties.—[a) Catarrhal (Sporadic); probably due to bacillus coli communis, (b) Amebic ( Tropical); due to ameba coli. (c) Diphtheritic (malignant); may be pri- mary .or secondary. Diagnosis. It depends upon the character of the stools —frequent, small, mucous, bloody, sometimes containing shreds of necrosed tissue; attended by colic, tenesmus, and various gastric and systemic symptoms. Prognosis.—The catarrhal form, favorable; amebic form, the mortality varies from 5% in temperate climates, to 70% in the tropics; diphtheritic form, unfavorable. TREATMENT. Mercurius corr.3*—Severe cutting, griping abdominal pain; distressing, persistent tenesmus ; almost constant straining ; stools small, slimy, green, or bloody; urine scanty, bloody, or suppressed; flabby, coated tongue; anorexia; sweat. Arsenicum.3*—Severe cases, with much exhaustion; dark, fetid, bloody stools, with shreds of tissue; burn- ing pain in the rectum; stool acrid and excoriating; clammy surface; weak, rapid pulse, Belladonna.1*—Much nervous excitement; violent fever; retention of urine; severe gastric derangement; nausea and vomiting; violent urging; scanty discharge of slimy, bloody stool, with tenesmus; abdomen distended, hot and painful; spasmodic, clutching pains. Useful in the early stage. Aloes.2*—Loud gurgling in the abdomen. Before stool, sensation of fullness and weight in pelvis; after stool, faintness. Stool bloody, jelly-like mucus. Tenesmus very severe. Nuxvom.2*—Violent tenesmus; pressing pain in the loins and sacral region; sensation as if the back were broken; great heat and thirst, with red face; the pains and tenesmus cease with the evacuation. Cantharis.1*—Scanty urine; tenesmus vesicae; stool of blood and mucus, like scrapings from the intestines; with the stool, cutting in the abdomen. Capsicum.2*—Cutting colic; thirst, but drinking causes shuddering; drawing pains in the back; stools of mucus, streaked with black blood; strangury. Ipecacuanha.2*—Stools green; frothy mucus; violent colic and tenesmus; anorexia; nausea; vomiting. Argentum nit.2*—Stools ropy, green, shreddy, bloody; constrictive pain in the rectum; burning soreness and constriction in the abdomen. DYSENTERY-TREATMENT-ASIATIC CHOLERA US POCKET-BOOK OF MEDICAL PRACTICE Aconite.1*—Early, with fever. Acid nit.2*—Diphtheritic dysentery. Cuprum.3*—Violent cramps in the legs. China.2*—Intermits; returns periodically. Colocynthis.Tr—Very severe colicky pains. Dulcamara.lx-^Autumnal, from cold and wet. Sulphur.3*—After violence of attack has passed. Rhus.2*—Low fever; involuntary; thin; at night. Colchicum.3*—Jelly-like, skinny stools; autumnal. Podophyllin.3*—Prolapse of bowel with every stool. GENERAL MEASURES. Rest.—Absolute rest in bed; even though he has the strength, the patient must not be about on his feet. Compresses.—Hot fermentations to relieve pain. Tenesmus.—Injection of boiled starch, with Laudanum, 30 drops. Discharges.—The dejections must be disposed of with antiseptic precautions ; the disease is infectious. Keep the clothing and the patient clean. Diet.—Simple and bland; milk, peptonized ; scraped meat ; a sustaining diet when there is much exhaustion. Pure water to gratify thirst. Irrigations.—In acute attacks, irrigate with water, as hot as can be comfortably borne. In sub-acute or chronic, irrigate freely with warm water (blood-heat) with Argen- tum nit., grs. x to the pint. ASIATIC CHOLERA. (EPIDEMIC CHOLERA ; CHOLERA MALIGNA.) Etiology.—It is due to infection by the comma bacillus (Koch). It enters the system in drinking-water or in food. Complications.—Gastro-enteritis ; suppression of urine; meningitis ; sloughing of the cornea ; abscesses over the body ; coagula in the right heart or pulmonary arteries; hemorrhage of the bowels ; bronchitis ; pneumonitis; erysipelas ; parotitis; diphtheritic inflammations of mucous surfaces. Prognosis.—Always grave. Most of the fatal cases occur early in the epidemic. The foudroyant form is almost always fatal. TREATMENT. Camphor.Tr—Early in the attack. The patient sud- denly loses strength, and looks pinched and blue; the skin becomes very cold ; the voice deep and husky; the skin shrivels ; intense distress and anguish at pit of stomach and burning in the bowels, the patient tossing in agony ; sometimes nausea and vomiting, but generally the evacuations both up and down are moderate and in- frequent. Dose.—"Give the patient three to five drops of the tincture, on a little sugar, every five minutes, and, in the intervals, assiduously rub him on the neck, chest, and abdomen with the same medicine, until the icy cold- ness of the body gives place to a return of vital warmth. "^Hahnemann. N. B.—For convenience Cholera is included in this Section. 120 CHOLERA ASIATICA-GENERAL MEASURES POCKKT-BOOK OF MEDICAL PRACTICE Veratrum alb.Tr—Cases marked by excessive vomiting and purging, with violent abdominal pains. Especially indicated when the attack commences with vomiting and purging. Pale and sunken countenance; hollow eyes, with blue margins; repeated and violent vomiting, with frequent, copious, watery, rice-water evacuations; violent colic, especially about the umbilicus. Dose:—Tr., 5 drops, frequently repeated. Cuprum acet.2*—Loss of consciousness; spasmodic cramps of fingers and toes; audible gurgling of liquids down the esophagus; ineffectual efforts to vomit; the diarrhea has ceased, but loud gurgling in bowels, indi- cating paralysis of the intestines. Cuprum is also rec- ommended as a prophylactic. Arsenicum.3*—Sudden and extreme prostration; vanish- ing of the pulse; great dyspnea; inexpressible anguish; constant tossing about; violent thirst, yet the least quan- tity of liquid is thrown up immediately; burning distress in the region of the stomach; complete suppression of urine. The medicine most trusted in collapse. Hydrocyanic ac.3*—Pulselessness; respiration slow, deep, gasping, taking place at long intervals. Secale3*; Phosphorus.3*—Profuse, watery stools, after the violence of the attack is past. Phosphoric ac.3*j Rhus.3*—The supervening- typhoid condition. Terebinthina2*; Cantharis.2*—For continued suppres- sion of urine. GENERAL MEASURES. Prophylaxis.—Pure drinking-water is the most efficient preventive. Rigid quarantine must be observed. The Patient.—Place the patient immediately in a warm bed. Keep him at perfect rest on his back, and sur- round him with hot bottles. Make friction with warm flannels. The room should be warm, but well ventilated. No food can be taken. Enemata of warm milk, even though rejected, are beneficial. Disinfectants.—Use disinfectants in disposing of dis- charges and soiled linen. Drinks.—Assuage thirst with cracked ice. Diet.—During the prevalence of cholera it is not necessary that those unaffected should adopt a rigid system of dietary. Avoid everything which would be liable to create indigestion, or produce relaxation of the bowels^ Water.—During the prevalence of cholera drink no water that has not been boiled and filtered. Thoroughly wash all fresh fruit. Euteroclysis.—When the patient has lost much serum, inject into the bowel, with a long rectal tube, normal salt-solution. Quantity:—One to two quarts. Tetnper- ature:—100° to 104° F. Frequency:—Four times daily; or, after each evacuation. Hypodermoclysis.—Injection may be made into the subcutaneous cellular tissue. Solution:—Sterilized water, 1 pint; Sodium chloride, 4 grams; Sodium carbonate, 3 grams. Temperature, 104° F. TYPHLITIS-APPENDICITIS-TREATMENT 121 ______________POCKET-BOOK OF MEDICAL PRACTICE Convalescence.—A return to ordinary diet must be gradual, as an attack of indigestion may excite relapse. Give no solid food till the stools are consistent and fecal. Begin with milk, thin gruels, broths, and digestible liquid food. Precautions.—Close all surface wellsj and those in the vicinity of drains and cesspools! Remove all filth, and use disinfectants freely. In cholera season direct your patients to observe regular habits in all things. All drinking-water must be boiled and filtered. Give strict attention to the first appearance of a diarrhea. TYPHLITIS. Definition.—Inflammation of the inner wall of the cecum. Etiology.—Irritation from food, trauma, or foreign bodies—gall-stones, hardened feces, etc. Symptoms.—Onset, slow and gradual; dull, radiating pain, worse by cough or pressure ; gastric symptoms; eructations ; nausea; constipation ; a sausage-shaped tumor in the right iliac fossa, from above downwards, parallel to the inner edge of the ileum ; the tumor feels like a pasty mass. Prognosis.—Favorable. Treatment.—Medicinal:—Belladonna2*; Nux vom.2*; Mercurius corr.3z; Arsenicum3*. General:—Procure evacuation of the bowels by free irrigation of the colon with warm water and turpentine. APPENDICITIS. (PERITYPHLITIS.) Etiology.—Irritation from the presence of a foreign body in the appendix, with bacterial infection and in- flammation. The foreign body is usually an enterolith (Yz the cases). Seeds are very rarely found (% the cases). Symptoms.—They vary greatly. Some cases run a latent course. Catarrhal Form:—Localized pain (sometimes radiating or diffuse); distension of the abdomen; vomiting oMood, bile, stercoraceous matter; fever (slight); consti- pation (sometimes thin diarrhea); scanty urine; thigh flexed; tumor at the lower border of the ileum, with crescentic area of dulness. Perforative Form.—Sudden pain and tenderness at McBurney's point ('/3 the distance from the umbilicus to the spine of the ileum, on a direct line); paroxysmal exacerbations of the pain; fever (102° -105° F.) hiccough; vomiting; coated tongue; anxious facial expression, cold sweat; hippocratic countenance; characteristic tumor in the right iliac fossa. TREATMENT. Belladonna.1*—The pain is sudden in onset; rendered intolerable by the slightest motion, even the jarring of the bed; signs of intense congestion and beginning in- flammation. Of no use unless given early. Mercurius corr.3x—Profuse sweat; painful, hot and hard swelling; alternation of chills and heat; face pale, tongue flabby, with white coating; constipation, or, slimy discharges. W 122 APPENDICITIS-PERITONITIS-TREATMENT POCKET-BOOK OF MEDICAL PRACTICE i Typhoid-like State.—Rhus tox3*—Lachesis.6* Arseni- |j cum.3* I Suppuration.—Hepar s.3* Silicea. 6x Peritonitis. —Bryonia.1* Mercurius.3* Cantharis.2x i Arsenicum.3* GENERAL MEASURES. Rest.—The patient must be kept at absolute rest in bed; use the bed-pan for evacuations. Insist upon this |j far into convalescence. Diet.—Light and bland; early, only pure water; pep- tonized milk; bouillon; in convalescence return gradually l to ordinary diet. Compresses.—Apply hot compresses over the seat of the inflammation. Anodynes.—Never give opium. '! Enema.—At the beginning of the attack clean the II bowel by an enema (warm water, ^ pint; turpentine, %oz.). Operation.—If the symptoms show no signs of subsid- ing at the end of 24 hours, at the very latest, operation is demanded. For special indications see Surgery. PERITONITIS. Varieties.— Primary (from exposure to cold); Secondary (from perforation; by extension; to general infectious pro- ■■: cess), (a) Circumscribed; Diffuse, (b) Acute; Chronic. (c) Fibrinous; Sero-fibrinous; Purulent. Symptoms.— Acute:—Sudden onset; chill; fever, 102- 104°; pulse tense and wiry (100-140); intense, cutting pain in the abdomen; sensitive to the slightest touch; j; thighs flexed; tympanites; anorexia; hiccough; nausea; vomiting; constipation; face pinched and anxious. \ Prognosis.—Always guarded. TREATMENT. j Aconite.1*—Early; great restlessness; high fever; rapid pulse; burning, cutting, darting pain in the abdomen, worse from slightest pressure; abdomen hot; great thirst. I Belladonna.1*—Cerebral congestion; throbbing caro- ; tids; great anxiety; dyspnea; very sensitive to light and noise; sudden shooting, darting, stabbing pains. ij Veratrum vir.Tr—Nausea and vomiting, with cold | sweat; strong, full pulse, with great arterial excitement; I respirations slow; face flushed; pupils dilated. Bryonia.1*—Splitting headache; stitching, lancinating pains in the bowels, worse from the slightest motion; tongue white and dry; great thirst; constipation. Apis.2*—Stinging, burning pain; scanty urine; dysp- nea; edema; absence of thirst. Arsenic.3*—Sudden sinking of strength; restlessness; thirst; vomiting; cold, clammy perspiration. Colocynth.^-Violent cutting, tearing pains; diarrhea; tenesmus; scanty urine; strangury Terebinthina.2*—Great distension of the abdomen; % weakness and prostration. PERITONITIS-APPENDICITIS-TREATMENT 123 _________POCKET-BOOK OF MEDICAL PRACTICE_______________ Cautharis.2*—Scanty urine, with almost constant stran- gury, passing but a few drops at a time; bloody urine. Mercurius corr.3x—Chills; perspiration; flabby, coated tongue; mucous stools, with tenesmus; weakness and emaciation. GENERAL MEASURES. Rest.—Absolute rest in bed, and quiet surroundings. Diet.—Milk, peptonized, or in any agreeable form; broths; nutrient enemata if the stomach is intolerant. Pain.—If it cannot be otherwise controlled, give Mor- phine subcutaneously, just enough to accomplish the purpose. Compresses.—Hot, light compresses to the abdomen; if there is meteorism, sprinkle with turpentine and sweet- oil, equal parts. With circumscribed inflammation, the ice-bag. Bowels.—Never give a purgative. The lower bowels may be cleared by a laxative enema. Vomiting.—Try sipping hot water; bits of ice ; -iced champagne. _______ ASCITES. (DROPSY OF THE ABDOMEN; HYDROPS PERITONEI.) Etiology.—Secondary to many conditions that cause obstruction to the portal circulation. Diagnosis.—Uniform distension; dulness changes with the position of the patient; succussion; prominent um- bilicus. It must be differentiated from (a) peritonitis with effusion; (b) ovarian cyst; (c) dilated stomach; (d) dis- tended bladder (the last two conditions have been, but should not be, mistaken for it). TREATMENT. Apocynum.—When there is scanty urine, it restores the renal secretion and removes the dropsical accumulation. D0se .-—Fluid-extract, 5 drops, 3 times daily ; infusion, 20 drops every 3 or 4 hours. If it causes nausea, give by rectal injection. Digitalis.—When the ascites is part of a general dropsy due to renal or cardiac disease (excepting aortic regur- gitation). Dose :—Tincture, 5 to 10 drops. Arsenicum.3*—Ascites as part of a general dropsy, secondary to disease of the heart or liver (cirrhosis). Great debility and prostration; emaciation; dyspnea; edema. Dose:—In extreme cases, give Fowler's solution. China.2*—Dropsy of anemia, or after exhausting dis- charges. General debility, sallow skin; diarrhea; scanty urine. Aurum.2*—Secondary to chronic hepatic disease. GENERAL MEASURES. Djet#—A strictly milk diet is very beneficial in many cases. Give pure water freely; it favors action of the kidneysi Baths.—Vapor baths are helpful. Paracentesis.—If respiration is embarrassed, tap the abdomen. SECTION X. DISEASES OF THE STOMACH. BV ARTHUR E. THOMAS, M.D., CHICAGO. PROFESSOR OF PRINCIPLES AND PRACTICE OF MEDICINE AND CLINICAL MEDICINE IN THE CHICAGO HOMCEOPATHIO MEDICAL COLLEGE. ACUTE GASTRITIS. Varieties.—[a) Primary; (b) Secondary; (c)Diphtheritic; [d) Phlegmonous. Etiology.—(a) Primary:—Excess in eating; Chemical: Large doses of salicylates, quinine, mercury, cubebs; Psychic: violent emotions; sexual excess; Thermic: Ice- water, hot drinks; Mechanical: Foreign bodies, fish- bones, etc.; Predisposition: Heredity. (b) Secondary:—Complication in acute infectious dis- eases; after operations; in chronic diseases—Bright's; liver; lung; heart; diseases that produce anemia. Symptoms.—Sense of fullness; stomach distended and painful; eructations; thirst; anorexia; pyrosis; salivation; pulse small, rapid; malaise; prostration; cerebral press- ure and frontal headache. Children may have delirium. Fever in half the cases. Diagnosis.—Must be differentiated from typhoid fever; infectious diseases; poisoning. Prognosis.—Favorable, except in extremes of life. TREATMENT. Aconite.2*—Hot, dry skin; hard, full, quick pulse; in- tense thirst, sharp, shooting pains; retching and vomit- ing; bilious vomiting; nervous restlessness. Of value in the first stages when the attack is due to cold, or shock of any kind. Arsenicum.3*—Vomits everything taken; intense thirst; drink little at a time; water disagrees; rapid prostration. Nux voni.2*—After eating improper food, unripe fruit; tongue coated yellow; fullness and pressure in the stom- ach; vertigo; pains shooting up the back of the neck, with headache. Veratrum alb.2*—Great suffering; nausea and vomiting; lips blue; nose pinched; eyes sunken; intense thirst; nothing staj-s on stomach; weak, rapid pulse; exhaust- ing diarrhea. Phosphorus.3*—Great soreness in the gastric region; cramps; pains radiating to the liver; nausea and vomit- ing; relishes cold water, but it comes up as soon as it gets warm. Bryonia.2*—Tongue coated white, or dry and brown; there may be no thirst, but the patient drinks frequently and copiously; epigastrium very sensitive; stitching pains in the stomach; constipation. Belladonna.3*—Often indicated in children, with-tender- ness of the abdomen; cutting pain; much fever; congestion of the head, with throbbing headache, nausea and vom- iting. (124) CHRONIC GASTRITIS-DIPHTHERITIC 125 POCKET-BOOK OF MEDICAL PRACTICE______________ Iris vers.1*—Acute gastritis, with bilious symptoms; specks before the eyes; then headache begins; distressing nausea; burning in the stomach; vomits mucus and bile. GENERAL MEASURES. Stomach.—When there is much fermentation, with nausea, and the stomach is full, it must be emptied by emesis. Use large quantities of tepid water to induce vomiting. After the stomach is empty, secure rest. When vomiting is a troublesome symptom counter-irritation over the stomach, or over the tenth dorsal vertebra, should be used. Equal parts of chloroform and alcohol, applied one dram at a time, on three or four layers of flannel, is the quickest and best. Diet.—No food; water, hot or cold, should be given by the mouth until pain and signs of gastric irritation are gone. Water at about 75° F. should be given in small quanti- ties to allay thirst. Begin to feed cautiously; first, white of egg stirred in water; then milk; beef-tea; corn- meal or rice-gruel, thoroughly cooked. Vichy-and-milk, equal parts, when there is tendency to acidity. DIPHTHERITIC GASTRITIS. Etiology.—It occurs as a sequence of laryngeal diph- theria; also sometimes accompanies scarlatina; pyemia; puerperal septicemia. Diagnosis.—Usually impossible before autopsy. PHLEGMONOUS GASTRITIS. (PURULENT GASTRITIS.) Etiology.—Infection of the submucosa by pyogenic cocci • Symptoms.—Much like intense Simple acute gastritis, with symptoms and physical signs of abscess ; temper- ature 104°-105° F.; restlessness ; headache ; insomnia; delirium. Prognosis.—Unfavorable. Treatment.—When diagnosis is possible surgical inter- ference is called for. CHRONIC GASTRITIS. Etiology.—Irregular diet ; improper food ; alcoholic liquors ; drugs. It may follow acute gastritis, or com- plicate chronic diseases of other organs. Diagnosis.—Often hard to determine ; must differen- tiate between ulcer, carcinoma, gastric neurosis, etc. The only way positively to decide is by test-meals, and analysis of secretions of the stomach. Prognosis.—Favorable if organic changes have not pro- gressed too far. Cases of long standing can be improved with care and treatment. ^ ^26 CHRONIC GASTRITIS- TREATMENT " POCKET-BOOK OF MEDICAL PRACTICE______________ DIAGNOSTIC POINTS OF TYPES OF CHRONIC GASTRITIS. Contents of Fasting Stomach. Acidit}*. Ferments. 1, Simple Chronic Gas-tritis. Limited amount of watery mu-cus ; le u oo-cytes; epithel-ial cells; round cells. Variable; free HC1 rarely present (lessen-ed in amount; combined HC1 present. Pepsin and ren-nin present in small amount; propepto ne formed in the stomach. 2. Chronic Mu-cous Gastritis. Much mucus; epithelial frag-ments. A t beginning-the HC1 may be normal; later it is low or absent. Pepsin and ren-nin absent. both p roen-zymes present. Ex peri mental digestion occurs on adding HCL 3. Chronic At-rophic Gastri-tis. Lancinat-ing' pains pres-ent in this form. Empty; no mu-cus. HC1 absent; HC1 deficient; no combined HC1. No enzymes, no proenzymes. 4. Acid Gastri-tis. Much mucus, piving- HC1 re-action. Amount of HC1 normal; or, hy-peracidity. Ferments in-creased. TREATMENT. Arsenicum.3x—Irritable stomach; does not retain food; heartburn; waterbrash; fullness and tenderness in the epigastrium; tongue red and rough; pulse feeble, acceler- ated and irregular; meats and cold drinks disagree; hot flashes, then cold; hands and feet cold; diarrhea. Argentum nit.2-* -Marked irritability, with sharp burn- ing, knife-like pains radiating to the sides or back; flat- ulence; useful in hyperchlorhydria and atonic gastritis. Antimonium crud.3x—Patient overloads the stomach; tongue coated white; stomach easily deranged. Valuable in atonic gastritis. China.lx—Often indicated in chronic gastritis compli- cating other diseases, viz.: malaria, anemia; splenic or hepatic disease. Constant satiety, with coldness in the stomach, craves spices, acids and stimulants; flatulence marked, lasting long after eating; farinaceous foods dis- agree. Digitalis.**—Useful in chronic gastritis complicating heart or renal disease. Will frequently relieve the pass- ive congestion, and stimulate digestion. Constant ptyal- ism and sensation of weight in the pit of the stomach. Hydrastis.2x—Dull pain in the pit of the stomach, with weak, faint feeling; sensation of " goneness " in the epi- gastrium, with palpitation of the heart, waterbrash. Nux vom.2x_Bitter, sour eructations; nausea after meals; feels empty after eating; small quantity of food satisfies. Phosphorus.3x—Sour eructations after meals; food or drink tastes bitter. Belching of gas; regurgitation of food CHRONIC GASTRITIS-GENERAL MEASURES 127 _______________POCKET-BOOK OF MEDICAL PRACTICE after meals; very useful when there is change in the stomach wall, or the sympathetic nervous system is im- plicated. Pulsatilla.^*—Vomiting after meals; vomits mucus; fat foods disagree; pain in the stomach after eating. GENERAL MEASURES. Atonic Forms.—Hydrochloric acid, dilute, 15 or 20 drops in a glass of water, divide into three doses, take the first one IS minutes after meal, and take a dose at intervals of 15 minutes until all is taken. Useful only in atonic forms of gastritis. Pepsin.—Not to be given except in cases where the se- cretions of the ferments are absent, as determined by more than one analysis. In atrophy, where the peptic glands are destroyed, pepsin should be used in combina- tion with HC1. Give three to ten grains after meals. Bismuth suhnitrate.—One to five grains at a dose, four times a day. Thirty grains in a cup of hot water may be used after lavage. Pour the mixture into the stomach, allow it to remain 10 to 30 seconds, then siphon off. It should not be used in atrophic gastritis. To relieve troublesome symptoms until the patient recovers, it is very useful in the mucous and the acid forms of chronic gastritis. Lavage.—Washing the stomach by means of the stom- ach tube is of -value in cases with dilatation, muscular inactivity, irritability, or undue fermentation. Use lav- age at bedtime, or the first thing in the morning. Fill the stomach two or three times with hot water. In mu- cous gastritis, 10 grs. of Sodium bicarb, may be used in the first water. Argentum nit. (one ounce of the 1% solu- tion) in the first water, followed by thorough washing, is indicated where there is irritability or fermentation. Bismuth subnitrate can be used in the same way. Solutions.—Sodium-chloride, Hydrastis, Menthol, Boric acid, or Hydrochloric acid, may be used in wash-waters, as needed. Contra-indications.—Lavage is contra-indicated when gastritis complicates: In grave heart lesions; aneurism of large arteries; recent hemorrhages of all kinds, in- cluding apoplectic, pulmonary, renal or gastric; advanced pulmonary tuberculosis, and emphysema. Recurrent tubes are not as satisfactory as the ordinary. Intra-gastric Spray.—Useful to make applications to the membranes of the stomach; it is not often of service. Indi- cations are much the same as for lavage. Electricity.—Faradic and galvanic electricity, applied locally by means of intra-gastric electrode, are useful as tonics. The sinusoidal current is preferable as a muscle tonic; it is of value in diminished peristalsis. Gymnastics.—Out-door exercise should be required. Balneological.—Treatment at springs is beneficial by reason of rest, change, and proper out-door exercise, with liberal use of good, pure water. 128 DIET IN GASTRITIS-GASTRIC ULCER POCKET-BOOK OF MEDICAL PRACTICE______________ Massage.—Where exercise is not properly secured, mas- sage, local and general, should be prescribed. The pa- tient may be instructed to massage his own stomach. Hot water, in combination with massage, gives marked re- sults. Have the patient take two cups of hot water 45 minutes before rising. Inflate the lungs, fix the dia- phragm, flex the legs, and knead the stomach; reverse, deflate the lungs, fix the diaphragm. Constipation.—In chronic gastritis it must be treated by diet, colon flushing, electricity, and exercise. In- crease the amount of water the patient drinks. Drink hot water at bedtime, and the first thing in the morning. DIET IN GASTRITIS. General.—Hot, cold or saline waters to increase diges- tion and relieve constipation. Have the patient drink a pint in the morning before rising. Simple Chronic Gastritis.—Breakfast-foods (except oat- meal); white bread; eggs, soft boiled; fresh meats (in moderate quantities); ham; fish. Vegetables in soup and purees; fresh fruit. Avoid all fried food, tea, coffee, and alcohol. Chronic Mucous and Atrophic Gastritis.—Small meals at regular intervals. Rare-done scraped meat-balls, broiled. white bread; toast; milk; butter; buttermilk; cooked vegetables (except cabbage; string beans; parsnip; egg- plant; sweet potatoes; oyster-plant). Fresh fruit, moder- ate quantities. Aeid Gastritis.—Albuminous foods, with small amount of starches and sweets, at first. As the case improves, increase the carbohydrates. Hot water before meals. Avoid sweets, stimulants, tea, coffee, and spices. Stew all fruits. GASTRIC ULCER. Symptoms.—Pain; vomiting; hematemesis; melena; change in the secretions; pyrosis. Ifidividual Symp- toms:—Pain:—In character, intense burning, stinging; occurs after taking food; increases as digestion pro- gresses; external pressure produces sharp pain in cir- cumscribed area in the stomach; often a tender spot near the spine, over the tenth rib; liquid food does not cause as much pain as solids. Vomiting:—Usually occurs during period of digestion; the proteids are usually di- gested; starches not changed. Hematemesis:—(50% of cases); the quantity of blood depends on the size of the vessel opened by the ulcer; large quantities usually in- dicate deep ulcer. Melena.—Blood may appear in the stools without hema- temesis; when ulcer is suspected, and stools are dark, test should be made for hemin crystals. Secretions:— HC1 invariably in excess; no change in the enzymes. Appetite:—Usually not much changed, but patient does not eat for fear of producing pain. Constipation:—Al- most invariably present. GASTRIC ULCER-TREATMENT 129 _______________POCKET-BOOK OF MEDICAL PRACTICE___________ DIFFERENTIAL DIAGNOSIS. HEMOPTYSIS. HEMATEMESIS. 1. Blood bright red, 1. Blood dark brown; foamy. partly coagulated; mixed with food; sometimes acid. 2. Physical signs point 2. Physical examination to pulmonary or cardiac reveals gastric or hepatic disease; moist rales. disease, or stasis in the portal circulation. 3. Pulmonary hemor- 3. Gastric hemorrhages rhage followed by rust-col- are frequently associated ored sputum. with tar-colored stools. Prognosis.—Usually favorable; recurrence is common; perforation may occur. TREATMENT. Argentum nit,2x—Symptomsof acute inflammation of the stomach; pain; retching and vomiting; epigastrium swol- len; eructations relieve; urine scant and high-colored. Useful to lessen the secretion of HC1. Uranium nit.2x—Of great value when symptoms of Ar- gentum nit. are present, but with copious urine. Arsenicum.3x—Violent burning in the stomach; vomit- ing of blood; great distress in the epigastrium; stomach painful to the touch. Of value to aid in correcting gas- tric secretions and indigestion. Phosphorus.3x—Thirst for cold drinks ; sour regurgi- tation of food; region of the stomach painful to touch; walking causes pain. Mercurius corr.3x—Vomits stringy mucus; coffee- ground vomit; burning in the stomach, extending up to the mouth; bloated, tender abdomen. Iodine.1*—Hunger ; great thirst; heartburn; nausea; vomiting after eating, with violent pain in the stomach ; Burning; gnawing. Kalibich.3x—Kali iod.2x—Lycopodium 3x—HydrastisTr may be indicated. GENERAL MEASURES. Rest.—Perfect rest of the patient must be secured. Diet._Milk exclusively is best., MUk-and-Vicby, equal parts, is sometimes taken better than pure milk. Broths and gruels may be given during convalescence. Hot or cold food or drink should not be given. Feed every three hours, except at night. Nutrient Enemata.—In protracted cases give the stom- ach absolute rest; put the patient to bed and nourish by nutrient enemata until the ulcer is healed. Boas' mix- ture is best:—8 oz. milk; yolks of 2 eggs; teaspoonful salt; one tablespoon claret; one tablespoon of wheat- flour. Acidity.—To overcome acidity, Carlsbad salts, one to two teaspoonsful in a glass of water; or Saratoga, Carlsbad, or Hawthorne water may be used. One or two teaspoons of lime-water may be used at each feeding. «*n GASTRIC ULCER-CARCINOMA I3U_____™ „™v «-»» nrvntrAL PKACTIC POCKET-BOOK OF MEDICAL PRACTICE Pain —Is usually controlled by overcoming acidity, proper'diet, and rest. Bismuth subnit., 5grs., in water. Argentum nit.2* 3 to 5 drops in water. Aromatic spirits of ammonia, 5 to 10 drops in a teaspoon of water (when there is no hemorrhage). When the pain is ga»- tralgic in nature, one or two drams of Chloroform-water often gives relief. Counter-irritation is sometimes of value, and should be tried when pain is not readily re- lieved. It should be used over both front and back. Hematemesis.—Absolute quiet; nothing to be taken by the mouth. Any remedy indicated should be given hypo- dermically when practical. Erigeron,Tr. China.Tr. Mil- lefolium.Tr. 3 to 5 drops; or, Ergot, 20 to 30 minims, used hypodermically. Five to 10 drops of Oil-of-Erigeron is a powerful hemostatic, that may be given by the mouth. When hemorrhage is copious inject one to two pints of normal salt-solution (teaspoon of salt to quart of water) into a vein. After hemorrhage feed by nutrient enemata. GASTRIC CARCINOMA. (CANCER OF THE STOMACH.) Symptoms.—Indigestion (similar to chronic gastritis); vomiting; pain; cachexia; hematemesis; tumor; no relish for meat; craves sours; pressure; fullness; eructa- tions; anorexia; pyrosis; singultus; constipation. Vom- iting:— (75% of cases) occurs irregularly, without regard to meals; large quantities evacuated at once; odor offen- sive; in some cases certain postures induce vomiting. Pain.—(80% of cases) usually constant; increased by eating; it may extend to the sides and to the scapulae. Cachexia.—Anemia and emaciation increase to ca- chexia; skin grey-white; wrinkled; frequently pruritus. Blood.—Fewer red cells; hemoglobin less than 60% of normal. Hematemesis.—Occurs in 50% of cases. Usually re- peated, and small in quantity. Coffee-ground in appear- ance, and sometimes requires careful examination to de- tect it, as it rapidly decomposes. Melena. Tumor.—Can be palpated in 50% of cases; usually movable and its relations changed by inflating the stom- ach. Pylorus, 60%; lesser curvature, 12%; cardia, 8%; other parts, 20%. Diagnosis.—Tumor; fragments of cancerous tissue in wash-water; Oppler-Boas bacillus; excess of lactic acid; absence of HC1 and digestive ferments; hematemesis; loss of motility; dilatation; general symptoms. Prognosis.—When the diagnosis can be made easily, operate. By diet and care the patient may live 18 months to two years. TREATMENT. Arsenicum.3x—Should be given in cases of gastriccan- cer. It will relieve many of the dyspeptic symptoms, as well as have a favorable influence upon the progress of the disease. Indications the same as for chronic gastri- tis. ULCER-CARCINOMA-GASTRALGIA-DIAGNOSIS 131 ______________POCKET-BOOK OF MEDICAL PRACTICE Conium.i*—Will often give relief when the pain ex- tends upward through the chest wall. Consult.—Argentum nit.3x; Hydrastis2x; Nux vom.3x; Kali bich.3x GENERAL MEASURES. Diet.—Feed every three hours during the day, Food should be largely liquid, or semi-solid; milk; bouillon; white-bread toast; meat; peptone; scraped beef; stewed apples; prunes. Dilute HC1.—Given in the early stages; 15 to 20 drops in a glass of water, to be taken in four doses 15 minutes apart, beginning 15 minutes after meals. Lavage.—For relief of dyspeptic symptoms, nausea and pain. The stomach should be washed the last thing at night, or first in the morning. Bismuth subnit., Men- thol, Boric acid, Sodium bicarb., or Argentum nit. may be used in the wash-water to prevent fermentation and decomposition in the stomach. Constipation.—Colon-flushing, or injections of sweet oil. DIFFERENTIAL DIAGNOSIS. Gastric Ulcer. Gastric Cancer. Gastralgia. Tongue dry and red, Tongue pale and fur- Tongue, variable; of- white strip down the red. ten pale, with indented center; or, smooth and edges. moist, lightly coated. Belching rare; water- Belching, frequent, fe- Belching of odorless brash. ' tid. gas, frequent. Taste unchanged. Taste, pasty, insipid. Taste, no change. Appetite good between Appetite diminished, Appetite irregular, the attacks; thirst. or absent; repugnance capricious. to meat, early. Sensation, burning; Sensation of oppress- Sensations, variable; circumscribed, boring ion, drawing feelings of at times hot; at others pains frequently radi- variable character; cold. ating through to the later, pain in the shoul- back. der. Pain rare when the Pain continuous; dull, Pain irregular; not stomach is empty, paroxysmal; decreased dependent upon eating; chiefly felt after eating; by pressure. frequently relieved by increased by pressure. eating or pressure. Digestion of starchy Digestion insufficient', Digestion. — Chemis- food frequently retard- deficiency of free HC1; try not essentially al- ed; digestion of meat products of decomposi- tered. normal, or even too tion; rapid; hyperacidity the rule. Vomiting usually af- Vomiting frequent, Vomiting variable. ter eating; frequently violent, often periodic; the first symptom. at times from empty stomach; consists of slightly digested food and cancer-cells. Hematemesis.—Clear Hematemesis.— Blood Hematemesis does not blood, or coffee-ground often decomposed; occur. masses, frequently re- quantity usually small; peated within a short recurs frequently. time; at times very profuse; bloody stools. Prevalence. — In the Prevalence. — Most Prevalence. — Occurs middle-aged; rare in common between forty at all ages; women of- children. and sixty. tener than men; fre- quently in combination with hysterical symp- toms. 132 GASTRECTASIA-GASTRIC NEUROSES POCKET-BOOK OF MEDICAL PRACTICE DILATATION OF THE STOMACH. (GASTRECTASIA.) Etiology.—(a) Due to muscular insufficiency, the stomach not being able to empty itself, although no ob- struction exists, (b) Due to pyloric stenosis. (For (a) see Atony of the Stomach, page 134.) (b.) Result of stenosis of the pylorus, due to cancer; cicatrices; ulcer; hypertrophy of pyloric sphincter; peritoneal adhesions; tumors in the liver or pancreas. Symptoms.—Tongue coated; breath offensive; appetite normal (at first becomes diminished or lost); a few cases are tormented with hunger; pyrosis usually present; pain not marked; usually a sensation of pressure and fullness; vomiting in the later stage, consisting of several quarts of food and mucus (very characteristic); constipation. Diagnosis.—The stomach never entirely empties itself; as determined by use of the stomach-tube in the morning. Inflation by means of the stomach-tube gives increased area of resonance. Inflation by administering soda bicarb, and tartaric acid is superseded by the stomach- tube method, which is preferable. lU Prognosis.—Cure is impossible, except by operation. Treatment, of dilatation due to stenosis is entirely die- tetic and mechanical. Diet.—The patient must eat frequently and little at a time. Liquids must not exceed three pints in 24 hours. Chicken, pigeon, birds, fish and sweetbreads, with a limited allowance of carbohydrates. General.—Electricity and lavage. CARDIOSPASM. (CRAMP OF THE CAKDIA.) Varieties.—Acute; Chronic. Etiology.—Gases; swallowed air; pure neurosis. Symptoms.—Pressure; dyspepsia; palpitation of the heart; prostration; headache; rapid, soft pulse. The stomach-tube meets with obstruction, and when it passes thecardia air or gas escapes. Food may collect in the esophagus, and be thrown up without being passed into the stomach. Prognosis.—May be relieved, but sometimes persists for years. Treatment.—Medicinal;—Igna.tia.3x; Rhus tox.3x; pul- satilla^x; Arsenicum3x; Nux vom.ix; Hyoscyamus3x; Sili- cea. <<*■ General:—Hygiene very important; use galvanic electricity. PYLOROSPASM. (cramp of THE PYLOKUS.) Cause.—Irritation, chemical and mechanical. Diag- nosis extremely difficult; requires the use of intra-gas- tric bag; test-meal, with salol or Potassium-iodide; test- ing the urine for saliva and for iodine. Give Potassium- iodide in wafers or capsules. Therapeutics,—Much the same as for Cardiospasm. Galvanic electricity. ^ GASTRIC NEUROSES 133 ______________POCKET-BOOK OF MEDICAL PRACTICE GASTRIC HYPERPERISTALSIS. (PERISTALTIC UNREST.) Causes.—(a) Hyperesthesia of the sensory nerve of the stomach; (b) Irritation due to HCl, organic acids, and gases; (c) Irritability of the motor nerves, a functional neurosis. Symptoms.—The contractions may be seen through the lax abdominal wall; gurgling noises; foul vomiting; im- paired nutrition (in marked cases). Prognosis.—Usually improvement; the neurosis disap- pears. Therapeutics.—Phosphorus3x; Ignatia3x; Arsenicum3x; Hyoscyamus. 3x General.—Galvanic electricity, perfect hygiene. VOMITING. (NERVOUS, REFLEX, OR HABITUAL VOMITING.) Varieties.—(1) Cerebral, or spinal (central vomiting); (2) Hysterical; (3) Reflex. Etiology.—(1) Cerebral:—Causes—encephalitis; menin- gitis; cerebral abscess and tumors; also acute anemia; hyperemia after concussion of the brain; occurs with emotional affections; after opium; chloroform; ether; nicotine; uremia; exophthalmic goitre, and tabes dor- salis. (2) Hysterical:—Accompanies hysteria; neurasthenia (rarely). (3) Reflex.—Pregnancy; diseases of any organ of the body may cause reflex vomiting. Treatment.—In each variety, according to the cause. INSUFFICIENCY OF CARDIA. Symptoms.—Regurgitation of food after meals, due to incontinence of the cordia (a rare neurosis). RUMINATION. (MERVCISM.) Cause.—An acquired habit. At first it is voluntary, but later becomes involuntary by habit. Treatment.—Associate the individual with some one to aid in breaking the habit. Mental effect is very valu- able. _______ PYLORIC INSUFFICIENCY. Symptoms.—Diarrhea, due to large particles of food; hot or cold drinks cause diarrhea; charged drinks cause tympanites of the intestines. Treatment.—Strychnia; Phosphorus. Diet,—Non-irritating, easily-digested food. ATONY OF THE STOMACH. (MYASTHENIA.) Etiology.—Occurs as a primary neurosis, due to per- sistent over-loading of the stomach, may be due to psy- chic influences (anger; fright; grief); may occur as a re- 134 GASTRIC NEUROSES-GASTRALGIA POCKET-BOOK OF MEDICAL PRACTICE_____________ flex neurosis, caused by diseases in other organs (liver; kidneys; intestines; sexual organs); a secondary neuro- sis in hysteria and neurasthenia, Diagnosis.—Physical signs same as dilated stomach, but the jejune stomach is empty when atonic, while it contains particles of food when dilated. Prognosis.—In pronounced cases recovery is rare. Treatment. — Strychnia phos.3x; Ignatia3x; Bella- donna3x; Podophyllum.3X General.—Dilute HCl where its secretion is dimin- ished. Electricity:—Sinusoidal and galvanic currents. Diet.—Small meals, but often. Restrict liquids. No narcotics or alcohol. ________ GASTRIC HYPERESTHESIA. Cause.—Chlorosis; anemia; irritating foods; spices; acids; salt; very hot or cold food. Gastralgia may ac- company or follow hyperesthesia. Symptoms. — Pulsation in the stomach. Ingestion of food causes discomfort; fullness; nausea; perhaps vomit- ing; pain may increase and last during digestion. Prognosis. --Favorable. Diagnosis. — Differentiate from gastralgia, which oc- curs when the stomach is empty as well as full; does not last longer than a few hours. Treatment.—Chin. ars.2x;—Argentum nit.3x;—Arsen- icum3x—Bismuth. 2x Diet.—Easily digested, non-irritating food. Milk until soreness and pain have entirely disappeared. All acids, alcoholic liquors, tea, coffee, spices, should be interdicted. GASTRALGIA. Causes. — Gastric ulcer; carcinoma; gastritis; acids; alkalies; peritonitic adhesions with pancreas, the liver and spleen; tabes dorsalis; malaria; nicotine; uric acid and gout; displacement of the uterus; inflammation of ovaries; ovarian neoplasms; it may be idiopathic. Symptoms*—Intense agonizing pain in the stomach; pressure often relieves; bowels constipated; urine sup- pressed; in hysterical cases, copious dilute urine. TREATMENT. Chin. ars.3x — Burning distress with sharp, knife-like pains, spasmodic in character; pricking colic; liver swollen, painful. Argentum nit.3x—Nausea; flatulence; stomach painful; bursting sensation; pain in the epigastrium, extending around to the sides. Bismuth.1*—Gastralgia complicating chronic gastritis; the pains extend through the body to the spine. Bryonia.2x—Sharp pains, increased by deep respiration; jarring the body produces sharp pain; stomach sensitive to pressure. Coninm.2x—Constrictive pain in the epigastrium, grad- ually extending to the left side; pain in the pit of the stomach, extending to the throat; spasmodic cough. ^ BULIMIA-ANOREXIA-HYPERACIDITY 13 5 ______________POCKET-BOOK OF MEDICAL PRACTICE Spigelia.2x — Soreness, with sticking pain in the epi- gastrium, worse on inspiration; pressure as from a hard lump in the stomach. GENERAL MEASURES. Counter-Irritation. — Over the epigastrium (chloroform and alcohol, equal parts, applied on flannel) is often efficient. Internally, Chloroform-water, 1 to 2 drams; or, Aromatic spirits of ammonia, 10 drops in 1 dram of water; or, Menthol, 1 to 3 grs. may give relief. Sodium bicarb., 10 grs., well diluted, will sometimes relieve; or, 3 drops of dilute Hydrocyanic acid. BULIMIA. Symptoms.—Impulsive sensation of hunger; pallor; weakness; roaring in the ears; boring pains, if hunger is not gratified. Acoria.—Absence of feeling or satiation; abundant meals do not satisfy. Treatment.—Arsenicum bromide.3x~Arsenicum alb.3x— Phosphorus. 3x—Belladonna. 3x—Opium. 3x NERVOUS ANOREXIA. Symptoms.—On account of loss of appetite and distress the patient cannot take food; anemia; slow, feeble pulse; cold hands and feet; insomnia. Treatment.—Strychniaphos.3x^Ferrum.3x—Strychnia ars.3x—China.2x—Rheum. *x—Gentiana.ix HYPERCHLORHYDRIA. (HYPERACIDITY.) Etiology.—Climate and occupation have marked influ- ence. Symptoms.—Burning, boring pains in the stomach, ra- diating forward or to the back; worse during digestion; pains appear later after taking albuminous than after starchy food; alkalies relieve the pain; albuminous foods digest rapidly; starchy foods do not digest; the stomach empties rapidly; occasionally cramp of the pylorus re- tains the stomach contents. Prognosis.—Favorable if of recent origin; often very stubborn to treat. Treatment.—Therapeutic indications are very much the same as for chronic gastritis. Alkalies.—Magnesia, Sodium bicarb., or alkaline mineral waters, viz., Saratoga, Vichy or Apollinaris may be used to overcome the immediate symptoms of in- creased HCl. Diet.—Beef; mutton; raw ham; cooked ham; pork; Swiss cheese; Roquefort; rye-bread; milk; cocoa; eggs. GASTROXIE. Etiology.—Mental exertion; emotional excitement; nic- otine; dietetic errors. Symptoms.—Periodic atypical flow of gastric juice. Attacks occur acutely, generally on an empty stomach. 136 GASTROXIE-HYPOCHYLIA-ACHYLIA POCKET-BOOK OF MEDICAL PRACTICE Frontal headache, with pressure and pain in the stom- ach; nausea; vomiting large quantities of gastric juice with HCl in excess; mucus and bile. Water increases vomiting, but relieves the pain in the stomach; attack occurs generally at night. Prognosis.—One attack predisposes to another. TREATMENT. Antimonium crud.3x—Fullness, as if the stomach was over-loaded; nausea; vomiting; stomach distended. Asafeti(la.2x—Lump in the throat; spasmodic contrac- tion of the esophagus; distention of the stomach; pulsa- tion in the pit of the stomach. Chamomilla.2x—Bitter, sour taste in the mouth; vomit- ing of bile, sour, slimy, or green mucus. China.2x—Nervous; anemic; bloating of the abdomen. Consult. — LycopodiumGx; Phosphorus3x; Pulsatilla.3x GENERAL MEASURES. Diet.—Avoid stimulants and narcotics, including tea ana! coffee. Plain digestible food, without seasonings. Hygiene.—Physical culture, out-door employment or exercise. No mental exertion. During Attack.—Overcome the excess of acid by the use of Magnesia; Soda bicarb.; Limewater. Use counter- irritation over the epigastrium. Lavage, with Bismuth- subnitrate in the water, as in chronic gastritis, HYPOCHYLIA. (SUB-ADICITV.) Etiology.—Secondary to neurasthenia, hysteria or tabes. Symptoms.—Symptoms of fermentation in the stomach; the condition and symptoms are similar to achylia gas- tric a. Treatment.—Remedies, same as under chronic gas- tritis. General.—KC1 should be given with food and after meals. Large doses of Strychnia may increase the flow of gastric juice. Use the faradic current. ACHYLIA GASTRICA. (PHTHISIS VENTRICULI.) Causes.—May be congenital. Primary secretory de- bility, or atrophy of gastric mucosa. Symptoms.—The condition may be latent for years without symptoms; it has been demonstrated by use of the stomach-tube in cases in which the patient had no dyspeptic symptoms. Dyspeptic symptoms usually lead to the use of the tube, and diagnosis. Treatment.—HCl usually is prescribed after meals to prevent fermentation and aid digestion. Dose:—20 drops of dilute HCl every half-hour, until 60 drops are taken. NERVOUS DYSPEPSIA-TREATMENT 137 POCKET-BOOK OF MEDICAL PRACTICE NERVOUS DYSPEPSIA. (NEURASTHENIA GASTRICA.) Etiology.—Mental overwork; excitement; sexual ex- cesses; alcohol; tobacco. Symptoms.—Variable; distress only on taking food; quality or quantity of food has little influence on the symptoms; indigestible food frequently causes no dis- turbance, while often the most digestible food causes distress. Nervous Symptoms:—Headache; giddiness; flashes before the eyes; ringing in the ears; rapid pulse; palpitation of the heart. Prognosis.—Guarded. TREATMENT. Agaricus.3x — Unnatural hunger; eructations; pains; gnavvings, cramps, fullness; irritable spine; cardialgia, lasting about three hours after meals. China.2*—Slow digestion; constant satiety, with cold- ness in the stomach; craves spices, acids and stimulants. Flatulence, but belching does not relieve. Ignatia.3x—Hunger in the evening prevents sleep; sen- sation of emptiness; spasmodic pains in the stomach. Nux vom.2x—Unnatural hunger; aversion to coffee, to- bacco; rancid heartburn after acid or fat food; pressure in the stomach one hour after meals. Indigestion due to business anxiety or sedentary habits. Phosphorus.3*—Pressure in the stomach after eating, with vomiting of food; ice-cold drinks relieve tempo- rarily, but are rejected as soon as warmed in stomach. GENERAL MEASURES. R,est.—Secure rest; after improvement is_ marked, change of environment, with psychic and physical quiet. Gymnastics.—Properly directed gymnastics, especially out-door exercise, Massage.—Under direction of a physician. Hydrotherapy.—Cold sponge-baths on rising in the morning. Irrigation and Lavage.—Use carbonated waters, or lemon-juice and sodium bicarb. Electricity.—Galvanic and faradic. electricity should be applied. Galvanic over the stomach and spine; faradic over the muscles and limbs. Djet.—Should be variable, well-cooked, easily digested and nourishing. SECTION XL DISEASES OF THE KIDNEYS. BY GEO. F. LAIDLAW, M.D. NEW YORK. FORMERLY LECTURER ON PATHOLOGY IN THE NEW YORK HOMEOPATHIC MEDICAL COLLEGE. RENAL HYPEREMIA. (CONGESTION OF THE KIDNEYS.) Etiology.—Acute congestion caused by exposure to damp cold, especially exposure of the feet; fright; toxic products of indigestion; infectious fevers. Chronic or passive congestion caused by valvular insufficiency of the heart and pressure of tumors or gravid uterus on the renal veins. Symptoms.—Indefinite feeling of illness, with great anxiety; dull pain in the loins; frequent, ineffectual urging to urinate; urine scanty, albuminous, turbid,and contains few hyalo-epithelial or blood-casts. General symptoms may be slight, or there may be fever, nausea, prostration and delirium, the "typhoid form" of renal congestion. Diagnosis.—By urinalysis, differentiating from lum- bago. Distinguish the acute form from acute Bright's disease by shorter course and absence of dropsy. Dis- tinguish "typhoid form" from typhoid fever and menin- gitis. Distinguish passive congestion due to the heart- disease from primary nephritis by examination of the heart and disappearance of albumin under Digitalis or other heart-stimulant. TREATMENT. Aconite.Tr—Fever; restlessness; thirst; anxiety; vertigo on sitting up; effects of dry cold or fright. Also, 30th. Berberis.3x—Lancinating, throbbing pain in the kid- neys, worse sitting or lying and rising from a stooping posture; better standing; backache, worse on waking; pains extend to the bladder, with urging to urinate; urine scanty and turbid; cramping pain in the bladder, whether full or empty. Bryonia.31—Typhoid form; sleepy; stupid; quiet; de- lirium on waking; dark red face; suppression of urine; vertigo and faintness on sitting up. Cantharis.lx—Burning pain in the kidneys; constant urging to urinate, only a few drops passing, with burn- ing pain; scanty, bloody urine. Digitalis.—In passive congestion, especially when de- pendent on failing heart; edema of the legs and depend- ent parts; dyspnea, worse while walking and at night, relieved by sitting up; blue lips. Dose:—The infusion is best, in dram or half-ounce doses, three times daily, with Nitroglycerin. Hydriodic acid.—A direct stimulant of renal excretion, in half-dram doses of the syrup. Opium.3x—Typhoid form; drowsiness; stupor; snoring sleep, with half-closed eyes and expiratory moan; red, (138) RENAL HYPEREMIA-ACUTE NEPHRITIS 139 _______________POCKET-BOOK OF MEDICAL PRACTICE bloated face; twitching and jerking of the limbs, consti- pation; effects of fright. Terebinth.lx—Scanty, bloody urine; in infectious dis- eases and after exposure. Veratrum viride.Tr—Fever, pulse full and rapid; con- gestion and throbbing of the head. Drop doses. Consult.—Remedies for Bright's disease, Uremia, and Anuria. GENERAL MEASURES. Patient.—Rest in bed; warmth; hot-water bag to the loins; hot pack if delirium or stupor appears. Diet.—For acute cases, rigid milk or gruel diet. Chronic cases must be well fed. Convalescence.—Avoid exposure, fatigue and spiced food as long as the urine contains casts or albumin. ACUTE NEPHRITIS. (ACUTE bright's disease.) Etiology.—Exposure to damp cold; infectious fevers (measles, scarlet fever, diphtheria, typhoid); pregnancy. Pathology.—Kidneys swollen. Tubules distended with degenerating epithelia and inflammatory exudate. In-/ terstitial tissue distended with exudate and round cells. Symptoms.—The first sign maybe puffiness of the face or ankles; it may begin with chill, followed by fever; dry skin; headache; nausea and vomiting; then dropsy. Fever may be absent. There may or may not be pain in the loins, or frequent urging to urinate; urine scanty; dark or bloody; brown or bloody sediment; sp. gr. high, 1028 to 1036;.much albumin; many casts (hyaline, epithe- lial, blood and granular); drowsiness; twitching of mus- cles and wandering mind indicate approaching uremia. Diagnosis.—Differentiate f rom the albuminuriaof fevers, which has scanty albumin and casts and no dropsy. Prognosis.—In the absence of uremia, immediate prog- nosis is good. Many cases recover; others progress to chronic nephritis. Marked uremia and scanty urine are unfavorable signs. Clear mind and profuse flow of urine are favorable. Death Occurs from uremia or edema of the lungs. GENERAL MEASURES. Patient.—Rest in bed; keep warm and dry. BatliS.—If dropsy persists, use hot pack, or hot bath (105° F.) followed by pack, but with caution, as uremia sometimes follows free sweating. Diet.—Avoid meat and meat broths; give a rigid milk diet; kumyss; gruel; arrowroot; rice; vegetable soup (avoiding onions); grape-juice. Purge.—In the beginning, a saline purge is useful (avoid sodium-phosphate). Dropsy.—For obstinate dropsy, acupuncture; elaterium; croton oil. Medicinal.—See page 141; also Uremia and Anuria. 140 CHRONIC DIFFUSE NEPHRITIS-TREATMENT POCKET-BOOK OF MEDICAL PRACTICE_________ CHRONIC DIFFUSE NEPHRITIS. (chronic bkight's disease; CHRONIC CROUPOUS NEPHRITIS.) Etiology.—Exposure to damp cold; physical violence; syphilis; malaria; it often develops insidiously, from unknown cause. Symptoms.—Often obscure. In all cases of chronic ill-health, the urine should be examined. First symptom may be uremic coma, convulsions, or puffiness of the face or ankles. Headache; visual disturbances (albuminuric retinitis); drowsiness; nausea; vomiting; intestinal in- digestion (with much flatulence); dyspnea; increasing dropsy. Urine:—Albumin (abundant); hyaline, epithe- lial, granular and fatty casts (may be scanty except in exacerbations); quantity, maybe normal (40to50ounces) for a long period, but there is a decrease of solids, espe- cially of urea and phosphates. As the fibrous tissue in the kidneys increases, the heart hypertrophies and the quantity of urine increase (70 or 80 ounces). After some months or years, the heart weakens, dropsy and dyspnea increase, the urine decreases (20 or even 10 ounces). Diagnosis.—The urinary signs are conclusive. Prognosis.—Generally unfavorable. If treatment is \begun early cures may be made. The disease may ap- parently remain stationary for from five to twenty years. Majority of patients die within three years after dis- covery of the disease. Favorable :—Nearly normal solids (especially urea and phosphates) ; normal heart-action. Unfavorable ;—Marked decrease in urinary solids ; rapid pulse and increasing dropsy. Death from uremia, or edema of the lungs. Pneumonia, pleurisy and pericar- ditis are frequent, and almost always fatal. GENERAL MEASURES. Uremia.—Uremic accidents arise from over-eating, constipation, exposure to damp cold, fright, or other strong emotion, and mental or physical fatigue. These must be avoided. Constipation.—Prevent by daily saline, preferably sodium-sulphate (never sodium-phosphate). Diet.—Should be varied, both meat and vegetable. At times of exacerbation of symptoms, exclusive milk-diet; milk-and-seltzer ; or gruel. Forbid onions, tomatoes, and rhubarb (because of oxaluria); also asparagus, strawberries, mustard, and other spices (they irritate the kidneys). Forbid nuts and cheese (except cream cheese) as aggravating the albuminuria. Baths.—Warm, full baths (95°F.) for 30 minutes daily. Daily dry frictions of the skin. Avoid cold water, especially sea-bathing. Daily inhalations of oxygen reduce the albumin. When dropsy is severe, incision, or, better, acupuncture. Caution.—Nephritic patients are easily poisoned, be- cause of the damaged excretory power, especially by opium, morphine, mercury, salicylic acid and sodium- phosphate. Consult also Uremia and Anuria. CHRONIC INTERSTITIAL NEPHRITIS-TREATMENT 141 _______________POCKET-BOOK OF MEDICAL PRACTICE CHRONIC INTERSTITIAL NEPHRITIS. (CIRRHOSIS OF THE KIDNEY; GOUTY KIDNEY.) Etiology.—Gout; lead-poisoning; alcohol; heredity. Symptoms.—Onset often latent; age 35-45; first signs maybe—Headache; indigestion; lassitude; dyspnea; epi- staxis; cerebral or other hemorrhage. Heart hypertro- phied; pulse, high tension; urine increased (70 tolOOoz.); sp. gr., 1004to 1014; albumin and casts scanty until late in the disease, when they are abundant; urea and phos- phates much decreased. Dropsy is infrequent, except at the last, with failing heart. Diagnosis.—Differentiate from simple polyuria by the decrease in solids; also the presence of albumin and casts. From hysteria by the general symptoms. Prognosis.—Bad. The disease may be prolonged or ar- rested, but cure is improbable. Death from uremia, cerebral hemorrhage, or edema of the lungs. Sudden death is common. TREATMENT. (therapeutics in acute and chronic nephritis.) Aconite.Tr—Exposure to cold; chill; cold skin; or hot, dry surface ; quick pulse ; restlessness ; thirst and fear of death ; urine scanty, or suppressed. Apis.Tr—Drowsy and thirstless; urine scanty and albuminous; post-scarlatinal dropsy, and edema of preg- nancy, rather than acute inflammatory state. Dose:— Tr. or 3x. Arsenic alb.3*—Persistent nausea and vomiting; thirst, drinking little and often; restlessness, anxiety and fear of death; dyspnea, worse after midnight and on lying down; relieved by sitting up; emaciation, or, general dropsy; pulmonary edema or pericarditis. Useful in both acute and chronic forms. Aurum mur.2x—Persistent use in the early stage of chronic interstitial nephritis is recommended. Berberis.Tr—Smarting and burning in the kidneys; passage of bloody urine, with heavy mucous sediment, followed by great exhaustion. Cannabis sat.Tr—Soreness in the kidneys; scanty, tur- bid urine, with frequent urging; acute nephritis. Cantharis.Tr—Acute nephritis; burning pain in the loins; severe vomiting; mental stupor, delirium or mania; constant desire to urinate; passing only a few drops of turbid, bloody urine; after scarlatina or diph- theria, with suppression of urine. Dose:—Tr. or 3x. Cuprum ars.3x—Uremic convulsions. Digitalis.—In subacute or chronic nephritis, when the pulse is weak or irregular, and dropsy or dyspnea ap- pear. Dose .'r-Dram to four-dram doses of Infusion are best, with iJs drop doses of Nitroglycerin. Ferrum met.3x—Marked anemia; pale; bloated; chilly; vomiting of food; congestion of the head, with epistaxis. Also, Ferrum phos. 3*- (Phosphate-of-iron is the basis of several popular " Bright's^Disease Cures. ") ^ 142 CHRONIC NEPHRITIS-THERAPEUTICS "fc POCKET-BOOK OF MEDICAL PRACTICE_____________ Glonoin.—In chronic nephritis with high-tension pulse; relieves headaches; dyspnea; edema. Dose: jj0 drop. Helleborns nig.—Stupor; grinding teeth; talking in sleep; rolling of the head. Post-scarlatinal dropsy. Dose: Tr. to 6x. Hydriodic acid.—In chronic nephritis, reduces albumin and has made cures. Dose:—Of syrup, 1 dram. Kali chlor.3x—Pallor; dyspnea; scanty, albuminous urine; subacute nephritis. Kali iod.—In syphilitic cases, 5 to 15 grains daily. Its continued use in small doses is helpful in the chronic in- terstitial form. Lycopodium.3c—Pain in the back, relieved by urina- tion; earthy pallor; vomiting of food; flatulence and con- stipation; frequent micturition at night; uric-acid sedi- ment; dyspnea; debility. Mercurius corr.3x—Earthy pallor; dyspnea; sore gums and fetid breath; aggravation during perspiration, and at night; urine albuminous, with many casts; albumi- nuria of pregnancy, diphtheria and syphilis. Acute ag- gravation of chronic interstitial nephritis. Nux vomica.—Morose, irritable temper; vertigo; press- ure in the stomach after eating; constipation; colicky pains; effects of coffee, tobacco and liquors. Dose:—Tr. to 30. Phosphorus.—Great nervous debility, with trembling; dim sight; vomiting of food and drink; albuminous and bloody urine, especially with fatty casts. Dose:—3x to30. Plumbum carb.6x—Produces chronic interstitial nephri- tis. Albuminuria with marked decrease in urea, urates and phosphates; cachexia; melancholy; amaurosis; con- stipation. Or, Plumbum iod. Rhus tox.—Subacute stage; effects of damp cold, with much muscular aching; dropsy slight. Dose:—Tr. to 6x. Sambucus.Tr—Face dark blue, with perspiration of head and neck; suffocative attack after midnight, wak- ing from sleep; relief sitting up; dropsical swellings. Sangninaria.6x—Uremic headaches; flatulent colic; co- pious nocturnal urination; faintness and weakness. Terebinth.i«—Congestion of the kidneys, with hema- turia; casts scanty or absent; albumin in decided amount; effects of exposure to cold. Diuretics.—Diuretics are harmful in active inflamma- tion of the kidneys. They are not curative, but, in per- sistent dropsy or uremia, they are useful palliatives, and prolong life. The dose is best given three times daily, after food; in urgent cases, every hour for several doses. The most serviceable are:—Acetate of potash, 10 to 30 grs. Apocynum infusion, 20 to 60 drops. Caffein citrate, 2 to 5 grs. Castanea vesca,'^. 5 to 20 drops; Digitalis infu- sion, half-dram to 4-dram; tincture, 5 to 20 drops; Digitalin, tJ0 to ^ gr. Diuretin, 5 grs. q. 2 h., 100 grs. daily. Spartein sulphate, ^ to 2 grs. Squilla, 1 gr. q. 2 h.; tincture, 10 drops. Strophantkus^r. 5 to 20 drops. Spirit-of-nitrous-ether, 1 dram. Scoparius, decoction, half-ounce; fluid-extract, 30 drops. WAXY KIDNEY-UREMIA-TREATMENT 143 ______________POCKET-BOOK OF MEDICAL PRACTICE __________ GENERAL MEASURES. Climate.—Dry, warm climate; or, in winter months, keep the patient indoors. Avoid tiring by exercise. Pro- longed rest in bed is valuable. Diet.—Vegetables and milk should constitute the prin- cipal food. Papoid, pepsin, and other digestive fer- ments are helpful. Abundant drinking of pure water. Avoid constipation. Forbid sea-bathing, from risk of uremia. WAXY KIDNEY. (amyloid degeneration; lardaceous degeneration.) Etiology.—Syphilis; tuberculosis; chronic inflamma- tion in bone, or prolonged suppuration. Symptoms.—Those of chronic diffuse nephritis, with presence of waxy casts in the urine. Diagnosis may be impossible during life. Prognosis.—Grave. Cure improbable. Treatment.—Radical treatment of bone diseases and suppuration may prevent development of the amyloid change. When established, its treatment is that of chronic diffuse nephritis. Underlying syphilitic taint re- quires Iodide-of-potash in material doses. Gold, Arsenic and Hydriodic acid antagonize the degenerative tendency. UREMIA. Nature.—An intoxication caused by the retention in the blood of the urinary poisons. Most frequent in Bright's disease, also occurs in obstruction of the ureters and in suppurative nephritis. Symptoms.—Acute uremia appears as a sudden attack of convulsions; coma; dyspnea; vomiting; 6r insanity. Chronic uremia presents headaches; visual disturbance, sleepiness; subnormal temperature; nausea; flatulent in- digestion; dyspnea; peculiar earthy pallor; fetor of the breath and skin; cramps and uneasy sleep. Diagosis.—The urine: albumin and casts; great de- crease in urinary solids, especially urea and phosphates. Differentiate from epilepsy, apoplexy, meningitis, alco- holism, and opium-poisoning, by urinary examination. _ Prognosis. — In acute nephritis, prognosis fair; in chronic nephritis, uremia is a grave sign; the patient may die in the first seizure, but more frequently survives sev- eral attacks. Sometimes remarkable recoveries are seen. TREATMENT. Elimination.—Acute uremia is an emergency case of poisoning, and requires prompt elimination and relief of convulsive symptoms. Purge with— Croton oil, 1 to 2 drops in pill; Elaterium, two grs. Sodium-sulphate, Vz oz. (hot concentrated solution). Irrigate the colon. Hot foments to the loins. Nitro-glycerin, ^, drop dose every half hour. Convulsions.—For the convulsions, chloroform inhala- tions. If the pulse is strong and rapid, Veratrum viride 144 UREMIA-TREATMENT-PYELONEPHRITIS ______________POCKET-BOOK OF MEDICAL PRACTICE___________ (Norwood's tincture) hypodermically in five-drop doses; it reduces the pulse and relaxes the tension of the body. (In overdoses, Veratrum causes coldness, nausea, faint- ness, and collapse. Revive with hypodermics of brandy and nitroglycerin.) Other remedies for the convulsions are: — Arsenitc-of-copper,3x; Chloral hydrate, 15 to 30 grs. by mouth; one dram, by rectum. Coma.—In acute coma, purgatives, diuretics, large enemata. Veratrum viride; inhalations of oxygen; Car- bolic acid 3x; Opium 3 to30; Bryonia.3to30. Heart.—In the chronic or "confirmed uremia" of chronic nephritis, the gross lesion is in the kidneys, but the danger is with the heart. When the heart flags, dropsy and pulmonary edema appear, and the urine be- comes scanty, prepare for uremia. Place the patient on strict milk diet for two weeks; especially avoid fish and alcoholics. Rest, preferably in bed. Protect from damp and cold. Purge and use diuretics. Full baths at 95° to 100° F. Avoid heavy sweating, as it may precipitate a uremic attack. If the symptoms improve, gradually return to full diet and activity. Vomiting. —In uremic vomiting, iced champagne. Half- drop doses Iodine.Tr- Drop doses of a 1 to 10 watery solution Hypochlorite-of-lime. Kreasote.3x Headache.—In uremic headaches, Nitroglycerin, r^0 grain; Hypochlorite-of-lime, solution, five drops, four times daity; Arnica 3x; Hypericum.Tr. PYELONEPHRITIS AND PYELITIS. (SURGICAL KIDNEY.) Etiology.— Acute form:—Renal calculus; gonorrhea; infectious fevers; traumatism; damp cold; invasion of colon bacilli. Chronic form:—Acute form persisting; tuberculosis; most common cause, retention of urine from enlarged prostate or chronic cystitis, with secondary infection of the kidneys. Symptoms.—Dull renal pain, one or both sides; inter- mittent discharge of muco-pus in the urine. Passage of muco-pus through the ureter may simulate renal colic. Fever slight, intermittent in character, with rigors and sweating. Urine albuminous, usually of low sp. e;r., 1010 to 1014. Casts infrequent. Diagnosis.—From cystitis, by presence of renal pain, greater quantity of albumin, and intermittent character of the discharge of muco-pus. Prognosis.—Acute form: favorable, if cause can be re- moved. In chronic form: unfavorable for absolute recov- ery; relapses are common, but life may be prolonged for many years. Prophylaxis.—Scrupulous cleanliness of instruments used in the urethra and bladder. GENERAL MEASURES. Acute Form.—Rest in bed. Skim-milk diet. Veratrum yir.Tr._Hepar.2x_Rhus tox.Tr._puisatiHa.3x_if pain is severe, suppositories containing % grain Ext. Opii, and PERINEPHRITIC ABSCESS-NEPHROPTOSIS 145 _______________POCKET-BOOK OF MEDICAL PRACTICE_____ two grains Ext. Hyoscyami, are necessary. Abscess demands careful aseptic surgery. Chronic form.—Keep the patient warm and dry. Abun- dant drinking of pure water. Avoid jolting or jarring the body, as in carriage-riding. In general, treatment is the same as in chronic nephritis. Boric acid, 5 to 10 grains; Benzoic acid, or Sodium-benzoate, 3 grains; Tere- binth, % drop; Haarlem oil, 5 drops; Sandal oil, 3 drops; Saccharin, 3 grains; Buchu Tr.; Uvaursi Tr.; Copaiba^; Chimaphila Tr., or other indicated remedy, sometimes relieve symptoms. Surgical measures, incision and drainage, removal of calculi or extirpation of tubercu- lous kidney have an element of risk, but are sometimes very successful in restoring health. PERINEPHRITIC ABSCESS. (PARANEPHRITIS.) Etiology.—Blows or falls affecting the loins, or invasion from suppurating appendix, vertebral caries, or pyelitis. Symptoms.—Renal pain ; tenderness; tumor ; thigh flexed on the abdomen. When suppuration occurs, chill, fever and sweat. Diagnosis.—From tumor and calculus, by history and constitutional symptoms. Prognosis.—Favorable. Treatment.—Surgical:—Incision and drainage as soon as pus forms. In injuries affecting the loins, the possi- bility of abscess should be remembered. The use of Belladonna, Mercurius, Arnica, Hepar, or Veratrum viride may prevent suppuration. MOVABLE KIDNEY. (nephroptosis; floating kidney.) Etiology.—More frequent in women, and on the right side. Straining of childbirth is a common cause. Symptoms.—Many nervous and "hysterical" symp- toms; reflex gastro-intestinal pains and flatulency; gen- erally worse during menstruation. Attacks of violent abdominal pain; nausea; vomiting; collapse; relieved by profuse flow of urine. The displaced kidney is discov- ered by palpation. Diagnosis.—By palpation differentiate from biliary colic; renal colic; gastric crisis of tabes. .From ap- pendicitis and peritonitis, by absence of fever. Prognosis.—Good, if kidney can be retained in place. Treatment.—Important, as nephritis and calculi are apt to appear in movable kidneys. During acute attack of pain, rest in bed; replace the kidney; if necessary, use Opium suppositories or Morphine hypodermically. In women, rest in bed during menstruation may prevent an attack. For permanent relief, an abdominal band- age with large pad pressing gently upward and back- ward, holding kidney in place. Radical treatment con- sists in lumbar incision and fixing the kidney in place. If general enteroptosis exists, fixing the kidneys may fail to relieve the symptoms. I4fi HYDRONEPHROSIS-RENAL TUBERCULOSIS POCKET-BOOK OF MEDICAL PRACTICE_________ "hydronephrosis and pyone- PHROSIS. Hydronephrosis.—Distension of renal pelvis and kid- ney with urine dammed back by obstruction of the ureter. The obstruction may be calculus, pressure of abdominal tumor, or twist in the ureter of a movable kid- ney. There is a tumor in renal region. Characteristic symptom is sudden disappearance of the tumor, with simultaneous discharge of urine from the bladder. Per- manent obstruction causes permanent dilatation of the kidney. Fluid aspirated from a recent case will con- tain urea and urinary salts. In old cases, urea is often absent. Pyonephrosis.—Distension of renal pelvis with pus. Any of the causes of hydronephrosis acting on a kidney already affected with pyelitis cause pyonephrosis; or hydronephrosis may become infected. Treatment.—In both cases, if the tumor is recent, mas- sage, with the use of diuretics, may reduce it. Other- wise, the treatment is surgical and mechanical. Aspira- tion may suffice. In pyonephrosis, chill, fever or col- lapse require prompt evacuation of the pus. RENAL TUBERCULOSIS. Etiology.—Infection of the kidneys by tubercle bacilli. Pathology.—Miliary renal tuberculosis is a part of general miliary tuberculosis. Diagnosis during life is impossible, and cure unknown. The common form is renal phthisis, in which a tubercular focus in the kidney or renal pelvis extends, causing caseation and excava- tion. It may destroy the whole kidney. Renal phthisis is usually secondary to prostatic, testicular, pulmonary or peritoneal tuberculosis, or bacilli may be present in the kidney at birth, remaining inactive for many years. Symptoms.—Obscure; may be those of pyelitis: Gen- eral debility; emaciation; hectic fever; or, only local symptoms—unilateral renal pain and frequent urination. Urine: at first clear; contains few bacilli; renal hemor- rhages common; finally pus (from tubercular pyelitis); bacilli more numerous; the bladder becomes infected. The disease often ends in diffuse nephritis, with dropsy and uremia. Diagnosis.—The presence of tubercle bacilli in the urinary sediment. Distinguish from renal and vesical calculus, cancer, and simple pyelitis. Early tuberculosis with no urinary sediment is often diagnosed "irritable bladder." Prognosis. — Some cases recover. Early extirpation of the affected kidney promises best results. With marked constitutional symptoms, dropsy, or uremia, the case is hopeless. Treatment. — Climatic treatment (as in pulmonary) has cured. Avoid alcoholic drinks; irritating foods. If the affection is limited to one kidney (determined by catheteri- ^ TUMORS OF THE KIDNEY-ALBUMINURIA 147 POCKET-BOOK OF MEDICAL PRACTICE zation of ureters) extirpation of the kidney is advisable. Avoid unnecessary instrumentation of the bladder. Hemorrhage.—Rest in bed; Gallic acid, 10 grs. every 2 hours; Geranium mac. (fl. ext.), 5 drops; Thlaspi (Tr.), 10 drops. Treat as in Hematuria. Purulent Urine.—Treat as in Pyelitis. TUMORS OF THE KIDNEY. Benign Tumors.—Fibroma; lipoma; angioma; adenoma; papilloma. Usually small and cause no symptoms. Cysts.—Retention cysts (in chronic interstitial ne- phritis). Congenital cysts (due to same process in fetal life). Neither form causes symptoms. Hydatid cyst may attain the size of an infant's head (rare in this country). Malignant Tumors.—Sarcoma and Carcinoma. Re- peated attacks of pain in one kidney, with profuse hem- orrhage and without apparent cause, always suggest malignant tumor. Varicocele may develop on the same side. The urine rarely gives a clue. If the growth is large, it may be detected by palpation. Finally cachexia develops. Diagnosis.—Differentiation from renal calculus is diffi- cult; in the beginning it is impossible, as cancer urine may have crystalline sediment. Distinguish from renal tuberculosis by absence of bacilli from the urine; from painful movable kidney by palpation. Prognosis.—Fatal, but very slow. Treatment.— See Hematuria for treatment of hem- orrhage. Relieve pain with suppositories of Ext. Opii and Ext. Hyoscyami (better borne for a long period than morphine). Morphine hypodermically, if necessary. For intractable painor hemorrhage, nephrectomy. Early nephrectomy may prolong life. MALFORMATIONS. Varieties.—Congenital absence of one kidney; horse- shoe kidney; lobulated kidney, and congenital floating kidney. Except floating kidney, they cause no symp- toms. ALBUMINURIA. Significance.—Inmost instances it indicates inflamma- tion or congestion of the kidneys. Albumin is found in the urine also in cystitis, prostatitis and acute urethritis; in anemia, scorbutus, some forms of dyspepsia, jaundice, and after severe muscular exercise. In women, the mix- ture in the urine of leucorrheal discharge, and in men, with fluid from the prostate and seminal vesicles, causes- a trace of albumin in the urine. Urine containing blood is always albuminous. Albuminuria of puberty, espe- cially in girls, usually disappears spontaneously, but may be the commencement of chronic nephritis. Treatment.—In all cases of albuminuria, however slight, the cause should be determined if possible, and 148 HEMATURIA-TREATMENT-CHYLURIA POCKET-BOOK OF MEDICAL PRACTICE______________ removed. All albuminurias which cannot be definitely attributed to extra-renal causes should be treated as of renal origin. It is safe to treat all renal albuminurias as probable renal congestion or nephritis. HEMATURIA. Etiology.—Most common causes:—Cancer; calculus; tuberculosis. Also, acute nephritis; hematophilia; in- fectious fevers; scorbutus; violent traumatism; suppressed menstruation; poisoning by phosphorus, terebinth and cantharis; in tropical countries, the action of the fluke, Bilharzia hematobium. Diagnosis.—Blood is recognized by the naked eye; guia- cum test; and detecting red-corpuscles with the micro- scope. Guiacum Test.—Shake equal parts of tincture of guiacum and tur- pentine in a test-tube. Add a few drops of urine. A blue color develops if blood is present. Location.—It is important to determine the source. Signs:—(a) Renal—blood intimately mixed with the urine; or, blood-casts; (b) Below the Kidneys—the blood settles quickly, leaving the urine clear; (c) Ureter— small cylindrical clots; (d) Bladder—large clots; (e) Urethra—oozing of blood, independently of urination. Epithelial cells aid in determining location. TREATMENT. Medicinal.—In general, no accurate indications for remedies can be obtained from the appearance of the urine; the choice must be based on the collateral symp- toms, or be empirical. For hematuria of fevers, scor- butus, or hematophilia—Phosphorus 6x; Crotalus 6x; — Kali chlor.6* In nephritis, the remedy appropriate to the inflammation. Empirical Remedies.—Geranium mac. (fl. ext.), 5 drops. Thlaspi. (Tr.), 5 to 30 drops. Secale 3x; —or, fl. ext., 10 drops. Terebinth.3* Hamamelis.3x Gallic acid, 10 grains. Sandal oil (the hematuria of calculus) 5 drops. Ipecac.6* Lycopus (Tr.), 5 drops. Millefolium (Tr.), ldrop. Operation.—Excessive or obstinate cases, surgical re- lief. HEMOGLOBINURIA. Symptoms.— The urine is brown or blackish-red. It is differentiated from hematuria by the absence of blood- corpuscles, though the guiacum test shows the presence of hemoglobin. Etiology.—It appears in the malarial fever of the South; typhoid; yellow-fever; also in chlorate-of-potash poisoning; cold and damp (paroxysmal). Prognosis.—Depends upon antecedent disease; in par- oxysmal form, good; in malarial form, bad. Treatment.—Rest in bed. Protect from cold and damp- ness. Avoid alcohol and irritating food (as in neph- ritis). Kali, chlor. and Ferrum phos. have relieved. Quinine, in the malarial form, is of doubtful value. NEPHROLITHIASIS POCKET-BOOK OF medical practice CHYLURIA. ("milky'' urine.) Etiology.— Filaria sanguinis in the blood (tropical dis- ease). Symptoms.—"Milky" urine, due to the presence of emulsified fat and albuminous matter. Rupture of lymphatics along the urinary tract may cause a non- parasitic form. Prognosis.—Uncertain; non-parasitic form, bad. Treatment.—No specific known; remove to cold climate (the parasitic form). LIPURIA. (FATTY URINE.) Etiology.—Found in obesity; diabetes; phosphorus- poisoning; excessive ingestion of fats. Symptoms.—Fat-drops (not emulsified) float on the surface of the urine. Treatment.—According to the cause; avoid fat food. ANURIA. (SUPPRESSION OF URINE.) Etiology.—In a mild form it occurs in all fevers; also in cholera; heart-disease; digestive diseases; renal con- gestion; acute or chronic diffuse nephritis. A form may be caused by obstruction in the ureters, as calculus; torsion; pressure of tumors. (For Polyuria, see Diabetes Insipidus.) Symptoms.—Complete or partial suppression of urine. Distinguish from retention by the use of the catheter. Treatment.—In the mechanical form, treat as for hy- dronephrosis, or calculus. In true anuria, treat as in renal congestion:—Warm baths; oxygen inhalations; subcutaneous saline injections; hot saline enemata. Remedies as in Renal Congestion and Nephritis. NEPHROLITHIASIS. (LITHURIA.) Nature.—The deposition from the urine in the kidneys or renal pelvis of crystalline sediment. Principal forms are lithic and oxalic, deposited from acid urine, and phosphatic and ammoniacal from alkaline urine. Symptoms.—Nephralgia, The formation and passage of sand may be painless, or may cause dull renal pain, and backache; there may be sharp exacerbations, with nausea, vomiting and ineffectual urging to urinate, re- sembling mild renal colic. The urine is slightly albu- minous and contains crystals, hyaline casts and a few blood corpuscles. Such an attack is known as nephral- gia, and differs from renal colic in the absence of real calculus and mildness of the symptoms. It is transient and leaves the kidneys uninjured. Treatment.—As for renal calculus. 150 RENAL COLIC-RENAL CALCULUS POCKET-BOOK OF MEDICAL PRACTICE RENAL COLIC. (STONE IN THE URETER.) Symptoms.—Agonizing pain in the region of the affected kidney, radiating to the stomach; down the ureter intothe testicle or thigh. Nausea; vomiting; constant, ineffectual urging to urinate and to stool. The diagnostic point is the sudden onset and sudden cessation of the pain. Diagnosis.—Differentiate from appendicitis and peri- tonitis by absence of fever and blood and casts in the urine; from biliary colic by the same signs, and absence of jaundice. Both forms of colic, if prolonged, may have fever. From intestinal colic, by urinalysis. TREATMENT. Pain.—Measures must be prompt and effective. Mor- phine, % to % gr- subcutaneously. Repeat in one hour if necessary, having the patient closely watched to de- tect any tendency to narcosis. Chloroform inhalations are not as good as Morphine. Apply hot fomentations over the loins and lower abdomen. Rectal injection of starch and laudanum (30 drops). Medicinal.—Berberis tinct. Tr—Give 5-drop doses, fre- quently repeated, during the attack; great relief some- times follows. For uric-acid stone—Coccus cacti.Tr. Hy- drangeaTr. (5 drops, 15 minutes to 1 hour). For oxalate- of-lime stone—Boro-citrate-of-magnesia; Coccus cacti.Tr' To aid expulsion of the calculus, Salicylate of soda, IS to 30 grs. After pain has ceased, watch for passage of calculus from bladder and treat as under Nephrolithiasis to prevent recurrence. RENAL CALCULUS. (gravel; renal colic) Nature.—Crystallization begins about a small clot of mucus or degenerating epithelia (probably about renal epithelia impregnated with the crystals), and increases in concentric layers, often of different salts. Symptoms.—Calculi retained in the kidney or pelvis may be painless, but usually cause intermittent renal pain and hematuria. Both pain and hemorrhage are worse on jarring the body. For many months the urine may show no sign of crystals or renal irritation. Finally, albumin, blood; and hyaline, blood,or epithelial casts, with crystals, appear. Sequelae.—Persistent nephrolithiasis causes chronic interstitial nephritis. Calculus lodged in the renal pelvis causes catarrhal or suppurative inflammation, "calculous pyelitis" and pyelonephritis. Treatment.—The object is the dissolving or removal of the calculus. Citrate-of-potash, 30 grs. every 3 hours; Benzoate (or carbonate) of lithium, 40 grs. daily; Lithia- waters (in large quantity) and Piperazine, 45grs. daily, are believed to have dissolved uric-acid stones. No solv- ent known for the oxalate and phosphatic. Haarlem oil (oil-of-cade, walnut-oil and laurel-berries) relieves symp- toms, especially when there is much catarrhal discharge. RENAL CALCULUS-TREATMENT 151 _______________POCKET-BOOK OF MEDICAL PRACTICE___________ Potentized remedies may relieve symptoms for many months, but there is no evidence of cure. Usually cal- culi must be removed surgically, and this should be done as soon as diagnosis is made. Prognosis.—In nephralgia, good. In retained calculus, interstitial or suppurative nephritis will develop unless it is removed. In renal colic, the immediate prognosis is good, except in case of impaction (infrequent). Renal colic usually recurs periodically, but is curable. TREATMENT. Nephrolithiasis (Lithuria).—The sediment consists of uric-acid and urates, the product of insufficient oxidation of nitrogenous food, the defect being in the liver and skin, and waste of nitrogenous tissue. Diet.—Eat meat only in moderation; eat freely of green vegetables; salads and fruits; avoid spices, fat, and foods forbidden in Oxaluria. Drink freely of pure water; Lithia, Piperazin water, carbonate-of-soda and alkaline waters are useful for periods of three to six weeks. Their prolonged use is inadvisable. Exercise.—Moderate exercise good. Avoid fatigue and heavy sweating, which concentrates the urine. Oxaluria.—Nature.—Sediments of oxalate of lime, like uric acid, are due to suboxidation and inefficient liver and skin activity. Also intestinal indigestion, neuras- thenia. Diet.—Foods rich in oxalic acid must be forbidden. They are: rhubarb, onions, tomatoes, spinach, pepper, sorrel, and tea. Chemical Treatment.— Nitro-muriatic acid, dil., 10 drops after meals. Neurasthenic cases require rest; glycerophosphate-of-lime. Phospliaturia.—True Phosphaturia, an excessive ex- cretion of phosphates, rarely causes phosphatic sedi- ment. Functional Phosphaturia.—Nature.—If the normal acid- ity of the urine is decreased, the earthy phosphates pre- cipitate, but this precipitation does not indicate an ex- cess of phosphates in the urine. Found in neurasthenic states, rich vegetable diet, cerebral abscess, meningitis or grave central nervous lesion, and administration of alkaline medicines. Diet.—Alkaline medicines should be stopped. Veget- ables and fruits used sparingly; eat meats, fish and shellfish. Treat the neurasthenia or dyspepsia. Secondary (Ammoniacal) Phosphaturia. — Nature. —It occurs chiefly in bladder from infection and putrefaction of catarrhal discharges, liberation of ammonia and pre- cipitation of ammonio-magnesian phosphate. Treatment.—Requires the treatment of the cystitis, and urinary antisepsis; Salol, 10 grs. 3 times daily; Boric acid, 10 grs. 4 times daily; Sandalwood oil; Haarlem oil. General.—Great water-drinkers do not have calculus. Free drinking of rain-water or distilled water prevents attacks of renal colic. SECTION XII. MENTAL DISEASES. BY A. P. WILLIAMSON, M.D. MINNEAPOLIS. PROFESSOR OF MENTAL AND NERVOUS DISEASES, COLLEGE OF HOMOEO- PATHIC MEDICINE AND SURGERY, UNIVERSITY OF MINNESOTA. mentaiTdiseases. (INSANITY.) Definitions.—Insanity is a departure from the norma! mental statusof an individual, depending upon some brain lesion. A delusion is a false belief; an hallucination is a false perception; an illusion is a mistaken perception. These control the insane in action and judgment. Varieties. — (a) Melancholia; (b) Mania; (c) Dementia; (d) General Paresis. Etiology.—Remote Causes:—Heredity; previous attack; organic disease of brain or cord; traumatism; age (25 to 40); syphilis; improper education. Exciting Causes:— Overwork; worry; disappointments; excesses; ill health; epilepsy. General Prognosis. — Favorable: — Exciting cause, physical; sudden onset; youth and vigor; delusions, changeable; no revulsion to food; mobility of pupil; cleanliness; continued jollity; steady progress to a crisis of excitement and then a gradual subsidence; slow accu- mulation of fat with brightening of mental faculties; re- turn of usual habits; absence of convulsions and paral- ysis; boils and abscesses. Unfavorable Symptoms:—Ex- citing cause mental or moral; gradual onset; attack after 50 years; single delusion, especially of persecu- tion; persistent refusal of food, requiring prolonged forced feeding; immobility of pupil, particularly a con- tracted pupil; filthy habits; persistent masturbation; ir- ritability of temper; progressive exhaustion with feeble circulation; accumulation of fat with progressive mental weakness; perverted sensations; pulling out the hair; bodily mutilation; convulsions or paralysis. MELANCHOLIA. (MENTAL DEPRESSION.) Symptoms.— 1. Simple:—Mental depression, without delusions or great physical disturbance. Prognosis good. 2. Acute.—Mental depression, prolonged; delusions; hallucinations; illusions; weeping; delusion of "un- pardonable sin," etc.; insomnia; restlessness; fear; anxiety; disposition to suicide (80%); contracted pupils; anorexia; constipation. Prognosis good. 3. Chronic. —Usually follows acute; nervo-bilious tem- perament; fixed delusions; mental depression constant; self-abasement; dyspepsia; constipation; suicidal incli- nation; analgesia. Prognosis bad. 4. With Stupor.—Profound mental depression and in- difference to surroundings; moves only when compelled; (152) MELANCHOLIA-TREATMENT-THERAPEUTICS 153 POCKET-BOOK OF MEDICAL PRACTICE neglect of person; filthy habits; saliva drips from mouth, mucus from nose; suicidal; subnormal temperature; weak circulation. Prognosis guarded. THERAPEUTICS. Aconite.—In acute cases when the patient is restless, mentally and physically. She is apprehensive and fears she is going to die; dreads men; changing mood, from anguish to tears. Particularly useful in young persons. Arsenicum.33—In asthenic cases, with physical rest- lessness. Anxiety;fears he has offended someone whose good opinion he desires; suicidal; tearful. Baptisia.Tr—Melancholia with stupor. Face flushed, dusky red; tongue dry and brown; breath offensive; looks and acts as if drunk; indifferent to surroundings; low muttering delirium; thinks he is scattered about. Bryonia.3x—Depressed; irritable; inclined to be con- trary and obstinate; apprehensive; fears he will never recover. Chamomilla.3x—Peevish; with restlessness; impatient; intolerance of noise; of being spoken to or any interrup- tion; general dissatisfaction with the world and every- thing in it; hallucinations of hearing of familiar voices. Cimieifnga.Tr—Marked depression, with sleeplessness; feels as if enveloped in a dark cloud; loss of interest in daily affairs; suspicious. Especially useful in cases complicated with uterine diseases. Pain or pressure in the vertex. ' China.3x—Tired of life; suicidal, but too indolent to commit the act; is ill-humored, but easily moved to tears; believes himself persecuted; general vitality lowered; anemia from lactation. Digitalis.3x—Great anxiety about the future; sadness and weeping; the depression seems to be temporarily re- lieved by copious flow of tears; fears death; fears that if he moves his heart will stop beating; profound weak- ness with slow pulse. Gelsemium.lx—Stupidity, with inability to think. Es- pecially useful when the depression follows bad news. General motor weakness, with aching all over; tongue tends to be dry; mental exhaustion from severe mental strain. Ignatia.3*—The most useful remedy in acute melan- cholia; great depression; wants to be alone and undis- turbed; easily angered; irritable and suicidal; intoler- able forebodings; wants to kill herself to get rid of her sorrow. Kali phos.3x—Neurasthenic states, with nervous dread; gloomy; looks on the dark side; loss of memory, depres- sion of spirits and irritability; sighing, with feeling of weakness at the epigastrium. Nux vom.3x—Irritable weakness and mental depres- sion; taciturn; mental restlessness, suicidal; easily an- gered, and is then homicidal. Pulsatilla,30*—Marked depression; weeps easily; very religious, prays and cries; worries about the future; 154 MANIA-TREATMENT-THERAPEUTICS _______________POCKET-BOOK OF MEDICAL PRACTICE timidity, accompanied by precordial anguish; sour eructations. Verat. alb.3x—Low spirits; physical weakness; extrem- ities cold; restless; suicidal; depressed, and yet easily angered and may be violent; sometimes in his despair he cries and howls. MANIA. (MENTAL EXCITEMENT.) Symptoms.—1. Acute Delirious: —Great mental and physical restlessness; vivid and changing delusions, hal- lucinations; noisy loquacity; great violence; aversion to family; insomnia; face flushed; fever; rapid pulse; dry tongue; typhoid-like symptoms. Prognosis guarded; mortality great. 2. Acute. —Mental and physical restlessness and ac- tivity; delusions; hallucinations; illusions; profane, noisy, obscene; violence; bites and strikes; insomnia. Prognosis fair; many recoveries. 3. Paranoia.—Usually primary; may follow acute; slow onset; often displays exaggeration of a cherished characteristic; sometimes taciturn, irritable; single de- lusion, usually of persecution; suspicious of others'mo- tives. Delusions of persecution lead to homicide. Prog- nosis bad. 4. Chronic. —Secondary; persistent adherence to delu- sions, especially relating to themselves, which control their actions, such as belief that they are kings, etc. Prognosis bad. THERAPEUTICS. Aconite.3x—Sthenic states; great mental restlessness; very talkative; fears of various kinds; easily angered. Belladonna.3* — Face flushed; pupils dilated; full, bounding pulse, and other signs of cerebral congestion; very irritable and violent; bites and strikes those near; numerous very vivid delusions. Cannabis Ind.1*— Hallucinations and delusions, con- stantly changing, but always of the same general char- acter. Everything is exaggerated, and time seems too long;generally good natured. Cantharis.3x—Paroxysms of rage, with intense sexual excitement and frequent desire to urinate; great violence; snarling, and biting those near. Hyoscyamus.1*—The most useful remedy in acute mania; great mental excitement; fears he will be poisoned; hal- lucinations of hearing; carries on long conversations with imaginary people; singing and laughing, but violent; erotic; restlessness, with muscular twitching. Stramonium.3x—Loquacious; wants company; fickle- minded ; at one moment cross and violent, and at the next good natured and jolly; hallucinations changeable; sometimes pleasant, and again inspire him with horror. Veratrum vir.i*—Violent; restless; dreads being poi- soned; delirious mania. Sulphur.6*—Is occasionally useful in chronic forms of mania, when the head is hot and the feet cold, or other DEMENTIA-VARIETIES-GENERAL PARESIS 155 ,______________POCKET-BOOK OF MEDICAL PRACTICE evidence of disturbed circulation. Ill-humored and quar- relsome; fixed delusions; believes old rags are silk, and pebbles are diamonds. (Also the 200th.) Calcarea carb.6*—Dementia: Dull of comprehension; misplaces words; thinking is difficult; easily moved to tears. Fat and subject to congestive spells, accompanied by vertigo and fullness of the head. (Also the 200th.) Calcarea phos.3*—Peevish and fretful; forgetfulness of recent events; does not recognize surroundings; wants to go home when already there. Especially applicable to young and undeveloped people. Coninm,3*—Extreme want of memory; difficult to remem- ber what he is reading; indifferent to business and fam- ily; vertigo on lying down. Mercurius sol.3*—Stupid; filthy; moans and groans; suspicious; irritable. Phosphoric ac.1*—Indifference to surroundings; mem- ory weak; weeps easily; general weakness and emacia- tion; dementia from masturbation. Veratrum alb.3*—Loquacity; incoherence; destructive; stupid; filthy; lewd in conversation and action; if not too stupid, cherishes the belief that he is some great person. DEMENTIA. (MENTAL FAILURE.) Symptoms.—1. Acute Primary.—Difficult to differen- tiate from melancholia with stupor; females most; age 15-30 yrs.; onset sudden; stupid and filthy; taciturn; no evidence of hearing; movements automatic; face pale and puffy. 2. Alcoholic.—"Old soaks;" rapid loss of memory; even forget their own names; will-power weakened; care- less of personal appearance; irritability; sub-normal temperature; gastric catarrh. 3. Masturbatic.—Pronounced mental weakness; apa- thetic and stupid; sits with head bowed; feet and hands cold and damp; moral perversion. 4. Senile.—After 60; onset slow; loss or memory, es- pecially of recent events; irritability; restlessness; in- decision; unnatural egotism; suspicious; delusions and hallucinations; senile walk and speech. 5. Organic.—Follows apoplexy and cerebral tumors; apprehensive; suspicious; loss of memory; hallucina- tions of sight and hearing; hemiplegia or convulsions. 6. Secondary.—Follows some other form of insanity; mental weakness; in degree varies from feeble will- power and slight loss of memor}7, to mental extinction. GENERAL PARESIS. Symptoms.—Characterized by progressive mental en- feeblement and physical weakness, with muscular incoor- dination. Men, 14; women, 1. First Stage:—Fibrillary trembling, especially muscles of the tongue; slight incoordination of muscles of speech; mental exaltation; exaggerated opinion of powers and past achievements? boastics" q£ iuxuvz expectations? delu- 156 GENERAL PARESIS-THERAPEUTICS _______________POCKET-BOOK OF MEDICAL PRACTICE___________ sionsof grandeur; imaginings of great wealth, or ability to perform impossible feats; spendthrift; moral perversion; indifference to family and business; personal careless- ness; irregularity and immobility of the pupil. Second Stage:—Marked muscular incoordination and physical paresis, with mental enfeeblement; epileptoid seizures and temporary paralyses; inability to pro- nounce labial explosives (p, b, f) or repeat rapidly allit- erative words (" round the rough and rugged rocks"); latent period may supervene, with return of considerable mental power, sooner or later succeeded by last stage. Third Stage:—Loss of power of locomotion; almost in- articulate speech; mental extinction; Jacksonian epi- lepsy; hallucinations of sight; filthy habits; bed-sores. THERAPEUTICS. Agaricus.3*—Great loquacity; sings and rhymes; too busy thinking of delusions to answer questions; indiffer- ent to everything; twitching of muscles, especially of the face; sleeplessness. (Also 30.) Arnica.3*—Dull; absent-minded; fails to finish sen- tence because of thinking of delusions; suspicious and apprehensive; tremulous weakness. Cimicifuga.Tr—Depressed; wants to be alone; answers questions hurriedly and evasively; tremulousness of small muscles around the eye and mouth. Cannabis Ind.3*—Incoherent; great mental exaltation; loquacity; tells of his hallucinations endlessly; good- natured; exaggerated ideas of time and space; sensitive to light and noise. Veratrum vir.1*—Depressed and suspicious; mind greatly confused; cherishes numerous delusions; thinks some one wants to poison him; severe attacks of cerebral congestion; temporary attacks of paralysis. GENERAL MEASURES. " The physician to such unfortunate creatures oug-ht to behave so as to inspire them with respect and at the same time confidence^' -HAHNEMAKiN. (" Lesser Writings.") Room.—Place the patient—if excitable or depressed— in bed in a room far removed from household and street noise. Do not use mechanical restraint; it is rarely needed; should never be resorted to until all other meth- ods have been tried. The best method is by the protec- tion sheet. Nurse.—A good strong nurse is necessary. Impress her with the importance of extreme kindness and gentle- ness; use encouraging words and a hopeful manner. Pay no attention to the rough language or delusions of the patient. Diet.—Vary it with the form of insanity. Most patients are anemic; hence it must be easily digested and nour- ishing. Milk (adding salt to aid its digestibility); raw eggs; boiled custard; broths; rare-beef sandwiches; bovinine; malted-milk. Massage.—It often quiets the patient. SECTION XIII. DISEASES OF THE NERVOUS SYSTEM. BY J. RICHEY HORNER, M.D. CLEVELAND. PROFESSOR OF NEUROLOGY AND ELECTROLOGY, CLEVELAND HOMCEOPATHIC MEDICAL COLLEGE. MYELITIS. (INFLAMMATION OF THE SPINAL CORD.) Varieties.—(a) Acute; Sub-acute; Chronic, {b) Trans- verse; Diffuse; Focal; Disseminated. Causes.—Exposure to cold ; over-exertion ; sudden strain; traumatism; after acute infectious diseases. In some cases the exciting cause is obscure. Diagnosis.—Sensory disturbances, with motor weak- ness, followed by sensory loss extending to the level of the lesion; hyperesthesia just above the upper limit of the lesion; girdle-sensation just below this. lilumbar&eg- ments are involved, vesical and rectal paralysis, also weak- ened tendon and skin-reflexes; flaccid paralysis; tendency to muscular atrophy, and reaction of degeneration. If dorsal segments are involved, the reflexes are present, and later they are exaggerated; contractures and spasms, though if the lesion extends completely across the cord, the reflexes are abolished. If in the cervical region, the arms as well as the legs are involved, the former gener- ally more severely. Other symptoms are:—Dry, cold skin; bed-sores; sexual disturbances; later, cystitis. TREATMENT. General.—Rest in the recumbent posture (not all the time on the back; change frequently from one side to the other); catheterization every six hours (beware of dirty catheters); enemata as required. To prevent bed-sores, have sheets, absolutely smooth; bathe the parts subjected to pressure daily, and anoint with glycerin or glycerin- cream; if the parts become red, apply a lotion of alcohol, or a weak solution of tannin-and-alum; if bed-sores de- velop, treat surgically-and antiseptically; relieve press- ure by appropriate pads. . Diet.— At first, milk, eggs, rice, toast, farina, and blanc-mange; later, a full diet. Electricity.—Not during the acute stage; after it has passed, interrupted galvanization from the sternum to the seat of the lesion, 10 Ma., ten minutes daily, reversing the current every half-minute. Massage and light exercise. Therapeutics.—If the cause is traumatic, Arnica3*; Hypericum.3* If due to exposure, Dulcamara; Rhus; Bellis perennis. If syphilis can be traced, Kali hydri- odicum in rapidly increasing doses, beginning with 10 grs. three times a day, and increasing; or, Mercurial inunctions; when the condition becomes chronic, Strych- nia crude, gr. is t. i. d. In uncomplicated cases, Arsenic; Mercurius ; Phosphorus ; Zincum phos.; Plumbum met. For the subsequent paraplegia, Lathyrus satmis. (157) 158 NEURITIS-TREATMENT-TABES DORSALIS POCKET-BOOK OF MEDICAL PRACTICE___________ NEURITIS. (INFLAMMATION OF NERVES.) Varieties.—Perineuritis; Interstitial; Parenchymat- ous. Causes.—Toxic (alcohol, lead, arsenic, etc.); trau- matic; post-febrile (typhoid, diphtheria, etc.); syphil- itic, malarial; "cold;" by extension. TREATMENT. Therapeutics.—Aconite3*, Gelsemium3* (diphtheritic); Strychnin2x (alcoholic cases, active symptoms subsided; prostration profound); Arsenic^* (pronouncedmotor par- alysis); Mercurius^*; Arnica3*; Argentum nit.Gx; Car- bon sulph.6x (ataxia); Hypericum3*; Rhus toxix; Ferrum phos.3* (acute form); Belladonna3* (atrocious pains); Nux vomica1* (alcoholic cases, active symptoms); Cimi- cifugaTr. (" toothache pains" in the limbs); Plumbum phos.3* (atrophic stage); CausticumGx (paralysis); Phos- phorus3*; Zincum phos.3* (degenerative form); Bellis perennis (alternates with chronic diarrhea); Berberis vulg.3* (lumbar and sacral plexuses); ^Esculus hip.3x; (lesser sciatic): Pareira brava3* (anterior crural); San- guinaria can.1* (circumflex nerve, deltoid paralysis); Anantherum mur.3** (neuritis in the upper dorsal roots). General Measures.—Remove the cause. Rest. Heat, by hot compresses or poultice. If unavoidable, ano- dynes; Antipyrin, 5 to 10 grs.; Acetanilid, 2 to 5 g^s. (large doses are dangerous); Sulphonal, 30 grs.; Kali brom., 15 to 30 grs.; Hydrobromate of hyoscin, TJg to £Q gr.; Morphia, y% to % gr. Avoid repetition of the dose if possible. Electricity.—Never faradism; never early; never in such manner as to give shock. Galvanism:—The posi- tive electrode to the seat of the pain; negative to the spinal origin of the nerve affected; gradually increase the current, and gradually diminish it. Massage.—By skilled masseur, not by inexperienced relatives and friends. Diet.—Plain, nutritious and unstimulating. Surgical Measures.—Where inflammation is intersti- tial, longitudinal section of nerves. LOCOMOTOR ATAXIA. [TABES DORSALIS.) Causes.—Syphilis (80%); exposure; traumatism; sec- ondary to myelitis. Age—middle life. Sex—males (90%). Diagnosis.—Intense weariness and heaviness of the limbs, no matter how much rest istaken; lightning pains (do not mistake for rheumatic pains; the pains are between, and not at the joints); loss of patellar-tendon re- flex; ataxia (inability to wal^ in the dark); Argyll-Rob- ertson pupil; paresthesias; history of syphilis (80%); bladder paralysis (retention and overflow-incontinence); delayed appreciation of sensation; at first stimulation, later loss of, sexual power; ocular paralyses, producing LOCOMOTOR ATAXIA-TREATMENT 159 ______________POCKET-BOOK OF MEDICAL PRACTICE _______ ptosis, strabismus, and diplopia (the latter appears early if at all); optic atrophy; joint affections (Charcot's joint); girdle sensation; gastric, renal, and laryngeal crises. TREATMENT. Argent nit.3*—Incoordination of movement; optic atrophy; unequal pupils; Argyll-Robertson pupil; trem- bling of the hands; complete loss of sexual desire; over- flow incontinence. Of use rather in the advanced stages. Secale.1*—Absence of knee-jerk; lightning pains; ataxia; staggering gait. Plumbum met.3*—First stages; severe paroxysmal pains, worse at night; anesthesia; impotence; amau- rosis ; retention of urine from paralysis of the bladder. Nitric acid.30—Syphilitic history; cerebral symptoms, such as headache, imperfect vision, mental depression, and irritability, together with lightning pains. Aluminum met.6* or Aluminum chloridum.3*—Ptosis; diplopia; paresthesia, particularly of the feet and legs; lightning pains; skin of the face feels as though covered with cobweb, or as if white of egg had dried upon it; pain in the back as if a hot iron had been thrust into the spine. Zincum.6*—It has produced in workmen marked inco- ordination of gait, and anesthesia; burning along the spine; pain at the dorsal vertebras; loss of sexual power. Intercurrent Remedies.—Ammonium mur.6*—Rending, tearing, painful jerks in the thighs, lower limbs, and joints, with a sensation of soreness; lightning pains, with no disturbance of coordination. Picric acid.1*—Asthenia; severe exhaustion from slight exertion; inordinate sexual desire. Kali liyd.—In syphilitic cases, especially where there is paralysis of single cranial nerve. Full doses—grs. xv., t. i. d., and increasing. For Lightning Pains. —Belladonna3*; Pilocarpine2x; Physostigma3x; Angustura3x; Strontia carb.3° (Relief while in water as hot as can be borne; lightning pains excessive.) Other remedies to be studied are—Silicea, Phosphorus, Berberis (in nephritic cases), Nux vom., ^Esculus, Nux moschata, Fluoric acid, Arsen. iod., Mercurius corr. GENERAL MEASURES. Electricity.—The static current, by heavy sparks to the soles of the feet, combined with positive insulation. Gal- vanism, a strong current (15 to 30 Ma.) applied along the spine and over the limbs, the anode being placed in the region of the lumbar vertebras; or an anode electrode (size, 1^X18 in.) along the length of the spinal cord, the cathode being moved about over the trunk and limbs; Erb's combined galvanism of the spinal cord and sym- pathetic. Farad ism—anode applied to the sternum, cathode to the skin of the back, and also the extremities, until a decided rubefacient effect is established.. Sinusoidal Current.— For Lightning Pains: One elec- trode to the nape of the neck, the other over the painful 160 TABES DORSALIS-NEURALGIA-TREATMENT POCKET-BOOK OF MEDICAL PRACTICE area. For Ataxia:—The foot-plate for the lower pole; the broad neck electrode for the upper. Treatment—For a week, ten minutes daily; then p.r.n. Hydrotherapy.—Hot baths (must be used carefully where the condition of ataxia has progressed far); luke- warm, temperature 95° F., ten to twenty minutes daily. For severe pains, dashes on the part of ice-cold water. Possibly benefit may be derived from visit to some of the watering places, as Hot Springs in America, Bad Naii- heim, Germany, or Lamalou, France. Suspension.—By modified Sayre's apparatus where lightning pains and trouble with the bladder are consid- erable. One to three minutes three times a week for six weeks, then stop for three months, and repeat. Contra- indicated by arterio-sclerosis and bulbar symptoms, and in the paralytic stage. Frankel's method of systematic exercise (see Dana, "Nervous Diseases," 4th Ed., p. 599). Diet.—Foods that are non-fermentative and digestible; nitrogenous and fatty foods. Suggestion.—Those patients do best who continually fight against the disease, and do not despair of finding something which will help them. NEURALGIA. Varieties.—Idiopathic (developing spontaneously); Symptomatic (toxic or reflex; or, organic disease of the nerve). May be (according to the nerve affected) epilep- tiform; hysterical; reflex; traumatic; gouty; etc. May be trigeminal; cervical; occipital; brachial; intercostal; lumbar; crural; visceral; sciatic. Causes.—Age (15 to 25). Sex, female (60%). Hered- ity; anemia; gout; infections; exposure; over-exertion; shock; traumatism. Season (mostly in winter). Diagnosis.—Pains shifting; paroxysmal; follow the course of nerves; no signs of organic nervous disease. Prognosis.—Good. Usually guarded in hysterical and neurasthenic persons, and where the system is broken down by age, disease, or dissipation. TREATMENT. Aconite.3*—Caused by cold, or checked perspiration; severe pains; congestive state; numbness; as though lack of circulation. Belladonna.3*—Surface extremely sensitive to light touch firm pressure relieving; pains come and go quickly; aggravated by light, noise, jar, or draft of air. Kalmia.3*—Neuralgia of the stump; one-half of the tace affecled from exposure to cold; aggravated by worry or mental exertion. Spigelia.3*—"Sun Neuralgia"; pale face; left-sided lace-ache; shooting pains; especially when the eye is affected. Arsenicum.6x_Malarial; worse from cold; intermittent; periodical; worse at night; surface feels cold; better from exercise. Mezereum.3*—Shooting pains radiating from below the eye; teeth decayed; surface extremely sensitive. NEURALGIA-TREATMENT-SCIATICA 161 ________ POCKET-BOOK OF MEDICAL PRACTICE Magnesia phos.3*—Paroxysmal; changing about; re- lieved by heat, pressure and rest; worse from cold and at night; accompanied by spasmodic muscular contrac- tion. Dose:—Give the 3x in hot water. Dioscorea.3x—"Bilious colic," relieved by bending backward (opisthotonoid); better in the open air and by walking about. CoIoc)'iith.3x— Facial neuralgia; abdominal neuralgia; sore, but relieved by pressure, and bending forward. Veratrum alb.3* — Facial neuralgia; gastric symptoms; gradual onset, increase and subsidence of symptoms. Hypericum.3*—Traumatic neuralgia. Kali ferrocyauide.1*—Neuralgic affections depending upon impoverished blood; exhausted spinal nerve center; cardiac palpitation; mental depression. Gelsemium.1*—Deep-seated pains; muscular contrac- tions; ocular neuralgia. Natrum mur.1^—Malarial cases; especially after the abuse of Quinia. Plantago major.3*—Pains about the teeth and ear. Cedron,1* and Quinia sulph.—Marked periodicity. Arnica.3*—Traumatic cases. Ranunculus bulb.3x—Pleurodynia. Byronia.3*—Intercostal neuralgia. Menyanthes.6*—Pains relieved by hard, firm pressure. GENERAL MEASURES. Applications.—Heat, by dry, hot air-bath (temperature 200° F. to 400° F.); hot-water bags; Japanese fire-boxes; painting the nerve with anodynes, as Cocaine, Aconite, or solution of equal parts of these; Belladonna, or solution of Helleborine (1% ), or Chloroform liniment. Rest. Electricity.—Galvanism:—Positive electrode on the sen- sitive points; negative on nerve-origin in the spinal cord. mild current, increasing in strength. Static spark; posi- tive faradism; cataphoresis with solutions as noted above. Diet.—Liberal; fats, cod-liver oil, particularly in ane- mic and neurotic subjects. Baths.—Of piain or salt-water; hot. Massage.—Gentle, between the attacks. Palliatives.—Where unavoidable, coal-tar derivatives, as Antipyrine (5 to 15 grs. every 3 to 4 hours), or Acetan- elid (2 to 5 grs.; larger doses dangerous); use 7vith caution. Surgical.—Nerve-stretching, or resection. SCIATICA. Causes.—Gout; exposure; strain; neurotic diathesis; pressure (as from hard seats); pelvic tumor; vertebral disease. Age, 40 to 50; sex, male; season, autumn and winter, mostly. Differential Diagnosis.—(a) Hip-joint disease (has pain in the hip on tapping the knee; temperature; deformity; sometimes spinal curvature), (b) Organic disease of the cauda equina (has sensory disturbances, motor paralysis, 162 SCIATICA-INTERCOSTAL NEURALGIA POCKET-BOOK OF MEDICAL PRACTICE rectal and vesical atony), (c) Muscular pains in the leg (are less severe, less sudden, less localized). Prognosis.—Good for cure in from three to six months; relapses sometimes occur. TREATMENT. Gnaphalium.3*—Intense pain along the sciatic nerve; feeling of numbness occasionally taking the place of sciatica; exercise of the feet excessively fatiguing. Colocynth.3*—Paroxysms of pain; feeling of numbness and partial paralysis; nutrition of the limb may be affected. Ammonium mur.6*—Pains worse while the patient is sitting; somewhat relieved while he is walking; entirely relieved when he lies down. Kali hydriodicum.1*—Pains worse at night; from lying on the affected side, of mercurial or syphilitic origin. Note.—Study remedies under Neuralgia. GENERAL MEASURES. Rest.—Absolute rest, secured by Thomas splint from the axilla to the ankle; firm bandage around the whole limb; Menthol locally. Electricity.—Galvanism:—Positive electrode along the course of the nerve, negative to the lumbar spine (15 to 20 Ma.), ten minutes daily; faradic wire brush. Massage.—Judiciously used. Nerve-Stretching.—As a last resort, nerve-stretching (30 to 40 pounds pressure). Palliatives.—Use no anodynes unless absolutely neces- sary. Then use Antipyrine (5 to 15 grs.) at intervals of three hours or longer; Acetanelid (2 to 5 grs.; larger doses are dangerous.) INTERCOSTAL NEURALGIA. (PLEURODYNIA.) Differential Diagnosis.—Myalgia has a history of rheu- matism; pains dull and scattered; tenderness; pains worse on taking deep breath. Exclude pleurisy and re- flex neuralgias. Painful points in intercostal neuralgia. TREATMENT. Therapeutics.—Ranunculus bulb. 3*; Arnica 3*; Acon- ite 3x; Arsenicum iod. 3x; Cimicifuga.3* General Measures.—Bandage as for fractured rib; local heat. Electricity.—Galvanism:— (Moisten the sponge of posi- tive electrode—place it over the seat of the pain; negative indifferent.) Faradism:—Secondary current, fine wire coil (10 to 15 minutes daily). Cataphoresis.—Cocaine solution (20%). TIC DOULOUREUX. (TRIGEMINAL NEURALGIA; PROSOPALGIA.) Nature.—Intense, persistent neuralgia, following de- structive changes in the nerve. Causes. — Exposure; depressing influences; carious teeth; old age. PROSOPALGIA-TREATMENT-BELLS PALSY 163 POCKET-BOOK OF MEDICAL PRACTICE Diagnosis.—Intense darting pains in the lower cheek of one side; flushed face; lachrymation; fluent nasal dis- charge; pains paroxysmal; made worse by cold air; eat- ing; drinking. Prognosis.—For permanent cure, guarded. TREATMENT. Natrum sulph.6*—Origin in exposure to continuously damp atmosphere. Argentum nit.6*—Infra-orbital and dental branches affected; pains intense, with unpleasant sour taste in the mouth. Verbascum.l*—Crushing as if with tongs in the painful parts; worse from 9 A. M. to 4 p. m., and from talking, sneezing, or change of temperature. Capsicum.3*—Burning, pungent pain in the face; worse from slightest draught of air. GENERAL MEASURES. Local.—Heat; local anodynes of Cocaine (4%), local injections. Electricity.—Gatvanism:—Positive electrode at the seat of the pain; negative at the cervical spine (3 Ma.), 5 min- utes, 2 or 3 times daily. Surgical Measures.—Nerve-stretching or resection; or, removal of Gasserian ganglion. BELL'S PALSY. (facial paralysis.) Varieties.—Peripheral; nuclear; cerebral; basilar. Causes.—Exposure; traumatism; infection; toxic agents; neurotic diathesis. Sex, male; age, 20 to 40 years. Symptoms.—Weakness of the facial muscles, unable to close the eye or pucker the lips; the angle of the mouth drops; speech muffled; reaction of degeneration. Prognosis.—For peripheral, good for cure in 3 to 5 months. If central, very guarded. TREATMENT. Aconite.3*—Acute stage; also in cases caused by ex- posure to strong, cold wind. In subacute cases use the twelfth dilution, or higher. Rhus tox.3*—Rheumatic diathesis, where the cause is dampness. Caustieum.3*—Where the condition has become chronic, with muscular twitchings and contractures; right side of the face. Belladonna.3*—Right side of the face; at times com- plicated with tic douloureux. Hypericum.3*—Caused by traumatism of the nerve. Consult.—Gelsemium, Cocculus, Ruta, Dulcamara. GENERAL MEASURES. The Eye.—Protection of the conjunctiva by an eye-shade. Electricity.—Never during first three weeks; after this, galvanism strong enough to produce muscular contrac- tions; positive electrode just in front of the ear, negative at motor points of muscles involved, five minutes daily. Massage.—If contractures occur, gentle massage and facial gymnastics. Ifid WRITERS CRAMP-COCCYGODYNIA '"^ POCKET-BOOK OF MEDICAL PRACTICE______________ WRITER'S CRAMP. (scrivener's, palsy.) Varieties.—Spastic; neuralgic; tremulous; paralytic. Nature.—Interference with the act of writing; spasms or tremor of muscles of the fingers and arm. Cause.—Neurotic subject; age, 25 to 40; sex, male; worry; dissipation; excessive use of the arm under forced strain; false position of the pen; exposure and toxic in- fluences. Diagnosis.—History of excessive writing; nerve-strain; electrical reactions normal; slight sensory disturbances; marked motor incoordination. Prognosis.—Very guarded; unfavorable, but cases may be cured. TREATMENT Therapeutics.—Gelsemium: Picric acid; Belladonna; Causticum; Cyclamen; Nux vomica; Ruta; Secale; Sel- enium; Stannum; Staphysagria; Zinc. General Measures.— Prevention:— Use a large pen- holder. Do not over-exert, as in contests of speed. Ma- thieu's instrument for writer's cramp. If possible, com- plete rest. Systematic finger and wrist exercises. Electricity.—Galvanism.—Positive pole to the cervical spine; negative over the affected muscles, 5 to 10 Ma.; 10 minutes daily. _______ COCCYGODYNIA. Nature.—Neuralgia of the lower posterior sacral nerves. Causes.—Exposure; injury; labor. Diagnosis.—Exclude hemorrhoids. TREATMENT. Therapeutics. — Arnica, Rhus, if traumatic. Other remedies:—Ruta; Kali bi.; Cistus; Tartar emet.; Paris quad.; Petroleum. General Measures.—Be sure there is no dislocation; make examination per rectum. Electrieity.—Galvanism; faradism; static. Surgical.—Amputation of the coccyx. ACUTE ASCENDING SPINAL PARALYSIS. Therapeutics.—Consult Phosphorus; Oxalic acid; La- thyrus sat.; Ledum; Aluminum. General Measures.—Warm baths and packs. Counter- irritation of the spine, and rest. MULTIPLE SCLEROSIS. (disseminated sclerosis; insular sclerosis.) Nature.—Paralysis or disturbance of function, as, tre- mor, nystagmus, perhaps paraplegia. Due to hardening of scattered portions of nerve tissue in the brain and cord. Causes.—Heredity; exposure; shock; traumatism; post- infectious (after typhoid and malaria). Age, between 20 and 30; sex, male. MULTIPLE SCLEROSIS-CEREBRAL ANEMIA 165 POCKET-BOOK OF MEDICAL PRACTICE Diagnosis.—Tremor increasing on voluntary motion; scanning speech; nystagmus; knee-jerk exaggerated; ankle-clonus present; ataxia; some weakness and numb- ness of the limbs. TREATMENT Thei'apeutics.—Consult Physostigma; Argentum nit.; Plumbum; Nux vomica; Phosphorus; Sulphur; Calca- rea; Lycopodium; Silicea; Thuja; Baryta carb.; Causti- cum; Crotalus; Gelsemium; Tarantula. General Measures.—Insist upon regular, systematic, quiet life. Central galvanization. Hydro-therapeutics. PSEUDO-HYPERTROPHIC MUSCU- LAR PARALYSIS. Nature.—Deposit of fat between the layers of muscular structure; inherited through the mother. Diagnosis.—Waddling gait; in rising from a recumbent posture the child "climbs up the legs "; lordosis; hyper- trophy of the muscles with hardness and loss of strength. Prognosis.—Incurable; the disease may last from ten to twenty-five years. TREATMENT. Therapeutics.—Phosphorus^*, or higher. Try thyroid gland, 5 grs. 3 times a day. General.—Faradism daily. Massage. Gymnastic ex- ercises. If contractures occur, tenotomy to relieve. Diet.—Carefully selected muscle-making food. CEREBRAL ANEMIA. Varieties.—Acute (fainting); Chronic. Causes.—General anemia; organic arterial changes; organic and exhausting diseases; disorders of digestion; fright; shock. Diagnosis.—Dilated pupils; the symptoms aggravated by upright position. TREATMENT. Acute.—Fainting. Place the patient in recumbent po- sition immediately; loosen neck and waistbands. Dash cold water in the face, then use pungent, volatile sub- stances, as Ammonia; Nitrite-of-amyl; Acetic acid. Electricity.—Faradic current to the epigastrium. Therapeutics.—Camphor Tr. or Veratrum alb.** a few drops on the tongue during the attack. After the attack —China; Veratrum alb.; Dachesis; Camphor. Chronic Anemia.— Therapeutics.— Kali carb.; Alumina; China; Arsenicum; Ferrum phos.; Calcarea phos. General Measures.—Build up the physical system. Feed the blood. Give malt preparations. Out-door exercise. Relief from mental labor. Electricity.—Static. _______ CEREBRAL MENINGITIS. (brain fever: cerebritis: encephalitis.) Varieties.— {a) Focal; {b) Diffuse. Symptoms.— Headache; fever; delirium; convulsive movements; and especially optic neuritis. Prognosis.—Always grave. 166 CEREBRAL MENINGITIS-GENERAL MEASURES POCKEf-BOOK OF MEDICAL PRACTICE_________ TREATMENT. Aconite.3*—Resulting from cold, violent emotions, or excited heart's action. Burning in the brain, as though moved by boiling water; arterial tension high; general surface of the body cold. Belladonna.3*—First stage; before effusion; drowsy, comatose condition, or furious delirium; congested con- junctiva?; extreme sensitiveness. Apis.3*—Follows Belladonna after effusion has taken place; licri enccphalique.'1'' Glonoin.6x—The brain feels too large for the skull; pupils dilated; flashesof light before the eyes; throbbing headache. Bryonia.3*—After effusion has set in; in mild delirium; livid face; stupor. Hellebore.3*—Mental torpor; sighing breathing; want of reaction; shocks as of electricity pass through the head; perhaps convulsions; constant, plaintive moaning. Arsenicum.6*—In the later stages; asthenic; character- istic facies; restlessness and thirst. Camphor monobromide.2* — Persistent vomiting; pale face; body cold; limbs rigid; head retracted; violent cramps. Opium.6*—Stupefaction; contracted pupils; bloated, purplish face; hard abdomen. Cuprum met.6*—Convulsions;distorted face; cold hands; blue fingers; twitching limbs; thumbs clenched in the palms of the hands. Zincum met.6* — Unconsciousness; eyes half closed; dilated, insensible pupils; cold extremities; impeded res- piration; weak pulse; cerebral torpor. Hyoscyamus.3*—Unconscious; talkative; raving; scold- ing; singing; picking at the bed-clothes; stupid expres- sion; eyes injected; aberration of sight. GENERAL MEASURES. Nursing.—Absolute mental and physical rest; dark- ened room; quiet surroundings; continuous application of cold water to the head by means of a rubber-tube skull-cap, siphoning the water from a vessel conven- iently placed (to be used during the stage of excitement, not during depression); hot-water bottles to the feet. Diet.—Nourishment frequently in small quantities; milk; if not much fever, beef-juice or broths; oatmeal or rice boiled three or four hours and strained through a cloth, —give hot or cold. As convalescence becomes established, milk-toast; farina; blanc-mange; scraped beef; pancrea- tized meat-broth; eggs; custard; and wine-jelly. CEREBRAL PARALYSIS. (CEREBRAL APOPLEXY.) Nature.—Mostly hemiplegia; or it may be crossed par- alysis—(face, one side; body, opposite side; due to in- volvement of cranial nerve and motor tract in the same lesion). Cause.—Due to cerebral (a) embolus; (b) hemorrhage; [c) thrombus; (d) abscess; (e) tumor. APOPLEXY-TREATMENT-GENERAL MEASURES 167 ______________POCKET-BOOK OF MEDICAL PRACTICE Diagnosis.—Embolus—paralysis in a few seconds; hemorrhage—in a few minutes; thrombus—in hours or days; abscess—in weeks; tumor—in months or years. Localize the lesion by study of the muscles affected. The paralysis is generally hemi-plegia; very rarely para-n\egia. Prognosis.—Generally good for partial return to nor- mal condition; never perfect use of affected parts, and often contractures. Treatment is unavailing if the cause is embolus or thrombus; acute softening of the brain will develop. TREATMENT. Belladonna.3*—If the cause is hemorrhage. Extreme congestion; throbbing of vessels; pupils dilated; con- vulsive movements; irregular pulse. Aconite.3*—Great arterial excitement; full pulse. Glonoin.6*—Similar to Belladonna, except the pulse is more powerful, and irregular. Opium.3*—Profound coma; marked stertorous breath- ing; dusky face; profuse sweat. Arnica.3*—Cause traumatic; tends to promote absorp- tion, hence should be given after the subsidence of acute symptoms; give high dilution. Nux vom.3*—Congestive condition of the brain favoring apoplexy. For those of sedentary habit, who have in- dulged in rich diet and alcoholic stimulants. Sulphur1^—To promote resorption, comes in where the action of Arnica terminates. Phosphorus.6*—Retards degeneration of arteries. For Predisposition—Nux vom.; Phosphorus; Baryta; Lachesis; Gelsemium; Hyoscyamus. For After-effects.—Causticum; Zincum;Cuprum;Plum- bum; Cocculus. GENERAL MEASURES. The Patient.—Place on the paralyzed side, with head and shoulders raised; the head in such a position as to facilitate flow of blood from the cranium; loosen the col- lar and all bands; apply cold to the head, and heat to the extremities; give absolute rest, both physical and mental; avoid exertion and excitement. Diet.—Very light. Electricity.—In chronic conditions, faradization. Mas- sage is useful. Abscess.—Treatmentis entirely surgical; trephine over the location of the abscess, and drain. Tumor.—If due to syphilis, Potassium-iodide in in- creasing doses. Begin with gr. xv., t. i. d.; rapidly in- crease to limit of the patient's tolerance,—perhaps as much as 1 oz. daily, in divided doses. Give in the form of a saturated solution, one minim representing one grain of the crude drug. Also treat symptomatically. Consult Belladonna; Conium; Hydrastis; Sepia; Calc. carb.; Graphites; Baryta carb.; Arnica. Surgical Measures.—To relieve pressure, trephine and procure drainage of cerebral fluid. Only Sfo of cases are operable. Insist on early operation. 168 APOPLEXY-PARALYSIS AGITANS POCKET-BOOK OF MEDICAL PRACTICE PARALYSIS AGITANS. Nature.—Progressive disease, with weak and rigid muscles; stooping attitude; paresthesias. Causes.—Overwork; anxiety; rheumatism(?). Sex,male; age, 40 to 60. Diagnosis.—Tremor in the hand (oftenest the left), then spreads over the body; the flexor muscles contract, the finger and thumb in writing-position; tremor can be momentarily controlled by voluntary effort (in multiple sclerosis, aggravated by same); body stooped; in walk- ing or running the upper part of the body seems to move faster than the lower; all the muscles become rigid; re- flexes absent; voice squeaky. Differential Diagnosis.—Senile tremor:—Occurs in the very old; and first in the head. Multiple Sclerosis:— Tremor more jerky, worse by voluntary movement; nys- tagmus; scanning speech. Post-hemiplegic tremor:— History; reflexes exaggerated; sensory disturbances often. Prognosis.—Unfavorable; incurable, but can be con- trolled. TREATMENT. Sulphate of duhoisine.— >_ milligram three to six times a day. Controls tremor for three or four days. It is poisonous when the daily amount reaches 4 milligrams. Hyoscyamine.—Instil into the eye one drop of solution (2 grs. to 1 oz.) of Hydro-bromide of Hyoscyamine. It can be repeated at stated intervals in the same strength, or strength of 1 gr. to 1 oz. It causes disagreeable dry- ness of the mouth and throat. Camphor bromide.—Dose:—\ to 15 grs. daily, Consult. — Plumbum6*; Mercurius6x; Tarantula!^; AgaricusTr.; Gelsemium3x; Kali brom.ix General Measures.—Warm baths; quiet, uneventful life; mild massage; temporary benefit from hypnotic sugges- tion. Electricity.— Static:— Negative insulation, 15 to 20 min- utes, followed by sparks along the spine. Galvanism:— Positive to the forehead, negative to the nape of the neck, 3 to 5 Ma., 5 minutes daily; or, large positive electrode over the sternum, negative up and down the spine, 10 Ma., 10 minutes daily. EPILEPSY. Nature.—Convulsions, with impairment or loss of consciousness, not due to organic disease. Causes.—Inheritance of neurotic tendencies; alcoholism of parents; intermarriage of neurotic persons, or of rela- tions. Age of development—10 to 15. Exciting Causes : — Injury; fright; infectious diseases; masturbation; syph- ilis; alcoholism; conditions acting reflexly, as intestinal, ocular, auditory, dental and digestive irritations. Jack- sonian is due to pressure on the motor tract. Diagnosis.—Aura; screaming; quick loss of conscious- ness; dilated pupils; tonic spasms; bitten tongue; loss EPILEPSY-TREATMENT-GENERAL MEASURES 169 ______________POCKET-BOOK OF MEDICAL PRACTICE of vesical and sometimes rectal control, are characteristic symptoms. Hysterical patients do not lose conscious- ness; do not hurt themselves in falling, nor bite the tongue, nor have incoordinate movements; nor have rise in temperature. Prognosis.—For cure very unfavorable; shortens life 10 to 15 years; 10% become insane; possibly &% get well. Condition may continue indefinitely. TREATMENT. Therapeutics.—Any one of many remedies may be in- dicated. The symptomatology must be closely studied; decidedly beneficial effects have resulted from a close application of the similia. The following remedies have undoubtedly had beneficial results : Rano bufo.3*—Positive results seem to have followed its use, not only in one case, but in several; history of masturbation or fright; aura from the stomach. Cicuta virosa.—Severe opisthotonos; facial cyanosis; tendency to hiccough while recovering; peculiar sensi- tive vesicular eruption preceding attack by a few days. Cuprum met.—Is a most perfect similia of the epileptic spasm. Consult.—Aconite3* (status epilepticus); CEnanthe cro- cataTr.; Solanum Car.Tr.; Borax3x; Dachesis; Argen- tum nit.3*; Ferrum-hydrocyanateix; Ignatia6x; Nitric ^cid; Verbena hastataTr. (12 drops every 4 hours); Kali mur.6x; Absinthium; Mellilotus; Lachesis; Nitric acid. Palliatives.—As a last resort—Potassium-bromide, or Strontium-bromide, not less than 60 grs. per day, in di- vided doses, and increase from day to day. GENERAL MEASURES. Electricity.—Static insulation, five minutes; positive, direct head and spine breeze five minutes, and conclude with mild, direct, positive spark to the lower extremities, every day, or three times a week. Hydrotherapy.—Epileptics should be given showers, douches, cold sponge-baths, wet packs, according to their needs and opportunities. Drink water freely. Exercise.—Moderate exercise, but not dancing or vio- lent amusements; sexual continence; extreme care in pre- venting masturbation. Insure mental and physical com- fort. Diet._Be very careful about the diet. But little meat of any kind; no pork, ham, sausage, veal, corned beef, boiled cabbage, turnips, or baked beans (string beans or green shelled beans are permissible); no salt mackerel; no fish or meats of any kind that have been salted or pickled; no lobsters, clams, sardines, cheese, pickles, bananas, nuts or salads; no tea, nor any drink of a stim- ulating character (particularly alcoholic), nor eat any- thing found by experience to disagree. Always eat light suppers. Never eat between-meals, nor after 6 o'clock p. m. Eat slowly, and not near usual time of attack. In the Attack.—Inhalations of Amyl nit., Ammonia, or Chloroform, to ward off a threatened attack. During the attack loosen the clothing; keep the patient from 170 EPILEPSY-GENERAL MEASURES-CHOREA POCKET-BOOK OF MEDICAL PRACTICE injuring himself. Pressure on both carotids, which makes pressure on the cervical sympathetic and par vagum nerves, will often shorten an attack. In female patients, pressure on the ovarian regions sometimes has alike effect. When the convulsions cease, draw the tongue forward, and turn the head to one side, that the half- paralyzed tongue may not fall on the larynx. Let the patient rest. Precaution.—Keep epileptics from dangerous places. CHOREA. (ST. VITUS' DANCE.) Varieties.—Sydenham's (common); Huntington's (he- reditary); Convulsive; Hysterical; Electric. Nature.—Irregular, muscular jerking; incoordinate movements. Causes.—Sydenham's:—Fright, injury, worry, rheuma- tism; age, 5 to 15; sex, females. Huntington ys;—Hered- itary; age, 30 to 50; sex—equal. Convulsive: —Irrita- tion; age—under 10. Hysterical:—Neurotic diathesis; reflex disturbances. Electric:—Rare, due to toxic in- fection. Prognosis.3*—For Sydenham's, favorable for cure in six weeks to six months; in other forms very unfavor- able. TREATMENT. Agarieine.3*—Attacks crosswise, e. g., upper right arm and lower left leg; nictitation; ravenous appetite, but difficult swallowing; condition worse on approach of a thunder storm. Causticum.3*—Right side worse; movements severe; tongue affected; speech staccato. Ferrum redactum.—Particularly in cases where there is marked anemia or chlorosis. Dose:—l gr. after each meal. . Ciuiicifuga.3*—Neurotic cases; cases occurring in girls at puberty; muscular pains; movements worse on the left side; mental symptoms. Pulsatilla.3*—Uterine symptoms; characteristic tem- perament; catarrhal gastritis. Hyoscyamus.3*—Local twitchings; severe cases; great prostration, perhaps anemia. Stramonium.3*—Movements general and violent; ten- dency to hysterical condition; extreme nervousness. Mygale.6*—Extreme cases; facial expression constantly changing; muscular actions continuous and violent, fre- quently emotional. Cina.3*—Condition reflex from the presence of worms. Also, Santoninei*; Spigelia.3* Iguatia.3x—Origin emotional; great excitability, or ex- treme mental depression; aggravation by cold, emotion, noise, or light. Tarantula.6*—Right arm and right leg affected; move- ment continuing even during sleep (Zizia). Veratrum vir.i*—Extreme congestion of nerve centers. CHOREA-GENERAL MEASURES-NEURASTHENIA 171 _______________POCKET-BOOK OF MEDICAL PRACTICE______________ Arsenic.—Anemic cases. Dose:—Fowler's solution, 5 minims, t. i. d.; increase gradually until the dose is 15 minims, then decrease gradually. Consult.— Phosphorus6*; Belladonna3*; Strychnia3*; Cocculus3x; Nux vomica.3x GENERAL MEASURES. Rest.—Complete rest, both mental and physical; stop attendance at school; interdict studies. In most cases put the patient to bed; have the surroundings cheerful and bright; encourage the patient as much as possible. Protect the patient from injury by proper padding of the bed. Do not restrain the patient by bandages. Sleep.—To promote sleep, warm baths, hot sponge bath, warm milk; only exceptionally hypnotics, as, e.g., Chloral-hydrate and Potassium-bromide, 3 to 10 grains of each at bedtime. Gentle massage. Diet.—It should be most nourishing; in cases of mal- nutrition, cod-liver oil; push feeding to the limit of powers of assimilation. Electricity.—Galvanism:—Positive sponge electrode to the forehead, negative to nape of the neck, 3 Ma., 3 minutes, followed by negative spong2 electrode on the sternum, positive up and down the spine, 10 Ma., 5 to 7 minutes. Repeat treatment three times weekly. Or, bifurcated negative in the hands, bifurcated positive on the parietal regions, 5 Ma., 3 minutes daily. Or, static insulation, 15 minutes daily. ______■ NEURASTHENIA. Varieties.—(a) Primary (appearing at adolescence); {b) Hystero (with reflex symptoms associated with disor- ders of the generative organs); (c) Climacteric; (d) Trau- matic; (e) General spinal irritation (spinal anemia, hy- peremia) ; [f) Anxiety neurosis (becomes possessed of a fixed idea, generally of having committed a wrong); (g) Angiopathic (nerve-supply of the blood vessels affected, causing a sensation of beating or pulsation involving the whole body; dermography). Causes.—Hereditary nerve sensitiveness; overwork or worry; shocks (with or without injury); infections; abuse of stimulants or narcotics; abuse of sexual functions; abuse of digestive functions. Differential Diagnosis.—Exclude—hysteria; hypochon- driasis; melancholia; incipient paresis; malingering. Prognosis.—Guarded as to complete cure; it may last from one to seven years, or longer. TREATMENT. Therapeutics.—Cerebral symptoms dominant; inability for mental labor:—Picric acid; Calcarea carb.; Kali phos.; Nux vomica; Gelsemium; Phosphoric acid; Phos- phorus. Hypochondriacal Tendency.—Aurum; Kali brom. (in a potency); Sulphur; Natrum mur. Insomnia.—When prominent, Ambra; Arsenicum; Cim- icifuga; Coffea crud. 172 NEURASTHENIA-GENERAL MEASURES-INSOMNIA POCKET-BOOK OF MEDICAL PRACTICE______________ Sexual Organs.—When markedly affected—Selenium; Picric acid (or its zinc salt); Phosphoric acid; Nux vom- ica; Lycopodium; Agnus cast.; Gelsemium; Platina; Sepia; Actea. In General.—Physostigma; Berberis; China off.; Plum- bum; Silicea; Piper methyst.; Moschus; Asafetida; Ig- natia. GENERAL MEASURES. Rest-Cure.—Where the condition is one of nerve-exhaus- tion, the Wier Mitchell rest-cure. If this is not possible, isolation and removal from the influence of sympathetic friends. Change of residence to moderately high mount- ainous regions; if sent to sanitarium, to stay not longer than six weeks at a time. At times, moderate physical labor, rather more than simple exercise. Out-door life in summer. As much as possible prohibit the patient's thinking about his condition. Avoid tight clothing, ex- citement or emotions. Correct uterine, orificial or sexual disorders. Diet.—It should be free, nourishing, fattening, consist- ing of fish, eggs, lean meats, vegetables, but particularly milk. Stimulating drinks should be prohibited; water in plenty. Hydrotherapeutics.—Cold water to the spine. Charcot- douche every other day. Cold baths in the morning. Electricity.—Static insulation and spark; positive for anemic conditions, negative when there is nervous excit- ability. Central galvanization, 3 to 5 Ma. daily. Mild general faradization. INSOMNIA. Causes.—Neurasthenic and vaso-motor (including he- reditary and habit insomnia). Vascular and cardiac (in- cluding heart-disease, arterial fibrosis, and general anemia). Auto-toxic or diathetic (including lithemia, gout and uremia). Toxic (including syphilis, lead, malaria, tobacco, and various drugs, such as coffee, tea and cocoa). TREATMENT. Ambra grisea.6*—Arises from worriment of the mind, as from business troubles; retires feeling tired, becomes wakeful as soon as the head touches the pillow. Calcarea carb.—Long wakefulness, as precursor of disease; sees visions on closing the eyes; starts and twitches at every little noise; the tongue gets dry. Dose:—Give (30th) every 3 hours during the day. Chamomilla.6*—Insomnia of children; start during sleep; twitching of the muscles of the hands and face; colic; one cheek red; head and scalp both in a hot sweat. Belladonna.6*—Drowsy, but cannot sleep; fidgety; cere- bral hyperemia. Coffea.l2x—Over-excitement of the mind; crowding of ideas prevents sleep; great mental strain. Ignatia.3*—Continuously worried;grief-stricken; men- tally depressed. INSOMNIA-TREATMENT-GENERAL MEASURES 173 POCKET-BOOK OF MEDICAL PRACTICE Hyoscyamus.3*—In children; twitch in sleep; cry out; tremble; awake frightened. Kali brom.1*—From over-excitement; when reflex; sees frightful images. Stramonium.3*—Intense nervous excitement; restless sleep; mental disturbances, possibly maniacal excite- ment. Sulphur.30—Patient sleeps at first; is roused, then cannot get to sleep again. Selenium.3*—Sleeps in cat-naps; wakens often and easily; at precisely the same hour early each morning, at which time his prevailing complaints are worse. Arnica; Gelsemium.—Sleeplessness due to bodily over- exertion. Dose:—10 to 15 drops. Cannabis ind.Tr—Nervousness; restlessness; neuralgic pains; hysterical condition. Dose:—5 drops one-half hour before retiring. GENERAL MEASURES. Hygiene.—Regular habits; cultivation of quieting in- fluences; have a low, hard pillow; be sure to go to bed warm, but have the room cold; have the stomach neither full nor empty; sip a cup of hot milk just before retiring; if wakefulness comes later in the night, eat a dry cr3.ckcr. Hydrotherapcutics.—Wet packs; hot foot-baths; hot general baths; cold douche down the spine. Any one of these just before retiring. Electricity.—Static negative insulation, 15 minutes daily, preferably late in the day. Galvanism:—Use a different one of the following methods at each alternate sitting:—(1) Positive to forehead; negative to nape of neck (2 to 3 Ma.) for 10 minutes. (2) Positive on the cervical vertebras; negative to the epigastrium (10 Ma.), for 15 minutes. (3) Positive on the cervical spine; neg- ative attached to a foot-bath (15 Ma.) for 15 minutes. Massage.—Gentle, systematic, intelligent massage. Hypnotics.—Avoid their use if possible. Sulphonal (15 grs. in hot water) not oftener than every other night. Hydrobromate of Hyoscine (hypodermically, .^g to r£0 gr ) not oftener than every four hours. Trional, Tetronal, Chloral-amid.—Same dose as Sulphonal. Passiflora.Tr—(30 to 60 drops) one hour before bed time. SECTION XIV. DISEASES OF THE SK1X. BY JOHN L. COFFIN, M. D. PROFESSOR OF DISEASES OF THE SKIN, BOSTON UNIVERSITY SCHOOL OF MEDICINE. ACNE. Causes.—Constipation, indigestion, or both (83^ of cases); uterine reflex. Symptoms.—Papules and pustules, generally second- ary to comedo. Location.—The face principally; sometimes the shoul- ders and back. TREATMENT. Medicinal.—Mercurius dulc.1*; Mercurius viv.3*; Nux vom.2x-6*; Hepar sulph.2x; Arsen. iod.3*; Lycopodium4*; Capsicum3*; Sepia.3* i Local.—Shampoo every night with flannel cloth, warm water and soap (if chronic and sluggish, with Tr. Sapo vir.), then dry and apply Unguentum sulph.; or, in pus- tular cases, R. Sulphur, 5%; Ichthyol, 5%; Vaseline, _j.; or, R. Sulph. precip., § ss.; Glycerin, 3 ij.; Spir. vini rect., §j.; Aqua Calcis, Aqua Rosae, "aa" iiij. M. Comedones should always be removed. The above local treatment is equally applicable here. Diet.—Avoid absolutely:—Confectionery; fried food, like doughnuts, griddles, etc.; excess of salt food; cheese; pickles; malt and alcoholic liquors; cocoa and chocolate. Drink an abundance of water. Fats in themselves are not contra-indicated; in strumous subjects they are indi- cated. ALOPECIA. (BALDNESS.) Varieties.—Two principal forms: Alopecia prematura and A. areata. A. Prematura.—It is often due to dandruff (q. v.). TREATMENT. Medicinal.—Arsenicum3x; Ferrum.i* Local.—R. Acid carbol., 3j.; Tr. Nucis vom., 3iv.; Tr. Cinchona rub., 3 iv.; Eau de Cologne. Ol. Ricini, ^_T _.viij. M. A. Areata.—Medicinal:—Strych. ars.2x-3x Local.—Hydrarg. bichl., grs. ij.; Alcohol and Aqua, aa _. ss. M. Rub this thoroughly into the patch with a small brush every night. (174) BARBER'S ITCH-OARBUNCLE-CHILLBLAINS 175 1 POCKET-BOOK OF MEDICAL PRACTICE BARBER'S ITCH. (TRICOPHYTOSIS BABBLE.) Cause.—It is purely parasitic. Symptoms.—Red, inflamed, lumpy condition of the bearded portion of the face, or affected part; pustulation; hairs broken off. TREATMENT. Local.—Pull the hairs out carefully over the affected area and apply Ung. Hydrarg. 01eate(5%), until consid- erable reaction is excited; then, Ung. Aqua Rosa?, un- til the acute inflammation subsides; then, twice a day, wipe off the patch with dilute vinegar, and rub in: — Sodium sulphite, 3j.; Vaselin _j. CARBUNCLE. Symptoms.—A circumscribed phlegmon with several points of necrosis. TREATMENT. Medicinal.— Arsenicum3*; Heparl*; Silicea.3x Local.—(1) Inject with a hypodermic needle deep into each point of necrosis, Carbolic acid (95%), and apply cold carbolized water dressing; or, (2) saturate a com- press with Potassium penman., grs. x. to _iv., and ap- ply constantly, keeping it wet with the solution; or, (3) fold a piece of aseptic gauze until it forms a thickness of six to eight layers, the surface area to be somewhat larger than the carbuncle to be covered. The gauze is first thoroughly saturated with Thiersch's solution, then ■ covered with a layer of ointment of Ichthyol (10%), and then applied to the carbuncle. A piece of rubber protective large enough to overlap the gauze is now placed on the same to keep in the moisture. A layer of cotton is placed on the protective, and then the bandage is applied and allowed to stay on for two days. When the patient returns to be rebandaged and to have the dressings re- newed, the cores are found to have separated from their respective walls, and at the next redressing, which is again in two days, they are found entirely separated, and can be easily and painlessly removed. CHILLBLAINS. Symptoms.—Circumscribed red or bluish swelling of the toes, and sometimes fingers; accompanied by intense itching and burning. TREATMENT. Medicinal.—Croton tig.3*; Apis.3* Local.—Bathe each day the feet in warm water, and rub vigorously with a Turkish towel for fifteen minutes. Apply night and morning Ichthyol and Turpentine, equal parts; or Acid phenic, grs. xv.; Ung. Plumbi., 3v.; Lanolin, 3v.; Ol. Amygdalae, 3ij ss.; Ol. Lavendulae, gtt. xx. M. et fiat unguentum. 176 DANDRUFF-CLAVUS-ECZEMA POCKET-BOOK OF MEDICAL PRACTICE DANDRUFF. Symptoms.—Branny desquamation of the scalp; greasy scales; scalp beneath, red and irritable, or pale and lead-color. TREATMENT. Medicinal.—Sulphur (crude, gr. j.) night and morning, Ferrum1 x, after each meal. Local.—Resorcin (5%) in alcohol and water, equal parts, or in Vaselin. R. Sulphur (5%); Resorcin (5%) Ung. Petrolati, §j.; M. In cases with irritable con- dition of scalp, Ung. Hydrarg. Ammon. (5%). These applications should be made about three times a week, and every two weeks shampoo the head with tar-soap. CLAVUS. (CORN.) Symptoms.—Circumscribed hyperplasia of the corneous layer over the joints of the feet and toes, due to pressure of ill-fitting boots. TREATMENT. Local.—Relieve pressure by change of foot-wear; bathe in hot water; apply for three or four nights: R. Acid Salicyl. (15%); ext. Can. Ind. (5%); flex. Collod., q. s.; M. Then bathe in hot water again. Repeat the pro- cess if necessary. For soft corns between the toes, wash in a solution of Tannin; dry, dust on a powder composed of; R. Zinci stearate, |j.; Acid Salicyl., grs. x.; Bismuth sub-nit., grs. v. M. Pack between the af- fected toes with dry absorbent cotton. ECZEMA. Causes. — Constitutional and Predisposing: — The (a) gouty (b) strumous, or (c) neurasthenic states. Exciting: —Any local irritation; indigestion; constipation; errors of diet; too abundant feeding (especially in children); lack of proper exercise and unhygienic surroundings; occupa- tion and traumatism. Symptoms.—Redness of the skin; itching; papules; ves- icles or pustules; crusts or scales; thickening and crack- ing. TREATMENT. In Gouty Subjects.—Diet:— Regulate the diet. Avoid— Excess of beef or mutton; sugar and sugar-containing foods ; all fried foods whatsoever; cheese; pickles; nuts; raisins; tomatoes; rhubarb; malt and malt liquors; wine and spirits. Take:—Other kinds of food liberally. Drink an abundance of water (not less than three pints a day). Exercise.—Regular exercise, especially of the arm and trunk muscles; out-doors, if possible. Medicinal.—Nux vomica 2x 3*-; Mercurius dulc. ix~3* ; Mercurius viv.3*; Lycopodium **; Carbo veg.3x; Capsi- cum2x; Podophyllum^*; Aloin1*; Rhus tox.3* In Strumous Subjects. — Hygiene:—Clothe warmly; plenty of fresh air. In children avoid too frequent bath- DIFFERENTIAL DIAGNOSIS POCKET-BOOK OF MEDICAL PRACTICE 177 DIFFERENTIAL Eczema. General.—No such systemic dis- turbance as in erysipelas. Skin.— Redness not shiny; vary- ing1 in degree; does not extend so rapidly. Sensation.—Itching. Area.—Diffuse. Duration.—A 1 w a y s tends to chronicity. Contagion.—Not contagious. Bacteria.—None. Eczema. Area.—Not sharply defined. Sensation.—Very itchy. Crusts.—Crust and scales dirty white, straw-colored, yellow or greenish. Surface beneath the crust moist and oozing. /l/o/i/.—Essentially a moist dis- ease. Duration.—Acute or chronic. Surface. — Flexor surfaces pre- ferred. General.—Systemic symptoms. Eczema. Lesions.—Multiform. Extent.—No such limitations as in scabies. Not contagious. Non-parasitic. DIAGNOSIS. Erysipelas. General.—Marked constitutional disturbance, fever, etc. Skin. — Redness shiny, glossy, extending rapidly from a central point. Sensation.—Burning and sting- ing Area.—More or less sharply de- fined. Duration.—Acute and self-lim- ited; never chronic. Contagion.—Highly infectious. Bacteria.—A specific germ. Psoriasis. Area.—Very sharply defined. Sensation.—Generally not itchy. Crusts.—Scales pearly white; glistening; never any crusting. Beneath the scale, pin-points of bleeding. Dry.— Always dry. Duration.—Always chronic. Surface.—Extensor surfaces pre- ferred. General. — Often no systemic symptoms. Scabies. Lesions.—Multiform. Extent.—Generally limited. Contagious. Parasitic. Eczema of Beard. Inflammation, Super- ficial. Very itchy. Surface.—Diffuse. Pustules without ref- erence to hair. Hairs not affected. Extent.—Tends to ex- tend to the non-bearded portion of the face. Alopecia—-It does not produce it. Not parasitic. Not contagious. Eczema of Palms. Patches diffuse. Itchy. Heals from peri- phery. May occur only on the palms. Surface apt to craclc deeply. , Tends to extend on to dorsum. No history of consti- tutional disease. Sycosis. Inflammation, deep- seated. Very sore and ach- ing. Surface.—More or less defined, the whole area being hard, swol- len and indurated en masse. Pustules.— Each one pierced by a hair. Hairs loosened over affected area. Extent.—Limited tc the bearded portion. Alopecia.—11 may produce it. Not parasitic. Not contagious. Psoriasis of Palm:-. Sharply defined. Not. Heals from center. Never alone on the palms. Not liable. None. Tinea Barbie. Inflammation, deep- seated. Itchy. Surface.—Many foci, each more or less de- fined. The whole sur- face nodular. Pustules.—Some only pierced by hair. Hairs broken off and some loose in follicle. Alopecia.—11 may produce it. Parasitic. Very contagious. Syphilis of Palms. Sharply defined. Not. Heals in center and extends on the margin. May occur alone. Is liable, but less so than eczema. Not. Generally history or other evidences. 178 ECZEMA-GENERAL AND LOCAL TREATMENT POCKET-BOOK OF MEDICAL PRACTICE ing, but anoint the skin with some bland and unirritat- ingoil. Diet.—Abundance of fats and proteids; moderate amount of sugar. Medicinal.—Calcarea phos.3*; Calcarea iod.l*; Cal- carea carb.3*; Arsen. iod'.2x-3x; Silicea3*; HeparsulphM; Rumex1*; Mercurius viv.3*; Croton tig.3* In Neurasthenic and Neurotic Eczema.—Diet.—The same as in the gouty, except that an abundance of easily assimilable fats should be taken. Avoid coffee, except to a limited extent. Hygiene.—Avoid fatigue, worry, excitement. Change of surroundings is often imperative. Medicinal.—Strychnia phos.2x; Strychnia arsen.2x; Ana- cardium3*; Viola2x; Arsenicum3*; Zinc phos.3*; Phos- phorus.3* Local.—In acute eczema soothe; in chronic stimulate. Acute Cases.—R. Lotio nig; Aq. Calcis; mix equal parts, just before using, and follow with dusting-powder. Or, R Aq. Ext. Calend., 3j.; Acid Carbol., 3ss.; Gljxerine, 3iv.; Aq. Rosae, §viij. M. Sop this on and allow it to dry, followed by dusting-powder, or Lotio Calamine ut seq.:—R Calamines prepar., 3iv.; Zinci Oxide, 3ij.; Glycerinae, 3jss.; Aqua ad fviij. M. Or, if itching is very severe:—R. Acid carbol., 3j.; Glycerins, 3iv.; Aq. Ros., §viij. M. Or, R. Thuja, 1 part; Aqua, 9 parts. If there is profuse exudation of serum, incor- porate in any of these lotions, except the first, 2 per cent of Bismuth subnit. Dusting-powder: R. Zinci Stearate, 1],; Lycop. pulv., §j.; Camph. (2%). M. This can also be made astringent by adding Bism. subnit. (2%), or Tannin (%fo). Purulent discharge, to any of the above, except the first, add from 2 to 10% Ichthyol; or, Ichthyol sol. in water, 5 to 10%. Sub-acute Cases.—R. Acid salicyl. (2%); Lassar'spaste, gj. M. Spread on lint and apply constantly. Or, Ichthyol (5%) ; Lassar's paste, §j. (especially if there is purulent exudation); or, R. Zinci carb. 3j.; Acid Sali- cyl., grs. x.; Vaseline, 3j.; Cerate Galeni, ad §i. M. Chronic Cases.—With much thickening and scaling:— 3. Pix liquida (5 to 10%) in Ung. petrolati, or in Ung. Aq. Rosa;. Or, Ol. Cadini (5 to 10%) in same base. Or, R. Sulph. (5%). Resorcin (5%) in same base. Or, R Liquor Carbonis detergens, 3j.; Zinci oxide, 3j.; Cerate Galeni, ad I]. M. Or, R. Acid Salicyl., grs. v.; Resorcin, grs. v.; Lanolini; Vaselini; Zinci oxidi; Amyli aa 3ij. M. Or, Compound Stearate of Zinc and Ichthyol, each 20 parts; Acid Salicyl., 5 parts; Glycerine, 10 parts and Albolin, 50 parts. Mix, and smear on. On parts where it is difficult to apply dressings, use as a base Unna's glycerine jelly, as follows:—Gelatine, 15; Zinci ox., 10; Glycerine, 30; Aqua, 40. M. In this can be incorporated any medicament desired. This EPITHELIOMA-ERYSIPELAS-ERYTHEMA 179 _______________POCKET-BOOK OF MEDICAL PRACTICE preparation should be warmed in a water-bath before applying. Eczeniatous "Don'ts."—Don't apply soap and water to a patch of eczema. Don't allow crusts and scales to ac- cumulate; remove them by maceration in oil. Don't allow the baby to be nursed or fed too often. Don't allow the child to "nibble " all the time between meals. Don't fail to cure your patient's habitual constipation. Don't forget that in any case of true eczema there is something the matter with the individual beside his skin, and that must be cured. Don't be frightened by the spook " sup- pression." EPITHELIOMA. Symptoms.—A small, pea-sized, scaly patch, lasting many months or years, very slowly increasing, with finally a tendency to bleed under the crust, and then more rapid growth, with hard, raised, waxy-looking, cartilaginous-feeling edge, and ulcerating center. Pain, at first absent; later, more marked. It is not apt to oc- cur under forty. Treatment.—Surgical.—Entire removal with the knife, taking a wide margin of sound skin; or, curette thor- oughly, apply Caustic potash in stick-form, and imme- diately neutralize by Acetic acid, or apply Marsden's Paste (Arsenious Acid, Gum Acacia, equal parts, mixed with water to a paste) for 24 to 48 hours, then after removal of slough, dust with Aristol. Internal medication is of no avail. ERYSIPELAS. Symptoms.—Headache; chilliness; nausea; malaise; elevation of temperature and pulse; coated tongue, and general constitutional disturbance; burning and sting- ing pains. Locally—bright, shiny, glossy redness, with marked swelling, beginning at a central point and ex- tending peripherally with great rapidity. TREATMENT. Eliminate meat from the diet. Medicinal.—Belladonna^; Arsenicum3*; Rhus tox.3*; Apis 3x; Cantharis.2x Local.—R. Acid Carbol. dil. .Alcohol, Aqua, equal parts. M. Keep the part wet all the time. Ichthyol from 5 to 25$ in ointment or lotion. Collodion will relieve pain and limit extent in nearly all cases. Or, Ichthyol, Lano- lin and water, equal parts. Or, Sodium-hyposulphite 3 to §; compress, saturated and applied constantly. Aqueous solution Cantharis. ERYTHEMA NODOSUM. Symptoms.—Round nut- to egg-sized nodules, bluish, or black-and-blue, on the shins and sometimes arms; pain like a bruise. Treatment.—Arnica3*; Ferrumi*; Cinchona2x; Chinia arsenicosum3*; Arsenicum.3* Local.—Compress of Arnica 3j to Oj. 180 ERYTHEMA-FAVUS—HERPES-ZOSTER POCKET-BOOK OF MEDICAL PRACTICE ERYTHEMA SIMPLEX. Cause*—Always a reflex from some internal condition, when not purely local from heat, cold or traumatism. Treatment.—That suitable to the internal trouble. Local.—Rarely necessary; sometimes a cooling lotion followed by a dusting-powder. FAVUS. Symptoms.—A parasitic, contagious disease of the scalp, characterized by pea- to coin-shaped patches, covered with yellowish crust; minute inspection shows individual hairs surrounded by cup-shaped sulphur-yel- low crust. Treatment.—Scrub with soap and water; remove all loose hairs and apply Ung. Hydrargyri oleati (5%) night and morning. If this irritates or sets up local inflamma- tion (which will do good rather than harm) stop and ap- ply Sodii hyposulphate 3j to fj, after sponging with di- lute vinegar. _______ HERPES. Symptoms.—Grouped vesicles occurring on a slightly inflamed base, drying into thick yellowish or brownish crusts. Location principally the face and genitals. TREATMENT. Medicinal.—Arsenicum3*; Bryonia^; Rhus.3* Local.—Paint in incipience with Collodion or Carbo- lized Cosmoline; Ung. Aq. Rosaj; Ung. Acidi borici; Ung. Adeps benzoati. HERPES ZOSTER. Symptoms.—Grouped vesicles along the course of nerve trunks, preceded, accompanied or followed by neuralgic pain in the affected part. TREATMENT. Medicinal.—Arsenicum^*; Strych. ars.2x; Rhus3*; Argent, nit.3*; Zinc phos.3*; Zinc valer.3* Local.—Morph. sulph., grs. ij.; Flex. Collod. § ss. M. Dust thoroughly with—R. Zinc ster.; Talcum, Amyli, aT 5 j-; Camph., 3ss. M. Apply a compress of dry absorbent cotton and bandage firmly. Or, Ichthyol (10%); Flex. Collod., 3ss. M. Paint on each group. If vesicles have ruptured, apply Aristol; or, Borated Ung. Aq. Rosas; or, Ichthyol (2%), Lassar's Paste, §j. M. For post-neuralgic pain, the constant current, posi- tive pole over nerve roots, negative over site of lesions. HYPERLDROSIS. Symptoms.—Abnormal sweating of any part, especially palms, feet and axillae. TREATMENT. Medicinal.— Silicialx; Calc. carb.3*; Calc. iod.3*; Ar- sen. iod.2x; Ferrum iod.2x HYPERIDROSIS-IMPETIGO-INTERTRIGO-PSORIASIS 181 ______________POCKET-BOOK OF MEDICAL PRACTICE______________ Local.—Bathe the part for ten minutes in a very hot solution of Tannin (1 3 to Oj.); dry, and apply one-half of one-per cent solution of Formalin, followed by dusting powder—R. Zinc ster., Lycop. pulv., aa %']■', Acidi borici, § ss.; Camph. (2%). M. Always change the hose every morning, dusting the above powder into the hose to be worn. Do not wear* the same boots or shoes two successive days. On the palms and soles, Ung. Bella- donna?, followed by dusting-powder. IMPETIGO. Symptoms.—An eruption of pustules on a slightly in- flammatory base, generally few in number, and conta- gious. TREATMENT. Hygiene.-—Cleanliness and improved surroundings. Mediciual.—Hepar sulph.2x Local.—Wash with Hydrogen-peroxide, 1 part to 3 of water, dry, and apply Carb. Cosmoline. Protect the part from scratching. _______ INTERTRIGO. Symptoms.—Chafing or abrasion of cornuous layer, generally where two surfaces come together. TREATMENT. Local.—R. Apply Sol. Argent, nit.; 1 to 1000. Dry and apply dusting-powder (dusting-powder, see Hyperi- drosis); or, apply a lotion of—R. Aq. Ext. Calend., 3j.; Glycerine, 3ij.; Acidi Carbolici, 3j.; Aq. Rosas ad §viij.; Or Hamamelis, 3j.; Acidi Borici, 3ss.; Glycerine, 3ij.; Aq. Rosas ad fviij. M. After any lotion, apply dust- ing-powder thoroughly and keep contiguous parts separ- ated by absorbent cotton filled with the powder. PSORIASIS. Symptoms.—Chronic disease characterized by rounded patches covered by a glistening white scale, beneath which appear pin-points of bleeding—most often taken for eczema. (See diagnosis of Eczema.) TREATMENT. Medicinal.—Strychnia arsenicos2x; Strychnia phos.3*; Arsenicum3*; Terebinth. 1* Local.—Bathe with soap to remove scales. If very acute, apply Ung. Hydrarg. Ammon. (5%); or, Acid Salicyl. (28%), Lassar's Paste, q. s. M. When in the sub-acute or chronic stage—R. Liq. Carbonis deleiq., 3j.; Acidi Salicylici, grs. iij.; Hydrarg. Ammon., grs. x.; Lanolini, 3ij.; Ung. Simplicis ad ly M. Or, ,R. Pix liquida (10%); Ung. Petrolati £j. M. Or, R. Chrysaro- bin (10 %); Acidi Salicylici (10%); Ether sulph. (15%); Collod. flex. (65%). M. Paint on the affected part. (Do not use this on the face, scalp or about mucous orifices.) For isolated patches where the eruption is not general, the following—R. Saponis viridis, §iv.; Ol. Rusci, §j.; Glycerine, §j.; Ol. Rosmarini, 3jss.; Spir. vini. recti., 182 SCABIES-RING-WORM-URTICARIA POCKET-BOOK OF MEDICAL PRACTICE_____________ (Jss.M. In generalized eruptions, R. Sulph. precip., grs. xv.; Resorcin, grs. xv.; Ung. Petrolati fj. M. SCABIES. (ITCH.) Symptoms.—Eczematous lesions on the webs between the fingers, flexure of wrists and elbows, axillas about the breasts in women, the genitals in men and ankles in children. Treatment.—Entirely local. Have the patient take a hot tub-bath for 20 minutes, scrubbing meanwhile with soap. Then dry the body and rub thoroughly with Ung. Sulph. (20%). Put on a complete suit of underclothes, stockings and white cotton gloves, these to be worn contin- uously night and day. On the second night repeat, with- out the bath, same the third night; on the fourth night take a warmbath, followed by a simple dusting-powder, and re- tire in clean bed-linen. The clothes and bed-linen should be immersed in hot water. TINEA TRICOPHYTINA. (RING-WORM.) Symptoms.—A round, slightly scaly patch, slightly vesicular on the advancing margin, with tendency to clear up in the center. On the scalp the hairs are un- evenly broken, presenting a ' 'gnawed-off'' appearance. It is parasitic and contagious. Treatment.—Local.—On the body wash the patch thor- oughly with soap and water to remove scales, and paint with Tr. Iodine, or, apply Ung. Hydrarg. Ammon. (5%); or, Ung. sulph. On the scalp epilate the hairs over the patch, and after wiping with vinegar and water, rub in Ung. Hydrarg. Oleate (.5%); or, Sodii hyposulphite, 3j., to Ung. Petrolati, §j. _______ URTICARIA. Symptoms.—The appearance of evanescent, pinkish papules, nodules or tumors, lasting from a few hours to a day, accompanied by intense stinging and itching. TREATMENT. Medicinal.—Arsenicum3*; Apis2x; Croton tig.3*; Nux vom.2x; Strych. phos.2x Diet.—Regulate the diet. Avoid berries; fish; nuts; pickles; spices; cheese;oatmeal, etc. Local.—Alkaline baths; Lotio Acidi Carbolici; or, R. Acidi hydrocyanici dil., 3j.; Glycerine, 3ij.; Aq. Rosa;, §vhj. 31. Or, R. Camph.,3ij.; Chloral hyd., 3ij.; M., et ad Ung. Aq. Rosas, Ij. M. Or, R. Menthol (3%); Aq. Cologne, §ij. The local application should be sopped on the itchy part, instead of scratching, and followed by a dusting-powder. SECTION XY. DISEASES OF THE EY BY C. J. SWAN, M. D. CHICAGO. ADJUNCT PROFESSOR OF DISEASES OF THE EYE AND EAR, HAHNEMANN MEDICAL COLLEGE AND HOSPITAL, CHICAGO. INJURIES TO THE EYE. ECCHYMOSIS OF THE ORBITAL REGION. (BLACK-EYE.) Causes.—Blows, orbital, or upon the nose. TREATMENT. Local.—Cold applications will prevent discoloration. After discoloration has occurred, Peroxide-of-hydrogen applied on cotton will bleach the part, followed by Stearate-of-zinc, rubbed in, will return it to its normal appearance. ------- PERFORATING WOUNDS. Prognosis.—Perforating wound of the eye is especially dangerous when in the cornea-scleral margin. Treatment.—Local:—Iced compresses; conjunctival sac washed with a saturated solution of Boracic acid every 2 hrs. Atropine (4 grs. to 1 oz.) 1 drop, 3 to 6 times a day. Caution.—If the sight is lost and symptoms of sympa- thetic inflammation appear in the other eye, enucleate at once. ------- BURNS. TREATMENT. Local.—Vaseline in the conjunctival sac. Atropin, 2 grs. to 1 oz., twice a day; in some cases bandage. FOREIGN BODIES. (IN THE CONJUNCTIVAL SAC.) Location.—Usually found imbedded in the cornea, or in the lid under the upper tarsal cartilage. TREATMENT. Local.—Instil 4% Cocaine solution. Remove the object with a pledget of. cotton if it is under the lid; or with a sharp instrument if it is in the cornea. Wash out with warm saturated solution of Boracic acid. If there is much abrasion of the cornea, bandage the eye. SYMPATHETIC OPHTHALMIA. Causes.'—If follows perforating wounds of the other eye; the period of transmission varies from two weeks to thirty years.- Early Symptoms.—Congestion and tenderness about the corneal margin; blurred vision; later, all symptoms of iridocyclitis. TREATMENT. Local.—Enucleation of the wounded eye. For the sym- pathizing eye, Atropin, 4 grs. to 1 oz., three or four times a day; hot fomentation of Hamamelis and water. Medicinal.—Belladonna2x; Mercurius3*; Silicea6*; Cal- adium3*; Rhus tox.3*; Bryonia.3* Note.—All solutions for local use, the dose is 1 drop. 184 HORDEOLUM-CHALAZION-BLEPHARITIS CILIARIS _______________POCKET-BOOK OF MEDICAL PRACTICE DISEASE OF THE LIDS. HORDEOLUM. (STYE.) Causes.—Debility; chronic blepharitis or conjunctivitis; exposure to winds; or, eye-strain. Symptoms.— Circumscribed redness and swelling of the lid margin; throbbing pain. TREATMENT. Local.—Poultice until it points; then incise. Remove the cause. Medicinal.—Graphites6*; Hepar sulph.3*; Pulsatilla^; Sulphur6*; Thuja.3* CHALAZION. (TUMOR IN GLANDS OP THE LID.) Causes.—Eye-strain; conjunctivitis, causing blocking of secretion of the lid glands. Symptoms.—Small tumor, non-inflammatory, in the substance of the tarsal cartilage; the skin is movable over them. TREATMENT. Local.—Evert the lid; make an incision through the conjunctiva, scrape out the contents of the cyst, and wash with Boracic acid solution. Medicinal.—Calcarea carb.6*; Causticum6*; Conium3*; Pulsatilla3*; Staphysagria3*; Thuja.3* BLEPHARITIS CILIARIS. (MARGINAL INFLAMMATION OF THE LIDS.) Causes.—Eye-strain; exposure to dust, wind, smoke; lice on the lashes; disease of the lachrymal sac. Symptoms.—Red lid; the margins often covered with crusts of mucus. Treatment.—Local:—Examine refraction; clean the lid margins twice daily with a soft cloth and soap-and-wa- ter, and, if necessary, Peroxid-of-hydrogen. Rub into the roots of the lashes the following; R. Hydrarg. ox. flav., gr. j.; vaseline, 3j. M. Or, R. Graphite, gr. j.; Vaseline, 3j. M. Mediciual.—Aconite3*; Alumin6*; Antimonium crud.3*; Apis6*; Argentum nit. 6*; Aurum mur.3*; Calcium carb.6*; Hepar sulph.3*; Mercurius3*; Sulphur.3* DISEASES OF THE_CONJUNCTIVA. ACUTE CATARRHAL CONJUNCTIYITIS. Causes.—Extension from nasal catarrh, or lachrymal disease; exposure to cold; dust; smoke; confinement in vitiated atmosphere; refractive errors; exanthematous diseases. When epidemic it is often contagious—called "Pink-eye." Symptoms.—Redness of the conjunctiva; muco-purulent discharge; lids stuck together in the morning; feeling of sand in the eye. CON JUNCTIVITIS -CATARRHAL-PHLYCTENULAR 185 ___________POCKET-BOOK OF MEDICAL PRACTICE________ TREATMENT. Local.—Remove the cause; look for a foreign body. Instil warm saturated solution of Boracic acid 2 or 3 times a day; or, Zinc-sulphate, 2 grains to the ounce, once a day. Or, in severe cases, Nitrate-of-silver, 2 grains to the ounce, once a day. Smear the lid margins with Vaseline at night. Or Argentamine vto x grs. to §j. applied with a brush and neutralized with warm saline solution. Medicinal.—Argentum nit.3*; Arsenicum3*; Euphra- sia3*; Merc, sol.3*; Pulsatilla-*; Zincum.6* CHRONIC CATARRHAL CONJUNCTIVITIS. Causes.—Exposure tocold, dust or smoke; confinement in a close atmosphere; extension from disease of the lachry- mal sac or nasal cavity; eye-strain. Symptoms.—Feeling of sand in the eye; itching and smarting of the lids; redness of the conjunctiva; crusts on the lid margins in the morning (caused by hyperse- cretions of mucus, mixed with effete epithelial cells); in severe cases, photophobia and lachrymation. TREATMENT. Local.—Warm saturated solution of Boracic acid in the eyes; Zinc sulph., grs. 2 to 1 oz. Argentamine, grs. x. to aqua, §j., neutralize with warm alkaline solution. Medicinal.—Aconite3*; Arg. nit.6*; Belladonna3*; Merc. sol.3*; Pulsatilla^*; Sulphur3*; Zincum.6* PHLYCTENULAR CONJUNCTIVITIS. Causes.—Predisposing:—The scrofulous diathesis and malnutrition. Exciting:—Any irritating influence— cold; dust; eye-strain; nasal catarrh. Symptoms.—Little red eminences at the margin of the cornea; in severe cases, extensive injection of the con- junctiva, and marginal haziness of the cornea; pain; lachrymation; photophobia; lids tightly closed; little or no mucous secretion; tendency to relapse. TREATMENT. Local.—Calomel powder dusted into the eyes daily; or, Yellow-oxid of mercury, grs. 5 to Vaseline, 1 oz., placed between the lids every other day. Saturated solution of Boracic acid, twice per day. Treat the nasal catarrh. Medicinal.—Calc. carb.6*; Graphites6*; Hepar sulph.6*; Mercurius3*; Pulsatilla3*; Sulphur.3* PURULENT CONJUNCTIVITIS. Varieties.—Gonorrheal conjunctivitis, purulent con- junctivitis of the new-born, opthalmia neonatorum, may all come under this head. Causes.—Infection or contagion from gonorrheal, leu- por'rheal, or decomposed or altered discharge from catar- rhal conditions. Symptoms.—Copious discharge, at first muco-purulent, then purulent; thick and yellow; edema of the lids; serous engorgement of the conjunctiva; sensation of heat and burning. 186 CONJUNCTIVITIS-DIAGNOSIS - TREATMENT POCKKT-BOOK OK M KDICAL PRACTICE TREATMENT. Local.—Iced compresses, not longer than one-half hour at a time. The eye washed out with Formaline, 1 to 2000; or, Boric-acid solution, every half-hour to every fifteen minutes. Ten-grain solution of Silver-nitrate brushed on the everted lids once daily and neutralized with salt solution. The edges of the lids must be smeared with Vaseline to prevent excoriation and stick- ing together. The dangers are, involvement of the cor- nea; infection of the other eye; or of the eyes of other persons. Medicinal.—Argentum nit.3*; Mercurius3*; Pulsa- tilla^ DIFFERENTIAL DIAGNOSIS Conjunctivitis. Keratitis. Iritis. Glaucoma. Secretion:— Secretion:— Secretion : — Secretion:— Mucus and muco- Mostly watery. Lachrymal. Lachrymal. Photophobia. Photophobia: — Photophobia. Photophobia : — Intense. Absence of. Injection:— I nj e c t i on:— Injection : — On Injection:—Apt Redness and in- Greatest at cor- cornea, -scleral to be greatest at flammation in nea-scleral mar- margin most pro- corneal margin early, or mild gin. nounced. when seen early. cases; greater in lids. Tension: — Lit- Te n s ion :—No Ten s i o n : — Tension:— tle or no change. change. Usually slightly increased. Much increased. Cornea:—Clear Cornea: — Cornea:—Clear Cornea:— Clear Clouded. in early stages. Iris:—Normal. Iris;—Normal. Iris:—Sluggish Iris:—Sluggish and pupil con- and pupil dilated. tracted. Aqueous:—Nor- Aqueous: — Nor- Aqueous:— Apt Aqueous:—Nor- mal. mal in the early stages. to be clouded. mal. Anterior Cham- Anterior Cham- Anterior Cham- Anterior Cham- ber:—Normal. ber:—Normal in the early stages. ber:—Normal. ber:—Shallow. Pain:— Feeling1 Pa in: — I n Pain: — Severe Pain / — Very of sand in theeye; branches of the in branches of the severe in branch- smarting and 5th. 5th. es of the 5th. burning. Note.—The reason that the expressions "when seen early," or "in early stages," are so often repeated is that in severe cases, after running for a time other structures are almost always involved, so that two or more of the conditions described may exist at once. TRACHOMA. ("GRANULAR LIDS.") Causes.—Infection from other cases of trachoma; gon- orrheal ophthalmia, after running its course, sometimes leaves trachomatous lids. Predisposing cause—poor nu- trition and unsanitary surroundings. Symptoms.—Characteristic hypertrophy and granula- tion of the palpebral conjunctiva; lachrymation somewhat increased; burning sensation; frequent relapses; the ocular conjunctiva may not be at all affected. TREATMENT. Local.—Zinc sulph., grs. ij., to 1']., once daily. Or, Argentum nit. grs. ij. to §j., once daily. Or, 10 to 20% sol. CORNEA-KERATITIS-ULCER-OPACITY 187 _______________POCKET-BOOK OF MEDICAL PRACTICE_______________ of Protargol in glycerine, daily. Tannic acid, grs. v., Glycerine, ?j., every alternate day. Argentum nit., grs. x., to Ij., brushed on irritated lids and neutralized with salt solution. Surgical treatment may be instituted for re- moval of granular tissue. Medicinal.—Arsenicum3*; Aurum mur.3*; Cuprum3*; Mercurius3*; Thuja.6* DISEASES OF THE CORNEA. KERATITIS. (INFLAMMATION OF THE CORNEA.) Causes.—Wounds of the cornea; foreign body; inflam- mation of adjacent tissues; scrofulous and syphilitic heredity; mal-nutrition; want and privation; inverted eye-lashes. Symptoms.—Pain; photophobia; lachrymation: cloudi- ness of the cornea; injected zone about the corneal mar- gin. TREATMENT. Local*—Hot fomentations of Hamamelis solution for the pain. Atropine, grs. ij. to §j., twice per day. Eyes protected by dark glasses. Medicinal.—Aurum mur.3*; Mercurius cor.3*; Mercu- rius sol.3*; Calcarea carb.6*; Sulphur.3* ULCER OF THE CORNEA. Causes.—Phlyctenular conjunctivitis and keratitis; purulent conjunctivitis; foreign body; inverted lashes; exanthematous diseases; deficient nutrition in children; infected wounds of the cornea; granular lids; malaria; lithemia. Symptoms.—Prof use lachrymation on exposure tolight; depression in the corneal surface, surrounded by cloudi- ness; the conjunctival as well as the sub-conjunctival vessels are apt to be infected; more or less pain; tightly- shut lids. TREATMENT. Local.—Bandage, exerting some pressure; hot applica- tions are sometimes useful to allay pain and promote healing; Atropine, grs. j. to §j., twice per day if the ulcer is central; if the ulcer is marginal and deep, Eser- ine, grs. yi to §j., once per day; Formaline, 1 to 2,000, is sometimes useful as a wash two or three times per day. In indolent ulcers, mild irritants, such as powdered Calomel or Yellow-oxide-of-mercury, grs. viij., to Vas- eline, I]., will hasten resolution. Medicinal.—Rhus tox.3*; Hepar sulph.6x; Siliceai2x; Arsenicum3*; Mercurius3*; Aurum3*; Thuja3*; Solution of sulphur. ______ OPACITIES OF THE CORNEA. (SCARS OF THE CORNEA.) Causes.—Deep inflammations and wounds of the cor- nea leave scars of more or less density. Symptoms.—Cloudiness, or dense white and smooth opacity of the cornea, without any inflammation or other 188 SCLERITIS-EPISCLERITIS-IRITIS-GLAUCOMA --------------POCKET-BOOK OF MEDICAL PRACTICE S^ESS3'wewPthn C^ the °pacity is cenTraTanl^ -e pupa, when there is more or less dimness of vision TREATMENT. I,..cal.—MUd irritants, such as powdered Calomel or Yeliovr-oxi a^of-Mercury, grs. v., to Vaseline, ft^S ^ST'S, M,dl Mdgentl3r ™^Sed through thecS -ds. V, hen the scars are dense and white, tattooing is a cosmetic operation of great value. The galvanic cur- rent, o or 6 milliamperes, the positive pole on the eye, and the negative at the nape of the neck, is sometimes help- MfdieinaL—Siliceal2x; Calcarea fluor.6x DISEASES OF THE SCLERA, IRIS AXD GLOBE. MLERITIS AXD EPISCLERITIS. (IXFLAMMATIOS OF THE SCLERA.) Cau»t>.—Usually found in those of a rheumatic dia- IT.ci: s. MffiDtoms.—Dull, heavy pains around the eyes; ciliary neuralgia; lachrymation and photophobia. Circumscribed «-s-eiI:n^- near the corneal margin and over the insertions Oi the muscle-, most req. er.tlv over the external rectus muscle: localised conjunct!- ,.i and sub-conjunctival injec- tion: crrr.ea may be cloudy at the point nearest the TREATMENT. Ltcal.—If the cornea is affected, Atropine solution, -r.i. to 5J. Refractive errors must be corrected. MtdicrtaL—Physiological doses of Salicylate of soda or TTr.te-creen oil: Rhus tox. 2s; Bryonia3*; Thuja3*; Sepi..*; Mercurius3*; Aconite3*; Terebinth.2* IRITIS. Can^. —Rheumatism and gout; syphilis; tuberculosis; after operation* and penetrating wounds of the eye; con- st tjtional diseases, "such as variola, typhoid, etc.; it taar occur from col.!s or eye-strain. s"i mptoms.—Ciliarv neuralgia, worse at night and in d»-"» weather i zone of injection about the cornea; the -^ni oc^*'.-ctetl and does not react well to light; sensi- tive to tvoch over the ciliarv region when pressure is made thr ugh the lids: the iris discolored; the eye sensi- tive to !;%) are sometimes useful. DISEASES OF THE MIDDLE EAR. ACUTE CATARRHAL INFLAMMATION. (OTALGIA ; EARACHE.) Causes.—The pressure of a foreign body or mass of hardened cerumen may produce an earache which is quickly removed in the common-sense way. It may be reflex from the stomach or from defective teeth. Expos- ure to cold; wetting the hair (a pernicious habit); abuse of quinine or salicylic acid; pressure of a foreign body, or hardened wax. TREATMENT. Aconite.2x—Earache following a sudden change of tem- perature; if in a child, there are usually the common congestive symptoms of the drug; noise, even music, is intolerable; tinnitus accompanies the violent pain; worse at night; aggravated by warmth; better during the day, especially in the open air. Unless given immediately ACUTE CATARRHAL INFLAMMATION-TREATMENT 193 POCKET-BOOK OF MEDICAL PRACTICE after exposure, in the writer's experience, Aconite is useless. In this respect its differs from Ferrum, which otherwise is very similar in its action. Where the period of usefulness of the former drug is short, the latter is in- dicated for several hours. Aconite, when indicated in earache, is most serviceable in the lower dilutions. Belladonna.3*—The patient is feverish; flushed face; headache; often, the sore-throat and other characteris- tic symptoms. In the ear digging, boring, tearing, shooting pains, which come and go suddenly. With each paroxysm of pain the child may start from his sleep and utter a sudden cry. The congestion of the tympanum and tympanic membrane is pronounced. Rolling of the head from side to side, moaning; tinnitus; usually some deafness; stitches in the throat on swallow- ing. All the symptoms are worse at night, and relieved from warmth. Borax.3*—An exceedingly nervous patient. The hear- ing power is apparently increased; the slightest sound startles; earache paroxysmal; with each attack a sud- den start; soreness and feeling of heat in the ear; dread of downward motion. The Borax earache comes on in the early hour of the morning and, unlike Belladonna, is made worse by warmth. Capsicum.3*—While not frequently indicated in acute earache, this remedy is of great value when the mastoid is painful to touch. There is burning pain in the ear, worse from cold and at night. Warm applications relieve the pain. Capsicum isgspecially to be thought of in sub- acute inflammation of the Eustachian tube, with great pain, and sense of dryness and heat in the throat, ex- tending to the ear. Cliamoniilla.3*—Sometimes useful in infantile earache; excessive fretfulness; desire to be carried about; digestive disturbances. The patient is worse at night, and from the slightest cold. Hot applications relieve the pain. Dulcamara.3*—Earache with every change in the weather, especially cold, damp or rainy; the neck stiff and painful; cracking sound in the ear, on moving the jaws. All the pains are relieved by the application of dry heat. Ferrum phos.3*—One of the most reliable remedies in acute earache. Cases following exposure to cold or wet weather. Like Pulsatilla, it has tinnitus, but, unlike it, there is no deafness. On the other hand, similar to Borax, there is abnormal sensitiveness to sound. The pain is throbbing, with a feeling of tension and heat in the ear, or there may be sharp, stitching pains, occurring in paroxysms. The patient feels better in the open air. Magnesia phos.3x—Otalgia purely nervous in origin. Pain in the ear, and also back of the ear. Worse in the cold air; aggravated by washing the face and neck in cold water. Hot applications relieve the pain. Plantago.3*—Tearing pains of a neuralgic character. The earache is reflex from dental irritation or associ- ated with toothache. 194 CATARRHAL INFLAMMATION-LOCAL TREATMENT POCKET-BOOK OF MEDICAL PRACTICE Pulsatilla.6*—Earache associated with tinnitus and deafness; sensation of fullness and violent pain, as if something were being forced out of the ear. The dart- ing, tearing, pulsating pains are worse in the evening and forepart of the night. The earache may come on as soon as the patient is warm in bed. He is better in the cool air, and cold applications relieve the pain. Pulsa- tilla is more useful in subacute cases, in earache accom- panying actual otitis. Sanguinaria.3*—Sometimes at the climacteric earache is an annoying symptom. This remedy is useful in such cases. There are tinnitus and painful sensitiveness to sudden sounds. The pain is worse in the open air. GENERAL MEASURES. Dosage.—In administering a remedy for earache it is well to give it in warm water, and at intervals of 10 to 15 minutes. By this method, rapid absorption takes place and relief speedily follows. Eustachian Tube.—In the treatment of earache, it is well to see that the Eustachian tube is opened either by Val- salva's method, or the Politzer bag. Applications.—Heat may be applied by gently pouring warm water into the external canal. Avoid the use of the piston-syringe; the force of the jet so applied may greatly aggravate the pain. Pour the liquid from a warm spoon; or, use a fountain-syringe near the level of the head. If the appliances are at hand, use steam in- stead of water. Rubber-tubing, attached to a radiator valve, is a splendid way of conducting the steam to the ear. Dry heat is grateful. Apply by the hot-water bag; bags of salt; or, the Japanese pocket stove. Oils.—In general, oils and fats are not to be used; they obscure the parts; this is objectionable if the case pro- gresses to the surgical point. However, the old house- hold remedy, laudanum and sweet-oil, has doubtless relieved many earaches. Warmed strained honey, fre- quently used in the country, is helpful because it applies and retains heat. Palliatives.—The vapor of Chloroform relieves some cases as by magic. To apply—Place in the bowl of a pipe a bit of cotton saturated with Chloroform; with the mouth over the bowl, force the vapor through the pipe- stem to the ear of the patient. Tobacco smoke may be used in similar manner. AconiteTr. Gr BryoniaTr. ap- plied on cotton gives relief in some cases. This may be used:— R. Camphor-chloral, 5 drops; Almond oil, 25 drops; Glycerine, 30 drops. Mix. Warm and drop into the ear. Or this:—Plantago major, 4 drams; Bella- donnaTr is drops; Aconite rad.Tr. io drops; Magendie's solution, 20 drops; Water to make 1 oz. Mix. Warm; drop into the ear every 5 minutes, if necessary. CHRONIC CATARRHAL INFLAMMATION. (CATARRHAL DEAFNESS.) Cause.—Always secondary to a primary chronic rhin- itis, with all the causes of the latter. CHRONIC CATARRHAL INFLAMMATION-TREATMENT 195 ______________POCKET-BOOK OF MEDICAL PRACTICE Diagnosis.—The history of the case renders the diag- nosis easy. By exclusion the aural lesion is readily located. Examination shows the external ear to be nor- mal; the tuning-fork on the mastoid proves the normality of the internal ear and auditory nerve. The dull and retracted tympanic membrane, the tinnitus, the aggrava tion from damp weather, and the deafness, all point to the middle-ear as the seat of trouble. TREATMENT. Factors.—In the treatment, three factors must be con sidered: (a) The remote cause; (b) the primary condi- tion; (c) the restoration of function. Remote Cause.—Correct:—Unhygienic surroundings; uncongenial climate; depraved general health. Primary Condition.—The chronic rhinitis must be re- lieved. Spurs; hypertrophied turbinates; polypi; ade- noids, or other abnormal nasal conditions must be re- moved. Nasal stenosis and aural health are never com- panions. Restoration of Function.—Open the Eustachian tubes once a day by Valsalva's method (holding the nose, in- flating the cheeks and blowing); or the Politzer bag; em- ploy some form of aural massage; use a modern electrical appliance; or, simply Siegle's pneumatic speculum. An excellent method of applying aural massage is the at- tachment of a telephone-receiver to an ordinary faradic coil. The vibrations may be increased or diminished in rapidity and force by the vibrator regulator. If the patient has no better facilities, the noise of a fanning- mill or saw-mill will be found of value. Spend IS minutes a day in the clatter of machinery. TREATMENT. Therapeutics.—In no other aural disease is such in- dividuality shown as in chronic catarrhal otitis. A resume of symptoms is out of the question. Careful study of the aural, nasal, throat and general symptoms will lead to the choice of the internal remedy, which is a necessity in the successful treatment of this obstinate condition. Compare the Calcareas; the Mercuries; the Kalis (especially Kali muriaticum); Hepar; Hydrastis; Pulsatilla; Sanguinaria; Causticum; Graphites; Silicea; Sulphur. _______ SUPPURATIVE INFLAMMATION. (otorrhea; "RUNNING EAR.") Causes.—It may follow the acute catarrhal form; or, scarlatina or other of the exanthemata. It may be an evidence of tubercular diathesis. Prognosis.—Favorable as to life, but, as ordinarily treated by the general practitioner, unfavorable as to cure. It is not "outgrown." Do not look upon it as trivial. In the acute form, if pain persist after the dis- charge is established, the prognosis must be guarded. In the chronic form the sudden cessation of the discharge and the development of pain are dangerous s mptoms. 196 SUPPURATIVE INFLAMMATION-TREATMENT POCKET-BOOK OF MEDICAL PRACTICE In each instance there is the possibility of mastoid in- volvement. TREATMENT. Capsicum*3*—Acute pain in and about the ear; mas- toid swollen and sensitive on pressure; useful in a chronic case which suddenly assumes acute s3rmptoms. Mercurius.6*—Suppuration, with glandular involve- ment; small perforation of the membrane; white, fetid, or bloody discharge. Hepar sulph.6*—Feeling of heat and discomfort in the ear, which is very sensitive to the lightest touch or the slightest cold. The discharge is slight, sour, and very offensive. Hydrastis.3*—Thick, tenacious, stringy muco-purulent discharge, which is bland and unirritating. The drop- ping of mucus into the throat is usually associated with the ear symptoms. Silicea.x2x—Useful in cases complicated with caries or necrosis of the ossicles or bony walls of the middle ear. The discharge is small in amount. The lining of the external auditory canal may be ulcerated. The perfor- ation of the tympanic membrane seems to repair rapidly under this remedy. Kali phos.6*—Chronic suppuration, when the discharge is thin and dirty; on slight manipulation the parts bleed. This remedy is especially to be considered in the cases of possible tubercular origin. Calcarea carb.!2x—The patient is inclined to fat; skin fair; flesh flabby; sweat of the head; discharge white, thick, sticky; tendency to the formation of granulation- tissue, tumors, or mucous polypi (Calc. iod.). GENERAL MEASURES. Acute Cases.—Paracentesis, if there be much bulging of the tympanic membrane. To make this operation, the head must be supported and the auditory canal well illuminated; make the incision carefully in the postero- inferior quadrant of the tympanic membrane. After puncture or spontaneous rupture of the ear-drum, make instillations of Hydrogen-dioxide (every 2 hours) Sub-acute and Chronic Cases.—Carefully syringe the canal; instil Hydrogen dioxide; wipe dry with bits of cotton; insufflate with impalpable powder of Boracic acid. Repeat this treatment often enough to keep the canal clean and dry (at first, about every day; later, once or twice a week). Complicated Cases.—In cases where there is necrosed or carious bone the ordinary antiseptic methods will fail. In such a case proceed as follows:—In a test-tube heat an ounce of water to about 115° F. With this mix one dram of Glycerinum pepticum (Fairchild) and four drops of Hydrocloric acid, C. P. (16 drops dilute acid, U. S. P.). Fill the external canal with this solution and allow it to remain half an hour. Syringe out the ear, wipe it dry and insufflate with Boric acid. Repeat the treatment after three or four days. Two or three treatments will be sufficient to digest the dead bone and cure the case. THE INTERNAL EAR-MASTOIDITIS 197 POCKET-BOOK OF MEDICAL PRACTICE MASTOIDITIS. Diagnosis.—The diagnosis is frequently difficult. There are two reliable signs:—(a) Local tenderness of the mastoid on deep pressure; (b) depression or sagging of the postero-superior wall of the auditory canal, close to the tympanic membrane. Be careful to examine both sides of the head, so to be sure that the tenderness is not physiological. The cringing of the patient will make this symptom unmistakable. Where an otorrhea has ex- isted, the cessation or lessening of the discharge may in- dicate involvement of the mastoid cells. There are pain and sleeplessness, with perhaps little if any rise in temperature. TREATMENT. Therapeutics.—The remedies and indications are fully considered under Suppurative Otitis. Operation.—In undoubted mastoiditis, the radical operation with trephine, chisel, or gouge, is indicated. This must be thoroughly done and under the strictest asepsis. As a life-saver its value is beyond computation. DISEASES OF THE INTERNAL EAR. Nature.—In the present state of aural knowledge, most internal ear conditions must be considered as symptoms rather than as diseases. Etiology.—Among the causes are defective development; hemorrhage; tumors; anemia; hyperemia; or, inflam- mation. These causes, of course, may or may not be due to general disease. Symptoms.—The hearing is impaired, possibly for all sounds, or for certain tones; the deafness may be total. On the other hand, there may be abnormal sensitiveness to noises, or perversion of sound. Tinnitus, nausea, and giddiness are common symptoms. TREATMENT. General.—The treatment consists in the improvement of the general health, or the removal of the primary con- dition. Therapeutics.—Refer to the remedies under Acute Ca- tarrhal Otitis. In addition, compare—Cinchona; Cheno- podium; Hydrobromic acid; Salicylic acid; Pilocarpin. ARTIFICIAL AIDS TO HEARING. Devices.—Many have been described. Unfortunately any inconspicuous instrument is likely to be a failure in every case. There have been recorded very few reliable instances of relief from the artificial "ear-drum. " In a general way it may be said that for all cases of deaf- ness, the instrument most certain of satisfac ory results is the '' London Hearing Horn.'' SECTION XVII. DISEASES OF THE NOSE, THROAT AND LARYNX. BY JOHN B. GARRISON, M.D. NEW YORK. surgeon to the throat department, new york ophthalmic hospital; laryngologist to Hahnemann hospital, and to the laura franklin free hospital for children. DISEASES OF THE NOSE. ACUTE CATARRHAL RHINITIS. (COLD IN THE HEAD.) Symptoms.—Chilliness; sneezing; watery discharge; aching; "stuffiness;" depression; fever; dry throat and mouth; frontal headache (severe if the sinuses are in- volved); the nasal discharge soon becomes thick and yellowish; smell may be lost. TREATMENT. Preventive.—Keep the body warm and dry; meshed linen underwear; thick soles to shoes; avoid bundling the neck. Camphor.Tr—As soon as the first chilly sensation is felt. A drop on sugar every 15 minutes; three or four doses will usually be sufficient to cause a feeling of grate- ful warmth, and no more will be needed. Aconite.2*—To be given as soon as the first indications of chilliness are present; particularly if after exposure to cold winds. Arsenic alb.6*—Free, watery, acrid discharge; frequent sneezing; nose feels stopped up, but still it runs and burns; edges of nostrils excoriated; burning discharge. Arsenicum iod.2*—Much like Arsenicum alb., with an added asthmatic tendency. Ammonium carb.3*—Acrid, watery discharge during the day; dry and stuffed at night, causing mouth-breath- ing. Euphrasia.Tr—Acrid discharge from the eyes; bland from the nose; constant sneezing. Mercurius.3*—Profuse, fluent, corrosive discharge; worse when warm in bed at night. Pulsatilla.3*—Frequent alternation of fluent and dry coryza; sneezes as soon as he gets near the heat, especially in the evening; feels better in open air. Fre- quently adapted for later stages of a cold. Sambucus.1*—Snuffles of infants; cannot breathe through the nose; starting from sleep from inability to breathe. -------- SIMPLE CHRONIC RHINITIS. Diagnosis.—The application of Cocaine shows a shrinkage of tissue; in hypertrophic rhinitis, there is no (198) 1 CHRONIC AND HYPERTROPHIC RHINITIS 199 POCKET-BOOK OF MEDICAL PRACTICE shrinkage. The lower turbinals can be pressed back with a probe; in hypertrophy they remain rigid. TREATMENT. Local.—Cleanse well the mucous membrane (see methods). Ammonium mur.3*—Clear watery mucus running from the nose; corrosive; itching in the nose; hoarseness, with burning in the larynx. Antimonium crud.3*—Margins of the nostrils crack; :old air pains the nostrils when breathed. Argentum nit.3*—Headache, with chilliness and sneezing; yellow or bloody discharge; itching. Calcarea carb.3*—Offensive smell in the nose, like rot- ten eggs; nose dry and stuffy at night, free during the day; cervical glands enlarged; tendency to fat; head sweats during sleep. Hepar sulph.3*—Frequent catarrhal attacks; sensitive to all draughts; bloody mucus. Hydrastis.Tr—Thick, yellow, sticky discharge; sensa- tion of a hair in the right nostril; inspired air feels cold to the nose; dull frontal headache. Kali bich.2*—Small ulcers on the septum; pain at the root of the nose; discharge yellow, and draws in strings. Phosphorus.3*—Green or bloody discharge; a little blood on the handkerchief every time it is used. Sanguinaria.Tr—Coryza with pain in the root of the nose; pain in frontal sinuses; dry, tickling cough; voice lost. Sticta.Tr—Fullness in the nose, with dryness of the mucous membrane; desire to blow the nose, but no dis- charge; dry cough, worse at night. HYPERTROPHIC RHINITIS. Symptoms.—Frequent cause of nasal obstruction; dull pains in the forehead and eyes; mental dullness. Diagnosis.—Cocaine does not shrink the turbinals; the probe does not easily move the anterior margin of the middle turbinals. Turbinates frequently in contact with the septum. Rhinoscopy shows, posteriorly, the lower turbinals enlarged, looking like a mulberry. A mass on each side of the septum having the appearance of t;rub-worms, often seen. TREATMENT. Instruments.—Knives; cutting-forceps; scissors; the galvanic cautery; the galvanic needle; caustics (Chromic acid; Tri-chlor-acetic acid; Glacial acetic acid). For the removal of posterior hypertrophies, the cold-wire snare. Operation.—To remove hypertrophied turbinals: — (1) Galvano-cautery.—Apply a solution (4%) of Co- caine (see Rule 6); use the galvano-cautery by having the knife at dull heat, and apply it flat on the hy- pertrophied area, keeping it in position long enough ;o produce a good eschar. (2) Galvanism.—Have the patient hold a sponge-electrode on one hand; insert the needle, attached to the negative pole, into the sub- 200 HYPERTROPHIC AND ATROPHIC RHINITIS POCKET-BOOK OK MEDICAL PRACTICE stance of the hypertrophy, and turn on a current of about ten milliamperes for from 3 to 5 minutes. Repeat once a week. (3) Scissors or cutting-forceps.—Insert carefully, and remove no more than is absolutely necessary to pre- vent contact. (4) Acids.—Fuse a very little on a silver probe; be careful to touch only the point selected. (5) Cold-wire snare.—Adjust carefully, using the rhino- scopic mirror or the finger to aid in placing it, and then tighten slowly, giving plenty of time to divide the mass, thus avoiding hemorrhage. (6) Saw.—All spurs or ridges that arise from the septum, touching the opposite wall, should be removed with the saw. Medicinal.—Ferrum iod.3*—The nose stuffed at night, so that he must sleep with the mouth open; suddenly re- lieved between 5 and 6 in the morning. Ammonium mur.3*—Stoppage of one nostril during the day, and both at night. Lycopodium.6*—Nose "stuffed"; breathing impeded; the child starts up, rubbing the nose. ATROPHIC RHINITIS. (DRY CATARRH.) Symptoms.—The membrane dry; the turbinals more or less completely absorbed; inspissated mucus, in crusts, adhering to the walls; the nostrils feel dry to the patient; erosion of the septum, due to picking off of scabs; sense of smell often lost. TREATMENT. Local.—Remove the crusts with Solution No. I., II., IV. or V. Rub thoroughly with pledgets of cotton, and when clean apply Sprays Nos. C, F, R, with the nebuli- zer. If scabs are very hard to remove, Hydrogen- peroxide, applied on cotton, to soften them. If ozena is present, use Solution No. III., once a day. Spray No. S, applied with the nebulizer, or directly to the mem- brane with cotton, has proved a most excellent remedy in the hands of the author to prevent the scabs from re- forming. Medicinal.—Alumina.3*—Old people; hard scabs; green- ish-yellow discharge; septum ulcerated; constipation. Argentum nit.3*—The nose bleeds when picked; also, apply locally as a stimulant. Aurum met.3*—Syphilitic caries; bones of the face ten- der to pressure; after abuse of mercury; mental despond- ency. Hepar sulph.3*—After abuse of mercury; the nose sen- sitive to touch. Kali bich.2x—Plugs and "clinkers" in the nose; ulcers on the septum look as if punched out. Kali iod.1*—Membrane very dry; dryness extending to the larynx, producing hoarseness. Mercurius sol.3* —Pain in the cheeks and frontal si- nuses; pains worse at night. Cinnabaris.3*—Dryness of the nose, with heavy pain at the base. FIBRINOUS RHINITIS-HAY FEVER 201 POCKET-BOOK OF MEDICAL PRACTICE Graphites.3*—Great dryness of the nose; discharge of lumps and masses of dried mucus. PURULENT RHINITIS OF CHILDREN. Etiology.—Dependent upon no dyscrasia. Increased mucous secretion, and rapid desquamation of epithelial cells. The first stage of dry catarrh, or ozena. Peculiar to children. Symptoms.—Yellowish muco-purulent discharge from both nostrils ; li dirty-nosed;" absence of odor. TREATMENT. Local.—Cleanse the nasal cavities daily with Solution No. I., using the post-nasal syringe. Use at night four or five drops of a bland oil (as Benzoinol), dropped into each nostril with a dropper. Caution.—Great care should be observed to press the piston of the post-nasal syringe slowly, to avoid throwing the solution into the eustachian orifices. Medicinal.—Alumina.6*—Thick, tenacious,yellow muco- pus, hard to dislodge. Calcarea carb.3*—Thick, yellowish muco-pus. CycIamen.Tr—Thick, yellow discharge, with much sneezing. Lycopodium.6*—Nose " stuffed up" at night. Natrum carb.3*—Thick, yellow discharge, with the nose red and scaly at the tip. FIBRINOUS RHINITIS. Symptoms.—First, chilliness; then fever; pain in the limbs; loss of appetite; sneezing; profuse, watery dis- charge; nasal stenosis; this followed by sero-mucous and muco-purulent discharge, also profuse. Diagnosis.—A pearly-white membrane covers the whole or part of the nasal lining; secretions must be carefully wiped off to discover it. Cocaine has little power to re- duce the swelling in these cases. Make a bacteriological examination when possible. Treatment.—Perfect rest in bed until the fever has abated. A sustaining diet. Remove all secretions; use Solution No. F, in nebulizer. Medicinal.—Ammonium caust.3*—Nasal discharge ex- coriating; great prostration. Apis mel.Tr—Prostration; drowsiness; thirstlessness. Arsenicum alb.3*—Restless; aggravation after mid- night; thirsty all the time, but a little satisfies. Lachesis.6*—Aggravation always after sleeping. HAY FEVER. (ROSE-COLD; HAY ASTHMA.) Svmptoms.—Itching of the roof of mouth and inner caitS? watery, nasal discharge; swelling of the nasa mucous membrane; difficult breathing; loss of smell and taste. Aggravation during the daytime. 202 HAY FEVER-DEFORMITIES-ABSCESS POCKET-BOOK OF MEDICAL PRACTICE TREATMENT. Local.—Anticipate the disease. About two weeks be- fore the attack is expected, commence to wash and steril- ize the nasal and post-nasal cavities with an antiseptic solution. This must be done thoroughly and frequently. Hydrozone (fa) at first; just before the onset (t\); (dilute with sterilized water). Diet.—Regulate the diet; meat in small quantities only; not more than once a day; avoid all sweets and starches. Medicinal. — Arsenicum iod.3*— Sneezing; acrid dis- charge from the nose, which excoriates; worse after mid- night; enlargement of glands at the posterior wall of the pharynx; prostration. Euphrasia.Tr—Irritation and sneezing all day, with copious, bland discharge from the nose; excoriating dis- charge from the eyes. Gelsemium.Tr.—Great prostration; intense frontal or occipital headache. • Kali iod.—Implication of accessory cavities; discharge watery and colorless; excoriating. SabadiIla.Tr—Great itching of the nasal membrane, with violent sneezing; profuse watery discharge from the nose and eyes; worse in the open air. DEFORMITIES OF THE NASAL SEPTUM. Symptoms.—External deformity may be detected in some cases; alternating nasal stenosis frequent; epis- taxis from no apparent cause. Diagnosis.—By anterior examination of the nasal cavities. TREATMENT. Operation.—(1) The Saw.—Remove the angle of bone. (2) Punch.—Remove a small portion of cartilage; or, make a stellate incision, allowing the septum to be restored to its natural position and retained there by nasal plugs or splints. (3) Forceps.—Refracture the septum, then, by properly adjusted splints, retain the position until union of the fragments has taken place. (4) Burs and Trephines. —Remove projecting deformities. ABSCESS OF THE NASAL SEPTUM. Causes.—Generally the result of traumatism. It may involve the whole anterior nasal cartilage, causing great deformity. Symptoms.—Soreness and tenderness on pressure; more or less increasing stenosis; low down in each naris a bulging mass, easily indented with a probe. Treatment.—Free incision, to evacuate the pus and prevent closure of the wound too quickly. Wash the cavity thoroughly with Electrozone (1 to 6) daily until it is healed. FOREIGN BODIES IN THE NOSE. Diagnosis.—A discharge from one nostril, consisting of muco-pus mixed with cheesy flakes, which are inspissated mucus, and characteristic. To confirm the diagnosis, SYPHILIS-ULCER-GUMMY TUMOR 203 POCKET-BOOK OK MEDICAL PRACTICE use a probe. In a young child, anesthetize with Cocaine or a few whiffs of Chloroform, to keep it quiet, to facili- tate examination. Treatment.—If the body is located anteriorly, it can usually be removed with a pair of forceps. If too large to remove in that way, crush it, and then remove in pieces. If in the posterior nares, place one finger in the pharynx and dislodge the body backward with a probe. PARASITES IN THE NASAL CATITIES. Occurrence.—Rare in temperate zone; not uncommon in tropics. Symptoms.—Formication in the nose, with frontal head- ache; muco-purulent, bloody discharges; severe nose- bleed if vessels are attacked; swelling of the nose and face. Diagnosis.—Easy to distinguish by careful examina- . .on. Treatment.—Inject into the nose Chloroform and water, equal parts. It may be necessary to open and cleanse the accessory cavities if the maggots reach them. SYPHILIS OF THE NASAL PASSAGES. Primary Ulcer.—Primary sore is rare in this locality. Diagnosis:—An ulcer, with a hard base, and granular surface; it bleeds easily on touch; no pulmonary dis- ease; if no marked epistaxis is present, and enlarge- ment of the sub-maxillary glands on the side of ulcera- tion is noticed, the case must be suspiciously watched, and the characteristic eruption (from 3 wks. to 6 ms. later) looked for. The Mucous Patch.—Scarcely ever found in the nose. Superficial Ulcer.—Ulcer with well-defined borders on the floor of the nose, turbinals or septum (the lattermost frequently) ; the surface depressed in the center and covered with thick, grayish-yellow discharge; this re- moved, shows an ulcer of light pink color; it bleeds easily; does not extend rapidlj'. Gummy Tumor.—It appears on the septum or turbi- nals; when on the septum it is smooth and round; usually normal in color; firm and hard to the touch; it develops rapidly, becoming full-grown in a few days, then re- maining stationary for a long time. TERTIARY SYPHILITIC ULCER OF THE NOSE. Diagnosis.—Boring night-pains of the gummy tumor disappear when its breaks down into an ulcer. The ulcer has a bright, shining, red areola, extending some distance. The probe discovers denuded bone. A pecul- iar clear-white, cheesy substance accumulates above the ulcer, which comes away in masses while cleaning, and is very characteristic. TREATMENT. Local.—The parts must be kept perfectly clean. Use an antiseptic solution frequently. Remove the necrosed tis- sue and any spiculae or sequestra? as soon as separa- , 204 NOSE-LUPUS-SCLERMA-POLYPUS POCKET-BOOK OF MEDICAL PRACTICE tion has taken place. Dust freely with Iodoform or Nosophen. Medicinal.—Corallium rub.3*—Chancre very red. Kali iod.1*—Gnawing bone-pains; throbbing and-burn- ing in the nasal and frontal bones; greenish-yellow and excoriating ozena; violent headache; tendency to infiltra- tion of bones as well as soft tissues. Mercauro.Tr—The lesion tends to reappear.. Lachesis.6*—After abuse of mercury; blueness around the chancre; nightly bone-pains; ulcers phagadenic; burning on touching. Nitric acid.3*—Granulations bleed easily; sensation of a splinter in nose; cracks in the corners at the margins of the nose or mouth. LUPUS OF THE NOSE. Diagnosis.—Ulceration shows a granular, elevated mass, covered with grayish mucus; is slow in destruct- ive action. For differential diagnosis between lupus, carcinoma, sarcoma and tuberculosis, use the microscope. Treatment.—Scrape away all diseased tissue. Apply, with a pointed glass rod, pure Nitric acid in which is dissolved copper filings (as much as will be taken up). Apply to the entire periphery of the ulcer. Treat twice a week. Attend to the general health. RHINO-SCLERMA. Diagnosis.—Hard, button-like plates or nodules just inside the nostril, or on the alas or upper lip; the first thing the patient observes is the hard feeling to the touch. The hardness increases, and the nose becomes flatter; it may extend internally until the larynx is sten- osed. Firm pressure causes pain that lasts some time. Prognosis, not good. Treatment.—Most authorities advise early removal with the knife, curette or galvano-cautery. Medicinal.—Conium.3*—Indicated by the stony hard- ness of the parts. NASAL POLYPI. Symptoms.—Difficult nasal breathing; violent sneez- ing; watery discharge, muco-purulent later; by reflected light a tumor appears, glistening and shiny; it can be moved with a probe. Treatment.—Removal with cold-wire snare, galvano- cautery snare, or forceps. Apply Cocaine solution (4%) be- fore operating. Stronger solutions are hardly necessary. With the cold-wire snare, insert the loop between the growth and the septum, turn it horizontally and allow it to slip upward, encircling the tumor; tighten the loop care- fully and slowly until the polyp is severed. Repeat this upon each tumor, and examine at the end of a week to dis- cover any polypi that may have been hidden in the cavi- ties but are apparent later. See the patient at intervals of a month or so for some time, and remove any tumors appearing. The hemorrhage is usually slight if care is taken not to injure the mucous membrane. FIBROMA OSTEOMA-SARCOMA-CARCINOMA 205 ______POCKET-BOOK OF MEDICAL PRACTICE NASAL FIBROMATA. Diagnosis.—The appearance of the growth is irregu- larly round; reddish-pink in color; hard in character; irequent epistaxis. They are rare in the nasal cavities. Treatment. — Surgical interference is necessary. Transfix the tumor with a needle; adjust the loop of a galvano-cautery snare. This method prevents severe hemorrhage, which is to be guarded against. NASAL OSTEOMATA. Diagnosis.—Determine the presence of bone by a probe; or, by the finger. Early external deformity is usual. Exophthalmos may be due to it. Often severe pain (pressure on the sensory nerves). The point of attach- ment is relatively small; frequently broken off; after which, remove as a foreign body. Operation.—Surgical measures are to be taken accord- ing to the size of the tumor. A free incision will, in many cases, have to be made. NASAL PAPILLOMATA. Diagnosis.—Small, grayish, w£irty growths, near the margin of the nostril. If far from the opening, they are softer and larger. Treatment.—Removal in the same manner as polypi. ANGIOMA OF THE NASAL PASSAGES. Diagnosis.—Tumor of reddish or purplish color. Treatment.—The cold-wire snare, with the loop at the extreme base of the pedicle before tightening; then tighten slowly, consuming hours, sometimes, to avoid hemor- rhage. Caution:—Do not puncture with a probe; severe hemorrhage results. SARCOMA OF THE NASAL PASSAGES. Diagnosis.—A flabb}', bluish-gray, pedunculated tu- mor, on the inner or outer wall of the cavity. Con- firm the diagnosis with the microscope. Treatment.—Complete eradication as soon as recog- nized. Use the curette. CARCINOMA OF THE NASAL PASSAGES. Diagnosis.—Use the microscope at once. Treatment.—Make an external opening; reach the regions invaded; remove all diseased portions. Results are discouraging. THE ACCESSORY SINUSES OF THE NOSE. Varieties. — Diseases of the maxillary, ethmoidal, sphenoidal and frontal sinuses, where pus issues from them. Diagnosis.—A discharge of pus from one nostril (the only other conditions which have that symptom are for- eign bodies; syphilis; neoplasm). The pus is bright- vellow; smells of sulphureted hydrogen. Apply Cocaine solution (4%); with cotton carefully wipe away all dis- 206 ACUTE NASO-PHARYNGITIS-ADENOIDS _______________POCKET-BOOK OF MEDICAL PRACTICE charge. In order to detect the origin press with a probe causing a free discharge, (a) Anterior discharge de- notes disease of the antral or frontal sinuses, or an- terior ethmoidal cells; (b) Discharge in the pharynx, comes from the posterior ethmoidal cells or sphenoidal sinuses, (c) Intermittent discharge is from the maxillary sinus, (d) Continuous, from the others. To promote dis- charge from the antrum, throw the head well forward; or, lie on the unaffected side. For the others, an up- right position. Exophthalmos is common in ethmoidal disease. In disease of the sphenoidal sinus sometimes sudden blind- ness (pressure on the optic nerve in the optic foramen); also exophthalmos. Treatment. — Establish free drainage in all cases. First remove all nasal obstructions. In maxillary sinus, remove the first or second molar tooth; drill through the tooth cavity and make an opening into the antrum. Cleanse the cavity by syringing through the artificial opening daily; use solution of Electrozone (1:6), until the solution escapes through the nasal orifice. Insert a silver drainage-tube, to keep the opening from healing shut. Experienced operators only should open the ethmoidal and sphenoidal sinuses. In all, order the use of cleans- ing and disinfectant solutions. The opening into the frontal sinus is made immediately below the eyebrow, and near the bridge of the nose. Incise through the skin, elevate the periosteum, open the bone with a drill or trochar. The normal orifice must be opened and kept patulous, to insure free drainage. ACUTE NASO-PHARYNGITIS. Symptoms.—Appears suddenly after taking cold; sen- sation of dryness and burning in the back of the throat and palate; feverish; headache; malaise; notable pros- tration. Treatment.—Aconite.3*—Dispense on No. 50 pellets, one every half-hour as soon as the first symptom appears until improvement is noted, then every two hours. A •hort time will usually serve to abort the whole condi- tion. . Camphor.Tr—On pellets, one every half-hour after the exposure, will usually prevent all symptoms from appear- Gelsemium.2*—Especially indicated where there is marked prostration, sensation of trembling and drowsi- ness. _______ ADENOIDS OF THE PHARYNX. (HYPERTROPHY OF THE PHARYNGEAL TONSIL.) Diagnosis.—Nasal stenosis; peculiar, vacant facial ex- pression. Chronic suppurative otitis; progressive deaf- ness; thick, tenacious nasal discharge; mouth-breathing and snoring during sleep; night-terrors are frequent. Confirm the diagnosis by digital exploration. ADENOIDS-TREATMENT-SURGICAL-OPERATION 207 , __________POCKET-BOOK OF MEDICAL PRACTICE TREATMENT. Medicinal.—In 3'oung children many cases will be cured by the administration of Calcarea iod.2*—One tablet be- fore each meal. Also, use a bland oil (benzoinol), drop- ping 4or 5 drops (with a dropper) into each nostril night and morning. Relief will be immediate in many cases. Surgical.—When medical treatment fails after a rea- sonable time, remove the growths. As an anesthetic, Ether is the safest. Operate in the early morning hour, fasting. Operation.—Place the patient on the right side, with a sand-bag to the back (in order to retain the position). Anesthetize the patient. Draw a rubber tissue-cap over the head (to prevent blood from soiling the hair). Fasten the mouth-gag in the left side. The operator stands at the right of the patient. Render the hands aseptic. In- troduce the fore-finger of the left hand into the mouth, along the right posterior pillar into the pharynx, retaining it there to guide the forceps, to prevent injury to the tis- sues. Insert the forceps by the right hand. Use first a large-sized forceps, suited to the size of patient; follow by a smaller pair; lastly, a curette, to smooth the walls of the pharynx. Meantime, the nurse is ready with small pieces of folded sterile gauze, held on handles, to clean the pharynx of all blood that accumulates as the opera- tor withdraws his instruments. The hemorrhage is usually of short duration. After the operation place the patient in bed; keep quiet for 24 hours. Diet, light and nutritious. [Some authorities advocate the use of the curette alone, claiming greater rapidity and equally good results.]_______ DISEASES OF THE NASO-PHARYNX. FIBROMA. Diagnosis.—Practically the same symptoms and treat- ment as that found under the head of Fibroma of the Nose.------- MYXO-FIBROMA. Diagnosis.—A tumor of a grayish-red color (the true fibroid has a characteristic whitish-pink tinge). Insert a probe to discover mobility. Treatment.—The treatment is purely surgical; re- moval is best accomplished with the cold-wire snare. In cases of very large tumor it requires skill and patience to adjust the loop. Apply Cocaine (4%) before apply- ing the loop. ------- SARCOMA. Diagnosis.—A microscopical examination only is cer- tain. Treatment.—A radical operation under an anesthetic, as early as recognized, would seem to be the only rational method. ---_— CARCINOMA. Diagnosis.—The microscope must decide. It is very rare. A 208 PHARYNGITIS-ELONGATED UVULA POCKET-BOOK OF MEDICAL PRACTICE DISEASES OF THE PHARYNX AND TONSILS. ACUTE PHARYNGITIS. Diagnosis.—Chilliness; dryness and soreness of the throat; constant desire to clear the throat; tongue coated; small yellowish patches on the post-pharynx or tonsils; general hyperemia of the mucous membrane, extending to the pillars, soft palate and uvula; the tonsils some- what swollen. TREATMENT. Local.—Solution No. I., II., IV., or V. Medicinal.—Aconite.3*—Throat dry; pricking; burning; febrile excitement. Belladonna.3*—Inflammatory redness of the soft palate, uvula and tonsils; throat very dry; burning, shooting pains when swallowing; constant desire to swallow. Capsicum.Tr—Chilliness down the back; the uvula feels elongated; the throat sore, smarting and biting. Gelsemium.Tr—Fauces dry, irritated and burning; the tonsils inflamed; burning in the esophagus. Hepar sulph.3*—The throat feels scraped; sensation of a fish-bone in the throat. Mercurius.3*—The throat raw, burning; the pharynx red and swollen; worse at night. Phytolacca.2<—The throat sore on the right side; sen- sation of red-hot ball lodged in the fauces; hot fluids aggravate. -------- CHRONIC PHARYNGITIS. Diagnosis.—The pharynx has a healthy color, but is tometimes studded with little elevations, between which is a glazed appearance. TREATMENT. Local.—Attend to the toilet of the nose and pharynx perfectly. Apply Calendula Oil to the posterior wall of the pharynx. Medicinal.—Argentum nit.3*—Mucus difficult to dis- lodge; must hawk much to expel it. Kali bich.2*—Throat sore; mucus in hard lumps from the posterior nares. Phosphorus.3*—Rawness and scraping in the pharynx; worse evenings; throat dry day and night. ELONGATED UVULA. Symptoms.—Constant irritation in the fauces; in some cases serious cough. _ Treatment.—Amputation. Apply solution of cocaine U%)' During operation, lay the instruments, not in use, in ^ans of Carbolic (2%%) or Lysol (2%) solution. After operation, wash them thoroughly in cold water, using soap and a brush; rinse in hot water and dry. For care of catheters, see under Enlarged Prostate. Brushes.—Washout all soap; soak them until bleached in Oxalic acid (sat. sol.); rinse in sterile water and store dry. Gauze and Cloth Articles.—Pin them up in small pack- ages in muslin wrappers and mark the contents outside with pencil. Subject them to live steam for 1 to 2 hours in an "Arnold" steam sterilizer, or by suspending them in a hammock, made by a sheet or large towel, above water in a covered wash-boiler. Or they may be boiled or wrung out of a weak antiseptic solution, and care- fully baked. The Room for Operation.—Avoid stirring up dust just before or during an operation. Remove heavy draperies and upholstered furniture and spread cloths wrung out of Carbolic sol. (2%%) on the carpet, or, if the floor is bare, wipe it with a rag dipped in the same. SUTURES AND LIGATURES. Silk or Linen.—Boil it in water for 5 minutes. Silk-worm Gut.—The same, or Carbolize it in Carbolic acid (95%). Silver or Iron Wire.—Boil or carbolize it. Catgut.—Formalin method:—Roll it tightly on glass reels or rods, not overlapping any strands. Place in Formalin (1:25) for 12 hours, then in running cold water for 24 hours. Boil in water for 10-15 minutes depending upon the size. Store in the following mixture, where it will turn dark: Iodoform (5%); Glycerine (4%); 95%- Alcohol(91%). M. J 278 ANESTHESIA-LOCAL-COCAINE-EUCAINE POCKET-BOOK OF MEDICAL PRACTICE i Morris' Method.—Wind it on reels or make it into small coils and place it in Commercial Ether, 1 week; in Bichlo- ride-Ether (1:4000) 1 week; Chromicize, if desired, and store in Bichloride-Alcohol (1:4000). fohnston's Quick Method.—Ether, 24 hours; then in the following solution: Bichloride, 20 grs.; Tartaric acid, 100 grs.; Alcohol, 6 ozs.; small gut remains 10-15 min- utes; large, 20-30 minutes. Store in Palladium Chloride and Alcohol (1 drop to 6 ozs.). Alcohol and Heat.—Place it with absolute alcohol in a screw-capped jar, and subject it to boiling heat, in a water-bath, for 2 hours, with the cap only moderately tight. Then screw down the cap and keep it stored. To Chromicize.—Soak the catgut for 8-24 hours (depend- ing upon its size and the desired degree of chromicization), in the following:—Potassium Bichromate, 15 grs.; dis- solved in Sterile Water, 1 fl. oz., add Alcohol, 15 fi. oz. Kangaroo Tendon.—Boil it in Alcohol for 1 hour. Store in Alcohol, 8 ounces, Palladium Chloride, 1 drop. Note.—Actively antiseptic liyatures are better than merely aseptic ANESTHESIA. LOCAL ANESTHESLi. Cold.—To produce surface anesthesia, apply a piece of ice dipped in salt, covered with a layer of gauze, or a bag containing finely chopped—Ice, 2 parts; Salt, 1 part. Or spray with Ether or Rhigolene, by an atomizer. A fine stream of Ethyl, or Methyl-chloride, directed upon the skin anesthetizes it in one-half to one minute. Carbolic Acid.—Paint the proposed line of incision, or needle-puncture, with carbolic acid 95$, and wait one to two minutes. Cocaine Hydrochlorate.—Use by the following methods:- Surface Application.—Maximum, 1 gr. The Eye—4$ solution, 1 to 2 drops, 3 to 4 times, at 5-minute intervals, Nose, Palate, Tonsils and Pharynx —2-4% solution, painted on 3 or 4 times, at 5-minute intervals, or 2$ spray. Urethra, Rectum, etc.—10% solution, by swabor syringe. Ulcers (for curettage), 4% solution, painted on. Hypodermic Injection.—Maximum, % gr. in all. Con- strict the part, if possible. Inject a 4% solution, two to three minims at a time, in several places. Caution.—In- jections into the Urethra are especially apt to be followed by serious symptoms. Eucaine Hydrochlorate is much less apt to poison than Cocaine, but, in rare cases, sloughing has followed its use. Its solutions may be boiled, and are used in the same manner as Cocaine solutions. Infiltration-Anesthesia.—It consists in injecting, in suc- cessive beads, or areas, one of the following solutions: R. Cocaine Hydrochlorate, 2, or 4, or i parts; Morphine hydrochlorate, U part; Sodium-chloride, 2 parts; Car- kolr\c a£d (S%), 3 parts; Cold sterile water, add 1,000 parts, M. Method:—The needle is entered at the edge of ANESTHESIA-GENERAL -ADMINISTRATION 279 _______________POCKET-BOOK OF MEDICAL PRACTICE one area to produce the next; the deep tissues are reached in the same way. There is no danger of poisoning, even if many injections are made, and it has been used for operations of considerable magnitude, as for appendicu- lar abscess, hernia, amputations, stretching the sciatic nerve, etc. Its disadvantages are the production of edema at the site of operation, and its slow action. GENERAL ANESTHESIA. PREPARATION OF THE PATIENT. J Bowels.—Give a saline cathartic (Mag. sulph., % oz.; 1 or, Mag. citrate, 1 oz.) 12 hours before, and a copious enema or colonic flushing, 3 to 4 hours before. Stomach.—Forbid solid food for 8 hours, and liquid for 3 to 4 hours before. Precaution.—Examine the heart, lungs and urine. As- • certain how the patient has acted under anesthesia on previous occasions. E Have at Hand.—Mouth-gag; tongue-forceps; hypoder- mic syringe (loaded with Strychnia &, Atropine TJg gr.); Amyl-nitrite pearls; inhalers — Esmarch's (for chloro- form)—towel-and-paper, or ALUs' (for Ether, or a mix- ture); bottle with grooved cork for the anesthetic; 2 towels; a basin; sweet-oil, or vaseline. ADMINISTRATION OF THE ANESTHETIC. Assistant.—Always have a third person present, as a . witness and assistant. Position.—Have the patient recumbent, only a very small pillow, and with the clothing loose about the neck : and chest. The Skin.—Apply vaseline, or oil the skin about the ■ nose and mouth, and lay a towel over the eyes to prevent irritation from the anesthetic. Mouth.—Clear the mouth of foreign substances, false teeth, etc. Bodily Warmth.—Prevent, the patient being chilled, or being burned by hot bricks, bottles, etc. A person anesthetized.is more susceptible to heat than when con- scious. Suggestion.—Gain the patient's confidence; reassure him; let him examine the inhaler; encourage him to breathe deeply. Have him count after you slowly as he goes under. Quantity.—Start with a little anesthetic, or hold the inhaler away from the face, and gradually crowd it, but do not choke or smother the patient. Crowd.—During the stage of excitement crowd the anesthetic, and get through. Uniformity.—In moderate or full anesthesia continue to administer a little at a time; do not let the patient vacillate from profound anesthesia to semi-conscious- ness. Total Quantity.—Use as little anesthetic as possible, and watch every breath, and all other symptoms con- tinuously. 280 ANESTHESIA-SYMPTOMS-ACCIDENTS-TREATHENT tOU POCKET-BOOK OF MEDICAL PRACTICE SYMPTOMS OF ANESTHESIA. Primary Anesthesia.—It is not followed by nausea, and can be used for short operations, such as opening ab- scesses. Have the patient hold up an arm and count. When the arm drops, and he stops counting, operate quickly. Incomplete Anesthesia.—It has a dilated pupil, reacting to light, and the conjunctival or corneal reflex present. When going under, respiration may be irregular and the pulse rapid from nausea or nervousness. Vomiting oc- curs in this stage. Stage of Excitement.—The pulse rapid, patient strug. gles; talks, sings; may vomit. Moderate Anesthesia.—It has a contracted pupil, re- acting to light, with the conjunctival or corneal reflex lost. General muscular relaxation occurs and the pulse and respirations grow regular. Full Anesthesia.—It has a contracted pupil, not react- ing to light, with the conjunctival or corneal reflex lost; general muscular relaxation; pulse regular and neither slow nor very rapid; respirations deep and regular. Profound (Dangerous) Anesthesia.—It has a dilated pupil, not reacting to light, with the conjunctival or cor- neal reflex lost; general muscular relaxation. Pulse may be rapid or slow, weak and irregular, and respirations may be deep and snoring, or shallow and irregular, ACCIDENTS. Vomiting.—Do not allow the patient to linger in the vomiting stage. If unavoidable, turn the head to one side and use a basin and towel. Respiratory Obstruction.—Remove the cause. Keepthe head thrown rather forward and the chin well up. Hold the tongue forward by the fingers behind the angles of the jaw, or by tongue-forceps, if necessary. Quickly extract a foreign body with the fingers or forceps; swab out mu- cus or vomited material. Tracheotomy early, if necessary. Artificial respiration. Respiratory Failure.—Partial inversion of the patient; artificial respiration (Sylvester method); rythmic trac- tion on the tongue (16 to 18 times a minute); rectal dila- tation; stimulation, by Strychnia (^5-t\j gr.). Circulatory (Heart) Failure.—Quickly invert the patient and inject Strychnia -fa with Atropine xJggr-! &ive in!ia1' ation of Amyl-nitrite; produce artificial respiration; knead the chest over the heart; dilate the rectum. Slap and rub the trunk and limbs, and keep up the bodily warmth. Resuscitation.—It should not be despaired of until the heart has stopped one half hour, and the body grows cold. TREATMENT FOR SEQUELAE. Vomiting.—For prolonged nausea and vomiting, keep the patient's head low; allow only hot water or pieces ol cracked ice for one or two hours; then a little strong, black coffee; no solid food for 8 hours. Inhalations ol Vinegar, lavage of the stomach; a mustard-plaster on the epigastrium; 6-8 hourly doses of—Campb. monobrom., CHLOROFORM-ETHER-MIXTURE-A. C E 281 ______________POCKET-BOOK OF MEDICAL PRACTICE Citrated caffein; Acetanelid, equal parts (1 gr.) are all of value. Other Sequelae.—As Shock, Renal Congestion, Bron- chitis, etc., are considered in the articles on those sub- jects. ANESTHETICS. CHLOROFORM. . Action.—It is a circulatory depressant; death generally comes from heart-failure. As administered, it does not irritate the respiratory tract, the stomach or the kidneys, as does Ether. Its effects are rapid. Its vapor should be mixed with 05% of air. An hour's anesthesia requires one to three fluid-ounces. Contra-Indications.—(a) All cases of heart-disease, ex- cept with aneurism or marked atheroma, (b) When the anesthetist is inexperienced. Parturition.—It is safe in labor-cases. ETHER. Action.—It is a circulatory stimulant, but the neces- sary quantity dangerously irritates the respiratory tract, the digestive organs and the kidneys, especially when these organs are delicate. Death from its use generally occurs after the patient leaves the table. Its vapor re- quires admixture with less air than does chloroform; some claim only 5%. An hour's anesthesia uses six to twelve fluid-ounces. Contra-Indications.—(a) When true albuminuria exists. (b) In children, old people and those having delicate bronchi and lungs, (c) When anuerism or pronounced atheroma exists; (d) When vomiting is much to be feared. (e) In operations about the nose and mouth, .(/) When rapidity of action and small bulk is much desired, (g) In the neighborhood of a naked flame. CHLOROFORM AND ETHER, MIXED. Proportions.—Chloroform 1 part, to 2 or 3 parts of Ether, by volume. Action.—The Ether, being a circulatory stimulant, overcomes the depressing effects of the Chloroform. The Chloroform, by reducing the amount of anesthetic neces- sary, prevents the irritating effects of the Ether upon the respiratory tract, kidneys and stomach. It requires a free admixture of air, almost as much as pure Chloro- form. An hour's anesthesia requires two to four fluid- ounces. Indications.—Many consider it by far the safest anes- thetic for general use. Deaths from its use are almost unknown. THE A. C E. MIXTURE. A. C. E.—The addition of Alcohol to Chloroform and Ether serves only to prolong the stage of excitement and render the anesthetic more bulky. Ether, itself, is a sufficient stimulant. A 9S? WOUNDS-TREATMENT-INFECTED-INCISED 606 POCKET-BOOK OF MEDICAL PRACTICE SCHLEICHS MIXTURE. Discarded.—The mixture of Petroleum-ether (Benzin) with Chloroform was intended to overcome the depress- ing effects of the latter, but careful experiments have shown that it depresses the circulatory system fully as much as pure chloroform. WOUND TREATMENT. RULES FOR AN ASEPTIC OPERATION. 1. Sterilize the site of operation as described, and sur- round it with sterile towels; or, work through a hole in a sterile sheet. In emergency, recently washed and boiled towels and sheets will do. Have everything sterile that touches the wound or cloth about it—hands, instruments, gowns or aprons, sutures, sponges, dressings, etc. 2. Stop hemorrhage completely before closing the wound. (See Hemostasis.) 3. For irrigation, sterile water; or, better, normal salt- solution. 4. Suture in layers; allow no dead spaces for the accu- mulation of fluids; permit as little tension on the stitches as possible. 5. Provide no drainage, unless, for some special rea- son, it is expected that fluids may accumulate in tha wound. 6. Dress with a dry powder, or collodion and cotton. Some prefer to apply a sterile strip of protective over the line of suture, and over this a pad of cotton moistened with an antiseptic lotion and covered by a sheet of pro- tective. TREATMENT OF AN INFECTED WOUND. 1. Avoid mixed infection by observing aseptic precau- tions. While disinfecting the skin about it, plug the wound with lodoform-gauze, and avoid washing septic matter into it. 2. Stop hemorrhage completely. 3. Disinfect the wound by irrigating all parts of it with a mild, warm antiseptic solutiou. Apply caustics or tissue stimulants, if indicated. Be sure that all for- eign bodies are remove'd. 4. Suture perfectly, in layers, providing for exit of in- fected fluids. Silk-worm gut sutures may be introduced and left to be tied later, when healthy granulating stir- faces appear. Never bury silk. 5. Provide for drainage by a rubber or glass tube with holes along the sides, or by a few strands of catgut or silk-worm gut, or a tightly twisted wisp of gauze. Re- move these as soon as possible, often after 48 hours. 6. Apply a moist antiseptic dressing. INCISED WOUNDS. Suture.—In suturing, unite the ends of divided muscles by "mattress " or "quilt " sutures. Unite the ends of a cut nerve, if large, with a stitch of fine chromicized WOUNDS-LACERATED-CONTUSED-PUNCTURED 283 _______________POCKET-BOOK OF MEDICAL PRACTICE catgut, transfixing them J-^g of an inch from the cut surfaces. If the ends of tendons cannot be drawn to- gether, lengthen them by splitting toward the cut end, and suture with kangaroo-tendon. Tendon-suture is more necessary in the forearm and hand than in the leg and foot. Other steps as described for an aseptic opera- tion or an infected wound, as the case may be. LACERATED WOUNDS. Treatment.—Trim enough to secure good coaptation, and treat as an "infected wound." LACERATED AND CONTUSED WOUNDS. 1. Stop hemorrhage; remove foreign bodies; disinfect thoroughly. 2. Trim up the wound, removing only such tags as are sure to slough; save all tissue on the face. The vitality of a part depends upon its circulation. See Indications or Amputation. 3. Introduce sutures, if practicable, allowing for free drainage. Apply a moist antiseptic dressing, e. g., Creolin (%-lfo); Acetate-of-aluminum (1%); or, Beebe's Lotion. Keep it warm, if necessary, to preserve the vitality of the part. The continuous, hot antiseptic bath is also used for this purpose. In Crushing Injuries.—Much tissue is saved by trim- ming off as little as possible at first, applying the con- tinuously hot antiseptic pack, and, after inflammation subsides and the lines of demarcation appear, trimming up the tissue left to fit, and suturing. Crushed Fingers.—-After cleansing and disinfecting, wrap each finger with several layers of narrow gauze bandage. Thoroughly saturate this with Comp. Tr. Benzoin; dry and apply more, until a stiff, antiseptic splint is formed. Do not disturb this dressing for 7-14 days, unless symptoms of suppuration arise. CONTUSIONS. Early.—Employ cold, elastic compression by a firm bandage over wool or oakum, and astringent lotions. Later.—After extravasation is ended, apply an Arnica compress (Tr. Arnica, 1 part; Water, 16 parts) and heat. Discoloration.—May be rapidly reduced by applying leeches to the spots. Blebs—Fracture-blisters.—Empty each one at the edge and apply an antiseptic dressing. Hematoma.—Try rest, and pressure with aseptic as- piration. If these fail, incise, evacuate, stop hemor- rhage and drain, observing rigid asepsis. Stimulate the cavity-wall, if necessary. PUNCTURED WOUNDS. Treatment.—If necessary, enlarge for hemostasis or thorough disinfection. Treat the wound as incised or lacerated, aseptic or infected, as the case may be. 284 INFLAMMATIONS-TREATMENT- COMPRESS-POULTICE f-° POCKET-BOOK OF MEDICAL PRACTICE TREATMENT OF SURGICAL INFLAMMATIONS. LOCAL MEASURES. Removal of the Exciting Cause.—As a foreign body. Rest.—Most important; sometimes indispensable; in- cluding immobility and relief from functional activity, e.g., muscular relaxation. Elevation.—Of the part, lessens congestion. Heat.— if intense, produces local anemia and pre- vents congestion. As generally employed, it relieves stasis and congestion (therefore pain), and promotes tissue- change and cell-activity. Dry Heat.—Is applied by bottles, or bags, filled with hot water; by steam; or hot-water coils; hot bricks; plates; sand-bags; shot-bags; or freshly-ironed flannel compresses. Hot Air.— At a temperature of 250°-300° F., gradually applied and removed, by the apparatus designed for this purpose, is of value in many cases of rheumatism, neu- ralgia, neuritis and joint affections. It is applied daily for %-l hour. Moist Heat.—Is especially useful in acute, infective inflammations. It produces great relaxation, even soft- ening to flabbiness, It is applied in the form of 1. Fomentations, or Stupes.—Dip a pad of flannel in hot water; wring it out by twisting it in a towel and apply, covering it with a thick waterproof material. Change the pads as often as they cool, applying the fresh pad the instant the cool one is removed. To avoid fre- quent changing, apply a steam or hot-water coil, or hot- water bag over the flannel. Turpentine Stupes.—After wringing out the flannel, sprinkle over it 10-20 drops of Turpentine, or add the Tupentine to the hot water. 2. Hot Antiseptic Compresses.—Intermittently hot:— Apply a thick layer of gauze wrung out of a hot anti- septic solution. Cover this with a protective layer of cotton and a bandage. This will not wet the bed, but cannot be reheated without removal. Continuously Hot.—Apply a very thick layer of gauze or absorbent-cotton, a layer of protective and a bandage. Cut holes through the bandage and protective at various points and into them pour, with a funnel, the solution as hot as can be borne. Arrange to drain off the surplus of solution for a few minutes. Repeat this every 1 to 4 hours. This is the most effective way of applying moist heat. Solutions.— Boracic acid (sat. sol.); Thiersch's solution; Creolin solution (y2 %)-, Tartaro-acetate-of-aluminum solution (1 %); Carbolic acid solution (1 cfc), for a short time only. 3. Poultices.—Are gradually being displaced by the dressings just described. Poultices favor microbic de- velopment in the skin, but may, however, be made up with a weak antiseptic solution. WATER-BATH-ASTRINGENTS-IRRITANTS 285 _______________POCKET-BOOK OF MEDICAL PRACTICE_____________ s Rules.—(a) Apply the poultice as hot as it can be borne. (b) Change it before it gets cold, (c) Have the next one ready when one is removed, (d) Keep it warm by a thick protective, and by external heat when practicable, (e) '■■ Peritonitis requires thin poultices. (/) Protect the part 5; when they are discontinued. Flaxseed or Linseed Poultice.—Add ground flaxseed slowly to a. little cold water, while stirring rapidly. Add boiling water and continue stirring after the right con- :; sistency is attained, thus making it smooth and lig.ht. ' Spread it evenly on a piece of muslin a little larger than , the finished poultice. Oil the surface of the poultice with Olive oil or Vaseline, and turn the edges of the muslin ;. over it. The surface may be covered with a thickness of gauze. Oatmeal and Bran Poultices—Are made in the same way. Thick Boiled Starch.—Made in the same way. Mustard Poultice.—Add to a flaxseed [poultice 1 part ■: of mustard flour for every 5 parts of flaxseed used; it should remain on the part only 10 to 20 minutes. 4. Water-Bath.—Continuous immersion of a part, or even of the whole body, in warm water or a weak anti- septic solution, is sometimes employed with great benefit for sloughing wounds and large purulent areas, burns, ; etc. Cold.—Constringes the vessels, prevents exudation, re- " tards cell-proliferation, favors absorption, and relieves 'm pain, swelling and tension. It is contra-indicated inin- " tense congestion, advanced inflammation, or in weak or debilitated patients. Dry Cold.—Is applied by rubber bags filled with - cracked ice or by ice-water coils. Protect the skin by 2 or 3 layers of flannel. Wet Cold.—Drop ice-water slowly from a bucket upon the surface covered with 2 or 3 layers of muslin or gauze; provide for drainage. Alternate Heat and Cold.—Is useful to stimulate the circulation of a part in chronic ailments, as in sprains, ulcers, etc. Compression.—Supports the vessels; prevents exudation and passive congestion and favors absorption. It should be applied from the extremity of the limb to a point above the affected area. Astringents aud Sorbefacients.— Often of use. Lead- Water and Laudanum (Tr. Opium, 1 part; Liquor Plumbi Subacetatis, 1 part; Water, 16 parts) is a cool- ing and soothing lotion and is applied on cloths, sat- turated. Tr. Iodine or Comp. Tr. Iodine, are used painted on. Silver Nitrate (Lunar Caustic), is brushed over, pure or in solution. Ichthyol in ointments (25-50%) or in solution (2-10%) is very valuable. The Mercurial Ointments are also useful. Counter-Irritation.—Relieves congestion early; later, it promotes absorption. Rubefacients.—Friction; hot water; Turpentine; Capsi- cum; or one of the following vesicants applied for a short time: pftfi ACUPUNCTURE-ACTUAL CAUTERY-LEECHING fc° POCKET-BOOK OF MEDICAL PRACTICE________ Vesicants.—Shave the part and apply—Chloroform Com- press, a few minutes; Ammonia and Lard, aa, 5 minutes; Cantharidal Collodion (or Plaster), 2-6 hours. Mustard and Flour, with luke-warm water, 15-60 minutes. The Resulting Blister.—Drain at the edge, and allow it to heal; or if prolonged irritation is desired, cut away its top and apply an irritating ointment, as a mercurial one. Several small blisters are better than one large one. Do not apply too near to the inflamed tissues. Poultices hasten vesication and diminish its pain. Acupuncture.—Is performed by inserting, aseptically, steel needles into the subcutaneous tissues for a few min- utes. Setons.—One or more strands of silk or other material are passed under the skin a short distance, and both ends are left protruding; the strands are moved back and forth at each daily dressing, and sometimes a stimulat- ing ointment is applied to them. Actual Cautery.—Is sometimes, though seldom, indi- cated, and is best applied by the Paquelin thermo-caut- ery, quickly, at a white heat, for vesication. Dry Cupping.—Apply a cup, exhausting the air by a pump; or, stick a pit of paper or cotton to the bottom of a wine-glass with collodion; saturate it with alcohol, light it, and apply the glass to the skin. Local Depletion.—Is accomplished by— Multiple-Puncture.—By needles or a sharp-pointed bistoury, observing asepsis. Scarification.—Aseptically, by needles or knives. Leeching.—Cleanse the skin, smear it with a little blood or milk, and apply the leech. Sprinkle it with salt to make it let go. Leeches should not be applied to in- flamed tissues, over large superficial vessels or nerves, or to parts having much loose cellular tissue. Wet-Cupping.—Apply a cup for a short time, scarify or puncture, and again apply it, exhausting slowly. Massage and Passive Motion.—Are of great service in chronic inflammations and when rest is abandoned. GENERAL TREATMENT. Diet.—Give plenty of nourishing and easily assimil- able liquids, as peptonized milk, milk-punch, egg-nogg, meat-juice, beef-tea, etc., gradually allowing solid foods. Hygiene.—Good ventilation and cleanliness are of the highest importance. Maintain free excretions. Stimulation.—Alcoholics are indicated where there is absorption of animal or bacterial poisons. Remedies.—Aconite2x ; Belladonna2x ; MercuriusS*; Hepar3x; Siliceabx; Arsenicum3x; Iodine3x; Mercurius iod.2x; Arsenicum iod.3x; as indicated. ABSCESS. Diagnosis.—It rests upon:—1. History.—Localized signs of inflammation; chills; irregularly high temperature; high pulse; sweats. 2. Fluctuation 3. Pointing. 4. Sur- ABSCESS- TREATMENT-HILTON'S METHOD 287 ______________POCKET-HOOK OF MEDICAL PRACTICE______________ face edema. 5. Exploratory puncture; (to be made with a fine needle under strict asepsis). Treatment.—Prevent pus-formation, if possible, by early treating the inflammation which leads to it. ACUTE ABSCESS. Drainage.—As soon as pus is diagnosed make free incision. Let the pus escape spontaneously, or use only very gentle pressure. Irrigate the cavity with sterile water or salt-solution, and follow with an antiseptic solution (preferably Carbolic). Never distend the cavity. Stop hemorrhage. Secure free drainage by fenestrated tubes, and, when necessary, by counter-openings at dependent points. Apply an absorbent, antiseptic dressing (usually moist). Irrigate and re-dress daily at first, removing the tubes as soon as the cavity will drain without them (often in 2 or 3 days). Put the part at rest and use local tissue stimulants if necessary. If the abscess is near large vessels or important structures, use:— Hilton's Method.—Incise the skin, nick the deep fascia, push a grooved director through the tissues until it enters the abscess, as shown by sudden decrease of resistance and by pus along the groove. Pass a forceps along the groove into the cavity and withdraw it with the blades spread apart. CHROMC ABSCESS. (COLD ABSCESS.) Treat the Cause.—Usually it is tuberculosis. Treat by hygienic and dietetic measures, internal medication, and, when due to bone or joint disease (as spondylitis), by mechanical means. Aspiration and Injection.—Under strict asepsis, draw , off the contents of the cavity through an aspirating needle or fine trocar. Wash out the cavity with saline solution and inject Iodoform emulsion (10% of Iodoform in Glycerine). Work this into every part of the cavity by manipulation. Repeat 2 or 3 times, if necessary. Opening.—Under the strictest antiseptic precautions, incise into the cavity and irrigate. Curette (thoroughly, if at all) the wall, or dissect it out, or cauterize it with Zinc-chloride (10%), or Carbolic (95%). Institute drain- age and apply an antiseptic dressing. Medicinal.—Calcareacarb.3x; Calcarea fluor.3x-6x; Cal- carea phos.3x;Mercurius3x; Mercurius iod.2x; Kali iod.3x; Iodine3x; Iodoform2*; Silicea&x, as indicated. SPECIAL CASES. Brain.—Trephine over the suspected spot and locate the pus definitely by exploratory puncture. Evacuate carefully and drain by a soft rubber tube. Antrum of Highmore.—Drain it into the buccal cavity by a gimlet-hole through the superior maxilla, just above the canine tooth, or through the socket of an extracted tooth. Breast.— Incise in a line radiating from the nipple, or enter the ab,scess beneath the breast by a cut at the in- ferior thoracic-mammary junction. ^ 288 ABSCESS-SINUS-FISTULA-CELLULITIS fc0° POCKET-BOOK OF MEDICAL PRACTICE Mediastinum.—Open by trephining through the sternum. If it has discharged through an intercostal space and does not heal well, make a counter-opening through the sternum. Empyema.—If repeated aspiration fails, resect a piece of a rib (6th on the right, 7th on the left) in the axillary line, open the cavity through the periosteum, which should be left, and evacuate slowly. Drain by one large or two smaller rubber tubes. Do not operate in tuber- culous cases. Lung.—Locate the cavity by exploratory aspiration, and leave the needle as a guide. Resect a piece of rib. If the two layers of pleura are not adherent, suture them together and wait 48 hours. Then open the cavity by thermo-cautery at a dull red. Drain by a rubber tube. Pericardium.—Aspirate in the 5th interspace. With the needle as a guide, make a one-inch incision to the pericardium and nick it. Introduce a forceps and with- draw open. Drain by a soft rubber % to ^ inch tube. Irrigate if the pus is foul. Liver.—Locate by exploratory puncture in the anterior axillary line, 7th or 8th interspace; mamillary line, just below the nipple; scapular line, below the angle of the scapula. When located, incise along the edge of the ribs. Stitch the liver to the abdominal wall, if it is not already adherent, by stitches into it an inch deep. Wait 48 hours. Then, with an aspirator-needle as a guide, open the abscess by the thermo-cautery at a dull red. Irrigate and drain by a very large tube. Appendicular.—See Abdominal Surgery. Peri- or Ischio-Rectal.—See Rectal Surgery. SINUSES AND FISTULA. Foreign Body.—Remove any irritating foreign body, as a silk ligature, necrotic bone, etc. Application. — Apply Carbolic Acid (95%), Lunar- caustic; solution of Zinc-chloride (10%) or Formaldehyde, along the tract. Curette.—If these fail, curette or dissect out the wall of the whole tract and stitch up the fresh wound. SURGICAL INFECTIONS AND FEVERS. DIFFUSE CELLULITIS. Synonyms.—Acute Cellulitis; Phlegmonous Inflamma- tion or Suppuration; Purulent Infiltration. Disinfect the Wound.—Open it up thoroughly; curette away all sloughing tissues (medulla of bone, if neces- sary, in compound fractures); disinfect with antiseptic irrigating fluids, or even mop the wound with strong dis- infectants, as Zinc-chloride (10%) solution. Drainage.—Open any edematous parts and pus-pockets, establishing free through-and-through drainage by coun- ter-openings, inserting rubber tubes. LYMPHANGITIS-ADENITIS-PHLEBITIS 289 _______________POCKET-BOOK OF MEDICAL PRACTICE Dressing.—Employ continuously hot moist antiseptic dressings, both to prevent and to limit suppuration. If these measures do not produce improvement in 6-8 hours, employ hot, continuous antiseptic irrigation. Finally, if necessary, resort to high amputation. General Measures.—Diet and stimulation, etc., as de- scribed for inflammations. Medicinal.—Arsenicum**; Arnica3x; Apis3x; Crotalus6x; BaptisiaTr.; Lachesis. *2x PURULENT EDEMA. General.—Treat as described for Diffuse Cellulitis. If high amputation is necessary, curette and apply strong antiseptics to the under side of the skin- flaps. ACUTE LYMPHANGITIS AND LYMPHADENITIS. Disinfect the wound as described above. Apply Tr. Iodine or Ichthyol to the inflamed areas and apply hot, moist antiseptic dressings up to a point above the inflam- mation. If suppuration occurs, evacuate, disinfect and drain. Remedies.—Arsenicum iod.**; Mercurius iod.2x CHRONIC ADENITIS. Nature.—It is generally tuberculous. Treatment.—Remedies should be tried, as in many cases they will cause the enlarged glands to disappear. But if, under internal treatment, the glands grow larger or more numerous, or begin to suppurate, operate, continuing in- ternal treatment afterward. Medicinal.—Arsenicum iod.3x; Calcarea carb.3x; Cal- carea fluor.3x; Calcarea iod.3x; Calcarea phos.3x; Carbo animalis^x; Conium3x; Iodide-of-lime (Nichols), y^-yi gr.; Kali iod.3x; Kali phos.3x; Mercurius bin.2x; Mer- curius prot.2x; Iodine3x; Phosphorus3x; Protonuclein (2-4 grs. 3-6 times a day). Operation.—Under strict asepsis dissect out the whole chain of glands, if possible, without rupturing them. Employ dry dissection by the fingers, and blunt dissector as much as possible, and avoid wounding large nerves and blood-vessels. If glands are ruptured, quickly sponge away their contents, dissect out the sac, and be- fore suturing the wound thoroughly irrigate with an Io- dine solution (1%). Close without drainage unless the wound has been infected during the operation. Other steps as under Wound Treatment. PHLEBITIS. Aseptic.—Rest in bed; elevation and compression of the part; cold early; heat later; paint with Iodine (Tr.) or Ichthyol. Medicinal.—Hamamelis^*, Lachesisi2x; Pulsatilla.lx Pyoplilebitis, Thrombophlebitis.—Ligate the vein above the septic focus and, if possible, below. Open the vessel and wash out the infective material. Apply a moist an- tiseptic dressing. Other measures as described for Pyemia. 290 ERYSIPELAS-FURUNCLE-CARBUNCLE-GANGRENE POCKET-BOOK OF MEDICAL PRACTICE ERYSIPELAS. Prophylaxis.—Isolate each case; burn all dressings; sterilize (by boiling) all clothing that comes in contact with the patient. Avoid contact of the discharge with abrasions of the patient's or attendants' skin. Local.—Hot moist compress of Creolin, 1%, or Carbolic acid solution; Ichthyol and water; or, Alcohol and water, equal parts. To these a little Laudanum may be added. Moist Compresses of Lead-water and Laudanum; Alco- hol; or, a Cranberry poultice (made by mashing up raw cranberries with cold water into a paste.) Salves.—Ichthyol (20-50%) in Lanolin. Medicinal.—Apis3x Arnica3x; Belladonnalx; Rhus.3x Anti-streptococic Serum, 10-30 cc, injected subcutane- ously, has given good results. General Measures.—Give nourishing, liquid diet; stim- ulate with Alcohol or Strychnia as required; maintain free excretions. Phlegmonous Erysipelas.—Institute radical treatment early. (See Diffuse Cellulitis.) FURUNCLE—BOIL. Locally. —Apply hot moist antiseptic dressing. As soon as pus is detected; incise aseptically and evacuate it. Apply a moist antiseptic dressing. The application of Ichthyol Ointment (10-20% in Lanolin) is of value to areas where the boils are multiple. General Measures.—Correct any digestive, sexual or constitutional disturbance or unsanitary condition which may be the cause. Medicinal.—Arnica3x, to prevent recurrence. Bella- donna 3x; Mercurius sol.3x; Hepar3x; Silicea.&x CARBUNCLE. Local.—Early:—Apply a cold antiseptic compress cov- ered with an ice-bag. Inject a few drops of Carbolic acid (95 %) into its center. When Foci Appear, apply continuously hot antiseptic compresses, and operate if necessary. Operation.—Anesthetize; thoroughly disinfect the skin. incise freely by crossed incisions, multiple if necessary, from edge to edge. Curette out all necrotic tissue and apply Zinc-chloride (10 %) solution. Dress with a moist antiseptic dressing. Note.— Never use the knife in dia- betic cases. General Measures.—Treat the low constitutional condi- tion predisposing to it. Give plenty of nourishing foods. Enc°u.rage the excretions. (See Septicemia.) Medicinal.—Apis3x; Arnica3x; Arsenic3x, Belladonna^; Bryonialx; Hepar3x; Lachesisi2x; Silicea^x, Sulphur.3* GANGRENE. Preventive Measures.—Relieve pressure, tension, or con- striction of the part. Employ warmth, massage and slighr elevation. Treat atheroma, diabetes or other con- stitutional condition which may cause it SEPTICEMIA-SAPREMIA-PYEMIA-TETANUS 291 POCKET-BOOK OF MEDICAL PRACTICE Wait for the Line of Demarcation.—Except in the cases to be mentioned meanwhile applying continuously hot, moist antiseptic compresses. Then amputate or trim up and suture. High Amputation or Excision at Once.—This is to be performed in all cases of progressive gangrene, either se- nile or diabetic. In amputating for senile gangrene, a clot higher up in an artery, which does not bleed, may sometimes be broken up and dislodged by a rubber catheter. General Measures.—As for septicemia. Feed liberally; stimulate with whisky or Strychnia, as seems necessary. SEPTICEMIA AND SAPREMIA. Remove the Cause.—Immediately evacuate pus or putrid matter from the tissues or from a natural cavity, as the womb, bladder, kidney, peritoneum, pleura, middle ear, or from an artificial cavity (abscess), and drain. General Measures.—Favor the Excretions by an active saline purgative and a hot bath. In many cases the in- travenous infusion of saline solution is of great value. Nourish Well.—Concentrated liquid foods every 3 hours. Stimulate.—Alcohol, and other stimulants as required. Medicinal.—Alcohol (large doses), has been much used; Arsenicum3x; Arnica3*; BaptisiaTr.; Crotalus^x; Lach- esis.^x Anti-streptococcic Serum has given good results in some cases. Dose, 10-30 cc. by subcutaneous injec- tion. ------- PYEMIA. General.—Treat the same as for septicemia; and in addition, watch for, and evacuate immediately, all acces- sible secondary abscesses. TETANUS. Prophylaxis.—Treat all wounds as described under Wound Treatment. Local.—When tetanus exists, look for a wound; open it; excise diseased tissue; cleanse with Hydrogen-Per- oxide; cauterize with Bromine or pure Nitric acid, and drain. General Measures.—Isolate the patient in a quiet, darkened, well-ventilated room. Keep the bowels open; catheterize if necessary; give nourishing liquid food. If swallowing causes convulsions, give an inhalation of Amyl Nitrite before the attempt. If this fails, administer Chloroform and feed through a stomach-tube or through a catheter passed through the nose. Medicinal.—Curare; Gelsemium; Passiflora; Physo- stigma. Phytolacca; Strychnia; and other drugs have been given in cases which have recovered. Antitoxin.—Recoveries have followed injections of Teta- nus Antitoxin hypodermically, and recently some have injected it into the frontal lobes of the brain. Dose: 15-20 centigrammes. Carbolic acid.—Remarkable results have followed sub- cutaneous injections of Carbolic acid (2%) solution. Dose:—first day, 10 cc, subsequent days, more gradu* ^ 292 ULCERS-PHAGEDENIC-VARICOSE-IRRITABLE " POCKET-BOOK OF MEDICAL PRACTICE_______^^^ ally, up to 20-30 c c. a day. Avoid marked symptoms of poisoning. Adjuvants.—Free stimulation with Strychnia, or, some- times, Alcohol. Relieve suffering with Morphine, Chloral, Potassium bromide, and anesthetics when necessary. ULCERS. Healthy.—Put the part at rest; elevate if possible; keep the ulcer clean and apply a non-irritating dress- ing, as— Senn's Dusting-Powder (Boric acid, 4 parts; Salicylic acid, 1 part). Dust on thickly and cover with gutta- percha tissue or oiled silk. Aristol.—Apply in the same way. Iodoform.—In some venereal cases. Beebe's Cerate.—Dry mutton-tallow, 3-4 parts; Olive oil, 1 part; Carbolic acid, 5% of the whole. Melt together, and stir while cooling. Spread thinly on muslin, and apply. Zinc Ointment may be used in the same way, but is not so good. Skin-Graft.—As soon as a healthy granulating surface appears, skin-graft large ulcers. Exuberant. — Shave or curette off the fungous granula- tions ; stimulate with Lunar caustic. Apply a non- irritating dressing and compression. Edematous.—Same treatment as just described. CbroniCj Callous or Indolent. — Curette or stimulate by caustic (especially Silver-nitrate). Cut through the hard edges>all around, by radiating incisions; dress with Balsam-of-Peru, or Comp. Tr. of Benzoin. Sloughing or Phagedenic.—Remove all sloughing tissue, and disinfect thoroughly, applying strong caustic. Ap- ply continuously hot wet antiseptic dressings. Constitu- tional Treatment.—Stimulate and nourish well. Irritable or Erethistic.—Curette; apply pure Carbolic acid or Lunar-caustic. Divide the exposed or imprisoned nerves by section through the floor of the ulcer. Chloral (20 grains to the ounce) allays the pain. Yaricose Ulcers.—Elevate the limb. Support the veins by an elastic stocking or by a rubber bandage applied from the toes up, just tight enough for each turn to hold the preceding one without reverses. Treat as described for Chronic Ulcers. These measures seldom or never give permanent benefit without radical treatment of the varicose vessels. Operations for Yaricose Yeins.—Before anesthetizing, while the patient is standing, apply a ligature about the upper-third of the thigh, just tight enough to obstruct the venous flow. Trendelenburg's Method.—Tie the internal saphenous vein at two points, below the saphenous opening, and divide it between the ligatures. Fergusson's.—Make a long incision over the vein and excise the part between the ligatures. ULCERS-SKIN-GRAFTING-BEDSORES 293 . _____________POCKET-BOOK OF MEDICAL PRACTICE______________ Schede's.—Circumcise the leg, in its upper third, down to the deep fascia, and excise all the vessels on each side of the wound. Local Measures.—In either of these operations use chromicized catgut for ligatures. After ligating, re- move the constrictor, suture the wound, and apply a dry powder dressing and a thin pad. Bandage the limb firmly from the toes to above the wound. Leave the dressing in place for 4 days, unless there are marked symptoms of inflammation; then sponge the wound with Alcohol and re-apply the dressing. Syphilitic Ulcers.—Dust with Calomelix; Mercurius sol.3x; Iodoform or Aristol. Lupus.—Curette thoroughly, removing all diseased tis- sue, and dust with Iodoform or Aristol. Treat the healthy ulcer, which should result, as has been indicated. If only a small area is involved, pply pure Nitric acid carefully. SKIN-GRAFTING. Prepare the Ulcer.—Curette the healthy ulcer lightly and irrigate it with hot normal salt-solution, stopping all hemorrhage by pads wet with the same. The Grafts.—Have the site from which the grafts are to be taken (the inner side of the thigh is best) thoroughly disinfected, and wash it with salt-solution. Draw the skin tense and with a wet razor shave off strips of only the upper layer of the skin. Apply the Grafts.—Straighten these out in a basin of : warm salt-solution, and apply them to the granulating : surface, fitting them to cover it. Dress the Grafted Surface.—Cover it with three layers of sterile gutta-percha strips (wet in salt-solution) and laid at right-angles to each other, with small gaps be- tween adjacent strips, for drainage. Over this apply a sterile pad of gauze wet with salt-solution; cover with a piece of protective, a layer of cotton, and a bandage. In 48 hours remove the dressing down to the gutta-percha tissue and irrigate with salt-solution. In 5 to 7 days remove the gutta-percha strips and dress as desired. Dress the skin-wound with a dry powder dressing. Epidermis.—Scrapings or minute clippings, will often start islands for skin proliferation. BED-SORES. Prevent.—By Cleanliness:—Keep the patient and his bed dry; bathe his shoulders and back once or twice a day; rub dry; then rub with Alcohol; dust with zinc- oxide, borated talc, or lycopodium powder. Remove Pressure.—Have a smooth, soft, elastic bed, or water-bed, or cushion. Put a ring-pad around any red- dened spot. Shift the patient's position often, if only slightly. Harden the Skin.—Apply salt and whisky (2 fl. dr. to the pint) or a mixture of—Alum (yi oz.), Camphor,Tr. (2 oz.), and the whites of 4 eggs. The Sore.—Remove all sloughs by an antiseptic poul- « 901 BURNS AND SCALDS-FROST BITES 4!" POCKET-BOOK OF MEDICAL PRACTICE______ tice and treat the remaining ulcer by a non-irritating dressing and stimulation. See Ulcers. BURNS AND SCALDS. Prognosis.—Fatal if a third of the bodily surface is affected. First Degree (Hyperemia).—Immediately apply one of the following: 1. A compress saturated with Sodium-bicarb, (sat, sol.), or, a solution of Picric acid (1 %). 2. A paste of Sodium-bicarb, and water, with a flax. seed poultice applied over it. 3. A paste of Vaseline and Sodium-bicarb., or of flour-and-lard, covered with gauze or cotton and pro- tective. 4. If these materials are not at hand, apply some other clean dressing that will keep the air out and the part warm. Second Degree (Vesication).—Large blisters or blebs should be pricked at the edge and gently evacuated, leaving the upper layer of skin. Apply one of the above dressings, preferably the Picric acid, Soda, or carbolized Vaseline. Third Degree (Eschars).—There is destruction through or beyond the skin. Anesthetize, if necessary, remove the clothing, trim away anj' dead tissue and apply a wet Picric acid or antiseptic compress, until all sloughs separate. Then treat the remaining ulcer as described under that subject. Large Surfaces.—Where a large area is burned, sus- pend the patient, by a sheet, in a warm bath of Soda- solution, until shock is over, or even until the sloughs separate. Then dress as described under Ulcers. Dressings.—Do not disturb them until the discharges loosen them. Absorbent-cotton, applied next to the skin, may be irrigated or washed off, thus avoiding the pain caused by pulling off gauze. General Treatment.—Treat shock as described under that heading. Watch for duodenal ulceration (remedy, Kali bich.) and for other complications—cerebral, pul- monary, renal, and septic. In exhaustion from suppura- tion, nourish well. FROST BITES. General.—Gradual Warmth.—Place the patient in a cold room, sponge the frozen parts with cold water, using gentle friction. Gradually raise the temperature of the room. Or place him in a bath at 60° F. and gradually raise it to 90° F. After a time wrap him in warm blan- kets and apply mustard-plasters over the heart and spine. Employ artificial respiration if necessarv. Give stimvr lants, in cool water, by mouth or enema", or subcutane- ously. Do not give hot enemata. Local.—Gradual Warmth.—Rub gently with ice, snow, or iced water, followed by dry, gentle friction. With re- LIPOMATA-FIBROMATA-CHONDROMATA-OSTEOMATA 295 ^ ______________POCKET-BOOK OF MEDICAL PRACTICE_______________ action, suspend the part and apply cooling applications, evaporating lotions, etc., for the pain. If the freezing is extensive, employ the continuous, mild, antiseptic bath. When the line of demarcation is established, amputate or excise the dead tissues. Treat cellulitis as described under that heading. Chillblains.—When of the feet, order the patient to take regular outdoor exercise, to wear large shoes, woolen stockings, to avoid tight garters and loitering near a hot fire, to sleep in warm stockings, bathe the feet twice a day in cold salt water, rubbing dry with a flannel, and to apply one of the following lotions :—1. Kerosene; 2. Olive-oil and Turpentine, equal parts; 3. IodineTn and Soap-linament; 1: 2.; 4. Cantharis,Tr-or Capsicum,Tr. and Soap-linament, 1: 6. TUMORS AND CYSTS. LIPOMATA. Diagnosis.—They generally grow slowly, in the subcu- taneous connective-tissue. Soft, doughy, movable on the underlying tissues, but often adherent to the skin. Cap- sulated or diffuse. Treatment.—If pain, inconvenience or cosmetic consider- ations indicate removal, incise over the tumor and tear or cut it out, observing asepsis. Introduce drainage for 24 to 48 hours. „ ------- FIBROMATA. Diagnosis.—Hard, dense, sharply-defined, painless; generally grow slowly. In the breast they are freely movable, but when arising from fixed structures, as the periosteum, they are adherent. Treatment.—Where they are easily accessible, remove them aseptically. Fibromata of the breast, in young women, generally yield to internal medication; Conium3x; Iodine?*; Iodide-of-Lime (Nichol's). Dose:—y3 to yi gr. Epulis should be dissected away, together with the un- derlying bone. Keloids should not be excised. Use cataphoresis; ap- ply an amalgamated stick of Zinc, covered with 3 to 4 layers of moist gauze, as the positive electrode, and ap- ply a large pad near by, as the negative electrode. Gal- vanic current, 5-15 Ma. —----— CHONDROMATA. Diagnosis.—They generally occur at the ends of bones and in the young. Smooth, nodular, inelastic, immovable, painless; grow slowly; often ossify. Treatment.—If medication fails, chisel off the growth and some of the underlying matrix, observing rigid asep- sis, especially in a joint. Amputation is sometimes necessary. Medicinal.—Calcarea fluor.6x; Hecla lava3x; Lapis albus3x; Silicea.6x 0S^^A Treatment.—Treat the diathesis which may be the cause, as syphilis, gout, etc. Removal is indicated for 296 MYXOMATA-MYOMATA-ANGIOMATA-SARCOMATA POCKET-BOOK OF MEDICAL PRACTICE pain, pressure on important structures or cosmetic effect. The removal must be thorough to prevent return. Al- ways remove subungual growths; split and remove part of the nail to do so. ________ ODONTOMATA. Treatment.—These are tumors arising from tooth tis- sue. They are sometimes confused with sarcomata of the jaw, but are not malignant, and simply require re- moval. ________ MYXOMATA. Treatment.—Complete aseptic removal, with cauteriza- tion of the surfaces from which they arise, if from mem- brane. MYOMATA. Course.—They sometimes become sarcomatous. (See Enlarged Prostate, and Uterine Tumors.) ANGIOMATA. Treatment.—Never employ injections. Capillary Angioma (Naevus).—Apply the positive galvanic electrode (%-l inch in diameter) covered with gauze saturated in Ergot (fl. ext.) or'Ergotol, and a flat pad, negative electrode near by; current, 10-15 Ma. Cavernous Angioma.—If small, use galvano-puncture with the positive electrode. If large, excise aseptically, The following is suggested for large cavities :—Insert an insulated needle and through it pass a quantity of finely- drawn gold wire, to which attach the positive electrode, 10-15 Ma. for % to 1 hour. Then cut off the wire pro- truding, leaving the rest inside. Arterial Angioma.—It requires the ligation of the ves- sels flowing into and out of the tumor, and excision of the tumor where possible. The gold-wire treatment just suggested may be of value. LYMPHANGI0M.1T A. Treatment.—Excise when possible. In other cases, multiple galvano or igni-puncture. SARCOMATA. Diagnosis.—Usually occurs before middle life, and is of rapid growth. Usually firm and fleshy, but some- times fluctuates. Usually non-capsulated, and is ad- herent to the surrounding tissues and undergoes early degeneration. Adjacent lymph-glands not involved early. Sarcoma originates in connective-tissue. Treatment.—Complete extirpation as early as possible, if it can be accomplished. Coley's Mixture (of erysipelas and prodigiosus tox- ines) should be tried with or without operation. Inject 2-3 m. the first day, and gradually increase the dose so as to cause a febrile reaction about once a week. Inject the fluid every day or two, near to, or distant from, the tumor. V______________________ ADENOMATA-CARCINOMATA-CYSTS 297 _______________POCKET-BOOK OF MEDICAL PRACTICE PAPILLOMATA. Ordinary Warts.—Apply fuming Nitric acid, and pare away the dead tissue until the acid penetrates to the base of the growth. A drop of Carbolic acid (95%) will relieve pain. Then keep the spot dry and dusted with an antiseptic powder. Or excise aseptically. Venereal Warts.—Especially when about the genitals, and numerous, often disappear if bathed often with Hydrogen-peroxide solution, dried thoroughly, and kept dusted with Calomel. Salicylated collodion, often ap- plied, sometimes causes them to disappear. Medicinal.—Antimon. crud.3x; Nitric acid3x; Thuja2x; Staphysagria.3x Other Papillomata.—Require complete removal, together with the tissues from which they spring. ADENOMATA. Treatment.—When they persistently increase in size or do not respond to treatment, excise them aseptically. When occurring in the breasts of young women (the so- called " fibro-adenoma ") they often disappear under medicinal treatment. See Fibromata. CARCINOMATA. Diagnosis.—Generally after the age of 30-35 years. Hard, nodular, adherent to the surrounding tissues, non- capsulated; neighboring lymph glands generally en- larged early. Treatment.—Thoroughly excise the tumor with plenty of adjacent tissue, as early as possible, and dissect out the adjacent lymph-glands. Of the Breast.—Remove the whole organ and the chain of lymphatics running into the axilla, in one piece if possible. Make an elliptical incision, wide of the nip- ple, one end of which extends up into the axilla. Ob- serve strict asepsis. Other steps as in Wound Treat- ment. _______ CYSTS. Varieties.—Retention-cysts; Sebaceous cysts ("Wen"); Exudation-cysts (ganglion), Dermoid cysts; Hydatid cysts. Treatment.—Excise, aseptically the whole growth, in- cluding the sac. If it is feared that a part of the sac is left, swab the cavity with Carbolic acid (95%) and drain for 24 hours. If due to constitutional disturbance, cor- rect it. _______ BONE DISEASES. ACUTE OSTEOMYELITIS. Treatment.—As soon as a diagnosis is made (pus will, probably, already be present), incise freely to the bone, through the periosteum, and locate the pus by drilling. Cut a groove in the bone; evacuate the pus; curette away all diseased, bony tissue; disinfect, cauterizing with a strong solution of Zinc-chloride; pack the wound for 72 298 CARIES — NECROSIS - FRACTURES POCKET-BOOK OF MEDICAL PRACTICE hours, leaving it open. Amputation, at the joint above, may be necessary in some cases. ACUTE PERIOSTITIS. Treatment.—Very early, during hyperemia; in some cases, hot dressings may abort the inflammation. Try the application of IodineTr-; Guiacol; Ichthyol. Even be- fore pus is formed, incise through the periosteum under local or general anesthesia. Leave the wound open, in- sure free drainage, and dress with a moist, perhaps hot, antiseptic dressing. Incise fingers at the "corners," rather than on the sides, palm, or back. TUBERCULOSIS. Constitutional Treatment.—Is very important. Diet and hygiene should receive careful attention. Medicinal.—Calcarea carb. ;Calcareaphos.; the Iodides; Ichthyol; Guiacol. Local.—Rest, by splints or extension, or both. Operation.—"Ignipuncture" (puncture into the focus with the thermo-cautery); curettage; or extirpation of the focus. CARIES AND NECROSIS. Treatment.—Remove all the diseased or dead bone by the curette, dry the walls and touch with Carbolic acid (95%). Leave the wound wide open and let granulations fill it in from the bottom. When the bony cavity is clean, dust it with Iodoform and pack it with decalcified bone- chips. FRACTURES. GENERAL CONSIDERATIONS. DIAGNOSIS. Method.—Make diagnosis under anesthesia, if neces- sary, by— 1. Crepitus.—Grating (felt or heard). 2. Abnormal Mobility. — Motion where it should not occur. 3. Easy reduction and spontaneous displacement. 4. X-rays; the fluoroscope, or skiagraph. 5. Deformity (not diagnostic); compare with the oppo- site side. PROGNOSIS. Simple Fractures.—If properly treated, usually re- recoyer without deformity. Exception:— Fracture of the clavicle. Compound Fractures.—May be followed by tetanus; suppuration; septicemia. Prognosis is grave in bad cases; guarded in the majority. Ununited Fracture, or Delayed Union.—Is liable to occur in (a) Intra-capsular fracture of the femur; (b) rracturesof the olecranon and patella; (c) fractures of the humerus and tibia, in debilitated subjects. FRACTURES-REPAIR-TREATMENT-BANDAGES 299^ POCKET-BOOK OF MEDICAL PRACTICE Fibrous Union.—Occurs, often, in fractures of the patella; olecranon; coracoid process of the scapula; and in some cases of delayed union. Progressive Neuritis. — Sometimes follows fractures, especially about the ankle and knee. Favorable Influences. — Perfect coaptation and im- mobilization; perfect circulation in the part; youth and perfect health. Unfavorable Influences.—Dyscrasia, as syphilis or tuberculosis; habitual use of alcohol or drugs; exposure; exhaustion; old age. REPAIR First Stage.—Absorption of debris—about 1 week. Second Stage.—Exudation of callus—about 2 weeks. Third Stage.—Ossification of callus—about 3 weeks. Fourth Stage.—Resorption of provisional callus—may take a year. TREATMENT. (1) Coapt the Fragments.—(<' Reduction;." " Setting.") —Anesthetize if necessary, to relieve pain and to relax the muscles. In some cases, continuous traction (exten- sion) is necessary to produce and to maintain coaptation. (2) Immobilize the Fragments.—Until union is estab- lished. This is accomplished by "fixed dressings;" as a plaster-of-Paris "cast, "or a hardened bandage, or by "removable dressings," as splints, fracture- boxes, etc. Muscular Relaxation.—In many cases where it may be difficult perfectly to reduce a fracture, if a proper dressing is applied the muscles will relax and the dress- ing will complete the reduction. In applying dressings allow for muscular relaxation and avoid applying them too tightly; remember that every turn of the bandage in- creases the pressure. Swelling.—If the patient is seen before swelling occurs, apply the proper dressing and cold at once. The dress- ing may have to be removed if too great swelling occurs later. If swelling is already present, apply a temporary splint, elevate, and apply heat or cold. When swelling has somewhat decreased, apply a permanent dressing, and change it, if it becomes too loose. Arnica3x inter- nally. When there is doubt as to whether the dressings are holding the fragments properly, it is best to examine with the X-rays, if possible. Plaster-of-Paris. — Kind: — Use the ordinary, coarse, "Michigan" plaster. Bandage Material.—Coarse crin- olin. It need not have the starch soaked out of it. Making the Bandages.—Tear the crinolin into strips the full length of the piece and wind into large rollers. Bake the plaster ^ to 2 hours in an oven. Then, wi'th a Beebe's plaster-bandage machine, or with a case- knife and a long table, spread the plaster on the crinolin strips just thick enough to fill the meshes and leave a thin layer on the surface. Roll into bandages, cutting when the roller is 2-3 inches in diameter. Keep these in a tight tin-pail or box. A 300 "CASTS"-SPLINTS-HARDENED BANDAGES "■* POCKET-BOOK OF MEDICAL PRACTICE Applying the Bandages.—As a lining, apply a smooth layer of "sheet wadding," or a soft, thick bandage ex- tending farther each way than the plaster is to go; on a leg or foot, an old stocking; for a jacket, an old under- shirt. Place 1 or 2 bandages at a time, on end, in a vessel of warm water deep enough to cover them. To make the plaster set quickly and hard, add a large table- spoonful of powdered Alum to each quart of water (salt makes plaster crumbly). When they are saturated, ap- ply the bandages, without squeezing, rubbing the layers together. Have the "cast" thicker at the edges and turn the lining back over them, to cover them smoothly. Keep the part in position until the plaster "sets." Care of the "Cast."—It should be "set" almost as soon as it is applied. Avoid breaking it before it is dry, 24-48 hours. To Remove.—Insert a strip of "tin" under it and cut it longitudinally with a saw-edged plaster-knife; or soak it in hot water and peel it off. Permanent Splints.—Almost indestructible, may be made by carefully removing plaster splints and saturat- ing them with thin, hot glue (2-3 applications) and cov- ering with cloth. Interrupted or Fenestrated "Casts."—Are made with straps of iron, bent so as to bridge over part of a limb. Each end of the irons has pieces of wire cloth or perfor- ated tin riveted to it. These catch the plaster of the bandage in their meshes and prevent the iron from work- ing loose. To expose a small area, a hole may be cut in an ordinary "cast." HARDENED BANDAGES. Starched.—Apply a lining. Then saturate, in water, a heavily starched, crinolin bandage and apply. Or apply a muslin bandage, rubbing thick, hot, boiled starch into each layer. Silicated.—Instead of the boiled starch, saturate the muslin with Sodium or Potassium silicate. A thin layer of plaster-of-Paris bandage may be applied over this (after covering it by tissue-paper) to hold it in shape until it dries. SPLINTS. Wooden Boards.—Sawed, not shaved; fe to % inch thick. Tar or Binder's-Board.—Soak it in hot water; mold it to the part, and bandage it on. It becomes hard, when dry. "Fiber."—Is sold at supply houses, and is used the same as "tar" board, but is much firmer; fa inch is thick enough. Sole-Leather.—May be used in the same way. Plaster-of-Paris Bandage.—Several thicknesses laid to- gether and wet, may be bandaged to a part for a splint. Tin, Perforated Tin, and Sheet-Iron.—Make good splints when bent to fit the part. COMPOUND FRACTURES-SPECIAL FRACTURES 301 POCKET-BOOK OF MEDICAL PRACTICE Wire Cloth.—Makes extremely good splints, is easily cut and molded for the part; and allows air to penetrate it. Use heavy cloth. Re-inforcing.—Any molded splint may be stiffened by a strap of iron riveted to it. Lining.—All splints should be lined by 3 to 4 thick- nesses of cotton "sheet wadding." Blanket Splint.—Fold a blanket lengthwise to a width equal to the length of the splint desired. Roll it from both ends, put the limb in the trough between the rolls and tie a bandage about them in 3 places. This is for temporary use. Board-and-Blanket Splint.—The /^ same, except that the blanket is f: rolled, at each end, over a board |*» about 4 inches wide. FRACTURE-BOX. Hinged.—Have the sides hinged, ^,^n(GHlft4cmK for easy dressing. Box. COMPOUND FRACTURES. Indications.—If amputation is not demanded, then— 1. Carefully remove all foreign matter and small de- tached pieces of bone from the wound. 2. Disinfect the wound thoroughly with a warm anti- septic solution, first cleansing the surrounding skin; avoid washing infective material into the wound. If an end of bone projects, do not reduce it before disinfecting. 3. Provide for free drainage; apply an antiseptic dressing, generally a moist one. 4. Apply an interrupted or fenestrated "cast," a fracture-box, or some splint that will allow easy inspec- tion and dressing of the wound. 5. When the wound heals, treat as a simple fracture. DELAYED OR NON-UNION. Indications.—When resulting in ununited fracture or pseudo-arthrosis. 1. Correct the constitutional and local causes of mal- nutrition of the part. 2. If a muscle or organized blood-clot is between the fragments, cut down and remove it. 3. Break up or remove any soft callus between the fragments; by a tenotome, drill or in an open incision. 4. Irritate the ends of the bone by rubbing them to- gether, by drilling into them, or by a seton passed be- tween them; or cut down and freshen them if necessary. 5. Drill, and wire, or screw, or nail the fragments to- gether, or fasten them together with kangaroo-tendon, or silk-worm gut, after exposing them by incision. 6. Apply a proper splint in all cases. SPECIAL FRACTURES. THE SKULL. Diagnosis.—Where any doubt exists about a fracture of the vault, incise, aseptically, down to the bone and feel •kM TREPHINING—FRACTURES OF THE VERTEBR2E aUt POCKET-BOOK OF MEDICAL PRACTICE_______ with the finger; tap on the bone with the handle of the scalpel. Blood, or cerebro-spinal fluid from the ears, nose or orbit, often indicates fracture at the base. Prognosis.—Always guarded; depends upon the amount of injury to the brain. Compound or depressed fractures or fractures of the base are more serious than simple fractures of the vault. TREATMENT. Simple Fractures without Depression.—Insure rest in bed, quiet, low diet, mild purgation, moderate elevation of, and cold to, the head. Medicinal.—Aconite; Arnica; Belladonna, as indicated, Simple Depressed Fractures.—Elevation of fragments by operation. Compound Fraeture without Depression.—Disinfect the wound and surrounding scalp. If a hair or foreign body is found in the fissure, convert the fissure into a groove by chiseling away the outer table along it. Compound Depressed Fractures.—(All punctured frac- tures. ) Operate and elevate the depressed fragments. Trephining.—Shave the whole scalp; disinfect it; and any wound. Expose the fracture by a "V" or "S" shaped incision. Remove a small piece of bone, using, ii necessary, the mallet and chisel, or trephine. In using the mallet and chisel, hold the chisel almost parallel to the surface of the skull. In using the trephine, remove the center-pin when it is started and feel often in the saw-groove, with a flat probe, to see if it has penetrated anywhere, going very carefully at the last. When sawed all around, remove the button with an elevator. Through the opening raise the depressed fragments with the ele- vator. If any fragments cannot be lifted up, it may be necessary to cut away parts with the chisel or bone- forceps. Smooth the edges of the hole. Avoid opening a sinus, but if one is opened, plug, compress, ligate or suture it. If there are clots outside or inside the dura, remove them and ligate the bleeding vessel. Fluids in the brain may often be located and sometimes drained by a fine aspirating needle. Closure. — Introduce drainage, if indicated; suture wounds of the dura with fine silk or catgut, permanently stop all hemorrhage, and suture the scalp with silk- worm-gut. Apply an antiseptic dressing and a head bandage. Instruments.—Razor, scalpel, artery forceps, retract- ors, flat-ended probe, trephine, bone elevator, mallet and chisels, bone-cutting forceps (Rongeur and Devilbis), dural separator, bone curette, aspirating syringe and needles, needles, needle forceps, catgut, silk-worm-gut, and fine silk. THIS SPJNK. FRACTURES OF THE VERTEBRJE. Diagnosis.—Deformity; crepitus; symptoms of injury to the cord; the X-ray. Prognosis.—Very grave; complete recovery rare. FRACTURES OF THE FACE-MAXILLA-HYOID 303 ______________POCKET-BOOK OF MEDICAL PRACTICE_____ Treatment.—Straighten the patient out, using careful extension and manipulation. Place him on a soft, flat bed with sand-bags to steady the spine; later, use a water bed, if possible. After-Treatment.—If toward the end of the first month symptoms of cord-injury are stationary, perform lami- nectomy, provided that it is not certain that the cord is destroyed. Plaster Jackets.—In some cases, continued extension by weight and pulley, etc., is beneficial. In all cases guard against bed-sores and attend to the evacuation of bowels and bladder. the: face. fracture of the zygomatic arch. Treatment.—Introduce a sharp instrument under the depressed fragment and lift it up. CRUSHING IN OF THE ANTRUM. Treatment.—If not opened, make an opening into it just above, and external to, the canine tooth. Introduce a sound, lift the bones into place, and pack with gauze for 7 to 10 days. FRACTURE OF THE SUPERIOR MAXILLARY. Treatment.—When the alveolar process is broken in, mold it into place, fasten any loose teeth to their neighbors and hold the parts together by the opposing jaw or by dental wax molded into a splint. Time of Repair.—Let the patient begin to masticate in 4 to 5 weeks. FRACTURES OF THE INFERIOR MAXILLARY. Prognosis.—More or less displacement often remains. Fig. 2.—Pattern for Jaw-Splint. Fig. 3.—Jaw-Splint. Treatment.—Coapt the fragments by manipulation, re- moving any tooth that interferes, and replacing it after coaptation. Apply a splint over the chin to prevent lat- eral pressure, and bind the jaws together with a Barton's or a four-tailed bandage. Feed through a tube passed between or around the teeth. Some cases may require a molded internal splint of dental wax or vulcanite, wiring the teeth, or even drilling the bone and wiring through a facial incision. In wiring the teeth, have the strain come on the teeth, not next to the fracture. Time of Repair.—It is fairly firm in 3 weeks. Let the patient masticate in 4 to 5 weeks. THE THROAT. FRACTURE OF THE HYOID. Treatment.—Throw the fragments into position by forc- ibly elevating the chin, or by a finger in the mouth and !rr 304 FRACTURES-STERNUM-RIBS-CLAVICLE POCKET-BOOK OF MEDICAL PRACTICE manipulation externally. Apply a high molded stock or collar to immobilize. Do not allow the patient to talk; control cough by drugs; feed by enema, later by a tube.' Time of Repair.—About 4 weeks; remove dressings in3 weeks. THE CHEST. FRACTURE OF THE STERNUM. Prognosis.—Favorable if uncomplicated. Treatment. — Reduce displacement by bending the patient back over a pillow during deep inspiration. Im- mobilize the thorax by adhesive straps passed clear around it, with overlapping ends. Keep the patient in a semi-erect position with the head thrown back somewhat. Time of Repair. — From 4 to 5 weeks; remove dressings in 3 weeks. FRACTURE OF THE RIBS. Prognosis.—Depends upon the severity of the visceral injuries complicating. Treatment.—Reduce depressed fragments by pressing the sternum and spine toward each other. Have the patient raise the arms from the sides, and during a forced expiration apply, over the fracture, a strap of ad- hesive plaster, 3 inches wide, completely encircling the chest, and pin the overlapping ends together. Change the plaster in 7 to 10 days. Time of Repair.—From 3 to 4 weeks; remove the dress- ings in 2% to 3 weeks. FRACTURE OF THE CLAVICLE. Prognosis.—Usually some deformity. Treatment.—Fold a stout piece of cloth along one side, and sew across one end. Drop the flexed elbow into the corner thus made, protecting the point of the elbow with a ring pad. Convert this into a sling by straps Fig. 4--Elbow Sling. from the fl"ee cor- ners around the neck. Place the hand on the well shoulder and put enough absorbent material between opposing skin surfaces to prevent intertrigo. Reduce by lifting the shoulder up- ward, outward and backward, and apply a modified Velpeau bandage (one in which the turns pass over the sound shoulder, instead of the affected one), passing across the chest toward the affected side. Sometimes a pad and strap is necessary to hold down an over-riding inner fragment. Avoid bandaging too tightly, and cover with a starched or plaster bandage. To Avoid Deformity.—In a girl, keep her on a flat, hard u ^lth a low Pillow> a narrow cushion between the shoulders, a shot-bag on the affected shoulder, the arm by the side, and the forearm across the chest. Fig. j.—Modified Velpeau Bandagk. FRACTURES-SCAPULA-HUMERUS 305 POCKET-BOOK OF MEDICAL PRACTICE Time of Repair.—Remove the dressings in 3 weeks. FRACTURE OF THE SCAPULA. The Body.—Treatment:—Reduce by lifting the shoul- der and manipulation. Apply a firm pad, to press it against the ribs, and a bandage to hold it in place, and immobilize the shoulder and arm. Remove the dressings in 3 to 4 weeks. The Spine,— Treatment:—The same. The Neck.—Displacement:—The glenoid fossa and humerus drop downward. Treatment:—Lift directly up on the humerus, lay the forearm across the chest at right-angles, and bandage in this position, with a flat axillary pad and absorbent material between the skin surfaces. Remove the dressings in 5 weeks. The Glenoid Fossa.—Prognosis:—It is apt to leave ankylosis. Complications:—It generally occurs with dis- location. Treatment:—As for fractures of the neck. Employ passive motion after 3 weeks. If necessary, break up ankylosis, under anesthesia, after 6 or 7 weeks. Time of Repair.—Dressings should not be per- manently removed for 4 or 5 weeks. The Acromion Process.—Outside the Acromio-clavicular Articulation:—Lift up the fragment by lifting on the humerus. Bandage as for fractures of the neck. Re- move the dressings in 4 weeks. Bony union is not likely. Inside the Acromio-clavicular Articulation:—Treat the same as a fractured clavicle. The Coracoid Process.— Treatment:—Apply a Velpeau bandage for 4 weeks. The Bicipital Insertions.—Treatment:—Push the ends of the tendons back into place as well as possible. Im- mobilize the shoulder with the elbow flexed. THE ARM. FRACTURE OF THE HUMERUS. The Anatomical Neck.—Treatment:—Apply a flat axil- lary pad, or an inverted " U" shaped splint of molded board, reinforced with an iron strap. Fit a shoulder-cap of the same, or of plaster-of-Paris bandage. Bandage these on with the forearm across the chest. Remove dressings in 5 weeks. The Surgical Neck,—Displacement.—Both ends inward. Treatment:—Produce extension; push the ends into place, and while doing this apply the dressing just described. The time of repair is the same. The Shaft.— Treatment:—As for the surgical neck. The Shaft, Lower Qnartcri-yDisplacement.— Upper frag- ment generally downward and forward. Treatment:— Produce traction and force the upper fragment upward and backward and into place. Apply a right-angled, T Fig% 0.— Pattern. Fig. 7.—Shoulder-Cap. anfi FRACTURES-ELBOW-RADIUS-ULNA *UO POCKET-BOOK OF MEDICAL PRACTICE________ posterior splint with a short, right-angled, anterior splint to prevent the bandage from cutting at the elbow. Re- move dressings in 3 to 4 weeks. The Condyles.—Prognosis:—-Permanent limitation of motion, even after 6 to 12 months, often results. Treatment.—Flex the elbow to nearly a right- angle; press the fragments into position, and mold a lateral, angular splint about the elbow so as to hold the fragments in place, and ban- dage on the splints. Fig 8 shows a lateral, angular elbow splint, braced with iron (be- fore molding). Some advise immediate incision and nailing of the fragments into place. Institute passive motion in 3 weeks. Remove the dressings per- manently in 4 weeks. ALL FRACTURES ABOUT THE ELBOWS. ^. «.-Elbow Splixt Prognosis.—Always danger of more or less permanent ankylosis or limitation* generally some temporary limitation for sev- eral months. Diagnosis.—Locate the four cardinal points, *. e. (11 Inner Condyle; (2) Outer Condyle; (3) Olecranon; (4) Head of the Radius. X-Rays.—Most valuable in exactly determining the situation and direction of fractures and of the effective- ness of any dressing applied. FRACTURES OF THE ULNA. The Olecranon.—Prognosis:—Union is apt to be fib- rous. Treatment:—Draw the upper fragment down and apply an anterior splint with the elbow very slightly flexed. Apply strips of adhesive plaster passing just above the small fragment, down and around the splint, to hold the fragment down. Drilling and wiring or nailing may be necessary. Institute passive motion in 3 weeks, always pressing down on the upper fragment. Time of union, 5 to 6 weeks. The Coracoid Process.—Complication:—Occurs with a backward dislocation. Treatment:—Reduce the disloca- tion and push the fragment into place. Apply a pos- terior, right-angled splint and an anterior pad to hold the fragment in place. Begin passive motion in 3 weeks. Remove the dressings, permanently, in 4 weeks. Just below the Coracoid.—Treatment:— Apply a poste- rior right-angled splint, with a pad at the back of the upper fragment to hold it forward, also an anterior, coaptation splint to hold the lower fragment backward. Remove the Dressings in 4 weeks. The Shaft.—Displacement:—Ends of the fragments are drawn toward the radius. Treatment;—Same as for the shaft of the radius. FRACTURES OF THE RADIUS. The Neck.— Displacement:—The head is drawn toward the ulna, and the lower fragment upward. Treatment: —Produce traction and apply a posterior, right-angled FRACTURES-RADIUS-CARPALS-PHALANGES 307 _______________POCKET-BOOK OF MEDICAL PRACTICE____________ splint, a small anterior, angular, coaptation splint, and pad the forearm in moderate supination. Plaster-of- Paris bandage may be used later. Remove the dressing in 4 weeks. The Shaft.—Displacement:—The ends of both fragments are drawn toward the ulna. Treatment.—Reduce by traction and manipulation; dress with the thumb upwards. Apply anterior and pos- terior, flat, board splints, extending from the elbow to the palm, just wide enough to prevent lateral pressure of the bandage. Hold the splints in place by strips of ad- hesive plaster passed around them near each end. Band- age outside, and put the forearm in a sling. Do not let the fingers get stiff; keep movingthem. Remove the dressing in 4 weeks. Lower End of the Radius.—(Barton's and Colles' Frac- tures):— Treatment:—Apply splints as just described, together with the following pads: (a) A thick palmar pad against the lower end of the upper fragment; this should be thickest on the radial side and tapering toward the ulna and toward the ends, (b) A small, dorsal ring- pad over the prominence on the back of the lower frag- ment. Remove the dorsal splint in 3 weeks, and the palmar a week later. Keep the fingers limber. Begin passive motion in the wrist in 3 weeks. FRACTURE OF BOTH RADIUS AND ULNA. Treatment.—Such combinations of the dressings de- scribed for either bone, as the location of the fracture in- dicates. THE WRIST. FRACTURE OF THE CARPALS. Treatment.—Push the fragments into place and immo- bilize by a plaster cast. Time of Repair:—About four weeks. Begin passive motion in three weeks. THE HAND. FRACTURE OF THE METACARPALS. Treatment.—Apply a long, straight, anterior splint, with a large pad or ball in the palm, and a straight posterior splint. Apply extension by an elastic, fastened to the finger by adhesive plaster, and stretched to the projecting end of the anterior splint. With the 1st or 5th metacarpals a tight, trough-shaped splint may be slipped on from the side. Remove the Dressings in 3 weeks. FRACTURE OF THE PHALANGES. Treatment.—Apply a trough- shaped sheet-metal splint, for the finger, and spread it out flat in the palm. Bend it so as to dress the finger in slight flexion. If extension is needed, apply it as described for metacarpal Fig. q.-Finger-Splint. fracture. The splint is made of sheet copper. Remove the dressings in 3 weeks; passive motion in 2 weeks. (See Lacerated and Contused Wounds.) 308 FRACTURES-PELVIC BONES-THIGH-FEMUR POCKET-BOOK OF MEDICAL PRACTICE __ THE PELVIS. FRACTURE OF THE COCCYX. Treatment.—Replace the fragments by external and rectal manipulation. Place the patient on a flat bed and introduce a tube, wrapped with gauze, into the rectum Time of repair, 4 weeks. FRACTURES OF THE PELVIC BONES. Complications.—Lacerations of the bladder, urethra, rectum, blood-vessels or nerves, often occur. Treatment.—Place the patient on a smooth mattress, replace the fragments> and apply strong adhesive straps encircling the pelvis, with pads where needed. If an acetabulum is broken or separated, treat like an inter- capsular fracture of the femur. Treat the complications as the nature of each demands. Remove the dressings in 6 weeks; let the patient be about in 12 weeks. THE THIGH. FRACTURE OF THE FEMUR. The Neck (Intra-capsular).—Time of Life:—Generally occurs in the aged, who do not bear confinement in bed well. Prognosis :—Bony union unusual. Treatment. —If the patient is very feeble, put him to bed for only 2 weeks, steadying the limb with sand-bags, and applying a few pounds of extension by weight and pulley. In other cases, at least undertake treatment by Buck's extension with a long, side, T" splint, or by a double-inclined plane, or by a Hodgen's suspension splint, or by a plaster-of-Paris dressing, with some ar- rangement to produce lateral pressure against the great trochanter through a fenestrum. The Neck (Extra-capsular). — Treatment:—By Buck's extension, with a long, side "T" splint, or by a double- inclined plane; or, by a plaster-of-Paris dressing. The Shaft (Upper Quarter).—Displacement:—The up- per fragment is drawn upward and forward. Treat- ment:—Flex the limb into line with the upper fragment and apply the double-inclined plane, or Hodgen's sus- pension-splint. The Shaft (Middle).— Treatment:—-By any of the dressings described below, together with molded board, trough-shaped; coaptation splints, extending from the knee to the groin. The Shaft (Lower Quarter). — Displacement: —The lower fragment is flexed on the leg. Treatment:—-By the double-inclined plane, Hodgen's suspension-splint, or the plaster-of-Paris dressing. (See below.) The Condyles.—Treatment:—Lateral, molded, angular, reinforced splints as in fractures of the humeral con- dyles. Remove the Dressings in 6 weeks; passive motion in 4 weeks. FRACTURE-BED. Bed.—Use a cheap, single bed; for an adult, have the side-pieces lengthened (to 7 or ll/2 feet) by a carpenter. Use any ordinary length, flat, even mattress, preferably SPLINTS-BUOK'S-LISTON'S-HODGENS 309 ,_____________ POCKET-BOOK OF MEDICAL PRACTICE of hair. Have a frame 7x3j£ ft. made of hardwood boards, 3 or 3^x1 inch, laid flat Over this frame, stretch heavy canvas (the length of the canvas cross- wise), tacking it on the under side of the frame. Have two thicknesses across the middle and a 7-inch hole where the perineum will lie; the hole is bound firmly about its edge. Lay draw-sheets from top to bottom, meeting at this hole. The stretcher lies flat on the mat- tress and is lifted and blocked up, when necessary, to place a vessel beneath for evacuation of the bowels. BUCK'S EXTENSION. Method.—Shave the limb below the point of fracture. Apply the ends of a broad strap of "moleskin" adhesive plaster (3 inches wide, for an adult) to each side of the limb below the point of fracture, thus making a stirrup 2 inches below the bottom of the foot. Have the ends of the plaster split from the knee up. Place, in the loop below the foot, a rectangular piece of board, to spread the adhesive away from the malleoli. Apply a bandage from the lower part of the leg to the fracture. Draw a strong cord, with a knot at its end, through a hole in the block, or fasten it to a screw-eye in the block, and run this cord over a pulley fastened to the foot of the bed, high enough just to raise the heel off of the bed. Fasten weights to the rope. Now, if coaptation-splints are in- dicated, fit and bandage them on while the fragments are coapted, an assistant making strong traction mean- while. LISTON'S LONG SIDE-SPLINT. Method.—It prevents rotation, and consists of a one- inch board, 4 inches wide, extending from the axilla to 3 or 4 inches below the foot, with a cross-piece at the bottom, which rests on the bed. This splint is fastened to the trunk and limb by adhesive-straps, or a starched bandage. The rope runs through a hole in the cross- piece, or over it. For children, have two side-pieces, to hold the legs apart. Weights:—For an adult male, 15 to 16 pounds; after a few days, 10 pounds. Raise the foot of the bed 3 to 5 inches for counter-extension. Re- move the side splint in 3-4 weeks; then gradually remove the extension. Keep the patient in bed for 6 weeks, then crutches for 2 weeks. DOUBLE-INCLINED PLANE. Method.—The leg is fastened to the lower incline, the foot strapped to the foot-board, and the patient is thus hung from the knee, the weight of the body producing the extension. The buttock should not rest on the bed. Remove it in 6 weeks. HODGEN'S SUSPENSION-SPLINT. Method.—It consists of a heavy frame of wire, or rod, with strips of muslin fastened across it to make a cradle. An adhesive-plaster stirrup, ap- Fig- /o-Hodgen's plied to the leg* is attached to Suspension- ,*: ,°' , ., « ,. Splint. the cross rod at the bottom. 310 FRACTURES-PATELLA-TIBIA POCKET-BOOK OF MEDICAL PRACTICE The cradle is slightly angled at the knee. The traction is obliquely upward, and the distance along the rope, from the splint to a pulley in the ceiling, is at least 10 feet. A weight of from 3 to 10 pounds is used. This apparatus allows the patient to be moved freely about the bed and allows easy access to any wound. PLASTER-OF-PARIS SPLINT. Method.—The patient stands, with the sound leg on a box, and is supported by two persons. Strong, snug casts are then applied, one from the axilla down to the knee, on the well side, and an inch or two down the broken thigh (if the fracture is of the shaft); another from the toes to just above the knee of the broken limb. When these are set, the patient is laid across 2 tables, anes- thetized if necessary, and while extension is applied and the fragments perfectly coapted, the cast is completed and allowed to set. The tables are drawn apart, thus allowing the plaster bandage to be easily applied'about the thigh and lapped over upon the parts already com- pleted. Remove the cast in 6 weeks. FRACTURES OF THE PATELLA. Prognosis.—Union is apt to be ligamentous, but may be bony. Treatment.—Apply a posterior splint and elevate the limb slightly. Reduce the swelling of the joint, aspirat- ing if necessary. In addition, use one of the following means for treatment: A. G. JBeebe's Leather Collars.—These are made of rather thin sole-leather, shap- ed, and beveled on the under side, about the patella, and having small hooks, for lashes, on three sides, except just _ where the patella comes. Fig. //.-Patella Collar. T£es? 2 collars are first laced . about the limb, above and below the bone, and are then drawn together by the wu*? OI? thei.r third sides' thus coapting the fragments. While drawing up the laces between the collars, apply a strip of thick paper or card to prevent pinching. The collars are applied outside the posterior splint. Hiring.—Under anesthesia and the strictest asepsis, wire the fragments together subcutaneously, drawing one end of a wire under, and one over the patella, by a curved needle with the eye in its point. Malgaigne's Hooks.—Introduce them under strict asep- «lLt« nP -em covered by an antiseptic dressing. Re- move the Dressings in 4 to 6 weeks. Begin passive motion, been w^dn° great strain for 4 to 6 months, unless it has THE LEG. FRACTURES OF THE TIBIA. rJ!Je ^ft'—Prognosis:—Delayed or non-union is not thZa^T? C?i*ons:-The skin is often punctured or the deep veins lacerated or ruptured FRACTURES-FIBULA-ASTRAGALUS-OS CALCIS 311 _______________POCKET-BOOK OF MEDICAL PRACTICE_____________ Treatment.—Coapt the fragments and apply a plaster cast from the knee to the toes. If there is much swelling, use a fracture-box or board-and-blanket splint until the swelling subsides. Remove the Dressings in 4 weeks; crutches for 2 weeks more. The Inner Malleolus.—Prognosis—.-The same as for Pott's fracture. Treatment.—Press the fragment into place and im- mobilize by a molded splint. FRACTURES OF THE FIBULA. Above the Lower Quarter.—Treatment:—Force the ends of the fragments away from the tibia by crowding the muscles between the bones, and treat as in fracture of the tibia. Remove the dressings in 4 weeks; crutches or a cane for 2 weeks more. In the Lower Quarter.—(Pott's Fracture.)—Prognosis:— Stiffness and lameness of the ankle is apt to remain for some time. Treatment:—Apply either of the following: Dupuytren's Splint;—A flat board, 4 inches wide, from the knee to 2 inches below the heel. Pad it heavily above the internal malleolus, to fill up the concavity of the leg. Ap- ply it to the inner side of the knee, leg and foot, with a strap of adhesive plaster passing around it and over the tip of the outer malleolus, and one or two just below the knee. Do not bandage over the fracture, and do not allow the leg to lie on the outside. A cross-piece will prevent this. A Plaster-Cast;—Straighten the foot into position, crowd the ends of the bone outward into place, lay a trough of ; some stiff material over the outer malleolus and fracture, to prevent pressure, and apply a plaster-of-Paris band- age from the toes to the knee. Remove the dressings in 3 weeks; crutches or cane for 2 weeks more. FRACTURE OF BOTH BONES OF THE LEG. Treatment.—Place in a temporary splint and reduce swelling. Then with plaster-of-Paris bandage apply a boot, and a collar grasping the tuberosities at the knee snugly, having the collar extend down to near the frac- . ture. When these are set, produce extension and coun- ter-extension on them, coapt the bones and complete the plaster " stocking " or cast. Remove the dressings in 4 weeks; crutches or a cane for 2 weeks more. Note.—When the ankle is immobilized, always have it at a right-angle. THE ANKLE. FRACTURE OF THE ASTRAGALUS. Treatment.—Push the fragments into place and immo- bilize by a plaster-of-Paris dressing, anesthetizing if nec- essary. Remove the dressing and begin passive motion in 3-4 weeks. FRACTURE OF THE OS CALCIS. Treatment.—Flex the leg on the thigh and extend the foot; push the loose fragment down into place and hold it there by adhesive straps, or by aseptic nailing or wir- ing. Time of union, 4 to 5 weeks. ^d 312 DISLOCATIONS-GENERAL CONSIDERATIONS " POCKET-BOOK OF MEDICAL PRACTICE_________ THE FOOT. FRACTURE OF THE METATARSALS AND PHALANGES. Treatment.—Coapt the fragments and immobilize by a plaster-of-Paris dressing. Remove the dressings in 3or 4 weeks. ________ DISLOCATIONS. GENERAL CONSIDERATIONS. Diagnosis.—It is made (anesthesia if necessary) by- 1. Restriction of motion in certain directions. 2. Change in the normal relations of the bones, as shown by (a) Deformity; (b) Measurement of the limb; (c) Attitude of the limb. 3. Absence of bone crepitus. 4. Bones generally remain in place after reduction. 5. The X-ray. _____ SIMPLE RECENT DISLOCATIONS. Prognosis. — Good, if properly treated. If the joint is used too soon after reduction, the dislocation may recur; this repeated, may lead to habitual dislocation. If not reduced shortly after the accident, an irreducible dislo- cation results. TREATMENT. Reduction.—Is indicated as soon as possible after the accident. Anesthesia is often required to relax the mus- cles and deaden pain. Reduction is best accomplished by- Manipulation.—See the special dislocations. Every- thing depends upon a correct anatomical knowledge. Extension and Counter-Extension.—By powerful mechan- ical contrivances. This may succeed where manipulation fails. Incision.—Down "to the bone. This is indicated (where the above measures fail) to relieve any obstacle to reduc- tion, such as constriction of the head of the bone by a small rent in the capsule. After-Treatment.—Immobilize the jofht and keep it at rest for about two weeks, applying moderate compres- sion. If there is severe synovitis apply heat or cold. OLD DISLOCATIONS. Prognosis.—Ball-and-socket joints are reducible after a longer period than other joints, and if left alone often result in useful artificial joints. Dislocated shoulders have been reduced after 4 months; .hips, after 2 months. Old dislocations of hinge joints never develop into useful new joints. TREATMENT. Method.—If motion causes no pain in a ball-and-socket joint, produce a new joint by persistent active and pai- sive motions. If it does, try— Reduction.—Anesthetize if necessary, break up ad- hesions by careful manipulation, or if \his fails to allow reduction, cut down and sever the restraining bands. DISLOCATIONS- COMPOUND-COMPLICATED-SPECIAL 313 _______________POCKET-BOOK OF MEDICAL PRACTICE Begin passive motion as soon as the acute inflammatory symptoms subside. If reduction is impossible or unsuc- cessful, make a false joint by resecting the head of the bone. ------- COMPOUND DISLOCATIONS. Prognosis.—Guarded. Much more serious than com- pound fracture. Depends upon the injuries to the sur- rounding structures and upon the chances of infection of the joint. TREATMENT. Amputation.—If amputation is not indicated, then pro- ceed as follows:— 1. Cleanse and disinfect the wound and the head of the bone, thoroughly, with a warm, antiseptic solution, first cleansing the surrounding skin; avoid washing in- fective material into the wound. 2. Reduce the dislocation. 3. Provide for free drainage; apply an antiseptic dressing, generally a moist one. 4. Immobilize the joint. Begin passive motion as soon as the condition of the wound and joint will permit. DISLOCATION COMPLICATED WITH FRACTURE. Prognosis.—Danger of ankylosis if the fracture is very near the joint. TREATMENT. Method.—Anesthetize; -reduce the dislocation by manip- ulation with careful traction while attempting to push the head of the bone into place. If the shaft of the bone is fractured, apply splints first. If these measures fail, incise down and drill into the bone, insert a gimlet or hook and drag the head of the bone into place, observing strict asepsis. Begin passive motion as soon as the frac- ture will permit. SPECIAL DISLOCATIONS. DISLOCATION OF THE LOWER JAW. Prognosis.—Good. It may be reduced after 4 months' standing. If not reduced, the jaw accommodates itsefrfto the new position, and, in time, a certain amount of mo- tion is acquired. Treatment.—Reduction:—Depress the lower jaw enough to free the condyle from the eminentia articularis of the temporal bone, and then push it back into its place. This is accomplished by inserting the thumbs (protected by cloth) behind the back teeth and making downward traction. A piece of wood may be used, as a fulcrum, between the molars; pry upward upon the chin and, when the con- dyle is free, push the jaw into position. After-treatment: __Apply a Barton's bandage; begin passive motion in 2 weeks. DISLOCATION OF THE VERTEBRA. Diagnosis.—Difficult to differentiate from fracture. Is made upon deformity; symptoms of cord injury; the X-ray. Prognosis.—Very grave; if the patient lives, he is apt to be paralyzed. Treatment.—The indications are to extend the spine 114 DISLOCATIONS-CLAVICLE-SHOULDER ■"^ POCKET-BOOK OF MEDICAL PRACTICE enough to disengage the locked parts and by gentle press- ure to replace the displaced bones. This is, however, extremely dangerous to do, though it has been success- fully accomplished in some cases. (See Fracture of the Spine.) DISLOCATION OF THE CLAVICLE. The Sternal End. — Prognosis:— Deformity is apt to result because of the great difficulty in maintaining re- duction, but no permanent disability of the arm results. Treatment.—Reduce by throwing the shoulder upward, outward and backward, and pressing the bone into place. Hold in Place:—Apply a small ring-pad upon the end of the bone and keep it pressed into place by a flat, steel spring passed over the shoulder with its ends strapped to the front and back of the chest. Over this apply the dressing described for fractured clavicle. Keep these dressings on for 6 weeks. The Acromial End.—Diagnosis.—Upward Dislocation: ■—(a) The shoulder falls down and in; (b) the arm cannot be raised over the head; (c) spontaneous displacement after reduction; (d) the outer end of the clavicle is prominent, overriding the acromion process. Downward Dislocation.—(a), (b) and (c) the same; (d) the acromion and coracoid processes are prominent; (e) the clavicle leads down toward the axilla, beneath the acromion and coracoid process. Treatment.—Reduce by pulling the shoulder outward and backward and pushing the bone into place. Hold in place by applying a pad over the end of the bone and a Desault or Velpeau bandage for 6 weeks. DISLOCATIONS OF THE SHOULDER. SUB-CORACOID. Diagnosis.—(a) Apparent projection of the acromion process and flattening over the deltoid muscle; (b) Du- gas' Sign.—The hand cannot be placed on the sound shoulder and the elbow touch the chest-wall at the same time; (c) the elbow is carried slightly outward and backward with the axis of the humerous pointing too much toward the chest-wall; (d) the head of the bone is not easily felt. Prognosis.—Usually good. Reduction is sometimes difficult. There is always danger of injury to the large nerves or vessels. Treatment.— Reduction—By manipulation (Kocher's Method):—Have an assistant hold the scapula. Flex the elbow to a right-angle, rotate the arm outward, raise the elbow upward and forward, rotate the arm inward, depress the elbow. Take care not to fracture the humerus. Fulcrum in the Axilla.—It the method de- scribed fails, place the knee or unbooted heel in the axilla, raise the arm sidewise and then lower it to the side while producing strong traction. When the knee is used, the patient is sitting; when the heel, reclining. AJter-care:— Apply a Desault bandage or place the fore- DISLOCATIONS-CLAVICLE-ELBOW-VARIETIES 315 POCKET-BOOK OF MEDICAL PRACTICE_______________ arm and elbow in a well-fitting sling for 3 weeks, be- ginning passive motion after 10 days. SUB-CLAVICULAR. Diagnosis.—(a), (b) and (c), as in the subcoracoid form; (a) the head of the bone is readily seen and felt beneath the clavicle; (e) shortening of the limb. Treatment.—Same as for Subcoracoid. SUB-GLENOID. Diagnosis.—(a), (b) and (c), as in the Subcoracoid form; (d) the head of the bone can be felt in the axilla; (e) considerable lengthening. Dislocatio Erecta.—When the arm is vertically up- ward, in which position it is held. Treatment.—Reduction.—By the knee or heel in the axilla with strong traction, especially outward. In dis- locatio erecta produce traction upward and outward. After-care, as for subcoracoid. SUB-SPINOUS. Diagnosis.—(a) and (b), as in Subcoracoid; (c) the elbow is carried outward and forward with the axis of the humerus pointing too much toward the chest wall; (d) the head of the bone is felt below the spine of the scapula; (e) some lengthening. Treatment. — Reduction. — Manipulation. — Raise the arm sidewise to a right-angle; rotate inward; sweep the elbow backward and inward while producing traction and pressing the head of the bone into place. Extension and Leverage:—Or, reduce by the knee or heel in the axilla. After-care:—As for Subcoracoid. DISLOCATIONS OF THE ELBOW. Varieties.—1. Both bones backward; often with frac- ture of the coronoid. 2. Both bones forward; with fracture of the olecranon. 3. Both bones outward or inward. 4. Ulna backward; often with fracture of the coronoid. 5. Radius forward—common. 6. Radius backward. 7. Radius outward — very rare. 8. Ulna backward and radius forward. Diagnosis.—Keep in mind the four cardinal points of the elbow—(1. Internal Condyle; 2. External Condyle; 3. Olecranon; 4. Head of the radius—and remember their relations. Prognosis.—Usually good; forward dislocations of the radius are liable to recur. Reduction.—Place a hand or knee in the bend of the elbow and while producing traction away from the elbow in both directions, pushing the bones into place; and in dislocations of the head of the radius, pronating, if for- ward; supinating, if backward. Subluxation of the Radial Head occurs in children under 5 years of age, and is reduced by forcible supination and traction with the elbow at a right-angle. After-care:— Immobilize with angular splints for 2 weeks, beginning passive motion after the first week. Complicating Fractures of the cor- onoid and olecranon are to be treated as described under fractures. 316 DISLOCATIONS-WRIST-HAND-RIBS-HIP POCKET-BOOK OF MEDICAL PRACTICE__________ DISLOCATIONS OF THE WRIST. Treatment.—Reduction.—Bend the hand in the direction toward which the carpals are dislocated and push the bones into place. After-care:— Immobilize the wrist for 2 or 3 weeks with a splint of plaster cast, allowing for free movement of the fingers. The prognosis is good. The Os Magnum.—Treatment.—Reduce by traction and manipulation. Immobilize for 3 weeks. DISLOCATIONS OF THE HAND. The Metacarpals.—Treatment.—Reduce bj traction and manipulation. Apply the splint used in fractures of these bones for 1 to 2 weeks. The Metacarpophalangeal Joints (of the Fingers.)- Treatment.—Reduction.—Bend the finger backward (un- der anesthesia) and slide the overriding bone into place along the dorsum of the other, using, if necessary, Levis' splint to grasp the finger. After-care:—Apply the splint used in fractures of these bones for 2 to 3 weeks. The Thumb.—Prognosis.—Reduction is often difficult because the head of the metacarpal button-holes the short flexors. Treatment.—Reduction.—Anesthetize. Adduct the thumb; produce extreme tension and suddenly flex, at the same time pushing the bone into place. After-care: —Same as for the fingers. The Phalanges. — Treatment.—Reduction.—Anesthetize. Bend the phalanx backward and slide the overriding bone into place along the dorsum of the other. After- care:—Immobilize for one week. DISLOCATIONS OF THE RIBS. Treatment.—Same as for fractures. For the costal car- tilages, also the same. DISLOCATIONS OF THE HIP JOINT. Prognosis.—Usually good. Reduction is sometimes difficult. The sciatic nerve is sometimes caught over the head of the bone. Reduction is safely attempted as long as 4 weeks after the injury. ON THE DORSUM ILII. Diagnosis.—The head of the bone lies upon the dorsum ilii. The thigh is flexed, adducted, and the foot inverted. The limb is shortened 2-3 inches. Reduction:—While producing traction away from the joint, strongly flex, adduct and invert the limb, then abduct, evert and ex- tend it. INTQ TH_ SACR0.SCIATIC NOTCH. Diagnosis.—The foot is inverted, the thigh is much flexed and adducted. The limb is shortened about one inch. Reduction.—Same as for dislocation upon the dorsum ilii. INTO THE OBTURATOR FORAMEN. Diagnosis.—The head of the bone is felt in its new lo- cation. The thigh is flexed and adbucted; the foot DISLOC ATIONS-HIP-KNEE-PATELLA-ANKLE 317 ____________POCKET-BOOK OF MEDICAL PRACTICE_______________ slightly everted. The limb is lengthened 1 to 2 inches. Reduction.—While producing traction, flex, abduct and evert the limb, then adduct, invert and extend it. UPON THE PUBES. Diagnosis.—The head of the bone is felt upon the public ramus. The foot is everted, the thigh abducted. The limb is shortened about an inch. Reduction.—Same as for the last form. TREATMENT. Method.—Anesthetize to reduce, in all hip dislocations, and reduce with the patient lying on his back. After-care.—Rest in bed with sand-bags to steady the limb for 3 to 4 weeks, beginning passive motion in the third week. If the acetabulum has been fractured, treat as de- scribed under fractures._______ DISLOCATIONS OF THE KNEE. Prognosis.—Favorable in simple dislocations ; it is usually incomplete. Varieties.—(a) Lateral; (b) anterior; (c) posterior; (d) rotary. Treatment.— Reduction:—Flex the joint over a fixed point, as the knee, and make traction in both directions away from it, pushing the bones into place. After-care: —Immobilize in a slightly flexed position, applying agents to correct the attending synovitis. Begin passive motion in the third week. An elastic knee support should be worn for several months. DISLOCATIONS OF THE PATELLA. Prognosis.—Usually favorable, except in case of com- plete rotation. Varieties.—(a) External; (b) internal; (c) rotary (on its own axis). .,.,_, Treatment.— Reduction:— Put the patient on his back; flex the thigh, fully extend the knee, and press the pa- tella into place, depressing the margin farthest away from the joint. If rotated, anesthetize and try manipu- lation. If this fails, make a cutting operation and re- duce by introducing a hook or screw into it. After-care; —As for dislocations of the knee. Ruptures of the liga- mentum patellae are to be treated as described under fractures. _______ DISLOCATIONS OF THE ANKLE. Prognosis.—Usually good. Often complicated with fracture of the fibula. TREATMENT. Anterior or Posterior.— Reduction:— Flex the joint over a fixed point, making traction in both directions away from it, and slide the bones into place. After-care: — Dress with a plaster "cast," or by adhesive strapping and molded splints for 3 weeks, beginning passive motion after 2 weeks. Lateral or Rotary.— Reduction:— Flex the knee and thigh, and with counter-extension at the knee, produce HI ft DISLOCATIONS-TARSALS-SYNOVITIS-ARTHRITIS at° */"""'V FOCKET.BOOK OF MEDICAL PRACTICE traction on the foot and push the bones into place. After- care:—As for anterior and posterior. If complicated by fracture of the fibula, treat as directed under fractures. Upward Between the Tibia and Fibula.—Reduction: - Anesthetize and reduce by powerful traction. After- care:—As just described. DISLOCATIONS OF THE TARSALS. Prognosis. — Good if reduced, but difficult to reduce. Treatment. — Reduction:—Produce traction, and mold the bones into place. After-care:—As for ankle dis- locations. DISLOCATIONS OF METATARSALS AND PHALANGES. Prognosis, and treatment, as in analagous conditions of the hand. JOINT DISEASES. SYNOVITIS AND ARTHRITIS. Differentiation from Sprain.—Pi essing the joint surfaces together increases the pain; drawing them apart eases it. In sprain, traction increases the pain. Treatment.—Rest and immobilization \>y splints is in- dicated whenever symptoms of inflammation are present. As soon as they subside, begin passive motion. Stages.—1st, Congestion; 2nd, Exudation; 3rd, Sup- puration; 4th, Ulceration, Caries, Necrosis. First Stage.—Rest; immobilization; pressure by a snug bandage (elastic or flannel). Extension sometimes re- lieves the pain. If acute, apply intense heat; if chronic, intense cold. Daily use of the hot air apparatus, at about 300° F., often benefits chronic cases. Remedies.— Arnica3x; Belladonna^; Calcarea phos.3*-; Iodine.2* Second Stage.—Rest, immobilization, pressure, some- times extension. If effusion is very great, aspirate it. If it remains after 1-2 weeks, aspirate and inject car- bolic acid (1-2 drs. of 5%, or 10-30 m. of 95% for the knee), diffuse it throughout the joint by manipulation, and again immobilize. External applications of Iodine or Ichthyol are often of value. Remedies.—Apis3x; Bryonia**; Calcarea^x; Helleborus2x; Iodine**; Phos- phorusSx; Pulsatilla.lx Third Stage.—Introduce a good sized aspirator needle into the joint, observing asepsis. (Puncture the skin with a bistoury.) Draw off the pus, wash out the joint with sterile water or salt solution and inject carbolic acid. If the inflammation is tubercular, inject iodoform emulsion (10% in glycerine) once a week. Immobilize, after injecting, until reaction subsides. If this fails, in- cise and drain. Remedies.—Merc, sol.3*; Hepar sulphur3x; Silicea6x; Iodine**; Calcarea phos.3* Treat any existing diathesis. Give good food with tonics and stimulants, as indicated. Fourth Stage.—If there is an open sinus, wash out the ANKYLOSIS-ARTHROTOMY-ERASION-RESECTION 319 _______________POCKET-BOOK OF MEDICAL PRACTICE joint every 1 to 3 days, and inject antiseptics—carbolic, iodoform, etc. If much diseased bone is present, per- form Erosion or Resection. ANKYLOSIS. Fibrous.—Try passive motion, massage, inunctions of Ichthyol, hot air or hot and cold douches, to obtain a movable joint. When these fail or improvement is too slow, anesthetize and forcibly break up the adhesions; then immobilize for a few days, and begin passive mo- tion, etc., as soon as is safe. Repeat this if necessary. Cut any shortened tendons that may interfere with mo- tion. Bony.—If the joint is in a useful position, leave it alone. If not, put it in a useful position by forcible rupture, ex- cision, or osteotomy. In the elbow, excision is indicated to get a movable joint. ARTHROTOMY. Indications.—To remove pus, foreign or adventitious bodies, for exploration, erasion, etc. Operation.—Under the strictest asepsis, incise into the joint. For the location of large incisions see under "Ex- cision. '' If the operation is clean, suture without drain- age and dress with a dry antiseptic dressing. If in- fected, introduce a drainage tube for 36 to 48 hours and dress with a moist antiseptic dressing. Instruments.—Scalpel, straight bistoury, scissors, dis- secting forceps, grooved director, artery forceps, dressing forceps, aspirating needles and syringe, probes, needles, catgut, kangaroo tendon, silk-worm gut. After-care.—Immobilize until the wound heals and any inflammatory reaction subsides and then institute mo- tions, massage, etc. ________ ERASION. Indications.—For the removal of diseased tissue, as in tubercular arthritis. It is oftener indicated, less severe, and generally more satisfactory than Resection. Operation.—Incise into the joint in the locations indi- cated under Resection, if an opening does not already exist. Curette, gouge, chisel, or cut away with forceps all diseased tissue. Washout with Carbolic acid (95%), followed immediately by alcohol, or if tubercular, irri- gate with a weak, mahogany-colored solution of Iodine. Provide for free drainage. Dress with a moist, antisep- tic dressing. Instruments.—As in arthrotomy; also bone curettes, gouge, chisel, rongeur, and Liston's bone forceps. After-care.—Immobilize the joint until ankylosis occurs or the wounds heal. _______ RESECTION, EXCISION OR EXSECTION. Nature.—Consists in cutting off the ends of the bones evenly (removing some healthy with the diseased bone) so as to produce better approximation. Indications.—Some cases of (a) injury, as compound dislocation, gunshot wounds, etc.; (b) disease, as tuber- 320 RESECTION-SHOULfcER - ELBOW-WRIST-HIP POCKET-BOOK OF MEDICAL PRACTICE_______ culosis of a joint; (c) deformity, as ankylosis in bad position. Instruments.—Same as for Arthrotomy, together with bone-saws, bone-cutting forceps, drills, silver wire, periosteal elevator. THE SHOULDER. Anterior Incision.—Incise 3 to 4 inches downward from the joint just external to the coracoid process. Separate the fibres of the deltoid, retract the long head of the bi- ceps to one side, elevate the muscular attachments with the periosteum. Saw the humerus, saving the tuberosi- ties if possible, and curette away any diseased bone from the glenoid fossa. Disinfect. Drain through a posterior opening for 24-48 hours. Dress with a small pad in the axilla, the arm by the side, forearm across the chest. After-care:—Allow the patient to get up and begin pass- ive motion after a week. Deltoid Flap.—This operation is also made, turning up a flap composed of the deltoid or by a transverse skin inci- sion over the muscle, sawing through the acromion pro- cess and turning the deltoid flap down. THE ELBOW. Incision.—Make a longitudinal incision to the bones, 4 to 5 inches long, with its middle over the olecranon a little to the inner side. Elevate the soft tissues and periosteum, guarding the ulnar nerve, and saw off the olecranon. Forcibly flex the joint. Saw the humerus through the base of the condyles and the radius and ulna at the level of the base of the coracoid after elevating the periosteum on all the bones. Disinfect, introduce drainage and dress with the forearm slightly flexed and midway between pronation and supination. Begin passive motion in a week, when the patient gets up. THE WRIST. Excision is seldom indicated; erasion is better. The joint is opened by incisions on the dorsum between the tendons. THE _ip< Anterior Incision.—Make an incision 3 inches long, downward and inward from a point y2 inch below and external to the anterior superior spine. Go at once to the bone, open the capsule, saw or cut the neck from above downward with the head " in situ," and then remove the head. Leave the great trochanter if possible, though it may be removed, if badly diseased, by prolonging the incision. Curette away all diseased tissue from the acetabulum. Posterior Incision.—Make a curved incision, 3-5 inches long, around the great trochanter, from a point midway between the anterior superior spine and the top of the trochanter, keeping well behind it. Expose the neck of the bone and perform the other steps as above. Disinfect the joint, introduce drainage, dress antiseptically, and apply a plaster splint with a fenestrum, as described un- der Hip-joint Disease. RESECTION-KNEE-HIP-JOINT DISEASE 321 POCKKT-BOOK OF MKDICAL PRACTICE THE ENEE. Method.—Make a U-shaped incision, cutting the patel- lar ligament and lifting up the patella in the flap. Flex the knee, cut the lateral and crucial ligaments, avoiding injury to the popliteal vessels. Circumcise and dissect back the periosteum, saw off the ends of the bones far enough back to get healthy surfaces and in such a direc- tion that when opposed they will make the limb very slightly flexed and with the natural lateral angle. Dis- sect away all infected membrane, etc. Disinfect, intro- duce drainage, and immobilize on a slightly angular, posterior splint with plaster bandage above and below. THE ANKLE. Excision is seldom performed; erasion is [much the better operation. The joint is best entered by incision behind and below the external malleolus, retracting away or dividing the peroneii tendons. HIP-JOINT DISEASE. Synonyms.—Coxitis; coxalgia; morbus coxarius. It is considered to be always tubercular. Diagnosis. — Examination: — Place the patient, un- dressed, upon a table or hard mattress. Note the posi- tion of the limbs and ant. sup. iliac, spines in relation to the axis of the spinal column. The length of the limb is measured from the ant. sup. spine to the external mal- leolus of the ankle. First Stage (Inflammation).—There is present: (a) Lameness, which often wears off during the day. (b) Limitation of Motion, due to reflex muscular spasm. (c) Flexion, slight, with slight adduction and inver- sion, but oftener with slight abduction and eversion. (d) Pain, in the front of the thigh or inside of the knee, worse at night, or from a blow upon the bottom of the foot, when the limb is extended. Second Stage (Effusion into the Capsule).— (a) Lameness pronounced, affected limb pushed ahead. \b) Limitation of motion, from muscular spasm and effusion. (c) Flexion with marked abduction and eversion, shown by . , . , (d) Apparent lengthening of the limb, from tilting of the pelvis when the abducted limb is drawn inward, a%) Arching of the back, away from the table, when the popliteal space of the affected limb is made to touch the table. (f) Pain, as in the first stage, but more severe; worse at nio-ht; patient starts and cries out in the sleep. (g) Atrophy about the joint, and of the thigh. Third Stage (Begins with Rupture of the Capsule). (a) Muscular spasm, preventing almost all motion. (b) Flexion, adduction and inversion of the thigh marked, causing , (c) Arching of the back, as in the second stage, but more marked, and ^ ,„ HIP-JOINT DISEASE-TREATMENT 322 ^orJET-BOOK OF MEDICAL PRACTICE (d) Apparent shortening of the limb, from tilting of the pelvis when the adducted limb is drawn outward. te) Actual shortening of the limb, from erosion of cartilages and bones, with displacement of the head of the femur. (f) Great pain, upon the least motion. (_■) Abscess about the joint, or a Discharging Sinus. PROGNOSIS. First Stage.—Under prompt treatment, perfect recov- ery may occur in a few weeks. In most cases a freely movable joint results. Second Stage.—Recovery, in from 6 to 24 months. Com- plete or partial ankylosis generally results. Third Stage.—Recovery always leaves ankylosis, gen- erally bony. Death often occurs from septicemia, tub- erculosis elsewhere, exhaustion, or amyloid degeneration, LOCAL TREATMENT. Rest.__Keep the patient in bed until every symptom of inflammation has subsided. Immobilization.—By a suitable splint. Thomas' Posterior Splint i s the cheapest and most practical. It consists of a long, heavy, iron strap, extending from about the spine of the scapula nearly to the ankle. To this are riveted lighter, cross straps, one to pass about the thorax just under the axillae, one about the thigh a little below the perineum, and one about the leg just above the ankle. These cross straps are bent about the parts and the ends may be locked together, in ,front, by wire loops. Suspenders, from the upper cross band, pass over the shoul- ders. The iron straps are covered with leather, bandage or adhesive plaster. To apply it, anesthetize, if necessary, straight- en the limb, and bandage the knee back to the splint. After-care.—When inflammation fully subsides, the patient is allowed to get about on crutches with a patte- under the well foot, to hold the diseased limb off of the ground. The splint may be shortened so that the lower band is just above the knee. If this excites no relapse, the use of the limb may gradually be resumed and effort made to produce a movable joint. A Plaster-Paris " Cast" may be used, but is not as cleanly as the Thomas' splint. It should extend from the toes to the axillae and down to the knee of the sound side. Extension.—Is seldom called for, if the immobilization is thorough, but it may be applied by Buck's apparatus with a side or with the Thomas' splint, or by the splints especially designed for this purpose. Injections.— Injections of Iodoform (Intra-articular and Parenchymatous) are of great value, and should be tried before resorting to more radical operations. (See Arthritis.) Operative Treatment.—May be indicated and is con- SPRAINS AND STRAINS-BURSITIS 323 POCKET-BOOK OF MEDICAL PRACTICE servative in some special cases. See Arthrotomy, Erasion, Resection and Chronic Abscess. General Treatment.—Fresh air, sunlight and nourish- ing food, even to forced feeding. Medicinal.—Arsenicum iod.2x; Calcarea carb.3x; Calca- rea iod.3x; Calcarea phos.3*; Ferrum**; Ferrum phos.3x; Iodinelx; Kali. iod.lx; Mercurius3*; Mercurius iod.2x; Phosphorus3x; Protonuclein (2 to 4 grs. four to six times a day), with tonics and stimulants as indicated. SPRAINS AND STRAINS. Definitions.—A sprain is a partial or complete rupture of ligaments; a strain of tendons or muscles. Diagnosis is made on: — (a) Absence of crepitus and rigidity, (b) Pain upon traction, (c) Tenderness over the ligament or tendon. Prognosis.—Recovery in 1 to 2 weeks with good treat- ment. TREATMENT. Rest*—The limb should not be used at all. Immobilization.—By adhesive-plaster strapping, plas- ter-of-Paris, or other hardened bandage. Compression.—By strapping or an elastic bandage. If seen very early, a "cast " may be applied before swelling occurs. Cold.—Early, to limit effusion or hemorrhage into the joint. Aspiration.—If the joint contains much blood. Heat.—If inflammation occurs. To Reduce Stiffness.—As soon as the acute tenderness subsides, apply massage, friction, passive motion, hot and cold douches, dry heat, local inunctions of Ichthyol ointment (50% in Lanolin). Adhesive Strapping.—(Of the Ankle.)—Shave about the joint. Have about 20 straps of rubber adhesive plaster, % to 1 inch wide, 8 or 15 in. long, torn lengthwise of the piece. Cover in every part of the skin, from the toes well up the ankle, applying the ends smoothly and tightly, letting the final ends fall where they will. Produce more pressure on the tender spots by small pads of cotton on them, under the straps. A ring pad may be neces- sary over the bony prominence on the arch of the foot. Apply a soft roller bandage over all. When the dressing gets loose take off some of the straps and re-apply them more tightly. When the soreness is about gone, allow the patient to use the joint a little and then gradually takeoff the plasters. Medicinal.—Aconitelx; Arnica3x; Belladoanalx; Hyperi- rum2x: Rhus.3x -------■ ' BURSITIS. Acute.—Rest and immobilization of the part, pressure, cold applications. If suppuration occurs, incise freely, evacuate, curette and pack with gauze for a few days. Chronic.—Rest and immobilization, pressure, counter- irritation. If these fai",' aspirate, wash out and inject a few drops of Carbolic acid (95%) and again employ rest 3?4 GANGLION-FLOATING CARTILAGES-POTTS DISEASE OC,T POCKET-BOOK OF MEDICAL PRACTICE_______^^ and pressure. If this fails, curette and pack, or dissect out the sac. ENLARGED BURSJ2. Example.—" Housemaid's knee. " Treatment.—Aspirate, inject Carbolic acid, and apply a splint and pressure by a bandage. Curette or dissect out, if necessary. GANGLI0N. Diagnosis.—A round, tense, fluctuating, freely movable swelling on the back of the wrist or front of the ankle. Treatment.—Rupture the sac by a blow from a book or sudden pressure, or by subcutaneous incision with the edge of a Hagedorn needle. Or inject 2 to 5 drops of Iodine tr. or 95% Carbolic acid into the sac with a hypo- dermic needle, after emptying the sac. Immobilize for a few days. FLOATING CARTIL4GES. Treatment.—To relieve locking of the joint, flex forc- ibly and suddenly extend. To Remove the Cartilage:- Bring it to a point where it can be felt, fix it with a needle or hold it with the fingers, administer a local or general anesthetic, incise into the joint and remove it Observe the strictest asepsis. POTT'S DISEASE. (spondylitis. ) Diagnosis.—It is based upon:— (a) Tenderness of the Spine.—The spine is sensitive to pressure at some point and to concussion, such as is caused by coming down upon the heels from tiptoes; the knees are bent in walking. The child screams when moved in its sleep. The patient tires easily, has a ten- dency to lean on things or brace the hands on the hips or knees for support. (b) Rigidity of the Spine.—The patient bends the knees and hips to pick up an object from the floor. Place him on the table and try to bend the spine backward by the legs. In cervical diseases, try movements of the head. (c) Deformity.—Abnormal prominence of the spines of one or more vertebrae causipg an angular deviation, sometimes slightly lateral. (d) Pressure Symptoms.—Chronic pain in the abdomen, often bilateral in the trunk or extremities, bladder irri- tation, grunting respiration, wry-neck, paresis or paral- ysis. (e) Spasm of the Psoas Muscle.—It is often present (j) Abscesses.—Pointing in the neck, or in the back ("lumbar"),- or in the groin ("psoas "), are common. TREATMENT. Local.—If the disease is in the lumbar or lower dorsal region* ,apply a plaster jacket, while suspending the pa- tient by head and arms. If, in tfie upper dorsal or cer- vical region, fasten a jury-mast to the jacket and sup- port the weight of the head and shoulders from this by a harness passing under the chin ^ud occiput. Or, better still, place the patient on a flat bed, with some ap- POTTS DISEASE-SPINAL CURVATURE 325 _______________POCKET-BOOK OF MEDICAL PRACTICE______________ paratus to prevent lateral motion, and produce extension by a weight and pulley at the head of the bed, which is slightly elevated for counter-extension. Keep on the im- mobilizing apparatus until all sensitiveness has disap- peared and bony ankylosis has taken place. Plaster-of-Paris Jacket.—Suspend the patient by a rope and pulley attached to a cross-bar from which hangs a harness which passes under the chin and occi- put. Have him reach up and grasp the cross-bar with the hands, in disease below the mid-dorsal region. The patient wears 2 tightly-fitting shirts, the outer one, sleeveless, to line the jacket. Apply the plaster bandage from the groin to the axilla?, just allowing for free motion of the arms and legs without cutting. Make the upper and lower edges thicker than the rest, and when nearly completed, turn the lining shirt back over the out- side of the jacket at the top and bottom and paste it down by a turn of bandage. Also take 2 or 3 turns across the front of, the abdomen. If Michigan plaster is used, the jacket should not be more than •& to 34 incn thick. To Straighten the Spine.—Some anesthetize the patient, produce traction above and below, and apply careful, but forcible, pressure over the prominence. Abscesses.—Cold abscesses generally disappear with proper treatment to the spine. See "Abscess." Hygienic Treatment.—Plenty of nourishing food, fresh air, sunshine, as for tuberculosis, elsewhere. Medicinal.—Calcarea phos.3x; Calcarea iod.3x;iodine2x; Mercurius iod.2x; Phosphorus3*; Silicea.6* SPINAL CURVATURE. ANTERO-POSTERIOR CURVATURES. Method.—These are treated by removing the cause, as rickets, congenital femoral dislocation, hip-joint disease, etc., by exercise, straightening out of the spine, and by jackets or braces to support the weight during develop- ment- LATERAL CURVATURE-SCOLIOSIS. Diagnosis.— Is often made at a glance. Deformity.—One shoulder is higher than the other, and on that side the scapula and ribs behind are more prom- inent, while the chest is flattened in front. The ribs of the opposite, lower or concave side are nearer to the brim of the pelvis. The line formed by the spines of the vertebras does not fully represent the curvature. Absence of pain in most cases until far advanced. TREATMENT. Remove the Cause.—If one leg is too short, apply a thick soled shoe. Insist that any habitual one-sided position be discontinued, even by a change of occupation, if necessary. Exercise.—In all cases, insist upon any and all exer- cises and positions which tend to lift up the low shoulder, to straighten out the spine, to press the ribs over to the concave side and to strengthen the muscles on the convex side. *?fi DEFORMITIES-HARE-LIP-CLEFT PALATE *6° POCKET-BOOK OF MEDICAL PRACTICE______ Jackets.—To support the spine while exercise is develop- ing the weak muscles, are indicated in only a very few cases where deformity is rapidly increasing. Patients are apt to rely upon the jacket and neglect the more im- portant exercise. They are made of plaster of Paris (split open and laced), woven wire (braced), loop leather, aluminum, etc., and are removed for exercise. Corrective Apparatus.—The patient may sleep over a sling of strong canvas, 8 to 10 inches wide, which passes under the convex side and is supported by uprights at the sides of the bed. Myotomy.—Division of the shortened muscles on the concave side of the spine, may aid greatly in straighten- ing up the patient. Constitutional Measures.—To aid the growth of the mus- cular system to correspond with the rapid growth of the bones, these should not be neglected. CONGENITAL DEFORMITIES. HARE-LIP. DOUBLE. Time for Operation.—From 3 to 6 months of age. Operation.—Trim up the middle portion and use it to form a septum for the nose. If the vomer projects, trim it off. Freshen the edges of the lateral portions and allow for cicatrical contraction at the line of union by making the freshened edges longer than the width of the lip with the convex side of the curve outward. Otherwise a notch in the lip will result. Dissect the lip up from the bones on either side, if necessary, to allow it to be easily drawn together. Pass sutures through the whole thickness of the lip, tying them like any interrupted suture. The vermilion border of the lip is first caught together by a fine suture. Do not use hare-lip pins. Dress.—With isinglass plaster straps or collodion and cotton, extending the dressing well over each cheek and drawing in the cheeks while applying so as to relieve ten- sion on the sutures. Instruments.—Straight bistoury, scissors, artery for- ceps, needles and needle forceps, bone cutting forceps, silk-worm gut, catgut. SINGLE. Operations.—The same as for double hare-lip, except that there is no middle portion to be disposed of. CLEFT PALATE. Treatment.—Operation as early as possible. The practical execution of these operations is so difficult, gen- erally, that they should be intrusted to a specialist. Sometimes the gap is so wide as to make closure from the sides impossible. In such cases, when the patient begins to talk, an artificial palate may be fitted. TALIPES-VARUS-VALGUS-FLAT FOOT 327 _______________POCKET-BOOK OF MEDICAL PRACTICE______________ CLUB-FOOT. TREATMENT. General.—Completely divide the tendons of all shortened muscles, subcutaneously (through a puncture) or by open incision, observing strict asepsis. In congenital cases, operate 2 to 3 weeks after birth; the earlier the better. In long standing cases, the bones are generally deformed and excision of a wedge of them is often necessary, be- side the tenotomy, to allow the foot to be straightened. Local.—Apply, over each puncture, or sutured incision, a very small pad of absorbent cotton slightly moistened with an antiseptic lotion, and hold it in place with a strap of adhesive plaster. Then, at once, apply a plaster cast from the toes well up the leg, twisting the foot into the proper position, or if possible, exaggerating the cor- rection, and holding it so until the plaster sets. Apply the turns of plaster bandage in the direction that will tend to draw the foot into position. Remove the cast in two weeks, or earlier if there should be any signs of in- fective inflammation, and apply a new one. Apply new ones every 2-3 weeks, endeavoring to gain some each time on the deformity. In some cases it may be neces- sary to repeat the tenotomy in 2-3 months. TALIPES VARUS. (TALIPES "equino varus.") Treatment.—The muscles of any or all of the following tendons may be shortened, and if found to be tense, should be divided and the foot treated as above, (a) Tibialis Posticus.—Incise just behind the inner malleolus, lift it up on a grooved director and divide, (b) Flexor Longus Digitorum.—Lift up and divide it in the same incision. (c) Tendo Achilles.—Puncture just in front of the tendon, yi^/i inch above its insertion, and divide it subcutaneously, cutting backward, (d) Short Flexors and Plantar Fa- scia.—Puncture at the middle of the inner margin of the sole and, passing the tenetome just above those struc- tures, cut downward subcutaneously. After the plaster boots are discontinued, a strong shoe is worn with a patch on the sole, thicker at the outer edge of the toes and tapering toward the inside and heel. TALIPES VALGUS. Treatment.—If from paralysis of the Tibialis Anticus, support the arch of the foot by carefully shaped pads or steel insoles in strong shoes. Treat the paralysis by electricity (Faradic and interrupted Galvanic currents), massage and such internal remedies as Strychnia, Phos- phorus, Nux Vomica. ,k If from spasm of the Peronei, divide through an open incision just behind the external malleolus. TALIPES EQUINUS. Treatment.—Divide the tendo Achilles, as described abOVe FLAT FOOT. (pes planus.) Treatment.—In cases of long standing, break up the 330 SPECIAL AMPUTATIONS-SHOULDER-JOINT a*U POCKET-BOOK OF MEDICAL PRACTICE____________ Tendons. — Draw down and cut off short the tendons and nerves divided, and allow them to retract back into the tissues. , Ligature.—Ligate the main arteries. Remove the com- pression slowly and ligate or twist all bleeding vessels. Control capillary oozing by hot, normal salt-solution and sponge the wound dry. Disinfection.—Disinfect the wound, if necessary. Suture.—Suture the periosteum and muscles over the head of the bone by catgut. Approximate the skin nicely by catgut or silk-worm gut. Do not trim the corners of the flaps too closely; any redundancy soon absorbs away, leaving a well-rounded stump. Infusion.—In all large amputations have everything ready for intra-venous infusion. In shoulder or hip am- putations havethevein already exposed, and, insome cases, infuse before operating. (See Shock and Hemorrhage.) Dress.—If a large stump, or if perfect asepsis has been impossible, provide for drainage, by a rubber tube, for 36-48 hours, and use a moist antiseptic dressing. If no oozing of blood or serum is expected, apply antiseptic powder and dry gauze. Over these dressings apply a thick compress of some elastic material, a tight bandage and a stump-bag. Keep the limb elevated for 36-48 hours. Instruments.—Large scalpel; long amputating knife, if desired; suitable bone-saws; dissecting-forceps; artery- forceps; scissors; periosteal elevator; bone-cutting for- ceps; bone-holding forceps; needles; needle-forceps; Esmarch bandage; cloth retractors ; catgut; silk-worm gut. ________ SPECIAL AMPUTATIONS. THE SHOULDER-JOINT. Mortality. — About 25 per cent. Operation. — Control hemorrhage by digital compres- sion of the subclavian by an assistant, or by a con- strictor held on the shoulder by Wyeth's pins (one an- terior and one posterior, passed upward from the re- spective ends of the axillary folds), or held by straps passing under the other arm. Have another assistant hold the arm and another to seize blood-vessels. Lateral Flaps.—Make a broad external one, including most of the deltoid, and extending a little below the level of the axilla and almost to its posterior border. Reflect this back, exposing the head of the humerus. Cut its muscular attachments and free it. Now, if a constrictor is not used, pass a knife just inside the humerus, and cut downward and inward for a short in- ner flap, while an assistant passes his thumbs back of the knife and compresses the axillary vessels until they may be ligated. Racket Method.—Incise down to the bone from a little below and in front of the acromion, 4 inches down the outside of the (adult) arm. From the middle of this make an oval incision around the inside of the arm, 2 AMPUTATIONS—ARM-ELBOW-HAND 331 _____________POCKET-BOOK OF MEDICAL PRACTICE inches lower inside than outside. Reflect the anterior and posterior flaps, and disarticulate.* THE ARM. Rule.—Save all you can up to the surgical neck of the humerus. Operation.—Have an assistant hold the arm. Use the flap, circular, or Teale's method. Anterior and pos- terior flaps are best in the upper third.* THE ELBOW. Operation.—Make a long anterior and a short posterior flap, or an elliptical operation, preferably lower in front. Lateral flaps may be used. In some cases the attach- ment of the triceps may be saved, turning the olecranon over the end of the humerus. In any case, have the con- dyles well padded. The key to the joint is the radio- humeral ligament.* THE FOREARM. Rule. — Save all you can up to one inch below the elbow. THE WRIST. (Radio-Carpal Articulation.) Rule.—Do not save the carpals. Operation.—Use the circular method, incising 1-1)4 inches below the styloid process. The cuff is only skin and fascia. Draw it together like anterior and posterior flaps, leaving the corners. Divide the tendons well up. In disarticulation arch the cut upward, beginning at either side. Leave the styloid processes if an artificial hand is to be worn.* THE HAND. (Through the Metacarpals.) Flaps.—Use anterior and posterior flaps. Save all of the thumb possible.* Below the Middle.—Use the circular method, reflecting the cuff of skin and fascia to a distance equal to the diam- eter of the limb. In retracting the cuff, slit up one side if necessary. Cut the tendons at this point. Draw the parts together like anterior and posterior flaps. Teale's method may be used. At or Above the Middle.—Use the circular method or anterior and posterior flaps with the length of each one equal to the diameter of the limb. The flexor flap re- tracts the more. After dividing the soft tissues to the bones, cut the inter-osseus tissues and use a three-tailed retractor when sawing the bones, sawing the radius a little in advance.* THE METACARPO-PHALANGEAL JOINT. All the Fingers at Once.—Flex the fingers on the palm and cut straight into the joints (from the end) for the short dorsal flap. Incise along the interdigital commis- sure for the long palmar flap, dissecting it up from the palm a little. Taper off the '5th metacarpal, if desired. Thumb.—Use the racket method with the "V " on the radial side and encircling well down the thumb. In ♦Other steps as in General Considerations (pag-e328). ^ AMPUTATIONS - PHALANGES - HIP POCKET-BOOK OF MEDICAL PRACTICE__________ dissection, leave the ball of muscle to oppose the fingers. Save the metacarpal bone if possible. Index Finger.—Use the racket method modified by rounding the dorsal incision well over toward the ulnar side, and the palmar incision extending well down the side of the finger, thus throwing the scar away from the side of the hand. Save the head of the metacarpal. Little Finger.—Use the racket method modified simi- larly. Carry the apex of the "V " well up and slope off the metacarpal bone to make a shapely hand. Middle Fingers.—Use the racket method, from the knuckle behind, extending around the finger well down, to give plenty of skin. To make a shapely hand, cut away the head of the metacarpal bone and taper the shaft through the incision prolonged on the dorsum. If a strong hand is desired, leave the head of the bone. The joints are entered first from the palm, then the dorsum, then the sides. If it is necessary to wholly re- move a metacarpal bone, do it through a prolongation of the dorsal incision.* THE PHALANGES. Rule. -Save every scrap of the thumb or index finger. If amputation is above the middle of the middle phalanx of a finger, suture the flexor tendons to the periosteum, or remove the whole finger. Operation.—Is best made with a long palmar and short dorsal flap. If at a joint, strongly flex it and cut straight into it from its end, for the dorsal flap. Disarticulate by cutting the lateral ligaments. Close with only a few sutures so as to favor drainage.* AT THE HIP. Mortality. — About one-third. Operation. — Wyeth's Method: — Apply an Esmarch bandage, if indicated, removing it when the constrictor is in place. Have two sharp steel pins ,*,jX10 inches. Introduce one an inch below and a little internal to the anterior-sup. spine of the ilium, emerging just back of the great trochanter; the other an inch below the crotch and internal to the saphenous opening, emerging one- half inch in front of the tuberosity of the ischium. Above these pins apply a tight constrictor. Protect their points with corks. Bring the hip well over the edge of the table. Have an assistant to hold and manipulate the limb. Make a circular incision to the deep fascia about 6 inches below the constrictor, and a longitudinal incision from the constrictor, passing over the great tro- chanter. Reflect the cuff of skin up to the lesser tro- chanter and, at this point, divide the muscles by a cir- cular incision to the bone. Strip away the soft tissues from the bone below this, to,allow room, and ligate the large vessels. Then dissect up the muscles above, keep- ing close to the bone. Open the capsule of the joint, forcibly flex, abduct and adduct the thigh, cut the terei ligament and disarticulate. Suture the tissues, es- Other steps as in General Considerations (page 328). AMPUTATIONS-THIGH-KNEE-LEG-FOOT 333 POCKET-BOOK OF MEDICAL PRACTICE pecially muscles, firmly together, and introduce a drain- age-tube for 48 hours.* THE THIGH. Rule.—Save every possible inch up to the trochanters. Operation.—The best is the long anterior and short posterior flaps. The circular, and Teale's method, are good in the lower part. The tissues on the back contract most; it is best to have the scar behind rather than on the end of the stump. Protect the anterior edge of the bone by a thick pad of tissue.* THE KNEE. Through the Condyles.—Use a long anterior and a short posterior flap, including the patella in the anterior flap. Saw through the condyles or a little above them, saw off the posterior surface of the patella, and turn the re- mainder up against the end of the femur, stitching it in place with kangaroo-tendon, silk-worm gut or silver wire. In some cases a longitudinally cut piece of the tibia with the attachment of the patellar ligament may be turned up against the sawed end of the femur, instead of the patella. At the Joiut.—Use long anterior and short posterior flaps, or an elliptical incision lower in front. Or make bilateral flaps, lower in front and the inner one longer, thus throwing the scar in the inter-condyloid fossa. Dis- articulation is accomplished by cutting from within, outward and downward.* THE LEG. Rule.—If the patient can afford an artificial leg, amputation is best made at the junction of the middle and lower thirds; if he will have to wear a "peg-leg," 2 inches below the tubercle of the tibia. Always leave the attachment of the patellar ligament, if possible. In the Upper Half.—Use curved bilateral flaps, higher behind. In the Lower Half.—Use the same, or the circular method, drawing the parts together like bilateral flaps. Round off the anterior corner of the tibia and divide the fibula higher up, sawing it first. Endeavor to get a good, thick pad of tissue over the lower end of the tibia and the scar behind. Guyon's Supra-Malleolar Amputation.—Make an ellip- tical incision downward and backward over the point of the heel and crossing the front of the ankle. Disartic- ulate, saw off just above the malleoli, and turn the back of the heel forward for the end of the stump.* THE FOOT. Rule.—if an artificial foot is to be worn, operate above the ankle, as described. Pirogoff's Amputation.—Incise horizontally across the joint between the tips of the malleoli. Connect the ends of this incision by another passing over the sole of the foot, but slanting one inch forward. Disarticulate. Strongly extend the foot and saw directly upward through the os calcis. Saw off the articular surfaces of Other steps as in General Considerations (page 328). ^ qoa ABDOMINAL SURGERY-C(ELI0T0MY-TECHNIQUE 33H- O-BVV pocKET-BOOK OF MEDICAL PRACTICE____________ the tibia and the malleoli, and turn the remnant of the os calcis up against the end. Fasten the two bony sur- faces together by wiring or by stitching the periosteum, Avoid wounding the posterior tibial artery, if possible. This operation leaves a very serviceable stump, as long as the other leg. Other Amputations through the foot are best made by a long plantar and a short dorsal flap, sawing through all the bones together wherever necessary and removing any small fragments which may be left. Transplant the tendon of the tibialis anticus if the first metatarsal is removed.* THE TOES. Operation.—Similar to those of the fingers. TREATMENT OF STUMPS. Motion.—As soon as union is firm, begin active and passive motion and massage. Support the circulation by an elastic bandage. Apply an artificial limb in from 2 to 3 months. Other steps as in General Considerations (page 328). ABDOMINAL SURGERY. CELIOTOMY. (" LAPAROTOMY.") Indications.—It is indicated for diagnosis or treatment of all serious cases of disease or injury of the abdominal contents when other measures are inefficient. TECHNIQUE IN GENERAL. 1. Preparation.—The patient, operator and his assist- ants should be prepared as described under Asepsis and Antisepsis and Anesthesia. Special attention should be given to clearing out the patient's alimentary tract 2. Opening the Abdomen.—Incise in the median line, preferably, cutting down, layer by layer, until the peri- toneum is reached. Grasp this by forceps on each side of the median line and carefully nick between them. In- troduce a finger, as a guide, into this opening and en- large it with scissors. Before opening the peritoneum, check all hemorrhage. Catch the parietal peritoneum to the skin on each side by forceps or two temporary stitches. 3. Exploration.—Unless pus has been set free, intro- duce as much of the hand as may be necessary and care- fully examine such parts of the cavity as require it; in some cases the whole cavity. 4. If Pus Escapes.—On opening the peritoneum, if pus escapes, ascertain whether it is circumscribed or dif- fuse. If circumscribed, wash out the pocket with a very gentle stream of saline solution, taking care not to dis- tend it. If the infected fluid is diffuse, before closing the cavity flush every part of it with large quantities of warm saline solution, giving special attention to the space between the liver and diaphragm. Draw out the intes- tines and carefully sponge off every coil. 5. Adhesions. —If adhesions are found between the wound and the suspected location, carefully separate ABDOMINAL SURGERY-OPERATIVE TECHNIQUE 335 ___________POCKET-BOOK OF MEDICAL PRACTICE ^them with the fingers ligating and cutting such bands ^ as may demand it. If it is suspected that they enclose a '■' collection of pus, wall off the rest of the abdominal cavity ^ with large fiat gauze pads, before proceeding. 6. Pus in au Organ.—If a pus-or fluid-containing organ can be isolated, draw it up outside of the wound, if pos- ; sible, and drain it; or ligate it off and remove it without 'opening, as seems indicated. If it cannot be isolated, ~ and lies against the abdominal wall or vagina, close the abdomen and open directly into it from without. 7. Abscess.—If an abscess cannot be managed by these methods, wall off the rest of the abdominal cavity with gauze pads, drain and wash it out through an aspirator- needle, or make a very small incision into it and rapidly sponge away the pus as it exudes. 8. Outside.—In operating upon abdominal organs, do ■ as much of the work upon them outside the abdominal ^cavity as possible. 9. Abrasions.—If possible, isolate abrasions, or lines of suture in the visceral peritoneum, by a layer of omen- „ turn caught over them by a few catgut stitches. il 10. Drainage.—If the infection is strictly localized, or much intra-abdominal oozing is expected, introduce a perforated glass drainage-tube (with rounded end) with a strip of gauze inside of it. Leave the tube in place for 24 to 48 hours or until any symptoms of peritonitis ""subside, drawing the fluid out of it every 4 to 12 hours with a sterile catheter and syringe. Sometimes a per- forated rubber tube, or gauze surrounded with perfor- ated gutta-percha tissue, is used as a drain. If the in- r fection is not 'strictly localized, depend upon thorough -flushing with saline solution and close without drainage. — 11. Closure. — Carefully coapt the peritoneum with a -continuous catgut suture. If necessary, introduce deep tension sutures down to the peritoneum, using silk-worm "• gut and tying them after the other sutures are finished. "Coapt each layer of muscles or fascia separately by a continuous suture of chromicized catgut, or, when desired, • by kangaroo-tendon sutures for the aponeuroses. For -the skin, use a continuous catgut suture, or interrupted silk-worm gut stitches. 12. Dressing.—Apply a narrow strip of sterile protect- ive directly over the line of suture, button-holing it, if .'necessary, for a drainage-tube. Over this apply a pad •: of sterile cotton moistened with an antiseptic lotion and cover with a sheet of protective, or use a dry powder or a collodion-and-cotton dressing, when no infection is •expected. 13. Avoid Hernia.—Keep the patient in bed for 3 weeks :if there is union by first intention, and instruct him to ; wear an abdominal supporter for 6 to 12 months after- ;ward. The supporter should contain little or no elastic, and should not have a thick pad over the scar. 14. Instruments. —Scalpel; scissors; artery - forceps; pedicle-forceps; 2 pairs of dissecting-forceps; long retract- ors; aspirating syringe and needles; irrigator; needle- <136 ENTERORRHAPHY-ENTEROSTOMY-COLOSTOMY k,'aU POCKET-BOOK OF MEDICAL PRACTICE forceps; pedicle or aneurism needle; large curved sur- geon's needles; calyx-eyed intestinal needles; or, fine cambric needles; fine silk; silk-worm gut; catgut; kanga- roo tendon; gauze sponges and pads; plenty of sterile salt in weighed packages, or sterilized salt-solution. Caution. — Count all instruments, sponges and pads before opening, and again before closing the abdomen. INTESTINAL SURGERY. Enterorrhaphy.—(Intestinal Suture.)—Stitch wounds in the intestine together by Lembert's, Dupuytren's, Cush- ing's, or Halsted's suture. These go through the serous, muscular, and submucous, but not the mucous coat, and CUSniNG. DUPCYTREN. LEMBERT. Fig. f?.—Sutures. fold the edges inward, approximating serous surfaces. Use fine silk, and catch into healthy tissues only. Intestinal Resection.—Place temporary gauze sutures through the mesentery, about the intestine above and below; cut away the diseased part of the intestine and a " V " of the mesentery attached to it. Ligate any bleed- ing vessels in the mesentery, suture its edges together, wash the ends of the intestine, inside and outside with warm saline-solution, and suture them together, or, if necessary to gain time, apply a Murphy button (No. 3 for a small intestine, No. 4 for the large). The Laplace anastomosis forceps are a great convenience for rapid end-to-end suture. Enterostomy is only to be performed in emergency for temporary relief. The method is about the same as for colostomy. Colostomy is best made in the left inguinal region. Make an oblique, 2-inch incision, lyi inches from the anterior-superior-spine, crossing a line drawn from that point to the umbilicus. Grasp the colon, and draw a loop into the wound. Hang the gut over a glass rod passed through its meso-colon next to it. Introduce stitches all around which catch together the skin, pari- etal peritoneum and visceral peritoneum. Open the gut at once if necessary'; otherwise wait 24-48 hours, when the rod is removed. If the opening is to be temporary, make a longitudinal incisipn in the gut. GASTRIC SURGERY-CHOLECYSTOTOMY 337 ^ POCKET-BOOK OF MEDICAL PRACTICE ^ Bodine's Method.—Stitch together, for 6 inches, the two ^ limbs of a loop of the gut with a line of suture on each ■^side of the mesentery. Stitch the parietal peritoneum to the skin all around the incision. Drop the united loop of intestine back into the abdomen until the ends of the .'lines of suture are level with the skin, and stitch it in place all around. Cut off part of the gut protruding, a little above the level of the skin. To close this artificial anus at any time, divide the septum between the two ends of the loop, and close the abdominal wound. Instruments.—Scalpel; artery-forceps; scissors; glass ; rod ^6-^x6 inches; surgeon's and intestinal needles;silk; silk-worm gut; catgut. GASTRIC SURGERY. Gastrorrhaphy.—Draw the edges of the wound together .. by a continuous suture through all coats, and then infold this seam by Lembert, Dupuytren, Cushing or Halsted sutures. Gastrotomy.—Incise the abdomen in the median line above the umbilicus. Short incisions may be made in the stomach across its long axis, long ones longitudinally midway between the two curvatures. Draw the part of the organ to be incised out of the abdomen and take care that none of the contents escape into the abdominal cavity. CHOLECYSTOTOMY. - Operation.—For Gall-stones.—Place a sand-bag under -"the patient's back. Incise at the edge of the right rectus " muscle, an inch below the ribs. Expose the gall-bladder <•'■ and surround it with pads. Emptying.—If it is distended, aspirate it, and examine .' it and the ducts by the fingers external to them. If there - are stones in it incise it and remove them by forceps, „ scoop or irrigation. If a stone is wedged into a duct, ', carefully manipulate it back into the bladder. If this ' fails, break it up with an instrument inside, or incise the '. duct and remove it. Wound.—Close wounds in the gall-bladder and ducts . by Lembert, Dupuytren, Cushing or Halsted sutures, and close the abdominal wound. Some stitch the gall- ' bladder to the abdominal wall about the incision (before opening it if the ducts are clear) and, in closing the ab- : domen, leave, for a week, a rubber tube, without perfora- tions, to drain off the bile. Occlusion.—Where the common duct is permanently ! occluded, connect the gall-bladder to the duodenum by a small Murphy button. Removal.—When the gall-bladder is dangerously dis- eased, or friable and can be easily isolated, it may be tied off and removed with the stones in it. Caution. —Danger lies especially in leakage of bile or septic matter into the peritoneal cavity. 333 APPENDICITIS-OPERATION-HERNIA pocket-book of medical practice APPENDICITIS. Anatomy.—McBurney's point marks the root of the appendix; it is a point 2 inches from the right anterior- superior iliac spine, on a line drawn from that spine fa the umbilicus. The end of the appendix may lie as far as 4 inches from this point in any direction. Diagnosis is made upon:—(a) General symptoms of peritonitis, especially vomiting constipation and high pulse, (b) Local symptoms of peritonitis—pain, tender- ness and muscular rigidity, sometimes a fluctuating tumor, especially marked at or near McBurney's point. (c) History of previous attacks. TREATMENT. General. — Rest in bed; bland nourishing liquid diet; turpentine stupes to the painful part of the abdomen; copious colonic flushings with warm water or saline solution; one or two 10 grain powders of Calomel and Sodium-bicarb., equal parts. INDICATIONS FOR OPERATION. 1. If in 6 hours after the beginning of the attack the symptoms are no worse, wait. 2. If 6 hours later they are no worse, wait; if they are worse, operate at once. 3. If 12 hours later they are better, wait. 4. If 24 hours later there is no further improvement, operate at once. 5. In all severe cases, operate at once. 6. If there is a tumor, operate at once. 7. Operate, if possible, in an interval between attacks, about 3 weeks after the attack, and in all cases, except such as make an absolutely clean recovery after a pri- mary mild attack. OPERATION. Incision.—Midway between the anterior-superior iliac spine and the umbilicus, parallel to the fibres of the ex- ternal oblique. If an abscess is located, incise directly over it. Removal.—If part of the omentum is firmly adherent to the organ, ligate it off and cut it away. Ligate the meso-appendix and divide it. Circumcise the peritoneal covering of the appendix one-half inch from the cecum and dissect back a cuff of it to the cecum. Ligate the denuded root of the organ and cut it off. Cauterize the stump with Carbolic acid (95%). Catch the cuff of the pe- ritoneum over the root of the organ and infold the whole into the cecum by intestinal suture. Abscess.—If there is an abscess about it, and it be easily reached without breaking up adhesions, ligate and amputate the organ; otherwise simply treat the abscess. x^ee^Uoeliotomy for steps not described.) HERNIA. DIFFERENTIAL DIAGNOSIS. Enterocele.—(Contains intestine.)—It is smooth; regular; J"oun,d5JtymPamttcon percussion; gurgles when manipu- lated; disappears with a flop when reduced. EPIPLOCELE-INGUINAL HERNIA-TRUSSES 339^ _____________pocket-book of medical practice Epiplocele.—(Contains omentum.)—It is doughy and uneven; not tympanitic; gives no gurgle and no flop. Entero-epiplocele.—(Contains both.)—Characteristics of both. Varieties.—The common forms are—fa)-.Inguinal; (b) Femoral; (c) Umbilical and (d) Ventral. :-,(See Intestinal Obstruction.) INGUINAL HERNIA. DIFFERENTIAL DIAGNOSIS. Varicocele.—It feels soft, doughy, and like a bunch of worms; appears first at the bottom of the scrotum on standing; no gurgling or tympanites. Hydrocele.—It is translucent; fluctuates; no gurgling or tympanites. Undescended Testicle.—Absence of the gland on that side; hard tumor in the inguinal region, with sickening pain on pressure. h ' Enlarged Inguinal Glands.—The tumor lies obliquely to the long axis of the canal; is hard; painful; freely mov- able at first; skin reddened; never appears suddenly. TREATMENT. Reduction.—See under Intestinal Obstruction. Trusses.—If properly fitted and worn continuously will generally produce a permanent cure in l/2 to 2 years in children. In adults, except when the rupture occurs from very severe straining, trusses are merely pallia- tive, preventing the descent of the gut and the attending dangers. .; Fitting.—Measure from the lower part of the opening to the ant.-sup.-spine, then around the body 1 inch be- low the iliac crest to the other ant.-sup.-spine, then to the upper part of the hernial opening, or if a double truss is worn, to the lower part of the other hernial open- ing. The pad lies over the external ring in direct hernia, over the internal ring in indirect. The truss should lie Close to the body beneath the iliac crest, should leave the abdominal and gluteal muscles free, and should pre- vent the descent of the gut without having a very strong spring. A double truss stays in position better than a single one, and is to be preferred where the other ring is weak. Hard pads are cleaner and do not irritate the skin as much as soft ones. A truss should not be uncomfortable after 2 or 3 days. Test.—A truss should prevent descent when the patient sits on the edge of a chair with legs apart, bends for- ward and cohghs. Use.—It is appljed before rising and removed after lying down. It should be kept scrupulously clean, and the skin under the pads bathed and dusted with borated talc daily. It should be. worn for several months after the pillars seem strong. Supporters are useful in large irreducible hernias, or in those which cannot be retained in the abdomen. 340 HERNIA-OPERATION-RADICAL CURE ° pocket-book of medical practice Indications for Operation.—Irreducible herniae, includ- ing incarcerated, strangulated and inflamed. Reducible hernia of over 3 months' standing in adults, or in chil- dren who have not improved after 1 year's use of a truss, Contra-indications.—Cough; straining in urination or defecation; urethral discharge; thin, atonic abdominal walls. OPERATION. Preparation.—Prepare the patient as described under Anesthesia, and Asepsis and Antisepsis. Wrap the scrotum in a sterile dressing. For Strangulated Hernia.—See under Intestinal Ob- struction. RADICAL CURE. Incision.—Make a 3-inch incision upward and outward from one-half inch above and external to the pubic spine, exposing the external ring and the external oblique muscle. If the hernia and rings are large, pass a director under the external oblique and divide it up to and over the internal ring. The Sac and Cord.—1. Make a small opening in the sac and introduce the forefinger as a guide in dissection, if it is empty. 2. With the fingers, separate the sac from the canal and cord, and for one-half inch all around inside of the internal ring. 3. If intestine is adherent inside the sac, free it and return it into the abdomen. If omentum, free it, ligate it off, by several small ligatures, and return the stump. 4. If the cord is enlarged by dilated veins, reduce its size by ligating most of them. 5. If the hernia is congenital, separate a strip of the back and all of the bottom of the sac from the rest, and catch this around the cord and testicle, for a tunica vagi- nalis, by a continuous catgut suture. 6. Pass the points of a forceps through a small open- ing in the abdominal wall, just above the internal ring, and out of the ring; catch the sac and draw it out through the opening, thus invaginating it. Secure its neck in the opening of a catgut stitch and cut off the rest of the sac 7. Or, take a long suture, with a needle at each end, and, beginning at the bottom, pass these back and forth through the sac up to its neck and then pass them through the abdominal wall, 4S inch apart, above the in- ternal ring. Draw the ends tight, thus doubling upthe sac into a wad just inside of, and above the internal ring, and tie them together. Stitching.—Lift up the cord and below it, by inter- rupted kangaroo-tendon stitches, and a round, curved needle, draw together the pillars of the internal ring, leaving just room at the top for the passage of the cord without constriction. If the external oblique has been divided and the rings are large, with thin pillars, this muscle may be included in these stitches, letting the cord pass out at, above or below, the site of the internal ring, wherever the muscles are thickest. Otherwise, stitch the HERNIA-FEMORAL-UMBILICAL 341 J;_________pocket-book of medical practice________ i external oblique over to Poupart's ligament above the : cord, by mattress-sutures of kangaroo-tendon, restoring » the canal and leaving an external ring just large enough - for tue passage of the cord. In the absence of kangaroo- . tendon, use silk-worm gut. The wound having been dried, coapt the skin with a continuous catgut suture. Dressing.—If all steps have been under strict asepsis, . as they should be, provide for no drainage; dress with a dry antiseptic dressing. After-Care.—Keep the patient in bed for 3 or 4 weeks. Do not apply a truss. Instruments.—Scalpel; probe-pointed bistoury; scissors; dry dissector; grooved director; artery-forceps; dissect- ing-forceps; short retractors; needle-holder; surgeon's needles; intestinal needles; smooth, round, curved needles; catgut; kangaroo-tendon (Marcy's); silk-worm gut; fine silk. FEMORAL HERINA. Reduction.—See under Intestinal Obstruction. Trusses.—Are not as likely to cure as in inguinal - hernia. They are fitted according to the same general rules. OPERATION. For Strangulated Hernia. — See under Intestinal Ob- struction. Radical Cure.—Incise the skin for 3 inches, from yi inch below the pubic spine, parallel to Poupart's liga- ment. Isolate the sac, ligate it at its neck and cut it off, dropping the stump into the abdomen. With 2 or 3 - kangaroo-tendon stitches,close the femoral ring by draw- ing together Poupart's ligament and the pectineal fascia, in a line from the pubic spine to the pectineal eminence. Close the canal by 4 or 5 stitches, drawing the falciform edge of the fascia lata to the pectineal fascia, allowing for the saphenous vein to escape at the upper and inner angle. Other steps as in Inguinal Hernia. UMBILICAL HERNIA. Trusses.—Will almost always cure recent cases in in- fants. For an infant, apply a hard pad, the shape of a plano-convex lens, flat side outward. (A large wooden button is good), and fasten it in place by a lyi inch strap of adhesive-plaster, passing clear around the trunk, and lapping. Change this strap as often as necessary to prevent soreness of the skin. A cure usually results in 1 to 2 months. OPERATION. Method.—Incise around the tumor, removing the um- bilicus and some skin. Open the sac, free any adherent intestine or omentum, removing the latter. Dissect away the sac from the surrounding muscles down through the whole thickness of the wall. Cut it away and unite the parietal peritoneum by a longitudinal, continuous, cat- gut suture. Suture the fasciae and recti mucles together by interrupted kangaroo-tendon stitches. Other steps as described under Coeliotomy. 342 RECTAL SURGERY—HEMORRHOIDS ° POCKET-BOOK of medical practice_______ VENTRAL HERNIA. Trusses or Supporters^ —Will not permanently'cure. Operation.—Essentially the same as for Umbilical Hernia. ________ OTHER FORMS. General.—They are to be treated along the lines laid down above, as their age, condition, etc., indicate—hy reduction by taxis or operation, cure by trusses or, usu- ally, operation. Operation.—It consists in exposure of the sac, its evac- uation, isolation, ligature and removal, and the closure of the hernial opening by kangaroo-tendon sutures. RECTAL SURGERY. CONGENITAL OCCLUSION. Treatment.—If the occluding tissue is merely a mem- brane, incise it and keep the opening patent with a tube wrapped with gauze. If thicker, anesthetize, introduce a a catheter into the bladder and make an antero-posterior incision at the site of the anus, working upward and backward. If the rectum is discovered, open it and, if possible, draw it down and stitch it to the anal margin. If it is not found after incising to a depth of 1 to \% inches, make an inguinal colostomy. HEMORRHOIDS. (PILES.) EXPECTANT TREATMENT. Diet.—Fobid alcohol, tobacco and constipating foods. Exercise.—To increase the hepatic secretions and pre- vent portal congestion. Bowels.—Use mild laxatives; avoid strong purgatives. Reduction.—Reduce the pile each time it prolapses, after cleaning it carefully. Local Astringents.—Frequent douches or injections with ice-cold water; lotions or suppositories of Hamamelis (fl. ext.], Sulphate-of-iron; Tannic acid; Alum. Sedatives.—A Calomel ointment allays pain and itch- ing. Cocaine % grain, or Morphine }i grain supposi- tories, relieve severe pain temporarily. Incise and turn out the clot in thrombotic piles. RADICAL TREATMENT. Operation.—Clear out the bowels thoroughly in prep- aration. Anesthetize and place the patient in the lithot- omy position. Thoroughly dilate the sphincters. For External Piles.—Catch the pile with a forceps or tenaculum and snip it off, cutting in lines radiating from the center of the anus. Catch the sides together with a continuous catgut suture. For Internal and Mixed Piles.—Catch the lowest pile first at its highest and lowest points with tenacula or forceps. With scissors dissect it up from below, incising in lines longetudinal with the gut, until only a strip of membrane RECTUM-PROLAPSE-ULCERS-FISSURE 343 _______________POCKET-BOOK OF MEDICAL PRACTICE and the vessels running into it from above remain. Li- gate this pedicle with silk or catgut and cut away the pile. Catch the sides of the wound together with a con- tinuous catgut suture. Clamp-and-Cautery.—Lift the tumor away from the rec- tal wall and grasp its base longitudinally with an 8 inch artery forcep or an Adams' hemorrhoidal clamp, includ- ing in its grasp only mucous membrane. If the pile is partly external, cut away this part before applying the clamp, stitching the incised edges together after cauter- izing. Burn the pile away with the Paquelin cautery at a red heat. Slowly relax the clamp, watching for hem- orrhage. Small hemorrhoids may be cured by simply puncturing them with the point of the cautery. Instruments. — Scissors; artery-forceps; 2 tenacula; needle-forceps; rectal speculum; needles; hemorrhoidal clamp; Paquelin cautery; silk; catgut. Dressing.—Rub Aristol or Iodoform over the suture lines. Take 4 or 5 inches of one-half inch, thick-walled, rubber- tubing. Wind it to one inch thick at the ends, thinner in the middle, with Iodoform gauze, tying it on. Lubricate this with Vaseline and insert it into the rectum, reducing the anal margin and letting the sphincters grasp the thin part. Apply a large gauze pad and a UT" bandage. After 4 or 5 tlays give a copious enema through the tube and the plug Will be expelled. PROLAPSE OF THE RECTUM. Expectant Treatment.—When the prolapse occurs, wash it with cold water and reduce it. If firmly caught, grease it with Vaseline, insert a finger into the rectum and em- ploy taxis around it. Apply a graduated compress to be worn except when at stool. Keep the bowels soluble and prevent straining; have defecation performed in a recum- bent position and precede it by a cold, astringent injection (Tannin; Alum;Hydrastis, fl. ext.). Astringent supposi- tories are sometimes valuable. Correct any attending genito-urinary trouble. Operation.—Make longitudinal strokes in the bowel with the cautery, or use the clamp and cautery, as for hemorrhoids. RECTAL ULCERS. Simple.—Empty the intestines, cleanse the lower bowel and, through a speculum, cauterize the ulcer with Silver- nitrate or Carbolic acid (95 c/c). Keep the patient in bed and on liquid diet, injecting daily, Olive oil with Iodoform or Ichthyol. If this fails, operate. Operation.—Anesthetize, dilate the sphincters thorough- ly, incise the ulcer, cauterize with pure Nitric acid and dress as for a piles operation. Fissure of the Anus.—Prevent constipation. Wash out the rectum with cold water and apply pure Ichthyol or Iodoform to the fissure. Operation.—Anesthetize, dilate the sphincters with the thumbs until they touch the ischia. Incise the floor of 9 *44 RECTUM-ABSCESS-FISTULA IN ANO *" POCKET-BOOK OF MEDICAL PRACTICE the fissure, curette it, andi brush it over with Silver-ni- trate. Dress as for a piles operation. Medicinal.—Graphites***; Nitric acid2x; Natrum mur.6* Tuberculous Ulcers.—General measures for the treat- ment of tuberculosis. Cauterize every week or so with Silver-nitrate and apply Iodoform emulsion daily. Oper- ation is generally not indicated. Syphilitic Ulcers.—General treatment for syphilis. Cauterize with Silver-nitrate. Apply, daily, a strong Calomel ointment, or a powder of Calomel, 1:10. RECTAL STRICTURE. Gradual Dilatation.—Prescribe rest; non-stimulating diet; warm water injections; mild laxatives; hot hip- baths. Treat any existing disease which may have caused it. If gradual dilatation is possible, gently pass, every other day, warm and well-oiled, gum-elastic or soft-rubber bougies, gradually increasing the size. Operation.—For fibrous strictures. Cleanse the bowels as thoroughly as possible. Anesthetize. Forcibly dilate the stricture with the fingers or some instrument. If necessary, incise it, cutting in the median line posteriorly. Thoroughly dilate the sphincters and dress with a tubal plug, as in a piles operation, but larger. After 5 days remove this and pass a large bougie every other day for 3 weeks, and at frequent intervals afterward. ISCH10-RECTAL ABSCESS. Treatment. — Incise, early, up beside the rectum from the skin surface, cutting in a line radiating from the anus. Open all branches of the abscess freely. Irri> gate with salt-solution, followed by Carbolic acid (S%\ and introduce a straight drainage tube for 48 hours. See under Abscess. FISTULA IN ANO. Indications for Operation.—All cases, except in the last stages of phthisis or where there is much cough. OPERATION. Method. — Prepare as for an aseptic operation. Pass a grooved director through the sinus and with it raise up all the tissues between the rectum and the skin. Pass a bistoury along the groove and divide the whole mass of tissue. Explore carefully for any branches and lay these open into the first incision. Cut the sphincters at right-angles to their fibres, and only once at an operation. Remove, with curette or scissors, all the walls of the sinuses. Irrigate with warm salt- solution, and pack the wound with Iodoform gauze. Instruments. — Bistoury; scalpel; scissors; grooved director; probe; artery-forceps; dissecting-forceps; sharp curette. After-Care. — Remove the packing after 48 hours and allow the wound to granulate up, simply keeping it clean. COCCYGODINIA PARACENTESIS ABDOMINIS 345 POCKET-BOOK OF MEDICAL PRACTICE COCCYGODINIA. Treatment.—Correct affections of the neighboring or- gans. If obstinate, divide subcutaneously all muscular and ligamentous structures from the borders and tip of the coccyx. If the coccyx is luxated and displaced, or carious, remove it. VARIOUS MINOR OPERATIONS. PARACENTESIS ABDOMINIS. ( '-TAPPING.") Indications.—Called for if the amount of effusion is so great as to seriously embarrass respiration or the heart's action. Operation.—Make an ink-mark exactly in median line, midway between umbilicus and pubes. Turn the patient on his side, near the edge of the bed. The bladder must be empty. Ascertain by percussion the presence of fluid at the spot to be pierced. Apply a broad flannel belt, or a sheet, around the abdomen, the ends crossed behind, and held by an assistant, who gradually draws it tight as the fluid is withdrawn. Tap through a hole cut in the cloth at the proper point. Incise the skin at point selected, and introduce the trocar. Draw off the fluid slowly. When all is out, seal the wound with plaster, and pin the band tightly around the abdomen. Observe strict asepsis. Dangers.—(1) Hemorrhage, from not keeping to mid- dle line; (2) wound of bladder, from not emptying it; (3) wound of bowel, from not tapping in a thoroughly dull spot, or from plunging the trocar too deeply; (4) fainting; (5) infection. _______ VENESECTION. Operation.—Patient recumbent. Apply tape to middle upper-arm, tight enough to congest veins, but not to affect pulse. Hang the arm down a little while; then choose the spot, usually the median basilic vein (look out for brachial artery); pass the lancet gently and obliquely into the vein, and enlarge the opening without deepening the incision. If necessary, make the patient work his hand, opening and shutting it; or grasp some small object. When sufficient blood has been withdrawn, remove the bandage from the arm, apply a pad to the wound, and bandage it by figure-of-eight. Wear the arm in a sling for several days. Observe strict asepsis. Instruments.—Bleeding-tape or bandage; bowl; lancet; pad; sponge and water._______ IN-GROWING TOE NAILS. Treatment.—With the point of a pen-knife insinuate a little roll of cotton beneath the in-growing corner and side of the nail. If there is much inflammation, treat by the measures described for Surgical Inflammations. In- struct the patient not to cut the corners of the nails shorter than the middle. Scrape the nail down in the middle to 946 BUNIONS- KIDNEY-INJURIES-MOVABLE "" POCKET-BOOK OK MEDICAL PRACTICE___________ relieve pressure. If these measures fail, remove the en- tire nail by avulsion and cauterize the matrix under anes- thesia. _______ BUNIONS. Treatment.—Restore the toe to its natural position (an osteo plastic operation is sometimes necessary), and hold it there by mechanical means, as by a splint or pads be- tween the toes. Direct the patient to wear wide-toed shoes and a U-or ring-shaped bunion-plaster to takeoff the pressure. If inflamed, treat as described in Surgical Inflammations—moist heat, evacuation of pus, etc. EXTRACTION OF TEETH. Method.—Seize the fang, with suitable forceps, well beyond the crown, pushing back the gum with the forceps. Rock the tooth outward, then inward, then direct pull. Caution.—If a healthy tooth should be drawn with the diseased, cleanse the socket; wash the tooth in warm water; replace it; retain by binding the jaws together. GENITOURINARY SURGERY. INJURIES OF THE KIDNEY. Operation.—If escape of urine or of much blood is suspected, make an exploratory incision as for nephror- rhaphy. Stop hemorrhage by hot water and packing, or the actual cautery. Close renal wounds by a purse- string suture. Provide for drainage. MOVABLE KLDNET. Treatment.—A truss, or pad-and-bandage should be tried, and will sometimes cure. This failing, perform— Nephrori'haphy.—Place the patient on the sound side with a pillow under the loin. Incise at the edgeof the erec- tor spinas muscle from one-half inch below the last rib to one-half inch above the iliac crest, and then curve forward along the iliac crest as far as may be necessary to ob- tain a 3 or 4 inch incision. Expose the organ. Have an assistant hold it in its normal position by grasping it through the abdominal wall. With a round, smooth, curved needle and kangaroo-tendon or silk-worm gut take 2 or 3 stitches one-half inch into the kidney sub- stance and catching the fascia in both sides of the wound. Tie snugly enough to hold the organ in place after scari- fying its surface about the stitches. Close the wound without drainage. Senn's Operation.—After exposing the kidney, pass a strip of Iodoform gauze around it through the perineph- ritic fat. Draw the organ well into place, leaving the ends of the gauze protruding. Remove the gauze after 3 or 4 days and allow the sinus to granulate up. After-Care.—Keep the patient in bed for 3 weeks and have a truss, or pad and bandage worn for 3-6 months. Other steps, as in Wound Treatment and Anesthesia. RENAL CALCULUS-PYONEPHROSIS-HYDRONEPHROSIS 347 POCKET-BOOK OF MEDICAL PRACTICE RENAL CALCULUS. Diagnosis.—Pa in in the loin or in the iliac region, on percussion, pressure or exercise. Attacks of nephritic colic. Urine.—Frequent urination during the day. At times blood and pus, shown to come from above the blad- der, by cystoscopic examination or ureteral catheteriza- tion. Sediment of urates, uric acid, phosphates or ox- alates; sometimes passage of small calculi. Exploration of the pelvis of the kidney by a ureteral bougie, tipped with dental wax to show scratches, is possible, especi- ally in women. The X-Ray. Indications for Operation.—When medical treatment fails to relieve, and there is no organic disease of the other kidney and not less than 1% of urea. Operation.—Incise down to the kidney as described un- der Nephrorraphy. If desired, locate the stone by punc- ture with a needle or pin. In any case open the pelvis of the kidney and explore it with the finger-tip. If nec- essary, examine the ureter with an elastic bougie (9-12 F.) or a uterine sound. Loosen calculi with the finger- nail and remove them by the fingers, scoop, forceps, etc. Stop capillary hemorrhage by hot saline irrigation or by packing. If practicable, suture the pelvis with cat- gut. Suture the wound, providing for free drainage. After-Care.—Remove the drainage-tube in 3 to 4 days, and allow the wound to close. Medical, dietetic and hygienic treatment to prevent recurrence. PERINEPHRITIC ABSCESS. Treatment.—Incise into the abscess by a short inci- sion at the site described for Nephrorrhaphy. Flush it out and drain. See Abscess. PYONEPHROSIS AND HYDRONEPHROSIS. Treatment.—If possible, remove the cause of the ob- struction, as a kink or twist in the ureter; abdominal tumors; obstruction in the urethra or bladder, etc. Catheterization.—Through the ureter is often possible, especially in women. Aspiration.—Relieves temporarily, and generally needs to be repeated; it may cure. Introduce the needle, ascep- tically, on the right side, midway between the 12th rib and iliac crest at the edge of the erector spinas; on the left side, just below the 12th rib. Nephrotomy.—Is generally necessary. Incise as for Nephrorrhaphy, and stitch the kidney to the fascia on each side of the wound. Then incise the kidney and after draining, carefully examine the ureter with an elastic bougie (9-12 F.) or a uterine sound. WOUNDS OF THE URETER. Operation.—The upper three-fourths can be reached by the extra-peritoneal method—through an incision made from a point one-half inch below the 12th rib, at the edge of the erector spina;, downward and forward one-half 348 URETERAL CALCULUS-ACUTE CYSTITIS POCKET-BOOK OF MEDICAL PRACTICE inch above the crest of the ilium and Poupart's ligament to its middle. The lower quarter is reached through the abdomen. A Longitudinal Wound may be sutured. If it cannot be reached, drain it through an incision posteriorly and it will granulate together. Uretero-cystostomy.—If a ureter is divided near the bladder, introduce the proximal end obliquely into a slit in the bladder and secure it in place by very fine catgut sutures, approximating serous surfaces. Uretero-ureterostomy.—If divided at a distance from the bladder, ligate the end of the lower portion with cat- gut. One-fourth inch below this make a one-half inch, longitudinal incision. With a fine strand of catgut, threaded at both ends, catch through one side of the upper portion of the ureter near the divided end; pass the needles through the slit and out through the ureteral wall one-half inch below it and, by drawing the threads, invaginate the end of the upper portion into the lower through the slit. If intra-peritoneal, catch folds of the peritoneum about the ureter. URETERAL CALCULUS. Operation.—Remove the stone through a longitudinal incision, reaching the ureter and treating the wound as described above. INJURIES OF THE BLADDER. Diagnosis of Perforation.—The catheter brings away blood or only a little bloody urine, and injected fluids or filtered air fail to distend the bladder or to return from the open catheter. Treatment.—If the wound is intra-peritoneal, open the abdomen, catch the edges of the wound together by a continuous catgut suture, and then infold this by approxi- mating serous surfaces, as in enterorrhaphy. Thor- oughly flush out the peritoneal cavity. Drain the blad- der by a retained catheter, for 2 to 5 days, or by a peri- neal or supra-pubic cystotomy. » If the wound is extra-peritoneal, stitch it up, if pos- sible, or drain it by a tube, and drain the bladder as just mentioned. Other steps as described under Cce- hotomy. ACUTE CYSTITIS. Local Treatment.—Remove the cause if it is still in action. Rest in bed; dry heat to the perineum; hot fomentations to the hypogastrium; prolonged, hot, rectal or vaginal injections; rectal or vaginal suppositories containing Ichthj-ol (1 to 2 grs). General Treatmeut.—Keep the bowels free; forbid alco- hol, tobacco, highly seasoned foods and acids; milk diet is best. Dilute and render the urine mildly alkaline or neutral by Lithium or Potassium-citrate (5 gr. doses) or by alkaline mineral waters. For pain, give supposi- tories containing Opium, 1 gr.; Belladonna Ext, \ gr.; CHRONIC CYSTITIS-CALCULUS-LITHOLAPAXY 349 POCKET-BOOK OF MEDICAL PRACTICE or, give Codeine or Morphine by mouth or hypodermati- c-ally. Medicinal.—Aconitelx; Belladonna!*; Cannabis sat. Tr.-ix; Cantharis^x; Chimaphila2x; Hyoscyamus2x; Mer- curius cor.3x; Sandalwood Oil (pure, 5m.); Sanmetto (5m.), Terebinth2x; Uva ursi, fl. ext., (5m.). CHRONIC CYSTITIS. Local Treatment.—If possible, remove the cause, as stone, enlarged prostrate, tumor, urethral stricture, etc. Have the bladder completely emptied 4 times in 24 hours, with a catheter if necessary. Wash it out daily with one of the following solutions: Boracic acid (sat. sol.); Ichthyol (yi-2% sol.); Protargol (){-2% sol.); Carbolic acid (\% sol.); Silver-nitrate (1:5000 or 1:10,000). To do this, introduce a catheter into the bladder or, if possible, force the solution into the bladder by a six-foot column of solution, while the patient tries to relax the sphincter- Use an irrigator with a bulbous tip which fits the meatus. General Treatment.—Keep the bowels free. Give nu- tritious diet without spices; forbid alcohol and tobacco. Enforce general hygiene. Medicinal.—Benzoic acid (3-3 grs.); Boracic acid (5 grs.); CannabisTr. sat.1*; Cantharis3-3x; Copaiba (5m. capsules); Cubebs (5m. or pulv., 5-10 grs.); Eucalyptol (5m.); Mercurius cor.3x; Pulsatilla!*; Salol, or Soda Sa- licylate (5 grs.); Pinus Canadensis (fl. ext.); Sandal- wood Oil (puriss. 5m. capsules); Sanmetto; Saw Pal- mettoTr. (5-30m.); Triticum repens, fl. ext., (15m.); Uva ursi, fl. ext., (5m.); Zea mays, fl. ext., (15m.). See Urethritis. Urotropin—Use it in cystitis when the urine is alkaline, or decomposed; it is a urinary antiseptic, being con- verted into formaldehyde in the system. Give internally. CYSTIC CALCULUS. (STONE IN THE BLADDER.) Diagnosis.—It is made by feeling and hearing con- tact of the stone with a sound, a Thompson's searcher. Have the patient on his back, knees drawn up and the bladder well filled with water. Make a careful and sys- tematic search in all parts of the bladder. A stone may also be shown by the X-rays, or by the cystoscope. Preventive Treatment.—Institute measures to prevent excess of the urinary solids that produce sediments. See that the bladder is completely emptied at least once a day. Operative Treatment.—It is indicated when stone is present. The safest and most satisfactory methods of re- moval are Litholapaxy or Suprapubic Cystotomy. Litholapaxy.—It is indicated, except when there is stricture, enlarged prostrate, atony of the bladder, renal complications, or a large or hard stone. Operation.—Prepare the patient.* With the patient on his back, thighs slightly apart and flexed, and the blad- der partially filled with water, carefully introduce a * As under Asepsis and Antisepsis, and Anesthesia. q«JO CYSTOTOMY-SUPRAPUBIC—MEDIAN PERINEAL **" POCKET-BOOK OF MEDICAL PRACTICE__________ Thompson's or Bigelow's lithotrite through the urethra, and when the blades rest in the lowest part of the blad- der, gently slide them together. If they catch the stone, screw them together and crush it. The blades may be rotated from side to side to catch the stone, but, when crushing it, should point forward. When the stone is re- duced to small fragments, close the blades, remove the instrument and, with a Bigelow's evacuator, wash out the fragments. Repeat these processes until all frag- ments are removed. ________ SUPRAPUBIC CYSTOTOMY. Preparation.—Prepare the patient.* Wrap the penis in antiseptic gauze. Have an assistant introduce into the rectum, above the sphincters, an oiled rubber bag, and distend moderately with air or water. Draw the urine with a soft catheter and inject 4 to 6 ozs. of warm Boric solution. Incision.—Incise the skin for 2 or 3 inches just abore the pubes, and carefully separate the tissues down to the bladder. If the peritoneum appears in the wound, retract it upward. With a round, smooth, curved needle, catch a guy-rope into the bladder on each side of its pro- posed incision. Make a one-half to three-quarters inch incision into the bladder, and quickly introduce the finger to hook under the stone, or to explore before the fluid is expelled. An electric light may be introduced for ex- ploration. Growths may be removed by Thompson's vesical forceps. Closure. — Introduce a three-eighths inch non-fenes- trated rubber tube just into the bladder, and suture the wound snugly about it, layer by layer. Hold the tube in place by a strand of silk-worm gut passed through it and the skin on each side. To this tube attach a long one to drain into a bottle, containing a little antiseptic solu- tion, beside the bed. Dust the wound with Aristol or Iodoform and apply a dry, gauze dressing around the tube. If the bladder has not been lacerated, close the incision without a tube and drain the bladder for 2-5 days by a retained catheter. MEDIAN PERINEAL CYSTOTOMY. Operation.—Prepare the patient* Incision:— Place the patient on his back with the thighs and knees flexed symmetrically. Introduce a grooved lithotomy staff into the bladder, and have an assistant hold it vertically in the median line and hooked close up under the pubes. Make a 1-lyi inch skin incision midway between the anus and scrotum. Then, with the knife edge forward, and the left forefinger in the rectum as a guide, incise deeply until the knife reaches the groove in the staff. In- cise the urethra backward for #' inch, introduce the clean forefinger and push it into the bladder. Closure. —Pass a. ys~y2 inch, thick-walled, nonfenes- trated rubber tube into the bladder, suture the wound *As under Asepsis and Antisepsis, and Anesthesia. URETHRA-INJURIES-URETHRITIS-STRICTURE 351 _____________POCKET-BOOK OF MEDICAL PRACTICE snugly about it, and leave in place for 3-5 days, or more if it is desired, to continue the perineal drainage for more than 2 weeks. OPERATIONS ON THE FEMALE BLADDER. Operation. — Exploration, and the removal of small stones may be performed through the dilated urethra. Other operations are made by suprapubic cystotomy. URINARY RETENTION. Reference. — See under Surgical Emergencies; En- larged Prostate; Urethral Injuries; Stricture. INJURIES OF THE URETHRA. Early Diagnosis.—Bleeding from the meatus, retention of urine, perineal or penile swelling, increased by at- tempts at urination; often a catheter cannot be passed. Treatment. — In severe perineal bruises and urethral lacerations, pass a metal catheter (about 18 F.) and leave it in place for 1 to 3 days. Apply pressure and cold or Lead-water-and-laudanum to the perineum. If a ca- theter cannot be passed, make a median perineal incision down to the point of obstruction and carefully search for the proximal end of the urethra. If'the end cannot be found, performSuprapubic Cystotomy and retxogradecathet- erization, thus having a guide into the bladder for the first catheter. With catgut, suture the ends together over a soft catheter, leaving it in place for 3 to 5 days. Drain the perineal wound with gauze for 4 to 8 days, and after 2 weeks pass large bougies frequently. FOREIGN BODIES IN THE URETHRA. Reference.—See under Surgical Emergencies. URETHRITIS. General.—All forms are to be treated along lines similar to the treatment of gonorrhoeal urethritis. See under Venereal Diseases. _______ URETHRAL STRICTURE. Diagnosis.—Determine the size, location and consist- ency by Otis' bougies, beginning with 15 F., having pre- viously slit the meatus if necessary. TREATMENT. Gradual Dilatation.—It is indicated Lor large- and some small-calibre strictures of the deep urethra, and soft strictures in the pendulous urethra. Have the patient urinate; wash out the urethra with sterile water and cleanse the meatus. Patient supine, thighs slightly flexed. Sterilize the curved steel sounds and lubricate each one with Glycerine or Carbolized olive oil. Begin with a sound whose point easily enters the stricture. Dilate slowly and do not use force enough to drive the blood from under your thumb-nail. Follow first the floor 352 URETHRA-STRICTURE-ELECTROLYSIS-DIVULSION POCKET-BOOK OF MEDICAL PRACTICE and then the roof of the urethra in passing a sound. Have a number of sittings 4 to 5 days apart, and gain only about '3 sizes F. at each one, up to size 32 F. If a very sharp reaction follows a dilatation, wait 8-10 days be- fore repeating. Electrolysis.—In expert hands, the use of a dilating electrode with the galvanic current, often cures. Internal Urethrotomy.—It is indicated for small or fibrous strictures in the anterior urethra. Prepare the patient.* Under strict asepsis, introduce the guide-and- staff of a urethrotome. Hold the staff exactly in the median line, introduce the blade and push it down through the stricture, cutting strictly in the median line. Pass a bulbous bougie to see that the stricture is com- pletely divided. After 4 days begin the regular passage of a full-sized sound, gradually increasing the interval from 2 to 7 days. Fort's Electrolytic Urethrotome.—It may be used without confining the patient to bed afterward. Connect the nega- tive pole to the blade, and the positive pole to a pad over the pubes, and pass the guide and blade into the urethra. When the blade strikes the strictures, turn on 10-15 Ma, and continue up the urethra until all strictures are di- vided. This takes about one-half minute, and causes little pain. Then pass a 22 F. sound. Divulsion.—It is performed in the same class of cases, using a Gross', Gouley's or Thompson's divulsor, and carefully observing asepsis. A large bougie is then passed and a catheter tied in the bladder for 3 or 4 days. External Urethrotomy.—It is indicated for strictures in the deep urethra that are tight, or not amenable to gradual dilatation. Prepare the patient.* Pass a grooved staff up to, or if possible, through the stricture over a filiform bougie. Incise as in Perineal Cystotomy. If the staff passes into the bladder, slit the stricture along the groove up to the bladder. If the staff does not pass the stricture, open the uretha yi inch in front of the stricture, hold the sides of the urethra apart with for- ceps, if possible, and pass a fine, probe-pointed knife or grooved director through the stricture into the bladder and slit the urethra up to the bladder. Pass a gorget into the bladder and along it pass a catheter. Pass a metal catheter from meatus to bladder, with the aid of a gorget if necessary, and leave it in place for 3 or 4 days. Tight Strictures.—Introduce a filiform bougie by care- ful and patient manipulation, if necessary introducing several at once to fill up pockets. When one passes, try to introduce another beside it, or, if this fails, tie the bougie in place for 24 hours, and try again. Or pass over it a railroad catheter, urethrotome or grooved staff, and open the stricture internally or by External Ureth- rotomy. Strictnre of the Meatus.—Incise from within outward posteriorly, with a curved bistoury. Introduce a bit of L*As under Asepsis and Antisepsis, and Anesthesia. 7^?R0STATITIS-ENLARGED PROSTATE-PROSTATECTOMY 353 -:\_______ POCKBT-BQOK OF MEDICAL PRACTICE .;rx>tton or, a't intervals, a meatus-bougie until healing is *;: complete. PROSTATITIS. 'J- Acute.—Treatment the same as for acute cystitis. If ^abscess occurs, open at once, through a median perineal ncision. Chronic.—Treat any accompanying posterior ureth- '---itis; remove stricture, phimosis, cystic calculus, etc. ■--Jive cold or hot hip-baths and cold or hot enemata. For- ?"oid highly seasoned foods, alcoholics and over-exertion. -::Vlilk the prostate and seminal vesicles as described vinder Seminal Vesiculitis. Passing a large steel resound (18-29 F.), so that the straight part enters the :,>3ladder, once a week, sometimes benefits. Medicinal.—See Cystitis, and Enlarged Prostate. ENLARGED PROSTATE. (HYPERTROPHY OF THE PROSTATE.) TREATMENT. ~- ■ Regular Catheterization.—It is indicated if catheteriza- tion is easy and painless, the patient intelligent and -lextrous, cystitis only mild, and the muscular tone of he bladder fair. Teach the patient how touse the instru- nent and to observe asepsis. ■-- Care of Catheters.—After using, wash them with cold :-(vater and soap, and dry. Before using, sterilize metal >r rubber ones by boiling; soak woven elastic ones 15 to . JO minutes in Carbolic acid 5%, Lysol 2(/e, or Mercuric oichloride (1:1000), and rinse in sterile water. Frequency.—If there are 3 ozs. of residual urine, cathe- _:erize at night only; if 6 ozs., night and morning; if over j ozs., once more in the 24 hours for every 2 ozs. up to 6 : :imes. Drainage of the Bladder may be instituted by a per- manent, silver, siphon-tube introduced by a Suprapubic ■ Cystotomy, by a self-retain ing catheter, introduced ^through a canula, or by a self-retaining tube, introduced ^Tby a Median Perineal Cystotomy. >' Prostatectomy.—The hard, fibrous nodules may be re- amoved by enucleation through a slit in the bladder mem- f.brane after suprapubic cystotomy, an assistant making ^counter-pressure in the rectum. Or the gland may be re- * moved through a curved incision across the perineum, and the bladder may, or need not, be opened from below, as seems best. Some make counter-pressure by a finger passed into the bladder by a suprapubic opening. After : either operation, free drainage of the bladder should be provided for 4-5 days. It is well to leave a catheter in the urethra for 3 days. A sound is passed after a week. •'_, Bilateral Castration.—It is generally followed by pros- 'tatic atrophy. Division of ligature of the vas deferens on both sides is less dangerous, and produces the same -results. ; Bottini's Operation.—It has given the best results of any operation, in the cases reported. The prostate is in- 854 SEMINAL VESICULITIS-0RCHITIS-EPIDIDYMIT18 OUT POCKET-BOOK OF MEDICAL PRACTICE__________ cised posteriorly on each side, latero-posteriorly, with a special electrolytic instrument passed through the urethra. Dilatation with a galvanic electrode, in the hands of an expert, often gives prolonged relief from symptoms. Gradual Dilatation.—With steel sounds, is of benefit General Measures.—Prevent indigestion and constipa- tion. Have the patient avoid cold, wet, alcoholics and sexual excitement. Advise warm clothing, fresh air, moderate exercise and the drinking of 3 pints or more of pure water a day. Medicinal.— Aconite1*, and Gelsemiumi*; alternation, when retention occurs. At other times, Gelsemiumk; Cimicifuga2x; Sulphur3x; Saw PalmettoTr. (5-30 gtts. 4 times a day). ______ SEMINAL VESICULITIS. Acute.—Same treatment as for Acute Prostatitis. Stop urethral treatment. Chronic.—Treat any accompanying posterior urethritis as described under Gonorrhea. Use hot rectal ene- mata. Milk the organs once a week by a finger in the rectum, stroking downward against the prostate, while the patient stands with the trunk bent forward at a right- angle and leaning on something, and you make counter- pressure above the pubes with the other fist. Abscess.—If milking does not evacuate the pus, drain by a rectal incision and wash out the cavity. ORCHITIS AND EPIDIDYMITIS. ACUTE. Support.—Throughout the disease, hold the whole scrotum up against the pubes by a square cloth folded diagonally, and the corners fastened to a waist-band. Early.—Paint the skin over the cord with Guiacol (15m.) and over the testicle with the same quantity dissolved in Glycerine (30 m.). Repeat this every 8 hours at first, gradually lengthening the interval to 24 hours on the third or fourth day. Then apply Vaseline if necessary. Keep the scrotum covered with a thick layer of cotton and a water-proof protective, changing the cotton daily. Pain.—If this treatment does not relieve pain, perform aseptic puncture of the visceral layer of the tunica in 2 or 3 places with an edged needle or tenotome. Hot fo- mentations of Hamamelis, or a Tobacco-and-flaxseed poultice, will relieve pain and reduce swelling. Later.—As the swelling partially subsides, strap the testicle with adhesive-plaster, or apply an ointment of Ext. Belladonna and Mercurial-salve, equal parts; or, Ichthyol (10%) in Vaseline. General Measures.—Avoid constipation, highly seasoned foods, alcoholics, tobacco and sexual excitement. Advise light diet, and rest in bed when possible. Medicinal.—Aconite!*; Belladonna!*; Clematis^*; Ham- amelislx; Mercunus3x; Pulsatilla!*; Sulphur.3* ORCHITIS-HYDROCELE-VARICOCELE-CIRCUMCISION 355 _______________POCKET-BOOK OF MEDICAL PRACTICE______________ CHRONIC. Treatment.—Support the testicle. Treat the cause— ; chronic urethritis, prostatitis, vesiculitis, etc. Apply Ichthyol (10-20%) in Vaseline; Lanolin or Vasogen. Strapping sometimes benefits. Relieve pain as in the acute variety. Tuberculous.—Before softening occurs, apply Guiacol and Olive oil (each 20 m.) daily. If the skin becomes sore, apply it to the cord and groin. After softening, remove the focus by incision and the curette. Castration is sometimes indicated. General measures for tuber- culosis. Medicinal.—Conium3x; Clematis3*; Calcarea iod.3x; Iodine2x; Iodide-of-lime (y\-yi gr.)lx; Kali iod.; Hepar sulph.3x; Pulsatilla. 2x SYPHILITIC ORCHITIS. Treatment.—Support the testicle and give general treatment for syphilis—Mercury, Kali iod., etc. Opera- tion is seldom necessary. HYDROCELE. Congenital.—The fluid can be returned into the ab- domen. Apply a truss as for hernia. Acquired.—Under strict asepsis, introduce an aspirat- ing-needle, draw off the fluid and, after washing out the cavity with sterile water, inject, for adults, 10-60 m. of Carbolic acid (95%), according to the size of the sac. Distribute the acid throughout the sac by manipulation. Support the scrotum and forbid active exercise for a few days. A permanent cure generally results in 2 weeks. This method seldom fails, but if it should, anesthetize, incise the sac, pack it with gauze for a few days and allow it to granulate together. VARICOCELE. General Treatment.—Reassure the patient; correct in- digestion and constipation; advise outdoor exercise; cold shower-baths; the use of a scrotal suspensory. Operation.—It is indicated if there is much pain, atrophy of the testicle, or hypochondriasis. Prepare the patient carefully. Incise down to the enlarged cord for lyz-2 inches. Separate the bunch of veins from the artery and vas. Ligate the veins at two places 1 to 2 inches apart, with catgut, leaving one end of each liga- ture long. Cut away the veins between the ligatures and draw the ends together by tying together the long ends of the ligatures. Other steps as in Wound Treatment. CIRCUMCISION. Preparation.—Prepare the patient. Local anesthesia may be employed by constricting the penis and injecting 4m. of a 4% Cocaine or Eucaine solution at each of 4 different points—dorsum, sides and frenum, and waiting 15 minutes. 356 CIRCUMCISION-OPERATION-DRESSING POCKET-BOOK OF MEDICAL PRACTICE Operation.—Loosen all adhesions to the glans by a probe or by retracting the foreskin, and snip the frenura. Catch the junction of skin and mucous membrane, front and back, with forceps or tenacula, and produce slight traction. Grasp the foreskin lightly with a pair of for- ceps, or between the handles of a pair of scissors, and cut it from back to front, a little higher on the dorsum. Slit up the mucous membrane on the dorsum and trim off the corners thus made. Stop hemorrhage by pinch- ing with a forceps or by torsion and, with interrupted catgut stitches, carefully catch the edges of the skin and membrane together. Introduce the stitches at the dor- sum and frenum first. Dressing.—Dust the line of suture with an antiseptic powder (Aristol is best here) and over it wrap a narrow strip of antiseptic gauze, not covering the meatus. SECTION XXI. VENEREAL DISEASES. SYPHILIS. STAGES, PERIODS AND MANIFESTATIONS. Incubation. — The period before a chancre appears. Duration:—10 to 90 days; average, three weeks. Primary Stage.—Chancre, and bubo of adjacent glands. DIFFERENTIAL DIAGNOSIS. CHANCROID. Appears.—2 to 5 days after expos- ure. Single ormultiple; auto-inocnlable; others may appear later. Begins as a pustule or an ulcer; re- mains an ulcer. Edges, sharp-cut,as if punched out, everted or undermined. Base, uneven, sloughy, yellow, tawny; sometimes as if covered with a false membrane; no gran- ulations. Discharge, profuse; purulent; of- fensive; auto-inoculable. Induration, purely inflammatory if present; shades off into the sur- rounding1 tissues; disappears with the ulcer. Tendency to invade the surround- ing healthy tissues. Phagedena not uncommon. Bubo.—Glandular enlargement in one-third of cases; generally after 3 weeks; single; large; rapid growth;painful; skin red and ad- herent; often suppurate. Progresses rapidly. Prognosis. — Local lesions more serious; tend to spread; no consti- tutional symptoms follow. Secondary Incubation.—It comprises the period after the chancre, and before secondary eruptions appear. Characterized by anemia ; chlor-anemia ; icterus; bone- pains; general glandular involvement, and fever. Dura- tion:—12 to 200 days; average, 6 weeks. Secondary Stage. — Characterized by cutaneous and membranous lesions (eruptions and ulcerations) and gen- eral lymphatic enlargement. Duration:—1-3 years. Intermediate Period. — After secondary symptoms dis- appear ; ending in recovery or tertiary symptoms. Duration:—2 to 55 years; average, 2 to 4 years. Tertiary Stage.—Characterized by infiltration of the tissues, by new cell-growth (gummata) causing deep (357) Appears.—10 to 90 days; average, 3 weeks after exposure. Generally single; if multiple.all ap- pear at once; not auto-inoculable. Begins as an erosion or a papule; re- mains an erosion; may ulcerate if irritable or inflamed. Edges, adherent and sloping toward the center. Base, smooth, shiny and red; some- times gray, black or livid; cov- ered with granulations. Discharge, scant}'; serous or sero- sanguineousjnot auto-inoculable; sometimes absent. Induration marked; sharply de- fined; does not shade off into the surrounding tissues; may greatly outlast the erosion. No tendency to invade surrounding tissues; "soon 4>ecomes circum- scribed; phagedena seldom oc- curs. Bubo.—Glands always enlarge; 1st or .M week; multiple, small, slow growth;/o/>i/«.v; thc» skin above is normal; rarely suppurate. Progresses slowly. Prognosis:—Local lesion, good; cir- cumscribed. Const jtu tional symptoms follow. 358 SYPHILIS-PROPHYLAXIS-CHANCRE-BUBOES ______POCKET-BOOK OF MEDICAL PRACTICE ulcerations of the skin and mucous membranes, which tend to spread; and lesions of all other tissues, especially the bones and nervous system. Duration:—Indefinite Occurs in about 12% of all persons infected. Mixed Infections.—These may occur, giving the appear- ance of chancroid, but with the well-defined and per- sistent induration of chancre. Other Conditions. —Herpes, Cancer and Lupus, must also be differentiated from chancre. DIAGNOSIS OF SECONDARY SYPHILIS. 1. History of a chancre. 2. Eruptions.—(a) Seldom itch, except on the scalp; (j) Arranged symmetrically (on the two sides); (c) Color- red; brown; purple; black; coppery ("raw ham"); (d) Polymorph us (several varieties at once); (e) Respond to Mercury. PROPHYLACTIC TREATMENT. Local.—Wash thoroughly any part which may have come in contact with the infection, in soap and water. If there is a break in the surface, cauterize with Nitric acid. Otherwise, bathe the surface for 3 to 5 minutes with a mild antiseptic solution. TREATMENT OF THE PRIMARY STAGE. General Measures.—Explain to the patient that the di- sease is curable, and take the case with the understand- ing that it will remain under treatment for 3 years (if a male), 4 years (if a female). Insist upon the discon- tinuance of alcohol as much as possible, and of tobacco entirely, and upon good hygiene in general. Have the teeth put in good condition. The Chancre.—Soak the part twice a day in warm salt water (about 1:32); wash it with a mild antiseptic, as Bichloride (1:2000 or 1:3000); or, spray it with Hydrogen- peroxide (diluted one-half). Dry, and dust with Calo- mel, Calomel and Bismuth-subnit. (equal parts); or, Aristol. If phagedena or gangrene arises—Anesthet- ize with Nitric acid; dust with Iodoform or Aristol;ap- ply warm, moist, antiseptic dressings; give nutritious diet, with stimulants or tonics if necessary, and secure sleep for the patient. After the ulcer has healed-Oint- ments, containing Ichthyol, or a Mercurial, hasten ab- sorption of the induration. Buboes.-If they tend to become large, or to suppurate, paint with Iodine Tr.; or, apply Ichthyol-and-lanoline; or, Vasogen (1:4); or, Mercurial ointment; and a band- croidalBubl SUppurate' treat as described under Chan- a *nt?™alMcation.-If the diagnosis is indubitable, nafnf i C^a"fe is so located as to be disfiguring or fSh.J ■ glle Mercuriu* sol.2x; or, Mercurius prot.2* toms a ^ giVC Mercury until constitutional symp- SYPHILIS-INUNCTIONS-FUMIGATIONS-INJECTIONS 359 _______________POCKET-BOOK OF MEDICAL PRACTICE Medicinal.—Arsenicum3x; Asaf etida3x; Corall i um rub.3x; Hepar3x; Kali bi.2x; Lycopodium6x; Phosphorus3x; Phos- phoric acidlx; Silicea^; Sulphur.3x These are sometimes indicated for complications, by the totality of the symp- toms. TREATMENT OF THE SECONDARY STAGE. General Measures.—Diet.—Plenty of meat and milk. Cod-liver oil, and other nourishing preparations are of value. Narcotics.—Tobacco should be stopped; alcohol used only as a medicine, in prescribed quantities. Clothing.—Warm enough to protect from damp and cold; flannels in winter. Hygiene.—Fresh air, exercise and sleep are invaluable. Cleanliness.—Sponge the chest and shoulders every morning with cold or tepid water, then with alcohol, and rub dry with a coarse towel. Dust the folds of the skin (axillae, etc.) with borated talcum. Take a hot bath twice, or a Turkish bath once, a week. Keep the mouth and teeth clean. Medication.—Mercury in some form almost continu- ously. Mercurius sol. or vivus.1-**—For mild cases without much glandular enlargement; syphilitic fever; nocturnal pains. Dose:—(grs. v., 4 to 6 times a day.) Mercurius prot.1*—Where the glands are much involved; alopecia, in intractible cases. Dose:—(2* grs. v., 4-6 times a day), ( grs. ii., 3-5 times a day.) Mercurius oin.l*—Much glandular involvement with tonsillar affections; Hunterian chancre. Dose:—(grs. v., 4-6 times a day.) Mercurius corrM—Rapidly-spreading, serpiginous ulcerations; iritis; swelling, redness and burning of the mouth, uvula or pharynx; syphilis of internal organs. Dose:—(grs. v., 4-6 times a day.) Cinnabar.2*—Secondary syphilis of the mucous mem- branes, especially nose and throat. Dose:—(grs. v., 4-6 times a day.) Inunctions.—Give for rapid effect, or when Mercury, internally, does not agree, or does not seem to take effect. Rub 20 to60grs. of Mercurial ("blue") Ointment, Oleate of Mercury (20%), or Mercurial Vasogen (33%), into the inside of the thigh, after washing it thoroughly with soap and water. Next time apply it to the other thigh, then to the inside of one arm, then the other arm, then the groin, the popliteal space, etc. Fumigations.—Sometimes useful in emergencies. Place 20-30 grs. of Calomel, or 15 grs. Calomel and 20 grs. Cinnabar, in the fumigator under a cane-seat chair. Throw a mackintosh or blanket about the patient and chair, reaching to the floor, and light the lamp. When the vaporization is complete, the patient puts on flannel drawers and shirt and cools off slowly in bed. Do not repeat oftener than every 2-3 days, and reduce the quant- ity of Mercury if the patient feels debilitated afterward. Injections.—Of mercurial solutions are not advisable. <»fin SYPHILIS-PSORIASIS-ONYCHIA-SALIVATION OOU POCKET-BOOK OF MEDICAL PRACTICE___________ Mercurial Baths.—Of value where the skin is delicate, and Mercury is not well borne internally; or, by fumiga- tion. Dissolve 240 grs. Bichloride and 80 grs. of Ammon. chloride in 4 oz. of water, and add it to the bath. Cover the tub with a blanket and remain in the bath for about an hour with only the head exposed. Beware of saliva- tion. . Intercurrent Remedies.—See Special Therapy. LOCAL TREATMENT. Cutaneous Lesions.—In general, Alkaline and Sulphur baths, with the application of a Mercurial ointment (Amnion. Merc, or Calomel). Circumscribed lesions may be painted with Collodion containing Bichloride (1 to 4 grs. to the oz. ). Crusts.---Remove; cleanse the surface antiseptically, and dust with Calomel, Calomel and Bismuth subnit, Aristol, or Iodoform. Psoriasis.—In the palms or soles. Apply Diachylon Ointment; Mercurial Plaster, or Iodine (Tr). Alopecia.—Keep the hair short, and brush it for three minutes daily. Wash the scalp daily with Bichloride solution (1:2000), and once a week with green soap and water, or with an egg and Borax wash (1 egg, 1 oz. Borax, 16 oz. water); then wash in warm water and dry. Apply every night a little of the following hair-tonic, or, if the hair is dry and brittle, rub in a little Sulphur and Vaseline ointment. Hair Tonic.—IJ. Tr. Canthardis, "ss.; Quin. Bisulph. Ac. Salic, aa grs., lx.; Ess. Cologn., 3j.; Alcohol, ad §iv. M. Internally.—See indications of Cinnabar; Graphites; Fluoric acid; Hepar; Nitric acid; Phosphorus; Sulphur. Onychia.—If acute, apply a hot, moist, antiseptic com- press; and open if pus forms. Sometimes the nail and matrix must be removed. If chronic, apply Ammoniated Mercury ointment and a finger-tip. Membranous Lesion.—To mucous patches and ulcers apply Silver-nitrate, and prescribe a mild, antiseptic astringent wash, to be used often. See Salivation. Internally.— Asafetida; Hepar; Mercury. Complications.— Syphilitic Fever:—Give internally, Baptisia*x; Bryoniaix; China2*; Gelsemiumlx; Mercurius sol.3x; Phytolacca!*; as symptoms indicate. Salivation.—Stop the use of Mercury for a time. Pre- scribe the use of a soft tooth-brush, a mouth-wash of Alum, Alcohol or Potass, chlorate, and water, or a mild antiseptic solution; sometimes a spray of Hydrogen- peroxide; Turkish or hot baths; nourishing, liquid food. Apply Silver-nitrate to ulcerated surfaces. Internally, Hepar sulphur. Organs of Special Sense and Nervous System.—See the articles on diseases of those parts. TREATMENT OF THE INTERMEDIATE PERIOD. General Measures.—As for Secondary Syphilis. Medication.—Mercurius qor.3x; or Protoiod.2*; grs. v.. 3 times, and Kali iod. and Soapwort (equal parts, SYPHILIS-HEREDITARY-SPECIAL THERAPY 361 POCKET-BOOK OF MEDICAL PRACTICE triturated together) grs. v., 3 times a day. Intercur- rent Remedies as seem indicated. Duration.—Continue treatment for 6 months after the last manifestation. TREATMENT OF TERTIARY SYPHILIS. General Measures.—As for Secondary Syphilis. Medication.—Kali iod. and Soapwort (equal parts triturated together) 5-10 grs. 4 to 6 times daily, as seems necessary, gives better results than Kali iod. alone. Kali iod.—Give, when used alone, in doses of grs. v. to lx., 4 times a day, according to the severity of the case. Intercurrent Remedies. — Mercury; Asarum; Arseni- cum; Aurum; Calcarea; Fluoric acid; Hepar; Kali bi.; Nitric acid ; Protonuclein ; Staphysagria ; Sulphur ; Thuja; etc. (See Special Therapy.) Locally.—Cleanse the ulcer with an antiseptic solution and dust with Mercurius sol.3x; Calomellx; Aristol, or Iodoform. Sometimes Protonuclein Special, locally, is of great value. MARRIAGE OF SYPHILITICS. Time.—A man should not marry earlier than 3 years after the initial leison, nor before he has gone 1 year without symptoms or medicinal treatment. Women should wait 1 or 2 years longer. HEREDITARY SYPHILIS. Reference.—See Diseases of Children. SPECIAL THERAPY IN SYPHILIS. Acid Fluoricum.3x—Tertiary affections of bones and skin; all discharges thin and acrid; cold relieves pain. Acid Nitricum.2* — Secondary affections of the muco- cutaneous outlets of the body; cases overdosed with Mercury, or with Kali iod.; cracks; fissures; easily- bleeding ulcers. Arsenicum.33*—Sypilitic cachexia; anemia; emaciation; debility. Dry and scaly eruptions. Ars. iod.2x—Syphilitic consumption; specific psoriasis. Asafetida.3x—Tertiary lesions of the long bones and skin; nervous symptoms. Aurum.6*—Lesions of facial and cranial bones; ozena; orchitis; cachexia; melancholia. Ferrum lactate.lx—Erethistic anemia. Graphites.6*—Syphilitic eczema; indolent skin affec- tions; ulcerations and glandular swellings. Hepar Sulphur.3x—Abuse of Mercury and Kali iod.; salivation; glandular enlargements; alopecia. Iodine.2x—Syphilitic cachexia; secondary lesions; pus- tular eruptions. KalL bich.2x—Ozena; pharyngitis and laryngitis; punched-out ulcere. Kali iod.Tr-lx—All tertiary lesions—syphilides, gum- mata, bone affections, etc. Secondary lesions; hereditary or after the abuse of Mercury. Intermediate period. 362 CHANCROID-SIMPLE-PHAGEDENIC-BUBO POCKET-BOOK OF MEDICAL PRACTICE___________ Mercurius.—All stages, especially the secondary. See Treatment of the Secondary Stage. Mezereum.3x—Thick, moist, scabby eruptions; neural- gias, etc., from Mercury. Nocturnal pains; exostoses. Phosphorus.3x—Plantar and palmar psoriasis; alopecia; exostoses of the skull and long bones; nervous affections. Protonuclein.—Syphilitic cachexia and anemia. Gland- ular onlargements. Dose:—Grs. ij-—Iv., 4-6 times a day. Phytolacca.lx—Secondary syphilis; rupia; mucous patches;enlarged glands; tonsillitis; rheumatism; nightly bone-pains. Stillingia.2x—Ostitis and periostitis of the long bones; Ozena; Syphilitic rheumatism and neuralgia. Sulphur.3*—Tertiary syphilides; abuse of Mercury. Thuja.2x—Syphilitic herpes, warts and condylomata; secretions acrid and corroding. CHANCROID. Diagnosis.—See under Syphilis. Prophylaxis.—See under Syphilis and Gonorrhea. TREATMENT. Simple Chancroids. — Cleanse the ulcer, dry it and apply a drop of Carbolic acid (95%) for anesthesia. Then cauterize it thoroughly with pure Nitric acid, reaching all parts. Afterward, wash it every few hours with a warm, mild, antiseptic solution, dry it and dust it with Aristol, Iodoform or Calomel. If a tight prepuce pre- vents reaching the ulcer, slit the prepuce on the dorsum. If a circumcision will wholly remove the ulcer, cleanse it carefully and circumcise. Phagedenic Chancroids.—These require continuously hot, moist, antiseptic dressings, after thorough cauteriza- tion. See under Ulcers. Medication.—Nitric Acid. 2*—Superficial ulcers on the glans or prepuce, looking clean, but exuding an offensive discharge. Or, deep, irregular ulcers with exuberant granulations. Mercurius.3*—Superficial, rapidly-spreading ulcers, with enlarged inguinal glands. Kali bi.2x—Deep, regular ulcers, as if punched out. Thuja.2x— Dirty, flat, eroded ulcers, surrounded by redness; sticky, foul discharge; burning pain. Condylo- mata often present. Chancroidal Bubo.— Early, apply IodineTr. or Ichthyol (20-33%%) in Lanolin or Vasogen. Apply a spica-ban- dage, and order rest. Internally, Mercurius3*, or Bella- donnaLx, as seems indicated. Later, apply a thin, moist, antiseptic compress, and over it a hot shot or water-bag. Internally, Mercurius.3* Some inject 15-30 m. of saline- solution. If suppuration is inevitable, give Hepar sul- phur.3* After Pus Forms:—Incise, curette (under anes- thesia) and wash out the cavity with sterile water and an antiseptic solution. Introduce a little gauze for 2448 i hours, to hold the wound open. Then allow the cavity GONORRHEA-URETHRITIS- ANTERIOR-POSTERIOR 363 _______________POCKET-BOOK OF MEDICAL PRACTICE to granulate up, stimulating if necessary. Internally, Silicea.6* ' GONORRHEA. Incubation.—One to twenty days; usually about four days. Anterior Urethritis.—Is confined to the penile urethra, i. e., the urethra contained in the corpus spongiosum. Posterior Urethritis.—In the membranous and prosta- tic portions, is marked by increased frequency in the desire to urinate, difficulty in expelling the urine, dull pain and a sense of heat and weight in the perineum and rectum, sharp pain, referred to the glans penis, with blood, at the end of urination; prolonged erections and frequent emissions. TREATMENT. Prophylaxis.—Wash the penis thoroughly after inter- course, and urinate, checking the stream suddenly a few times to flush out the fossa navicularis. As soon as pos- sible bathe the glans and prepuce with Ichthyol ( 20%) or Protargol (1%), watery solutions, and inject the anterior urethra with the same, retaining it for 3 to 5 minutes. No method is unfailing. GENERAL MEASURES. Diet.—Plain and light; milk is very good. Avoid highly spiced foods, acids, asparagus, effervescing drinks; take coffee or tea only once a day. Narcotics.—Forbid alcoholics altogether, and tobacco as far as possible. Rest.—Recumbent position as far as possible. Forbid ovef-exertion, all violent exercise, sexual excitement and the companionship of women. Support the testicles by a supensory. Excretions.—Avoid constipation. Advise the free drink- ing of water between meals. Keep the urine mildly alkaline by Vichy-water or Soda-bicarb. 5 to 10 grs.; or, Lithium-citrate, 3 to S grs., 4 times a day. Keep the in- tervals between urination as long as possible. Cleanliness.—Exercise the greatest care that the eyes do not become infected. Prescribe a "gonorrhea-bag," to be worn with a little cotton in the bottom, which is changed when soiled. Advise frequent sponge-baths. LOCAL TREATMENT. Caution.—When the deep or posterior urethra is not in- volved, use only anterior injections or irrigations. Injections.—Anterior injections and irrigations may be intrusted to an intelligent patient. Just before the pro- cedure the patient urinates, having held the urine as long as possible beforehand. He sits on the edge of a chair with a roll of toweling behind the scrotum. The left hand holds the glans and opens the meatus, the right hand manipulates the syringe or irrigator-tip. Injec- tions are made with a 2 to 3 fl. dr. urethral syringe, with a soft-rubber point. The fluid is injected slowly, and held, by compressing the meatus for 2 to 10 minutes. It 364 GONORRHEA-INJECTIONS-ACUTE URETHRITIS POCKET-BOOK OF MEDICAL PRACTICE_________ is best to inject 2 to 3 syringefuls of warm water before using the medicated fluid. Syringe.—Irrigations are made with the Valentine's syringe-tip, or Kiefer's two-way tube, attached to an irrigator or fountain-syringe. About 2 quarts of solution are used each time. Deep Injections.—Posterior injections and irrigations should be made only by the physician. After urinating, the patient sits on the extreme edge of a chair without a perineal pad. The irrigator or syringe-tip is introduced into the meatus and, after injecting or irrigating the anterior urethra, the patient is instructed to relax the sphincter muscle and the force of the stream is gradually increased up to a six-foot column. If the fluid does not enter the bladder after a few minutes, a soft-rubber catheter (12-16 F.), with the eye near the point, is at- tached, and inserted just far enough to cause the fluid to enter the bladder. When the desired amount of fluid has entered, the catheter is withdrawn and the patient urinates the fluid out. For posterior injections, 2-5 fl. oz. are used; for irrigations, 2-3 bladderfuls. Aggravation.—Aggravation of symptoms often follows urethral injections, instillations, local applications or instrumentation. Forewarn the patient. ACUTE URETHRITIS. Hot-water.—Immerse the penis as often and as long at circumstances will permit, in water as hot as can be borne. Injections or irrigations of the anterior urethra J 4 to 6 times a day with water at 100°-115° F. are of great value. Boric-acid solution (1:100) may be substituted. IProtargol.—A silver proteid compound has been used with the greatest success. In anterior injections a solu- tion {%-!%) is used 3 to 4times a day,or a 2% solution [ once a day, and less frequently as the case improves. For posterior injections, a yi-2% solution is used once a day. The injections should be continued for 7-10 days after the gonococci and discharge have disappeared, or should be displaced by astringent injections at this time. Potassium Permanganate.—Solutions, used according to Valentine's method, are very successful, but should be followed up for a week or two by astringent injections. It is used hot as follows: First day, 2 anterior irrigations (1:2000-1:4000); second day, 2 anterior irrigations (1:3000-1:4000); third day, 1 intra-vesical and 1 anterior (1:6000); fourth and fifth days, 1 intra-vesical (1:3000); sixth and seventh days, 1 intra-vesical (1:3000-1:1:2000); eighth and ninth days, 1 intra-vesical (1:2000-1:1000); tenth day, 1 intra-vesical (1:1000) and 1 anterior (1:5000). Hot irrigations of Permanganate (1:13000-1:12000) are often used before injections of other agents, especially where edema, exists. L Ichthyol.—It is used with success, rivaling that of Pro- targol, and is less expensive. A few injections of a watery solution (5-10%) is said sometimes to abort with- out irritating, if used at the earliest symptoms. Later, _________________________________________ CHRONIC URETHRITIS-IRRIGATIONS-INJECTIONS 365 ______________POCKET-BOOK OF MEDICAL PRACTICE anterior injections of—Ichthyol, 45 grs.; Glycerine, loz.; Water, 16 oz. Posterior injections of a watery solution of Ichthyol (2% ) are also used. Hydrogen-Peroxide.—Dilute to a 2-4 volume solution; use asan anterior injection, 3 to 4 times a day. Astringent and Stimulating Injections are especially useful after the gonococci have disappeared and only a slight discharge remains. The following watery solu- tions are good:—Hydrastis, fl. ext. (1:3); Zinc-sulphate, or chloride (2-8 grs. to 1 oz.); Silver-nitrate (1-4 grs. to 1 oz.); Zinc-permanganate (1 gr. to 8 ozs.); Acetic acid (3-6%); Pinus Canadensis fl. ext. (1:3). CHRONIC URETHRITIS. Strictures are often the cause; remove them as de- scribed under Urethal Stricture. Patches.—Granulated or ulcerated patches are treated by instillations to the affected spot, of 15-20 m. of one of the following solutions (using the Keyes-Ultzmann deep urethral syringe): Silver-nitrate (1-40, usually 5-10 grs. to the oz.); Protargol (5-10%); Ichthyol (510%). Or the same, or somewhat stronger solutions, are applied to the diseased patches, through an endoscope, by cotton on an applicator. These treatments are given every 2-7 days and, if convenient, are preceded by a Permanganate ir- rigation. Irrigations.—Irrigations of the whole urethra with Permanganate (1:12000, increased to 1:2000), Bichloride (1:20000) or Ichthyol (2-3% ) are of value. Injections. —Injections of astringent or stimulating solutions are to be used, when no definitely localized lesion is found. See Acute Urethritis. Sounds.—Cold steel sounds, passed every 2-3 days, stimulate the atonic membrane after the discharge has ceased, and prevent recurrence. URETHRITIS. Medicinal.—Agnus Castus.1*—Gleet; yellow discharge; loss of sexual power and coldness of the parts. Argentum Nitrate.3*—Subacute and chronic; burning on urination, with frequent desire; blood-streaked dis- charge. Cannabis 8ativa.Tr—Smarting, burning, stinging dur- ing urination; constant urging; copious, thin discharge; prepuce swollen and painful; strangury, pains extending into the scrotum, with dragging in the testicles. Cantharis.2*—Extension toward the bladder; blood free, or in the discharge or urine; cystitis. Copaiva.—Constant desire to urinate; painful, bloody urination; profuse, yellow, purulent discharge; chordee. Dose:—5m. capsules, t. i. d. Cubeb.Tr—Gonorrhea, especially in the stage of decline. Dose:—10m., or pulv. 5-10 grs., /. i. d. Gelsemium.Tr—Acute stage, early; moderate discharge; smarting and burning at the meatus; little pain; frequent urination. Dose;—l-2m. every 3 hours. 366 BALANITIS-BALANOPOSTHITIS-CHORDEE-PHIMOSIS POCKET-BOOK OF MEDICAL PRACTICE Hepar-sulph.3*—Muco-purulent discharge in those who have had several attacks. Ichthyol.—Has given good results. Dose: — S grSi capsules, /. i. d. Mercurius.2*—When the inflammatory process is accom- panied by free exudation into submucous tissue, and thickening of the urethral walls, producing great dimin- ution in the size of the stream of urine, and chordee. Mercurius cor.3* — Violent tenesmus, burning and scalding. Mercurius iod.3*—Subacute and chronic; enlarged in- guinal glans; indurated patches along the urethra. Methylene Blue has been used with success in some cases. Dose:—2 grs. capsules, t. i. d. Pinus Canadensis. — Is useful, especially in sub-acute and chronic urethritis. Dose:—Fl. ext., 10m., /. i. d. Santal Oil.—Is of the greatest value in all stages. Dose:—Absolutely pure, 5m. capsules, t. i. d. Sulphur.—Gleet; thickening of the urethral walls. Thuja.—Painless gleet; thin discharge; prostatic in- flammation. Consult.—Aconite; Belladonna; Campsicum; Camphor; Digitalis; Erigeron; Pulsatilla; Sepia; Terebinth. TREATMENT OF COMPLICATIONS. Ardor Urinse.—Urinate with the penis in hot water. Keep the urine alkaline. Balanitis.—Bathe the glans often with warm Boracic- acid solution; dry, and dust it with Boracic-acid powder. Balanoposthitis.—Reduce the edema by soaking in hot Boracic solution, and treat as for Balanitis. Bubo.—Treat the same as Chancroidal Bubo. Chordee.—Empty the rectum; cool room; light covers; hard mattress; cold applications; Camphor-bromide, 2 grs. every 3 hours during the evening and night, if nec- essary. Suppositories of (Opium, 1 gr., Camphor, 2 grs.). Phimosis.—Soak the penis in hot Boracic-acid solu- tion. Inject a mild antiseptic solution under the fore- skin. If this fails, slit up the prepuce on the dorsum, or circumcize. Paraphimosis.—Soak in hot water, or bind with an elas- tic bandage to reduce edema. Then compress the head of the penis with one hand and produce traction at the constricting band with the other. If this fails, cut the constricting band with a probe-pointed bistoury. Other Conditions.—For Cystitis, Prostatitis, Seminal Vesiculitis, Orchitis, etc., see Genito-Urinary Surgery. Marriage.—The patient should not marry until the urine shows permanent absence of pus, threads and gon- ococci. [ END OF SECTIONS BY L. W. B.l SECTION XXII. APPENDIX. BACTERIOLOGY. PATHOGENIC MICRO-ORGANISMS. BACILLUS TUBERCULOSIS. The Snutum.—Have the patient (preferably on first waking in the morning) wash the mouth thoroughly with pure water. After the first spell of cough and expec- toration (to clear away bronchial mucus), have the pa- tient make a second effort at cough, and what is raised is to be expectorated into a clean, wide-mouthed bottle. Caution:—Avoid obtaining "mouth sputum." Time of Examination.—Results are best if the examina- tion is made inside of 24 hours. The Specimen.—Deposit a quantity of the sputum on a clean glass slide, and spread it slightly. Hold it over a black surface; there will usually be found a number of grayish-yellow, irregular, translucent granules (caseous matter), smaller than the head of a pin. Pick up a granule with a clean pointed instrument; spread it over the surface of a clean cover-glass. If the granules of caseous matter cannot be found, a particle of pus is next best; the mucus rarely contains bacilli. Exact Method.—If specimens obtained in this way fail to reveal bacilli, take the mass of sputum and partially digest it with Caustic-potash; collect the solid portion by the centrifuge. If a few bacilli are present this will usually secure them. Incipient Phthisis.—If there is no expectoration, secure spray by forcible cough against a clean glass plate (see p. 51). Staining.—1. Spread the cover-glass with a thin (not too thin, nor yet too thick) layer of the sputum to be ex- amined. 2. Dry it in the air. 3. Fix it by passing through the flame 3 times. 4. Stain in Para-fuchsin. 5. Pass it through the flame 10 times, keeping it steaming. 6. Wash with water. 7. Wash with solution of Sulphuric acid (10%). 8. Again wash with water, washing out thoroughly. 9. Counter-stain (30 seconds) with Methylene-blue (don't overs tain). 10. Wash with water until very faint blue remains. 11. Mount in Canada-balsam (if mounted in water the bacilli appear larger). 12. Examine with oil-immersion lens {fa in.). Identification.— Shape:—It is rod-shaped, with rounded ends, and a slight curve; often occurs in pairs, placed (367) 368 KLEBS-LfEFFLER BACILLUS-GONOCOCCUS POCKET-BOOK OF MEDICAL PRACTICE end-to-end, or overlapping;.many have a "beaded " ap- pearance; the bacillus tuberculosis has no spores. Size:— Length, 1.5-3.5/u; breadth, 0.2-0.5 fit (micromillimeter). Diagnosis.—Its presence is absolutely pathognomonic of tuberculosis. At times a number of specimens will be examined before its presence is detected. Differentia- tion:—It must be distinguished from the smegma bacillus (placed in 60% alcohol the s. b. parts with its stain), and from the bacillus leprcz (exclude it clinically). KLEBS-L02FFLER BACILLUS. (BACILLUS DIPHTHERIA.) The Specimen.—To obtain:—Use a cotton swab, on the loop-end of a sterile wire; scrape it over the surface of the pseudo-membrane, and on the mucous membrane at the margin oi the pseudo-membrane; place in a sterile test-tube; close with a pledget of cotton. To Prepare.—Place a particle of the membrane on a clean cover-glass, spreading it in a thin and uniform layer, using a. sterile platinum loop. When dry, fix by passing through the flame 3 or 4 times. Staining.—Stain with Loffler's alkaline solution of Methylene-blue; time—5 to 10 minutes; rinse; place on a slide; examine with oil-immersion lens (j*j in.). Identification.—The bacillus is non-motile; size: (var- iable) average length, 2.5// to3//; breadth, 0.5// to 0.8/*. Shape:—(variable) sometimes straight, or slightly curved rod; irregular forms are characteristic—rods withoneor both ends terminating in a little knob; rods, broken at intervals into round, oval or straight segments. Diagnostic Yalue.—It is only diagnostic as confirma- tory of clinical signs and symptoms. The virulent form is found in the throats of healthy persons who have been in contact with diphtheria-patients. It persists in the throats of convalescents sometimes 5 weeks (occasionally longer). Culture-test.—Make a smear-culture on blood-serum; keep the test-tube at blood-heat (98° F.) for 24 or 36 hours (carrying in the pocket will do it). If the specific bacil- lus diphthence is present there will be colonies of gray- ish-white, moist drops; in this length of time other bac- teria will not have developed sufficiently to interfere. Ihis test is absolutely decisive. GONOCOCCUS. (MICROCOCCUS GONOSKHB^.) The Specimen.—Obtain some of the discharge from the urethra (or, in the female, the vagina). Spread a thin layer on a cover-glass. Dry in the air, and fix in the fl ame. Staining.—Stain (without the aid of heat) with satu- rated alcoholic solution of Methylene-blue; time—5 to 15 minutes. Wash with water. Stain with saturated alco- holic solution of Eosin, 5 to IS minutes. Wash in water; dry; mount. The gonococci will be stained blue (the nuclei of pus-corpuscles will also be blue),otherelements, red. Examine with oil-immersion lens. GONOCOCCUS- PLASMODIUM MALARIiE 369 ______________POCKET-BOOK UK MEDICAL PRACTICE Identification.— Size:—Diameter, 0.8 to 1.6/*. Shape:— Roll-shaped diplococcus; non-motile; no flagellar, no spores; occur in pairs (sometimes four); each one is not a perfect hemisphere—the approximated surfaces are slightly concave. They are found in the gonorrheal pus- cells. Diagnosis.—It is the specific cause of gonorrhea. In the early stage of the disease the gonococci grow in the superficial epithelial cells; later, they penetrate to the deeper layers. It is constantly present in gonorrhea; also found in the sequela?—endometritis; salpingitis; oophoritis; cystitis; peritonitis; arthritis; conjunctivitis; endocarditis. Precaution.—In diagnosis account should be taken only of cocci enclosed in cellular elements (these alone are characteristic). Note:—A coccus similar in appearance tothe gonococcus is sometimes found in urethral discharges, but it can be distinguished by the fact that it will stain by Gram's method {the gonococcus will not). THE BLOOD. PLASMODIUM MALARLE. (organism of laveran.) METHOD OF EXAMINATION. Time.—Eight hours before or after a chill is best. Obtaining the Blood.—Location—the lobe of the ear. Wash it with soap-and-water, and dry with a cloth; sterilize. Make a puncture at the bottom of the lobe, steadying it with the fingers of the left hand. Use the point of a sharp lancet, or a bayonet-pointed surgi- cal needle (a sewing needle is not satisfactory). Make a quick, sharp stab, about one-quarter inch deep. Do not squeeze the blood out; let it flow spontaneously. Gently wipe away the first 4 or 5 drops. The Specimen.—When another drop has formed, as it hangs pendent, touch it (without touching the skin) with the center of a clean cover-glass, warmed before using. Hold the cover-glass with forceps, or, if in the fingers, by the edge in such manner that the finger will not come in contact with the surface. Drop a second cover-glass on the first, spreading the drop between them. At once, holding the two parallel and horizontal, draw them apart, by sliding motion, in such manner aa to leave an evenly-distributed film of blood on each glass. Let them dry; or, if for immediate use, place a cover- glass, blood-side down, on a slide. Examination.—Use an oil-immersion lens (fa inch). Select a portion of the slide where the corpuscles do not overlie each other. The number of organisms varies greatly. Sometimes their discovery requires long and patient search. If Quinine has been recently taken, they may be absent. During the chill they retreat to in- ternal organs (spleen, liver). Identification.—In examining the slide watch carefully in order to detect, (a) any especially large corpuscle; (b) 870 DIET IN DISEASE-NASAL FEEDING POCKET-BOOK OF MEDICAL PRACTICE_________ any especially pale corpuscle; (c) anything black or dark brown; (d) any movements. The Malarial Organism.—(a) The " hyaline form:"-\\ appears in the corpuscle as a light spot in the pale greenish-yellow of the cell (they must be distinguished from white circles to be found in the center of many normal corpuscles under certain conditions of light and partial drying), (b) The pigmented form:—The pigment appears (in the corpuscles) as a group of small black dots, having active rapid motion (after motion ceases, with the death of the pigment-granules, they look like small masses of dirt, which may have accidentally in- vaded the field owing to want of care in preparing the slide). If in doubt, get a fresh slide, with the pigment- granules still in motion; identification is then not diffi- cult, (c) Segmented form:—At this stage a body forms having radiating lines, with the pigment-granules in the center; it finally splits up into another generation of young organisms, (d) Flagellate form:—Late in the life- history, some of the organisms show arms, or flagells, which sweep the field with a wavy motion. Diagnosis.—The presence of the Plasmodium in the blood is absolutely diagnostic of malaria. The various forms of the disease are readily differentiated clinically. DIET IN DISEASE. ARTIFICIAL METHODS OF FEEDING. NASAL FEEDING. Indications.—In the refractory (prisoners) who attempt voluntary starvation; the delirious; the maniacal and the insane, who refuse food; in some cases of diphtheria, and other throat affections; when taking food by the mouth is impossible. Tube.—Use a soft-rubber catheter, size about No. 8 E. Attach it to the rubber-tube of a fountain syringe. Food.—Milk, broths, or any liquid food can be used. Suantity.—From a pint to a quart. 'ethod.—If there is resistance (as in mania) have the patient held by a sufficient number of able assistants; the patient sitting, either in bed or in a chair. The hands and arms must be well secured, to prevent inter- ference. The head must be firmly held. Passing the Tube.—Anoint the catheter with vaseline or a bland oil. Have the catheter detached from the tube. Enter the point in one nostril and pass it back along the floor of the nasal cavity; keep passing it, with gentle force, and it will without difficulty find its way to the pharynx and into the esophagus. Accidents.—The end of the catheter may pass over the patient's tongue, and, if refractory, be caught between the teeth. Pinch the nostrils, to stop breathing, make pressure on the supra-orbital nerve, and the patient will quickly open the mouth and release it. Withdraw the catheter and begin again. I have known the point of the catheter DIET IN DISEASE -RECTAL ALIMENTATION 371 ______________POCKET-BOOK OF MEDICAL PRACTICE to enter the larynx. But in most cases the instrument passes without difficulty into the esophagus, especially in non-refractory patients, who must be told to "swal- low " when feelingtheend of the catheter in the pharynx. Administration.—As soon as the catheter is in the esophagus (which will be when about 2 inches still re- main outside the nostril) attach the tube of the fountain syringe, raise the bag, and in a few moments the liquid food will all be in the patient's stomach. Advantage.—This is an efficient mode of feeding, and should be more widely used by the general practitioner having cases to which it is applicable. RECTAL ALIMENTATION. Indications.—(a) Prolonged reflex vomiting (preg- nancy; seasickness); (b) gastric ulcer; (c) gastric can- cer; (d) inability toswallow food (as in coma; delirium; paralysis); (e) stricture in the alimentary tract; (f) in low conditions, when absorption by the stomach is sus- pended; (g) in fevers; (h) gastric hemorrhage; (i) ex- treme irritability of the stomach from any cause. Preparation.—(a) Cleanse the rectal surface of all mucus and feces; (b) allay irritability of the rectum, if it exists. Tube.—Size—diameter, for adults, about % inch; chil- dren, No. 12 or 14 velvet-eyed flexible catheter. Length— for adults, about 12 inches (or more). Quality—soft and flexible, but not somuchsoasto "double up" in the bowel, or so stiff as to give pain, or damage the mucous mem- brane. Syringe.—A hard-rubber piston-syringe, capacity, 2 oz. Fill the syringe, hold it point upward and expel air, then attach the tube to the nozzle. Position of the Patient.—Place the patient on the left side, with the hips raised high on pillows. The Sims gynecological position is best. Method.—Anoint the tube with oil, vaseline, butter or lard (never with glycerine). Insert it slowly, with a gently twisting, insinuating motion, up into the sigmoid flexure. Distance.—In the adult pass the tube in from 10 to 12 inches, or as high up as possible (the sigmoid veins com- municate with the inferior mesenteric; the veins of the lower rectum with the inferior vena cava). Retention.—If the patient is conscious, caution against straining. Withdraw the tube not too slowly. If there is danger of non-retention, have the hips raised high, and with a soft compress, press firmly against the anus for 20 or 30 minutes. uantity.—Two ounces should not be much exceeded. emperature.—A little less than blood-heat—90°-%° F. Number of Injections.—This depends upon the irrita- bility of the rectum. Begin by six-hour intervals; it may be possible to increase to four, or three hours. Care of the Rectum.—If injections are given for a long time, flush the rectum (with a double catheter) once daily S 072 NUTRIENT ENEMATA-LAVAGE *'* POCKET-BOOK OK MEDICAL PRACTICE__________ with soap-and-water; give a nutrient enema immediately after the cleansing. If diarrhea is produced, suspend for a time, and resume later. Irritability of the Rectum.—To allay irritability, 5 or 6 drops of McMunn's elixir may be combined with the enema. Caution.'—The Opium interferes with the powers of absorption of the mucous membrane, and its use must be limited. NUTRIENT ENEMATA. Absorbable.—Properly prepared meat, milk, eggs, and other albuminous substances are readily absorbed. Non-Absorbable.—Fats and oils (including yolk of egg), and starches, are not readily absorbed. Milk.—This is a useful and available rectal aliment. Remove the cream; heat to the proper temperature; add a little salt (never add the salt before heating). Icon- ized mi Ik is readily absorbed. Egg.—Use the whites only. Add the whites of two eggs to the proper quantity of peptonized milk. The white of egg may also be added to other nutrient materials. Meat.—If given in fluid form, or partly predigested, the proteids are readily absorbed. Beef.—Raw beef, scraped into a paste; mix with warm milk; add Ex'tract-of-pancreas. Beef and Pancreas.—Take one part of fresh pancreas, and three parts of fresh beef; remove all fat; scrape or mince fine; rub into a soft paste with warm water. In- ject with a wide-nozzled syringe. Beef-Powder.—Take of Beef-powder (p. 373), 1 oz.; skimmed milk, 2 oz.; liquor pancreaticus, 2 drams; mix. This is very nutritious. L Feeding the Unconscious.—Use only liquid food. Give it with a spoon, or, in some cases, a medicine-dropper. It requires the presence of at least half-a-dram in the pharnyx to excite reflex deglutition. In comatose infants and young children, with the child on the back, bland liquid food can be poured into a nostril. LAVAGE OF THE STOMACH. Indications.—See Section X., Diseases of the Stomach. Instrument.—A long soft-rubber tube, which is made for the purpose. It has a bulb midway between the ends; one end is funnel-shaped, or a glass funnel can be attached. The Patient.—The patient should be seated in a chair. Explain to him the process, and reassure him so that he may not become "panicky " if he feels " as if he would choke " as the tube passes the larynx. Have him keep the head straight (not to either side at all) and thrown backward. Introduction.—Anoint the end of the tube with olive-oil or butter (white-of-egg is less apt to nauseate). With the patient's head thrown back and the mouth wide open, push the tube over the dorsum of the tongue, to the pos- terior wall of the pharynx, and down into the esophagus. LAVAGE-GAVAGE-PASTEURIZED MILK 373 _______________POCKET-HOOK OF MEDICAL PRACTICE As the tube passes the pharynx, if the patient is in- clined to resist, or become "panicky," reassure him by asserting that all is right, and order him again and again to "swallow." The tube can then be pushed on. If it halts at the cardiac orifice, raise the funnel-end and pour in a small quantity of warm water, and it can readily be pushed into the stomach. Lavage.—Raise the funuel-end; slowly pour in the fluid adapted to the case under treatment (pages 127-131). To empty the stomach, lower the tube over a foot-tub or basin set on the floor or a stool, and the contents of the stomach will flow out. Measure the quantity intro- duced, so as to leave none. Precautions.—In early attempts the patient will be inclined to vomit; usually it is not necessary to remove the tube; still encourage him to swallow. If there is hyperesthesia of the pharynx, paint it with solution Cocaine (4%). Siiralimentation.—Take % pound of beef-powder; add it to 3 times as much milk; salt. Introduce it into the stomach by the tube. Twice a day at first, with gradual increase. GAVAGE. Forced Feeding.—Liquid foods may be introduced into the stomach by means of the tube. Debove Method.—This consists in administering beef- powder and milk in phthisis. Its use should be confined to cases of laryngeal phthisis, in which there is almost intolerable pain on swallowing. Beef-Powder.—Take raw beef; remove all fat and gristle; chop it fine; make it absolutely dry in an oven (150° F.); when dry, grind in a mortar and pass through a fine sieve. Six pounds of beef make one pound of powder., PREPARATIONS OF MILK. STERILIZED MILE. Method.—The milk is heated to 212° F., and this de- gree of heat maintained for ll/2 hours. The milk is placed in bottles, stopped with cotton plugs, the bottles placed in a closed container (Arnold Sterilizer), and exposed to steam. Changes.—All pathogenic germs are destroyed. But other changes take place in the constituents of the milk which impair its nutritive value and its digestibility. It will keep for several days. Use. — Its use is objectionable; it should be limited to the necessities of travel, or in hot weather in places where ice is not obtainable, PASTEURIZED MILE. Method.—The milk, in bottles, is heated to 167° F., and this degree maintained for 20 minutes. Changes.—It destroys most pathogenic germs (typhoid, tuberculosis, diphtheria, cholera, and the pyogenic; spores ' 374 PEPTONIZED MILK-MATZOON-BEVERAGES POCKET-BOOK OF MEDICAL PRACTICE_______ are not destroyed). The digestibility of the milk does not seem to be impaired. Use.—In hot weather all milk to be fed to infants should j be ' * Pasteurized.'' It should be diluted the same as raw milk. Do not continue its use indefinitely. In adults, chronic cases, when there is feeble casein-digestion. PEPTONIZED MILE. Method. —Take of fresh milk, 1 pint; water, 4 ounces; add Sodium-bicarb., 15 grains; Extractum pancreatis, 5 grains. Place the bottle in a vessel of hot water (105° to 115° F.) for from 6 to 20 minutes (shake at intervals). To arrest the process of artificial digestion, place the bottle on ice; or, bring to the boiling-point. If the milk is to be fed at once, this not necessary. In order to pep- tonize the milk completely, continue the process for 2 hours. Use.—In infants, when there is acute indigestion; it should be diluted, as in the case of ordinary milk. KUMYSS. f Method.—Take of fresh milk, 1 quart; water, 2 ounces; {sugar, x/2 ounce; yeast cake, a piece yz inch square; put it in a stout bottle, and wire down the cork; keep at a temperature of 60° or 70° F. for one week (shake the bottle 5 or 6 times each day); place on ice. Use.—In acute and chronic indigestion; in phthisis; in irritable stomach. MATZOON. Method.—This is similar to Kumyss, but is preferable in some respects. It is very useful in chronic indigestion in adults. It contains double the amount of nourishment found in Kumyss. JUNEET. i Method.—Take of fresh cow's-milk, lukewarm, 1 quart; add 2 teaspoonsful of liquid rennet (it can be had at i grocers'); stir for a moment; let it stand until coagulation takes place. Serve cold; season with sugar and nutmeg. This is a favorite dish for the sick. FOOD FOE, THE SICK. BEVERAGES. Indications.—Fever-patients, especially when there is delirium or stupor, in which conditions they are unable to make their wants known, often suffer from want of water. In all such cases water should be offered at fre- quent intervals. But pure water, if taken too freely, is apt to disorder the stomach and bowels. It is found that the addition of certain substances to water greatly in- creases its power to quench thirst. Acids, in particular, seem to possess this power. A weak infusion of cas- carilla or orange-peel, acidulated slightly with dilute hydrochloric acid, is a favorite thirst-allaying drink for fever-patients. RECIPES. Raspberry Vinegar.—Put a pint and a half of the best wine-vinegar to three pounds of raspberries, in a glass BEVERAGES FOR THE SICE-RECIPES 375 _____POCKET-BOOK OF MEDICAL PRACTICE_______________ or porcelain vessel; let this stand for two weeks, then strain without pressure. Put into bottles well-corked. Apple-Water.—One large, juicy apple; three cups cold water. Let the apple be a juicy, finely flavored one. Pare and quarter it. Put on the fire in a closely-covered sauce pan, with the water, and boil until the apples stew to pieces. Strain the liquor as soon as it is taken from the fire, pressing the apple hard in the cloth. Set away to cool. Sweeten to taste with white sugar. Drink ice- cold. Good when there is constipation. Lemon Whey.—Put a quart of new milk into a sauce- pan and stir it over the fire until it is nearly boiling; then add the juice of one lemon and let it simmer for fif- teen minutes, skimming off the curd as it rises. Add the juice of another lemon, skim for a few minutes, strain, and it is ready for use. Wine-Whey.—Recipe.—Fresh milk, 1 pint; sour wine, 1 wine glass; sugar, 1 teaspoonful. Put the milk into a shallow sauce-pan; bring it to the boiling point; pour in y2 the wine; stir gently and let it simmer; skim off the curd that rises. In a few minutes pour in the rest of the wine; skim the remaining curd; sweeten; when cold it is ready for use. Use:—In fevers, and in the gastro-enteric affections of children and adults. Mint-Water.—Boiling water, yi. pint; green spearmint leaves, a handful. Bruise the leaves, put into a dish, cover with boiling water; steep fifteen minutes. Drink hot or cold. Good in nausea. Tamarind-Water.—Tamarinds, one tablespoonful; Ice- water, one gobletful; Sugar, one teaspoonful. Stir the tamarinds in the water until dissolved; strain and sweeten. Good in constipation. Flax-seed Lemonade.—Four tablespoonfuls whole flax- seed; one quart boiling water; juice of two lemons; sugar to sweeten. Put the flaxseed in a pitcher, pour on the boiling water, cover it and let it steep for three hours. When cold add the lemon-juice and sweeten to taste. If too thick, thin with cold water. Let the patient have it ice-cold. The last two recipes make soothing drinks in throat and lung troubles. Barley-Water.—Take of pearl barley, 2 oz.; wash it well with cold water; drain off and reject the wash- water. To the barley add 1%. pints of water; boil for 6 hours in a covered vessel; add water as it evaporates; strain into a pitcher, and keep it in a cool place (in the refrigerator). Take out as needed and warm it for use. Thick Barley-Water.—Wash the barley as above. Put it in a sauce-pan, pour over it two quarts of cold water, bring to a boil, and let it boil for two hours. Pour into a pitcher with the thin peel of half a lemon; set it on ice to become perfectly cold. When cold, take out the lemon-peel and sweeten to taste. Barley-Water.—Boiling water, two cups; barley, two tablespoonfuls. Wash the barley and soak, it half an hour in a little luke-warm water, and stir, without drain- ing, into the boiling water, salted very slightly. Sim- 376 BEVERAGES FOR THE SICE-RECIPES POCKET-BOOK OF MEDICAL PRACTICE__________ mer one hour, stirring often. Sweeten to taste and strain before using. This may be used temporarily as a substitute for milk when the latter disagrees. Egg-Lemonade.—Beat up one egg to a froth; make one goblet of lemonade, using the juice of an entire lemon; sweeten to taste, stir in the egg and add pounded ice. This is a delicious and refreshing drink for the sick, and has, moreover, some nutritive value. Hot Lemonade.—Lemon-juice, two tablespoonfuls; boil- ing water, one gohletful; sugar, one tablespoonful. Put all into a hot bowl and stir for a few minutes. Drink hot. Good when it is desired to induce perspiration. Oatmeal-Water.—Oatmeal, two tablespoonfuls; cold water, one pint. Stir the meal into the water, and let it stand one hour; strain and drink cold. A refreshing drink in hot weather. Good in constipation. Sago Milk.—Sago, one tablespoonful; cold water, one teacupful; fresh milk, one quart. Wash the sago and soak it over night; put it into a farina kettle; boil till clear; sweeten. Drink hot or cold. Elm Tea.—Take nice slippery-elm bark, break it into bits, pour boiling water over it, cover and let it stand until cold. Take with ice, and sweeten if desired. Gum-Arabic Water.—Gum Arabic, two teaspoonfuls; hot water, one pint; sugar, one teaspoonful; lemon-juice of one lemon. Put all into a pitcher; keep it on a hot stove till the gum is dissolved. Use when cold. The last two may be used as demulcent drinks in throat troubles and coughs. Cafe-au-Lait.—Fresh, strong coffee, and boiling milk, equal parts. Strain the hot coffee through some muslin into the pot from which it is to be served. Add the hot mill* immediately, set the pot on the hot stove for five minutes, and it is ready to serve. Coffee and Egg.—Make a cup of strong coffee, adding boiling milk as usual, only sweetening rather more; take an egg, beat yolk and white together thoroughly; boil the coffee, milk and sugar together, and pour it over the beaten egg in the cup in which you are going to serve it. This simple recipe is used frequently in hospital prac- tice. A sick person, needing nourishment and having lost appetite, can often be sustained by this when noth- ing else can be taken. Egg-water.—Cold water; one gobletful; whites of two eggs; sugar to sweeten. Stir the eggs gently into the water, but do not beat them; add the sugar, or a little salt. This is a bland, and yet nourishing, drink,which can be taken by a delicate stomach, when everything else is rejected. Toast-water.—Cut thin slices of bread, and toast till nicely brown, with no suspicion of burning. Put several such slices into a bowl and pour over enough boiling water to cover. Cover the bowl closely, and let it steep until cold. When cold, strain, sweeten to taste and put a piece of ice into each glass. It may be flavored with lemon-juice. L__ _____________ DIET FOR CONVALESCENTS-RECIPES 377 ______________POCKET-BOOK OF MEDICAL PRACTICE DIET FOR CONVALESCENTST Mutton Chops.—They should be broiled over a clear fire for six or seven minutes; turn frequently, and do not prick with a fork. Serve hot; season with salt and pep- per after they come from the fire. Game.—Pigeon, quail and snipe are especially accept-' able to the convalescent, and will tempt the returning appetite. Broiling is the best mode of cooking. Chicken.—Tender spring chicken may take the place of the game when the latter is not to be had. Omelette.—Two eggs; one cupful buttermilk; one-third teaspoonful soda; three tablespoonfuls flour. Beat up the eggs, stir them into the buttermilk with the flour, add the soda, some salt, and stir all to a creamy con- sistence. Put three tablespoonfuls of this batter onto a hot, buttered griddle. When one side is brown, fold it on itself, turning one-half on the other. Serve hot and eat with butter. Potato Surprise.—Scoop out the inside of a sound po- tato, leaving the skin attached on one side of the hole, as a lid. Mince up finely the lean of a juicy mutton-chop, with a little salt and pepper, put it in the potato, pin down the lid, and bake or roast. Before serving—in the akin—add a little hot gravy if the mince seems to be too dry. Tomato Soup.—Peel six good-sized tomatoes and cut them into small pieces; put them into a sauce-pan, with a quart of water, and boil until tender; season with salt and pepper. Now stir into the water half a teaspoonful of baking-soda. Lift the kettle from the stove when stir- ring in the soda, or the soup will run over as it foams. Boil again, and add a pint of sweet milk. Bring to the boiling point once more. Put broken crackers into a dish, pour the soup over them and serve immediately. This is an excellent dish for convalescents, being often taken with relish when nothing else tempts the appetite. It may be used in all cases except where there is a ten- dency to looseness of the bowels. Spanish Cream.—One quart milk; yolk of three eggs; one-half box gelatine; two tablespoonfuls sugar. Soak the gelatine for an hour in the milk, put on the fire and stir well as it warms. Beat the yolks very light with the sugar, add to the scalding milk, and heat to boiling point, stirring all the while. Flavor with vanilla or lemon. When almost cold, put into a mould wet with cold water. Cottage Cheese.—Heat sour milk until the whey rises to the top. Pour off the whey, put the curd in a bag and let it drip for six hours, without squeezing it. Put it in a wooden bowl, chop fine with a wooden spoon, salt to taste, and work to the consistence of soft butter, adding a little cream and butter as you proceed. Mould into balls and keep in a cool place. It must be eaten when fresh. 378 BATHS-BRAN-SALT-MUSTARD-MERCURIAL POCKET-BOOK OF MEDICAL PRACTICE BATHS. Bath. Cold TEMPERATO Water. 33° to 65° F. 65° to 75° ..75° to 85° 85° to 92° 92° to 98° .98° to 112° RE OF BATHS. Vapor. Air. Temperate. Tepid...... Hot........ 90° to 100° 100° to 115° 11S° to 140° 96° to 106° 106° to 120° 120° to 180° Bran-Bath.—Boil four pounds of bran in one gallon of water, strain, and add the liquor to sufficient water for a bath. Use to allay irritability of the skin, and to soften it in squamous diseases. Salt-Bath.—Add rock-salt in the proportion of one pound to four gallons of water. Use as an invigorating bath, and to lessen susceptibility to cold. Alcohol-Bath.—An ounce of Alcohol to the quart of water Use for the same purpose as salt-bath. Sulphur-Bath.—Twenty grains of Sulphuret of potas- sium to a gallon of water. For skin-diseases and rheu- matism. Mustard-Bath.—Add a handful of mustard of the ordi- nary hot bath, or a smaller quantity to a foot-bath. Use when stimulating action is required. Cold Douche.—Lower the patient's head, place rubber- cloth beneath, and pour cold water from a pitcher over the crown of the head, the pitcher being slowly and gradu- ally raised higher and higher, so that the water may fall with more force. Use in sunstroke, and intense cerebral congestion. Wet-Pack.—Spread a'comfort and several blankets on the bed, and over these a sheet wrung out of cold water. Remove all the patient's clothing; lay him in the middle of the sheet, draw the edges of the sheet over, and wrap the patient in it snugly, then draw over one side after another of the blankets and comfort, and make all snug. Put cold wet compress on the forehead. Use to reduce temperature in typhoid, and to develop delayed eruption in scarlet, and other specific fevers. Blanket-Bath.—A blanket is wrung out of hot water, and wrapped around the patient. He is to be packed in three or four dry blankets, and allowed to rest quietly for thirty minutes. The surface of the body should then be well rubbed with warm towels, and the patient made comfortable in bed. This is a ready means of inducing perspiration. Mercurial Bath.—Seat the patient in a chair; surround all, from his neck to the floor, with blankets; under- neath the chair place a spirit-lamp, having above it a metal plate; on the plate put 60 to 180 grains Bisulphuret of mercury. Use in the treatment of secondary syphilis. HYPODERMIC MEDICATION DISINFECTANTS 379 _______________POCKET-BOOK OP MEDICAL PRACTICB______________ HYPODERMIC MEDICATION. Method.—Select for injection the flexor side of the arm, over the biceps muscle, or abdomen, near the umbilicus. Pinch up a fold of integument between the thumb and forefinger, insert the point of the needle well beneath the integument, inject slowly, withdraw carefully. As a rule, not more than one-half the usual dose, as given by the mouth, should be injected. TABLE OF DOSES. Muriate of Morphine........................gr. yitoyi Sulphate of Morphine...:'."..................gr. y% to yi Sulphate of Atropine.....................gr. T$5 to ^ Strychnine.................................gr. 12a to in Sulphate of Soda...............;..... .---grs. 2 Sulphate of Quinine........ .. '.%............grs. 2 to 4 Squibb's liquor of Opium...................gtt. 5 to 40 Magendie'S solution.........................gtt. 3 to 20 Tincture of Hyoscyamus....................gtt. 10 to 20 Tincture Cannabis..........................gtt. 10 to 20 Ergot, Fl. Ext..............................gtt. IS to 30 DISINFECTANTS. Formalin.—Use a 2% solution (Formalin, 3 drams, to water, 1 quart). With a cloth wet in this solution, wipe off all articles in the room—floor, walls, furniture, etc. To be used for purposes of disinfection after contagious diseases. Copperas.—Take of copperas(Sulphate-of-iron), 2 lbs.; water, 1 bucketful. Use freely for privy-vaults, water- closets, catch-basins, cess-pools, and the like. Zinc-Chloride.—Take of Zinc-chloride, 1 lb.; water, 2 gals. Use in the chamber-vessel or bed-pan into which typhoid or dysenteric discharges are received. Also for general purposes of disinfection. Zinc-Sulphate.—Take of Zinc-sulphate, 1 lb.; Carbolic acid, 2 oz.; water, 4 gals. Keep a tub of this solution, and in it place all soiled clothing and bed-clothes from patients with infectious diseases. Mercuric-Bichloride.—Take of Mercuric-bichloride (Corrosive sublimate), 1 part; water, 1,000 parts, tor water-closets, and the like. This is a most efficient dis- infectant, but dangerous because of its highly poisonous character. Add some coloring-matter, so as to be able to distinguish it from clear water. Carbolic Acid.—A weak solution does little good; a strong solution is corrosive. There are better disinfec- Ozone.—Take of Permanganate-of-potash, yi oz.; Ox- alic acid, }4 oz.; water, 1 oz. Mix well. In two hours add a small quantity more of water. This will generate a large quantity of ozone for the atmosphere of a sick- Fir'e —Fire is the best disinfectant. When possible, burn e'verything that has been in contact with the sick suffering from contagious diseases. 380 VITAL CAPACITY-WEIGHTS AND MEASURES POCKET-BOOK OF MEDICAL PKACTICK VITAL CAPACITY. Definition.—The capacity of the lungs, in cubic inches of air, as measured by the spirometer. The vital capacity varies according to sex, height, weight, age and disease. Sex.—The vital capacity of man exceeds that of wo- man, of the same height, by about thirty-eight inches. Height.—There is an increase of eight cubic inches hi vital capacity for every inch in height between five feet and six feet. , Weight.—Excess in body-weight is associate^ with diminished capacity in the proportion of about one cubic inch per pound excess. Age.—From thirty to sixty years the vital capacity • decreases nearly one and one-half cubic inches per year. Disease.—In lung diseases the vital capacity is always diminished, and bears a certain relation to the extent of the lesion. TABLE. VITAL CAPACITY OF MALES AND FEMALES, AT DIFFERENT HEIGHTS. Feet. Inches. M. P. Feet. Inches. M. F. 4 7 126 88 5 4 198 160 4 8 134 96 5 5 206 168 4 9 142 104 5 6 214 176 4 10 ISO 112 5 7 222 184 4 11 158 120 5 8 230 192 5 0 166 128 5 9 238 200 5 1 174 136 5 10 246 208 5 2 182 144 5 11 254 216 5 3 190 152 6 0 262 224 WEIGHTS AND MEASURES. To learn to write prescriptions, in terms of Grammes, is really a very easy matter indeed, it being only neces- sary to bear in mind the following approximate EQUIVALENTS: 1 Grain (gr.) equals .06 Gramme (Gm.); 1 Drachm (3) equals 4. Grammes (Gm.j; 1 Ounce (5) equals 30. Grammes (Gm.);hence, To convert Grains (or M.) into Grammes, multiply by .06; To '' Drachms (or A3) into Grammes, multiply by 4; To ' • Ounces (or fl§) into Grammes, multiply by 30.* •More accurately, .065 (.06); 3.9 (4) 31.1 (30). BODILY TEMPERATURE. Temperature.—Average, in health, 98.6° F. (37° C). In the rectum and vagina it is 0.9° to 1.3° F. higher. The daily range rarely exceeds 1.8° F (1° C.) above or below the average. The axillary temperature may fall to 97° F. without collate, or rise to 100° F. without fever. POISONING-ANTIDOTES 9R1 ______________POCKET-HOOK OF MEDICAL PRACTICE POISONING. EMETICS. Apoinorphia.—Solution in water 1:50; inject five to ten drops hypodermically. This is the most prompt and effective emetic known. Ipecacuanha.—Powdered, thirty grains in water. Sulphate of Zinc.—Thirty grains in water; repeat if necessary. Prompt and safe. Sulphate of Copper.—Five to ten grains dissolved in water. i" , Mustard.—A tablespoonful in a half pint of warm water. Common Salt.—Two tablespoonfuls in a half pint of tepid water. ANTIDOTES. _ Multiple Antidote.—R. Saturated solution Sulphate of iron, ^ijss.; Water, fxx.; Calcined magnesia, §ij.; Animal charcoal, §j. Keep Iron solution separately, and the Magnesia and Charcoal mixed in a bottle of water. When required for use, pour all into bottle together, and shake. Give ad lib., a wineglassful at a time. This is a perfect antidote to Arsenic, Zinc and Digi- talis; it delays the action of Salts of copper, Morphine and Strychnine, and slightly influences Salts of mercury. For Opium.—Atropia sulph., one-fortieth grain, or Tr. Belladonna, fifteen drops, repeated if necessary. Strong coffee, ad lib. For Arsenic.—Dialyzed iron, ounce-doses, frequently repeated. Hydrated peroxide of iron, give ad lib. Iron rust. For Strychnine.—Chloral, thirty grains, repeated if necessary; Bromide of potassium, §ss.; Animal charcoal, ad lib.; Tannic acid, ad lib.; Chloroform; Ether; Nitrate of amyl, by inhalation. For Acids.—Lime water, ad lib.; Chalk-and-water; Magnesia, mixed in water; Ammonia and water, §j. to §viij.; Ashes; Plaster from the wall; Tooth powder,in water; Soap and water. For Alkalies.—Vinegar, freely; Acetic acid and water; Lemon juice; Muriatic acid, freely diluted with water; Any dilute acid. For Narcotics.—Coffee, strong, given freely; Nitrate of amyl,by inhalation; Ammonia; Galvanism; Stimulants. Stimulants.—Wine; Whisky; Brandy; Ammonia; Tea; Coffee; Ether. Instruments. — Stomach-pump; Hypodermic syringe; Soft-rubber catheter; Enema syringe. ^ 382 POISONING-GENERAL DIRECTIONS POCKET-BOOK OF MEDICAL PRACTICE GENERAL DIRECTIONS. Emetic.—Give the emetic that can be most speedily ob- tained. If it is a corrosive poison, give copious draughts of demulcent drinks, followed by an emetic, and the ap- propriate antidote. If the emergency is great, and no emetic at hand, give copious draughts of tepid water even though it be dirty or greasy; then run the finger down the throat, to excite vomiting. The action of an emetic is facilitated if large quantities of fluid be swal- lowed. Depression.—If present, must be combatted by stimu. lants, warm applications to the extremities, friction, gal- vanism, and, if the respirations fall below ten per min- ute, artificial respiration must be employed. Catheterize the bladder in prolonged cases. Battery.—One pole to the side of the neck, the other over pit of the stomach, or muscles of the chest. Or, touch the two poles to different attachments of the mus- cles of the chest, using a strong current, sufficient to excite pain, and produce efforts at crying. Flagellation.—In poisoning with narcotics, to combat the depression, and keep patient from sinking into fatal stupor, slap the skin with wet towels, spat the skin sharply, rub the soles of the feet with a stiff hair-brush; make every effort to rouse him. Walking the patient only adds exhaustion to stupor—better lay him on a lounge and use flagellation. Douches.—To aid in rousing when there is stupor and depression, dash cold and warm water alternately, upon the head and chest. In apparently hopeless cases, two or three sharp blows on the chest, delivered in quick succession,will sometimes restore the heart's action. Stimulation.—Alcoholic stimulants may be used if the poison is not a narcotic. Coffee may be employed as a stim- ulant in Belladonna, Opium, and other narcotic poisoning; give an enema of a pint of hot, strong coffee. Ammonia may be given by inhalation, or by injection into veins. Strong tea is an excellent stimulant, and it also anti- dotes many poisons; Give by the stomach, if possible. Whiffs of Ether, by inhalation,will stimulate the heart's action. Demulcents.—In cases of poisoning by corrosive sub- stances, give, after the administration of the antidote and emetic, large quantities of mucilaginous drinks; pref- erably white of egg and water. Demulcent Drinks.—Milk; White-of-egg and water; Oil; Linseed tea; Gruel; Flour-and-water; Boiled starch. fcrive in large quantities. C^ ___ POISON AND TREATMENT 383 _______________POCKET-BOOK OF MEDICAL PRACTICE POISON AND TREATMENT. POISON.—Unknown. Treatment.—Provoke repeated vomiting. Give demul- cent drinks; Multiple antidote; Stimulate, if necessary; Artificial respiration, if necessary. POISON.—Cocaine. Treatment.—Place the patient recumbent; Cold water to drink; Cold wafer to the face, neck and chest; Hypo- dermic, Strychnia (£> gr.); Amyl nitrite (inhalation); Nitro-glycerin (rJ5 gr.) Chloral (grs. xx) by enema, for tetanic rigidity; Artificial respiration for respiratory failure; Stimulants; Diuretics and the catheter, if neces- sary. To prevent:—During Cocaine anesthesia, give (once or twice) a hypodermic of Trinitrine (1 m. of a 1% sol.) POISON. —Opium—Morphine—Laudanum— Chloral. Treatment.—Provoke repeated vomiting; Give strong coffee, etc.; Inject Belladonna; Rouse by flagellation (do not walk the patient); Artificial respiration. POISON.—Arsenic—(Paris-Green; Scheeles's-Green). Treatment.—Provoke repeated vomiting; Give dialyzed Iron, etc.; Give dose Castor oil; Secure rest; Stimulate, if necessary. POISON.—Strychnine —Picrotoxine. Treatment.—Provoke vomiting once or twice; Give pur- gative; Give Chloral, etc.; Secure absolute quiet. POISON.—Acids—(Sulphuric, Nitric, Muriatic, Oxalic, Carbolic). Treatment.—Give an alkali; Provoke vomiting;Demul- cent drinks; Stimulate, if necessary. (Alcohol antidotes Carbolic acid.) _______ POISON.—Alkalies—(Ammonia, Soda, Potash, Lye). Treatment.—Give an acid (vinegar); Provoke vomiting; Demulcent drinks; Stimulate, if necessary. POISON.—Corrosive Sublimate—Tartar Emetic. Treatment.—Provoke repeated vomiting; Give strong tea, freely; Give raw eggs and milk; Give dose Castor oil; Stimulate, if necessary. POISON.—Phosphorus. Treatment.—Provoke vomiting; Sulphate of copper, sol. grs. iij, every 5 ms., till emesis; Epsom salts, fss.; No oils or fats. ________ POISON.— Nitrate-of-Silver—(Z««ar Caustic). Treatment.—Strong solution salt and water, very freely; Provoke repeated vomiting. 384 POISON AND TREATMENT POCKET-BOOK OK MEDICAL PRACTICE POISON.—Sugar-of-Lead. Treatment. — Give Epsom salts repeatedly; Provoke repeated vomiting; Give demulcent drinks; Give dose Cas- tor oil. _______ POISON.—Aconite. Treatment. — Provoke vomiting; Stimulants, freely; Digitalis tinct. gtt. xx, hypoderm.; Mustard over heart; Artificial respiration. POISON.—Digitalis. Treatment.—Provoke vomiting; Give strong tea; Give stimulants; Recumbent posture. POISON. — Belladonna — Stramonium — Hemlock — Toad- stools— Tobacco. Treatment. — Promote vomiting; Stimulants, freely; Hot, strong coffee; Opium, tinct., gtt. iij—v, or more; Cold to head, galvanism, flagellation; Artificial res- piration. _______ POISON.—Chloroform —Carbonic-Acid Gas. Treatment.—Abundance of fresh air; Pull the tongue forward, clear the mouth; Loosen clothing—head low. Alternate cold and warm douche; Inhalations Amyl nitrite—Ammonia; Artificial Respiration!—Battery. POISON.—Alcohol. Treatment.—Stomach-pump, or emetic; Ammonia and water; Battery and flagellations; Cold douche to the head; Artificial respiration. POISON.—Decayed Meats and Vegetables. Treatment.—Provoke vomiting; Give a purgative; Give solution of Permanganate-of-potash. ARTICLE.—Glass. Treatment.—If particles of glass have been swallowed, let the patient eat large quantities of bread-crumbs and potato, to envelop it—then give an emetic. Do not let it pass into the bowels. _______ Final Note.—Should those who use this book seek in its pages for that which they fail to find, if they will communicate the fact to the author the subject will be included in some future edition if it rightfully belqngs in a work of this character.—Ch. G, IMPORTANT NOTICE. To Physicians using this Book:—If your dilutions are made according to the method introduced by the new "Pharmacopoeia of the American Institute of Homoeopathy " the 2x dilution must be used whenever the lxisrecouimeuded. The tinctures are of greater strength than those made ac- cording to the old Pharmacopoeias, and allowance must be made accordingly. INDEX 0 r ^ INDEX ^ Abdominal Surgery. 331 Typhus........... 70 Abscess............2*7 Acute............287 Appendicular.....2SS Brain............288 Chronic...........287 Empyema........288 Isehio-Rectal.....288 Liver.......103, 288 Lung.......46. 288 Mediastinum.....2tS7 Nasal Septum.....20-2 Pericardium .....288 Perinephritic .... 145 Peri-Rectal......288 Peritonsillar.....209 Retropharyngeal. 27 Subphrenic.......103 Accidents in Labor.222 Accouchement......219 A. C. E. Mixture ...281 Achy lia Gastric a —136 Acid Gastritis......1*26 Acne ..............174 Active Hyperemia of the Liver.......101 Hyperemia of the Lungs......... 45 Actual Cautery.....286 Acupuncture.......286 Addison's Disease ..100 Adenitis...........289 Acute............ 36 Retropharyngeal. 27 Adenoids of the Pharynx.......206 Adenomata.........297 Adncxa, Inflamma- tion of.........246 .Estivo-A ulumual Fever.......... 77 After-Pains........822 Ague............... 75 Albuminuria.......147 Alcohol Bath.......378 Alcoholism......90-273 Alcoholic Inebriety. 90 Alopecia............174 Amenorrhea........238 Amputations.......328 Arm..............331 Circular Opera- tions...........329 Disinfection iu...330 Elbovv............331 Elliptical Method 3*40 Elap Operations. 321* Eoot..............883 Forearm .........831 General Rules—328 Guvon's..........833 Hand ........... 331 Hip..............332 Incision in.......:;29 Indications for.. .828 Infusion in......330 Knee.............838 Lateral Flaps ....830 Leg ............888 Ligature in.......330 Amputations.......:{-2s Metacarpals......831 Technique.......329 Oval ............329 Periosteum in___•{•.''I Phalanges.......832 PirogofT s........883 Prognosis........320 Racket Method ...329 Radio-Carpal.....331 Shoulder-Joint...330 Special...........830 Suture in.........330 Teale's Method. .329 Thigh............833 Time of.........829 Wrist...........331 Wyeth's Method .382 Amyloid Kidnev___143 Liver........'....108 Anal Fissure.......348 Fistula...........344 Anemia.......... 96 Cerebral.........165 Anemias, Essential. 96 Anesthesia.........878 Dangerous.......280 Full..............280 General..........279 Incomplete.......280 Local.............278 Profound.........280 Sequelae......... 280 Symptoms........280 Anesthetics.........281 Aneurism.......... 66 Pulmonary....... 66 Thoracic......... 65 Angina Pectoris___ 66 Angioma Nasal Pas- sages...........205 Angiomata.........296 Ankylosis..........319 Anorexia, Nervous . 135 Anteflexion........ 248 Anterior Poliomyel- itis............ 30 Antidotes to Poisons 381 Antisepsis..........274 Compresses.......284 Antiseptics.........274 Antitoxin, Tetanus.291 Diphtheria....... 8 Anuria...........149 Anxiety Neurosis. ..171 Aorta.............. 59 Aphthous Stomati- tis ............. 26 Apoplexy, Cerebral .166 Appendicitis... 121-338 Diagnosis........386 Indications for Operation......838 Appendicular Ab- scess ...........288 Aristol.............274 Arterial Angioma.. 296 Arthritis...........818 Deformans....... 86 Rheumatoid...... 86 Arthrotoiny........319 Articular Rheuma- tism ........... 83 387 Ascites.............123 A s c a r i s Lambri- coides.......... 86 Asepsis.............274 Aseptic Operation ..282 Asiatic Cholera.....HI) Euteroclysis in... 120 Hypodermoclysis in..............120 Asthma............ 48 Astringents.......285 Ataxia, Locomotor .15s Atony of the Stom- ach.............133 Atrophic Gastritis.. 1 •»;:) Concussion.........274 Congenital Deform- ities............:{•_>(; Syphilis.......... m Congestion,Kidneys 188 Lungs............ to Congestive Chill.... 77 Dysmenorrhea ...240 Conjunctivitis .....184 Chronic.........185 Diagnosis of.....186 Phlyctenular.....is.) Purulent.........185 Constipation.......Ill Constitutional Dis- eases........... s:i Constrictors........268 Consumption....... 51) Contracted Pelvis .. 232 Contusions........288 Convalescence, Diet 87! Convulsions........ 28 Causes........... 28 Cord, Prolapse of .. 228 Corn...............178 Cornea, Diseases of. 187 Inflammation ....187 Opacities.........187 Ulcer............187 Coxalgia...........821 Coxitis...........321 Cramp of Canlia... 182 of Pylorus........132 Creolin............275 Cretinism, Sporadic 36 Croupous Nephriti».14U D Dandruff...........U« Death of Fetus......234 Deformities, Nasal Septum.........802 Pelvic..............231 Delirium Tremens. 00 Delivery, Secund- ines...........280 Dementia..........153 Dengue............. « Diabetes........... W> Insipidus....... 87 Mellitns.......... *6 Diagnosis of Labor.81« of Pregnancy —218 Diameters, Pelvic 231 Diarrheas, Infant .. 24 Diarrhea...........1'"- Diet in Disease.....390 in Convalescence .37< Diffuse Cellulitis .. 288 Nephritis.........1*« Dilatation, Cardiac. 62 of the Stomach... 132 DIPHTHERIA INDEX POCKET-IiOOK OF MEDICAL PRACTICE FISTULJE Diphtheria........ 7 Albuminuria in .. 7 Antitoxin in...... 8 Cardiac Paresis in 10 Complications of. 7 Diagnosis of...... 7 Diet in.......... 9 Hydrogen Perox- ide in ......... 9 Incubation of___ 7 La rj nueal........ 9 Nasal............ 9 Paralysis in...... 7 Prognosis of..... 7 Prophylaxis of ... 9 Sequelse of....... 7 Diphtheritic Gastri- tis.............125 Diplococcus Intra- cellularis...... 14 Pneumoniae...... 37 Dislocations........312 Ankle............317 Clavicle..........814 Complicated......313 Compound........313 Diagnosis . .....312 Elbow............315 Fingers..........810 Hand.............316 Hip-Joint........316 Knee............317 Lower Jaw.......813 Old...............312 Patella...........317 Recent...........312 Ribs..............316 Special ..........818 Shoulder........314 Tarsals..........818 Vertebra?.........313 Wrist............316 Displacement, Ut©«- rine.......281, 248 Dissection-Wounds .270 Disseminated Scle- rosis ...........164 Dog-Bites.........271 Dou l»l e-I ncli ne Plane..........309 Douche, Cold.......378 Dropsy of Abdomen 128 Dry Cupping.......286 Ductless Glands___ 96 Duodenal Ulcer___114 Dupuytren Suture..336 Duration of Labor.. 221 Dysentery..........118 Dysmenorrhea.....240 Congestive.......240 Mechanical.......240 Membranous.....240 Neuralgic.......246 Dyspepsia, Nervous. 187 Ear-Ache..........192 Ear, Diseases of___190 Hematoma of___191 Wax Impaction... 191 Eccbymosis,Orbital 1S3 Echinococcus, Liver 107 Eclampsia, Puerpe- ral............225 Ectopic Pregnancy .257 Early Months.....257 Interstitial......257 Later Mouths.....25S Old Cases.......258 Ovarian..........257 Tubal............257 Eczema...........17« of. Auricle........191 Causes.........176 Diet..............176 Diagnosis........178 Treatment.......176 Edema of Larynx. .213 of the Lungs..... 45 Effervescent Baths . 64 Eifg-Watei-.........376 Elbow-Sling......304 Elongated Uvula ...208 Emergencies, Sur- gical ...........203 Emetics...........382 Emphysema........ 4S Empyema......55, 288 Incision in....... 57 Resection in...... 67 Siphon Drainage. 58 Surgical Measures 55 Thoracentesis--- 56 Thoracoplasty___ 58 Encephalitis.......165 Endocarditis....... 60 Ulcerative........ 60 Endocervicitis......244 Endometritis.......245 Acute...........245 Chronic..........245 Enlarged Bursa- ... 824 Prostate.........358 Enteric Fever...... 70 Enteritis...........112 Entero-Colitis..... 24 Enterorrhaphy.....386 Enterotomy........386 Entoxoa........... 35 Enuresis........... 83 Ephemeral Fever... 78 Epidemic Cholera ..119 Influenza......... 88 Types............ 88 Epididymitis.......354 Epilepsy ...........168 Episcleritis ........188 Episiotomy.........220 Epithelioma.......179 Epulis..............295 Erasion............319 Erethistie Ulcers .. .292 Erysipelas ....178,290 Phlegmonous.....290 Erythema Nodosum 179 Simplex..........180 Essential Anemias.. 96 Ether............. 281 Eucaine Hydrochlo- rate............278 Euculyptol........275 Excision of Joint*. .819 Ankle............821 Excision of Joints ..319 Elbow...........320 Hip..............820 Knee.............321 Shoulder.........820 Wrist............820 Exophthalmic Goitre 68 Exsection of Joints. 319 Extravasation, Uri- nary .......... 268 Exuberant llcers .292 Eye. Black.........183 Burns of.........183 Diseases..........183 Foreign Bodies in 183 Injuries.........183 Strain............189 Wounds of.......183 Face Presentation ..221 Facial Paralysis.. ..163 Ealse Croup........ 18 Famine-Fever..... 80 Fatty Urine........149 Fauces, Lupus of. .210 Mycosis of........209 Syphilis of......216 Tumors of........211 Favus.............180 Febricula.......... 77 Febris Icterodes ...' 79 Feeding, Artificial .370 Female Bladder___351 Femoral Hernia___341 Radical Cure.....841 Strangulated.....341 Fenestrated Casts.. 300 Fergusson's Opera- tion ............292 Fetus, Death of ....284 Fever.............. 88 Cerebro-Spinal... 14 Dengue.......... 78 Ca lent lira........ 82 Intermittent..... 75 Relapsing........ 80 Pernicious...... 77 Pneumonic....... 37 Remittent........ 77 Rheumatic....... S3 Scarlet........... 10 Simple........... 7* Typhoid.......... 70 Typhus..... ..... 74 Yellow........... 79 Fevers............. 70 Fibrinous Rhinitis.201 Fibroid Phthisis . .53 <■ Complications___53'/ Physical Signs... 58'/ Prognosis........53'/ Fibromata.........295 Nasal............205 of Naso-Pharynx. 207 of Ovary.........266 of Uterus........252 Fiebre de Borras ... 7» Filix Mas......... 35 Fissure of Anus ... 343 Fistula;.............288 in Alio............344 389 FISTULA INDEX POCKET-BOOK OF MEDICAL PRACTICE HEMORRHOIDS Fistula; ............288 lie n it ;il..........258 Rectal...........259 Urinary.........258 Hat Foot...........327 Pelvis........... 232 Floating Cartilages.324 Kidney......145,846 Fomentations .....284 Forceps............227 Blades...........227 Cephalic Applica- tion...........227 Contraindications 228 Indications for...227 Locking.........227 Pelvic Application227 Traction....227, 228 Food Infection..... 93 Foreign Bodies___271 in Bladder.......271 in Bronchi.......273 in the Ear........190 in the Esophagus.271 in the Eye........183 in Larynx.. 214, 272 in the Nose......202 in the Rectum___271 in the TissueN ... 27 I in the Urethra. 271 Formaldehyde......275 Fracture-Blisters ..283 Box..............301 Fractures..........298 Ankle............811 Antrum..........303 Arm..............305 Astrairalus.......311 Barton's.........807 Carpals ..........307 Colles'...........807 Chest............304 Clavicle..........304 Coccyx...........808 Delayed Union.... 301 Diagnosis........298 Elbow............806 Face .............303 Femur...........308 Fibula...........811 Finder Splint ...307 Foot............812 General Consider- ations ..........29S Hand.............807 Humerus.........805 Hyoid .......... 803 Inferior Maxillary303 Jaw-Splint.......803 Leg.............810 Lower Jaw........303 Malgaigne'sHooks310 Metacarpals......807 Non-Union.......801 Os (aids.........811 Patella...........310 Pelvis............308 Phalanges........307 Pott's . ..........311 Prognosis........298 Radius...........306 Repair.......... 299 Kibs.............:j04 ^ Fractures..........298 Scapula..........805 Shoulder-! ap---305 Skull............301 Spine ............302 Sternum ........804 Superior Maxil- lary...........303 Thigh............808 Throat...........303 Tibia......... ...310 Treatment in Gen- eral .......... 209 Ulna.............806 Vertebral........802 Wrist..........307 Zygomatic Arch. 303 Frost Bites.........294 Furuncle..........290 Gail-Bladder, Dis- eases of........101 Gall-Stones.......110 Operation........887 GallopingConsump- tion............ 50 Ganglion...........324 Gangrene ..........290 Gangrenous Stoma- titis............ 26 Gastralgia... 181, 134 Gastrectasia........132 Gastrica, Achylia... 136 Gastric Cancer.....180 Carcinoma.......130 Diff. Diagnosis. 131 Sureery..........837 Ulcer......128, 181 Gastro-Enteric In- fection ......... 24 Lavage........... 25 Gastro-Enteritis ...117 Gastritis, Acute___124 Chronic..........125 Diet in..........128 Diphtheritic.....125 Hyperperistalsis .133 Hyperesthesia___134 Phlegmonous___125 Purulent ........125 Gastrorrhaphy.....387 Gastrotomy........337 Gastroxie..........135 Gavage............378 General Anesthesia. 279 Paresis...........158 Genital Fistulae ...258 Tuberculosis.....262 Primary.......262 Secondary......262 Genito-Uuinary Surgery.......346 German Measles___ 14 Germicides.........274 Glaucoma.....186, 189 Hleet..............365 Gonococcus.........368 Gonorrhea .........368 Acute Urethritis..864 Anterior Injec- tions ...........863 390 Gonorrhea.........gag Astringents .... [$$;, Chronic Urethri- tis ............860 Chordee..........866 Complications ...366 Deep Injections .864 General Measures 363 Hydrogen Perox- ide.............86.1 Ichthyol..........864 Incubation.......3ii:g Injections ......368 Internal Medica- tion ...........365 Marriage.........36(i Potassium Per- manganate .....364 Protargol........364 Gonorrheal Vagini- tis ...........243 Goitre............ 106 Gout.............. 85 Gouty Kidney.....141 Granular Lids......186 Gravel .............1511 Grave's Disease.... 68 Green-Sickness .... 06 Gunshot Wounds .. .270 Gynecology.........238 H Habitual Constipa- tion...........114 Vomiting.........183 Halsted Suture.....886 Hammer-Toe.......328 Hardened Bandages 300 Hare-Lip..........826 Hay-Asthma .......201 Hay Fever..........201 Heat-Stroke....... 92 Heart.............. 59 HemateiiKSls......129 Hematoma Aurls...l91 Hematuria.........14s Hemoglobinuria ... 14s Hemophilia........ 99 Hemoptysis........ 46 Hemorrhage.......268 Actual Cautery .. .265 Acufllopressure.. .264 Acupressure......264 at Labor.........224 Bladder..........8«« Epistaxis.......8*j» Esmarch's........263 Ligation........261 Mikulicz's Pack 264 Petit's...........263 Post-Partum.....224 Rectum ..........266 Saline Solution. ..266 Spanish Windlass 268 Stimulation......266 Styptics..........264 Torsion..........264 Hemorrhagica...... 99 Hemorrhoids..116,842 Astringents......842 Clamp andCam>ry343 HEMORRHOIDS INDEX POCKET-BOOK OF MEDICAL PRACTICE LIDS Hemorrhoids.. 116, 842 External.........342 Internal..........312 Mixed...........342 Sedatives.........342 Hemoptysis ........129 Hemostatic Meas- ures............263 Hereditary Syphilis 34 Hernia.............338 Diagnosis........339 Enterocele.......338 Entero-epiplocele 339 Epiplocele......339 Femoral..........341 from Hydrocele . 339 from Undescended Testicle........339 from Varicocele. 339 Inguinal.........339 Pelwe Floor......250 Radical Cure... .340 Strangulated..... . .....269, 840 Supporters......339 Taxis............269 Trusses.....339, 341 Umbilical........341 Unusual Forms ...........269, 342 Ventral ..'....... 342 Herpes.............180 Zoster..........180 Hip-Joint Disease.321 Hol>-\ail liver.....105 Hodgen's Suspen- sion Splint.....309 Hodgkin's Disease.. 98 Hordeolum ........184 Hydatid Cyst of the Lung ......... 68d Hydrocele.........855 Hydrocephalus.....234 Acute............ 31 Hydronephrosis___ ...........146, 347 Hydrops Peritonei.. 123 Hydrosalpinx.......246 Hydruria .......... 87 Hygiene of Preg- nancy ........218 Hyperacidity......135 Hyperchlorhydria ..135 Hyperemia, Liver ..101 Renal............138 Hyperesthesia, Gas- tric ............134 Hjlierldrosis.......180 11 y per peristalsis, Gastric........133 Hypertrophic Rhin- itis.............199 Hypertrophy, Cardi- ac.............. 61 Ungual Tonsil ...210 Pharyngeal Tonsil206 of the Tonsils ....209 Hypochylla.........186 Hypodermic Dosage 379 Hypodermoclysis .. .236 Hystero-My omcc - tomy..........251 Icterus Gravis......108 Ichthyol..........275 Idiopathic Anemia.. 97 Ileus...............115 Impetigo..........lsi Incised Wounds .... 282 Incontinence of Urine 33 Indigenous (jastro- Flnteritis.......117 Indolent Ulcers.....292 Inebriety, Alcoholic 90 Infant-Feeding.....36« Condensed Milk ..36fi Modified Milk .... 36 Pasteurization ... 366 Peptonized Milk.. 36 Sterilized Milk... 36 Top-Milk......... 36 Infantile Scurvy ... 82 Spinal Paralysis. 30 Infected Wound .... 282 Inflammations, Sur- gical ...........284 Infiltration - Anes- thesia ..........278 Purulent.........288 Influenza, Epidemic H8 Infusion. Saline... .266 Ingrowing Toe Nails345 Inguinal Hernia___339 Injuries, Bladder ..348 Crushing.........270 of Kidney........346 of Urethra........351 to the Eye........Is3 Pelvic Floor......259 Insanity............152 Insect Bites.......271 Insomnia..........172 Insufficiency of Car- dia ............133 Pyloric ........188 Insular Sclerosis ... 164 Intercostal Neural- gia.............162 Intermittent Fever. 75 Internal Ear.......197 Interstitial Nephri- tis, Chronic ... Ill Neuritis..........168 Intertrigo........181 Intestinal Catarrh .112 Obstruction. 115, 268 Resection .......336 Surgery..........836 Suture...........886 Worms........... 35 Intoxications....... 90 Intubation......... 19 Accidents........ 20 After-Treatment . 20 Intussusception ... 268 Inversion of Uterus. 252 Iodine..............275 Iodoform..........275 Iris, Diseases of ...188 Iritis.........186, 188 Irritable Ulcers ....292 Ischlo - Rectal Ab- scess......288, 344 Itch...............182 Jail-Fever ....... 74 Joint Diseases......318 Junket.............374 K Kainala .......... 35 Keloid...........295 Keratitis.....18«, 187 Kidney, Amyloid ...143 Injuries.........346 Lardaceous.......143 Malformations . .. 147 Movable.........145 Tumors of........147 Waxy............143 Klebs-I.oeffler Ba- cillus ..........368 Culture-Test.....368 Identification .... 368 Staining.........368 Kumyss............374 Labor, Accidents at 222 After-Care...... 222 a fter-Pains......222 Bowels...........222 Diagnosis of......219 Diet..............222 Duration of.......221 Prognosis of......221 Retention of Urine222 The Vagina......222 The Vulva........222 Lacerated Wounds. .2*3 Laceration of the Cervix ...222, 261 Bilateral.........261 Stellate.........261 of the Perineum.. ..........223, 259 Prophylaxis of. . 220 Unilateral........261 La Grippe.......... 88 Laparotomy.......334 Lardaceous Kidney 143 Larynx, Diseases of 211 Edema of.........213 Foreign Bodies in 211 Neuroses of.......214 Syphilis of.......213 Tuberculosis of.. .213 Tumors of........214 Laryngitis.........211 Acute........18, 212 Atrophic........ 212 Sicca ............212 Subglottic........212 Laryngysmus Strid- ulus............ 29 Latent Gout........ 8li Lavage of Stomach .872 Laveran, Organism of............. 369 Lead-Poisoning___ 92 Lembert Suture___336 Leucocythemia .... 98 Leukemia......... 98 Lids, Diseases of... 184 391 LIGATURES pock Ligatures..........277 Sterilization.....277 Liponiata..........295 Lipuria............149 Listnu's Side-Splint 309 Litheuiia.......... 86 Litholapaxy......349 Lithuria...........149 Liver Abscess......288 Amyloid..........108 Diseases..........101 Malarial.........106 Syphilitic........106 Tuberculous......107 Lobar Pneumonia.. 37 Local Anesthesia.. .278 Depletion........286 Locomotor Ataxia.. 158 Lungs............. 37 Abscess........ 2.**8 Hydatid Cyst.....53'/ \eoplasms......53-/ Syphilis..........53'/ Lupus.............293 of the Fauces.....211 of the Nose......204 Lymphadenitis .... 289 Lyinphangiomata ..296 Lymphangitis......289 Lysol...............275 in Malarial Liver.....106 Malarial Organism .370 Male Fern, Oil of... 85 Malformations of Kidney........147 Malignant Tumors of the Fauces.. .211 Mania.............152 Mania-a-Potu...... 90 Marriage of Syphi- lids ..........861 after Gonorrhea. .366 Mastitis......226. 285 Mastoiditis....... .197 Hatzoon............874 Measles............ 12 Complications ... 13 Eruption ......... 14 Eyes............. 14 Lungs ............14 Prognosis........ l;j Sequelae.......... 13 Treatment....... 18 Mechanical Dysmen- orrhea ........240 Median Cystotomy..850 Mediastinal Abscess 288 Melancholia........152 Membranous Dys- menorrhea .....240 Meningitis, Cere- bral ............1G5 Cerebro-Spinal... 14 Tuberculous...... 31 Menorrhagia.......239 Menstruation, Dis- orders of.......238 Mental Depression. 152 Diseases..........15-j Therapeutics. ... 154 INDEX iT-BOOK OF MEDICAL Mental Depression.. 152 Excitement.......152 Mercurial Bath.....378 Merycism..........183 Metritis........ .. 245 Curettage in......245 Puerperal.......235 Metrorrhagia......239 Micrococcus Gonor- rhea' ..........368 Middle Ear, Dis- eases of.........192 Milk-Infection..... 23 Milk, Pasteurized..373 Peptonized'.......374 Sterilized........873 "Milky"' Urine... 149 Mitchell Method for Cancer......... 93 Modified Velpeau.. .301 Morbilli........... 12 Morbus Coxari us .. .321 Maculosus Werl- hofll............ 99 Morphinism........ 91 Movable Kidney___ ...........145. 345 Mucous Gastritis ...126 Multiple Pregnancy 234 Signs........... 234 .Multiple Sclerosis.. 164 Mumps............ 17 Mustard Bath......378 Myasthenia.........133 Mycosis of the Fau- ces.............209 Myelitis............167 Myomata...........296 Myomectomy.......254 M y x edematous Idiocy.......... 36 Myxo - Fibroma of Naso-Pharynx.. 207 Myxomata.........296 N Nanus..............296 Nasal Feeding......370 Nasal Fibromata .. .205 Osteomata......205 Pharyngitis......200 Papillomata......205 Polypi..........204 Nasal Septum, De- formities of___202 Alt .cess of......200 Naso-Pharynx, Dis- eases of........207 Carcinoma of.....207 Fibroma of.......207 Myxo-Fibroma of. 207 Sarcoma of.......207 Necrosis of Bone___298 Neoplasms of the Liver.......... 107 Adenoma........107 Angioma _______107 Carcinoma .......107 Fibroma .........107 Sarcoma .........107 Neoplasms of the Lung...........53(2 392 OTALGIA Nephritis, Acute ...I'M Climate.........14.) Croupous___ "|ii"i Diet...........;.j4!; Diffuse.........'.14(1 Interstitial.......141 General Measures 142 Therapeutics.....111 'I reatment . . . . |4| Nephrolithiasis.. !..i4!i Nephroptosis.......14,-) Nephrorrhaphy.....340 Nephrotomy........34; Nerves, Inflamma- tion of.........158 Nervous Anorexia .. 185 Dyspepsia........187 Vomiting.........133 Neuralgia..........160 Intercostal......too Trigeminal.......162 Neuralgic Dysmen- orrhea .........240 Neurasthenia Gas- trlca...........13; Neuritis.........1,1s Neuroses. Cardiac . 69 of the Larynx .214 Neurasthenia...... 171 Angiopathic..... 171 Climacteric ......171 Hystero..........171 Traumatic....... 171 Nipples, Sore......226 Noma...........26 Non-Union.........801 Nose, Accessory Sin- uses of.........203 Diseases of...... 198 Foreign Bodies in 202 Lupus of.........204 Nose and Throat Sprays........216 Solutions.........217 Nutrient Enemata.. .......73, 129,871 O Obstetric Bag......219 Bed......i.......2111 Obstetrics..........21s Obstruction, Intes- tinal......115, 26s Occlusion of Rec- tum............342 Odontonuita........296 Oil of Male Fern... 35 Oligocythemia..... 96 Oligochromemia ... 96 Oophorectomy — 254 Opacities of the Cor- nea............ 187 Operation, an Asep- tic.............2S2 Ophthalmia Sympa- thetic .........183 Orchitis............354 Osteomata .........205 Nasal ............295 Osteomyelitis......297 Otalgia............19- OTITIS INDEX POCKET-BOOK OK MBIMCAL PRACTICE PULMONARY Otitis Externa Cir- cumscripta.....190 Otitis Media. Acute. 192 Media Suppura- tiva ............195 Otorrhea...........195 Ovarian Cysts......256 Carcinoma.......256 Cystic Tumors___256 Fibroma.........256 Sarcoma....... .256 Solid Tumoi-'j __25(i Tumors........ 256 Ovaritis...........246 Acute ..........246 Chronic.......246 Oxaluria..........151 Oxyuris Vcr.niru - larls........... 36 Papilloma! a........297 Nasal.............205 Paracentesis A b - domlnis... 12$, 345 of Pericardium... 60 Paralysis Agitans .168 Ascending Spinal 164 Cerebral .........166 Facial............163 Pseudo-Hypertro- phic............165 Parametritis...... 247 Paranephritis......145 Parasites,Intestinal 35 Nasal Cavitie*.. .208 Parotitis......... 17 Parry's Disease — 68 Passive Exercise ... 65 Passive Hyperemia of the Liver.... 102 Pasteurized Milk...373 Pathogenic Micro- organisms .....867 Peliosis Rheuma- tica .......... 99 Pelvic Cellulitis ...247 Deformities.....231 Diameters........231 Floor, Injuries of 259 Peritonitis . 235, 247 Pelvimetry.........231 Pelvis, Contracted..282 FTat .............232 Peptonized Milk. 374 Perforation ofBlad- der.............34S Pericardial Abscess.288 Pericarditis........ 59 Paracentesis In... Oil Perihepatitis.......102 Adherent.........102 Dry..............162 Exudative........102 Suppurative.....103 Tuberculous......103 Perimetritis .......247 Perinephritlc A b • scess......145, 347 Perlneorraphy.....259 Perineum, Head at.220 Laceration of 223.259 Perineuritis.......158 Periostitis.........298 Perl-Rectal Abscess.288 Peristaltic Unrest. 133 Peritonitis.........122 Ulrcamscrihed___122 Diffuse...........122 Fibrinous........122 Pelvic.....235, 247 Primary.........122 Puerperal........235 Purulent.........122 Secondary........122 Sero-fibrinous___122 Tuberculous......122 Peritonsillar A b - scess...........209 Perityphlitis ......121 Pernicious Jaundice I OS Pernicious Inter- mittent......... 77 Algid............. 77 Comatose........ 77 Delirious......... 77 Icteric........... 77 Varieties......... 7 7 Vomiting of Preg- nancy ........218 Pertussis.......... 18 Inhalants in.....101 Pes Planus.........327 Pessaries.......... 250 Petit's Constrictor.. 263 Phagedenic Ulcers.. 292 Chancroids.......362 Pharyngitis........208 Pharynx, Adenoids of.............206 Diseases of.......208 Phlebitis......235, 289 Puerperal........235 Phlegmonous Ery- sipelas .........290 Gastritis........125 Inflammation ___288 Suppuration......288 Phlyctenular Con- junctivitis .....185 Phosphaturia ---151 Phthisis Florida... 50 Fibroid...........58o Pulmonalis ...... 50 Ventriculi........186 Piles..........116, 842 Pin-Worms ........ 86 Placenta Previa... 228 Plasmodium M a - lariae...........869 Identification ....369 Plaster "Cast"... 2»9 Plaster-of-Paris... 299 Splint............810 Pleurltls........... 54 Pleurodynia........162 Plumbism.......... 92 Pneumonia......... 87 Pneumonic Fever... 87 Phthisis........ 60 Pneumonitis...... 87 Pneumonokoniosis .58rf Podagra............ 85 Poisoned Wounds... 270 Poisoning,..........381 Poliomyelitis An- terior Acuta.... 30 Polyhydramnios___233 Polypi, Nasal......201 Polyuria.......... 87 Pomegranate-Root. 85 Post-Partum Hem- orrhage ....... 224 Potassium Perman- ganate ........ 275 Pott's Disease___ 324 Poultices.........284 Psoriasis of Palms.. 17 8 Premature Expul- sion ............232 Pregnancy, Diagno- sis of...........218 Ectopic...........257 Hygiene .........218 Multiple..........284 Placenta Previa ..223 Tubal...........257 Presentations, Man- agement of.....228 Breech...........229 Chin-Posterior.. .229 Face ...........229 Transverse.......230 Vertex ...........22* Primary Anemias... 96 Procidentia........251 Prognosis of Labor.221 Progressive Perni- cious Anemia... 97 Prolapse of Rectum. 343 of the Cord.......228 Uterine......-...280 Prophylaxis of Uter- ine Displace- ments ..........251 of Laceration.....220 Prosopalgia........162 Prostate, Enlarged.353 Bilateral Castra- tion ...........353 Bottini's Opera- tion ............353 Catheterization 353 Prostatectomy___353 Prostatitis .........353 Pruritus Vulvse.....241 Pseudo-Angina Pec- toris ........... 67 Pseudo - Hypert ro- phlc Paralysis. .165 Pseudo- Leukemia.. 98 Pseudo - Mem bra u - ous Laryngitis , 19 Iodide-of-Lime In 18 Psoriasis......178, 181 Ptoniaiii-Poisoning. 93 Puerperal Cystitis.. 285 Eclampsia........225 Lochia In.........236 Metritis..........235 Peritonitis.......285 Sapremla.......237 Sepsis............234 Septicemia.....284 Serum-Therapy in 280 Puulca Gran........ 85 393 PULMONARY INDEX POCKET-BOOK OF MEDICAL PRACTICE STILL-BORN IHilmonary Aneur- ism ............ 66 Pulmonary Tuber- culosis ......... 50 Alimentation.....536 Altitude.......... 53 Camp-Life.......53c Climate......... 53 Dcbove Method...586 Forced Feeding . 536 Pulmonary Tuber- culosis ......... 50 Home Treatment. 53 Inhalants....... 58c Lung-De ve I op- ulent ..........53'f Night-Sweats.....53t Nostalgia........53« Open-Air.........53c Septicemia......53< Sputum..........53< Sunshine.........53' Treatment........ 51 Pumpkin-Seed..... 35 Punctured Wounds.282 Purpura............ 98 Hemorrhagica 99 Rheuroatica...... 99 Simplex.......... 99 Purulent Infiltra- tion..........288 Conjunctivitis ....185 Gastritis........125 Rhinitis..........201 Pyelitis............144 Pyelonephritis.....144 Pyemia............201 Pyloric Insufficiency 133 Pylorospasm.......182 Pyonephrosis.. 146, 347 Pyosiilpinx........246 Pyothorax...... 55 Quinsy R Rachitis........... 32 Raspberry Vinegar .875 Reactionary Hem- orrhage ........266 Rectal Alimentation 371 Rectal Fistula)......259 Stricture........344 Surgery..........842 llcers...........343 Rectocele..........261 Reflex Vomiting... 183 Relapsing Fever___ 80 Remittent Fever___ 7 7 Renal Calculus. 150,347 Colic.............150 Hyperemia.......138 Oxaluria.........151 Phosphaturia___151 Tuberculosis.....140 Reposition of Uterus 280 Resection, Intesti- nal .............386 of Joints.........819 Respiratory Failure 280 Obstruction......280 Retained Secundines223 Retention, Urinary 267 Retroflexion........249 Retropharyngeal Abscess ........ 27 Adenitis.......... 27 Retroversion.......249 Rheumatism, Artic- ular........... 83 Rheumatoid Arthri- tis ............ 86 Rhinitis, Acute.....198 Atrophic........200 Chronic..........198 Fibrinous........201 Hypertrophic.....199 Purulent.........201 Syphllltle........203 Rhlno-Sclerma.....204 Ring-Worm........182 of the Scalp...... 35 Rose-Cold..........201 Rotheln............ 14 Rottlera............ 35 Round Worm....... 86 Rubefacients.......285 Rubeola............ 12 Rubella............ 14 Rumination........183 " Running Ear "... 195 Rupture of the Uterus.........224 S Saline Baths...... 64 Salpingitis.........246 .Acute.............246 Chronic..........246 Tuberculous......246 Salt Bath..........378 Sapremia...........291 Sarcomata......... 296 Nasal Passages... 205 of Naso-Pharynx .207 of Uterus.........255 Ovarian..........256 Saturnism.......... 92 Scabies.......178, 182 Scarlatina........ 10 Diet.............. 12 Hyperpyrexia___ 12 Nephritis........ 10 Treatment...... 11 Varieties......... 10 Scalds..............294 Scars of the Cornea ls7 Schede'8 Operation 292 Schlclch's Mix- ture ...........282 Sciatica..........161 Sclera, Diseases of.. 188 Selerltls............188 Sclerosis, Dissemi- nated ..........164 Insular...........164 Multiple..........164 Scoliosis...........325 Scorbutus......... 82 Scrivener's Palsy... 164 Secondary Hemor- rhage ..........266 Secundines, Deliv- ery of ........22(1 Retained.........223 Seminal Vesiculitis.864 Senile Vaginitis___24:' Senn's Dusting- Powder ....274, 292 Sepsis, Puerperal .284 Septum, Nasal, Ab- scess of.........202 Deformities of.... 202 Septicemia.........291 Puerperal........234 Sequel* from An- esthesia ........280 Serum - Therapy in Puerperal Sep- sis .............236 Setons..............286 Ship-Fever......... 74 Shock..............261 Silver-Lactate.....276 Silver-Nitrate......276 Simple Chancroid ..862 Vaginitis.........24;; Sinuses............2ss Skin Diseases ......174 Grafting ...292,293 Sloughing Ulcers .292 Small-Pox......... 8(1 Snake-Bites........271 Solutions, Nose and Thront........217 Sorbefaelents.......2H3 Sore Nipples .......226 Spasm of the Glottis 29 Spasmodic Croup... 18 Specific Vaginitis. 242 Spina Bifida........82S Spinal Cord, Inflam- mation of......153 Curvature ......325 Spirillum Fever... 80 Spirochcete of Ober- meler.......... SO Splints...........300 Spondylitis........324 Sporadic Cretinism. 36 Sprains............823 Sprays, Nose and Throat.........216 Stenocardia........ 66 Sterilization.......276 Alcohol aud Heat.27s Bladder........277 Catgut ...........277 Chromicize.......2•_ Sutures..........'-'_'. Urethra..........'{>' Vagina..........377 Sterilized Milk.....8..1 Still-born.........«1 394 STOMATITIS INDEX UROTROPIN POCKET-BOOK OF MEDICAL PRACTICE Stomatitis,Aphthous 25 Catarrhal.....25 Gangrenous...... 25 Mycosa.......... 26 Ulcerative....... 25 Stone in Bladder .. .349 Gall.............110 in Kidney........347 Tonsil............209 Ureter...........150 Strains.............328 strangulated Her- nia............269 Stricture of Urethra 851 Stupes.............284 St. Vitus'Dance .170 Stye................184 Sub-Adicity........186 Subglottic Laryngi- tis .............212 Subphrenic Abscess 103 Sulphur Bath.....37s "SummerDiarrhea" 21 S u p p r e 8 s i o n of Urine..........149 Suppurative Otitis Media..........195 Perihepatitis.....103 Suprapubic Aspira- tion ...........268 Cystotomy....... 350 Supra - Renal Ex- tract ...........217 Surgery............263 Surgical Emergen- cies ...........263 Fevers...........288 Infections....... 2sS Inflammations ...284 Kidney..........144 Sympathetic Oph- thalmia ........183 SymptomaticAnemia 96 Symptoms of Anes- thesia ..........280 Sycosis.............17S Syphilitic Liver ... 106 Orchitis.........355 Ulcers ..........293 Ulcer, Nose .... 203 Syphilis............357 Alopecia..........360 Buboes...........358 Chancre..........358 Congenital....... 34 Cutaneous Lesions360 Fumigations.....359 Hereditary....... 34 Incubation.......357 Inunctions.......359 Local Treatment. .360 Marriage.........361 Medication.......359 Membranous Le- sions'...........360 Mercurial Baths..360 Mixed Infections.368 of Nasal Passage 203 of Palms.........17s of the Fauces.....210 of the Larynx ....213 of the Lungs.....53'/ Pharyngls........210 Syphilis............357 Prophylaxis......358 Salivation........360 Special Therapy. .361 Stages and Pe- riods ...........357 Treatment. Gen- eral Measures 359 I n te rmedinte Period.......360 Local..........360 Primary Stage .368 Secondary Stage 369 Tertiary Stage..361 T Tabes Dorsalis......158 Taenia?............. 35 Talipes Equlnus.. ..327 Valgus...........827 Varus...........327 Tamarind Water.... 375 Tannic Acid........276 Tape-Worm........ 35 "Tapping" the Ab- domen .........845 Taxis...............269 Tetanus...........291 Antitoxin........291 Thiersch's Solu- tion........... 274 Thomas' Posterior Splint..........322 Thoracentesis...... 56 Thoracic Aneurism. 65 Throat-Cut........270 Diseases of.......198 Thrush............. 27 Thymol ............267 Tic Douloureux .... 162 Tinea Barbae.......178 Tonsurans........ 35 Tricophytina.....182 Tonsillitis..........209 Tonsils, Diseases of. 208 Hypertrophy of... 209 Tooth-Pulling.....346 Tourniquets........263 Tracheotomy.......272 Trachoma..........186 Transverse Presen- tation .........230 Treatment, Wound.282 Trephining.........301 Trichiniasis........ 89 Trichinosis........ 89 Trigeminal Neural- gia ............162 True-Croup........ 19 Tubal Pregnancy. .257 Tuberculosis of Bone298 Genital..........262 of the Larynx ...213 Pharyngls........211 Renal ............146 Tuberculous Epidi- dymitis ........355 Liver.............107 Meningitis....... 31 Perihepatitis.....103 Salpingitis.......246 Tumors and Cysts .. 295 Tumors.......233, 295 Adenoma.........147 Angioma.........1 47 Benign...........233 Fibromata.......295 in the Glands of the Lid.........1S4 Malignant, . 147. 233 of Fauces........211 of Kidney.......147 of Larynx, Benign 214 Malignant......215 of Uterus.........252 Ovarian.........256 Papilloma-........147 Turpentine.........267 Stupes...........284 Typhlitis..........121 Typhoid Fever...... 70 Cold Pack........ 73 Diet.............. 73 Disinfection..... 72 Drinks........... 73 Hemorrhage ... . 74 Hydrotherapy___ 78 Perforation...... 7 1 Rectal Alimenta- tion ............ 78 Sponge-Bath..... 78 Stimulants ...... 73 Treatment....... 70 Tympanites...... 74 Typhus Fever ..... 74 I Ulcerative Stomati- tis.....:........ 26 Ulcers............292 of the Cornea.....187 of the Duodenum .114 Gastric.....128, 131 of the Rectum... 343 Syphilitic,of Nose 208 Umbilical Hernia.. .341 Uremia.............143 Ureteral Calculus .. ...........150, 348 Wounds.........347 Uretero-Cystotom y. 348 Ureterotomy......348 Urethra............351 Female...........241 Urethral Caruncle. .241 Divulsion........352 Electrolysis......352 External Urethro- tomy ...........352 Fort's Urethro- tome...........352 Injuries.........351 Internal Urethro- tomy ...........352 of the Meatus. .352 Stricture ........351 Tight Strictures. .352 Urethritis..........851 I rle-Add Diathesis 86 Urinary Extravasa- tion ...........268 Urinary Fistulae___25s Retention...267, 351 Urotropin..........349 395 URTICARIA INDEX PQCKET-BOQK OF MEDICAL PRACTICE ZOSTER Urticaria...........182 Uterine Displace- ment.......231,248 Body, Carcinoma of..............253 Curettage........254 Fibroids ........252 Flbromyoma.....254 Hystero-Myowec- tomy.........254 Inflammations . .244 Inversion........252 Acute ..........262 Chronic........252 Complete.......252 Partial.........252 Myomectomy ..... 254 Oophorectomy — 254 Prolapse.........250 Complete.......250 Partial.........260 Sarcoma.........255 Tumors ..........262 Uterus, Reposition of.............260 Rupture of.......224 Uvula, Elongated .208 V Vaccination........ 84 Vagina, Diseases of.841 Vaginismus .......241 Vaginitis...........242 Senile.......... 242 Simple...........242 Specific.........242 Varicocele..........855 Varicose Ulcers — 292 Varicose Veins.....292 Fergusson's Oper- ation...........202 Schede's Opera- tion ............293 Trendelenburg's Method.........292 Varicella........... 14 Variola............ SO Conflue-ntes...... 81 Discreta.......... 81 Hemorrhagica ... 81 Varioloid........... SO Vaso-Constrietor...217 Velpeau Modified Bandage......304 Venereal Diseases..357 Warts............297 Venesection.......345 Ventral Hernia.....342 Verniicularls Oxyu- rls............. 36 Version...........230 Cephalic........280 Contra - Indica- tions ...........230 Indications.......230 Pelvic............230 Podalle...........280 Vertex Presentation 228 Vesicants...........286 Vital Capacity......380 Vomiting......... 138 from Anesthesia.. 280 Habitual.........133 Nervous..........183 of Pregnancy.....218 Vomiting..........133 Reflex............183 Vulvitis............242 Vulvo-Vaginltls... .235 \V Warts............297 Water-Bath........285 Wax Impaction.....191 Waxy Kidney.......143 Weichselbaum ..... 14 Weights and Mea- sures..........380 Wen ...............2«7 Wet-Cupping......286 Wet Pack..........37s Wine-Whey.......875 Worms............ 86 Wound Treatment. .282 Dissection....... 270 Gunshot..........27(1 Poisoned.........270 of the Eye........1S3 of Ureter.........847 Writer's Cramp___164 Yellow Atrophy of the Liver.......108 Yellow-Fever ...... 79 Zoster............. ISO MEMORANDA. MEMORANDA. /' >4l «-m •«# ■M< NLn DD137ms •, NLM001374159